PACIFIC COUNTY — Getting clean is hard. Getting clean in the country can be even harder.
Like a lot of other rural places, Pacific County has never had many treatment options for people looking to quit heroin, painkillers and other opioid drugs. This month, however, Willapa Behavioral Health will begin offering “Medication-Assisted Treatment,” a promising, if controversial, approach to treating opioid addiction.
Participants will take buprenorphine, a drug that eliminates the extreme discomfort of withdrawal, making it easier for them to work with Willapa’s substance abuse and mental health experts on the behavioral and psychological aspects of conquering addiction.
“We have a very strong Puritan ethic towards substance abuse — ‘These people had fun, so we won’t do anything about it,’” said Dr. MaryAnne Murray, the veteran substance abuse expert who will oversee Willapa’s new program. “We’ve been very punitive.”
As a result, Murray said, mainstream treatments mostly consist of abstinence-based programs, which emphasize medical detox or going “cold-turkey,” and methadone clinics, which substitute controlled daily doses of methadone, a long-acting opioid, for the user’s drug of choice.
While these methods do work for some, they have serious drawbacks, Murray said. Methadone can be abused. It carries a heavy stigma, and the side-effects and required daily clinic visits make it tough for patients to lead normal lives.
Twelve-step and other abstinence-based programs often aim to treat addiction without addressing underlying mental health issues. Many require addicts to tough it out when intense cravings and withdrawal symptoms kick in. People who can’t tolerate the discomfort may leave treatment feeling more defeated and ashamed than ever, Murray said. According to the National Institute on Drug Abuse, 40 to 60 percent of opioid addicts relapse after treatment in abstinence-based programs.
A promising alternative
Buprenorphine, commonly sold under the brand-name Suboxone, offers hope to people who have been unsuccessful at getting clean because it works differently from other drugs used to treat opioid addiction. Methadone triggers the same receptors in the brain as heroin, fentanyl and other opioids. It prevents withdrawal and frees addicts from the endless pursuit of the next fix, but it can also alter the user’s mental state. A drug called naltrexone has the opposite effect, blocking the brain’s opioid receptors, reducing cravings and making it so that a user can’t get high. It can be helpful, but makes users more susceptible to overdose if they quit taking it.
Buprenorphine prevents withdrawal and helps reduce cravings. To prevent abuse of the drug, it’s administered with naloxone, the drug used to quickly “reverse” opioid overdoses.
“That’s to prevent creative chemistry,” Murray joked. “I get to work with the most creative people in the universe.”
According to Murray, one major advantage of buprenorphine is that it offers greater freedom and privacy. Patients don’t have to build their lives around daily clinic visits.
“They can go to the pharmacy and get the prescription filled, and they can’t do that with methadone,” Murray said. Additionally, pregnant women can safely take the drug.
Changing demands and attitudes
Willapa already offers medication-assisted treatment with naltrexone and disulfiram, a drug that will make alcoholics “barf their toenails off” if they consume even tiny amounts of alcohol, Murray said. But until fairly recently, only physicians could offer buprenorphine under “very strict rules,” including a 30-patient limit. That made it very difficult for rural clinics — which already have a hard time recruiting and keeping doctors — to get programs going.
Murray also works for the Ocean Park treatment center Free By the Sea, where providers have had difficulty accommodating patients who want to try buprenorphine.
“We were sending people to Seaside, Portland or Seattle for this, which took a whole lot of time and effort,” Murray noted. “Prescribers wanted $400 to $500 cash down and a couple hundred for each subsequent visit.”
Over the last couple of years however, the number of people seeking treatment for opioid addiction has increased nationwide, and the federal Drug Enforcement Agency has relaxed its buprenorphine rules somewhat. Now, qualified physicians assistants and nurse practitioners can administer the drug. Experienced providers can get licensed to serve a larger number of patients.
Murray expects to reach her 30-patient limit quickly. As of Jan. 10, she had “four or five” patients who were ready to start as soon as she gets final approval from the feds.
How it works
Before Murray’s buprenorphine patients can get better, they have to get worse.
“They’re supposed to come to me sick and in withdrawal,” Murray said. During a comprehensive interview and medical evaluation, Murray works with new patients to figure out how much of the drug they should take. While the recommended starting dose is just two milligrams, Murray finds that many seasoned addicts need as much as 16, 24 or even 32 milligrams to achieve stability. Many providers set patients up for failure because they incorrectly believe they should prescribe very low doses, Murray said.
“The goal is to maintain them so that they are comfortable enough to be able to get on with the rest of life,” Murray explained. “If we keep people in a permanent state of partial withdrawal, it’s like the worst flu you can imagine. They’re so uncomfortable they can’t go to school or work.”
Under federal law, clinics don’t have to require patients to participate in a drug treatment program, but Willapa will. The clinic offers mental health services and an intensive outpatient treatment, and a less intensive “step-down” program for people who have been clean for longer.
Some doctors and traditional treatment providers are skeptical of medication-assisted programs, Murray said, partly because they believe those who use maintenance drugs haven’t achieved true sobriety. She points out that people with other types of preventable or manageable medical conditions aren’t judged nearly so harshly for using medicine instead of willpower.
“Wouldn’t it be great if folks with diabetes cleaned up their habits so that they no longer needed insulin and medication?” she said.
Controversy and hope
There are serious risks associated with buprenorphine, as well as critics of Medication-Assisted Treatment programs. Speaking off the record, a member of the county’s drug court panel said some local substance abuse experts aren’t enthusiastic about the new program because they’ve seen people fail at MAT programs. Patients have also been known to sell their medication on the black market, because users sometimes take it to keep from getting sick when they can’t get their drug of choice.
After decades of working with addicts, Murray is still full of compassion for her patients, but she also believes in holding them accountable. She requires new patients to check in with her frequently so she can make sure they are dosed correctly and using the drug as prescribed.
“The real trick to successful buprenorphine treatment is to develop a relationship where the people will be honest with me — and using urinalysis to back that up,” she said. She also uses a prescription monitoring program to make sure patients aren’t obtaining opioids from other sources or diverting their medication.
“I don’t support entrepreneurship,” Murray said.
There’s also controversy about how long people should stay on buprenorphine. Murray’s goal is for patients to taper off of the drug after a year or two of stable, sober living, but she thinks there are some patients who need to be on the drug for the long-term.
Under careful medical supervision, she said, the benefits outweigh the risks.
“When people are prescribed buprenorphine, their criminal behaviors decrease significantly because they don’t have to lie, cheat and steal to get their fix,” she said, adding that participants are less likely to get — or spread — Hepatitis C and other communicable diseases. They are also less susceptible to health crises, including blood infections and abscesses, and more likely to qualify for treatment programs.
Most importantly, Murray said, treatment makes it possible for her patients to discover their potential and lead more fulfilling lives.
“If this saves the person’s life, so what if they need it forever?” Murray said. “… If they’ve cleaned up their lives, why wouldn’t they deserve that?”