Regulations, shortages keep addicts from getting treatment
By Julie Havlak
Carolina Journal News Service
Friday, August 10, 2018
RALEIGH — When addicts show up at emergency rooms, there’s a good chance they will not find help.
“I see individuals walk into the emergency department, saying, ‘I’m fed up, I’m done, I want to stop doing heroin. Can you help me?’” Dr. Stanley Koontz of New Bern said. “And usually … I’ll send the majority of them home.”
Treatment programs are saturated, and patients often are left to battle addiction on their own. Doctors place part of the blame squarely at Uncle Sam’s feet, many health professionals said.
America’s war on drugs has mutated in the past decade almost as radically as real warfare has during the past century. Where President Nixon once declared war, and Nancy Reagan preached “Just Say No,” politicians and doctors alike are rebranding addiction as a disease and replacing abstinence with medication-assisted treatment.
On the front lines of the fight against addiction are buprenorphine and methadone, drugs that block cravings and withdrawal symptoms. But getting more addicts medication-assisted treatment programs is an uphill slog, slowed by skepticism within the industry, shortages of providers, and lawmakers’ regulations, experts said.
Buprenorphine and its cousins either are hailed as life-saving drugs or suspected as the next chimera in America’s search for a “magic bullet.”
“You can have a woman who is shooting up the night before, and within 24 hours she can go to work and take care of her children,” said Dr. Francis Gorrigan, CEO of Solas Health in Pinehurst. “All signs of an addictive disorder pretty much vanish.”
Buprenorphine also has a dark side. Lawmakers slapped regulations on the treatment after buprenorphine leaked out of doctors’ offices, spread on the streets, and infiltrated North Carolina’s prisons.
In the Brunswick County Detention Center, inmates smuggle in buprenorphine strips behind mailing stamps and in the creases of books.
“We do occasionally have someone going through heroin withdrawal, and it is just horrific,” Brunswick County officer Emily Flax said. “But it is mostly for the high.”
Some doctors disagree.
A few go so far as to shrug at drug diversion in the hopes that somewhere, the drugs are helping addicts detox rather than die in an overdose, said Dr. Jeffrey Singer, a surgeon and senior fellow at the Cato Institute.
“There is a lot of data now suggesting that most of the suboxone (buprenorphine) that is sold on the street is sold to people who are worried about going into withdrawal. They are not using it to get high,” Singer said. “Oxycodone is the drug to get high on, heroin is the drug to get high on. Buprenorphine is no big deal.”
Current law restricts the number of patients that doctors can treat with buprenorphine. If they apply for a waiver and complete eight hours of training, physicians can treat up to 30 patients in the first year, 100 the next, and can eventually apply to treat up to 275.
“The government is getting in the way of themselves if they want to stem the tide of opioid addiction. They have made it impossible, especially for the poor,” Gorrigan said. “What has occurred from this is an artificial shortage of treatment, and what occurs from that is that most providers of buprenorphine charge cash … which most people can’t afford.”
The inspections, the regulations, and the fears of drug diversion have scared primary doctors away from prescribing medication-based treatments, Singer said.
“The volumes are incredible,” WakeMed Vice President Rick Shrum said. “Placing them in enough good hands is the real challenge.”
While patient caps were meant to stop the rise of illicit buprenorphine empires, the restrictions exacerbate the shortage of care, doctors said.
“I don’t think (the cap) is high enough at all,” Koontz said. “When somebody finally says they need help, I’ll be honest with you, we take their blood, we make sure they don’t have an underlying medical condition, and we say, ‘Here’s our list or resources, we’ve called around, nobody has beds, here you go.’”
“Usually they grow just as discouraged and quickly relapse because it seems like the impossible journey,” Koontz said.
The restrictions are tightest on methadone, which carries a higher risk of abuse. Patients have to travel to a methadone clinic, where nurses watch them take the dose each day for the first 90 days.
“There are underserved areas, where you have to drive 100 miles to the methadone clinic,” Singer said. “And most people don’t have the means or the patience to drive back and forth to the methadone clinic that’s not nearby every day.”
To operate a methadone clinic, doctors must apply through three federal agencies, qualify for an Opioid Treatment Program license, and jump through other hoops meant to choke drug abuse.
“It’s very, very tightly regulated by the state and federal government,” said Eric Morse, who operates eight opioid treatment programs. “You’re inspected constantly and randomly by the state and DEA.”
About 12,000 providers actively prescribe buprenorphine in the United States, according to the National Alliance of Advocates for Buprenorphine Treatment.
“I can tell you from the front lines, it’s a narrow window when someone says they’ve finally had enough, ‘I want help,’” Koontz said. “You have to try to get them into (treatment), but the issue is that the psychiatric and substance abuse systems for many years have been broken.”
Carolina Journal News Service is provided by the John Locke Foundation of Raleigh.