Column: A life-saving heroin drug is restricted and shunned

The heroin and pain pill crisis is a full-blown epidemic in our community. But treatment for this addiction crisis is inadequate and the death toll continues to grow. This is the first of a series of columns examining a broken system. You can also watch our WCPO 9 On Your Side special, "Heroin: Fixing a Broken System" at 7 p.m. Thursday.

David Holthaus researched these stories for eight months, with help from WCPO's Heroin Advisory Board, a group of experts, parents and recovering addicts. Holthaus has been a Cincinnati journalist for more than 25 years and is currently managing editor, opinion and engagement for WCPO.com.

At the age of 18, Kori Warman started down a path of abusing the powerful painkillers Percocet, Oxycontin, Opana and, eventually, heroin.

Now 25, she’s survived when so many others didn't. Clean for four years, she cares for her 3-year-old son and runs an at-home business. She gives much of the credit for her recovery to a prescription medicine she takes every day called Subutex.

But Subutex, and its better known cousin Suboxone, isn't widely available to help the tens of thousands of addicts here. And it isn't just here — the drugs are hard to come by around the country.

Despite their proven effectiveness and their approval by the U.S. Food and Drug Administration, the use of Suboxone and Subutex is restricted by the federal government and is actually frowned on by many in the addiction treatment community.

As a result, addicts desperate to get off heroin can be discouraged from turning to a potentially lifesaving medication or are forced into buying it on the black market. It’s another obstacle in treating the epidemic of addiction, an epidemic that continues to get worse year by year. 

“It’s an effective therapy when used appropriately," said Dr. Mike Kalfas, one of the few doctors in Northern Kentucky who uses the medications to treat addicts. "Very effective."

Suboxone is a prescription medication often taken in a film that’s dissolved under the tongue.

Subutex and Suboxone calm the intense cravings that drive addicts to abuse heroin. Suboxone also has the benefit of containing naloxone, the same ingredient used in Narcan, which reverses the effects of heroin. That makes it difficult, if not impossible, for a recovering addict on Suboxone to even get high from heroin.

Warman said Subutex has saved her life.

“I haven’t touched heroin in four years,” she said. 

During that time, the father of her son Jackson died from an overdose, as did several friends. Some of those friends died after unsuccessfully seeking treatment with the medications.

After the chaos and ravages of her years of addiction, it has helped her resume some semblance of a normal life.

“It helps me function in a society I don’t think I could function in otherwise,” she said.

Kori and her son, Jackson

She’s fortunate. The federal government has set limits on how many patients a doctor can treat with Suboxone, making it difficult to even find a doctor who can accept a new patient.

The limits were set because Suboxone and Subutex are themselves made from opioids and can be addictive if used improperly. But critics of the limits point out the government set no limits on the prescribing of pain pills such as Oxycontin. The overuse and overprescription of Oxycontin and other painkillers is partly blamed for leading to the heroin crisis.

In all of Kentucky, only 54 doctors are certified to see the federal limit of Suboxone patients, which, until a few months ago, was set at 100.

In all of Ohio, with more than twice the population of Kentucky, the government has certified only 80 doctors to see the maximum number of patients, according to figures from the Substance Abuse and Mental Health Services Administration. 

In August, the U.S. Department of Health and Human Services raised the limit to 275, but government red tape has meant some doctors, including Kalfas, have yet to be approved for the higher limit.

Waiting Weeks for Medicine

For Warman, just getting in to see Dr. Kalfas took persistence and patience, traits not commonly found among addicts.

Dr. Mike Kalfas

For four weeks in 2009, she called his office every day trying to get an appointment, but the answer was always the same – the doctor cannot take new patients. He was at the federal limit on Suboxone patients.

Then one day an opening was available and she got on the calendar. But it was another six weeks before she could get in, be assessed and get her prescription.

“I counted down those days,” she said. “And of course, being an addict, I used that whole time.”

Waiting that long while still abusing heroin could easily have been fatal. In the traditional health care world, making a diabetic or asthma patient wait that long to receive medication also could be fatal.

It’s also unheard of.

But government regulators, insurers and treatment professionals don't treat addiction the same way as other diseases. 

“Some insurance companies now only pay for one year of medication,” said Dr. Roberto Soria, chief medical officer of Crossroads Center, an addiction complex based in Avondale. “If you did that with a diabetic, there’d be hell to pay.”

Abstinence from Medication

Lawmakers placed limits on Suboxone and Subutex because they are potentially dangerous if abused. But much of the treatment community shuns the medicines completely. Treatment professionals steeped in the 12-step program of Alcoholics Anonymous and Narcotics Anonymous usually avoid the medication in favor of total abstinence from drugs.

Instead, they urge addicts to “surrender yourself to a higher power,” and ”work the steps,” hallmark traditions of AA.

It’s a view that still dominates the treatment profession today, and abstinence and AA has worked for many. Its philosophies, slogans, meetings and communities of recovering addicts have been a path to recovery. 

But the scope of this steadily worsening epidemic, and the growing death toll, has physicians and others demanding treatment that includes broader use of the new medications and more reliance on science-based methods.

“Oncologists have better rates of recovery from the worst cancers known to man than we do from abstinence-based therapy,” said Dr. Shawn Ryan, president of BrightView Health, a Norwood-based outpatient addiction clinic.

Warman encountered those attitudes when she first sought Suboxone.

"We don't get a euphoric feeling. We feel normal."

“My mom said, ‘No, you’re not substituting one thing for another,’” she said.

She went to AA meetings, where she felt singled out when she said she was taking Suboxone.

“I felt very judged in some of those rooms,” Warman said. “They’re very harsh on you because you’re not in ‘recovery.’”

In Kentucky, the state-sponsored treatment program called Recovery Kentucky does not permit Suboxone or another treatment drug, methadone, in its 15 residential treatment facilities, which include Brighton Recovery Center for Women in Florence and Grateful Life Center, a residential men’s facility in Erlanger.

Brighton Center, Grateful Life Center and the other Recovery Kentucky facilities this year permitted their residents to use Vivitrol, a medication that blocks the effects of heroin and can ease cravings. Vivitrol is usually delivered with a monthly injection and is not derived from an opiate, making its use more palatable to those in the AA community.

The director of Recovery Kentucky, Mike Townsend, agrees addiction is a disease. But he explained why the statewide program shuns medications for that disease.

“We’re not a medical program,” he said. “We’re a spiritually based program that uses the 12 steps. We recognize that Suboxone and methadone are legitimate medical treatments and if people opt for that type of program, we can refer them to that approach.”

'It Helps Me Be a Mom'

Although Suboxone is an opiate, those who take the prescribed doses don’t get high from it.

“We don’t get a euphoric feeling,” Warman said. “We feel normal.”

For her, the medication is essential to enable her to function, to care for her child, to work and to live the kind of life she’s envisioned for herself.

“It helps me be a mom,” she said. “It helps me not worry about using. It helps me get out of bed and feel normal, like I can fit into society, like I can do this today.”

Feeling normal and fitting into society are feelings heroin addicts often lose because their brains are taken over and rewired by heroin. With Suboxone, Subutex and methadone, they can take safe, controlled medicines prescribed by physicians and lead lives not centered around scoring heroin.

That is the goal of every addiction treatment program. And it’s likely those programs would be more successful with a more open attitude toward medication and a wider, legitimate availability of it.

"If it was more in reach for people, there would be so many fewer overdoses," Warman said.

"I've had probably 20 or 30 of my friends reach out to me for help in finding a doctor," she said. "I've had maybe five get in to see one. Probably six or seven of them passed away."

That's tragic in any event, but especially so with potentially life-saving medication within reach.

MORE FROM THIS SERIES:
• The shadow system of treatment
• Heroin addicts: 'We can't just throw them out'
• 'Body brokers' profit from heroin addiction
• One long road from heroin addiction to recovery