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Hopkins Medicine Magazine - Load Bearers

Hopkins Medicine magazine Spring Summer 2011

Load Bearers

In the long haul of battling drug addiction, a partner who cares can be key to breaking the cycle of dependency and despair.

By: Mat Edelson
Date: May 20, 2011


Polly Becker addiction illustration
1 2 3
illustration by Polly Becker

Physically, the brothers sit about a yard apart. Psychically, their distance can be measured in light years, a gulf marked by despair, dependency, and disappointment. These are the wrenching emotions that wash over Danny Bryce’s face, for what else can one feel when he beholds a thrice-fallen hero?

In Danny’s mind, Bobby Bryce (names have been changed to protect patient privacy) is exactly that, the beloved older brother, a shell of his former self, caught in the throes of recurring heroin addiction. Now in their 50s, at an age when many of their childhood cronies have long since passed from this earth owing to drug abuse, there is a palpable sense between the brothers that they are incredibly fortunate to be alive. Yet there is weariness too, from one man who has, one day at a time, conquered his addiction for the last 10 years, and another who, try as he might, can’t quite get it together.

That very yin and yang, the dichotomy in the drug lexicon between the man who is clean versus the one who is dirty, has brought them to this place, the Addiction Treatment Services at Johns Hopkins Bayview. For at 57, Bobby Bryce has reached the point where he’s been told by his counselors that to get well, he needs more than himself, more than even the Hopkins counselors can provide.

He needs someone clean. He needs someone who cares. He needs the man who used to idolize him.

Otherwise he needs to get out.

 

For decades, treatment for opioid-dependence—i.e., heroin addiction—has operated on two levels: “What we know works” versus “what we usually do.” The latter can be summed up in one word.

Methadone.

First approved as a painkiller in America in 1947, methadone’s benefits—low cost (a fraction of heroin’s price) and high effectiveness (it lasts up to 36 hours in the body, negating the devastating daily high and lows that heroin users experience)—made the synthetic narcotic the lesser of two evils as far as addiction counselors were concerned. Yes, patients were still dependent upon a drug—that’s the daily “maintenance” aspect of what’s commonly known as Methadone Maintenance Therapy (MMT). But the rapidity with which methadone could replace a heroin addiction was irresistible to providers.

“Methadone is a powerful drug,” says Michael Kidorf, associate director of Addiction Treatment Services at Johns Hopkins Bayview. “It produces big changes in individuals. Someone who is using upward of $80 to $100 a day in heroin could come on to a methadone program, and if he was there from one to two weeks and raised to a reasonable methadone dose, would dramatically reduce his heroin use.”

Sounds good, but solely giving methadone to a heroin addict may be like providing only one snowshoe to a man crossing the Arctic.

Kidorf says that research involving other forms of addiction—alcoholics have been particularly well studied—shows that addicts fare better when treatment is combined with a community partner (notably a spouse) who attends counseling sessions. Said partner, in addition to becoming educated about negotiating addiction, runs interference outside the clinical setting against the environmental stressors that compromise efforts to control an addiction. Such community support appears to have a powerful therapeutic impact toward the goal of breaking addicts away from the negative social networks that often encourage addictive behaviors. Whether it’s taking someone to church, bowling, or bingo, the person acts as a bridge, introducing the addict in recovery to other drug-free individuals.

“The saying in the clinic is, ‘If you hang out in the barbershop long enough, you’re going to get a haircut,’” says Jessica Peirce, a clinical psychologist and associate director at Bayview’s ATS. “Where the patient spends their time and who they spend it with has a direct impact on how well they’re going to manage their drug addiction.”

Given that evidence, one would think that community support counseling models would be widely adopted by providers dealing with substance addictions like heroin.

’Tis not the case. According to Kidorf, a variety of factors have kept the vast majority of treatment centers in what addicts call “Gas ’n Go” mode: That’s where methadone is provided on a daily basis to clients but little else is offered in terms of counseling, let alone counseling that includes a community partner.

“Patients are not that interested in counseling, they may not have a lot of experience talking about their problems; words for them have been used not just to help but to hurt,” says Kidorf. “The patient wants methadone. The least resistant way if you’re offering services is to give the patient what they want. So it’s been an easy jump for providers to say, ‘Well, methadone’s effective, we don’t want to bother patients with the other stuff, though we have to offer some amount of counseling to meet regulations, so let’s keep that to a minimum.’”

Then there’s the cost of intensive counseling. “In the average clinic, due to issues of how they’re funded, you’ve got counselors with case loads of 40 to 60 people. How much counseling can they provide?” asks Kidorf. “The question becomes, how do you develop a system where you can work within these funding limits, offer counseling to a population that in the beginning is not interested in it, but your feeling is they might benefit from it?

“That’s the trick. And that’s where this clinic has moved forward.”

For the past 15 years, Kidorf and Robert Brooner, founder of Addiction Treatment Services at Bayview, have built the framework that they call “a stepped approach” to addiction treatment. Methadone is dispensed, but how it’s dispensed, and when, is completely conditional. If one of ATS’ 450 or so patients follows all the rules—their urine checks are consistently negative for illicit drug use, they have perfect attendance for mandatory counseling sessions—they are placed in Step 2. This means they receive weeklong take-home doses of methadone and only have to show up at the clinic once a week. If they keep up this behavior for six months, they’re placed in Step 1, which calls for only monthly counseling sessions.

That’s if they’re compliant. But if they slip consistently, missing sessions or using drugs, they can work their way down to Step 4. At this level, all take-homes are eliminated and the counseling demands are great: nine weekly one-hour sessions in all (one individual and eight groups), including counseling to learn coping and stress management skills to control the severity of their relapse, and general therapy.

Most telling is the requirement, unique to Step 4, that patients identify and bring a Community Support Person (CSP) to counseling sessions. Not surprisingly, ATS Clinical Program Coordinator Jeanine McClain says her patients, who cloak their drug use in denial and secrecy, often have a common reaction to this condition. “They hate it, they don’t want to do it, there’s a lot of resistance,” she notes. “They’ll say, ‘I’m not bringing anyone in. It’s my problem: I’m not dragging anyone else in!’”

 

But the truth is, they no longer have a choice.

They call it ‘extensive treatment.’ I call it the kick in the ass I really need,” admits 51-year-old Kim Goldano. That “extensive treatment” is at the heart of the approach to treatment at ATS, a carrot-and-stick model that essentially says, ‘If you want your methadone, you’re going to have to earn it.’

It’s tough love with a heart: Break commandments enough and you’re out, but you’re right back in the next day if you’re willing to play ball. Not that the game is easy for someone like Goldano, who freely admits, “That’s my best buddy. Heroin.”

Goldano has reached Step 4, the last step before she walks off the proverbial cliff. She’s in the program, and while the methadone quells her craving for heroin, she’s still using illegal drugs; in her case, street-bought benzodiazepines such as Xanax. While testing positive for illegal drugs won’t get you kicked out of the program, missing counseling sessions will.

So will failure to find a Community Support Person. The CSP can be anybody who is clean (a mouth swab confirms their status) and is willing to put in the time. It’s not trivial. The CSP agrees to attend one group counseling session per week and to take the patient on outings to drug-free social settings. The patient agrees to allow the CSP access to all their medical records, including the right to call ATS counselors if their charge should fall off the wagon.

Brooner admits that when he and Kidorf first broached the idea of requiring a CSP for patients, he wasn’t sure what kind of response they would get. Would patients refuse and leave? Conventional wisdom suggested these were people who had burned their family and friends so often that they had no one in their lives who was drug-free.

Perhaps it’s fear of losing their methadone, but whatever the reason, compliance was far greater than even Brooner imagined. “Within this environment, Michael’s work has shown that patients will both identify drug-abstinent people and bring them into treatment at very high rates—about 90 percent in a clinical population where 50 percent would be considered a home run,” says Brooner.

At any given time, Kidorf estimates that 10 percent, or roughly 50 patients, are in Step 4, faced with having to find a CSP.

Not surprisingly, Goldano says her reaction to bringing in an outsider was the same as that of any longtime addict who has destroyed numerous relationships. “My first reaction was, ‘Are you nuts? Who is going to come with me?’”

It turns out the answer was her mother, Sandy. Despite having ridden the hellish wave that is addiction for nearly 20 years with her daughter, Sandy Goldano was still hopeful. And with good reason. When Kim first entered ATS in the late 1990s, she regressed to Step 4, and Sandy became what the program at the time called her “significant other.” The benefits were almost immediate. Working with the counselors and her mother, Kim stopped her benzodiazepine use for over a month, and Sandy got her daughter back.

“I wanted to do it for her if it was going to help her out,” says Sandy, now 78. “I enjoyed it. We did different [outside] activities. We went shopping, I also have a lot of friends, older like me, we belong to a club and I took her there. It was things for her to do, maybe not her age group, but something for her and I to do together, and she enjoyed it.”

Reflecting back, Kim says she should have stayed in the program, but circumstances dictated otherwise. Her brother convinced her to leave ATS and join him at the addiction program he attended, which required far less monitoring. “I remember the last time I went [to Bayview], my counselor came out to the car and said to my mother, “I think this is a big mistake.”

The counselor was right. At the new center, Kim said the program was more typical of what she’d seen over the years. “I’d breeze through to pick up my methadone. There was a counselor there who’d I see as I passed his door. It would be like, ‘Hi Gary, how ya doin?’ And he’d say, ‘Kim, you had a dirty urine. We need to talk.’ And I’d keep on walking, saying ‘Oops, Gary, I gotta’ go to work.’ And off I’d go.”

It took years of recurring use, and dismissal from her job as a grocery cashier, for Kim to hit rock bottom, but she eventually returned to ATS in early 2011 for a simple reason. “I know in this program they care about you. They know that what they’re asking you to do is hard, but they know you can do it. And they always let you come back,” says Kim.

Kidorf, ATS medical director Van King, and several colleagues concluded, in the July 2005 issue of the Journal of Substance Abuse Treatment, that more than 93 percent of their opioid-dependent patients in Step 4 were able to identify and bring a community support person to at least one joint counseling session. Of those who took advantage of this “social support intervention,” roughly 78 percent abstained from drug use for a month.

“The patients who find a good CSP, generally they’ll come back and say, yes, they initially resisted it, but it’s the best thing they ever did,” says ATS counselor McClain.

“They’ll actually defend this requirement with other patients who’ve just been placed in Step 4 and who are complaining, saying, ‘I don’t know anyone drug-free, I can’t bring in anyone, I think it’s stupid.’ They’ll speak up and say that by bringing in someone, it really helped them to get drug-free. And I think that means more coming from someone who has been in their shoes.”

Michael Kidorf says ATS’ model is unique—it’s certainly the only program with such high levels of counseling in Baltimore City, and perhaps the only one of its kind in the state—but that shouldn’t be the case. It’s not a matter of money; Brooner notes that ATS’ reimbursement rate is no greater than that of other addiction programs statewide—but rather how the program’s resources are used.

Specifically, says Kidorf, ATS has an all-hands-on-deck approach, where even senior staffers pitch in and have clinical responsibilities such as running counseling sessions. They also take advantage of the power of numbers. “We enhance services not through individual sessions, but group sessions,” says Kidorf. “In fact, most of our enhanced work is in group therapy.” Those group sessions focus on eight recurring themes, such as managing anger and criticism. 

In a field where victories can often be measured in weeks or days, educating both patients and their CSPs on the concept that drug dependency is a chronic disease to be managed, as opposed to a moral failing to be obliterated, may be ATS’ greatest accomplishment. For patients like Kim Goldano, the acceptance that they’ll probably be on methadone for life—“I’ll probably die on methadone,” she says—isn’t really all that different from diabetics finally accepting they have to take insulin; it may be the first step in moving toward a management mindset that allows those who are heroin dependent to live a stable, responsible life.

 

That’s the hope that Danny Bryce has for his older brother. Though Danny was able to kick his various addictions through a religious conversion, he’s still waiting for Bobby to find his way through his drug malaise. It’s been a long, hard struggle; Danny has been Bobby’s CSP several times now, and, frankly, his patience is wearing thin. But they share too much history, too much empathy, for Danny to give up on Bobby now. For decades, they not only used drugs, they lived drugs, as runners whom people trusted with thousands of dollars to score the dope that others demanded.

In time, Danny found the church, but Bobby only kept finding the needle. And if anyone doubts the power of addiction, one need only listen to Bobby’s answer to the question of whether he and his friends were ever afraid of seeking the ultimate high. “I’ve seen guys OD, and other people come around and say, ‘Where’d he get that dope from?’ And you’d tell them and they’d run straight there, pay for it, and go do it themselves. And if you die off it, that’s some good dope.”

Changing that mindset and a social circle built entirely around drug use might seem impossible, but the brothers are still trying. “This is my oldest brother, and I don’t want to lose him,” says Danny, looking his brother in the eye. “It’s love that’s going to bring us out of this.”

As trite as it might sound, part of ATS’ counseling, using role-playing and education, is teaching Bobby and others how to “just say no.” He’s had his chances in the past—jail got him clean—“but then you get around certain people, you get right back into it. I wonder about how dumb I was, falling back on that track,” he says. “But you learn, you learn. Now I’m doing pretty well. People have offered me drugs, I turned it down. It shocked me that I turned it down, I just walked away, the last few weeks.”

Hearing this, Danny just nods, a neutral expression on his face. Perhaps he’s heard it all before. Perhaps not. But maybe what’s most important, as they stand to leave, is that they’re not fighting this battle alone. Walking a narrow corridor, they come to its end and briefly clasp hands, Bobby turning right, Danny left.

“I’ve got another session,” says Bobby.

“Take care,” answers Danny. *

No Easy Fix

Does all the handholding involved with the “stepped approach” to addiction really work?

Michael Kidorf says that depends how you define “success” in relation to the clientele at Bayview’s Addiction Treatment Services. While the average patient stays for nine months in their program, the greatest dropout period occurs shortly after entry; that’s when counselors lose about 10 to 15 percent of participants. Still, many patients have been in ATS for years.

During that time they may cycle repeatedly through the steps. While some might see this as a failure, Kidorf says that conclusion is shortsighted for it doesn’t take into account the complexity of his patient’s cases. Heroin addiction is often far from their only problem. By his numbers, 40 percent also have cocaine dependence, and another 10 to 15 percent each have alcohol or benzodiazepine issues. Perhaps a third also have contributory psychiatric issues such as chronic depression or bipolar disorder. “Then you have medical problems, family problems, employment issues…they may be coming here for heroin addiction, but all these other issues come into play into how well a person is going to do.”

Given all these potential co-morbidities, and his belief that drug addiction is a chronic disease that waxes and wanes throughout life, Kidorf argues that success needs to be measured in small but quantifiable increments. A few months clean, or the charted realization that, with each year, a given patient is spending less and less time in Step 4—all are reasons to have belief in the individual and the program.

By paying attention to all the problems that may afflict the addict—job counseling is offered as part of treatment, as is referral to psychiatric staff and an examination by an on-staff physician’s assistant who can bridge patients to a primary care provider—ATS, as Kidorf notes, “can’t be accused of not caring for our patients.” —Mat Edelson

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