Bringing legal Suboxone to rural corners of a region in crisis

A chain of clinics in New Hampshire and Vermont hope to increase access for addicts hoping to get clean.

Over the past two decades, easy access to prescription pain pills has led millions of Americans to addiction. This wave of opioid abuse has more recently triggered a heroin epidemic, as users turn to the powerful street drug when Percoset or Oxycontin become too expensive and hard to find.

The opioid crisis has hit New England particularly hard. From 2012 to 2013, heroin-related emergency room visits more than doubled in New Hampshire. In the same time period, heroin deaths nearly doubled in Vermont, and the governor there dedicated his entire 2014 State of the State address to what he described as a “full-blown heroin crisis.”

Now, a Dartmouth medical school student is trying to bring affordable addiction treatment to clients in hard-to-reach rural areas, where a dearth of specialists and medication-assisted therapy centers can lead to long waitlists for addicts trying to get clean.

An access problem for Suboxone

In 2002, the Food and Drug Administration approved Suboxone for use in medication-assisted therapy for prescription drug and heroin users. The drug combines the opioid buprenorphine with naloxone, an opiate blocker that prevents users from injecting the drug, and is billed as less addictive than methadone and less likely to lead to overdoses.

In 2013, generic buprenorphine entered the market in the U.S.

Suboxone was the first drug of its kind designed to be prescribed straight from doctor’s offices to increase access. But today, in largely rural areas in the Northeast, it can still be hard to find doctors or treatment centers prescribing it.

“I tried numerous times, but I just got sick of not being able to get in,” said David Bunker, 27, a recovering addict who lives in Sunapee, New Hampshire, near the border with Vermont.

Bunker, who has striking, deep-set blue eyes and tattoos covering his forearms and hands, said he tried to get into treatment programs twice over the past four years, when each of his sons were born. The first time, the handful of treatment centers he called were full.

“I was depressed,” Bunker said. “It sucks not being able to get help when you really want it, and then when it takes so long, you keep trying and trying and you don’t get nowhere, you just give up.”

When he called around more recently, he said the closest treatment center with availability was in Massachusetts, three hours away.

The federal Substance Abuse and Mental Health Services Administration runs a website where patients can search for nearby addiction service providers.

In a search this week, WHYY found 31 listings within a 20-mile radius of a residential address in downtown Philadelphia for providers using buprenorphine in treatment.

From David Bunker’s grandmother’s house, where WHYY interviewed him in New Hampshire, there were just two. One of those had a waitlist and was not taking new patients.

Source: U.S. Substance Abuse and Mental Health Services Administration’s Behavioral Health Treatment Services Locator

Suboxone billed as a safer replacement drug

Methadone has historically been the replacement drug of choice for opiate addiction. It attaches to pain receptors and fully activates them, so it reduces cravings and eliminates withdrawal symptoms. But it can be dangerous: if users take more of the drug, they can get higher, overdose, and die.

Suboxone works differently.

“As you increase the dose of the drug it reaches a limit of what it will do,” said Dr. Matthew Duncan, a psychiatrist in Hanover, New Hampshire.

“You can’t get the same kind of elevations in what people might consider a high, and you can’t really overdose on it the same way, because at a certain concentration in your system it reaches a maximum occupation of those receptors and hits a ceiling.”

Overdoses are less likely than with methadone, but Suboxone is still a powerful opioid, and overdose deaths are possible.

Though the drug was designed with accessibility in mind, federal drug treatment officials say there is a treatment gap in some parts of the country. 

In 2013, there were nearly 4,000 Vermonters treated for opioid abuse, according to the state department of health. By the end of that year there were as many as 1,200 people waiting for treatment. This summer, following the roll-out late last year of a new state-wide drug treatment network, the waitlist dropped to around 400.

Nationwide, about 28,000, or two to three percent of all U.S. physicians, have the federal waiver needed to prescribe buprenorphine, according to federal data. Of those, less than a third have requested to treat the upper limit of 100 patients. The rest are bound by the lower limit of 30.

Some doctors are wary of the additional Drug Enforcement Agency scrutiny providers are subject to, and psychiatrist Matthew Duncan said there is a laundry list of other reasons why physicians in private practice be hesitant to become Suboxone prescribers.

“Because of these caps on how many people you can treat, because you have to get a separate license, you have to pay for that license, you have to do separate training,” Duncan said.

“A lot of doctors don’t have a comfort level with prescribing this medicine, and many people don’t have a comfort level of dealing with people who have addiction issues, and so the access is very restricted.”

Suboxone as a street drug

The prescribing limits were intended, in part, to allow for strict monitoring of outgoing pills and deter unscrupulous doctors from starting pill mills, but Suboxone has still trickled out onto the streets and into prisons. Now, it is both a treatment and an illegal drug of choice for users around the country. Suboxone was called the ‘double-edged drug’ in an extensive and critical New York Times article last fall.

Recovering addict David Bunker started using Percoset with his friends when he was 16. He moved on to Oxycontin, another prescription painkiller, and then to methadone.

He bucked the growing national trend of transitioning to heroin, because, he said, he saw what it did to his mother when she used. Still, at age 18 he was sent to prison for four years for second-degree assault.

When he got out, he started on Suboxone he bought off the street, because it didn’t show up in parolee drug tests. When his $35 per-pill habit became too expensive, he started, at first unsuccessfully, looking for treatment programs.

Access to all types of healthcare is more difficult in rural areas, but for addiction treatment services, some compounding factors make it even more complicated, said Dr. Benjamin Nordstrom.

“First off, there’s a lot more methadone in urban areas,” said Nordstrom, who worked until a few years ago in Philadelphia and now runs Dartmouth Hitchcock Medical Center’s addiction services.

Patients have to go to methadone clinics every day to pick up their drugs, so the model doesn’t work as well in rural areas as it does in cities.

“(In cities) there’s reliable public transportation, so people can get to their appointments, and they can get to their clinics,” Nordstrom said. “That is very different from the reality of practicing in this kind of environment.”

A medical school student offers a solution

A few years ago, in the middle of this opioid epidemic, Dartmouth Medical School student Jeff DeFlavio was starting to see some of these heroin and pail-pill addicted patients.

During a family practice rotation as part of his medical school curriculum, he treated one patient who managed to stay clean until her fifth month of pregnancy, but ultimately relapsed and contracted Hepatitis C.

“We had been taking care of her, we had been meeting with her every week, and we hadn’t done the one thing that would have actually maybe helped her the most,” DeFlavio said.

That one thing, in his mind, was prescribing her Suboxone.

DeFlavio noted a lack of affordable addiction treatment services in his area, so during a year off of medical school to get his MBA, he recruited his former professor and launched his own network of clinics in Vermont and New Hampshire, called Recover Together. 

“We got malpractice insurance for him, and rented a space, and just started,” he said.

DeFlavio, 28, opened his first clinic in March, and plans to open his fifth before the end of the year.

Recover Together overcomes prescribing limits by pooling together multiple doctors into one system. It tries to make treatment accessible by putting clinics in the center of towns hard-hit by addiction, where clients can walk, relying on drug counselors on the primary patient point-of-contact, and charging just $50 a week, plus the cost of Suboxone.

At the core of the program are mandatory, weekly group therapy sessions, where clients talk about how to avoid triggers and relapses. At the session, patients are drug-tested and given their weekly Suboxone prescription.

DeFlavio currently has about 200 patients, and employs a medical director, and five other physicians who work for him a few hours a month, some former teachers and medical-school mentors.

The federal Substance Abuse and Mental Health Services Administration is currently trying to figure out ways to increase access nationwide to opioid treatment therapy, specifically with buprenorphine.

Robert Lubran, the head of pharmacologic therapies at the agency, said he is a little surprised more businesses like DeFlavio’s haven’t cropped up in the dozen years since the drug was approved.

“I would have expected we’d see more by now,” Lubran said.

“There are not a lot of what you’d called integrated primary care, mental health, substance abuse treatment programs that are using buprenorphine, but we’re seeing a trend where that’s growing.”

A world of difference

David Bunker started going to Recover Together meetings late last winter. Though the drug he is using hasn’t changed, he said getting it legally, as part of a treatment program, makes a huge difference.

“I didn’t have to worry about trying to find my next fix, I didn’t have to worry about trying to get it off the street and then getting arrested, and then end up back in prison, because I’m trying to straighten my life out,” Bunker said.

The group therapy component was a necessary evil for Bunker, who has an anxiety disorder and is nervous speaking out his struggle with addiction even one-on-one. But the therapy has grown on him.

“From the time I started until now, there’s a big change in me opening up and talking about my addiction with other people,” Bunker said. “I feel more comfortable.”

Bunker has been clean and held down the same job at a sawmill for a year, and now lives with his fiancé and two children.

“Until he got with the right people, and got on this path, I really was scared for him, I really was,” said Jeannette Childs, Bunker’s grandmother.

“I think it’s made a world of difference.”

Jeff DeFlavio, now in his fourth year of medical school, has decided not to complete a residency program, which would allow him to become a fully qualified doctor.

Instead, he plans to build his business full-time, to address a crisis created by decades of opioid over-prescribing. 

“(It’s) something that is entirely at the doorstep of the U.S. medical establishment and every physician who’s practicing in the United States,” DeFlavio said.

“A lot of people have gotten hurt because of it….and for the most part physicians are not prepared to help them.”

DeFlavio said he feels a responsibility to help stem the tide of addiction an earlier generation of doctors helped create.