A national leader in the field of drug rehabilitation, Dr. Tennant is the author of more than 200 scientific papers, books and videos on the subjects of neurochemistry and drug dependence. He is the Executive Director of the
Research Center for Chronic Pain and Dependency Disorders and the Executive Director of the Community Health Projects Medical Group. He has served as a Public Health Fellow for the U.S. Public Health Service, as an Associate Professor at the UCLA School of Public Health and is a member of the Drug Abuse Advisory Committee of the Food and Drug
Administration. He is a Narcotics Training Consultant for the California Highway Patrol and the California Department of Justice. Dr. Tennant was the Keynote Speaker at the
Conference on Human Detoxification, Los Angeles, 1995.
“I am indeed delighted to be here this afternoon and to share with you what I hope will be somewhat of a historical perspective, and to bring you up to where I believe we stand medically relative to what is known as
detoxification. I first heard the word “detoxification” in the year 1968. I was an Army surgeon in Europe. Even at that time the U.S. Army had to start doing something about its drug problems. Between the years 1966 and 1968, they had established in New York City what they called “detoxification centers.
I cannot tell you who coined that term. It referred primarily at that time to heroin addicts, who were put in hospitals and administered methadone to withdraw them from
heroin. Shortly after that time, the term detoxification came to mean “the substitution of a long-acting
drug in the bloodstream for a short-acting drug that you are attempting to stop.” And that is a definition that to some extent
continues until this day. Needless to say, the terminology and activities of drug treatment have since taken quite an odyssey. What I would like to impress upon you is that, rather than getting caught up in semantics, it is critical today to
understand that a huge amount of neurochemical and biochemical research has
gone on in the last 10 or 12 years. Above all, we now know about metabolite
This work goes back to 1961, when a man who won the Nobel Prize, by the name
of Axelrod, took a rat brain and put it in a test tube. On it, he put
cocaine and amphetamine and he saw that dopamine and noradrenaline, or
norepinephrine, were displaced from the brain. A few hundred studies from
that time up until now have shown very clearly that one of the fundamental
effects of drugs, once they hit the bloodstream, is to go to biochemical
reservoirs in the body and displace from those reservoirs such things as the
endorphins, acetylcholine, cortisone and some other biochemicals. This is
true with every drug of abuse that we know about-nicotine, anabolic
steroids, marijuana and all other compounds. The drug comes in through the bloodstream to reservoirs and biochemicals are
displaced. What reservoirs are we talking about? The major one in the body
is the pituitary gland. The second most important are the adrenal glands,
probably the hypothalamus in the brain is number three. You have also huge
reservoirs in the spinal column, the sciatic nerve and other big nerve
endings in the body.
It is very critical for everyone who deals with drug dependence to
understand that if, for example, you take heroin long enough your natural
body levels of endorphin will deplete-your body will make less of it because
the drug provides it. If you take drugs like cocaine long enough at a high
enough dose, your body stores of dopamine will deplete. Once you get this
depletion, the body sets up what we call a “craving cycle,” desiring more of
the drug to make up for the chemical that you have depleted.
The second basic science principal that you need to know about is that these
chemicals that I have just talked about work in the body by attaching to
something that we call a “receptor site.” I’m sorry that we call it a
receptor site, because it’s something of a misnomer. I wish that we called
these things “electrical trigger points.”
The term “receptor site” comes from research with diabetes. Many years ago,
endocrinologists knew that when the blood glucose went up after you ate a
carbohydrate meal, the rise in blood glucose acted like a drug of abuse. It
calls forward out of the pancreas reservoir something called insulin. The
insulin and glucose then travel together and they are received on muscles
like your biceps and your quadriceps. The little spots on the muscles that
receive the insulin and the glucose were called “receptors.”
That wasn’t so bad, but then the cardiologists got into the act and they
wanted to have cardiac “receptors.” And then the lung people wanted to have
their receptors. And then disaster hit: The psychiatrists wanted their
Maybe they should have been called “trigger points.” It is body chemicals
attaching to receptors in the brain, in the spinal cord, in the heart, in
the kidney, in the intestine, that make the body work. And we now know that
drugs of abuse go to those receptors and trigger those receptors. That’s why
we all like our caffeine and our nicotine. And our carbohydrates, and our
marijuana, our cocaine and all of these other compounds-because we can not
only release certain chemicals, we can make those “trigger points” get
triggered. The third thing that you need to be aware of is a fairly recent discovery.
In my way of thinking, I don’t think this conference would be being held
today if we hadn’t discovered this. That is this: once a drug of abuse hits the bloodstream and makes its first pass through
the liver, the drug is altered and something called a “by-product,” or
a “metabolite,” is formed. We now know that the component of a drug of abuse that we get addicted to is
the metabolite of the drug, not the drug itself. This is a terribly
important concept. In other words, heroin is converted to morphine in less
than 120 seconds after it hits the bloodstream. We don’t really have heroin
addicts, we have morphine addicts. We don’t really have cocaine addicts, we
have benzoylecgonine addicts. Even alcohol has a metabolite. Nicotine has a
metabolite called cotinine. Marijuana has two primary metabolites.
It is the metabolite that supports the addiction. It is the metabolite that
gets stored in the body fat, and to some extent it is the metabolite that
gives you some of the signs of drug influence. Certainly the long-term
effects of the drugs derive from the metabolites.
Apparently, once a drug hits the bloodstream, the body says, “Gee, the
body’s taken in a toxic substance. I’ve got to get rid of it.” It tries to
rid itself of the drug of abuse by excreting it-through the breath, through
the bile, through the urine. (It also has the mechanism to change the toxin
to a metabolite.)
Here’s where the rub comes in. We don’t know much about these metabolites
yet. We used to say they were inactive, they were inert. We now know
different. We do know the body makes the metabolite and it will store it in
the reservoirs, and in some cases it uses the metabolite. In other words, if
you have a shortage of endorphins, fine. It will use the metabolites of
heroin or morphine as a substitute.
If you’re short of your dopamine, it will use the metabolites of
methamphetamine and cocaine as a substitute. If your nicotine, after several
years, has driven out some of your serotonin, the cotinine and other
metabolites of nicotine will be happy to substitute, at least for a while.
What we don’t know is how destructive those metabolites are. We really don’t
have a good feel for that. We don’t like them when we find them in the body
and, of course, we try to get them out of the body. Three
things occur when you take drugs: one is, the metabolites get formed;
secondly, the drugs will attach to these trigger points known as receptors;
and thirdly, drugs of abuse will deplete natural body chemicals, and in fact
substitute for them. What we call drug dependence is really a substitution
When you want to get yourself recovered, you’ve got to stop your chemical.
Your body has got to not only wash out residues, but your natural body substrates have got to come back up to pretty normal levels. And your receptor
sites have got to re-function for you to recover and to stay clean and dry.
If your receptor sites and your neurochemical substrates do not come back up
to a pretty normal level, you will probably remain a lifelong addict.
Let’s get back to detoxification. In its traditional sense, it was a
substitution. You may be familiar, for example, with something called a
drug’s “half life.” Turns out that, in the field of dependence, we don’t
care about a drug’s half life, we care about the whole life.
The whole life of heroin is about six hours. In other words, if you go out
here on the streets of Los Angeles and spend your twenty bucks for a fix of
heroin, you’ll get six or eight milligrams of heroin. You will intravenously
inject it, and it will remain in the bloodstream above a level of five or
ten nanograms for four to six hours-at which time, if you are truly
addicted, you will have to re-use. That’s why a typical heroin addict will
have to inject three, five up to eight times a day, depending on their
biology and how dependent they’ve become.
Methadone, on the other hand, after a single dose can stay 24 hours and a
new compound known as levo-alpha-acetylmethadol (LANM) will stay in the
bloodstream 72 hours. So the original concept of detoxification back in the
60s and the 70s was to give a dose of methadone which would last 24 hours
and the heroin therefore could be washed out since it didn’t last as long.
Do drugs really stay in fatty tissue? Yes, they do. Dr. Beckmann and I did a
small study to actually prove that for the first time. You can take a simple
urine specimen, or a blood specimen today, and for a cost of about four
dollars you can determine whether an individual is addicted. At least, you
can get a good clinical idea that they are addicted simply by knowing the
metabolite levels that you can expect to see for the addict, or for the
heavy binge user, for the occasional user, or the person trying to withdraw.
Once we had low-cost technology to measure metabolite levels, we were able
to plot “washout curves.
Consider the typical washout time for a cocaine addict. Over a period of
around 15 or 16 days, the level of metabolites in body fluids goes down to
zero. With a methamphetamine addict, on day one the patient may have 3,000
nanograms of amphetamine metabolites in the urine. At the end of 25 days it
is cleared out. Another example is PCP, which has metabolites that really
like to store in the fat. The level may start at 500 nanograms and at the
end of 43 days, there will still be some trace levels.
It was the determination of these washout curves some six or eight years ago
which really gave us the real scientific information that those compounds
are stored in the body somewhere, and that “detoxification” or withdrawal
had to take on a new meaning. And that was, “How do we clear the body of all these metabolites?”
What I would like to leave you with, indelibly in your mind, is this next case.
This is a routine, run-of-the-mill cocaine addict, of which America thinks
we might have 300,000, half a million, a million-we don’t know.
This man starts out at day one, starts to detox down, and by the fifth sixth
day of treatment his metabolites have cleared out. But guess what? His
craving comes back, and he relapses. What happened there on day six or
seven? The receptor sites are no longer coated by either dopamine or the
metabolites of cocaine. So he’s sitting there in withdrawal and in craving.
And so he re-uses. He makes another run at cleaning up, and on the
nineteenth day he re-uses. He repeats this cycle over about a six or eight
week period four or five times before successfully completing detoxification.
In summary. Fat soluble metabolites or by-products store in the “tank.” You
should also be aware that it’s not just the fatty tissue. These metabolites
also store in brain tissue, in the adrenal glands, in nerve endings-throughout the body. This stuff becomes a poor substitute for natural body
chemicals. The number one job is to try to get all of these metabolites and
by-products out of the body. And I must say that I have been a great fan of
this particular treatment approach for quite some time, because that has
been one of the fundamental tenets of their program.
In our field, nutritional supplements are a must. A certain drug treatment
program in the US has for some time championed the simple nutrients. They
are great adjuncts to treatment. It is no secret that when we take someone
into rehabilitation, they are pretty malnourished. We have done extensive
studies on vitamin levels in serum and nutrient levels in serum, and addicts
are terribly malnourished.
I would like to talk about some of the serious complications that we are
seeing today, to raise the flag even higher for the need for proper
detoxification, or if you prefer, “purification” or withdrawal. It is
essential to get metabolites out of the. body. There are three basic effects
on the immune system: cortisone depletion, leukocyte suppression and
abnormal proteins. Leukocytes are the white blood cells that wander around
the body grabbing up viruses like the AIDS virus. The metabolites have a
very deleterious effect on the immune system.
Another thing that metabolites may do, as well as the drug itself, is damage
the receptors. This is the tragedy. Once the receptors get damaged enough, we know that the person may not return to a normal mental or physical state. I don’t have time to go into all the syndromes that result, but they cross a wide panorama, from diabetes to schizophrenia, to adrenal gland insufficiency, to poor memory, poor motivation-almost an Alzheimer’s state. They can be very mild or very severe. Another thing is not well appreciated at all, but it is serious. We know that the metabolites of cocaine and amphetamine, and maybe of pcp and marijuana, constrict blood vessels. What that means is the blood vessels are shut down, to the point that you do not get enough blood in the brain or to the heart.Why do I point this out? The epidemic in recent years of crack babies, heart attacks and strokes is due to the blood vessels being cut off. The blood cannot carry glucose or oxygen, and so tissue
dies. The last complication I want to bring to your attention has to do with
immune suppression and the infectious diseases that are plaguing the addict population. All of you are aware of AIDS.
Interestingly enough, in our intravenous drug addicts in California, we find
only about one percent with AIDS. We don’t know why. But 92 or 95 percent of
them have hepatitis C. Hepatitis C has become the plague of the intravenous
drug addicts of California, and it appears that most of them are going to
expire of complications of the disease.
Most of them are expiring somewhere between the ages of 48 and 55, usually
after about 30 to 35 years of carrying the virus. If they have shared
needles as little as two, three or four times, they probably carry the
hepatitis C virus. There is no vaccine for it, there is no treatment for it.
Hepatitis C spreads like AIDS, primarily by blood exchange. It will spread
to some extent by sex, it will spread to the babies. It apparently can also
spread slowly by other “post-contact” routes- saliva, or air. We know that
20 to 25% of alcoholics carry hepatitis C, but we don’t know where they got
it. Among non-addicts, forty percent of the hepatitis C cases in the state of
California do not have a risk factor, such as a blood transfusion,
intravenous drug use, or sexual contact with someone who carries the virus.
We do know that the intravenous drug addict is the reservoir of hepatitis C.
This is bringing in a dimension that we have never had to deal with before.
The bottom line is that throughout the state, there is great, great concern
about these infections, and we don’t know what they mean.
We are very concerned about the infectious diseases, we are very concerned
about what we now understand are the biochemical changes that occur in the
addicts, and we are very concerned as to what all this means for the general
population and what public policy should be.
Let me close by saying that it’s been an honor and a pleasure to be
associated with this treatment center. The program that we have here is a
first-class program. It’s a program that should be done by everyone before
they get into the clutches of a physician. You don’t want to rely on us
physicians. By the time we get the patient, it’s the end of the road.
There’s no other referral. I can’t say that seriously enough.
We have three hundred and some thousand intravenous drug addicts in
California that have been identified. They, in effect, are a dying
population. They need all the care and humanity that we can give them. I
salute you for being interested in this and I appreciate the opportunity to
be here today.
Forest Tennant, M.D., Dr.
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