I once a long time ago wrote a diary about this topic, being personally someone afflicted with opiate addiction, and it sparked very much interest, and got me started writing out against the so-called "War on Drugs".
With a group of drugs called Opiates or Opioids, namely Heroin and Oxycontin (oxycodone), growing very much into a new "boom" in the United States and across the world, this topic becomes even more important. When we took down the Taliban, that the year before we invaded Afghanistan changed it's policy to outlaw opium production (sucessfully), anarchy reigned. Now most of Afghanistan's economy comes from opium crops, and the Heroin that is produced along the Afghan-Pakistan border where Bin Laden was allegedly hiding, largely by Pakistani Intelligence that we support.
The situation in Afghanistan/Pakistan is very grim, and heroin is cheaper and more potent than every across Europe due to it (we get our high quality heroin in the United States from Columbia or Mexico.)
But this isn't a political diary. This is about the treatment for "the hardest drug", so that we may better understand it - and there is plenty of law along the way.
This diary as alluded lead to a ton of diaries posted in a series regarding the War on Drugs, and am the only one who pays any attention to the Dkosopedia Drug War Page. I am vehemently against the Drug War, better known as prohibition, but I do not necessarily support full legalization of all drugs. I certainly don't think tomorrow you should be able to buy, say, Heroin, in your corner drug store like candy. However, I think that that is more logical than our hypocritical, brutally harm inducing (to the user), brutally harm inducing (to society), corrupt, anti-freedom policy that currently stands (that "one pissed off liberal" just wrote another eloquent diary about, albeit largely about marijuana, #1 on the rec list.) For a round-up of just how many things are wrong with our drug policy, see my most recent diary on the topic.
It is in understanding treatment for Heroin addiction that understanding of important concepts such as "harm reduction" come from. The new DATA law is vvery interesting - as is how Congress illegally delegated their powers to the executive branch saying the DEA could pull the plug on the DATA (the law is explained in depth a bit later) whenever they wanted. Even though it was completely logical and effective, the anti-drug policies still shine through even in "compssionate" legislation such as this.
Another thing you need to know is that I myself am afflicted with opiate addiction, and have been in maintenance treatment as you will read for over 6 years now - but was nearly forced to lose it when temporarily moving to Australia, which would have induced a month-long withdrawal syndrome that is extremely unpleasant and a very high likelyhood of relapse. I say that not just from the statistics, which are intimidating to say the least, but knowing the "taste" that returns should I not get my medication. You will read all about it.
I am going to post the diary I wrote back then with some minor touching up. While you read it, consider the fact that heroin addiction is so hard to overcome that maintenance with other opiate drugs becomes necessary and how it would be easier and make more sense to just give addicts - most of which whom can't help themselves - what they need. Believe me, there is little to no joy in Heroin addiction. You just keep trying to feel normal.
Ok, let's get into it.
(A Personal Statement)
Let me get one thing out of the way: heroin has been stigmatized to no end, largely due to the needle use involved. However, due to the great increase of potency that heroin has had in the past decade or two, needle use is no longer necessary for those who aren't hardcore addicts. There is large growth in suburban sniffers and smokers, as well as large growth in use of prescription opiates (properly known as opioids, except for codeine and morphine, but I will use opiates anyway,) especially Oxycontin [generic name oxycodone], which spreads out to rural areas as well as suburban areas, and it's a HUGE problem. It's even hitting the rich - just look at Rush!
And then I continued, saying a bit about my personal opinion regarding drugs and thee morality associated with using them, and their relative dangers (to each other):
Now, back to what I was saying: is heroin (and other opiates) bad? Hell yes! I am not, nor will I EVER, advocate heroin use. But it's bad for one reason and one reason alone: the addiction/tolerance. Every single other reason is due to the drug war. Every last one. This is my opinion, and you are free to disagree. Let me also make clear that I am not downplaying the problem of addiction and tolerance: it's a HUGE, HUGE problem - as you will soon learn about. Now, a large group of street addicts are worthy of the stigma - there is no doubt there - just go to a crummy methadone clinic if you have any doubts. But there are also large groups of opiate addicts you have no idea existed. If you are so inclined, visit alt.drugs.hard [where mostly current users are], on usenet, and speak to some of these people. They are intelligent, thoughtful, friendly, and to some extent, as much as is possible, in control. Unfortunately that's still very little.
If you limit heroin to sniffing and smoking, let's just say that I would rather that than be an alcoholic. Alcohol causes permanent bodily harm, and even death. Heroin does not [overdose is a problem but could largely be controlled with legalization(at least for addicts) - by knowing what you are getting, and giving the cure for overdose out freely - and doesn't occur very often in those who aren't shooting. Yes, there is a CURE for overdose. The most common is naloxone, an opiate ANTagonist, which means it blocks opiates from working. You will feel like the worse kind of shit imaginable after getting a shot of that - but your life will be spared.] What else does alcohol do? It causes violent and other nasty behavior, for one. Opiates do not, except perhaps to those desperate to get what they need to feel normal. It causes far more deaths in car crashes, heroin doesn't impair your driving ability to THAT much of an extent - although it surely does - unless you are "nodding" (falling asleep.) It also has life threatening withdrawals - as do tranquilizers - heroin does not. It's just as addictive as smoked or sniffed heroin, and ALMOST as hard to get off of, in the long term. I just want to make the point that just because something is legal, doesn't mean it's "OK".
Let me say something again: I am not advocating opiate use! You WILL regret it! I promise you. You will be chasing that "virgin" high for the rest of your life, and might wind up unable to experience the pleasure you were once able to. It's not a fun life, and it's surely not glamorous. Let me also make it clear that there is no "soft" opiate (except, perhaps, opium.) Everyone starts, that is the people who aren't on the street, with "soft" opiates. It doesn't last - and even if it does, the differences between them and heroin are minimal at best. The thing that makes heroin so much different than other opiates is the so-called "rush" - it rushes your brain faster than any other opioid, and causes great feelings of pleasure, even after your tolerance is sky-high. Maintenance meds are different, and I will explain.
Ok, that personal rant out of the way, I give you The Treatment for Heroin and Opiate Addiction:
The Basics
Well, in that personal statement, I have explained very much about the non-legal and non-political aspects of this, so I will largely try to keep this on topic. But there are many concepts I need to explain, first. I hope I am not boring you too much, and thank you for taking the time to read it. I promise I will get into something interesting.
I didn't tell you what maintenance is, for those who don't know, and it's a very fundamental concept to all of this. Maintenance is when you take another opioid instead of heroin, "maintaining" your addiction. At face value, that doesn't sound very productive. But it is, and I will now tell you why. At the current time, there are two maintenance medications: methadone, and buprenorphine[Subutex/Suboxone]. There was a third, LAAM, legally no different than methadone, which worked for a whopping three days, but it was pulled from the market (in the USA) because of lack of interest and the potential for heart attacks it causes (one of the few opiates, if not the only, to have such problems.)
So why is maintenance important, and a very necessary option for heroin and opioid addiction treatment? Why isn't it "trading one addiction for another"? Because depending on the study you are looking at, nevermind anecdotal evidence, your chances of success at long-term abstinence are anywhere from 5-15%. No one knows why this is, at least not yet, but even after the withdrawals are over, "the easy part" according to just about anyone, the hard part begins - long term abstinence. "Willing it" just doesn't seem to work - believe me, I have tried. Your brain seemingly gets rewired to treat heroin like the most basic of your biological needs, lasting anywhere from 6-12 months to the rest of your life. It's like trying to "will" yourself not so sleep, or eat, or fuck. Over the long term.
So that's why it's important, because your chances of abstinence are so low, and people just want to live normal lives (and buprenorphine is a HUGE step towards that goal, as opposed to methadone, I will explain.) The important question many must be asking themselves is what makes it any different than heroin? There is a world of difference between methadone/buprenorphine and heroin/other opiates. The first and foremost is the duration of action and the time to peak effects. They both prevent withdrawals for 24 hours (or more), meaning you will not be constantly running around looking for a fix, and you won't have the ups and downs of heroin - once stablized, you will essentially just feel normal - not high, not low. Your body will adjust to the drug and make itself work as if it wasn't there. Ideally, at least, there are some very unique people out there. The fact that it takes nearly 2 hours to reach peak effects means you just simply don't get high from these drugs - unless you are "niave" to opiates, that is, in which case you wouldn't be going into maintenance. As I said, it let's people live normal lives - people on methadone, undetectable, are lawyers, engineers, even doctors. You would be amazed.
Buprenorphine is different than methadone, and it's vital. I will get into the legal differences and implications in a minute, but let me get the final bit of basics out of the way. Buprenorphine is a "mixed opiate agonist/antagonist," well, actually, it's better described as a "partial opioid agonist." Describing this is beyond the scope of this diary. Let's just say there are several things about buprenophine that make it very different pharmacologically than methadone, which I will describe:
1 - It is a much weaker drug. It won't leave you with a sky-high tolerance to opioids.
2 - Following that, even though it's weaker, it has an antagonist effect - meaning it blocks other opioids from working (i.e. heroin.) - quite well in fact, but not as well as was originally believed
3 - Following THAT, It seems to fix what heroin broke, and anecdotal evidence clearly implies that you are often more sucessful getting off buprenorphine than methadone.
4 - Finally, the withdrawals of buprenorphine are mild at best in relative comparison to other opiates, especially methadone. Methadone withdrawals are a month of utter, utter hell.
There are two major downsides to buprenorphine, which I will also list for you.
1 - As I said, it's, simply put, "weaker." This means that it can't satisfy all addicts - although the specific tolerance and level of addiction of the addict seems to play only a small role in this.
2 - Due to it's opioid-blocking effects, the transition of getting on to buprenorphine from heroin or other opiates can be quite painful, especially if it's not done properly - and most doctors have no idea what the hell they are doing in this regard.
One final thing to say about buprenorphine - poorly understood, but it seems that it helps greatly with cocaine addicts. Getting into this is beyond the scope of this diary.
Well, I hope that's about it for the technical mumbo-jumbo. I hope you are sticking with it. On to some more relevant stuff.
The Law
So what is the law regarding maintenance treatment, and how has it evolved? When and how did buprenorphine come into the picture, and how is it different?
Let me start by saying methadone maintenance treatment has been around since the 1960s. It has very much proof as to it's effectiveness, as well as something very important: it is far cheaper, for society, to have an addict on methadone than on the streets on heroin. That's some food for thought for conservatives.
Methadone has some very strict laws regarding it's use. These laws vary from state to state, but under the Federal CSA (Controlled Substances Act, as amended, which is the federal law controlling almost all of prescription and illegal drugs,) only doctors with special certification, working in special clinics, can prescribe methadone. In most cases, "prescribe" isn't really the word. The users need to show up, every day, sometimes within as little as a one hour period, to get their methadone. Most clinics have a ridiculous rule that you must piss heroin positive in order to get on heroin - causing people who have been clean a few days but just can't take it to go out and get high needlessly. Only after testing clean and going every day for 6 months or more do you get any "takehomes." These takehomes start for weekends and work there way up, after several years, to monthly (in some cases.) Usually two weeks is about all you can expect. I don't know exactly how much of this is federal law, state law, or not law at all, unfortunately. I will look further into it if there is interest.
So the laws regarding methadone (and LAAM before it was discontinued,) are pretty harsh. It's hard to imagine anyone making it through that instead of just scoring a bag. Or getting screwed because of a momentary lapse of judgement. That brings us to buprenorphine, which comes in two forms - Subutex, which is just buprenorphine, and Suboxone, what is commonly used, which contains an extra ingredient - naloxone. This is added to prevent abuse. If taken normally, it does nothing. If injected, it causes massive withdrawals. This is what I am taking.
So what makes buprenorphine different? In 2000, under Clinton, the 106th Congress passed the Drug Addiction Treatment Act of 2000, otherwise known as the DATA. You can search Thomas for info on this, including the full text of the bill and the Yea's and Nay's. Unfortunately I can't link it, as it only keeps what is generated temporarily. The DATA amended the CSA (Controlled Substances Act) to allow normal doctors, who either meet certain qualifications or take an 8 hour class, and apply to the DEA and SAMHSA (Substance Abuse and Mental Health Services Administration), to prescribe Schedule III opiate agonists (opiate drugs), that are FDA approved for opiate addiction treatment (methadone is Schedule II - meaning this act doesn't apply to it.) You can get a regular prescription from a qualified physician, and fill it at your local pharmacy (alas, most local pharmacies, especially chains, are very reluctant to fill these prescriptions and in many cases will make up blatant lies.) The doctor is in full control of your treatment, and you can take home up to a month's supply as soon as he sees fit. This is a major step forward. Unfortunately, it has yet to spread to the streets, and only the upper-class drug addicts have been able to make use of the drug, and it's a real shame.
Methadone clinics are afraid to be put out of business, and have done everything they could to stonewall this and the FDA Approval of Buprenorphine for Opiate Addiction every step of the way. Now, even though this law was passed in 2000, there were no opiates that were Schedule III or above that were FDA approved for opiate addiction. Buprenorphine was in clinical trials for nearly two decades, being stonewalled every step of the way by everyone who had an interest in seeing addicts suffer or keeping the cash in the methadone lobby's pockets. It finally was approved by the FDA in October 2002, and available in pharmacies next January, 2 and a half years after the DATA was passed, despite ample evidence of it's effectiveness. Buprenorphine has been used in other countries with great success (although some abuse has been reported when heroin supplies ran dry, like in France,) for a long time. It is currently used in dozens of countries, including much of Europe, Canada, and Australia.
It's interesting to note that immediately before the FDA approved it, the DEA rescheduled it to Schedule III from Schedule V (the lowest.) Reading the petitions to the DEA was both fascinating and frightening, hearing misguided assholes demanding it be in Schedule II with things like Hydromorphone (Dilaudid) or Morphine. Luckily they decided not to put a stop to the whole thing by doing so, and they put it in Schedule III. They put both Subutex and Suboxone in Schedule III, which makes little sense, as Suboxone is specially formulated to greatly reduce any potential for abuse.
Now, let me finish this part off by saying that congress did something blatantly illegal when they passed this law - they delegated their powers to the executive branch, putting it into the law that the DEA can pull the plug at any time. While I find this unlikely at this time because this drug is used mainly for upper- and middle-class drug addicts, such as Rush I am sure (eventually at least,) it is still a scary thought. Even if they didn't put this little disclaimer in there, it would matter not, as the DEA could reschedule the drug at any time to Schedule II, putting it with methadone, and then the special provisions of the DATA would no longer apply.
I said some of the following in my recap, but it contains other important things I didn't say:
Why this is important
Well first of all, we are going to see a huge resurgance in hard drug use - if we haven't already. Poor economic times lead to this - nevermind the HUGE crop in Afghanistan, which, luckily (for US,) will flood Europe and Russia and very little will wind up in the USA. The Heroin in the USA comes from Columbia (East Coast) and Mexico (West Coast,) and small amounts from East Asia, mostly on the East Coast. But it's still a matter of supply and demand, and I can tell you that scoring heroin on the streets of New York has never been easier.
So with a resurgance in drug problems, we have two issues - the first being getting the people that need help, help. The second being the "war on drugs" might return as it started - and that won't be pretty. With drug laws being toned down or outright decriminalized in many places, I am afraid of a backlash. The homosexual "acceptance" has had a backlash - that's for sure.
In fact, the drug war bears a great resemblence to the evolution of homosexual rights, only the drug war is further behind. First, it was a crime. Then, it was a disease. Now, (for homosexuality,) it is a right - yet still viewed as a problem by most in society. I am waiting for drug users to reach the next step.
Drug law reform needs to be properly framed, and treatment as opposed to incarnation needs to be the only option. Sending low-level non-violent drug users to jail is not only counterproductive, but a huge waste of money, and ruins many, many lives. Here in New York the Rockefeller Drug Laws were laxed - which is a big step for us here, but it is far from what can be deemed "reform." Somehow we need drug laws that will discourage new users, even though I personally believe it to be a civil right, many others do not. I think what I do with MY body is MY right. And if you disagree, I wonder why most feel that people can do what they want with their body when it comes to abortion, but not with drugs. If proper heroin maintenance is given to addicts, the problems of heroin addict to society would virtually dissapear.
Besides that, the drug war is a complete and utter failure. It causes crime, causes people to become homeless and poor, causes needless deaths, the repercussions are endless - and this is blatantly obvious. We cannot continue such a fundamentally flawed policy, whether you believe drug use is a right or not (the founding fathers seemed to think so, I might add.)
Why else is this important? Because as I said way up at the top, there is nothing more important in my mind than our civil liberties - and it is something that must be defended - it is the last door to full-blown tyranical fascism that needs to be crossed. We must fight tooth and nail to stop any futher incursions into our liberties as Americans. (BTW, look up "liberty" in the dictionary. Tell me if you can honestly say to me that currently applies to America.)
Perhaps in another edition I will write the history of the drug war and drug use in America - and how, seemingly, drug use wasn't really a problem until the government propagandized it and created prohibition, the correct word for the current situation. Alcohol prohibition didn't work, and drug prohibition is working far less. Ending drug prohibition would go a long way towards curbing crime on all levels.
Well, that's the heart of it. I then posted a conversation regarding AA/NA and/or abstinence-based treatment, but I will not include thatas it is quite long and not top priority in my opinion, there being more than enough information to digest here. If you want to see it, read the original diary, and look for the part about a post by "glibfidget".
I promised to include other treatment options (besides maintenance and abstinence) and certain "harm reduction" policies (the current strategy today), and I am going to deliver. Some of this is also from the comments that arose from the diary.
Besides abstinence and maintenance, there are essentially two other treatment options. One is called "Rapid Detox." It is nothing new, and I have never heard a positive word about this method except from those trying to sell it to you. This is what I had to say about Rapid Detox, as well as a mention about the other new potential option, ibogaine:
"It's absolute quackery"
It's for people looking for miracle cures - and it just plain doesn't work. It's been around for quite some time now, it's no "breaking" treatment. It also costs ridiculous amounts of money. [Thousands of dollars]
Someone coming out of rapid detox has the lowest chance of success at abstinence of all - 5% at best. You just can't close your eyes and wake up cured. It DOES work in that you don't experience withdrawals - but if you ever see one of these things, up close or filmed, you wouldn't even consider it. It's downright horrible. They put you to sleep and force your body to go through what it needs to to be clean compressed into a 6 hour period. There have been deaths, and I wouldn't be surprized if it's shut down eventually. On top of that, you have protracted withdrawal symptoms, more minor nagging symptoms that continue longer than they should.
I have yet to meet anyone in the "loop" that had anything positive to say about rapid detox.
The only other treatment they have is this stuff called ibogaine. Well, that's not exactly true - they have plain symptomatic treatment for withdrawals, but NOTHING works to cure heroin withdrawals. Nothing - save one exception. There is a blood pressure med called Clonidine that depresses one area of the brain that heroin does - but far from all. So it does help - in some people - but others report no help or worsening of symptoms.
Back to ibogaine...it's this stuff that makes you have something resembling an unpleasant acid trip. Apparently some people think that when you take it, it does something to you that makes you look at your life and no longer want drugs. It has had mixed reviews, but there are some reports of success in clinical studies, which I need to catch up on.
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I will look for some further info on Ibogaine, including a link to a site possibly with info about it, and hopefully provide that. My opinion on it is it might be worth a try, but it's no miracle cure. I think we are mostly seeing the power of placebo here. But I will investigate further, it's overdue on my part.
I never did investigate Ibogaine all that much further. Perhaps I should.
Now for Harm Reduction - what SHOULD be the only motivation and logical outcome of any drug policy.
Harm Reduction
The current stragegy of the government, after much lobbying, is called "harm reduction." This means that while we still send people to jail, while they are using we will do what we need to reduce harm (to everyone involved.) This mostly includes:
1 - Education and Addict Outreach
2 - Needle Exchanges
Needle Exchanges have done extroadinarily well, at least here in New York (I am positive there are places that need to catch up on this.) They essentially allow addicts to trade used needles for old ones. The goal is preventing the spread of HIV - and there is plenty of evidence of it's effectiveness in this regard. Guiliani opposed the first needle exchange tooth and nail, but eventually relented. The other important thing needle exchanges do is take used needles - thus preventing, to a certain extent, spent needles in places they shouldn't be.
Many states, including now New York, have also taken the step of making needles over-the-counter, meaning you can just buy them without a prescription. They are fairly cheap, and this is an important step for the type of junkie who would rather not go to a needle exchange - or where there are none available (or available at the time the junkie needs the needle.) I hope the other states that haven't implemented this follow the lead.
As for addict outreach, it's not nearly what it should be. Street addicts, most homeless and have HIV, need to be hit on the head with a stick to really get through to them, and many are very fearful of going to jail. I hope to see improvement here in the coming years.
Well, that's it for now - again. Hope I have given you what you have wanted, like I did the first time.
The original diary can be found in the archives here, and a follow-up "advanced edition" may also be found in the archives here.