‘I was sick and I needed medicine’
Treating drug addiction with drugs
Road to Recovery: Second in an occasional series on breaking the grip of opioid addiction
Every morning, a 32-year-old Bostonian named Mike places an orange tablet under his tongue just before leaving for work. An acrid, citrusy flavor fills his mouth as he packs his briefcase and walks to his job in the Financial District.
The slowly dissolving tablet contains buprenorphine, and Mike says the medication is the reason why today, after 10 years of shooting heroin, he has a white-collar job, a luxury apartment, and plans for graduate school and marriage.
But no one at his workplace knows about the little orange pill, and Mike asked the Globe not to publish his last name to keep it that way.
Mike faces a double stigma — against addiction and against the medication that enabled him to overcome it.
Addiction specialists say there are many people like Mike, productive citizens who secretly take buprenorphine or a similar, older medication — methadone. They describe patients transformed, free of cravings and the compulsion to take illicit drugs, and ready to start rebuilding their lives.
Yet people like Mike seldom tell their stories, afraid the revelation will undermine their success in a world still uneasy with the notion of taking a drug to treat drug addiction.
Methadone and buprenorphine (best known by the trade name Suboxone) are both opioids. They create physical dependence, and buprenorphine is often sold illegally as addicts seek relief from withdrawal or obtain a high by mixing it with other substances.
Learn more about the different types of medications used to treat opioid addiction.
But extensive research shows that opioid-addicted people who take properly prescribed buprenorphine or methadone are much less likely to relapse and overdose than people who try to recover without medications. Despite that, according to a national estimate, only about a third of people in addiction treatment take medications.
Regulations that restrict access are part of the problem. But the notion that the medications merely "replace one addiction with another" has fueled resistance among mutual-support groups such as Narcotics Anonymous, certain treatment programs, and even patients seeking treatment.
Tony Ramos, a 26-year-old in recovery for three years, who is active in 12-step fellowship groups in northern Massachusetts, expressed this common view: "If I’m taking an opiate every day, how am I sober?"
A 10-year battle
Buprenorphine came on the market in 2002, before heroin addiction overtook Mike’s life. But he wouldn’t learn about it until years later.
In his first attempt at recovery, Mike’s family sent him to the renowned Hazelden Betty Ford Foundation clinic in Minnesota. It was 2011, and the treatment at Hazelden in those days consisted of group and individual therapy, and working the 12 steps that originated with Alcoholics Anonymous. Then he was sent to an aftercare program in Oregon, where he quickly relapsed.
In 2012, after Mike left, Hazelden’s leaders started offering buprenorphine to patients, convinced by the growing evidence of effectiveness.
"If I had gone to Hazelden a year later, my entire life trajectory would be vastly different," Mike said. "This didn’t have to be a 10-year battle."
After Hazelden, Mike moved on to other abstinence-based programs, only to relapse again. The message he kept getting was that he wasn’t trying hard enough.
After living and shooting heroin for a time in Arizona, he moved back East, where he was introduced to a relatively new medication for addiction — Vivitrol, a once-a-month injection that prevents a person from experiencing opioid euphoria. Mike started to improve, moved to a new city, got a job.
Vivitrol is not an opioid and can’t be diverted for illegal use, an advantage over methadone and buprenorphine, but the evidence for its effectiveness is not as strong.
For Mike, it worked only partially. Vivitrol blocked the high but didn’t eliminate the desire to get high, especially as the medication started to wear off after about 20 days. Every month, in the third week after getting his shot, Mike would start using heroin again; he started putting off his next shot so he could use longer.
The experience opened Mike’s mind to the possibility that willpower was not necessarily the answer, that a better medicine might work. So he set about finding a doctor who would prescribe buprenorphine. It wasn’t easy. Doctors in his area either didn’t prescribe it or were booked.
Before they can prescribe buprenorphine, physicians must undergo eight hours of training, but many don’t want to take the time or are reluctant to work with addicted patients. And those who do take the course are limited by law in how many patients they can treat.
Finally, Mike found a psychiatrist who could prescribe the medication. Before long, his cravings were gone. He got a job at a consulting company and started dating again. Far from supplanting his heroin use with a new addiction, the little orange pill erased the symptoms of addiction altogether.
"Everything started to click again," Mike said. "I finally realized that it didn’t have anything to do with how hard I was working the program. I was sick and I needed medicine."
Mike doesn’t expect to take buprenorphine for the rest of his life, but after three-and-a-half years, he’s in no hurry to stop.
‘A dark side’
Not everyone who takes buprenorphine undergoes a lasting turnaround like Mike’s. About half the people on medication for addiction relapse after six months. But among those who don’t take medication, 90 to 95 percent relapse after six months, and many die of overdoses.
With data like that in mind, the administration of Governor Charlie Baker has made a priority of increasing access to anti-addiction medications.
The state Department of Public Health requires all outpatient and residential treatment providers to give each client complete information on treatment options and establish collaborative relationships with providers that dispense anti-addiction medications. Programs are forbidden to deny admission to patients on prescribed medication for addiction.
It’s an uphill battle, according to addiction specialists, who say that many treatment centers and recovery homes continue to discourage their clients from taking medication.
Still, prescriptions for buprenorphine are starting to increase in Massachusetts and elsewhere. The Urban Institute, a nonprofit research organization, found that medication-assisted treatment provided to Medicaid patients increased 19 percent from 2011 to 2017, and that Massachusetts ranked eighth in units prescribed per capita.
Quantity of antiaddiction medications purchased by Medicaid programs, 2017
Units reimbursed for buprenorphine for opioid use disorder and naltrexone per 1,000 Medicaid enrollees
Source: Urban Institute
Irfan Uraizee/Globe Staff
Dr. Barbara Scolnick doesn’t share the enthusiasm for such trends, even though she prescribes buprenorphine at a Quincy clinic. She is part of newer crosscurrent among people who see value in the medications, but question advocates’ and health officials’ singular focus on a pharmaceutical fix.
"Suboxone has a dark side," Scolnick said, using the trade name for the medication. Patients have trouble getting off it, she said. One of her patients has resorted to using a razor blade to slice her dose into ever-tinier pieces as she struggles to break free.
Scolnick sees other patients mixing other drugs with their prescribed buprenorphine and getting stuck in "a low-grade cycle of misery."
"The death rates are going down, but it’s not a life worth living," she said. "I’m not sure Suboxone is the answer like everybody is saying."
Massachusetts Medicaid spending on patients with opioid use disorder
About 60 percent of the money used to treat opioid use disorder in Massachusetts was spent on methadone, buprenorphine, and naltrexone.
Buprenorphine and naltrexone
Emergency service providers
Non-24-hour specialty behavioral health services
24-hour specialty behavioral health services
Yan Wu/Globe Staff
Suboxone was not the answer for Joe Curran, a 29-year-old from Massachusetts who now lives in Hopkinton, N.H. He’d been shooting heroin for a few years when he went to an outpatient treatment program that provided him with the medication, along with group and individual therapy. In a way, the buprenorphine worked: He tried to get high with heroin, but the drug blocked its effects.
That drove him crazy. "So I just switched drugs," Curran said. While on buprenorphine, he also injected cocaine — a dangerous mix that eventually sent him to the hospital.
The problem, as Curran sees it, might seem blindingly obvious: Addicts like to get high.
"We don’t necessarily want the effect of the drug to go away," he said. "We want all the bad consequences to go away."
After dozens of failed treatment programs, Curran finally reached the point where he truly wanted get to sober — something he achieved seven years ago, by working the 12 steps at a sober house in Maine.
Today, he is the 12-step director at Granite Recovery Centers, a New Hampshire treatment program that requires total abstinence — no medication.
Opioid-addicted people who leave rehab without medication risk a deadly overdose if they relapse. But clearly some achieve sobriety without medication, and they swear by what worked for them.
Ritchie Farrell, a writer and motivational speaker whose documentary "High on Crack Street" was the basis of the 2010 film "The Fighter," escaped his heroin addiction more than 30 years ago.
He sees some of his former drug-using companions in Lowell still lining up at the methadone clinic, having made little of their lives.
Farrell is convinced his successes would not have been possible without total abstinence. He supports using medication as a bridge to recovery, but not keeping people on it for years. "It’s like we’re throwing away a generation," he said.
Taking a prescribed drug like buprenorphine perpetuates physical dependence, but doesn’t create a substitute addiction. It is not simply "doing drugs" in another form.
"It not only helps people stay alive, but also helps people to regain incredible function in their lives," said Dr. Laura G. Kehoe, medical director of the Substance Use Disorder Bridge Clinic at Massachusetts General Hospital.
Unlike with heroin, it’s virtually impossible to overdose on buprenorphine, she said. "The most common side effect," Kehoe said, "is that people say, ‘I feel normal.’ "
Kehoe and other addiction specialists say patients should stay on the drug for as long as they benefit, often several years or even a lifetime — as would be the case for any chronic illness treatment. She’s had patients who were pressured by others to get off medication — and ended up relapsing and overdosing.
Dr. Sarah E. Wakeman, medical director of Mass. General’s Substance Use Disorders Initiative, senses a moralistic view of addiction driving the resistance. "This idea that somehow with addiction people have to suffer, that it has to be hard, is really unfortunate and one of the reasons why people are still using and dying," she said.
While it’s not ideal if people are mixing other substances with their buprenorphine, "that’s still better than that person being on the street injecting heroin," Wakeman said.
Amy, a Boston-area homeless woman who declined to reveal her last name, is one of those struggling in the nether world between raging addiction and settled sobriety.
Amy, 37, "fell in love" with opioids as a young adult when a friend gave her some Vicodin. As she moved on to heroin, she lost her job, her marriage, her son, and her home. She made a dozen attempts at recovery over 14 years, including taking methadone for four years.
About a year and a half ago, Amy started on buprenorphine, and that worked better for her. While on methadone, she was still taking illicit pills, but — for her — buprenorphine blocks their effects.
"It helps with my cravings," she said. "It gives me energy to make me want to actually do things."
Since then Amy hasn’t been taking any illegal drugs, but she’s been drinking heavily. Recently she resolved to get off alcohol — but faced the headwinds of a sometimes hostile system.
It took a week to get into a detox center, but there she wasn’t allowed to stay on her buprenorphine. Sick with withdrawal from both alcohol and buprenorphine, she left that program after three days.
In a recent interview, Amy said she’s back attending a support group at the South End Community Health Center, and taking only prescription medications, including buprenorphine. She’s struggling to stay sober while waiting, once again, for a bed in a treatment program.
"Every second of the day, I want to have a drink," she said. "It could happen at any time."
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