SALT LAKE CITY — Metal tools clashed against the ground as Brandon Billmire tumbled off his stool and onto the floor of the hotel maintenance shop where he worked.
His face and hands were turning blue, his skin was turning cold. After being flooded with meth and heroin nonstop that day, his body was giving up the fight.
A quick-thinking co-worker started CPR and called 911, saving Billmire’s life. But nothing could stop him from doing drugs, not even cardiac arrest. The next day, he went right back to using.
Now, 2 1/2 years later, Billmire, 33, sits in the lobby of Davis Behavioral Health Center. His ice blue eyes dart restlessly around the room. He’s legally blind and although his vision may be hazy, his mind is clear. Thanks to an addiction-fighting drug called Suboxone, he is alive and has been clean for nine months.
The use of prescription drugs in combination with counseling to treat addiction is growing in popularity across the country. For many people suffering from opioid addiction, medications like Suboxone, Methadone and Vivitrol are the key to survival. These drugs help addicted individuals control intense cravings while they work through the emotional and financial problems at the root of their addiction.
But there are barriers to this solution:
- Some physicians, treatment providers and patients are reluctant to treat drug addiction with other addictive drugs, despite research showing positive outcomes.
- Ten of Utah’s 29 counties do not have any health care providers who can prescribe addiction-fighting drugs that contain Buprenorphine, such as Suboxone.
- There are about 250 doctors and nurses in the 19 counties who have the necessary credentials to prescribe Suboxone, but because drug-dependant patients are such a challenging group to deal with, only half of them actually treat people with addiction.
- Publicly funded treatment programs are making addiction medication available to low-income people clients. But the public system is only able to treat about 15,000 of the estimated 146,000 people who need substance abuse treatment in Utah, the majority of whom are unemployed and uninsured.
- There are 14 state- and federally certified opioid treatment clinics in Utah where people can get daily doses of methadone and other medications. But these clinics are only found in five counties and are largely unrecognized by private insurance providers. Most of them only get Medicaid coverage for the medications they dispense, with no coverage for counseling, physical exams, urine tests or any of the other services they are mandated to provide.
“There has been a stigma about using medications in treatment because some people equate that to replacing a drug with a drug,” said Brent Kelsey, of the Utah Division of Substance Abuse and Mental Health. According to Kelsey, medications have been underused to address the opioid crisis in the past, but now the division is working to expand access.
Billmire owes his sobriety to a program at Davis Behavioral Health, funded by Intermountain Healthcare, which set him up with a Suboxone prescription that allows him to function normally and curbs his cravings for more harmful substances.
“It’s made all the difference. I’ve got my life back," said Billmire, who has two sons, ages 12 and 3. “I’ve been able to be a father and a husband again.”
Across the state, money is being poured into medication-assisted treatment training and resources, thanks to a recent $6 million federal grant. Treatment providers are working to open new opioid treatment clinics in Price and Murray, provide medication to people in jail and train doctors on how to treat addicted individuals.
“No matter what you think of it, this care does help keep people alive,” said Linda Moore of Project Reality, a nonprofit that provides medication-assisted treatment in Salt Lake and Provo. “And this is such a deadly disease right now.”
Naloxone: A medication that rapidly reverses an opioid overdose. It is an opioid antagonist, meaning it reverses and blocks the effects of other opioids. It can be injected or administered via a nasal spray and quickly restores normal respiration to a person who has stopped breathing because of an overdose. Cost: $40-$100 for one kit.
Methadone: A medication that allows someone with an opioid addiction to function normally and keep their cravings at bay. Methadone is a full opioid agonist, meaning it fully activates the opioid receptors. It is usually taken by mouth and dispensed by certified opioid treatment provider clinics. Like other opioids, it is addictive. Cost: $50-$180 a month.
Buprenorphine: A partial opioid agonist medication, meaning it activates the opioid receptors in the brain but to a lesser degree than a full agonist like methadone. As a result, it is less addictive. Buprenorphine can be prescribed by a doctor who has gone through the required training and has a waiver. The cost of brand name Subutex is $51-$147 a month.
Suboxone: A drug that combines Buprenorphine and Naloxone. Cost: $117-$483 a month.
Naltrexone: A nonaddictive opioid antagonist drug that stops cravings. Vivitrol is a popular form of extended-release Naltrexone that only needs to be administered once a month. Unlike Methadone and Buprenorphine, patients need to have completely detoxed before starting Vivitrol. In addition, patients are at a high risk of overdosing if they relapse after being on Vivitrol. Vivitrol cost: $1,050-$1,700 a month.
The story of someone who comes out of rehab and immediately overdoses and dies is all too familiar for those in the treatment field. Research shows that medication-assisted therapy is more effective than quitting cold turkey for longtime drug users because it helps them stay sober longer.
Medications like Methadone and Suboxone work by blocking the high caused by other opioids and reducing cravings and withdrawal symptoms. Most importantly, they help decrease overdose deaths, according to National Institute on Drug Abuse.
“These medications help sustain people for much longer so they can address both their physical and psychological dependence,” said Shannon Terwedo, owner of a medication-assisted treatment clinic called Metamorphosis. “It is a chronic and relapsing condition. It is not necessarily something that is cured.”
For that reason, some people end up taking Methadone or Suboxone for many years.
Cathy from Salt Lake City and her husband have both been on a low dose of Methadone for nearly two decades.
“I’m 57, but I don’t look a day over 40,” Cathy says and laughs. She agreed to tell her story on condition that only her first name be used.
Cathy was introduced to heroin at a young age and saw her mother overdose when she was just 12 years old. Now that she’s found something that works, she plans to continue taking Methadone for the rest of her life.
“I look at it as this: I’m not out doing crime, I’m not getting locked up anymore,” said Cathy, who works at Primary Children’s Hospital and sometimes speaks at events to warn kids about the dangers of drug use.
Others believe it’s best to eventually taper off of these medications, which are addictive themselves and have the potential to be diverted and sold on the streets.
Either way, medication-assisted treatment has been proven to work better than detoxing suddenly and trying to remain abstinent. Without medication to sustain someone through the long-term recovery process, continued relapse is much more likely.
“The programs that just do detox and charge you $20,000 — those people are making money hand over foot,” said Todd Eury who works with an opioid treatment clinic in St. George. “Is there a science and value to detox? Yes. But they need continued support. Otherwise, you will have people going through a cycle.”
Even though medication-assisted treatment has been around since the 1970s, providers have been reluctant to treat people with addiction by giving them one drug to replace another, worrying that physical dependence on a medication is just as bad as addiction to an illegal substance. Now, as the way people think about addiction is changing, this type of treatment is slowly being made available to those who desperately need it, treatment providers say.
Trouble in rural Utah
Ten of Utah’s counties still lack a doctor who can prescribe Buprenorphine, and only half the 250 doctors and nurses who have the credentials to prescribe it actually do so.
In an effort to change that, University of Utah psychiatrist Elizabeth Howell spearheaded the Southeastern Utah Addiction Medicine Coalition, a small team focused on training rural health care providers in addiction treatment.
According to Howell, the stigma surrounding drug use makes doctors less willing to treat patients with addiction. Because Buprenorphine is an addictive substance with the potential for misuse, and because addiction is a challenging disease to treat, doctors are required to undergo an eight-hour training course and obtain a waiver before they can prescribe this medication.
“There have been people we’ve met who have the waiver but haven’t used it because they don’t want those patients in their practice,” said Howell.
Before funding for Howell’s project ran out, she helped several providers in Grand and San Juan counties get waivers to prescribe Buprenorphine. If the initiative is revived, she hopes to focus next on Carbon County, which tops the list for both overdose deaths and opioid-related emergency department visits in Utah.
Alicia Quintana, age 44, is one of the people in Carbon County who has struggled to find help with her addiction.
Price, where she lives, is a small mining town surrounded by mountains. It has a Walmart but no malls, and less than 8,500 people. There, Quintana works as the executive housekeeper at Holiday Inn Express and is the mother of six children.
Carbon County currently has seven listed Buprenorphine prescribers, most of whom are capped at 30 patients, though some can see more. Quintana said that lack of information and patient limits made seeing a doctor difficult.
“The heroin was just so much easier to get,” she said.
In addition to a lack of prescribers, Carbon County also lacked a certified opioid treatment provider, or OTP clinic, where someone like Quintana could go to get a daily dose of Methadone. As a result, Quintana had to drive 75 miles to a clinic in Provo, leaving at 4:30 a.m. to get there by 6 a.m., in order to get a dose that would last her the weekend.
Only five counties have certified opioid treatment clinics that can provide patients with counseling and daily doses of medication. But soon, Carbon County will be added to the list.
Four Corners Behavioral Health, the local authority for addiction treatment in Carbon, Emery and Grand counties, has contracted with a private nonprofit called Project Reality to open a new opioid treatment clinic in Price.
Karen Dolan, director of Four Corners, hopes the clinic will support up to 100 patients.
“We’re not just handing out medicine but rebuilding lives,” she said.
Still, Dolan is concerned about community pushback because of the stigma associated with methadone clinics. Some community organizations have questioned her about whether it’s right to give drugs to a drug addict. It’s this stigma that keeps people from getting help, she said.
“People don’t get help until they’re in late, late stage disease with addiction because there is so much fear and shame,” said Dolan. “Our goal is to intervene earlier.”
Christine Brooks, who owns and operates a private opioid clinic in St. George, knows what happens when a patient can no longer pay for treatment, which costs between $17 and $23 a day.
“They go right back to active use,” she said. “It’s devastating to me.”
Pregnant moms without an income often come into Brookstone clinic seeking treatment, said Brooks.
She personally funds several needy patients, but without a funding source, is unable to treat everyone who comes in.
Only 17 percent of the people who seek opioid treatment in Utah have full-time jobs, and nearly 60 percent do not have insurance, according to data from the Utah Department of Human Services.
It is nearly impossible for this population to afford the expensive medications they need on their own.
A $6 million federal grant is helping to make a difference by providing medication-assisted treatment funding to clinics and treatment centers across the state.
The Federal State Targeted Response grant, which the state applied for and received earlier this year, is supposed to last for two years and may help hundreds of people get medication-assisted treatment during that time.
But divided among the state’s various counties and programs, the impact of the money will be limited and is a temporary fix that doesn’t reach everyone who needs it.
For example, Central Utah Counseling which covers Juab, Sanpete, Millard, Wayne, Sevier and Piute counties received a total of $66,000 from the grant. An estimated 3,870 people need substance abuse treatment in that area, but the money will only be able to support a couple dozen on addiction medication. So far, Central Utah Counseling has spent $7,000 to support just four patients on Vivitrol.
“I think everyone was unhappy with how much money anyone got,” said Shannon Terwedo, director of an opioid treatment clinic called Metamorphosis in Ogden, which will be able to support new patients with some of Weber County’s funding.
But treatment providers are optimistic that increased awareness of medication-assisted treatment will encourage continued public support.
“The patients sell the program,” said Moore with Project Reality, which is using some of the funding to support their new opioid treatment clinic in Price as well as a new location in Murray. “The turnaround you see is incredible.”
Moore said Project Reality’s growth, made possible by the grant money, will increase access and save lives.
“It will be interesting to see six months from now if that expansion is happening the way we’d hope,” said Moore.