Tagged Mental Health

Addiction Clinics Market Pricey, Unproven Treatments To Desperate Patients

Jason was hallucinating. He was withdrawing from drugs at an addiction treatment center near Indianapolis, and he had hardly slept for several days.

“He was reaching for things, and he was talking to Bill Gates and he was talking to somebody else I’m just certain he hasn’t met,” his mother, Cheryl, says. She remembers finding Jason lying on the floor of the treatment center in late 2016. “I would just bring him blankets because they didn’t have beds or anything.”

Cheryl had taken Jason to the clinic out of desperation. Jason, now in his late 30s, has struggled with addiction since he was a teenager. Cheryl saw his drug use escalate after he was prescribed a benzodiazepine for his anxiety, and he eventually began using heroin and meth. Over the years, Jason would try to get into recovery, but treatment programs didn’t help him for very long.

“I thought he was going to die,” Cheryl says. (KHN and NPR are using only first names because Jason worried he would lose his job if his employer found out about his addiction history.)

In late 2016, she saw a local TV news segment about a clinic called Emerald Neuro-Recover. The staff there treats addiction with something called NAD therapy, an IV infusion that can contain amino acids and other nutritional supplements, including nicotinamide adenine dinucleotide, a compound found in living cells.

The infusion, which is delivered over 10 to 15 days, cost $15,000, and it wasn’t covered by insurance. But the TV report said Emerald’s treatment was “proven to wipe drug cravings away.” Cheryl was intrigued.

Emerald and dozens of other companies across the U.S. say NAD therapy can address conditions from anxiety to depression to chronic fatigue and even Alzheimer’s.

And clinicians offering the treatment say that it reduces or stops cravings for alcohol or illicit drugs in up to 90% of patients. The treatment has gained attention on addiction recovery blogs and in the mainstream media.

But such claims about NAD therapy and addiction are not supported by scientific evidence, and they may conflict with federal and state regulations against deceptive marketing of medical treatments. Emerald and other addiction treatment clinics use these claims on websites, social media and in the news to attract clients looking for help. Emerald even used patients’ stories to promote the therapy — in some cases, more than a year after the patients returned to using illicit drugs.

In an interview with Side Effects Public Media, Emerald leadership defended its use of the therapy. “It’s not really controversial; it’s just novel or new,” says John Humiston, a family medicine physician and the company’s medical director. “The cravings we expect to be gone within days.”

Earlier this year, Emerald leadership discussed NAD therapy with Side Effects but cut the interview short amid questions about the treatment’s efficacy. Company officials declined another interview and did not respond to follow-up questions via email. For that reason, Side Effects was unable to ask them about Jason’s case.

Treatment centers touting high success rates can sound appealing to vulnerable people suffering from addiction or to their families, even if there’s no solid evidence to support their methods. “[Clinics] know this is a really desperate population,” says Basia Andraka-Christou, a health policy researcher focused on substance use disorders at the University of Central Florida.

Unsubstantiated claims have long been a part of addiction treatment. For instance, in the late 19th century, a doctor dubbed his formula the “Double Chloride of Gold Cure” and sold it via mail order for addiction, claiming a 95% cure rate. “In a week the desire to drink will be gone,” read one advertisement.

More recently, NAD therapy is among a wide range of unproven treatments currently marketed to people with addiction, including the herbal extract kratom and other types of supplements. The FDA and the FTC cracked down on a few of these last year but have limited resources to police the market for unproven treatments. And that leaves consumers on their own to sort out fact from fiction.

While patients spend time and money on ineffective treatments, they miss out on proven therapies that can reduce their risk of relapsing, including behavioral counseling and medications approved by the FDA for treating addiction, says Andraka-Christou. “We do actually now have evidence-based treatments available,” she says. “But you still do have these quack treatments popping up.”

A vial containing the mix of supplements that Emerald uses in its infusion treatments.(Jake Harper/Side Effects Public Media)

A Hard Sell

Numerous companies make bold claims about NAD therapy. A Las Vegas clinic says, “IV NAD+ therapy has a 90% success rate at reducing cravings and a 7% relapse rate.”

clinic in Pooler, Ga., says NAD therapy can provide “rapid reduction or even elimination of cravings, restoring clarity of mind and enthusiasm to be alive.”

Another center in Greenville, S.C., says, “Withdrawal signs of addiction go down approximately 70-80% on the first day and continue to decline as the therapy progresses.”

Similar glowing testimonials from Emerald led Cheryl and Jason to meet with Emerald leadership in late 2016, including founder Joe Pappas and patient liaison Amora Scott. Cheryl recalls, “They said, ‘This is going to fix it. … It has never not worked for us. It works for everyone.’”

Jason insisted his mother shouldn’t pay thousands of dollars for his treatment. She had already spent too much money on him. They decided not to come back.

“Well, then Amora started calling me and calling me and calling me,” Cheryl says. Unknown to Jason at the time, Cheryl says Scott persuaded her to pay for the treatment upfront.

Cheryl took out an advance on her credit card and met Scott at a gas station to hand over the money. “When I gave her that check, I looked at her and said, ‘This is to save my son’s life,’ ” Cheryl recalls.

Fifteen thousand dollars could seem like a bargain for such a quick fix — one that “restore[s] the brain to its pre-addiction neurologic state,” according to a press release from Emerald.

But there has been little research on the effects of the formulas used by Emerald and similar clinics.

“I don’t know where those claims could come from, but it doesn’t seem realistic to me,” says Emily Zarse, an addiction psychiatrist in Indianapolis. She says there’s insufficient evidence to support using NAD therapy over other standard treatments: “There’s no actual data on any of these things.”

Brain scans from Emerald show what it claims to be before (top) and after (bottom) images of a woman’s brain following NAD treatment. The images appear in an Emerald brochure, including text that says, “The brain is more calm after 12 days of NAD+ Amino Acids Therapy.”(Emerald/Screenshot by Side Effects Public Media)

For an additional $400 fee, Emerald patients can have their brain scanned at a nearby clinic to document their progress with NAD therapy. An Emerald brochure shows a series of scans from a woman whose “brain is suffering from alcoholism.” Areas that glow red, orange and yellow — “HYPERACTIVE and OVERACTIVE” — totally disappear from the scans after 12 days of NAD therapy, according to the company.

“This is totally bogus,” says Leslie Hulvershorn, an addiction psychiatrist at the Indiana University School of Medicine with expertise in brain imaging who reviewed the images via email. “We do not have research in our field that allows us to use EEG or any other brain imaging technique to document treatment response.”

NAD, which is an important coenzyme in several cellular processes, including energy metabolism, is being researched at Harvard for its role in aging. Supplements claiming to boost NAD levels have recently gained popularity for purported anti-aging benefits. But NAD’s benefits in addiction treatment are unproven, and providers cite unpublished research to make sweeping claims.

One pilot study cited among some NAD therapy providers shows close to 90% of patients have reduced cravings after 10 days of treatment. The study falls short of the standard used by the scientific community to weigh evidence: It did not compare NAD therapy to a placebo or other treatment. It also did not undergo rigorous peer review, and the results have not been published in a scientific journal.

A doctor involved with that study, Richard Mestayer, says he is used to skepticism. Mestayer runs a clinic in Springfield, La., that offers NAD therapy. He says it is unclear how NAD therapy helps with addiction but that his personal experience convinced him it works.

“I think there’s a lot of stuff we don’t know yet,” he says. “I was a skeptic, but when a two-by-four hits you in the head every time, you say, ‘Oh, I better pay attention.’”

Dangerous Withdrawals

The hallucinations started several days into Jason’s treatment at Emerald. Cheryl wanted to take him to the emergency room.

Rapidly withdrawing patients from benzodiazepines can cause dangerous side effects, such as seizures — it can even be fatal, says Zarse. “There are two types of withdrawal symptoms that can kill you: alcohol and benzodiazepines,” she says. “It can cause enough misfiring in the brain that it can lead to brain death.”

The standard treatment is to slowly wean someone off benzodiazepines. “They even give benzos for benzodiazepine withdrawal in jail — that shows you how serious this is,” Zarse says.

Still, Cheryl says, Emerald staff told her to take Jason home rather than to the hospital. She decided to go to the ER anyway after Jason tried to throw himself through a wall.

Jason was still hallucinating when he arrived at the ER, and then the seizures started. “He was just totally out of it for about three days,” Cheryl says. “Not even alert.”

One of the doctors who treated Jason noted in his medical records: “Unclear exactly what this NAD substance/medication is.”

When Jason left the hospital, he returned to Emerald to finish the treatment. “I didn’t know what else to do,” he says.

Jason says the therapy didn’t work. He white-knuckled his way through abstinence for three months before he relapsed. “One day out of the blue, I called somebody up and just was going to do it one time,” he says. “You know how that goes.”

Marketing Unapproved Substances

The federal Food and Drug Administration has not approved NAD therapy, according to a spokesperson for the agency.

Substances marketed as treatments for specific conditions are considered medications and must be approved by the FDA for that purpose, says Andraka-Christou. For medications, FDA approval requires three phases of human clinical trials. Without that approval, it would violate FDA regulations to market a treatment for that condition.

More broadly, making unsupported claims about a medical treatment or supplement violates federal rules. Both the FDA and the Federal Trade Commission regulate how companies advertise treatments and supplements.

But no publicly available information could be found to show that either agency has taken enforcement action against any clinic offering NAD treatments.

Spokespeople for the FDA and the FTC said via emails that their agencies could not comment on specific cases. “All advertising under our jurisdiction must be true, not deceptive, and supported by competent and reliable scientific evidence,” wrote the FTC spokesperson.

“The FDA takes action against companies that engage in ‘health fraud,’” said the email from the FDA.

Lack of FDA action doesn’t mean it is acceptable for clinics to market the therapy, says Chris D’Adamo, an assistant professor at the University of Maryland who researches dietary supplements.

“The FDA can be slow, and it’s understandable because there are so many [potential enforcement issues] out there,” he says. “There could still be cause for concern.”

Patient Stories

Since its inception, Emerald has featured patients’ stories on social media and in news coverage, much of which uncritically repeats the company’s claims about ending addiction. But several of these same patients went to jail for drug and alcohol offenses soon after being treated at Emerald.

In a 2017 TV news story about Emerald, a man says that Emerald helped him get his alcohol and pill addiction under control. Reached by phone, he told Side Effects that he reluctantly said those things to get the TV interview over with. “[NAD therapy] was a complete waste of my time and my family’s money,” he said. “It did absolutely nothing for me.” (He asked to remain anonymous because many of his family and friends don’t know about his addiction, and he worries about his future job prospects.)

He added that he also experienced a seizure when the doctor quickly cut him off from alcohol without antiseizure medication. He says he started drinking again about a week after he finished NAD therapy, and he was arrested for drunken driving a few months later.

In another video Emerald posted on YouTube in 2017, an Indianapolis man is seen leaving Emerald on a sunny day. “I feel wonderful,” he says. “Using heroin, I had a lot of racing thoughts, anxieties, cravings. All that’s gone.” He tells other people who use heroin to go to Emerald.

Six months later, he was in jail for possession of a syringe. Reached by phone, he said that the treatment didn’t work for him, and that he received it free of charge.

Emerald still promoted patients’ stories like these on social media until December 2018. The company began removing content from its website, YouTube and Facebook shortly after Side Effects began reporting this story.

Emerald executives declined to provide Side Effects with a patient to interview.

Asked about cases of relapse among Emerald patients, Humiston replied: “What I’ve seen is that [the treatment is] very effective.” Humiston started work at Emerald in January 2019, but he was a medical adviser for the company before then, and emails between Cheryl and Emerald staff indicate that he was consulted about Jason’s treatment there.

Dr. John Humiston and Star Voigt, former CEO of Emerald, in January at the Emerald clinic.(Jake Harper/Side Effects Public Media)

Origins Of Treatment

Humiston says he believes in the treatment he offers: “It’s got quite a reputation of success. Nothing’s 100%, although for most people, it is 100%. That’s been my experience.”

But Humiston acknowledges that he does not regularly track patients’ long-term outcomes: “That’s the reason to get a study organized,” he says. Last year, Humiston told a local TV station that a clinical trial was forthcoming, but it has not materialized.

Humiston first learned about NAD therapy from a man named William Hitt. Hitt is often credited with originating the treatment, but he was not a doctor or a researcher. According to a lawsuit brought by the state of Texas in the mid-’80s, he falsely claimed to be a doctor when he treated AIDS patients with “injections of the patient’s own filtered urine.” Forced to shut down in Texas, he moved to Tijuana, Mexico, where Humiston worked with him from 2003 until his death in 2010.

Humiston himself has had trouble with his medical license. The Medical Board of California reprimanded him, according to investigation documents, for committing “gross negligence in his care and treatment” of his teenage son, who almost died in 2016 when Humiston failed to seek proper treatment for the boy’s heart infection. Documents say Humiston began performing IV treatments on the boy before he was 3 years old, which may have caused the boy’s heart issues.

Asked about the investigation, Humiston said there was “inaccurate information put in there” but that he accepted a public reprimand from the medical board “just to end it.” He did not respond to emailed follow-up questions about the disciplinary case.

Humiston applied for an Indiana medical license in November 2018, and the state granted it. He became Emerald’s medical director in January. He is at least the sixth doctor to work with the company in its three years of operation.

‘I Owe Her The Money’

When asked in January about Emerald’s claims and the origins of NAD therapy, Star Voigt, the CEO at the time, declined to answer further questions. “We’re trying to help people,” she said. “So if you’re going to go into that, then I’m going to ask you kindly to leave.”

Side Effects sent further questions via email, but the company did not answer them. Instead, Voigt sent a statement from Humiston expressing concern that Side Effects’ reporting wouldn’t be balanced or objective. Voigt left the company soon after.

Cheryl, the patient Jason’s mother, wrote to Emerald founder Pappas a few months after her son left Emerald. She told him that Jason was facing an $11,000 medical bill from his hospital stay and that he still struggled to stay away from illicit drugs. She reminded Pappas that stopping benzodiazepines cold turkey — what Jason went through at Emerald — is dangerous and goes against standard medical practice.

Cheryl wanted a refund so she could pay off Jason’s medical bill. “Can we compromise?” she wrote.

Scott, the patient liaison, wrote back that Humiston believed Jason should be tested “for mold … infections, and/or inflammation in the blood and body.” Instead of a refund, Emerald offered further NAD treatments and another therapy — for $3,000.

Cheryl and Jason declined the offer. “First, do no harm,” Cheryl wrote back. She filed complaints with the FTC and the state attorney general, but nothing came of it. (Indiana law allows the state attorney general to prosecute companies for deceptive advertising. The office would not confirm or deny whether it is investigating Emerald’s practices.)

The hospital eventually did waive the $11,000 bill. But Cheryl still has not received a refund from Emerald.

“I feel like I owe her the money,” Jason says. “At some point, I’ll pay it back.” He says he finally got help with his addiction through a local 12-step program that he has been part of for two years. Looking back at his treatment at Emerald, he says he felt duped into trying NAD therapy. “I think it’s taking advantage of people.”

“I can’t believe that no one stops them,” Cheryl says. “You’ve got these people selling snake oil, and they’re getting away with it.”

This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News.

Scores Of People Born Through Artificial Insemination Are Finding Out Their Fathers Are The Doctors Who Performed Procedure

With the growing use of consumer DNA tests, many have been left reeling by the news that the sperm donors that their mothers selected are not their fathers. “You build your whole life on your genetic identity, and that’s the foundation,” said one woman. “But when those bottom bricks have been removed or altered, it can be devastating.” In other public health news: Lyme disease, gene editing, a blood test for Alzheimer’s, employee wellness programs and more.

Government Was On Cusp Of Alerting Public About Opioid Crisis 13 Years Ago. Why It Didn’t Remains A Mystery.

Top government officials flagged “disturbing” data around opioids and addiction back in 2006 and requested urgent action be taken. Then-U.S. Surgeon General Richard Carmona agreed to issue a call to action. But then the momentum fizzled after a new surgeon general came on and 13 years later, the crisis continues to grip the country.

MDMA, Or Ecstasy, Shows Promise As A PTSD Treatment

The first time Lori Tipton tried MDMA, she was skeptical it would make a difference.

“I really was, at the beginning, very nervous,” Tipton said.

MDMA is the main ingredient in the club drug known as ecstasy or molly. But Tipton wasn’t taking pills sold on the street to get high. She was trying to treat her post-traumatic stress disorder by participating in a clinical trial.

After taking a dose of pure MDMA, Tipton lay in a quiet room with two specially trained psychotherapists. They sat next to her as she recalled some of her deepest traumas, such as discovering her mother’s body after Tipton’s mother killed two people and then herself in a murder-suicide.

“In the embrace of MDMA,” Tipton said, she could revisit that moment without the usual terror and panic. “I was able to find such empathy for myself.”

Scientists are testing how pharmaceutical-grade MDMA can be used in combination with psychotherapy to help patients with a severe form of PTSD that has not responded to other treatments. Unlike street drugs, which may be adulterated and unsafe, researchers use a pure, precisely dosed form of the drug.

MDMA is not yet available as a treatment for PTSD outside of clinical trials. But proponents are aiming for approval by the Food and Drug Administration, which granted breakthrough therapy status to MDMA-assisted psychotherapy in 2017.

Researchers are conducting Phase 3 clinical trials at more than a dozen sites. Clinicians who treat PTSD are hopeful the next round of trials will show that MDMA treatment is an effective option to relieve patient suffering.

“The problem is we haven’t had a new drug to treat PTSD in over 17 years,” said Dr. Sue Sisley, a physician and president of the Scottsdale Research Institute, based in Arizona. “There are certain illnesses that are just intractable and not responsive to traditional therapy, and we need to start thinking more broadly.”

But MDMA is a Schedule I controlled substance, which means it currently has no accepted medical use and has a “high potential for abuse” (something that MDMA’s therapeutic proponents dispute). Because of that designation, the current research trials are privately funded by the Multidisciplinary Association for Psychedelic Studies, or MAPS.

‘Anywhere I Would Feel Unsafe’

Tipton struggled for years with PTSD before she was treated with MDMA. She said life with PTSD was like “seeing the world through dirty goggles.”

“Anywhere I would feel unsafe,” the 40-year-old from New Orleans said. “I would feel like I had to always be vigilant because if I didn’t, something bad was going to happen.”

Tipton described her 20s as a catalog of tragedy and trauma. It began when her brother fatally overdosed in her home. After his death, she began caring for her mother, who struggled with mental illness. In 2005, Tipton’s mother killed two people and then herself. Tipton discovered their bodies.

“I completely just disassociated. I couldn’t believe what I was seeing,” Tipton said.

“When you have PTSD, you are living in this constantly triggered environment,” says patient Lori Tipton. More than a year after getting MDMA-assisted psychotherapy in a clinical trial, Tipton no longer qualifies as having PTSD.(Will Stone)

The traumas continued to pile up. The place she lived was destroyed when Hurricane Katrina hit New Orleans, and the following year, she was raped.

As the years went by, Tipton had panic attacks and terrible anxiety. She tried everything to treat her symptoms: talk therapy, antidepressants, hypnotherapy, meditation and yoga. Nothing worked. She went through life exhausted and apathetic, constantly triggered and struggling to be intimate with people close to her.

Then Tipton enrolled in the Phase 2 clinical trials for MDMA-assisted psychotherapy.

MDMA And Therapy Together

MDMA was first synthesized in 1912, and its therapeutic benefits were studied in the 1970s. But those efforts stalled when the U.S. federal government — in light of the growing popularity of ecstasy as a recreational drug — designated it a Schedule I drug in 1985.

In recent years, research has resumed, funded by private sponsors such as MAPS.

The treatment protocol in the current trial calls for a 12-week course of psychotherapy with specially trained therapists. During that time, there are two or three daylong sessions, which begin with the patient taking a calibrated dose of MDMA in pill form.

The treatment begins with patients swallowing a calibrated dose of MDMA in pill form.(Courtesy of the Multidisciplinary Association for Psychedelic Studies)

A team of two therapists, generally one man and one woman, then guide the patient through the eight-hour MDMA “session.” Later, there’s follow-up talk therapy, without the drug, to help the patient process feelings, thoughts or impressions that came up while under the influence of the drug.

“MDMA allows you to contact feelings and sensations in a much more direct way,” said Saj Razvi, a Colorado-based psychotherapist who was a clinical investigator in the Phase 2 trials.

How MDMA works in the brain is not completely understood. The psychoactive drug boosts chemicals like serotonin and oxytocin. It also tamps down activity in the amygdala, a part of the brain that processes fear. This may lead to a state characterized by heightened feelings of safety and social connection.

“Trauma happens in isolation,” Razvi said. “One of the things that MDMA does is, really, lets you know that you are not alone.”

PTSD In Remission

After the Phase 2 trials of MDMA-assisted treatments concluded in 2017, researchers found that 54% of the 72 patients who took MDMA had improved to the point that they no longer fit the diagnosis for PTSD (compared with 23% in the control group).

And the beneficial effects of the treatment appeared to increase over time. A year later, the number who no longer had PTSD had risen to 68%.

“That was astonishing,” Sisley said. “Even with the best pharmaceutical regimen, you rarely ever see patients go into remission.”

Dr. Sue Sisley, president of the Scottsdale Research Institute, has spent much of her career working with people who have severe PTSD.(Will Stone)

She said she hopes to offer her patients MDMA-assisted psychotherapy as soon as possible, maybe before the drug receives full FDA approval.

Brad Burge, a spokesman for MAPS, said that, beyond sponsoring the MDMA trial, the organization is working to get the FDA to include the drug in its expanded access program, which can allow individual patients to be approved to use drugs that are still being studied.

Burge said the goal is to make MDMA-assisted psychotherapy available as a prescription treatment in a specialty clinic to anyone with PTSD.

And MAPS is working to persuade public and private insurance plans to cover the treatment, Burge said. He estimates that for patients paying entirely out-of-pocket, a 12-week course of treatment would cost between $5,000 and $10,000.

Most of the cost is for the guided therapy, not the actual drug.

Transformative Treatment

Tipton describes her treatment with MDMA as transformative.

She was able to let go of the troubling feelings surrounding her mother’s death. And, she unearthed other memories, too, feelings of joy that had been sealed away.

By her last MDMA session, Tipton was even able to talk about her sexual assault.

A year later, she was reassessed and no longer qualified as having PTSD. Tipton said she believes the treatment saved her life.

“Everything is at my fingertips for me in a way that it never was before,” she said. “I want that for everybody.”

This story is part of a partnership that includes KJZZ, NPR and Kaiser Health News.

Among Hurdles For Those With Opioid Addictions: Getting The Drug To Treat It

Louis Morano knew what he needed, and he knew where to get it.

He made his way to a mobile medical clinic parked on a corner of Philadelphia’s Kensington neighborhood, in the geographical heart of the city’s overdose crisis. People call it “the bupe bus.”

Morano, 29, has done seven stints in rehab for opioid addiction in the past 15 years.

Buprenorphine is a drug that curbs cravings and treats the symptoms of withdrawal from opioid addiction. One of the common brand name drugs that contains it, Suboxone, blends buprenorphine with naloxone.

Combined with cognitive behavioral therapy, it is one of the three FDA-approved medicines considered the gold standard for opioid-addiction treatment.

Morano had tried Suboxone before — he had purchased some from a street dealer and had used it to get through his workday, when he couldn’t use heroin. It kept the misery of withdrawal sickness at bay. So he had a sense of how it would make him feel. He’d always sort of thought of it as a crutch. But after a slip following his latest stint in rehab, he said, he committed to recovery.

“I can’t do this anymore, and I need something,” Morano said.

The bupe bus — a project of Prevention Point Philadelphia, the city’s only syringe exchange program — is part of Philadelphia’s efforts to expand access to this particular form of medication-assisted treatment, known as MAT, for opioid addiction.

Morano was first in line at the mobile clinic.

When the doors of the bus heaved open, Dr. Ben Cocchiaro waved Morano inside, where they squeezed into a tiny exam room. Cocchiaro and Morano discussed how buprenorphine might help Morano’s recovery succeed this time, and whether he’d be open to seeing a therapist. Cocchiaro gave Morano instructions on how to take the medication, and then called a pharmacy to authorize a prescription.

To date, much of the research on barriers to buprenorphine access has focused on the fact that too few medical providers are certified to write the prescriptions. According to federal law, doctors must apply for a special waiver from the Substance Abuse and Mental Health Services Administration, or SAMHSA, to prescribe buprenorphine. To get the waiver, a doctor must undergo eight hours of training — and can prescribe the drug to a maximum of 30 patients at a time, to start. Given these constraints, many doctors don’t bother.

But pharmacists are also a part of the problem. Because they fill the prescriptions, pharmacists are the gatekeepers for the drug, and not all of them are willing to take on that role. Increasing pharmacists’ involvement in distributing buprenorphine might be just as important as persuading more doctors to prescribe it, according to Dan Ventricelli of the Philadelphia College of Pharmacy.

“We can write a bunch of prescriptions for people,” he said. “But if they don’t have a pharmacy and a pharmacist that’s willing to fill that medication for them, fill it consistently and have an open conversation with that patient throughout that treatment process, then we may end up with a bottleneck at the community pharmacy.”

Richard Ost owns Philadelphia Pharmacy, in the city’s Kensington neighborhood. He says he has stopped carrying Suboxone, for the most part, because the illegal market for the drug brought unwanted traffic to his store.(Nina Feldman/WHYY)

Just a few blocks from the bupe bus in Kensington, Richard Ost owns an independent pharmacy. He said his store was one of the first in the neighborhood to stock buprenorphine. But after a while, Ost started noticing that people were not using the medication as directed — they were selling it instead.

Buprenorphine acts as a partial opioid agonist, which means it’s a low-grade opioid. When taken in pill or tablet form, it’s unlikely to cause the same feelings of euphoria as heroin would, but it might if it were dissolved and injected. Many people buy it on the street for the same reason Morano did: to keep from going into withdrawal between injecting heroin or fentanyl. Others buy it to try to quit using on their own.

“We started seeing people do it in our store in front of us,” said Ost. He said it’s unethical to dispense a prescription if a patient turns around and sells it illegally, rather than use it. “Once we saw that with a patient, we terminated them as a patient.”

Ost explained that the illegal market for Suboxone also meant customers trying to stay sober were being continually targeted and tempted.

“So if we were having a lot of people in recovery coming out of our stores, the people who were dealing illicit drugs knew that, and they would be there to talk to them and they would say, ‘Well, I’ll give you this’ or ‘I’ll give you that,’ or ‘I’ll buy your Suboxone’ or ‘I’ll trade you for this.’”

Ost said that eventually his staff didn’t feel safe, and that neither did the customers. He understands the value of bupe but said it just wasn’t worth it. He mostly has stopped carrying it.

Even those pharmacies that aim to stock buprenorphine can run into problems. Limits set by wholesalers require pharmacies to order the drug in small, frequent batches. Though pharmacies can apply for exemptions to order more at a time, or to have a higher percentage of their total stock consist of controlled substances, doing so invites a higher level of scrutiny from the wholesaler and, in turn, the Drug Enforcement Administration.

Another issue is that doctors and pharmacists receive different education about how long buprenorphine should be prescribed before tapering a patient off it. Many medical providers might prescribe the drug for long-term treatment, based on recent SAMHSA guidelines, while pharmacists may view longer courses of treatment as posing the risk of long-term dependency.

“It’s not even that they’re on different pages,” said Ventricelli of the College of Pharmacy. “It’s that they’re reading completely different books.”

If a patient going through withdrawal can’t get buprenorphine quickly, the stakes are high. Silvana Mazzella, associate executive director at Prevention Point, said that when it’s not available, patients are more likely to turn back to heroin or fentanyl.

“We’re in a situation where if you are in withdrawal, you’re sick, you need to get well, you want help today, and if you can’t get it through medication-assisted treatment, unfortunately you will find it a block away, very quickly, and very cheaply,” she said.

Doctors with Prevention Point have found a pharmacy near the bupe bus that will reliably dispense buprenorphine to their Philadelphia patients. It’s a neighborhood branch of a local chain, called the Pharmacy of America.

The head pharmacist, Anthony Shirley, said he’s comfortable filling the scripts because he trusts that the doctors at Prevention Point will write prescriptions only for patients who need the medication. He has heard firsthand from patients who say buprenorphine saved their lives.

“That’s something you can’t really put a price tag on,” Shirley said. For him, the calculation is simple: His store is in an area where many people need buprenorphine. That means it’s his job to get it to them.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Opioid Crisis Prompts Law Enforcement, Libraries To Embrace Experimental Solutions

A controversial program in western Massachusetts designates a wing of the county jail for court-ordered addiction treatment for men who have not committed a crime. Meanwhile, a number of libraries nationwide add social workers to their staffs to help the growing number of patrons with drug addiction or mental illness. In other news on the drug epidemic: an alleged online opioid drug dealer goes on trial.