End Stigma against Medically Assisted Recovery
By Joseph Markman. The Enterprise. Posted Mar. 24, 2015 at 2:24 AM Updated at 2:43 AM
Paul grew up in a middle class family and earned a college degree. He has worked as a professional on the South Shore for the last 20 years.
His story, by now, is familiar.
In his early 30s, Paul went into the hospital for surgery and came out with a 30-day prescription for OxyContin, a powerful painkiller containing oxycodone. Back then, in the late 1990s, OxyContin was new to the market and easily abused.
Paul used his supply and went back for more. Eventually, leaning on several different doctors and the black market, he was using 160 milligrams of OxyContin per day.
When Paul finally sought treatment, he started with short-term detoxification programs. After that, he turned to methadone – a synthetic opioid that is widely used to treat addiction. Typically taken as a liquid, methadone fits into the same brain receptors as other opioids, acting with a longer, less-powerful effect that can help stave off cravings.
The rules for methadone are stringent. Most recovering addicts must visit a clinic every day to get their dose. Some, like Paul, follow the rules and work up to be able to take home 13 days worth of methadone.
But when Paul would try to wean off the drug, his cravings would return and he would relapse.
“Your legs hurt, you can’t walk,” Paul said. “It was a terrible feeling. You’d become depressed because all the sudden your opiate receptors are empty.”
In 2004, Paul started using a recently approved drug, Suboxone, to help in his recovery. Suboxone is a combination of buprenorphine – a synthetic opioid – and the overdose-reversing drug naloxone, included to thwart misuse.
The results, for Paul, were impressive. He no longer had to visit a clinic every day, and Suboxone had an even less powerful and longer-lasting effect than methadone.
Aside from a couple of short-term relapses, Paul, now 50, has been in recovery for a decade.
“It’s just an incredible life of family and meaningful relationships I didn’t have,” said Paul, who is from Brockton. “I went from a life of isolation to being able to participate in society.”
Yet one part of Paul’s story remains troubling. Like many addicts recovering thanks to drugs like buprenorphine, Paul worries about people finding out. He did not want to use his full name for this article, concerned about what friends, and especially his employer, would think.
Those on the front lines of the state’s opiate epidemic say the stigma associated with drug use and medically assisted recovery remains one of their biggest challenges.
“Addiction is more like a lot of chronic medical illnesses than we’re willing to accept,” said Dr. Kevin Hill, a substance abuse physician at McLean Hospital in Belmont and a psychiatry professor at Harvard University. “If you’re diabetic, a doctor may put you on insulin. Everyone knows someone who uses an inhaler. Those treatments are socially accepted while medications to treat opioid addiction are not.”
The debate over medically assisted recovery has long been part of the national conversation about the opiate epidemic.
Plymouth County Sheriff Joseph McDonald believes those drugs can play a role in short-term recovery, but that “we need to be focusing on things that lead us to abstinence.”
“We sort of re-assigned their addiction from a street drug to a prescribed drug,” McDonald said. “I know there are success stories. But it’s a quality of life issue. Their quality of life on methadone or Suboxone is as someone who is on a drug.”
The abstinence approach is hotly contested by doctors like Sylvester Sviokla, an addiction physician from Brockton who runs a Suboxone treatment program in Warwick, R.I. Sviokla, a recovering addict and Harvard-trained doctor, authored the book “From Harvard to Hell and Back” in 2013.
Sviokla sees 100 patients at his clinic, all of whom must take regular urine tests and undergo counseling. Suboxone is prescribed in the form of a foil that is placed under the tongue and dissolved.
“They get a little bit of energy. It stays in the receptor longer than methadone and it gets locked in tight,” Sviokla said. “Suboxone gives people their life back. They are doing so well, they are getting their kids back, they are getting promotions.”
As of December 2014, a daily census showed that 18,169 people in Massachusetts were seeking treatment in some way for opioid addiction, according to the state Department of Public Health. That does not include patients at U.S. Department of Veterans Affairs facilities.
Of those, some 6,000 to 8,000 are in a medically assisted treatment program, estimated Colleen LaBelle, a registered nurse and member of the governor’s task force. She runs Boston Medical Center’s opioid treatment program and trains doctors seeking to provide buprenorphine.
The programs that LaBelle oversees support 3,000 patients with buprenorphine treatment. Access remains a challenge, however. Federal guidelines allow doctors to serve only up to 30 buprenorphine patients in their first year, after undergoing eight hours of training to receive a waiver from the U.S. Drug Enforcement Agency. After that, they may see up to 100 patients. LaBelle said efforts are underway at the federal level to lift that cap and to allow nurse practitioners and physician assistants to prescribe buprenorphine.
Dr. Amanda Wilson is the president and CEO of CleanSlate Centers, serving about 4,500 patients in Massachusetts, the vast majority of whom are prescribed buprenorphine. They get the medicine through insurance coverage and nearly 60 staff doctors.
Yet the stigma may be the hardest barrier to surmount, she said. Only 3 to 5 percent of physicians nationwide, for instance, have been certified to provide buprenorphine, according to LaBelle.
“There used to be a negative feeling about depression 30 years ago,” Wilson said. “We have to eliminate the shame so that people recognize this is a chronic brain disease.”