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 unwilling to treat patients with addictions and say they are often recalcitrant and disturbing to others in their waiting rooms.
- Insurance coverage is limited. Few private insurers and state 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. 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.
Dr. 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 where approved medications are not provided to everyone who needs them," Clark said. "We used to consider people with mental illness inferior, even possessed. 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 his stint in 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 addiction medications such as buprenorphine reduce drug cravings, but 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.
Dr. 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, Dr. 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, Georgia, 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 said he isn't interested in arguing with those who believe in addiction medications, because in his view there has not been adequate research on the long-term effectiveness of either approach. "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's 2001 book, Clinician's Guide to the Twelve Step Principles, embraces the approach first laid out in 1935 by Alcoholics Anonymous, "a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem."
He still says addicts who want abstinence-based treatment should get it. But, he said, medication should be offered. Like other addiction doctors, Seppala stresses that medication should be combined with counseling and group therapy whenever possible. Given the horrific 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.
The scope of the epidemic is staggering. Since 2008, more than 115,000 Americans have died from overdoses of prescription opioid painkillers and nearly 39,000 have died from heroin overdoses — reaching an overall death rate of 9 per 100,000 in 2014. That's six times the drug overdose death rate of the 1970s, according to data from the US Centers for Disease Control and Prevention.
New data from the CDC indicate the death toll from this epidemic has not yet peaked. Prescription opioid overdose deaths rose 16 percent from 2013 to 2014, to nearly 19,000. Heroin overdose deaths rose 28 percent and deaths from relatively new illicit opioids, such as fentanyl and tramadol, spiked 79 percent.
According to the US Department of Health and Human Services (HHS), nationwide medication-assisted treatment capacity has increased somewhat in the past decade, but not enough to keep pace with the worsening opioid epidemic.
Many of the nation's hardest-hit areas are rural and suburban. Rates of addiction are much higher in those areas and the shortage of providers is even worse.
"There are entire communities that are devastated by this epidemic," Clark said. "If you have an opioid addiction, the odds are good that many, many in your world have the same disease. I've treated adolescents and their parents and grandparents."
Nationwide, nearly 22 million people have some kind of substance use disorder, but only one in 10 goes to a treatment center, according to the most recent survey by the US Substance Abuse and Mental Health Services Administration. In contrast, the treatment rate is as high as 80 percent for other chronic diseases such as diabetes, asthma, heart disease and high blood pressure.
Addiction to opioids, including heroin and prescription pain pills, is difficult to treat. Not everyone recovers. Among those who do, most relapse at least once before entering a period of sustained recovery. For the millions of opioid addicts who are uninsured, homeless or recently incarcerated, getting on medication — and staying on — is a struggle.
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