Pubdate: Sun, 29 May 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: Beth Macy
Note: Beth Macy is the author of "Factory Man: How One Furniture 
Maker Battled Offshoring, Stayed Local - and Helped Save an American Town."


Lebanon, Va. - LATE on Christmas night 2013, April Hileman was 
summoned for a drug test. She had broken the curfew imposed on her by 
a drug court and relapsed with the opioid pills she'd been hooked on 
for six years. Earlier that day, Ms. Hileman had driven to a 
neighbor's house here in far southwestern Virginia to buy a handful 
of Suboxone pills, or "Box," as the drug is sometimes called. After 
she tested positive, Judge Michael Moore of Russell County ordered 
her to jail, and her 3-year-old daughter spent the rest of the 
holidays with relatives.

Like methadone, Suboxone prevents "dopesickness" and reduces 
cravings, without getting you high. It is now the gold standard for 
opioid addicts in medication-assisted treatment, or M.A.T. A 
combination of the opioid buprenorphine and the anti-overdose drug 
naloxone, Suboxone is supposed to give addicts a chance to get their 
lives together before they taper off it.

But Suboxone can get you high if you inject it or snort it or take it 
in combination with benzodiazepines, a sometimes fatal blend. And Ms. 
Hileman, then 24, did all those things.

Among public health officials, the effectiveness of M.A.T. has become 
an article of faith; after all, treatment with buprenorphine and 
methadone has been found to cut opioid overdose deaths in half when 
compared to behavioral therapy alone, and it's hard to argue with 
that. An addict treating his opioid disorder with Suboxone, many 
argue, is no different from a diabetic taking insulin. But 
increasingly, law enforcement officials - and many former addicts and 
their families - are lining up on the other side, arguing that 
Suboxone only continues the cycle of dependence and has created a 
black market that fuels crime.

Many judges in Virginia's drug treatment courts are refusing to 
approve Suboxone treatment, especially for those who have already 
abused the drug. But last year the White House Office of National 
Drug Control Policy announced that it would not fund drug courts that 
cut off access to M.A.T. Judges who won't comply will be forced to 
scale back or scare up additional state and county funds. And now 
President Obama's proposed 2017 budget includes $1 billion for the 
expansion of M.A.T. What looks like a common-sense investment in 
Washington looks more complicated here in Appalachia, where the 
OxyContin "hillbilly heroin" epidemic began back in the 1990s and 
where opioid overdose death rates remain among the highest in the 
nation. These are the "Box Wars."

The problem is the plethora of cash-only Suboxone clinics that 
operate without proper counseling or monitoring procedures. Oversight 
is crucial because drug testing alone doesn't effectively reveal 
whether a participant is taking more Suboxone than prescribed.

For years Ms. Hileman had been "Box shopping": Addict friends drove 
her to clinics across the Tennessee border, in Kingsport or Bristol, 
and paid her visit fees of $100 to $150 in exchange for six or seven 
Suboxone pills or films, which dissolve in the mouth. Eventually the 
drug court cut off her M.A.T. But even with a prison sentence of two 
years and nine months hanging over her head for drug-related felony 
thefts if she didn't obey the drug court's rules, she continued using 
and selling black-market Suboxone.

Ms. Hileman's judge, Judge Moore, doesn't believe in treating people 
who have abused Suboxone with Suboxone, instead favoring abstinence 
with rigorous drug counseling and testing, and near daily monitoring 
by drug-court probation and surveillance officers.

"I know people Suboxone has helped, but unfortunately a lot of the 
clinics are not forthright in trying to taper people off," said Mark 
Mitchell, the Lebanon police chief and a member of Judge Moore's drug 
court team.

For some clinics, losing customers means jeopardizing profits. Chief 
Mitchell's town had three clinics before one was shut down in 2014 
for poor record-keeping and excessive prescribing. "For a town of 
3,400 people to have three Suboxone clinics?" he asked. "That's 
absurd." (While the Drug Enforcement Administration is pursuing pill 
mills nationwide, representatives from the agency and the United 
States attorney's office in nearby Abingdon declined to comment on 
continuing investigations.)

In a region where Suboxone seems to have replaced coal as the 
economic driver, 80 percent to 90 percent of all crimes committed in 
Russell County are drug-related, most involving black-market 
Suboxone, law enforcement officials say.

When residents and law enforcement agencies point to these numbers as 
proof that M.A.T. isn't working, public-health officials argue they 
are ignoring science. Why allow the criminal element to trump 
life-or-death concerns?

"Overwhelming evidence shows that Suboxone improves outcomes in 
people with opioid-use disorders," said Dr. Nora Volkow, director of 
the National Institute on Drug Abuse. She cited a 2014 study of 
opioid addicts that found that after 42 months, 31.7 percent were 
clean and no longer on M.A.T., and 29.4 percent were also clean but 
still receiving M.A.T. But almost 31 percent were off treatment and 
back on illicit opioids. (The relapse rates for patients who don't 
receive M.A.T., though, are likely worse; a 2015 study of heroin 
addicts who used methadone or buprenorphine found a relapse rate 50 
percent lower than among patients who did not get the medication.)

"Let's be clear," said Dr. Andrew Kolodny, a longtime Suboxone 
prescriber in New York and executive director of Physicians for 
Responsible Opioid Prescribing. "The real crisis is the severe 
epidemic of opioid addiction and overdose deaths that's devastating 
families across the country."

Dr. Kolodny ranks anti-Suboxone judges like Judge Moore in a category 
with climate-change deniers and people who believe vaccines cause 
autism. "When there's really dangerous heroin on the streets, I'd 
rather see Suboxone out there, even if it is being prescribed 
irresponsibly or is being sold by drug dealers," he said.

I've encountered zero climate-change deniers among the M.A.T. critics 
I've interviewed. Rather, I found police officers routinely putting 
in unpaid overtime and probation officers called to work on Christmas 
Day. Judge Moore himself serves Thursday night dinners to addicts - 
including Ms. Hileman - who meet in the basement of his church.

Ms. Hileman, now 26, insists that quitting Suboxone saved her life. 
The last time she relapsed, in September 2014, her probation officer 
sent her back to jail after she tried to fake a drug test by hiding 
her daughter's urine in her jeans. Now she works two jobs, has 
regained custody of her daughter and moved to another town, away from 
her old drug crowd.

Others are not so lucky. In heroin-inundated Roanoke, where I live, I 
first ran into the Box Wars last year, while driving a 26-year-old 
heroin addict whom I'll call Erica to weekly recovery meetings. I 
tracked her ups and downs, and walked her baby around in the back of 
the room when he got fussy.

She was arrested on suspicion of stealing plumbing equipment from 
Lowe's with the intention of pawning it to buy heroin. At the local 
jail, she was so strung out she had no idea that she was five months 
pregnant until a sheriff's deputy handed her a prenatal vitamin after 
a routine pregnancy screen. She delivered a healthy, opiate-free baby 
while in treatment, and started attending a Narcotics Anonymous 
meeting led by Vinnie Dabney, a recovering heroin addict who also 
leads Suboxone support groups.

"If you're a regular opioid user, and you decide you want to stop, 
Suboxone can be a bridge that allows you to get where you want to 
be," he said. "But if you stop on the bridge and get stuck there, 
it's not so good."

Will Erica get stuck on the bridge, or cross to the other side?

She recently stopped going to meetings and returning my calls. "Too 
tired, falling asleep," she texted me one Saturday before I was to 
drive her to an N.A. meeting.

She denied that she had relapsed. "I think she's gone back to using, 
but she won't admit it, " her mother told me. "I found papers in the 
bathroom, like what heroin comes in." She added, "And she went 
through her brother's room and stole his clothes - that's what 
addicts do." A judge recently decided to transfer custody of Erica's 
baby to his grandmothers.

While Erica's mother was initially hopeful about her daughter's use 
of M.A.T., she was unable to secure appointments with a doctor who 
monitored its use rigorously and accepted insurance. (The ones who 
did had waiting lists, having reached their federally mandated 
100-patient cap.) "Lots of money to be made for suppliers, doctors 
and medication," her mother said. "The only addicts I have met who 
are still successful in recovery are addicts that chose to bite the 
bullet and detox."

My friend Jamie, whose two sons are recovering heroin addicts who had 
also abused Suboxone, was equally conflicted. Her younger son claimed 
he had figured out how to separate the opiate from the naloxone 
inhibitor, injecting pure buprenorphine to get high, until he 
"decided it was more productive to sell it on the street for $25 and 
buy a cheaper bag of heroin instead," she told me.

He finally got clean without M.A.T., but only after long stints in 
inpatient rehab centers at a total cost of about $60,000.

IN Tazewell County, the jurisdiction neighboring Judge Moore's, I 
spoke to Jack Hurley Jr., a Circuit Court judge who is chairman of 
the operations committee for the statewide drug court advisory 
committee. He allows Suboxone when the court psychiatrist recommends 
it, which is for about 35 percent of participants. Among the 16 on 
his docket: a 48-year-old disabled coal miner who abused opiate pills 
for a decade, is not on Suboxone and is thriving, finally, after 
several relapses; and a 26-year-old mother who for six years abused 
opioid pills, including black-market Suboxone, and now takes 10 
milligrams of prescribed Suboxone a day and has not relapsed.

Though he's had a handful graduate after being weaned off Suboxone, 
many don't, and those inconsistencies weigh on him. And yet he's 
counted 13 drug-free babies born while he has run Tazewell's drug 
court, several to mothers on M.A.T. (Like Erica, they took a drug 
called Subutex because Suboxone is not recommended for pregnant 
women.) "How do you put a price on that?" he asked.

Judge Hurley invited me to sit in on a recent open drug court 
session. The last to report was the newest participant, a 37-year-old 
man who showed the judge an 11-inch scar on his arm from decades of 
injecting crushed-up opioids. Though he'd taken prescribed Suboxone 
during a nine-day detox, he did not have a prescription for M.A.T. 
and swore he had not taken any drugs since.

"I have a big question: How clean are you going to be today?" Judge 
Hurley asked.

"Should be nothing," the man said.

Minutes later, the bailiff returned with the results from his test: 
positive for Suboxone.

"Well, he's going to spend the night," Judge Hurley said. "Let him 
out in the morning. And tell him not to look me in the eye and lie again."

Judge Hurley shook his head. He has known the man's family for 20 years.

"Is it right to put him on the drug he wants to be on?" he asked.

But if the court psychiatrist recommended it, Judge Hurley said he 
would allow the man the use of M.A.T.
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