Five days a week, Cristin wakes up before dawn and calls her employer to get her assignments for the day. As a mobile phlebotomist, the 36-year-old from Meriden visits assisted living residences, nursing homes and drug rehabilitation centers where patients need medical tests.
At the rehab centers she tells her personal story to cheer patients up. “They’re often depressed and feel really crummy about themselves,” she says. “I say, ‘Keep doing the right thing, and it will get better.’” To prove it, she rolls up her sleeve. “I show them the marks on my arm and say, ‘I used to be in your position,’” she says. “‘It is possible!’”
If someone is struggling with severe dependence, they may be out on the street or doing desperate things to try to support their habit. There can be health consequences and legal consequences if they can’t start treatment right away. Carla Marienfeld, MD
With the help of Carla Marienfeld, MD, formerly an assistant professor of psychiatry at Yale Medicine, and the staff at the nonprofit APT Foundation, which provides substance use disorder treatment and related services, Cristin is now in control of the opioid use disorder she acquired as a teenager.
“She’s been able to escape a lot of the negative cycles that occur with long-term substance abuse,” Dr. Marienfeld says. She’s successful in her job, happy in her relationship and even thinking about having kids. “She’s made wonderful decisions and has really come a long way.”
Addressing an epidemic
Cristin (who asked to withhold her last name) is among the millions of Americans who became addicted to opioids after prescriptions for medications such as Oxycontin (oxycodone HCI), Percocet (oxycodone and acetaminophen) and Vicodin (hydrocodone bitartrate and acetaminophen) became widely available to pain sufferers in the 1990s and 2000s. People who could no longer get pills sometimes turned to heroin, also an opioid, which is cheaper and may be easier to find.
“There was large-scale over-prescribing, then substantial misuse,” explains Richard Schottenfeld, MD, a professor of psychiatry Yale Medicine.
The most visible indicator of the public health problem has been a dramatic rise in overdose deaths. There were more than 33,000 in the United States in 2015. It is the leading cause of death among young people 18 to 35 years old.
When ingested or injected, opioids enter the bloodstream and act on receptors in the brain that affect pain and pleasure. They block painful sensations and activate the brain’s reward center, creating feelings of bliss and reinforcing the drive to continue use. After repeated exposure, the person needs to maintain high blood levels of opioids just to feel normal.
If a person who has become dependent stops taking opioids, he or she suffers severe withdrawal symptoms such as chills, shakes, nausea and vomiting. Even after the sickness subsides, the brain remains fundamentally changed. Without opioids, the person feels depressed and anxious. The reward system is constantly asking for more, and former opioid abusers report daily cravings that can last for years, perhaps for the rest of their lives.
Coming-of-age among opioids
Cristin swallowed her first Oxycontin in 1998, when she was 18.
Her family doctor had prescribed it after a car accident left her in constant pain from bulging disks in her lower back. Physical therapy wasn’t helping, and Cristin had heard about an amazing new pain reliever from her parents, who worked as nurses. She says: “I said to the doctor, ‘I heard this medication is good for pain. What do you think?’”
Cristin took the pills as prescribed, and they helped with her back pain, allowing her to keep working as a waitress in spite of the disk problems. But after about a year her doctor refused to renew her prescription, saying she had been taking the pills for too long. The doctor referred Cristin to a pain clinic, where she might find other ways to keep her back pain in check. But the clinic did not take her insurance, and as Cristin scrambled to find an alternative opioid withdrawal symptoms set in, including chills and vomiting. “My boyfriend at the time, his brother was into heroin,” she says. “He said, ‘Try a little bit of this.’ I sniffed it first, and it made all my sickness go away.”
After a few months, sniffing heroin stopped mitigating her pain, and another friend encouraged her to try injecting the drug. “I said, ‘Why would I do that?’” Cristin says. “He said, ‘You’ll use less of it and feel it stronger.’ I let him do it for me, and I was blown away.”
She spent most of her 20s addicted to heroin, drifting through low-paying jobs, squalid apartments and drug-using acquaintances. She detoxed and relapsed too many times to count.
Yale Medicine is out front on addiction
Most doctors view addiction as a chronic disease, akin to diabetes. “When you get it, you don’t get rid of it,” Dr. Schottenfeld says. “It’s hard to recover from.” With so many Americans dependent on opioids, “hundreds of thousands of people will need ongoing treatment for prolonged periods of time,” he says.
The good news is that some treatments work well. Medications such as methadone and buprenorphine can stimulate the opioid receptors enough to eliminate the drug cravings, without getting a patient high. “The goal is to help patients feel normal,” Dr. Marienfeld says. Then they can focus on other aspects of their lives, such as working or parenting.
Treatment without medication rarely works. “You get extraordinarily high relapse rates, 85 to 90 percent in a year, and an enormous risk of overdose death,” Dr. Schottenfeld says. Opioid users have long had trouble getting help with their addiction. “Treatment hasn’t been readily available,” Dr. Schottenfeld says. “It’s difficult to get, expensive and not necessarily covered by insurance.”
Yale Medicine has long been at the forefront of addiction research and outreach. Herb Kleber, a Yale professor of psychiatry, pioneered ways to help opioid users detox using medication, and in the 1960s, Yale Medicine ran one of the first methadone clinics. Recently the work of Yale doctors helped get Food and Drug Administration approval for buprenorphine, which is offered as a regular prescription. “Our studies helped bring it into primary care settings,” Dr. Schottenfeld says.
Now physicians can complete training and receive a special waiver to prescribe buprenorphine. Dr. Schottenfeld and Dr. Marienfeld have helped dozens of local physicians in Connecticut—mostly psychiatry residents, family practitioners, primary care doctors and internal medicine specialists—receive the training.
Meanwhile, organizations such as the APT Foundation work with physicians such as Dr. Marienfeld to help people start treatment the moment they are ready. “A lot can happen to someone who is living the life of an addict in a short period of time,” Dr. Marienfeld says. “If someone is struggling with severe dependence, they may be out on the street or doing desperate things to try to support their habit. There can be health consequences and legal consequences if they can’t start treatment right away.”
Through those combined efforts, “We’ve seen some very big increases in the numbers of people able to enter treatment,” Dr. Schottenfeld says. Many, like Cristin, have been able to conquer their addiction and return to healthy, productive lives.
Help for the whole patient
In 2006 a detox center insisted that Cristin seek long-term treatment. “I was forced onto the methadone, which I kind of didn’t mind,” she says. “I wanted a way out.”
Cristin continued her methadone treatment at the APT Foundation, which provides treatment regardless of insurance coverage or ability to pay. She benefited from its comprehensive approach, including broader psychiatric care, which can be an important component.
At APT, Cristin started meeting with Dr. Marienfeld. “She’s awesome,” Cristin says. “By far, the best psychiatrist I’ve ever had. And I’ve gone to quite a few.”
Dr. Marienfeld learned all about Cristin’s history and the life struggles that played into her opioid addiction. She had difficult relationships with her parents and suffered from anxiety. “I don’t like being around a lot of people, or out in public for too long,” she says. She could never get her brain to turn off at night when it was time to go to sleep.
She unburdened herself to Dr. Marienfeld. “She shows sincere caring for my well-being. And I’m street-smart, so I can tell when someone is really listening,” Cristin says.
Dr. Marienfeld suggested natural ways for Cristin to deal with some of her problems, such as relaxing and drinking herbal tea before bedtime to avoid insomnia. She prescribed medications for issues such as the anxiety, and because Cristin loves to read she often sent her home with book recommendations.
A new treatment option
Cristin stayed on methadone for about five years, for withdrawal avoidance and for help otherwise feeling normal. But she didn’t like the stigma associated with the drug. And methadone treatment is inconvenient, requiring people to visit a clinic every day to receive their dose or, at best, take home a week’s worth.
Patients who stop methadone suffer from high rates of relapse to illicit drug use. But when patients are stable in their lives, have support and have not used illicit drugs in a long time, doctors may try to taper them off in the hope that they may be among the small percentage who do well without medication.
Cristin wanted to stop methadone, so under the guidance of Dr. Marienfeld, she dropped her dose a few milligrams every two weeks, until she was down to just 4 mg per day. Then she stopped entirely. “Even with that,” she says, “I had to deal with withdrawal symptoms for about three months.”
Cristin did well for a few months, but she was still surrounded by a lot of reminders of her past drug use.
One day she called Dr. Marienfeld and told her, “I’m feeling kinda unsure.” Her boyfriend was about to get a large sum of money. “He wasn’t in the same mind frame that I was,” Cristin says. “I didn’t want to put myself in the situation where I could use and that would be OK.”
The doctor sprang into action. “She said I would be a good candidate for buprenorphine,” Cristin says.
Methadone and buprenorphine have different pros and cons. For example, methadone has a wider range of doses and blood levels are easily monitored to tailor doses to individual’s needs, but buprenorphine has less overdose risk.
So doctors make a careful determination about which treatment is best for each patient. Treatment with extended release injection naltrexone, which is administered by intramuscular injection monthly and works by a very different mechanism, is also an option for some people who prefer not to take medications that stimulate opiate receptors.
Cristin’s buprenorphine prescription is administered through sublingual strips. “You put them under your tongue and let them dissolve, and that’s it,” says Cristin, who takes two at home every morning.
“It blocks opioids, but doesn’t make you feel sick,” she says. “It’s a pain reliever, too, but not to the point where you feel numb. And it doesn’t make you feel tired. You’re more alert.”
She started focusing on her career, deciding to follow her parents’ footsteps into health care and became a home health aid, then a certified nurse assistant and finally a certified phlebotomist. “I had an inkling I’d be good at it,” she says.
Working with needles is not a problem. “Now, when I see one, I associate it with the medical field. I don’t think about how I would have used it years ago,” Cristin says.