Advocates push to expand use of medications to treat addiction

Kimberly Bussey became addicted to painkillers with her first dose.

She had miscarried a baby, a loss that left her suffering physically and emotionally. When she returned from the hospital, her boyfriend offered her morphine that he bought on the street.

"The medications don't just take away the pain," Bussey said. "They make you feel really, really good."

Within a year, Bussey had lost her job, her car and her house. Worst of all, the single mother also lost custody of her 5-year-old son. When Bussey couldn't afford pills, she turned to heroin.

She tried repeatedly to get help, going to detox more than a dozen times over three years.

Bussey managed to quit long term, however, only after attending a six-month, residential rehab program in 2008. Later, she began taking a medication called buprenorphine, also sold under the brand name Suboxone. Like methadone, buprenorphine eases withdrawal symptoms, decreases drug cravings and dramatically cuts the risk of relapse in people addicted to opiates, a class of drugs that includes heroin and morphine-like pain killers such as Vicodin and Oxycontin.

"The medication definitely helps," said Bussey, 35, who has been drug-free for nearly seven years. "I don't want to say it's a cure-all. It takes a lot of ongoing internal, emotional work, along with the medication, to stay clean. .. But I can't say that I would be clean without it."

Medications that treat addiction – buprenorphine, methadone and a third named naltrexone -- are a cornerstone of the Obama administration's plan to combat the opiate epidemic.

One consequence of the addiction epidemic: The death rate from drug overdoses more than doubled from 1999 to 2013, according to the Centers for Disease Control and Prevention. Drug overdoses now kill nearly 44,000 Americans a year – more than car accidents.

Opiate addicts who are given such "medication-assisted treatment" cut their risk of death from all causes – from overdoses to car accidents – in half, said Melinda Campopiano, medical officer at the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration.The medications also halve a person's risk of becoming infected with HIV, the virus that causes AIDS.

These medications are "an essential component of an ongoing treatment plan" that allow people to "regain control of their health and lives," said Nora Volkow, director of the National Institute on Drug Abuse.

The medications work by blocking or partly blocking the effects of opiates, preventing patients from getting high if they use drugs, said Emily Feinstein, director of health law and policy at the National Center on Addiction and Substance Abuse at Columbia University in New York.

Yet only 40% of the 2.5 million Americans who could benefit from medication-assisted treatment actually receive it, according to SAMHSA.

The American Society of Addiction Medicine has called for greater use of medication-assisted treatment. So have a number of members of Congress – including Sens. Edward Markey, D-Mass., and Rand Paul, R-Ky. – who have introduced bills to expand medication-assisted treatment.

'Government-sponsored addiction'

Rep. Tim Murphy, R-Pa., sees long-term use of medication-assisted treatment not as a lifeline but as "government-sponsored addiction" that substitutes one form of drug dependence for another. Increasing the use of buprenorphine is risky, he said, because it's already being sold illegally, Murphy said.

"The narrow-minded approach for the past decade has been to simply expand access to methadone or buprenorphine and erroneously call it treatment," Murphy said. "You can't call it treatment if we are simply swapping out a street drug for a synthetic, government-sanctioned one."

Richard Welch, who was addicted to heroin for 22 years, said taking methadone didn't cure that addiction. In fact, he continued to use drugs while taking methadone.

Welch said he failed to quit drugs while on methadone because "I was still dependent on something." He became drug-free in 1997, after going off methadone.

Giving up both methadone and heroin "has been the biggest blessing and victory in my life," said Welch, now the executive director of Teen Challenge New England, which runs Christian-oriented rehabilitation programs in Vermont and Connecticut.

Teen Challenge is one of many rehabilitation programs around the U.S. that shun medication-assisted treatment. Narcotics Anonymous – known for its 12-step model – is a "program of complete abstinence." Although everyone is welcome at meetings, the group advises members to abstain from medications used to treat addiction, spokeswoman Jane Nickels said.

Many recovering addicts say that medication-assisted treatment carries a stigma.

Anna Cromwell, 56, said her boyfriend initially discouraged her from using methadone. "He thought it was a crutch," said Cromwell, of Baltimore, who used heroin and other drugs for two decades before beginning methadone four years ago.

Medication-assisted treatment has given her a new life, Cromwell said. Along with methadone, her Baltimore program provides counseling, support and daily meetings. Cromwell said she has a sponsor, whom she can call any hour of the day. The program also prompted her to be diagnosed with depression and anxiety, for which she now takes medication.

"On days when I feel down, I try to talk to someone," Cromwell said. "I just feel normal now."

Directors of the Hazelden Betty Ford Foundation encountered resistance from both outside and inside the organization when it embraced the use of medication-assisted treatment two years ago.

Both the Hazelden Foundation and Betty Ford Center, which merged last year, had subscribed to a "total abstinence" philosophy. But leaders realized that "we're in the midst of a crisis and we need to do so much more," said Marvin Seppala, the Hazelden Betty Ford Foundation's chief medical officer.

"I've been criticized by multiple people around the country," Seppala said. "They say we've turned our back on our heritage as a 12-step program."

Seppala compares fighting addiction to battling cancer. Just as doctors often treat cancers with multiple therapies – including surgery, radiation and drugs – doctors should be willing to use a variety of treatments to help people suffering from addiction, he said.

Bussey said she understands both sides of the debate.

Although Bussey said she does feel dependent on buprenorphine, the drug doesn't rule her life the way heroin once did. She's able to give back to the community, volunteering with local food banks and helping other recovering addicts at the rehab center she once attended.

"I'm no longer out there doing things that are harmful to my body, doing things that are going to put me in prison or teach my children that it's OK to lie, cheat and steal," Bussey said. "I need the medication to keep me level and balanced. But all the bad stuff that goes with addiction isn't there."

'Living proof that you can live a normal life'

Many patients would like to try medication-assisted treatment but find that their insurance won't cover it or severely limits coverage, said Kelly Clark, president-elect of the American Society of Addiction Medicine.

"No insurer questions me when I prescribe Vicodin for pain," said Anna Lembke, who directs the addiction medicine clinic at the Stanford University School of Medicine, in testimony before a subcommittee of the House of Representatives' Committee on Energy and Commerce. "But if I want to prescribe Suboxone to help an addicted patient stop taking Vicodin, I typically have to spend hours fighting an insurance company to get the prescription approved."

Medicaid programs in at least 17 states don't pay for long-term methadone treatment, according to the Legal Action Center, who advocates for people with drug addiction.

Some insurance plans cap the amount of time that people can receive medication-assisted treatment, Clark said. That can cause patients who need the medications long term to relapse, she said.

"Some people can taper off of it, but some people need it forever," Clark said. "We don't tell people, 'Let's decrease your dose of statins and see how you do.' The goal of treating your cholesterol is not to get you off statins. The goal is to decrease your risk of a heart attack."

States could expand access to treatment by requiring private insurers to cover the medications, Feinstein said.

While any doctor can provide naltrexone, the government tightly regulates methadone and buprenorphine because of their potential for abuse.

Methadone can be dispensed only at licensed specialty treatment programs. Buprenorphine, which is considered less likely to cause overdoses than methadone, can be prescribed at a doctor's office. Doctors who undergo eight hours of training can prescribe buprenorphine to 30 patients in their first year and 100 patients a year after that, according to SAMHSA.

Only a fraction of doctors can now prescribe these medications.

Although 877,000 physicians can write prescriptions for controlled substances, only 29,000 are authorized to prescribe buprenorphine, according to the Office of National Drug Control Policy. Most of those doctors are limited to 30 patients.

The bill introduced by Sens. Paul and Markey would allow doctors to prescribe buprenorphine to 100 patients in their first year and to seek permission to treat an unlimited number after that. The bill would also allow nurse practitioners and physician assistants to prescribe buprenorphine for the first time.

Murphy opposes that expansion, saying that he doubts physicians will have time to properly monitor and drug test more than 100 patients.

Bussey said she continued using drugs for 18 months after she began taking buprenorphine. For four months, she even sold some of her prescription in order to buy more heroin. When her doctor found out, he dismissed her.

Almost seven years ago, Bussey decided to stop taking drugs for good. She bought buprenorphine on the street to eliminate her craving for heroin.

Like Bussey, some people buy buprenorphine on the street because they are trying to "self medicate," taking the drug to wean themselves off opiates or treat withdrawal symptoms, said Michelle Lofwall, an associate professor at the University of Kentucky College of Medicine's Center for Drug and Alcohol Research. Her research shows some people buy buprenorphine on the street because they can't find a doctor to prescribe it legally.

Bussey found another doctor willing to prescribe buprenorphine legally, as well as provide counseling and support. She hasn't used illegal drugs since.

The change in her life has been dramatic.

Four years ago, Bussey regained custody of her 14-year-old son, who lived with her mother while she was using drugs. At first, her mother opposed Bussey's decision to take buprenorphine, even threatening to take her son back. Over time, her mother realized the medication helps Bussey to stay sober, and the two are rebuilding their relationship. She's also trying to rebuild her credit, another casualty of her addiction.

Today, Bussey is married and has a second son who is 5. She and her husband own a tattoo shop in Lakeville, Mass., and rent their own home, with an option to buy in two years.

Buprenorphine "has helped us immensely," Bussey said. "We're living proof that you can live a normal life."