By the time Belmarie Lugo stepped into the treatment clinic in January 2022, her body was malnourished. Her connections to her family had fractured, and she estimates she had overdosed on heroin and fentanyl more than a dozen times.
Now, nearly two years later, Lugo is in recovery. She’s mended her relationships with her parents and brother, and she is finally able to contemplate her future — something that was not possible in the past when she was under the influence of illicit opioids.
Lugo, a resident of East Hartford, attributes much of her turnaround to the methadone maintenance program she enrolled in at the Root Center, which is the largest provider of medication-assisted treatment services in Connecticut.
“I’m victorious because of this place,” Lugo said, as she sat in one of the counseling rooms at the Root Center’s Manchester office. “It’s so easy to go backwards.”
Methadone is one of several medications that are used to help people with opioid use disorders to lessen their dependence on lethal narcotics while limiting the pain and most severe symptoms that can accompany opioid withdrawal.
The precisely measured dosages of methadone that are prescribed to patients at places like the Root Center have been proven to lessen people’s chances of relapsing and dying from an overdose.
Even more, the health professionals who administer methadone — and another commonly used treatment drug called buprenorphine — say the medications enable people to find new jobs, to regain custody of their children and to more easily recover from the mind-altering effects of opioids.
Lugo is just one of the tens of thousands of people who benefitted from a methadone treatment program in Connecticut in recent years, but state officials want to see that number increase even more to combat the state’s ongoing epidemic.
A special advisory committee, set up to manage roughly $600 million in opioid settlement funds for Connecticut, published a report earlier this year that laid out several key strategies for curtailing opioid overdoes in the state, and it argued that increasing the accessibility and use of methadone and buprenorphine would be the most effective approach to stemming the mounting death toll.
Evidence-based
That wasn’t the first time that Connecticut officials received that advice.
A state report that was published in 2016 made the exact same recommendation, citing the mountain of medical evidence surrounding the two opioid treatment medications and the comparative success of those medications when compared to abstinence-based recovery programs.
“There is very strong evidence for treatment using medications. And I don’t say ‘very strong’ lightly,” said Dr. Joshua Sharfstein, the vice dean of the Johns Hopkins University school of public health.
Sharfstein helped organize a coalition of more than 30 health organizations to create several basic principles that states and local governments can rely on when spending their settlement funds, which they are receiving through several lawsuits that were filed against major opioid manufacturers, distributors and retailers.
Two of those principles are that the settlement money should be used to save lives and that it should be directed toward efforts that are backed up by medical evidence.
Sharfstein, who also cowrote a book titled “The Opioid Epidemic: What Everyone Needs to Know,” said treatment programs that incorporate methadone and buprenorphine meet both of those principles.
The effectiveness of medication-assisted treatment, Sharfstein said, has been reviewed by the American Medical Association, the American Psychiatric Association and the National Academies of Sciences, Engineering, and Medicine.
And research has suggested that the use of methadone and buprenorphine in treating opioid use disorders can substantially reduce people’s chances of fatally overdosing — some studies suggest by up to 50%.
“For a disease that is killing many Americans, that is a significant reduction in mortality that you can get with appropriate treatment that includes medications,” Sharfstein said. “And that I think is just an incredibly important point to keep in mind as officials are thinking about expanding access to treatment.”
Loosening the regulations
Connecticut saw a significant increase in patients who were receiving methadone or buprenorphine over the past decade as part of their treatment for opioid use disorders.
The number of people receiving methadone at a federally regulated clinics in Connecticut jumped between 2012 and 2017 from roughly 14,000 to more than 21,000. And the number of people who were prescribed buprenorphine through a licensed medical provider grew from roughly 21,000 in 2015 to an estimated 30,000 in 2020.
But those numbers have largely plateaued since then.
The same cannot be said for the number of overdoses linked to heroin, fentanyl and prescription painkillers, which have claimed the lives of nearly 5,000 Connecticut residents since 2020.
The researchers who put together the report this year for the state’s Opioid Settlement Advisory Committee said that staggering loss of life is evidence enough that more needs to be done to connect people with medication-assisted treatment and to retain those patients once they enroll in a program.
If there is any benefit of the COVID pandemic, it’s that the federal government has allowed the relaxed policies to remain in place.
Robert Heimer, Yale Professor
“There are no reliable estimates of the number of people in the state at risk for overdose who would benefit from treatment with medication for opioid use disorder,” the researchers wrote. “Nonetheless, the rising number of opioid overdoses indicates there is an unmet need for these treatments in the state.”
There have been several big changes in recent years to make it easier for people in Connecticut and the rest of the United States to access medications for opioid use disorders and to continue using those medications once they start.
Federal legislators passed a law late last year that removed a long-standing requirement for doctors to have a special waiver if they wanted to prescribe buprenorphine to patients with opioid use disorders.
That waiver requirement severely restricted the number of physicians who could legally administer buprenorphine to their patients in the past.
The federal government also lowered one of the biggest barriers that patients often encountered once they were enrolled in a methadone treatment program: how much methadone someone could take home with them from a clinic.
Prior to the coronavirus pandemic, most patients receiving methadone had to report to a federally licensed clinic nearly every day to receive their dose of the medication under the supervision of staff. It was part of a tightly regulated system that had been erected around methadone in the United States over decades.
The public health emergency in 2020, however, prompted the federal government to allow a larger number of people to take home up enough bottles of the liquid methadone to last them up to 28 days, and federal officials are now pushing for a permanent regulatory change that would allow patients to continue to benefit from that practice.
Dr. Robert Heimer, a professor at Yale University who has widely studied opioid addiction, said the loosening of the federal rules surrounding methadone and buprenorphine is likely to have a positive effect.
“We’re finally moving away from that. Thank goodness,” Heimer said of the federal regulations. “If there is any benefit of the COVID pandemic, it’s that the federal government has allowed the relaxed policies to remain in place.”
Unmet needs
Even so, Heimer and other medical professionals argue there are still barriers that limit how many people are utilizing methadone and buprenorphine in Connecticut.
The new report that Heimer helped to produce for Connecticut’s opioid settlement advisory committee listed several of those obstacles.
There is still an inadequate number of physicians willing to prescribe buprenorphine to their patients, the report noted, and some pharmacies don’t even stock it.
Adequate transportation to the state’s licensed methadone clinics, which are largely concentrated in the state’s urban centers, can still be a problem for newer patients who need to show up in-person on a daily basis at the beginning of their treatment.
Additionally, Heimer said, some of the methadone clinics in the state have operating hours that don’t accommodate patients who have jobs at odd hours, or other methadone providers don’t have physicians at all of their sites who are capable of performing the required physicals on patients who are starting methadone treatment.
Steven Zuckerman, the CEO of the Root Center, which operates more than 10 sites in Connecticut, said his organization has the capacity to treat more people.
Even though the Root Center already serves nearly 6,000 patients a day, Zuckerman said his staff is capable of administering the first dose of methadone to someone the same day they walk in.
Medicaid and Medicare, which insures more than 90% of the Root Center’s patients, covers the cost of that treatment, he said.
The bigger issue, Zuckerman said, is addressing all of the other related issues that many of the patients have.
People with opioid use disorders may be unemployed. They may be fighting to regain custody of their kids. They might be facing legal charges. Some have other mental health disorders that have gone untreated. And many don’t have reliable housing.
Data collected by the state last year found that nearly 8% of the people who overdosed in 2022 in Connecticut were either homeless or struggling with housing instability.
Zuckerman argued that the nearly $600 million in settlement funds that the state is expecting to receive over the next two decades could be used to help correct some of those issues for people entering treatment.
“Getting the medication-assisted treatment is the initial step. Obviously, that starts the whole ball rolling. But once sobriety comes for you, there’s so much else that’s needed to get you moving,” Zuckerman said.
The report produced for the state advisory committee this year suggested portions of Connecticut’s opioid settlement funding could help by expanding the operating hours at existing methadone clinics or by financing new mobile methadone clinics, which federal and state regulators also recently approved.
The report also suggested that the settlement funds could be used on a variety of related services for patients with opioid use disorders, including improved transportation services, help with insurance enrollment, employment assistance program and subsidized child care services.
“Any tactics that increase uptake of methadone or buprenorphine treatment and increase retention in treatment are ones that will reduce overdose deaths,” the report said.
In Lugo’s case, she was able to rely on her family members to help with many of her most basic needs once she entered treatment.
Her brother, who is also in recovery, provided her with a place to live above his barber shop in East Hartford. And her father was also available to support her.
“It takes an army just for one person to recover,” Lugo said.
Stopping the stigma
The biggest impediment to people accessing methadone and buprenorphine, however, isn’t caused by a government regulation, and it can’t be solved solely by spending opioid settlement funding.
It’s the public stigma that keeps many people from utilizing those treatment medications, several people told The Connecticut Mirror.
Heimer, the Yale professor, said there is still a misconception among large portions of the American population that taking methadone or buprenorphine to treat opioid use disorder is like trading one drug for another.
“The problem is that the 50 years of a very controlled, draconian approach to dispensing methadone has led to methadone being stigmatized,” Heimer said. “So even though it’s been easier to get, I don’t think there has been a huge increase in the number of people taking advantage of it.”
That stigmatization can persist even after people realize the benefits the treatment medications can have on someone who is struggling with an opioid use disorder.
Heimer recounted an interaction that he had a few years ago with a woman he met at a community event. The woman, who was in her twenties, was a strong advocate for methadone. She told Heimer that the medication allowed her to work through her opioid use disorder and to reconnect with her family and her child.
Eventually, she told him that she was doing so well on her treatment program that she was considering halting her use of methadone.
Heimer said he tried to persuade the woman not to do that, and he emphasized that if the treatment was working she should stay the course. He explained to her that using opioids for a significant period of time can change someone’s brain chemistry.
Despite that warning, Heimer later learned the woman died of an overdose within six weeks of their conversation after she stopped utilizing methadone as part of her treatment.
“There’s still this overwhelming belief — unsupported by data — that abstinence, not taking opioids, is the proper end goal for people with opioid use disorders,” Heimer said.
He said that is like arguing that a diabetic needs to stop using insulin, or that someone with high cholesterol needs to stop taking their statin medication.
Some advocates don’t even like to refer to methadone and buprenorphine as medication-assisted treatment for that very reason. They believe it makes those forms of treatment seem out of the ordinary, when, in fact, they are the gold standard for treating someone with an opioid use disorder.
Lugo said she’s seen people voice those negative perceptions in the past, but she said she wouldn’t have made it as far in her recovery without the methadone treatment she’s received over the past two years.
“They don’t see it as a disease,” Lugo said.
This story is part of an ongoing series on opioids in Connecticut. Want to share what you know? Send your tips and personal stories to tips@ctmirror.org