Springfield doc pushes Rx for heroin epidemic

Dr. Salvador Ceniceros is on the front lines of southwest Missouri’s heroin epidemic — besieged by as many as 15 calls a day from new patients seeking treatment for a crippling disease.

He can’t sign any of them up right now — not because he can’t handle the additional patient load or because he can’t afford to absorb the cost of treating these addicts, many of whom are on Medicaid or Medicare.

It’s because federal law limits him to treating 100 patients at a time with a highly effective medication for opioid addiction, called buprenorphine. And his quota has been full for three years straight, with slots only opening occasionally and a waiting list that never gets shorter.

“It’s just a constant flood of people trying to get it,” he says, because buprenorphine works. It’s better than detox and abstinence. It’s better than methadone.

“Of all the medicines I prescribe, that’s the one that gives me the greatest reward in terms of seeing how people turn their lives around pretty quickly,” Ceniceros says.

Many of his patients, previously debilitated by heroin cravings, are now fully functional — working full time and supporting their families. Without buprenorphine, he says, “they’d still be out on the street — hustling or dead.”

Ceniceros and other addiction experts say if Congress lifted the 100-patient cap on buprenorphine, it would eliminate his waiting list and stanch the public health and law enforcement crisis created by the scourge of heroin. But he is not holding his breath for action from Washington.

As the heroin epidemic has spiraled in Missouri and across the country, Congress and the White House have offered a slow and sometimes counterproductive response, doctors and drug policy experts say.

That’s partly because it’s a complex problem, requiring difficult and sometimes controversial solutions. And there is no powerful lobby for addicts, most of whom want to stay anonymous and rebuild broken lives, not become a poster child for drug policy reform.

“We don’t have a pink ribbon,” says Stuart Gitlow, past president of the American Society of Addiction Medicine and an addiction disease specialist in Rhode Island. “There is no nationwide ‘Walk for Addiction,’ no celebrity spokesperson. We’re not that kind of disease.”

Without that kind of political pull, Gitlow adds, “we often lack the ability to get even the most basic legislation passed.”

The buprenorphine limit is a good example of what happens when you mix drugs, addiction and politics. And it’s just one example of good intentions gone bad when it comes to federal drug policy, Gitlow and others say.

Lawmakers have also poured money into interdiction and enforcement, even though experts say incarceration is not an effective solution to the heroin crisis. They often still approach the issue with the perception that addiction is a choice, not a disease. And they sometimes allow the stigma associated with addiction to color the debate.

“Lawmakers still feel like this is a decisional problem, rather than a chronic neurobiological disorder,” said Corey Waller, a Michigan physician who chairs the addiction society’s legislative committee. “They think somehow someone has decided to be a heroin addict, that this was a decision they made one morning. It’s not, and people’s lives are horrible and filled with guilt and shame.”

Heroin use has doubled over the past decade, and the death toll from overdoses has climbed in every state. In Missouri, more than 200 people have died each year, from 2011 through 2013, from heroin overdoses and other heroin-related causes. In Springfield, the spike in heroin use is reflected in drug seizure data. Local police seized 180 grams last year — up from 12 grams in 2011.

Nationally, heroin overdose is now the No. 1 cause of injury-related deaths in the United States, killing 43,982 people in 2013, according to the Centers for Disease Control and Prevention.

Those startling statistics have captured Washington’s attention, forcing a shift in the debate and creating a sense of urgency among lawmakers.

There are now more than 20 bills pending in Congress aimed at curbing opioid and heroin addiction. Last month, the White House rolled out its latest initiative targeting the heroin surge — a $2.5 million program to help law enforcement officials collaborate with public health workers in tracking the epidemic.

Missouri lawmakers are getting involved too. Sen. Claire McCaskill, D-Mo., has signed on to legislation that would provide funding to educate doctors and patients about opioid abuse and create a federal registry to track opioid-related deaths. And earlier this year, a Senate subcommittee chaired by Sen. Roy Blunt, R-Mo., approved a $35 million spending increase for public health programs aimed at combating opioid addiction.

“We’ve seen a lot of positive rhetoric from the Obama administration and Congress that you can’t incarcerate your way out of this problem,” said Michael Collins, policy manager at the Drug Policy Alliance, an advocacy group. But when it comes to translating that rhetoric into action, he says, policymakers often take “one step forward and two steps back.”

The heroin epidemic has its roots in Washington’s fight against another drug scourge: the abuse of prescription drugs such as OxyContin and Vicodin. As law enforcement cracked down on the availability of those powerful opioids, they became more expensive — and heroin emerged as a cheaper option.

“We asked law enforcement to get OxyContin off the streets ... and they did that very effectively,” saysDr. Mina Kalfas, an addiction expert and family physician in Northern Kentucky, a one-time epicenter for “pill mills” that dispensed opioids. “But that created a problem because there was not treatment for people who were addicted” to prescription drugs, he says, so they moved to heroin.

“Now here we are 15 years later,” Kalfas says, “and our jails are overcrowded, our treatment system is overwhelmed, and we’ve got a bigger problem than we had to start with.”

“Our whole approach is punitive,” Kalfas says. “The way we’ve attacked this problem from the get-go is ‘We’ll just lock ’em up until they’re ready to quit using. We’ll punish this away’.”

Now, he says, “the years we have spent not treating (addiction) as a disease are coming back to haunt us.”

In Washington, the policy gears are shifting, but no one has stepped on the gas. Some lawmakers are pushing for a broader response that treats the heroin epidemic more as a public health issue than a criminal problem. Others are calling for an overhaul of the criminal justice system — softening mandatory minimum sentences, for example, for lower-level drug offenses.

But those sweeping changes may get bogged down, particularly in a partisan Congress more concerned with avoiding an imminent government shutdown than with solving the growing heroin problem.

“I’ve heard a lot of lip service,” Ceniceros says of policymakers in Washington. “But I don’t see any action.”

Until that changes, Ceniceros says his legislative priority is winning one small change that would make a huge difference — lifting the buprenorphine cap.

Fifteen years ago, Congress passed the Drug Addiction Treatment Act, which made it legal for doctors to prescribe opioid addiction medications in their offices “as opposed to a specialized clinic setting” if they secure a special waiver. But doctors are limited to treating 30 patients during their first year and 100 patients annually after that.

Because the treatment was new and happening for the first time in a doctor’s office setting, those caps were thought to be a reasonable starting point. Buprenorphine is classified as a Schedule III narcotic. In prescription drug formulations, such as Suboxone, it works by blocking opioid receptors in the brain and minimizing withdrawal symptoms.

Now, the treatment regimen, called medication-assisted therapy, or MAT, is a proven success and widely accepted. Given in combination with behavioral therapy and other counseling, 70 to 80 percent of patients become stable.

“This is not rainbows and unicorns,” says Waller. “This is real.”

But a pending bill to lift the caps has not gained traction in Congress. Some doctors worry lifting the cap would undermine the quality of treatment for addicts and increase street access to another powerful drug with potential for misuse. John Sorboro, a psychiatrist and addiction treatment specialist in private practice in Ohio, is among those urging caution.

He says allowing more primary-care doctors to treat addicts would lead to a revival of “pill mills” where doctors dole out drugs in exchange for cash without any additional services or care.

“You’d have, I’m afraid, the Wild West,” Sorboro says. “Buprenorphine has the lowest abuse potential of any drug in its class, but it’s still an opiate.”

Ceniceros says there are valid concerns about buprenorphine diversion. In the Springfield area, he says heroin users have started buying it on the street to stave off withdrawals if they can’t get their heroin fix.

“It’s not to get high because buprenorphine doesn’t get you high,” he says. Instead, addicts keep it with them “in reserve if they can’t make a buy of their regular stuff because (heroin) withdrawals are so horrendous.”

Other states have seen a similar pattern — with street addicts using buprenorphine to wean themselves off heroin or to avoid withdrawal between highs.

Gitlow, the Rhode Island addiction expert, says that while there is potential misuse of buprenorphine products, the drug is much safer than other opioids doctors can currently prescribe with no restrictions.

“We can write as much Percocet and OxyContin prescriptions as we want to,” he said. “It’s the safe drug we’re limited from.”

Gitlow says if this were any other disease, Congress would never limit how many patients doctors could treat. “Imagine if oncologists could only treat a certain number of patients with a certain type of cancer,” he said. “No one would stand for that. But because this is addiction and we’re talking about heroin addicts, it’s OK to put a roadblock in the way of their getting care.”

Ceniceros agrees the stigma associated with addiction is a huge barrier. He says Congress should lift the cap, putting safeguards in place to ensure that practitioners who treat more than 100 patients are doing so in a carefully monitored program. Doctors should be required to offer counseling services and monitor patients with urine tests to ensure they are not selling their buprenorphine, he says.

In the meantime, Ceniceros says, “I’m just trying to keep my head above water.”

And so are the people on his waiting list.