Still Not Enough Treatment in the Heart of the Opioid Crisis

This article was originally published at Stateline, an initiative of The Pew Charitable Trusts, and was written by Christine Vestal.

HUNTINGTON, W.Va. — This city, where the rate of drug overdose deaths is nearly 10 times the national average, has done more than most to fight the heroin and prescription painkiller epidemic.

Local police have been diverting drug users to specialized drug courts for treatment. The city opened a syringe exchange program to reduce the spread of infectious diseases among drug users. And doctors and nurses from a local hospital have developed a model facility to care for the hundreds of opioid-dependent infants born to heroin-addicted mothers.

But instead of getting better, Huntington’s opioid problem is getting worse.

In just one afternoon last month, 28 people in this city of 50,000 overdosed on heroin. Since January, 773 people have overdosed on opioids (including prescription painkillers and heroin), a 24 percent increase over last year. An estimated 8,000 Huntington residents are addicted, mostly to opioids.

“It’s really an overwhelming situation,” said Dr. James Becker, medical director of West Virginia’s Medicaid program and professor of family medicine at Marshall University in Huntington. “My best friend’s son just died of a heroin overdose. It is absolutely everywhere in the community.”

Nationwide, less than half of the 2.2 million people who need treatment for opioid addiction are receiving it, according to the U.S. Department of Health and Human Services. Even in Huntington, which is more focused on the problem than many other places, the barriers are daunting.

A fragmented treatment system, widespread bias against addiction medications and a shortage of trained workers often thwart those seeking help. Instead, they show up in emergency rooms, or reach out to local doctors, nurses and clergy.

Like other states that have expanded Medicaid under the Affordable Care Act, West Virginia is trying to make it easier for recipients of the federal-state health insurance program for the poor to find and pay for effective addiction treatment.

So far, however, greater availability of Medicaid coverage has not made a dent in the growing need for treatment, local officials say.

Effective Medications

Unlike other drug addictions, opioid and heroin addiction can be treated with one of three medications—methadone, buprenorphine and Vivitrol—that have provenmore effective at keeping people from abusing drugs than abstinence and 12-step therapies that don’t include the medications.

But in Huntington, and much of the rest of the country, spiritual-based recovery programs are favored over medications by the general public and even some medical professionals. 

“Many people believe that substance abuse is a weakness of personality and that a person needs to get a handle on their disease, and in that sense, they think that relying on a drug that replaces the drug of abuse is somehow a weakness,” Becker said.

“That’s not the view of most people in the medical community,” he said. “We understand that addiction is a disease, and that there are a lot of treatments out there that work for some and not for others.”

Still, Susan Coyer, director of Huntington Comprehensive Treatment Center, a methadone clinic next to a McDonald’s in downtown Huntington, said she has not received a single referral from any medical professionals in the two years she has been running the center.

Methadone is a long-acting opioid that acts as a replacement for heroin or prescription painkillers without producing euphoria. It eliminates physical withdrawal symptoms and drug cravings while allowing patients to function and hold down jobs. 

Approved for addiction treatment in 1964, it has proven highly effective at keeping people in recovery from drug abuse. But federal regulations require patients to show up at a clinic every day to take their dose, making it an inconvenient treatment option for many. 

Huntington’s highly visible clinic treats nearly a thousand patients every day, filling up downtown parking lots with cars and patients and generating resentment among local residents.

Patients are almost all from Huntington or nearby towns, although a few come from surrounding counties. Many have been taking the addiction medication for years, sometimes off and on, depending on how long they can afford the $15-a-day fee.

According to Coyer, the clinic could serve up to 250 more patients if it hired more counselors. “We’re here to help,” she said. “We want to be part of the community.”

Methadone has a very bad reputation in Huntington and in West Virginia, said Jim Johnson, Huntington’s former police chief who is now the mayor’s director of drug control policy.

West Virginia is one of the 17 states where Medicaid does not pay for methadone, and it has had an adversarial relationship with methadone clinics for decades. Methadone clinics weren’t allowed in the state until 2001, and after nine for-profit clinics set up shop in West Virginia, the Legislature in 2007 placed a moratorium on opening any more.

Local Resources

Huntington has the highest rate of opioid overdose fatalities in a state ranked No. 1 in the nation for overdose deaths. By its own calculations, West Virginia’s second largest city has an overdose death rate that is nearly 10 times the national average of 14.7 per 100,000 people in 2014.

Those numbers persist despite the fact that for a city of its size, Huntington is rich in addiction expertise. Its experience illustrates how difficult it is to address the problem.

“People in Huntington have far more treatment choices than folks in most of the rest of the state,” said Karen Yost, CEO of Prestera Center, a large nonprofit mental and behavioral health treatment center based in Huntington, which serves roughly 5,800 opioid addicted patients throughout the state.

The city is not only a magnet for people who want to sell and use drugs, it’s increasingly becoming a place people come to for treatment, she said.

Huntington has two hospitals, St. Mary’s Medical Center and Cabell Huntington Hospital, as well as Marshall University, a major research institution with a medical school and residency program.

It has a state-supported psychiatric facility, Mildred Mitchell-Bateman Hospital, which provides addiction services, as well as a federally supported community health center, Valley Health.

A handful of local private practice physicians and psychiatrists also provide medication-assisted treatment and other addiction services. And two well-known residential recovery centers, Recovery Point, for men, and Her Place, for women, offer abstinence-based programs.

Even with this wealth of talent and facilities, Huntington residents who seek help for their addictions usually encounter waitlists, and most are unaware of the potential treatment options they have.

At Valley Health, Dr. Zachary Hansen and two other physicians, along with a team of psychologists, case workers and administrators, treat about a hundred patients. By adding two more addiction counselors, he said he hopes to double his patient panel over the next year. 

For now, though, he has an 18-month waitlist and only occasionally squeezes in new patients, when there is a dire need.

In the last month, for example, he accepted Glen Coleman, 39, as a new buprenorphine patient. The reason: His wife, Jillian, who just delivered an opioid-dependent girl and has been under Hansen’s care since her pregnancy began, said she was afraid she might relapse if her husband didn’t get into treatment.

Quality vs. Quantity

Approved in 2002, buprenorphine acts as a replacement for heroin or painkillers, relieving withdrawal symptoms and cravings without the euphoria, similar to methadone.

But unlike methadone, it can be prescribed by doctors in an office setting, making it much more convenient for people with jobs and families. Patients simply pick up a monthly supply of the medication at a drug store and take it on their own. 

West Virginia has about 300 physicians with a license to prescribe buprenorphine. About 100 of them serve Medicaid patients, Becker said. Many doctors who prescribe buprenorphine, typically sold as Suboxone, do a good job of providing counseling, group classes and drug screenings to ensure patients are using it as prescribed and staying in recovery, Becker said.

But others in West Virginia and elsewhere provide little counseling and fail to adhere to national protocols requiring drug screenings, Becker said. Known as cash clinics, these practices require a monthly cash payment of $300 or more in advance and usually give patients more medication than they need. That allows many of them to end up selling their extra doses on the street.

In an effort to weed out these lower-quality buprenorphine prescribers, Becker said West Virginia’s Medicaid program is developing stricter rules about counseling, drug screenings and retention of patients. If more doctors would adhere to the new standards, the cash businesses would lose customers, he said. 

“What patient wouldn’t want to get better treatment and have it all paid for with their Medicaid card?” Becker said.

But Hansen said he and some other doctors in the state already are providing what they see as adequate counseling and drug screenings. They worry the new rules could make it difficult and costly to continue providing services under Medicaid, much less expand their treatment capacity.

Despite the heartbreak of having to turn away patients, Hansen said he firmly believes in providing as much individual counseling and group therapy as possible.

Separate Worlds

Huntington officials often point to two residential 12-step programs that don’t offer medications as an example of the kind of addiction treatment they would want for their own family members. Even though most realize recovery programs without medications don’t work for everyone, they would prefer their loved ones beat their addictions without taking them.

Run by native son and former heroin addict Matt Boggs, the facilities, one for men and one for women, house nearly 200 patients. Both are almost always full. An open bed is typically filled within a day.

To successfully get opioid addicts into full recovery, Boggs and his staff of mostly recovering addicts recommend at least a six-month stay, a substantial commitment for people with families and jobs.

Dr. Michael Kilkenny, who heads the county health department and Huntington’s syringe exchange, acknowledges that many addicts need medication to help them stay away from drugs. But Huntington also needs more residential centers and beds for short stays for people in crisis, he said; that’s where more money would come in handy.

“There’s a six-month waitlist for good places like Recovery Point,” Kilkenny said. “For somebody ready to go tonight, that might as well be forever.”

Kilkenny’s view is shared by many in this religious rural state. Residential recovery is the preferred, if not the only, option many will consider. But residential facilities are costly to build and operate, and little scientific research exists to prove their effectiveness.

Johnson said the city’s extensive outreach and education efforts are starting to change some people’s minds about addiction medication, his included. But for many, he said, “the Earth will always be flat.”

“Every one of us has biases about the problem and we bring these biases to our approach to treatment,” Becker said. “But this epidemic is so severe that we have to get over that and all think the same way about reducing the crisis.”