As the COVID vaccine rollout begins, there seems to be a glimmer of hope that the coronavirus pandemic will eventually end. Meanwhile, America’s other, decades-long epidemic rages on. More than 40 states have reported an uptick in opioid deaths since March; overdose-related cardiac arrests (mostly attributed to opioids) rose by 50 percent this year; and paramedics are citing more naloxone use, a sign that overdoses in general are on the rise, not just deadly ones.
Nora Volkow, director of the National Institute on Drug Abuse, tells me the opioid crisis “looks to be getting worse,” and hopes the increased fatality might lead to a greater acceptance of more thorough treatments for opiate use disorder (OUD), like Brixadi, a weekly or monthly shot of buprenorphine poised to be approved by the FDA this month. Buprenorphine, a partial agonist of opioid receptors in the brain, is widely considered the gold standard of managing OUD, despite being largely inaccessible to those who need it.
In 2002, the FDA approved two buprenorphine products, Suboxone and Subutex, for the treatment of narcotic addiction in what’s largely considered the most significant event in addiction medicine since the introduction of methadone maintenance in the 1960s. Since then, medication-assisted treatment with buprenorphine has proven to be at least twice as effective as abstinence-based treatment, leading to endorsements from the Department of Health and Human Services, the World Health Organization and the American Society for Addiction Medicine.
“I don’t think there are any areas where the data is shaky,” Volkow says. “Studies have shown that outcomes are much better with medication-assisted therapy because it significantly decreases risk of relapse, and reduces transmission of infectious diseases, like HIV and hepatitis C.”
Buprenorphine itself is an opioid, but as only a partial agonist, it doesn’t bind to opioid receptors fully and elicit euphoria. Think of opiate receptors like locks into which very specific keys fit — e.g., Oxycontin, Vicodin, fentanyl, heroin, methadone, etc. Vivitrol (naltrexone) and Narcan (naloxone) also work in this lock, but unlike opioids, they don’t create dependence; they’re simply blockers, sticking their key into the lock and breaking off the handle. Buprenorphine, on the other hand, turns the receptor only halfway on, before pulling the handle off the light switch to not allow additional opioids to further stimulate it. As such, unlike methadone (a full agonist), buprenorphine is nearly impossible to overdose on alone, and the receptor remains stimulated enough to avoid dreaded symptoms of opiate withdrawal (namely, anxiety, nausea, vomiting and abdominal pain).
Methadone has the longest history of medicated treatment for OUD, having been used since 1947. Due to its potential for overdose, however, the government has siloed it in special programs called opioid treatment programs, the only place you can get it. Because buprenorphine is comparably safe, it can be obtained by (some) primary care doctors. Despite being limited, this access is crucial, Volkow says, for bringing OUD treatment out from the shadows. “Accepting buprenorphine into the health-care system means we’re accepting addiction as a mainstay disease, to be treated like any other.”
The thing is, buprenorphine also has limitations. Suboxone, for example, only lasts 24 to 36 hours, meaning that withdrawal begins the day after the most recent dose. Only a month’s supply can be prescribed to avoid diversion, and often much less. Prisons and jails have been particularly reluctant to permit buprenorphine, due to fear of diversion, Volkow says, despite prisoners with OUD being exceedingly likely to fatally overdose upon release due to waning tolerance. In 2017, the Massachusetts Department of Public Health found the opioid overdose death rate is 120 times higher for those recently released from incarceration compared to the rest of the adult population. This is particularly unfortunate given that evidence-based, medication-assisted therapy exists, but remains largely unavailable to people who need it the most.
Diversion, in this context, is “the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person,” a major driver of which is opioid abuse. Diversion of buprenorphine, however, is very uncommon, comprising less than 1 percent of all reported drugs diverted in 2014 per the DEA Office of Diversion Control. And when it does occur, it’s primarily used for managing withdrawal. “The evidence is clear that the primary driver of buprenorphine diversion is lack of access to buprenorphine treatment,” confirms James Gasper, the substance use disorder pharmacist at the California Department of Health Care Services.
“Diversion isn’t a sign of an individual’s failure to take their medication appropriately,” explains Justin Kunzelman, co-founder of Rebel Recovery Florida. “It’s a sign that the system hasn’t allowed adequate access, so much so that people have to go to the street to get substance use disorder care. Who buys buprenorphine as their everyday drug? In 20 years on the street, I never, ever had someone come to me and say, ‘You know where I can score some bupe?’ If people were illicitly sharing heart medication, would we say they were abusing it, or would we wonder if we aren’t providing enough medication to those who need it?”
Diverted or not, the orange, 8-milligram strip of Suboxone is applied under the tongue, and tastes like a combination of nail-polish remover and lime-flavored Band-Aids. Doug, a pseudonymous, 27-year-old middle school teacher in New York State who has been in recovery for three years, says it can take up to 40 minutes to fully dissolve the medication, during which time he can’t eat or drink — an unfortunate reality when he’s gotten a late start to his morning. “I’d lie and tell people [at work] I was on nitroglycerin for low blood pressure.”
Doug’s dissent into OUD follows a now-familiar pattern. He was prescribed codeine as a tween to treat a painful, swollen throat caused by mono and loved the way it made him feel. When he was given opiates in high school following a skateboarding injury, it began a years-long, on-again, off-again love affair with prescription painkillers that eventually landed him in rehab. When he got out after 39 days, he brought Suboxone strips with him. The steadiness and consistency they provided allowed him to move into an apartment with his girlfriend and work long hours to pay off his debts. He made amends wherever he could, got a Master’s degree and became a teacher.
A year ago, after hearing his rehab doctor sing its praises, he switched from Suboxone to Sublocade, a monthly buprenorphine injection approved by the FDA in 2017, joining Probuphine, a six-month buprenorphine implant, as the only FDA-approved extended-release formulations. “Sublocade is a miracle drug and the closest thing we have to a cure for the opioid epidemic right now,” Doug declares. “‘Liberating’ is the right word for it, as is ‘smooth’ and ‘normal,’ since that’s how it feels compared to Suboxone strips, which made me jittery, nauseous and experience moderate withdrawal in the morning. Sublocade has completely resolved those issues.”
Doug is fortunate to live in a state whose Medicaid program covers extended-release buprenorphine, and the experience of people living in the most progressive states, like New York and California, can be wildly different from those who don’t. The California Medi-Cal system, for example, offers robust access to medications for the treatment of OUD, including naltrexone long-acting injections, methadone maintenance at opioid treatment programs and both sublingual (i.e., under the tongue) and long-acting injection of buprenorphine — all of which are available without prior authorization and at no cost. “We can’t put barriers in place for types of treatment,” Gasper tells me, explaining that his department has greatly expanded the number of Medi-Cal beneficiaries receiving treatment with buprenorphine, from 1,265 in 2010 to 30,627 in 2019. On the flip side, in Kentucky, doctors report not being able to access buprenorphine of any kind for patients on certain Medicaid managed-care programs.
In 2016, in Upstate New York, Doug was broke, technically homeless and in dire need of intensive rehabilitation — which is why he considers the New York State of Health website and hotline “literal life-savers.” With them, he was able to secure free insurance overnight, which covered a week in a detox facility and 39 days of rehab in a residential, medication-assisted OUD therapy setting. (He left after 39 days because that’s when counselors said he was ready to step down to outpatient therapy, not because of an insurance cap. Some people stayed longer.) His insurance also fully covered a prescription to Suboxone, and later Sublocade, for which he pays $16 a month.
Again, Doug’s story isn’t typical of the nation as a whole. “I hear heartbreaking stories from inside and outside of the U.S., from people who fall into the category of ‘the working poor’ — the sweet spot where you get absolutely fucked on insurance because you can’t afford decent coverage but also aren’t poor enough to qualify for free health care like I did,” says Doug, who now runs a volunteer email service helping people get clean online.
Essentially, you need to be rich enough or have premium insurance to afford the medication — $1,659 per month for Sublocade — or poor enough to be on Medicaid. Some insurance plans refuse to pay for it altogether, so many who work 60 hours per week for low wages are shit out of luck.
This also means that people who try to get a hold on their habit before they lose everything are screwed. “But those like me who have lost everything to their addiction, and have therefore lowered their statistical odds of ever beating it, are in a better position to get clean through medication-assisted therapy than those who haven’t. I’ve literally advised someone to quit their job so that they could do inpatient and get Sublocade through their state’s medicaid program. I was hesitant to give that advice, but this person had tried everything else and really needed medication.”
As Doug mentioned, there’s also the issue of getting off Suboxone, which can be difficult and ironically often requires detox, despite it being commonly used to detox from other opioids. Erin, a pseudonymous 38-year-old call center worker in Oregon, spent a year tapering off Suboxone, successfully decreasing her dose to two milligrams, but going below that raised issues. “I started having cravings again and thoughts about being okay to do heroin just once,” she tells me. “I didn’t want to do that so I asked my doctor about extended-release options.”
And so, in December 2019, she also switched to Sublocade. When we speak, she has just returned from receiving her 12th injection, to great effect — i.e., no cravings or unstable emotions. What really attracted her to Sublocade is how easy it reportedly is to get off of. “The real advantage of Sublocade is that it covers people long after the injections have stopped,” explains David Kan, a psychiatrist in California specializing in addiction medicine, who tells me that six months after the last injection, he still detects high levels of Sublocade in patients. “Studies have shown that when people stop the medication, they don’t tend to withdraw badly. And even if they return to use, the protection against fatal overdose is still likely there.”
Erin will soon step down to getting shots every other month, with the goal of being opioid-free by the end of next year. Despite the obvious logistical and mental-health benefits of extended-release buprenorphine formulations to people like Erin, Medicaid enrollees seldom receive Sublocade, according to an April report from the Urban Institute. Rather, Volkow says, states tend to cover the least expensive option, typically the generic form of daily Suboxone (Zubsolv), which costs about $140 a month. “That has to change,” Volkow tells me.
Moreover, even if someone is fortunate to have the right insurance, access to doctors who can legally prescribe buprenorphine can be limited because the doctor is required to have an X waiver on their DEA license. Due to stigma held by many health-care providers toward people who use drugs, there’s a hesitancy to get an X waiver because they may not want people who inject drugs in their waiting rooms. Along these lines, Doug found it “impossible” to access a Suboxone doctor and was forced to go through an actual rehab. “I called a lot of them in tears,” he says. (Not to mention, once a physician receives an X waiver, only 100 patients are initially permitted out of the gate.)
The stigma against medication-assisted treatment extends to some factions of 12-step, too, explains Leah, a 21-year-old recovering heroin addict in Seattle, where she now works at a daycare. “People [I’ve met] in Narcotics Anonymous say you’re not really sober if you take this medication, which I disagree with.” Some AA groups do permit prescribed medication, and AA’s official stance is that it has no opinion on medication-assisted treatment (positive or negative); that said, it won’t interfere if individual groups exclude people based on buprenorphine usage. Plus, as Leah has experienced, in the eyes of NA, people in recovery aren’t clean before they abstain from all drugs, including Suboxone and methadone. And so, NA advises its member groups not to let individuals on medication-assisted treatment share at meetings, be speakers or sponsors or hold any trusted positions within the organization.
This is generally true of rehab facilities as well. Case in point: Research recently published in the Journal of the American Medical Association finds that only 29 percent of the 368 programs they contacted offered medication like buprenorphine, while another 21 percent actively discouraged its use.
Ryan Hampton, a 40-year-old in recovery from OUD and author of American Fix: Inside the Opioid Addiction Crisis — And How to End It, finds this ridiculous. Buprenorphine saved his life, and nothing angers him more than innovation in the addiction recovery space being stifled. “People should be welcomed into treatment centers and 12-step meetings while on buprenorphine of any kind, because that’s what they need to get better,” he argues. “We’re in the midst of a dueling public health crisis right now. Are we really going to sit here and debate morals around medication? We should take the science that we have and put it to work. Medication-assisted treatment saves lives. We must get more innovative in terms of care delivery for addiction treatment, and hopefully, a new presidential administration will make that possible.”
As for Doug, he credits Sublocade specifically — as well as access to comprehensive insurance — for being able to become a teacher in a leading school district, which he acknowledges isn’t something most former heroin addicts can say. “My heart breaks for the people who won’t ever get to experience this kind of reversal in fortune,” he says. “Imagine a world in which all addicts had the second chances I’ve had. I was the rare exception where the system worked for me and not against me.”
“I feel like I’m living proof that addicts can be a good investment and net benefit to society when they aren’t discarded,” he continues. “I doubt many would argue that I’d be more useful dead or still using than I am teaching.”
He stops himself and reconsiders for a moment before finishing as emphatically as possible: “Actually, some would argue that, but fuck them.”