Finding Normal

http://www.daytondailynews.com/n/content/oh/story/news/special-reports/2009/02/09/ddn020909heroininside.html

Treatment choices limited to daily doses at clinic

From behind secure glass and a barred door, nurse Linda Bostick gives Project Cure client James Lilly his daily methadone dose A woman receives her methadone dosage through a window at Project CureCarl Moyer of Miamisburg, a recovering heroin addict, credits Project Cure with saving his life. 

DAYTON — Three buckets catch raindrops dive-bombing through a leaky pipe in a ceiling at the Project Cure methadone clinic in Dayton.

In the clinic's narrow hallway, staff members walk sideways to avoid colliding with the line of patients waiting their turn at the dosing window.

The obsolete building at 1800 N. James H. McGee Blvd. bulges with desks, file cabinets, medical supplies and staff who fiercely protect their clients.

It's a big operation in a small building.

Administrators want to move into a larger, more modern facility, but finding a neighborhood willing to welcome a center for hundreds of recovering opiate addicts hasn't been easy.

"So far, we haven't turned anyone away, but we're running out of space," said Denise Walder, Project Cure's clinical outpatient supervisor. "We've outgrown this building."

So it goes with heroin treatment these days. The number of young people getting hooked on heroin is up, and so too is the number of those wanting to get off it.

Between 1992 and 2007, patients treated for heroin abuse in Ohio multiplied five times, to more than 7,000 a year.

Treatment centers like Project Cure are feeling the pinch. Project Cure served just 50 patients a day as late as the 1980s. In the summer of 2008, just under 500 clients received daily doses of methadone at the Dayton clinic — an increase of about 140 a day over 2007. By January, the number had jumped to nearly 700 a day.

"The increase has been very quick, very noticeable," Executive Director William Holly said. "We're searching for the reason."

What addicts seek: immediate relief from dope sickness and the intense craving for heroin.

What they find: few options, long lines and waiting lists.

The good news is that while heroin has made a comeback, the addiction can be treated. Unfortunately, the choices for recovering addicts are largely dictated by where they live.

"That's a problem. Whatever your county has, you're stuck with," said Dr. Eugene Somoza, a psychiatry professor at the University of Cincinnati and director of the Cincinnati Addiction Research Center.

Along with the VA, Project Cure is the only publicly funded methadone maintenance center in the Miami Valley.

Nationally, the number of heroin addicts is estimated at 900,000, but only about a fifth make it to treatment. More than 4,000 each year die from heroin-related illnesses: overdoses, HIV, hepatitis C.

Intense vomiting, diarrhea, panic attacks and chills often accompany withdrawal.

It's like the flu, but worse.

"Addiction is a chemical change that occurs in the brain," said Angela Cornelius, director of the Ohio Department of Alcohol and Drug Addiction Services, in budget testimony before the Ohio General Assembly. "Addiction isn't about bad choices. Once addiction takes over, the individual can no longer make responsible choices. Addiction controls that person's actions."

The granddaddy for treating that addiction is methadone, although it has its critics. Montgomery County Drug Court Judge Mary Katherine Huffman advocates drug-free therapy: counseling, programs such as Narcotics Anonymous and a no-excuse policy of abstinence.

Methadone clinics push those treatments, too. But addiction specialists say the odds for recovery improve with drugs such as methadone and — the new kids on the block — Subutex and Suboxone.

One is tried and true. Methadone was pioneered in Nazi Germany as a pain medicine. Subutex and Suboxone were only approved by the U.S. Food and Drug Administration in 2002.

Both treatments stop the withdrawal symptoms and eliminate cravings.

Both have drawbacks.

But without question, both also save lives.

Tired of the hustle

Each weekday, buses, cars and even stretchers bring opiate addicts to the Project Cure clinic in Dayton. They're here to drink a red liquid from a paper cup: their daily dose of methadone.

Some have traveled miles to get here.

And, of course, for some it's taken years.

For 35-year-old Carl Moyer of Miamisburg, it wasn't the 2½ years in a Florida prison cell, the thefts from his father's auto parts shop, or the estrangement from his children that sent him to Project Cure.

It wasn't even the time he found himself in a bathtub at a friend's house in Miamisburg, weighing 98 pounds and dope-sick from heroin withdrawal, trying to rip off the plastic casing on a razor with his teeth.

Moyer sliced his mouth in a desperate attempt to get at the metal edge. When the blade finally shook free, he slid it across one wrist, then the other, again and again.

"I was watching the water turn red," he said. "I was thinking about how my life used to be."

Outside the bathroom, friends pounded on the locked door. They believed Moyer had heroin and wasn't sharing.

"They kicked the door in," Moyer said. "They were mad because I was bleeding in their bathroom."

Instead of calling paramedics, the friends helped Moyer dress, escorted him to a nearby alley and abandoned him. Once they cleared the scene, they called 911 and told police where to find Moyer.

"My whole body was tingling," Moyer said. "I knew I wasn't far from death."

Moyer survived, spent years living from one heroin injection to the next before, in his words, he "got tired of the hustle."

That fatigue brought him, more than two decades after his mother first introduced him to marijuana, to the doorstep of Project Cure, the clinic that the late Dr. Ahmad Zafr founded in 1971 for recovering addicts like himself.

Project Cure

This year marks the 40th anniversary of the use of methadone to treat heroin addiction in the United States, and it remains the most widely used treatment for opiate addiction.

Methadone works by suppressing the intense cravings of narcotic withdrawal for up to 36 hours. It also blocks the high if heroin is used.

"It really stabilizes people," said UC's Somoza.

Some patients stay on methadone for more than a decade, and even for the rest of their lives. Project Cure has at least one patient who has been in treatment since the 1980s, Walder said.

The weaning process is done on an individual basis. Federal regulations require yearly evaluations to determine whether patients should continue. It's not unusual for clients to drop out — or get kicked out — and come back, sometimes more than once.

Methadone clinics are highly regulated. The addict must take the medication in front of a nurse, who at Project Cure stands behind a locked door and slides the cup through an opening in a window. Urine also is routinely checked.

The monitoring is necessary because of concern involving methadone abuse. In 2004, nearly 4,000 deaths were related to methadone, although the statistics include addicts and nonaddicts. In 2005, that number reached almost 4,700.

Many of Project Cure's clients rush into the clinic before work, arriving just as the door opens at 6:15 a.m. "We've had lawyers in here, teachers, students. Addiction can hit anybody," Walder said.

To help with the bottleneck, the clinic last year extended its dosing operation by three hours, to 3:30 p.m. Only on weekends, when clients are allowed extra doses to take home, is the ritual broken.

Holly said there also has been a dramatic switch in who seeks treatment. When the clinic first opened, most of its clients were black.

"There has been a significant change in our clientele," Holly said. "They've gone from being predominantly black to predominantly Caucasian."

The shift began about three years ago.

"It seems like, for some reason, young Caucasian teens begin to deal with prescription drugs — OxyContin, Vicodin — and then they move progressively toward heroin." Holly said. "We're doing everything that we can to turn that around."

About 30 percent of the patients who go through treatment at Project Cure use opiates again.

"Everybody here is not ready to get off drugs, in the beginning," Walder said.

Moyer says he is no longer using heroin. He doesn't mind the repeated trips to Project Cure for methadone. In fact, he is grateful for them. The trips keep him busy.

"I respect the program I'm in. I appreciate it. I depend on it," Moyer said. "I'm a drug addict. I will be all my life. I'm no angel, but I want to get clean. I want to be productive."

A new treatment

Treating a heroin addiction doesn't have to mean waiting in line at an overcrowded facility for a daily cup of liquid medication.

In downtown Xenia, TCN Behavioral Health Services Inc. offers residents of Greene, Clark and Madison counties detox, counseling and drug therapy, and clients often don't even have to wait in line.

Many hard-core addicts still require methadone to recover. TCN dispenses the drugs Subutex and Suboxone, which contain the active ingredient Buprenorphine.

Approved for use in 2002, Subutex and Suboxone take away some of the stigma — and hassle — from addiction drug treatment.

"Any doctor can get a license to prescribe it," Somoza said. "At least you don't have the stigma of having to wait in line at a methadone clinic."

Addicts first take one Subutex pill each day for five days to eliminate the cravings and withdrawal symptoms. After that, they go on Suboxone, a maintenance drug, that contains the ingredient Naloxone, which provides a sort of fail-safe against abuse. Those who try to inject Suboxone suffer withdrawal.

"It's virtually impossible to overdose on Buprenorphine. The only way to overdose is to take another medication, like Valium or antidepressants, that prevent the body from getting rid of it," Somoza said.

Recovery, of course, requires more than a pill. Like Project Cure, TCN addresses both the physical and psychological aspects of addiction, offering group counseling, one-on-one sessions and life-skills training, along with drug therapy.

The building in Dayton and and the one in Xenia couldn't be more different. TCN, at 476 West Market St., has a spacious waiting room, assessments are done on the spot and the 11-bed Creekside in-patient treatment center, where clients go to detox, is nearby. In fact, it's in the same building. Christopher House, a residential treatment center for recovering addicts, is virtually next door.

There is one major drawback to Buprenorphine, however.

"Anybody who needs more than 70 milligrams of methadone — about half of all addicts in treatment — Buprenorphine would not work for them," Somoza said.

The pill therapy is also more expensive. Methadone is priced at about a penny per milligram, while one 8 mg tablet of Suboxone costs $6.50.

TCN offers a sliding scale for residents of the three counties it serves, but its funding is being threatened. About $1.6 million of TCN's funding for alcohol and drug abuse programs comes from the Greene County Mental Health and Recovery Board's operating levy. That levy expires at the end of 2009, and a bid to renew the 1.5-mill levy, plus an increase of 0.5 mills, failed in November.

"Without those levy funds, programs like this could disappear," said Lynn West, TCN's chief operating officer.

Last year, 2,072 people sought treatment for substance abuse at TCN, a 12 percent increase since 2005.

The program works for people like Eli Day of Xenia, who can't see himself going to a methadone clinic. "I've known people who've used heroin just to come off methadone," Day said. "I wouldn't ever use it."

'I know what I need to do'

Day is like a lot of heroin addicts in recovery. He's been there before.

A heroin user since he snorted the drug on his 18th birthday — "I never thought I could get addicted" — Day graduated from Christopher House in the spring of 2008. He got a roofing job and looked into taking college-level classes. Confident in his sobriety, he began cutting back on his daily maintenance dose of Suboxone.

"I wanted to be off everything," he said. "I didn't want to trade one drug for another."

Soon he began cutting back as well on support group meetings and counseling sessions.

He relapsed Dec. 21, the Sunday before Christmas. He had arranged to buy a laptop from an old friend, who offered Day a clean needle. Day resisted, but arranged to meet the friend again to make a payment on the computer.

"All the way there I was fighting with myself. The obsession was eating at me," Day said. "I did it. Oh, my God, I hated myself. My body had that heroin feeling, but my head was thinking about all the things I had learned about recovery."

Still, he kept using.

On the Saturday after Christmas, his girlfriend told him she was pregnant. The news made him regret his relapse even more: He had a baby on the way.

Still, he kept using.

"I had thoughts of running my car into a tree. I felt so bad about relapsing," Day said. "Once you've done heroin, it becomes an obsession. It just eats at you and eats at you until you're doing it again and again."

On Jan. 5, before TCN opened its doors, Day was waiting in the cold, hoping to be the first person served. He went through detox at Creekside and is continuing his recovery at Christopher House.

"I have to put my recovery first. I have to fill that spot dope used to fill," Day said. "I know what I need to do."