Summer House

Individuals, who engage in substance abuse use, are often facing more than one issue. Research literature has shown, time and time again, that there is a stereotypical personality that accompanies the addict, rightly named, the ‘addictive personality’. Some characteristics that accompany said individual are as follows:
 

* Impulsivity
* Difficulty in delaying gratification, sensation seeking
* Nonconformity combined with a weak commitment to the goals for achievement valued by the society.
* Social alienation and a general tolerance for deviance.
* Poor tolerance for stress, increased sensation of distress
 

This is being outlined, to assist the lay person in understanding why addicts cannot just stop using drugs. Substance use is not just an action it is in effect a lifestyle. This implies that in order for an individual to stop utilizing drugs, he or she must not only actually stop using but must change aspects of personality that may lead him or her in that unhealthy direction. Once this has been outlined and agreed, the individual next needs to decide a plan of action. It is unadvisable for an individual to attempt to stop using drugs on his or her own. Breaking such habits is difficult for anyone with the assistance of others let alone as a solitary mission.
 

So, now the question comes, inpatient or outpatient?
 

Research conducted over the last few decades indicates that longer treatment periods are associated with more positive outcomes. On average, a treatment period of three months was correlated with more positive results. In the case of substance abuse treatment, this is to mean less incidence of relapse. Patients expressed more positive feelings towards more intense treatment plans. So, those individuals who were in residential treatment and received one on one consistent attention were more likely to indicate a better sense of overall satisfaction in regards to treatment. However, there is little statistically significant difference between outpatient and inpatient long term treatment recidivism. Meaning, long term effects of staying clean do not differ.
 

In order to understand the above findings, one must integrate the information previously presented. In order for substance use to cease permanently, an individual must totally change his or her behavior and surroundings. Going into a residential facility assists in removing one from his or her life. This cuts out locations and individuals that probably assisted in facilitating drug use. One is also in the presence of others with a similar goal. All of these factors are positive and if one can integrate them into his or her psyche, inpatient treatment can longitudinally provide the basis for healthy living. The one factor that proves to sabotage all this is properly presented in one question often asked by residents of treatment programs:
 

What Happens When I Get Out?
 

It is a valid question. In a controlled environment anything is possible. If temptation is outlawed, the individual does not have to utilize his or her decision making skills because in effect, the decisions are made for them. Substance users in this context can be thought of as a child. As children, our parents monitor our behaviors and our actions often giving us the proverbial slap on the wrist if we reach too close to the fire. As adults, we must utilize our decision making skills or else we have the potential to be severely burned. For this reason, substance abuse recovery must take place in small steps with much reinforcement utilized.
 

The main variable shown to influence whether treatment programs work or not is continued monitoring. One study that analyzed outcomes of parolees who participated in treatment communities (TC), either outpatient or inpatient, found that the outcome variable: return to prison, was correlated with longer participation in ‘aftercare’ treatment programs. Thus, those individuals who left prison and had some level of reinforcement, was more likely to stay clean and not return to incarceration.
 

McLellan (2004), a researcher out of the University of Pennsylvania, compares substance abuse treatment to treatment for any other chronic illness. Mclellan point out, that what will make treatment effective is the three following variables noted:
 

* Making treatment options attractive
* Offer options/alternatives
* Constant and continued monitoring of the individual
 

It is no shocker that most people are more inclined to do something they view as positive or attractive. So, first things first, treatment options should be something that the individual in fact beckons to the individuals tastes. Varying options in the form of treatment (i.e group versus individual therapy for instance) keep treatment ‘entertaining’ if you will, thereby making continued treatment as an option. Finally, when an individual leaves treatment he or she needs to continue with what we will call ‘stabilization’. Whether that means switching from residential to outpatient treatment or joining a group like alcoholics anonymous or narcotics anonymous after intense treatment depends on the individual and the program from which he or she graduated.
 

No one program will fit every individual as every person is different. Residential treatment may very well be the best option for some and not for others. It is up to the individual to decide what will suit him or her better. Having said that, when considering substance abuse treatment one must remember that treatment consists of a plan that must unfold longitudinally. Changing one’s behaviors and in effect, one’s personality is a long process which, with proper guidance and support can occur. Like any task worth undertaking it takes time, perseverance and most importantly assistance from those who can help to attain a life free of drug use.

Acupuncture is an Eastern medicine technique that has been utilized for centuries. It has been used for various physiological issues in Asian culture but only more recently has entered the United States. Since it’s induction into popular culture, use of acupuncture has been broadening to treatment for many different health problems. Some of which include: back and neck pain, sports injuries, knee injuries, fibromyalgia, headaches, digestive and gynecological problems, among other things. One of the uses that surprises most people, is acupuncture as a method to treat symptoms of substance abuse withdrawal.

A Treatment Found by Mistake

It was 1970 and a neurosurgeon by the name of H.L. Wen, the only one in all of South China, was getting ready to use electro-acupuncture as a method of surgical analgesia. The patient who happened to be withdrawing from opium, reported a relief in symptoms of withdrawal. Wen immediately canceled the surgery and went looking for patients who were also experiencing symptoms of withdrawal. Wen utilized the same acupuncture treatment and found that these patients also experienced a reduction in symptoms. It was at this moment that acupuncture as treatment for substance abuse withdrawal came into fruition.

How Can Acupuncture Reduce Withdrawal Symptoms?

• Physical withdrawal symptoms are reduced.
• Relieves: depression, anxiety, and insomnia brought on by withdrawal.
• Specific withdrawal symptoms include:
o cravings
o body aches
o headache
o nausea
o sweating
o muscle cramping

What exactly is Qi?

Qi, pronounced chee, is achieved by inserting needles into routes underneath the skin which are called ‘meridias’. The only translation for the word Qi, which is not exact, is ‘vital energy’. If Qi is working properly it protects the body and makes the transition from one body state to another smooth. Chinese medicine works under the assumption that sickness occurs when energy cannot flow through the meridas freely. The needles utilized in acupuncture work by unblocking the meridias and allowing Qi to flow freely.

How Does Acupuncture Treatment Work?

There are points in the ears that pertain to specific organs in relation to detoxification treatment. To be more specific, this includes: the liver, kidneys, lungs, and the nervous system. Needles are placed in each ear, which relate to each organ mentioned prior. The entire treatment takes approximately forty five minutes. This is a good time for the patient to relax, meditate and take this time to think about changes that need to occur in one’s life. One of the reasons that acupuncture helps to relieve symptoms, is because endorphins, a natural body chemical, are released. Endorphins can be called the ‘happy hormones’. Endorphins tend to reduce cravings, ease symptoms of withdrawal and also tend to increase feelings of relaxation.

How Do They Know Where to Stick Those Needles?

The Chinese have been utilizing the proper acupuncture points for years; however, it wasn’t until 1955 that Paul Nogier, a French doctor completed research on these positions. Dr. Nogier, when testing for electrical activity on the surface of the skin, found that all the traditional acupuncture points on the body had a parallel point on the human ear. From that point on, needle stimulation of the ear, otherwise known as auricular acupuncture has been used. This type of stimulation has particular benefit in substance abuse treatment as it allows for several treatments to take place simultaneously thus eliminating the need for privacy.

What Does the Treatment Feel Like?

When needles are placed in the individual’s ears, they may begin to feel warm or start to tingle. Some people do not feel anything and others may even fall asleep. Regardless of which response the person has, they are all natural and normal. Acupuncture is a treatment which will not reap immediate results. It is only after treatments taking place over time, that a true benefit will be felt. The important thing to remember is that it takes time for the treatments to show results.

What is the Detoxification Process?

The purpose of detoxification is to remove toxins from the blood stream that have been building up due to substance use. Your body is able to filter out the toxins that have been stored up. This improves the circulation of blood throughout the body. It is possible to feel out of sorts during this period. One may have aches and pains and may not be sleeping well. Some people have even reported dreaming about substance use. If any of these symptoms occur, it is advisable to let the acupuncturist know in order to alter the pressure points utilized or add additional points in.

Is Acupuncture Treatment a Sufficient Form of Substance Abuse Treatment?

No. Acupuncture is a wonderful complementary treatment to add on to traditional for substance abuse management. In order for substance abuse to be effectively dealt with, a whole team of professionals need to be incorporated. If an individual is interested in natural treatments such as acupuncture, it is advisable to locate a program that specializes in Holistic addiction treatments.

Introduction
 

Cocaine is a intensely powerful addictive stimulant that acts directly on the brain. Cocaine was first extracted from the leaf of the Erythroxylon coca bush, which is endemic in South America, West Indies and Indonesia. Cocaine is one of the most commonly abused drugs and the majority of the individuals who use cocaine are also users of other drugs. The drug can generate a feeling of euphoria, hyperactivity and mental alertness. It can be rapidly highly addictive leading to relentless mental and physical problems.

The neuro-stimulating properties of the coca leaves are thought to have played some role in the development of the Inca People. Soon, the Spanish invaders quickly discovered the euphoric effects of the coca plant and introduced the plant to the Europeans, who also developed a great liking for the plant and its stimulating effects.
 

History
 

The plant was used for medicinal purposes as early as the 15th Century in Europe. In the 18th Century, concentrated forms of cocaine became available and it was soon discovered that the plant extract had some medical benefits. The drug was then widely used as a topical local anesthetic and because of its mental stimulating properties, was also used to treat depression. The use of cocaine in tonics and elixirs became widespread and it was also added to coca cola.
 

However, soon it was soon observed that drug was addictive and had profound effect on the psyche of the individual. Because of cocaine’s potent side effects, in the early part of the 20th Century, the Pure Food and Drug Act was introduced, which required that all cocaine be labeled in all medical products. However, this did not limit the use of cocaine and addiction to cocaine reached endemic proportions. In 1914, the Harrison Narcotics Act was introduced and banned the nonprescription use of cocaine products and labeled cocaine as a narcotic.
 

The Harrison Narcotics Act did nothing to diminish the use of cocaine and over the next 50 years, cocaine became the number one illicit drug used in North America. In the 70s and 80s, a new cheaper formulation of cocaine became available on the market and it has today become the favorite drug among teenagers and socially deprived individuals. By the mid-1980s, the emergency rooms were again becoming full with individuals with cocaine-related problems. Physicians again re-affirmed the abuse potential of cocaine.
 

Today, cocaine is classified as a Schedule II drug — it has towering potential for abuse and can only be administered by a doctor for legitimate medical uses. Today, the medical use of cocaine is limited to topical anesthesia of the upper respiratory tract and eye because the vasoconstrictive properties of cocaine are desirable during these procedures. However, it is not available in majority of the hospitals in North America, because safer and better agents are available.
 

Addiction Potential
 

Cocaine is an addictive psycho-stimulant with euphoric effects. The addictive properties of cocaine are thought to be due to brain dopamine D2-receptor stimulation. Dopamine is released as part of the brain’s reward system and is implicated in the high that is typical of cocaine consumption. Patient dependence depends on a number of different factors, including genetics, social and environmental factors, preexisting medical and mental conditions.

There are two fundamental forms of cocaine: powdered and "freebase." The powdered form easily dissolves in water whereas freebase is a mixture that has not been neutralized by an acid. The freebase form is usually smoked or snorted.
Warning signs of cocaine use include a change in behavior, acting isolated, careless about personal appearance, loss of interest in school, family, friends and frequently needing money. Physical exam may reveal red eyes, runny nose, frequent sniffing, change in eating and sleeping patterns and a change in friends

Cocaine induces an artificial “high” that gives its user a feeling of limitless ability and energy. When users come down, they are usually depressed, nervous, and crave for more. Todate, it has been impossible to predict who will become addicted and when the fatality will occur.
 

Frequency of Use
 

In the US, as of 2005, according to the Office of National Drug Control Policy, more than 3 million people in the United States are considered long-term cocaine users. Cocaine abuse is also widespread universally and has become a major public health issue in North America. Data suggest that the prevalence of cocaine use in the world is approximately 13 million people, or 0.23% of the global population. Cocaine use is also increasing in a number of Latin American countries, including the countries that are the main producers of cocaine.
 

All races and both genders are known to use cocaine. Individuals between the ages of 18-30 are the most frequent users. Men not only are more heavy users but also account for more overdose and toxicity from cocaine.
 

Routes of Intake
 

Cocaine may be inhaled (snorting), injected or smoked. Irrespective of the method of intake, cocaine is still a potentially deadly agent. Most individuals report that the psychotic features and habituation are more rapid and pronounced after smoking cocaine, compared to other methods. The “high” generated with smoking is instant but of a shorter duration, but the addiction potential is the same by all routes. Like all illicit drugs, injection of drugs carries with it the potential for transmission of HIV/AIDs. This becomes of more concern when the needles and other injection paraphernalia are shared.
 

A common route of transportation of cocaine is by swallowing cocaine packed in condoms. Body stuffers usually hide packages of cocaine in the rectum, vagina or mouth. These individuals usually get away until the packages rupture and cocaine intoxication becomes obvious.
 

Street cocaine is often accidentally/intentionally contaminated during the preparation process in order to dilute the cocaine used and increase profits. Commonly used cocaine adulterants may include local anesthetics, phenytoin, sugars, amphetamines, phencyclidine, phenylpropanolamine, quinine, talc, and others.
 

Mortality/Morbidity
 

Data from the Drug Abuse Warning Network (DAWN) indicate that there are about 4-5000 cocaine related deaths annually in the US. Cocaine-related deaths are rare and not always due to high dose intoxication. The lethal dose of cocaine remains unknown. Fatalities are multifactorial, and, often the cause remains unknown. Occasionally, massive exposure of cocaine occurs in body packers and results in rapid death.
 

However, the majority of cocaine users are prone to serious long term medical complications. These complications may include seizures, abnormal heart rhythms, heart attacks, stroke, blindness, liver and kidney failure, lung fibrosis and heart failure.
 

Symptoms
 

Cocaine has numerous physiological and psychological side effects. The adverse effects of cocaine’s appear almost immediately after a single dose, and fade away within a few minutes or hours. Cocaine can cause intense vasospasm of blood vessels, dilate pupils, increase the heart rate and blood pressure and can also generate a febrile response.
 

The psychological effects include euphoria, decreased fatigue, extreme hyperactivity and mental lucidity. The sense of sight, sound and touch are over amplified. During the cocaine euphoria, the need for food, sleep and personal hygiene are significantly absent. The majority of individuals report that cocaine aids them completing simple chores swiftly, whereas others experience mental confusion and are unable to carry out any tasks

The quicker the cocaine is absorbed, the more intense is the “high”, however, the duration of action is short lived. The euphoria from snorting may last 15-30 minutes, while that from smoking may last 5-10 minutes. Increased utilization can diminish the period of stimulation due to development of tolerance. High doses of cocaine and/or extended use can generate an aggressive paranoid behavior, tremors, vertigo, muscle twitches, extreme restlessness and auditory hallucinations.
 

When addicted individuals discontinue using cocaine, they frequently become depressed. This may lead to additional cocaine use to lessen the depression. Extensive cocaine snorting is known to cause ulceration of the nasal mucous membrane and even perforate the nasal septum. Cocaine-related deaths are often a consequence of cardiac arrest or seizures followed by respiratory arrest.
 

When both cocaine and alcohol are consumed, the adverse risks are increased by several folds. Combination of cocaine and alcohol in the liver is known to generate a substance called cocaethylene, which is known to potentiate cocaine’s euphoric effects and also increasing the danger of sudden death.
 

Treatment of Acute Intoxication
 

Patients with cocaine poisoning may exhibit severe CNS and cardiovascular dysfunction, leading to a loss of airway protective reflexes, cardiovascular collapse, and mortality. The goals of pharmacotherapy are to neutralize toxicity, reduce morbidity, and prevent complications.
 

The immediate control of mental agitation is critical in preventing the mortality associated with cocaine overdose. Benzodiazepines are the mainstay of therapy and may be used generously until sedation is accomplished. Avoid physical restraints in patients with psychomotor agitation because they may interfere with heat dissipation. Seizures should be aggressively treated because they may worsen hyperthermia, rhabdomyolysis, hypoxia, and acidosis. In some cases, ventilatory support and neuromuscular blockade may be required

Body packers and body stuffers may require critical care monitoring. The body packers pack their gastrointestinal tract with bags of cocaine. However, occasionally the cocaine-containing package ruptures or the packages may cause gastrointestinal obstruction.
 

All symptomatic body packers and body stuffers require intensive therapy. Charcoal may have to be introduced in the stomach to bind the cocaine and prevent absorption and surgery may be required to remove the packages.
 

Asymptomatic patients may be treated with laxatives and bowel irrigation to remove the cocaine bags. Surgical removal may also be indicated in patients with bowel obstruction.
 

Some individuals may suffer a Cocaine washout syndrome (cocaine crash syndrome) which is characterized by sudden and severe exhaustion with mental slowness, depression, suicidal ideation, anxiety and increased appetite, lasting as long as 18 hours after the last consumption. Cocaine washout syndrome is usually self-limited, and only requires supportive therapy.

Once the acute phase is stabilized, patients may require further therapy to treat the complications of cocaine. It is highly recommended that these individuals enter into a rehabilitation therapy program.
 

Treatment approaches to Addiction
 

Treatment of cocaine addicts is a multi million dollar business. Treatment programs are available throughout North America. The treatment is complex and involves changing the mind as well as altering the psychological, social, familial and environmental factors
 

Pharmacological Approaches
 

There are no approved medications currently available to specifically treat cocaine addiction. Few emerging compounds currently being investigated to assess their safety and efficacy in treating cocaine addiction include disulfiram, terguride, topiramate and modafanil. Additionally, baclofen, a GABA-B agonist, has shown promise in a few individuals who use excessive cocaine. The use of anti depressant drugs has been recommended during the early phase of cocaine abstinence, because of the moderate depression that occurs.
 

Behavioral Interventions
 

Many types of behavior therapies have been used to treat cocaine addiction, and involve both residential and outpatient approaches. Behavioral therapies are frequently the only available effective treatment for cocaine addiction. However, amalgamation of both medical and behavior treatments are more effective in the treatment of cocaine addiction.
 

Behavior therapy which has been shown to be beneficial includes vocational rehabilitation, career counseling, contingency administration and cognitive-behavioral treatment. Therapeutic communities (TCs), or residential programs with intended lengths of stay of 6 to 12 months, present another option to those in need of treatment for cocaine addiction. TCs concentrate on remobilization of the individual to society, and can incorporate on-site vocational rehabilitation and other helpful services.

Enrollment in deterrence programs, such as Narcotics Anonymous, may be of benefit for some patients.

Heroin is a powerful addictive drug sweeping the United States causing intense euphoria and strong physical dependence in its users. Heroin is processed from morphine; a naturally occurring substance extracted from the seedpod of certain varieties of poppy plants and appears as a white or brown powdery substance.
Heroin is highly addictive because it enters the brain rapidly and affects those regions of the brain responsible for producing physical dependence. This dangerous drug affects all decision-making, reaction time, the way one thinks, actions, and memory.
 

Heroin addicts, who use regularly, develop a tolerance. To get the same effect from the drug, the user must have higher doses, which in turn causes physical dependence and addiction. Despite the glamorization of heroin chic in films, fashion, and music, heroin use can have tragic consequences that extend far beyond its users. Fetal effects, HIV/AIDS, tuberculosis, violence, and crime are all linked to its use. Long-term effects of heroin use are also devastating to the body and mind.
 

The affect of heroin on the body is dependent on the method of administration. Heroin can be taken orally, which is metabolized into morphine before crossing the blood-brain barrier; snorted, which results in onset within 10 to 15 minutes; smoked, which has immediate effects; intravenously injected, which results in rush and euphoria within 7 to 8 seconds; and, intramuscularly injected which takes longer but results in onset within 5 to 8 minutes. Finally, heroin can kill. Of all reported drug abuse deaths, heroin is one of the top two most frequent. As with any drug addiction and physical dependency, withdrawal symptoms occur if use is reduced or stopped.
 

Withdrawal can occur anywhere from a few hours to 72 hours after the last dose and symptoms can include: drug craving, restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, cold flashes, and kicking movements. For the user trying to quit, medications and behavior therapies are the most common treatment options.
 

First, the medications Methadone and Buprenorphine have proven to be successful in treating heroin addiction. Methadone, a synthetic opiate, blocks the effects of heroin for about 24 hours. Buprenorphine is the most recent addition to the array of medications available for treating addiction to heroin and other opiates. This medication is different from methadone in that it offers less risk of addiction and can be dispensed in the privacy of a doctor’s office. Other medications include naloxone and naltrexone, both of which block the effects of morphine, heroin, and other opiates.6 In addition; there are many effective behavioral treatments available for heroin addiction. These can include residential and outpatient approaches. Contingency management therapy uses a voucher-based system, where patients earn "points" based on negative drug tests, which they can exchange for items that encourage healthful living. Cognitive-behavioral interventions are designed to help modify the patient’s thinking, expectancies, and behaviors and to increase skills in coping with various life stressors. Treatment can and should be integrated with support services to enable the heroin user to return to a stable and productive life.
 

In conclusion, heroin addiction is a terrible way of life but can be overcome with hard work, a support group, a drug rehabilitation program or center and pure determination.

Since the 1960s, many addicts have reported that even a single dose of ibogaine, a hallucinogenic alkaloid extracted from the root of an African shrub, helps them kick their habit by reducing their cravings for drugs. And there is hard evidence to back these claims, as well. Ibogaine was first introduced as a potential treatment for opiate addiction by Howard Lotsof, who took the drug in 1962 looking for a psychedelic experience, and awoke 30 hours later with no cravings and no withdrawal symptoms, despite being a heavy heroin user at the time. Lotsof was able to develop and follow an ibogaine maintenance program, which he then followed for three years while remaining opiate free. In 1986, Lotsof opened a company by the name of NDA International to advocate for the use and research of ibogaine and its active constituents as anti-addictive compounds.

Since ibogaine aides in the cessation of addiction, it started to be used to deal with opiates and other substance addictions. Ibogaine has only been introduced to Western scientific medicine but has documented use by the Bwiti tribe in Central Africa for centuries. At lower doses ibogaine has the ability to increase energy and mental alertness and appears to decrease the desire for food and drink. Higher doses (20+ mg/kg) of ibogaine have a larger psychoactive property, and is used ritualistically in initiation rites for its potent hallucinogenic properties.
 

Barbara E. Judd, CSW did a study on ibogaine and stated that the most difficult aspects of treatment are getting the patient to enter treatment.  She notes that the three major obstacles are the fear of detoxification lack of insight, and the inability of patients to control their urges to use drugs. It was in these three areas where she felt the benefits of ibogaine treatment far outweighed those of traditional methods. Judd further states that psychological fear of pain and withdrawal prevents many addicts from even attempting detox. Addicts feared having to deal with the emotions that lead them to use in the first place. Judd adds that when patients learn the benefits of ibogaine they are more willing to try it.
 

Like all forms of detox, ibogaine is not without risks and side effects. At therapeutic doses, ibogaine has an active window of 24 to 48 hours, is often physically and mentally exhausting and produces ataxia for as long as twelve hours. Nausea that may lead to vomiting is not uncommon throughout the experience. These side effects reduce the attractiveness of ibogaine as a recreational drug at therapeutic doses, however, at lower doses ibogaine is known to have stimulant effects. It is still a controversial and experimental drug and there are some cases of fatal cardiac arrhythmias.
 

There are two types of ibogaine treatment. The first type of treatment is oriented toward addiction, most commonly heroin dependence, and typically involves dosages in the range of 15 to 25 mg/ kg .5-8 The second type of treatment, also know as “initiatory," involves a dosage on the order of 8 to 12 mg/kg, or about half of the dose used for addiction and is used for spiritual insight and facilitating psychotherapy.  In addition to reducing craving, ibogaine often promotes a sense of wellbeing that can last from weeks to months. As the studies into the nature of ibogaine progress, scientists have discovered that ibogaine’s anti-additive properties are actually two-fold. First, when the substance is consumed, the body produces a chemical called noribogaine. Noribogaine blocks the brain’s receptors that control cravings. Noribogaine also increases dopamine and serotonin levels, which elevate feelings of wellbeing.

So while ibogaine is not a substitute for drugs, and is not addictive, ibogaine is a chemical dependence disruption and a chance for patients to get a head start on recovery. Ibogaine enables the patient to focus on the underlying causes of addiction without going through the intense withdrawal symptoms that accompany most types of detoxification. And, even if there are some remaining symptoms after ibogaine detox they are more tolerable than other detox approaches. Studies show that ibogaine has the ability to drastically attenuate drug withdrawal in all patients and, in 90 percent of treated patients during one case study, to interrupt the patient’s craving to continue drug use for periods of time ranging from as short as two days to as long as two and a half years from a single treatment.

Miami Herald — Most everybody in this neighborhood coffee haunt has been hooked on something. The high school dropout with beauty-pageant looks has been fending off a heroin habit for two decades. The former football player says he is clean now after years of popping pain pills. Santa Claus succumbed to alcohol.

Nineteen of the fallen are here tonight for therapy and healing, for a second — or a third or fourth — chance, hoping to reclaim a piece of their lives. They form a circle in the pebble garden behind KoffeeOkee, which is owned by Harold and Dawn Jonas, former users who now help others kick drug and alcohol habits and answer the question: What now?

A resort on the Atlantic in Palm Beach County, Delray Beach has another, less obvious civic profile: Florida’s sobriety capital. Like Hazelden in Minnesota and Utah’s Cirque Lodge and the communities that surround them, it is a place to dry out, clean up. Its recovery community is spirited and multilayered, a dense mesh of dozens of treatment facilities, counseling centers and residential housing that gives addicts a wide-reaching chance for recovery and permanent lifestyle change.

This is where people start over. And sometimes stay.

”You want to be here if you are struggling with an addiction,” says Anna O’Connell, 43, who has been in and out of detox for crack cocaine, heroin and alcohol over the past 20 years and attends therapy sessions at KoffeeOkee. “This is the closest thing to family; this is where you feel safe.”

Treatment for addictions that the medical community now accepts as chronic diseases ranges from private $10,000-a-month treatment centers to free coffee, counseling and karaoke at java houses such as this one, which hosts formal therapy sessions twice a week and informal gatherings even more often.

MANY, FROM ALL OVER

The size of South Florida’s recovery community is difficult to estimate because only one layer — facilities with residential treatment beds — is licensed by the state. Delray Beach alone offers more than 1,200 beds in transitional houses — a second layer — according to the South County Recovery Residence Association in Delray, which monitors halfway residences.

Every week in Delray, about 5,000 addicts attend 12-step meetings that stretch from 7 a.m. to 11 p.m. At Crossroads Club, a squat stucco complex off Lake Ida Road, about 700 people walk through the doors every day to attend 120 meetings aimed at a swath of needs, from treatment for cocaine addiction to obsessive cluttering, says Susan Miller, executive director, a recovering alcoholic.

Addicts arrive from as far away as Oregon and Rhode Island and from as nearby as South Beach. They face daunting odds: Relapse rates range from 40 to 90 percent, depending on the client’s dedication and will power, sustained treatment, and follow-up care, according to the National Institute on Drug Abuse.

”My parents sent me here to try to turn my life around,” Rani Canosa, 21, a pretty, petite college dropout offers one Monday night at KoffeeOkee. “Alcohol made me feel good. I would be really, really happy, then really, really sad, then just miserable.”

Canosa, from a Baltimore suburb, started drinking seriously as an 18-year-old freshman in college. Soon she could consume a 12-pack of beer and a half-bottle of vodka in a two-hour stretch.

She had tried treatment centers in Maryland and Pennsylvania but returned home only to relapse once she was back among friends and familiar haunts.

Canosa has been in Delray Beach since Aug. 29, out of treatment at the Wellness Resource Center in nearby Boca Raton since Feb. 5. She lives in a halfway house and works as a barista at KoffeeOkee.

”The truth is, if I was home, I would be drunk or looking to get drunk,” she says softly, never making eye contact. “I actually want to be here.”

COLLECTIVE STRUGGLE

But what distinguishes this vibrant recovery community from similar places elsewhere, is a growing sober social infrastructure, an informal network of places for people to mingle without the colossal temptations of drugs and alcohol.

”Delray Beach is a microcosm of the various layers of the recovery process,” says Howard Lerner, clinical director of the Addiction Treatment Program at South Miami Hospital. “Those struggling belong to a fraternity.”

Here, even in the midst of fighting for sobriety, addicts can go dancing at popular clubs that hold sober nights, sing karaoke at a sober coffee house, listen to live music at a sober juke joint, call in to recovery radio shows, roar into the sunset with a sober motorcycle club and pray at a Bible study just for them.

”The struggle with an addiction can be forever,” says Harold Jonas, a mental health counselor. “So all we really want is for people to be healthy and to laugh and have hope and be part of the world, not just the recovery community.”

The collective sobriety struggle here is no longer anonymous. Recovering addicts live among ”normies” and often work on Atlantic Avenue, the city’s glittering ribbon of sidewalk cafes and boutiques and galleries.

”When you are on this journey, it’s incredibly important to feel like you are not alone, to see and be around people just like you,” says nattily-dressed Jonah Yolman, now 22 months on the clean side of a wicked crack-cocaine addiction.

Yolman, 29, sitting in a Starbucks on Atlantic Avenue, quietly acknowledges two people ordering coffee who are in one of the dozens of 12-step anonymous programs. He talks casually about the familiar identifying signs of people in recovery: the relentless smoking and coffee drinking, the trails of cigarette butts and empty coffee cups and candy wrappers. And the most obvious sign: people tightly clutching books with dark covers, their 12-step guides.

”We are everywhere, living and working in this city,” says Yolman, a counselor at a local treatment facility who promotes two sober nights at area clubs. He and a partner are also launching a similar sober club night in August at a South Beach club (sobernightlife.com).

“People come here and enjoy the weather, the beaches, low-key atmosphere and try to start over.”

NATIONAL REPUTATION

In some ways, Delray’s recovery community draws its inspiration from a small, rural town in Minnesota that over the years became a magnet for recovering addicts, from marquee rock stars like Eric Clapton to the anonymous souls who came looking for peace and order.

Since 1949, addicts have famously flocked to Hazelden, which started as a farmhouse retreat in Center City for men working their way through programs based on the 12-step principles.

Over the years, teams of doctors, counselors and chaplains developed a holistic approach to rehab now emulated worldwide.

More than three decades ago, Delray’s first sober houses opened for people making the transition from residential care to independent living. The houses — a yellow clapboard with a sweeping porch on one street, a peach bungalow with a white-picket fence on another — are sprinkled within neighborhoods, around public squares, near churches.

Rents range from $125 to $175 weekly for a room and access to kitchens and family areas. Most landlords require random drug tests, and some perform bed checks or monitor whether their clients have reported to work.

Two years ago, Crossroads Centre in Antigua, a drug-treatment program founded by Eric Clapton, opened in the city. And in February, Lecreshia Hall, a Boca Raton psychiatrist, started Hallway of Life Recovery Center, a faith-based, 28-bed transitional facility for women, on a quiet residential street near downtown.

”When I did the research to find the best place to open, Delray Beach kept coming up,” says Hall, who leads Bible study on Tuesdays. “The idea of our center is to teach our clients how they can use the Bible to help in recovery.”

But Delray Beach’s national reputation as a recovery community has been unsettling for some residents.

”We don’t mind taking care of the people living here, but we don’t particularly like people coming from all over the country or the world to recover,” says City Manager David Harden. “But it’s a fact of life, and so we have tried to be supportive of the community.”

Harden says Delray Beach gives money each year to the Drug Abuse Foundation of Palm Beach County, the county’s oldest chemical-dependency treatment and prevention center. The Commission also sold city property to Crossroads Club several years ago, allowing the center to expand.

Over the years, residents have complained to city officials about the lack of security and control at some sober houses. Owners need only a landlord permit to run them, a reality that makes strict regulation difficult.

Jonas, who heads the South County association and runs the coffee shop, says problems stem mostly from unscrupulous landlords who hope to turn quick profits at the expense of fragile tenants and the surrounding neighborhood.

”You got some of these operators who don’t manage the property or the tenants, then they put the people out and leave them homeless,” Jonas says. “There are some operators we would all be better off without.”

FINDING SOLACE

Jonas came to Florida 20 years ago full of reasons to give up. But with the help of his father, who put him in a West Palm Beach treatment center, he cleaned up and stayed put.

A slight guy with a thick mustache and a thicker Philadelphia accent, Jonas sits in the lounge of his coffee shop one afternoon rattling off his story with sobriety’s detachment and confidence.

Pot by 13. Then acid and speed and cocaine. Graduation to alcohol. Bottomed out in the injection world of cocaine and heroin.

Jonas entered rehab in 1987. He married Dawn, a recovering cocaine addict (they met in a 12-step group), and went back to school, earning an online master’s degree in counseling psychology from Antioch University and a doctorate in addiction studies from International University in St. Kitts.

”You come out of a situation like that broken and with very little to hold on to,” Jonas says. ‘You come out of treatment and you say, `Now what?’ ”

So Jonas and his wife — who recently celebrated her 22nd clean year — began working to answer this huge question, working to help define what life after treatment really means.

In 2000, they launched sober.com, a Web clearinghouse for 30,000 recovery programs nationwide. And for 10 years, he operated a recovery residence in Delray Beach. She runs a home for women in recovery.

Two years ago, they opened KoffeeOkee, in many ways ground zero for the recovery community. Inside is a cozy mix of velvet wingback chairs and bistro tables and a small cafe offering every coffee, tea and juice imaginable but absolutely no alcohol. The walls are covered with bulletin boards offering testimonials, treatment and housing ads, and calendars outlining the month’s sober activities.

A piano sits in the corner with a dried white rose on top, a delicate memorial to Valerie, a drug counselor who died a year ago.

Of an overdose.