The Options and Obstacles to Treating Heroin Addiction
Five years ago, 6 percent of the people who entered the Staten Island YMCA’s substance abuse treatment program were addicted to heroin. Today, it’s 30 percent.
“The largest percentage of people that come to us, the substance that they’re most often using is heroin,” says the program’s executive director, Jacqueline Filis. “It was a slow increase in the beginning, but starting in 2013 it became more pronounced.”
Another 20 percent of patients are addicted to prescription opioids. “Right now, a little more than half of our people are coming in as a result of the opioid epidemic,” Filis says.
In 2014, the epidemic was responsible for more than 27,000 overdose deaths in the United States, raising new questions about how best to combat addiction to opiates, which researchers say is harder to overcome than most other types of addiction.
For decades, treatment has centered on an abstinence-only approach, consisting of detox and rehab, accompanied by counseling or group therapy, many inspired by the 12-step model. But as deaths have surged, many experts have begun rethinking that approach, arguing that opiate addiction should be treated the same as a chronic disease — like diabetes or depression. Abstinence and counseling is not enough, they say. Medication must also be an option.
The methadone option
Despite this shift, such treatment can be hard to find. In 2013, medication-assisted treatment for opioid addiction was available in just 9 percent of the 14,148 facilities included in the National Survey of Substance Abuse Treatment Services.
When medication is available, the oldest and cheapest option is methadone. Introduced in the 1960s, methadone can help a user stave off cravings and withdrawal symptoms. It can also block the effects of any heroin that a patient might take during treatment.
However, since methadone can produce a milder version of the high that patients get from heroin, it can potentially be diverted to sale on the streets and be abused. Because of this risk, people on methadone maintenance therapy must go to a clinic each day to receive a dose of methadone under medical supervision. According to the Pew Charitable Trusts, there are roughly 1,400 clinics licensed around the country to dispense methadone, though most are clustered in cities, making access a challenge for those in suburban or rural areas.
Some people have been on methadone for years, and are able to function normally, but because it is a narcotic, there can be a stigma attached to treatment.
“There’s a view that treating opioid addiction with opioid medication is not really treatment, that it’s simply substituting one drug for another and that someone shouldn’t be considered ‘clean’ or ‘abstinent’ if they’re on that medication,” says Dr. Andrew Kolodny, senior scientist at The Heller School for Social Policy and Management at Brandeis University.
“Methadone became stigmatized almost immediately,” says Dr. Mary Jeanne Kreek of Rockefeller University. Kreek was part of the team that originally studied methadone as a potential treatment for opioid addiction in the 1960s. She notes that although methadone clinics operate under strict regulations, they continue to be shunned by some communities.
“Here in New York City, we’ve had a decrease, not increase, in the number of methadone clinics. Why? Stigma. Why? They don’t make money. Why? Not in my backyard.”
When the Staten Island YMCA began exploring the best ways to treat heroin addiction, there was initially resistance to another medication that has worked: buprenorphine.
“There was resistance even within our own staff,” according to Filis. Five years later, she says, the mindset has changed. “As long as you’re not abusing your buprenorphine, then you are sober in our eyes.”
While methadone can be used for any level of addiction, research indicates that buprenorphine may be the best option for those with mild to moderate dependence, and it carries a lower risk of overdose. Like methadone, buprenorphine is a narcotic that can be crushed, snorted or injected to get high, so to address this issues, it is often combined with naloxone, a drug carried by first responders to reverse opioid overdoses. This combination is marketed most commonly as Suboxone — a film that’s placed under the tongue and slowly dissolves — and is less likely to be abused because the naloxone will trigger withdrawal symptoms.
Unlike methadone, buprenorphine and buprenorphine-naloxone are considered safe enough to be prescribed by a doctor and taken at home. As opioid and heroin addiction has shifted from major cities to more rural areas, buprenorphine has been held up as a possible treatment solution for people who live too far from methadone clinics.
There are two main stumbling blocks for patients trying to access buprenorphine or buprenorphine-naloxone. In order to prescribe either, physicians must first obtain a waiver from the Drug Enforcement Administration. Once physicians have the waiver, there’s a federal limit on how many patients they can prescribe to — 30 in the first year, and 100 patients per year thereafter. And even if a physician has a waiver, many are reluctant to prescribe, notes Kolodny, leading to long waiting lists.
Slightly fewer than 32,000 physicians currently have waivers to prescribe buprenorphine, according to federal data — with almost 70 percent of them certified to treat 30 patients, and the remaining 30 percent allowed to treat 100. By contrast, there are currently no limits on prescribing opioid painkillers. In 2012, doctors wrote 259 million prescriptions for opioid painkillers.
“The drugs that can cause this problem don’t have limits, some of which would be reasonable,” Kolodny says, “And we have, I believe, excessive barriers to a safer drug that may be one of the only ways to get out of this mess.”
Earlier this week, the National Governors Association called for medical training on prescribing painkillers, drug monitoring and limits on prescriptions to tackle over-prescribing. In the same statement, they called for removing federal barriers on doctors prescribing buprenorphine.
Naltrexone and Vivitrol
In 2010, the Food and Drug Administration approved another medication to treat opioid addiction — a long-acting injection called Vivitrol. It’s a form of naltrexone, a tablet that was already being used to treat alcoholism.
Naltrexone is not a narcotic, so there’s no danger of it being abused. Instead, it blocks the effects of heroin and opioids, but it can only be used on patients who’ve undergone detox. It has been popular with drug courts and prisons, and has to only be injected once a month, unlike methadone and buprenorphine which have to be taken daily. One drawback is its price: $1,000 per injection.
Rebecca Hogamier, director of the Division of Behavioral Health Services for Maryland’s Washington County Health Department, sees many people addicted to opiates or heroin who have come through the legal system. The treatment program she oversees offers both buprenorphine and Vivitrol.
“If someone is not using opiates on a daily basis and can maintain 10 days of abstinence from opiates, we’ll start them on Vivitrol,” Hogamier says. “Our biggest success has been starting people on Vivitrol in the jail, because they are clean.”
After being released from jail, people are ordered by the court to show up to treatment. Hogamier says only 50 percent used to show up before the program started using Vivitrol. After they started the injections, 75 percent of people showed up to treatment. Around 80 percent of the people given Vivitrol also stayed in treatment for longer, she says.
Such figures haven’t been enough to convince everyone, though. While naltrexone and Vivitrol have been approved to treat alcoholism, experts like Kreek say there is less evidence of their effectiveness in treating opioid addiction.
“It doesn’t hurt anyone who’s an alcoholic,” Kreek says. “But for opiate addicts, they have a relative endorphin deficiency. To block their opiate receptors with [naltrexone or Vivitrol] makes them feel rotten 24 hours a day.”
Vivitrol is “probably an appropriate treatment for someone who hasn’t been addicted for very long, and who lives in a very controlled setting,” Kolodny says. “But particularly for heroin injectors, you see high drop out rates, and patients don’t stick with it.” According to Kolodny, that increases their risk of overdosing if they relapse.
Hogamier says anyone who has detoxed completely is at a higher risk of overdose. “It’s not just Vivitrol, it’s anybody that has a period of time clean.”
Deciding on treatment
To be sure, experts say there is no “cure” for addiction. What medications like methadone, buprenorphine and naltrexone do is offer addicts space, control and relative normalcy in their lives in order to deal with their addiction through counseling, behavioral therapy and support groups. Research says those who get medication along with counseling are more likely to stay in treatment, and have a lower risk of relapse.
Treatment is an individual choice, and what works for some people may not work for others. To some extent, availability might decide what sort of treatment someone chooses. Insurance can also be a deciding factor — sometimes Medicaid, Medicare or private insurance will cover treatment for substance abuse, but often it’s a struggle to find coverage.
In some cases, a patient may choose the medication that’s least likely to interact with other prescription they’re on, says Dr. Melinda Campopiano, a medical officer at the federal Substance Abuse and Mental Health Services Administration. But she points out that one of the biggest barriers to treatment — beyond effectiveness, beyond cost and accessibility, beyond stigma — is that many people who need treatment aren’t ready to seek it yet.