Illustration by Erin Perfect.

The first time I talk to Dr. Claude Curran, it’s a cold Friday evening in Fall River, Massachusetts. We’re in his office, which is the bottom floor of a weathered Victorian. He owns the whole building, but the top two floors are empty. He used to rent one out to another doctor, doing the same work he did, but that doctor left, and now he thinks that sharing space invites a lot of unnecessary trouble. There’s a shopping cart blocking the stairwell in the first floor landing.

“Lookit, I’ll tell you what I know,” Curran says to me in a flat New England accent. “When Adam was there in the Garden, that was the first time man has ever felt alone, in pain. He needed something to not feel lonely. If God had given him OxyContin, there wouldn’t have been any need for Eve.”

He laughs, though he’s maybe kind of serious. Curran is a conservative Catholic. He has a vanity plate that reads, “DUBYA.” There are biblical affirmations tacked to the walls in the office. I had lazily assumed that when I spoke to doctors who treat addiction I’d find a monolith of liberal atheists, but the job cuts across all demographics, like the disease it treats. This is difficult work that many won’t attempt; those who do draw on all sorts of motivations, from religious devotion to harm-reduction beliefs to communal desperation, sometimes a combination of them all. In Curran’s waiting room, I can hear a small box TV buzzing with Catholic public access, a soft voice-over attempting to describe paradise.

The key to what Curran is talking about is pain. In a place like Fall River, there’s a lot of pain—the personal kind, the social kind, the kind born of generations of either physical labor or joblessness. It’s a ready-made set piece, all empty, faded-brick buildings. The kind of town that has had an opiate epidemic for decades. To Curran, providing patients here with addiction medication is something akin to being a doctor with malaria pills in a jungle.

“What does the Hippocratic Oath say?” he asks me. Before I can answer he does: “It says that if you can provide them something to make them feel better, you provide it.”

Curran was an early adopter of buprenorphine, a medication for the treatment of opiate addiction that, unlike methadone, was approved for use in a general office setting. A doctor can take an eight-hour course and apply to get a waiver to prescribe buprenorphine, and, for the first time ever, could treat someone suffering with addiction. Instead of waiting in line at a clinic each morning for a dose, patients could visit their doctors monthly, receive a prescription, and medicate like anyone else.

The difference between the drugs is chemical—methadone is a full opiate agonist, the way heroin is. It binds to your opiate receptors and produces euphoria without any ceiling, until overdose. Buprenorphine is a partial agonist: it binds much longer and tighter to the opiate receptors than methadone (blocking other opiates from binding) and it stimulates them, but only to a ceiling of 47 percent stimulation. So, those consistently using buprenorphine experience a limited or nonexistent high, and are unable to feel the effects of any other opiate. In the US, buprenorphine is most commonly combined with naloxone, an anti-overdose drug, creating a medication (usually called Suboxone, though there are other brands) that’s extremely difficult to abuse: it produces withdrawal symptoms the moment someone attempts to use it intravenously.

Curran began prescribing in 2002. He was stunned by the results, and so were his patients. The first patients went out and told others, and there were many others. But he wasn’t supposed to treat an endless supply; at the time, a doctor was capped at thirty buprenorphine patients in any given year. Curran hit his cap in less than a week. In a matter of months, he was looking at over 700 people in need. He didn’t know what to do. He tried to get local methadone clinics (who were authorized to dispense buprenorphine) to take his patients, but they were unwilling to use anything but methadone.

“The people kept coming,” he tells me. “It was like Schindler’s List.”

It’s hard to turn away someone prostituting for drug money because of a number you’re not supposed to cross. And this is where the Hippocratic Oath comes in. He prescribed to all of them.

“They told me I was the biggest violating doctor in America,” he says.

When the DEA agents—young blonde women in professional attire, like pharmaceutical reps—first showed up at his office in 2005, it was a surprise. The waiting room was full, and his patients watched as the officers told him to start letting people go.

“They told me I was the biggest violating doctor in America,” he says.

The Massachusetts Board of Registration in Medicine came after his license, but he didn’t go down quietly. He fought in court and led rallies at the JFK Federal Building in Boston, demanding greater access to the medication. He kept his license, but was dropped by several major state insurers. More worrisome, he had to release over 600 patients back to the streets. That’s when Curran started keeping his death list, a Word doc on his ancient office iMac. We scroll through it together. Sometimes he stops to tell a story about a name. He doesn’t update as much anymore. When he got to 1,200 names of local people dead from overdose, it began to feel like a pointless exercise.

* * *

I should stop here to say that I do not claim objectivity. Which is sort of the problem when you try to talk about addiction—everybody has experienced it or seen it in some way; everybody feels strongly about it, a feeling often accompanied by a remarkable willingness to comment as an expert. The anecdotal, the moral, the belief system, all become evidence.

As Dr. Corey Waller, Chair of the Legislative Advocacy Committee of the American Society of Addiction Medicine, said to me, “If you’re an oncologist and you go to a party, nobody comes up to you at that party and starts telling you what you need to understand about cancer.”

Here’s what I bring to the conversation: I had a brother who overdosed and died a couple of years before buprenorphine was available. He had been on methadone, and was kicked out of a clinic when his urine came up dirty. This was in New York during the Giuliani years, and the mayor was committed to restricting methadone and promoting abstinence-only programs. My brother tried to get clean on his own. He did, for about six weeks. Then he relapsed and, his tolerance lowered from the abstinence, died alone.

There is another person I love very much who took buprenorphine after many years of opiate addiction. That person has been taking buprenorphine for four years, and is highly functional.

I will not refer to that person by name when I say that I’m so happy they’re alive when I didn’t think they would be, and proud of them for the treatment they’ve sought and continued. No one wants to be identified as being in remission from this disease; with that remission comes the admission of the disease. And if a disease comes with so much shame that it requires anonymity, how much are we really considering it a disease?

Even what I just said, about being proud of them, is a shitty way to put it. Pride brings with it a value system. Pride is not a medical word. They have a chronically relapsing condition that, for the moment, is being effectively treated. There is no morality to that treatment; it just is.

And my brother who died—I shouldn’t have called his urine dirty, I shouldn’t have called his drug-free six weeks clean.

A semantic debate seems frivolous in a conversation about over 20,000 people dying a year. But you can’t separate the deaths from how it is we think they died, or what we so deeply believe is the right way to try to save them. We accept now, more and more, that addiction is a disease. Okay, good. Now see how hard it is to find the words that make it seem like we believe that.

* * *

When Curran’s office is open, it’s still always full. He stays right at the patient limit for buprenorphine, and also provides other psychiatric treatment for Fall River’s poorest residents.

On any given day, there are twenty people crammed into the waiting room, another five or so smoking out on the little porch. When I go out there and ask questions, the answers are like this:

J: I was working cleanup after a hurricane in the 80s. Some wreckage fell and I lost my toes. It’s a lot of pain. I like booze, and Vics and Percs. It’s hard to get Suboxone. I’m still on the waiting list at the clinic in New Bedford—they just never called back. I was buying it for $10 a pill on the street. I know a lot of people who need it who can’t get it. Not friends. All my friends are dead.

Or M: My father was an addict. My brother, now my brother-in-law, too. My brother died; it was a suicide by cop sort of thing. He couldn’t get treatment, he didn’t want to keep using, he didn’t want to go through withdrawal. He had a standoff with the Taunton cops and they shot him. You can read about it in the paper.

Or B, who’s scared to go home because she lives with her mother and her mother’s boyfriend assaults her when her mother is out. B was on methadone for a while, hated it, tried to get off it, and ended up attempting suicide in withdrawal. After that, she was a patient of Curran’s for about a year. A few months ago, he kicked her out of treatment. He pill-counted her and, a couple of times, the number came up wrong. She stopped taking the medicine for a while, started selling it and using the money to buy heroin. She says it started on one of those days when her mother’s boyfriend did what he did and she wanted to feel different than how she felt. She says she shouldn’t have done it. She’s here to ask Curran to take her back. She can’t find a doctor with room on their cap limit who takes Medicaid.

She rocks as she speaks. She rubs her hands together. She asks if I can put in a good word for her. She looks like a junkie. She looks like someone who needs her medication.

Curran can’t take her, I know. There isn’t room, and he’s trying to lay low. He ends up prescribing two weeks worth to buy her time. He calls this compassion. Many others would call it against best practices. Either way, it’s a desperate gesture, and probably ineffective.

I text B for a while, trying to find a time to check in and see if she’s gotten treatment. For a couple of weeks she answers; then she stops.

* * *

Opiates were first legislated in the Harrison Act of 1914. At the time, you could get opium over the counter, and that had become a booming, unregulated business. The Harrison Act required that anybody importing or selling opiates register with the IRS and pay a special tax on the product, or else possession would be illegal. It exempted doctors explicitly using these drugs in their medical practices. In 1919, however, the Supreme Court ratified the Harrison Act, specifying that the practice of medicine did not include prescribing narcotics as a maintenance medication to those already addicted.

That was the accepted norm for half a century, until the Narcotics Addiction Treatment Act of 1974, which first defined, under Federal law, maintenance treatment, allowing for the heavily regulated use of methadone to treat addicts. Methadone is as potent an opiate as heroin. If abused, it produces a higher overdose rate. It was not deemed safe for prescription, but special Opioid Treatment Program (OTP) clinics could dispense controlled, daily doses, taken in the facility.

This was, and remains, a controversial decision, part of a still prevalent narrative about the folly of replacing one drug with another; look back to the ratification of the Harrison Act, the determination that addiction treatment was somehow outside the purview of medicine. The primary model for treatment of any addiction in the US has been the 12-step, total-abstinence model; thus, many still see methadone as helping to sustain a junkie. Less discussed in 1974, and still today, was the fact any doctor can prescribe methadone to any patient to treat pain.

Buprenorphine was made legal for the treatment of opiate addiction in response to the pain pill epidemic of the late 90s. It had been used in many European countries for decades, but in the US, it remained as distrusted as it was necessary. Politicians didn’t like the idea of enabling doctors to dole out another opiate without limits. These weren’t experts; these were lawmakers afraid of another prescription drug epidemic, who didn’t distinguish much between buprenorphine and other opiates whose addictions it was meant to treat. The end product of this ambivalence was the Drug Addiction Treatment Act of 2000 (DATA 2000).

There’s a reason why federal agents could show up in Curran’s office without a warrant, demand his records.

Nick Reuter was the senior public health analyst of the Substance Abuse and Mental Health Services Administration (SAMHSA) when the law was passed. He remembers it like this:
You have to understand, the patient cap numbers were provisions of an experiment. You had the senate and congress arguing. Nobody really understood; this was uncharted territory. The president wasn’t sure it was the right thing to do at all. There was a lot of caution. I think the senate said, why don’t we cap it at twenty patients? And congress said, how about forty? Thirty was in the middle. None of these numbers were founded in science.

In 2006, the cap of thirty patients per doctor was increased to 100 after the first year of treatment. The change was essentially smuggled into law—a single sentence in an otherwise unrelated bill called the Children’s Health Act. Though there have been recent signs of change, buprenorphine remains the only medication in America that mandates a patient limit for prescribing doctors. With that cap comes unprecedented regulation. There’s a reason why federal agents could show up in Curran’s office without a warrant, demand his records. Unlike with any other medication (including the pain pills buprenorphine was approved to combat), buprenorphine prescribers agree to random audits by the DEA.

“My first DEA visit was routine; they were very respectful, professional,” Dr. Richard Saitz tells me. Saitz works at Boston University, a leader in the addiction field, and helped write the curriculum for the certification course. “That being said, it was horrible. I’m a doctor. I have a working office. My staff is there, my waiting room is full, and these cops walk in with the blue jackets and everything.”

The DEA says most audits are uneventful, and most doctors say agents are sympathetic. But some encounter agents who assume that if they’re empowered to investigate something then it must be criminal. Saitz, with his robust staff and record-keeping system, says he felt interrogated, but safe.

“I imagine a doctor in a one-man office, trying to see his patients and comply,” he says. “I honestly don’t know what I would do.”

* * *

I meet Scott Houghton at his home in Connecticut because he doesn’t have a doctor’s office anymore because he’s no longer a doctor. He lives in a wooded, affluent suburb full of fancy new houses made to look old. His house has now been refinanced to its last possible refinancing. He fears he’ll lose it.

It took a long time to convince Houghton to speak with me. Local press coverage of his trial for illegal narcotics sales included quotes from a state attorney calling him a “classic narcissist” with “no contrition of any kind.”

Houghton had been a small-town doctor with his own general practice, treating the whole community. Like most doctors, he’d never received any education in addiction medicine. When many patients began to confide in him about their painkiller dependencies, including incidents of heroin abuse, he was stunned, but wanted to help.

He fell in love with the work. There’s no population, he discovered, that by and large wants so badly to be better. He hit thirty patients very quickly his first year. He says he did not exceed thirty; the case against him says otherwise. Houghton hit his patient cap almost immediately, and began having to turn perspective patients away weekly. Again, he says he didn’t exceed the number; the case against him says otherwise.

When the Connecticut DEA entered his office, Houghton, like Curran, was surprised, but unworried. It never occurred to him that he could have been doing something wrong.

“I was giving my patients the best possible care,” he says. “My patients were getting better. I’m not a person that’s ever gotten in trouble.”

Houghton refused to give up his buprenorphine license, refused to admit to any wrongdoing, and ended up on trial, facing forty-seven felony counts, varying from illegal prescribing of narcotics to failure to maintain controlled substances records.

Houghton rummages through boxes to find me the official case brought against him. The case emphasizes ways he exhibited improper care and acted without good faith—the idea is if you add up perceived wrongdoings, improper care becomes “illegal prescribing.” It claims that he accepted cash for services (he says he did this for some patients who wanted no insurance record of addiction treatment; it’s not illegal), didn’t provide urine screening (he denies this; it’s also not illegal), didn’t provide access to counseling (he says he gave each a referral and, again: not illegal).

Early on, the case mentions that he received between $300,000 and $400,000 prescribing buprenorphine over the course of thirty months. If you think about Houghton as a doctor charging for patient visits, and spread that out over nearly three years, you find a general practitioner making a middle-class living. If you want to see him as a guy taking money for drugs, you find The Wire.

Then there was the claim that Houghton exceeded his patient limit. Every patient the DEA saw as extra was potentially illegal. This is a place where medicine and law are incongruous. For Houghton, a person he admitted once who then did not continue treatment didn’t count as a patient. Or one who’d weaned off. Or one he discharged when he caught them selling medication. But with no language in the law to specify the definition of patient, the DEA can choose to count every name on a chart.

“The prosecutor kept saying I was responsible for her son’s death,” Houghton says. “That was hard to hear. Like I’d killed somebody.”

Houghton speaks to me for three hours. His wife hovers by the kitchen counter nodding sadly, then angrily, then sadly again. Their teenage son walks in, leaves. Houghton mostly speaks in a monotone—this is a story they’ve been living with for five years now. The emotion picks up when he describes the prosecutor’s strategy of inviting the family of a former patient who overdosed to court.

“The prosecutor kept saying I was responsible for her son’s death,” Houghton says. “That was hard to hear. Like I’d killed somebody. He wasn’t my patient when he died. I hadn’t seen him in months. He died from painkillers prescribed by doctors who weren’t on trial.”

Hundreds of patients sent letters to court praising Houghton. An addiction expert from a nearby hospital testified on his behalf. Houghton wanted to keep fighting, but his lawyer said good luck trying to show a jury the nuances of addiction treatment, and he’d run out of money. He pled guilty under the Alford doctrine, in which a defendant does not admit to criminal wrongdoing and asserts his innocence. But he acknowledged that he’d lose.

Here’s the thing: I have no idea if Scott Houghton was a good doctor, but I’m not sure if that matters. He wanted to, did, help some people, and you don’t have to believe that his patients were receiving the best possible care to believe that it was better for them that he existed. When his practice was shut down, 100 or so people in various stages of remission were left, overnight, without access to medicine they needed.

Houghton tried to place them. Many, he couldn’t. He tried to keep tabs on patients for a while; now he mostly doesn’t want to know what happened.

* * *

Dr. Irwin August lived a town over from Houghton, but most of his addiction practice was based in Fall River, trying to help Curran when he was hemorrhaging patients. That was until, one day, he and his wife Barbara (a licensed social worker who managed his office) were watching the local news and saw Houghton leaving court. They didn’t know the guy, but the moment they saw DEA agents, they figured he was a buprenorphine prescriber and had a good idea what was about to happen.

Sure enough, their phone started ringing the next day—Houghton’s patients looking for help. The phone hasn’t stopped since, even now that Dr. August’s license has also been revoked. The Augusts started working immediately to absorb some of Houghton’s patients; at first they could only see a handful, practicing out of a conference room in the office of a local lawyer sympathetic to the cause.

“His patients were wonderful,” Barbara says to me in their living room. “Stable, back with their families. He was a wonderful doctor. They loved him.”

The Augusts reached out to Houghton and became friendly. They agreed to begin shifting their practice more into Connecticut, but didn’t want to pull out of Fall River until all their patients could be placed—a large clinic was set to open in nearby New Bedford and they wanted to get as many patients in there as possible. Slowly and, Barbara emphasizes, carefully, they expanded, moving to a bigger office and taking more former patients of Houghton’s.

First, the DEA came to their house. They returned, months later, to the office—jackets on, crowded waiting room right around lunchtime, that now-predictable story. This time it was a Connecticut agent and a Massachusetts one. Between the two locations, they argued, August was over his cap. They told him to start cutting.

“This is a good doctor,” Barbara tells me. “This is a man who is helping people, and they’re telling him to stop?”

Again, the patient count was disputed—does someone count as a patient if they’re admitted for intake, but refused treatment? If they’re on a waiting list at the New Bedford clinic and need a holdover until a spot opens?

Barbara says things really escalated when she went to Houghton’s trial and the DEA saw her in court handing notes to Houghton’s lawyer. She returned to the office and an agent was there demanding her husband’s buprenorphine license. Barbara asked what the patients were supposed to do if her husband left them, instantly, without treatment. The agent said it didn’t matter. The patients weren’t the point.

* * *

There are roughly 30,000 doctors currently allowed to prescribe buprenorphine in the US.

Of those, most don’t take advantage. The closest guess I’ve heard is 8,000. That’s about 1 percent of all doctors in the country, prescribing at various, limited levels.

A recent Pew study showed that only three states in America have 100 percent buprenorphine availability for all the state’s opiate addicts. Massachusetts and Connecticut are near the top, with over 75 percent coverage, little comfort to those still searching. In the entire US, less than 50 percent of opiate addicts can find the medicine.

Among active prescribers, it’s impossible to know which don’t accept insurance for their office visits. This is common in the field, adding extra pressure for addicts seeking treatment—if there’s an available doctor in the area, can they afford it? I’ve spoken with doctors who charge $100-$150 per monthly visit. I spoke with one who charges $250 and told me, this treatment only works if the patient has some skin in the game. Some of Houghton’s former patients were taken by a doctor in New Haven, and were suddenly forced to absorb fees of $450 per month. Nick Reuter says the highest price he heard about was in New York: $7,200 for an intake fee.

In a high-profile article about buprenorphine, provocatively titled “Addiction Treatment With a Dark Side,” the New York Times wrote, “A volatile subculture has arisen, with cash-only buprenorphine clinics feeding a thriving underground market.”

It’s a damning portrayal, the notion of doctors refusing insurance, demanding extra payment. The implications about their motivations are clear.

And, yes, there are bad addiction doctors, just as there are bad doctors in every field of medicine. But with any other type of treatment, patients have the rights of a free-market consumer. They can choose the doctor they think provides them the cheapest, best care. That doctor can then treat them. And any doctor can see enough patients to be able to make a living on paltry Medicaid reimbursements, if that’s their business model. It’s not uncommon for doctors specializing in diabetes in low-income communities to see 1,000 patients; the volume allows them to survive.

For a doctor specializing in addiction, there can never be a high volume of patients. And reimbursements for 100 office visits a month don’t add up to much. Combine the restriction with a patient-base that often requires extra monitoring, and the need for additional office support and record-keeping systems in case of a DEA visit, and you’ve got a downright inhospitable business climate, an easy place to find a villain if you’re looking for one.

* * *

Dr. Tom Reach serves another epicenter of America’s opiate crisis. He runs six clinics across eastern Tennessee and western Virginia. His patients come from as far as three hours away, from West Virginia and Kentucky, two of the most restrictive states in the US when it comes to medication-assisted treatment and also two of the states with the highest overdose rates.

Reach is the kind of doctor that the Times might warn us about—a man who used to shoot hydromorphone on the job, who lost his license for writing scrips in exchange for sex and ran off to Mexico to start a full-on drug smuggling business while he waited for an overdose to kill him.

It’s the heart of the Appalachian corridor—depleted coal towns nestled into the mountains, that he drives me through, pointing out the window at barren, three-block downtowns, saying, “Place like this, you’re looking at a 60 percent abuse rate.”

Reach is the kind of doctor that the Times might warn us about—a man who used to shoot hydromorphone on the job, who lost his license for writing scrips in exchange for sex and ran off to Mexico to start a full-on drug smuggling business while he waited for an overdose to kill him (details are fuzzy because he’s unsure about the statute of limitation).

He fell in love in a small Mexican town. She helped him get sober and, after nearly a decade away, he clawed his way back into American medicine, eventually redoing his residency in his forties at the only place that would take him: Eastern Tennessee State University. ETSU had an early buprenorphine treatment center (since dissolved), and he saw a chance to help a population he very much understood. He’s since built a robust business, charging $300 a month for what he calls the leading standard of care (urine screening, group meetings, individualized attention), catering to an impoverished, undereducated population left ravaged by pain-pill mills.

I sit with him as he does intake on a 23-year old boy who looks even younger than he is. He’s from Appalachia, VA. He’s quiet and frightened. Reach tells him he doesn’t need to be. The boy nods.

“Have you used this week?” Reach asks.

The boy looks unsure.

“Don’t feel like you gotta lie to me,” Reach says. “Nobody’s blaming you. Nothing’s going to happen if you say yes.”

“Yessir,” the boy says.

He haltingly reveals that, in the past week, he’s used both heroin and meth. He says he tried to get a slot at Reach’s facility five weeks ago, and was put on the waiting list until cap space cleared. This was the first available opening. He’d tried the only other clinic a reasonable distance away, but it was too expensive.

Reach asks to see his arm, to look for tracks. Again, the boy hesitates. He sort of curls in on himself in shame.

Reach rolls up his shirtsleeves and points to the scarring from his forearm up to his bicep.

“Can’t be this bad,” he says.

The boy’s face changes. He rolls up his own shirtsleeve and now they’re comparing.

“These ain’t nothing,” Reach says, touching the boy’s arm. “These still have a chance to fade.”

The boy first used when he was twelve. His dad hurt his back working on the coal trains, and was just lazing around all the time. His friends at school told him that was from Percocet, told him to steal some. He’s been abusing some combination of painkillers and nerve pills ever since. When he was fourteen, he overdosed on Xanax. He used buprenorphine on the street for close to two years before he ever got it at a clinic. He says he didn’t do it to get high; he did it so he wouldn’t get dope sick.

He has a kid who’s five, but the kid’s mother just moved out of state and didn’t tell him where. When he’s clear-headed, he’s going to try to find out.

“Sir, I don’t think I’m a genius, but I’m better than this,” he tells Reach. Reach tells him that he seems like someone who could do well in college, and the boy’s posture straightens.

When Reach leaves to go process his intake papers, the boy tells me he has three brothers. The stable one manages a Burger King, helped him with the $300 and drove him to the clinic. He lives with his other two brothers. One is actively shooting heroin. I ask if this is a problem and he says he hopes not; he wants badly to be clean this time, so he’s going to keep to his own room. He says, “Mister, I don’t usually talk this much.” I ask him why he’s talking now. “Just hopeful, I guess.”

I find myself moved. Then I wonder whether I’ve been conned by someone who’s been a baby-faced dope-fiend for a decade now, and knows what notes to play. Then I realize how ingrained my reaction is.

This is a doctor’s office, and that boy is a patient beginning treatment. It took him over a month to get treatment, during which time he lived with the staggering danger of continued intravenous drug abuse. He has no frame of reference for a non-addicted life. He’s returning to a home full of the substances he’s trying to avoid, in a town of under 2,000 people where he knows every place to buy.

The odds are that he’ll fail. No, the odds are that he’ll suffer relapses while attempting to treat a chronically relapsing disease in a community rife with treatment hazards.

And so what if he relapses? So what if the treatment doesn’t work for him? So what if he ends up selling his prescribed medication for others to abuse, and those people are, at least temporarily, abusing something that’s much less likely to kill them? How can those scenarios be worse than this boy not receiving care?

Right now, he’s hopeful. He looked happy when he called himself hopeful.

* * *

In my days visiting with Dr. Reach, the Tennessee Bureau of Investigation issues a press release titled “Heroin, Buprenorphine Drug Busts on the Rise.” It makes no distinction between the two substances’ potencies and potential uses.

The narrative is that, thankfully, prescription opioid seizures are down, due to increased regulation, but filling the void is “a growing appetite for heroin and…buprenorphine.” It includes this quote from Tennessee’s Commissioner of Mental Health and Substance Abuse Services:

It’s troubling to see these ‘so called’ painkiller replacement therapies dispensed by unlicensed clinics getting patients hooked and dependent on another drug, just as they were to prescription pain pills.

The press release is forwarded around between Reach and other doctors in the state, as well as the man running the political action committee that Reach started last year. He formed the PAC to advocate against a state proposal that would cut off a patient’s Medicaid coverage for buprenorphine prescriptions after two years.

“Can you fucking believe this?” he says. “This is bible belt shit. This is the notion that addicts are sinners and sinners deserve to go to hell but before they go to hell they deserve to go to jail.”

The idea behind this is to promote weaning into total abstinence and prevent indefinite medication maintenance, despite the fact that the medication’s label defines its primary use as maintenance. A similar law exists in Michigan—patients are cut off after a year of treatment, their doctors left scrambling to apply for a complicated waiver to continue treatment. After Maine passed a two-year cutoff for buprenorphine and methadone prescriptions, the overdose rate spiked and they had to repeal it.

Reach is fired up.

“Can you fucking believe this?” he says. “This is bible belt shit. This is the notion that addicts are sinners and sinners deserve to go to hell but before they go to hell they deserve to go to jail.”

Reach invests a lot of money into both the PAC and the high-powered DC law firm he’s kept on retainer ever since the first time one of his doctors came under DEA scrutiny. The most recent incident happened just the day before I arrived. The Virginia DEA audited Reach’s newest doctor, still in his first few months of prescribing. That doctor, Keith White, is in his residency, moonlighting at Reach’s clinic while deciding if he’s willing to make a career out of this treatment.

“This is everything I’ve worked my whole life for,” he tells me. “I get reprimanded by the DEA and that’s it. It’s all gone. I believe in this work, I really do, but I don’t know if I can risk it.”

The DEA stayed at the clinic for four hours, reviewing every patient.

“They kept talking to me like I’d done something wrong,” he says. “The big thing was that they had this prescription that didn’t have my signature on it. We make copies of everything; the staff must’ve just forgotten to throw one out. I don’t know.”

White tells me that if Reach’s lawyers weren’t there, he would have probably just handed over his buprenoprhine license right then. To put into context how valuable his ability and willingness to prescribe are in the area, consider his primary employer: White is completing his residency at the VA hospital in Johnson City, TN, where there are only two doctors who write prescriptions for buprenorphine maintenance. It’s the only VA serving an enormous swath of the Southeast, from Nashville to eastern Kentucky, into parts of North Carolina. In emergency care, they’ll detox someone with buprenorphine, but it’s against policy to maintain them.

White says it doesn’t matter what his own feelings are, it matters how the world is. And in this world, it’s very tempting for him to stop treating addicts.

“I don’t want to do that,” he says. “In any other medical scenario, it would be considered patient abandonment—leaving someone you care for out in the cold.”

* * *

There’s a couple sitting in the waiting room at one of Reach’s Virginia facilities, the one closest to the Kentucky border. The man was in treatment for eighteen months and weaned himself off; the woman is nearing a year of treatment.

I ask her how it’s going and she says good, and he rubs her forearms over her sweatshirt in support, offers her another sip of his Mello Yello. He says it’s his fault she started using. He started on a coal job, just to get him through the day. Everyone he worked with was using. When the pills were too expensive, he‘d drive thirteen hours up to Massachusetts for the cheapest heroin.

I ask him who told him about buprenorphine and he says no one, he just Googled “Best way to get off Oxy.” He was on six different waiting lists before he found a clinic. It’s an hour drive to here from their home in Harlan, Kentucky.

He still has his job and that’s lucky because it means private insurance. Kentucky recently passed a bill disallowing Kentucky Medicaid patients from filling Medicaid prescriptions from doctors who don’t accept Medicaid for their office visits. Reach’s facilities lost 200 patients. Later, he’ll call an office assistant who’s been trying to keep track of the lost patients. She’ll cry into the phone, describing the one who got beaten to death in downtown Harlan in a drug deal gone wrong, the one who hung himself in his family’s garage.

The couple is tired.

She says, “Way I see it, they don’t want people to get help,” and when I ask who, she shrugs. It’s hard to say exactly. “I think they consider us to be a lost cause.”

She’s only relapsed once in her year of treatment, because she couldn’t get her prescription filled. This is a surprising new barrier that’s cropped up in these parts: pharmacies that say they’ve run out of the medication. The DEA has oversight on pharmacies, too, and there are quotas for the amount of controlled substances one can dispense before being red-flagged, potentially fined. These quotas are determined by the Morphine Equivalency Dose metric, which uses morphine as a control and determines the length of time a single milligram of any other substance bonds to opiate receptors in comparison. Buprenorphine, its efficacy depending on that long bond, has a higher MED than OxyContin. When a large enough buprenorphine clinic opens in a high-use area, those MED limits can be hit quickly.

“We spent four days driving back and forth through Virginia and Kentucky,” she says. “All along the border. No one would give me it. I asked one pharmacist, what do I do? He said it wasn’t his problem.”

Finally, she broke down. She took something. She needed something, she says.

She’s in college. She wants to be an addiction counselor. Who better than her, she asks. Her fiancé keeps rubbing her arm.

Reach’s staff has been trying to keep track of how many patients have been turned away by pharmacies. They’re nearing 300. Some patients were told that the medication would be doled out on a first-come first-served basis, then to wait outside so as not to disturb other customers. Some pharmacies simply said go away.

“We ain’t bad people,” another woman tells me later that afternoon. “We’re just trying to get right.”

* * *

I keep visiting Curran, and we keep having the same conversations. At some point, he puts a new sign up in his office with directions for where patients can go for urine screens, something he never used to require. The last time I visit, I point to the sign and ask him how it’s working.

“Fine, sure,” he says. “But then someone has traces of cocaine in their piss, what do I do? Say aha, kick them out?”

I call more doctors and their voices run together—frustrated, tired, occasionally amused. Stuart Gitlow, former president of ASAM, tells me that he hasn’t done intake on a patient in years. Every person who finally gets into his practice has been using buprenorphine on the street in the interim.

He laughs, and says, “What does that tell you?”

It tells you whatever you want it to. Law enforcement can say, this is a drug that’s abused. Gitlow can say, people treat themselves when we give them no other option.

It’s a frustrating conversation, but the deaths have become so un-ignorable that the conversation is starting to shift. There’s legislation up before the senate to significantly increase access to buprenorphine. The Obama administration is becoming proactive, pledging a huge increase in federal funding for medication assisted treatment.

And finally, just last week, Obama’s Secretary of Health and Human Services officially proposed an increase to the patient cap to 200. It’s a huge step, one that, when I began researching this piece, seemed impossible to most of the doctors I spoke to. Still, it’s a timid change after a decade of ever-rising mortality rates and cries for help. And, still, the press release highlighted the proposal’s promise to “minimize the risk of drug diversion.” Buprenoprhine remains the only drug with a patient cap.

At the root of all this is how we choose to see people. We are evolving in terms of who we deem worthy of care, but why are we evolving so slowly, and why has that evolution necessitated so much tragedy? Too many doctors are unwilling to see addicts, while many others have been frightened away from necessary work because criminality was written into compassion. Too many patients have died because of treatment they couldn’t find, because it’s so hard to believe that people like them can be treated.

They didn’t deserve to die. They deserved care.

Lucas Mann

Lucas Mann was born in New York City and received his MFA from the University of Iowa, where he was the Provost’s Visiting Writer in Nonfiction. He is the author of Lord Fear: A Memoir (Pantheon, 2015), and Class A: Baseball in the Middle of Everywhere (Pantheon, 2013), which earned a Barnes & Noble Discover Great New Writers Selection and was named one of the best books of 2013 by the San Francisco Chronicle. His essays have appeared in Slate, Gawker, Barrelhouse, TriQuarterly, Complex and The Kenyon Review, among others. He teaches writing at the University of Massachusetts Dartmouth and lives in Providence, Rhode Island with his wife.

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12 Comments on “Trying to Get Right

  1. respectfully, while suboxone can be useful – it is little better than methadone. Just because it’s an agonist antagonist matters little, it has less respiratory depression but the same or worse addiction as methadone. Furthermore – the naloxone in it does nothing, it has a lower binding affinity than suboxone. The only current medication we truly have for opiate addiction that actually gets people off, is ibogaine hydrochloride, which is still illegal in the united states.

  2. It is very sad that addiction steals so many lives.. in my city there is a a large number of heroine addicts, and the biggest concern about prescribing butes is patient abuse.. they take more than they should.. or sell them on the streets.. and it has resulted in several deaths.. the main cause of drug use is to cover the pain you feel inside.. trying to kick a drug habit without any help.. is like trying to put out a fire with gasoline..

  3. My heart broke, and my blood pressure rose. I KNOW injustice. But this just…. beyond anything I’ve known. And that’s bad.

  4. Buprenorphine saves lives. The difference between a patient on buprenorphine and an addict abusing drugs is that the addict in recovery (the patient) on buprenorphine is rebuilding their life while the addict abusing opioids is destroying their life. The only reason the government limits access to buprenorphine is that it cost less to bury an addict than to treat one.

  5. “The difference between the drugs is chemical—methadone is a full opiate agonist, the way heroin is. It binds to your opiate receptors and produces euphoria without any ceiling, until overdose.”
    This sentence gives an incomplete and unfair perspective on methadone. Many, many people are functioning very well, for years, on this medication. It does not produce euphoria; it’s purpose is to eliminate craving, period. Heroin addicts with long histories do better on methadone than on suboxone. All these medications are useful for our clients; it is unfair to characterize, negatively, one of the most effective pharmacotherapies out there in the way that your author has.

  6. I just read this article, more than a year after it was apparently written, and I’m actually surprised by the ignorance displayed in one or two of the comments. People don’t overdose on buprenorphine, and I’m fairly certain they can’t – it’s not physically possible. It has a self-limiting action due to the naloxone, such that you can keep taking more and more, but it won’t make a difference. That’s one of the things that make it such effective as an addiction medication. But ignoring that fact for a moment …

    I take prescription pain medication for my back – it’s legally prescribed (though it’s becoming harder and harder to find physicians willing to treat genuine chronic pain, due to the legal risk. But I digress…), I’ve never been “high” from it and I take it only as prescribed. I’m not “addicted” to it, but I am physically dependent upon it (there is a big difference). However, I recently moved out of state and had difficulties finding a new physician and, as a result, I ran out of my medication. I therefore went through opiate withdrawal. The withdrawal was so unbelievably miserable that I found myself on a 6th floor ledge about to jump, simply to make the pain and misery stop. I have no desire to die and have an otherwise great life (good job, nice home, etc) – I was just that miserable that I was willing to die to make it stop! I even went to an ER and they were completely useless – worse than useless, in fact. Why do you think suicide rates among chronic pain patients and opiate users are so high? Opiate withdrawal is a fate almost worse than death.

    So, my point – if there is a drug that help people avoid the misery that I felt, let them have it. And if you’re afraid they’ll divert it – let them have it for free (similar to methadone clinics). After all, they won’t be able to sell it to buy heroin if it’s available free of charge elsewhere. It’s absolutely ridiculous that the government limits the number of suboxone patients a doctor can treat. And as a result of those limits, the doctors that do prescribe it end up charging an amount that’s typically out of reach for the bulk of the population they should be treating.

    The government’s policies towards opiates in general – legal and illegal – are reactive, short-sighted, and ultimately harmful. They’re actually doing more harm than good in their efforts to placate the public and convince them they’re fighting a “war on drugs.”

    1. The government needs to feel the pain and experience of an addict and see if they can deal with it and see if they change their minds

  7. so true ,to just taking the medicine does not help. We all have something in common ,a hidden memory
    Of a dramatic ordeal and need to get counseling to get to the root of what is the hidden problem. Believe me I am one of the lucky ones who got
    though it all and raised 3 boys whom I am so proud of, if I did not seek the help only God knows.I am 64 yes.old and still fighting my disease.

  8. I am a patient of one of the Doctor’s and he is a great person with his patients and puts there well being first I know he treats people for free at times he’s always their for them as much as he can

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