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Opinion

Addicted to a Treatment for Addiction

April Hileman of Lebanon, Va., tried to overcome an addiction to opioids with Suboxone, which is supposed to help people wean themselves off drugs. Instead, she found herself addicted to Suboxone.Credit...Mike Belleme for The New York Times

Lebanon, Va. — LATE on Christmas night 2013, April Hileman was summoned for a drug test. She had broken the curfew imposed on her by a drug court and relapsed with the opioid pills she’d been hooked on for six years. Earlier that day, Ms. Hileman had driven to a neighbor’s house here in far southwestern Virginia to buy a handful of Suboxone pills, or “Box,” as the drug is sometimes called. After she tested positive, Judge Michael Moore of Russell County ordered her to jail, and her 3-year-old daughter spent the rest of the holidays with relatives.

Like methadone, Suboxone prevents “dopesickness” and reduces cravings, without getting you high. It is now the gold standard for opioid addicts in medication-assisted treatment, or M.A.T. A combination of the opioid buprenorphine and the anti-overdose drug naloxone, Suboxone is supposed to give addicts a chance to get their lives together before they taper off it.

But Suboxone can get you high if you inject it or snort it or take it in combination with benzodiazepines, a sometimes fatal blend. And Ms. Hileman, then 24, did all those things.

Among public health officials, the effectiveness of M.A.T. has become an article of faith; after all, treatment with buprenorphine and methadone has been found to cut opioid overdose deaths in half when compared to behavioral therapy alone, and it’s hard to argue with that. An addict treating his opioid disorder with Suboxone, many argue, is no different from a diabetic taking insulin. But increasingly, law enforcement officials — and many former addicts and their families — are lining up on the other side, arguing that Suboxone only continues the cycle of dependence and has created a black market that fuels crime.

Many judges in Virginia’s drug treatment courts are refusing to approve Suboxone treatment, especially for those who have already abused the drug. But last year the White House Office of National Drug Control Policy announced that it would not fund drug courts that cut off access to M.A.T. Judges who won’t comply will be forced to scale back or scare up additional state and county funds. And now President Obama’s proposed 2017 budget includes $1 billion for the expansion of M.A.T. What looks like a common-sense investment in Washington looks more complicated here in Appalachia, where the OxyContin “hillbilly heroin” epidemic began back in the 1990s and where opioid overdose death rates remain among the highest in the nation. These are the “Box Wars.”

The problem is the plethora of cash-only Suboxone clinics that operate without proper counseling or monitoring procedures. Oversight is crucial because drug testing alone doesn’t effectively reveal whether a participant is taking more Suboxone than prescribed.

For years Ms. Hileman had been “Box shopping”: Addict friends drove her to clinics across the Tennessee border, in Kingsport or Bristol, and paid her visit fees of $100 to $150 in exchange for six or seven Suboxone pills or films, which dissolve in the mouth. Eventually the drug court cut off her M.A.T. But even with a prison sentence of two years and nine months hanging over her head for drug-related felony thefts if she didn’t obey the drug court’s rules, she continued using and selling black-market Suboxone.

Ms. Hileman’s judge, Judge Moore, doesn’t believe in treating people who have abused Suboxone with Suboxone, instead favoring abstinence with rigorous drug counseling and testing, and near daily monitoring by drug-court probation and surveillance officers.

“I know people Suboxone has helped, but unfortunately a lot of the clinics are not forthright in trying to taper people off,” said Mark Mitchell, the Lebanon police chief and a member of Judge Moore’s drug court team.

For some clinics, losing customers means jeopardizing profits. Chief Mitchell’s town had three clinics before one was shut down in 2014 for poor record-keeping and excessive prescribing. “For a town of 3,400 people to have three Suboxone clinics?” he asked. “That’s absurd.” (While the Drug Enforcement Administration is pursuing pill mills nationwide, representatives from the agency and the United States attorney’s office in nearby Abingdon declined to comment on continuing investigations.)

In a region where Suboxone seems to have replaced coal as the economic driver, 80 percent to 90 percent of all crimes committed in Russell County are drug-related, most involving black-market Suboxone, law enforcement officials say.

When residents and law enforcement agencies point to these numbers as proof that M.A.T. isn’t working, public-health officials argue they are ignoring science. Why allow the criminal element to trump life-or-death concerns?

“Overwhelming evidence shows that Suboxone improves outcomes in people with opioid-use disorders,” said Dr. Nora Volkow, director of the National Institute on Drug Abuse. She cited a 2014 study of opioid addicts that found that after 42 months, 31.7 percent were clean and no longer on M.A.T., and 29.4 percent were also clean but still receiving M.A.T. But almost 31 percent were off treatment and back on illicit opioids. (The relapse rates for patients who don’t receive M.A.T., though, are likely worse; a 2015 study of heroin addicts who used methadone or buprenorphine found a relapse rate 50 percent lower than among patients who did not get the medication.)

“Let’s be clear,” said Dr. Andrew Kolodny, a longtime Suboxone prescriber in New York and executive director of Physicians for Responsible Opioid Prescribing. “The real crisis is the severe epidemic of opioid addiction and overdose deaths that’s devastating families across the country.”

Dr. Kolodny ranks anti-Suboxone judges like Judge Moore in a category with climate-change deniers and people who believe vaccines cause autism. “When there’s really dangerous heroin on the streets, I’d rather see Suboxone out there, even if it is being prescribed irresponsibly or is being sold by drug dealers,” he said.

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In Lebanon VA., High Power is one of the better Suboxone clinics there.Credit...Mike Belleme for The New York Times

I’ve encountered zero climate-change deniers among the M.A.T. critics I’ve interviewed. Rather, I found police officers routinely putting in unpaid overtime and probation officers called to work on Christmas Day. Judge Moore himself serves Thursday night dinners to addicts — including Ms. Hileman — who meet in the basement of his church.

Ms. Hileman, now 26, insists that quitting Suboxone saved her life. The last time she relapsed, in September 2014, her probation officer sent her back to jail after she tried to fake a drug test by hiding her daughter’s urine in her jeans. Now she works two jobs, has regained custody of her daughter and moved to another town, away from her old drug crowd.

Others are not so lucky. In heroin-inundated Roanoke, where I live, I first ran into the Box Wars last year, while driving a 26-year-old heroin addict whom I’ll call Erica to weekly recovery meetings. I tracked her ups and downs, and walked her baby around in the back of the room when he got fussy.

She was arrested on suspicion of stealing plumbing equipment from Lowe’s with the intention of pawning it to buy heroin. At the local jail, she was so strung out she had no idea that she was five months pregnant until a sheriff’s deputy handed her a prenatal vitamin after a routine pregnancy screen. She delivered a healthy, opiate-free baby while in treatment, and started attending a Narcotics Anonymous meeting led by Vinnie Dabney, a recovering heroin addict who also leads Suboxone support groups.

“If you’re a regular opioid user, and you decide you want to stop, Suboxone can be a bridge that allows you to get where you want to be,” he said. “But if you stop on the bridge and get stuck there, it’s not so good.”

Will Erica get stuck on the bridge, or cross to the other side?

She recently stopped going to meetings and returning my calls. “Too tired, falling asleep,” she texted me one Saturday before I was to drive her to an N.A. meeting.

She denied that she had relapsed. “I think she’s gone back to using, but she won’t admit it, ” her mother told me. “I found papers in the bathroom, like what heroin comes in.” She added, “And she went through her brother’s room and stole his clothes — that’s what addicts do.” A judge recently decided to transfer custody of Erica’s baby to his grandmothers.

While Erica’s mother was initially hopeful about her daughter’s use of M.A.T., she was unable to secure appointments with a doctor who monitored its use rigorously and accepted insurance. (The ones who did had waiting lists, having reached their federally mandated 100-patient cap.) “Lots of money to be made for suppliers, doctors and medication,” her mother said. “The only addicts I have met who are still successful in recovery are addicts that chose to bite the bullet and detox.”

My friend Jamie, whose two sons are recovering heroin addicts who had also abused Suboxone, was equally conflicted. Her younger son claimed he had figured out how to separate the opiate from the naloxone inhibitor, injecting pure buprenorphine to get high, until he “decided it was more productive to sell it on the street for $25 and buy a cheaper bag of heroin instead,” she told me.

He finally got clean without M.A.T., but only after long stints in inpatient rehab centers at a total cost of about $60,000.

IN Tazewell County, the jurisdiction neighboring Judge Moore’s, I spoke to Jack Hurley Jr., a Circuit Court judge who is chairman of the operations committee for the statewide drug court advisory committee. He allows Suboxone when the court psychiatrist recommends it, which is for about 35 percent of participants. Among the 16 on his docket: a 48-year-old disabled coal miner who abused opiate pills for a decade, is not on Suboxone and is thriving, finally, after several relapses; and a 26-year-old mother who for six years abused opioid pills, including black-market Suboxone, and now takes 10 milligrams of prescribed Suboxone a day and has not relapsed.

Though he’s had a handful graduate after being weaned off Suboxone, many don’t, and those inconsistencies weigh on him. And yet he’s counted 13 drug-free babies born while he has run Tazewell’s drug court, several to mothers on M.A.T. (Like Erica, they took a drug called Subutex because Suboxone is not recommended for pregnant women.) “How do you put a price on that?” he asked.

Judge Hurley invited me to sit in on a recent open drug court session. The last to report was the newest participant, a 37-year-old man who showed the judge an 11-inch scar on his arm from decades of injecting crushed-up opioids. Though he’d taken prescribed Suboxone during a nine-day detox, he did not have a prescription for M.A.T. and swore he had not taken any drugs since.

“I have a big question: How clean are you going to be today?” Judge Hurley asked.

“Should be nothing,” the man said.

Minutes later, the bailiff returned with the results from his test: positive for Suboxone.

“Well, he’s going to spend the night,” Judge Hurley said. “Let him out in the morning. And tell him not to look me in the eye and lie again.”

Judge Hurley shook his head. He has known the man’s family for 20 years.

“Is it right to put him on the drug he wants to be on?” he asked.

But if the court psychiatrist recommended it, Judge Hurley said he would allow the man the use of M.A.T.

Beth Macy is the author of “Factory Man: How One Furniture Maker Battled Offshoring, Stayed Local — and Helped Save an American Town.”

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A version of this article appears in print on  , Section SR, Page 4 of the New York edition with the headline: Addicted to a Treatment for Addiction. Order Reprints | Today’s Paper | Subscribe

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