Carol Anderson of Mount Horeb recently found herself in the unusual position of helping her 29-year-old daughter buy drugs illegally.
It's not a parental role she ever envisioned, but a life was at stake: The drugs were meant to help her daughter get off heroin.
After an emergency room visit last year, Anderson's daughter Emily, who had been hooked on heroin for two years, was given a five-day supply of Suboxone, a drug that quells the craving for opiates like Oxycontin, Vicodin and heroin. The supply was supposed to help Emily detoxify, but when it ran out, she needed more to keep her heroin cravings at bay.
But even though Suboxone – a combination of buprenorphine and nalaxone — is proven to dramatically increase the chances for opiate addicts to kick their habit, it's difficult to get. Doctors must get certified to prescribe it. But despite certification training taking only eight hours, few get it.
"You can't get Suboxone just anywhere," says Anderson, who works for a large health care company.
Anderson had a line on a certified doctor, but his employer wouldn't let him prescribe the drug. She went to other doctors she found on a list of certified physicians, but the soonest her daughter could be seen was a month.
"In the meantime, Emily had gone through the detox process at home — which by the way is not fun to watch as a parent — so our only alternative at that point was to buy it on the street," Anderson says.
Emily, uninsured and unemployed, sought help from Dane County, which by statute is the alcohol and other drug abuse (AODA) treatment provider of last resort. She went to the county's contracted outpatient treatment provider, Journey Mental Health, to get treatment and hoped to obtain some legally prescribed Suboxone.
"Even when you get accepted into a program like at Journey, you don't get the Suboxone until you've seen a doctor there, and you don't see a doctor there until you've got a therapist or a counselor lined up," Anderson says. "You don't get a counselor until you've been through several group meetings."
All that took several weeks, during which Anderson would drive to Madison with her daughter every few days and hand her $60 to buy four pills at $15 a pop.
"The person who was selling this out of his home was somebody who had been through treatment and had used Suboxone and no longer needed it, but he continued to get it prescribed and was selling it," Anderson says. "Quite an entrepreneur if you think about it."
Eventually Emily got a legal prescription, and now Anderson buys her daughter's Suboxone from a pharmacy as she undergoes treatment.
Emily's story is not unique. Like many heroin addicts, she started out on Oxycontin, a prescription pain reliever. That drug's manufacturer changed the formulation in 2010 to make it less effective when snorted. So Emily turned to heroin, a cheaper, more powerful alternative that's seeing a resurgence of epic proportions.
Suboxone works by latching onto the same brain receptors as opiates, delivering a high that curbs cravings but without producing the same euphoria that gets people addicted to opiates in the first place. It also blocks opiates from attaching onto the receptors, so it neutralizes the high experienced by taking heroin or other opiates.
Suboxone isn't the only drug designed to get people off opiates. Methadone has been around for decades, but Suboxone has emerged as a safer alternative, easier to administer, far less addictive and with fewer side effects.
"If people are on some sort of a treatment program, there's about an 80 percent chance that they're going to relapse unless they're on medication-assisted treatment," says Cheryl Wittke, executive director of Safe Communities of Madison-Dane County, which is spearheading city and county efforts to curb the epidemic of opiate addiction.
But she adds, "In terms of medication-assisted treatment … that's always been an issue because it's expensive and there are just a few clinicians in town that provide that kind of stuff."
About two years ago, a Harvard Medical School-affiliated McLean Hospital study found that 49 percent of study participants were able to maintain sobriety with Suboxone, but when they were weaned off the drug, 90 percent went back to abusing opiates.
Yet despite its proven track record, uninsured addicts face financial hurdles to obtaining Suboxone. Dane County, which this year will spend about $6.4 million on addiction treatment for 6,000 to 7,000 people – about 10 percent of them opiate addicts – only pays for traditional abstinence-based treatment.
"It's cost prohibitive," Todd Campbell, alcohol and drug abuse services manager for Dane County, says of medication-assisted treatment.
The opiate epidemic has been good for Reckitt Benckiser Pharmaceuticals, the maker of Suboxone. In 2012, the drug generated $1.55 billion in U.S. sales. But last year the FDA approved a generic tablet version of the drug. Facing declining sales, Reckitt Benckiser has begun selling the drug only in a dissolvable filmstrip form, claiming it reduces the chance of accidental ingestion by kids.
While the competitive landscape takes form, the drug remains pricy — especially for the 15 percent of Suboxone users who pay cash.
Out-of-pocket costs for Suboxone run about $250 to $300 a month for the uninsured. And Anderson was paying about $450 a month on the street.
The county also doesn't pay for methadone, which is sometimes the best option for heavy heroin users.
"We have two private clinics in Madison that provide methadone maintenance," says Campbell. "That's funded either though private pay — people come up with money on their own — or Medicaid pays for that, as well as some other insurance."
The only drug-assisted treatment offered by the county is a pilot project funded by a $60,000 state Department of Justice grant that provides about 20 recently released Dane County inmates with Vivitrol. Unlike Suboxone and methadone, Vivitrol doesn't reduce opiate cravings but instead renders opiates ineffective.
Recovering addicts like Emily can either go without medication or find a way to pay out-of-pocket.
"Medication-assisted treatment is probably the most effective," says Campbell. "It does increase your chances of having a positive outcome. But there are people who have recovered without medication-assisted treatment as well."
Anderson says Emily didn't think that was an option.
"Emily states she would not have succeeded without our continued purchase of Suboxone on the street while she waited to get into Journey, and then waited until she could see a counselor, and then waited until she could see a prescribing physician," she says.
While counties are obligated to provide treatment for those who can't pay for it, the treatment plan is designed around available dollars, not need, says Dr. Richard Brown, a UW expert on substance abuse treatment and screening.
"They're on the hook to deliver treatment, but the loophole is that when their funds run out, then they're not on the hook," Brown says. "And then there is nobody else that steps in and fills those gaps."
Sue Moran, Journey's clinical director, says that addicts involved in the organization's Suboxone clinic "tend to do really well."
"Once they get stable, their lives improve," she says. "They return to work, they return to family relationships. Things really do get better for them. But what we've found is it's not just the medication itself. It has to be medication with treatment."
Moran says there's been a constant demand for drug treatment in recent years, and there are only so many patients her staff can handle.
"We constantly have people coming in," she says. "The stream never stops. There's a huge need in the community, and there just hasn't been enough funding to meet the need. We haven't gotten increased treatment dollars, not specifically for opiates."
Brown says Suboxone's proven effectiveness should prompt policy makers to rethink priorities for treatment options.
"Unfortunately many people still have inappropriately negative attitudes toward those kinds of treatments," he says of medication-assisted treatment. "Especially here in the Midwest, we tend to be very stoic. We think people should just stop."
In a health care system that spends countless dollars on cancer, heart disease, diabetes and high blood pressure, the widespread problem of addiction is often considered a personal failing, not a disease, he says.
"There's good documentation that addiction is a disease of the pleasure-reward system of the brain," he says. "Those cells of the brain are dysfunctioning so that it drives urges and cravings and makes it very difficult for people to quit."
He says the rewiring of the brain around addictive chemicals creates a condition comparable to epilepsy.
"If we look under the microscope at those brain cells for epilepsy or addiction, they look normal," he says. "But we've shown by other various tests and scans that they don't function normally."
But treatment for epilepsy and other medical conditions, he says, is funded. Addiction, he says, often isn't taken seriously.
It's especially perplexing, he says, because every dollar spent on effective treatment saves several dollars down the road in costs associated with medical treatment for drug abuse and incarcerating drug offenders.
"We're the wealthiest country in the world and we spend so much for heart disease, stroke, cancer," Brown says. "Why do we make this distinction that we're not going to spend money for addiction? It's as much a disease as all those other diseases."
Brown points out that for insurance plans offered under the Affordable Care Act, or Obamacare, drug treatment coverage is mandatory.
"Fortunately things are changing under health care reform, which strengthens previous laws on mental health and alcohol and drug treatment parity," Brown says. "The advantages there are occurring so far mainly for patients who have commercial insurance. But county treatment programs are not held to the same law."
Wisconsin lawmakers have passed a number of bills aimed at opiate addiction, introduced by Republican Rep. John Nygren, whose daughter has struggled with heroin. One of those bills, signed Monday by Gov. Scott Walker, would create two regional treatment centers in rural, underserved areas, at a cost of about $2 million.
While advocates call that a step in the right direction, it pales next to a proposal by Vermont Gov. Peter Shumlin to spend $10 million on opiate treatment, expanding capacity by 40 percent and prevention efforts by 14 percent.
With only 627,000 residents in the entire state of Vermont, that $10 million is the equivalent of increasing opiate addiction treatment funding in Dane County — population 500,000 — by roughly $8 million. Officials can't say how much Dane County currently spends on opiate addiction treatment. But with 10 percent of those in county-funded treatment programs addicted to opiates, that breaks down to about $640,000 of the $6.4 million the county is spending this year.
Meanwhile, as heroin becomes more available, demand for treatment shows no sign of abating. The scope of the problem is beyond any easy fix, say treatment advocates, and will require a full-scale mobilization of public health efforts.
"It's a community health problem," says Anderson, whose involvement with her daughter's recovery has put her in contact with others undergoing the same plight. "It's a public health issue that we need to give as much attention to as we did when AIDS was a problem. It's on that level." ￼