Categories
Recovery

Ya Either Quit or Ya Don’t — Redefining “Recovery”

I grew up with a super-problematic drug user of a mother. For her, someone who couldn’t ever use drugs responsibly, being in “recovery” meant not using drugs.

For most of us, however, using drugs without going completely overboard is possible. And, even though I’ve also proven myself to be a long-term, often-problematic drug user, I consider myself to be “in recovery” even though I still use drugs.

Due to mounting drug-related legal issues, I turned to medication-assisted treatment — a.k.a. Suboxone — in September 2019. My reason for seeking an alternative to illicit opioids was strictly legal in nature — I was tired of the legal consequences associated with drugs and drug paraphernalia like syringes.

Although I only used illicit opioids once in my first two months of medication-assisted treatment (MAT), I eventually returned to using heroin and diverted prescription pain pills more often. Since January or so, I’ve been reducing my illicit opioid use and the resulting problems that often follow my drug use; I’ve also improved my life in various other ways, such as cleaning my house and brushing my teeth more often.

But, still, most of modern America wouldn’t consider me as being “in recovery.”

What’s the deal? Why can’t we consider this ongoing transition I’m going through as being “in recovery”? And, even if I don’t end up quitting drugs in the long run, we should still consider this change I’m currently going through as being just that — recovery.

Changing What Recovery Means

My purpose here is to ultimately attract more long-term, often-problematic drug users and their less-problematic counterparts into bettering their lives, specifically by decreasing their drug use and any resulting drug-related problems.

I think we can go about doing this in several ways. Here are some ideas I’ve got.

Note: Even if you don’t think some or all of these ideas hold water, I hope you agree that we should, in fact, want to actively change the definition of being “in recovery” from drug addiction or otherwise-problematic drug use.

Addiction Treatment Outfits Shouldn’t Require Patients to Have Substance Use Disorder

The modern addiction recovery industry excludes countless people who don’t fit the diagnostic criteria for substance use disorder; they haven’t gone to jail multiple times, soiled and severed relationships with family and friends, or turned to morally-questionable means of making money.

Though I’m just an MAT program enrollee, not a provider, I understand that Suboxone programs and methadone clinics across the Volunteer State can only treat people who have opioid use disorder or are dependent on opioids. This might not be true — the state’s opioid treatment program (OTP) and office-based opioid treatment facilities (OBOT) guidelines can be found but are difficult to read through; also, since I’m not a provider, I don’t have any real-world experience with state or federal regulatory agencies and their enforcement of such guidelines. However, generally speaking, MAT programs don’t accept people unless they meet the diagnostic criteria for opioid use disorder — and, yes, they treat people with alcohol use disorder, though, since I’ve got no experience with alcohol addiction treatment, I don’t want to speak on the issue.

What if Suboxone and methadone clinics accepted patients who didn’t have substance use disorder? And, more importantly, what if they still allowed patients to test positive for other drugs without potentially being fired?

Then, I wouldn’t have to worry about refrigerating “clean” urine in anticipation of drug screens. Programs wouldn’t have to waste as much money drug testing me, either, if abstaining from drugs that you’re not prescribed wasn’t a requirement — I should note that most, if not all, programs around here allow patients to test positive for THC and its metabolites, so we are able to smoke weed as an alternative to other drugs (or just smoke weed for the hell of it, for that matter).

Addiction Treatment Facilities Should Also Offer Less-Intensive Outpatient Services

Here in rural Middle and West Tennessee, the only addiction treatment outfits we’ve got are full-fledged rehabs, methadone clinics, and Suboxone programs — and I’m sure we’ve got halfway houses and sober living facilities. There might be a few facilities lingering around that don’t fit any of these five labels. Oh, and you can’t forget Narcotics Anonymous (NA), Alcoholics Anonymous (AA), and other 12-step-based programs.

All of these outfits inherently support complete abstinence from drugs — yeah, Suboxone (buprenorphine) and methadone are both very much “drugs,” but usually aren’t “abused” with the intention of getting high — and don’t have much lenience for being “in-between,” like I am right now.

Also, I think addiction treatment providers — which can include plain-Jane mental health practices, as counseling proves helpful to many former often-problematic drug users — should offer less-intensive services that provide an added sense of structure in patients’ or clients’ lives. An example of this could be life planning.

And, yes, I recognize that this section doesn’t include many concrete, well-defined examples of “less-intensive outpatient services.” I usually don’t like writing about things unless I offer concrete, well-defined recommendations for fixing the problems I point out. However, simply sparking the conversation about redefining recovery is my primary goal here — and that’s something you can help me with.

I’m Asking You for Help

Even if you’re not involved with any addiction treatment outfits or drug user-oriented organizations, I encourage you to take to social media and ask people who are in recovery, involved in addiction treatment circles, or otherwise interested in or active with any drug-related entities to reconsider what “recovery” means. You don’t have to share this article with them — it’d be great if you did, but it’s most certainly not necessary.

Categories
Drug User Advocacy From Personal Experience Recovery

Pharmacy Hopping — A Nearly-Unavoidable Reality

Alright. So, I’m prescribed Suboxone® and a stimulant. Won’t say which one, but you could guess its name and probably be right.

Tuesday, I checked in for my weekly visit at the MAT program I’m going to — fortunately, they let me talk to the counselor (not that I’m interested in counseling in the slightest right now… it’s a requirement) and the doctor over the phone. I did have to drop off my urine, though. Love pissing in cups. Fucking love it.

So, they sent my Suboxone RX to the pharmacy — keep in mind both the clinic and the pharmacy are over an hour away from home — and I stroll over to the pharmacy. They say it’ll be 30 minutes.

I wait.

And wait.

I go back to the pharmacy, they say THEY DON’T HAVE ANY GOD DAMN SUBOXONE®!

Okay, whatever. They say they’d get some Thursday.

Guess what? It’s Thursday! AND THEY SAY THEY WON’T HAVE ANY GOD DAMN SUBOXONE® UNTIL SATURDAY!

Okay, whatever. I’m used to the bullshit at this point.

This pharmacy is the only one I know — mind you, I’ve tried nine different pharmacies in the area at this point — that will take discount cards. And, no, I don’t have insurance.

Luckily for me, I don’t take as much Suboxone® as I’m prescribed. Luckily for me, I lie to my doctor and say I take more than I actually do. Just so I can avoid bullshit like this — if I hadn’t been saving up meds, I’d be in brutal withdrawal right now. Fun. Oh so fun.

So, now I’m going to a different pharmacy that’s an hour away — it’s in the same area the first preferred pharmacy is, for the record — to get my Suboxone filled without a discount card.

But wait — they don’t have the stimulant in stock until tomorrow.

Aren’t We Supposed to Avoid Pharmacy Hopping?

Yeah. Pharmacy hopping is what gets us in trouble. It’s what gets us on the radar. It’s what gives us “druggies” a bad name.

But that’s what I’m forced to do today — pharmacy hopping. Oh, the joys of being a dopehead. But, this is what I signed up for.

Categories
Drug User Advocacy From Personal Experience Recovery

Current American Medication-Assisted Treatment Conventions Aren’t All Ideal

While medication-assisted treatment (MAT) programs across the country have reduced harm that enrollees otherwise would have experienced without enrolling, some feel that MAT hasn’t been expanded far enough throughout the United States. I can’t help but feel glad it’s legal here in Tennessee, though I also believe our current MAT system is far from ideal — I think we can all agree on that.

Refraining from future drug use would best serve my interests, as I’ve long proven myself to be an often-problematic drug user. Most people can moderate their drug use to avoid addiction and dependency, but I’m not one of those people. While I still use illicit drugs today, I’m in a much better spot now that I’ve reduced my overall intake and largely maintain myself with buprenorphine (Suboxone).

Medication for opioid use disorder (MOUD) prescribers — those are the physicians licensed to prescribe methadone or buprenorphine — are morally incentivized to not tolerate “dirty” urine drug screen results, as knowingly allowing program enrollees to continue illicit opioid use and be maintained using Suboxone could get prescribers in trouble. How would allowing a patient to “get by” with illicit opioid use reflect on a physician if the patient died of an opioid-involved overdose?

Wouldn’t be too cash money, would it?

On the other hand, I wish long-term, addicted/dependent — both in my case — opioid users could be maintained on Suboxone while still using illicit opioids. In my case, since I reduced my other-than-Suboxone opioid use big time, I’ve done myself a solid by seeking out MAT program enrollment. Before getting on Suboxone in September, I found myself in almost-entirely-mental opioid withdrawal every week for anywhere between two and four days.

This cycle got started because I’d have enough money to afford anywhere from three to five days’ worth of using opioids — I could never afford to use throughout the week without interruption — before regressing into a shell of myself until I got paid again. I lived each day during this cycle constantly tracking the time in anticipation for my next high. I wasn’t very psyched about living, either — I felt indifferent about the potential of experiencing overdose. In other words, I never once worried that life was whizzing by too quickly during the three or four years consisting entirely of my oh-so-depressing, constantly-repeating week-long cycle.

After starting Suboxone, I didn’t fiend for heroin — more like a fentanyl-heroin mixture knowing the modern American illicit opioid market — or other opioids as I used to. I also stopped contemplating an “accidental” suicide via opioid overdose. Life was better, in general.

I worry that medication-assisted treatment programs’ firing of patients who test positive for non-prescribed (often-illicit) drugs seems to stand in contradiction to the tenet of keeping patients on — or at least constantly offering them MOUD access — MOUD in favor of returning to the (often-illicit) opioid use they came from, which is typically more dangerous.

Here’s my issue: is it better for MAT programs to (1) allow enrollees to use other opioids and be maintained on Suboxone or methadone or (2) kick enrollees out after testing positive for other opioids an arbitrary one-too-many times?

I think number one is the better option. Here’s why.

What’s the Point of Medication-Assisted Treatment?

I don’t think there’s an objectively-true purpose of medication-assisted treatment. We must ask ourselves what we value most from MAT programs to formulate a worthwhile answer — only then can we hope to define the purpose of MOUD maintenance.

Here’s What I Value From MAT Programs

I think MAT program enrollees’ often-problematic opioid use should decrease as a result of their buprenorphine or methadone use — that’s one performance indicator we can use. Their exposure to risky or detrimental scenarios (i.e., visiting a high-crime area to source illicit drugs) should wane — the second metric we’ve got. And, most importantly, their quality of life should improve — albeit this third metric is considerably harder to quantify. These are the central values I want from medication-assisted treatment.

No, these are not the almighty three “values” I hope to get from MAT. You’re encouraged to pick and choose your own values — don’t just blindly follow mine!

Of course, I recognize MAT as a super-solid alternative to opioid use — and even alcohol use (naltrexone). Whether you have opioid use disorder per the DSM-5 or not, MAT can help you. Even though I didn’t have a physical dependency to opioids before I enrolled in an MAT program — I didn’t experience the same “flu-like,” for lack of a better word, opioid withdrawal symptoms that so many others do; dealing with the mental fallout of ceasing opioid use was the big issue for me, personally — Suboxone maintenance was still a good fit for me.

Again, I think medication-assisted treatment is great for dealing with opioid use disorder and otherwise-problematic opioid use.

What Does the Volunteer State Want From Medication-Assisted Treatment?

The Tennessee Department of Mental Health & Substance Abuse Services’ medication-assisted treatment page states, “The prescribed medication [Suboxone, methadone, or naltrexone] operates to normalize brain chemistry, block the euphoric effects of alcohol and opioids, relieve physiological cravings, and normalize body functions without the negative effects of the abused drug.”

While this definition outlines the physiological effects of suboxone, methadone, and naltrexone, it doesn’t address any higher-level, overall goals for people involved in medication-assisted treatment programs.

Many medication for opioid use disorder prescribers in Tennessee are weighed down by looming regulations. Some are more comfortable than others with regularly accepting “dirty” drug screens — a more-appropriate term might be “positive drug screen” — from patients without firing them. Others fear regulatory backlash if they don’t act in accordance with state guidelines, which encourage prescribers not to retain patients’ enrollment if they submit just four positive drug screens in a two-year period, among other stringent regulations.

What Does Tennessee Want From MAT Program Enrollees?

All MAT programs’ prescribers want to see patients exhibit abstinence from illicit drugs while taking their prescribed dose of buprenorphine, methadone, or naltrexone. Some programs are willing to let regular cannabis use slide, though not anything more than that. Programs also aren’t cool with alcohol use, either.

Due to pressure from the state, however, prescribers often are constrained to appease the state by doing things that aren’t conducive to successful treatment outcomes.

The state’s regulations state that any enrollees who test positive for illicit drugs four times — the text actually reads, “Upon a second/third/fourth positive drug test result within six months of the first/second/third positive drug test result,” which means four positive drug test results for illicit drugs could span a 24-month period at longest — are required to “address the on-going [sic] multi-drug use through increased group and individual counseling, intensive outpatient [sic] and residential clinical treatment.” Imagine getting kicked out of a MAT program because, after pissing dirty four times in two years, you refused to go to residential inpatient clinical treatment.

The aforementioned document is 44 pages long and is packed to the brim with strict guidelines that make it difficult for prescribers to best help MAT program enrollees.

Consider This Scenario

Assume Bob is a regular illicit opioid user who lives in Tennessee. Bob has proven himself to be an often-problematic drug user, having found himself in legal, financial, familial, relational, social, mental, and physical trouble from his opioid use.

Bob solicits a medication-assisted treatment program that prescribes buprenorphine and shortly after enrolls in the MAT program.

Bob’s frequency and intensity of illicit opioid use decreases thanks to his enrollment and regular dosing of Suboxone. However, he still continues to use — just not as often or as much at once. Bob also doesn’t go on binges like he used to.

While Bob will be allowed at least one slip-up, he faces inevitable termination from the program if he continues to submit urine for drug tests that test positive for opioids. Assume that Bob maintains this pattern of use, regularly taking both illicit opioids and the Suboxone he’s prescribed.

Ask yourself — what do you think will happen if Bob is dismissed from the program? Do you think he’ll be better off enrolled in the MAT program and allowed to continue his concurrent consumption of illicit opioids and the Suboxone he’s prescribed or better off dismissed from the MAT program?

Here’s What I Think

Often-problematic drug users continuing their illicit drug use is rarely a good idea. As a long-term, often-problematic illicit opioid user myself, I’ve faced all the problems Bob has and more — I know that continuing to use opioids is a bad idea, at least for me, personally.

The most ideal outcome for Bob is to ultimately cease his illicit opioid use, if not quit the use of all drugs, opioid or not.

Would it be better for Bob, assuming that he wants to continue using illicit opioids, (A) to remain on Suboxone and use other opioids less often or (B) to be dismissed from the MAT program and use illicit opioids on a daily basis?

I think, although not ideal, (A) is the better option.

People in Bob’s shoes could be fired from MAT enrollment if they tell their prescribers that they plan on continuing illicit opioid use. In order to hide evidence of illicit opioid use, they’d have to secure “clean” urine — that which only tests positive for buprenorphine and nothing else — and sneak it in the MAT program’s facility on a regular basis.

Responsibilities of MAT Program Professionals

How responsible is my Suboxone prescriber if he’s okay with me continuing my use of illicit opioids, even though I’d still be on Suboxone and I’d be using less than before beginning Suboxone maintenance?

I don’t think it’d be responsible of him at all. What if I overdosed or another negative outcome occurred?

Is it good enough to have an MAT program enrollee reduce illicit opioid use (i.e., Bob’s scenario above) or would a MAT program physician be settling for less by allowing a patient to do so?

Even the most forward-thinking harm reductionists can see the problems with drawing the proverbial line between these two situations.

The Effects of Buprenorphine on an Opioid-Dependent Patient’s Brain

Before I got on Suboxone, I used illicit opioids as often as I could afford them. I’d be able to spend anywhere from one to four days high in a row upon getting paid. The rest of the week, I’d lay in bed unable to concentrate, nothing short of depressed, and interested in nothing more than the next time I’d be able to get high.

This pattern of use went on for at least two years, if not three or four.

What a way to live, huh?

When I got on Suboxone, I was actually able to finish Youtube videos to the end — not to mention feel joy from watching them. I felt more stable; on Suboxone, I’ve never acted like I would when I was super duper high, and, similarly, I’ve never felt as low as I used to after my binges were over — and that happened consistently… every… single… week.

Suboxone has also deterred me from using illicit opioids on several occasions because I knew I’d end up wasting my money thanks to buprenorphine’s opioid-blocking effects.

Also, although this doesn’t have anything to do with my brain, I’ve been around criminal activity much less than when I was actively using. That makes me feel better and reduces the likelihood of me being sent to jail or otherwise dealing with the criminal justice system.

Where Should We Go From Here?

Personally, I want be able to still use heroin and other illicit opioids on occasion and take Suboxone regularly without facing termination from the MAT program I’m enrolled in.

Going forward, I think patients enrolled in MAT programs should be able to use illicit opioids if they so choose without the risk of being kicked out. It’s safer for me to take Suboxone six days of the week and illicit opioids one day rather than me not use Suboxone at all and only use illicit opioids; I also feel confident that my quality of life is higher this way.

I don’t feel confident in asserting that my idea is the way to go. I certainly think what I proposed above is a good idea, but medical professionals, addiction specialists, mental health practitioners, social services workers, criminal justice system members, long-term illicit opioid users, and others need to spark up a discussion about this before we do anything. None of us know with certainty what’s best — but many of us feel we need change, and change is where we need to start.

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Harm Reduction Recovery The Volunteer State

What Do Tennessee’s Regional Overdose Prevention Specialists (ROPS) Do?

Nestled deep inside the Bible Belt, Tennessee is big on tradition and conservative values. As you might imagine, harm reduction — reducing harm done to and experienced by drug users — isn’t very big here.

Here’s a good rule of thumb — the more left-leaning a state is, the more likely existing harm reduction infrastructure can be found there (e.g., California, New York). Places like Tennessee don’t have much in place; we’ve got at least six state-recognized Syringe Services Programs, at least one county health department-run syringe disposal program, and 21 Regional Overdose Prevention Specialists (ROPS).

Billboard from the Tennessee Department of Mental Health & Substance
Tennessee billboard promoting free naloxone.

ROPS are employed by the Tennessee Department of Mental Health & Substance Abuse Services to hold regular naloxone trainings and distribute the life-saving drug. Although the Volunteer State certainly isn’t the only government to employ people acting in such roles, Tennessee is unique in its use of “Regional Overdose Prevention Specialists” as a title.

Man holding a single unit of Narcan naloxone nasal spray still in its packaging.
Man holding Narcan (naloxone) nasal spray.

The Background of ROPS

In late 2017, the Tennessee Department of Mental Health & Substance Abuse Services released its “TN Save a Life Program.” Ostensibly, this four-pronged program was rolled out due to the rash of opioid use and resulting opioid-related deaths that initially broke out some 10 to 15 years prior.

The TN Save a Life Program was designed to deal with fallout from the opioid epidemic and consists of the following components:

  • The so-called “Project ECHO,” a project with Vanderbilt University touting the end goal of helping clinics, hospitals, and emergency rooms beef up access to medication-assisted treatment programs, a.k.a. opioid replacement therapy, through the provision of telemedicine services.
  • The creation of “regionally-specific resource guides.”
  • The staffing of 20 “Regional Overdose Prevention Specialists” throughout 13 regions within the Volunteer State. These people hailed from a variety of backgrounds, including “recovery, paramedics, and Certified Peer Recovery Specialists,” taken directly from the DMHSAS’s website. Now, there are 21 ROPS.
  • A state-wide media campaign.

Who Do ROPS Serve?

This comes from the same website mentioned above: ROPS primarily tend to first responders, entities that provide treatment and recovery services or community-oriented resources, and people considered at risk of overdose — including their family members and friends.

These aren’t the only beneficiaries of ROPS — “all interested community members” can be trained in responding to opioid overdose with naloxone.

Regional Overdose Prevention Specialists hold training sessions across the region they’re assigned to. There are 13 regions in terms of ROPS distribution. Northwest Tennessee, a nine-county area home to 254,000 people, is labeled Region 6N.

What Do Trainings Consist of?

Just as there are three primary audiences, there are three main topics that ROPS’ training events cover:

  • Raising public awareness for facts about the opioid crisis and the trends that currently define it, how addition works, and best practices for administering naloxone.
  • Attempting to nip drug-related stigma in the bud.
  • Spreading knowledge of harm reduction, why it’s important, and defining what the practice consists of.

A Real-World Example of a Regional Overdose Prevention Specialist

Melesa Lassiter, Region 6N's Regional Overdose Prevention Specialist, running a naloxone training seminar in Humboldt, Gibson County, Tennessee.
Melesa Lassiter holding a naloxone training event in Humboldt, Tennessee, on Oct. 2, 2018.

Melesa Lassiter has served as Region 6N’s Regional Overdose Prevention Specialist since Oct. 2017. She’s part of the Weakley County Prevention Coalition (WCPC), which oversees her role as ROPS.

Although WCPC engages in prevention-based drug use efforts, thanks to Ms. Lassiter’s status as ROPS, she stands out as one of the only prevention coalition employees in Northwest Tennessee to be active in harm reduction — even though naloxone distribution is the lowest-hanging fruit on the harm reduction tree, we very well can consider it “harm reduction.”

Via a local public housing authority office, Martin Housing Authority, name-brand Narcan is made available for pickup. She also holds naloxone training events, including specialized sessions designed just for law enforcement, among other intended audiences.

By no means are these all the things ROPS engage in, though everything mentioned here collectively acts as the meat-and-potatoes of their job duties. What each individual Regional Overdose Prevention Specialist does will vary based on the organizations that oversee their duties for the state.

Ms. Lassiter, for example, may be more likely than the average ROPS to carry out prevention-based programming at local schools — such messaging is a major focus of local prevention coalitions like Weakley County Prevention Coalition.

In Full Disclosure — Do ROPS Fall Short of Their Intended Goals?

Regional Overdose Prevention Specialists, due to the town hall-style nature of their trainings, often fail to reach the most disadvantaged regular drug users (e.g., injection opioid users). This isn’t to say they completely fail to train these people or meet them where they’re at with naloxone, though. As ROPS continue to make a name for themselves across the Volunteer State, more injection opioid users, for example, will come to perceive these state-sanctioned harm reductionists as legitimate and worthwhile.

Much like anywhere, people here — especially long-term, often-problematic drug users like me — exhibit discretion in assessing new or otherwise-too-good-to-be-true opportunities. I think the average level of discretion exhibited by the most disadvantaged drug user here in Northwest Tennessee is higher than average, nationally-speaking, that is.

People can be surprisingly unwilling to open themselves up to offers of free safe drug use supplies. One time, I visited an area of West Tennessee that was populated by a relative fuckton of people experiencing homelessness to have my help refused by all but one person despite the fact I shot heroin in front of them!

Here in Northwest Tennessee, for example, the overwhelming majority of locals who’ve received syringes, naloxone, and other harm reduction supplies from me weren’t aware of ROPS when I first met them — since then, little has changed.

The most disadvantaged people who use drugs — those who are cordoned off from society — are unlikely to trust opportunities like opioid overdose response training or free naloxone because people here aren’t used to having others provide them safe drug use supplies.

To reach these objectively-worse-off, often-problematic drug users is by continuing to advocate for harm reduction and the fair treatment of drug users.

In places like rural West and Middle Tennessee, where there’s little interest in drug user advocacy, activating drug users, illicit drug retailers, and laypeople alike as grassroots harm reductionists is arguably our best tool.

In Closing

All considered, Regional Overdose Prevention Specialists are a valuable resource in improving the treatment of drug users. Although they only pluck the harm reduction tree’s lowest-hanging fruit — naloxone distribution and training — I think we’ll look back at ROPS as being pioneers of modern-day harm reduction here in the Volunteer State.

Categories
From Personal Experience Recovery The Volunteer State

Suboxone Is Too Difficult to Get

We’re in the midst of an opioid epidemic here in the United States. It’s worse here in Northwest Tennessee than most places across the country — not the worst, but it’s certainly not great.

There are a few central reasons why opioid use here is so likely to result in overdose, if not death. First off, the lack of regulation in the market means batches of opioids can’t be screened for contents or purity. Put simply, opioid users, like me, don’t know what we’re using.

Second, there’s a lack of resources necessary to healthy, fulfilling lives here in rural Tennessee. Many of us struggle to even find transportation to get to mental health practitioners or physicians, let alone pay for them in the first place.

Third, although this fits into the “resources” problem mentioned above, it’s difficult for long-term, dependent opioid users to seek out and secure opioid replacement treatment, also called medication-assisted treatment (MAT), in the form of buprenorphine (Suboxone, Subutex) or methadone.

A Personal Aside

I am a long-term drug user. Opioids have been by primary drug of choice since, give or take a month, June 2014. Not for pain — just ‘cause they’re hella fun. #ItsLit

But seriously, drug use isn’t cool. #ItsNotLit I self-medicated depression and anxiety with opioids before opioid dependency caused — well, worsened is the proper term — mental health issues on its own accord.

I began injecting heroin about two, maybe two-and-a-half or three years ago. I first snorted heroin for a few months or a year prior to graduating to injection drug use. I moved from street-sourced pharmaceutical opioid tablets to heroin, and later from sniffing heroin to injecting the drug, for cost’s sake.

Earlier this year, after an arrest, I was tired of the legal issues associated with illicit drug use. Thus, I sought out treatment at a buprenorphine prescriber in Jackson. I went as far as Jackson, an hour or more away from me, because there aren’t many prescribers in Northwest Tennessee. More on that below.

Things That Make It Difficult for Opioid Users to Get on Suboxone or Methadone

This article solely focuses on the area-specific challenges that plague long-term illicit opioid users such as myself here in Northwest Tennessee, though these issues aren’t just specific to Northwest Tennessee — they’re rampant all over rural Tennessee, if not the entirety of the state.

Due to the fact that the federal government upholds excessive regulation around buprenorphine prescribing, these things also hold true throughout the United States.

Cost

I’m not particularly a fan of airing my personal information out into the ether, but I want everyone to know just how expensive Suboxone really is.

The prescriber I go to charges $275 monthly for just one visit. The physician prescribes 28 days’ worth of Suboxone for that price. If you go weekly, it’s $100 per week. Everybody at this clinic has to start off going weekly for at least 6 weeks.

These excessive costs make it difficult for people to get their foot in the door — and $275 isn’t on the higher end, either; once people do gain entry to medication-assisted treatment programs, they’re still going to get their heads busted by facilities that specialize in opioid replacement therapy.

56 generic Suboxone films cost $388 at the pharmacy I go to. They don’t take discount cards. I don’t have insurance. None of the 11 health insurance plans I was offered by Healthcare.gov this year covered Suboxone.

Right now, it costs $663 per 28 days. It initially set me back $788 per 28 days.

Like, fuck — might as well stick to heroin!

Pharmacies Aren’t Willing to Fill

Pharmacies don’t like filling prescriptions for controlled substances.

Especially for Suboxone.

The idea is that people on Suboxone and other controlled substances are more likely to abuse their medications than run-of-the-mill medications and pester pharmacies for early fills and cause a scene.

Is this true? No idea. On the surface level, I totally understand the merits behind this ideology. Is it right? No.

The pharmacy I use is an hour away from my house. It’s a small mom-and-pop pharmacy that doesn’t take discount cards. I’m forced to pay cash. At least I get treated like a human, though.

I tried to fill at Walgreens in that city, but they said since I didn’t live there, they weren’t willing to fill. My prescriber is a quarter-mile — a five-minute walk — away from that Walgreens. Whatever.

I tried to fill at a CVS where I live, but the pharmacist said they were at capacity for buprenorphine prescriptions, meaning they couldn’t welcome any more. That’s a lie. There’s no such thing as an upper limit of Suboxone prescriptions — or any prescriptions — that a pharmacy can fill. Whatever.

I tried Walmart. They said they’re not licensed to dispense buprenorphine. That’s a lie. “While qualified practitioners are required to have waivers to prescribe or dispense buprenorphine under the Drug Addiction Treatment Act of 2000 (DATA 2000), pharmacists and pharmacies are not required to have any credentials for dispensing these medications beyond those for other Schedule III medications,” SAMHSA’s official website says. Whatever.

I tried the closest Walgreens to where I live. They don’t stock buprenorphine. Whatever.

Is it their responsibility to fill my prescription? Not at all. I shouldn’t have gotten myself into this situation in the first place. I should eschew drug use in favor of a better life.

All long-term opioid users should do the same — stop using drugs — unless given a prescription for chronic pain or something. However, this doesn’t work, in practice.

SAMHSA Limits the Number of Prescribers Who Can Legally Prescribe Suboxone

I’m not going into the specific limitations that SAMHSA, the Substance Abuse and Mental Health Service Administration, places on buprenorphine prescribers.

Just know that there’s a reason why less than 4% of all licensed physicians in the United States are able to prescribe Suboxone to chronic, dependent opioid users. That reason is SAMHSA.

Yeah, I get it — what if doctors started misprescribing Suboxone? I get it.

However, one thing’s for sure: not helping the already-underserved populations of people suffering from opioid use disorder by making buprenorphine and methadone, the two go-to opioid replacement drugs, widely available harms us. Family members, friends, and communities lose people to the opioid epidemic left and right, especially in rural Tennessee.

Statistics About This Lack of Prescribers

In the nine-county area that makes up Northwest Tennessee, there are about 254,000 people. There are only 19 buprenorphine prescribers licensed to prescribe Suboxone or Subutex for opioid use disorder.

Fucking awesome.

The United States Department of Health and Human Services designates certain parts of the United States as “federal shortage areas,” which, obviously, have shortages of health professionals based on various criteria.

7 of NWTN’s 9 counties have medically underserved populations (MUP) in terms of primary care physicians. The other 2 are medically underserved areas (MUA). MUA refers to the entire county’s geographic area, whereas MUP refers to the people in the area. To make it simple, all of the counties here don’t have enough doctors.

9 of NWTN’s 9 counties are considered to have a shortage of federal mental health professionals and are deemed “Whole County Geographic” shortages. That means no matter where you live in NWTN, the entirety of this region has a shortage of federal mental health professionals.

What You Can Take Away From This

Suboxone and Subutex both contain buprenorphine, a long-lasting, relatively safe opioid that satisfies long-term, physically-dependent opioid users’ brains’ opioid receptors. That means no withdrawal symptoms, physical or mental.

When I didn’t have opioids over the past 3+ years, when my opioid use really started to progress, I laid around, did next to nothing, and my depression and anxiety symptoms worsened.

Now, since I started Suboxone in mid-September, I haven’t felt depressed at all. I don’t have to worry about overdosing because I don’t use heroin. I don’t have to worry about the legal issues associated with illicit drug use.

Other long-term opioid users largely report the same: their mental health improves and stabilizes, they don’t have to live highly-dangerous lifestyles with short life expectancies, and they don’t have to worry about the legal issues arising from daily drug use.

We need to make buprenorphine and methadone more widely available. The single most effective means of doing this would be severely loosening the existing regulations supported by SAMHSA.

As more practitioners could prescribe buprenorphine, the cost of getting a Suboxone prescription would decrease big time. Filling the prescription would still cost a lot, but as demand for Suboxone increases and stigma associated with Suboxone users decreases — a direct result of loosening government regulation on buprenorphine prescribing — I feel that costs incurred by end-users of Suboxone would drop.