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Ali Boast, a nurse at Magee’s Pregnancy Recovery Center (PRC), sits behind the wheel of a red Kia Sportage and sips from her coffee mug. It’s 7:00 a.m. on a Friday, and she’s left her home in Pittsburgh to drive north an hour to Butler, an old manufacturing town. Boast occasionally passes lines of bare trees, but primarily the scenery of these 35 miles is a suburban sprawl alternating between car dealerships and strip malls. Her final destination, a rural outreach center, is in one of these strip malls.
The PRC was one of the first clinics to use a whole-person team-based model for opioid-dependent pregnant women. This means the center addresses all parts of a patient’s care under one roof by providing medication-assisted treatment (specifically using buprenorphine), counseling, access to a peer navigator (who has experience in recovery), group sessions, prenatal care, delivery, and assistance with issues like housing and transportation.
When most people think of medication for opioid addiction, they think of methadone, which is a full agonist, meaning it allows a morphine-like response. Buprenorphine, on the other hand, is a partial agonist — it blocks some of the opioid receptors, providing a partial opioid response. This means that most patients report a decrease in cravings — perhaps more energy, but not a real high. Also important, the doctors prescribing the buprenorphine are obstetricians, working in tandem with the counselors, nurses, and peer navigators, which results in more comprehensive care.
When the PRC applied for a Center of Excellence grant through the state of Pennsylvania, one of the key components was not only expanding its central Pittsburgh clinic, but also its outreach to rural communities. In the past year, the PRC opened five rural centers. It picked communities without easy access to Pittsburgh and with high overdose rates. Assuming women would flock to the centers, Boast is surprised that Butler is its biggest clinic, with just four consistent patients.
She suspects the reason patient numbers are low at the PRC’s outreach centers is related to transportation — it’s often difficult to get around even within a county. Another issue is insurance. Magee is housed within the University of Pittsburgh Medical Center (UPMC), which is not only a big hospital system, but also one of the main insurance providers in western Pennsylvania. Unfortunately, many people in Butler County have insurance that the PRC doesn’t accept, through one of the city’s primary employers, the community college. Boast has faith that the center’s numbers will grow as word of mouth spreads. The goal, she says, is to have each of the five rural clinics open for a full day every week.
When state representatives started researching ways to fund centers that would make quality opioid addiction care available to more people, they used the PRC as a prototype. The clinic was already using medication-assisted treatment, behavioral health services, and assistance with other issues like housing. Starting in 2017, Pennsylvania provided $500,000 grants to so-called Centers of Excellence around the state dedicated to a common goal: team-based whole-person care for those with opioid use disorders.
In January of this year, in response to the state’s opioid epidemic, Pennsylvania Governor Tom Wolf made a 90-day disaster emergency declaration, usually reserved for natural disasters. In addition to setting up an opioid command center, this declaration reduces regulations to do things like get patients into treatment programs faster and provide them with naloxone (an overdose reversal drug) more easily.
The declaration gets rid of prior authorization for buprenorphine prescriptions, which can delay access for 24 hours. This is a long time when you are trying to abstain from using illicit substances and going through symptoms of withdrawal. The PRC would also like to see telemedicine regulations advance to the point where they can prescribe in real time. Right now, patients see a nurse at the rural clinic and then get on a video conference call with the prescribing doctor, but prescriptions still have to be written ahead of time.
Some are skeptical about Wolf’s declaration, because it’s temporary. It can be extended, but Trump’s similar 90-day public health emergency declaration in October 2017 had no noticeable impact. Trump’s declaration was extended for another 90 days in January; however, the administration is not using it to ask Congress for more funds. As Senator Bob Casey said, “In an ideal world, we’d have unlimited funds.” Most of the federal funds currently being used are left over from Obama-era initiatives. In the newly approved budget deal the Trump administration finally asked for increased funds to combat the opioid epidemic.
Trump’s public health emergency declaration, if nothing else, would seem to align him with those who argue that we need to think about and treat the opioid epidemic as a public health emergency and not a law enforcement issue. However, much of what Trump and his administration actually say contradicts this approach. In May, former Alabama senator and current Attorney General Jeff Sessions promised that the Trump administration would be tough on drugs — bringing back “war on drugs”–era punishments. Pennsylvania is among 20 states that allow dealers to be prosecuted for drug-induced homicides when someone they sold to dies from an overdose. In early March, Trump announced that he wants to push that further and allow the death penalty in these cases.
Trump is looking to Singapore for guidance, which has a zero tolerance policy, while most of the health professionals I talked to tended to cite Portugal as a model. Portugal decriminalized all drugs in 2001, almost exclusively treating drug use as a health problem, not a criminal justice problem. Since then, the country’s overdose deaths have fallen by 85 percent. Statistically, the “tough on drugs” approach doesn’t work for the United States: We’ve tried it, spending billions of dollars locking people up, with our overdose rates only increasing. And yet, Trump isn’t the only one who is trying to straddle the line between “tough on drugs” and public health emergency and ending in contradiction.
Ricki, a young mom and PRC patient, sees the center’s gentle approach as the reason she’s in recovery. She receives support from her family, which greatly helps as well. But her dad, although grateful to the PRC, still thinks the United States needs “stiffer penalties.” Or so he explained to me while waiting for his daughter to finish an appointment, as we sat next to his sleeping granddaughter in the waiting room. His plan? If you overdose twice, mandatory 90 days in jail; if you’re caught selling, mandatory five years in jail. This would do something, he insists, although minutes later he’s explaining that addiction is a sickness, yet we aren’t treating it like one.
These contradictory approaches are similar to the Trump administration’s. They are simultaneously interested in punishment and treatment-based solutions. Part of what people seem to struggle with is the incomprehensible actions of addicted people. We can rationally understand that addiction is a disease that makes people do irrational things, but it also just doesn’t make sense that people with opioid use disorders keep using in the face of overdose, destroying their lives and the lives of the people around them.
Jason Snyder, who oversees the Center of Excellence grant program, watched his two brothers die from heroin addiction and is in recovery himself. Yet even he gets frustrated. It’s hard, Snyder explains, “to see people who were saved from an overdose by naloxone overdose again within 24 hours.” We don’t want to think we’re letting people with addiction get away with something. Even the PRC, whose goal is to be understanding and open about addiction, has limits on how many times a woman can be noncompliant — through multiple failed drug tests or missed counseling sessions or OB appointments. And it makes sense that it has these rules, because each woman is required to sign a contract so they know what they are getting into and have goals to reach. But if they are pushed out of the program, what then?
A study at the PRC run through the social work department at the University of Pittsburgh continued to work with women who were discharged because of noncompliance to make sure they stayed involved in other clinics. Researchers found “no numeric difference in their outcomes for success.” In other words, when these initially noncompliant women continued to receive help, they found recovery at similar rates to those in the PRC.
Most of the time, we think of addiction as a disease, but it’s one that we still blame on the addicted person. As Mitch Hedberg, a comedian who died from an overdose at the age of 37, once joked, “Alcoholism is a disease, but it’s the only one you can get yelled at for having. ‘Goddammit, Otto, you’re an alcoholic!’ ‘Goddammit, Otto, you have lupus!’ One of those two doesn’t sound right.” Individual approaches and contradictions in thinking are one thing. But from our federal government? That’s another thing entirely.
In Trump’s State of the Union address, he spoke briefly of getting “tougher on drug dealers and pushers.” He spent far more time talking about a New Mexican police officer who saw a woman shooting up and decided to adopt her baby. As honored guests, Trump invited the officer and his wife to stand for a round of applause. He did not mention the child’s opioid-dependent birth mother; he only praised the police officer. As it turns out, the mother and her partner went into rehab, but nothing was mentioned about whether she wanted to keep her baby or the complicated power dynamics in this situation. The PRC has found that pregnancy is a high motivator for opioid-dependent women to change their lives, and it works to help women keep their children.
Part of what Boast likes about Fridays, when she works at PRC’s outreach center in Butler, is that it’s quieter than the main clinic in Pittsburgh. She has time to catch up on her charting, and she gets to spend more time with the women since they have so few patients.
Today, one patient missed her appointment, so she’ll have to travel to the Pittsburgh location on Monday to get her buprenorphine prescription. Boast worries because the patient said she had enough to make it through the weekend, but she should be completely out of medication. It’s such a tightly controlled substance that there is no overlap in prescriptions; a patient should have just enough to make it to their next appointment. Boast asks, “The question becomes: Did she stop taking it and use, or has she not been taking as much as she was prescribed all along?”
This means another hard conversation. Boast loves this work, and she loves these women, with whom many medical professionals often get frustrated. “I enjoy their honesty, their realness, their stories,” she says. But it can be hard, and each patient needs individual care. Boast doesn’t know how she’ll deal with this patient on Monday or even what the exact situation is, but she knows she will deal with it.
I ask her the question I’ve asked everyone I’ve talked to for the past six months: “If you were in charge, what would you do to address the opioid epidemic?” Boast says she thinks we’re already moving in the right direction. But we need to do more, especially with mental health: “Right now, psychiatrists have no incentive to treat people on Medicaid.” For this, and for everything the PRC does, they need an administration committed to funding supportive policies.
Pennsylvania is working to give them that through Governor Wolf’s declaration and the Center of Excellence grants, which was developed by looking at the good work that people who see this epidemic daily were already doing. And it doesn’t hurt that this grant program is run by Snyder, who has direct experience with the opioid epidemic.
No one I talked to, including Snyder and Senator Casey, seems particularly worried about funds, because this is just too big of an issue. But Casey did express fear over attempts to cut back Medicaid, which would leave many Americans without coverage for treatment of opioid use disorders. “You can’t use the language Trump’s used and support wacky right-wing bills to decimate Medicaid expansion,” Casey explained.
But every day, it’s more of that contradiction. We have a president fighting for the death penalty for drug dealers, who talks about getting people into treatment, but then holds up a single family who adopted a baby as the standard, without mentioning the mother at all.