In Rehab, ‘Two Warring Factions’

MURFREESBORO, Tenn. — Just past a cemetery along a country road, an addiction treatment center called JourneyPure at the River draws hundreds of patients a month who are addicted to opioids and other drugs. They divide their days between therapy sessions, songwriting, communing with horses and climbing through a treetop ropes course. After dinner, they’re driven into town in white vans for 12-step meetings.

It is a common regimen at residential treatment programs, but as the opioid epidemic persists, JourneyPure is evolving. Though its glossy website doesn’t mention it, the company is ramping up its use of medications to blunt the torturous withdrawal symptoms and cravings that compel many with opioid addiction to keep using. There is substantial evidence backing this approach, which is supposed to be used in tandem with therapy. But because two of the three federally approved medicines are opioids themselves, it is spurned by people who believe taking drugs to quit drugs is not real recovery.

Addiction experts say such resistance is obstructing efforts to reduce overdose deaths and help addicted Americans get their lives back on track, even as many drain their savings or go into debt paying for repeated stints in residential rehab. Two-thirds of the patients admitted to JourneyPure’s program here over the last three months said it wasn’t their first time in treatment.

“I’m watching the dominoes fall on our industry,” said David Perez, JourneyPure at the River’s new chief executive, who has helped lead the push toward using more medication-assisted treatment. “People are dying, and we are feeling more and more impotent to stop it. That is what’s shifting beliefs, more than anything.”

The internal tensions over JourneyPure’s changing policy, and how proactively it should promote medication as an option, reflect an often reluctant shift taking place in the drug treatment world.

At the same time, the Trump administration’s view on medication-assisted treatment has evolved from critical to fully supportive. Tom Price, Mr. Trump’s first Health and Human Services secretary, appalled many addiction experts by saying, “If we’re just substituting one opioid for another, we’re not moving the dial much.” But Mr. Price’s successor, Alex Azar, a former pharmaceutical executive, has embraced the approach.

When the administration announced $1 billion in new grants to expand access to treatment earlier this year, it emphasized that only programs that made these medicines available were eligible. Mr. Azar has also enlisted his agency’s Center for Faith and Opportunity Initiatives, to reach out and explain the importance of medication to religiously affiliated providers of treatment and recovery services, which tend to embrace an abstinence-only approach.

More than 70,000 people in the United States died of overdoses in 2017, and opioids were the main driver. But nationally, 49 percent of the nearly 3,000 residential programs that treat opioid addiction still don’t use any of the medications proven to save lives, according to an analysis by amfAR, a foundation that funds AIDS research. Even so, that is an improvement over 2016, when 58 percent weren’t using any of them.

The strong evidence for medication-assisted treatment has yet to win over not only many treatment providers, but patients themselves. Heather Ramsey, 30, who is six months pregnant, was prescribed one of the medications, buprenorphine, at JourneyPure. Addicted to pain pills and Xanax for half her life, she had finally sought treatment because, she said, “My body can’t take it no more.”

Despite her doctor’s assurances that medication was the safest, surest protocol for her, Ms. Ramsey, from rural East Tennessee, feels guilty about it.

Patients during a therapy session at JourneyPure.CreditIlana Panich-Linsman for The New York Times

A whiteboard at JourneyPure invited inspirational quotations.CreditIlana Panich-Linsman for The New York Times

“I feel like I’m kind of, in a sense, cheating the program,” she said one afternoon in the living room of a residential cottage, adjusting her ponytail after a group meeting with a recovery coach. “Because I’m still depending on a substance to make me feel normal, and that’s not why I came here.”

Anti-craving medications are not a silver bullet; relapse is common even among people who take them, and some in fact do better with an abstinence approach. But there is substantial evidence that buprenorphine and a similar drug, methadone — which has faced ideological resistance on and off for decades — reduce the mortality rate among people addicted to opioids by half or more; they are also more successful at keeping people in treatment than abstinence-based approaches. A federally funded study last year found that naltrexone, a non-opioid medication that JourneyPure has offered to some patients since it opened in 2015, was just as effective as buprenorphine.

But naltrexone, also known by the brand name Vivitrol, is more expensive and people tend not to stay on it as long. It is also harder to start because it requires a long detox period first.

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Insurers are starting to pressure providers to use medication assisted treatment, or M.A.T.

“It’s really the linchpin of our strategy going forward — I can’t overemphasize that,” said Daniel Knecht, vice president of clinical strategy and policy at Aetna. “But too often you have to convince the caregivers, as well as the patients, that M.A.T. is the cornerstone.”

Sam MacMaster, JourneyPure’s co-founder and chief clinical officer, is among the wary. He acknowledges the power of medication to “stop the chaos” that envelops the lives of addicted people, but worries it will squeeze out therapies that help them learn “how to connect, attach to other people and healthy things.”

“My fear is we are heading in the direction where it’s enough; that there’s a wholly pharmaceutical solution to addiction.”

Sam MacMaster is the co-founder and chief clinical officer of JourneyPure. He is skeptical of the efficacy of medication-assisted treatment.

It’s true that if medications became the main form of addiction treatment, the pharmaceutical industry would benefit — an outrageous outcome, critics of the approach believe, given the industry’s role in creating the opioid epidemic. But medication-focused treatment would also threaten residential programs like JourneyPure, a for-profit company with locations in Florida and Kentucky as well as Tennessee. It charges an average of $15,000, and up to $26,000, for a monthlong stay, though many of its patients have private insurance that covers most of the cost.

Change started to come to the JourneyPure program here in Murfreesboro with the hiring of Mr. Perez as chief executive a year ago. He came from a treatment center in Memphis that has long used medication, and was struck by the resistance to it in Middle Tennessee, where even liberal Nashville still has just one methadone clinic.

A few months later, JourneyPure hired Dr. Stephen Loyd, who had been the medical director for the Tennessee Division of Substance Abuse Services. Dr. Loyd himself went through treatment for addiction to painkillers in 2004 and in his state role, became an evangelist for medication-assisted treatment.

Now he has a similar role as medical director for JourneyPure’s Middle Tennessee programs, where a few months ago he presented his bosses with a “manifesto” outlining how he wanted the company to use medications more aggressively, including by expanding its outpatient clinics and providing buprenorphine to more patients across its sites.

“You’ve got these two warring factions — the M.A.T. side and the abstinence-based side,” he said. “It’s almost like our national politics. Where’s the John McCain? Here, it’s going to be me.”

The medication that JourneyPure and other residential treatment programs use most is naltrexone, because it is not an opioid. It blocks the brain’s opioid receptors, preventing any high in patients who try to use opioids while on it. JourneyPure typically offers patients an initial shot near the end of their stay, with the option of returning monthly for more.

At Dr. Loyd’s urging, JourneyPure has also decided to let residential patients take buprenorphine, also known as Suboxone, if he recommends it. In the past, the company had used the medication only to help detoxing patients get through withdrawal.

JourneyPure uses an approach known as trauma-informed care, where patients explore traumatic experiences from their past that might help explain their addiction, and learn new ways to cope. Most patients also have mental illnesses like bipolar disorder or post-traumatic stress disorder that need to be treated, Mr. MacMaster said.

Songwriting and spending time with horses not only help people open up and feel valued, company leaders say, but add to the allure of residential treatment.

“If we went purely science-based, nobody would come to treatment because it would be boring,” Mr. Perez said.

JourneyPure uses trauma-informed care, where patients explore traumatic experiences from their past that might help explain their addiction, and learn new ways to cope.

Residents get ready for dinner at JourneyPure. The many therapeutic activities help add to the allure of residential treatment. “If we went purely science-based, nobody would come to treatment because it would be boring,” said David Perez, JourneyPure’s new chief executive.

A patient’s daily cleaning schedule has given her something to keep her busy since leaving rehab. Patients are assigned a recovery coach to meet with weekly after they are discharged.

Some of Dr. Loyd’s patients have been arrested for taking the very medications that he and many researchers feel are crucial to their recovery. Miranda Nichols, 25, initially came to JourneyPure a year and a half ago for heroin addiction. When she left after a month, she said, she got a Vivitrol shot but it was so expensive — her co-payment was $600 — that she never got another.

She returned to shooting heroin, then got pregnant and switched to buprenorphine she bought on the street back home in Alabama because, she said, she could not afford the cash-only clinics that prescribed it there. There, she got charged with theft and “chemical endangerment of a child,” the latter because she was taking buprenorphine without a prescription. After a stint in jail, she returned to JourneyPure with a court’s permission for more treatment.

Dr. Loyd, who had just started working at JourneyPure when she returned, put her back on buprenorphine; Ms. Nichols gave birth to a healthy son in June, after spending three months at the treatment center. She is working for a plant company in Nashville and living with the baby at a recovery home that allows buprenorphine. She lost custody of her two older children after her arrest, however. Her case is supposed to go to trial next year, and Dr. Loyd is writing a letter of support.

“People are getting more educated on buprenorphine now,” Ms. Nichols said. “They see my story and what kind of person I am, and they see how it actually works.”

“But,” she added, “back in Alabama, I could still go to jail for up to 20 years.”

Miranda Nichols and her son Sawyer.

Here in Tennessee — where overdose deaths rose by 9 percent in 2017, to 1,776, the highest number on record — the state did little to promote medications for addiction treatment until recently.

Over the past year, though, it has started doling out federal funds for expanding medication-assisted treatment to 15 nonprofit programs around the state. State health officials are training employees of the programs how to use the medications and, at times, talking them through their reluctance.

“They had to change their business rules, their philosophy,” said Taryn Sloss, assistant commissioner for the Tennessee Department of Mental Health and Substance Abuse Services. “A lot of them were abstinence-based and had people in recovery on their boards who thought, ‘If it was good enough for me, it’s good enough for everyone else.’”

Because they’re not eligible for government grants, for-profit companies like JourneyPure don’t face as much pressure to embrace medication-assisted treatment. They are regulated through a state licensing process, but Tennessee, like most states, doesn’t require medication to be part of their treatment protocol for opioid addiction. Nor do accrediting bodies like the Commission on Accreditation of Rehabilitation Facilities, although the commission has started requiring programs to help patients access medication if they want it.

“We should make it the standard in terms of running a treatment program that’s licensed by a state in the 21st century,” said Michael Botticelli, who served as the drug czar under President Obama and now leads the Grayken Center for Addiction at Boston Medical Center.

It was late summer at JourneyPure; the horses were grazing behind the barn, and a river burbled behind the cluster of cottages where patients live. Around a conference table in the main building, tensions were crackling over medication-assisted treatment.

Dr. Loyd was there, as were Mr. MacMaster and Patrick Dunn, the company’s chief of operations development.

“There’s a small group who will probably need to be on M.A.T. for the rest of their lives,” said Mr. MacMaster, who quit drugs and alcohol 30 years ago, mostly through 12-step programs. “But everybody in this room knows drug-free recovery is really the gold standard.”

“I have to disagree,” Dr. Loyd said.

As a state official, he said, he had seen people enter the state’s drug court programs on medication, only to be forced by a judge to go off it and pursue abstinence-based treatment.

“These people were vulnerable, at high risk of overdosing and relapse,” he said. “We have to keep as many people alive as we can.”

Shannon Siedzik came to JourneyPure from New Jersey to be treated for heroin addiction. She said she wasn’t interested in medication because she’d had a previous reaction to buprenorphine.

It’s a message that Dr. Loyd has taken on the road, giving a talk called “The Addicted Brain” in churches and other forums across the state. He did so one recent evening in downtown Murfreesboro, to a group that included an emergency room doctor still in scrubs, parents whose children had struggled with addiction and staff from a nearby drug court.

“When I get a kid coming in that’s been to five abstinence-based programs, and he’s overdosed and he’s been Narcanned four times and he’s 23 years old, I am absolutely going to talk to him about medication 100 percent of the time,” he said, referring to the drug Narcan that revives people from overdoses.

“Matter of fact,” Dr. Loyd continued, “I’m going to try to talk him into it, because I know it’s his best shot at living. Yet I have people out there all the time, right now, that will throw rocks at this kid and shame him for being on it.”

An unfinished puzzle at JourneyPure, left, and Dr. Stephen Loyd, the facility’s medical director. “Medication is a way to level the playing field,” he said.

Ms. Siedzik before bedtime at JourneyPure. After she was released from rehab, she chose not to take methadone as part of her recovery.

On a frigid December afternoon, a group of JourneyPure patients gathered for dialectical behavior therapy, which teaches mindfulness and “distress tolerance” for getting past negative feelings and events. Shannon Siedzik, 26, diligently took notes. She had come from New Jersey to be treated for heroin addiction, her fourth attempt at rehab, she said. Her insurer had approved only a weeklong stay, and she said she wasn’t interested in medication — she’d had an allergic reaction to buprenorphine when she tried it once.

Dr. Loyd had met with her that morning and urged her to try methadone, but she was resisting. A JourneyPure discharge planner had already arranged for her to move into a recovery home in Nashville that did not allow any of the medications.

“I feel pretty good leaving here,” she said, though she added, “I won’t know where to go if that craving happens.”

After therapy, Ms. Siedzik returned to the house she was sharing with a dozen other women for a 12-step meeting led by a JourneyPure recovery coach.

Following the meeting, Christmas music tinkled and several housemates prepared dinner while she stared out the window. Dr. Loyd’s plea had jarred her.

“He’s worried about me relapsing and overdosing and dying,” she said quietly. “It upsets me because it’s kind of true. It scares me — like, a lot.”

Dr. Loyd had urged her to call Nashville’s only methadone clinic once she left JourneyPure and offered to help find her a spot at a different recovery home that allowed medication.

“It’s not a bad idea,” she said. “But I’m thinking about the future, getting off of it — how hard will that be?”

The next morning Ms. Siedzik got a ride to a recovery home indistinguishable from all the other houses on the street in a neighborhood about 15 minutes from downtown Nashville. She hoped to get a Narcotics Anonymous sponsor, a job waitressing and a spot on a recreational soccer team.

A week later, she had not called the methadone clinic and said she felt happy with where she had landed.

https://www.nytimes.com/2018/12/29/health/opioid-rehab-abstinence-medication.html