Methadone clinics aren't just for heroin addicts anymore.
Every day, Americans hooked on painkillers are lining up for methadone, a synthetic version of morphine that gained acceptance in the 1960s as way to wean addicts off heroin. Now the drug has found a new mission in the fight against opioid-based prescription painkillers, the nation's fastest-growing drug problem.
"We treat mainstream America," said Ed Ohlinger, the regional director for 10 private, for-profit addiction treatment centers in the Southeast owned by CRC Health Group, including the Volunteer Treatment Center in Chattanooga.
In Tennessee, methadone clinics now mainly treat prescription drug addicts. Heroin users account for only 4 percent of methadone clinic patients, according to a state survey, while a whopping 78 percent of patients are there for prescription drug addictions. An additional 17 percent of clinic patients said they are hooked to both prescription drugs and heroin.
Roughly 2,000 new people annually seek treatment at private, for-profit methadone clinics in Tennessee because of dependence on opioid-based painkillers such as oxycodone, according to a presentation made last year by state Department of Mental Health and Substance Abuse Services Commissioner E. Douglas Varney.
So why are so many more people getting hooked on pain pills? Largely because doctors are prescribing more and more opioid medications, which are either derived from the same poppy used to make opium or are synthetic versions made in a lab.
The decade between 1997 and 2007 saw a 600 percent increase in opioid prescriptions. In Tennessee, enough prescriptions were written in 2001 to give every single person age 12 and above 21 pills of oxycodone, which is used in OxyContin, and 51 pills of hydrocodone, an active ingredient in Vicodin.
The current use of methadone is just the latest chapter in an ongoing cycle of drugs treating other drugs. Heroin was first marketed by the German drug company Bayer to get addicts off morphine.
Opium's addictive qualities - and potential to wreak social havoc - have been known for centuries.
The British fought the Opium Wars in the 1800s to force the Chinese to accept opium, on which the Brits had a monopoly. It is said that the influx of opium led to the downfall of the Chinese Empire.
Soldiers in the U.S. Civil War got hooked, too, with 10 million opium pills and nearly 3 million ounces of other opium powders and tinctures issued to Union forces alone, according to the BBC. Confederate Gen. Braxton Bragg, criticized for missteps in Chattanooga-area battles, may have been hamstrung by opiate addiction due to his poor health, historians speculate.
Because of its history, modern-day American doctors were reluctant to prescribe opioid-based painkillers. That changed in the 1980s when two influential medical publications suggested that the painkillers could be given without the potential for addiction. Meanwhile, pill manufacturers launched aggressive marketing campaigns promoting the drugs.
Now, the CDC says the country is in the throes of an opioid "epidemic."
And that epidemic is driving patients to methadone clinics to help curb their potentially deadly addictions. The CDC says the benefits of methadone - it relieves cravings for opiates and only needs to be taken once a day - include reduced risk of diseases spread by needle-sharing, such as hepatitis and HIV, reduced criminal activity, improved family stability, better employment potential and improved pregnancy outcomes.
But methadone clinics have their critics, too.
They say the treatment of prescription pill addiction may just switch one addiction for another.
"No incentive to detox"
These for-profit clinics seem to have a built-in financial incentive to keep their patients hooked, which could hurt their patients' chances of ending their dependence on methadone, Rod Bragg, assistant commissioner of Tennessee's Department of Mental Health and Substance Abuse Services, told Bloomberg News.
"With a nonprofit, the incentive is to get people to treatment and wean them off," Bragg said. "When you have a for-profit and cash-only business, there is no incentive to detox them. In fact, there's an incentive not to detox them because of the continual cash flow."
Also, Bloomberg News reported in March that at least five states - West Virginia, Minnesota, Indiana, Pennsylvania and Maine - were considering legislation to tighten oversight of methadone clinics after allegations that take-home doses of the drug were contributing to illegal street sales and even deaths. Treatment clinics often offer buprenorphine, an opioid that's the active ingredient in Suboxone, and it has wound up as a street drug.
"Any substance that's out there, people can find a way to abuse it," said Michael Rabkin, spokesman for Tennessee's Department of Mental Health and Substance Abuse Services, which monitors drug treatment clinics along with the Tennessee Department of Health.
Tennessee filed new administrative rules regulating methadone clinics and other nonresidential opioid treatment facilities in September 2012, he said.
Drug treatment clinics have a place among the treatment options available to people hooked on prescription drugs, Rabkin said.
"People need to have a lot of options," he said.
600 percent more morphine
A Nov. 14 New Yorker magazine article titled "Who is responsible for the pain-pill epidemic?" says that before the 1980s, U.S. doctors had been reluctant to prescribe narcotics except for such purposes as relieving post-operative pain or cancer pain.
Then, a 100-word letter to the editor in a 1980 version of the New England Journal of Medicine reported that less than 1 percent of patients at Boston University Medical Center who received narcotics while hospitalized became addicted. Then, a 1986 study in the journal Pain concluded that for non-cancer patients, narcotics could be safely prescribed to selected patients with little risk of the "maladaptive behaviors which define opioid abuse."
"At around the same time, the companies that manufactured these narcotics - including Purdue Pharma, Johnson & Johnson, and Endo Pharmaceuticals - began to aggressively market their products for long-term, non-cancer pain, including neck and back pain," the New Yorker states.
In the years since, opioid use has skyrocketed and the CDC has dubbed the issue an epidemic.
"The CDC doesn't take the word 'epidemic' lightly," CDC Deputy Director Ileana Arias, Ph.D., is quoted as saying in an American Society of Addiction Medicine article.
Drug distribution soared through the pharmaceutical supply chain from the equivalent of 96 milligrams of morphine per person in 1997 to about 700 milligrams per person in 2007, according to the CDC. Morphine, which has been sold commercially since 1827, is the most abundant opiate found in opium and is the benchmark for opioid painkillers.
The epidemic's severity varies from state to state, according to the CDC, but is worst in the Southwest and Appalachia.
Back pain leads to addiction
Seeking treatment at a methadone clinic wasn't an easy step for Kalen Bryan Kerby to take two years ago.
Now he hopes others in his shoes will consider it.
"They're better than what people think," Kerby said. "It has changed my life. There's a lot of people that it helps."
The 28-year-old Valley Head, Ala., man sought methadone treatment after getting hooked on opioid-based prescription painkillers.
He suffers from severe scoliosis and two bulged spinal discs. Kerby was 19 or 20 when his family physician prescribed 20 milligrams of generic oxycodone, twice a day along with Percocet, a mix of oxycodone and acetaminophen, as a "breakthrough" pain reliever to be taken when pain spiked.
"I've had back problems and foot problems since I was a kid," he said. "I just wanted the pain to stop. I didn't care how they did it."
The pills helped the pain. But Kerby put strain on his body doing heavy labor, including laying asphalt and as a concrete finisher. The prescription for the oxycodone pill he took twice daily increased to 40 milligrams, then 60 milligrams and finally 80 milligrams with Percocet three or four times a day as needed. By the time he was 22 or 23, there was no kicking the drugs.
"I was hooked good - really good," he said. Eventually, "I got to realizing it was just a flat-out addiction."
What it's like inside
Like the morning rush at a Starbucks cafe, cars, pickups and sport utility vehicles start packing into the Volunteer Treatment Center's parking lots while it's still dark. The clinic, at 2347 Rossville Blvd., opens at 5:30 a.m. seven days a week.
Drug treatment clinics open early in the morning so that patients can take their medicine before work. Patients line up inside the clinic and watch red and green lights over a row of private booths staffed by licensed practical nurses.
When one patient is done, the green light comes on and the next person enters and closes the door.
The nurse takes the patient's identification number and makes sure the photo that appears on a computer screen matches the person seeking medication.
Then, through an opening in a window inside the booth, the nurse hands over the methadone or a similar opioid-derived treatment drug, buprenorphine, in tablet or liquid form. The nurse makes sure the patient downs the dose.
Traveling to the clinic every morning to take methadone isn't convenient for most patients.
"I hurt for them. Just having to come here every day," clinic director Anita Eason said. "But if they're not coming here, they're out seeking."
However, after patients have had counseling, tested negative for illegal drugs and spent enough time showing up at the clinic for medication, they're allowed take-home medications, which makes getting treatment simpler.
It's a privilege that patients can lose. At any time, the clinic can do a "bottle check" to see if clients are consuming more than their daily dose. If they are, the take-home medications go away, and the patient has to line up at the clinic.
"Methadone hits street"
Critics say that take-home drugs can find their way onto the street. A Bloomberg News article published in February said that methadone was leaking into illegal street sales via take-home doses in Indiana, Kentucky, Virginia and West Virginia. Investigators in each of those states have linked such "diverted" doses to clinics operated by CRC.
State authorities found in June 2011 that the Volunteer Treatment Clinic failed to supervise take-home doses properly in a case "clearly indicative of drug diversion," according to Bloomberg.
Authorities in Dade County, Ga., had similar fears, Sheriff Ray Cross said. Dade County commissioners voted unanimously in April 2011 to ban methadone clinics in an unsuccessful attempt to stop the Tri-State Treatment methadone clinic from opening in the county's north end near Interstate 24.
"So far, we haven't had any problems with it," Cross said.
Not everyone is put off by methadone clinics - investors, for example.
Bain Capital, the private equity firm co-founded by Republican presidential candidate Mitt Romney, paid $723 million in 2006 to buy the Rossville Boulevard methadone clinic's parent company, the CRC Health Group. CRC is the nation's biggest chain of for-profit methadone clinics, the Daytona Beach News-Journal wrote in an April article.
Romney had left Bain six years before the purchase.
The methadone clinic industry is one of the most lucrative sectors in health care due to its cash-only nature and a profit margin that can top 20 percent, Bloomberg reported in February.
Over the past seven years, Bloomberg reported, private equity firms have invested more than $2.2 billion in substance-abuse treatment and behavioral health companies in 62 deals, according to PitchBook Data Inc., a Seattle-based research firm.
"Not just a number"
The Volunteer Treatment Center has a plaque on its wall showing that it's a member of the Chattanooga Chamber of Commerce.
But its Rossville Boulevard location is hardly upscale. Adult book stores, used car lots, liquor stores, bars - and another methadone clinic - are some of the other businesses that line the route that turns into Chickamauga Avenue and U.S. Highway 27.
"There's still a stigma in what we do," Ohlinger said.
Inside, a maze of hallways is lined with doors. Only a few doors lead to medication booths; most lead to small offices where counselors meet patients. A day care area is just inside the lobby. It's decorated with a mural that patients made.
This methadone treatment costs $12.50 a day - more than $4,500 a year if taken daily. Most clients pay out-of-pocket. None of the clinic's patients were court-ordered to be there, Eason said. They sought treatment themselves.
Kerby started taking methadone at the Volunteer Treatment Center on Rossville Boulevard and then switched to Tri-State Treatment in Dade County because it's closer to home.
"I've never failed a drug test. They call me the ideal candidate," he said. "If you do what you're supposed to do, it will turn your life around 100 percent."
The counseling is what Kerby really likes about going to the clinics.
"I wasn't just a number. That made me feel so good," Kerby said. "And talking to all the people in there that were in the same boat that I was."
"Pretty soon, I'm going to start tapering down until I can get off," Kerby said.
Contact staff writer Tim Omarzu at firstname.lastname@example.org or 423-757-6651.