Here’s the original story I wrote on medically-assisted treatment recommendations in Ithaca’s much-written-about drug policy; it was cut down a bit on the end for print, since Vivitrol wasn’t mentioned in the mundanely-named “Ithaca Plan.” I thought it worth fleshing out what exactly the issues with these treatments are right now, since no one else was doing it, and especially since in a lot of places recommending something like a methadone clinic would raise hell all on its own (hello, Williamsport!). This story ran as part of our March 2 cover package, a week after the plan’s official release. Photo is mine, of Nicole Pagano, who has an honest-to-goodness soda counter in her pharmacy.
Beyond the potential “supervised injection facility” for heroin addicts not yet taking steps to recovery, there are many more recommendations in the new city drug policy for new and increased services to help those who want to get and stay off dope. A large part of building the comprehensive “recovery-oriented treatment continuum” the plan proposes is getting people access to what’s called “medically-assisted treatment” – that is, drug treatment that help dull cravings for the dangerous street stuff.
Mayor Svante Myrick said last week that one of the plan’s “low hanging fruit” could be convincing more physicians to prescribe Suboxone – the brand name for a combination of buprenorphine, an opioid, and naloxone, which deters use by injection. Under federal regulations, a doctor can only prescribe the drug to 100 patients at a time.
“If the mayor has a special relationship with the president and he would like to sign an executive order to lift the cap, that would help,” said Dr. John Bezirganian, one of four doctors in Tompkins County currently certified to prescribe Suboxone.
Bezirganian has a private psychiatry practice and is medical director for county mental health and the Alcohol and Drug Council (ADC). Since he started prescribing Suboxone about 15 years ago, he’s treated 520 people with the drug – about 20 of his initial patients are still with him today.
In earlier days, if someone came to him off the street and asked for Suboxone, he told them to go to the ADC, and then he could generally promise to get them onto the drug once they graduated from treatment. Because of the limit on prescriptions, now he has to make choices about his patients.
“To some extent I’m playing God a little bit, but I have to pick the best available people,” Bezirganian said. “If I have to make a choice of a single mother who’s sober and working against someone dabbling in other drugs. A young single guy might say that’s not fair. And it’s not fair. But that’s the way it goes.”
The original limit was 30 Suboxone patients per practice, “but they raised it to 100 because no one was signing up,” Bezirganian said.
A special Drug Enforcement Agency number must be issued for a Suboxone provider. There is a seven-hour course to get certified on the drug, some of which is mere “hoop-jumping training,” Bezirganian said. More so than the training itself, he thinks that more doctors don’t participate because of the effect they think prescribing Suboxone might have on their private practice.
“I think many primary care doctors would be fine if they have five people they like and can do it for them, but they don’t want 30, 50, 100 people coming in the door saying ‘Hi, I want Suboxone,’” Bezirganian said. He gets four or five calls a week, and keeps a few spots open in case someone in special circumstances, like pregnancy, needs the drug.
“If I had the spigot open it’d be limitless,” Bezirganian said. “If all doctors could prescribe it, I don’t know how big it would be.”
Nicole Pagano of the Green Street Pharmacy said she has developed a “good working relationship” with ADC and Cayuga Addiction Recovery Services (CARS) since she opened her shop in 2010.
“I can spend hours and hours and hours on the phone to figure out insurance,” Pagano said. “We try to work out insurance ahead of time. Sometimes we can use coupons for the medication to help someone cover the cost for the first few days … If we can’t treat someone today, they might be lost tomorrow.”
Pagano strives to foster a “judgment-free zone” at GSP; she said many people going on Suboxone are in a situation where they’re afraid of losing their children.
“With no other disease do you have the pharmacist look at you like, ‘Oh, another one of those,’” Pagano said. “Everyone who comes in here is dealing with something … One day of heroin use is more dangerous than a lifetime of Suboxone.”
People in recovery dealing with the aide of methadone right now have to leave Tompkins County to get their treatment. The Ithaca Plan recommends adding a methadone clinic here or even, as Myrick has floated, a mobile unit to distribute the drug.
Monika Taylor, director of chemical dependency at Crouse Hospital, Syracuse, said that there are currently seven patients commuting from Tompkins County on a daily basis to the Crouse methadone clinic. Her clinic can serve up to 650 people at any one time under state regulations, with a waitlist about nine to 12 months long and about 350 people deep right now. The program admitted 265 people in 2015, its most in a year since opening in 1975, and is serving about 550 people at the moment.
The only issues that can move someone up the wait list are either pregnancy or being HIV positive.
“It’s challenging for people to understand we can have a wait list with capacity,” Taylor said. “The problem is when you admit someone into treatment a lot goes into that – methadone is a controlled substance and it requires pretty close monitoring. For the first three weeks or so there’s daily assessment of somebody in that induction phase to get to that therapeutic dose where they’re neither sedated nor going through withdrawal.”
Most people in treatment of opioid addiction do receive some kind of medically-assisted treatment, according to Angela Sullivan, executive director, of ADC. About 33 percent of ADC’s approximately 500 patients last year were admitted for opiates as their primary drug – up from about 5 percent in her first year, 2011. Of that 33 percent, about 27 percent of their total patients received some form of medical assistance.
Heroin-assisted treatment is also mentioned in the plan as something to be explored – providing addicts who don’t respond to Suboxone or methadone with synthetic heroin is a “last resort,” though, according to Peter Schafer of the New York Academy of Health.
One medical treatment unmentioned in the plan is Vivitrol, the brand-name for naltrexone, an opiate blocker that also treats alcohol dependency, which can be prescribed by any doctor and requires a monthly injection.
Alkermes, Vivitrol’s parent company, is “going to every county and pushing it in jails,” Bezirganian said. Because of serious interactions with opiate use, “they tell you only to prescribe it to people who are highly motivated, like an anesthesiologist with a drug problem or people on state parole,” the doctor said.
In an ideal world, Bezirganian said that Suboxone would be widely available for people no matter what other recovery steps they’re taking.
“Some people aren’t that interested in the whole recovery thing, going to groups, which is part and parcel of coming to an agency,” Bezirganian said. “For people coming in using lots of heroin, you could start them on a good dose and lower it over time. You can let people detox themselves.”