Heroin

Treatment for Heroin Addiction:
The Behavioral Model

Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.

“ADDICTION,” AS DEFINED BY THE NATIONAL INSTITUTE ON DRUG ABUSE¹

Once an addict, always an addict. This is both a myth and a truth that addicts live by. Those who continue to use heroin behave as addicts do. Those who stop using and begin the recovery process must remember that once they use again, they awaken the disease of addiction. If you take away the heroin from an addict, what you have is still an addict, complete with questionable decision-making skills and an assortment of psychological bruises sustained during his or her years of abusing drugs.

Treatment and recovery from heroin addiction is a long process. It is the rare individual who, of his or her own volition, decides one day to just put down a heroin habit and never use again. Most heroin users are coerced into treatment, either by the criminal justice system, through intervention on the part of family members and friends, or as a result of personal calamities that force them to make life-changing decisions. The usual response by an addict when his or her behavior is confronted is an attempt at controlled use, which inevitably leads to loss of control and failure: “I knew I had a problem with heroin, but I didn’t really want to stop using altogether; I just wanted to learn how to use only on the weekends.” This is a familiar refrain to the professionals who treat heroin addicts. It is part of the denial of the disease—similar to the first thought of a person diagnosed with cancer: It can’t be. The person who becomes addicted to heroin has to go through a process, often requiring several attempts at treatment, before the addiction becomes manageable and he or she is able to get on in life without heroin. American society expects the heroin addict to be treated once and be forever cured. This is not realistic and seldom occurs, leading many to view the efficacy of treatment skeptically.

“Once an addict, always an addict” can be heard in the meeting rooms of Twelve Step fellowships like Narcotics Anonymous and Alcoholics Anonymous across America. It reminds addicts that unless they are vigilant, they can easily use drugs again, and that once they use, they quickly return to their old ways. The idea of controlled drug using is debunked; the only hope for a life not controlled by heroin is through total abstinence from all drugs. The slogan reinforces the belief that it is the first drink or drug that will do the damage. Addicts learn to accept this concept and embrace the clean lifestyle of recovery from addiction. The slogan has been echoed, however, by those who do not understand addiction in order to disparage any treatment attempt: If “once an addict, always an addict,” they say, then a drug addict can’t be cured, so why waste time and money trying?

Defining addiction as a relapsing disorder bolsters the belief that treatment does not work. What many fail to see is that although relapse is part of the disease of addiction, it does not have to be part of the recovery process and, in fact, is not part of the lives of many recovering heroin addicts.

How did the myth that treatment doesn’t work get started? Does it have a basis in the accumulation of statistics that document failed treatment and recovery attempts?

Personal bias against addicts and resistance to the understanding that heroin addiction is a disease color the perceptions of many. It is a tug-of-war that those who work in the drug treatment field struggle with almost daily. If many addicts don’t fully grasp that they have a disease, how can the layperson be faulted for having doubts about the effectiveness of treatment?

Early Government Treatment Efforts

The U.S. government’s earliest attempts to modify heroin addicts’ behavior took place at the Public Health Service Narcotic Hospital in Lexington, Kentucky. It opened on May 25, 1935, in response to studies conducted during the 1920s on America’s growing opiate-addicted population. The hope was that heroin addicts’ behavior could be modified and corrected enough that they could complete a treatment program and return to productive lives in society.²

The Lexington facility was a combination hospital, farm, and prison for its patients. The majority of the patients were, in fact, federal prisoners incarcerated under the sentencing guidelines of the Harrison Narcotic Act of 1914. Some were sentenced to probationary terms that called for completion of a treatment program; they were released once they were deemed to be cured. A small percentage (4%) were voluntary patients who underwent a recommended six-month treatment program. Those patients who were prisoners served the full term of their sentences at the facility.

Prison reformers in the 1920s advocated strenuously for a long-term prison/farm to deal with heroin addicts. The number of prisoners with heroin problems was also a growing concern to the wardens assigned to guard them. The wardens knew they did not have the appropriate facilities to manage addicts properly. However, the idea that prison could be a place where rehabilitation occurred was still relatively new. Prison reformers like Thomas Mott Osborne and Frank Tannenbaum proposed a prison system that was meant not just for punishment but that actually took steps to alter criminal thinking and behavior. They envisioned prisons as separate communities where inmates could acquire the skills necessary to be good citizens upon release. They believed that work ethics and values could be instilled in the offenders if given the proper environment.

The Public Health Service hospital in Lexington grew out of this prison reform movement. In 1928, Stephen Porter, a Republican congressman, introduced a bill that would establish a “narcotic farm”; the bill was approved in 1929, and Lexington opened its doors in 1935.

The surgeon general at the time, Hugh S. Cumming, hailed the new facility as a way to correct the behavior of heroin addicts. He described addicts as people who were unable to deal with the complexity of American society. The industrial age was in full swing, and the styles and mores of urban life were spreading across the country. Gone were the days when America was a predominantly agrarian society. But Cumming and others apparently felt that immersion in the cultural models of a bygone era could help heroin addicts of diverse backgrounds.

Each patient at the Lexington hospital was to have a job assignment that ranged from furniture repair and manufacturing to an assortment of farm-related activities. Patients tended crops, slaughtered animals, and raised hens. The belief that America’s agrarian past held the key to personal and civic health was evident in the design of the hospital as a farm. The problem inherent in the concept is that the hospital was supposed to be preparing patients for a return to a modern industrial and urban society. Most of the patients were from the larger cities, had never been on a farm, and would never see a farm again. A review of the first year’s patients showed that the voluntary patients were mostly farmers who had become addicted to opiates as a result of medical conditions. The rest were men from the cities, where heroin and the netherworld of organized crime reigned. It should not have surprised anyone that those patients who returned to the city upon release did not fare well.

In 1923, Dr. Lawrence Kolb, a psychiatrist who studied addicts extensively during the 1920s, was assigned to the Public Health Service Hygienic Laboratory in Washington, DC, where he worked with 200 addicts. In 1925, after two years of research, he published his findings in a series of articles stating that the cause of opiate addiction was a preexisting psychoneurotic deficit. As discussed in chapter 4, Kolb described addicts as individuals who suffered from inferiority complexes and who used drugs to soften or mask feelings of inadequacy. The implication was that these were people who were not particularly talented or capable and who were unable to compete in a changing society.³

Kolb also felt that there was really no need for a long-term prison hospital. He believed that given two weeks without opiates, an addict could be detoxified, achieve abstinence, and be adequately treated psychiatrically. Ironically, this was the man whom the government chose to be the first medical director of the Public Health Service Narcotic Hospital.

It is hard to imagine the thoughts or reservations Kolb must have had concerning his new assignment, given his belief that such an institution was unnecessary. But he had been a psychiatrist with the Public Health Service since 1909 and as such was accustomed to following orders and accepting assignments as any career bureaucrat must do. Being a conscientious public servant, Kolb must have put his personal philosophies aside and assumed the responsibilities entrusted to him.

Kolb instituted a three-phase treatment plan. The first phase lasted thirty days, the first ten of which were dedicated to withdrawal, or detoxification. During this time, the patient was interviewed and assessed, and a profile was pieced together. The patient’s relatives and friends were also interviewed to gain as much information about the patient as possible. A course of treatment was then written from medical observations, psychosocial information, and the patient’s criminal history.

The second phase of treatment lasted the major part of the addict’s stay. During these months, patients were given work assignments, lived highly structured lives, and built themselves back up mentally and physically. The Public Health Service hospital was described as a healing environment, where new values could be learned. The third phase was preparation for the addict’s return to the outside world. Ideally, the social services staff members at the hospital helped in returning the addict to a softer, gentler, more supportive environment than the one from which he or she came. Gainful employment was a stated goal. The reality, however, was that very few patients returned to jobs and supportive families. Most went right back to their old haunts, unemployed and devoid of any meaningful support network. This was arguably a setup for failure and led to high rates of relapse among early patients. The failures were heralded as evidence of the futility of the effort by those who were skeptical of treatment for heroin addiction. Many, including Kolb, labeled these relapsers as thrill seekers, incorrigibles incapable of recovering. The onus for failure was placed on the addict, not the treatment protocol, nor was it yet understood that drug addiction is a chronic relapsing disorder.

Studies of relapse rates were conducted during the 1940s and 1950s. In 1965, John O’Donnell, a sociologist who worked at Lexington, analyzed these studies and concluded that an 80% relapse rate was the norm for heroin addicts. He cited problems with the methodology of the follow-up data and with how relapse was defined, taking exception to the idea that even short episodes of drug use qualified as a relapse. His findings were used by the pessimists who believed that treatment didn’t work and that addicts were primarily antisocial types who were better off in prison. These same pessimists supported the theory Kolb had expressed: that addicts were thrill seekers incapable of even modest accomplishments, such as staying away from drugs.

By the 1970s, other treatment facilities had sprung up around the country, and in 1974, the Lexington hospital was closed and turned over to the Federal Bureau of Prisons. The program failed despite the social, psychological, and medical services offered. Even the low patient-to-staff ratio (two to one) could not overcome the prison-like setting. The attempt to instill traditional agrarian social values and work habits proved ineffective with hardened addicts from the inner cities. The result was that addicts were more likely to wind up in prison than in treatment.⁴

Synanon and the Therapeutic Community Model

In the early 1950s a group of narcotic addicts banded together to form Synanon, one of the first therapeutic communities, in California.⁵ The group was led by Charles Dederich, a narcotics addict who believed that addicts were better off without the established medical and psychiatric communities. Synanon members resented that doctors and society had branded them as incurable criminals as a result of their drug-seeking and using behaviors.⁶

Synanon borrowed aspects of Alcoholics Anonymous and devised an aggressive group therapy style that confronted the manipulative behavior of heroin addicts. Group members did not believe in employing professionals; all of the counselors and leaders were ex-addicts themselves. This approach, which came to be known as the therapeutic community model, was a response to the unwillingness or inability of the health care system to help the hard-core heroin addict.

Therapeutic communities became known for using rather severe tactics in confronting addicts’ behaviors. Stories abound of addicts being forced to shave their heads, wear signs, and even submit to the occasional diapering, in which an addict was asked to sit in a corner wearing a diaper and a sign that proclaimed him a baby.

Synanon flourished into the 1960s and was acclaimed for its tough-minded approach to treating heroin addiction. The organization began to fall apart in the 1970s, however, when Dederich’s increasingly bizarre behavior drew the attention of law enforcement officials. In 1978, Dederich and two members of Synanon were accused of placing a rattlesnake in the mailbox of a lawyer, Paul Morantz, who was involved in several lawsuits against Synanon. Dederich and the two members were convicted in 1980 of conspiracy to commit murder. Dederich was sentenced to a five-year probation and the other defendants received jail terms.

In 1985, Synanon found itself in court again, this time for allegedly defrauding the Internal Revenue Service. In a twenty-two-count indictment, nine of the top Synanon officials were charged with falsifying records and avoiding taxes. They were slapped with liens totaling $55.6 million in back taxes and penalties. Among those charged was Cecilia Dederich, daughter of the founder.⁷

Synanon’s ability to raise money was highlighted in 1986 in Forbes magazine, which detailed how the organization pulled in an estimated $30 million per year “manufacturing and selling ballpoint pens, coffee mugs, and desk clocks customized with corporate logos” to major corporations.⁸ Synanon clients included Western Union, IBM, RCA, and H. J. Heinz. The group reportedly used the pitch that it was doing good work with its profits and that the Synanon products generated funds for treatment. The magazine reported that Synanon’s sales force was particularly aggressive. One of the group’s prospective clients said, “Once they have you as a sales prospect, they don’t let go.”⁹

The combination of legal problems and mismanagement eventually led to Synanon’s demise. Dederich, who once proclaimed Synanon a religion, died at age eighty-three in March 1997.

The Twelve Steps

Just as Synanon was in its infancy, another group of narcotic addicts in southern California founded Narcotics Anonymous in July 1953. This Twelve Step fellowship was closely modeled after Alcoholics Anonymous, with the same guiding principles of anonymity and self-help.

AA traces its roots to Akron, Ohio, and the chance meeting of two men, a stockbroker from New York and a local physician. Bill Wilson had been fighting a losing battle with alcohol his entire life and was sober just six months when he met Dr. Robert Smith, known as Dr. Bob, in June 1935.

Wilson had come to realize that by sharing his story with other alcoholics, he could stay sober. When a deal went sour while he was on business in Akron, Wilson became fearful that he might start drinking. He sought out another alcoholic to talk to and was directed by local clergy to Dr. Bob, whose drinking exploits were well-known among the locals.

Dr. Bob was deeply affected by the talk he had with Wilson and shortly thereafter stopped drinking. He had his last drink on June 10, 1935, and remained sober until his death in 1950. He was the first man Wilson was able to enlist to his way of thinking, and the date of Dr. Bob’s last drink marks the advent of Alcoholics Anonymous. The two men joined forces and began making calls to hospital wards, where they shared their experiences with hopeless alcoholics.

Eventually, groups spread to New York and Chicago. By 1939 they published their “Big Book,” or basic text, Alcoholics Anonymous, which served as a guidebook for getting sober. It included personal stories and “Steps” that needed to be taken in order to remain sober.

The major difference between AA and NA is that addiction is seen as all-inclusive. Members of NA believe they have a problem not with a specific substance but with the disease of addiction. Any mood-altering substance is to be avoided. The first step of Alcoholics Anonymous reads “We admitted we were powerless over alcohol—that our lives had become unmanageable.”¹⁰ Narcotics Anonymous amended this to “We admitted we were powerless over our addiction, that our lives had become unmanageable.”(Emphasis added.)¹¹

Membership in Narcotics Anonymous grew rapidly throughout the United States, and in 1972 a central office, called the World Service Office, was opened in Los Angeles. Narcotics Anonymous meetings can be found throughout the world today with a membership estimated to be in the millions.

Today, Narcotics Anonymous, Sex Addicts Anonymous, Overeaters Anonymous, Gamblers Anonymous, Debtors Anonymous, and many, many more self-help groups are based on the Twelve Steps.

Undoubtedly, AA and its principles also have been a major influence in the recovery of millions around the world. One of the most prominent organizations in the field of recovery that bases its program of treatment on the Twelve Steps of AA is the Hazelden Foundation.

Hazelden and the Minnesota Model

Hazelden was incorporated as a treatment center on January 10, 1949. Hazelden’s first director, Lynn Carroll, wanted to make Hazelden a place where alcoholics could heal themselves through the principles of AA. It was his experience with recovery in AA that shaped the daily curriculum for the alcoholics who made their way to Hazelden. Carroll believed in AA, knew that it worked for many, and applied its principles faithfully. The course of recovery was straight AA philosophy. Carroll talked to the men about the Steps and explained the process of a recovering life to them, with great success.

Later, Hazelden began following a multidisciplinary approach with cooperation between the professional and nonprofessional fields. An experiment that had begun in the 1950s at Willmar State Hospital in Minnesota, with alcoholics learning AA philosophy and being treated by members of the medical profession, was expanded and carried out at Hazelden during the 1950s and 1960s. This multidisciplinary approach came to be known as the Minnesota Model.¹²

Hazelden began to treat alcoholics with psychiatrists and psychologists, nurses, chaplains, social workers, and alcoholism counselors, all while keeping the AA Twelve Steps as the core of its treatment philosophy. This model proved to be the most well-rounded, holistic approach that had ever been used, producing effective results. The Minnesota Model has in some way affected virtually every treatment modality since and remains the basis for treatment at Hazelden today.

At Hazelden, a team of chemical dependency counselors, psychologists, medical personnel, spiritual care counselors, case managers, wellness specialists, and continuing care specialists is involved in designing and delivering care to each patient. Members of this multidisciplinary team assess the needs of each patient and cooperatively develop a treatment plan that is tailored to the individual. Each patient’s length of stay, withdrawal needs, course of treatment, and continuing care recommendations are determined by factors unique to the individual.

Hazelden has made significant changes over the years in the way withdrawal from heroin and other opiates is managed. As research on opiate detoxification began to show better patient retention and outcomes for patients who were tapered off over a longer period of time, Hazelden changed protocols for opiate detoxification. Where medications such as clonidine were once used for opiate detoxification, sometimes resulting in inordinate discomfort, Hazelden now uses a slower taper of buprenorphine. Other medications are prescribed as needed to address some of the discomfort related to opiate withdrawal.

Hazelden is one of the few U.S. treatment facilities still able to offer a traditional twenty-eight-day course of treatment. The twenty-eight-day time period was arrived at by experiment—it seemed to be enough time for alcoholics to detoxify and begin absorbing AA education while rebuilding their physical strength.

The patient begins the admission process with an interview to assess the extent of his or her heroin usage and to ensure that he or she receives proper medical attention during withdrawal. The new patient will be given a bed in the medical unit where he or she will be monitored before being transferred to a primary rehabilitation unit. Heroin addicts are usually kept in the medical unit for just a day or two unless they are exhibiting severe withdrawal symptoms. Because heroin withdrawal is not life threatening, addicts are moved into the rehab phase as quickly as possible.

During these first days of treatment, a psychological assessment and medical examination are done, and a drug history is written. From this assessment, a treatment plan is devised. The new patient is assigned to a room in a residential unit where he or she will live with twenty to twenty-four other men or women.

By the end of the twenty-eight-day treatment period, the heroin addict will have learned about the Twelve Steps of AA and completed the first five; ideally, he or she will have had a spiritual awakening that will give him or her the extra push needed to face the world again. The addict will have gone through peer evaluations in which his or her blind spots to recovery were pointed out, and he or she will have spent considerable time reflecting on his or her life. Patients are taught to embrace the program of recovery offered by NA and AA and are given help in finding a Twelve Step group following discharge. At Hazelden, the addict is treated with respect and dignity, perhaps for the first time in his or her life. He or she leaves the center prepared to reenter the human race as a proud, sober member.

When it is time for a patient to leave, Hazelden will often recommend a halfway house where the addict can live for anywhere from a few months to a year. Hazelden stresses that the keys to success upon discharge are establishing relationships with other recovering people, giving oneself enough time away from drugs to change life habits, and following the directions of people in AA/NA.

The high success rate Hazelden realizes with its patients could be due to the thoroughness of the Minnesota Model. Many who have been through this type of program say it was the spiritual healing and their involvement with AA/NA that saved their lives. They claim that being treated with respect was new to them, and that it gave them a sense of dignity. One thing seems clear: An addict who shows up physically, spiritually, and emotionally bankrupt can turn his or her life around in a program that spiritually awakens a belief in himself or herself and some sort of Higher Power. It seems this belief is needed to address and heal the physical and emotional bruises and scars left after life as a heroin addict.

The Haight Ashbury Free Clinics and the Community-Based Treatment Model

Not everyone makes it to a treatment center like Hazelden, however. Some may be caught without insurance, forcing them to rely on community-based treatment programs funded by local, county, or state funds. There are many of these programs around the country. The advent of managed care has made them the only recourse for many addicts trying to recover. It is to such programs that those on public assistance, for example, are most often referred. Many cities throughout America have provided services to heroin addicts via freestanding treatment centers like the Haight Ashbury Free Clinics in San Francisco, California.

Founded in 1967, the Haight Ashbury Free Clinics have provided treatment to addicts for more than forty years. Through four decades, the clinics have seen drug trends come and go, and as the trend cyclically returns to a heroin epidemic time and time again, they see a substantial increase in the number of heroin addicts they treat.

Treatment at the Haight Ashbury Free Clinics is administered, as the name implies, free of charge. The clinics have consistently treated an average of 300 patients a month with approximately 150 more on their waiting list. According to author Richard Seymour, former information and education director at the Haight Ashbury Free Clinics in San Francisco and editor of the Journal of Psychoactive Drugs, heroin addicts present a unique challenge in treatment. The clinics use a modified medical model in combination with a behavioral science approach. In a 1997 interview with the author, Seymour said that “the more tools there are available to treat addicts with, the better chance the addict has of recovering.”¹³

The heroin addict who enters treatment at Haight Ashbury is usually in some state of withdrawal, so he or she receives a drug such as clonidine or any of the many other drugs that lower blood pressure and alleviate some withdrawal symptoms. Once the addict is past the withdrawal stage, he or she is prescribed naltrexone, an opioid antagonist that will block the effects of a heroin dose and diminish cravings for opioids.

Treatment is open-ended and delivered on an outpatient basis. The first two weeks are devoted to stabilizing the patient physically so that he or she is able to take part in group therapy sessions, where the work of recovery begins. Patients receive psychosocial counseling individually and in groups. The program consists of five full days per week, and Seymour described it as “diagnosis-driven treatment,” meaning that each case is different and that what might work for one addict will not necessarily be effective for another. Each individual requires a specific treatment plan for his or her own circumstances. “Motivation is the key,” Seymour reported. As an example, he described two patients, one an airline pilot, the other a homeless person living on the street. What motivates the pilot to recover may not have any significance for the homeless individual. Figuring out a patient’s motivators is essential to designing a successful treatment plan.¹⁴

All of the clinics’ patients are educated about NA/AA and are encouraged to attend meetings regularly. Most patients wind up going through about a year of treatment and then resume their lives and return to work or school. While they are in treatment, random urine tests are given to check their sobriety. Although Haight Ashbury requires total abstinence as part of its program, it does not use the urine tests to police or discharge patients; rather, it uses the tests as a diagnostic tool to see where the patient is in his or her recovery program.

The district of Haight Ashbury has long been known for its population of hard-core drug users. The clinics have been successful in treating many, but they lose many others. Seymour believes that applying the best of the medical and behavioral models helps achieve results, and that it sometimes takes a combination of modalities to reach an addict and arrest his or her disease.¹⁵

In essence, whatever it takes is in order. At Haight Ashbury, a combination of the medical and behavioral approaches with a Twelve Step model meets the needs of a wide range of individuals. Treating hard-core users, the clinics have done “whatever it takes” for more than forty years.

The clinics’ founder, Dr. David Smith, a former president of the American Society of Addiction Medicine, explained that an opiate epidemic naturally occurs after a stimulant epidemic like the ones the United States has experienced like clockwork from the 1950s through the 1980s with cocaine, and from the 1990s through now, with methamphetamine.

Dr. Smith (now chair of addiction medicine for Bayside Marin Treatment Centers) asked, what comes after an opiate epidemic? Another speed epidemic, this time methamphetamine. Working on the front line, the staff at the Haight Ashbury Free Clinics use all the tools available from both the medical and the behavioral toolkits. The drugs used by addicts may change, but the nature of addiction never does.

Does treatment work? There are skeptics who feel it does not. During a 1996 presentation, Dr. Herbert Kleber, professor of psychiatry at Columbia University Medical Center and director of the Division on Substance Abuse at the New York State Psychiatric Institute, said “The skepticism about treatment effectiveness arises from misunderstandings about improvement versus cure, chronic relapse, the failure to distinguish rehabilitation from habilitation, and the visibility of failures and anonymity of successes.”¹⁶ Kleber stated that it is probably more accurate to say that treatment can work rather than to say that treatment does work.

There are many variables in the treatment of heroin addiction, as we have seen, and there is probably no one sure way to treat it effectively. To some extent, our society’s problems in judging the effectiveness of treatment modalities come as a result of our preconditioning.

Dr. Kleber pointed out that in judging addiction treatment, laypeople and professionals alike expect a combination of the effects of penicillin and a smallpox vaccine, with lifetime immunity after one dose. It would be unfair to judge the effectiveness of any treatment modality based on the expectation of instant cure.

Addiction is a chronic relapsing disorder. It is also a progressive disease. In the same way, recovery is progressive. Many times, addicts learn from their relapses and improve with each failure and new treatment attempt. They might not get it on the first try but find success on the third or fourth. It must be remembered that for many active addicts the goal is learning how to control using. Many relapses are exercises toward this end. With each uncontrollable episode, or relapse, the addict grows closer to accepting his or her powerlessness with respect to the drug. Because success is measured by total abstinence, it is no wonder that many view treatment skeptically. Many experts argue that progress should be the barometer for gauging drug treatment success.

If not for the sake of the addict, treatment makes sense for the sake of society. Treatment’s cost benefits and its positive impact on society make it worth the money. In 2008, the U.S. federal government estimated that 20.1 million Americans regularly used illicit drugs, 70.9 million used tobacco products, 58.1 million engaged in binge drinking of alcohol, and 17.3 million were heavy drinkers of alcohol;¹⁷ all this at a cost of more than $534 billion in healthcare, criminal justice, and lost productivity.¹⁸ Reductions in criminal activity, drug use, and risky sexual behavior are but a few of the positive impacts treatment can have on society.