New Ways To Stay Clean

When Colin Martinez turned 43 a couple of years ago he was living under a bridge in Denver. By his count, he had devoted 31 years to getting wasted. "I smoked crack or freebased for 16 years," he says. "I injected heroin, injected cocaine, snorted cocaine and heroin, popped pills, smoked opium, smoked pot and hashish. I took anything--a lot of it on the same day." He worked off and on after quitting high school in the '70s. He also married and had several kids. But addictions crowded everything else out of his life. He stole from employers to keep himself in drugs. He skipped out on his family for weeks a time. And despite countless trips through detox, he never really got clean. "If they were hassling me about cocaine," he says, "I'd do something else instead." When he awoke one morning to find his buddy's cold corpse beside him, he knew he was approaching the same end.

Things couldn't be more different today. In a last-ditch rescue effort, Martinez's father sent him to the Caribbean island of St. Kitts two years ago to take part in an experimental-treatment program. This time, Martinez didn't return to his old haunts as soon as his urine was clean. He moved to Florida to join a community of other recovering addicts. And with that support in place he has managed, for the first time since the age of 12, to stay free of drugs. Instead of peddling stolen car keys, he now works as a staff assistant at the University of Miami. "I have friends and a job, and I like who I am," he says. "I never thought I'd even be able to flip hamburgers again, but I'm doing purchasing and handling accounts." He is also communicating with his children. "My life has been a mess," he allows, "but today it's pretty cool."

Overcoming addiction is never simple. The risk of relapse is so high--roughly half of all patients fall off the wagon within a year of detoxification--that many health-care professionals consider treatment a waste of time. When researchers at California's Kaiser Permanente health plan surveyed doctors and nurses a few years ago, most viewed medical intervention as "ineffective" and "inappropriate." The truth is not so grim. Addiction may never be as treatable as strep. But with medication and intensive, long-term support, even the most inveterate abuser can succeed.

Drug dependency is less a failure of will than a miscarriage of brain chemistry. Substances like cocaine and heroin don't simply feel good; they reconfigure the reward system that makes things feel good. By releasing the chemical messenger dopamine at critical moments, our neurons reward survival-enhancing activities, such as eating and lovemaking, and give us strong incentives to repeat them. Addictive substances artificially boost dopamine's effects. And as we adapt to their pleasures, the quieter state that once felt normal begins to feel like blight. The recovering addict's challenge is to live with that sensation.

For people hooked on heroin and other opiates, medication can make getting clean a lot easier. Morphine and its cousins, including heroin, all work by docking with a cell receptor called mu. By stimulating this receptor, they slow the transmission of pain signals within the brain, while increasing the release of dopamine. Methadone, the most widely used medication for heroin addiction, works by a similar mechanism. But because it is taken up more slowly, it produces a much milder sensation. Unlike heroin, methadone can be taken orally, and its effects last 24 hours instead of four. By downing a cup of powdered solution each morning, an addict can ward off withdrawal without having to shoot up, deal with pushers or walk around looking drugged. The regimen substitutes one form of dependence for another, but addicts in methadone programs are more likely to have jobs, less likely to commit crimes and less prone to HIV infection.

Unfortunately, most of the people who could benefit from methadone don't receive it. To guard against abuse and overdose, the federal government restricts the drug to specially licensed clinics that please no one. Few recovering addicts are comfortable parading in and out of these clinics, and no neighborhood wants to house one. Eight states have no methadone clinics at all. The only alternative medication is naltrexone (Revia), which is available by prescription but even less popular among addicts. Naltrexone works like a chastity belt, sealing off the mu receptor to make it inaccessible to heroin. The drug will send an untreated addict directly into withdrawal (not a good idea), but it can help a clean addict stay that way. It's used mainly by "lawyers, physicians and business executives," says Columbia University psychiatrist Herbert Kleber--"people who have good jobs and risk losing them if they relapse."

In the near future, heroin addicts may have a third alternative. The new drug--buprenorphine--acts like extra-mild methadone at low doses, tickling the mu receptor to create a barely perceptible buzz. But unlike methadone, it's neither intoxicating nor dangerous at high doses. If a user takes more than the prescribed amount, it jams the receptor, diminishing the high instead of exaggerating it. Reckitt Benckiser Pharmaceuticals of Richmond, Va., has applied to market buprenorphine as an under-the-tongue lozenge called Suboxone, and federal approval is expected soon. Because doctors will prescribe it directly, experts say it may double the number of heroin addicts receiving treatment.

Cocaine and methamphetamine pose a knottier problem. They, too, hijack the body's reward system, making sobriety feel like purgatory--and there is not yet a pill to ease that trauma. Counseling, therapy and training may not ease the pain as readily as medication, but these interventions can be powerful. "Addiction affects every aspect of an individual's interaction with the world," says Dr. Alan Leshner, director of the National Institute on Drug Abuse (NIDA). "People in recovery need to know how to control their behavior, how to function in their families, how to go back to work."

Many clinics employ variations of the traditional 12-step program, which centers on admitting one's powerlessness and seeking divine guidance. But most also take concrete steps to change people's responses to their environments. One approach, known as contingency management, uses rewards to keep recovering addicts on track. At Johns Hopkins University, for example, researchers have created a "therapeutic workplace" where participants earn vouchers for rent and food by working as data-entry operators. Their wages rise as their skills increase, but they lose earnings if they fail a urine test or behave unprofessionally. Without the monetary incentive, says Dr. Frank Vocci of NIDA, patients might rightly believe they had little to lose. Given a chance to get high, "they would ask themselves, 'Why not?' " he says. "Now they have an answer."

Will cocaine users ever have their own version of methadone, naltrexone or buprenorphine? Researchers have tried for years to create a cocaine blocker, but with little success. Unlike the opiates, which directly stimulate a receptor, cocaine works by blocking the receptor that neurons use to reabsorb dopamine after they release it. As Dr. Donald Landry of Columbia University observes, it's hard to make a drug that blocks a blocker. If you seal off its target, you've simply reinvented the drug. But researchers are now pursuing a new approach. Instead of blocking cocaine's target, they're exploring ways to neutralize the cocaine molecule itself, whenever it enters the bloodstream. At Yale, for example, researchers have started tests on a vaccine that may block the drug's effects for six months at a time. With luck, it could reach the market by 2004.

One way or another, the arsenal against addiction is sure to expand. Leshner, of NIDA, estimates that 60 drugs are now under study as treatments for cocaine addiction. One of the most controversial, a botanical called ibogaine, may help alleviate a broad range of dependencies. This natural hallucinogen is illegal in the United States, but University of Miami neuropharmacologist Deborah Mash has spent five years studying it at the Healing Visions Institute for Addiction Recovery in St. Kitts. Patients take it just once, and many say it not only masks withdrawal symptoms but gives them new perspective on their lives. "It doesn't work for everyone," Mash says, "but for detox from opiates it's a slam dunk." According to Mash, cocaine users benefit, too, though less dramatically. So do alcoholics. Critics say the evidence is only anecdotal, but ibogaine is the treatment that started Colin Martinez on his current two-year rally.

Even when it works, medication is only one step toward recovery. Beating addiction requires every tool on the table--medication, counseling, social support, family support--and keeping up the fight when you're losing. As Martinez has learned, treatment isn't a war but a long, slow siege.

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