Marvin Seppala wrote a book on conquering drug addiction with counseling and group therapy.
The spiritual, abstinence-based strategy pioneered by Alcoholics Anonymous and adopted by Narcotics Anonymous helped him overcome his own alcohol and cocaine addiction when he was 19. As medical director of Minnesota’s Hazelden clinic, he watched it work for patients.
He believed in it — and then he changed his mind.
In 2007, Seppala began working at Beyond Addictions, a now-defunct treatment center in Beaverton, Ore. Instead of relying solely on counseling and 12-step programs, the center gave its patients a relatively new medication, buprenorphine, to relieve their drug cravings.
Back in Minnesota, his patients had been bailing out of treatment to use illicit drugs again. In Oregon his patients on buprenorphine weren’t relapsing or overdosing — they reported feeling “normal” again.
Nearly a decade later, physicians and brain researchers say that drugs such as buprenorphine, methadone and naltrexone are the most effective anti-addiction weapons available. Nevertheless, more than two-thirds of U.S. clinics and treatment centers do not offer the medicines. Many refuse to admit people who are taking them.
The result is that hundreds, perhaps thousands, of Americans are dying unnecessarily, victims of an epidemic that killed more than 28,000 people in 2014 — more than homicides and almost as many as highway fatalities. At the beginning of his State of the Union address last week, President Obama took note of the opioid epidemic, saying that helping people addicted to prescription drugs was a bipartisan priority.
The research is unassailable: Staying in recovery and avoiding relapse for at least a year is more than twice as likely with medications as without them. Medications also lower the risk of a fatal overdose.
Addicts who quit drugs under an abstinence-based program are at a high risk of fatally overdosing if they relapse. Within days, the abstinent body’s tolerance for opioids plummets, and even a small dose of the drugs can shut down breathing.
And yet, as the country’s opioid epidemic worsens — every day, more than 70 Americans die from overdoses, and the numbers are climbing — only about a fifth of the people who would benefit from the medications are getting them, according to a study by the Johns Hopkins Bloomberg School of Public Health.
“When we discovered medications that worked for AIDS, deaths immediately plummeted. It became a chronic disease instead of a terminal disease,” said Andrew Kolodny, chief medical officer of the Phoenix House treatment centers, based in New York.
“This epidemic could be the same,” he said. “We have medications for addiction now. But unfortunately, we’re not making them available enough.”
People who could benefit from the medications are not getting them for numerous reasons. Among them:
●Too few health-care professionals have specialized training in addiction medicine. Although some primary care doctors have stepped in to fill the void, most are reluctant to treat people with addictions and say these patients are often recalcitrant and disturbing to others in their waiting rooms.
●Insurance coverage is limited. Few private insurers and Medicaid programs cover all of the medications approved by the Food and Drug Administration. When they do, they typically limit the dosage or how long patients can take the medication or require them to first try group therapy, which is cheaper.
●Many leaders of traditional drug treatment centers, such as national detox chains and residential rehab programs, are recovering addicts who conquered their own addictions without medication. The same is true of Narcotics Anonymous. They reject the notion that an addict can truly recover from a drug problem by becoming dependent on a different drug.
●Greater use of medication could cut into the centers’ revenue, by reducing the number of people who opt for expensive residential stays. And smaller clinics that might want to add medication services would have to hire a physician to do so, which many of them could not afford.
Kelly Clark, an addiction specialist in Kentucky and president-elect of the American Society of Addiction Medicine, said some of the resistance is cultural, rooted in a widespread belief “that drug addiction is a moral failing and that people should just get over it.”
There is no other disease for which doctors do not prescribe approved medications to all who need them, Clark said. “We used to consider people with mental illness inferior, even possessed,” she said. “Scientific advances have combated stigma around a wide variety of brain diseases, but not addiction.”
Hazelden was one of the many treatment centers that resisted the use of medication — until Seppala returned from Oregon in 2009 and began pushing the board to shift course. Hazelden started offering the medications shortly thereafter.
“It’s hard to argue when you have patients dying of overdoses,” Seppala said. “We said, ‘This is truly a crisis. We can’t just base our service on philosophy, we have to look at the data and base our treatment on the best way to save lives.’ ”
Opponents say that while addiction medications such as buprenorphine reduce cravings, they don’t attack the underlying psychological problems that often go with addiction. Nor do they address shame, guilt and self-loathing, as counseling does.
Robert Mooney’s belief in abstinence has never wavered. As medical director at Vista Taos, a treatment center in New Mexico, he refers his patients elsewhere if they want to take medication. “What we do here is abstinence-based, because there are some people that nothing else will work on,” he said.
Mooney, a psychiatrist and board-certified addiction specialist, beat his own addiction to alcohol and cocaine with an abstinence-based approach, and he grew up in an abstinence-based treatment business. His parents, John and Dot Mooney, a surgeon and a nurse, overcame their own drug and alcohol addictions through abstinence and opened a treatment center in Statesboro, Ga., in 1971 to help others tread the same path.
“I tell patients, ‘We’re going to take you off all medications and give your brain a chance to land, and it’s going to be a long road.’ You need to prepare people for that.”
Mooney says there hasn’t been enough research on the long-term effectiveness of either medication or abstinence. “But let’s at least hang on to an abstinence-based philosophy, because we absolutely need it as part of the solution,” he said.
Seppala, who wrote “Clinician’s Guide to the Twelve Step Principles” in 2001, says addicts who want abstinence-based treatment should get it. But, he said, medication should be offered. He stresses that medication should be combined with counseling and group therapy whenever possible. Given the toll of the drug epidemic, “we ought to put everyone on some sort of medication and give them all the psychosocial counseling we can,” he said.
A 2000 federal law requires doctors to seek a special waiver from the Drug Enforcement Administration to prescribe buprenorphine, and it limits their number of patients to 30 in the first year and to 100 in subsequent years.
The Department of Health and Human Services may loosen the patient limit this year. Last week, an FDA advisory panel recommended approval of a long-lasting form of the drug that could reduce the risk of relapse associated with daily doses of the pill or a dissolving film that is placed under the tongue. Probuphine, a surgically implanted device that would deliver a steady dose of buprenorphine for six months, might also cut down on illegal street sales. The FDA is expected to consider the recommendation next month.
Methadone can be dispensed by only about 1,400 licensed clinics nationwide. Because most of them are in major cities, the medication is unavailable to most in rural areas. Patients must show up every day to receive their dose under the supervision of a licensed professional.
Vivitrol, an injectable form of naltrexone, is not a narcotic and therefore not similarly regulated. Instead of fulfilling the addicted brain’s perceived need for opioids, it blocks the effect of the drugs and thereby reduces cravings.
Any doctor can prescribe and administer Vivitrol. But it has a major drawback: To avoid severe and dangerous withdrawal symptoms, patients must avoid opioids completely for at least seven days before receiving the first shot. For many, that means residential treatment, which can be costly. The drug itself is also expensive, at $1,000 per month.
Research on Vivitrol’s long-term effectiveness is still to come, but its use is spreading, particularly in jails and prisons. Patients are also increasingly opting for Vivitrol because the shots are effective for 30 days, tempering the temptation to stop daily doses to get high.
For advocates of medication-based treatment, recent policy changes are cause for optimism. The Affordable Care Act allows states to expand health insurance coverage to more adults and makes it mandatory for Medicaid and private insurers to cover substance abuse treatment.
In the past, Medicaid covered only low-income pregnant women, children and disabled adults. A severe drug or alcohol addiction, while debilitating and life-crushing, did not qualify on its own as a disability.
Under the ACA, 30 states and the District have opted to expand Medicaid to low-income, able-bodied adults, giving millions of poor Americans coverage for addiction treatment. The health law also requires all state Medicaid programs and all insurance companies to cover the gamut of recommended treatments for addiction.
In addition, the federal Mental Health Parity and Addiction Equity Act, although not enforced everywhere, requires insurers to pay for proven addiction treatments at the same dollar level as medical and surgical treatment for other diseases.
“There has never been a better time to confront the addiction problem we have in this country,” said Michael Botticelli, director of the Office of National Drug Control Policy.
“We know so much more about addiction from years of scientific research,” Botticelli said. “We know that substance-use disorders are diseases of the brain, that they can be chronic and relapsing. But we also know that, like other diseases, they can be prevented, treated, and people can recover.”
This article was produced by Stateline, an initiative of the Pew Charitable Trusts.
In the U.S. nearly 22 million
people have a substance-use disorder.
1 in 10 goes to a treatment center.
Since 2008, more than 115,000
Americans have died from overdoses of prescription opioid painkillers.