Drug therapy injects change into wary recovery community

by: TRIBUNE PHOTO: CHRISTOPHER ONSTOTT - Oxford House resident Elizabeth Smith says if her house is forced to accept an addict taking methadone her own recovery would be threatened. Government officials say she may not have a choice.  Elizabeth Smith is two years into recovery from a 15-year heroin addiction. There are many things in her future about which she is uncertain. One thing she knows for sure, however, is that her Oxford House, where she lives with four other women in recovery, has become the foundation stone of her sobriety.

Any of the women in Smith’s house can, without explanation, insist that one of the others immediately take a drug test. One failed test means the housemate must leave. That’s how committed the women in Smith’s house — all previous hard-core addicts — are to sobriety.

Smith is also certain that she doesn’t like the idea that her Oxford House, and the 45 other Oxford Houses in the Portland area, will now no longer be able to insist on a completely clean and sober environment. At least not according to her definition.

Whether Smith likes it or not, addicts who have opted for methadone treatment, and who wish to live at an Oxford House, can no longer be kept out. State health and housing officials, under pressure from the federal government, are telling Oxford Houses throughout the country that people taking methadone are protected under the Americans With Disabilities Act and cannot be discriminated against when they apply for housing.

But for heroin addicts such as Smith, methadone patients have simply traded one high for another, and being around them is like being around other users — the last thing someone in recovery should do.

“If we voted someone in here who was on methadone I would not be safe,” says Smith, who years ago tried methadone treatment herself. “Just seeing the person under the influence of it, not necessarily even nodding out, just the flush, the sweats, seeing those things would make me think about it and how much I like that feeling. Knowing it is in the house, whether it’s in a $5 lock box or not, I wouldn’t be safe.”

Oxford Houses are the most popular recovery housing in the Portland area. They are universally hailed by addiction counselors, who often turn to the houses when their patients need a supportive place to live after months of inpatient treatment. But the changes they are undergoing are part of a widespread evolution in Portland’s addiction recovery scene.

Recovery centers are beginning to confront a new wave of addicts, as detailed in a Tribune series last May. Initially hooked on prescription painkillers,

many young and middle-class addicts have turned to cheaper street heroin to feed their addictions. These younger addicts are getting arrested and sentenced to probation or parole that includes mandatory treatment. But they are not responding to the traditional treatments that have been effective with older, long-time addicts.

Criminal justice officials and the people who run addiction programs have been searching for different ways of dealing with younger opiate addicts. For an increasing number, the answer is turning out to be one of the most controversial pieces of the recovery puzzle, what is called medication-assisted therapy. Prescription methadone, available to addicts for decades, may be on the cusp of a major resurgence.

‘Any excuse they can’

A few years ago, addicts being treated with methadone were simply not allowed at local recovery centers.

Today, at the two 36-bed residential centers run by nonprofit Volunteers of America as recovery housing for men and women on probation and parole, up to 15 beds are dedicated for residents taking methadone.

At a downtown DePaul Treatment Centers facility, a new program has pregnant women on methadone living side by side with recovering women practicing abstinence (see sidebar).

At Hooper Detox in North Portland, 12 indigent heroin addicts have received injections of Vivitrol, a $1,000-a-shot medication that is supposed to eliminate their ability to get high from opiates.

Medication advocates say the changes represent long overdue progress, and that it’s about time people in the recovery community begin to embrace methadone and newer options as treatment for addicts. Methadone, they say, saves lives, keeping heroin addicts from overdosing. And abstinence therapy has failed to help the majority of addicts become clean and sober long-term.

But others say methadone for the vast majority who receive it is not a treatment because few use it to escape addiction. Instead, they say, most are kept on a maintenance dose that can last many years or even entire lifetimes. They are not in recovery, according to this view, but victims of a policy known as harm reduction, driven by data that shows that on methadone, addicts no longer burden society by committing crimes, spreading infections through needle-sharing and overwhelming emergency departments.

The controversy surrounding where to place addicts being treated with methadone is a microcosm of the larger controversy about which treatments should be available for whom.

For Kathleen Trebb, the imperative has become to do something different, even on a trial basis. Trebb, deputy director of community justice for Multnomah County, was being told by the nonprofits who treat the county’s probationers and parolees that their treatment models weren’t working. Their clients were leaving treatment in unprecedented numbers, even knowing they would be violating the terms of their probation.

A pilot project was hatched to try methadone on some of those patients, who would have to live with the other clients because the county had no other options.

“When I was younger I said there’s no way that I would support methadone,” Trebb says. “Now after reading the literature and doing so much research on it and talking to clients who have been successful and knowing people are dying on heroin, I’m willing to try anything.”

Pam Kelly, director of rehabilitation services for Volunteers of America, says that last year more than one in three of the probationers and parolees admitted to the men’s residential center were addicted to either heroin or painkillers. Five years ago, Kelly says, that would have been about one in eight. Many of the residents are younger and not as genuinely interested in a clean and sober life.

Staff has had to receive special training to deal with a methadone population. For instance, addicts treated with methadone are known for chipping — sharing doses or secretly using illicit drugs and psychiatric medications that heighten the high from methadone. The Volunteers of America staff is learning how to spot signs that clients are chipping, or augmenting their methadone with street heroin.

Afternoon sleepiness is a well-known sign that a methadone patient’s morning dose is wearing off, though methadone proponents say careful dosing can limit that side effect. But Kelly says the effect has led to some complaints by other residents in the women’s center.

“I’m not getting medicine for my addiction, why are they getting medication?” says Kelly. “And it’s particularly hard when they see people nodding off in a group.”

Greg Stone, director of the men’s residential center, says when alumni and some staff at his center learned patients would be living with methadone clients, they were outraged.

“They thought it was the worst thing that could happen to our program,” he says.

So far, the men’s center has had only two residents on methadone. One lasted only two days — “he clearly wanted to use methadone only to get loaded,” according to Stone. The second has been living at the center for six weeks and appears sincere in his approach to recovery.

The stakes are high.

“It’s going to give some people a reason to say, ‘Hey, if this guy can get loaded it gives me an excuse to say I can use too,’ ” Stone says. “And one thing about addicts is, they’ll use any excuse they can.”

Stone, who has worked at the center for nearly 20 years, says that once a heroin addict relapses, several other addicts in a facility tend to follow. “It’s a huge contamination, more so than with other drugs,” he says.

Before accepting methadone patients, the residency centers maintained a rule that anybody using narcotics had to be separated from the rest of the residents. That meant a resident who had a tooth pulled by a dentist and was prescribed Vicodin for the pain was confined to his or her room for 24 hours so the other residents wouldn’t see that resident high. That type of segregation isn’t possible with residents feeling the effects of methadone 24/7.

Still, the beds at the VOA center are reserved for probationers who are considered at highest risk to re-offend. If some of those men and women can be stabilized and turned away from lives of crime, Kelly says, the benefit to society would be enormous.

Kelly says she’ll consider the pilot program a success if the methadone clients stay in treatment longer than those practicing abstinence. But she says not everybody will be using the same barometer. The real data may come a year or more after clients have left inpatient treatment, and that may be a reflection of whether they continue to receive methadone once back living on their own.

“What the county wants to really know,” Kelly says, “is if those getting methadone don’t commit crimes at the same rate.”

Dirty little secrets

A mixed population is even more risky at Oxford Houses and other similar models for those who are in later stages of recovery. In an inpatient facility residents live amongst staff who are ready to intervene should a resident feel tempted. At Oxford Houses, it’s just five to 10 men or women living and recovering in their own shared home.

Mike Hermens, state chairman of Oxford Houses of Oregon, says there are a handful of Oxford-style houses that have been set aside for people on methadone therapy, but that all the houses have been told they cannot discriminate should someone apply who is taking methadone.

Hermens is concerned, despite attempts to ameliorate the situation.

“The suggestion we put out is if you’re going to admit somebody on methadone to your house, that person is required to be on some sort of program to wean them off of it,” Hermens says. “I know people who have been on methadone for 10 years and they’re just addicted to methadone.”

The suggestion doesn’t make Oxford House resident Smith feel safe. Smith gave birth to one of her children while on methadone and says withdrawing from the methadone took longer and was just as painful as the withdrawals she’s experienced from heroin.

Smith says she’s also concerned about some of the practical safeguards involved in having methadone in the house. For instance, she says, when a woman in her house needs to take a drug urinalysis, the inexpensive, quick test they use simply shows up negative or positive. A methadone resident would naturally test positive, so the house would have to use a more expensive, mail-in test which specifies what drugs are showing up.

Smith has known about 100 methadone patients and only one or two of them didn’t cheat at least a little bit — sharing doses with each other or using other drugs for a more potent high. That would expose the other house residents to more than just methadone, she adds.

Karen Wheeler, addictions program manger for the Oregon Health Authority, says mixing populations is not an ideal plan, but discriminating on the basis of a medical disability, in this case medically treated addiction, is illegal. Wheeler says addicts receiving methadone probably don’t think the new situation is ideal, either.

“They don’t like to think they’re triggering somebody or they’re an outcast or they don’t belong in the recovery community,” Wheeler says. “They would rather be around people in recovery who are also using medication-assisted treatment.”

On the other hand, Paul Molloy, founder of Oxford Houses, doesn’t think segregating methadone patients in separate houses would represent a better solution because there would be less incentive for residents to eventually transition away from methadone. Methadone-free, clean and sober housemates might be a great influence, he says.

Studies have shown that about half of Oxford House residents suffer from psychiatric illnesses such as depression in addition to addiction, Molloy says. So residents are accustomed to having psychiatric medications in their houses. Methadone might just represent one more, harder test.

“It’s like the old story, we used to be concerned if we put an Oxford House near a bar,” Molloy says. “The fact of the matter is, if you’re an alcoholic or drug addict you have to decide internally that you’re not going to use.”

One of few residences with a history of mixing recovery populations is the Gresham residential treatment center run by nonprofit CODA, where at any given time between eight and 15 of the 75 beds are occupied by methadone patients. Tim Hartnett, CODA’s executive director, says other patients have voiced concerns, but nobody has left since the mixing started three years ago.

“In some respects, people are expecting the worst and our experience doesn’t support that at all,” Hartnett says.

Jay Wurscher, coordinator of alcohol and drug services for Oregon’s Child Welfare Division, says the new policies are long overdue.

“Now we don’t have the luxury to ignore the needs of people taking methadone,” Wurscher says. “The dirty little secret is where they’ve been living. We don’t know. We just sort of assume they’re making it on their own.”

Next week: Harm reduction for whom?

by: TRIBUNE PHOTO: CHRISTOPHER ONSTOTT - Heroin addict Mary Hansen downs one of two daily doses of methadone that are keeping her stable and heroin-free through her pregnancy.

Pregnant addicts face new choices

What Mary Hansen calls her million-dollar question is just five months away. A longtime heroin addict, the 37-year-old Hansen began taking methadone when she discovered she was pregnant in early November. Her high-stakes question concerns what happens after she delivers the baby.

When the recovery community talks about long-term methadone treatment resulting in harm reduction, they are referring to a model which many addicts say could just as easily be called a lesser of two evils choice.

Nowhere is this more obvious than at local nonprofit DePaul Treatment Centers, where an innovative program has a handful of pregnant heroin addicts, including Hansen, using methadone through the course of their pregnancies.

These women are living in a DePaul residential facility with as many as 30 other women who are practicing sobriety. Chris Farentinos, chief operating officer for DePaul, says some of the other residents have voiced concerns about having to live with the women taking methadone, but overall there have been no noticeable conflicts.

The program is not intended to treat the pregnant women with methadone in the sense that eventually doses will be lowered and the women can escape drug dependency. In fact, lowering doses during the pregnancy is discouraged.

“Our objective while they are here is not to reduce the methadone,” Farentinos says. “It’s actually to get them the skills they need in order to do a safe delivery and be in the community after that.”

After the women deliver their babies, most are referred to outpatient drug therapy, Farentinos says. And many, she says, will continue to take methadone long after they have given birth.

Farentinos says that some of the women they see have been taking heroin for so long that permanent structural changes have taken place in their brains. They will never be able to function normally without drug assistance, she says, and lifelong methadone is much preferable to street heroin.

“Sometimes they cannot cope with life without a certain dosage of opiates to just feel normal, and sometimes it’s not going to change,” Farentinos says.

Medical research supports the DePaul program and others like it, says Leonardo Pereira, assistant professor of maternal-fetal medicine at Oregon Health & Science University.

Pereira trained at a methadone treatment center in Philadelphia, taking care of pregnant women on methadone. He says most of his patients became pregnant while hooked on heroin and that asking them to embrace abstinence during their pregnancy would simply not have worked.

Staying on street heroin risks overdose, which could result in a death sentence for both mother and fetus, Pereira says. Also, if a woman continues to use heroin while pregnant and runs out of cash, the horrific withdrawal associated with the drug could cause her to lose the child she is carrying.

Pereira says methadone has not been associated with birth defects. Actually, neither has heroin. Both drugs cross the placenta and force the child, once born, to go through withdrawal. With methadone moms, the newborn is given consecutively smaller doses of the drug for the first two weeks of life until weaned off its addiction.

Pereira says a few studies have shown that such children are at an increased risk for becoming adult addicts themselves, but that the association might simply be a result of having been born into families that model addictive behavior. And pregnant women on methadone, he says, are more likely to follow through on doctor visits and other forms of pre-natal care.

Constantly chained

Most of the pregnant women on methadone therapy that Pereira has treated are in their teens or early 20s, and he’s seen some of them change their lives after getting through pregnancy and delivering a basically healthy baby.

“Pregnancy is often a motivating factor for them to come clean,” he says.

Hansen, who graduated from the University of Washington and was divorced seven years ago, knew immediately that she would have to change after a home pregnancy test came up positive.

“I was scared. I felt desperate and I knew I did not want to use while I was pregnant,” she says.

Her first four or five days at the DePaul residential center, Hansen was kept segregated from the other women because the side effects, including nodding off in the afternoon, might trigger other patients.

Today she takes low-dose methadone twice a day and says the right dose has been found so that she is completely functional and displaying no side effects. She has no desire to take heroin.

“It quiets that monster of cravings,” Hansen says.

Hansen says she’d like to taper her methadone dose after her child is born, and try to become drug free. But she knows that choice is risky, for her and her child. On methadone she’s stable; off methadone she might not be.

She takes other medications — one for anxiety, another to treat a blood clotting disorder. She isn’t thinking of halting those therapies. But there is a strong part of Hansen that wants to be methadone-free as a mother.

“With methadone, you daily have to take your dose, otherwise you start to get sick (withdrawal). So you’re constantly chained to your medication,” Hansen says. “Sometimes I just want to wake up and go about my day and not take anything.”

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