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How treating opioids with more opioids has divided the recovery community

He sat in the doctor’s office in Naples, Florida, feeling drug sick. He thought that if this didn’t work, maybe nothing would.

Greg Frye’s drug use started in high school. First weed, then mushrooms, acid, cocaine. He wanted to live wild like Jim Morrison. Despite the drugs, he managed to stay on the football team and make good grades. He eventually dropped out of school, but got a job in real estate. He did well, making vice president by 25. For a long time, he held it together. Until the opioids.

His first taste was Percocet, a painkiller prescribed after he had his wisdom teeth taken out. It made him feel warm and fuzzy, like he had no problems in the world. Later he tried oxycodone, which led to other pills, then heroin. Soon, opioids “became my food,” Frye said. He began going to the bathroom every half hour at work to snort heroin and cocaine, thinking no one noticed.

Soon his life began to unravel. His fiancee had been using too, and injected him with a needle for the first time. Where before he had found her beautiful, her eyes now looked vacant and glazed. His friends began to overdose around him. The ones still alive were like “the walking dead.” It seemed that the entire town of Naples was on opioids.

Then in 2006, when he was 26, Frye went on a six-day bender with his brother and fiancé, and blacked out while driving. A priest found him passed out in a church parking lot, mid-injection, and called the cops. Frye was arrested, went through withdrawal in jail, was sent to rehab, came out, and started using again. He wanted to get clean. He had a three-year-old daughter, and he didn’t want her to grow up seeing him like this. He’d heard about a new medication, a semi-synthetic opioid, that was supposed to relieve withdrawal symptoms and get rid of cravings. It was called Subutex.

The downtown Naples area is pictured on Tuesday, Sept. 19, 2017. Photo by Logan Newell

“I was just desperate for anything to get away from it,” Frye said. “Because I could get off drugs for a week, but then I’d start feeling like I wanted something, and would get somebody to come over, and then get right back on it again.”

Frye waited two hours in the doctor’s office that day. When he finally got in, the doctor prescribed him 8mg of Subutex, a small orange tablet in the shape of a stop sign. Afterward, as he sat in his car outside the office, he suddenly felt normal; the medication worked that fast. “All of a sudden it was just no more zombie. It was very even and I just felt like I should feel.”

Frye relapsed, but then started taking Subutex again, and it ultimately kept him clean. His ex-fiancée — the couple separated, as both fought addiction — died from drug-related sepsis and he became a single dad. Opioids change you, he said. But medication “opened the door for me to get away from that.”

Fighting drugs with drugs

As America’s opioid crisis deepens, millions are now on some form of medication-assisted treatment, including Subutex and its sister drug, Suboxone. The treatment, which combines medication with behavioral therapy, was described to PBS NewsHour by clinicians as the “gold standard” for treating opioid addiction.

For decades, methadone was the primary drug prescribed to help heroin addicts quit. It works by stimulating the brain’s opioid receptors, but the very thing that makes it work also leaves it open to abuse. Today, are other options.

There is the still-new, mostly unproven naltrexone, branded as Vivitrol, which works by blocking the brain’s opioid receptors and is prescribed as a monthly injection.

And there is Suboxone, a combination of two drugs, buprenorphrine and naloxone, which crowds out other opioids from the receptors, dampening euphoria and lessening withdrawal to curb cravings.

In 2016, after growing evidence to support the use of medication-assisted treatment, real government dollars were put behind it. First, in September 2016, the Obama administration announced $53 million in funding. And then in December, Congress passed the 21st Century Cures Act, which authorized $1 billion in funding over two years for state grants, the large part of it directed toward medication-assisted treatment.

Florida alone received more than $27 million from the Cures Act, with a focus on methadone and buprenorphine (Suboxone) maintenance. The state is expected to receive another $27 million next year.

But as the number of opioid deaths rises, people in the treatment and recovery field remain sharply divided over whether medication is the best approach — and whether it should continue to receive the majority of government funds. While clinicians who spoke to the NewsHour said medication was the best option to improve survival rates, others in the recovery community see it as a crutch that doesn’t fix addiction long-term.

In May, that division came into focus when then-Health & Human Services Secretary Tom Price told a West Virginia newspaper that he worried the medication was “just substituting one opioid for another.” After distraught practitioners and researchers signed a letter asking him to “set the record straight,” Price ultimately walked back those remarks.

America is at a juncture in the story of opioid treatment, with the next chapter likely to focus on how the funding is distributed, and how much of it will go to medication-assisted treatment. At the heart of that decision is an important but difficult question: is survival more important than sobriety, and at what cost?

How to deal with the crisis

Collier is a sunny southwestern Florida county of strip malls and palm trees, where pop music blasts from passing cars and sunshowers are a regular occurrence. It is a place that feels like summer year-round, but where former users in recovery say there’s not much to do. Not even in Naples, Collier’s best-known city. The county has also become a hotspot for opioids, which flooded in from Palm Beach, Dade and Broward counties, and elsewhere around the state.

Florida is unique for its large elderly population, which leads to a higher rate of prescriptions, and increases the number of opioids flowing through the state. It was also known for its “pill mills,” where unscrupulous doctors churned out prescriptions, until law enforcement shut many of them down.

The Collier County sheriff’s office said that after the mills were shut down, many people simply replaced pills with harder drugs on the street. The oxycodone addicts turned to heroin. More and more, the heroin was laced with fentanyl, among the most powerful opioids. “Poly use” increased, a term for people combining different drugs.

In 2015, the most recent year data is available, opioids directly caused the death of 2,538 Floridians; over the past few years in Collier County, heroin, fentanyl, and oxycodone showed up again and again in medical examiner reports. When the Collier County sheriff’s office implemented a mapping system to track heroin overdoses, it found 47 in the county since April. Over the past year and a half, the Collier County EMS administered Narcan, a medication used to reverse overdoses, more than 400 times.

Video by Justin Scuiletti and Elizabeth Flock

How to deal with the crisis has become an increasingly pressing question in Collier. The county has had a drug-free coalition since 2005, meaning that local treatment centers, nonprofits, police, drug courts and others dealing in recovery work together. But those groups don’t always agree.

The David Lawrence Center in Naples, a 50-year-old public treatment facility, recently made the philosophical shift to embracing medication in treatment, after decades of practicing abstinence-based therapy.

Nancy Dauphinais, the center’s chief operating officer, compares the approach to earlier battles against AIDS. “When you look at how AIDS deaths skyrocketed and, from a logical point of view, how you address an epidemic, the first thing you do is you reduce mortality however you can,” she said. “Because if you can’t keep people alive, you can’t help them.”

Five miles south, at St. Matthew’s House, a faith-based nonprofit that runs a large recovery program, the approach is very different. At St. Matthew’s, as in Alcoholics Anonymous, they see the only solution as total abstinence, arguing that medication only hampers efforts to get clean.

“Ten or 20 years from now, they’re going to look at this as the Dark Ages of rehab, because people have bought into the line that the only way to deal with this is to keep these people on medication,” said Vann Ellison, the president and CEO of St. Matthew’s House. “But we’ve known for decades that getting them off mood-altering chemicals leads to a productive, healthy and independent life. I mean, just listen to our guys.”

‘Listen to our guys’

Study after study that shows that medication is effective in treating opioid addiction, but many opioid users are resistant. In Justin’s Place — the recovery program at St. Matthew’s House — not a single former user who spoke to the NewsHour felt positively about using drugs to get off drugs.

Most saw it as a crutch, one that distracted from their efforts to get clean. Almost all said they had diverted it, meaning they either used a medication like Suboxone on the street to get high, often in combination with other drugs, or they used it to avoid withdrawals, or they sold it to someone else to buy drugs.

Justin’s Place preaches the abstinence-based model to the people it serves. It also practices a philosophy Ellison said he took from the late C. Everett Koop, the U.S. surgeon general who served during the AIDS crisis and the crack cocaine epidemic. “They asked him what would it take to really guarantee people that we have good success” with addicts, Ellison said. “And he said we need to isolate them on an island for years to give them a chance of staying sober.”

At Justin’s Place — Lunch is served to men staying at the LaBelle Inn in LaBelle, Fla., on Wednesday, August 23, 2017. Photo by Logan Newell

Justin’s Place is a year-long program (instead of 28 days, like many other rehab programs), with the option to stay longer. In its men’s program, at least six months of that time is spent at an inn in largely rural LaBelle, Florida, an hour and a half from Naples, and away from other drug users, dealers, and the pressures of daily life. During that time, the men go through the “12 steps” (a recovery program adopted from Alcoholics Anonymous), as well as go to church and work with peer mentors. They also help operate the inn, which is open to the public, and whose grounds include a volleyball court, a pool, and a river on 47 quiet acres. It feels a bit like summer camp, and also a bit like living on an island.

At a recent dinner at Justin’s Place, a meal to which the men are required to wear dress clothes, they took turns giving affirmations over their fettucine alfredo. They said they were grateful for their sobriety, for the meal, for sober fun, for “all y’all” (“all y’all!” the room calls back) – and for “spreading the news that there is no life on Suboxone or blues,” blues being slang for the opioid Roxicodone. For these men, taking Suboxone or doing any maintenance therapy with medication feels too much like taking opioids.

(It has also not escaped the men’s attention that Suboxone’s maker is accused by 35 states, including Florida, of violating antitrust laws to create a monopoly over its drug; to them this feels like the abuses of the pharmaceutical companies that helped create the opioid mess.)

Earlier that day, in a group session, Joe Garcia, who grew up in Naples and said he had “gotten mixed up with the wrong people,” told the story of his addiction to other members of his small group in the program. It began after his parents both died when he was young and ended with him using a needle to shoot up Suboxone.

“That was the end of the run for me,” he said. “By 23, I had spent three of my birthdays in jail, eating Honey Bun birthday cakes… Then in jail a guy told me I looked like a good kid. He said he had heard about Justin’s Place. My family didn’t want to talk to me then. So I got out my Bible. I had to have some kind of plan to better my life.”

After several months at Justin’s Place, he now had plans to go to barber school. “I’m tired of being that loser that nobody wants to see. This is a small testimony of my life.” Everybody in the room applauded.

Afterward, the men talked about Suboxone, how many of them had used it on the street like Garcia, or how, when taking it in combination with benzodiazepines, a depressant, it made you feel “robbed out of your mind.” How they made lots of money selling it. How when they stopped taking it they got bad withdrawal symptoms: diarrhea, sweating, the feeling that your skin had bugs on it. How it blocked you from wanting to take opioids but didn’t prevent you from using drugs.

(Clinicians say people are less likely to experience withdrawal symptoms if tapered off Suboxone slowly, with the advice of a doctor. But many acknowledge the Suboxone diversion problem, and that the medication does not block a desire to take non-opioid drugs.)

“If I want to get high, I’m a drug addict, that’s not going to stop me from using crack, meth,” said Greg Hansen, from Port Charlotte, Florida, who was addicted to Dilaudids and Xanax before Justin’s Place. Or from using benzos or coke, other men said.

St. Matthew’s claims to have a 90 percent success rate for those who make it through its recovery program, but many never get to that point. That week, seven people had relapsed in their independent living apartments in Naples, the program’s next step after living in LaBelle.

IN RECOVERY — Joe Garcia poses for a photograph in LaBelle, Fla., on Wednesday, August 23, 2017. Photo by Logan Newell

And Garcia said 12 of the 13 people in his initial small group hadn’t made it. But for those who would complete the program, said Ellison, they’d live a life truly independent of drugs.

The session closed with one man saying that after getting clean at Justin’s Place, he could finally remember his dreams. Another said he could now read books. He had worried his brain was permanently fried.

After the session, Ellison said that his resistance to medication in treatment stretched back to his time working at a Naples treatment facility, “where you’d see doctors prescribing people medications, and they’re leaving more impaired than they came in.”

His years at St. Matthew’s had only solidified that belief. Many users who come to Justin’s Place have already detoxed elsewhere — either in jail, going cold turkey, or at a treatment center, often with the help of a medication like Suboxone. But once they come to Justin’s Place for recovery, they must be off all medication, or they are not allowed in.

“We’re not opposed to medications in detox. We’re opposed to keeping, or maintaining, drug addicts on mood-altering drugs,” said Ellison, who claimed one former user who came to Justin’s Place on Suboxone could barely stay awake over his coffee, despite taking his medication as prescribed.

First, save lives

The David Lawrence treatment center isn’t the first in Collier County to make the shift to medication-assisted treatment. The center is following in the footsteps of places like Hazelden Betty Ford, the nationally-renowned treatment organization, which has a location in Naples, and which made the shift in 2012 after years of espousing an abstinence-based approach.

When it became clear that the opioid addiction problem was becoming an epidemic, “That changed the game,” said Brenda Iliff, the executive director of Hazelden in Naples. “We had to bring in different tools.”

The shift cost them some supporters, but not as many as expected. “I think it’s because of the calamity of the opioid epidemic. People are dying… You sit in front of a mom whose kid died, and you’re going to do anything you can to prevent the next one.”

A room is seen at the David Lawernce Center in Naples, Fla., on Thursday, August 24, 2017. Photo by Logan Newell

In 2015, the David Lawrence Center made the same calculation, when it had the opportunity to participate in a statewide initiative to look at Vivitrol.

For decades, the center had taken an holistic, abstinence-based approach. It viewed addiction not only as a biological and psychosocial disease, but a spiritual one. It talked of engaging the body, heart, head and soul to help people heal. The center’s defining physical feature, a sprawling banyan tree out front, was planted to give visitors a sense of serenity and peace.

But with 91 Americans dying every day from opioid overdoses — 10 of them a day in Florida — the center decided it was time to try something different. Dauphinais said she was convinced to make the change after studying how retroviral therapy had stemmed deaths from AIDS.

“That was the turning point for me where I really said, ‘OK I need to be open to [this] treatment,’” she said. She knew that the available medications weren’t perfect, but decided that “we have to save people’s lives first and then work with them to get to the quality of life that they want [later].”

When David Lawrence began its Vivitrol pilot, she said, participants were wary. But the center worked hard to educate people about the medication’s benefits and drawbacks. And a year later, David Lawrence got another big funding boost for medication from the 21st Century Cures Act, with $333,883 to use from April 2017-2018 for anyone treated with methadone, buprenorphine (Suboxone) or naltrexone (Vivitrol).

Some of this state and federal funding for medication may have come as a result of aggressive lobbying by Vivitrol’s maker, but Dauphinais said this mostly does not bother her. For a public health center that is often badly strapped for cash, the Cures Act was a much-needed infusion. Especially in a state that ranks almost last nationwide in mental health services funding, and whose lawmakers were unaware when they recently lost $20 million in federal funding to combat the opioid crisis. (A month later, Florida Gov. Rick Scott proposed $50 million for the crisis.)

As a result of the Cures Act funding, the center is now able to make another big shift: from only prescribing Suboxone short-term, for detox, to also prescribing it on an outpatient, long-term basis, as maintenance therapy. Dauphinais hopes to get its first participant in the next 30 days.

As to the risks that the drug will be abused by outpatients, she said, “it’s better to have to deal with a diversion problem than a death problem.” New studies, she argued, show maintenance therapy can be more effective than just giving people medication in detox. But she also acknowledged that the longer people were prescribed Suboxone, the harder it might be to get off it.

“I hear and believe it is extremely difficult to come off of Suboxone long-term,” she said. “We hope that there will be a better solution to that. But again, what is the goal? The goal is to reduce mortality.”

Where the dollars go

Five years after being prescribed Subutex, Greg Frye decided it was time to stop taking it.

He was 40 now, and felt ready to be free of a drug that had been a “necessary evil,” an evil that he could now shuck off. He couldn’t wait to travel without the fear of losing his prescription. He couldn’t wait to feel that there were no drugs in his system at all.

But he was also worried, because he remembered what happened the previous time he stopped taking Subutex, that it felt like he was “in a furnace with the flu.” That he couldn’t sleep for months. He was nervous to taper, even under the supervision of his doctor. It made him question whether he should have been on medication all these years. Maybe he could have come off sooner. Maybe he could have taken a smaller dose.

After all, he told himself, it wasn’t really the Subutex that did it. It was wanting to get clean. It was facing life “with all its problems,” and finding things beyond himself — God, his daughter, his future.

But he also knew that it was easier in hindsight to imagine he could have done it alone.

“If I never took [medication] what would have happened to me?” he said. “I wouldn’t have made it I don’t think.”

It’s these questions about the use of medication in treatment that keep Judge Janeice Martin up at night. Martin runs Collier County Drug Court, just down the road from Frye, where she’s watched hundreds get clean and graduate, and hundreds drop out. She’s also watched state and federal dollars get funneled toward medication, at the exclusion of other services that she’s seen work in her court.

Drug courts seek to keep nonviolent offenders out of jail, with varying rates of success. Martin’s court has a success rate of about 50/50.

Martin is a second-generation drug court judge; her father mostly dealt with alcohol and cocaine abuse in his court, instead of prescription drugs. Since Martin took over the court in 2011, the program has been tweaked several times, to be less punitive, to be more therapeutic — and to consider how medication fits in.

Collier County Drug Court partners with David Lawrence to provide medication to those who want it, but Martin said it is rare that someone opts in. Participants in her court, she said, see it much the same as the former users at St. Matthew’s House: “as a tether, and their quest is to cut all tethers.”

Martin is also careful to never push medication in her court, she said, because she is not a doctor, and because the science is changing fast. She has also never seen medication work on its own, without therapy, which is why all the 21st Century Cures Act funding for medication scares her.

Greg Hanson, 29, poses for a photograph in LaBelle, Fla., on Wednesday, August 23, 2017. Photo by Logan Newell

“So far, the dollars have me a little bit worried that we’re going to be seeing medically-assisted treatment in a vacuum,” she said, “without also going to clinicians who can perform the necessary treatment to accompany that.”

A drug court grant from the Justice Department for which David Lawrence recently applied also includes a stipulation about medication in treatment.

On a recent Tuesday in Martin’s drug court, former opioid user Nicholas Potter graduated in front of the judge and other drug court participants: a prosecutor, public defender, probation officer, case manager, and clinician from David Lawrence. As he stood somberly in the heavily air-conditioned, windowless room before the court’s official seal, Martin praised Potter for the positive attitude he brought to therapy. “It has not always been easy,” she said, and he nodded.

“But when you just tell someone about your problems it helps,” he said, adding that detox got him off drugs, but it was group therapy and AA sessions that turned his life around. “Today I will not pick up or use.”

For Potter and many like him, Martin believed, medication alone would have fallen far short. Meanwhile, the second round of funding from the Cures Act has yet to be dispensed; in a recent statement, former HHS head Price said they were taking time to decide where the money would be allocated to “remain responsive to this evolving epidemic.”

Martin hoped that more funding would be put toward trained counselors, beds in inpatient and outpatient facilities, and safe living spaces for recovering addicts.

“Those are the resources that I see bearing the most fruit over the long haul,” she said. “And we need an awful lot more of them if we’re going to get our arms around this issue.”