Editor’s note: This is the second of a two-part series on opioid addiction on the Kenai Peninsula. For the first part, check the Dec. 31 edition of the Peninsula Clarion.
It might have been a pretty standard process to treat the patient’s infection except that the doctors had to work around her heroin addiction.
The infection had been caused by injecting the drug. She left the hospital against medical advice twice because she couldn’t go without heroin, despite nearly having died both times. She went two weeks without antibiotics, which risked her life. It was a frustrating problem for Dr. John Nels Anderson, her primary care provider, who’d been working with her to get her off the drug.
Anderson, a family practice doctor in Soldotna, is one of a handful of doctors on the Kenai Peninsula licensed to treat patients for chronic opioid addiction by prescribing them opioids. It may seem counterintuitive to give an addict more of the substance they are addicted to, but the idea is to gradually wean them off.
Dr. Michael Merrick, a family practice doctor in Kenai, treats opioid addicts daily. It can be years between when a patient first presents and when they will finally be clean, and sometimes, it doesn’t happen at all.
“If the patient is interested (in quitting), they’ll push themselves,” Merrick said. “That doesn’t happen as much as you’d like it to happen. What happens is patient get on it, and they’ll say, ‘Don’t even talk to me about that, Dr. Merrick. I’m doing really good, he said.’”
Drug abuse sometimes presents in subtle things — extra needle marks in a patient’s forearms, more financial trouble, losing a job. Patients will run out of their prescriptions too soon, either from taking too much themselves or selling it.
But the one thing not to do is to discharge them.
“If you have somebody that screws up, you don’t kick them out on the street,” Anderson said. “What they’re likely to go back to is a heck of a lot worse than whatever you can do for them.”
There are a few drugs available: buprenorphine, naltrexone, naloxone and methadone are the main drugs, with a collection of different combinations under brand names. Suboxone is the most common brand and does the job. Plus, it cannot be injected because a chemical will trigger withdrawal .
However, the cost can be prohibitive for the uninsured. A shot of naltrexone without insurance costs about $1,350, and Suboxone costs about $7 per dose. Generic buprenorphine costs about $3 per dose, but for a patient taking two doses a day, that can add up to more than $2,000 per year.
Because of the cost, Anderson said he prefers methadone. But it is illegal to prescribe methadone as a treatment for addiction — it can only be legally used to treat chronic pain. There are currently three methadone clinics in Alaska — in Anchorage, Fairbanks and Juneau. Even there, slots are limited.
“(Methadone) is dirt cheap,” Anderson said. “But if you live in Barrow, if you live in Dillingham, if you live in Bethel, you’re out of luck.”
The mobility is one of the advantages to Suboxone, Merrick said. He has fishermen and oil rig workers whom he outfits with enough Suboxone to live their lives as normally as they can while not returning to heroin. He keeps an eye on them, though.
“If you come to me and you’re still using heroin, you’re still using the pills, then okay, I give you a week of Suboxone, and I’ll see you next week,” Merrick said. “It’s the same as any other disease where if you’re not doing well, you have to come to the doctor more often.”
He has been prescribing the drug since 2004, when the national Drug Enforcement Administration began issuing licenses for doctors to treat patients with opioid addiction by prescribing opioids. Doctors have to complete training and apply to the Substance Abuse and Mental Health Services Administration. They are limited as to the number of patients they can take on: 30 in the first year and 100 after that if they choose to expand.
The Drug Enforcement Administration watches carefully, including unannounced inspections for the doctors that dispense controlled substances in their clinics rather than just prescribing it.
“The diversion unit, people fly in from Seattle once or twice a year and they go through your records and see what you’ve got,” Anderson said. “They’re merciless if they find anything that they think is out of line.”
Chronic management is just one facet of addiction that doctors face. To prevent overdose deaths, Dr. Sarah Spencer wants to outfit everyone she can with a naloxone kit.
“People will go immediately into withdrawal — start shaking, sweating, vomiting, possibly,” Spencer said. “And we’ve found that it’s just as effective as a nasal spray, and people are a little less scared of that than drawing it up from a bottle into a syringe.”
Spencer, a family practice doctor at the Ninilchik Community Clinic and at the Homer Medical Center, hands out blue bags about the size of pencil cases with step-by-step instructions.
It’s not just heroin addicts, or even just those addicted to prescription medications — she also gives them to patients who take medications that may interact. Many people take one medication on a consistent basis and have no issue, but if they add another without knowing that the two could interact, they risk overdosing.
Spencer advocates reclassifying naloxone as an over-the-counter drug rather than a prescription-only drug. The more patients with one on hand, the better, and it doesn’t have the abuse potential of other opioid addiction treatments such as Suboxone, buprenorphine or methadone, she said.
“This drug is absolutely safe,” Spencer said. “You wouldn’t want to abuse this.”
Naloxone doesn’t solve the problem — it just buys the patient time while emergency responders can get to a hospital. Many heroin addicts do drugs with a friend, and if the friend is afraid to call the cops for fear of being arrested, the kits are especially crucial, Spencer said.
“This is a great tool that is available,” Spencer said. “But the trouble is, no doctors are prescribing it. You don’t even need the DEA license to prescribe it. But no one is doing it.”
It’s not just the patients that face a negative stigma. Doctors also wrestle with treating patients with opioid addiction, either from their peers or from the public.
Some doctors choose not to apply for the DEA license to treat opioid addicts. Only 26 doctors in Alaska currently have licenses to dispense buprenorphine, and many opt out because they don’t want to take on patients seen as high maintenance or possibly high risk, Merrick said.
Spencer agreed. Compliance is an issue across the board, with patients who have a variety of conditions. Even getting patients to comply with simple things, such as diet and exercise, can be difficult.
“You see up to 50 percent success rates with this medicine,” Spencer said. “It works way better than a lot of the other medicine, like diabetes and blood pressure medicine, that we prescribe.”
Anderson said he didn’t want to get the license in the first place but eventually changed his mind. He was already treating some addicts in his regular practice, and the added tools to treat them helped, but he still doesn’t treat very many.
Merrick said one day, doctors may look back on suboxone as a crude way to treat addiction, the way we look at iron lungs as a treatment for polio today.
“It was a horrible thing. But it’s either that or you die. All of a sudden, polio vaccine comes out, and you don’t need iron lungs anymore. In fifty years, people will say, ‘Can you imagine that doctors in 2015 were using buprenorphine?’”
Reach Elizabeth Earl at firstname.lastname@example.org.