The Uphill Battle
Medically assisted treatment is proven effective but still
challenged
Described as the "gold standard" for curing opioid addiction, medically assisted treatments have put many in the community at loggerheads over whether they are actually effective.
The last time former EMS worker Kevin Wintermute talked to his friend, he was thrusting the nozzle of a Narcan spray into the friend's nostril. After regaining consciousness, his friend thanked Wintermute and said, “You always have my back.”
His friend had overdosed for the fifteenth time. That night, before leaving his friend’s home near Shawnee, Ohio, Wintermute warned him: “One of these times, I won’t be able to bring you back.”
The next time Wintermute was dispatched, it was too late. His friend was already dead.
Kevin Wintermute, police chief of Shawnee, Ohio, sits inside the one-man police station, which also doubles as a village hall.
Photo by Bharbi Hazarika
Narcan, also known as Naloxone, can reverse overdose, but it is often the last, most desperate option for a person suffering from opioid addiction. Less drastic medical treatments for opioid-use disorder are available, but mired in discord among lawmakers, medical professionals and recovering addicts who view therapy and personal resolve as the only solutions to addiction. Those attitudes can be discouraging for an already stigmatized population in Appalachian Ohio, where many people search feverishly for any way out of drug addiction.
Medication and therapy: Better outcomes, additional problems
A combination of medication and therapy, called "MAT," is linked to better outcomes than therapy alone, according to opioid use disorder treatment guidelines laid out by the American Society of Addiction Medicine. The medications restore balance to the brain circuit affected by addiction, allowing the patient to enroll in therapy, where they then can address psychosocial issues that led them to drug misuse.
Most forms of drug addiction do not have any effective medically assisted treatment, but opioid addiction does. The U.S. Food and Drug Administration has approved three drugs as medications for opioid use disorder -- methadone, buprenorphine and naltrexone.
Both methadone and buprenorphine are regulated opioids that ease cravings and withdrawal symptoms, according to the National Institute on Drug Abuse. The third and latest medication is naltrexone — commonly known as Vivitrol — which also relieves cravings, but it’s a non-opiate preference among law enforcement and recovery facilities in Appalachian Ohio.
Evidence abounds that those medical treatments work.
One 2009 study reviewed 11 clinical controlled trials of methadone against another treatment without opioid replacements in four countries, including the United States. That study found that patients on methadone are much more likely to stay in treatment than those without. Another study from 2003 compared buprenorphine and buprenorphine with naloxone treatment against a placebo control group in eight sites across the United States. The same study found that 20.7% in the buprenorphine group and 17.8% of the participants on the combined treatment tested negative for illicit opiates, compared with 5.8% in the placebo group.
OhioHealth office manager Pam Michael holds a box of Sublocade, a buprenorphine shot, which they administer at the clinic.
Photo by Bharbi Hazarika
Those medications can be taken on a short- or long-term basis, depending on the patient’s treatment plan, according to U.S. Substance Abuse and Mental Health Administration. For the most part, methadone is administered in regulated clinics, which patients can routinely visit following a prescription by their doctor. Buprenorphine, on the other hand, can be administered at a doctor’s office. To prescribe buprenorphine, the health care provider needs to apply for a waiver and be federally certified. Any prescriber can offer Vivitrol without specialized training or a waiver.
However, to take Vivitrol, the patient needs to be clear of opioids for seven to 14 days and continue to avoid using any opioids while the naltrexone is in their system. Consuming opioids while on Vivitrol can lead to withdrawal-like sickness, which is much worse, said James Gaskell, medical director of Athens City-County Health Department. That puts a heavy responsibility on a doctor who must decide whether their patient is fit for a Vivitrol treatment.
“Withdrawing from opioids is stressful, and if you have a person who's already unwell, who has a cardiac condition or pulmonary condition, you might not want to offer them Vivitrol,” Gaskell said. “You might rather offer them mild opioid and have them withdraw from their heroin while they're taking their buprenorphine.”
Methadone and buprenorphine allow the patient to slowly wean off the harder drugs and are suitable for those who cannot or do not want to go through the sickness and pain of withdrawal, Gaskell said. While medical professionals, for the most part, consider those medications as the “gold standard” for opioid use disorder treatment, some in the community are not so sure.
Travis Bookwalter and his wife, Ashley, co-founders of Summit Recovery center in Logan, Ohio, believe medically assisted treatment programs are best fit to treat those who have a mental or physical health condition that disables them to cope with withdrawals. Their experience serving patients on MAT have made them skeptical toward the efficacy of those treatments.
In 2021, one of the residents who was on buprenorphine sold the pills that they got from their clinic, Ashley Bookwalter said. Still, the Bookwalters agree that medically assisted treatments save lives, but believe that a holistic recovery means letting go of those treatment drugs at some point.
“I am supportive of alternative recovery paths because my concept of it is that not everyone can go the exact same path,” said Travis Bookwalter, who has worked as a chemical dependency counselor for three years. “But I am a firm believer that all paths lead to abstinence.”
For some others, the journey to recovery doesn’t always end in abstinence. Lindsay Hall, who works as a counselor at a methadone clinic in Scioto County, said the health care provider should tailor the treatment to fit the patient’s needs and goals.
“Everyone's path to recovery is different,” Hall added. “Everyone's struggle is different. And if we can all just, like be there to support each other, we would have a better outcome.”
Dean Wilson, judge at Perry County drug court, is quick to dismiss methadone and buprenorphine treatment, except for buprenorphine injections, which are typically administered by health care providers in a clinic. However, he doesn’t prevent participants at his drug court from using the treatments if they have been legally prescribed.
Wilson explained that one of the reasons behind his mistrust is that drugs such as methadone and buprenorphine – especially the take-home ones – have “street value,” meaning they are often sold illegally and misused. In 2019, 28.3% of buprenorphine users misused buprenorphine products, according to the U.S. Drug Enforcement Administration.
Despite buprenorphine's sometimes illicit use, the DEA recognizes its validity as a medication to treat opioid-use disorder. During the COVID-19 pandemic, the DEA relaxed strict regulations to allow greater access and availability to the drugs.
In 2019, Ohio Governor Mike DeWine signed an executive order to create RecoveryOhio advisory council, an initiative to address the stigma associated with addiction, substance use prevention, treatment and recovery support services. The initiative continues to expand naloxone distribution sites and other prevention and treatment measures, such as supporting more physicians to become licensed buprenorphine prescribers, said Eric Wandersleben, director of media and outreach at Ohio Department of Mental Health and Addiction Services. One of the priorities of the council has been to increase the availability of medically assisted treatment across Ohio.
Yet across Appalachian Ohio, several doctor’s offices are apprehensive or haven’t made those treatments available to many seeking treatment options. Nationally, there is still a substantial gap between the number of people suffering from opioid-use disorder and the capacity to treat them with opioid-use disorder medication, according to the 2021 Treatment Improvement Protocol from the U.S. Substance Abuse and Mental Health Services Administration. In Appalachian Ohio, where resources are scarce, the lack of those treatments lands a heavy blow.
Christopher Meyer is an addiction doctor and a buprenorphine provider in Athens, Ohio. He chalked up some of that reticence of rural medical communities to the stigma in dealing with “addicts.”
He would know. Meyer started his career as a gastroenterologist, a doctor who treats problems in the digestive system, and himself became addicted to drugs. “For 30 years,” he recalled. “I was an extremely high functioning, impaired physician.”
Meyer now has spent five years treating hundreds of people with substance use disorder. He says his typical patient comes from a broken home. Most days, Meyer is at his office at Ohio Health from dawn to dusk, after which he leaves to see the residents at John W. Clem Recovery Houses, which includes two sober living facilities called Clem and Briggs houses. Meyer helped to start the recovery homes 16 years ago, and more than 650 people have walked through the doors since then.
This photo shows Christopher Meyer, an addiction treatment doctor, sitting inside Clem house, a recovery home in Athens, Ohio.
This photo shows a close-up of Meyer's hands.
This photo shows Christopher Meyer, an addiction treatment doctor, sitting inside Clem house, a recovery home in Athens, Ohio.
Christopher Meyer, a doctor who specializes in addiction medicine, sits at the Clem House, a sober living home which he started in 2006. The pictures on the wall behind him are: John W. Clem, whom the center was named after, and Richard Briggs, the first house manager of the recovery home (left to right).
Photos by Bharbi Hazarika
Meyer explained that it’s up to the treatment provider to ensure that they customize the patient’s plan to ensure success. The only way to do that is to offer as many treatment options as possible, he said.
“The biggest problem is that a lot of the time substance use disorder is viewed by them, or their family, or other health care providers as a character defect, or moral weakness,” Meyer said. “Rather than a disease.”
Medical treatment also suffers from stigma
For Amanda Snellings, who was a former addict, having access to buprenorphine gave her the courage to start her journey to recovery.
Snellings, a treatment navigator at Perry Behavioral Health Services, waged a long battle with addiction before she was ready to accept help. In 2018, during a health check-up, she found out that she was pregnant. She said she will never forget when the social worker knocked on her door and said Snellings could lose both her children and the one in her womb if she didn’t stop abusing opioids. That’s when she decided to seek treatment.
Snellings was on buprenorphine for months. She said it helped her kick heroin. Although she relapsed, she finally found her respite in Vivitrol. She has been in recovery for three years and no longer uses any medication for opioid-use disorder. Still, she laments the lack of access to other opioid medication treatment options in the early days of her recovery.
“If I wanted to go to a methadone clinic, I would have had to drive all the way to Columbus and would have to go every day and early in the morning, seven days a week,” said Snellings, who lives in New Lexington, Ohio, about 50 miles from Columbus. “That's a lot of work!”
Though buprenorphine administrators are available in some parts of Ohio, methadone clinics are hard to come by. In the 32 Appalachian Ohio counties -- which covers more than a third of the state and is home to more than 2 million people – there are only 15 methadone clinics and 56 providers who administer buprenorphine, according to the treatment locator web page of the U.S. Substance Abuse and Mental Health Services Administration. The hardest hit counties – such as Scioto, Gallia, Ross and Meigs – have the fewest methadone and buprenorphine treatments available.
Methadone and buprenorphine providers in Ohio's Appalachian counties
The map shows the locations of buprenorphine and methadone providers in Appalachian Ohio region.
BUPRENORPHINE PROVIDER
METHADONE PROVIDER
Infographic by Bharbi Hazarika
Source: Substance Abuse and Mental Health Services Administration
Another barrier: Bias by some healthcare workers
Some healthcare providers feel people who abuse opioids aren’t worthy of treatment and believe resources can be better spent elsewhere, according to Berkeley Franz, a community-based health studies professor at Ohio University.
Franz has done extensive research into the barriers to treatment access among those with opioid-use disorder, and has found that the discussions among healthcare providers concerning opioid addiction treatment available often boils down to the issue of “Who deserves it?”
In 2021, Franz and her colleagues surveyed 408 board-certified physicians in Ohio to investigate any physician bias toward treating patients with opioid use disorder. The researchers found that physicians in rural areas of the state, including many parts of Appalachian Ohio, spent less time focusing on patients with opioid-use disorder compared to their urban counterparts. Researchers also found that far fewer doctors in rural areas were certified to be buprenorphine providers, despite the fact that the government has lowered requirements for buprenorphine waivers in an effort to encourage more physicians to provide the treatment.
The misconception of methadone and buprenorphine as a substitution for harmful opioids has contributed to the lack of access, Franz said. For the most part, she explains that buprenorphine and methadone are difficult to misuse.
“What these medications do really effectively is keep people from dying," Franz said. "They allow (patients) to usually live a very functional and recovered life on a kind of a low dose of opioids that produces no kind of pleasurable effects in the brain at all."
“It just keeps them from craving opioids," she said. "And then it keeps them from using injections, which has a huge risk for HIV and hepatitis C and other infectious diseases.”
'Self-medication' just shifts the addiction
That stigma and shame is a deterrent to opioid-use sufferers who want to get treatment. And despite the success of medically assisted treatments, some are hesitant to trust the medical remediation process –– specifically methadone and buprenorphine.
Kacey Decot, a substance use case manager in Portsmouth, Ohio, sees the benefit of using medically assisted treatments, but views long-term use as another form of drug dependency.
Decot has been clean for five years after spending nearly two decades battling substance abuse. She recalls trying to kick the habit of snorting opiates by resorting to methamphetamine, more commonly referred to as "meth." During rough withdrawals, meth soothed her, she said.
“I was so tired of going through the withdrawals from the heroin when I didn't have it, and meth would kind of comfort me in those withdrawals,” Decot said. “I definitely have heard most people state that methamphetamine, or just any sort of amphetamine, is their cushion to comfort them if they are just sick and cannot get opiate.”
Many opioid addicts turn to meth when they are trying to get off opioids, because they either think it’s cheaper and less harmful or that it’ll help them wean off opioids. But Decot explains that’s not the case. The substitution only leads to another addiction, she said.
“It's usually like you're either an opiate user or you're an amphetamine user, for the most part,” Decot said. “So, whenever someone who dabbles in both of those, it's usually because of that, they just get whatever is available, so that they don't get sick and that they can get a high.”
“When you're still battling that (addiction), on the street,” she added, “you're going to go for either the methamphetamine or suboxone ... to help get off of the drugs, which ultimately just leads to another addiction.”
Illegal meth use is increasing across the state, according to a 2020 report from the Ohio Department of Mental Health and Addiction Service. The same report found that out of the 184,725 urinalysis specimens submitted to one statewide testing service, 8.5% tested positive for meth. Psychostimulants like meth were involved in more than 26% of the overdose deaths in Ohio in 2021, according to an analysis of overdose death counts retrieved from Ohio Public Health Information Warehouse.
*The data for 2021 is incomplete and may be subject to change, according to Ohio Public Health Information Warehouse.
Psychostimulant’s share of all overdose deaths
Psychostimulants are increasingly causing more overdose deaths in Ohio. The majority of the psychostimulants in circulation in the state is methamphetamine, according to officials.
Infographic by Bharbi Hazarika
Source: Ohio Public Health Information Warehouse; Ohio Department of Health
Brad Agriesti, a probation officer at Perry County drug court, said most of the offenders brought to court lately are meth users. Most meth used by the defendants usually are laced with the opioid fentanyl, he said. Fentanyl is a synthetic opioid that is almost twice as potent as heroin, according to the U.S. Drug Enforcement Administration.
“When you talk to some of them who come in if they have a pending case, they’ll say, ‘I only did meth,’” Agriesti said. “No, you don't know what was in that. You don't know what it was laced with. You think you just did a lot of meth, but no, it was laced with fentanyl; it was laced with cocaine; it was laced with whatever.”
Harm reduction and prevention offer stopgap measures
Contrary to public belief, Ohio doesn’t have an unparalleled rate of drug use compared to the rest of the country, according to Shae Dalrymple, communication director and naloxone distribution specialist for Harm Reduction Ohio, a nonprofit that champions drug policies that reduce harm. But Ohio does have a bigger problem with overdoses. “What we do have is high levels of drug-adulteration, leading to overdose,” Dalrymple said.
The average illicit substance use among Ohio residents was 12.74% per capita, slightly lower than the national average of 13.24% in one un-specified month, according to SAMHSA’s 2019-2020 National Survey of Drug Use and Health. Yet, overdose rates in Ohio surpass the national average, with 38.3 deaths per 100,000 people, compared to 21.6 deaths per 100,000, nationally in 2019.
Overdose death rates nationally and in Ohio
A comparison of overdose death rates involving all drugs and opioids across the United States and Ohio in 2019 show that people in Ohio die of overdose at a much higher rate.
Infographic by Bharbi Hazarika
Source: Kaiser Family Foundation
Fentanyl’s share of all overdose deaths
Those deaths are partly linked to the fentanyl-contaminated drugs, which are more potent and can prove fatal, Dalrymple said. In 2020, more than 81% of overdose deaths in Ohio were caused by fentanyl or similar synthetic.
Harm reduction strategies play a significant role in preventing drug-related deaths and the spread of diseases by offering services such as syringe exchange services, safe consumption sites, fentanyl testing kits, naloxone distribution sites, among others.
In 2019, an Ohio State University team of students came out with a text alert service and an app under The SOAR Initiative, a non-profit that offers harm reduction services. Through the app, anonymous users can both report and receive “bad batch” alerts about tainted drugs in the community. The app also collects data from county coroners’ offices and health departments to report high overdose rates in neighborhoods and any contaminated batches in circulation.
“A ‘bad batch’ is any drugs that is unknowingly laced with fentanyl,” said Pranav Padmanabhan, executive director of the SOAR Initiative. “What we're seeing in the drug supply – and this is sort of been going on over the last like 10 years – is increasingly non-opioid drugs like cocaine, meth pills. They are either intentionally being laced with fentanyl, or there's contamination with it. So, now, a lot more people are overdosing and dying.”
Infographic by Bharbi Hazarika
Source: Ohio Department of Health
Fentanyl is a potent synthetic opioid, a small dose of which can prove fatal. Increasingly, drugs are being adulterated with fentanyl and sold to substance users who aren't
aware about the tampering.
The app is currently available in central, southwest and northeast Ohio and has more than 1,260 users. Padmanabhan and his team plan to expand to the southeastern counties during the project's next phase.
In Athens, Ohio, the county health department opened a harm reduction clinic five years ago, where they offer clean syringes and needles. Syringe or needle exchange programs are valuable to those with substance use disorder to prevent spreading diseases such as hepatitis and HIV/AIDS, but also to prevent infected wounds and abscesses. The average visitor at the clinic brings in 20 to 30 needles for the exchange weekly, Athens City-County Health Department reported.
In 2021, the clinic welcomed 3,398 visits, exchanging 94,672 needles. James Gaskell, the director for Athens City-County Health Department, said those numbers are on the rise. Athens County, with a population of 65,327, reported 180 cases of hepatitis B and C in 2015, almost 500% increase since 2008. Following the introduction of the Athens harm reduction clinic in 2017, local hospitals observed a gradual decline in those infection cases. In 2021, Athens County Health Department reported 95 cases, a triumph in the eyes of Gaskell.
Athens County Hepatitis cases; Syringes exchanged
Infographic by Bharbi Hazarika
Source: Athens City-County Health Department
Syringe services can be helpful in reducing contagious diseases. In Athens, Ohio, hepatitis cases reduced, following the
introduction of the harm reduction clinic.
And yet they are rarely seen across Ohio. There are 22 syringe exchange facilities throughout the state, only eight of which are in Appalachian Ohio.
"There's some pushback about syringe exchange programs, because there are some people who are not well informed and think that this is enabling the substance using community,” Gaskell said. “But I think it provides a way, a safety net for them ... the more times you see them, and the more times you interact with them, the more likely you are to have them seek therapy.”
Challenging stigma to save lives
Initially hesitant to administering buprenorphine, Melinda Ford, a family-medicine doctor in Athens, Ohio, changed her mind after talking to a patient who was dealing with addiction and asked her for help. Ford has since been certified to offer addiction treatment and began administering buprenorphine in her clinic.
But her altruism came at a cost. When patients from her family clinic would visit the ER, they felt judged.
“(ER physicians) sometimes assume anyone who lists me as their doctor must be an addict and the assumption immediately seem to be that they are drug seeking,” she said. “And so that stigma has made it harder to do my job.”
Ford explains that in Appalachian Ohio, there is a sense of hopelessness in public health discussions about treating addiction that hampers the quality and access to care. A lot of the physicians are reluctant to treat addiction and think it pointless, she said.
Still, Ford says that treating those with addiction is the most rewarding part of her work.
“There's nothing like seeing somebody get their kids back or a mom have a healthy baby or people go to school or get jobs that they couldn't before,” Ford said. “There are people who flame out in pretty horrific ways. But in general, watching the successes is totally worth it.”
In Shawnee, Wintermute, the police chief and former EMT, points to the walls of the police station that are covered in artist-renderings of the town, depicting lively scenes of an idyllic small-town. Outside the station, people are scarce and many of the buildings along the town’s Main Street look unkempt. Shawnee hardly resembles the artists' renderings of what could be.
This picture is an artist's rendering of an idealized version of Shawnee's Main Street.
This photograph shows Shawnee's Main Street in February 23, 2022.
This picture is an artist's rendering of an idealized version of Shawnee's Main Street.
Picture of Shawnee, Ohio, on the wall of the village police station. The main street in Shawnee.
Photo by Bharbi Hazarika
Most of the friends who Wintermute grew up with are dealing with the ramifications of addiction or have already died from overdose. He said if it weren’t for his allergy to opioids, he, too, likely would have succumbed to addiction.
“It’s easy for people to say, ‘just don’t do the drug,’” Wintermute said. “But once the evil gets a hold of you, it's stronger than anything in this world.”