Chemical treatment for the addicted brain
As access to the traditional recovery system has narrowed, another door has opened with growth in the chemical treatment of addiction.
Heroin and its chemical relatives draw the user in with relaxation and euphoria and hold them with pain when they try to stop. In the interim, the drugs hijack and interfere with brain systems, physically ingraining the need to continue.
Tolerance and physical dependence are natural responses, the body shifting to accommodate the presence of a new substance. Heroin or opioids quickly become one of the basic bricks in the user’s chemical makeup, and removing them throws the user into physical and psychic chaos: bone pain, diarrhea, vomiting, sweating, muscle spasms and cramps, insomnia, powerful cravings.
The idea of opioid maintenance therapy is to plug the gap left by the removal of heroin or painkillers with a dose of a less harmful opioid calibrated to push back the pain and need without getting the user high.
Dependence and addiction are not synonymous. Chemical dependence — signaled by withdrawal pain — is a natural response to long-term heroin or opioid use. Addiction to heroin or opioids includes dependence but is characterized by drug-seeking and a compulsion to use beyond the disincentive to stop provided by withdrawal. Chemical therapies target the chemical side of addiction and are therefore paired with psychological and behavioral therapy.
The most common therapy drugs are the opioids methadone and buprenorphine. Administered in the proper dose, both are designed to fit the gap left by heroin or other opioids, fend off cravings, and prevent the patient from getting high with other drugs by blocking off the relevant receptors in the brain. Buprenorphine is most often paired with the opiate overdose reversal drug naloxone or Narcan, and sold under the brand name Suboxone.
Detractors object to treating drug addiction with more drugs, and contend that the patient is still in an altered state. Supporters hold that even if a patient needs Suboxone or methadone for the rest of their lives those lives will be longer, safer, more productive, more their own, less damaging to others and generally better than the alternative, when that alternative is chasing drugs or relapsing to an early death.
In Franklin County, addiction treatment is centered in Greenfield. Community Substance Abuse Centers offers methadone treatment out of an unassuming clinic on Shelburne Road, where up to 100 patients — 90 last year — receive daily doses.
CleanSlate Addiction Treatment Centers offer Suboxone and Vivitrol treatment, with a clinic on Main Street since 2009.
“We’re seeing a number of people coming to us because they know people who have died recently,” said Dr. Suzanne Smith, medical director of the Greenfield CleanSlate office, in late January.
Overdoses had increased significantly at the time.
In February, CleanSlate Chief Medical Officer Dr. Maria Russo-Appel said the Greenfield center had 485 patients in treatment, and had just opened a waiting list for the first time. The patient population includes local residents and others travel ing from around the county, primarily Orange and Athol, and from out of state.
Suboxone at home
Russo-Appel said the program has a 62 percent retention rate over two years. Retention is bolstered by the approach to treatment.
Unlike methadone, Suboxone is prescribed in take-home doses, rather than administered in-clinic. The number of doses issued at one time increases, and the number of visits for check-ins and urine screens decrease over time.
“We measure success not by the number of clean urines you have. We measure success by other parameters, like you are now employed, you’ve got stable housing, you’ve got your kids back from DCF, you have rebuilt relationships that you’ve lost,” Russo-Appel said.
Urine screens are a factor — monitoring both for relapses and to confirm the patient is taking rather than selling their prescription.
“There are many three-strikes-and-you’re-out programs. We’re not that; we’re a harm-reduction program,” she said.
Ideally, users are eventually weaned off the medication with gradually decreased doses, but this may come years later or never.
The concept of being “clean” is raised frequently in relation to Suboxone and methadone, a semi-philosophical discussion that may or may not have a place in medical treatment of a disease.
To Russo-Appel, it matters.
“The concept of being clean is about … leading a sober life. The sober life is one in which you have control: control of money, control of relationships, housing, employment; that’s the sober life,” Russo-Appel said. “And that is what our patients get back with Suboxone. It is literally a miracle I witness every day.”
The company runs exclusively on insurance. Most insurers cover addiction treatment, and if the prospective patient does not have insurance, the office helps find it. Russo-Appel believes strongly in opioid replacement therapy, and would like to see lifted some restrictions such as that limiting the number of patients per prescribing doctor to 100.
Individual doctors may also prescribe Suboxone if licensed to do so. Dr. Ruth Potee, until last year one of two such doctors in the county, said a growing number have since undertaken the brief training process required. Individual doctors may not be treating hundreds of patients, but can integrate Suboxone into their medical arsenal for the three-to-five patients already in their practice who might need it, she said.
Methadone is Suboxone’s older cousin, approved three decades earlier. The drug hits opiate receptors more thoroughly than buprenorphine, has a narrower threshold between what will block cravings and what can kill — more often in its capacity as a prescription painkiller — and is now often a second resort to buprenorphine where the latter fails.
Sheriff Christopher Donelan said in February he is considering a Suboxone program for county jail inmates, 80 percent of whom have drug abuse problems.
“We’re reviewing right now with our medical director about whether it makes sense to have a Suboxone program … properly supervised by our medical department, but we don’t have that right now,” he said.
At present, the Franklin County Sheriff’s Office collaborates with CleanSlate with another of the center’s chemical options. Vivitrol or naltrexone is a monthly injection intended to block opiate receptors in the brain, and is approved for both opiate and alcohol dependence, and is often administered for six months to a year if a patient is weaned off Suboxone. Donelan said a trip to the clinic for a shot is now a last step before release.