Pubdate: Sun, 27 Apr 2014
Source: Star-Gazette (NY)
Copyright: 2014sStar-Gazette
Contact:  http://www.stargazette.com/
Details: http://www.mapinc.org/media/1005
Author: Jason Whong

WAITING LISTS FOR ADDICTION TREATMENT GROW, AS REGION SEES INCREASE IN 
HEROIN USE

Robert, who had used other illegal drugs, fell into heroin addiction
in 2007 when his best friend introduced him to it.

The 29-year-old Ithaca man, whose name is being withheld because of
the stigma attached to addiction, injected heroin off and on for about
six months until not using the drug meant withdrawal symptoms.

For Robert, the hook soon wasn't the high.

Rather, it was the need to avoid the sickening, unbearable effects of
withdrawal. Robert sought help but found that, at first, access to
heroin was far easier than a way out of addiction.

Today, the recovering addict climbs into a taxi cab at 5 a.m. every
weekday for a 60-mile drive to Crouse Hospital in Syracuse, where he
receives methadone treatment. And that came only after a two-month
delay on the program's waiting list, which is now often nine months or
longer.

Across the Southern Tier, getting hooked on heroin is easy. Getting
unhooked - in itself an onerous regimen - can be impossible because of
the shortage of medication-assisted treatment programs.

Even treatment programs that don't rely on substitute medication are
tight: An in-patient drug treatment facility in Elmira often sees
patients from Owego, Binghamton and Syracuse.

In the Southern Tier, the only methadone treatment program is at
United Health Services in Binghamton. The closest other in-state
methadone clinics are in Rochester and Syracuse. Addicts in a
methadone program typically must show up six days a week to receive
their doses at the start of treatment.

Addicts who seek buprenorphine treatment can choose from only a
handful of doctors in the region who write prescriptions for it, and
many of those don't take Medicaid, which pays for the treatment of
most addicts in the state.

Not all kinds of drug treatment involve using substitute medications,
but using replacement drugs such as methadone, buprenorphine and
naltrexone can help people addicted to opioids, such as heroin, or
prescription pain killers, said Henry Bartlett, executive director of
the Committee of Methadone Program Administrators of New York State
Inc.

"Every kind of treatment works for some patients," Bartlett said.
"When dealing with chronic, long-term opiate addiction, using
addiction medicines combined with counseling has a far greater
likelihood of success than any other treatment approach."

Opioid addicts who seek medication-assisted treatment using methadone
or buprenorphine have about a 50 percent chance of staying off illicit
opioids at first, but for people who stay in treatment past six
months, the number goes up to roughly 70 percent or higher, Bartlett
said.

Reviews published in November and commissioned by the Substance Abuse
and Mental Health Services Administration found treatments using
methadone and buprenorphine help patients reduce their use of illicit
opioid drugs. Both of those drugs are regulated more strictly than
other medications.

Doctors also can prescribe a third drug, Vivitrol, without special
permission from the federal government. Alan Wilmarth, who runs the
methadone treatment program at UHS in Binghamton, said Vivitrol is an
option for people who haven't abused opiates for a long time.

Replacement medicines The National Institute on Drug Abuse, part of
the National Institutes of Health, estimates that about 23 percent of
people who use heroin become dependent on it. Locally and nationally,
health professionals have reported that people who became addicted to
prescription pain killers, themselves opioids, turn to heroin as a
less expensive alternative.

Dependent on heroin, Robert, the Ithaca addict, experienced withdrawal
symptoms, which he described as "freezing and sweating at the same
time" if he didn't keep injecting the drug. So he kept doing so.

"It got to the point where it was destroying my life so much and
tearing apart my family ... making complications for me, and I was
just sick of being sick all the time," Robert said.

To get off of heroin, Robert first tried using buprenorphine, a
prescription heroin replacement drug, which he bought on the street,
but he didn't have much success.

"I didn't trust it after that, so I decided I had to go the methadone
route," Robert said.

But there was no methadone clinic nearby for Robert. He contacted
Crouse Hospital in Syracuse in December of 2008, and was placed on a
waiting list for its opioid treatment program.

He had to wait only about two months before the hospital could take
him, but now the methadone clinic can have a waiting list of nine
months to a year, said Mark Raymond, manager of the Opioid Treatment
Program at Crouse.

"There's other ways of getting help," Raymond said. "But if this is
the way you're choosing to get help, then yes, there's a delay in
getting treatment." People who want to get into a methadone clinic can
seek other services while they're waiting to get in.

In response to the higher need for methadone treatment in the state,
the clinic in late December received approval to expand its capacity
from 500 to 800 patients. In mid-April, the clinic had 511 patients
and a goal of expanding to 800 after two years, if the need for
treatment persists.

The methadone clinic in Binghamton does not have a waiting list
because in the past year it received permission to expand from 75
patients to 150, said Wilmarth, who expects the clinic will operate
below capacity so emergency cases can be admitted.

Waiting lists can hamper an opioid addict's ability to overcome
addiction, said Art Johnson, commissioner of social services in Broome
County.

"They generally want to go to treatment when there's a crisis,"
Johnson said. "So when the crisis blows over, they don't want to go to
treatment until the next crisis happens, and if there's a long wait to
get in, it's not good."

An addict waiting for months to get into a methadone program is common
in upstate New York, Bartlett said.

"In New York City, you can probably get into treatment ... within a
matter of a few days," he said. "In upstate New York, it's pretty sad.
. The good news is, there's a wonderful clinic; the bad news is it
might take you six months to get in."

For people seeking treatment in methadone clinics, areas like the
Southern Tier west of Binghamton, the central Adirondacks, central
Catskills and St. Lawrence Valley are "like a desert," Bartlett said.
"There's just nothing there."

'Maintenance treatment' Patients using methadone receive what doctors
call "maintenance treatment," in which they receive the drug as a
replacement for heroin or other illicit opioids and receive regular
counseling. The drug satiates their opioid craving and prevents
withdrawal symptoms. Patients on a proper dose are not getting high or
getting sick from withdrawal, which lets them function.

Patients in maintenance treatment can receive methadone indefinitely.
Getting off of it isn't necessarily the purpose of the program.

"There's no proof that a patient will have more success going off the
medication than they will by staying on it, and there's no evidence
that suggests that staying on the medication is harmful in any way, if
you're taking it as prescribed," Raymond said.

Federal regulations for methadone clinics are strict. When starting
treatment, a patient usually goes to the clinic Monday through
Saturday to receive medication on-site. Some days they also get
counseling, and on Saturdays, they'll get a take-home dose for Sunday.

That routine goes on for several months until the patient is
stabilized, and gradually they can receive more take-home medication.
Patients can't just take a month's supply of methadone doses home when
they start. "You don't want to give an early patient who is unstable
three take-home doses, because they might take them all at once and
kill themselves," Bartlett said.

Wilmarth cautioned against seeing methadone as a panacea.

"There are a cohort of patients who need that level of supervision
that's provided with a methadone clinic; however ... Suboxone (a
version of buprenorphine designed to fight abuse of the drug) can be a
very effective medication-assisted treatment venue for the opioid
population," Wilmarth said.

"A lot of people who want methadone, we determine not to be
appropriate," he said. "Maybe they're a candidate for Suboxone, or
maybe they're a candidate for abstinence-based treatment, if they're
young and have a very short history of addiction."

But many doctors in the area who prescribe Suboxone for maintenance
therapy don't take Medicaid, Medicare or other insurances, which can
act as a barrier to people seeking replacement drugs, Wilmarth said.

Brian Hart, director of community services for Chemung County's mental
health department, said his most recent list shows roughly 11 doctors
between Corning, Elmira, Ithaca, Bath and Vestal who have federal
permission to prescribe buprenorphine. Some are primary-care
physicians, some are psychiatrists.

"The treatment that's out there isn't necessarily ready for the
dramatic increase that seems to be happening," Hart said. "On an
outpatient basis, there are few doctors that are trained in giving
specific treatment modalities for opiate addiction, and methadone
clinics are certainly not close by."

There are 29 doctors in the 607 area code who are certified to write
prescriptions for it, according to data from the Substance Abuse and
Mental Health Services Administration.

But nationwide, about half of doctors who can write such prescriptions
don't do so, and while federal regulations allow each certified doctor
to prescribe it for as many as 100 patients after their first year, in
practice, the number is often lower.

Of doctors who have received permission to prescribe buprenorphine but
don't currently do so, Wilmarth said many of them started out writing
the prescriptions without pairing them with counseling, and stopped
after getting poor results.

Bill Rusen, chief executive officer of Cayuga Addiction Recovery
Services in Trumansburg, said it's up to the physicians to decide how
many they will treat with the drug.

"We're not comfortable with our physician having to cover, like, 70
people, because we can't do that well," Rusen said, estimating that an
appropriate cap for his service might be around 35 or 40 under current
conditions.

Cost of treatment Medicaid, the public health insurance for low-income
residents, pays for 65 percent of opioid addiction treatment patients
in New York, according to the latest data from the state Office of
Alcoholism and Substance Abuse Services. Self-payers pay for 10
percent, private insurance pays for 9 percent, while 8 percent of
patients had other government insurance such as Medicare, and another
8 percent had no source of payment identified.

Of the drugs used to treat opioid addiction, Methadone is the least
expensive, at less than $100 per month.

Buprenorphine costs about $350 to $400 each month.

Naltrexone, prescribed as Vivitrol, an injectable extended-release
suspension, costs between $700 to $1,200 a month, but it comes with
the benefit of only needing one injection monthly. In some patients,
it has a similar effect as buprenorphine or methadone.

While the shortage of drug treatment resources continues upstate,
recovering heroin addicts like Robert will continue to spend about two
hours in a cab each weekday morning from Ithaca to Syracuse and back
for perhaps a five-minute visit to his methadone treatment program.
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MAP posted-by: Matt