INVESTIGATORS: The battle over opioid treatment

- A drug used to treat opioid addiction, Suboxone, is backed by overwhelming scientific evidence as to its effectiveness and ability to keep addicts from a fatal relapse, yet many proponents of 12-Step abstinence are opposed to using a drug to treat a drug addiction. 

Shelly Elkington believes the consequences of the philosophical divide can be fatal. She tried to get her daughter, Casey Jo, on Suboxone. She was scheduled for an appointment the day she died. 

Casey Jo was a champion swimmer in high school and was diagnosed with Crohn’s Disease in her senior year. A doctor prescribed fentanyl patches for the pain and she was hooked before she knew it. As a freshman at North Dakota State last year, she weighed just 80 pounds.

"She was afraid to be without medications, that was her biggest fear," her mother said.  "Did that keep her from going into treatment? Yeah, she saw the alternative as being without them something she couldn't fathom."

When Elkington heard about Suboxone she thought it could help Casey Jo get off the meds and make the cravings go away.  

When she called a local addiction treatment program, they wouldn't discuss it, objecting to the very idea of using one drug, to get off another.

"He wouldn't not only not do Suboxone, they didn't believe in it. It wasn't part of their treatment model and they didn't think it was helpful," Elkington recalled.

Suboxone is the same drug a doctor was bringing to Prince, the morning his body was discovered at Paisley Park. They were a day too late.

Elkington has turned her daughter's death into a cause, joining Senator Amy Klobuchar in supporting a bill still sitting in Congress, that would greatly expand access to medically assisted treatment, including Suboxone.  

SUBOXONE ADVOCATES

Dr. Mark Willenbring runs a small addiction clinic in St. Paul that provides Suboxone.

"Rehab is what you do when you don't have a real treatment. We used to treat breast cancer with prayer too and we don't do that anymore, and shouldn't be treating addiction with prayer, either," said the former Director of the National Institute of Alcohol Abuse.

He has become an outspoken critic of 12-Step abstinence-based treatment programs.

Everyone has opioid receptors in their brains, like a runner's high, the body makes naturally-occurring opioids in the form of endorphins. 

But opioid pain killers like OxyContin, Percocet, Fentanyl, and the street drug, heroin, flood the brain with opioids. 

Many addiction experts, like Willenbring, believe those external opioids shut down the body's own production. 

"You can no more will your brain to produce more opioids than you can will your pancreas to produce more insulin," added Willenbring.
   
Methadone and Suboxone are also opioids and satisfy those same receptors, without getting you high. 

Methadone is one of the most tightly regulated drugs in America. There are 15 methadone clinics in Minnesota, serving about 6,675 patients, who in many cases go every day to receive a dose of methadone in liquid form. In the wrong dose, or the wrong hands, methadone itself can be deadly.

Suboxone, also known as buprenorphine, has abuse potential as well. It can be prescribed by any doctor who takes an eight-hour course.  Only 128 Minnesota doctors are authorized to prescribe Suboxone. Until recently, each doctor could only have 100 patients, the max is now 275.

"There's only one proven effective treatment for ongoing opioid addiction and that's maintenance treatment with either buprenorphine or methadone. They're both equally effective," said Willenbring.

That's also the conclusion of the World Health Organization, the Institute of Medicine, the National Institute of Drug Abuse, the Office of National Drug Control Policy, and almost every other credible organization in addiction that believes in evidence based medicine. That the best treatment for opioid addiction is indefinite or possibly, lifelong maintenance on an opioid replacement therapy. 

Dr. Gavin Bart is head of addiction medicine at Hennepin County Medical Center in Minneapolis (and in full disclosure, a colleague of reporter Tom Lyden's husband).

He said multiple studies show about 80 percent of patients who complete abstinence-based treatment are using again within two years. 

"The data are very clear that results of multiple trials using this approach, the majority of patients return to opioid use and with that there's a fairly high chance of death compared to people who used medication to treat their opioid addiction," Bart said.

That's because someone coming out of treatment, or even jail, has lost their tolerance. What got them high before, can now be fatal.

There were 216 opioid overdoses last year (2015), 111 from heroin, which has become a cheaper substitute.

HAZELDEN

Three years ago, Hazelden, the holy grail of 12-Step abstinence, broke with tradition, and began offering Suboxone. 

Dr. Mark Seppala is Hazelden's Medical Director and became alarmed back in 2012, when six people overdosed and died, after leaving the facility for opioid treatment. 

He admits, for some in the 12-Step community, using Suboxone, is heresy.

"It's primarily 12-Step oriented abstinence based groups saying 12-Step spirituality is all you ever need versus other people saying it's a brain disease. Let's do medication and the truth is we've tried to take this middle ground, let's do both, let's do all of that and more, everything we can to help these people." Seppala said.

MN ADULT & TEEN CHALLENGE

Minnesota Adult and Teen Challenge is one of the largest addiction programs in Minnesota

"There are people out here who say their brain is so damaged by opioids that they can't survive without opioids and that's a lie," said Saul Selby, Clinical Director at the organization.

Selby, who is not a doctor, told Fox 9 he's had clients trying to get off methadone and Suboxone. He said they became addicted to what they thought was a cure. 

"If there were treatment centers like Teen Challenge that could keep people in for a year, you would see much better outcomes for opioid treatment," Selby said.

Problem is few insurance companies will pay for a year of residential treatment, so recently even Teen Challenge began accepting clients using Suboxone, but taking it for only a few weeks, as a kind of detox, or bridge, to abstinence.

According to Bart, such a short taper is also a high risk for fatal relapse.

"And in those situations during the first two weeks after stopping the medication, there's a nine times greater chance of dying than the general population," Bart said.

Selby could not tell Fox 9 how many people overdose after leaving Teen Challenge but said "periodically we hear about that but it's not many." 

But Elkington says it happens every day in America, and it doesn’t have to. 

“I can’t think of any better outcome for Casey, than for her to have been addicted to Suboxone,” she said.

INFORMED CONSENT

Under state law, patients going into state licensed treatment programs are given an informed consent handout that tells them about treatment options. The statement reads, in part: “Because methadone and buprenorphine are themselves opioids, some people view these treatments for opioid dependence as substitutions of one addictive drug for another.” 

Critics, like Dr. Willenbring, believe that statement doesn’t go far enough in describing the greater weight of scientific evidence supporting medically assisted treatment. 

“Why is the state licensing these people who are offering prayer as a treatment?” Willenbring asked. 
 
Minnesota Human Services Commissioner Emily Piper declined repeated requests for an interview to answer that very question, but said in a statement: “We support a range of effective treatment options, including both abstinence-based treatment and medication-assisted treatment.”  Piper said DHS plans to make recommendations in the next legislative session to “strengthen those options.”

Minnesota Senator Amy Klobuchar has been advocating for a White House proposal that would supply $1.1 billion in funding to address the opioid epidemic, and would provide medically assisted treatment.  That measure has not been acted upon by the Republican-controlled Congress. 

Last month, all four major health insurance carriers in Minnesota agreed to provide Suboxone coverage without prior authorization requirements.

For more information about opioid treatment and overdose prevention, please view the following links:

Options for Opioid Treatment in Minnesota and Overdose Prevention, from DHS

Opioid Overdose Prevention Toolkit, from Substance Abuse & Mental Health Services Administration (SAMHSA)


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