THE GREAT DIVIDE OVER DETOX

The perennial rivalry between doctors who support methadone to arrest
heroin addiction and those who prefer to use naltrexone is in full
swing again, writes Julie Robotham.

It is midday and the mood in the room is intensifying. Separated by
flimsy hospital curtains, three men are battling to push an addiction
out of their bodies and the fight is getting physical. Tom moans and
mutters as he paws at the wall. Rafik flings his bare legs repeatedly
against the metal barriers around his bed. Jonathan tries to haul himself away.

Their detoxification from opiate dependency will peak within the next
hour as the drug naltrexone purges the body's sensitivity to heroin
or its synthetic substitute, methadone. It is like going cold turkey
on fast forward, with all the symptoms of withdrawal packed into a
couple of hours.

The men are sedated, so they will remember nothing of this
afternoon's struggle in the small treatment room behind an Ultimo
medical centre. But they are conscious enough to breathe and swallow
independently and respond to instructions.

A doctor and a nurse calm them, repeatedly whispering in their ears,
stroking and soothing them, taking their blood pressure and checking
vital signs. They lie quietly for a moment, then the fight starts up again.

When they wake they will feel exhausted and wrung out. Insomnia,
appetite loss, aches and pains and possibly nausea and diarrhoea,
will persist for a week or two. But the soul-tearing agony of
withdrawal itself will be behind them. Before they leave, each will
have a slow-release pellet of naltrexone implanted in his abdomen.
For the next three months it ensures that even if they were to take
an opiate they would feel no effect from it.

Long considered the rogue in the addiction treatment pack, rapid
opioid detoxification is back. With revised treatment regimes,
heavy-duty psychological support to keep the recently detoxed on
track, and $150,000 in grants from health minister Tony Abbott, its
proponents say it has a new legitimacy.

Certainly its old image was thoroughly tarnished. The last time the
technique was in the news was in 1999, when Dr Siva Navaratnam's
Liverpool clinic, which had conducted an aggressive publicity
campaign, offered to waive its $7000 fee for people referred by an
MP. The local state MP, Paul Lynch, complained in Parliament: "Heroin
addicts have quite enough difficulties without being exploited in
this fashion." The clinic later closed its doors.

The people Ross Colquhoun treats in the Ultimo clinic, Psych n Soul
Addiction Treatment and Psychology Services, are far removed from
stereotypical street users. At least a third want to be free of
methadone - the government-funded maintenance drug for addicted
users- rather than illegal heroin. Almost all hold jobs and have
family responsibilities.

For one young father recently detoxed at the centre, "not even his
wife knows what's going on," says psychologist Colquhoun. "Each of
them reports being overwhelmed by an addiction that's hard to beat
and has the potential to destroy their lives. There's a whole lot of
issues, particularly for men. They find it difficult to confront
mental health issues."

Colquhoun says the ethical way to offer rapid detox is to select
patients who are highly motivated to succeed, maybe only 10 per cent
of those wanting to go drug-free. They must commit to counselling to
tackle their addiction psychologically as well as physically, and
they need good social support.

They also need to be able to pay. The package of six counselling
sessions and the detox costs $3500, plus $1000 for an implant, which
is not registered for medical use in Australia and is imported under a waiver.

Counselling costs $150 a session. It is critical because naltrexone
wipes out the drug-tolerance patients have built up, so there is no
safety net if they start using again. Overdosing at this stage is a
real risk, and can be fatal.

Colquhoun says he will soon publish a study of his patients that
found 80 per cent of 41 patients given an implant had not returned to
drug use six months later, compared with 55 per cent of 42 who took
naltrexone orally.

So in the range of treatments for addiction, where does naltrexone
fit? "In a museum," says Dr Alex Wodak. "In a glass case, with a
panel on the front saying this treatment was popular from this period
to this period .. The evidence tells us it's expensive, it's
ineffective and it kills people."

Wodak, the director of alcohol and drug services at St Vincent's
Hospital, says methadone service providers have a responsibility to
help people off the treatment, but only if they are medically,
psychologically and socially prepared. "You tell me you've been on
methadone for four years and haven't been on heroin for 18 months,
and you're back with your husband, and your parents see you again,
and you've paid off your debts, and you've got your little girl back,
and you think you can manage; then we'll make out a plan and I'll
help you to do this - slowly and carefully," he says.

Phasing methadone doses down to zero typically takes three to six
months, says Wodak.

Statistics do not say who is in methadone maintenance, or for how
long or how successfully. Of about 50,000 in NSW who have ever been
treated since its debut in the 1970s, 16,000 are receiving treatment
now. The NSW Health Department says 38 per cent of people who start
methadone treatment are still in the program a year later. It is
apparent that many people do quit methadone; whether this is a happy
transition to a drug-free life or through death and disaster is unclear.

According to a pooled analysis of 13 Australian drug treatment
trials, conducted by the National Drug and Alcohol Research Centre in
2001, rapid detoxification was the most effective way of getting
people off drugs in the short term, but in the longer term many
dropped out of naltrexone treatment. By contrast, methadone was
judged the most cost-effective therapy and patients were more likely
to remain in treatment.

For every 100 people retained on methadone for a year there are 12
fewer robberies, 57 fewer break and enters and 56 fewer vehicle
thefts, according to an estimate last year by the NSW Bureau of Crime
Statistics and Research.

If Abbott's largesse to the naltrexone camp is meant to express
disapproval towards services like methadone, which keep people away
from crime and unsafe injecting, then Wodak is livid. "What's wrong
with the guy? Rapid opioid detoxification has failed as a science -
there isn't a study he can quote that shows it works - and it's
failed in the market."

But Wodak says drugs policy may be very different from drugs politics.

"Publicly they attack harm-minimisation. Then discreetly, when no
one's looking, they're very supportive ... they've given $70 million
over seven years to enhance needle and syringe programs, and that's a
wonderful policy. Thank God they didn't walk the talk. I far prefer
them being hypocritical than being ideological."

When Dr Andrew Byrne saw Abbott's cheque go to naltrexone, he called
the minister's office in dismay. If anyone could use a cash infusion
it is Byrne, a Redfern GP whose methadone clients suffer horrendous
poverty and social dislocation on top of their addiction.

"The naltrexone implant industry apparently continues unchecked,
uncontrolled and largely unreported, despite hundreds of Australians
having these implants every year," says Byrne. "It's distressing to
think that either it's a good modality that you can't extend [because
there is insufficient scientific evidence to convince authorities],
or you believe good doctors shouldn't be touching it with a barge
pole. We're dealing with a life-threatening condition. It's not the
place for amateurs, enthusiasts or people with a good hunch."

That does not move Colquhoun. He detects a lingering view in some
quarters that, "if you don't do a hard detox you're not going to
appreciate it".

But every patient he treats has made previous attempts to come off
drugs - in residential facilities, where the dose is agonisingly
scaled down, or alone in bed. Rapid detox, he says, "gives them a
positive start to their recovery. They've suffered enough in my view.
They deserve an option."