MICHAEL BARAJAS TOOK his first vacation this year, at the age of 33.
For most of his life, the Aberdeen native had no interest in leaving town — unless it was to pick up or deliver drugs.
“Nothing else mattered but getting high,” he says, “so why would I go anywhere?”
Since he’s been sober for nearly three years, Barajas’ world has broadened in ways that seemed inconceivable when he was camping in abandoned houses, focused only on “getting well” with another bump of OxyContin, heroin or whatever he could get his hands on.
He’s now working full-time for a company that manages rental properties in Ocean Shores. He’s engaged and shares a house with his fiancée. On their trip to California in January, they visited her family, checked out the scene at Venice Beach and strolled the Santa Barbara pier.
Barajas credits his recovery to a medication called buprenorphine, or bupe, and a new type of clinic that’s part of a statewide push to make the treatment more accessible.
Also known by the brand name Suboxone, bupe is a synthetic opioid similar to methadone but much safer and less powerful. In former drug users like Barajas, it doesn’t cause euphoria and it actually prevents them from getting high if they take other opiates. The medication blocks withdrawal symptoms and calms the jangling brain circuits that trigger cravings and the temptation to relapse.
“It’s opened up a whole lot of doors for me,” Barajas says during a recent, monthly visit to the MAT (medication assisted treatment) Clinic at Summit Pacific Medical Center in the tiny town of Elma. “Instead of being locked in that mental state where my brain is constantly telling me I want that feeling of being high, I can now do things and experience life and grow as a person.”
The clinic’s lead nurse, Beth Hindbaugh, beams.
“I’m super proud of you,” she says.
ENCOURAGEMENT AND COMPASSION are integral to the clinic’s philosophy. So is upending the traditional — often punitive — approach to addiction treatment.
Behavioral therapy, detox and 12-step programs long have dominated recovery paradigms, but evidence increasingly shows that medication, especially buprenorphine, is far more effective.
Patients taking bupe or methadone are half as likely to relapse or overdose as those who get only counseling. In fact, adding talk therapy to buprenorphine-based treatment doesn’t significantly improve success rates, according to several studies. Medication for addiction is linked with a drop in arrests and fewer emergency room and hospital visits, which reduces the economic toll.
“Getting on Suboxone results in a more complete and longer sobriety than anything else we do,” says Dr. Shawn Andrews, founder and medical director of the Elma clinic. Though it doesn’t work for everyone, the medication can be life-changing for many.
“People get their lives back. They get their kids back. They go to school; they get better jobs and contribute to society,” she says.
But fewer than 1 in 5 Americans with opioid addiction receives any type of medication, with the highest gaps among people of color. Widespread use of buprenorphine, which was approved by the FDA in 2002, has been hampered by medical bureaucracy, restrictive regulation, doctors’ reluctance to treat drug users and the stubborn misconception that medication is a crutch, not a true path to recovery.
“There’s a pervasive attitude that people who struggle with substance use disorders are just weak, that they could quit if they wanted to,” says Dr. Charissa Fotinos, acting state Medicaid director at the Washington State Health Care Authority. “But we know from the brain science that they can’t. This is not a willful act. This is not a moral failing.”
An estimated 2 million people in the United States suffer from what medical experts refer to as opioid use disorder, a term that acknowledges the disease-like impact on the brain and body. Overdose deaths reached an all-time high of 100,000 during the second year of the coronavirus pandemic, driven in large part by a flood of fentanyl, which is much deadlier than heroin.
In the face of the ongoing crisis, Washington is among several states shifting to a strategy described as medication-first and low-barrier. The goal is to dismantle obstacles and make it easier to get buprenorphine to those who need it most.
Over the past several years, the state has received more than $130 million in federal opioid response grants, and some of that money has gone to create 25 new treatment sites, like the one in Elma. Most are low-barrier, and many are located in places frequented by people with addiction: needle exchanges, emergency rooms, shelters and jails. Local governments and organizations are also adding low-barrier options; King County now has 33.
“We’ve recognized that there’s a group of folks who aren’t comfortable or don’t feel safe in the regular health care system because they’ve been judged or stigmatized,” Fotinos says. “So let’s just be where they are, and if they’re ready and willing and interested in treatment, let’s provide it for them right there.”
THE ELMA CLINIC, 30 miles west of Olympia, demonstrates many of the elements for success — even in rural Grays Harbor County, which has the state’s highest rate of overdose deaths and few doctors willing to prescribe buprenorphine. Patients don’t need appointments. If they meet the criteria, they can walk out the same day with medication instead of having to wait weeks for their first dose. That’s an important change, because delays can plunge people into withdrawal and send them scrambling for drugs to stop the misery. State regulators recently lifted limits on the amount and duration of bupe treatment, removed some insurance barriers and raised payments to doctors. They did away with a long-standing requirement that patients also enroll in talk therapy.
In low-barrier programs, no one is booted out for relapsing. If someone wants to cut down on heroin use but continue using other drugs, such as meth, that’s OK, too. The idea is to help all patients reduce their risk of overdose and improve their lives and health — even if it’s just baby steps at first.
Addiction experts compare it to treating patients with high blood pressure or diabetes. Doctors don’t kick them out if they smoke or sneak a piece of birthday cake, but that’s the way people with substance use disorder are often treated.
“Recovery is an incremental process for most people,” Andrews says. Even the most motivated patients usually stumble before it sticks. For people who lack stable housing, it’s even more challenging.
“It’s very hard to stay sober if you’re sleeping in a tent and rats are nibbling at your feet,” Andrews says.
BARAJAS FOLLOWED A typically twisting path.
Growing up with a mother addicted to meth, he assumed drug use was the norm.
“Since I was probably 12 years old, I’ve always been on something, whether it was booze or pills or cocaine,” he says. He occasionally stole, but mostly sold drugs to make money, chalking up a string of arrests and jail time.
His first attempts to get clean were through cold-turkey therapy programs. He didn’t find the counseling helpful but did OK for a while until a series of calamities pushed him over the edge. An injury cost him his livelihood as a logger. His house burned, his grandmother was diagnosed with cancer and he got hit by a car.
Smoking opioids ruined his marriage and his relationship with his daughter, but it eased the suffering.
“It just numbs you from life, and your body doesn’t hurt until you’re out of drugs.”
Barajas’ first stint at the Elma clinic ended in relapse. Then his girlfriend at the time died of an asthma attack because she was too high to find her inhaler.
“That was the big push I needed for myself,” Barajas recalls. “I thought, ‘What if my daughter were to find me like that, laying on the ground?’ ”
He was so ashamed of his relapse, he almost didn’t return to the clinic. “I’m thankful they didn’t say, ‘Your chance is over. You failed,’ ” he says. “They want you to come back and keep trying.”
WASHINGTON’S LOW-BARRIER sites are still too new to measure their impact, and disruptions from the pandemic haven’t helped, Fotinos says. At least 24,000 people have received treatment through the new programs since 2018, but retention rates aren’t clear, and the number of Washington residents with opioid addiction is also increasing.
Caleb Banta-Green, of the University of Washington’s Addictions, Drugs and Alcohol Institute, conducted the state’s first low-barrier pilot project at Seattle’s downtown needle exchange in 2017 and found that even among a largely homeless population, buprenorphine slashed overdose deaths and reduced opioid use. Nearly 80% of drug users surveyed said they wanted to quit, with medication by far the preferred method. But another analysis found most people don’t initially stay on the medication for the recommended minimum of six months.
To evaluate the method on a larger scale, Banta-Green and his colleagues are collecting data on overdoses, deaths, relapse rates, hospitalizations and arrests from six clinics across the state.
The link between drugs and crime also makes prisons and jails important players in expanding buprenorphine treatment. At the South Correctional Entity (SCORE) jail in Des Moines, for example, eight in 10 people booked are on some kind of intoxicant, says Lt. Jeffrey Gepner.
Those on opioids used to be left to endure withdrawal with no medical intervention, which can sometimes be deadly. In most cases, guards would mop up the vomit and diarrhea, move prisoners to another cell, then repeat the process, says Gepner, who now leads the jail’s medication assisted treatment program.
Buprenorphine is provided to inmates sick from withdrawal and to those who want to continue or start a treatment program. Many jails and prisons have similar programs, and more are adding them after a lawsuit in Whatcom County that argued it was illegal for correctional facilities to deny addiction treatment.
“The goal here is to say: ‘We’ll get you stabilized. We’ll hook you up with someone on the outside to help you with treatment. We’ll even give you a ride to your first appointment,’ ” Gepner says. Continuity of treatment is crucial because former inmates face an extremely high risk of overdose death after release.
But Gepner acknowledges there’s only so much he and his team can do during a brief window of incarceration. In most cases, it doesn’t come close to addressing the complex tangle of circumstances that contribute to addiction, from trauma and mental illness to poverty and homelessness.
Some experts worry the pendulum is swinging too far toward medication as a quick fix and away from more holistic treatment, including counseling.
Dr. Kenneth Stoller, who directs the Johns Hopkins Broadway Center for Addiction in Baltimore, says treatment narrowly focused on medication could sell patients short. In his program, buprenorphine and other meds are part of a comprehensive package that includes helping patients find housing, connect with psychiatric care and work on skills such as parenting.
The program’s therapists provide individualized care and aren’t afraid to “push and pull” patients past obstacles to help them achieve their goals, he says — something medication-first clinics shy away from.
“I worry that the system will eventually see treatment as equivalent to providing medication,” he says. “And that the result will be that patients get fewer resources than they deserve, and that their outcomes will be suboptimal and that providers and society will in turn blame the patient.”
EVEN AT LOW-BARRIER clinics, patients aren’t just given a prescription and left to fend for themselves. Nurse-managers provide moral support and talk through issues from the medication itself to other aspects of their clients’ lives. Staff members help patients explore housing options and connect with social services and more intensive counseling. At the STEP clinic (Support, Treatment, Engagement, and Pride), in Seattle’s Central District, some staff members are themselves in recovery, which helps them empathize and understand what clients need, says medical director Dr. Eliza Hutchinson, of Country Doctor Community Health Centers.
The clinic is tucked in a corner of the Hepatitis Education Project’s syringe service, where people can pick up clean needles, toothbrushes, socks — and now, if they qualify, a Suboxone prescription.
Hutchinson started the program primarily to reach those who aren’t able to navigate the maze of conventional medicine because their lives are upended by drug use and other complications, from lack of housing to mental illness.
“We tend to see folks with a lot going on that makes it challenging to stabilize them,” she says.
Randy Gaspard, who is living in an apartment after several years being unsheltered, drops in often. Through his years of addiction, Gaspard, 56, was arrested repeatedly for burglary. He tried getting sober with methadone, which is more tightly regulated than bupe and requires daily clinic visits. He’d schlep across town and wait in line, only to encounter some problem that meant he had to start over.
With buprenorphine, patients get prescriptions for several days, a week or even a month, depending on their circumstances. The medication costs between $80 and $200 a month, which is covered by Medicaid, Medicare and most private insurance. Regular urine tests help ensure patients are taking their bupe, not selling it.
“I’m not saying it’s peaches and cream,” Gaspard says of the treatment. “But it’s a hell of a lot better. I’m not dope-sick all the time, and I’m not running around out there trying to find it.”
AS GASPARD WRAPS UP his visit, Alicia Burden sweeps into the clinic with cheery greetings and a stack of pizzas to share. She works as assistant manager and sometime-delivery driver at a Domino’s in the area.
Burden started using drugs as a teenager, and her addiction led her into prostitution, theft and — eventually — violence. She fatally stabbed a man who she said was attacking her, and she was sentenced to 11½ years in prison.
As her release date approached, Burden started Suboxone treatment because she feared she might relapse.
“I didn’t trust myself,” she says. “Being an addict is not just a one-time thing. It’s a forever thing.”
Nearly two years into her treatment, things are going great, she tells Hutchinson. “I’m not having any cravings. I don’t even dream about it anymore.”
Work is good, she’s in a relationship, and she and her boyfriend are talking about having a baby. While many people continue taking buprenorphine for the rest of their lives, Burden tells Hutchinson she wants to start tapering off with the goal of quitting completely.
“I just don’t want to be on anything anymore,” she says.
After the appointment, Burden, 35, stops to gather socks, syringes, lip balm, lotion and packages of the overdose prevention drug Narcan. She’ll pass them out to people who are homeless and using drugs in her University District neighborhood. She understands what they’re going through, and tries to serve as a model to show that change is possible.
“I’m always excited about everything,” she says, “because I just wake up glad to not be dead or in a coma on the streets.” She hopes some of the people she helps eventually will find their own way to recovery.
“Some people aren’t strong enough,” she says. “They’ll do it when they’re ready.”