…by Colin Brewer…
Greetings from London and thanks, everybody, for what are — amazingly for this field — almost entirely positive comments on the ‘language’ analogy that I first suggested in 1989 and that my co-author Emmanuel Streel and I have been writing about since 2003. (Emmanuel is a neuropsychologist but also a psychopharmacologist.) Since Marc has honoured me with an invitation to do a guest column, here it is, partially in response to comments following the previous post.
First, my removal from the medical register had absolutely nothing to do with rapid opiate detox under anaesthesia. From about 1995 to 2001, we detoxed over 700 people with this technique without any significant problems. It wasn’t even discussed at my hearing. I qualified in 1963 and when I saw my first heroin detox two years later, it was routine to use generous sedation if severe distress tempted patients to withdraw from treatment rather than from heroin. If patients can withdraw — slowly or quickly — without much medication, that’s fine by me, but if they can’t (and there are many in that category) I think it is the traditional duty of doctors to make unpleasant procedures as comfortable as possible. Does anyone — apart from the extreme ‘no pain, no gain’ fundamentalists — seriously disagree with that? Consequently, for patients who wanted to try or resume abstinence, we offered a wide range of withdrawal techniques, from slow tapers, through 4-5 day withdrawal with mainly oral sedation to 24hr techniques under oral and/or intramuscular sedation to i/v sedation and full General Anaesthesia. (Historical note: at one point, I was threatened with a lawsuit by the Spanish-Israeli CITA group who claimed I had infringed their ‘patented’ GA detox technique. Apart from the fact that the use of particular drugs (as opposed to the details of their manufacture) can’t be patented in Europe, I had described and published the technique, in an admittedly obscure journal, several years before they first used it.)
Because addiction treatment provided by the National Health Service (NHS) was so lousy in the 1980s and 90s (for example, the addiction establishment were very anti-methadone maintenance from 1980-1999), there were long waiting lists for in-patient withdrawal, and when they were eventually admitted, completion rates in one of our flagship centres were barely 25%, of whom nearly half had relapsed four weeks later. We therefore found ourselves treating many people who would not normally have considered — or been able to afford — private treatment, and quite a few more prosperous patients whose insurance had refused to continue paying or who had simply impoverished themselves through repeated self-funded treatment. For this large group, we devised a home detox programme that involved training the family to act as carers. As with all our detoxes, after completion and naltrexone (NTX) induction, we very strongly encouraged patients to take family-supervised oral naltrexone for at least six months and, after 1997, 
to have a NTX implant, to increase the chances that they would get through the crucial and often difficult first couple of months, when relapse rates are highest. We did around 2000 home detoxes before one family fatally misunderstood the instructions. Naturally, I feel bad about that but I don’t feel bad about trying to devise affordable treatment. I think that case made the difference between a reprimand and being removed from the register, but many addiction clinicians and academics in Britain (and several abroad who gave evidence for me) will tell you that the establishment were out to get me and were looking for excuses.
Marc asked me if I’d ever written anything about the hearings. I haven’t, and these are my first published comments, but the two most bizarre features were (1) some three weeks spent by the panel trying, unsuccessfully, to prove that a case not written by one of our counsellors, whose handwriting was similar to mine, had actually been written by me, even though one of his notes read: ‘Must discuss this with CB’! and (2) a serious — as in six-fold — miscalculation by two of our leading academics of the methadone equivalent of another opiate.
If Marc thinks I look a bit weird in some of the online images, that’s probably because they were taken when I was trying to force my way through a rat-pack of paparazzi after the final hearing. Fortunately, the clinic I set up continues and is still doing most of the things that we had been doing up to the hearings. Some of those — e.g. using slow-release morphine for people who don’t get on well with methadone or buprenorphine — are now pretty normal, at least outside the USA. The clinic is also expanding its patient groups to include the growing problem — though it’s still small by US standards — of prescription opiate abuse and the management of ‘therapeutic addiction’ to opiates in pain problems. I only have an advisory role these days but we hope to extend what Emmanuel and I suggested should be called ‘Antagonist-Assisted Abstinence’ (AAA – geddit?) to benzodiazepines. Using s/c or slow i/v flumazenil infusions, it’s quite easy to take people off fistfuls of diazepam and other benzodiazepines in five days with very little discomfort, and a flumazenil implant is being developed in Australia.
The clinic still does plenty of maintenance treatment, and I was told recently that the new emphasis on ‘recovery’ (read: we don’t like indefinite methadone maintenance) means that, as in the 1980s, increasing numbers of well-functioning methadone-maintenance patients — many with good jobs that they don’t want to jeopardise by having to take weeks or 
months off for withdrawal — are being put on forced reductions. I never claimed to be perfect (as we say in the trade, ‘if you haven’t made any mistakes. you’re not seeing enough patients’) but I don’t think that anything I did caused remotely as much misery and disaster to opiate addicts as the policies encouraged by the addiction establishment in the face of mounting evidence for the value of methadone-maintenance treatment.
Finally, I wrote a paper a few years ago suggesting that harm reduction in family planning (avoiding unwanted pregnancies) could teach some useful lessons to conventional harm reduction (avoiding unwanted addictions), in that it uses a variety of techniques and tries to fit the treatment to the particular needs of the patient, rather than the prevailing ‘one size fits all, take it or leave it’ approach of so many clinics and — even worse — rehabs. I’ll provide references to this and other papers on request.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
I did 2 URODs (drs coleman & gooberman) & I can tell you going “under the knife” did little for me. Addictor switching is the norm bc the entire premise for the treatment is invalid. Wrong premise = wrong treatment, for this and any other health issue. Would never do it again. Not to mention the staph infections everyone got either from the treatment itself or the implants and the crazy cost for it all for no better than chance results. Naltrexone OD was also common as the implants are not regulated. Total nightmare.
Addictor switching (by that I assume you mean changing to a different drug) is not uncommon but equally, it is not the norm for everyone who seeks withdrawal. There are many for whom only one drug is really a problem and who have never had a problem with others. However, its up to the patient to make an informed choice after an honest discussion of the possible approaches and many illicit drug users are well informed – more so than with alcoholics in my experience. I’ve met both the doctors you mention and I think neither of them would put opiate maintenance on the treatment menu (Gooberman in particular is a devoted 12-stepper) whereas – possibly uniquely for a private clinic – we offered both naltrexone and maintenance. Thanks to the NHS, British doctors still tend to do what’s best for their patients rather than what’s best for their income. If patients weren’t sure, we could easily put them on maintenance for a few days or a few weeks while they thought about it and I sometimes advised it anyway to give their lungs or veins a break. Independent academic studies of implants and Vivitrol show them to be a useful addition to the menu. The term UROD is a trademark of CITA and shouldn’t be used, since the ‘ultra-rapid’ bit is misleading. It’s no more rapid than any other method that enables patients to have a full dose of NTX (or an implant) within 24 hours. In some countries – Spain for one – you can ROD for free in several health service hospitals.
Colin – we will never agree that URODs (call it whatever ya like) is a good tx for addiction, opiates or whatever. Ask Coleman about Sara who’s records got buried with her (yea, the old “we didn’t tx her here’ BS) as she OD’d and died in a hotel down the street from his office (she died of acute naltrexone poisoning, but of course he tried to blame her by insisting that she relapsed already despite being unable to really walk yet). She’s not alone. The legal lists alone go on & on. Wrongful death aka just another dead addict. Addictor switching is the norm. I was in one of the first studies on naloxone w/ Dr Bright in Richmond. It’s the norm in reality bc it doesn’t address the engine driving addiction. Want to feel nothing? Put yourself an implant in. You wont feel happy, sad, excited….nothing. This is supposed to help? What valid theory backs any of it? Desperate ppl do this desperate & deadly thing. And you actually said “informed.” No one could possibly be told what they’re in for anywhere close to being “informed” of everything going on, let alone be prepared for the abuses that are sure to come. Sorry, I just couldn’t disagree with you more.
Dear Marcus. I’m afraid it’s not just that we disagree about the usefulness or otherwise of naltrexone in opiate dependence or about the superiority of various rapid and accelerated detox methods for initiating NTX treatment. The problem for me is that you seem to believe in a condition called ‘acute naltrexone poisoning’ that doesn’t actually exist and that must cast doubt on your sweeping criticisms. NTX is one of the safest and least toxic drugs around. Apart from very very occasionally causing a mild and reversible skin rash (of which I saw one case in 20 years) there are no reports of any clinically significant damage to organs, let alone deaths. (I’ve just checked again on Medline.) Early anxieties about liver toxicity have not been confirmed and NTX is regularly used to treat the extreme and demoralising itching that can happen with severe liver disease. A patient who swallowed a month’s supply of tablets was none the worse for the experience. Very few treatments work for everyone and none in addiction because addiction happens for a variety of reasons. I can easily believe that NTX (or abstinence) didn’t work for you but that’s no reason to vilify it.
Then why did I experience non stop electrical shocks to the base of my skull after the Dr the Stapleford centre (Dr George o Neil pertga Australia)whom the Stapleford sent me to .He insisted I bring 2nonths worth of my 50mg×10 per day script you wrote me along to his “detox centre “/a cracking house where the “nurse “(just released from prison no medical training )stole my medication she put in the safe (her bag ).The rest was handed out the back door to Dr o Neil’s Thursday NA meeting applauded in the local rags and community for its large turn outs.He would hand out free scripts at the back door after along with my amps.on a 1000mg per day detox I was left on a urine a faeces stained mattress covered in bin liners .I paid £1000’s for this treatment and a fee to the Stapleford for sending me.After 48 hours of extreme withdrawal a 16 year old Mormon was dispatched to encourage me that God would make me ok.Tgen Dr o Neill turned up overdosed me with horse tranquillisers. I was blue and choking on vomit when a volunteer had popped in to see how I was found me on said mattress.When I regained the ability to walk I returned to his clinic and asked he return the fraudulent fee he had extorted from my poor parents.He knew my mother was awaiting a heart transplant and although I have no history of violence or criminality whatsoever. Proceeded to dial my parents number on loud speaker and began to my horror acting out a fake physical assault from myself was being launched at him. I then returned to London to the Stapleford. I was twitching from the implant and jerking every few seconds I hadn’t slept once since he put it in.i was given 8x50mg methadone amps a day to override the implants awful effects.I was then told weeks later there was little or nothing to be done as I would inevitably overdose as the implant faded .all I’d done was survived a horrific rape and prolonged torture as a 15 year old while working in NY .I had ptsd. Your clinic charged sent me ,recommended and used Dr o Neil’s implants in your clinic.i used to think you an amazing man .I was 20 and in pain.now I’m older .I realize your clinic was the opposite of helpful. So I’m just one of the mistakes you have to make…as your old saying goes.
I’m dyslexic please forgive my horrific grammar etc.
What a horrific story! Thank you for sharing your terrible experience on the blog. I can’t comment on exactly what’s true and what’s not, but I have heard other very mixed reviews of this form of treatment, provided either in London or elsewhere. I suppose the take-home for readers is…beware!…and don’t walk into any unconventional treatment context without being extremely vigilant.
It is so nice to hear from Colin Brewer and hope he continues to share his considerable experience and wisdom. Like the clinics he was associated with, we too offer patients choices. There is no issue or controversy as regards to the treatment of alcoholism – medical detox with benzos for 3-5 days and naltrexone to prevent relapse, combined with behavioral counseling.
Opioids pose the biggest challenge. It is regrettable that the treatment is based on as Colin said – what is best for their income. How else can you explain the draconian restrictions placed on using methadone and buprenorphine and the patients missing out on treatment options.
I would love for Colin to talk more about the politics of opioid treatment and what are the possible solutions to the growing problem.
Thanks Percy. If I get invited to do another post, I will certainly discuss America’s disastrous War on Drugs. I have always opposed it both on libertarian grounds and because it has made the problem even worse, except in one or two small and highly controlled states like Singapore. Like the 2003 Iraq War, the US dragged a largely reluctant world into joining the fray. As with Iraq, many countries have had second thoughts but I see no signs that the main combatant is about to surrender. I once suggested a Society for the Return of Victorian Values in Addiction. You could buy opiates without a prescription in Britain until about 1916 and the world did not come to an end.
Dear Colin,
I would love to keep in touch with you and here is my email address: percymenzies@arcamidwest.com
I completely agree that the War on Drugs has been a monumental failure but so has ‘treatment’. It is time we declare war on bad treatment.
A case in point is the present treatment of opioid addiction. There is growing consensus that addiction is a learning process, but the treatment of opioid addiction is antithetical to the hypothesis. We are telling patients addicted to opioids that they will need life-long treatment with opioids like methadone and buprenorphine! To make this approach more palatable the, opioid substitution treatment (OST) is called Medication Assisted Treatment (MAT). You probably are aware that methadone and buprenorphine dominate the field while naltrexone is barely used. Here is a link to an interesting article written by a physician in recovery. I would love to get your feedback and from anyone else commenting on this story.
https://www.thefix.com/do-suboxone-and-methadone-prevent-us-experiencing-true-recovery
I’m an old patient of yours from ecclestone street, is there any way I can contact you, both you and Dr Tovey were the best Drs I had. I am not script hunting.
Always interested to hear from old patients Phoenix. Write to me c/o 25a Ecclestone St SW1W 9NP, put a ‘please forward’ note on the envelope and enclose your email address or mobile number. Or if you have my old mobile, it hasn’t changed since I retired.
Colin –
Thanks for the insights. I live in New York State, a very unenlightened precinct in the drug war. To give you an idea how much resistance there is, I recently registered as a Multiple Sclerosis patient for medical marijuana. Having spent $500 and gone to 2 interviews with doctors (why?) I then spent a week and 3 hours talking to support people to register online. The process was frustrating and mystifying and I have a professional background in tech support! It would have made a technophobe give up in frustration. For marijuana, mind you, a relatively harmless substance that maybe 10% of the population buys and uses outside the law already.
Your willingness to persevere and work on behalf of REAL addicts is heroic. As we say to soldiers, “Thank you for your service.”
Dear Sir,
Thank you for your post. I’m not sure where you are located, but from what I see in news documentaries and read in the press, several cities in the States are going outside the box of repressive treatment policies to deal with the current opiate painkiller and heroin epidemic…. Seattle, for example.
I am a long term methadone maintenance patient, 15-20mgs daily. I’m not young, and my brain needs the opiates to produce the dopamine needed for motivation, desire and pleasure, and no doubt other neurotransmitters as well. I’m not a doctor, but the depression that hit me when I stopped all opiates for almost a year was nasty and exhausting.
The brain can no doubt adapt to total opiate abstinence after only several years of heroin use, but past the age of 50, it doesn’t work anymore, and the depression is slow and steady, not fatal but always present…in my experience. But anything beyond survival mode seemed impossible. I am a survivor, yes, but I still have a lust for life, and with the daily methadone and a certain anti-depressant, I can partially satisfy that lust for life and I have faith that I can be there for others in my life, my sons and other family and intimate friends…and I can be there for myself…a blessing.
Thank you,
BobbyG
Hi Bobby. I agree that anyone who still felt awful months after withdrawal should probably resign themselves to indefinite opiate maintenance. The basic principle of methadone maintenance is really no different from nicotine maintenance and only the puritan purists are not pleased that so many smokers have changed to vaping. They’re still addicted but their lungs and other organs are relatively unharmed. I met one of my first MMT patients recently. He’s now in his 60s and was just collecting his prescription for a couple of months holiday in India. Happily, British regulations allow us to do this.
Hey BobbyG
My sister is a long-term methadone addict (since she was 20 to now 59). She was trying to reduce recently and the chaos it brought into her life, meant the family encouraged her to just stay on the dose (she’s on 100mgs). It seems to me she is best just seeing out her life that way … it’s been so long. But I do wonder sometimes. I see that she has not developed strong judgement, self-motivating neural networks and perhaps I shouldn’t be this negative, but I’ve kinda got to the point that I accept that she will never change, despite how much I try to motivate and encourage her. It was interesting to read your story.
Hi Margot. It’s certainly possible, even likely, that MMT can suppress spontaneity, judgement, and hamper other cognitive-emotional capacities. But we should always ask: what did the person start with? People who choose any kind of “maintenance” may already have a sense of self that is weakened or beaten down in some way–perhaps leading to the original addiction, but not necessarily.
I’m saying that we emerge from childhood either with a tendency to believe that we are capable of forging our own future or with a tendency to try to find (and maintain) safety in a cruel or dangerous world. Of course these are poles on a continuum — there’s lots in between. But I think that a characterological belief in oneself as capable of transformation, change, and self-initiated improvement is fundamentally discrepant from the theme of any form of maintenance. In which case, we can’t blame methadone for the life story that unfolds.
Very poignant points Marc. My sister did start from a very insecure base in life. Seeing her as “finding safety in a cruel or dangerous world” is very much likely how she felt … still does feel. By giving her ‘permission’ to stay on the ‘done though, we’ve removed the little motivation she had to reduce. But at the end of the day, she must be engaged in her own recovery for her to achieve any lasting change. But we should never give up hope.
Hello Margot, thank you for your comment about your sister, following my post. Again, I’m not a medical pro, but 100mgs of methadone is a lot, in my experience, so the effects you described are probably very real and will not change. On the other hand, 100mgs probably keep her totally heroin-free, which my 20mgs do not. I use once in a while. In fact my worst periods of shooting and sniffing heroin and cocaine (speedballs) occured when on 40mgs of methadone daily. Quitting methadone is much tougher than dope. It took me five months of freezing, falling asleep, sleeping badly and more, reducing 5 by 5 and then 1 by 1 under 10. I went to NA meetings and shared my pain and cold, and somehow went to work everyday and saw my sons regularly.
The depression that followed was not desparate but was all encompasing; for example, I could not get hard for sex with women I liked and was attracted to. So it was not worth it to follow the NA way.
Now, with the anti-depressant and the low-level methadone, and here in Paris, it is free and available a month at a time – vive les français!! – I am a new man and person. I still have bad days of no creativity or motivation, but I have a lot of good days. I look after and listen to others, and have some self respect. Baruch hashem, god bless, and bless Marc as well.
Maybe your sister could reduce the meth and take an anti-depressant. Check it out!!
BobbyG
Thanks for telling us your story, BobbyG, and for alerting people to a very different perspective on MMT and its pitfalls than I offered above. In fact, I was suggesting that there are personality issues that encourage MMT before ever choosing that route…which remain in play and are perhaps exacerbated in the following years. You are talking about how difficult it is to get off methadone, which is fundamentally important to understand, and your description of how it has helped you, and your explanation of the importance of dosing as another variable in the equation, are critical to help round out the picture.
Please forgive me if this is not totally on the subject but it relates to powerful tool I have begun to use on a daily basis and may help others struggling with various addictions:
I recently began to use Wim Hof Breath work as part of my twice daily meditation.
Think that breath work can be a powerful additional tool in breaking out of addictions. I am finding it enormously helpful to help me break out of old addictive patterns. Where I used to slip back into old patterns or use slips to give me permission to binge (my current preferred default addiction is around food and subsequent change in brain chemicals making me “Zoned Out”)
I use Breath work every day and sometimes several times a day. I was introduced to it at Tony Robbins event but learned more about it from Wim Hof videos online
Here are my thoughts and experiences on Breath work. It obviously brings copious amounts of oxygen to the system. I experience it as energizing, but also on some level it seems to clear out some of the chemical changes I discovered would occur when I first slipped up. It makes me feel more clear and more committed to making choices to stay clear and free.
Breath work is highly intentional and needs will but it is also in a paradoxical way kind of addictive – but in a positive way. Now if I slip up I find myself doing breath work and getting back on track instead of reinforcing old patterns
Think that escaping addiction to some extent requires or benefits from some of the same approaches that led to addiction in the first place. I am unapologetic about using and needing breath work and find appropriate places to use. I use breath work now the way someone else might go and smoke a cigarette. (Smoking a cigarette is breath work with all the downsides of chemical ingestion and the addiction of nicotine – meaning less health and less freedom.)
What do you think would happen if people collectively more and more instead of “Smoke Breaks” took “Breath work breaks”?
I have to admit that it is with some relief that I found this blog (linked from a blog of Marc’s).
I am a health professional who struggled with addiction to alcohol for too many years. I won’t go into a drunk-a-log, but suffice it to say I did a rehab treatment twice, was ‘forced’ to attend AA meetings (that boast a whopping 5-10% success rate), be monitored with random UDS etc. When my underlying anxiety was FINALLY treated properly, I lost ALL desire to drink. As a result, I have been sober now for 5 years.
I have recently switched states and when applying for my license, I was honest and disclosed my past history with addiction and treatments for it. I also indicated that since I have consciously made the decision to stop drinking I have achieved considerable success both in my personal and professional lives.
And this is where things got interesting…..I am under threat of being mandated into rehab (for my sobriety???) and monitoring (both at a considerable cost to myself).
That one cannot get sober without AA and addiction physicians etc seems lost on the ‘experts’ here. There are those AA professionals that can’t fathom a life without AA ‘support’. I agree with an earlier poster (not sure if it was here) that both AA and ‘professional opinion’ (here) like to victimize the ‘illness’. I am not powerless and I refuse to be told I am. That I have a horrid past is 100% accurate. That I have absolutely NO desire to ever go back to that was of ‘living’…I’m told is ‘irrelevant’. I am further told that the ‘disease’ is lying in wait.
For me, getting sober included a lot of personal counseling. I needed to (and am thankful that I could) deal with family of origin issues. With therapy, and abstinence, I have found peace and happiness. It’s a glorious thing!!
That ‘expert’ opinion does not believe this is possible…..well, quite frankly, it boggles my mind.
Anyways, that’s just my story. And I’ve no doubt it is NOT unique.
No, your story is not unique…but I feel sad to hear it. How bizarre that you should be thrust back into that world in order to provide a rubber-stamp, and as you say one that stands for very little, when you have been so successful pursuing your own change and growth.
The US is slow to progress in its philosophy of addiction treatment — very slow in fact. But change is happening…around the world and, bit by bit, in the US as well. Stay tuned to our blog and you’ll hear a lot of echoes of your experience and much endorsement of the idea that quitting happens in very different ways for different people.
Dearest Dr Brewer,
It is a person writing simply’Naltrexone My Saviour ‘CARO 2001.
Was a piece of Art made for a Dr that saved my life and certainly should never forget that He is a ge nuis
Dear Dr Brewer
I was a student Nurse on placement in 1999 where you practiced in Essex. I saw first hand how patient’s desperate for a humane way to detox from Heroin benefitted so much by having detox with anaesthesia. I found your approach kind and revolutionary and such a shame thst this approach was not used by the NHS. The detox in the nhs is abysmal and the staff attitudes very punishing and uncaring. You attitude was so compassionate to the user and it has stuck with me my whole career.
Hi Josephine Smith ,
This was a excellent informative post you have shared on this page about the gyrotonic stabilistation ,but If less than five years has passed, you can fill out the form and check “For Information Only.” An officer will decide if you can get special permission to come to Canada temporarily and you have criminal convictions in Canada but no foreign convictions, you can apply to the Parole Board of Canada for a record of suspension. You do not need to fill out this application.
Thanks.
I visited the centre 2001 and have been clean off heroine for 20 years know professor brewer saved my life the centre was brilliant with my retox and aftercare.