The United States is flush with opioids, a type of powerful painkiller that doctors prescribe to help patients deal with chronic and acute pain.
Prescriptions for opioids have been skyrocketing since the early 1990s, when changes in prescribing practices and the introduction of new powerful painkillers changed the market. In 1991, the National Institute on Drug Abuse reported that doctors wrote 76 million prescriptions. By 2011, that number had risen to 219 million. West Virginia has one of the highest prescription rates of opioids in the United States and it ranks in the top 10 for the highest rate of prescriptions given out for high-dose opioids and extended-release opioids — both of which are targets for abusers.
The explosion in prescriptions has subsequently led to an explosion in overdoses and abuse, leading the federal government to dub opioid abuse an epidemic . A U.S. Center for Disease Control and Prevention (CDC) report in January revealed that drug-overdose deaths reached a new high in 2014 , totaling 47,055 people with West Virginia taking the lead. The State had the highest drug-overdose death rate in the United States, where overdose deaths per 100,000 people was: 35.5.
Opioid treatment has long generated controversy. Opioid maintenance therapy, or using a legal opiate, like Suboxone, to reduce a person’s urge has been supported by many who regard it as a practical, cost-effective strategy that prevents death and illness generated by street drug use and allows people, who suffer from addiction to resume “mainstream” lives. But opponents argue that it simply replaces one addiction for another.
A fragmented treatment system, a widespread bias against addiction medications and a shortage of trained workers often thwart those seeking help. Instead, they show up in emergency rooms, or reach out to local doctors, nurses and clergy.
So why is it so complicated? Why IS getting opioid maintenance therapy in West Virginia harder than you think?
- THE GREAT SUBOXONE DEBATE
Before exploring the different aspects of opioid addiction treatment, let’s shed some light on how opioids work in the brain:
Opioids are attached to receptors in the brain. Normally these opioids are the endogenous variety that are created naturally in the body. Once attached, they send signals to the brain of the “opioid effect,” which blocks pain, slows breathing, and has a general calming and anti-depressing effect. The body cannot produce enough natural opioids to stop severe or chronic pain nor can it produce enough to cause an overdose.
Opioids target the brain’s reward system. The overstimulation of this system, which rewards our natural behaviors, produces the euphoric effects sought by people who misuse drugs and teaches them to repeat the behavior.
In 2002, there was an abundance of optimism surrounding Suboxone when it was approved for treatment of heroin and prescription opioids. Suboxone is an opioid itself, but with a twist. This medication can allow one to regain a normal state of mind – free of withdrawal, cravings and the drug-induced highs and lows of addiction.
What Is Suboxone and How Does it Work?
There are two medications combined in each dose of Suboxone. The most important ingredient is Buprenorphine, which is classified as a ‘partial opioid agonist,’ and the second is Naloxone which is an ‘opioid antagonist’ or an opioid blocker.
A ‘partial opioid agonist’ such as Buprenorphine is an opioid that produces less of an effect than a full opioid when it attaches to an opioid receptor in the brain. Oxycodone, hydrocodone, morphine, heroin and methadone are examples of “full opioid agonists.” An opioid antagonist like Naloxone is a medication-assisted treatment option that also fits perfectly into opioid receptors in the brain.
When Suboxone is taken correctly, the Naloxone is not absorbed into the bloodstream to any significant degree.
What’s So Good about Suboxone?
Buprenorphine tricks the brain into thinking that a full opioid like oxycodone or heroin is in the lock, and this suppresses the withdrawal symptoms and cravings associated with that problem opioid. Buprenorphine is a long-acting form of medicated-assisted treatment, meaning that it gets stuck in the brain’s opiate receptors for about 24 hours. This gives the person with opioid addiction a 24-hour reprieve each time a dose of Suboxone is taken.
If a full opioid is taken within 24 hours of Suboxone, the patient will quickly discover that the full opioid is not working – they will not get high and will not get pain relief. This 24-hour reprieve gives the patient time to reconsider the wisdom of relapsing with a problem opioid while undergoing medication-assisted treatment.
Another benefit of Buprenorphine in treating opioid addiction is something called the “ceiling effect.” This means that taking more Suboxone than prescribed does not result in a full opioid effect. Taking extra Suboxone will not get the patient high. This is a distinct advantage over methadone, another medication-assisted therapy drug. Patients can get high on methadone because it is a full opioid. The ceiling effect also helps if Buprenorphine is taken in an overdose – there is less suppression of breathing than would result from a full opioid.
Additionally, success rates, as measured by retention in treatment and one-year sobriety, have been reported as high as 40 to 60 percent in some studies. (According to NIH, there has been little data on treatment for patients addicted to prescription painkillers, especially in the offices of primary care doctors).
How Is Suboxone Taken As a Form of Medication-Assisted Treatment?
Because it is long-acting, (24 hours or more) Suboxone only needs to be taken one time per day. It should be allowed to completely dissolve under the tongue. It comes in both a 2 mg and 8 mg tablet, and a 2 mg or 8 mg strip.
However, if a Suboxone tablet is crushed and then snorted or injected the Naloxone component will travel rapidly to the brain and knock opioids already sitting there out of their receptors. This can trigger a rapid and quite severe withdrawal syndrome.
The strips are now the preferred delivery because they have less potential for abuse by people with opioid addiction (they cannot be crushed), serial numbers on the strip packs help prevent trafficking, and the strips dissolve more rapidly than the tablets.
Suboxone can be prescribed by doctors in an office setting. West Virginia has around 221 to 235 physicians with a license to prescribe Suboxone.
Dr. Carl R. Sullivan, director of addiction programs at WVU Medicine, believes that Suboxone is the best thing that has happened for opioid addicts.
“But it must be used with a medication-assisted treatment program. A lot of people get better,” Sullivan said. “It is the standard of care, and it offers hope where there is no hope.”
Sullivan challenges the perception that opioid maintenance therapy is trading one addictive drug for another.
“People don’t argue when medication is prescribed to treat chronic diseases such as diabetes yet condemn it with opioid addiction treatment,” Sullivan said. “Both are diseases that might require taking treatment for life.”
What’s So Bad about Suboxone Anyway?
There are two accepted uses for Suboxone as a means to help someone recovering from opiate addiction. First, Suboxone can be used during detox to help ease the worst symptoms of withdrawal. This ensures that the recovering addict is free of the strongest physical compulsions to use.
Secondly, many physicians, dealing with addicts possessing a long personal history of chronic opioid abuse, will prescribe a Suboxone maintenance plan.
This is when the patient – typically, a long-term heavy opioid abuser – will be kept on Suboxone for a considerable length of time – months, or even years. The goal of the maintenance plan is to keep cravings manageable until such time as the addict’s brain slowly returns to normal.
This is not a perfect solution, and critics of long-term Suboxone maintenance decry the practice as simply swapping one opiate for another.
Federal law limits individual physicians to no more than 100 Suboxone maintenance clients at a time.
According to The Substance Abuse and Mental Health Services Administration (SAMHSA), there is a misuse potential associated with Buprenorphine/Suboxone.
Because of Buprenorphine’s opioid effects, it can be misused, particularly by people who do not have an opioid dependency.
- THE COST OF CARE
While methadone can cost $3,000 to $3,500 per patient per year, generic Suboxone costs two to three times as much, according to the National Association of State Alcohol and Drug Abuse Directors.
Some insurance companies strictly limit the drug. Medicaid isn’t ideal for providers either. It covers the drug but pays only a tiny fraction of the office visit, making it far easier for the well-insured to obtain than the poor.
Many doctors who dispense the drug take cash only. VICE notes treatment with Suboxone at some facilities can cost as much as $8,000 per month. Depending on the health insurance company, some portion of that cost is covered and the rest of the cost is the patient’s responsibility.
Addicts going outside Medicaid face potentially prohibitive costs that they can’t bear. Prices will vary depending on the dosage and on the quantity that a doctor has prescribed. At CVS Pharmacy, 8mg/2mg of Buprenorphine/Naloxone (60 sublinguals) cost $220.09, while at Walgreens it is 236.41 and in Rite-Aid $315.64.
In addition, as of 2013, Medicaid in 48 states required a prior authorization for Buprenorphine, the active ingredient in Suboxone. West Virginia’s Medicaid program, like those of many other states, requires that as well.
Moreover, many doctors are already at the 100-patient limit and just can’t take any more patients.
- THE WAIT FOR CARE
When addicts decide to get treatment for addiction, it is a huge step, and generally comes from a moment or period of mental clarity. The longer they take to get started, the more they are at risk to give in to their addiction.
In the Comprehensive Opioid Addiction Treatment (COAT) clinic run by Sullivan in Morgantown, the waiting time to be admitted for treatment has reached one year. According to Sullivan, the waiting lists in clinics represent a huge setback in the system.
When someone who is in the grip of these drugs reaches out for help, AND then encounters these waiting lists, that moment of clarity can be fleeting. The system as it exists now isn’t always there with a warm embrace.
- DOCTOR SHORTAGE
The nation’s doctors appear to be inadequately prepared to help with the opioid epidemic and the problem begins in medical school. A report in 2012 by The National Center on Addiction and Substance Abuse revealed that medical schools devoted little time to teaching addiction medicine — only a few hours over the course of four years.
Medical faculties have traditionally eschewed teaching the subject, in part because many physicians viewed addiction as a personal vice rather than a disease. And, even now, some doctors who specialize in addiction treatment are skeptical that the best care for the problem comes out of a medical model.
In a March report, the California Health Care Foundation cited inadequate medical school training as one of the challenges in treating patients addicted to opioids.
“Most physicians just don’t know anything about addiction,” Sullivan said. “They want to specialize in surgery or pediatrics, not deal with addicts.”
Ty Reidenbaugh is a resident physician at WVU Hospitals. He is getting ready to start his addiction psychiatry fellowship next summer. He talks below about his approach to treatment.
The White House has also been pressuring medical schools to improve instruction on opioid addiction, issuing pledges for schools to sign, promising to change their curricula.
In a University of Washington study, based on 2012 data, researchers found that 30 million Americans lived in counties without a single doctor certified to prescribe Suboxone.
As of mid-January, in hard-hit West Virginia, there are just 235 doctors who are certified to dispense Buprenorphine, according to the Drug Enforcement Administration. TheMental Health Services Administration (SAMHSA) puts the number at 221.
The map below locates doctors around Morgantown, who are licensed to dispense Suboxone.
- ANTI-DRUG MINDSET IN RURAL COMMUNITIES
Many U.S. states remain loyal to abstinence-only treatment. Rural communities, particularly, many of which exist in West Virginia, tend to stigmatize medication-assisted therapy. Many people believe that substance abuse is a weakness of personality and that a person needs to get a handle on their disease. In that sense, they think that relying on a drug that replaces the drug of abuse is somehow a weakness.
For some of those opposed to drug maintenance therapy the reasons are straightforward. The goal of a healthy recovery from drug addiction is just– recovery. The very word implies that life will get better as the person returns to a life free of active addiction. Recovery does not mean “simply not getting any worse.”
Opponents believe addicts in successful recovery know they have to make changes in their behaviors and actions to stay clean and sober. They understand that they have to avoid the people, places, and things that are conducive to the destructive life of an addict.
Critics of Suboxone maintenance also flatly state that the practice is contrary to the idea of an addict living a completely drug-free life. Long-term Suboxone patients never get to the root of their addiction problem. And, because the psychological aspects of addiction are never addressed, quality of life for the not-really-recovering addict never improves. In many cases, other substances are taken to replace the missing effects of the heroin/opiate – Xanax, cocaine, and especially, alcohol.
In other words, the person is still an active addict – they’re just not taking opiates.
Alternatives to drug-based therapy
Generally, there has been little data on anti-drug treatment for patients addicted to prescription painkillers. To help address this issue, one of the non-profit organizations that provides long-term residential addiction treatment centered on the Therapeutic Community model “MAAR”, conducted research over a period of eight years and reported the following findings:
Of Opioid-dependent clients, who completed ERR (Extended Recovery Residence), 56 percent reported abstinence at the two year contact point.
Some anti-drug treatment programs add the component of faith to the mix. While each facility is structured slightly differently, most religious recovery facilities combine the teachings of their faith with traditional non-spiritual recovery methods. Most faith-based rehab programs are designed for people who already practice a certain faith.
Some programs are less forceful with the inclusion of the religious component. They provide secular-based treatment as well as the option to pursue spiritual support. Those struggling with addiction, WHO feel a spiritual void but are not certain what they specifically believe, may find this type of program to be a better fit.