Alexander DeLuca, M.D.
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Frequently Asked Questions about Addictions and Addiction Treatment
aka "The Addiction FAQ"

Alexander DeLuca, M.D.; circa 1999. Originally written for my patients at the Smithers Addiction Treatment and Research Center.  
 
See also:
Frequently Asked Questions (FAQs) About Naltrexone, and Index of Naltrexone References and Resources
 

Table of Contents (Questions marked with *** have answers, so far.)

     0.   Naltrexone for Patients who Wish to Moderate or Control Their Drinking***

  1. What are the side effects of Antabuse and Revia? ***
        
  2. What are 'side effects?' ***
        
  3. How long do I have to stay in treatment? ***
        
  4. Why is it a problem to have a romantic relationship with another patient in the treatment program?
        
  5. If I have a problem with heroin/cocaine does that mean I have a problem with alcohol, too? ***
        
  6. Why do I have to go to AA meetings? ***
        
  7. How do I know that I'm an "alcoholic" or an "addict"? ***
        
  8. Why don't my family members trust me? ***
        
  9. Why do I need to involve my family in treatment?
        
  10. What do my relationships have to do with my addiction?
        
  11. I've been in treatment for a while now, but I don't feel any better. Why not?
        
  12. How am I going to have fun if I don't use?
        
  13. Is it necessary to have a clinician who is in recovery him/herself?
        
  14. 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?***
        
  15. Is Smithers using moderation management in inpatient treatment?***
        
  16. What are sobriety medications and how might they help me reach my recovery goals?***
        
  17. Are there medications that might help problem drinkers achieve moderation goals?***
        
  18. What is Ultra-Rapid Opiate Detox (UROD) and how is it different from Rapid Opiate Detox (ROD)?***
        
  19. I've decided to do a Moderation Management 30 (30 days abstinence). Are there any materials I can use to prepare for this? ***
        
  20. 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 ...***
        
  21. 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?***
        
  22. Hey Doc, why is there so little research testing naltrexone as an aid to problem drinkers trying to moderate?***
        

1. What are the side effects of Antabuse and Revia?

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 the medicine.
  • 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 symptoms.

    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.

..alex...
- Alexander DeLuca, M.D.
adeluca@doctordeluca.com 
circa 1999


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2. What are 'side effects?'

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.

..alex...
- Alexander DeLuca, M.D.
adeluca@doctordeluca.com 
circa 1999


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3. How long do I have to stay in treatment?

Oiy! What difficult questions you ask, bubbala. Gee, I don't know.

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 like this:

  1. 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.

  2. 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.

  3. 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! :-)

..alex...
- Alexander DeLuca, M.D.
adeluca@doctordeluca.com 
circa 1999


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4
. Why is it a problem to have a romantic relationship with another patient in the treatment program?
    

[This is the answer to the question, which has not yet be written.]

 

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5. If I have a problem with heroin/cocaine does that mean I have a problem with alcohol, too?
    

“My problem is with heroin/cocaine. Does that mean I have an alcohol problem, too?”

 Maybe, 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:

  1. use other drugs mostly after you’ve had a few drinks, or 

  2. when you stop using other drugs your drinking increases substantially, 

then you should probably consider stopping or reducing drinking as well as drug use.

Researchers 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.

The bottom 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!


Fred Rotgers, Psy.D.
circa 1999

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6. Why do I have to go to AA meetings?

You don't. You don't have to do anything, and nothing has to happen. 

..alex...
- Alexander DeLuca, M.D.
adeluca@doctordeluca.com 

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7. How do I know that I'm an alcoholic or an addict?

First of 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”?

 All 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!

 The 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.


Fred Rotgers, Psy.D.
circa 1999

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8. Why don't my family members trust me?

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 you." 

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>


..alex...
- Alexander DeLuca, M.D.

adeluca@doctordeluca.com 
circa 1999

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9. Why do I need to involve my family in treatment?
    

You don't.

More complete answer to follow <smile>.

 

10. What do my relationships have to do with my addiction?

[This is the answer to the question.]


11. I've been in treatment for a while now, but I don't feel any better. Why not?
    

[This is the answer to the question.]


12. How am I going to have fun if I don't use?
    

[This is the answer to the question.]

 

 

13. Is it necessary to have a clinician who is in recovery him/herself?

No.
    
[More complete answer to follow.]

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14. 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?

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 significantly.
 
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 elevated"
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.


..alex...


- Alexander DeLuca, M.D.
adeluca@doctordeluca.com 
circa 3/2000

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15. Is Smithers using "moderation management" in inpatient treatment?:

Very short answer: NO.

First of 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.

 There 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.

 The '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.

 The 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 related problems.

What makes 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" intake.

 For 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.  

At Smithers, 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 drinking. 

Thanks for 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.  

..alex...  

7/9/2000
Alexander DeLuca, M.D.
Chief, Smithers Addiction Treatment and Research Center
 

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16. What are sobriety medications and how might they help me reach my recovery goals? 

Click on this link to obtain the document in a new window.


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17. Are there medications that might help problem drinkers achieve moderation goals?

[ Note: 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: adeluca@doctordeluca.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 definite...

Maybe.

Naltrexone (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.

In 1995, 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:  

1)   Had significantly lower craving scores,

2)   Stayed in treatment longer

3)   Had better outcomes (less problems related to drinking)

4)   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 guilty.”

5)   Finally, the naltrexone group did better with tests of cognitive (thinking) function, which has not been explained (to my knowledge).

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 social drinking.

The second 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 drinker’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 alcoholics.  

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.  

..alex...
Alexander DeLuca, M.D.
1/2001

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18.  What is Ultra-Rapid Opiate detox (UROD) and how is it different from Rapid Opiate detox (ROD)? - 1/2001

1) 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 article about ultra-rapid opiate detoxification from the Associated Press. Somehow in our field, the terminology ends up being very confusing. ]

1) 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).

I 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.

We 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.

2) How to do convert a patient from daily heroin to daily naltrexone in 4-5 days.
Briefly, this is how we used to do it at Smithers Addiction Treatment & Research Center:

Admit 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.

On 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).

Most 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).

The 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.

That's 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 well.

This 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.

And 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.

Oh 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 <sigh>.

Too 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 do it.

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3) My qualms about UROD - four basic problems I have with the procedure
Now, my ideas and feelings about UROD:

1) 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 happens.

2) 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 to UROD.

3) 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.

4) 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.

I 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.

Too 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.

Please excuse the length of this post. Hopefully it was interesting or useful to some of you.

..alex...
Alexander DeLuca, M.D., FASAM
adeluca@doctordeluca.com 
1/2001

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19.  I've decided to do a Moderation Management "30" (30 days abstinence suggested as a prerequisite to practicing moderation in MM.) Are there any materials I can use to prepare for this?

[ 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... ]

----- Original Message -----
To: MM@MAELSTROM.STJOHNS.EDU
From: kkmmagic
Sent: Monday, September 06, 1999 2:40 PM
Subject: For those preparing for a '30'

As 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 the end:

"Ask yourself: What is my potential if I change?  What will it free me up to become?  How will my life be enhanced?"

"Change requires energy, effort and attention.  You will not be ready to move into the action stage until changing your behavior becomes your highest priority."

"Commitment 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 stages."

"Have 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."

"People 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."

re: 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."

"Once you commit yourself to an action date, guard against finding excuses or reasons to delay it, which can weaken your will."

"Going public with your intended change increases anxiety, since you may feel embarrassed if you fail.  Public commitments are more powerful than private pledges."

"Courage is not the absence of fear, but the ability to act in the face of fear."

"Here 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.

1 = Never

2 = Seldom

3 = Occasionally

4 = Often

5 = Repeatedly

_______   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.

In 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."

KK (5/38)
From: kkmmagic - posted 2/2001 on MM listserv

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20. [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 ... 

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 medication."

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 OCD.


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 closed-in.


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 take advantage.

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 repels.

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.

..alex...

2/11/2001
Alexander DeLuca, M.D.
adeluca@doctordeluca.com 

21.   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?

*What you need to know about alcohol, acetaminophen (Tylenol), and liver failure.*

Alcohol 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.

Normally 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.

Alcohol 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 first place.

Consumption 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.

THIS 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!

Tylenol 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.

..alex...
5/27/2001

ADDENDUM 6/2/2001:

Madame Bozo wrote:

Active 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?”

Sure, 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.

Liver 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 of Tylenol.

Taking 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.

What 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.

I 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.

Fear-mongering 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.

..alex…

Alexander DeLuca, M.D.
adeluca@doctordeluca.com

22.  Hey Doc, why is there so little research testing naltrexone as an aid to problem drinkers trying to moderate?

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:

http://www.doctordeluca.com/library.htm#NaltrexoneUse

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 meetings."

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 "dependence."

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 weep:

http://www.doctordeluca.com/Documents/PrimaryDocuments.htm/

[END]

 

Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D.

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Originally posted: circa 1999

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