While the media was consumed last week with the debate over childhood vaccinations, the Obama administration, spurred on by a stunning investigation by the Huffington Post, quietly took an important step in another realm where medical science has been doing battle with ingrained superstition: heroin addiction. The public health consequences here are just as big, if not more so. Alas, unlike with vaccines, where holdouts like Sen. Rand Paul are becoming increasingly isolated, the reality-grounded side here has further to go in overcoming the flat-Earthers—and thousands of Americans are paying with their lives.
The policy question here has to do with a medication, buprenorphine, that has been shown to be highly effective in treating addiction to heroin and prescription painkillers. The medication, which goes by “bupe” for short and is sold under the trade name Suboxone, is similar to methadone in that it eliminates an opiate addict’s cravings for heroin or pain pills, giving him or her the opportunity to regain a sense of normalcy and carry on with life without seeking a dangerous high. But Suboxone differs from methadone in that it is more difficult to abuse for its own high, and can therefore be prescribed to be taken at home—it is taken orally in the form of a small hexagonal tab—rather than having to be taken at a clinic like methadone, with all the stigma and inconvenience that comes with doing so. While it of course does not work for everyone, the drug’s overall effectiveness and relative safety is why the Food and Drug Administration approved it for use in 2002, and why addiction researchers now regard it as an immensely valuable tool in the fight against opiate addiction.
You would think that this would have made the medication as common as Nicorette gum in a country that is facing a debilitating surge in heroin addiction, as more and more Americans hooked on prescription painkillers—including many of middle-class and suburban backgrounds—turn to the drug for a cheaper and more accessible high. In 2012, 265,000 more people reported using heroin in the previous 12 months than had reported doing so a decade earlier. And in a study released last fall, the Centers for Disease Control found that heroin deaths doubled in just two years, between 2010 and 2012, in the 28 states that the study focused on. Between 2012 and 2013, the CDC reports that heroin-related overdoses jumped 39 percent nationwide, to a total of 8,257—not all that far behind the tally of firearms homicides that year, 11,208.
Despite this burgeoning crisis, Suboxone treatment is awfully hard to come by. Part of the problem, as I described in an article in 2005, is that federal authorities imposed restrictions on the drug even as they approved it for use, requiring doctors to jump through cumbersome hoops to be allowed to prescribe it and capping the number of patients any one doctor can prescribe it to. Those restrictions have since been loosened somewhat, but as the Washington Post recently reported, they are still limiting access, as are the reluctance of many physicians to accept opiate addicts as patients, the cost of the drug, and restrictions that some state Medicaid programs and private insurers have on covering it. The lingering wariness of Suboxone in some medical and official circles has not been helped by articles in the press that have overstated the medication’s risk and overhyped the tendency of it to be sold on the black market—a natural outcome with a drug that makes opiate addicts feel better but is hard to come by through legal channels. (Making official suspicion of Suboxone all the more confounding is that local and state governments have been increasingly eager to propagate another medication to combat the heroin scourge—naloxone, trade name Narcan, which is used to reverse overdoses when they occur.)
Late last month, though, came an entirely new explanation for Suboxone’s limited reach in many heroin-wracked parts of the country. Following a year-long investigation, Huffington Post released a powerful multimedia package, edited by Ryan Grim and centered on a 20,000-word article by reporter Jason Cherkis that described a whole other source of resistance to the medication: the drug-treatment industry’s self-interested bias against a medical approach to treating opiate addiction. Cherkis focuses on Kentucky, where, despite an especially large spike in heroin deaths, the main publicly funded network of treatment programs remains insistently—and infuriatingly—wedded to an abstinence-based, 12-step approach to addiction recovery, despite the programs’ high drop-out and failure rates and the heaps of research showing that heroin dependence is so difficult to overcome that many addicts have far better prospects if they taper off the drug for months or years using a “maintenance” medication like methadone or Suboxone. Kentucky, reports Cherkis, “has approached Suboxone in such a shuffling and half-hearted way that in 2013, just 62 or so opiate addicts treated in all of the state’s taxpayer-funded facilities were able to obtain the medication that doctors say is the surest way to save their lives. Last year, the number fell to 38, as overdose deaths continued to soar.”
Cherkis introduces readers to one after another set of parents mourning children in their 20s who dutifully went through medication-free 12-step programs, only to relapse and fatally overdose soon after their release (a time when addicts are particularly vulnerable to overdosing, because their tolerance has decreased during detox). And he introduces us to one after another anti-science obstructionist in the local treatment industry and judicial system, where judges insist that addicts can only avoid jail time for a stay in treatment if they avoid Suboxone. There is the intake supervisor for one treatment center who, when asked if Suboxone might’ve saved a former client who fatally relapsed, shrugged and responded: “Could have. But it’s not sobriety. It’s being alive. But you’re not clean and sober.” There is the state senator in northern Kentucky—which is being hit particularly hard by the heroin wave—who compares using Suboxone to being “in bondage.” And there is the judge who oversees Kenton County’s drug court, who won’t allow Suboxone for defendants’ treatment plans. When presented with the data that shows how risky it is to detox without medication, he says, “I’m not an expert on what works and what doesn’t work.” A sign was recently posted outside a Kenton County courtroom addressed to all “Suboxin users,” warning that “IF YOU WANT PROBATION OR DIVERSION AND YOUR ON SUBOXIN, YOU MUST BE WEENED OFF BY THE TIME OF YOUR SENTENCING DATE.” (The only thing as glaringly poor as the court’s grasp of science, apparently, is its spelling.)
You’d think that penny-pinching state and local governments would see the constant cycling of addicts through ineffective programs run partly on public dollars as a classic case of waste and unaccountability. “It’s a service that rewards the failure of the service,” Dr. Bankole Johnson, the chairman of the University of Maryland School of Medicine’s psychiatry department, tells Cherkis. “If you are going to a program, you don’t succeed and you pay X-thousand dollars. When you fail, you go back—another X-thousand dollars. Because it’s your fault.” Instead, Cherkis reports that political pressure is pushing the other way—elected judges are worried about being seen as approving opiate maintenance medication for addicts.
The picture is not entirely bleak, Cherkis reports. The top drug-addiction officials in Kentucky are speaking up for Suboxone, and a few major treatment centers elsewhere in the country, such as Hazelden in Minnesota and Phoenix House in New York, have incorporated Suboxone, with positive results. And now, Cherkis’ piece may force some progress of its own: Last week, the White House’s Office of National Drug Control Policy announced that it would forbid drug courts that receive federal funding, as some in Kentucky do, from barring defendants from going on Suboxone. The office’s interim director, Michael Botticelli, even tweeted a link to Cherkis’ article, with the endorsement:
Medication for opioid use disorders=standard of care. Too many ppl are dying to withhold this valuable treatment. http://t.co/GKil92lu9h— Michael Botticelli (@Botticelli44) January 29, 2015
There is much more the federal government could do to overcome resistance to a drug that offers to do so much good. It could use the leverage of federal funding for publicly supported treatment programs to get them to accept Suboxone treatment, just as it is now applying its leverage against drug courts. It could work to further loosen the restrictions on prescribing Suboxone, since it won’t do addicts any good if drug courts become more open to the medication, but they can’t actually find it. It could pressure the dozen or so states that have strict time limits on Suboxone in their Medicaid programs to loosen them so that addicts aren’t prematurely cut off from the medication, with fatal results. And of course it must keep cajoling Republican-led states to accept Obamacare’s Medicaid expansion and thereby make tens of thousands of opiate addicts newly eligible for coverage for Suboxone treatment.
But the pressing need for such steps is now more visible to all because of Cherkis’s reporting. In a just world, it will win the Pulitzer Prize for Public Service.