If Prescription Drug Addiction Is a Disease, Why Does the Law Make It So Hard to Get Treatment?

Many opioid addicts want to try to quit with the help of medication, but tight federal rules can make those difficult to get.

Former heroin addict David Fitzgerald sits outside a rehabilitation clinic in Portland, Oregon on March 12, 2014.
AP Photo/Steve Dykes
Dec. 7, 2015, 8 p.m.

In 1990, Emily vomited over the course of three straight days. She couldn’t sleep. She felt cold. She felt fe­ver­ish. She felt ex­cru­ci­at­ing pain throughout her body.

It wasn’t the flu: Emily was go­ing through a bout of with­draw­al, try­ing to kick a heroin ad­dic­tion after nearly three years of us­ing.

It was a sad end­ing to Emily’s stint liv­ing in New York, where she moved primar­ily be­cause drugs were more ac­cess­ible there and en­joyed a party life­style in which heroin came easy. But after three years, her fath­er came to pick her up. Emily was open with him about her drug us­age, and the two mu­tu­ally agreed it was time to go back to Michigan in hopes of a fresh start.

It didn’t last. After the pain of with­draw­al was over, the lure of the drugs was still there. It was a drug that had at first giv­en Emily so much pleas­ure, and she missed it.  “The whole time, even though with­draw­al had been so hor­rible,” Emily said, “[all] I could think about was get­ting back to New York and get­ting high again. It was like an ob­ses­sion. It was like none of the bad stuff had ever happened—all I could do was re­mem­ber the good times.”

And soon enough, she began pop­ping pills when she could find them, but that proved dif­fi­cult in Michigan, so she turned to drink­ing al­co­hol and tak­ing diet pills in ex­cess in­stead. When she moved to Cali­for­nia in the late 1990s, paink­illers—the drug she really craved—were once again ac­cess­ible, kick­ing off a cycle of ad­dic­tion, with­draw­al, and re­lapse.

“There’s al­ways this part of my head that just wouldn’t let go,” said Emily, who now lives in Michigan. “There’s something about that par­tic­u­lar drug, opi­ates, it just settles my brain, and I just feel a calm and a total lack of anxi­ety. And I just feel com­fort­able in the world, and that’s just something that I’ve nev­er had in any oth­er situ­ation with any oth­er sub­stance or nat­ur­ally. So I couldn’t for­get that—no mat­ter how much that I talked about it and knew I would get in trouble.”

Dur­ing those dec­ades, Emily (I agreed to use just her first name to al­low her to speak openly about her per­son­al his­tory) tried a bat­tery of tech­niques in­ten­ded to help her quit. She tried be­ha­vi­or­al ther­apy, group ther­apy, ab­stin­ence-based meet­ings—but noth­ing jump­star­ted Emily on a long-term path of re­cov­ery.

But around Feb­ru­ary, she em­barked on a course of ther­apy that has been the most suc­cess­ful yet: pre­scrip­tion drugs aimed at help­ing pa­tients kick opioid ad­dic­tions. Emily said her crav­ings dis­sip­ated. She tried pop­ping a pill once, just to see, and didn’t get high. So, Emily says, what’s the point of tak­ing a drug you don’t crave and that wouldn’t give you a buzz any­way? “Why waste your time and money? That’s the way I feel about it,” she said.

The use of one pre­scrip­tion drug to kick an ad­dic­tion to an­oth­er is coun­ter­in­tu­it­ive, but medi­cine coupled with ther­apy is in­creas­ingly com­mon in treat­ing opioid ad­dic­tion—and re­flect­ive of a school of thought that opioid ad­dic­tion is best ad­dressed not as a crime or as a mor­al fail­ing, but as a dis­ease.

But while the tech­no­lo­gies and mind-sets have shif­ted, the pub­lic policies gov­ern­ing opioid ad­dic­tion have moved more slowly, to the point where, for some pa­tients, laws are stand­ing between them and the new treat­ments, which couple ther­apy with med­ic­a­tion.  

The White House and Con­gress are try­ing to play catch-up. The ad­min­is­tra­tion has taken steps to in­crease ac­cess, such as dol­ing out grants to com­munit­ies and look­ing to change a rule lim­it­ing the num­ber of pa­tients phys­i­cians can treat with one of the drugs. And Con­gress has a host of bills aimed at stop­ping the pre­scrip­tion drug and heroin epi­dem­ic ravaging com­munit­ies na­tion­wide. (Pre­scrip­tion paink­iller-re­lated deaths quad­rupled from 1999 to 2013, and sim­il­arly, heroin-re­lated over­dose deaths nearly quad­rupled from 2002 to 2013, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Pre­ven­tion.)

Some of the activ­ity is aimed at in­creas­ing the avail­ab­il­ity of the three Food and Drug Ad­min­is­tra­tion-ap­proved med­ic­a­tions for treat­ing opioid use dis­order: meth­adone, bupren­orphine, and nal­trex­one.

Meth­adone clin­ics have been around for dec­ades. The drug works to al­ter how the brain and the nervous sys­tem re­spond to pain and can block the ef­fect of paink­illers and heroin. And it helps re­duce crav­ings and can pre­vent with­draw­al symp­toms in thera­peut­ic doses. Called an opioid ag­on­ist, it acts on the same tar­gets in the brain as oth­er opioids do. The Sub­stance Ab­use and Men­tal Health Ser­vices Ad­min­is­tra­tion web­site warns it can be ad­dict­ive, “so it must be used ex­actly as pre­scribed.”  

More re­cently, an­oth­er medi­cine entered the mar­ket­place. Bupren­orphine won FDA ap­prov­al in 2002, and it helps re­duce or pre­vent with­draw­al symp­toms and di­min­ishes crav­ings.(Emily uses a form of this, called sub­ox­one.) Called an “opioid par­tial ag­on­ist,” it can pro­duce the ef­fects of oth­er opioids, but it does so at a weak­er level than heroin and meth­adone.

In 2010, an in­ject­able form of nal­trex­one—which blocks any high a per­son would feel if they took heroin or a paink­iller—won FDA ap­prov­al (nal­trex­one was first ap­proved in 1984). This shot form is called vivit­rol, and it’s in­jec­ted about once a month. The pill form of nal­trex­one is taken daily. There’s a catch with nal­trex­one, though: It’s the only opioid-use dis­order med­ic­a­tion re­quir­ing pa­tients to have gone through the full, pain­ful de­tox pro­cess—and that can be a turnoff and dif­fi­cult for some long-time drug users.

The way to tell which treat­ment is best for a par­tic­u­lar per­son, at least ac­cord­ing to the Amer­ic­an So­ci­ety of Ad­dic­tion Medi­cine, is through an in­di­vidu­al as­sess­ment, which helps pro­fes­sion­als form a treat­ment plan.

When someone de­cides on med­ic­a­tion-as­sisted treat­ment, though, his or her op­tions may already be lim­ited. That’s be­cause med­ic­a­tions aren’t al­ways ac­cess­ible. 

With meth­adone, clin­ics are highly reg­u­lated, re­quir­ing a pleth­ora of li­censes and cer­ti­fic­ates, and pa­tients gen­er­ally must take their medi­cine daily at a clin­ic (and typ­ic­ally must live close enough to get there every day). When I vis­ited one in Mont­gomery County, Mary­land, I saw where people pick up their daily dose; they stand in front of a win­dow, like the one di­vid­ing a bank tell­er from a cus­tom­er, and take a swig of li­quid meth­adone in front of a health pro­fes­sion­al.

With bupren­orphine, the law—called the Drug Ad­dic­tion Treat­ment Act of 2000, or DATA 2000—lim­its the num­ber of pa­tients whom health pro­viders can treat with the medi­cine from 30 in their first year to 100 af­ter­ward (the Health and Hu­man Ser­vices De­part­ment an­nounced in Septem­ber that it would re­vise this reg­u­la­tion but has not yet de­tailed what the change will be).

In Dr. Corey Wall­er’s clin­ic in Grand Rap­ids, Michigan, one of the most pop­u­lous metro areas in the state, the hard cap at 100 means turn­ing away ad­dicts look­ing for help. Once in a while, one of his pa­tients will trans­ition off bupren­orphine, leav­ing an open slot. And his clin­ic re­cently hired a phys­i­cian, open­ing 100 slots. Wall­er, who is also an Amer­ic­an So­ci­ety of Ad­dic­tion Medi­cine le­gis­lat­ive ad­vocacy com­mit­tee chair, said those would likely be filled in six to eight months.

While us­ing med­ic­a­tion to treat ad­dic­tion is gain­ing pop­ular­ity, there are still some in Con­gress con­cerned about loosen­ing re­stric­tions. Rep. Tim Murphy, who chairs the House En­ergy and Com­merce Over­sight and In­vest­ig­a­tions Sub­com­mit­tee, told Na­tion­al Journ­al in Oc­to­ber that the idea of lift­ing the cap on bupren­orphine pre­scrip­tions was “very con­cern­ing.

“Med­ic­a­tion-as­sisted treat­ment can be help­ful,” the Pennsylvania Re­pub­lic­an said in an in­ter­view. “It can be one of the pil­lars of the bridge, but it’s not the whole bridge, and it’s cer­tainly not the des­tin­a­tion.”

He, along with a dozen oth­er House mem­bers, signed a let­ter to HHS Sec­ret­ary Sylvia Math­ews Bur­well ur­ging the de­part­ment to ana­lyze the qual­ity and ef­fect­ive­ness of med­ic­a­tion-as­sisted treat­ment prac­tices be­fore chan­ging the lim­it.

“We know very little about the DATA 2000 waivered prac­tices, how many pa­tients are in them, what treat­ment ser­vices they re­ceive, how long they stay in treat­ment, and how of­ten they use il­li­cit opioids or di­vert the bupren­orphine that is pre­scribed to them,” the let­ter states.

For health pro­viders, what “re­cov­ery” en­tails—and the best path to get there—var­ies widely from pa­tient to pa­tient. With all the op­tions, in­clud­ing the three dif­fer­ent med­ic­a­tions, 12-step pro­grams, and in­pa­tient and out­pa­tient re­cov­ery cen­ters, they say it’s im­per­at­ive that all op­tions are read­ily avail­able to those look­ing to start the pro­cess.

There’s been a broad­er re­cog­ni­tion that ab­stin­ence-only re­cov­ery mod­els such as 12-step pro­grams aren’t the holy grail of treat­ment they were once thought to be, and that medi­cine, coupled with ther­apy, can lead to long-term re­cov­ery.

“Some of that really has been brought about by this opi­ate epi­dem­ic and the find­ing that these med­ic­a­tions are in fact quite ef­fect­ive for treat­ing the opi­ate-de­pend­ent per­son,” says Dr. Mar­garet Jar­vis, an Amer­ic­an So­ci­ety of Ad­dic­tion Medi­cine board sec­ret­ary. But, she ad­ded, the shift isn’t com­plete: “The stance that all people need to do is get in­to coun­sel­ing and 12-step work is very, very in­grained. There are a lot of people who have worked with that idea for dec­ades, and so for them to be able to make use of the med­ic­a­tions, is hard; it’s really hard.”

The tide is turn­ing to­ward us­ing med­ic­a­tion in con­junc­tion with ther­apy, agrees Larry Gamble, man­ager of Mont­gomery County De­part­ment of Health and Hu­man Ser­vices spe­cialty be­ha­vi­or­al-health ser­vices, though he also said there’s still a ways to go. If a res­id­ent walks in­to the clin­ic with a his­tory of opioid use, of­fi­cials strongly re­com­mend medi­cine in ad­di­tion to ther­apy, Gamble says. But, of course, the pa­tient has to con­sent, and then health pro­viders work on the best step for­ward.

It boils down to find­ing the right treat­ment for the right pa­tient at the right time, says Wall­er. Be­cause with every oth­er dis­ease, he says, doc­tors talk through the risks and be­ne­fits of each treat­ment course—in­clud­ing med­ic­a­tion—and sub­stance-use dis­orders should be no dif­fer­ent.

For Emily, it’s sub­ox­one, coupled with ther­apy, that she cred­its with keep­ing her away from opioids since about Feb­ru­ary. She has been clean for about this long at least three dif­fer­ent times (twice were dur­ing preg­nan­cies), only to fall back in­to the ab­use-with­draw­al cycle. “It’s tough be­cause you’re fight­ing against your brain,” she says.

And that’s why she’s hop­ing this time is dif­fer­ent. For most people with sub­stance prob­lems, ad­dic­tion is a treat­able con­di­tion, but it’s also typ­ic­ally a chron­ic one—mean­ing long-term care can be re­quired.

Still, as the months go by, Emily sees a reas­on for hope. Be­cause this time does feel dif­fer­ent. She can feel the med­ic­a­tion work­ing, the phys­ic­al crav­ings sub­dued. She at­tends 12-step meet­ings as much as she can. She has ap­point­ments every two weeks with a doc­tor and weekly ones with a ther­ap­ist that, Emily says, really un­der­stands her.

And she’s be­come the kind of moth­er who helps her child get ready for school, in­stead of sleep­ing in late. She lives in Michigan, work­ing nights and week­ends in the phone room of a mar­ket re­search com­pany, a job she’s held for about 10 years, but for the first time she now has goals of her own: be­com­ing a drug and al­co­hol coun­selor. She plans to go back to school by at least the fall semester.

“I’m look­ing at start­ing life over again at 50,” Emily said, “and I’m really look­ing for­ward to that.”

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