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As heroin use rises, treatment experts reflect on their efforts
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Zander Tatum looks out over the city of Prescott, Arizona, where he attended his latest recovery program. Tatum went into rehab for the first time on his 15th birthday. - photo by Deseret Connect
This is the third in a three-part series. Read part one: "The new face of heroin addiction." Read part two: "How families can work together to fight heroin addiction."

It's 6 p.m. on Friday night, which means Zander Tatum's shift is finished at the Prescott, Arizona, Sonic. He heads home, weaving through his neighborhood on foot because his driver's license was suspended.

Tatum, who's been in and out of rehab since his 15th birthday, has struggled with opioid addiction for more than six years. First hooked on Xanax, he tried OxyContin and other prescription pills before turning to heroin.

"Heroin's cheaper and you start to throw some of your ideals and standards and all those things you said you'd never do out of the window," Tatum said.

The growing availability of heroin in America has put the drug into thousands of young people's hands. And, in turn, it's put an increasing amount of young adults into rehab.

The 2014 National Drug Threat Assessment Summary showed that young adults between the ages of 20 and 34 comprise the largest group of heroin addicts entering publicly funded treatment facilities. In 2011, 53.2 percent of users in heroin-related rehab fell into this age range, a 23 percent increase over 2007.

Addicts of this age present new challenges for addiction experts, many of whom began their career working with recovering users in their 40s and 50s.

"It's kind of a different ballgame now," said Bradley Lander, clinical director of addiction psychiatry at Ohio State University's Wexner Medical Center.

That's because young adults, armed with a sense of invincibility, often don't seek help unless its demanded by family members, compelled by the court system or they've run out of money to buy heroin on the street. All three situations serve as imperfect sources of motivation, complicating a recovery process that's already stacked against the group, because of the difficulty of withdrawal and the extreme level of emotional maturity required to overcome cravings, said David Gastfriend, CEO of the Treatment Research Institute in Philadelphia.

The good news for addicts is that medication-assisted treatment options coupled with counseling can reopen the path to a successful life. But widespread implementation of these strategies will require cooperation from national policymakers, whose hesitation is hard for Gastfriend to understand.

"If we were willing to spend $600 on airbags in every car coming out of Detroit, because we wanted to stop automobile deaths, we should be willing to spend for the medication and treatments needed to stop this epidemic," he said.

Medical-assisted treatment

Treatment for a heroin problem varies based on the severity of addiction.

For those who seek help before becoming physically dependent on the drug, something like Narcotics Anonymous might be enough, Gastfriend said. But for the vast majority of heroin users, more serious, long-term treatment is their only hope.

The most successful programs recognize that heroin addiction is a "biopsychosocial-spiritual disease," Gastfriend said, and address four distinct factors that prolong addiction: physical dependence, poor emotional health, inadequate social support and an absence of meaning or purpose in life.

"An addict needs medical care to stabilize, counseling to understand the thought processes that promote addiction, a healthy, supportive environment and a purpose" in order to leave heroin behind, he said.

The first aspect of addiction, physical dependence, is addressed through drugs like methadone and buprenorphine, which reduce the pull of heroin and lessen withdrawal symptoms.

"One of the things that is really an advantage for people who are addicted to (heroin) is that we have some really state-of-the-art medication-assisted treatments available," said Kimberly Kirby, director of behavioral treatments and application research at the Treatment Research Institute.

Methadone, which has been the most prominent treatment option for opiate addiction since it was used to cure Vietnam veterans of their dependence on the drugs in the 1960s and 1970s, is also an opioid, acting on the receptors in the brain that reduce pain perception. But it's slower-acting and longer-lasting than heroin or painkillers, meaning that addicts can stabilize their day-to-day emotions without suffering through acute withdrawal symptoms, as they do with heroin.

Because it's an opioid, methadone is also habit-forming. Addicts treated with this kind of therapy generally take a daily dose, waiting in line for their pill at methadone clinics with other recovering opiate users day after day, Kirby said. It's effective, but one more burden on a group of people struggling to stay clean. Public facilities are generally government-funded, but costs add up in other forms, such as in the time spent in line.

Buprenorphine is also an opioid but is designed to improve on methadone therapy. As a less potent drug, it reduces the risk of overdose, which means addicts are trusted to keep more than one dose with them, reducing trips to clinics or medical treatment providers.

But Gastfriend said he's most impressed by vivitrol, which was made available for heroin addicts in the last four years.

Unlike other treatments, vivitrol is an opiate blocker. It fills the receptors in the brain impacted by heroin, meaning that addicts have no reason to relapse because they won't be able to get high while taking it.

The issue with vivitrol is that it's still gaining traction in the treatment landscape, which limits its availability, Gastfriend said. Additionally, it's expensive, because treatment centers that use vivitrol must first assist recovering addicts through detoxification and provide counseling for at least the four to six months people generally follow a vivitrol regimen.

Financial support is a concern throughout the treatment industry, Kirby said, especially at clinics that offer free services. She noted that some policymakers hesitate to allocate additional funds to addiction programs built around offering recovering users more drugs.

"There's a philosophical block," Kirby said. "Some people don't want to consider the possibility of treating an addiction with another medication."

Counseling

Although medication-assisted treatments make detox and stabilization possible, recovery isn't complete without long-term counseling, Gastfriend said.

Programs come in a variety of forms, including one-on-one counseling, group therapy and family sessions, Gastfriend said. A majority of treatment centers rely on a 12-step model, which has long been associated with recovery from alcoholism.

Kirby, who, in recent months, has been studying family centered therapy, said that one of the major themes of counseling is rebuilding. Addicts, especially those like Tatum who began using heroin in their late teens or early 20s, need to be equipped with basic life skills, learning how to find and hold a job and repair relationships with family and friends they hurt while on the downward spiral of addiction.

Additionally, counseling helps recovering addicts resist relapse, which means helping them confront both physical and emotional pain without turning to drugs. This aspect of treatment addresses the psychological and spiritual aspects of addiction.

"You have to learn how to cope again," Lander said. Counseling teaches people how to manage emotional crises, as well as deal with everyday ups and downs.

"The drug (cravings) are going to start screaming. And we have to be teaching them how to say no again and again."

Second chances

Now 21, Tatum's been sober since finishing a six-month recovery program at a Prescott treatment center. He lives in a house atop a hill with two other recovering addicts, leaning on the support of the community to stay clean.

Staying close to treatment counselors is crucial for addicts hoping to kick heroin for good, Gastfriend said, as prolonged withdrawal symptoms can continue for months after a user last got high.

These symptoms, which include irritability, insomnia and fatigue, are subtle but aggravating for recovering addicts attempting to return to everyday life, he said. When confronted with stress on top of these emotions, a former heroin user can be pushed over the edge, resulting in relapse.

Another explanation for Tatum's living arrangement is that fellow former addicts are less likely to judge a person who's trying to build a new life for themselves, an effort that's hindered by heroin's lasting impact on emotional development, Kirby said.

"Heroin makes structural and functional changes in the brain. It messes with your motivational systems and your ability to make decisions and think about the long-term consequences of your behavior," she said. For young adults who began using when their brain was still developing, the impact is devastating.

While their peers were graduating from college and launching careers, young heroin users were consumed by addiction. It's a daunting setback, which is why Kirby emphasizes patience and forgiveness when she works with parents.

"I help them understand that (addiction) is not a moral failing on the part of their kid," she said.

For Tatum, sobriety means acknowledging that not everyone will understand his journey. It's up to him, he says, to focus on the joy of leaving heroin behind.

"It doesn't sound like a big deal for most people. Like, 'Good job, kid. You're not sticking needles in your arm. Good for you, he said. "But I don't know, for someone like me to never think that you were ever going to find a way out and wanting to stop and not being able to. I don't think I can really put (how recovery feels) into words."

This is the third in a three-part series on heroin addiction produced in partnership with the Walter Cronkite School of Journalism and Mass Communications. For more on the series, visit http://hookedaz.cronkitenewsonline.com/
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