Prescription for failure
Most public funding to fight opioid addiction goes to maintenance drugs instead of long-term residential recovery—and opioid deaths keep increasing
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NEW YORK—If you step onto the Staten Island Ferry, which connects the borough to Manhattan, you’ll see posters all along the walls that proclaim in all caps: “SEE AN OVERDOSE? CALL 911. YOU COULD SAVE A LIFE.” The overdose reversal drug Narcan (generically known as naloxone)—which many first responders now carry as a matter of course—saved 286 lives on the island in 2017.
The island has New York’s highest mortality rate from the opioid crisis and a spotty network of substance abuse facilities, one with the tagline, “THE FINE DINING OF TREATMENT.” But even with national attention and public funding, the opioid epidemic is worsening, and money is not making it to long-term residential recovery options. Instead, localities like New York are devoting their treatment funding to maintenance drugs like Suboxone.
By itself, this maintenance strategy so far is not working. The overdoses are increasing at a dramatic rate, even after previous years of overdose deaths already lowered U.S. life expectancy. Data for 2017 U.S. fatalities isn’t finalized yet, but the Centers for Disease Control and Prevention (CDC) recently announced that drug overdoses were up 30 percent last year. In total, the CDC counted 142,000 drug overdoses in the United States last year. Overdoses are now the leading cause of death for Americans under the age of 50.
“We’re having a Vietnam War every nine or 10 months,” said addiction doctor Sandy Dettmann, a member of the Christian Medical and Dental Associations, referring to the number of overdose deaths. Dettmann laments the government’s meager approach to the crisis. “When do we put a four-way stop sign in? Do we do it after two people are killed, three people? Do we do it after the mayor’s kid is killed? I don’t know what we’re waiting for here.”
In New York, nearly 1,400 people died of drug overdoses in 2016, and partial numbers from 2017 showed an increase in deaths. I talked to a Staten Island cab driver who had a customer recently who, when he ducked into the car, explained that if he passed out there was Narcan in his coat pocket.
New York City last year set up an annual $38 million fund to fight the opioid crisis. About half of the funding goes to law enforcement efforts to fight the spread of drugs, and most of the rest goes to Narcan, the drug that reverses an overdose, and Suboxone.
Suboxone, generically called buprenorphine or “bupe,” is a synthetic opioid (like methadone) that counters opioid cravings. Currently 43,000 city residents are on daily opioid maintenance drugs—Suboxone (13,600) or methadone (30,000)—most of those through Medicaid. The city hopes to increase the number of New Yorkers on Suboxone chiefly to 58,000 by 2022, since Suboxone is supposed to be less addictive and needed for a shorter time than methadone. The mayor’s office did not return requests for comment.
The city has also unveiled a $3 million public relations campaign for methadone and Suboxone, with personal stories from people who say the drugs have kept them alive. “I am living proof that buprenorphine treatment works,” says one ad testimonial from a woman named Chelle.
Luke Nasta, the executive director of a residential recovery facility on Staten Island called Camelot, said he isn’t against Suboxone but that the city was cherry-picking Suboxone success stories: “I can cherry-pick too.” He says he contacted the city to ask that it do PSAs about long-term residential recovery, too. He did not receive a response.
Used properly, Suboxone has a record of keeping addicts from overdosing. But the focus—locally and nationally—on funding Suboxone as the magic solution to the opioid epidemic shows some of the simplistic thinking that led to the epidemic in the first place, as unscrupulous doctors are overprescribing it in similar ways to the doctors who once overprescribed opioids.
“There is some bad medicine being practiced out there,” said Dettmann, who is a federally authorized Suboxone prescriber. “If I can get you addicted to Suboxone, you’re going to be my patient for quite some time. … The problem is that we don’t have doctors to prescribe it the right way, who understand it’s an adjunct, it’s not a cure.” If one of her patients won’t do counseling alongside Suboxone, for example, Dettmann will force the patient to taper off the drug.
On the other hand, some Christian doctors like Dettmann say Christian recovery programs are making a mistake in nearly universally dismissing Suboxone. They say the drug can offer an overdose-free window for patients to do the real work of recovery like counseling or job training.
None of the Christian residential recovery programs in New York I contacted allow residents to be on methadone or Suboxone. Staffers at Christian recovery programs say they often receive people who have tried every other form of recovery and need something that gets at deeper spiritual needs. Opiate substitutes, they say, dull the ability to address the addiction.
Holistic long-term recovery options like residential programs are more expensive, have little funding, and are hard to come by. The number of beds on Staten Island for long-term recovery is “very small,” according to Dr. Janet Kim, who runs Beacon Christian Community Health Center on the island, serving a low-income population. Beacon refers patients with opioid addiction to Nasta’s Camelot, which is not faith-based but aligns with Beacon’s holistic approach to addiction.
Camelot is a beautiful historic building sitting on the grounds of a crumbling tuberculosis hospital. It has only 45 beds, which are full most of the time. That lonely residential program on the island receives state funding, but hasn’t seen funding from the city or the federal government.
At Camelot, nine of the men in the program are on Suboxone. The program will maintain clients if they’re already on methadone but doesn’t start anyone on methadone. Camelot does prescribe Suboxone at the facility but only in rare cases and with the requirement that it is part of “intensive counseling.” Nasta doesn’t see medication as the primary form of treatment.
Nasta grew up on Staten Island and became addicted to heroin as a young man more than 40 years ago. At the time the island had no residential rehab programs, so he went to a program in Spanish Harlem (Exodus House) for several years. He was on methadone for a time and said the daily dosage made him feel trapped and dependent on the government: “Liquid handcuffs.” It was years of therapy and drug abstinence that helped him.
AS THE USE OF SUBOXONE has expanded, associated problems have expanded as well. The Substance Abuse and Mental Health Services Administration reported that from 2005 to 2010, the number of individuals with buprenorphine prescriptions increased from 100,000 to 800,000. Over that same time period, the number of emergency room visits related to buprenorphine increased from 3,161 to 30,135.
Like methadone, buprenorphine can depress breathing—although so far the drug has a safer record. There are instances of buprenorphine overdoses, but New York rehab staffers I talked to said the more common situation is where someone tries to come off Suboxone and then overdoses on another drug like heroin.
The family of a Connecticut college student who overdosed and died in 2016 is suing the makers of Suboxone, saying that their son became “completely addicted to Suboxone.” Bradley Allen was 19 and had recently tried to come off Suboxone, even enrolling in a rehab program, but once off of the drug he overdosed on heroin and died.
The Centers for Disease Control and Prevention doesn’t track bupe deaths. Medical examiners often don’t test for it when they’re dealing with an overdose death. Tennessee is one of the rare states with bupe data; in 2016 it showed 67 of the state’s 1,600 overdose deaths involved buprenorphine.
Doctors must get federal authorization to become authorized bupe prescribers, but that only requires eight hours of training. There is evidence of shoddy doctors handling bupe prescriptions. A recent New York Times investigation found that federal bupe prescribers have a higher rate of disciplinary action than the general doctor population.
One doctor in Pennsylvania, Thomas Radecki, was federally authorized to prescribe bupe despite having lost his license in Illinois and then having a disciplinary history in Pennsylvania. With the bupe authorization, he ran four all-cash clinics called “Doctors and Lawyers for a Drug-Free Youth” and began selling huge volumes of buprenorphine (specifically Subutex, the pill form of Suboxone). In 2016, he was sentenced to 11 to 22 years in prison for overprescribing the pills and trading drugs for sex with patients.
“An addiction bomb went off in Clarion County,” District Attorney Mark Aaron testified at the county sentencing hearing. “We’re still dealing with the effect of the actions of Dr. Radecki to this day.”
The Christian doctor in Michigan, Sandy Dettmann, said even as the government expands bupe funding, few good doctors want to take on that unsavory patient population, which is perceived as manipulative and violent. Dr. Janet Kim confirmed that doctors are wary on Staten Island as well. As doctors are hesitant to become bupe prescribers, and as the crisis continues to worsen, Dettmann doesn’t see her caseload slowing down at all.
“I do this because I’m passionate, but it’s a lousy field to be in,” Dettmann said. She said she made $6,000 last year. Her voicemail is always full, with patients’ financial and spiritual needs. They’ve typically burned all their bridges and seek her out as a friend.
In her conversations with patients, Dettmann sees a “drift toward Jesus” that excites her. While she prescribes Suboxone, she sees the spiritual side as the answer to the underlying longing: “We’re looking for a substance, anything, to help us deal with the human condition.”
A radically different approach
Twenty-five-year-old Tommy Van Warner tried Suboxone, but it did little to help him. Since high school, he struggled with addiction to opioids, beginning with pills that flowed through the school hallways. One year when he was in high school, Florida pharmacies doled out 650 million oxycodone pills. His parents didn’t notice any signs of addiction until he didn’t show up at school one day. They spent four days frantically searching for him before finding him on a concrete floor of an abandoned building in the fetal position, barely breathing.
His parents, Rick and Mary Van Warner, estimate they have spent at least $200,000 on his treatment. One rehab place in Utah cost about $6,000 a month. Their son has relapsed 13 times and been revived from overdoses. They haven’t received any public money to help with his care; insurance covered some pieces of his treatment early on, but that soon ended.
“Recovery is a big business, and it’s very difficult to distinguish between the centers that are in it for the money or ... for the right reasons,” said Rick, a former journalist who wrote about the experience with his son in a new book, On Pins and Needles. When Tommy was on Suboxone, Rick found it was only a crutch.
“He ends up taking the Suboxone so much that he’s so doped out, it’s like he’s on opioids,” said Rick.
Rick and Mary found a more creative solution: detoxing their son at home. They include him in every family activity—they have three other children—and make sure he has time for therapy. Rick is convinced that the home treatment is why their son is still alive.
They have a room where he suffers through the withdrawal symptoms with blankets and a vomit bucket. The family dog curls up next to him for the duration. He’ll sleep a lot. Once he’s up for it, his mom will make him soup. Rick said during his recovery from the last relapse, he came back to himself much faster. Tommy is seeking an escape from “mental pain, emotional pain,” Rick said. Heroin is “a drug of isolation.” So for the Van Warners, the family has to be part of the fight against it.
“There’s no comprehensive approach anywhere,” said Rick. —E.B.
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