Going to the MAT: The messy world of drug treatment

Elodie Reed

By Elodie Reed

Staff Writer

The Facts

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ST. ALBANS — Addiction is not clean, straightforward or pretty.

Picture a 10-year-old sipping her first alcoholic beverage with her mom and then, three years later, popping her first pill.

That’s a quick look at the childhood of St. Albans area native Lacey Partlow, 22. Her teenage and first adulthood years have been spent in treatment for opiate addiction, which is also messy.

It’s a story familiar to all who’ve been following the opiate addiction crisis. It involves relapse, rehab, the medication-assisted-treatment (MAT) drug Suboxone – bought illegally on the street and attained legally through a doctor at the Lund family support agency – counseling, social services, and continued dependence on that maintenance drug to stay clean of other illicit drugs.

What isn’t necessarily common knowledge is the whole delivery system of MAT, and why it’s the Vermont Dept. of Health’s chosen method of treatment, whether it produces successful outcomes, how it really works long-term for individuals and their communities, and how it can be better managed in a place like Franklin County.

For Partlow, her daily doses of Suboxone – a combination of buprenorphine and the opiate blocker naloxone that comes in 2, 4, 8 and 12 mg sublingual strips made by British pharmaceutical company Reckitt-Benckiser (approved by the Federal Drug Administration in 2002) – have helped her find stability. She’s been clean for almost three years.

With her prescribed daily 4mg dose to remove withdrawal symptoms and the desire for the euphoric high, Partlow has been able to use the support of services and positive role models to help get her own apartment and retain custody of one of her two young children.

However, there are downsides to Suboxone. The drug comes with warnings about illicit use (snorting and intravenous injection), dependence, overdose, and potential death when used by people who are not opioid dependent.

Partlow’s seen that in the people around her. “I’ve had, like, strangers walk up to me and ask where to get it,” she said. “I know people inject it, they snort it – they just do it to get the high. I have family and close friends that get it, only take half of what they’re supposed to and sell the rest to try and buy other drugs or support their lifestyle.”

Partlow is also experiencing the dependence associated with MAT drugs.

“I’ve tried weaning myself off it but it’s extremely hard,” she said. “I started getting withdrawal symptoms – I haven’t relapsed in three years. I didn’t want to set myself up for failure.”

New system

While she stays on Suboxone, Partlow is part of the Vermont Hub/Spoke initiative, an opiate addiction treatment model enacted by the Vermont Legislature as Act 135 and overseen by the Vermont Department of Health since 2012.

Seven “hubs” throughout the state provide screenings, referral and services for opiate addiction treatment while 123 doctors – such as Partlow’s Lund program doctor – act as “spokes” statewide and prescribe MAT drugs. They are licensed to do so in accordance with the U.S. Drug Addiction Treatment Act of 2000.

Prescriptions for buprenorphine or Suboxone are usually for a week or several weeks’ worth of doses. Doctors also prescribe daily methadone doses that are dispensed and taken by patients at hubs.

In both cases, patients are required to submit to regular monitoring through random urinalysis and medicine-counts. If patients are found to be consistently using other illicit drugs, abusing the MAT drug or diverting it, they are kicked off the program.

In Franklin County, there are 12 doctors approved to prescribe MAT drugs, and the hub is Burlington-based Howard Center, which has a satellite office in St. Albans. According to the most recent Medicaid Spoke report, 376 Medicaid beneficiaries were receiving opiate addiction treatment in Franklin County in March of this year, the second highest number behind Chittenden County (at 400).

Dept. of Health deputy commissioner Barbara Cimaglio said in a May interview that Vermont’s Hub/Spoke approach and MAT emphasis are based on scientific literature and evidence-based results. “Medication-assisted-treatment is the most researched treatment that we have,” she said.

Cimaglio added that those seeking treatment for opiate addiction are placed in care appropriate for them through doctors, group or individual therapy, daily clinics and/or residential treatment, not only MAT. But MAT is attractive since, in its buprenorphine version, there’s capacity to treat more people.

“It became an alternative for people going to these [daily] clinics,” said Cimaglio. “We have in the last several years really doubled the number of people getting treatment for opiate addiction.”

One Dept. of Health data set shows that between 2004 and 2013, the number of people statewide in treatment for opiate addiction grew from 1199 people to 4043 people.

Many of those people in fact received – and may still be getting – MAT. A January report submitted to the Legislature by Health Commissioner Harry Chen said that 70 percent of the 2013 Medicaid beneficiaries statewide who were diagnosed with opioid dependence received MAT.

In addition, the results of an anonymous Messenger survey issued in May showed that of 70 local respondents who said they were receiving treatment for opiate addiction, 67 used MAT by itself or in conjunction with other types of treatment.

Does MAT work?

Due to its prevalence in opiate addiction treatment, a pertinent question arises: Is MAT successful in helping solve the problem of opiate addiction?

Like everything else surrounding addiction, the answer is not easy. It begins with the definition of success, which could be abstinence, harm reduction, cost savings or something else depending on whom you ask.

From the Dept. of Health perspective, opiate addiction is a public health crisis, and success is defined by reduction of health costs and secondary social costs. Studies have shown that for every dollar spent on addiction treatment, $1.80 is saved.

According to Vermont’s Chief Medicaid officer Tom Simpatico, a report is underway to measure the savings the state has seen thus far in its treatment of opiate addiction. It’s anticipated completion date is Jan. 2016.

“The early reviews we’ve done, we’re saying yes, we’re going in the right direction,” Simpatico said in a May interview.

Even with the report, there is no comprehensive set of data collected by the Dept. of Health to measure how MAT affects the outcomes of individuals or the communities they live in. Unfortunately, we don’t have a really fancy data system that follows all these people and says, ‘Hey, these people are doing better or, some of them are doing better,’” said Simpatico.

The measurements that are available are the number of people entering treatment (see above) and the MAT program retention rate. According to Chen’s report submitted to the Legislature this year, 73.5 percent of Vermont patients receiving MAT, which is intended to be long-term treatment, were still in the program after 90 days in 2014.

Community complexities

For many Franklin County service providers, MAT, and its effect on opiate addiction, is associated with ambiguity. While it certainly helps their clients stop using and to get on their feet, it also presents complex challenges.

At Northwest State Correctional Facility, for instance, Suboxone and buprenorphine are less associated with treatment – which the prison offers for only the first 90 days an inmate on a MAT program is there – and more with contraband.

According to Superintendent Greg Hale illicit drugs circulate throughout the prison. “The majority of what we see is Suboxone, or buprenorphine,” he said in a June interview. The small, dissolvable strips are easy to conceal in the mail and a number of other places.

“People bring it in their body cavities [too],” said Hale.

In addition to spending a lot of time searching for drugs, Hale said an illegal substance so highly valued – a Suboxone strip is valued at $300-$400 in prison – poses a risk for both inmates and correctional officers.

“Offenders that have drugs are going to great lengths to keep them, protect them,” said Hale. “It certainly ups the danger level.”

On the outside, Community Corrections district manager Sherry Caforia in June said of MAT drugs, “It’s a tough, tough thing.” On the one hand, clients using Suboxone, buprenorphine or methadone correctly tend to not commit as many new crimes.

“Suboxone really does help them,” she said.

On the other hand, Caforia said she and her parole officers see a lot of misuse of the drugs.

“We have people that are prescribed [Suboxone] that shoot it,” said Caforia.

Caforia added that buprenorphine is readily available for her clients to find and buy illegally. “It just seems like it’s flooding the streets,” she said. “[We] see more Suboxone use than any other drug right now.”

St. Albans Police Department confirmed MAT drugs are circulating in St. Albans. “We’re doing some undercover drug work in the city and we’re actively buying illegal substances,” said Chief Gary Taylor last month. “There is a market for methadone, there is a market for Suboxone.”

Taylor said Suboxone is sought after and costs between $20 and $30 per 8 mg strip. “It’s more than it used to be,” he said. By comparison, Taylor said a unit of heroin, a bag, costs between $25 and $30.

SAPD focus their resources primarily on arresting drug dealers. “We’re trying to attack a supply chain,” said Taylor. We’re not really effective in going after the [illicit MAT drug] users.”

On the bright side, Taylor said the MAT drugs, taken as prescribed, have helped reduce crime overall in conjunction with concentrated law enforcement in the area.

“It’s not great but it’s better,” he said. “I feel pretty good about the progress we have made here.”

Department for Children and Families district director Alix Gibson said last week that DCF’s biggest challenge is deciding how to work with opiate-addicted clients who can’t attain opiate addiction treatment or are kicked out of their program.

“When programs are full, we work with a lot of families that are getting Suboxone off the street,” said Gibson. “They’re telling us because it’s Suboxone, it’s OK.”

Of the 67 people who said they were using MAT in the Messenger survey, 34 said they were prescribed their drugs while 22 said they bought it on the street before getting into a program. Eight people said they bought it solely on the street, and three people didn’t answer the question.

Gibson added that DCF has to decide on a case-by-case basis how to handle that situation. “We’re really grappling with that,” said Gibson. “It’s one of the complexities.”

Northwestern Counseling & Support Services provides coordination supports to the hub and spokes for Franklin County and also treats adolescents with opiate addiction. NCSS also struggles with what to do when people who show up at their doors and have been kicked off a MAT program.

“We certainly see that fallout,” said Dr. Steve Broer, director of behavior health services at NCSS. However, he said coordination between NCSS and other medical providers is getting better with more resources than there were in the past. “In the beginning… they weren’t really organized in a system,” he said. “That has improved.”

At the Voices Against Violence shelter, Laurie’s House, director Kris Lukens said MAT drugs are used legally, with success, as well as misused and diverted. She also sees the unique event of abusers getting their victims pregnant so the perpetrator can get access to buprenorphine – which is automatically given to pregnant mothers with opiate addiction to ensure the baby’s safety – during those nine months.

“It’s basically reproductive coercion,” said Lukens. “It is a tactic. That’s the situation where it’s not great.”

At the Tim’s House homeless shelter, executive director Linda Ryan said it’s challenging to have clients who battle opiate addiction using buprenorphine-based drugs when she also has people who are trying to abstain all together.

“It creates issues for people who are coming out of [residential treatment] who are trying to stay clean and sober,” said Ryan in a May interview. She added that she feels it’s a safety risk to keep those drug doses – whether prescribed or bought on the street – at the shelter.

“We don’t have medical staff here – those are highly regulated drugs,” she said. “We can’t keep it on site because I’m afraid if people knew it, we would be robbed.”

How to stop

One individual who agreed to be interviewed this week on the condition that his last name not be used highlighted the biggest difficulty for individuals on MAT drugs: how to stop using them.

Chris, 60, said he was misusing prescription pills and other opiates for six years before he was put on an MAT program with Suboxone. After a year, he wanted to wean off the Suboxone, to which his doctor replied that would not be possible.

Chris unsuccessful tried to wean himself off of it. He relapsed, was suicidal and was brought to the inpatient psychiatry unit of the Central Vermont Medical Center in Barre for two weeks. At that point, Chris decided to quit cold turkey. He’s been clean for almost two years.

“I’m done now. I’ll never take Suboxone again,” said Chris. He said Suboxone created issues like sleeplessness and restless legs, and Chris still felt like using. He added that it felt like a continuation of the addiction process because he depended on another drug to get through the day.

“I knew I had to looking within myself to heal myself,” he said. “I stopped looking out. It’s going to be me.” He now relies on spirituality, meditation and the family at Martha’s Kitchen to help him face his challenges in life, but no drugs.

“Now I’m free,” he said.

Howard Center Clinical Director Ed Williamson said in an interview last week that Chris – and Partlow – are not unique in their struggles.

“If you’re looking at it from a harm reduction model, [MAT] is absolutely the best thing to do,” said Williamson. “I like to refer to it as a platform to stabilize your life. The hard part about it is, it’s really difficult to get off of it.”

Of the 71 people who responded to the Messenger survey and said they were using MAT prescribed or not, 31 said they were having a hard time getting off of it – 23 said no, and 17 didn’t answer the question.

Definite success

Though they are admittedly hard to kick, MAT drugs, in conjunction with counseling and support services, have allowed people with opiate addiction to completely change their lives.

Take Dan Reynolds, a 27-year-old St. Albans native who’s recreational use of marijuana while he attended Missisquoi Valley Union High School led to harder drugs and opiate addiction, selling drugs, joblessness and homelessness. After seven years, Reynolds put a stop to it.

“I was just fed up with it,” said Reynolds in an interview this week. “I had to make a decision, and the decision I made was treatment.”

After some initial relapses, Reynolds eventually stopped using and has been on Suboxone – through now-retired Dr. Fred Holmes and Northern Tier Health Center for Health (NOTCH) in Swanton – in conjunction with counseling for six or seven years. He continues to pick up his prescription once a month.

In the meantime, Reynolds has found work, housing, and a life partner. Thanks to his job at Peck Electric the past few years, he recently bought a home in a suburban neighborhood in Essex with his girlfriend, Carrie Hall. They live there with their two daughters, Natalie, 3, and Faith, 11 months, a dog, and a kitten.

“I don’t want to be sick anymore,” said Reynolds. “I just want to be normal.”

He added that he’s slowing weaning himself off the Suboxone – he’s now down to 20 milligrams a day, which is about two-thirds of his original dosage. “Still working on it but, in the next five years, I’ll definitely be off it,” Reynolds said. “It’s just a crutch.”

What to do

Stories like Reynolds’s, Chris’s and Partlow’s; the relative newness of Vermont’s Hub/Spoke and MAT approaches; the lack of statewide comprehensive data; the complexities community organizations face; the challenge for individuals to get off a MAT drug; and the question this story couldn’t answer despite dozens of interviews and various data sets – does MAT treatment actually create more opiate dependent people? – they all make it clear: opiate addiction and its treatment are messy and complicated, and they beg more consideration.

Every community organization and state agency district spokesperson interviewed for this story said he or she wanted to have a direct discourse not only with each other, but with the Dept. of Health and local medical providers to better coordinate and monitor the Franklin County response to opiate addiction.

“There’s more ways to keep on top of it and work together a little more,” said Lukens. “I don’t think that’s necessarily happening [with] the medical community. There’s some of that, but not to the extent its really needed.”

Jill Berry Bowen, the CEO of Northwestern Medical Center – which provides a majority of the MAT spokes in Franklin County – agrees.

“I think there could be better connections,” she said in an interview last month. On NMC’s end of things, Bowen said doctors have stepped up to treat opiate addiction, but her staff has trouble providing wrap-around services for addiction patients who need non-medical support out in the community.

“We’re in the early stages,” said Bowen. “I think we’re all figuring out what the state has taken on.”