Months in prison didn’t rid Daryl of his addiction to opioids.
“Before I left the parking lot of the prison, I was shooting up getting high,” he says.
Daryl has used opioids such as heroin and prescription painkillers for more than a decade. Almost four years ago, he became one of more than 200 people who tested positive for HIV in an historic outbreak in Scott County, Indiana. He went on a bender after his diagnosis, he says.
But about a year ago, Daryl had an experience that made him realize he might be able to stay away from opioids. For several days, he says, he couldn’t find drugs. He spent that time in withdrawal.
“It hurts all over. You puke, you get diarrhea,” Daryl says. But his best friend offered him part of a strip of Suboxone, a brand name version of the addiction medication buprenorphine, a long-acting opioid prescribed for people who are addicted to heroin or other opioids. The medication reduces cravings and prevents withdrawal.
Daryl says he injected it and his symptoms disappeared. Daryl is his middle name, which Side Effects is using to protect his identity because it’s illegal to use buprenorphine without a prescription.
“I didn't crave nothing. I wasn't sick. My belly didn't hurt. I wasn't hurting in my joints,” he says. Weeks later, Daryl again struggled to find drugs, and the grind of daily opioid use had worn on him. He didn’t want to spend the rest of his life on heroin.
He could easily find buprenorphine in his area, and it lasted longer. He decided to use it on a regular basis, which he says reminded him of his life before opioids. “At first it felt like I was high,” Daryl says. “But I think that’s what normal feels like now. I have not been normal in a long time.”
Buprenorphine is one of just three federally approved medications to treat opioid addiction. It’s possible to misuse it because it’s an opioid itself — people snort or inject the medication to get high. And patients with prescriptions can sell or give it away, which is known as diversion. Some policymakers and officials, such as Kentucky Attorney General Andy Beshear, point to diversion as a reason to regulate buprenorphine prescribers more, and they compare some buprenorphine providers to “pill mills,” stand alone pain clinics that are seen as a contributor to the opioid epidemic.
"This is a drug that, if used in the right way, can be a positive," Beshear told NPR last year. "We worked so hard to shut [pill mills] down. If we can't learn from our past and make sure we don't repeat those mistakes, then shame on us." Beshear's office did not immediately respond to a request for comment.
But addiction treatment professionals argue the problem of buprenorphine diversion is often misunderstood. The black market exists, in part, because addiction treatment can be hard to find, and the availability of the drug on the street can be helpful, they say.
Dr. Kelly Clark, president of the American Society of Addiction Medicine, says for one thing, buprenorphine is not as dangerous as other opioids.
“We care about diversion from a public health standpoint because of the risks of overdose, and the risks of overdose with buprenorphine are minimal,” she says. Buprenorphine’s effects are less potent than those of heroin and fentanyl, and the medication can block other opioids. It can even cause the onset of withdrawal symptoms if taken too soon after another drug.
It is possible to fatally overdose from buprenorphine — especially if people don't have a tolerance to opioids or they mix it with other substances — but it’s rare. Nearly 1,600 people died of opioid-related overdoses from 2010 to 2017 in Marion County, Indiana, where Indianapolis is located. But just 12 people died with buprenorphine in their system, according to data from the coroner’s office. The office blamed just one death on buprenorphine alone.
Buprenorphine’s attributes mean few people use it to get high. There’s research to back that up, and the medication is often formulated with naloxone, which reverses opioid overdoses. That reduces its appeal as a recreational drug.
Instead, more people use it to prevent withdrawal, and to try and stay away from other illegal drugs like heroin and illicit fentanyl. Some addiction experts argue that self-treatment with buprenorphine can reduce harm because it’s used in place of more dangerous substances that are blamed for the continued rise in overdose deaths.
“It was not diverted buprenorphine that's responsible for our current situation,” says Dr. Zev Schuman-Olivier, an addiction specialist and instructor at Harvard Medical School. “The majority of people ... are using it in a way that reduces their risk of overdose.”
“It's definitely illegal,” says Daryl. “But would they rather me be driving to Louisville and picking up two eight balls of heroin?”
Dr. Michelle Lofwall, an addiction specialist and researcher at University of Kentucky, says people often try to treat themselves when they struggle to get into real treatment. “These people want help, and they tried and they didn’t succeed. So now they’re going to go get it if it’s available,” she says.
Professional treatment with buprenorphine can be hard for patients to get. Prescribers must get a special waiver to prescribe the medication, and still only a fraction of doctors take that step. And federal rules limit the number of people they can treat, a cap that is unique to buprenorphine.
Policymakers have debated expanding access to the drug in recent years to help curb the opioid epidemic. Federal guidelines changed under the Obama administration to increase the number of prescribers and the number of patients they can treat. Nurse practitioners and physician assistants can now apply for a waiver to prescribe buprenorphine. And doctors who meet certain requirements can now treat up to 275 patients, instead of the previous limit of 100.
This year, the U.S. House of Representatives passed legislation to allow some advanced practice nurses to prescribe buprenorphine. The Senate has yet to act on that proposal.
Law enforcement officials and other policymakers point to cash-only buprenorphine clinics as drivers of diversion. Some buprenorphine clinics don't take insurance, which makes treatment expensive for patients. It can cost hundreds of dollars a month, so a patient may sell part of their prescription to afford their care. And such clinics may offer lower quality treatment because they don’t have to adhere to rules imposed by insurers. For instance, some insurers require that patients receive counseling to get a buprenorphine prescription.
Critics say that more regulation and enforcement actions are needed to stop such operations. For instance, Indiana’s attorney general supported legislation this year to add regulations to buprenorphine prescribers in the state, although the legislation ultimately failed.
Basia Andraka-Christou, an assistant professor and addiction policy researcher at the University of Central Florida, concedes that cash-only buprenorphine prescribers may offer lower quality care. “You have a bit of a hierarchy in my experience,” she says. But increasing regulations or shutting prescribers down would limit treatment options for people with opioid addiction, Andraka-Christou says.
“I guarantee you, they're either going to go and buy heroin and get high, which surely is not a great policy solution here,” she says. “Or they're going to go buy Suboxone on the street.”
A step toward real treatment
This street treatment is not ideal. Patients need a treatment professional to help them figure out the right dose and to address other mental health needs that are common among people with addiction. But Lofwall says people will often realize they want professional help after trying the medication illegally.
“They've had it and they know it works for them and they want to get it legally,” says Lofwall. “They want to get their life back.”
Daryl had a similar experience. Several weeks after he began using buprenorphine regularly, Daryl tried to sign up for insurance so he could get help. “I think if I had never started [Suboxone] on the street... I wouldn't have no interest in doing nothing but getting high,” he says.
He still hasn’t made it into treatment. He had trouble starting his insurance, and the market for illicit buprenorphine can be fragile. Daryl struggled to stay away from heroin when the person he bought buprenorphine from lost their prescription. Addiction can take years to conquer, but Daryl says his time on buprenorphine allowed him to see a way back to a normal life.
“I'm at a point of my life now where I know I've got to change something, or I'm going to go back to prison,” he says. “I'm definitely ready to do something different.”