needle exchange heroin

As America comes to grips with its surging heroin epidemic, so too are health care providers coming to grips with an internal debate challenging their preconceived notions and deep-rooted philosophies about the best model of treatment to break such addiction.

Over 90 percent of addiction treatment providers in America still rely on an abstinence-only 12-step model, which typically disavows any use of medication-assisted treatment (MAT) – the prescribing of less-dangerous medication that decreases a patient’s craving for heroin or powerful painkillers, along with extensive behavioral therapy. To many adhering to this abstinence-only philosophy, such MAT drugs – which patients build a dependence on and sometimes continue using as prescribed for years – are simply the trading of one addiction for another.

However, a growing consensus of peer-reviewed research and health professionals are calling for a revolution in the field of opioid addiction treatment, as decades of data from across the globe point to MAT including proper therapy and counseling as a best practice in the field. Though the 12-steps model of Alcoholics Anonymous has served as a blueprint for the treatment of alcoholism in America for nearly a century, this research suggests addiction to opioids is a different beast, the treatment of which cannot simply be cut and paste with the same expected results.

As recent legislation in states like Kentucky has cracked down on so-called “pill mills,” overdose deaths involving prescription painkillers has now been joined by heroin as addicts switch to the cheaper and more available opioid. Relapse for those in the midst of treatment for heroin addiction is especially dangerous, as their tolerance for the drug has vanished after periods of abstinence, and their previous dosage would bring the high risk of an overdose.

Such consensus on the research of heroin addiction treatment is slowly beginning to trickle into Kentucky, as evidenced by the recent announcement by Louisville area behavioral health care provider Seven Counties Services of a new program fully embracing the therapy plus MAT model.

Seven Counties’ new vice president of addiction services Scott Hesseltine is a recent transplant from Minnesota’s Hazelden Betty Ford Foundation, which was once deeply rooted in an abstinence-only model that shunned MAT. However, seeing an alarming rate of relapse and heroin overdose deaths among patients, Hazelden CEO Marvin Seppala tasked Hesseltine with scouring research in the field to come up with a new treatment strategy. What they devised was a model that combined their 12-step model of therapy with MAT, including the use of Vivitrol and Suboxone.

How Suboxone (buprenephrine) works | Source: The National Alliance of Advocates for Buprenephrine Treatment
How Suboxone (buprenephrine) works | Source: The National Alliance of Advocates for Buprenephrine Treatment

Vivitrol is administered through a monthly injection of the non-narcotic drug naltrexone, which attaches to brain receptors and blocks opioids from having their typical pleasurable effect. Suboxone is a daily film or tablet placed under the tongue and its main component is buprenorphine – which itself is a long-acting opioid, though it blocks the same receptors from other opioids, reduces craving and significantly reduces withdrawal symptoms. Though it can initially produce a mild high and will create a dependence, there is a ceiling-effect that does not increase the high if more opioids are consumed, and it is virtually impossible to overdose on alone.

Suboxone also contains naloxone, the drug used to revive people who have overdosed on heroin, so if melted down and injected in the attempt to abuse it, the drug will send the user into an immediate and very unpleasant withdrawal. If taken properly, it theoretically allows the patient to remain functional in society and avoid the destructive and compulsive behavior of an addict.

The results of the new treatment program — Comprehensive Opioid Response with 12 Steps, aka COR-12 — for Hazelden’s patients in Center City, Minn. were astounding, as post-treatment overdose deaths in the first year plunged to zero. Seven Counties is now implementing the same program in Bullitt County and plans to duplicate it in more locations by the end of this year, greatly expanding their current use of Vivitrol and introducing patients to Suboxone on a limited basis for the first time.

When rolling out this new COR-12 program in March, Seven Counties CEO Tony Zipple referred to its adoption as part of their “reinvention of addiction services.” That reinvention continued two weeks later, when Seven Counties announced their affiliation with large nonprofit Centerstone – a network of behavioral health care providers in the South and Midwest – a move Zipple described as a way to “stay ahead of the curve” in a rapidly changing field.

Centerstone CEO David Guth says their affiliates also have changed with the times, as they too once shunned the MAT model of treatment due to their deep-rooted abstinence-based philosophy. However – partly due to the findings of their research institute — Guth says Centerstone now embraces MAT in order to treat opioid addiction, as “we just couldn’t ignore the data.”

“We were all abstinence-based, I’ll just tell you that,” says Guth, noting such treatment was largely built around alcoholism, which is far different than opioid addiction. “But when the science and the evidence emerged on this, you just can’t ignore the evidence. And the outcomes with MAT are phenomenal. So you’re seeing that wave change.”

But this wave change to MAT still faces plenty of resistance among providers in the field of addiction treatment and the criminal justice system in Kentucky, who often view Suboxone in particular as more of a scourge than part of the solution to the heroin epidemic.

The Rise of Suboxone

Much of the criticism of Suboxone relates to its growing black market through diversion, as some who are prescribed the drug melt it down to inject it or sell it for heroin. As shady painkiller pill mills began to subside and heroin leaped into its place, prescriptions for Suboxone also have increased. Due to law enforcement concerns over diversion and some unscrupulous doctors writing prescriptions without the accompanying counseling and monitoring, new regulations have made it extremely difficult to provide MAT for low-income patients.

The state-funded Recovery Kentucky network of residential addiction treatment facilities in 15 locations around the state remains wedded to an abstinence-only model that resists MAT, even touting their ability to help those abusing Suboxone to kick that habit. Until recently, not only did county drug court judges send addicted criminals exclusively to such abstinence-based programs, but they required opioid addicts currently using Suboxone to discontinue use of the drug.

The Healing Place in Louisville is the largest and oldest addiction treatment provider of the Recover Kentucky network, whose members have emulated their model that is widely seen as a leader in treating alcoholism. But when it comes to MAT and Suboxone as another tool in the toolbox for fighting heroin addiction, The Healing Place has made it clear they won’t have the same reinvention as Seven Counties – even as the percentage of their patients addicted to heroin has leaped from under 1 percent four years ago to 95 percent today.

As Healing Place chief program officer Patrick Fogarty wrote in a recent column on their website regarding advocates of MAT and Suboxone: “Those of us who are on the front lines have a different perception of this theory or what science has told us to believe.”

The FDA first approved the prescription of Suboxone by doctors in 2002, following research showing the drug cut heroin overdose deaths by nearly 80 percent in France during the 1990s. Legislation in Congress allowed doctors to apply for a waiver to prescribe Suboxone after completing a training course, limited to a maximum of 30 patients at a time in the first year and 100 in following years. As opposed to methadone — the most common form of MAT at the time that must be taken daily under supervision at a clinic, due to a greater potency and threat of diversion – Suboxone hypothetically offered patients the freedom to live a normal life while buying time to safely work through the root causes of their addiction in therapy and counseling.

Suboxone_SL_Tabs
Suboxone | Photo via Creative Commons

Demand for Suboxone has spiked along with the rise in heroin use – in many areas exceeding the capacity of doctors willing and able to prescribe it. In areas with few providers, which were usually more rural, patients would be forced onto wait lists if they wanted to begin a Suboxone program, but the overwhelming majority of heroin addicts had no other option than an abstinence-only 12-step program.

This was the case in Kentucky, as described in last year’s 20,000-word Huffington Post article by Jason Cherkis, who recently was named a finalist for the Pulitzer Prize. While the state doesn’t track the treatment history of those who die from a heroin overdose, Cherkis worked his way backwards to do so with 74 of the 93 victims in three northern Kentucky counties in 2013, finding through their family members that most had experience with abstinence-based 12-step treatment, and detailing the accounts of several who died days or weeks after being discharged from long-term residential treatments.

Cherkis also described the resistance to MAT and Suboxone in particular, despite a growing national consensus of experts touting the pressing need to increase access to such treatment. Such advocates include the federal National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration, the American Society of Addiction Medicine, and most recently, the administration of President Barack Obama and members of Congress.

The U.S. Department of Health and Human Services announced a proposed rule last month to increase the amount of patients a doctor can prescribe Suboxone to at one time to 200, which could go into effect by the end of this year. Legislation to increase this limit to 500 recently passed a U.S. Senate committee by a wide margin, with Kentucky Sen. Rand Paul as one of its co-sponsors.

Kentucky’s state legislature also took a step to move toward treatment instead of incarceration for heroin addicts last year, passing a law to allow county health departments to set up their own syringe exchanges to prevent the sharing of needles and spread of HIV and Hepatitis C. The law also mandated for the first time that medical students receive training in addiction treatment and appropriated more money for treatment programs, though an overwhelming majority of those funds go to ones that do not use MAT.

While judges used to be able to force drug court participants off of drugs like Suboxone after six months in order to avoid jail, federal pressure led the Kentucky Supreme Court to prohibit them from doing so last year. Despite more judges getting past the stigma around MAT, according to current figures provided by the Kentucky Administrative Office of the Courts, only judges in 14 counties refer participants to treatment that includes MAT. Despite nearly half of drug court participants being addicted to an opioid, only 40 of the 2,420 current participants in drug courts – less than 2 percent – are referred to MAT treatment. There are only 15 referred to treatment with Suboxone.

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