Synthesis

When Jail is

Even in her teens, *Melanie’s health was a battle. To work through the pain, she popped

the top on her prescription pain killers that helped her make it through each day with a

little less suffering. Later, as a young mom of two, she needed more medicine each day to

help her get by. But before she knew it, the battle she was fighting was addiction, and the

one thing that had given her relief from her continued pain was now igniting her suffering.

*Patient’s name has been changed to protect her anonymity.

70 KENTUCKY LAW ENFORCEMENT | Fall 2015

Brain n scasc n of non-drug user

KELLY FOREMAN | PROGRAM COORDINATOR

PHOTO BY JIM ROBERTSON

Not the Answer

“I never had any legal issues or

anything like that,” Melanie said of the six years between realizing she had become an addict and getting help. “It was just, financially, you can have a lot of issues, be- cause you’re struggling not to be sick. At some point you go from being high to be- ing sick, and you have to have at least that one pill a day or you’re going to be vomit- ing over a toilet and it’s going to be bad. So financially, you will do whatever you have to do to get what you need.”

Today, Melanie is a patient at The Infin- ity Center, a mental health and substance abuse treatment center in Ashland. She takes Suboxone daily as just one part of the medicine-assisted treatment she re- ceives at the center to help wean her off her addiction. She views Suboxone the same way any person would who needs a medication to help them be well.

“I have a diabetic son,” Melanie said. “He couldn’t make it a day without his insulin. For me, while I’m getting better, I can’t make it a day without my Suboxone.”

The Infinity Center owners, Will and Ashley Carter, say Melanie’s situation is not uncommon. What is unique is that Melanie is one of hundreds of suffering addicts who are receiving a holistic-style treatment including Suboxone and cogni- tive behavioral therapy, Will said. Many opioid-addicted Kentuckians are not that lucky, because the resources available in the state to help this population are griev- ously limited. At the Infinity Center, Ashley said even with the growth of the practice over the past few years, there is a waiting list of roughly 300 people at any given time.

“Unfortunately, the life of someone seek- ing addiction treatment would be calling a

center like this and us saying, ‘OK, we are glad you’re ready for treatment, we will see you in six weeks,” Will said. “And those six weeks are considerably less than everyone else. Trying to find resources if you are la- beled as an addict, those limited resources are cut in half because you’re considered a waste of money.”

Those limited resources mean addicts seeking treatment often have nowhere to go to get their lives back, Will said. It leaves them on the street and subject to interac- tions with law enforcement.

“Addiction is something we still know very little about,” he said. “And what we do know evolves constantly. What we know is that if you’re using opiates, we can physi- cally put you in a room for three days — five days at most — and we can get you out of the acute stage of addiction. What does that mean? We can detox you, and we can get all that crap out of your system. We can watch that patient go through horrid with- drawals including vomiting, nausea, diar- rhea and increased blood pressure.

“We can watch them walk out of a detox clinic and start using drugs again,” Will said. “And the reason is that we really don’t treat the addictive behavior — the reasons behind why people become addicted.”

THE SUBOXONE CEILING “Suboxone is a partial opioid antagonist,” Will said. “In the very simplest of terms it means that an opiate such as methadone — which is another popular treatment — is a full opiate. So the receptors in the brain are wide open and they stimulate the recep- tors in the brain. What Suboxone does as a partial opioid antagonist is it caps those receptors, so it creates a ceiling effect.

What You Need to Know about Opiate Addiction Treatment

Brain scan of drug user

72 KENTUCKY LAW ENFORCEMENT | Fall 2015

“It allows the patient not to get high,” he continued. “But it also stops them from craving.”

Abusing Suboxone is a waste of money, Will said. Because that “ceiling” is created once a patient takes 16 milligrams of the drug. Unlike other drugs, taking more than 16 milligrams does not produce a high.

“Now, you can take so much opiates that you bust through that ceiling,” he said.

“But if you bust through that ceiling, it is the worst possible flu symptoms a person could ever expect because they throw themselves into precipitated withdrawal. So it has that neat safety mechanism.”

Suboxone is not the only medicine The Infinity Center and other addiction treat- ment centers use to help patients addicted to heroin and other opiates. Bunavail, a relatively new drug was FDA approved for opiate treatment in June 2014. Unlike Sub- oxone, Bunavail is administered via a film that adheres inside the patient’s cheek. Zubsolv is another pill-form medication that dissolves under the tongue. The base of each of these medications is buprenor- phine. Unfortunately, Will said Subox- one is the one that seems to have a street value and has received the most negative publicity.

In June, the Lexington Herald-Leader published an article titled, “Drug that was supposed to stem Kentucky’s heroin epidemic creates a whole new problem.” In it, one doctor compares the use of Suboxone treatment to Kentucky’s trou- bling pill mills.

“But what happened is that a minor- ity of Kentucky doctors started to see Suboxone patients on a cash basis, asking for as much as $300 for an office visit that included a prescription for the maximum allowable amount of Suboxone,” the article states. “Patients often received no therapy or drug testing. Some patients were on the maximum dose indefinitely.”

This style of Suboxone distribution led to diversion of the drug, the article states, because of the increased number of pre- scriptions available on the street.

Will concedes that he has seen his share of “bad medicine” that has led to the growing stigma against Suboxone treatment. In fact, The Infinity Center was created in part with the understanding that successful treatment for the addicted population includes a lot more than hand- ing patients a prescription and a bill.

“I think a lot of providers would agree with me that, unfortunately, there are bad clinics that practice bad medicine,” Will said. “But there are good clinics that prac- tice good medicine. We need to increase the availability for treatment instead of decreasing it and overregulating these physicians.”

Will has a deep admiration for local law enforcement who work hard to cut down trafficking, shake-and-bake meth labs and heroin usage, he said. He is emphatic that diversion is unacceptable. But without increasing the availability of substance abuse treatment, he also understands the plight of the addicted population.

Unfortunately, there are bad clinics that

practice bad medicine. But there are good

clinics that practice good medicine. We need

to increase the availability for treatment.

Ashley Carter, above, and her husband, Will Carter, below, opened the Infinity Center recognizing the need for holistic addiction treatment. Patients in their Ashland clinic receive both medicine-assisted treatment as well as cognitive behavioral therapy, combined with strict accountability to avoid diversion of their medication.

“Where do they go? Because I wouldn’t lay in withdrawal,” he said. “You wouldn’t lay in withdrawal. No one would. So what do we do with this population? How do we treat them? You can’t just bust an addict and throw them in jail and hope they will stay clean, because that never works. Right now we bust them, fine them, put them in jail and we really don’t have the infrastruc- ture for treatment.”

SYSTEMATIC ISSUES WITH TREATMENT The son of an addict, Will entered the healthcare field resolving to serve in any capacity — except addictionology.

“Jesus has a sense of humor, that’s all I can say,” he joked.

His work at a mental health practice evolved into addiction treatment, which led him to begin working on compliance and eventually consultations for other doctors attempting to treat addiction ef- fectively. He quickly recognized systematic issues with the way physicians were work- ing to treat addicts.

“In order to write a prescription for Sub- oxone, you have to have a unique identifier that is regulated by the DEA,” he said. “So you have to apply for this special number and take an eight-hour class, which can now be done online. And during those eight hours it’s about compliance and the standard of care for prescribing Suboxone. After you complete the course, you can see 30 patients for the first year. After that, you can only see 100. That’s it. I think that’s really important for law enforcement to know. We don’t have the ability to be a pill mill factory because they limit the number of patients we can actually see.”

Eight hours of training on these regu- lations is simply not enough to prepare a physician for treating this population, Will said. They know the rules they have to fol- low, but some didn’t know how to struc- ture it. Often, Will said, he would work with doctors, help them set up their prac- tice and anywhere from two to 12 months later he would go back and help them cre- ate an exit strategy.

“He or she would become completely overwhelmed,” Will said. “Keeping up with the regulations and this population — they are a very needy population. The doctor would get burned out, frustrated and they would just quit doing it. Or they would run it into the complete ground and then call

Since when is treating a disease, returning people to productive lives and pre-venting premature death a “good idea gone wrong?” Several statements from the June 20 article, “Drug that was supposed to

stem Kentucky’s heroin epidemic creates a whole new problem,” warrant further discussion.

First, Suboxone is not a medication that should be considered a temporary or quick fix. I wish there were such a solution because addiction is a devastating, chronic, relapsing brain disease that destroys communities, families and lives.

The medical evidence clearly shows that treatment with medications, such as

use and behaviors known to spread HIV and hepatitis C. Similar to medications for diabetes or ADHD, the medication allows patients the chance to live produc- tive lives and have meaningful relationships — but it is not a cure or magic bullet.

A person with diabetes, for example, must modify behavior and take medica- tion to optimize treatment. When diabetics struggle with their treatment plan, we do not dismiss them from our practice or say we will no longer prescribe medica- tion to them. Also we do not talk about regulating treatment of other diseases, even ADHD, which is treated with a controlled substance that is often diverted.

We should apply the same logic when talking about buprenorphine and opioid-use disorders, being sure not to demonize the medication, the illness or the people who want treatment. Doing so will only take us further from helping those suffering and from solving this problem that affects us all.

The article mentions “cash clinics,” suggesting that these are bad doctors who charge cash for treatment involving buprenorphine. However, until 2014 in Kentucky, Medicaid would not pay for a physician visit for opioid-use disorder. The only model of care that was possible was cash payment. Despite the new coverage by Medicaid for these services, there continue to be long waiting lists at our clinic, at the University of Kentucky and even a year-plus wait list at the public methadone clinic. People are literally dying while waiting for treatment.

Would we tolerate this if we were talking about diabetes treatment, while people were losing their eyesight, having strokes and dying prematurely? Why won’t more doctors provide the treatment for Medicaid patients? Perhaps the Herald-Leader can investigate this.

Lastly, the article addresses the increased Medicaid spending on buprenor- phine and the fact that it’s diverted and abused. Drs. Michelle Lofwall and Jenni- fer Havens of the University of Kentucky have shown that lack of access to treat- ment is the primary cause of buprenorphine diversion in our state.

If you were diabetic but you couldn’t get in to see a doctor, wouldn’t you get insulin through other means?

While Medicaid is spending more money on buprenorphine, we know that every dollar invested in addiction treatment saves up to $12 in health care, drug- related crime and criminal justice costs. Until we recognize opioid-use disorder as a medical issue primarily and a law-enforcement issue secondarily, we won’t make progress in fighting Kentucky’s opioid epidemic.

Every person in this state is related to or knows someone living the daily hell of this disease, yet many continue to pass judgment on those affected and de- monize the medications used to treat it.

It’s time for everyone in Kentucky — including the media, politicians and phy- sicians — to work together to fight this epidemic.

Opinion column submitted to Lexington Herald-Leader and published June 29, 2015. Re-printed with Rutherford’s permission.

Don’t wimp out of the fight against opiate addiction DR. MOLLY RUTHERFORD | PRESIDENT OF THE KENTUCKY CHAPTER OF THE AMERICAN SOCIETY OF ADDICTION MEDICINE AND THE CHIEF MEDICAL OFFICER OF RENEWED YOU CLINIC

a window from an office manager kind of practice,” Will said. “And that’s what sepa- rates us.”

Additionally, the Infinity Center has its own laboratory, an on-staff pharmacist, an occupational medicine physician, a psy- chiatrist and a pain management physician. However, Will said, the pain management physician does not practice pain manage- ment in the Infinity Center because there is

“no grey area in medicine.” “If you are a substance abuse patient and

you come in for treatment because you have a drug problem, and, during the course of treatment you sustain an injury,” Will said,

“you don’t get to pick substance abuse treat- ment and pain management. You get to pick one or the other. The only choice the patient has is to be re-integrated into a system where he knows it may destroy his life to start taking pain medicine again.

“Pain management is a very legitimate area of medicine — done correctly,” he continued. “Sometimes we have patients come in who would be more suited for pain management than substance abuse. The physician is able to assess that patient and say, ‘You’re not appropriate for our program, we need to refer you to pain management.’ We would never take someone’s money and set them up for failure, we feel it’s unethical. So we put this board of doctors together to increase the chances for success as much as we possibly can.”

TREATING THE BEHAVIOR The need for a holistic approach to treat opi- ate-addicted patients is critical, Ashley said, because it is rare that a patient seeks help for their addiction who isn’t facing other serious issues.

“Whether their kids are with social ser- vices, they are in a domestic violence situ- ation or they have lost everything and they are homeless,” Ashley said. “We screen them and try to identify all the triggers that are contributing to their drug use. Or, if they have had a relapse, we see what is contrib- uting to those relapses. We have two social workers on staff because we know people are not going to be successful in treatment if they don’t know where their next meal is coming from. If their physical needs are not met — food, shelter, clothing, medical conditions — they are not going to succeed. We can’t just give them a prescription and everything is all better.”

me when they’re in trouble to get them back into compliance.”

Even if the doctors were doing every- thing right, those trying to treat addicts from their private family practice were fighting a losing battle.

“You’d have grandma in the waiting room getting her diabetes medicine next to the classic addicted patient passing out, and grandma wouldn’t want to come back

to that practice,” Will said. “Or you’d have patients in the lobby asking if other patients wanted to sell their pills.

This is the reality of the addiction population.”

Doctors were giving up and the number of opiate- addicted patients in and

around Kentucky was growing dramatically.

Will decided if he was going to continue in this field, he needed to design something that would be structured strictly as an addiction

clinic. The staff members would be familiar with the addicted

population, the doctors would be board certified in addictionology and there would be fail-safe mechanisms in place to make it impossible for a doctor to go into non-compliance. Drawing on his wife Ashley’s social work expertise, they also recognized the need for a fully-functioning mental health division. With those needs in mind, The Infinity Center was born.

“We are unique in the aspect that before we write a prescription for a patient, they come in and do a urine drug screen, we get liver function tests, we get blood work

— we do a full work up on patients,” Will said. “We have found through experience that a lot of these patients, contrary to popular belief, have not seen a physician in five, sometimes 10 years. When they reach bottom and we get them, we want to offer them the most services we can, because we don’t know how long we’re going to have them. Relapse does happen. So when we get them we are going to test for things like HIV and Hepatitis. Our patients don’t even see a physician until they meet with a clinical therapist and attend group therapy twice a month.

“So it’s not a cookie cutter, come in, pay a fee and get a prescription through

assisted treatment

behavioral therapy

74 KENTUCKY LAW ENFORCEMENT | Fall 2015

The Infinity Center employs its own lab personnel for a variety of purposes. Among them is the option during a urine drug screen to test for the metabolite in a patient’s system to ensure that their body is metabolizing the medication and they didn’t tamper with the urine sample to provide a false report, Will said.

These are people with lives and families like everyone else, Ashley said. The patients seeking help at the Infinity Center don’t al- ways fit the addict stereotype. In fact, Will said, many of the center’s patients are nurses and doctors’ wives — people who are in and around the medical field and have access to the medication.

“During intakes, we have seen that most people who already have Suboxone in their systems are either coming from another treatment facility or bought it on the streets in an effort to not be sick until they can get into treatment,” Ashley said. “It’s not that they say, ‘I’m using this with a bunch of other drugs.’ They say, ‘I have to take care of my family and this is the only way I can do it. It took me three weeks to get into treatment, so I did what I had to do.”

People, places and things are what have to change in order to keep a patient in recov- ery, Will said. The goal of using the structure of medicine-assisted treatment is that the patients can be stabilized on the lowest pos- sible milligrams of one of the buprenorphine- based medicines in order to get them — and keep them — out of withdrawal.

“Then we incorporate cognitive behavioral therapy and accountability,” Will said. “We treat the underlying mental health condition and then it’s a scale where we continuously lower the milligrams of medication so that we can hopefully one day get people off this medication.”

Recognizing the opiate-addicted popula- tion as people fighting a chronic disease is the first step toward understanding that whether you are a law enforcement official, medi- cal provider or legislator, the end goal is the same — helping Kentuckians lead healthier lives.

“I think knowing that the medication isn’t just used as a means to get high or to make a profit and that a lot of people are using it trying to maintain a normal life is important,” Ashley said. “Explore that further with the people [officers] encounter and don’t assume everyone is doing something bad with the Suboxone. We don’t want it to be diverted, but assuming everybody who has it in their possession has it for a bad reason, I don’t think is really fair. I think if they saw that side of things a little more, it would benefit our pa- tients and the people they encounter.”

Kelly Foreman can be reached at [email protected] or (859) 622-8552.

Every patient at the Infinity Center must submit to therapy sessions as part of their treatment before they receive any medication.

Brian Ramsdale serves as security in the Infinity Center, another part of the Carter’s system to prevent diversion and keep their patients accountable.

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