When it comes to the chronic disease of addiction, sometimes love alone isn’t enough to pull you through.
That’s what 28-year-old Brad Hoder experienced. In 2018, he was about to lose visitation rights after overdosing while his son was in the apartment. He had tried a treatment facility before, but relapsed just three months after. Despite his looming loss of custody, he still struggled to stay away from opioids.
He’d battled addiction for about a decade at that point, starting in high school with prescription opioids, which then became heroin and later methamphetamine. He didn’t think he could get through treatment without assistance from medication, so in June 2018, the Pathfinder unit at the Center for Alcohol and Drug Treatment in Duluth connected him with recovery resources, which included a prescription for Suboxone.
He knew about Suboxone — a prescription opioid that contains buprenorphine, to curb opioid cravings and withdrawal symptoms, mixed with naloxone, which can reverse overdoses and negate a high from the drug if injected. It’s used to help people with opioid-use disorder regulate their brains to feel normal enough to focus on recovery, stay in treatment and rebuild the lives addiction may have torn apart.
Hoder had been self-prescribing Suboxone for about five years. The problem was, Hoder could only find Suboxone on the street, which wasn’t a long-term solution. Even when his son’s mother was pregnant, the doctor encouraged them to continue to use Suboxone, but wasn’t sure where to refer them to get a prescription for it.
“It was like this hopeless feeling because we need to stay on it, but what do we do? We heard people were going to the (Twin) Cities, but we just didn’t know what to do or how to go about it,” Hoder said.
Bridging the gap
Tim Kufahl, a family medicine doctor at St. Luke’s Mount Royal Medical Clinic in Duluth, said he noticed a similar lack of accessibility when he was in North Minneapolis for his residency, so he completed training for his X-Waiver, which grants the ability to prescribe buprenorphine for opioid use disorder. When he came to Duluth in 2015, he was the only physician with an X-Waiver in the Twin Ports and across the Arrowhead region.
“Out of necessity, or kind of de facto, I became the Suboxone addiction specialist even though I’m a family doctor,” Kufahl said.
Kufahl and other Northland doctors and nurse practitioners have been working to increase accessibility to Suboxone since then, including training more hospitalists and emergency room staff. Eight hours of training is required for physicians, while nurse practitioners and physician assistants must do 24 hours of training.
In mid-January, under the Trump administration, the U.S. Department of Health and Human Services announced it would increase accessibility by no longer requiring physicians to have the waiver to prescribe buprenorphine. However, the change was quickly reversed on Jan. 27 under the Biden administration, stating the change was “premature” but pledging to increase practitioner access to the drug.
“I became the Suboxone addiction specialist even though I’m a family doctor.”
— Tim Kufahl, St. Luke’s Mount Royal Medical Clinic
“Prescribing Suboxone and treating opioid use disorder and addiction really does take some skill,” Kufahl said. “I think any doctor could pick it up and do it, but a really big part of medication-assisted treatment is that people are doing recovery, and Suboxone is just an aid to let people do that. Simply prescribing Suboxone without having that concept in mind or knowing how to manage patients — I was startled by that.”
Other Suboxone advocates in the region agreed with Kufahl that the training is important. Lisa Prusak, a doctor at the Duluth Family Medicine Clinic, said it’s now required for University of Minnesota Medical School residency participants to get the waiver, and most residents are eager to take the training.
“We know this is a huge burden on individuals and on our community, and anything we can do to help that is why we’re here,” Prusak said of the residency program’s participants.
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Addiction is statistically worse in rural communities, where there is less access to treatment options. Joseph Bianco, a family medicine doctor for Essentia Health’s Ely clinic, said being able to prescribe Suboxone in these rural settings can help overcome that barrier.
While the use of methadone to treat opioid addiction currently requires a specific clinical setting with additional supervision, Suboxone can be used with more independence. Rural residents who may not be able or willing to drive long distances to a methadone clinic in larger cities like Duluth now have the option for medication to be prescribed locally.
According to an online buprenorphine registry, about 40 medical professionals in the area are certified to prescribe the drug in Duluth, Cloquet, Ely, Proctor, International Falls, Two Harbors, Hibbing, Bigfork, Floodwood, Grand Rapids, Aitkin, Virginia, McGregor and Grand Marais, Minnesota, as well as Ashland and Superior, Wisconsin.
In St. Louis County, there were 302 opioid overdoses in 2020, 31 of which were fatal, according to the Lake Superior Drug Task Force. There were 231 overdoses with 22 fatalities in 2019 and 151 overdoses with 13 fatalities in 2018. As of March 29 of this year, there have already been 80 overdoses and seven overdose fatalities in the county.
The HHS declared the opioid crisis a public health emergency in 2017. Across the nation, 1.6 million people had an opioid use disorder, according to the 2019 National Survey on Drug Use and Health, and 70,630 people died in the U.S. from a drug overdose in 2019.
“Before COVID, this was the issue,” Bianco said. “But we still have an epidemic within a pandemic, and the epidemic is getting worse. It has a lot to do with diseases of despair — people are using more drugs, they’re using more alcohol, there’s more suicide, and it has to do with this whole despair from COVID.”
“It has a lot to do with diseases of despair — people are using more drugs, they’re using more alcohol, there’s more suicide, and it has to do with this whole despair from COVID.”
— Joseph Bianco, Essentia Health’s Ely clinic
One of the main goals of the area’s recovery specialists is harm reduction. According to a 2018 National Institutes of Health-funded study, treating opioid use disorder with buprenorphine decreased overdose deaths by 38%. The main goal of harm reduction is to help people through withdrawal and cravings by providing a safer option than what’s on the street, Bianco said.
However, there’s still a huge stigma surrounding medication-assisted treatment, in both the medical and recovery communities. Keri Hager, a clinical pharmacist at the Center for Alcohol and Drug Treatment, said many people believe replacing one opioid for another isn’t truly recovery, but she and other advocates argue that medication like Suboxone helps get people their lives back.
“Would it be great if everyone could just stop and not need a medication? Yes, but we know that doesn’t work nearly as well as offering a medication to get them out of withdrawal and stabilize them,” Hager said. “This is especially important now, given much of the illicit opioid supply is adulterated with fentanyl — a much more potent opioid.”
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A common analogy used in the recovery community compares the chronic diseases of addiction and diabetes. Taking insulin keeps a person with diabetes alive and functioning, but they have to continue to take the medicine to regulate their functions. Suboxone is the same — many people in recovery are able to greatly reduce their intake, but some people will need to continue to use Suboxone for the rest of their lives in order to feel “normal.”
Hoder, for instance, started on 18 milligrams of Suboxone a day. Now, he takes 3 milligrams a day, and is aiming to come off the medication at some point. But he knows he can’t rush the process. Hoder said he’s noticed stigma surrounding medication-assisted treatment in recovery communities because it isn’t seen as a truly abstinent or sober path. This belief can push people to try to come off the medication too soon and put themselves at a higher risk for relapse, overdose or death.
“It gives you a chance to feel somewhat normal,” Hoder said. “You’re able to live a normal life with it. Without it, we’ll get through the physical withdrawal, but the mental portion of it — it gives us that extra support against the mental withdrawal and a fighting chance to build things in your life that you don’t want to lose.”
Since he started his recovery journey in 2018, Hoder has been able to get his life back. He’s able to be with his son and he now uses his experience to help others through their recovery at the Human Development Center in Duluth, where he works as a peer recovery specialist.
A community effort
Suboxone itself is not a cure for opioid-use disorder. But when paired with other recovery resources, like counseling, therapy and support groups, patients are more likely to retain their recovery and stay in the programs.
There are quite a few entities in the Twin Ports dedicated to providing support during recovery, ranging from inpatient and outpatient treatment centers, support groups, detoxification units, and medication-assisted treatment like methadone clinics or buprenorphine prescriptions. There has been a collaborative effort between community organizations and the use of several state and federal grants to discover what steps are missing to get people into recovery and how to fill those cracks.
There are even services, like Rural Aids Action Network and Harm Reduction Sisters, that help people with addiction stay as safe as possible by providing sterile needles and sharps disposals, as well as fentanyl test strips and naloxone.
“When people are heard and they define what they want to do and we walk with them, we see folks are able to sustain their recovery.”
— Beth Elstad, Recovery Alliance Duluth
Hager said since she took on her role at Center for Alcohol and Drug Treatment about two years ago, she’s already noticed a change in the collaboration between health care systems, treatment and recovery organizations, law enforcement and the judicial system. This community network has created a chain of accountability, so people with addiction have specialists to walk with them through their recovery instead of just handing them a pamphlet at the emergency room or jail and hoping they can navigate finding help on their own.
That’s what Beth Elstad does at Recovery Alliance Duluth. As a co-founder and executive director, Elstad and the RAD team talk to clients about what they hope to get out of their recovery experience and walk alongside them. RAD’s services also include assisting with transportation to or from the emergency room, treatment, detox or jail, or helping clients connect with housing or other resources.
“Recovery is very individualized. We really believe it’s self-directed and we believe people know what they need and what they want, and we’re in it to support them through that journey,” Elstad said. “And it works. When people are heard and they define what they want to do and we walk with them, we see folks are able to sustain their recovery.”
Still not perfect
Although the effort to help people recover from opioid use disorder is increasing, there are still barriers to be overcome. Prusak said one huge barrier has been insurance coverage of Suboxone. Not all insurance companies cover Suboxone, and providers for people on public assistance seem to all have different rules, Prusak said. Some pharmacies are also unable to give people more than one strength of Suboxone at a time, even though easing into dosage with gradual increases or decreases is a common way people start on the treatment drug.
“We have so many times that a patient will go to the pharmacy and the pharmacist will say, ‘I can’t give you those,’” Prusak said. “Well, here we have a patient in withdrawal and we don’t know that they can’t give it to them unless the patient tells us or the pharmacist calls us. It’s just another barrier.”
Overall, the area’s recovery specialists said they just want people to understand that addiction is a chronic disease that alters the brain. People can become addicted to opioids through dependency on prescription medications or by using opioids found on the street.
“People don’t wake up one day and say, ‘Oh, I think I’m going to be an addict.”
— Lisa Prusak, Duluth Family Medicine Clinic
“People don’t wake up one day and say, ‘Oh, I think I’m going to be an addict,’” Prusak said. “It’s like this horrible roller coaster that people get on and they just can’t get off because the minute they try to quit, their brain just starts screaming for this stuff.”
The biggest barrier to medication-assisted treatment, people say, is still that stigma — and change starts with individuals. Elstad said a starting point is using language that has more positive connotations that put the person first. For example, instead of “addict,” say a person who is experiencing addiction or a person in recovery. A “relapse” is instead a return to use or a person experiencing substance use disorder.
Education, Bianco added, goes a long way. Taking the time to understand the disease and its treatment options, as well as the statistics supporting medication-assisted treatment, can help people offer empathy and support to loved ones or community members with their journey of recovery.
“We had a real problem here, and by being able to have access to this, we can save people’s lives,” Bianco said. “This is a harm reduction strategy. You hear people say, ‘Well you’re just substituting one opioid for another.’ Yes. We are. But it’s a safer opioid and it works.”