March 01, 2008 10:09:36 AM
The Quick Fix
A sore back. A sprained ankle. Everyday mishaps can lead to a prescription for painkillers – and to abuse.
By JUDITH NEWMAN
When did Valerie Black know she was in trouble? Was it when her doctor increased her fentanyl patch – the powerful opiate that blunted the pain of Crohn’s disease and debilitating menstrual cramps – from 25 micrograms to 50? Or 75? Or 100? Was it when she began going through one patch a day, instead of one every three days? No. It had to have been when she and her husband, a prominent California attorney, decided to spend time at their home in Canada and she accidentally left the country one patch short.
“That night, I lay on the ground, screaming.” recalls Black (her last name has been changed), a 45-year-old PTA president who, for the past three years, had gotten her fix not from the corner drug dealer but from a pharmacist. “I was crawling out of my skin.” Frantic, she rushed to the emergency room of the local hospital and got another patch; it was hardly the first time the ER had seen the fallout from opiate abuse – however unintentional.
When she next saw her regular physician and told him how serious she felt her need for the drug was, he seemed puzzled. She had genuine pain; he had offered her a solution. Would a diabetic not take insulin because she didn’t like feeling “dependent”?
But to Valerie, this was not like being a diabetic; it was like being a junkie, except she had never even smoked a joint in her life. And she wanted out. She had heard about a four-day program in Orange County that uses anesthesia-assisted detox: Patients are knocked out and then receive a medication that flushes the opiates from their system and blocks cravings. The treatment condenses withdrawal – which typically means ten unbearable days of sweating, shaking, nausea, and cramping – into about two hours. “I didn’t think I could get off the fentanyl by myself,” she says. “This treatment sounded like my only hope.”
Valerie, a birdlike blonde dressed in jeans and a vintage T-shirt, still trembles (a symptom of the last remnants of the opiates’ leaving her system) as she tells me her story. A couple of days ago, she started the Waismann Method, perhaps the country’s premier program for rapid detox. Since it launched in 1997, more than 3,000 patients have successfully completed the treatment.
We are sipping green tea and nibbling apricots at Waismann’s Domus Retreat, where Valerie will recuperate for a week before rejoining her family. Domus, a luxurious transition house in a secluded Spanish-style ranch, houses a maximum of six residents, many of whom are “accidental addicts,” people who took painkillers for injuries or chronic illnesses and found themselves hooked. Here, behind the hibiscus-covered gates, they can eat healthily, see a therapist, get a massage, or do nothing at all, while contemplating life without a monkey on their backs.
The number of people in the United States using prescription painkillers is, in a word, staggering: Between 1997 and 2005, sales of the five major painkillers (codeine, morphine, oxycodone, hydrocodone, and meperidine) rose 90 percent, meshing neatly with the increase in money spent on drug marketing, which then went from around $11 billion to nearly $30 billion. Today about 5.2 million people abuse pain relievers, according to the government’s latest figures, and that number has been steadily rising.
Of course, used responsibly, the meds are key in managing chronic pain. And the vast majority of people do use the drugs appropriately. But then, so do many who get hooked. The horseback-riding tumble, the whiplash from a minor car crash, the careless twisted ankle: all painful mishaps that may result in a prescription for meds – and difficulty in getting off them. Against this backdrop, the face of today’s drug abuser is changing. Yes, there are still the lost souls nodding off on the street and the celebrities enjoying the high. But a growing contingent of abusers are high-functioning professionals or affluent stay-at-home mothers like Valerie Black.
And where there is a mushrooming drug epidemic, there will be new (revenue-producing) efforts to treat it, which is where rapid detox fits in. Waismann is one of perhaps a dozen programs specializing in rapid or anesthesia-assisted detox that have popped up across the country in the past decade. The method is expensive (Black’s treatment came to $16,500), and insurance doesn’t cover it, though the program is less costly than some of the fancier rehab centers. Critics say rapid detox is a fad, part of the country’s misguided romance with the quick fix, a ploy to avoid the hard work of recovery. The risks – including, in rare cases, death – outweigh what they see as the overblown benefits. Advocates contend that rapid detox is the future of drug treatment, that it is a safe and effective way to eliminate the humiliation, sickness, and failure associated with rehab.
For Valerie Black, the Waismann program is simply this: the thing that saved her life.
To appreciate why prescription painkillers are so addictive, it’s important to understand the economics of pleasure. Chemically, our bodies are a complex interplay of supply and demand. When the body’s demand for pleasure exceeds our ability to supply it naturally because we’ve been flooding the body with synthetic feel-goods in the form of opiates, we develop a craving. And in some cases, we become psychologically dependent or even physically addicted.
Here’s why. We all have receptor sites in our brains that are activated by our natural opiates, the endorphins released when we exercise or eat dark chocolate or watch George Clooney – anything that gives us a lift. Natural endorphins block pain as well as create a feeling of well-being. Synthetic opiates like Vicodin or Percocet also attach to opiate receptors; they attach to lots and lots of them. When opiates from outside the body are constantly attaching and detaching from the receptor sites, the receptors change shape.
Over time, fewer opiate molecules fit fewer receptor sites, so in order to block pain as effectively, or create the same feeling of well-being, you need more and more of the opiates. And once the drug supply stops, there are tons of receptor sites craving a fix. Desperately.
The jagged hell of opiate withdrawal is caused by a surge in norepinephrine. “It’s what gives us our fight-or-flight response,” says Rick Sponaugle, M.D. who founded Florida Detox, a rapid-withdrawal program in Tarpon Springs, Florida. “A surge of norepinephrine, which causes fear, anxiety, constriction of the stomach and bowels, twitches, dilated pupils, shakes, muscle cramping, high blood pressure – it’s supposed to kick the body into high gear if we need to fight or escape a bear. Our bodies are meant to tolerate it for ten to fifteen minutes. It’s not supposed to last for days. But that’s what happens with withdrawal.”
Going cold turkey being as ghastly as it is, it’s not surprising that in traditional treatment centers, where you’re monitored and undergo cognitive therapy while your body takes days to metabolize the opiates, the relapse rate after one year is between 75 and 85 percent, according to most reports. Waismann boasts statistics that are almost the reverse: After tracking patients for one year following treatment, it found that roughly 70 percent remained opiate-free.
Waismann’s co-director Michael Lowenstein, M.D., points to their intense medical supervision and individually tailored treatment to explain their success rate. Here is the basic protocol: After a patient fills out a detailed medical questionnaire, she undergoes an exhaustive workup – urinalysis, liver and kidney-function tests, and EKGs to check for arrhythmia. (Even though a patient may not feel the full brunt of withdrawal while she’s asleep, she is still withdrawing. And withdrawal is extremely stressful on the body.)
Most rapid-detox centers put the patient under general anesthesia; Waismann uses a much lighter form of sedation. Rather than patients’ being asleep for three to four hours, says Lowenstein, “we’ve refined the treatment to the point where they are asleep for 60 to 90 minutes. The shorter the duration, the less risk. “The main opiate-cleansing agent is Revex, a “narcotic antagonist” that essentially muscles the opiates out of the way, attaching its own molecules to the opiate receptors. It is, in a sense, the Sweet’N Low of opiates, satisfying the physiological craving for the drug without providing the “calories”. The patient is monitored in the hospital ICU for at least one night and sometimes more. In other programs, patients are often sent home right away, which can increase the risk of complications. (Almost all the reported deaths from rapid detox have occurred after the procedure, when the patient is theoretically safely home.) Waismann patients are referred to psychological counseling to help them stay clean after they leave the hospital.
Critics contend that the approach shortchanges the psychological aspect of the process. A 2005 study in the prestigious Journal of the American Medical Association (JAMA) measured the effectiveness of rapid detox against other medical methods and found no evidence that its benefits outweighed the risks.
“Not everyone can afford it, and it’s not for everybody,” fired back Waismann’s Lowenstein. “But it’s safe and effective... and we have a very high success rate.”
If there is a higher success rate – and the JAMA researchers would like to see the Waismann results documented in a peer-review journal – it may have something to do with human faith in throwing money and technology at a problem. “There’s some fundamental bias inherent in the idea that it’s expensive and high-tech, and there’s a placebo effect attached to a high-tech procedure,” notes Eric Collins, M.D., coauthor of the JAMA study. “But I’d tell anybody to try safer, cheaper alternatives first.”
Clare Waismann, a soignẻ, 40ish Brazilian with a curtain of honey-blonde hair, brought the method to the United States. She is by no means against the conventional 30-day treatment model, but she firmly believes that traditional rehab is not necessary or even desirable, for the accidental addict. “In conventional rehab, you have to define yourself as a drug addict and admit that you are powerless and that you may in fact be vulnerable to addiction your entire life,” Kavin explains. “This simply isn’t true for everyone.” Also, she adds, you have to drop out of life for at least 30 days, “which for a lot of powerful, high functioning people may be both embarrassing and unnecessary.”
It’s been five months since Valerie completed the Waismann program. She now admits that the treatment was by no means easy. “The first month was incredibly difficult. I was so weak I could barely get around. It was like I had lead in my legs. It wasn’t nearly as bad as cold-turkey withdrawal, with the shaking and diarrhea” – essentially what happened when she went 24 hours without her fentanyl patch in Canada. “But it was a different kind of awful.” The Waismann Method recommends the use of naltrexone, a nonaddictive drug that helps block opiate craving, preventing relapse, once a day for up to nine months. But Valerie refused to take it. “I knew I wasn’t going to go out looking for drugs again,” she explains. “And I didn’t. I wanted everything out of my system. But maybe I made it harder on myself by not using it. And even though they say there is no withdrawal, there is some. It’s not exactly physical. It’s more like... there are no endorphins left in your system. So you just feel blank. You have to build them back up.”
And so she did. To deal with the pain, Valerie began doing yoga, “which helped immensely” and may have also aided in replenishing her system’s natural endorphins. Soon, her relationship with her family also changed. I wasn’t numbed out anymore. I had returned to them. “You know,” Valerie says, thinking back on the three years she spent at the mercy of an opiate, “it was like being in jail in your own body. Now I’m out of jail. I’m free.”
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