Why it’s so hard to break an opioid addiction
More than a decade later, Dr. Tony Gargano doesn’t remember her name so much as her struggle.
His patient was addicted to heroin. She was in physical pain and miserable. He tried to get her into a methadone clinic for treatment, his only option at the time. But the closest clinic was in Arlington, and the 100-mile round trip was too far for her to travel and too difficult.
She killed herself.
“I will never forget how my inability to help her made me feel,” said Gargano, a doctor with PeaceHealth Medical Group in Bellingham.
If he had known about Suboxone at the time, he would have prescribed it.
“She could have received it from the safety and convenience of her own doctor’s office and her quality of life and pain would have improved dramatically, enough that she would have been unlikely to take her own life,” Gargano said in an interview with The Herald.
These days, he is part of a new regional network of doctors and other medical providers fighting to save people who are addicted to opioids. They are turning to primarily three different medications that allow their patients to stabilize and return to their lives. The effort here is part of a Washington state pilot project funded by federal dollars.
Known as medication-assisted treatment, the effort uses methadone, naltrexone and buprenorphine/naloxone combined with counseling and therapy. The U.S. Food & Drug Administration has approved the medications for such purposes.
Suboxone is a brand name for medication that contains buprenorphine/naloxone.
Like the rest of the state and nation, Whatcom County is struggling with an opioid epidemic.
But few of the nation’s doctors are licensed to prescribe buprenorphine/naloxone, which is the medication that is used the most to treat people addicted to opioids.
About 5 percent of doctors — 43,109 as of June 2018 — were licensed to do so, according to a June 23 New York Times article that explored the challenges faced by one doctor in Iowa.
In 2017, 693 people in the state died from an opioid-related overdose, according to the 2018 Washington State Opioid Response Plan.
In Whatcom County, 69 people died from opioid-related deaths 2012-2016, according to the Washington state Department of Health.
The idea of treating drug addiction in such ways isn’t new — methadone has been used for decades to treat people addicted to heroin, for example — but it remains controversial. Medication-assisted treatment is effective, those in the field said, and removing the stigma around it is necessary.
“We often hear the argument that methadone and buprenorphine are just substituting one opioid addiction for another — that they are a ‘crutch,’ ” said Dr. Adam Kartman, one of the doctors in the new network.
“Just as effective treatments for fractures may include crutches, effective treatment of opiate use disorder may also use crutches to speed recovery,” he said.
Others said the effort was akin to treating illness.
“It’s no different than somebody taking insulin to control their diabetes,” said Chris Watras, the M.A.T. program manager with Sea Mar, one of the partners in the network.
Opioids include prescription painkillers — such as oxycodone, hydrocodone and methadone — and heroin, which is illegal.
Most addicts said they abused prescription opioids, known by brand names that include Vicodin, OxyContin and Percocet, before using heroin.
Medication-assisted treatment helps people who are addicted get into treatment and remain in recovery, Kartman said.
“M.A.T. is currently the most successful approach to help people stop using heroin, fentanyl or other opioids, which in turns allows them to focus on improving their own lives rather than seeking the next fix they need just to feel well.”
He said that supervised use “cuts the risk of death by half in opioid use disorder” and improved the success rates of long-term recovery.
“Numerous scientific studies demonstrate this,” Kartman said. “Our experience with people in our community also supports this, person after person.”
Kartman, founder of Cascade Medical Advantage in Bellingham, created the regional network that serves Whatcom, Skagit, Snohomish, Island and San Juan counties. It was launched in July 2017 as part of a pilot for western Washington.
Medication-assisted treatment isn’t new in Whatcom County. Kartman, who is board-certified in addiction, has been providing it for a decade. Gargano has been doing it for a number of years as well.
What the network does is broaden the reach of medication-assisted treatment.
The goal is to help more people through a coordinated response, Kartman said, as well as train and help other medical providers treat addiction.
So far, 902 people have received care through the network that includes Whatcom County. Exactly how many were county residents isn’t being tracked yet by the state.
“We’re probably just addressing a quarter of the need, if that,” Kartman estimated.
Of the 902 people receiving treatment in the region, 45 percent of those being helped were ages 26 to 35.
A grant from the federal Substance Abuse and Mental Health Services Administration was used to launch the pilot in Washington state.
The network serving the five counties that include Whatcom is one of six hub and spokes in western Washington, providing treatment to a total of 3,717 people since July 2017.
Another three hub and spokes are planned for eastern Washington, according to Dr. Charissa Fotinos, deputy chief medical officer for the Washington State Health Care Authority.
Cascade Medical Advantage serves as the region’s hub. Its partners, or the spokes, are Catholic Community Services, Sea Mar, PeaceHealth, Pioneer Human Services as well as the Lummi and Swinomish tribes.
All offer medication-assisted treatment as well as various services that a patient might require during the complex process of recovery, Kartman said.
“It is really helping people get back their life, reconnect with family or friends that they have lost or damaged relationships with because of their use. We’ve got some real success stories,” said Donna Wells, director of Catholic Community Services Recovery Center.
The FDA has approved three medications to treat addiction. Methadone is one.
The other two are buprenorphine/naloxone, approved in 2002, and naltrexone, approved in 2010. These two can be prescribed by doctors and other medical providers after they get special training.
Methadone can only be dispensed through a federally licensed methadone clinic when it’s being used to treat addiction.
They work in a number of ways.
“They help block cravings and urges to use. They re-establish the feeling of being normal and well rather than sick with the flu,” Kartman explained of intense withdrawal symptoms that include vomiting and diarrhea. “Medications help people by blocking the euphoria if they slip one time and use an opiate.”
Medicaid and most private insurance pays for such treatments, which can last for years depending on each person’s needs.
People getting such care are “treating their addiction and are often rewarded with a return to normalcy,” Kartman said.
“We simply cannot afford to marginalize people with addiction,” Kartman said. “The effects of this disease in our community are tremendous.”