Wider medication use could be the future of treatment

by: TRIBUNE PHOTO: CHRISTOPHER ONSTOTT - Patients pick up their doses from the methadone dispensary at CODA, a nonprofit that specializes in addiction recovery.Tim Hartnett, the executive director of the oldest methadone clinic in Multnomah County, believes we are on the cusp of a new age of recovery treatment that will increasingly rely on medications to help people deal with their addictions and stabilize their lives.

That’s precisely what most worries Leonard Arnold.

“We are where mental health was 30 years ago,” says Hartnett, who heads CODA Inc., a nonprofit that specializes in addiction recovery.

Thirty years ago, before Prozac, relatively few people suffering from depression and anxiety were given medication. Conventional talk therapy was considered the most viable option for the most common psychiatric problems.

Today, a variety of pharmaceuticals are often prescribed as a first response.

The driver of a new age of addiction therapy, Hartnett says, will be changing attitudes toward medications such as methadone. Increasingly, the goal of addiction therapy will no longer be to replace an opiate such as heroin with a drug such as methadone and then to wean the patient off, the experts say.

“What will happen in the next few years is that idea will wither,” Hartnett says. “People will approach substance use disorders like (they do) diabetes and other chronic health conditions.”

In the view of Hartnett and many others in the recovery industry, soon those who are on a long-term, even a lifetime dose of methadone will be viewed no differently than diabetics who take insulin.

Arnold, a 62-year-old resident counselor at the Volunteers of America men’s inpatient addiction center, lived a heroin addict’s life from the time he was 23 until he turned 49. He tried abstinence therapy many times and methadone once before embracing sobriety 12 years ago. His view of methadone is shared by many heroin addicts who have turned to a drug-free life.

Arnold can’t quite say why drug counseling worked for him 12 years ago, when it had failed so many times before. Typically, counseling would help him become clean and sober for a while, and then he would relapse. He says the VOA inpatient program was part of the solution, but he also says luck played a role.

“There’s some kind of a magic that happens,” Arnold says.

Arnold is worried that the price of putting more addicts on medication will be that magic. If he had stayed on long-term methadone therapy, he suspects he would have never been pushed to try the hard work of clean and sober recovery time after time.

Army of zombies?

Multnomah County health officials have been talking for more than a year about an epidemic of heroin and prescription painkillers in the Portland area. County recovery programs have begun experimenting with more drug therapy for a new wave of younger opiate addicts who are resisting traditional treatments.

Arnold’s take? “It makes you lazy. We’re going to create an army of zombies,” he says. “In my heart, I truly believe that.”

David, a 43-year-old single father of two, says he is anything but a zombie. The Vancouver, Wash., resident, who has fashioned a career in marketing, was put on methadone 16 years ago because he become addicted to prescription painkillers after breaking his wrist. He has kept to a maintenance dose since.

David (who asked that his last name not be used) says before starting methadone he had become suicidal. On methadone, he has no desire for painkillers, and his lifelong obsessive/compulsive tendencies have abated. He’s up at 5:30 every morning and asleep by around 10 each night, he doesn’t get tired in the afternoon, he doesn’t sweat uncontrollably and he’s never felt high on methadone.

Which explains why he hasn’t wanted to stop taking his maintenance dose for the past 16 years, but makes curious a recent decision — David has begun tapering his dose in hopes of getting off methadone.

David’s reasoning? He’s thought of moving out of Portland, but on methadone that is difficult. Methadone, a controlled substance, is only dispensed through state-accredited clinics (David’s is CODA). If he moved to another city, the process of starting a relationship with a new methadone clinic would be arduous.

Applying for new jobs in the Portland area is difficult for David because he takes methadone. Knowing the methadone will likely turn up, after taking an employment-related drug test, David is contacted by the lab and told that the test revealed methadone. He then provides proof of a prescription. The potential employer is not privy to that confidential medical information.

On one occasion David went through an interview process and was told by the owner of a company that he had a job. David then revealed to the owner that his drug test would show he took methadone, and the job offer was withdrawn.

(EDITOR'S NOTE: This section of the story has been clarified to show David's process when taking employment-related drug tests.)

Nearly everyone who learns he takes daily methadone assumes David is a heroin addict, though he’s never tried the drug. He says he’s been kicked out of 12-step support groups for addicts because he takes methadone, seen by many addicts as a substitute addictive drug. When he had teeth pulled, the dentist, aware of David’s history and methadone use, refused to prescribe painkillers that David says he needed.

Mostly, David says he is ready to try quitting methadone because during the 16 years he’s gone to enough support groups and received enough counseling and gained the confidence that comes with increasing age. He estimates his chances of becoming drug-free are 50-50 as he steadily lowers his dose of methadone this year.

“I have enough tools in my bag that if I know it’s not working, I will stay on the methadone,” David says. “I will never go back to using pain pills. That life is done for me.”

Changed brains

Addiction medications have been slow to gain wide acceptance, mostly because people in the addiction community tend to form opinions based on personal experience and observation. Arnold has known addicts on methadone who continued stealing to support opiate habits. David isn’t one of them.

The two men see methadone through different lenses.

Dennis McCarty, an Oregon Health & Science University researcher who specializes in addiction treatment, says a growing number of studies show that addicts kept longer on addiction medications do better. Addicts stay off heroin, and alcoholics stay away from drink. They stay out of jail. They require less inpatient health care. The principle known as harm reduction works.

But there is scarce data showing the medications increase the odds that addicts will someday become drug-free, according to McCarty.

“There are people who have gotten off methadone and lived drug-free, but they are rare,” he says.

Hartnett says that increasingly, the question no longer matters. Jay Wurscher, coordinator of alcohol and drug services for Oregon’s Child Welfare Division, agrees. Behavior and harm reduction matter, he says.

“Why does anybody care if somebody’s on methadone if they’re clean and sober and functioning?” Wurscher says.

But Arnold is among those who look at the Prozac revolution, apply its 30-year-trajectory to medication for addiction, and see a cautionary tale. He says he could see health insurers, drug companies and a public enamored with quick fixes eventually driving policy.

“As a society, we’re capitalists,” Arnold says. “If it’s easier, they do it. Get them out of our hair. We don’t really want to explain or understand what’s going on.”

According to McCarty, less than 1 percent of the money spent on addiction treatment in this country is spent on medication. Insurers, he says, are eventually going to see the benefits of paying for methadone and other pharmaceuticals.

“These medications can save the health plans money in the long run,” he says.

Last year, McCarty visited Amsterdam to study a program that takes the idea of harm reduction one giant step further. There, the government is prescribing heroin to patients for whom methadone treatment isn’t working — they are still committing crimes to feed their heroin habits.

“They’re healthier and less involved in criminality,” McCarty says of the addicts who are supplied heroin. “From the Dutch perspective, the total cost is less.”

Ten years ago, CODA had 450 clients on methadone. Today, there are about 670. And a quantum leap may take place when insurance companies embrace the cost effectiveness of putting a patient on $5-a-day methadone.

Federal guidelines require a patient to try addiction counseling before methadone can be prescribed. Making addiction medications more available, Hartnett says, will take more than simply changing attitudes. Doctors and nurses, he says, are just beginning to get training in addiction and the possibilities of long-term medication as treatment.

“Walking through this clinic 10 years ago, you saw people with gray hair. Now you see people with skateboards,” Hartnett says. “We’ve in effect created a generation of people who will have changed brains because of prescription drug use, and they will become our clients.”

New drug gives addicts one shot at recovery

Dr. Jessica Gregg was wondering how many of her latest patients would come back for a second shot.

One shot of Vivitrol costs about $1,000. It lasts for a month. During that month, addicts, no matter how much heroin or how many prescription painkillers they ingest, get no effect. And Vivitrol isn’t addictive.

Central City Concern’s Hooper Detox center received funding this year for a pilot project using Vivitrol, which is a time-release version of the drug Naltrexone. Starting last November, 30 opiate addicts could volunteer to get free Vivitrol shots.

When the trial was announced, 24 men and women signed up to take Vivitrol immediately after they went through the week- to 10-day process of removing other drugs from their systems.

Eleven of the 24 made it to their first shots, about par for the course for opiate addicts, says Gregg, the Hooper Detox medical director. Usually, after a day or two of sobering up, at least half change their mind about any addiction therapy, and most of Hooper’s clients are homeless.

Five of the 11 Hooper clients started the first round of Vivitrol shots in early November, and all came back for a second month’s shot. Four returned for a third shot in January. Linda Hudson, Vivitrol program manager for Hooper, says a few have asked about a fourth shot, but there's not enough supply.

Of the first 11 who started on Vivitrol, a few have reported trouble sleeping. A few say they miss the pleasure high from heroin. But they are coming back.

“They like the life they’re living, and they want some insurance,” Hudson says.

Hudson and other Hooper staff will be asking questions and keeping data on those who receive Vivitrol. As addicts, will they miss the high they get from heroin? Will they suffer depression? Will they continue to attend addiction support groups?

Along with Oregon Health & Science University researchers, Hooper's staff will look at health care costs for clients while they are free from heroin and painkillers.

Those support groups, along with individual counseling that can lead to working with Central City Concern housing specialists, could be critical. The freedom from drugs such as heroin will be temporary, Gregg acknowledges. Most addicts are taught in counseling that if they return to their old settings with familiar friends and familiar habits, they will likely return to their familiar drugs.

New therapies

But Gregg cautions that a drug-free life might not be the only way the measure the program’s success. If the clients remain drug free for the two or three months they are on Vivitrol, and require significantly less health care than they normally would, maybe, she says, the $1,000-a-month shot might still be worth it. If those extra months on Vivitrol help clients do the work to change their lives permanently, so much the better.

Some private health insurers cover Naltrexone, which can be taken as a $500-a-month daily tablet. Hooper clients are being tested with the more expensive time-release Vivitrol because of suspicion that many might not take their daily dose while out on the street, or might even sell it.

Methadone is the best known and researched medication for addiction, but newer drugs such as Naltrexone and Suboxone are among the new therapies.

OHSU researcher Dennis McCarty says there is little long-term data on Naltrexone, which was only approved for use in the United States two years ago. Short-term studies show it may be as useful for alcoholics as for opiate addicts.

Suboxone is less regulated than methadone, so it is more easily dispensed, and easily abused.

The first large-scale study on the use of Suboxone for people addicted to prescription painkillers was conducted two years ago. It showed about half of the study’s 600 participants reduced their use of prescription painkillers while they received Suboxone. Once the Suboxone was stopped after three months, 92 percent went back to their addiction levels.

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