Thursday, September 9, 1999
His name is Gunner, and unlike a certain presidential candidate from the state of Texas, Gunner is more than willing to look you directly in the eye and answer the question: "Have you been a serious drug user?"
From the time he was a teenager out on the streets of Salinas, Gunner, with a resourcefulness and energy that would be the envy of any Type-A entrepreneur, was earning thousands of dollars a week, month after month, year after year, in order to feed his $500-a-day heroin habit.
"Since I was a kid, I was a dope fiend and all I had was dope fiend friends," says Gunner, who has been off heroin now for five years and who, at age 47, seems to have made peace with his past and found hope for the future.
"My thing was armed robberies, and just to keep me well I was shooting $500 a day. I got 13 robbery convictions and spent 20 years in prison just to get drugs. It was a serious game with me and I had shootouts with the cops. I was a kid, man, and found myself in San Quentin. I was even shooting up in Quentin. Hell, I didn''t know what the world was about."
What has enabled Gunner, and approximately 300 other heroin addicts in Monterey County to get off heroin and turn their lives around is, ironically, another powerful and highly addictive drug--a pharmaceutical opiate known as methadone. Methadone is currently administered at two treatment centers in Salinas--The Methadone Clinic, which has been in operation since the early ''70s and is run by Community Human Services, and Valley Health Associates, a non-profit clinic also located in Salinas.
From the comfort of our material well-being and socially sanctioned vices, it is logical to ask why any of us should sympathize or try to understand the seemingly self-inflicted misfortunes of a "low-life junkie."
In point of fact, there is much to learn and understand if we take the time to listen to people like Gunner.
For one, we quickly see how irrational and sanctimonious current drug policy has become, and how the stigma of addiction denies the addict''s right to be treated with humanity.
We also see a darker version of ourselves echoed in the addict''s story, how the driving impulse to score is not too far removed from the rampant consumerism and bloated materialism that is undermining positive social values.
Most importantly, by listening to the addict''s story, we can learn about compassion and humility, and how in the absence of hope, opportunity and faith, anyone can be driven to addiction.
"It controls your life man. You see people leave their wives and kids-- everything over it," says Gunner. "If heroin was legal, people such as myself on methadone would never have become criminals if they were able to go to their own doctor who wrote a prescription for medication to handle it that way."
For those who remain indifferent or untouched by the addict''s plight, Gunner offers a word of warning.
"If they were to shut down the clinic, there would be a crime wave here you couldn''t believe because every one of these people would have to fix somehow. You''d have hundreds of addicts stealing, robbing, and killing people for money everyday.
"If it wasn''t for the clinic, I would either be dead right now or doing a life sentence in prison, one of the two," adds Gunner, echoing the refrain of numerous addicts enrolled in the treatment program. "The clinic literally saved my life and gave me a chance."
Rising Tide According to statistics compiled several years ago by the American Methadone Treatment Association, an estimated 810,000 Americans were addicted to heroin, with approximately 179,000 enrolled in a methadone treatment program.
A study on heroin and methadone published in 1996 by the Lindesmith Center, a drug policy clearinghouse and think-tank, indicated an 80 percent increase in heroin-related "episodes" in hospital emergency rooms between 1990 and 1993, with the average purity of street heroin rising from 5 percent during mid-''80s to between 40 and 60 percent in many major cities today.
The human cost of that increasing purity is reflected in the 41 heroin-related deaths that have occurred here in Monterey County between 1996 and 1999 (to date).
A more recent study just released by the U.S. Department of Health and Human Services indicates that between 1992 and 1997, about 232,000 people have entered treatment facilities for opiate addiction, a 29 percent increase.
The startling rise in the number of people seeking help for opiate addiction confirms what health officials have been warning for a number of years, that the growing availability, purity, and reduced cost of heroin is creating a tidal wave of addicts that no "War on Drugs" is capable of containing.
Ironically, there was a time decades ago when the federal government appeared willing to treat opiate addiction as primarily a medical/health issue. The promotion of methadone treatment for heroin addiction received its first impetus under the Nixon administration back in the early ''70s. Although methadone had been recognized as an effective treatment for addiction in the early ''60s, there were fewer than 400 methadone patients in the entire country as late as 1968. Under the direction of Nixon and the feds, there were 73,000 patients by January 1973.
The need to refocus and re-emphasize the treatment of opiate addiction as a medical/health issue is born out by the statistics on drug arrests and incarceration.
About 60 percent of all federal prisoners in the U.S. have been locked up on drug offenses. Here in California, 7.5 percent of California''s 23,000 inmates were imprisoned for drug offenses in 1980. Of today''s 158,000 inmates, about a fourth of men and 35 percent of women were sentenced on drug offenses.
Magic Bullet? First synthesized by German scientists searching for a substitute for dwindling morphine supplies during WWII, methadone blocks the withdrawal symptoms associated with heroin addiction. With a half-life in the body of four to eight hours, an addict must shoot heroin two to three times a day to avoid withdrawal. With a half-life of up to 48 hours, methadone enables the addict to better stabilize his life.
A 1990 National Academy of Sciences'' Institute of Medicine study found that methadone maintenance yielded the most positive results in warding off withdrawal symptoms and suppressing, but not totally eliminating the cravings for heroin.
Methadone does not produce the euphoric high of heroin, nor does it create tolerance in the user. The drug is administered orally, and based on the addict''s history and level of heroin use, methadone, when administered in sufficiently high doses and sufficient frequency, allows the addict to live a fairly "normal" life.
"The advantages to being on methadone is it''s legal, it is not injected, there is access to counseling, and there is a decrease in health risks," explains Dr. Edgar Castellanos, medical director of The Methadone Clinic for the past five years. "That is basically it."
Among health and law enforcement officials, there is general consensus that methadone treatment has reduced the violent street crime, the number of drug arrests and imprisonment, and the deleterious health risks associated with heroin addiction and intravenous drug use.
Because it is administered orally, methadone treatment has reduced the rates of HIV, hepatitis and tuberculosis among addicts. The one downside of methadone treatment is the fact that the drug is as highly addictive as heroin, making the addict dependent on his or her visits to a treatment center for an indefinite period of time.
"One of the things I tell clients a lot is that methadone has a stronger withdrawal than heroin, although I think it''s harder get off heroin," says Castellanos, who estimates there is a waiting list of from 30-60 patients at his clinic. "In theory, you do have to take methadone for the rest of your life, although the program is designed to come off in a year or two. There are people who have been on the program five years, and there are people nationwide who have been on methadone over 20 years. We do take people off methadone, but how many people stay off--that is a tough question. What methadone gives you is an opportunity to get your personal life together, to sever connections with those giving you the drug."
The Seduction of the Needle "Heroin is a very addicting drug, and it''s difficult if not impossible for some people to get off of it," explains Robin McCrae, executive director of Community Human Services.
In the case of Doris, a lifelong Salinas resident, it was years of mental and physical abuse at a very young age by her mother, as well as numerous personal tragedies over the course of her life, that led her to become addicted to heroin by the time she was 15.
"Heroin was my choice of drug," says Doris, with a matter of factness that evidences regret but no shame. "It made me feel invisible, in my own world and I didn''t care how deep or how strong a hold the drug took. I was in love with it and enjoyed it. I wanted to be numb and heroin helped. It was a good way to not have to deal with things, with the reality of the world."
Like many other addicts, Doris fed her $100-a-day habit through shoplifting and other petty crimes, setting herself on a revolving cycle in and out of prison, struggling to kick and becoming addicted again and again.
It wasn''t until Doris enrolled in The Methadone Clinic in 1993, and had access to counseling, that she was able to rein in her addiction. Doris'' control over her addiction is often tenuous, but her ongoing success she says, is due to methadone enabling her to restore ties to estranged family members.
"I was so involved with the drug life that I was blind to everything else," says Doris. "It''s a new experience for me having someone to care for and love. I''m not ashamed of anything I''ve been through. There are a lot more people out there like me who just need guidance and help to get where we all need to get in our lives."
In a very real sense, methadone has given Doris a fresh start, although she continues to pay a price for her years of drug dependency.
"At this point in time I''d be afraid to get off," she says. "I''m not through with my problems yet, but hopefully I won''t need it one day. What I''m doing now is learning to live. I was always on the streets and never did the things other people do. Now I go into the store and buy things. I sit down to a regular meal. I get bills and pay them. To me that is exciting. I''m going where I left off at age 10 or 12.
"I don''t miss getting high anymore. Things are the way they''re supposed to be now. I''m learning to see the way other people are through their eyes instead mine, which were always fogged. It''s different and not always easy, but now I have people who care."
If you ask health officials and clinicians who deal with addicts why heroin has such an insidious grip on users like Doris, they will tell you the reason--heroin delivers, but only up to a point. It is a drug that promises the world at first, but just as quickly takes it away.
"The curse of heroin is that it works, and it gives the user something no person on Earth can give them," says Gemma Perry, intake coordinator for The Methadone Clinic. "The first time is the best time, the first time is free but then you chase [the high] and nothing ever meets it."
To understand just how powerful the lure of the needle can be, Perry relates a common occurrence that happened to users when they first came to the clinic.
"We used to show on in-takes an AIDS video showing people shooting up," relates Perry. "Looking at the needle was enough of a trigger to get someone to go out and score. We stopped showing the video. We''ve heard horror stories about users in early withdrawal who were so addicted to the needle they will shoot anything."
A Cry for Help To better appreciate the horrors of heroin addiction, one only need talk with Marilyn, a client at The Methadone Clinic who openly reveals the psychic and physical scars from her years of heroin use.
During an interview about her struggle with addiction, Marilyn, as though unsure her words and story were convincing enough, suddenly jumped up out of her chair and raised her pant legs to reveal the massive skin grafts she needed after flesh-eating bacteria from contaminated heroin nearly devoured both her legs.
Those physical scars serve as a powerful reminder to Marilyn about how far she''s come and how far she could fall if she again succumbs to the allure of heroin.
"I thought of all the shit and ugly stuff in heroin and I just decided I didn''t want to use anymore," says Marilyn of her decision to kick. "I had so many dreams to pursue I couldn''t do with heroin. Now I feel safe on methadone, and after using heroin for 25 years I now have no desire for it, so there''s something to be said [for the treatment]."
Marilyn became addicted to heroin in her early 20s, stumbling into casual use at first out of anger at her husband''s own occasional use. Upon the eventual breakup of her marriage, Marilyn quickly found herself within the grip of addiction.
"I was a needle user from the start even though I was scared to death of needles," says Marilyn. "I was unhappy with life and decided I didn''t want to live anymore. Heroin took away all the pain and I was happy to be strung out. I was usually dealing to pay for the heroin, and I had a $300-a-day dealer''s habit. I was using platefuls a day of cocaine and injecting heroin. It didn''t feel like a problem. But little did I know it would take everything I love from me for the rest of my life."
Through her enrollment at The Methadone Clinic, Marilyn has been able to reclaim a part of her life. Marilyn is currently enrolled at Hartnell College studying to become a drug and alcohol counselor. She stays rent free with friends in exchange for household help and does other odd jobs to help cover her $275-a-month out-of-pocket expenses at the clinic. She goes to the clinic every day and is allowed two "take-home" dosages every week.
Marilyn is often accompanied by her 10-year-old daughter to the clinic. "She loves it because she knows it''s what''s keeping me clean," says Marilyn, now 45 and feeling more secure about her future. "I have time for her in my life now and I don''t think about drugs."
A Penny Saved is a Penny Earned The social benefits of methadone treatment on a pure cost basis have been clearly demonstrated in recent state studies on drug use.
A recent report by the state Legislative Analyst Office on the cost benefits of drug treatment cited a 1994 study indicating that $200 million spent on drug treatment saved the state $1.5 billion during fiscal year 1991-92. More recent studies indicate the state saves $7 for every dollar spent on recovery programs.
In the U.S. only 7 percent of the cost of a methadone program is spent on the drug itself; the rest is for counseling, health screenings and medical exams and drug testing. Depending on the individual and his circumstances, some of the costs of treatment are covered under Social Security and MediCal.
According to county Behavioral Health Director Robert Agnew, the state determines the funding rate, which is set at $7.37 per methadone dose, $13 for every 10 minutes of private counseling, and $3.60 for every 10 minutes of group therapy.
Here in Monterey County, Community Human Services received $459,000 in funding from the County Alcohol and Drug Program, while Valley Health received $94,000 for their methadone maintenance programs, which cost on average between $250 and $300 per month per patient.
Mission Control Methadone and methadone treatment are two of the most highly controlled drugs and drug programs in the U.S., regulated by the Federal Drug Administration, the Drug Enforcement Administration, and the Substance Abuse and Mental Health Services Administration. Dosage levels, admission criteria, and length of treatment are just some of the areas dictated by federal and state regulations.
Doctors are not allowed to prescribe methadone for addicts outside of designated treatment programs, while prescriptions for methadone can''t be filled at pharmacies.
Authorities argue that tight regulations are necessary to keep patients from abusing and/or selling methadone, but advocates say such problems are exaggerated. Critics of the current system contend that allowing physicians to prescribe methadone would go a long way toward helping many more heroin users recover from addiction.
"Federal regulations by far are fairly liberal, but some of the main criticisms with the system is people do not have access to treatment, partly because private physicians can''t distribute it," comments Jocelyn Woods, executive vice president of the National Alliance of Methadone Advocates--and herself a methadone user. "The only federal regulations that are bad is the main one that says methadone can only be administered from a clinic, and that creates a monopoly."
The demand for increased access to methadone treatment may in fact be making headway at the federal level. Just last month, the Clinton administration proposed accrediting hospitals and doctors to prescribe methadone as part of an overall reform of current methadone treatment centers.
From Agnew''s perspective, the time, money, and effort spent in methadone treatment is well worth it. "We collaborate with the county''s drug court program and work with probation on how to divert [addicts] out of the criminal justice system," says Agnew. "Methadone has proven itself to maintain a group of individuals off illicit drugs and provide the means to return to a life of normalcy."
The point made by Agnew, as well as many addicts and clinicians, is that methadone treatment should be viewed as a medical issue, often comparing methadone to insulin or nicotine skin patches.
"They are taking a drug but people take drugs for a variety of health reasons," says Agnew.
Just how effective methadone is in keeping addicts off heroin and out of prison is subject to debate, in the absence of hard and fast statistics. According to Beth Shirk, of Monterey County''s drug treatment court, the results of methadone maintenance treatment are less than conclusive.
"Twenty-five percent of our client load are heroin addicts, with 10 percent of those on methadone," Shirk explains. "Methadone clients have not fared as well as other addicts who detoxed off all drugs and then go through drug treatment. In some respects methadone is another drug, and my experience is many individuals on methadone are also using other illicit drugs at the same time. Recovery from drug addiction includes far more than not using drugs. It means changing thinking, looking at issues that led to drug use in first place."
How effective such changes in treatment will be will likely depend on a radical change in physicians'' perceptions of addicts as people with a medical problem.
"Currently there is discussion of dispensing methadone from certain private physicians," explains Castellanos. "It''s the monitoring of the patient that limits an outside physician''s ability to treat patients, and not many doctors are treating addicts. A lot of it has to do with a desire to deal with folks with drug addicted problems. Physicians are busy and don''t have time to work with folks with drug addictions. The medical community doesn''t deal with addicts well, and with the stereotypes put on the addict, the addict feels it and is ashamed and won''t discuss it with physician. They hide it."
Standard Operating Procedure Given the bizarre, and often byzantine rules and regulations regarding methadone treatment, an addict often has to be totally gone before he or she can get help.
"Track marks are advisable," says Perry, with just a trace of irony in her voice. "To be admitted for a 21-day detox you have to shoot opiate, prove you used for the past two or three months, and have symptoms of opiate withdrawal. For longer than 21 days you have to document a two-year history of use or show you''ve been on parole or have an arrest record."
According to Castellanos, anywhere from a gram to three grams of heroin a day is considered heavy use. A gram-a-day-user requires anywhere from 40-50 milligrams of orally administered methadone to block out withdrawal symptoms.
"We have clients who may need to be on 80 to 100 milligrams, although the average dose is 60 to 90 milligrams," says Castellanos.
All patients admitted to the maintenance program must detox first.
"If you have a real high level of use, the 21-day detox lets you know the methadone works," explains Perry. "The worst thing is to have to fight your mind, and with the detox mentally you realize you don''t have to throw something into your arm. We break that cycle of needle use."
After detox, clients are admitted to the methadone maintenance program. According to Perry, based on assessment of clients on site, it''s been determined that 50 percent of clients who do the 21-day detox go on to full maintenance within a year. Counseling is mandatory in the maintenance program, as are random drug tests.
"Most clients come voluntarily," says Castellanos, who notes that clients run the gamut of socioeconomic backgrounds and age. "Some are tired of stealing, tired of the life they''re leading. They run out of veins and start shooting into muscles, getting abscesses, losing jobs and families. All had issues going on with being caught up in the legal system. That helps as an incentive. The bottom line is they''re tired and want change."
Based on his experiences, Castellanos says addict self-referral and extensive counseling are critical to successful treatment.
"Long lasting results have to come from the addict, that is why self-referral is a good thing," says Castellanos. "When you get court-ordered treatment a good patient has to want it. Treatment carries a higher meaning when self-referred."
Final Cure "I feel methadone treatment is very beneficial to the community," says Michael McFarland, deputy director of Community Human Services. "Given that we''re looking at a life change, all we can do is facilitate that change for the client to give them other alternatives to former behaviors. If [you define results] as being improvement in the quality of life, it''s definitely worthwhile when you look at the reduction in crime and exposure to disease."
For Gunner and his fellow patients, the battle against addiction can only be measured one day at a time. It is a long and uncertain struggle, requiring vigilance and not a little bit of faith.
"It gets real lonely and I get a lot of temptation every time I think about it," muses Gunner. "What you''ve got to do is a hard thing, but you have to cut everybody loose, everybody you know who used drugs. The clinic has been a lifesaver for me but you got to want it. Why be sick every day? Why steal and rob and do everything else you do to let something control you like that? You have to find something you want in life more than heroin."