Health

Treating America’s Opioid Addiction

Part 3: Searching for Meaning in Kensington. 

Episode 235 | October 14, 2018

Treating America’s Opioid Addiction Part 3: Searching for Meaning in Kensington by Distillations: Science + Culture + History

This is the third and final chapter of a three-part series. See Part 1 and Part 2.

“We should never, ever forget that addiction treatment is a search for meaning in a place other than using drugs.” —Nancy Campbell, historian of drug addiction.

In the final chapter of this series we travel to the heart of our modern opioid crisis. In what is now a notorious Philadelphia neighborhood called Kensington, we meet two victims of the epidemic and follow them on two distinct paths toward recovery.

Our current devastating opioid crisis is unprecedented in its reach and deadliness, but it’s not the first such epidemic the United States has experienced or tried to treat. In fact, it’s the third

Treating America’s Opioid Addiction is a three-part series that investigates how we’ve understood and treated opioid addiction over more than a century. Through the years we’ve categorized opioid addiction as some combination of a moral failure, a mental illness, a biological disease, or a crime. And though we’ve desperately wanted the problem to be something science alone can solve, the more we look, the more complicated we learn it is. 

Credits  |  Research Notes  |  Transcript

Credits

Hosts: Alexis Pedrick and Elisabeth Berry Drago.
Reporters: Mariel Carr and Rigoberto Hernandez, with additional reporting by Meir Rinde.
Senior Producer: Mariel Carr
Producer: Rigoberto Hernandez
Audio Engineer: James Morrison 
Photo illustration by Jay Muhlin.
Additional audio production by Dan Drago.
Additional music courtesy of the Audio Network

Research Notes

Interviews:

Claire Clark, author of The Recovery Revolution: The Battle over Addiction Treatment in the United States. 
Nancy Campbell, historian and director of Science and Technology Studies at Rensselaer Polytechnic Institute.
Chris Marshall, former member and director of the Last Stop.
Miranda Thomas, Kensington resident.
Joseph Garbely, vice president of medical services and medical director of the Caron Treatment Centers.
Lara Weinstein, primary care physician, Project HOME and Pathways to Housing PA 
Special thanks to Jennifer Reardon of Temple Health Communications and to Joseph D’Orazio and David O’Gurek. 

Sources: 

American Addiction Centers. “Can Suboxone Get You High?” Brentwood, TN: American Addiction Centers, 2018.
American Addiction Centers. “Pros and Cons of Methadone.” Brentwood, TN: American Addiction Centers, 2018.
Campbell, Nancy, and Anne Lovell. “The History of the Development of Buprenorphine as an Addiction Therapeutic.” Annals of the New York Academy of Sciences 1248 (Feb. 2012): 124–39.
Clark, Claire. The Recovery Revolution: The Battle over Addiction Treatment in the United States. New York: Columbia University Press, 2017.
Giordano, Rita. “Opioid Addiction Treatment with Medicine Works Best. Why Don’t More Young People Get It?” Philadelphia Inquirer, April 10, 2018. 
Oransky, Ivan. “Vincent Dole” [obituary]. Lancet 368 (Sept. 16, 2006): 984.
Rockefeller University. “The First Pharmacological Treatment for Narcotic Addiction: Methadone Maintenance.” Rockefeller University Hospital: 100 Years of Bridging Science and Medicine website. New York, 2010.
Shuster, Alvin M. “G.I. Heroin Addiction Epidemic in Vietnam.” New York Times, May 16, 1971.
Thompson-Gargano, Kathleen. “What Is Buprenorphine Treatment Like?” Farmington, CT: National Alliance of Advocates for Buprenorphine Treatment.
Villa, Lauren. “Methadone and Suboxone: What’s the Difference Anyway?” Drugabuse.com.
Waldorf, Dan, et al. Morphine Maintenance: The Shreveport Clinic 1919–1923—Special Studies No. 1. Washington, DC: Drug Abuse Council, April 1974.
Whelan, Aubrey. “She Was Just out of Rehab. She Was Excited about the Future. Three Hours Later, She Was Dead.” Philadelphia Inquirer, June 26, 2018.  
Winberg, Michaela. “Kensington’s Famous Last Stop Addiction Recovery Center Prepares to Move.” Billypenn.com, March 26, 2018.

Archival Sources: 

Efootage.com. Richard Nixon “Law & Order” Speech—1968. Video.
John Chancellor. “Washington, DC Heroin Addiction.” NBC Evening News. February 4, 1971.
Columbia Center for Oral History. Marie Nyswander, oral history. New York: Columbia University Libraries, Oral History Archives, 1981.

Transcript

Treating America’s Opioid Addiction Part 3: Searching for Meaning in Kensington

>>EL SOUNDS<<

Chris Marshall: As soon as you come down the steps of this EL platform, this first corner is where you can buy works all the time during the day…nighttime not so much. And the next corner up, drugs. All the drugs in the world.

>>STREET SOUNDS<<

Mariel: We’re in Philadelphia, in November of 2017. It’s cold and dreary out and a man named Chris Marshall is showing us around a neighborhood called Kensington. As soon as we get off the elevated subway people a guy is selling needles and other injection equipment.

Chris Marshall: We call them "works." That's that whole rig right there, and you can see at the tip there's blood on the bottom of it where the needle meets the plastic. This is a common sight in Kensington. You know?

Mariel: There are parts of this neighborhood have been rapidly gentrifying in recent years, but other parts make up the heart of this city’s devastating opioid crisis. In 2017 88% of deaths in Philadelphia involved opioids. The city had to hire an additional medical examiner just to process all of the bodies. And it’s not just locals: Philly has become a hot-spot for drug tourists. People travel here from all over the country because they hear about the city’s especially strong heroin and fentanyl.

Chris Marshall: You'll see going under this bridge, there's probably people living under this bridge right now. Yeah, see, watch, you'll see when we get there. Beds just laid there. They'll set up shop here for about a couple weeks, and then the cops will kick them out and they'll just move to another place. Look over there, they got mattresses, everything that they need to be comfortable down here.

Mariel: Chris Marshall spent years abusing opioids. And like so many other people his addiction started in the medicine cabinet: one Percocet led to three, and soon he had a pill problem. He checked into a weeklong detox program hoping to get rid of his habit. But instead he was introduced to heroin.

Chris Marshall: All week long all I heard was, "Heroin, heroin, heroin." I didn't feel like I was like anybody else in this program because I had a pill problem. I didn't participate or anything. That was my first time in recovery. But that didn't last long because on the way home a lady who was with me, lived around the corner, offered me a ride home. She heard my story over the week and said, "Hey, Chris, you never did heroin before? Are you serious?" I said, "Yeah, I never did it." She's like, "You want to try?" I'm like, "I just spent a week in detox. Hell yeah I want to try this thing!"

>>MUSIC<<

Chris Marshall: When she injected that, when she put heroin in my body the very first time, like I said before, it was like all the love I had ever put out in the world came back and gave me a real big hug all at once. And I said, "Man, I have arrived. This is the way I was supposed to feel my whole life and never did."

>>EL SOUNDS<<

>>MUSIC<<

Alexis: Hello and welcome to Distillations, a podcast powered by the Science History Institute. I’m Alexis Pedrick.

Lisa: And I’m Lisa Berry Drago.

Alexis: And this is the final installment of our three-part series on the history of opioid addiction treatment in the United States.

Lisa: In part one we told you about the first wave of treatment. After the Civil War many people became addicted to opiates after getting a doctor’s prescription, just like how we got into our crisis today. Treatment was confined to sanitariums and asylums, and people with opiate addictions were mixed in with those who had with mental illnesses. This first wave ended when heroin and morphine were made illegal in 1914.

Alexis: The second wave was limited to two federal prison hospitals called Narcotic Farms. Now when they opened in 1935 doctors and scientists were confident that science would deliver a cure for opioid addiction. But by the 1960s that cure hadn’t materialized, and a growing sense of futility set in. The Narcotic Farms closed, and left a void in treatment.

Lisa: Part two of this series traces the beginning of the third wave. It focuses on the story of Synanon, an unconventional recovery organization that filled the void when it opened in 1958. Synanon was distinct from the treatment systems that had come before because it wasn’t run by doctors and it wasn’t a prison. It was based on the idea of mutual aid: addicts helping other addicts.

Alexis: Synanon eventually failed as well. It was run by an eccentric leader and it ultimately became a violent cult. But the philosophy at its core—addicts helping addicts—is still in used by addiction programs today, as the third wave continues.

Lisa: Distillations is based in Philadelphia. This is our home. And we set out to produce this mini-series because like most Philadelphians we’re deeply concerned about this crisis and the people it’s hurting. We’re a podcast about science, culture, and history, so we decided the best role we could play would be to tell a side of this story that’s unknown. A history of medicine

story about the ways we’ve treated opioid addiction in this country for more than 150 years. But right here, in 21st century Philadelphia, this is where the story started for us. Our producers Mariel Carr and Rigo Hernandez have been reporting this series. And Mariel is going to take over from here.

Chapter One: The Last Stop

Lisa: Chapter One. The Last Stop

Mariel: Chris Marshall says that his whole life went downhill after that first bag of heroin. He started to abuse many drugs, including heroin and fentanyl. He became estranged from his family and started living on the streets of Kensington. But amazingly, Chris was able to his life around. When we met him, he’d been sober for almost six years. For people like him, who are struggling with opioid addiction in 2018, there’s no easy path to recovery. But there are paths. And one option looks a lot like the early days of Synanon.

Jay: I've been here for like four days and I'm still detoxing a little bit. I've been trying to get clean for like more than ten years.

Mariel: We’re with a man named Jay at a recovery program in Kensington called The Last Stop. He didn’t want to share his last name.

Jay: I'm 34 years old. At this point, I've burnt out everything in my life so I really have nothing. Wound up homeless in Kensington and I'm not even from Philadelphia right. So I'm grateful for this place. So I guess what the program claims to offer is that there's a solution, right? The freedom from the obsession to use, right? So that's the answer, you know?

Mariel: Chris Marshall can relate to everything Jay says. In 2011 Chris Marshall’s bout with homelessness ended when he was arrested for identity theft. He went to jail for 10 months and got sober there.

Chris Marshall: The day I got out, I went to this shelter, and on the way into the shelter, I was offered drugs. I had my brown paper bag with what little belongings I had and I ran inside and I see a security guard, and I said, "Hey listen, I'm released to here. I just spent ten months to prison, I'm about, close to 11 months clean, and I don't want to get high." The security guard, he introduced himself and said he had four and half years, and he said: "listen, if you want to stay clean, this is not the place to be." Go somewhere that was safe, so I went to the Last Stop.

Mariel: The Last Stop is a bare-bones, make-shift recovery center in Kensington, in the heart of Philadelphia’s opioid crisis. It’s where we heard from Jay earlier. And it’s where Chris Marshall found his salvation. The people who live there and run it call it “ghetto recovery.” It is right in the thick of the epidemic. Right outside its doors people are shooting up, nodding out, and overdosing. Inside its ramshackle: bare cinderblock and brick walls, a concrete floor, a clear view of the rafters, and a lot of insulation foam. But there are also touches that show quite clearly that people really care about this place: a vase of flowers, still-inflated happy birthday and new baby balloons, and a sign that says: “Trust god. Clean house. Help others.” On one wall people with more than a year clean have written their names and sobriety dates. And on another wall are the dates of other people’s deaths: Franklin Clark, RIP in god’s love 2017. Christopher Reid

Snyder, 8/17/18. You don’t have to have a certain kind of insurance to get help at the Last Stop. In fact, they don’t bill insurance. And they don’t take any grants or public money. People pay what they can to stay, get fed, attend 12-step meetings, and help the next person who comes in the door.

Chris Marshall: We were a bunch of addicts and alcoholics just helping each other out. Just like the 12-step programs says. You know help each other out. We weren't getting paid for it, we were just doing it because we wanted to help people out.

We were grateful that somebody helped us out. When somebody was able to pay the rent, it was cool, because they weren't really paying their rent. They were paying rent for the next guy to come in, because the person who came in before them paid rent and kept the doors open for them to come in. That's how this thing worked. It was built on a wing and a prayer, man.

Mariel: The Last Stop has been going for 17 years and in that time many people have attributed its sobriety to it. In communities of people who struggle with addiction, it’s gained a reputation as a legitimate recovery program. And this is a badge of honor in a world where poor oversight has caused a lot of corruption in the drug treatment world. If you listened to Part Two of this series it probably reminds you of the very early days of Synanon. Synanon pioneered a model of treatment where people struggling with heroin addictions lived together and helped each other remain completely drug-free. It was called a Therapeutic Community—and it would be the first of many for opioid addiction. The Last Stop subscribes to that same philosophy of mutual aid: addicts helping addicts remain drug free. Total abstinence is a defining characteristic of therapeutic communities like this. And it works for some people. In part two we heard from two men who have been sober for several decades because of this model. But it’s extremely difficult, and it’s also dangerous. If you’re abstinent and then you relapse, your tolerance has gone down, so you’re really likely to overdose.

Robert: unfortunately with the relapse a lot of times it's ... it hits you fast, and you don't even realize until after you've done it.

Jay: Hopefully we'll be ready when you come back. If you come back. If you're alive and not in jail.

Robert: Right. If you're lucky enough to survive it, come on back.

Mariel: For all people who follow an abstinence-only approach to quitting opioids, there’s an 80 to 90% chance of relapse after 30 days. You are far more likely to fail than you are to succeed.

Because of this reason and others, abstinence-only Therapeutic Communities like the Last Stop do not work for everyone. Fortunately, abstinence-only is not the only way to go: there’s also something called medically-assisted treatment. One option is taking Naltrexone, an anti-craving drug that’s also prescribed for alcohol abuse disorder. Another option is medically-assisted maintenance treatment—when someone takes a daily dose of one opioid, like methadone, to stay off a different opioid like Oxycontin, heroin, or fentanyl. In the U.S. today, methadone is one of two drugs available for maintenance treatment.

Chapter Two: Methadone.

Alexis: Chapter Two. Methadone.

Nancy Campbell: Somebody who has used opioids for a long time needs some version of an opioid in order to feel well, in order feel complete, in order to feel like they can go about their everyday life and not constantly seek an opioid.

Miranda: I think that it's a miracle they have stuff like this because it really helps people.

Miranda Thomas My name's Miranda Thomas. I'm 26 and I'm from Kensington in Philadelphia.

Mariel: We’re with Miranda Thomas at a methadone clinic in downtown Philly. Methadone is an opioid, and it has some of the same effects and risks as heroin. You can get high on it, you can get addicted to it, and you can overdose on it. But it’s longer-acting than heroin, so it doesn’t wear off as quickly. When it’s used right it relieves withdrawal symptoms for someone fresh in recovery. And it prevents cravings for other opioids, like heroin and fentanyl, by supplying enough of the opioid to make you feel okay, and to have a sense of well-being. But it shouldn’t knock you out or make you feel euphoric. The idea is to maintain, not get high.

Miranda: Methadone doesn't make you high, the only time it makes you high is if you mix certain pills with it, and stuff like that. Methadone actually helps with the withdrawal so you're not sick, depending on what your dosage is.

Mariel: At a high enough dose it also has a so-called “blockading effect” where even if you were to take heroin, the methadone would block the heroin’s effect.: It’s late September, 2018. And it’s a gorgeous and crisp sunny day, the first one after what feels like a month of rain. The clinic is a few blocks from City Hall and across the street from the Philadelphia Inquirer.

Miranda grew up in Kensington, the same neighborhood Chris Marshall showed us around. The heart of the opioid crisis. She started using heroin as a teenager.

Miranda Thomas: I started when I was about 18. I started sniffing it and before you know it I was shooting it. My mother was once on heroin when I was younger. So I kind of was raised around it and was introduced that way.

Mariel: Miranda’s petite and pretty. I’d actually call her adorable. She has light brown hair that comes to her shoulders and she seems pretty put together: she’s wearing makeup and has a sort of casual-urban look going: she’s wearing leggings and sneakers with a denim jacket. The only striking thing about her appearance are her three face tattoos. Two are small and faded but one is pretty big. It’s above her right jaw, about the size and shape of a large band-aid and it says “sucka-free” in cursive. Miranda stopped using drugs on her own for a while. But then last year something happened and she suddenly started again—

Miranda Thomas: My mom passed away and I started struggling with addiction really bad. We were really close. And I had two years sober right before she passed, and when she passed I relapsed.

Mariel: Throughout the past year Miranda’s been using not just heroin but also seeking out fentanyl. And a lot of it. Much of the heroin in Philadelphia is already laced with Fentanyl, and is now the number one drug killing people in the city today. Miranda didn’t want to be one of those people. So she showed up at this clinic, desperate.

Miranda Thomas: I was a mess. And I think they seen that, and I cried to the doctor I said, "you know, I can't be like this anymore, I need help. I'm 26 years old," I said, "I don't wanna die yet. Like, I really need help." And he helped me.

Mariel: Miranda was started on a dose of methadone the next day. When we met she’d been going to the clinic every day for the last two weeks. It’s still so early, but so far it’s working. She hasn’t used any other drugs in that time. Miranda says something like the Last Stop, where you give up drugs completely, wouldn’t work for her.

Miranda Thomas: Right now I'm not strong, I still can't let go of my mom, it's been almost a year in two weeks, I'm still not strong enough to be on my own. So it's kinda using it as a little push right now. I just want to get my life, basically, in order and live a certain decent life. Whatever you call normal anymore because I'll never be completely normal again because I'm an addict. But at least live a certain normal life, how everybody else lives. Not sleeping on the ground. Eating at normal times. Making groups, go to school, you know, a normal 26-year-old do. That's what I'm trying to do.

Chapter Three: The History of Methadone Maintenance Treatment

Lisa: Chapter Three. The history of methadone maintenance treatment.

Mariel: Medication assisted treatment is now the gold standard throughout the world. But it didn’t become that way overnight. For all the people like Miranda Thomas, who think that methadone is a miracle—and there are many of them—there are also many who don’t approve of it. Because, to be clear, methadone is also an opioid. In order to embrace it as a solution to addiction, you might have to redefine your definition of success, of sobriety. Today Methadone is almost synonymous with addiction treatment, but that’s not how it started. Methadone is a synthetic opioid, and when it was created in Germany in the 1930s they were just looking for an analgesic—that’s a painkiller—because they had an opium shortage. After World War II the United States got Germany’s methadone as a spoil of war and scientists immediately tested it.

They thought it might be something they were looking for.

Nancy Campbell: What they were trying to find was a nonaddictive analgesic, a nonaddictive painkiller. That was their holy grail.

Mariel: That was Nancy Campbell, a historian of drug addiction. The scientists who tested methadone were working at a lab called the Addiction Research Center. It was a part of a

government-run prison hospital for heroin addicts in Lexington Kentucky. From 1935 through the 1960s the institution was one of just two facilities that treated heroin addiction in the entire country. Part one of this series dove deep into this so-called Narcotic Farm, so check it out if you haven’t already. These scientists had great hopes for methadone, but they didn’t exactly come true.

Nancy Campbell: So they are looking at this drug, and they're realizing actually this is not nonaddictive. We are not going to allow it to be put out as a painkiller.

Mariel: But they found a use for it in their detox unit: they started using it to taper newly- admitted patients off heroin, instead of making them quit cold turkey. Methadone is still used in this way in detox programs. But the seed of its use for maintenance treatment was planted here at the Narcotic Farm, when it was observed by a young psychiatrist named Marie Nyswander.

>>MUSIC>>

Mariel: In 1944 Marie Nyswander was fresh out of Cornell medical school and wanted to join

the Navy as a surgeon. But she couldn’t, because she was a woman. And the Navy didn’t accept women, so after switching her focus to psychiatry she served her country by working for the United States Public Health Service at the Lexington Narcotic Farm. We’re going to play some excerpts from a 1981 oral history with her, conducted by Columbia University.

Marie Nyswander: Prison is a terrible thing. If you’re not experienced with it, or if you have any kind of a personality that cares about your fellow man, working in a prison will simply blow you up with rage and frustration.

Mariel: Dr. Nyswander, who I’m going to call Marie, didn’t have any experience with people addicted to drugs before she got to Lexington. Most people didn’t. It wasn’t something they covered in medical schools then—not that it really is today either.

Marie Nyswander: You’re not taught very much. In fact I don’t think we were taught anything. Just nothing was known. They weren’t admitted into hospitals. They weren’t allowed in the emergency rooms. You weren’t allowed to treat them. Addicts were supposed to go to Lexington, Kentucky.

Mariel: When she treated patients at Lexington Marie had to follow an official psychiatric diagnostic manual, which said that all drug addicts were psychopaths.

Marie Nyswander: I think that it was just thoroughly indoctrinated that addicts were the lowest form of creature. I don’t know. There seemed to have been some impression that they had some kind of wild, maniacal pleasures that the rest of us didn’t know about, and for which they should be punished, I guess.

Mariel: But during her time at Lexington Marie realized that her patients were not all psychopaths. And that if they weren’t always the loveliest people, it could be that none of us are our best selves when we’re incarcerated. When she left the Narcotic Farm Marie set out to be a

psychoanalyst, but she kept getting pulled back into drug addiction research. She inadvertently became an expert, and wrote a book called The Drug Addict as Patient. It was sympathetic and unorthodox, and it captured the attention of a doctor named Vincent Dole. He had been an obesity researcher but had recently shifted his focus to heroin addiction. And he asked Marie to collaborate on new research in 1964.

Claire Clark: Together they developed this sort of unorthodox hypothesis, and that was that narcotic addiction wasn't caused by a sociopathic personality, which was what a lot of people thought. That instead, craving for drugs was basically a biological condition, almost like a metabolic disorder, like the kinds that Dole used to study. And that it could be treated primarily with pharmaceuticals.

Mariel: Claire Clark is a historian of medicine and behavioral scientist. She’s also the author of the book, The Recovery Revolution: The Battle over Addiction Treatment in the U.S. She says that Vincent and Marie started a counter-intuitive experiment: they started giving narcotics to heroin addicts. First they tried heroin but it didn’t work.

Marie Nyswander: It was impossible to keep them comfortable. It was an impossible task. The patients were not happy. They were looking at their watches and going in and out of withdrawal, comfortable for maybe an hour. Never got dressed. Never had any goals other than waiting for the next shot. The dosage went up and up, and this was not a program designed to make them high, but simply to keep them comfortable. I could not make them function.

Mariel: The program was starting to seem like a pretty clear failure. They’d tried heroin, morphine, dilaudid, and hydrocodone and cough medicine. And none of them worked. But then they tried methadone. They gave patients the same dose of methadone that they’d used for the other drugs. And it was high. Higher than had ever been used before for detox.

Marie Nyswander: We were very scared of that amount. Methadone had never been used in those high amounts. At any rate, the transition was made, and the next day, or the day after, there were two young men that were unlike anything that we had previously seen. They were dressed. Their color was good. They weren’t thinking of drugs. They wanted to go to school. It was clear that they were ready for rehabilitation or something and I didn’t believe it.

Mariel: The results were remarkable. Because methadone is longer-acting than other opioids the patients stopped obsessing about heroin all the time. They could think about other things. They could do other things: go to school, get jobs, have lives. And perhaps most importantly for political reasons: they stopped committing crimes.

Claire Clark: Dole and Nyswander then sort of concluded that once people were exposed to narcotics, their bodies underwent this permanent biological change, and that after the exposure they just needed the drugs in a visceral way, like a diabetic needs insulin, just as like a replacement to make them functional again.

Mariel: This theory of permanent biological change has since been disputed. But they were right about most of it.

Nancy Campbell: We now recognize that there is considerable neuroplasticity involved. As a neurological condition, those kinds of changes can be reversed and can be recovered from and can be healed. Many people, however, have lifelong grapplings with the opioids. If they started using young, they have many, maybe many decades of experience with these drugs, and they really need to be supported throughout the rest of their lives.

Mariel: It’s probably not all that surprising that the idea of giving opioids to people addicted to heroin was counter-intuitive at first. A colleague of Marie’s first suggested it to her. He asked her:

Nyswander: “Marie, did you ever stop to think what’s so wrong with giving addicts drugs?” I almost fainted, and I almost threw him out of the house. I left the room. I had to get a hold of myself.

Mariel: Counter-intuitive and controversial as it was, the idea of maintaining addicts on drugs wasn’t new. England’s heroin maintenance system began in the 1920s. And there was opioid maintenance in the U.S. too, starting after the Harrison Act made opiates illegal in 1914. All of those post- Civil War medical addicts didn’t just disappear. Individual doctors and then clinics maintained them, mostly on morphine but sometimes heroin. And with surprising degrees of success and support from their communities. Until they were all forced to close by the mid- 1920s.

>>MUSIC<<

Mariel: Vincent Dole and Nyswander published their findings in 1965 and their study led to the reversal of the nation’s ban against maintenance treatment. If it had been a different time they might not have had such success, but there was a new heroin epidemic sweeping the U.S. People were desperate for a solution and the only other options out there were therapeutic communities and they were getting a reputation as the only way rehabilitate heroin addicts. But then along comes methadone maintenance, and it’s working too: except it’s much cheaper, faster, and it’s based 100% in science. Therapeutic Communities weren’t so happy with Dr. Dole and Nyswander’s study.

Claire Clark: Those findings really ran contrary to the beliefs of TC providers, because they viewed recovery not as a metabolic disorder, but as a kind of arduous process of personal maturation. It could not be achieved in like a couple weeks of taking a substitute drug therapy, from their perspective.

Mariel: The Federal Bureau of Narcotics—which was the precursor to the DEA—didn’t like the idea of methadone maintenance either. But again, timing was on the side of the doctors. Part of the perceived problem was that with heroin addiction came crime. And you know who really didn’t like crime? Richard Nixon. And he campaigned on restoring law and order when he ran for president in 1968.

Nixon: My friends, let me make one thing clear. This is a nation of laws and as Abraham Lincoln has said, “no one is above the law, no one is below the law” and we are going to enforce the law. And Americans should remember that if we are going to have law and order.

Mariel: Nixon was convinced that methadone could help bring down the crime rate, and he poured money into it.

NBC Evening News. February 4, 1971: One of the bright points in the Nixon's administration, the Anti-Crime Program is the city of Washington DC., where the crime rates have been going down. The city has one of the country's largest Methadone programs, which involves a drug substitute therapy to reduce heroin addiction,

Mariel: Vincent Dole and Marie Nyswander followed 750 methadone patients over four years. At the end they found that eighty-eight percent of them hadn’t been arrested during that time. A subset of fifty-nine percent of them had become “productive members of society.” They had jobs. It seemed like science had finally solved the opioid addiction problem—by treating it as a chronic disease. The magic bullet had arrived. In many ways this was true. And in many ways, it wasn’t.

Chapter Four: Buprenorphine: The Other Maintenance Drug

Alexis: Chapter Four. Buprenorphine. The other maintenance drug.

Nancy Campbell: Methadone maintenance, no one in the addiction field really liked methadone except Vince Dole and Marie Nyswander.

Mariel: This is Nancy Campbell again.

Nancy Campbell: Everyone else thought this is an agonist. People can overdose on it. It's just going to be a problem, so why don't we try to find something else that isn't an agonist?

Mariel: Before we go any further, welcome to the technical part of the show: where we learn the difference between opioid agonist and antagonist. But before we get into these, we need to talk about our brains.

Nancy Campbell: Sure. This is sort of pharmacology 101. In our brains, it was discovered, actually at the narcotic farm, there are multiple opiate receptors in our brains.

Mariel: In order for an opioid to have an effect on your body it has to attach to one of these receptors—that’s how it sends messages to your brain and tells it to block pain, slow breathing, and feel calm. Imagine the receptor as a golf tee.

Nancy Campbell: And when a drug comes along in the form of a golf ball and it sits on that receptor, you can't put anything else on that golf tee. Right? That golf ball is sitting on the golf tee. That's an agonist.

Mariel: Heroin, morphine, Oxycontin and yes, Methadone, they’re all opioid agonists. They’re the golf balls that sit on that golf tee. Part of why Methadone works for maintenance treatment is that if a person takes a high enough dose, it will fill that opioid receptor, that golf tee, and won’t let any other golf balls. The golf tee will be occupied. But because methadone is still an opioid it can make you high, it’s addictive, and you can overdose on it. And that’s where opioid antagonists come in.

Nancy Campbell: Now, what's an antagonist? Well, an antagonist is something that comes along and, like a golf club, moves the golf ball off the golf tee and it sits on that golf tee in such a way that the agonist golf ball can't get back onto that receptor. So you need an antagonist if you are going to reverse an overdose, for instance. You need an antagonist to come along and knock the agonist off the receptor and fully occupy the receptor.

Mariel: The drug Naloxone, or Narcan, is an opioid antagonist. That’s the nasal spray that can reverse an overdose. But how do opioid antagonists fit into maintenance treatment? This is where buprenorphine comes in.

Nancy Campbell: So, from the late '60s on, the people at the narcotic farm, in particular, were interested in could they find something that was both. That was a partial agonist and a partial antagonist? And could they find a drug that had a profile that was unlike methadone, morphine, heroin?

Mariel: There were many candidates. But the most promising one was Buprenorphine, a partial agonist and partial antagonist. It is simultaneously the golf ball and the golf club.

Nancy Campbell: And they really liked what they saw because people got enough of the buzz they were looking for, they got enough of the effects that they wanted, but there was a ceiling effect and it was a long acting drug. So they couldn't really overdose on it. They got enough of it that they weren't that interested in heroin and they could stay on it. And so, buprenorphine is a really different kind of drug than any that we had seen prior to the 1970s, and it was explored in the 1970s as an alternative to methadone.

Mariel: Maybe you’re surprised to hear that Buprenorphine has been around as early as 1970. Because it took a lot longer to become widely available.

Nancy Campbell: It took 30 years because pharmaceutical companies are not particularly interested in innovating in the area of drug addiction. It was basically treated like an orphan drug. No one thought there was a big market for it, and then people begin to realize there's a huge market for it, because we're having actually a huge pharmaceutical opioid problem in this country.

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Nancy Campbell: In this country we've had great faith that science is going to solve the drug addiction problem. And the one way that that has come true, frankly, is Buprenorphine. That's really only one of the examples we can point to and say, all right, that came out of the search for a non-addicting analgesic. It came out of the search for an addiction therapeutic for a pharmacological agent that would support addiction recovery. That's what that drug is meant to do. We don't have very many other examples of drugs that are on the market for that purpose.

Mariel: Opioid use disorder is now considered a chronic disease that requires long-term care— like diabetes. In this analogy, buprenorphine would be insulin. Where a better-fitting parallel for methadone might be dialysis.

Nancy Campbell: Another reason that an alternative to methadone was sought in the 1970s was that people who have less time using an opioid can often do better on Buprenorphine. So, they don't need to be switched onto a life-long opioid like methadone. They can actually benefit from Buprenorphine because the changes that opioids have on our brain and body are not as settled.

Mariel: One of the best things about buprenorphine is where you can get it. See, there was another reason that it took until 2003 to hit the market: the people who developed it were worried about it falling into the same trap as methadone.

Nancy Campbell: The methadone clinic system was problematic from the beginning because there was a not in my backyard kind of attitude.

Mariel: By law, methadone can only be prescribed for maintenance treatment out of a standalone clinic, like the one where we met Miranda Thomas. It can’t be prescribed by a regular doctor’s office or in a hospital. The whole system is a result a compromise with the DEA in the 1970s, because Methadone is classified as having a high potential for abuse. It’s a schedule two drug: in the same category as Oxycodone and Fentanyl. So it was pushed into clinics, which themselves were pushed out of the way.

Nancy Campbell: People didn't want a methadone clinic in their neighborhood, they wanted it on the other side of the tracks, and so the methadone standalone methadone clinic system, everybody knows the only reason you're going to the methadone clinic is to get methadone, right?

Mariel: The clinic where we met Miranda is very centrally located. It’s near buses, trains, and subways. But a lot of clinics, especially in rural areas, are hard to reach. And people need to reach them every single day.

Nancy Campbell: Then along comes buprenorphine, and the people who wanna develop buprenorphine say “we can't have this drug prescribed in a standalone system. We want this drug to be able to be prescribed in the VA system, we want this drug to be prescribed

by doctors in offices and hospitals. We don't want this drug to be in a sense tarred with the same brush as methadone.”

Mariel: They were successful, and today doctors who get special training can prescribe buprenorphine out of their offices. Doctors like Lara Weinstein, a primary care physician at a non-profit in North Philadelphia. It’s called Pathways to housing and it finds people places to live and then addresses any other issues they may have. A few years Dr. Weinstein got trained and licensed to prescribe buprenorphine, because a lot of her patients have opioid abuse disorder.

Weinstein: Yeah, it was the first time I felt like I personally could make a difference in addiction for my patients directly. And looking back, I didn't know what I was getting into. It just seemed like the right thing to do at the time. But it's such a rewarding part of my practice, that I'm really glad.

Mariel: When we were researching this episode, we read countless stories of patients who had turned their lives around because of buprenorphine. We know that they’re out there. But we didn’t meet anyone with a story like this. And maybe we didn’t look hard enough. But it might just be that we weren’t looking in the right place. Dr. Weinstein’s patients are living on the streets, without money or support networks. She says that she pictured an idyllic scenario in her mind when she started prescribing buprenorphine, but she had to reset her expectations.

Weinstein: You know the traditional thing for this, you know, someone comes in, I'm going to get off this stuff, get my life back ... I'm making this up because I've never really seen it happen, but they get right on buprenorphine, they get their house, they get a job right away, which is really tough, they start saving money, they reunite with their family, and they move back to the suburbs -- I don't know. You know, that doesn't really happen, but there's some elements of that that you can find here and there in pieces of people's lives, but for us, a lot of times, folks come in here in really, really bad shape. They've been sleeping on the street, they're physically sick, they're dope sick, and they're also very traumatized, which comes out a lot as anxiety and anger. And it's initially hard to even have a conversation with them.

And I think we take a lot of pride in trying to create a space where the person feels like we're going to listen to them and we really care about them and we can see the light in them despite the dirty, torn clothes and everything that's going on with them. The wounds and the abscesses and the blood and the other bodily fluids. And that that person can get a shower and wash their clothes. That's awesome, you know? That's awesome. Especially because we see it. It might not sound so great to say, "Okay, you're excited about a person taking a shower," but when you see the transformation, and they can feel just a little bit better and maybe feel a little bit better about themselves, that's why we're here, and that's more than enough.

And if they want to come back in a couple days and talk about buprenorphine? Great!

And if all it does is give someone eight hours of not having to find a bag of dope, to just take that pressure off them for that period of time, and then they go back to using, but they have that experience, then maybe they'll come back later. They often do.

Mariel: Dr. Weinstein’s changing expectations have to do with that idea of redefining success with opioid addiction. And her thinking is in line with a philosophy called harm reduction: it focuses on reducing the negative consequences surrounding drug use, instead of a sort of tunnel- vision approach to 100% sobriety. Harm reduction use in practice involves clean-needle exchanges and safe injection sites, and the general well-being of drug users.

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Mariel: Scientifically, buprenorphine is kind of a miracle drug. But for someone to turn their life around it can really only be one part of the puzzle. Someone trying to get sober still needs a job, a home, and a support network. And I’m guessing that people who already have these things in place do better on buprenorphine.

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Mariel: In the U.S. today Buprenorphine is most commonly prescribed under the brand name Suboxone—which is actually buprenorphine combined with Naloxone—the opioid antagonist that can reverse overdoses. That combination makes it harder to tamper with, and harder to overdose on. And this is important, because it’s not as strictly controlled as methadone. And a fair amount of it gets diverted onto the street.

Chris Marshall: Now we're walking backwards but if you're walking up this way, as soon as you come down the steps of this EL platform, you're offered works, Suboxone. They'll be like works, subs, works, subs. For some reason they sell the Suboxone right there, as soon as you get off.

Mariel: We’re with Chris Marshall again, underneath the El in Kensington.

Chris Marshall: Right now just talking to you, I seen a transaction for Suboxone, I seen somebody just buy works over there. They're not doing it to get high, they're doing it so they're not dope sick. You know? They don't wanna be dope sick ... See somebody's offering to sell dope right now. But, you don't wanna be dope sick going to work and stuff like that so you pick up a suboxone and it'll last you 24 hours or more without getting sick. It's $10. And also, there's a delusion that people think "Well, it's a medication too so it's not so bad, I'm only doing subs, I'm not doing dope,"

Mariel: It’s hard to know exactly how much Suboxone is getting diverted onto the street, but people seem to agree that it’s a lot. And one reason is simple supply and demand. It’s not that easy to get it through an official channel. Doctors can prescribe it, but only if they’ve gone through special training. And even then they have caps on how many patients they can treat. One emergency room doctor told us that of the estimated 70,000 heroin users in Philadelphia, if all of them decided to seek out buprenorphine maintenance treatment just a fraction of them would be

able to get help. There isn’t enough capacity to treat them. All of this has helped create a black market. There are some safeguards against diversion—Dr. Weinstein checks her patients’ urine to see if they’re still using other opioids. She also says that patients take their first dose at the pharmacy, in front of a pharmacist. But it’s not fool-proof. And she’s made peace with that.

Weinstein: I do require the folks, if I'm prescribing buprenorphine for them, it needs to be for them and they need to take it. However, I can live with the fact that some people are selling their buprenorphine and it's going out into the community, because it's not a bad substance, and it might be the way that some other people do get started on it.

Mariel: Diversion of buprenorphine is an unintended side effect of avoiding methadone’s rigid clinic system. With methadone you’re required to show up at the same place every day and get counseling along with the medication. With Suboxone, you can get pick up a prescription with no strings attached. And this makes all the difference for some people. But it doesn’t work for others.

Weinstein: Sometimes, people decide, This isn't really what I need right now. "It's not structure enough for me. I need methadone."

Mariel: This is actually exactly what happened to Miranda Thomas. She tried Suboxone before Methadone. But it didn’t work out. And the first hurdle was getting seen by a doctor.

Miranda: Yeah, Suboxone it took a while, it took me almost two months before I actually seen a doctor. So I was still using every day and they had me like going to all these different places, then the doctor was on vacation, it was horrible. I said this ain't gonna work for me. Plus the non-structure with me. ‘Cause all you do is go and pick up your pill and leave. I need structure, ‘cause I have too much time on my hands, and with the time you have time to overthink things, and I was using still, and I need like groups and stuff which they do here.

Mariel: But Methadone maintenance is a huge time commitment and it requires near perfect attendance. Which is difficult if you have a job. Or you’d like to get a job.

Miranda: because you gotta come here every single day. It takes up a lot of your life, you know? It becomes a lifestyle, you're here every day, you spend most of your time here.

Mariel: But right now it’s exactly what Miranda needs.

Miranda: I think that it's better with the Methadone and the structure, because why would you have a place where you just go and get a chemical and leave? I don't think that's what's keeping people sober, I think that the groups is what helps people. ‘Cause you're with other people that have the same problem as you, you don't necessarily feel like you're alone. Like sometimes in addiction you feel like you're alone, and I felt like I needed to be around other people who are having the same issue as me, so I can know that I'm not alone.

Mariel: Miranda’s onto something: studies show that a combination of medication and therapy is the most effective way to treat opioid use disorder. More effective than either approach on its own. But only about one-third of drug treatment programs in the U.S. today offer maintenance treatment. In this field there’s a tendency for people to claim that their way is the only way. In a therapeutic community like the Last Stop, people tend to look down on maintenance treatment.

John: They're basically using a crutch as a substitute. So really they're not getting clean. It's an opiate. Suboxone, it's just an opiate. Try not taking that for a couple days and that's even worse than the anxiety getting off of dope, they say. It's how bad do you want it?

Do you want this obsession to be free?

Mariel: The perception is that if you’re on buprenorphine or methadone you’re still using drugs, even though studies show that medication-assisted treatment is remarkably effective at reducing overdose deaths. And right now, especially in Philadelphia where the drugs are very strong, the stakes that come with relapsing are very high. Many experts, including Nancy Campbell, see combining methods as imperative.

Nancy Campbell: I think we need recovery that is much more broadly informed. Not operating from one philosophy, or from one kind of position. A good example of that, I think are therapeutic communities, which were initially drug-free, are now actually offering methadone and buprenorphine.

Chapter Five: Fancy Rehab

Lisa: Chapter Five. Fancy Rehab.

Mariel: We started this episode telling you about the Last Stop in Philadelphia—lovingly referred to by its members as “Ghetto Recovery.” It welcomes anyone who comes in and truly wants to get clean. Regardless of what they have to offer monetarily. On the opposite end of the spectrum are places like one we visited outside of Reading Pennsylvania called Caron Treatment Centers. Caron is doing so much right, but it’s also very expensive, and therefore not accessible to most people. We talked to their medical director, Dr. Joseph Garbely.

Joseph Garbely: You can see these are hospital beds here, not regular beds. You could see what's nice about Caron is, we don't just get the skinny little hospital beds. We get a double bed that is a hospital bed so that they're very comfortable here. That's really important with the view and all. It's a nice place to land.

We get patients here on their worst day, typically. We really want to make sure that they feel at home and comforted, because if they don't, they're going to leave treatment. The drug is calling their name. They want the drug badly. Unless we can provide them with some degree of comfort and give them medications to get rid of their cravings and reduce their withdrawal symptoms, they will leave treatment early.

Mariel: Caron feels like an upscale hotel. It’s in rural Pennsylvania and each room has a view of rolling green hills. There are hardwood floors and high-end furniture, and there’s water dispenser has tomatoes and basil leaves floating in it. Caron tailors treatment for each patient,

incorporating everything we’ve talked about in this episode so far and more. Peer-led 12-step programs are a big focus—just like at The Last Stop and other therapeutic communities. But Dr. Garbely explains why they work scientifically.

Joseph Garbely: Acceptance by a group is crucial, because there's a lot of shame and guilt that comes with the disease of addiction and to come into a milieu like folks do here and to go into the rooms of alcoholics anonymous and narcotics anonymous and meet people that accept you for who you are is very therapeutic and very helpful. What's happening in that process scientifically, is we are changing the salience of different stimuli. What's happening is, they move further and further away from their drug of choice, the salience or importance for that drug goes down and down and down, and the salience or importance of natural rewards, one of them being a sense of community, goes up and up and up. If you're going to meetings and you're around people that accept you, and they embrace you and they love you til you love yourself as they say in the rooms, the importance of that stimulus continues to go up and up and up and you're really starting to heal the brain, if you will.

Mariel: Caron also includes any and every evidence-based therapy that has been proven to work. Including Medication-assisted treatment. As long as it’s just one part of the treatment plan.

Joseph Garbely: I mean it's medicated assisted treatment, not medication as treatment. The MAT, you have to understand what it actually stands for, and it needs to be part of an opioid use disorder treatment plan because the relapse risk is so high and fatalities follow that. The overdose rate in this country is astronomical. We're losing a generation and we have to do something to reduce that relapse rate and the overdose that comes with that.

Medication assisted treatment is necessary.

Mariel: They give some patients the anti-craving drug Naltrexone to help stave off cravings. And they use Buprenorphine to wean new patients. They also use Suboxone for maintenance, but only when it’s deemed appropriate. The average length of a stay at Caron is 30 days. After discharge Caron follows up with each patient for one year. Dr. Garbely says their success rate after this one year is 77%. But there is no one standard definition of success or a way to measure it so it’s hard to say how this compares to average. Although I think it’s safe to say that Caron is doing much better than average. And I think that if everyone struggling with opioid use disorder had access to a place like Caron the national average would probably be much lower. But right now Garbely says only about 10% of people who need treatment get it at all.

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Mariel: When we set out a year ago to tell this complex history we were guided by a very naïve question: why hasn’t science been able to solve this problem? If we’ve been dealing with it for 150 years, shouldn’t we have figured it out by now? Claire Clark says that one issue is that people don’t learn from history.

Claire Clark: What's happened is that instead of reliably publicly funding drug treatment, and overseeing it, we have this long history of pumping money into treatment when a drug problem becomes an "epidemic" and then having the funding dry up as other political issues take precedence. What this does is leave us unprepared for the next wave of drug use, and the cycle inevitably starts again. We've seen it. We're probably in the third wave of it now. The late 1800s, the 1960s, and here we are living through it again.

Mariel: It seems like part of the reason we haven’t solved this problem is because we haven’t agreed on what a solution looks like.

Claire Clark: I would say that, yeah, all addiction treatment is shaped by morals and values, and the question is really whose morals, and which values, and what's the goal of treatment, and is anything less than total abstinence acceptable? Really, I think the hardest thing in addiction treatment research is deciding on the dependent variable. So, what's the ideal outcome of treatment, and what determines success? This is really still an open question. Is it total character reformation like TC researchers were measuring? Is it lower crime rates, like Nixon thought? Is it infectious disease prevention, like people in favor of harm reduction strategies argue? These are all still hot topics within the field today.

Mariel: There’s another complicating factor, which is that opioid use disorder is a complex disease that is only partially explained—and can only be partially treated—by science. There are so many other things that factor into whether a person will become addicted in the first place, and how hard it will be to quit. Additional factors like past trauma, comorbidities, mental illness, and someone’s economic state are all pieces of the puzzle.

Nancy Campbell: I do not think that there is a one size fits all answer to the problem of addiction We should work towards harm reduction oriented addiction treatment in which we meld the principles of harm reduction with whatever treatment modality people find successful for themselves, and effective for themselves, and meaningful for themselves. Because we should never, ever forget that addiction treatment is a search for meaning in a place other than using drugs. So people are looking for a new kind of meaning.

Mariel: For 150 years we’ve been looking for science to deliver a solution to this problem, and Nancy Campbell, a historian of medicine, thinks maybe it’s time to start looking at what’s causing the problem in the first place.

Nancy Campbell: So one of the things that I think we have seen is that we've gone too far in terms of looking at the neurobiochemistry at the sub molecular level at the neuroscience. We have not seen the benefits that our investment in the neurosciences of addiction should warrant. We have not seen the translation into pharmacological treatments, into any intervention whatsoever. And so it does seem to me that the social context, the economic context and the political context in which people come to use these drugs, we should really look at that. Why are people using these drugs? Have we perhaps invented an unlivable world? Do we have work that satisfies people and that allows them

to create and live the kinds of lives that they want? I mean, I look at that and I say we should be looking at some pretty basic changes in terms of our social economic and political contexts, rather than looking at the sub molecular level of the ways in which the opioids effect our brains.

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Lisa: Thank you so much for tuning into this last episode of series on the history of opioid addiction treatment in the U.S.

Alexis: While we’ve been working on these episodes Distillations magazine has been working on a story about how we arrived at our current crisis. So make sure to check it out at Distillations DOT org. And, please subscribe to our show wherever you get your podcasts!

Lisa: We have an important Public Service Announcement: there’s been a growing movement to get Narcan into the hands of regular people, not just first responders, and it’s been helping save

lives. It’s surprisingly easy to get and use this nasal spray that can reverse overdoses. Just go to Narcan.com to find out more. And remember that people still need emergency care after it’s used.

Alexis: Distillations is more than a podcast. We’re also a multimedia magazine.

Lisa: You can find our videos, our blog, and our print stories at Distillations DOT org.

Alexis: And you can also follow the Science History Institute on Facebook, Twitter, and Instagram.

Lisa: This episode was reported by Mariel Carr, Rigoberto Hernandez, and Meir Rinde.

Alexis: And it was produced by Mariel Carr and Rigo Hernandez.

Lisa: This show was mixed by James Morrison and our theme music was composed by Zach Young.

Lisa: For Distillations, I’m Lisa Berry Drago.

Alexis: And I’m Alexis Pedrick.

Both: Thanks for listening.