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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