Table of Contents (Questions marked
with *** have answers, so far.)
Naltrexone for Patients who Wish to
Moderate or Control Their Drinking***
- What are the side effects of Antabuse and Revia?
- What are 'side effects?' ***
- How long do I have to stay in treatment? ***
- Why is it a problem to have a romantic relationship
with another patient in the treatment program?
- If I have a problem with heroin/cocaine does that
mean I have a problem with alcohol, too? ***
- Why do I have to go to AA meetings? ***
- How do I know that I'm an "alcoholic" or
an "addict"? ***
- Why don't my family members trust me? ***
- Why do I need to involve my family in treatment?
- What do my relationships have to do with my
- I've been in treatment for a while now, but I
don't feel any better. Why not?
- How am I going to have fun if I don't use?
- Is it necessary to have a clinician who is in
- If someone is on the borderline for cirrhosis and
was told to stop drinking in order to give the liver a chance to
heal, how long does it take for a liver to heal?And once the liver
has healed, can a person go back to drinking in moderation?***
- Is Smithers using moderation management in
- What are
sobriety medications and how might they help me reach my recovery
- Are there medications that might help
problem drinkers achieve moderation goals?***
- What is Ultra-Rapid Opiate Detox (UROD) and how is
it different from Rapid Opiate Detox (ROD)?***
- I've decided to do a Moderation Management 30 (30
days abstinence). Are there any materials I can use to prepare for
- Why would any professional recommend AA for dual
diagnosis patients? ... I have noticed that people who are using
psychiatric medication are often told that they aren't really
sober or clean ...***
- I had a friend who died suddenly of liver failure
when she took tylenol after a night of heavy drinking. How could
this have happened?***
- Hey Doc, why is there so little research testing
naltrexone as an aid to problem drinkers trying to moderate?***
Disulfiram (Antabuse) and naltrexone (Revia) are sometimes
called sobriety medications, medications that can help a person avoid
the alcohol or drugs which have caused them harm. While they are most
commonly used in early recovery, the first three to twelve months,
some people continue to take them for a lifetime.
[For more information on how disulfiram and naltrexone work,
please refer to "Sobriety
Medications" in the Library
section of this website. For general information on side effects go to
"What are side effects?" in this FAQ.]
Common disulfiram side effects:
- The most common side effect of disulfiram is nothing. Most
people who take the medication every day experience no effect of
any sort at all.
- An odd taste in the mouth usually described as 'metallic'.
This almost always goes away by itself over the first two weeks on
- Disulfiram can make some people feel sleepy, and this is an
example of a side effect that isn't all bad. We commonly advise
patients, that if the medication makes them tired, then 'cop the
side effect' and take it at night for the ever so common and
dreaded <in voice of doom:> Insomnia of Early Recovery
<smile>. Usually, though, people get used to it quickly and
it rarely causes tiredness after the first week or two.
Uncommon disulfiram side effects:
- There have very rarely been reported cases of a reactive
hepatitis, inflammation of the liver that subsides when the
medication is discontinued. It is a good idea to get blood tests
of liver function before starting disulfiram and again several
weeks later (or sooner if you didn't feel well).
Common naltrexone side effects:
- A mild-to-moderate headache and muscle aches and upset
stomach are not uncommon during the first several days of 1 pill
(50mg) daily. Interestingly, alcoholics use the term 'flu-like'
while (detoxified and clean for a week) heroin addicts identify
the feeling as a very mild withdrawal. Both are correct: the aches
are probably due to withdrawal from one's own endorphins
stimulated by starting suddenly with a high dose.
This unpleasantness can be avoided very easily by starting with a
very small dose and building up over the first week to a full
dose. So, 1/4 pill daily for 2 days, then 1/2 for 2 days, then 3/4
for 2 days and then finally one 50mg pill daily. Start the
medication this way, and you probably won't experience the
These symptoms, if you get them at all, rarely persist beyond 5-7
days regardless of how you were started on the medication.
Uncommon naltrexone side effects:
- I have often heard it said that dysphoria (feelings of
persistent sadness) and depression are a significant side effect
in a significant number of people such that they could not stay on
naltrexone. I have never actually encountered this in a patient,
so I have my doubts about how common this actually is.
- Alexander DeLuca, M.D.
By "Side effects" we usually mean actions or effects a
medication has other than the ones we want. The effect of the aspirin
you took for your headache is no more headache. The side effect is the
upset stomach you sometimes get from aspirin. There is a special type
of side effects that I call "induction effects." These are
side effects that are common when you first start taking a medication
but which usually go away over a period of days to weeks if you
continued to take the medication.
An example of an 'induction effect' is a disulfiram
side effect: a metallic taste some people get when they first
start disulfiram (Antabuse) which very quickly goes away over days to
a week if they continue the medication.
- Alexander DeLuca, M.D.
Oiy! What difficult questions you ask, bubbala. Gee, I don't
Seriously, I really do not know how long you should stay in
treatment, or whether you'd ultimately be better off in a six month
Therapeutic Community (TC) or going to AA meetings twice a week. My
field, Addiction Medicine, is a primitive field. This isn't cardiology
where they've done all of this painstaking research and can really
tell you, with confidence backed by studies, what treatment you should
have for what you got.
[ And by the way, us treatment provider types should be asking
ourselves the same question from the other point of view, and that is,
"When IS your treatment done?" How do we know when enough is
enough? But this is another discussion for another FAQ. ]
So I can't tell you how long you should stay in treatment, but I
can maybe help you figure it out for yourself. Ask yourself questions
- Have the forces that brought you into treatment been
stabilized, or are they all still in play at gale force just
outside the door? I mean, something has to have changed, right? If
you are going back into the same situation, with the same people,
in the same state of ill health, in the same frame of mind, and
the same array of financial and social problems, what can you
expect? And if that is your situation then you *really* need to
stay in treatment 'cause you're going to need a lot of help.
- Do you know what your problems actually are, or are you not
sure? If you are sure, then is the treatment you are in likely to
give you the skills you need to tackle the problems or not? If
not, simple, you're done with this treatment. But usually we're
not so sure what the problem is, and we're not so sure what we
need to learn. In this case I say, 'Go slow, if you can, and don't
be in such a rush to take everything on by yourself again.' Maybe
this treatment won't ultimately help much, but maybe it will, and
anyway you're not sure so just stay put.
- Are you feeling good, enjoying being alive, supporting
yourself through your own contributions? Have your various
relationship problems gotten better or gone away? Are you
comfortable in the world, with your level of self-help support?
Enjoying work and friends? If this is you, and you still want to
be 'in treatment,' become a counselor! :-)
- Alexander DeLuca, M.D.
[This is the answer to the question, which has not yet be written.]
problem is with heroin/cocaine. Does that mean I have an alcohol
maybe not. Each individual is different in the extent to which use of
multiple drugs is a problem in their lives. The key issue is how your
heroin and cocaine use are related to your drinking, if at all. If you
find that you:
other drugs mostly after you’ve had a few drinks, or
you stop using other drugs your drinking increases
then you should probably consider stopping or reducing drinking
as well as drug use.
know, within broad limits, how much drinking is likely to harm you. In
a study done with over 700 drinkers seeking treatment at the Addiction
Research Foundation in Toronto, Canada, researchers were able to
define how much drinking was likely to result in harm to the drinker.
People who exceeded a certain level of drinking (4 drinks per day, 16
drinks per week for men; 3 drinks per day, 12 drinks per week for
women with a “drink” defined as one 12 ounce beer, five ounces of
table wine or one shot of hard liquor) were much more likely to have
problems related to their drinking than people who stayed below those
limits. Of course, these limits are quite general--but they do provide
a rough guideline for you to evaluate your own drinking.
Here is a
quick self-assessment. If you are regularly (twice a month or more)
exceeding 4 drinks in a day (males) or 3 drinks in a day (females),
then your drinking is probably placing you at risk for bigger
problems. If your drinking is strongly associated with other drug use
(i.e. you only use cocaine after you’ve been drinking for a while),
then you are also at increased risk for relapse to those other drugs
if you continue drinking.
line is that you have to examine your drinking in relation to the rest
of your life, and decide whether it makes sense, in terms of the risks
you are running, to reduce or stop altogether. Of course, if you want
to reduce the risk of drinking to zero, then stopping altogether will
probably do the trick!
You don't. You don't have to do
anything, and nothing has to happen.
- Alexander DeLuca, M.D.
all, let’s talk a bit about labels. Both of these terms are labels
that people apply to themselves or others, neither of which tells very
much about the person except that someone believes there is a problem
with alcohol or drugs. And both of these terms carry a very negative
connotation that tends to demean and deflate already troubled
individuals. After all, how many of us would say “I want my kid to
grow up to be an alcoholic/addict”?
of this is to say that labels aren’t as important as people and
lives. The issue isn’t what I label myself or someone else, it’s
how I or you can live a healthier life. If alcohol or drug use is
getting in the way of a healthy life--and in this I include social,
family, mental and physical health--then that’s a problem worth
examining and doing something about. If you want to label yourself an
“alcoholic” or “addict” by all means do so, but don’t get
mired in self-pity over your self-label--do something about it!
bottom line is that you have to look at your alcohol or drug use
closely and honestly and ask yourself “is my drinking/drugging
hurting me or others or placing anyone at risk of harm?” If the
answer is “yes”, then consider making some changes, either by
coming to treatment or your own efforts.
Probably because you've earned their mistrust.
When we finally make the decision to stop or moderate, alcohol
or drugs, and get into a treatment program or therapy or self-help
group, we often renounce our 'old' behaviors (like lying, cheating,
stealing) for new behaviors (like taking responsibility for one's own
actions, honesty, and generosity). And it feels wonderful!
And, filled with this new spirit and resolve, we are then puzzled that
our family members and friends are not sharing our euphoria, and
instead are still doing their old behaviors (like questioning where
we've been and what we've been doing, smelling our breath for alcohol)
and generally treating us with the same anger, hurt, and mistrust they
layed on us when we were using.
And it hurts. And it makes us angry. "Why can't they see
I've changed?" we cry.
And all of this is understandable, and yes they will trust you
again, and treat you like a responsible adult, but it takes time. A
lot of us broke a lot of promises, and relapsed a lot of times.
So forgive the mistrust, the checking for bottles or fresh
tracks, the disrespectful questioning from the people who love us.
Focus on your new discipline, new behaviors, new program, whatever. To
paraphrase a famous line, "Through your works, they will know
It'll probably take a lot less time than you think. Funny how
when you stop compulsively hurting someone they start to relax around
you and lighten up. <smile>
- Alexander DeLuca, M.D.
More complete answer to follow <smile>.
[This is the answer to the question.]
[This is the answer to the question.]
[This is the answer to the question.]
[More complete answer to follow.]
This is an important and good question about the *process* of
alcoholic liver disease, and about the effect of moderating alcohol
intake or abstaining on the liver once it has become damaged
To understand the damage alcohol causes, let me first explain a
little bit about how the liver is constructed and about how liver
cells do their various tasks. Blood from the gastro-intestinal tract
(mouth, esophagus, stomach, and intestines) is brought first to the
liver where it sort of percolates through and between the cells
which are loosely applied to each other to facilitate as much blood
as possible getting 'up close and personal' with the liver cells as
possible. The liver cells take nutrients and toxins (like
alcohol) and medications (or whatever) from the blood and
produces various proteins needed for blood clotting and detoxifies
the toxins and breaks down the drugs. The liver cells do these jobs
using chemicals called enzymes that are inside the cells.
When liver cells are damaged and die (which can be caused by toxins
like alcohol but also by viral infections like Hepatitis B and
Hepatitis C), the enzyme chemicals, which should be inside the liver
cells doing their various jobs, leak out of the damaged cells into
the blood stream. If a doctor takes a blood sample and the amount of
liver chemicals in the bloodstream is higher than normal, it is an
indication that something is killing the cells allowing the enzymes
to leak out. These enzymes have names like: GGT, SGOT, SGPT, and are
collectively known as "Liver Function Tests." So
if the doctor tells you that:
-- "your liver is inflamed," or
-- "your liver function tests are
it means the levels of these chemicals in the blood test is too high
indicating ongoing damage to the liver.
If alcohol is the cause of the increased liver function tests, then
stopping alcohol consumption will generally lead to decreased liver
cell death, and lower (more normal) liver function tests. Perhaps
this is the "healing" process you refer to in your
question? Alcoholic liver disease is reversible (meaning if you stop
drinking it'll get better) up to a point. If too many liver cells
die and are replaced by scar tissue then at some point the liver is
irreversibly damaged and this is known as "cirrhosis of the
liver." Usually by the time this sort of permanent scarring
occurs the patient is showing symptoms of a liver that is not
functioning well. For example, the patient may become
"jaundiced" which means that the whites of their eyes
turns yellowish which means there are now too few functioning liver
cells left to clean the blood, or the patient may start to have
problems with bleeding because the liver is too damaged to make
clotting proteins anymore. In extreme cases the patient needs to
have the entire liver replaced in a liver transplant operation.
So, if the doctor told you that the "liver is on the borderline
for cirrhosis," my guess is that this probably means that the
pattern of liver function blood tests indicates significant and
chronic cell damage with some evidence of impaired function due to
scarring, but not so much damage that all hope is lost for
significant recovery of normal liver function. If the person stops
drinking for, say, 3-6 months, and repeat blood testing shows
normalizing liver function, most doctors would strongly advise this
person NOT TO RETURN TO DRINKING AT ALL. The reason is that this
liver has already shown itself to be sensitive to alcohol and
significantly damaged, and the risk of further damage from even
moderated drinking is too serious to play around with.
If the person decided to return to drinking once the liver had
"healed" a bit, (despite being given the good advice
stated above), then I would advise drinking as little as possible,
certainly not more than one or two drinks a day, and would re-check
the liver frequently for return of active liver disease.
- Alexander DeLuca, M.D.
all, Moderation Management (MM) is a self-help group, not a treatment.
Smithers has no relationship with MM except that MM holds a weekly
meeting on our site, a courtesy we have extended to Alcoholics
Anonymous (AA) for decades. These meetings are held during hours the
space is not being used by any Smithers program, and are in no way
part of the Smithers Addiction Treatment and Research Center.
is research that shows that patients who attend self-help groups
regularly stay in treatment longer and have better outcomes. AA and NA
(Narcotics Anonymous) are routinely recommended to all patients at
Smithers, and MM or other self-help programs suggested if the patient
refuses to try (or return to) AA or NA.
'treatment' at Smithers is cognitive-behavioral in general. Some
groups, especially those for people thinking about coming into
treatment or those ambivalent about returning to treatment after
relapse, are 'motivational enhancement' groups. That is, they are
manual-driven, group implementations of a psychological approach known
as "Motivational Interviewing" (see book of same name, I
think, by Miller et al). Smithers motivational enhancement groups are
employed on both inpatient and outpatient services.
core of the Smithers treatment is what we call the "Core-20"
- twenty semi-structured, manual-driven, cognitive-behavioral, group
sessions constituting what we feel provides the clinical basics of
self-understanding, and psychological techniques to achieve and
maintain an abstinence-based sobriety. Abstinence is, *by far,* the
safest and best approach for people with significant alcohol or drug
Smithers different from a lot of treatment centers is that we work
with people's ambivalence about their substance-use and about
treatment, and we do not refuse to work with people who are not sure
they are "addicts or alcoholics."
For example, a patient might be having just a few
substance-related problems, or a loved-one feels they have a problem
but they are not convinced they need to quit entirely. If such a
patient is not judged to be a danger to themselves or others, and is
not so medically compromised that *any* continued use would result in
serious risk of acute medical problem, and if such a patient refuses
to take the suggestion of immediate abstinence-oriented treatment,
then I will sometimes do an intervention known usually as "a
trial of controlled drinking" which involves strict limitations
on alcohol intake and patient recording of the circumstances and
emotions regarding any deviation from the "controlled"
example, the patient agrees to the instructions:
-- no more than two drinks on any drinking occasion, and
-- not more than one drinking occasion per day, and
-- if you have more alcohol than this, please write down a brief note
including date, time, circumstances and feelings, so that we can
review your experiences with this in (usually) two weeks.
The patient is often surprised that they are unable to stick to the
limits and then has a better understanding of why they should strongly
consider a 'trial of abstinence'
:-) as their next therapeutic maneuver.
such a "trial of controlled drinking" is *ALWAYS* an
outpatient procedure because, by definition, inpatient treatment is
abstinence-oriented, and anyone sick enough to need inpatient
treatment is usually too sick for a trial of controlled
the question, _____. It has given me a chance to clear up some
confusion resulting from recent very misleading New York Magazine, New
York Post, and New York Times articles.
Alexander DeLuca, M.D.
Chief, Smithers Addiction Treatment and Research Center
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Click on this link to obtain the document in a new window.
I am actively soliciting experiences from people using naltrexone to
achieve moderation goals. These will be collected in the Library
section of this web site under the heading: Experiences
of naltrexone use in Moderation Management.
If you wish to contribute such an experience, please email me at: email@example.com
Thanks in advance. ..alex... 6/23/2001 ]
Are there medications that might help people
involved in a Moderation Management program? The answer is a
(Revia) is a medication that has been used in the treatment of opiate
dependence for some 30 years. It is a “pure opiate antagonist of
high affinity” which means, in English, that naltrexone occupies
opiate receptors on brain cells, and holds on tight. So if a person on
naltrexone shoots 5 bags of heroin, nothing happens because the
morphine (that heroin breaks down to in the body) cannot get into the
receptors, which are “blocked” by naltrexone molecules.
several studies of the highest quality (“double-blind, placebo
controlled”) demonstrated that people with alcoholism who took
naltrexone while in group treatment (Coping Skills Training in O’Malley’s
study and cognitive-behavioral treatment in Volpicelli study)
did better in several area’s of recovery. Compared to patients
receiving the placebo + group therapy, the patients on naltrexone:
Had significantly lower craving scores,
Stayed in treatment longer
Had better outcomes (less problems related to drinking)
Some patient in both placebo and naltrexone groups “slipped”
and had drinking episodes. But the reaction to the alcohol was VERY
different between the two groups. The alcoholics on placebo who had a
drinking episode did what alcoholics usually do when they break their
abstinence – they got drunk and went on binges of various
intensities. The naltrexone group, on the other hand, tended to have a
couple of drinks and stopped. When asked why they stopped drinking,
the reasons tended to be positive. For example, “It was late and I
had to get up early the next day,” or “I felt full,” or “I
just felt like going home.” This is in radical contrast to the
alcoholics on placebo who, when asked why they stopped gave the usual
negative reasons, like, “My sponsor will be disappointed with me,”
“my wife will kill me,” and “knew I should not drink and felt
Finally, the naltrexone group did better with tests of
cognitive (thinking) function, which has not been explained (to my
In my own
experience (with only two patients who choose to join Moderation
Management and pursue a goal of moderation) naltrexone can be a major
help in the early months of their recovery. One patient, in treatment
at a traditional treatment center, but pursuing moderation not
abstinence, had been on naltrexone and stopped it after a few months.
She told me that after stopping the medication she found herself
thinking about drinking more, fighting urges to drink beyond her
limits, and the like. This woman is still successfully moderating
having completed treatment. She told me that while on naltrexone
moderate alcohol use felt the same as it did without naltrexone; that
is, on naltrexone she found she could more easily stay with the MM
limits, and that naltrexone did not interfere with her enjoyment of
patient found that taking naltrexone made it MUCH easier to stay
within MM guidelines even in situations where a lot of heavy drinking
was going on. He credits naltrexone with helping him gain experience
of non-abusive drinking felt like, and that in this way, the
medication facilitated his recovery process.
Both of these
patients, to my knowledge, are now off naltrexone now and have not
returning to abusive/binge drinking.
We think that
naltrexone is blocking the abnormal surge in endorphins in response to
alcohol, that distinguishes problem drinkers from normal drinkers,
thereby making the problem drin
ker’s response to alcohol more
similar to that of non-problem drinkers. It is the endorphin surge
that we think causes that strong urge to have another drink and
another drink that characterizes binge/problem drinkers and
So, to answer
the question succinctly: Yes, there may be medications that can help
people in early Moderation Management recovery achieve their 30 day
abstinence period, AND might help people stick to the MM limits more
easily and with less struggling. I think a short course of naltrexone,
say 3 months, might help Moderation Management people to learn and get
used to moderate drinking.
Alexander DeLuca, M.D.
What is the difference between UROD and ROD?
2) How to do convert a patient from daily heroin to
daily naltrexone in 4-5 days.
3) My qualms about UROD - Four problems I have
with this procedure.
Hi John, thanks for posting the interesting
about ultra-rapid opiate detoxification from the Associated Press.
our field, the terminology ends up being very confusing.
What is the difference between UROD and ROD?
What Dr. Gooberman does is better called Ultra-Rapid Opiate
Detoxification, or UROD, to distinguish it from Rapid Opiate
Detoxification (ROD) [which is also not a great name] which refers to
detox procedures in which one takes a patient addicted to heroin on
Day 1 and converts him or her into a patient on Naltrexone maintenance
over a period of 4-5 days. I think it was first published by Kleber et
al at Yale in a setting we would now call Level IID or "intensive
outpatient detox." I could never get the procedure as published
by Yale to work. Essentially, in that regimen the patient was given,
on day one, 10mg of diazepam and 0.2mg of clonidine, followed after
one hour, by an oral dose of Naltrexone (I think 25 or 50mg).
did exactly that once, on the old Smithers inpatient detox unit ('A6')
in 1991 (I think). I have never seen a person become so ill, with
delirium plus projectile vomiting and diarrhea. It was a nightmare of
a day -- trying to get enough clonidine and diazepam into this guy to
get him out of severe withdrawal.
did eventually developed an inpatient Rapid Opiate Detox procedure
that worked very well - by which I mean the patients did not have
vomiting and diarrhea, delirium, and severe withdrawal. The 'trick' is
to let the patient metabolize what opiates they have 'on board' before
inducing them onto naltrexone.
How to do convert a patient from daily heroin to daily naltrexone in
Briefly, this is how we used
to do it at Smithers Addiction Treatment & Research Center:
to detox unit on day 1. For the first 2 days allow the patient to go
into withdrawal treating the symptoms with up to 1.5 mg of clonidine
using a combination of a TTS#2 patch and 0.1 mg pills and diazepam up
to 60 mg in a day (in rare cases more - I think 80 was the highest 24
hour amount I ever used). Patients varied widely in the amount of
symptomatic medication they required to be not too uncomfortable. ROD
patients on the unit were excused from groups and meetings that were,
then, mandatory for everybody else. Some ROD patients walked around
and went to groups and required relatively less clonidine and valium;
more commonly, the patients mostly slept but were easily aroused and
able to take food and fluids by mouth.
hospital day 3 (the second morning they woke up on the detox unit) the
patient was awakened at 9AM and given 10mg of diazepam and 0.2 mg of
clonidine PO (remember, they still had the TTS#2 patch on). Usually
the patient went back to sleep. At 10 AM the patient was given
approximately 12.5 mg of naltrexone PO ('approximately' because it is
hard to cut half a naltrexone tablet into precise quarters - I should
have dissolved the tablet in water - duh - but that never occurred to
me until right now).
of these patients were well enough to eat lunch 2 1/2 hours later.
What precipitated withdrawal there was would happen on this day and
would be treated symptomatically. But mostly patients were more
symptomatic from the clonidine and valium than from precipitated
withdrawal (which is sort of the point of this process).
remainder of the time on the unit (2 days usually) was mostly spent
letting the patient recover from the clonidine and valium they had
been given. On hospital day 4 (the third morning) the patient was
given 25mg of naltrexone, and on day 5 they received 50mg and were
discharged. Patients were lucid, eating, walking not staggering, and
talking on discharge - tired and beat, but not sick. They were
prescribed clonidine for another week if they wanted it (most did
not). Back then I did not prescribe benzo's to help make them more
comfortable for the first day or two out of the hospital (I would do
so today). Discharge meds were clonidine 0.1 - 0.3mg per day if they
wanted it (TTS patch removed on discharge), and doxepin 25-50 mg for
sleep. We tried to get the ROD patients appointments to start
outpatient group treatment within 3-5 days after discharge.
it. Very NOT traumatic and NOT dramatic. Letting the patients clear
their receptors gradually over 48 hours, loading them up with
clonidine and diazepam over that period of time, and only then start
with the lowest dose of naltrexone on the third day, worked quite
was, I think, the only routinely offered rapid "clonidine to
naltrexone" detox offered in NYC and we did it for years. The
inpatient unit where we did most of these would be classified ASAM
III-D. There was one outpatient treatment center (not Smithers) that
wanted all of their heroin addicts on naltrexone, and they referred to
us everyone who failed the traditional outpatient clonidine and
benzodiazepine (without propoxyphene) detox that they offered. And
patients coming to Smithers who met criteria for inpatient opiate
detox could choose the 4-5 day ROD or the then-traditional 7 - 10 day
methadone taper. We pitched ROD to managed care as a 'value-added'
detox, and they accepted it because it was half the time of the
methadone tapers that were being done in those years.
now, before I state my qualms about UROD, let me say that what I had
intended to try, with selected patients, was to shave off 2 or 3
inpatient hospital days by doing the two day heroin washout in a
special reclining chairs in a room on the detox unit reserved for ASAM
Level IID (intensive outpatient) detox treatment; with the patient
going home at night with a sober adult family member or friend to stay
with them to make sure they didn't hurt themselves because of being
unsteady from the clonidine and valium and who could bring the patient
safely back to the hospital the next day. Probably would have tried to
keep the clonidine and valium as low as possible in this scenario - on
an inpatient unit I always tried to err on the side of too much
medicine, not too little. Anyway, I was going to play with it and
figure out a regimen that worked and required fewer inpatient days.
well, maybe in some other lifetime, or perhaps one of you has a
physical plant and staff up to trying it. Smithers is designed and set
up to be able to do four different ASAM Levels of detox, and has the
evaluation unit front-end capable of distinguishing different levels
of severity and need. Because the entire Roosevelt part of Smithers is
on three contiguous hospital floors, re-assessing detox patients in
the afternoon would allow one to move a patient up or down Levels of
care as they progressed or worsened *on a daily basis*. This is the
sort of detox system called for in this age of MC, and it was my holy
grail to get up to the level of doing that. Almost made it
bad they (Smithers) don't have enough MD's anymore (as of December
2000) to operate the system as designed, and are currently unable to
do ANY outpatient detoxification for lack of docs. So they refer their
outpatient detox candidates to me; really. (This is a deeply strange
planet we inhabit.) But the design and the structure and much of
the forms and protocols are done and exist, so Smithers can get back
up to the level of operating a truly classy,
modern, detoxification system if they want to and can get the staff to
If I put you under anesthesia and then punch you and kick you, you
will wake up sore and beaten... you just won't know who hit you. Being
under anesthesia doesn't mean the trauma didn't happen. I suggest to
you that giving a heroin-addicted brain hundreds of mgs of antagonist
(naloxone and naltrexone usually) is a violent and traumatic thing to
do, whether or not the patient is awake to experience it as it
One shouldn't do violent and traumatic things to patients unless there
is some clear advantage gained by the patient. Where is the advantage
of UROD over ROD? Patients come out of UROD very sick and remain so
for days. They are not going to work the next day. Gooberman himself
said on network TV 12/31/2000 that the UROD procedure only
accomplished 2/3 (or did he say 3/4?) of the acute detox process. So
both UROD and ROD produce naltrexone-blocked patients who can do their
ADL's (Activities of Daily Living) in about the same time frame (4-7
days). Also, the three thousand dollar price tag for UROD does not
include the cost of travel and the dreary motel room in NJ that you
will need for a few days unless you happen to live next door to one of
Lance's clinics. (And you *better* bring someone with you, because you
*WILL* need help.) So we are talking about maybe $4000 or $5000 which
is significantly more than 4 days at Level III (rehab level) at
Smithers in Roosevelt Hospital during which you could accomplish the
same naltrexone induction in a safe medical environment and without
massive brain trauma. So, there is no significant time or cost benefit
It is every addict’s fantasy that if they can just get off heroin,
everything will be fine - and to go to a clinic, take a lot of drugs,
fall asleep and wake up cured! -- this is a very, very alluring idea.
Too bad it's not true. Detoxification is NOT the problem, and you do
not wake up cured, or even well, from a UROD procedure. What I am
saying is that it is wrong to use addicted people's misinformed
desires against them, and the ads and brochures for UROD that I have
seen ARE misleading.
Granted I've only worked with UROD patients who have had negative UROD
outcome's, like the gentleman who was taking as much heroin as he
could get to overcome the blockade because he felt so sick for days
after UROD (thank God for naltrexone's strong affinity for opiate
receptors!) - this guy had also tried to use kitchen implements to
surgically remove the naltrexone pellet Dr. Gooberman had sutured into
him. Ugly, ugly, ugly. We have seen several UROD failures at Smithers,
NYC being close to NJ. The UROD cases that go bad can go very, very
badly indeed which is another difference between UROD and all other
methods of opiate withdrawal treatment.
am not universally condemning UROD. There probably are people for whom
UROD makes the most sense or who really want that sort of procedure.
Lord knows we have too few ways of doing things in addiction medicine,
too few choices for patients, not too many.
bad most of the outfits that promote UROD have taken patents out on
the procedure. (Personally, I think this is wrong. We all stand on the
shoulders of giants who did the basic research which we then cobble
together to make 'treatment protocols.' I guess I am just an
old-fashioned romantic about medicine and research.) Unfortunately,
patenting a procedure makes it kind of difficult to then test that
procedure in a properly designed research protocol.
excuse the length of this post. Hopefully it was interesting or useful
to some of you.
Alexander DeLuca, M.D., FASAM
[ I clipped this from a post to the MM listserv.
Originally posted in 1999, "kkmmagic" reposted it in 2/2001
and I really like it.- ..alex... ]
Sent: Monday, September 06, 1999 2:40 PM
Subject: For those preparing for a '30'
I was reading Changing for Good (CFG) this morning, I found some
things I thought might be helpful for those who are struggling with
the idea of doing their '30' , for those who have already decided
to begin their '30' on 9/9/99, and those who might be struggling with
the 'relapse' cycle. Be sure to look at the self-assessment test at
"Ask yourself: What is my potential if I change? What will
it free me up to become? How will my life be enhanced?"
requires energy, effort and attention. You will not be ready to
move into the action stage until changing your behavior becomes your
includes not only a willingness to act, but also a belief in your
ability to change, which in turn reinforces your will. People
begin to use commitment during the preparation stage, and continue to
apply its techniques well into the action and maintenance
confidence in your evaluation of the pros and cons of changing, so you
honestly believe your life will be enhanced rather than diminished by
the action you are about to take."
often weaken their wills by putting action off for too long; by
relying exclusively on willpower, which puts too much pressure on this
single process; by drinking alcohol, which reduces anxiety but also
strength of mind; or by taking premature action, which can damage a
personal belief in the ability to change."
Setting a date: "Choosing a date to begin can help prevent both
premature action and prolonged procrastination, and can help make your
action as convenient as possible. The date should be realistic,
but it should also be scheduled as soon as possible, so you can
capitalize on your decision-making momentum."
you commit yourself to an action date, guard against finding excuses
or reasons to delay it, which can weaken your will."
public with your intended change increases anxiety, since you may feel
embarrassed if you fail. Public commitments are more powerful
than private pledges."
is not the absence of fear, but the ability to act in the face of
is a brief self-assessment to check your progress with
commitment. Once again, be honest and realistic. Fill in
the number that most closely reflects how frequently you have used the
methods below in the past week to combat your problem.
I tell myself that if I try hard enough I can change my problem
I make commitments against giving in to my problem.
I use willpower to keep from engaging in my problem behavior
I tell myself I can choose to change or not.
order to be ready to take effective action, your score on this
self-assessment should be 14 or higher. If your score is lower,
you have more work to do on the commitment process before you
can move forward successfully."
From: kkmmagic - posted 2/2001 on MM listserv
You wrote to Ask-An-Addiction-Doc:
"I spent many years in AA. I have noticed that people who are
using psychiatric medication do not fit into AA very well, and are
often told that they aren't really sober or clean if they are taking
I have also had this experience many times, and it is easy to
become outraged at what amounts to the same level of medical expertise
one would find in a deli or bar being delivered by someone who has
appointed himself, somehow, an authority, or 'old timer'.
Yes, it makes me crazy when I hear about people being told to
discontinue their psych meds in self-help groups.
But, AA itself is quite clear about this in their various writings
- that people should do what their doctors tell them to and that AA
wants not to interfere with this relationship.
Sometimes individuals say stupid things, and sometimes they say
stupid and dangerous things at which point they must be opposed with
correct information. I find myself providing this function
occasionally on the Moderation Management listserv.
But also it is not all one way. AA can be a very good place for
mentally ill people. I went to meetings in NYC west village group I
affectionately referred to as "Fruits and Nuts" for a year
circa 1987. In that group were several obviously mentally ill people -
I mean they rocked back and forth, mumbled quietly to themselves
sometimes and so on; various flavors of schizophrenic, bi-polar, and
But when they spoke, we listened, and no one shut them up or laughed,
even though sometimes the content was hard to follow or disturbing.
When we went out for cig breaks, they stood on the edge of our
group, but at least they were *part of* it.
We sat next to them, and we held their hands or not as they
preferred at meetings' end. They had a desire to stop drinking, and we
recognized them as members. And I saw one or two get a little better
over that year, standing closer, sharing a laugh or a cig. Less
Now, I think that meeting room was one of the very few places those
people could expect to be received with human dignity, even if all
they could do was rock back and forth in the corner.
So, I think it's complicated. Like so much human effort, there is
such incredible potential for goodness in the coming together, and so
many opportunities for ignorant or mean individuals to screw it up or
You also wrote to Ask-An-Addiction-Doc:
"I have collected first person stories, as well as a well
known documented case, of people who were coaxed into going off their
medication and either ending up hospitalized,
suicide, and in a newspaper case, commit murder."
I would be very interested in these, though they will surely hurt
and anger me. But the question is where else should we recommend the
substance-abusing mentally ill go? This is not a well funded and
prized segment of our larger society, and such people are incredibly
fortunate if they can connect up with a clinic for monthly meds or a
psych-oriented group or two a week. Where should we advise they spend
the other evenings?
Sometimes we see the dark side of AA which is the same dark side of
any gathering of humans, and because it is our AA, our house, it makes
us crazy to see it defiled, to watch it hurt people when that happens.
I mean, we see the bad stuff in AA and correctly criticize it. BUT, it
is AA that is *always* there. *Everywhere.* And most of the time the
door is open and the coffee is on.
I spend some time now with Moderation Management, have attended their
meetings, follow their online groups, cheer when new face-to-face
meetings open up in some city or other. Donate money, try to help. [We
have TWO MM mtgs a week <puffed up pride>, because we are NYC
after all :-) ]. And I think MM can be a great thing and I want to
help it grow and reach out to the problem drinkers / users that our
narrow 'abstinence uber-alles' traditional approach confuses and
When you hang in MM a little, you notice once again how BIG AA is.
And you also notice again how incredibly inclusive it can be, and how
powerful BIG and INCLUSIVE really is. I hope someday MM is big enough
to have the problems we are discussing. I hope they will be as
basically compassionate and inclusive. I know they'll make a lot of
the same mistakes.
It all comes down to who is in the room that evening, you know?
Who's there, who is taking the responsibility to be there, to help.
You wrote to Ask-An-Addiction-Doc:
" Aren't professionals who send their clients to AA open
to lawsuit if something like this happens?"
Hell, I don't know. We need to find an Ask-A-Lawyer for this one.
Alexander DeLuca, M.D.
you need to know about alcohol, acetaminophen (Tylenol), and liver
consumption changes the way that acetaminophen (Tylenol) is handled by
the liver. The injury to the liver is not caused by normal doses of
acetaminophen itself, but through the production of a toxic chemical
produced when the liver metabolizes (breaks down) the Tylenol.
the liver has stores of a chemical called glutathione which combines
with the toxic metabolite (called NAPQI) and thereby protects
liver cells from being killed by it. If the liver doesn't have enough
glutathione, NAPQI binds to liver cells and causes "hepatic
necrosis," which means death of liver cells.
causes depletion of glutathione by causing it to be broken down by the
liver faster than normal. Chronic alcohol intake can also causes
people to eat poorly so they don't make enough glutathione in the
of 1 bottle of wine, six cans of beer, or nine ounces of liquor over
the course of a single evening is enough to increase the
amount of Tylenol that is converted to NAPQI when the Tylenol is
taken AFTER the alcohol is cleared from that body.
MEANS THAT TYLENOL IS MOST TOXIC EXACTLY WHEN WE ARE MOST LIKELY
TO TAKE IT IN HIGH DOSES: THE 'MORNING AFTER' WHEN WE TAKE IT TO
TREAT OUR HANGOVERS!
can cause liver failure all by itself when taken in a massive overdose
- it simply overwhelms the amount of glutathione the liver has to soak
up the toxic NAPQI. There is an antidote, called N-acetylcysteine,
which is very effective when given early (within 15 hours) of the
overdose. Unfortunately, some patients may develop such rapid and
complete liver destruction that, while a liver transplant could
save them, they die before a donor liver can be found.
Ingredients per tablet (from my 250 CT Excedrin bottle):
Acetaminophen - 250 mg
Aspirin - 250 mg
Caffeine - 65 mg
So is that as much as is (possibly dangerous) in Tylenol?”
acetaminophen is acetaminophen regardless of what it’s combined
with. But I don’t want to unnecessarily concern or alarm people
here. I was responding initially to a post that mentioned the
potentially harmful combination, and so I wanted to explain the
pharmacology behind the concern. But major league liver damage from
Tylenol + alcohol is NOT common. I’ve not looked up the statistics
on this, but I’ve never seen a case in over a decade of hospital –
based addiction work, nor do I remember hearing of any.
failure and death from Tylenol overdose is, tragically, not uncommon,
and often occurs to young people who very likely intended to make a
suicidal gesture, not actually kill themselves, by swallowing a bottle
Tylenol, or Excedrin, as directed on the label will not cause death or
permanent liver injury to anyone in reasonably good general health. In
association with chronic starvation and pre-existing severe liver
disease, for example in a classical ‘Bowery’ type alcoholic,
perhaps normal-ish (perhaps 3-4 times the recommend two tablets) doses
of Tylenol could be the straw that broke the camel’s back, but
otherwise there is absolutely no reason why you should avoid Excedrin
or Tylenol if it helps with your pain unless you go on week-long
benders without eating and take handfuls of the stuff.
the particulars of the young person who the original poster mentioned
had died were, I do not know. But I’m guessing it was a LOT of
alcohol and a LOT of Tylenol and a LOT of not-eating; or the
unfortunate person had some freakish inherent susceptibility.
only meant to explain the pharmacology that underlies the potential
toxicity of the combination of alcohol and acetaminophen because I
think find this sort of thing interesting. And thank you for the ‘duplicate’
posting, because in trying to explain the chemistry of the
alcohol-drug interaction, I failed to put the entire matter in any
sort of real-world perspective.
is not what I am about; I got lost in the task of explaining the
science, and sincerely apologize for any unnecessary worry I’ve
caused. I will amend the FAQ tomorrow to correct this; thank you
again, Madame Bozo.
Alexander DeLuca, M.D.
Very excellent question, and one which people
ought to start HOWLING about to their representatives in
congress who, after all, fund the NIH, NIAAA, and NIDA
which decide where the money, YOUR MONEY, goes.
Right now, the overwhelming percentage of funds spent on
alcohol research focus only on "alcohol dependent"
people. Hardly any funds are spent on how we might help the much
larger, far more costly to society, group of people, the
"problem drinkers" like the people you find in
Moderation Management meetings.
It is important for you to realize, that you problem
drinkers ARE THE MAJORITY, yet the 'Treatment Industry' offers
you nothing in the way of engagement and treatment,
telling you instead to "come back when you hit
bottom" and other such odious nonsense. One little thing
we can and are doing is collecting the experiences of people who
are using naltrexone to help them achieve their moderation
goals, which you can see at:
When (then Dupont, now Merck) re-introduced naltrexone as
ReVia for the treatment of alcoholism, sales went nowhere. The
Treatment Industry, the addiction docs and counselors,
were almost unanimous in ignoring the very excellent
research that this drug might help, just as they had ignored
decades of research that antabuse, when supervised, can help
greatly in early recovery.
Why? Because the 'Treatment Industry Suits' somehow feel
that ANY medication somehow threatens their
'abstinence-uber-alles' world view. That if we were all
just good little addicts and alcoholics we'd (after
paying for detox and rehab) simply "not drink and go to
What we are seeing now is a grassroots resurgence in
interest in naltrexone. The Treatment Industry ignored
it; it is the people who suffer with alcohol related
problems who are bringing this drug into the mainstream.
And again, it is you PROBLEM DRINKERS THAT ARE THE MAJORITY, but
you will find damn little research being done on
naltrexone as an aid to moderation.
Why? Because the forces of abstinence-uber-alles, are very
powerful. They have money, and they crush people and
institutions that don't tow their narrow line. Take if from me,
I know. So researchers and academic institutions are
very, very wary of terms like "controlled
drinking" and "moderation" and very little money
flows that way.
Let's name a few names, shall we: the NCADD, the Smithers
Foundation, and the "Alliance for Recovery"
(whose "President" is Neil Scott and which is probably
just a front for the Smithers Foundation.)
Check out what these people did to the alcohol research center
at Rutgers approximately 30 years ago. Check out what
these same people did to the Smithers Addiction Treatment
and Research Center in July 2000 when we merely suggested
that we might be able to help people suffering from alcohol
problems earlier if we stopped demanding they swear allegiance
to abstinence on the first visit. Find out how these
organizations took out a full page ad in the New York Times
(that's about $90,000) in order to purposefully mislead and
confuse the public about our efforts to modernize addiction
treatment at the Smithers Center and about the tragedy of Audrey
Kishline's fatal motor vehicle accident, which actually had
absolutely nothing to do with each other.
<sigh> So the question, "Hey Doc, why is
there so little research testing naltrexone as an aid to problem
drinkers trying to moderate?" is a very good, and a
very important question. The answer is that the
"abstinence-uber-alles crowd" is very strong, and very
rich. And they control, often in subtle ways, where the research
dollars get spent. And that is why so very little research is
done on the MAJORITY, the problem drinkers, and is instead spent
on the much smaller problem of alcohol and drug
Here's a link to a web page that will tell you more
than you ever wanted to know about how the Treatment Industry
Suits, the Corporate Cowards, and the Tyrannical Philanthropies
go about intimidating and crushing new ideas; read it and