A Suboxone wrapper discarded by the side of Route 100. Suboxone is used to treat opiate addiction. File photo by Elizabeth Hewitt/VTDigger
The Deeper Dig is a weekly podcast from the VTDigger newsroom. Listen below, and subscribe on Apple Podcasts, Google Play, Spotify or anywhere you listen to podcasts.
When Burlington officials last summer announced an effort to expand access to buprenorphine, it made national news: Chittenden County was the first jurisdiction in the country where prosecutors said they wouldn’t charge people for misdemeanor possession of the opioid withdrawal medication.
“Essentially, we wanted to flood Chittenden County with this drug,” says State’s Attorney Sarah George. “We knew that heroin was already flooding our community. So we wanted to create this other market.”
By providing a lower, controlled dose of an opioid, buprenorphine has proven to be effective at reducing overdose deaths. And it’s become a key component of Vermont’s medication assisted treatment program: In fiscal year 2018, the brand name version Suboxone topped the state’s prescription spending list.
Lawmakers this week heard testimony on a bill, H.162, that would make it legal in Vermont to possess buprenorphine without a prescription. But the effort has been met with skepticism.
U.S. Attorney Christina Nolan, who prosecutes federal criminal cases, notes that the drug remains a Schedule III substance under federal law — meaning possession without a prescription is illegal. Last week, she released a strongly worded statement arguing that legalizing it would increase the supply of an opiate that some people may still abuse.
“It sends the message that it’s okay to use buprenorphine outside the medical context,” Nolan says. “And I think more people will start doing it.”
VTDigger is underwritten by:
Officials from the Department of Public Safety have echoed those concerns in public comments and committee testimony.
But advocates say Nolan’s stance doesn’t reflect the reality of how this drug is used outside of treatment centers.
“There’s really no world in which people who want to get high are going to use buprenorphine over heroin or fentanyl,” says Maia Szalavitz, an author and journalist who covers national drug policy.
Szalavitz says the stigma around addiction prevents these drugs from being made fully accessible.
“If we had these drugs in cancer treatment, we’d be dancing in the streets and making sure everybody got them,” she says. “But in the addiction world, we’re like, ‘oh no, that’s not really recovery.’”
Scott Pavek, a drug policy reform advocate in Burlington, says that when he was suffering from opioid use disorder, he only used illicit buprenorphine as an alternative to heroin. With rare exceptions, he’s seen others do the same.
“If we’re ever enabling them to make the decision between one or the other, why would we not,” he asks, “knowing that the alternative is a drug poisoning crisis?”
George says the push to expand buprenorphine access in her Chittenden County jurisdiction — and to stop prosecuting possession cases — has shifted local attitudes about buprenorphine arrests.
“I have seen that conversation change in such a dramatic way,” she says. “And less people are dying.”
While opioid-related overdose deaths across the state rose in 2018, Chittenden County’s rate dropped by half.
George says the skepticism about decriminalizing buprenorphine is misguided. “Yes, it can be dangerous,” she says. “But they’re ignoring the alternative. And I don’t think that’s fair.”
On this week’s podcast, George and Nolan discuss the push to decriminalize buprenorphine in Vermont. Plus, Pavek and Szalavitz describe how they’ve seen the drug impact people’s lives.
Scott Pavek: So in the course of my life and having opioid use disorder, I used buprenorphine on two separate stints. The first time I was 18. And the second time was, I think, 20 or 21 or so. And both times I acquired it, I guess illicitly, or I acquired illicit buprenorphine.
This is Scott Pavek. Scott lives in Burlington. For six years, he’s been in recovery from opioid use disorder.
Pavek: I had heard it through word of mouth, so I hadn’t heard about it in a medical setting. Obviously, I wasn’t getting my own opioids in a medical setting. And I heard that some people were using this as a way to not use opioids.
What was it that made you not want to use opioids and seek out an alternative?
Pavek: I was wrapping up high school, I think it was the summer after my high school graduation. And it was just at that point, I was already sick and tired of being sick and tired, as they say. I was experiencing withdrawal symptoms, and just for the first time, being in a lot of difficult situations to acquire opioids. So between being sick and being unsafe, and then on top of that, just watching my peers at the time lead, quote, unquote, normal lives, going off to college. It was a perfect storm of motivation to try it myself.
Nowadays, buprenorphine is available from treatment providers across the state. When Scott started using it, that wasn’t the case.
Pavek: It was acquired the same way I acquired all other substances. You know someone who knows someone.
They were orange stop signs, they were pills back then.
Once you took it, what was the effect?
Pavek: I mean, I wasn’t experiencing the the agony of withdrawal. Granted, I was a 17- and 18-year-old kid who was trying to medicate himself, not knowing what the medication was. But eventually I found some sort of dose at the time that allowed me, as I remember, some degree of functioning, in the sense that — the sweating and shaking and nausea that was readily apparent to the outside world, I could tamp that down and go through my daily life with a bit more ease.
Scott said buprenorphine ultimately wasn’t what pushed him into recovery. But it gave him an important degree of stability.
Pavek: It was just a matter of finding anything that was safer or more reliable than the things I was putting into my body on a regular basis. And again, that period of trying to treat myself didn’t last, but had I not had it at the time, I’m not sure if I wouldn’t have overdosed, and not even entered treatment. So I definitely give it credit for for keeping me alive while I was in active use.
Maia Szalavitz: We have two drugs in our pharmacopoeia that are proven to cut the death rate from opioid addiction by 50 percent or more if you continue to take them. Now, if we had such drugs in cancer treatment, we’d be dancing in the streets and making sure that everybody got them. But in the addiction world, we’re like, “oh no, that’s not really recovery.” And so we have stigma that is associated with these drugs because we don’t understand how they work and what addiction actually is.
This is Maia Szalavitz. She covers drug policy for places like Time and Vice, and she wrote a book about the neurology of addiction called Unbroken Brain.
Szalavitz: Why would you treat opioid addiction with an opioid? Well, this is an interesting question, and this goes to the nature of addiction itself. Basically, with opioid addiction, once you lose your tolerance, you are extremely vulnerable to death from overdose. And in an environment where the market is flooded with various forms of fentanyl, it is really important for people to have protection, since relapse is a common part of recovery.
This is why these drugs are so valuable. What they do is they prevent people from experiencing withdrawal, they give them a steady state of opioid in their systems, which may have been lacking before they began using, and may have been why they were one of the 10 to 20 percent of people who try these drugs and end up becoming addicted.
Policymakers in Vermont have recognized that buprenorphine is effective at reducing opioid-related deaths. It’s become a key component of the state’s medication assisted treatment program. Last year, the brand name version Suboxone topped the state’s prescription spending list.
But last summer, officials in Burlington made an effort to expand access beyond the state’s treatment system.
Sarah George: Essentially, we wanted to flood Chittenden County with this drug. Which I understand sounds kind of crazy. But we knew that heroin was already flooding our community, and so we wanted to create this other market for people to be able to take something that could, and probably would, have a much better chance of getting them into recovery.
This is Chittenden County State’s Attorney Sarah George. She helped lead an effort that would get more hospital emergency departments and clinics licensed to provide buprenorphine. But she, along with Burlington’s mayor and police chief, also wanted to make it easier for people to get buprenorphine on the street.
George: We kind of came to the conclusion that if we want more of this in our community, we need to make sure that people feel safe having it and not fear arrest or prosecution for possessing it. So that was how we came up with the idea of not arresting or prosecuting for it. So not only was it sort of to preempt that more people would be possessing it, or at least that was our hope — but it was also to just send the message to people that if you have a choice between getting heroin and getting buprenorphine or Suboxone, we want you to get buprenorphine and Suboxone. We want to encourage that.
That was about eight months ago. I’m curious, how have you evaluated the effects of that program since then?
George: Yeah, it’s interesting because you almost have to prove a negative, right? Like, I don’t know how many we’ve prevented, because I haven’t got any, right? All of the chiefs in Chittenden County agreed that they wouldn’t arrest for it. I do know, unfortunately, not by numbers or any good data, but I know that there have been law enforcement officers who have told me that they found somebody in possession of a strip or a pill and gave them the option — basically said, if this isn’t your prescription, can I bring you to Safe Recovery or can I bring you to the ED and get you one? And they’ve done that.
One of the officers that I remember talking to told me, you know, I gotta be honest, I wasn’t thrilled about this, I didn’t really get it. And then I had this conversation with this person, and they didn’t know about the ED program or Safe Recovery, and to be able to bring them there and get them this prescription, I could just tell like it was their first glimpse of hope that they’d had in a long time. And he’s like, so I get it, you know? It just took that one time for him to see somebody feel like somebody else cared about them and really wanted them to have this thing that they’d already gone through some effort to possess illegally, that they could go and get it legally.
Michelle Childs, Office of Legislative Council: This will be a quick walkthrough. You’ll see, it’s a short bill.
This week, lawmakers heard testimony on a bill that would make it legal to possess buprenorphine and Vermont without a prescription.
Childs: First section is amending your current criminal provisions for possession, dispensing and sale.
Basically, the bill would remove buprenorphine from the list of drugs that can get you charged with misdemeanor possession. If you buy a small amount on the street, and you don’t have a prescription for it, that’s OK.
Scott said this kind of policy could save someone who was in his position.
Pavek: I know, had I been arrested when I was 18 and trying to get my life on track at the time, I would have been absolutely devastated. Just the idea that I would have been punished for trying to do something to better myself, or the idea that I would have received the message that the state considers whatever substance is in your pocket to warrant the same criminal penalties.
I mean, so long as heroin and other opioids are illegal to possess, shouldn’t we provide a differential? Some sort of incentive that says, OK, although substances are still illicit, there’s a reason, or we recognize that there’s a utility in you possessing this? And certainly in light of a drug poisoning crisis, I mean, there are alternatives. Would you rather have someone possessing a bag of heroin, bag of fentanyl, really, that they can’t assess the potency of? Or would you like them to have a pill or a strip of Suboxone with a determined potency, determined effect?
If this bill became law, Vermont would be the first state in the country to decriminalize buprenorphine. But it’s still a Schedule III controlled substance under federal law — it’s illegal without a prescription. And last week, Vermont’s top federal prosecutor put out a statement that said she intends to uphold that law.
Christina Nolan: I was trying to express a counter view as to the opinion voice by some law enforcement officials that they are interested in sort of unilaterally decriminalizing diverted buprenorphine. That is buprenorphine that is used, possessed, maybe even trafficked outside the medical context.
This is U.S. Attorney Christina Nolan.
Nolan: It is my view that that would undercut both our efforts to reduce drug supply in Vermont and our efforts to reduce demand by preventing children from taking the first risk in terms of drug use, and also reduce demand by getting people into responsible addiction treatment.
Just to clarify, what exactly do you see happening? If we say, as a state, we’re not going to prosecute this, what’s the next step beyond that?
Nolan: It sends a message that it’s OK to use buprenorphine outside the medical context. And I think more people will start doing it because they’re hearing from certain leaders that that it is OK. And there aren’t going to be any consequences. And I guess, not only is it contrary to the existing law, that law enforcement officers like myself are sworn to uphold, it is contrary to what the medical experts say. So if you look at the American Association for Treatment of Opioid Dependence, if you look at the literature from the National Institute on Drug Abuse, if you look at the literature from Substance Abuse and Mental Health Services Administration, which is part of HHS, all of them say — I’ll just quote the first organization I listed, they say: “The diversion of any opioid at any time, and particularly during an opioid epidemic, is unwise. Our argument has always been that one cannot define a diverted opioid as being therapeutic.” They also say induction onto buprenorphine as medically-assisted treatment, quote, “must be conducted in an organized therapeutic manner. And it requires enormous clinical vigilance through a well-coordinated team of professionals who are engaged and working with the patient.”
So the risk is that people will think it’s OK to do it, particularly young people, but people of all ages, and that then it will only deepen their addiction as they use opioids outside of clinical setting. And there’s risks of overdose.
Do you believe that everybody who might need that kind of treatment has access to it?
Nolan: I believe we do a better job in Vermont of getting people access than probably anywhere else in the country, and I think the Howard Center and everyone else involved in that should be extremely proud. I think that the absence of waiting lists, or at least, if there are any waiting lists, very low waiting lists, and the number of people enrolled, shows we’re doing about as good a job at least by nationwide standards as we possibly can. And like I said, there are now, new points of access at Howard Center, Safe Recovery and UVM Medical Center. We always need to think about what more we can do to help people access treatment. Transportation is an issue for a lot of people. I sit on the governor’s opioid coordination council. And we talked about, for example, that issue of what can we do to help people actually get to these treatment facilities.
So we always want to think about what more we can do, but our goal’s got to be to get people on drug-free lives, not settle for them being addicted and using drugs that could cause them extreme damage, both socially and medically.
I guess certain people think, well, it’s better to have people using a dangerous drug, buprenorphine, than an arguably more dangerous drug like fentanyl, but you could make that argument about oxycodone or cocaine. We need to send a message to people that we want to rescue you from the torment of addiction by getting you into treatment and by prosecuting the dealers who would profit from your suffering, not that we want to encourage you to continue to be on drugs of any kind that are dangerous and addictive.
This is where harm reduction advocates like Sarah George diverge. Their primary goal is less to wipe out someone’s addiction, and more to stop them from risking their lives.
George: To believe that, or at least to think that that’s a valid response, ignores the fact that individuals who cannot easily access buprenorphine or who choose not to are going to choose heroin. Because it’s cheaper, and in a lot of places easier to get. And then we’re surprised when they die.
And I just think that that ignores the real evidence that people who are taking buprenorphine — yes, it gets abused. I am not going to say that nobody ever abuses buprenorphine, but it’s very rare. Most people take it in order to not take heroin. So I think that anybody who believes that the street use is dangerous, yes, it can be dangerous, but they’re ignoring the alternative. And I don’t think that’s fair. I think that’s just not looking at the whole picture. You’re looking at one part of it to justify the entire argument.
Here’s Maia Szalavitz.
Szalavitz: It’s, I mean, it’s not a very desirable opioid. There is really no world in which people who want to get high are going to choose buprenorphine over heroin or fentanyl.
There’s two ways of using buprenorphine. And one way is for the person to be stable and to be getting your life together and to not be using any other additional drugs and to be basically as much in recovery as somebody who is completely abstinent. The only illegal drug they’re taking, or the only opioid drug they’re taking, is the buprenorphine that is prescribed to them. They no longer have the hallmark of addiction, which is compulsive use despite negative consequences.
Now, the second way to use buprenorphine is kind of sporadically when you want to break from your active addiction, and to sort of make it so that you can avoid withdrawal and function using your bupe, and then maybe get high on weekends, or get high, you know, whenever you feel like not taking your buprenorphine and getting high. Now people would say, oh my god, that’s horrible. We’re just enabling addiction, or stuff like that.
No, what that does is — every time that person uses a dose of buprenorphine rather than a dose of what is sold as heroin, that what is likely to be fentanyl, they are not playing Russian roulette that day. And that means that they have a chance to stay alive and to get into more sustained recovery. As we used to say in ACT UP in the ’90s, dead people don’t recover. You know, you can’t get better if you’re not with us anymore. So this harm reduction use of buprenorphine is really important. And the move to decriminalize possession of it really sends a strong signal there, that we’re not going to prosecute you for just trying to avoid withdrawal for one day.
Pavek: Certainly talking about leading ourselves into a dangerous situation — I mean, the reality is today that people with substance use disorder, and increasingly people not just using illicit opioids, but methamphetamine and cocaine, are increasingly risking exposure to fentanyl. In some markets, it’s guaranteed. And depending on who you are, that is a recipe for death. That is a recipe of not taking your proper dose, assuming that the dose you’re taking is correct, overdosing in an unsafe place, and not being able to be revived.
The alternative for what we’re talking about is supplying a drug that doesn’t do that. Which has a very, very, very different risk of overdose. And something that has specified doses and know what the product is. For the most part, drawing on my personal experience, if you’re using buprenorphine outside of a treatment setting, certainly if you’re acquiring illicitly, you’re usually not using opioids. And if we’re ever putting people in this, enabling them to make the decision between one or the other, why would we not, knowing that the status quo is a drug poisoning crisis here in Vermont?
Are there aspects of it that you feel like policymakers still aren’t quite grasping the way that you see them?
Pavek: Sure. Maybe something to illustrate the difference, or what we could be doing here is — to give a full accounting, and I certainly don’t have the dates and signatures, but I’ve met a lot of people who have substance use disorder or who are in recovery. That’s based in a mostly Vermont context. I know a lot of people who use opioids and a lot of people who use alcohol, particularly. And a lot of those people have died. A lot of them. I can’t count how many people have died from an opioid related overdose in my own life, among my friends and family.
I can count the number of people I’ve met who developed a dependence on buprenorphine after recreational use. So those were three people. Every single one of them is alive today. And I know that the sample sizes are small, but I think that’s the difference that illustrates things most clearly for me, is the fact that all those people that started out — we might be introducing a new degree of risk, and all those people are enjoying recovery today. Meanwhile, the people who couldn’t access buprenorphine are dead.
Subscribe to The Deeper Dig on Apple Podcasts, Google Play, Spotify or anywhere you listen to podcasts. Music by Blue Dot Sessions.
Bagikan Berita Ini
0 Response to "The Deeper Dig: Drawing the line on recovery drugs - vtdigger.org"
Post a Comment