MURFREESBORO, Tenn. -- Just past a cemetery along a country road, an addiction treatment center called JourneyPure at the River draws hundreds of patients a month who are addicted to opioids and other drugs.
They divide their days among therapy sessions, songwriting, communing with horses and climbing through a treetop ropes course. After dinner, they're driven into town in white vans for 12-step meetings.
It is a common regimen at residential treatment programs, but as the opioid epidemic persists, JourneyPure is evolving. Though its website doesn't mention it, the company is ramping up its use of medications to blunt the torturous withdrawal symptoms and cravings that compel many with opioid addiction to keep using.
There is substantial evidence backing this approach, which is supposed to be used in tandem with therapy. But because two of the three federally approved medicines are opioids themselves, it is spurned by people who believe taking drugs to quit drugs is not real recovery.
Addiction experts say such resistance is obstructing efforts to reduce overdose deaths and help Americans with addictions get their lives back on track. Two-thirds of the patients admitted to JourneyPure's program over the past three months said it wasn't their first time in treatment.
"I'm watching the dominoes fall on our industry," said David Perez, JourneyPure at the River's new chief executive, who has helped lead the push toward using more medication-assisted treatment. "People are dying, and we are feeling more and more impotent to stop it. That is what's shifting beliefs, more than anything."
At the same time, the federal view on medication-assisted treatment has evolved. Tom Price, President Donald Trump's first Health and Human Services secretary, appalled many addiction experts by saying, "If we're just substituting one opioid for another, we're not moving the dial much." But Price's successor, Alex Azar, a former pharmaceutical executive, has embraced the approach.
When the administration announced $1 billion in new grants to expand access to treatment earlier this year, it emphasized that only programs that made these medicines available were eligible.
More than 70,000 people in the United States died of overdoses in 2017, and opioids were the main driver. But nationally, 49 percent of the nearly 3,000 residential programs that treat opioid addiction still don't use any of the medications proved to save lives. Even so, that is an improvement over 2016, when 58 percent weren't using any of them.
The strong evidence for medication-assisted treatment has yet to win over not only many treatment providers, but patients themselves. Heather Ramsey, 30, who is six months pregnant, was prescribed one of the medications, buprenorphine, at JourneyPure. Addicted to pain pills and Xanax for half her life, she had finally sought treatment because, she said, "My body can't take it no more."
Despite her doctor's assurances that medication was the safest, surest protocol for her, Ramsey, from rural east Tennessee, feels guilty about it.
"I feel like I'm kind of, in a sense, cheating the program," she said after a group meeting with a recovery coach. "Because I'm still depending on a substance to make me feel normal, and that's not why I came here."
Anti-craving medications are not a silver bullet; relapse is common even among people who take them, and some in fact do better with an abstinence approach. But there is substantial evidence that buprenorphine and a similar drug, methadone -- which has faced ideological resistance for decades -- reduce the mortality rate among people addicted to opioids by half or more; they are also more successful at keeping people in treatment than abstinence-based approaches.
A federally funded study last year found that naltrexone, a non-opioid medication known by the brand name Vivitrol, was just as effective as buprenorphine.
Insurers are starting to pressure providers to use medication-assisted treatment.
"It's really the linchpin of our strategy going forward -- I can't overemphasize that," said Daniel Knecht, vice president of clinical strategy and policy at Aetna. "But too often you have to convince the caregivers, as well as the patients, that [medication-assisted treatment] is the cornerstone."
Sam MacMaster, JourneyPure's co-founder and chief clinical officer, is among the wary. He acknowledges the power of medication to "stop the chaos" that envelops the lives of people with addictions, but worries it will squeeze out therapies that help them learn "how to connect, attach to other people and healthy things."
"My fear is we are heading in the direction where it's enough; that there's a wholly pharmaceutical solution to addiction."
In Tennessee -- where overdose deaths rose by 9 percent in 2017, to 1,776, the highest number on record -- the state did little to promote medications for addiction treatment until recently. Over the past year, though, it has started doling out federal funds for expanding medication-assisted treatment to 15 nonprofit programs around the state.
Because they're not eligible for government grants, for-profit companies like JourneyPure don't face as much pressure to embrace medication-assisted treatment. They are regulated through a state licensing process, but Tennessee, like most states, doesn't require medication to be part of their treatment protocol for opioid addiction.
Accrediting bodies like the Commission on Accreditation of Rehabilitation Facilities also do not require medication in treatment, although the commission has started requiring programs to help patients access medication if they want it.
"We should make it the standard in terms of running a treatment program that's licensed by a state in the 21st century," said Michael Botticelli, who directed the White House Office of National Drug Control Policy under President Barack Obama and now leads the Grayken Center for Addiction at Boston Medical Center.
A Section on 12/30/2018