Scientists and doctors say the case is clear: The best way to tackle the country's opioid epidemic is to get more people on medications that have been proven in studies to reduce relapses and, ultimately, overdoses.
Yet, only a fraction of the more than 4 million people believed to abuse prescription painkillers or heroin in the U.S. are being given what's called medication-assisted treatment.
One reason is the limited availability of the treatment. But it's also the case that stigma around the addiction drugs has inhibited their use.
Methadone and buprenorphine, two of the drugs used for treatment, are themselves opioids. A phrase you often hear about medication-assisted treatment is that it's merely replacing one drug with another. While doctors and scientists strongly disagree with that characterization, it's a view that's widespread in recovery circles.
Now, the White House is pushing to change the landscape for people seeking help. In his 2017 budget, President Obama has asked Congress for $1.1 billion in new funding to address the opioid epidemic, with almost all of it geared toward expanding access to medication-assisted treatment.
The White House is also highlighting success stories. At the National Prescription Drug Abuse and Heroin Summit held in Atlanta in March, Obama appeared on stage with Crystal Oertle, a 35-year-old mother of two from Ohio. Oertle spoke of her spiral into addiction, which began with prescription painkillers and progressed to heroin. She tried unsuccessfully to quit on her own several times, before being prescribed buprenorphine a year ago. "I personally couldn't get through the withdrawal symptoms," Oertle said in Atlanta. "I couldn't tough it out. I know some people can. I couldn't do it. This last time has been the most successful recovery for me."
Her experience isn't unique.
"I've seen people with opioid-use disorders go through inpatient treatment without medications time and time and time again, without ever being offered alternatives," says Michael Botticelli, director of National Drug Control Policy at the White House. "We wouldn't do that with any other disease. If one treatment failed for you, we'd say, let's look at other possible treatment options."
Botticelli says patients should consider the evidence for medication-assisted treatment and together with their doctors make a decision about what's best for them.
Methadone and buprenorphine have been tested in scores of clinical trials. Researchers have found that when combined with counseling, they significantly reduce opioid use and keep people in treatment longer.
"We have tons of experience with patients who remain in treatment for months and years, who do very well on relapse-prevention medicines," says Dr. Marc Fishman, medical director at Maryland Treatment Centers in Baltimore. He says among his patients, primarily young people, about half remain with the program six months into treatment. Studies have shown far worse outcomes for patients who detox without follow-up medications, with relapse rates topping 90 percent.
Still, there are many people who stand by the so-called abstinence route — recovery without the use of medications. Their views are informed by personal experiences and deeply held beliefs about what constitutes true recovery.
For years, Juan Ramirez, 56, led a high-risk lifestyle to support his use of prescription painkillers. "When you start robbing drug stores and drug dealers because of your drug habit, your life is not working right," he says.
A friend told Ramirez about a doctor in Baltimore who prescribed Suboxone, a brand of buprenorphine. He liked the way Suboxone made him feel, so he would often exceed the dosage, buying pills from other patients so he wouldn't run out. He stopped using other narcotics and, overall, he felt more functional. Still, after three years of seeing the doctor, he never felt like he'd achieved full recovery. "I was still an addict," he says. "It was just legal."
That line of thinking extends to some people whose mission is to help people in recovery, including David Lidz, a recovering alcoholic, who runs a group home in Hagerstown, Md. The home has 10 beds for men who are transitioning out of intensive drug treatment back into daily life. In addition to beds, Lidz offers the men work with his contracting business, refurbishing houses. The emphasis is on hard work, personal responsibility and purpose. It's what worked for Lidz in his recovery, but even he knows it doesn't work for everyone.
When he started his work as a recovery advocate, Lidz knew little about medication-assisted treatment and had yet to form an opinion about it. Soon, he started getting reports from the group home that someone's Suboxone had been stolen, or someone looked high, or that people were trading, selling and snorting Suboxone. "That to me just looks like heroin," Lidz says.
So he made a decision: He wouldn't accept anyone on it.
Today, that stance is threatening the group home and his business. "Now we've been told by clinical settings that we're essentially blacklisted, that they can't even mention our program if we won't take people on opiates, on Suboxone," Lidz says.
He worries it could lead to missed opportunities for people like Charles Testerman, who came to Lidz's group home after several months in drug treatment. Testerman describes his years of drug use as "doing everything to excess." He drank, smoked marijuana, and got hooked on prescription painkillers and later heroin. When he couldn't afford heroin, he bought Suboxone on the street, hoping it would help him stop using other drugs. It didn't work.
"I was doing Suboxone in the mornings, as well as Adderall to bring myself up. Then at night, I was taking Xanax, smoking weed and drinking, just to go to sleep every night," Testerman says. "It was just a constant cycle."
Today, he has an apprenticeship with a master woodworker at a place called The Stoner Farm, Anglicized from Steiner, the name of the family who built the place. Testerman is working to restore an early 19th century barn there. "I feel great, happy to be out here doing this," he says. "It's just nice to wake up in the morning and not have to do anything to feel normal."
Fishman, the addiction doctor in Baltimore, knows there are people like Testerman who find the strength to have what he calls a life-changing conversion without medications. But, he cautions, not everyone can do it, and it's not scalable. He wants to convince the doubters that medication-assisted treatment is the best tool available at the moment, and, in making his case, he's willing to acknowledge its limitations.
"This doesn't change my claim that it should be the standard of care," he says. "But we don't have the penicillin for addiction. These are not curative medications. In having a nuanced, thoughtful discourse with people who might disagree with us, acknowledging those limitations I think would make us more credible."
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