Inside the fight over Suboxone, a life-saving drug with stigma

LYNNWOOD — At the clean-and-sober house on Larch Way, there’s no heroin allowed. No blue fentanyl pills. No meth.

But one banned substance stands out against the rest: Suboxone.

Many doctors herald the medication as a gold standard for addiction treatment. The federal and state governments are working to expand access to the drug as opioid overdose deaths soar to new heights.

Yet the medication is caught in the middle of a tug-of-war. Doctors and some patients, both trying to loosen the grips of the opioid epidemic, disagree on whether Suboxone should be a part of the solution.

Suboxone comes in thin strips that dissolve under the tongue. It blunts cravings and withdrawal symptoms. And, by blocking a key receptor in the brain, it prevents users from getting high on street drugs. Research suggests it can cut the risk of overdose deaths in half.

It also contains a type of opioid.

“A drug is a drug is a drug,” said Robert Smiley, who oversees the Larch Way house and three other sober houses in Lynnwood and Everett. Some of his residents taper off Suboxone to secure one of those 73 beds.

Smiley thinks clinics are prescribing too much of the medication. He says it gets people high. He points to a black market: “Heroin dealers carry heroin and Suboxone. They sell them both.”

But doctors say stigma and misunderstanding are preventing people from taking a life-saving medication. Meanwhile, their patients are more at risk of overdosing than ever before as fentanyl floods the community. Dealers have laced Xanax, cocaine, heroin and meth with fentanyl, unbeknownst to buyers.

At Providence hospital in downtown Everett, addiction specialist Dr. Todd Carran estimates a fifth of his patients are refusing the medication.

“And it’s the reason that concerns me the most,” he said. “They’ve often been told that taking Suboxone is just replacing one opiate with another, or that they’re not sober if they’re on Suboxone.”

Carran calls Suboxone “remarkably side-effect-free and safe.”

With chronic fentanyl users, Carran considers the abstinence approach “highly unlikely to be successful.”

“The withdrawals are too severe. They last too long,” he said. “The cravings are severe, and the amount of brain dysfunction that occurs in the first few months is very high.”

When unmedicated withdrawal symptoms get too painful, his patients often end up relapsing.

Carran fears letting his patients go cold turkey could be doing more harm than good.

Patients are at higher risk of overdosing after a period of sobriety, when their tolerance depletes. Without medication in their system, they can be in a more dangerous position than when they first sought help at the hospital.

“It’s sort of an ethical problem for me,” Carran said.

‘The chances of you dying’

When John Merrell first arrived at the Larch Way sober house this year, he was tapering off Suboxone.

On the front porch, where residents smoke cigarettes together, his new roommates had opinions about his medication.

“People were like, ‘That’s not really recovery,’” Merrell said.

The 42-year-old agreed. He wanted off the medication.

After a gunshot wound several years ago, it was doctors and “pill mills” that got Merrell hooked on Oxycontin. It wasn’t hard to find clinics that peddled the opioid to feed his addiction.

Then the pills dried up. Merrell turned to heroin.

These days, he’s a self-described cynic when it comes to pharmaceuticals. He’s skeptical about doctors pushing another opioid billed as a cure for addiction.

“It all comes back to money. I mean, that was the same reason they were pushing Oxycontin,” he said of Suboxone. “When you understand history, you can see how it repeats itself.”

Down the road, Mishele Rutherford sometimes ponders the same question. She prescribes Suboxone at Evergreen Recovery Centers. She knows patients get physically dependent on it.

“In 20 years, is this going to be a problem? Am I going to be part of this problem? Everyone stuck on Suboxone?” she said.

Those doubts fizzle when she considers the evidence.

“We’ve seen (Suboxone) in action long enough,” she said. “There’s not a lot of negative side-effects, even long-term.”

Even if fentanyl and Suboxone are both habit-forming, she said, one destroys lives while the other saves them.

For Rutherford, it’s easy to see why anti-Suboxone rhetoric is so prolific in the recovery community.

“It wasn’t that long ago that in AA, even taking an SSRI for depression was considered not all right,” she said, referring to drugs used as anti-depressants. “So this is longstanding.”

She agrees with some critiques of “big pharma.” And she thinks her patients could advocate for change in the medical field — but not if they die from an overdose.

From 2018 to 2021, Snohomish County’s fentanyl deaths more than tripled. So far this year, 44 of the county’s 50 opioid overdose deaths were due to fentanyl.

Faced with that reality, Rutherford is getting more aggressive with her patients.

“Do you know the chances of you dying are pretty high now?” she says to them. “Is that what you want?”

That pressure can backfire.

Pushy doctors were a turn-off for Everett mom Alissa Long. In 2018, she tapered off Suboxone against the recommendation of her doctor, who wanted her to continue into a third year.

“I didn’t feel supported when I tried to get off Suboxone,” she said. “These nurses and doctors now, they push it so hard, even when you tell them you don’t want it” in detox. “They’ll still call you in and ask you every six hours if you want a dose. And when you’re in pain like that, and you’ve already made up your mind, it’s frustrating.”

After relapsing on fentanyl earlier this year, Long is trying abstinence now. Partly because of pushy doctors. Partly because of the $360 monthly bill that came with the prescription. And partly because “the shame of taking Suboxone” she felt in the past.

Medication-assisted treatment “is really a personal choice,” Long said. “And the stigma about what it takes for people to get clean really needs to end.”

‘A bit dubious’

Chris Wright woke up in the hospital after 32 days in a coma. It was 2019. He had overdosed on heroin.

When doctors put him on Suboxone, the cravings went away, he said, “but I was basically getting loaded in the hospital.”

“Suboxone makes you high,” he said. “I don’t care what anyone says. It feels exactly like heroin.”

It’s a common complaint with Suboxone.

But if you ask Carran, it’s impossible.

“If you are opioid-experienced, if you’ve ever taken opioids before, you cannot get high,” he said. “You cannot get a euphoria from Suboxone.”

The main drug in Suboxone only partially activates opioid receptors in the brain.

Carran has a theory about patients insisting they’re intoxicated.

“What they often misinterpret is the fact that Suboxone will relieve their withdrawal,” Carran said. “They interpret that as being similar to fentanyl or any other opiate they take that relieves their withdrawal.”

Rutherford, at Evergreen Recovery Centers, concurred.

“Anything that makes them feel a little different, they consider a high,” she said.

She also described patients confusing drowsiness from Suboxone with “nodding off,” which can be a precursor to a deadly overdose.

Some Suboxone critics say they’re OK with the medication. Wright said it’s fine if patients only use for two weeks or so. Smiley said he’d be OK with Suboxone if providers stuck to 4 mg or less.

But a standard dose of Suboxone is 16 mg. Anything below 8 mg is considered low.

Providers differ on how long Suboxone should be prescribed. Some programs use the drug during detox, then taper clients off to avoid long-term dependency.

But the brain can take years to heal from chronic opioid use. Patients are often surprised at Providence and Evergreen when doctors recommend they use Suboxone for at least a year. Providence expects 15% to 25% of patients to stay on Suboxone even longer.

Carran has no concerns about long-term use.

“There’s no evidence that it decreases their life expectancy in any way, shape or form,” he said. But he understands patients who don’t want to be dependent. “I guess if you talk to a diabetic, they don’t like being dependent on insulin, either. Nobody likes being dependent on a medication.”

The doctor isn’t worried about the black market for Suboxone, either. Folks struggling with addiction use the drug to avoid withdrawals when they’re not using.

As for stories about people using illicit Suboxone recreationally, Carran said: “I find it a bit dubious, to be honest.”

‘It isolates us from recovery’

Judge Joe Wilson fist-bumps each defendant he oversees in Snohomish County’s recovery court. Formerly known as “adult drug treatment court,” the two-year therapeutic court oversees people struggling with addiction and facing non-violent felony charges.

For years, the Superior Court judge banned participants from using Suboxone, or any other medication-assisted treatment (MAT).

Wilson changed his mind in 2018.

Sitting in his corner office in downtown Everett, he recalled the defendant who swayed him: a pregnant woman on methadone, another FDA-approved medication for addiction.

“People patiently explained to me that it was a medical decision,” Wilson said, “and the dosage she was taking was not negatively impacting her.”

By the time she graduated, she had been sober over 500 days, was taking good care of her child and had secured stable housing, Wilson said.

That doesn’t mean the judge is enamored with MAT or Suboxone.

“My belief is abstinence-based,” Wilson said. “To be free of all mood and mind-altering substances.”

Wilson gets why there’s a stigma around Suboxone. He got sober a decade or so ago.

“You’ve got to understand that as an addict, you’ve been told your whole life that you need to get your (expletive) together, and you can do it alone. ‘You’re not trying hard enough.’ ‘Pull yourself up by your bootstraps,’” he said.

People are internalizing that, the judge said, “and transferring it to another suffering addict.”

It’s true, said Jennifer Cunningham. The Everett mom hears the same rhetoric in some 12-step meetings. She kicked a heroin addiction five years ago and is now prescribed Suboxone.

“The stigma’s hard,” she said, watching her daughter at a playground. “Because I’ve witnessed so many people go back out and not come back — and die. People say those on Suboxone are still junkies. That they’re still loaded. … It isolates us from recovery, and from feeling a part of the community.”

Through the years, Wilson said, “I’ve come to learn that recovery is individual.”

And the drugs have changed.

“I’m not sure I’d survive in today’s climate,” he said. “And clearly (medication-assisted treatment) is the only thing holding back a tidal wave of fentanyl overdoses.”

Claudia Yaw: 425-339-3449; claudia.yaw@heraldnet.com; Twitter: @yawclaudia.