‘This is my sanctuary’
An innovative Suboxone program is reframing opioid treatment in rural New Mexico
The Taos News
QUESTA, N.M. — For nine years, Danny Chavez tumbled through a vicious cycle of hospital beds, jail stints, rehab programs, and months in prison. Amid the turmoil he lost his job, his family’s trust and most of what he loved in life.
But today, Chavez, 39, is putting the pieces back together, thanks largely to a treatment program in Questa that combines medical care and group therapy.
New Mexico and Taos County are in the midst of an opioid epidemic that shows no signs of relenting. Between 2010 and 2014, 47 people died of drug overdoses in Taos County. The county’s overdose rate is well above the state and national averages.
In Northern New Mexico, many communities lack the resources to meet the opioid fight head on. Social problems endemic to rural New Mexico ― poverty, domestic violence, and a lack of access to adequate health care ― contribute to rampant drug use.
That’s why some experts see hope in a drug treatment program that addresses not only the addiction, but its causes as well.
For almost a year, Dr. Gina Perez-Baron ― a feisty general practitioner at the Questa Health Center ― has used Suboxone to stabilize opioid addicts. When properly prescribed, Suboxone relieves cravings and withdrawal symptoms without giving patients a potent high.
But Suboxone is only the first step in an intense treatment regimen in which a doctor and a therapist work side-by-side. By taking on deep-seated issues like depression, anxiety and chronic pain ― conditions that can trigger relapse ― Perez-Baron says patients have a chance at real, long-term recovery.
“If you want your life back,” she says, “you’ll get it back here.”
***
Chavez never planned on being a junkie.
He drank, smoked a little weed and was arrested a few times as a young man.
But it wasn’t until he turned 30 that he really tasted addiction.
In 2007, Chavez (not his real name) felt a sudden intense pain in his abdomen. Doctors eventually diagnosed it as pancreatitis — an inflammation of pancreas that is often treated with pain medication.
At the time, Chavez says he hated pills. He wouldn’t even take Tylenol for a headache. But when he got to the hospital, nurses hooked him up to a morphine drip to numb his throbbing gut.
The feeling was euphoric.
“I still was in pain, but I could breath,” Chavez says. “I had relief.”
When he left the hospital, doctors put Chavez on a prescription for painkillers. He was responsible and took his recommended dose. But over time, as he built a tolerance, the effects started wearing off sooner. So he took more. If he burned through his monthly prescription early, his friends always had a couple extra. There’s always someone with a few pills. Always.
“This town is drowning in them,” Chavez says.
Because sharing pills was so casual, so common, Chavez still felt in control. But the addiction was insidious. It came on in slow degrees. At some point, it became too big to manage.
“Your hunger for things goes up and up,” Chavez says. “I started to need them.”
To satisfy that need, Chavez says he sacrificed everything he loved in my life. He took advantage of friends and family, borrowing money with no intention of paying it back. He lost a good job. He stopping going to the mountains. And he stole.
In 2011, Chavez reached a breaking point. He burglarized a local business to pay for more pills, and he got caught.
Facing three felony charges, Chavez was released on bond and forced to enroll in a 120-day rehab program in Española. Chavez says the program didn’t help much, though he admits he wasn’t ready to get clean. He was just going through the motions. He relapsed almost immediately after leaving.
“I didn’t feel like I was working on my sobriety one bit,” Chavez says. “I didn’t feel like I wanted to be different. Be better.”
In 2013, he relapsed soon after departing yet another rehab program. Officers found Chavez drunk. He was arrested and tested positive for opiates.
“[Chavez] has been given ample opportunity by the court to make behavioral modifications yet has failed to do so,” his parole officer wrote in a court filing. “A sentence to [prison] will provide just punishment for his crime and several violations of probation.”
The judge agreed. Chavez spent the remainder of his sentence in the state penitentiary.
Chavez says he kept to himself in prison. The withdrawals were shattering, and he got jumped and stabbed by other inmates. His time inside left him with post-traumatic stress disorder, he says, and it exacerbated his anxiety and other symptoms of trauma.
Amid all his legal troubles, Chavez was still suffering from chronic pain. In nine years, he was hospitalized 12 times. He was given pain pills every time.
***
Perez-Baron, the doctor in Questa, says programs to treat addiction have ignored underlying factors that lead people like Chavez into a cycle of failure. She believes prevailing cultural attitudes — which tend to link addiction with weakness of character — make recovery harder. “You have folks going through a revolving door of recovery and relapse, and the stigma that surrounds dependence and addiction distracts us from addressing some of the roots of the problem,” she says.
Perez-Baron rattles off a list of “co-occurring conditions” that are often at the heart of addiction ― chronic pain, insomnia, trauma, attention-deficit/hyperactive disorder, depression, and anxiety.
If left untreated, these conditions (which are sometimes the initial cause of the addiction itself) often make it impossible for addicts to stay clean. Chavez says his pill dependence probably stemmed from trauma. But the roller coaster of addiction, and the additional baggage of prison time and failed relationships, made bucking the drug even tougher.
In the maelstrom of opioid addition, Perez-Baron says there’s no way to get at those deeper issues. Users are too frenzied to treat thoroughly.
That’s where Suboxone comes in. It’s like a pause button.
“If we’re looking at long-term abstinence, the focus really has to be on the behavioral health and co-affective conditions,” Perez-Baron says. “Suboxone is what makes them able to stay plugged in.”
Chavez knew for a long time that he was in trouble. And he wanted to be better. But the cravings sucked up any motivation to get well. “When you’re an addict you’re on the fence and it’s hard to give 100 percent,” he says. “It’s not that you don’t want to be a better person or a sober person. You just don’t have a choice.”
***
For years, Perez-Baron saw patients suffering from addiction one-on-one. She’d prescribe Suboxone and offer referrals to a therapist.
The approach was inefficient and ineffective. Individual appointments limited the number of patients she could serve. In a rural area ravaged by addiction, she couldn’t meet demand. Plus, referrals to outside therapists forced patients to schedule yet another appointment, and doctors and therapists often failed to craft a customized approach to treat each patient.
So in August 2015, the Questa clinic pioneered a new approach to treatment: group therapy.
These days, Perez-Baron and Liz Sump, a licensed mental health counselor, meet once a week with around a dozen clients at a time. They do meditation and a therapy session with Sump, then go over medical issues with Perez-Baron. It’s a model Perez-Baron developed after working in high-end residential treatment programs, the kind meant to treat doctors who find themselves addicted to opioids.
Providers look at nutrition, exercise, self-care, psychology, psychiatry and medicine. And they add a lot of oversight and build trust. Perez-Baron says she tweaked that “gold-standard” approach to fit an out-patient setting.
“When you create a place for that, people get well,” she says. “So if we know what works, why can’t we bring that here?”
For Sump, the model is a dramatic improvement over her previous work, which required chasing down doctors to learn about medical conditions that might impact her counseling. “It was hard to get them to tell me where their clients were at on a monthly basis, and that’s if they wanted to talk to me at all,” Sump says.
The support group gives patients a safe place to share their experiences with others fighting the same battle.
“We’re all parallel with each other,” Chavez says. “We relate to each other’s feelings of hopelessness, pain, anger, and resentment. And we can talk about our cravings. Because we all have cravings.”
The group model has also allowed the little clinic to increase its patient volume, by treating three groups of up to 14 patients. Patients face mandatory weekly urine tests to ensure accountability and honesty.
Testing dirty does not mean a patient is kicked out of the program. Relapse doesn’t mean weakness. It means treatments need tweaking.
This was new to Chavez, who would be locked up if he failed a drug screen while on probation. In January, off probation and new to the program in Questa, Chavez relapsed. But instead of being reprimanded, he got more support.
“I don’t care that you stumbled,” Perez-Baron says. “I care what you did immediately after that. Some folks stumble and they disappear and we never see them again. But the ones that come back, typically with that big pile of shame, those are the ones. That’s where recovery happens.”
***
Although group therapy is the focus of the Questa clinic’s model, Suboxone, and the relief from cravings that it provides, is also integral. Yet the drug is the subject of intense medical debate.
Fourteen years after it was approved by the FDA to treat opioid addiction, there’s still little consensus on how best to use it. Should it be prescribed indefinitely, or should patients be forced to taper off? How much does counseling really help? And can patients who taper stay clean?
Various academic studies on Suboxone have shown mixed results.
A notable 2011 study by the National Drug Abuse Treatment Clinical Trials Network found that about half of patients treated with Suboxone and “standard medical management” were clean at the end of three months. But eight weeks after the treatment ended, only 9 percent of participants had stayed clean. The results did not change for a group that got additional counseling.
For her part, Perez-Baron is adamant that most studies on Suboxone have asked the wrong questions. She thinks it takes at least a year or two of intense medical and behavioral health treatment for addicts to get stable enough to taper off Suboxone with minimal risk of relapse. A study measuring who stays clean after tapering off in just three months is inherently flawed, she says.
Still, research like the 2011 study has taken some of the shine off Suboxone as a silver bullet for solving addiction. Some doctors argue Suboxone is just trading one drug for another. Others suggest long-term use can create its own addiction problem.
That danger is well known in Questa, where in 2014 a toddler suffered severe brain damage after he ingested a Suboxone tablet illegally obtained by his father.
To keep prescription Suboxone off the streets, participants in the Questa program can be kicked out if they’re caught selling or giving the drug to anyone else.
John Hutchinson, a doctor of pharmaceuticals and director of health outreach with Holy Cross Hospital, has publicly weighed in on the ways Suboxone can be misused. But he also sees its potential.
Hutchinson is an advocate for Suboxone combined with behavioral health therapy and mandatory drug testing ― exactly the model that’s been put in place at the Questa clinic .
“It’s beautiful,” Hutchinson says. “If you’re going to use Suboxone, that’s the way to do it.”
Combining medical treatment and intensive therapy to combat addiction is gaining traction nationwide. Similar programs exist in Santa Fe and Albuquerque. Such models are less common in primary care settings, like the Questa clinic.
Hutchinson says Perez-Baron’s program is especially impressive because it’s happening in a rural, impoverished community. He says it took a “heroic effort” to get a dedicated therapist despite a lack of resources. The program also had to be available to Medicaid patients, who make up the vast majority of participants.
“This is a big city service in tiny Questa,” Hutchinson says.
August 4 was Perez-Baron’s last day at the Questa clinic. She recently took a job as medical director for Las Clinicas del Norte, which serves patients in Taos and Rio Arriba counties. She hopes to put the same treatment model in place there.
The program in Questa will continue with a doctor who calls in via video conferencing . It’s not yet clear when or if an in-person doctor will take over.
Running this kind of program in such an isolated area takes dedication from the doctor and therapist. Perez-Baron is unusually motivated. It might be tough finding a replacement.
As a physician, Perez-Baron says the progress shown by patients in the program is incredibly rewarding. “I think if more doctors saw the reward, more doctors would be invested in it,” she says.
***
As with any intervention, gauging the effectiveness of the Questa program can be a challenge. Academic studies tend to focus on who stops using and for how long. Perez-Baron’s measures of success go beyond absolute abstinence.
Clinical indicators show the program is working. There’s been a 40 percent decrease in trauma as measured through a questionnaire. Depression rates are down 28 percent. And self-reported anxiety is down 4 percent.
Perez-Baron says these mental and physical benefits coincide with quality of life improvements. Of her female patients with children, 78 percent have been reunited with kids they lost because of addiction. Two patients have started their own businesses. Two more have gone back to school.
As she likes to quip: “It’s a country song played in reverse .”
Some patients have also stumbled. Six have been arrested in the last 12 months. And four have gone to the ER in the last year because of illicit drug use.
Perez-Baron says the ultimate goal of the Questa program is to get patients off Suboxone entirely.
So far, Perez-Baron says only one participant has tapered completely off the drug without relapse. That’s partly because the program has only been around a year and no one is pushing patients to taper. There’s no timeline. No pressure.
It’s a cautious approach, but Perez-Baron say it’s necessary so patients have time to learn the skills to cope with life off drugs.
“I know there are those who would say I’m a fool for saying anyone could taper off of Suboxone,” she says. “But I’m willing to be that fool. And I’m willing to put that possibility in the hands of my patients by making them well-armed to make that choice.”
But can a treatment program that may last for years really survive in a rural clinic strapped for resources?
Perez-Baron and her staff say the treatment model has not been especially burdensome, in part because the program isn’t overwhelmed with patients.
While there’s a rising demand for opioid addiction treatment in Northern New Mexico, a daunting application and intake process at the Questa clinic tends to weed out anyone who isn’t committed . Even then, Perez-Baron says just 30 percent of those patients make it three months without dropping out. Some don’t like the approach. Some have a hard time commuting to Questa, especially those who have to come from more than an hour away. Other just aren’t ready to get clean.
***
Chavez, now in his seventh month in the Questa program, says the model works. He understands his addiction. He knows his triggers. He also knows the consequences of not getting clean.
For the first time, he says he’s getting help from people who want to understand his addiction as well as he does. He says he’s finally climbing out from a very deep hole.
“This program saved my life,” he says. “I’ve never wanted to help myself as much as I want to now because of these people. This is my sanctuary. This is where I feel safe.”
For him, the short-term benefits of Suboxone and therapy have been stability and peace of mind.
Chavez says he’s happy now. He’s mended a torn relationship with his parents. He has a steady job and is taking on side work to pay off his debts.
Last month, Chavez had his first real victory on his march toward recovery.
He was back in the hospital because of more abdominal pain. The nurse asked him if he was on any medications. Chavez knew if he lied about Suboxone he’d get morphine. And he wanted it bad.
But he didn’t lie. He thought about how Perez-Baron and everyone at the Questa group would react to another relapse. He didn’t want to let them down. And he used lessons from the program to overcome the craving.
Chavez felt proud in that moment of strength. But he was immediately reminded that small successes for a recovering addict are bittersweet.
Twice now, he says nurses have completely changed their demeanor when they learn he’s on Suboxone. They talk to him differently. They are less kind. Their attitude suggests they don’t see him as a patient, but as an addict.
That kind of judgment means Chavez and others in the group have to hide in the shadows, even after they’ve emerged from the darkness of addiction.
Some recovering addicts have lost jobs when employers learn they’re on Suboxone. Patients in the Questa program know that being open about their recovery can also hinder it. So their triumphs get muted. A small conference room in the Questa clinic is one of the few places where they can celebrate their recovery.
Chavez is adamant that he wants to taper off Suboxone. He’s already cut his dose in half since starting the program. But he’s not rushing into it. For him, it’s important to know he’s not tied to any drug.
“Free,” he says. “I want to be free.”
