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January|February 2006
Tribunal on Trial David Bosco
A Court in a Storm Aaron Kuriloff
To Have and Hold a Green Card Melissa Nann Burke
A Fix for Junkies Jay Dixit
Setback in Stone Collin Campbell
The Prudent Jurist By William H. Simon
A Wink and a Nod By Len Costa

A Fix for Junkies

Can a new medicine prevent drug users from getting high?

Jay Dixit

TWICE A WEEK, GEORGE ROACH WOULD LEAVE THE HOUSE in Philadelphia where he lived with his mother and travel by subway to the Center for Studies of Addiction at the University of Pennsylvania. After signing in, the lanky 25-year-old would be led to an office in the back. And after providing a urine sample, he would be handed three small yellow pills, which he would promptly swallow under the watchful eye of a nurse or doctor. The pills were naltrexone, a medicine that prevents heroin users from getting high. Roach, a former heroin addict, recently completed his naltrexone treatment—and he's certain that had he not taken this opiate blocker, he would be in jail or dead.

Other former addicts who have used naltrexone can also attest to its effectiveness. A Penn study of probationers and parolees with previous heroin addictions found that while 30 percent of those who were not treated with naltrexone suffered relapses, only 8 percent of those being administered the medication went back to using drugs—and they relapsed only because they stopped taking it. This points to the major drawback of naltrexone: The medication wears off after a few days, and successful treatment depends on the ability and willingness of an addict to show up twice a week at a clinic in order to take the pills.

Given how effective naltrexone has proven to be, and how unreliable drug users generally are, some medical experts believe that naltrexone should be compulsory for addicts convicted of nonviolent crimes. Others believe that making it mandatory is too draconian, but that addicts should be given a strong incentive to take it—by offering it to them either as a way of avoiding prison or as a condition of early release. "If they're on this medication, they cannot relapse; it's physically impossible," says Dr. Charles O'Brien, who heads the Center for the Studies of Addiction. "All you have to do is require that they take the medication."

This smacks of coercion to some civil libertarians, however, and many in the legal community share their view. Penn's and 23 other drug clinics and hospitals across the country recently completed a clinical trial of an injectable form of naltrexone, called Vivitrex, that has proven to be effective for as long as a month. The Food and Drug Administration is expected to approve its use later this year, and if and when approval is granted, the legal and ethical quandaries posed by naltrexone will become even more acute.

Naltrexone is part of a family of drugs called opiate antagonists. It works by attaching itself to the opiate receptors in the brain, blocking the effect of various chemicals—endorphin, serotonin, and dopamine—that, when stimulated by opiates like heroin, combine to create a buzz. A person taking naltrexone finds it impossible to get high. Although naltrexone was first approved by the FDA in 1984, only in the last decade has it been used to treat addicts. But its success is no surprise to many people in the drug treatment business. "Psycho-social treatment is fine, but we have better solutions now," said Dr. Clifford A. Bernstein, the medical director of the Waismann Institute, a detox center in Beverly Hills, Calif. "There's no substitute for modern medicine, and naltrexone gives you the best chance you'll ever have."

Not many drug users have been given that chance. The Department of Health and Human Services estimates that only 3 percent of people treated for heroin addiction in specialty settings like rehab clinics receive naltrexone. According to Charles O'Brien, the overall figures are not much better: He estimates that fewer than 10 percent of the nation's 1.1 million regular heroin addicts have ever been given the medication. And while the success rates have been impressive, it's also clear that naltrexone, at least in tablet form, is most effective with addicts who are highly motivated, like people whose jobs have been jeopardized by their drug use.

George Roach didn't have a job to save, but he was motivated. He started using heroin as a teenager and spent the next five years drifting in and out of prison and detox programs. "I wouldn't be out two days before I'd start getting high again," he recalled. In July 2004, while serving an 11 1/2- to 23-month sentence in a Philadelphia prison for dealing drugs, Roach was caught stashing Valium, Xanax, and other pills under his mattress and was sentenced to 10 days in solitary confinement. It was there that he resolved to clean up his life—to shake his heroin habit and become a better father to his two-year-old daughter, who was born while he was in jail.

Several months after being released, Roach was in a rehab center in Eagleville, Pa., when a Penn psychologist came to talk about naltrexone and to seek volunteers for a clinical trial. Roach signed up. He admits that his friends were skeptical of his ability to stick with the treatment and stay clean. "Other people didn't think I was serious," he said. But with the help of naltrexone, Roach was able to resist the heroin cravings. "You know you can't get high, so right away, it gets you thinking different, like, 'Why am I gonna waste my money?' "

BUT ROACH'S DETERMINATION IS RARE AMONG ADDICTS, and it is for this reason that O'Brien advocates taking the decision about naltrexone out of the hands of addicts. Addicts, almost by definition, aren't good at managing their personal affairs, and O'Brien believes that naltrexone is the best hope they have for staying clean and becoming responsible, productive citizens.

To O'Brien, the case for naltrexone will become even stronger when Vivitrex arrives on the market. "With the oral, while they're on it, they're great, but if they don't show up to get the medication, or if they forget to take it, then they're not covered after a couple of days," he explained. "The injectionable is much more powerful—all you have to do is give one injection and they won't get addicted for 30 days." O'Brien wants the use of naltrexone to be made a mandatory condition of early prison release for convicted addicts, and he brusquely dismisses concerns about the ethics and legality of such a move. "All you're doing," he said, "is you're depriving them of the ability to get euphoria from heroin, and it's not as though they have a civil right to get that."

But Philadelphia Municipal Court President Judge Louis J. Presenza, who presides over the city's primary drug court, strongly disagrees. "Is it illegal to use heroin? Certainly," Presenza said. "But do people have a choice to make as to whether they want to take it or not? They certainly do. People make bad choices all the time, which they have a right to do." He applies the same logic to naltrexone. Although he gives drug defendants who appear before him the option of taking it, Presenza opposes making its use compulsory. "I will not mandate naltrexone," he said. "When people can rationally decide what they want to do, then I don't know that we should be in the business of forcing them to take medication that they have a right not to take."

Roach, on the other hand, couldn't be happier about taking naltrexone. He now sees his daughter each Tuesday and Sunday, is not using heroin, and is not smoking pot or drinking either. He said, "I don't even want to get high no more."


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