Medications work really well for opioid addiction. Most rehab facilities don’t use them.
Ian McLoone was at his son’s first birthday party in 2011 when his drug addiction rehab center called him at his Minneapolis home, telling him he needed to come back early.
McLoone quickly realized he was in trouble. The day before, he had missed curfew while chaperoning another client’s family visit for the inpatient facility. After the call, McLoone told his family that he had to go, and left, embarrassed. Over the next few days, he would be forced to “sit on the bench.”
“It was literally a bench out in the hallway,” McLoone told me. “You would sit there from after breakfast time until just before dinner time.”
While on the bench, McLoone, who was in treatment for opioid addiction at RS Eden, a treatment center in Minneapolis, couldn’t participate in most group sessions. He couldn’t attend lectures. He couldn’t talk to others in the program or eat with them. He couldn’t watch TV or use the phone. He just had to sit — in public, in silence. It was all part of RS Eden’s approach to treatment, as McLoone described it: “We’re going to break you down in order to build you up again.”
McLoone is now doing well, staying off heroin since 2010. But he said that RS Eden had little to do with his recovery. Instead, he credited his use of methadone, a medication for opioid addiction.
In fact, McLoone said RS Eden pushed him to get off methadone — leaving him feeling stigmatized about using the medication. McLoone’s mom had to convince him to stay on it. As she told him, “Why wouldn’t you use every tool at your disposal to get it right this time?”
This is the reality of America’s drug rehab industry.
Medications like methadone, as well as buprenorphine and naltrexone, are considered the gold standard of care for opioid addiction. Studies show that the medications reduce the mortality rate among those patients by half or more, and keep people in treatment better than non-medication approaches.
Yet rehab facilities in the US often treat medications with skepticism or even scorn, while embracing approaches with little if any peer-reviewed scientific evidence, like the bench.
The majority of addiction treatment facilities don’t offer medications. According to federal data, only 42 percent of the nearly 15,000 facilities tracked by the Substance Abuse and Mental Health Services Administration (SAMHSA) provide any type of medication for opioid addiction. Less than 3 percent offer all three federally approved medications: methadone, buprenorphine, and naltrexone.
As a result, the best response to an opioid epidemic that’s contributed to the more than 700,000 drug overdose deaths in the US since 1999 is vastly underused. Hundreds of people have now responded to the survey for Vox’s Rehab Racket project with complaints that evidence-based treatment — including medications — is expensive, hard to find, and sometimes outright shunned at addiction care facilities.
Medication isn’t the only effective way to treat opioid addiction. Other approaches, including cognitive behavioral therapy, motivational interviewing, and contingency management, also have evidence backing up their ability to treat addiction.
Still, for opioid addiction, medications “should be the first-line option,” Keith Humphreys, a drug policy expert at Stanford, told me. “Not forced, but every single person should be offered that in any decent program treating opioid addiction.”
Addiction treatment facilities often reject evidence-based approaches
When it opened in the 1970s, RS Eden at times forced patients to shave their heads and wear diapers as punishments. The approach came from the Synanon movement — to which one of RS Eden’s founders belonged to, RS Eden president Dan Cain told me. The formal Synanon organization, which began as a drug rehab program and turned into what’s now widely characterized as a “violent cult,” no longer exists, but some of its teachings remain in the addiction field today.
By the time McLoone got into RS Eden (on a court order and paid for by the state), it had long gotten rid of head shaving and the diapers. But it still used the bench punishment and another technique, also from Synanon, called “the game”: Over the course of a typical week, patients would write down and submit complaints about others in the program. Those complaints would be read out loud by staff in group sessions, during which people would be expected to defend themselves — at times devolving into shouting matches and nearly fist fights as emotions ran high, McLoone said.
Cain acknowledged that his program “made mistakes.” It no longer uses the bench, but still uses “the game,” he said. He generally defended RS Eden’s practices.
“‘Confrontation’ is a term that there’s a lot of variables in and different levels in,” Cain told me. “We believe that people have to own who they are before they can be motivated to be somebody else.” He added, “We do focus on breaking through that level of denial.”
Meanwhile, opioid addiction medications remain difficult to access for many.
Other addiction patients have told Vox about struggles to find medication treatments. Eitan, who asked to use their Hebrew name as a pseudonym, sought help for a drug problem going back to their teenage years — after their mom died of an asthma attack because she couldn’t afford her inhalers.
But in two separate programs in Arizona — Mirasol Recovery Centers and Desert Star Addiction Recovery Center — Eitan said they were pushed into a restrictive, unhelpful 12-step approach. Though the programs said they used other treatment methods, Eitan felt the programs were hostile to questions about them. And neither made medications available to Eitan.
“It left me not really wanting to have treatment,” Eitan told me. “I felt really condescended to a lot of the time.”
Richard Poppy, owner of Desert Star, told me that “we’re not ‘it’ for everyone,” and said, contrary to Eitan’s experience as a patient, that the program does support medications, although it doesn’t initiate buprenorphine or methadone. Mirasol has since shut down its drug addiction treatment services, focusing on treating eating disorders.
Eventually, Eitan moved to Massachusetts, where they now get addiction treatment at the Boston Medical Center. There, the staff was quick to offer medications for addiction. Eitan got on naltrexone, which they said has helped reduce cravings for both alcohol and opioids. (The evidence for medications for alcohol addiction is generally weaker than it is for opioid addiction, but experts say it’s a good option for some patients.)
“I didn’t want recovery to mean that I spend the rest of my life miserably fighting cravings in 12-step meetings,” Eitan said. But, they added, that was seen as the only path to recovery in the treatment facilities they attended before Boston Medical Center.
How medications for addiction work
In the 1980s and ’90s, France faced a heroin epidemic that got as many as 300,000 people addicted and led to hundreds of overdose deaths each year along with a rise in other drug-related problems, such as HIV and hepatitis. In 1995, French officials responded, in part, by expanding doctors’ ability to prescribe buprenorphine.
From 1995 to 1999, the number of people in medication-based treatment increased. According to a 2004 study published in The American Journal on Addictions, overdose deaths in the same time span in France fell by 79 percent.
It’s the kind of model, experts and advocates say, that the US should move to replicate.
There are three federally approved medications for opioid addiction: buprenorphine, methadone, and naltrexone.
Two of them, buprenorphine and methadone, are opioid agonists. As opioids, they activate the same kinds of receptors in the brain that, say, painkillers or heroin would. (Indeed, both can be used for pain treatment.) But when taken as prescribed, at a consistent dose, neither gets the patient high. Instead, the medications just stop the withdrawals and cravings that are linked to addiction — stabilizing a patient’s condition and giving them space to rebuild.
Both of these medications have strong scientific and medical evidence behind them. Methadone in particular has been around for decades, and is one of the most studied addiction treatments in the world. Every major public health organization — the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, the American Medical Association, and the World Health Organization — considers opioid agonist treatment a vital approach for combating addiction.
Naltrexone is the newer medication of the three. It’s not an opioid agonist. Instead, it blocks the effects of opioids up to certain doses, making it much harder to get high or overdose on the drugs. It can also reduce cravings for some people. While it has less evidence behind it, research suggests that naltrexone works well for some patients. The catch is that it requires full withdrawal, which makes it far more difficult to initiate for people than buprenorphine, which only requires partial withdrawal, and methadone, which doesn’t require withdrawal at all.
Naltrexone can also be used for alcohol addiction, along with medications like disulfiram and acamprosate. Although evidence suggests medications don’t work quite as well for alcohol as they do for opioid addiction, they’re a good approach for some people, like Eitan, who was temporarily on acamprosate as well.
There are no equivalent medications, at least not yet, for cocaine or meth.
But despite their effectiveness, the available medications are often stigmatized with a common trope that they “replace one drug with another.” On its face, this is literally true: The medications do substitute, say, heroin or alcohol.
But the context matters. The issue with addiction is not just drug use. Most people use some kind of drug — caffeine, alcohol, or medications. Some people are even dependent on these drugs, whether someone needs coffee to get going in the morning or insulin to survive.
What makes addiction a medical disorder is not just drug use or even dependence, but continued, compulsive use despite negative consequences. So someone would be unable to stop using heroin even when it poses serious risks to his health, career, or family. It’s only then that drug use becomes a drug use disorder.
The medications alleviate those problems, turning a drug use disorder back into just drug use. That’s why they reduce all sorts of drug-related problems, including the risk of death.
The medications don’t work for everyone, and different medications might work better for different individuals. Some people may need the medications for months or years, while others benefit for the rest of their lives. With a condition as individualized, complex, and difficult to treat as addiction, the correct treatment is going to vary from person to person.
Broadly, though, medications are proven to be effective for addiction.
As Eitan put it, “It’s definitely not a silver bullet. It’s not like I took the medication and emerged cured. But about a week or a week and a half after taking it, I had this experience where I was like, ‘I didn’t think about substances today.’” They added, “There was a break.”
Why the addiction treatment field frequently rejects medication
Despite the evidence, many addiction treatment facilities don’t offer any medications. Some outright shun the medications — perpetuating the stigma that they simply replace one drug with another. That’s deeply unusual compared to the rest of the health care industry, in which medications are, obviously, used quite often to treat medical conditions.
Cain, the president of RS Eden in Minnesota, called methadone an “opioid replacement drug” and “more a tool than a solution.” He acknowledged some people might need to be on a medication for the rest of their lives, but said it “can be problematic” and ultimately would like to see patients “titrate off” medications like methadone during or after RS Eden’s program. “In terms of ‘encourage to get off,’ I think that’s a bit difficult to define,” Cain said.
In McLoone’s experience, RS Eden’s message was clear: He felt pushed to get off methadone — until his mom intervened. (RS Eden didn’t speak specifically about McLoone’s case, citing patient confidentiality.)
The resistance toward medications stems from the moralization and stigma that has wrapped addiction treatment for decades. For most of American history, addiction has been viewed as a moral failing, not a medical condition. So addiction was kept out of the health care system — leaving it to religious and spiritual groups, the criminal justice system, and Alcoholics Anonymous, Narcotics Anonymous, and other 12-step modalities to fill the void.
It’s in this environment that the current model of what many Americans think of treatment — the 28-day stay in rehab — took off. Known as the “Minnesota Model,” the concept was popularized by the Hazelden Foundation, now the Hazelden Betty Ford Foundation, as a way to treat people with addictions. The idea: People go to an inpatient setting for one month or several months, often outside the community where they use drugs, to cure themselves of their drug addiction.
Paul Earley, president of the American Society of Addiction Medicine (ASAM), described the Minnesota Model as “a hodgepodge of efforts” that “combined a little bit of AA, a little bit of psychosocial treatment, and a little bit of group therapy.”
“It was an acute care metaphor,” he explained. “You went to treatment for 28 days. And then when you left, they said, ‘Good luck. Go to AA meetings, and it will all work out.’ That works for a very small subset of people who have addiction.” He added, “But because there was nothing else, that grew throughout the United States, and that metaphor of shorter-term care for a chronic illness took hold.”
At the same time, some people in the addiction field took things further — leading to the kind of confrontational approach popularized by Synanon and the “tough love” industry more broadly.
This history has led to a system that would appear ridiculous if it were applied to any other medical condition, said Kim Sue, medical director of the Harm Reduction Coalition, which focuses on services that treat and mitigate the harms of drug use and addiction.
“It would be like sending a bunch of patients with insulin-dependent diabetes to camp,” Sue told me. “Then saying, ‘We’re going to give you your meals every day. You’re going to go to group every day about how to be a better diabetic. We’re not going to give you any insulin. Instead, we’re going to make you exercise, have counseling about your bad eating habits — things like that.’ And then send people out and say, ‘Good luck. We’ve endowed you with the skills to better handle your disease,’ and expect people to get better.”
Addiction treatment doesn’t have to be this way
A reprieve came for McLoone after four months at RS Eden, when he was accused — falsely, he said — of misusing opioids and kicked out.
He then found an outpatient program at the hospital and clinic chain Fairview, which he said worked better for him, while he stayed on methadone. He went on to grad school at the University of Minnesota, getting training to be a counselor for addiction and mental health issues.
In 2015, he tapered off methadone, struggling with the many restrictions people taking the medication face. Due to rules around how methadone is stored, secured, and dispensed, patients at first have to go back to the clinic at least once a day to get methadone, earning the right to take home a limited amount of medication after months or years. Travel can be a burden, with strict, often complex rules on whether patients can go to other clinics to get methadone when they’re out of town.
“Traveling became really difficult. Working became difficult. Fitting it around my schedule became very difficult,” McLoone said.
McLoone was in a place in his life in which he felt comfortable tapering off methadone. But some patients may need it indefinitely — just like someone with diabetes needs insulin — and the strict rules around methadone could get in the way.
“No other medication is prescribed in this way,” Sue, of the Harm Reduction Coalition, said.
Buprenorphine can be prescribed in a traditional health care setting, but it too faces unique restrictions. Doctors have to go through an eight-hour training course to get certification to prescribe it, and nurse practitioners and physician assistants have to go through a 24-hour training course. The restrictions are one reason that, according to the White House opioid commission’s 2017 report, 47 percent of US counties — and 72 percent of the most rural counties — had no physicians who could prescribe buprenorphine as of 2016.
Since methadone and buprenorphine are opioids themselves, the rules are meant to make it harder to get and illegally sell the medications for misuse. (Naltrexone, the non-opioid option, doesn’t face similar restrictions.) But the laws and regulations have also helped create an environment in which rehab facilities are more likely to try unproven methods than medication-based treatments with decades of scientific evidence.
“When you see people who’ve been through the ringer — people who have been through 20 detoxes and 10 rehabs — it just makes you think: ‘Well, what are treatment centers doing?’” Sue said. “It’s really a disservice, because it’s kept failing, and we’ve never looked at why you keep revolving in and out of this very dysfunctional system.”
Looking back, McLoone, who worked at a food shelf before he went into addiction care, said it was his time at the bench at RS Eden that led him to a new career. “I knew in my heart that there had to be a better way,” he said. “There had to be more respectful, more humane, more dignified, and more scientifically valid approaches out there.”
Now he’s trying to change the addiction treatment field from within. In 2013, after graduate school, he started working at the Alltyr Clinic in St. Paul. The clinic was founded by Mark Willenbring, who was previously profiled in the New York Times for his efforts to apply evidence and research to addiction treatment. Today, McLoone is the lead therapist there.
He supports medications, McLoone said, but also understands people’s concerns: “I think my experiences on methadone also helped me appreciate the nuances and ambivalence that most people feel about taking medications in general, and I can understand acutely how and why people feel hesitant about taking a medicine, especially one that requires a longer-term commitment.”
But for him, staying on methadone was “by far the best decision I could have made.”
“I was able to finish rehab, get a job shoveling asphalt that summer, working my ass off,” McLoone added. “I got into grad school. I got through grad school. And I was able to really have the life and the family and the career that I had dreamed of. Methadone absolutely facilitated that and helped to make that possible.”
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Photographs by Jenn Ackerman of Ackerman + Gruber, a husband and wife team based in Minneapolis, specializing in advertising, corporate, and editorial photography.
Author: German Lopez