PORTLAND — When he was a boy, Andrew Kiezulas did not like going to the doctor.
“I would run from the doctor’s office, I hated needles,” Kiezulas, 33, said Feb. 5, during at gathering at the Portland Community Recovery Center at 468 Forest Ave.
But even if he never grew to like needles, he did grow to use them as a heroin addict.
Law enforcement and public health officials in greater Portland have said opioid use and addiction, especially with heroin, is increasing, based on overdose calls, the number of administrations of Narcan, which blocks the effects of opioids, and how much heroin is being seized.
Addiction treatment is a complex picture that starts with an addict seeking sobriety. It also requires a strong support system and medicines to stanch cravings and withdrawal.
But doctors, counselors and officials leading the recovery efforts now worry about policy changes that could make sobriety and recovery all the more elusive.
Kiezulas, now leading the Maine chapter of Youth in Recovery, has been sober for more than two years and is studying chemistry and math at the University of Southern Maine.
He is also helping PRCC Director Steve Croteau and peer coach Ben Skillings of Amistad, a city-based agency providing mental-health services and programs, by providing peer support to addicts hospitalized because of overdoses.
“It is probably the time when they are the most vulnerable and the window is open,” Skillings said.
Even if only to say hello and show what is possible, or to help with referrals and encouragement if an addict is ready to try sobriety, Croteau said the peer visits are important.
“We have been losing people way too much,” he said. “It just pisses me off and makes me so scared, I want to do more.”
Croteau wants to end the perception of heroin or opioid addicts as societal outcasts who cannot or will not save themselves.
“Nobody starts out thinking, I’m going to shoot up. You get there so gradually,” he said. “My goal is to have as many people in the public as possible understand these are good, kind contributing kids who have made horrible decisions. It is not who they are right now.”
Skillings, Kiezulas and PRCC peer support supervisor Niki Curtis said ending up in the hospital once may not be enough to deter an addict from future use, and a decision to stop using may not be triggered by a single event; it may take several accumulated episodes.
Curtis said peer outreach would have helped when she woke up in the hospital.
“They knew I was in there because of my drug problem,” Curtis said. “What if somebody had come in and said ‘I know what you are going through’?”
While asking for help may be tough, getting it can be more of a challenge for opioid addicts, and will likely require an “opioid maintenance therapy” of methadone or suboxone.
“Nobody wants to be an addict, most are looking for a way out,” said Caroline Teschke, clinical programs director at the India Street Public Health Center. “We need to focus on more opportunities to get people into treatment.”
At Mid Coast Hospital in Brunswick, Dr. David Moltz, medical director of outpatient behavioral health, said the hospital treats about 300 opioid-addicted patients, almost triple the number treated in 2010.
“It is our experience that the path patients take to recovery most often includes a medication that works to control their withdrawal symptoms, a counselor or group that provides support and education about addiction and how to manage it, a supportive family member or friend, and for most, 12-step program participation,” Moltz said.
The medications most used are methadone and suboxone, which can be eliminated, over time.
“Both work to relieve opioid withdrawal and craving, but they have different mechanisms, and each has strengths and weaknesses,” Moltz said.
He said methadone is a “full agonist, it works like other opioids on opiate receptors in the brain. The higher the dose, the more the effect. This means that it will work for any degree of addiction.”
Buprenorphine, the active ingredient in suboxone, is a “partial agonist.”
“This means that it attaches to the opiate receptor, but it stimulates it only partially, enough to avoid withdrawal and craving, but not enough to cause intoxication,” he said.
In his Feb. 3 State of the State address, Gov. Paul LePage vowed to provide more law enforcement tools for drug prosecution and interdiction, but a proposed shift in MaineCare reimbursements could threaten addiction recovery efforts.
“More Mainers are dying from drug overdoses than traffic deaths. Too many babies are being born addicted to drugs. … We cannot allow vicious, out-of-state drug traffickers to use Maine as their marketplace. My plan will hunt down these criminals and hold them accountable,” LePage said.
The state Department of Health and Human Services plans to end MaineCare outpatient reimbursements for methadone treatments.
A press release from DHHS spokesman David Sorensen said department research shows suboxone to be as effective an opioid maintenance therapy as methadone, with less risk of overdose.
Sorensen said the shift to suboxone prescribed by primary-care physicians instead of methadone dispensed at clinics will allow doctors to better treat other medical conditions common to substance abuse.
There are 119 suboxone providers who report to the DHHS, Sorensen said.
Moltz has his doubts of the effectiveness of the plan.
“Only a small subgroup of patients can be effectively treated by primary care, without the intensive psychosocial treatment that is provided in a comprehensive program, and programs in the state do not have the capacity to accommodate the increase that would occur,” he said.
The state currently spends $8 million for methadone reimbursements, and Sorensen said shifting at least 80 percent of methadone users to suboxone would save $4.2 million in state and federal funding in the next two years.
Moltz said methadone programs should still play a role in treatment.
“By law, methadone can only be dispensed in a program which generally requires daily attendance. This means much closer monitoring and control than a monthly prescription in a busy doctor’s office,” he said.
Reimbursements for methadone and suboxone treatments are capped at two years unless a prior authorization is granted.
Capping MaineCare reimbursements upsets Croteau, and Chris Corson, the substance abuse prevention coordinator who oversees the Portland Overdose Prevention Project.
“I am personally involved,” Croteau said Feb. 4. “I don’t think it is OK at any cost to be all right with the kids overdosing and dying. It would be like putting limits on cancer treatments.”
Corson compared the cap to telling diabetics they can only get two years of insulin treatments.
“Time frames for things to go away, we don’t do that,” he said.
Curtis said suboxone did help her, but can be abused as surely as methadone.
“It was a crucial stepping stone that helped me while I was learning more about my disease. But I absolutely did abuse it,” Curtis said.
The required permitting to prescribe suboxone can also make it hard to find a physician willing to work with it. Curtis, a Presque Isle native, said there was one doctor in her area who prescribed suboxone, and he was in demand.
“I don’t think he was prepared for the level of dishonesty he was going to see,” she said.
Last month, seven people were arrested on charges of smuggling suboxone strips into the Maine State Prison in Warren. The suboxone was allegedly purchased out of state and shipped to Mid-Coast residents who then sent the strips to a prisoner in greeting cards. According to the Bangor Daily News, a strip costing $5 could sell for $400 in the prison.
Cumberland County Sheriff Kevin Joyce said he has seen the same method used in jail smuggling.
Interdicting incoming drugs is one thing, but Corson said getting more support and guidance to prisoners who are being released is a necessary recovery step. The county jail does not offer treatment beyond detox protocols, because stays are often too short for treatment to take hold. Yet an inmate who has been drug free for a stay is among the most vulnerable to an overdose if they start using upon release.
Curtis said she became sober when she realized the effects of her addiction on her family.
“It was the broken relationship that was going to happen with my son,” she said. “I lied to him and I saw the reflection in his eyes. I was fearful he would stop loving me.”
Kiezulas was hospitalized at least twice, including to treat gall stones that were gangrenous. In one stay, he watched a man in the next bed refuse pain medications while being treated for hernias.
“I found out later he was four months sober and in the program,” he said. “That’s how willing he was to live.”
Finding willing volunteers to visit hospitalized overdose victims is part of the redemption Skillings said is key to his recovery.
“The chance I was given by Amistad and my work played a part in saving my life,” he said.
Amistad peer coach Ben Skillings, left, and Portland Community Recovery Center Director Steve Croteau would like to have recovering addicts visit hospitalized overdose victims to provide peer support. “We have been losing people way too much. It just pisses me off and makes me so scared,” Croteau said Feb. 5.
Andrew Kiezulas and Niki Curtis have each been sober for 2 1/2 years. Kiezulas leads the state chapter of Youth in Recovery and Curtis is a peer support supervisor at the Portland Recovery Community Center.