Doctors reluctant to use heroin addiction medication

Even though it is famous for the "Minnesota Model" of treating addictions through abstinence and support, Minnesota has been slow, some doctors say, to embrace a drug that can help people hooked on heroin.

Now, with heroin addictions mounting, a Burnsville family practice doctor believes a key solution lies in getting more primary care physicians to prescribe the medication — but says many of his colleagues are reluctant to do so.

Dr. James Eelkema appealed this fall to large medical groups such as Allina and HealthEast to certify more doctors to prescribe an oral drug called Suboxone. The drug addresses an addict's cravings and prevents withdrawal, but generally isn't addictive and doesn't need to be given at special clinics.

None took an interest, he said, and one medical director finally told him, "How many times can I say 'no?!' "

"I've seen the good things that happen with Suboxone," said Eelkema, one of 105 Minnesota doctors who is federally certified to prescribe the drug. "People thank me. They call it a miracle. But the big-box clinics don't want to deal with it."

Eelkema is motivated by an emerging epidemic of heroin and opioid addiction in Minnesota. Overdose deaths — there were 291 last year — are now as common as traffic fatalities. Hospitalizations for heroin addiction rose from 2,181 in 2009 to 5,128 last year.

Laws to reduce the abuse of prescription opioids unwittingly turned more addicts to heroin, which is being provided in Minnesota in a purer form to hook customers who can no longer get painkillers.

"We ended up with so many people addicted to pain medications," said Dr. Marvin Seppala, chief medical officer of the Hazelden Betty Ford Foundation. "The folks that deal heroin recognized this … so they dropped the price of the heroin and increased its quality over time."

Methadone has long been the standard treatment for heroin addiction. The drug mimics illicit opioids in the brain but doesn't produce the euphoria that addicts crave or the flu-like withdrawal symptoms that follow. The drug is addictive, though, and at least in a patient's first year is administered only through daily visits to methadone clinics.

In 2002, federal officials sought to expand access to Suboxone, or equivalent drugs containing buprenorphine, by allowing doctors to prescribe it on an outpatient basis if they gained proper certification. The drug works like methadone, but contains an ingredient that eliminates its addictiveness when taken orally.

Eelkema took the eight-hour certification course and soon found addicts from Fergus Falls to Mankato at his solo practice.

One was Heidi, 38, who started heroin at a boyfriend's prompting six years ago and soon was mixing it with meth. While she never stole from family or work, her life was consumed with paying for heroin — even though she didn't like how it made her feel.

"When you're using," she said, "your life is crazy. You don't prioritize anything."

She credits family, including her boyfriend's parents, and Christian faith for quitting, but said she ultimately needed the Suboxone dissolving strips that Eelkema prescribed to her. "They should be giving it away on the street," she said. "People want to get off of [heroin] so badly."

Addiction experts agreed in principle with Eelkema's call to expand drug treatment. Seppala said heroin has come back in a different market — an older, white and increasingly rural population of men and women who live far from urban methadone clinics.

"Heroin is available in rural areas in ways that it never was in the past," he said.

An Allina spokesman said the health system isn't pursuing Eelkema's primary care approach, but is aggressively pursuing other strategies.

HealthEast's medical director for addiction care, Dr. David Frenz, agreed that more prescribers are needed in a state where the Minnesota Model — developed at Hazelden and known internationally — worked for other addictions, but not for opioid dependency. (Hazelden now includes drug therapy in its approach to opioid addiction treatment.)

Still, Frenz called it a "tough sell" for primary care doctors. Some worry that addicts will scare off other patients. Others say they're already under pressure to improve the care of existing patients.

Doctors don't even want to treat their own patients if addiction enters the picture, Frenz said. "Say you're a family doctor in Little Falls, Minnesota, and your patient becomes addicted to the Vicodin you were prescribing. A lot of doctors don't want to get involved at that point."

Asking primary care doctors to prescribe Suboxone also has risks if they lack the time to closely monitor the patients, Frenz added. The drug is often misused by addicts to eliminate withdrawal symptoms between heroin injections. His HealthEast clinic uses a variety of checks for misuse — including, initially, weekly appointments and urine tests. "These are time-consuming and often challenging patients," he said.

Heidi, who agreed to an interview if her last name wasn't published, would take Suboxone prescribed to her boyfriend to avoid withdrawal symptoms until they could scrape up money to drive to the downtown corners or even suburban hotel rooms where heroin was sold.

After a breakup this spring, she got her own prescription, she said. "I have no cravings. None."

Heidi since has earned business back, emerged from bankruptcy and has her own apartment.

Eelkema retired from practice last month but continues his advocacy. He monitored patients and controlled their doses, but said some probably misused Suboxone or sold it to friends looking to avoid heroin withdrawal.

The drug isn't addictive, he argued, and misuse isn't a reason for primary care doctors to avoid it. He offered Heidi as case in point — a patient whose first illegal usage led her to seek it for successful treatment of her addiction.

"It spreads the word among the heroin [and] narcotic community that Suboxone is available," he said, "and that it works."