Chapter 7: Stigma, Harm Reduction, and the Future of Medication-Assisted Treatment

Killing Us with Stigma

At a time when heroin use and overdoses are exploding across the country, Tennessee just passed a law tightening restrictions on Suboxone (buprenorphine), one of the most effective treatment options available to opiate-dependent people.

Advocates for laws like this rely on the excuse that Suboxone is sometimes misused, which is true. But what’s missing from this equation is that its misuse can be an unintended consequence of restricting access to it. What’s also ignored is that, even when it’s misused, Suboxone is safer than unregulated street drugs like heroin or prescription pain medications.

Buprenorphine, the active ingredient in Suboxone, causes less respiratory depression (the usual cause of overdose) than other opioids because it only partially activates the brain’s opioid receptors. There are very few cases of overdose death by buprenorphine, and almost all those cases involved mixing with other drugs.

Stigma contributes to the lack of accurate information available to the public on medication-assisted treatment (MAT) and its effectiveness. It also contributes to policies that severely restrict access to those who need it most, directly contributing to the likelihood of increased diversion of these medications.

Maine’s Governor Paul LePage is pushing to cut funding for methadone clinics in favor of suboxone, despite the fact that 98% of patients in MAT programs rely on methadone and methadone is still considered the “gold standard” for treatment by the CDC.

Methadone treatment has been controversial for decades, despite studies that indicate long-term success rates as high as 60-90%. We see and hear plenty of methadone horror stories, but the media rarely covers the lives of those who have been saved by MAT (props the Gainesville Times for being one of the few to take that bold step).

Lack of Availability

Because of laws restricting the number of methadone clinics in certain areas (like the one in Indiana, which was just eased after a wave of overdose deaths and an HIV/HCV outbreak) or the number of patients allowed by clinics and suboxone doctors, patients seeking treatment are often left on waiting lists or unable to find treatment where they live.

I live in rural North Georgia, about 70 miles north of Atlanta. There are no methadone clinics and one Suboxone doctor in my county. The nearest clinic is over 30 minutes away. In eastern Tennessee there are only two cities with methadone clinics. In Mississippi there is one clinic. North Dakota and Wyoming have none. (A methadone clinic directory is available here, and a list of Suboxone doctors here)

Even in large cities with multiple clinics the wait time can be weeks or months. Having been in that situation, I know I’m not the only heroin user who never made it to my intake appointment.

The art of quitting opiates and other drugs is delicate. It has to be done on the patient’s schedule. When someone is ready for treatment, that opportunity needs to be available immediately, because next week their mind might be somewhere else. (Once, I changed my mind after checking myself into a hospital, which led to an awkward showdown with an elderly security guard and enough ativan to put an elephant out for a week)

To become eligible to prescribe Suboxone, doctors must pass a special course, after which they’re eligible to prescribe to 30 patients at a time. This limit can eventually expand to 100. No other drug is administered or regulated in this way and it creates a barrier to treatment that not only makes getting an appointment difficult, but makes office visits nearly impossible to afford, on top of the cost for the medicine.

Many patients coming off years of misusing drugs don’t have insurance, or even a job, so that money comes out of pocket. Considering the low risk of overdose and abuse (some people do misuse Suboxone–I’ve tried and got absolutely nothing, so take that for what it’s worth), and the high cost of people dying from overdoses, spending time in jail or prison, and drug-related property crimes, increasing the patient limit is critical toward making suboxone a viable route for treatment.

Teaching Harm Reduction to Counselors

In my 3+ years in a methadone program, I had five different counselors. Not only did that complicate building a relationship with someone I could trust, it put me at a greater risk for relapse. The counselor had no idea why I was sitting in front of them, aside from the notes my previous counselor had typed into a computer.

During my time in that methadone program, I was never taught about or provided naloxone, instructed what to do if I witnessed an overdose, or any other harm reduction practices. The only thing we heard was not to take benzos (xanax, klonopin, etc) which is certainly good advice, but that didn’t stop it from happening.

Even when I failed a drug test, there was no discussion about why I failed, how dangerous it might have been, or how I could have at least made the situation less dangerous.

Fortunately, I discovered SMART Recovery not long after entering that program, and learned the skills there. But from what I’ve seen, and what evidence from other clinics indicates, there’s a desperate need for methadone counselors to be trained in harm reduction practices.

One of the groups I work with, Georgia Overdose Prevention, is visiting methadone clinics across the state to train counselors about naloxone and how to administer it. When we raise the idea of providing naloxone kits to patients, a group that often has direct access to the most at-risk drug using communities, the issue is tabled until later; which boggles my mind. It seems that, even if they have to absorb the cost, their legal obligation of patient overdosing would be greatly reduced.

The fact that such an important issue is treated with so little concern demonstrates not only the need for teaching harm reduction skills to counselors and clinic directors, but proving the value of harm reduction in those settings.

Alternative and Progressive Treatments
As we continue our struggle to de-stigmatize methadone and suboxone programs and patients, there are progressive treatments that reveal promising research–and are likely to make steam blow out of the ears of some US journalists and politicians.

Heroin-assisted treatment (HAT) has been used in parts of Switzerland, the UK, Germany, Spain, Denmark, Belgium, Luxembourg, and recently Vancouver, as a second-line treatment when methadone and suboxone treatments fail.

HAT patients are administered controlled amounts of pharmacological-grade heroin in a safe, clean setting with sterile equipment. Contrast this to sitting in a car, ducked down, seat-belt wrapped around your arm, trying to find a vein (with a needle you’ve been using since who-knows-when), praying the cops don’t roll up on you. Never mind there’s no telling how potent or what’s contained in the shot of dope you just put in your arm.

HAT can be effective for patients where other forms of MAT have failed. It has the benefits of reducing use of unregulated and unsafe street heroin, reducing crime, has better retention rates than other forms of MAT, and reduces demand for heroin on street markets–which leads to a reductions in violent and nonviolent crime. (More information on HAT from the Drug Policy Alliance, The Lancet, and the British Journal of Psychiatry)

Alternative treatments, such as ibogaine and other psychedelics, will require more research before they’re viable, but show promising results. Some long-time heroin users have reported being “instantly cured” after ibogaine treatment, but such treatment is illegal in the US, making research difficult and treatment (which might be administered by someone with no medical credentials) dangerous.

The Future of MAT and Saving Lives the Hard Way

We have decades of evidence demonstrating the success of MAT, yet stigma and legal restrictions around these treatments create barriers that are literally letting people die, suffer, and waste away in prison cells. Our nation’s ‘War on Drugs’ has literally become a ‘War on Drug Users.’

To end on a bright note, the medical and drug treatment communities are finally casting aside the old, failed methods of drug treatment in favor of evidence-based treatments–individual and family psychotherapy based on a biopsychosocial model that treats the whole person, MAT, and new alternative treatments that were unimaginable just a few years ago.

The future of drug treatment and life for those living with SUDs shows promise for improvement, but it’s going to take hard work, from many angles. Whether we’re out in the streets or in the halls of our legislative buildings we can, and with the right determination will, make it happen.

FSDP is dedicated to bringing together these resources and people to neutralize stigma, advocate for more common sense drug policies, and employ our collective power to stand up and “Just Say No” to the War on Drugs– and the stigma, pain, and death it leaves in its wake.

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