America’s Health-Care System Is Making the Opioid Crisis Worse

Arcane rules and outdated beliefs about addiction are keeping many people from getting treatment.

MA8 / Mukesh Kumar / Shutterstock / The Atlantic

Outside a liquor store in a rough part of Trenton, New Jersey, a one-eyed woman with sores on her face walked by, seemingly in a hurry.

I asked if she used heroin, and when she said she did, I asked her whether she had ever considered treatment. She said doctors have dismissed her. They tell her she’s choosing her “lifestyle.” The woman—who, like others, wouldn’t give me her name because of the stigma associated with addiction—said that at one point she tried to get on Suboxone, a medication that reduces cravings for heroin. It didn’t work, she complained. She says she was on a 12-milligram dose, far lower than the maximum dose of 32 milligrams.

She turned to a few other drug users standing nearby and plotted where to get food. Meanwhile, the woman’s companion, a man with a green-dyed beard, told me about his own struggles with addiction. His voice tinged with bitterness, the man said that when he’s asked doctors for help quitting heroin, they have given him referrals to rehab programs that have turned out to have long waits or otherwise have rejected him.

One of the pair’s friends—a stringy-haired woman who told me she has a crack addiction—chimed in to say that in the past, she’s gotten high just to boost her chances of being admitted into a rehab.

Given addiction’s tendency to ravage a person’s life, it’s not clear how many of these are simply one-off misunderstandings between a busy doctor and a desperate patient. But something clearly isn’t working. Though opioid deaths have declined in some parts of New Jersey, in several counties—including Mercer, which surrounds Trenton—the death toll continues to climb. Meanwhile, more than three-quarters of people with drug addictions in New Jersey go untreated. From January 2017 to January 2018, overdose deaths in New Jersey rose by 21 percent, compared with just 7 percent nationally.

The stories of the people I met in Trenton who are dealing with addiction reflect the many ways heroin users not only in New Jersey, but in every state, can tumble through the cracks of the American medical system. Had a doctor placed the one-eyed woman on a higher dose of Suboxone than the one she claimed she was given, the medication might have worked. And the referrals to rehab programs her companion said he received from his doctors were not necessary, because any doctor can get licensed to prescribe Suboxone. Unlike the better-known methadone, Suboxone does not have to be prescribed at a special, carefully monitored facility.

For the past two years, the number of Americans dying of drug overdoses each year have outnumbered those who died in the entire Vietnam War. But there’s an overwhelming consensus among experts on how to bring deaths down: Opioid addicts should be treated as soon as possible, and with medication. When France allowed any of its primary-care doctors to prescribe buprenorphine, which is a form of Suboxone, heroin-overdose deaths plummeted by 79 percent in four years.

In almost every U.S. state, meanwhile, doctors, patients, and experts describe a situation in which too few doctors offer Suboxone cheaply or for free. Instead, addicted patients tend to be funneled into rehab programs, many of which are pricey, unavailable, or ineffective. “Most of the general public thinks you should go to rehab if you have opioid addiction,” says Adam Bisaga, a professor of psychiatry at the Columbia University Medical Center. “But 70 percent of the success is giving [patients] the medication.” Adding things like housing and psychotherapy can bring the success rate up, but, Basiga adds, “the core of it is really medication.”

He puts it this way: “If you have diabetes, you need insulin. Without insulin, you will perish.” Without easy access to Suboxone and other medications, people addicted to heroin continue to perish at a terrifying rate.

The grim overdose statistics in New Jersey are in part a matter of geography: The state is wedged between the drug-trafficking hubs of New York and Philadelphia, attached to a port, and webbed with well-developed organized-crime networks. “I’ve had patients tell me, ‘I had to go out of state, because no matter where I go in New Jersey, it’s so easy [to get drugs],’” said Rachael Evans, a doctor at the Henry J. Austin primary-care clinic in Trenton.

But the state’s medical system could also be doing more. Only one-quarter of all addiction-treatment providers in New Jersey offer medication-assisted treatment, a category that includes Suboxone. Perhaps because Suboxone is so scarce, many heroin users seem to have gotten the idea that their only option is a residential program, which many experts now believe aren’t as essential as just getting started on Suboxone. In Atlantic City, I met a 54-year-old heroin user who was smoking a clove cigarette outside a drop-in center for the homeless. She told me that if there was a way to get Suboxone, she would “definitely” get on it. But she said treatment programs are hard to get into, especially because she does not have a photo ID.

An older man who said he was a veteran was also looking forward to “getting into treatment” for his heroin addiction. But he worried that a residential treatment program won’t help him in the long run, because it wouldn’t allow him to keep a job. He’s homeless, and he needs to earn money so he has somewhere to go once he’s clean. “Right now I have nothing in my pockets,” he said. “If we go in six months, we come out, we’re still broke.”

There are, however, examples around the state of addiction treatment performed in a way that aligns with the scientific evidence.

New Jersey actually has a higher-than-average number of doctors who have become licensed to prescribe Suboxone. In every state, doctors are required to take an eight-hour class before they can do so, despite the fact that no such class was required to prescribe the prescription painkillers that ignited the opioid epidemic. Nationally, only about 5 percent of all doctors have this Suboxone license, and in 2011, 43 percent of all U.S. counties had no doctors who could prescribe Suboxone. About 1,660 physicians and nurses have the license in New Jersey, which has about 9,500 total primary-care doctors and psychiatrists.

But many drug users are poor, and not every licensed doctor accepts insurance. Doctors at places like the Henry J. Austin clinic in Trenton and at Project H.O.P.E. in Camden do. Lynda Bascelli, the chief medical officer of Project H.O.P.E., told me some patients ask to transfer their Suboxone treatment to Project H.O.P.E. after they realize it both accepts Medicaid and prescribes Suboxone. “Some of the patients might have been to a physician that had a cash-only practice, and they did the best they could to pay to be seen so they could get their prescription,” she said.

If people use heroin, and would like to quit, they can walk into an appointment with a primary-care doctor at these clinics, just like they would if they had strep throat. Unless they want to be, they aren’t referred to an inpatient program or detox center. Doctors at places like Project H.OP.E. and Henry J. Austin prescribe enough Suboxone so that the patient feels like it’s working. This system allows heroin users who have jobs to keep them while they recover from their addictions, just like anyone with any other chronic illness would.

Places like Henry J. Austin have a markedly gentle approach that would seem anathema to abstinence-only drug-rehab programs, which believe that Suboxone simply replaces one drug with another. Many rehab programs require their clients to avoid all drugs and alcohol or face being kicked out, but Henry J. Austin gives patients repeated second chances. To them, firing a patient for relapsing makes as much sense as discharging a diabetic patient for eating cake. “There’s this fantasy that [doctors] can create accountability by being mean,” said Evans, who is Henry J. Austin’s chief medical officer. She says it takes patients about seven attempts at treatment before it works, so relapsing is to be expected.

The doctors at Henry J. Austin follow a “harm reduction” approach that is popular with many public-health advocates: They remain clear-eyed about the fact that some people will continue using heroin, and they try to minimize the dangers associated with its use. They give heroin users Narcan, the drug that reverses overdoses, and advise them to never use alone. Evans says she has gone so far as to tell gobsmacked parents to buy their 15-year-olds clean needles so they can safely use at home.

Outside of clinics like these, the addiction field is rife with outdated information. One of the most common reasons why doctors won’t get licensed to prescribe Suboxone is that they don’t believe the treatment works. Another common misconception, according to Evans, is the idea that people who relapse “weren’t ready to quit getting high.” Instead, she says, most people addicted to heroin are just trying to avoid the agonizing pain of opioid withdrawal, which feels like a severe flu and can last up to six months. “Most people who are actively using are not seeking euphoria,” Evans said. “They’re avoiding pain.”

Suboxone can help ease these withdrawal symptoms and cravings for heroin, though it can take about 18 months for it to work fully. It does make patients technically “dependent” on another drug—the Suboxone—but it is much safer to use than heroin or OxyContin.

Last month, President Trump signed an opioid bill that eased some of the obstacles to treatment, and the president’s commission on opioids last year called for broader prescribing of Suboxone and other types of buprenorphine. But “the opioid crisis is so vast that this bill is not going to solve the whole problem,” says Anna Lembke, a psychiatrist and addiction expert at Stanford University.

Several experts have said that fully tackling this epidemic would require something more like the Ryan White CARE Act, which was passed during the HIV epidemic and put AIDS drugs in the hands of thousands of patients, regardless of their ability to pay. Imagine a heroin user who wakes up feeling dope sick, with diarrhea or nausea, and knows where to buy a bag of heroin to make the sickness go away. If the bag of heroin is easier to find and cheaper than Suboxone, the person will keep using. “If we want to see deaths come down, treatment has to be less expensive and easier to get,” says Andrew Kolodny, a co-director of opioid-policy research at Brandeis University. Kolodny estimates that an investment of about $60 billion over 10 years is roughly what’s needed to curb the opioid crisis.

Meanwhile, other actions taken by President Trump will make addiction treatment even harder to access. People with addiction are already more likely to be uninsured than those who aren’t addicted, and their insurance status can affect their access to Suboxone and other medications. But the changes to Obamacare made by the Trump administration are predicted to swell the ranks of the uninsured.

Medicaid payment rules further complicate the process of treating people addicted to heroin. Bascelli’s clinic in Camden employs one full-time staff member just to obtain prior authorizations from insurance plans for Suboxone. Still, a patient might leave with their Suboxone prescription, arrive at the pharmacy, and still be asked to wait for 72 hours for the medication to be approved by their insurance. “People overdose and die in that window,” Bascelli said.

Some doctors might be more likely to treat addiction patients if they had support from a psychologist or other mental-health expert. At Henry J. Austin, Lee Ruszczyk, the clinic’s senior director of behavioral health, works with the medical doctors to deliver small bursts of mental-health help during medical appointments. This is because in New Jersey, doctors are allowed to bill Medicaid for a patient’s medical visit and a mental-health visit that occur on the same day. But in some states, this isn’t allowed, forcing clinics to eat the cost of one visit or the other. In Sacramento, California, doctors at One Community Health told me they lose $200 to $300 per visit if addiction patients see a psychotherapist and a medical doctor on the same day, because only one visit will be reimbursed by Medicaid. (A spokeswoman for the California Department of Health Care Services defended this practice by saying that the rates these clinics are paid “specifically accounts for all of the costs of all of the services in a day.”) Some other states’ Medicaid rules require patients to “fail” at other types of treatments before they’ll be granted access to Suboxone.

Arthur Robin Williams, a professor of clinical psychiatry at Columbia University, says some insurance plans require doctors to mail or fax drug-testing results to prove the patient is free of other drugs before starting the patient on Suboxone, or demand to see the provider’s psychotherapy notes. Because Williams wasn’t officially listed as the primary-care physician for one 22-year-old patient, Williams once had trouble getting the patient his Vivitrol—another medication that can treat heroin addiction. The man relapsed and developed a bacterial heart infection. “He wound up in the hospital for three months and had to have part of his heart transplanted, because his insurance wouldn’t pay for his Vivitrol,” Williams said. “They make it so onerous.”

I asked more than a dozen experts why more doctors don’t prescribe Suboxone, and over and over, they said the biggest factors are stigma and fear. Addicted patients are perceived as being disruptive or devious. The average medical student spends only a few hours learning about addiction, and some doctors might simply be befuddled by how to treat addicted patients. Bisaga pointed out that it took years before primary-care doctors, rather than specialists, began treating ailments like depression and diabetes.

When antidepressants became popular in the 1980s, drug companies conducted medical-education courses, complete with free meals and trips, for primary-care doctors interested in learning about depression and its treatment. Pharma-sponsored trips come with their own pitfalls, but in the case of Suboxone, says Mack Lipkin, an internal-medicine expert at NYU Langone Medical Center, “there still has been no concerted effort to get the word out to primary-care doctors.” Similarly, the Ryan White care Act came with funding for special training centers so that doctors could learn how to treat AIDS. There’s nothing like that for Suboxone.

For doctors, there can be a benefit to overcoming the Suboxone apprehension, however. Several doctors told me that once they began prescribing Suboxone, treating heroin users became the most rewarding part of their jobs.

It’s one of the few remedies that can instantly stop a deadly disease in its tracks and transform the patient’s life. It is as close to a miracle drug as people addicted to heroin can hope for. “It’s not often that you see this individual looking like an entirely different person,” Bascelli said. “Treating opioid dependence with medication has brought the joy back to practice.”