Freedom seekers

DAVID STONER REMEMBERS THE FEELING OF SMOKING MARIJUANA for the first time as a self-conscious 11-year-old. Soon after, he tried liquor. He relished the instant confidence boost even as it burned the back of his throat.

“That sense of doubt in myself melted away,” Stoner recalled. For the first time, he felt comfortable in his own skin. The more he tried, the more he felt accepted by his peers. Alcohol and marijuana laid the groundwork for experimenting with cocaine and pills.

Then, he met a girl.

The woman who is now his wife introduced Stoner to OxyContin, heroin, and, eventually, fentanyl. “And before I knew it, I was physically dependent on opiates,” he said.

Twenty years ago, the solution to Stoner’s problem could be summed up in three words: Just say no. Not anymore.

For decades, “quitting”—or what addiction specialists refer to as abstinence-based recovery—was the goal for drug users seeking to break free from the grip of addiction. But now, the long ravages of the opioid epidemic and the rising potency of street drugs are pushing many experts to rethink their approach.

Stoner’s wife lived in terror of the debilitating, flu-like symptoms that accompany opioid withdrawal, and he quickly adopted her fear. He had one focus: securing his next high. He hated the lies he told and the money he stole to satisfy his obsession, at the time primarily heroin: “I just found myself doing more and more things that I thought I would never do.” Though Stoner enrolled in multiple rehab programs, the periods of sobriety that followed never lasted long.

So he decided to try something different. The couple located a nearby methadone clinic and traded illegal opioids for a legal one. Methadone, obtained by prescription, stimulates the brain’s opioid receptors, but to a lesser degree than heroin or fentanyl. Every day at 5 a.m. the Stoners rushed to the clinic before loading equipment into their truck and heading to landscaping jobs around the city of Huntsville, Ala.

Medications like methadone and buprenorphine, designed to blunt withdrawal cravings and block users from getting high, are now considered the gold-standard addiction treatment by the U.S. surgeon general and other specialists. With the government’s seal of approval, medication-assisted treatment options are rapidly gaining ground, especially as opioid-crisis settlement funds start to trickle down to state and local governments.

But critics warn medication-assisted treatment is not a cure. Instead, it creates lifelong patients—and allows the pharmaceutical industry to continue cashing in on a crisis it helped create.

David Stoner is currently at a Christian rehab program in Huntsville, Ala. Ronald Pollard/Genesis

JOHN WILSON GO HIS START in the addiction treatment field in 1995—just one year before Purdue Pharma patented its infamous OxyContin pill. The company aggressively marketed its painkiller to clinics across the country, claiming it wasn’t addictive.

Back then, Wilson’s employer, Credo Community Center, boasted a 15-bed treatment facility, and everything was abstinence-based. In Wilson’s mind, that was exactly as it should be. He had grown up on “Just Say No” campaigns, and medication-­assisted treatment (MAT) seemed like “substituting one drug for another.”

At the time, MAT had already been around for about three decades, ever since treatment providers started experimenting with methadone in the 1960s. In 1966, researchers discovered buprenorphine, the generic term for medications like Suboxone, Buprenex, and Subutex. But the Food and Drug Administration didn’t approve the drug for addiction treatment until 2002.

So Wilson felt skeptical when Credo’s executive director decided to start offering medication-assisted treatment. Day after day, Wilson sat behind the clinic’s glass window and watched people come in for their regular doses. They looked haggard and gaunt, and many had abscesses covering their bodies.

Wilson wasn’t the only one hesitant about MAT back then. The treatment had been controversial for decades, since most people viewed it as switching one opioid for another. But experts say that skepticism has shifted with the advent of fentanyl—a drug 100 times stronger than morphine and the primary culprit in 90 percent of more than 81,000 opioid-­related deaths in 2023.

Wilson’s aha moment came several months after Credo began using MAT. He noticed a change in the appearances of those seeking treatment. “They were healthier,” Wilson said. “And they were alive.”

One day, he overheard a snatch of conversation between one of the patients and her attending nurse. The woman had just regained custody of her daughter. That was enough to convince Wilson: “We’re doing something right here.”

MAT is supported by more than just anecdotal evidence. Several studies show the treatment to be highly effective at decreasing the risk of fatal overdoses and retaining patients in treatment. A study of over 17,000 adults in Massachusetts who survived an overdose between 2012 and 2014 found opioid deaths decreased 59 percent for patients taking methadone and 38 percent for patients receiving buprenorphine compared with those not on a medication regimen.

These documented successes have propelled MAT into mainstream medical acceptance. Since the early 2000s, U.S. doctors have written more than 170 million buprenorphine prescriptions.

In 2019, about 1,690 opioid treatment programs (OTPs) offered medication-assisted treatment. Three years later, the Substance Abuse and Mental Health Services Administration (SAMHSA) reported that number had grown to about 2,070.

In 2022, about 700,000 patients regularly visited clinics for MAT.

Alan, who is getting treated at a nearby methadone clinic while trying to kick his heroin addiction, sits inside his tent at the homeless camp where he lives in Aberdeen, Wash. Associated Press/Photo by David Goldman

FOR $32 A DAY, STONER AND HIS WIFE lived relatively normal lives. But a troubling question lingered in the back of Stoner’s mind: What would happen when he stopped taking the drug? And he wasn’t sure he wanted to live shackled to the local methadone clinic—a cost that far exceeded that of their daily doses.

The couple chose their apartment for its proximity to the clinic. They turned down vacations out of fear of missing their daily visit. “My wife refers to the methadone as ‘liquid handcuffs,’” Stoner said. “It was a major, major factor in a lot of the decisions we made.”

According to the National Institute on Drug Abuse (NIDA), the average estimated cost of methadone treatment and its accompanying support services comes to about $126 per week or $6,600 per year. Buprenorphine treatment, including biweekly doctors’ visits, costs about the same.

Although NIDA points out that medication-assisted treatment contributes to big-picture savings—thanks to greater personal productivity, fewer run-ins with the law, and fewer overdose emergencies—footing the bill can still be challenging for people already struggling to make ends meet.

Eventually, money got tighter, and Stoner and his wife began rationing their doses. When the budget didn’t allow them to go every day, the couple went to the clinic for two days in a row and then skipped a day.

But they couldn’t stay away for long. “It’s the fear of withdrawal,” Stoner said. “I was scared to miss a day going to the clinic because I knew I would not be able to go to work.” Patients who abandon MAT too abruptly go through the same frightening opioid withdrawal symptoms as addicts who stop using illicit drugs like heroin and fentanyl.

That makes transitioning off MAT difficult. Joe Deegan, an addiction counselor who has decades of experience with hospital-­based treatment programs in Charleston, W.Va., said doctors are increasingly unwilling to help patients do it. (Deegan agreed to speak to WORLD on the condition we make it clear he isn’t speaking for the hospital where he works.)

Suboxone was originally intended to be a “transition medication” rather than a lifelong prescription, Deegan said. But as fatal overdoses skyrocketed, doctors lost sight of the notion that patients could come off MAT given proper support. “You need to let people know what their options are,” Deegan said. “And if they choose, they should be given the option to come off the medication.”

But that’s risky: Studies show patients who quit MAT often return to illegal drugs, with fatal consequences.

A study of nearly 9,000 patients found that 1 in 20 sought treatment for an overdose at least once in the first six months after ending buprenorphine treatment, regardless of how long the MAT regimen lasted. The research, published in December 2023, found most patients relapsed after discontinuing the medication and about 45 percent of patients who ended buprenorphine after six months visited the emergency room.

“Some people do successfully transition off, but it’s the work of years,” said Keith Humphreys, a professor of psychiatry at Stanford University who has researched addiction treatments for three decades. But Humphreys doesn’t view that as a negative. He compares addiction to other health conditions that require ongoing treatment. “We don’t ask how many people get off insulin for diabetes. We assume it’s going to be a lifetime thing.”

THAT’S GOOD NEWS FOR THE COMPANIES manufacturing and dispensing MAT drugs.

During the pandemic, Medicaid became the primary payer for buprenorphine prescriptions. Between 2010 and 2017, the Urban Institute found Medicaid spending on MAT prescriptions jumped from about $190 million to about $888 million—a nearly five-fold increase.

Today, it’s a lucrative industry. Last year, Suboxone manufacturer Indivior raked in about $1 billion in revenue—income mostly generated through buprenorphine product sales. When adjusted for inflation, that’s about one-third of what Purdue Pharma averaged in annual revenue after OxyContin debuted on the market in 1996.

Dr. Timothy Allen witnessed that potential for profit firsthand. Allen has spent 23 years practicing addiction medicine as both the director of a methadone clinic and at an outpatient Suboxone center. “There’s a lot of money involved in this,” he told us. “Methadone clinics are absurdly profitable.”

Patients spent about $30 per day on their medication regimen, according to 2018 estimates Allen provided. He estimated the clinic made roughly $10 million in revenue and spent just under $1 million on staff salaries and rent. Allen did not have access to the cost of the methadone, so his estimate does not factor in that expense. However, he noted that “it is not a very expensive drug” and said the clinic was far more profitable than the two-doctor family medicine clinic he currently owns, which makes about 6 percent in profit. Most estimates peg the average profit margin for private healthcare clinics between 12 and 35 percent.

Despite the money rolling in, Allen said he noticed a tendency to cut operating costs at the expense of patient well-being. Clinics often don’t employ enough counselors and are poorly maintained, he said. “They try to cut corners on everything while they’re making millions of dollars in profit,” he said.

Others have more far-reaching concerns. Brandon Lackey is chief program officer for the Foundry, a residential, abstinence-­based program in Bessemer, Ala. He believes the whole MAT industry, not just methadone programs, is riddled with unhealthy incentives that value profit over people.

“You have the healthcare system, government, and insurance companies who have come together and determined that medicating people with substance use disorder is in everyone’s best interest,” Lackey said. “It’s the largest treatment modality shift, as well as the largest financial resource shift, in the history of the treatment industry itself.”

While he acknowledged that MAT has been highly beneficial for some, Lackey said these drugs have contributed to many of his clients’ substance use disorders. And he argues they have not slowed the nationwide overdose epidemic.

“Many of our clients report that poorly regulated MAT clinics have become the new pill mills in America,” he said. “Clients report not meeting with doctors, partial prescriptions being filled based on how much cash they have at the time, lack of cooperation to taper off of the medications, and being told that this is ‘a lifelong treatment.’”

But Keith Humphreys with Stanford University, who also serves as a scientific adviser for a company that makes buprenorphine, pushed back against the idea that making and prescribing MAT is a major moneymaker for the industry. He insisted the biggest pharmaceutical companies are wary about investing in what is still “a stigmatized area” of medicine, so it’s mostly smaller and medium-sized companies involved in producing MAT drugs. And when compared with pharmaceutical cash cows like cancer or Alzheimer’s medications, “these drugs are cheap,” Humphreys said.

Teresa Smith, a nurse, prepares doses of methadone in the lab at the Human Service Center in Peoria, Ill. Fred Zwicky/Journal Star via AP

FOR ABOUT THREE YEARS, Stoner and his wife continued their crack-of-dawn appointments at the methadone clinic. But then, the world shut down. The COVID-19 pandemic crippled their landscaping business, and the Stoners couldn’t come up with the cash for their daily regimen.

With nothing to take the edge off their cravings, the couple resorted to the much cheaper fentanyl. The synthetic opioid is a gold mine for dealers. It’s incredibly cheap to produce and up to 50 times more powerful than heroin. But it often kills their customers.

Stoner’s wife overdosed about three times a week at the height of the couple’s fentanyl addiction. The anti-overdose drug Narcan became a household staple. “And for several of those [overdoses] we didn’t just have to Narcan her. We had to call an ambulance,” Stoner said. They watched several friends die in rapid succession. A new terror began competing with Stoner’s fear of withdrawal—the fear of overdose and death.

Desperate to stave off their deadly cravings, the couple got back in line at the methadone clinic. But Stoner knew it wasn’t a cure. Their methadone visits mirrored the habits of addiction that brought them to the clinic in the first place. Opioids still controlled their lives, and when methadone wasn’t available, they always ran back to the substances they were trying to escape.

So he started to wean himself off the drug. Dose one day. Skip two days. When the clinic’s doctor noticed Stoner’s less frequent visits, he asked to speak to him privately. Stoner explained he was trying to ease himself off the medication: “The doctor actually tried to talk me into not doing that. And I went against medical advice,” Stoner remembered. “He just wanted me to keep buying this product. That’s what it seemed like to me.”

The doctor didn’t seem to understand that, for Stoner, a life spent vacillating between deadly drugs and less risky alternatives didn’t feel like recovery and certainly wasn’t freedom.

That’s a concern that resonates with Haley Walker. She’s the executive director of Rea of Hope, an abstinence-based women’s recovery program based in Charleston, W.Va.—the epicenter of the opioid epidemic. She said lots of women come into her program listing Suboxone and Subutex as their drugs of choice.

Walker, who just celebrated 15 years’ sobriety after graduating from Rea of Hope in 2009, insists she and her staff are not against MAT. “It does save lives,” Walker said. “It keeps people breathing long enough to recognize the need for change.” But she said Rea of Hope staff want more for women than just keeping them back from the brink.

“‘Not dead’ is not our goal,” Walker said. “Obviously, yes, we want our women to live. But past that—free of dependency, free of the chains that bind.”

But not everyone sees it that way. The rise of MAT has made it more difficult for Walker to secure state and federal grants for her program: “When we’re asking for funding, and we have to say that we do not provide clinical resources for medication-assisted treatment, it takes us out of the running.”

Walker can sometimes find loopholes. She explains that even though Rea of Hope does not provide MAT, it does offer “comprehensive clinical referral services” for applicants it thinks wouldn’t be a good fit for its program but might benefit from other treatment paths.

But that doesn’t always work. And Walker said the amount of money West Virginia’s Bureau for Behavioral Health allots to Rea of Hope also has “slowly dwindled” over time.

That’s made Walker particularly vigilant. She carefully surveys participants and graduates to provide concrete ­evidence of the program’s effectiveness.

Beating addiction is tough, and Walker is under no illusions about that. Only about 1 in 3 women made it through Phase 1 of her organization’s program last year. But for those who stick it out, Rea of Hope data spanning nearly two decades shows 79 percent are still “clean and sober,” 84 percent are working, 90 percent are living in a safe place, and almost all have no new legal problems.

Success rates are even higher for those who complete Phase 2 of the program, residing in Rea of Hope’s sober living apartments.

About three-quarters of the women are still attending self-help meetings. “I think that, in itself, speaks volumes,” Walker said.

Scientific data also backs up Walker’s position. One Cochrane review of 27 studies found 42 percent of people attending Alcoholics Anonymous meetings remained sober for a year compared with 35 percent of people receiving other therapies. In a 2019 study, Adult and Teen Challenge, a network of Christian residential rehab programs that do not allow participants to use MAT, contacted 340 former students between 8 and 20 months after program completion. Seventy-eight percent remained sober.

Dr. Barry Zevin with the Department of Public Health in San Francisco talks with a patient who uses buprenorphine for a substance use addiction. Lea Suzuki/San Francisco Chronicle via AP

OVER THE COURSE of a few weeks, Stoner whittled his daily methadone dose down to about 30 milligrams and then decided to call it quits. “I was horribly, horribly sick for about 10 or 11 days,” he recalled. Though the flu-like symptoms passed, the sluggishness lingered. “But eventually, I felt like a normal human being again without the opioid.”

He stayed sober for close to a year. Until tragedy struck. Two close friends died, and his wife left to attend a rehab program in Minnesota. Stoner found himself alone in the house and began abusing crystal methamphetamine. He lost nearly 50 pounds in roughly 90 days.

“One day I was sitting there and I had a needle in my arm and I was just disgusted with myself, and I thought, ‘I’m not doing this anymore.’”

Stoner decided to join a Christian residential rehab program in Huntsville, Ala., that doesn’t allow any form of MAT. “I’ve seen a lot of guys come through here that I thought were absolutely hopeless,” Stoner said. “I saw a miraculous change in their life. And I decided that’s what I wanted.”

So far, he’s more than four months into the nine-month program. Men at His Way take classes, receive counseling, and find jobs. After that, they have the option to stay in the program’s after-care homes for at least three months. “They want to change the root of the problem, not just the symptoms,” Stoner said.

He’s tried His Way once before, but this time he believes he’s there to stay—with no plans ever to return to illicit drugs or any kind of medication-assisted treatment.

“When I was in the methadone treatment, my life was more manageable,” Stoner said. “I was managing a business. I had an apartment. I had a vehicle. I was paying my bills. But I had not made any internal change.”

Stoner has found another landscaping job, but is in no hurry to leave his new community.

“This is the only place I’ve ever been to that really feels like it’s bigger than not doing drugs.”