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Addiction--What's Really Going On?: Inside a Heroin Treatment Program

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I received this book hoping that it would be different from the few other books out there that discuss the oh so scary and frightening "junkies" in those down and dirty "inner city" methadone clinics and the "brave" people who work there, dishing out "tough love" and making snide remarks to their colleagues about "catching" patients in their "tricks".

Sadly, I was deeply disappointed.

As a Certified Methadone Advocate with a degree in professional nursing who does a great deal of educational work on a national level, and who sits on the Board of Directors of several national and local methadone organizations, I was APPALLED at the numerous myths, misconceptions and outright falsehoods throughout this book! I scarcely know where to begin.

Deborah McCloskey states that:

"Our clinic physician would start most people out at 40 to 60mgs, which should be enough to hold most addicts......In one of my sessions an old timer--a client--taught me about their world. She stated that any more than a 40 mg dose was just to get high, or they were still getting high. SInce the average dose was 80 mgs, I kept that fact in the back of my mind."

IN FACT, the average dose required to control symptoms in the majority of patients--and they are PATIENTS, not "clients"--is 80 to 120 mgs. Many patients require much more, due to tolerance, metabolism, certain diseases, etc. The dosing spectrum runs from about 20-30mgs all the way up to 1,000 mgs in rare cases. DUe to the phenomenon of tolerance, these patients are ALL tolerant of their dose and are not impaired in any way. Studies show that tolerant patients can drive, work, operate heavy machinery, etc with no cognitive impairment, regardless of dose.

Furthermore, allowing some patient to advise you of a myth they heard on the street somewhere (i.e., any patient over 40 mgs is trying to get high)and accepting it as a FACT is ludicrous. Patients hear and believe all kinds of myths--methadone turns your insides orange, methadone rots your bones, etc etc. It's up to the staff to counter those myths with the TRUTH--with science and fact--not accept them at face value, for Pete's sake! Patients who remain on low doses are usually the ones seeking to get high, because they know that doses over 80 mgs will block the euphoric effects of other opiates, so they keep their methadone dose below that amount so they can keep using. The fact that she, as a counselor in a clinic, is unaware of this is extremely disturbing.

She then says:

"The highest dose any of us had ever seen was 180 mgs. It was inconceivable how this client could function on this high of a dose. The 180mg client wanted to transfer from somewhere else to our clinic, but there was no way we could accommodate that dose morally, ethically or legally"

Again, this shows an appalling lack of knowledge of basic pharmacology, tolerance, metabolism of drugs, industry standards, or Best Practice guidelines.

Methadone was invented in the 1940's as a painkiller. The average dose given for pain is 5 to 10 mgs. One can clearly see that if we were to give a person with no opioid tolerance a dose of 30 or 40 mgs, they would be extremely sedated and quite possibly die. Such a person might think that if 5 to 10 mgs causes them to be pretty drowsy, then 30 to 40 mgs (the usual starting dose on the first day at a methadone clinic) must leave people unable to function! But of course, this is not the case--because these patients have a huge opioid tolerance.

By the same token, a patient who is stable on 100 mgs might imagine that someone on 200 mgs must SURELY be zonked out of their minds--because they know THEY would be. But again, because of individual tolerance and other factors, this is not true, and there is no way to tell the difference between a patient on 20 mgs and one on 300mgs by their cognitive abilities, demeanor, appearance, etc. The fact that she is unaware of this is, again, appalling and totally unprofessional. And she used this lack of knowledge and unprofessionalism to DENY a patient the right to move to a new city, because her clinic would not treat him.

Then she states:

"The concept of a dose increase as a solution (to withdrawal symptoms) never worked for me. I would do anything to prevent an increase simply due to the difficulty in eventual dose tapering. The fact that many of the clients were driving to and from the clinic and were out on the road, period, was my motivation."

Again, dozens of studies have been done, all showing the same thing--as long as the patient is not using other drugs and is stale on their dose, driving ability is NOT impaired in any way.

Stating that she would "do anything to prevent an increase" is flatly pathetic. These patients do not feel any kind of "high" or euphoria from their doses, and after a long time on the same dose, most patients will need a small increase to keep symptoms under control. McCloskey assumes that all patients will be getting off methadone so it's best to keep doses low. Not only is it false that tapering is easier from a "low" dose, but Best Practice Guidelines state clearly that patients should be encouraged to remain on MMT "for as long as they are receiving benefit from it". Patients who leave treatment relapse at a rate of 90% within one year.

Methadone treats a brain chemistry imbalance caused by a lack of natural opiates (endorphins). Sometimes this occurs naturally, leaving the person especially vulnerable to opioid abuse, and other times it is caused BY the opioid abuse itself. Sometimes it is temporary, but in many cases this is a permanent imbalance, causing the patient, when abstinent, to experience severe depression, anhedonia, exhaustion, anxiety and irritability. Most patients cannot long tolerate such ongoing misery, and relapse to opioid use.

Methadone restores the balance in the brain chemistry in the same way that insulin replaces the insulin no longer made by the diabetic pancreas. We do not encourage others who have chronic mental or physical diseases to cease taking the medication that is controlling the symptoms, because we know that if we do, the chances are enormous the disease will become active again. Yet, knowing this about methadone, McCloskey states that she does everything she can to avoid an increase, and elsewhere in the book she talks of her constant badgering of patients to get off methadone.She seems to view patients as dirty, smelly liars and cheats who must be closely watched lest they "get over" on her or try to "trick" her.

Overall, I was thoroughly disgusted by this book, and I am equally saened to read reviews that seem to think it's just great.

When I attended school to be an LCDC, our teacher warned us that there was a huge prejudice in the field against medication assisted treatment, and told us that we should do all we could to present a truthful perspective on this to our patients--but sadly, it seems the same old rumors, myths and nonsense are still out there.

Deborah McCloskey truly has a passion for working with heroin addicts, and that passion shows through in this book. Each story offers a heart-rending view of an addict and the people who care about them, the addiction and working to the other side, becoming drug free. McCloskey shows that while there is no easy fix, with understanding and care, and the proper medical treatment; all addicts have the means needed to change their life.

The characters are richly drawn, and you will find yourself rooting for them and caring about them. The actual discussion on the use of methodone and the psychology of addiction will prove useful to anyone with a loved one, friend, or family member in the grip of any addiction.

I would highly recommend this book for anyone who is considering pursuing a career in psychology, social work, or addiction counseling. You will find it invaluable. The book is written to appeal to the every day reader, too. You will learn from it, cry for the addicts, and cheer on the people in the trenchs working with addicts every day.

Description: (From book jacket)

"Addiction: What's Really Going On? contains powerful true-life stories woven together to form a tapestry filled with pain, joy, defeat, and success. The entire book is molded around Deborah McCloskey's heartfelt desire for her clients to be free of drugs. Her counseling methods both endeared her as "the counselor to get" and locked her into a decade of searching for better ways to help those she felt were stuck on the merry-go-round of a methadone system. This book should be read by teachers, hospitals employees, college students, government officials, and our general adult population whether addicted, sober, or straight."

Review:

Being a student of medicine, I was very anxious to read Addiction: What's Really Going On?, a book about life inside a heroin treatment program. This was a truly impressive read, both about the author's experiences with patients in the program and the addict's experiences. I had always known what I had heard on television and in books about addiction, but never had I been pushed into the reality of the addiction itself. So much emotion that it made me understand addiction almost like a disease instead of someone's mental inability to cope without the drug. I recommend this to anyone who has ever been curious about the topic and especially those who are dealing with their own, or a loved one's addiction; whether heroin or any other addictive substance.

Rating: On the Run (4.5/5)

*** I received this book from LibraryThing Member Giveaways in exchange for an honest and unbiased review.

I'm astonished and appalled over the the inaccurate information in this book and the disparaging view of addicts it depicts. It's frightening to know that some will read this book and believe that they are being educated about methadone treatment and the realities of addiction. Ms Sinor swears that the stories in the book are true but as a recovering addict and long time methadone patient I have a very hard time believing that. Claims like that she smelled a sweet smell when she walked into the clinic that she later determined to be methadone that she says smells like cotton candy really makes me wonder if she's really ever been to a methadone clinic at all or if she is just seriously embellishing her story. Methadone does NOT smell anything like cotton candy and it certainly does not smell so strongly that you can smell it in a room.
Nothing described in the book is familiar to me or anything I've experienced as an addict on the street or at the methadone clinics I've attended. Of course it's possible that California addicts are a completely different animal than addicts elsewhere but I highly doubt it.

The way McCloskey describes her "clients" sounds more like complete fiction than anything I've ever known to be the truth. It is NOT true that methadone patients are filthy, come in wearing their robes, pull up their shirts and show their breasts left and right, drive like maniacs, refer to the staff as "bitch", chase their dose with beer, pee and throw condoms in the clinic stairs, constantly manipulate and play tricks, defecate in front of a counselor as revenge or for any reason, etc. I could go on. Fact is that the majority of methadone patients are regular people with addiction. Sure, there are patients with various mental illnesses or other problems that do have behavioral problems but they are the rare exception not the rule as McCloskey would have you believe.

With the proper treatment the patients' addiction will be under control and the majority of patients will look, live and act like everyone else. Unfortunately the problem at McCloskey's clinic, which she is clearly a large part of herself, is the fact that the patients aren't getting proper treatment. It's substandard to say the least. But what can you expect with counselors who don't understand the basic pharmacology of methadone and how the treatment method works? Did anyone at that clinic bother to read the research that has been gathered over the past 40 years? Did they bother to learn best practice standards? Or did they use each other and their equally uneducated patients to educate themselves?

By the time McCloskey started working at her clinic it was already known how important and individual dosage is. It was already known that the longer a patients stays in treatment the better the outcome and some have to stay in treatment for life. But McCloskey clearly didn't know that or she just ignored it and continued to fight very needed dose increases and push her patients off medication prematurely simply because she thought that's how it should be done. No wonder the majority of the clinic's patients were still using. It's like giving a headache patient half a Tylenol and wonder why his headache doesn't go away. MMT isn't much different.
Methadone does not work at subtherapeutic doses and the average therapeutic dose is 80-120mg, much higher than what was given at this clinic. Some people need much, much more to treat their symptoms. Doing everything to prevent increases, as McCloskey said she did, is directly harmful for the patients and probably one of the worst thing a counselor can do, right next to pushing patients to start tapering.

Ideally a patient should be on a sufficient, stable dose for a period of at the very least two years before a taper starts. But McCloskey's patients never even got to a sufficient stable dose before they were pressured into tapering based on the erroneous belief that methadone is just another drug and taking it is not being clean. Of course this is not true. Methadone is a medication to treat the symptoms of opiate addiction. It's no different than taking medication to treat the symptoms of bi-polar disorder or any other chronic disease.

Throughout the book McCloskey repeatedly pats herself on the back about how much compassion and respect she has for her patients and how different she is. But her constant disparaging remarks and disdainful descriptions of them tells a different story. It sickens me that this is how some people who are supposed to help addicts get better view their patients.

McCloskey also mentions, smugly, on several occasions that she is "educated". She is a CADC - Certified Alcohol and Drug Counselor which is accomplished with a 16 week course. Actually the numerous grammatical errors in the book shows a lack of education. I was just as astonished over the poor writing as I was over the content in the book. I'm quite surprised that the book was even published with so many sentence structure and punctuation errors.

I could frankly write a book about everything that is wrong with "Addiction: What's really going on" but I'll end it here. I just want to end it by urging every future reader of this book to take the information in it with a big grain of salt. It does NOT convey a true depiction of what opiate addicts are like and how a methadone treatment and clinic works.
If you are interested in learning about methadone treatment you can check out [...] and [...]

This book sounds like it was written as a work of fiction. This person worked at a methadone clinic? I don't even believe it.

"Methadone does not alleviate pain." Really? Then why is it prescribed as a pain medication for people with chronic pain.

An eightball is a mixture of heroin and speed? Nope. A speedball is heroin with speed; an eightball is an eighth of an ounce of speed or coke.

Most of the clients smell? Most of them have 7 kids already and are still prostituting themselves? There are used condoms on the stairs in the clinic? A female counselor watches male clients giving their observed urine sample? All the clients are urine tested on one day? Codeine is a drug the clinic doctor was worried about (rather than vicodin, percocet, or oxycontin?) (that's a myth) Fenesin contains codeine? People in hot climates "sweat out" the medication? (It doesn't- it is just guaifenesin , an expectorant!) Anything more than 40 mgs is just a client trying to get high? The clinic had the computer setup where on a client's birthday, the Happy Birthday song would "chime on cue?" WHAT? Where did this person get this stuff?

And then there is the inconsistency. In one paragraph she states that addicts are labeled and it's unfair and they can't escape it, but then turns around and says "the cry of 'I'm an addict' was more of an excuse than anything else."

The writing is just as poorly executed as the research for this book. The comma splice is the author's favorite grammatical device. "I was very lucky, I had a tremendous amount of freedom to practice my style of therapy." "Todd called me down to his office, he was going to assign me a new client." Those are separate sentences! Use a period or semicolon.

I would not be surprised if I found out this book was actually a work of fiction. The bad writing and general ridiculousness are not redeemed by any informative or compassionate message. It's an expose by someone who doesn't know what she's talking about.

This story is a superbly written narrative of what it's really like to work in a methadone treatment program as a counselor. It doesn't hide the real issues of addiction behind any dazzling storyline, just plain, simple, truthful documentation of real occurrences. Being a substance abuse counselor myself, I know exactly what the author experienced, and at times it was so eerily similar to my experiences it brought a tear to my eyes. I also especially appreciated the way the author included her personal life as well as her professional life in this book. It was a great portrayal of the delicate balance often required between both lives when you're in a counseling position such as hers. This a great read and should be highly recommended for new counselors to get a feel of what it's really like before embarking upon a most difficult career.