News

Major push on to increase access to addiction medication

Written by David Wenner/PennLive | Jul 14, 2018 7:00 AM
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Newsrooms across the commonwealth have spent years documenting the opioid crisis in their own communities. But now, in the special project State of Emergency: Searching for Solutions to Pennsylvania's Opioids Crisis, we are marshalling resources to spotlight what Pennsylvanians are doing to try to reverse the soaring number of overdose deaths.

WITF is releasing more than 60 stories, videos and photos throughout July. This week, you will find stories about police intervention, courts and treatment.

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Carissa Lehr checks the box in which she stores daily doses of methadone. Methadone is available only from federally-controlled clinics. People can receive it only if they pass regular screenings for illegal drugs and participate in other forms of treatment such as counseling. Lehr, who has built a track record of complying with treatment, is allowed to take home doses rather than go to the clinic every day. (David Wenner/PennLive)

 

At a little before 9 a.m., Carissa Lehr stands on the porch of her mobile home. Inside, her toddler son will soon wake, and Lehr will make him a waffle in her spotless kitchen.  

Her life looks vastly different from a few years ago, when a decade-long addiction to painkillers and heroin controlled her every move. The 33-year-old credits the reversal to two things: The birth of her son. And methadone.  

Methadone is one of three medications increasingly used to treat addiction to opioids and is now considered the "gold standard" for treatment. It amounts to the most promising solution, and one that is increasingly backed by evidence, to a soul-sapping aspect of opioid addiction: the tremendous craving that can persist even in people who are fully devoted to recovery, and the subsequent relapses and return to full-blown addiction.

Methadone prevents the excruciating withdrawal sickness that happens when people addicted to opioids try to quit. Although methadone is also an opioid, it doesn't produce the high that comes from heroin and other illegal opioids. And while people using methadone must take it daily to avoid withdrawal, they don't suffer the all-consuming craving and preoccupation that is part of heroin addiction. They can live normal lives and focus on things like their job or caring for their children.  

Unfortunately, access to the medications can still depend on where someone lives. In rural parts of the state, which have some of the nation's highest fatal overdose rates, the medications remain scarce. The shortages persist several years after rural county coroners and others began sounding an alarm, and the realization that medications are a crucial part of the solution. "We definitely still have a lot of work do. I think we're taking the right steps," says Jennifer Smith, Pennsylvania's secretary of drug and alcohol programs.

Carissa Lehr gets her methadone at a clinic a few miles from her home near Mechanicsburg. In the beginning, she had to go every day. A nurse would pour the red liquid into a cup and watch her drink it.

Now that Lehr has a track record of embracing her treatment program, she goes a few times per week and is allowed to take home doses for the other days. She stores them in a double-locked box high in a cupboard, far out of reach of her son.  

Medication alone isn't considered effective treatment. Lehr also attends recovery meetings and counseling. Temptation occasionally tugs, but now she feels equipped to withstand it.      

"There are still days when I have a thought. But it doesn't take me long to remember all of the negative and get out of it," she says.

Making a difference

The other two medications commonly being used to treat opioid addiction are buprenorphine and naltrexone. Buprenorphine, often used in a form called Suboxone, is another opioid used to prevent withdrawal and cravings without making the user high.

Naltrexone isn't an opioid and works differently, blocking the effects of opioids so that if the person were to use heroin, they wouldn't get high. A popular form of naltrexone, called Vivitrol, requires only a monthly injection.

All three are approved by the U.S. Food and Drug Administration. Combined with counseling, they comprise what's known as "medication assisted treatment."  Studies show that people trying to recover from opioid addiction using one of the medications are 50 percent less likely to die from an overdose than those who try to recover without it. They also stay in treatment longer, and are more likely to return to treatment if they relapse.

But that option isn't available to many.

About 200 people come regularly to a clinic within the Pennsylvania Psychiatric Institute near midtown in Harrisburg. Open since November and with easy access to public transportation, the clinic has been attracting about 20 new patients per week.

Some receive methadone, which can only be dispensed at federally-approved locations. Some get prescriptions for buprenorphine, which can only be prescribed by doctors and nurses who have special certification. Some receive injections of Vivitrol. Some, still in the early, shaky days of recovery, receive one-day doses of buprenorphine, which in larger quantities is sometimes used to get high or sold on the street.

Counseling and other forms of help are also available at the clinic, which is run by Penn State Health and made possible with a $1 million grant from the state. It's one of numerous places where people who live in Dauphin or Cumberland counties can go for medication-assisted treatment.

Rural areas hit hard

Barely 25 miles away, just over the mountain in Perry County, the situation is starkly different. 

There, says county Commissioner Brenda Benner, access to medications to treat opioid addiction is "very, very limited."

Perry, like other rural areas, has been hard hit by the opioid crisis. For example, Beaver and Armstrong counties each had nearly 60 fatal overdoses per 100,000 people, according to recent statistics compiled by Pennsylvania coroners. Many other rural counties have fatal overdoses rates far about the national average of about 20 per 100,000 people.

In Perry, the rate matches the national average. But because Perry has no hospitals, Benner suspects its overdose rate is undercounted for reasons such as overdose victims being transported to out-of-county facilities. The situation is serious enough that Perry has equipped its probation officers and ambulance crews with naloxone, the drug that can reverse an opioid overdose, according to Benner.

But when asked where people can get medications to treat opioid addiction near communities such Landisburg, Shermans Dale or Loysville, Benner says "I am not aware of anywhere"

"I don't think people really understand how great the need is," she says.

The situation brightened somewhat with the planned opening of a medical clinic run by Harrisburg-based Hamilton Health near Newport. The clinic includes a state-funded treatment center where people can go for Vivitrol injections or prescriptions for buprenorphine.

But that still leaves many in Perry County to travel long distances to get medication and counseling. If they lost their driver's license because of their opioid addiction, or lost their car to the financial ruin that often results from the addiction, that distance can be insurmountable.

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Just For Today, a non-profit in Lemoyne, Pa., plans to use telemedicine, and possibly a nurse operating out of a van, to take Vivitrol to remote parts of Perry and Dauphin counties. (David Wenner/PennLive)

 

Treatment centers launched

Pennsylvania has spent tens of millions in state and federal money to make treatment more available. It has helped launch a handful of centers, like the one run by Penn State Health in Harrisburg, around the state.

The goal is for the centers, run by big health care systems including UPMC, Geisinger and WellSpan, to become regional "hubs." The intent is for the hubs to run full-service treatment clinics, while also connecting with doctors and organizations in outlying areas, to help them provide medication-assisted treatment.

The state has also established 45 "Centers For Excellence" with a goal of expanding access to medication assisted treatment. Some but not all are in rural areas.

And Gov. Tom Wolf's administration has changed Medicaid rules and is working with hospitals so people who survive an overdose can immediately receive buprenorphine. Wolf has told private health insurers he expects them to provide undelayed access to the medications used to treat opioid addiction, and most have done so.

Gaps are being filled. But it's a big, long job. 

Steve Barndt, executive director of Just For Today, a Cumberland County-based non-profit focused on recovery, is well aware of gaps. His organization, which distributes naltrexone shots at its streetfront location in Lemoyne, is mulling a mobile clinic to take them to Perry and northern Dauphin counties.

Barndt is also working on a telemedicine arrangement so a nurse can give the shots at a Perry County firehouse.  

"The cavalry is coming, but they're slow. People are dying," he said.

When willpower won't work

In the early years of the opioid crisis, the standard treatment was similar to the approach used to treat alcoholism, centered on the idea the key to recovery was not taking a single drink or dose of a drug.  

Overcoming addiction was viewed as mainly a matter of willpower.

Pam Gay believed it. She spent  34 years as a nurse before becoming York County's coroner in 2014, just in time to document her county's record-setting spike in fatal overdoses.

She was struck by how many of those who died of overdoses had recently been abstinent, either because they were in treatment or in jail. She concluded that of the 125 people who died of overdoses in the county in 2014 and 2015, 70 had recently

been clean.

The problem is that opioid addiction rewires the brain so that craving and temptation exist for months or even years after the person has gone through withdrawal and embraced recovery.

"What we're seeing over and over is these individuals fighting so hard to be abstinent when they die," Gay said. "I think we need to look at other things, because a 12-step program is not really cutting it for them."

For a long time, there was a stigma against people who used medication to treat addiction. People said they were replacing one drug with another, and that someone couldn't claim "true recovery" unless they were entirely drug free.

The opioid crisis is changing that.

That's obvious at Gaudenzia Inc, which at any given time is working with 300 to 400 people using naltrexone in their recovery in Pennsylvania, Maryland and Delaware.

"It's a help. It keeps people alive. It's life and death with a lot of opioid patients," says Mark Sarneso, the director for Gaudenzia's central and western regions.

But he warns against the idea that medication-assisted treatment is a "silver bullet."

"The gold standard is really counseling and treatment," he says. "None of these medications work without concurrent treatment."

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