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“I’ve seen someone go from everyday use to putting themselves on methadone and not using heroin,” said Alicia Brunelli, an outreach worker with the N.C. Harm Reduction Coalition. But those people made that decision for themselves, she added.
Making that decision is a difficult step. For many North Carolinians, the next phase of navigating the labyrinth of treatment — and finding a way to pay for it — can be daunting endeavors.
The NCHRC’s Raleigh office keeps on hand supplies — including sterile syringes, fentanyl test strips, cotton and syringe access program identification cards, which protect participants, employers and volunteers from being charged with possession of syringes or other injection supplies.
Brunelli said she might bring some of these supplies when staffing tables at health fairs, though she’s careful to leave many of them under the table. “We don’t want to be a trigger to someone,” she said.
More conspicuously, the front room is stocked with pantry staples, most notably jars of pickles. They’re donations from a local food bank, available for anyone to take, she said.
Brunelli said she is there to provide services, whether it’s navigating treatment options for opioid use disorder or helping with a resume, when requested. If she hasn’t heard from someone in a while, she doesn’t reach out in case her call prompts the person to start using again.
This ethos of meeting people where they are by understanding individual and community needs before promoting positive change is a core tenet of harm reduction, an approach to substance use that’s central to the mission of organizations like NCHRC.
Connecting to care
Harm reduction, which has evolved since its conception in the 1980s, is a set of strategies, including safer use, managed use and abstinence, aiming to reduce negative consequences related to substance use. The Biden-Harris administration made enhancing evidence-based harm reduction efforts a drug policy priority for its first year in office.
“We don’t promote any type of treatment modality or … anything like that,” said Jesse Bennett, NCHRC executive director and a former IV drug user.
“We pretty much just lay it all out there — what’s available, the pros and cons of each — and then folks make their own decisions.” He also makes sure everyone knows the success rates of each program or service.
Though some people are somewhat familiar with their options, for many, navigating the matrix of services in a way that suits their individual needs can be challenging.
“The systems in place don’t make it easy for people,” Brunelli said.
To start, an individual who’s ready to seek treatment will have to decide what form of treatment — ranging from evidence-based, medication-assisted treatment to 12-step, abstinence-based treatment — is best for them.
Many people think treatment means going to 12-step meetings or abstinence-based programs, said Louise Vincent, executive director of the N.C. Urban Survivors Union. “A lot of people don’t want to do that, and that’s not where they are, and so they don’t even try,” she said.
When it comes to abstinence-based treatment, retention rates are low, Bennett said. Because stigma is often associated with relapse, the chances of a patient reengaging are minimal.
Though this approach can work well for one person, it doesn’t work for a lot of others and can put someone at a higher risk of death, Vincent said.
Using medications to get off drugs
Another type of treatment is medication-assisted treatment, now sometimes called medications for opioid use disorder, an evidence-based treatment that theoretically relieves symptoms of withdrawal, allowing some patients to sustain recovery.
MAT uses medications — buprenorphine, methadone and naltrexone — in combination with counseling and behavioral therapies to treat substance use disorders through a “whole patient” approach.
“The medical evidence for a medication-assisted treatment is so strong that to recommend something that doesn’t involve methadone, buprenorphine or naltrexone in the treatment of opioid use disorder, in my opinion, is malpractice,” said Dr. Eric Morse, an addiction and sports psychiatrist with the Morse Clinics and Carolina Performance.
Despite its effectiveness, one study conducted at Johns Hopkins University found that, of residential addiction treatment facilities surveyed, relatively few offered patients medications for opioid use disorder: 29.8% offered extended-release naltrexone, 33.3% offered buprenorphine, and 2.1% offered methadone.
Needle exchange programs, which provide safe disposal methods for used syringes and distribute sterile ones, are important because they act as the front line where people get connected to care, Vincent said.
People who go to syringe service programs are more likely to seek treatment because they are already involved with a group, she said. “They have built-in relationships with people that can help them navigate these systems.”
The relationship component is critical, particularly for some populations such as the formerly incarcerated. Those dealing with substance use are 40 times more likely than a member of the general population to overdose within two weeks of leaving jail, according to data from the N.C. Department of Health and Human Services.
Part of the reason is the lack of proper education around substance use, said Bennett of the N.C. Harm Reduction Coalition.
Many think they can use the same amount of drugs as they did before they were incarcerated, while, in reality, tolerance to opioids can decrease in as little as 24 hours, putting people at higher risk of overdosing, he said.
Withdrawal symptoms — which may include muscle aches, stomach pains, fever and vomiting — can be debilitating and last for days or even weeks, said Mike Davis, an educator in a TED-Ed video. “People who are addicted to opioids aren’t necessarily using the drugs to get high anymore, but rather to avoid being sick,” he said.
In North Carolina, only a handful of jails offer MAT.
“Most jails will take you off these medications,” said Dr. Carlyle Johnson, director of provider network strategic initiatives at Alliance Health, which has been working with the Durham County Detention Center to phase in a MAT program over the past two years.
If people are coming out of jail, Johnson wants them connected to medication on discharge or, even better, while they’re in jail, she said.
Navigating ‘the treatment industrial complex’
Beyond carceral settings, people also often learn about their treatment options by word-of-mouth. “Most of my patients are referred by my patients,” Morse said.
“Oftentimes, they don’t know about the other options,” he said. “Usually, on the phone before they ever come to my office, we talk to them to make sure that what they’re stepping into makes sense for them.”
When it comes to connecting those interested in treatment with services, Bennett said, it’s important for the outreach team to know what services are available in both their county as well as the surrounding ones, in case, for example, the local detox facility is full.
As a result, factors like transportation can pose a barrier to accessing treatment.
Bennett also said that high-priority needs around food, housing or transportation can vary by city or county. In Wake County, for instance, food needs are great, while in Western North Carolina, unhoused populations need roofs over their heads, he said.
Sometimes people are more focused on the drug or substance instead of creating supportive environments that satisfy the social determinants of health, Brunelli said.
Even if individuals find their way to a treatment facility, getting a specific treatment can be challenging. Finding a way to pay for the treatment throws another roadblock in the path of an addicted person.
Substance use services must meet a variety of regulations and licensing requirements at federal and state levels. Inconsistent regulation across the industry emerges as new approaches and treatment types shift over the years.
For example, patients can obtain medication-assisted treatment in several settings, all of which are subject to different licensing requirements. When determining which MAT setting best suits the needs of an incoming patient, Morse considers three factors: their motivation, their proximity to a clinic and the cost.
Opioid treatment programs, or OTPs, commonly known as methadone clinics, offer counseling and recovery services but are the only programs that can dispense methadone, a synthetic opioid, for the treatment of an opioid use disorder. These programs must undergo an accreditation process and receive certification from the Substance Abuse and Mental Health Services Administration’s Division of Pharmacologic Therapies, as governed by federal law.
Most people don’t realize these programs also offer naltrexone and buprenorphine, Morse said.
Methadone is taken daily as a liquid, powder or disket on-site and under a provider’s supervision, until, after a varying period of time where enough urine drug screens prove negative, patients can take methadone at home. Some advocates say that methadone reform, such as around dosing or take-home requirements, is needed.
At the start of the COVID-19 pandemic, the government allowed clinics to provide take-home doses to stable patients. Early research indicates no surges in methadone overdoses or illegal sales, suggesting that restrictions around methadone could be relaxed in the future.
Another setting where MAT is available is in office-based treatment programs, or OBOT, an outpatient service where clinicians can provide patients with buprenorphine (an opioid agonist) and/or naltrexone (an opioid antagonist requiring full detox before use), approved by the U.S. Food and Drug Administration in 2002 for treating opioid use disorder.
Morse said he usually recommends that his patients start with an opioid treatment program before graduating to an office-based treatment program. A methadone clinic often offers patients a faster path to recovery and less expensive treatment than an OBOT, where oftentimes providers don’t accept Medicaid or Medicare.
For some, office-based treatment removes barriers because fewer requirements, like transportation, are put on the patient. Daily dosing, though potentially on-site, typically takes place in the patient’s home without provider supervision.
OBOTs also provide patients with integrated behavioral health care, or mental health and substance use treatments in the same location, Bennett said, which is an asset. “They’re getting the same messaging all the way across the board,” he added.
For patients in rural areas, accessing opioid treatment is difficult. In North Carolina, 86 licensed OTPs, which are more concentrated in urban areas, serve the state.
One study conducted by researchers at the Brown University School of Public Health and others found that of the counties surveyed, those with highly segregated Black and Latinx communities had more facilities providing methadone per capita, while counties with highly segregated white communities had more facilities distributing buprenorphine per capita.
In June, the U.S. Drug Enforcement Administration finalized a rule to expand access to MAT options by allowing those authorized to dispense methadone to add a “mobile component,” or what’s sometimes called a “methadone van.” This rule eliminates the separate registration requirement and removes the moratorium placed on authorizing new clinics in 2007.
The new rule could also help address the shortage of providers, who must meet the needs of the estimated 3 million people in the U.S. with opioid use disorder.
Bennett said having mobile treatment services would be a game changer, especially in rural North Carolina. “We have a lot of folks that want to access various services or go to treatment, but they don’t … have transportation, or they can’t get to the place, or it’s not in their county,” he said.
While it can be a helpful tool for practitioners treating people with addiction, some regulations limit their ability to reach patients.
Physicians, nurse practitioners and physician assistants must apply for a waiver to provide buprenorphine to a limit of 30, 100, or, in some cases, 275 patients each year. Prescribing naltrexone, another medication used in MAT, doesn’t require a waiver.
“A lot of people think that, and I include myself in this, is that we’re actually ... overregulating buprenorphine treatment,” said Alex Gertner, an addiction researcher and M.D./Ph.D. candidate at the University of North Carolina.
Providers require certification only if they’re prescribing buprenorphine for addiction treatment, not pain treatment, he said.
Morse acknowledges that, while frustrating, the limits prevent any one provider from essentially operating a buprenorphine mill. “I think that it’s worth it for providers to actually go through the training,” he said. However, he said, the inconsistent aspects of the regulations don’t make much sense.
Last year, Gertner published a study on buprenorphine treatment quality, since some policymakers and providers were concerned that efforts to expand buprenorphine access would lead to low-quality treatment, he said.
“We didn't find any evidence of that,” Gertner said. Between 2014 and 2017, when the study was conducted, he saw the quality of treatment generally improve.
In 2019, N.C. Attorney General Josh Stein wrote a letter to Congress, urging lawmakers to loosen regulations on buprenorphine prescriptions. “Particularly for rural North Carolina, we need as many people out there treating SUD [or substance use disorder] as possible,” he has since said. The act he references was reintroduced in the Senate this year.
Other areas of treatment, such as recovery homes — also known as “halfway houses” — and patient brokering, have limited regulations. Patient brokering happens when a third party procures patients, usually with good insurance coverage, for a treatment facility in exchange for kickbacks. The facility may or may not provide treatment while billing the patient’s insurance company for upward of tens of thousands of dollars.
States like Florida have come down hard on the practice, making patient brokering illegal. “We do not want fly-by-night operations to essentially commit fraud when they’re not providing any meaningful treatment,” Stein said.
“We call them body snatchers here,” Bennett said, adding that conversations around how to regulate the recovery home industry in North Carolina have been going on for several years.
“What we’re trying to avoid now is what we’re running full steam into is the treatment industrial complex,” Bennett said.
“What happens is, if you … don’t get ahead of some of this stuff … it becomes like the Wild West.”