FARGO — Joe Moran once spent three years living on the streets of Minneapolis. He began abusing alcohol as a teenager and later turned to methamphetamines. But his life descended into a much grimmer place when he found himself in the grip of opioids.
His opioid addiction, which ultimately led him to street drugs including heroin, started with a prescription painkiller for an injured toe.
“A sprained toe — I probably didn’t need an opiate,” he said. “That’s how my addiction started.”
Moran, who hid his earlier drug abuse from the prescribing doctor, quickly became a prescription pain medication seeker, making repeated visits to clinics, dentists and emergency rooms.
“I just started going to the hospital a lot,” he said. In time, however, doctors became suspicious of his repeated claims of intolerable pain, and Moran’s legal access to opioids abruptly ended.
“They finally caught on,” he said. “They eventually cut me off.”
The addiction took over Moran’s life. He was only able to work and otherwise function while using opioids. He tried quitting, but kept relapsing because of painful withdrawal symptoms.
Once, he said, “I spent three weeks in torment on my couch” going through withdrawal.
His break came with another prescription — a drug called Suboxone, which helps curb cravings for opioids and reduces withdrawal symptoms.
“The withdrawals are what kept me using,” said Moran, a Fargo resident who was abusing opioids for a dozen years until he got help from the prescription to Suboxone, which combines buprenorphine and naloxone, enabling addicts to wean themselves from opioids.
After six years of treatment with Suboxone, Moran is now able to stay off opioids without relying upon the medication, and he continues the ongoing work of maintaining his sobriety.
“I’m in a healthy, stable place,” he said. “I can’t say never, because I’m still an addict at the end of the day.”
The approach that Moran credits with getting him off opioids, called medication-assisted treatment, is increasingly available in area clinics, as health providers are becoming more involved in treating opioid addiction.
The embrace of medication-assisted treatment is in parallel with more restrictive practices in prescribing opioid painkillers.
At Sanford Health, for instance, opioid prescriptions in the Fargo region area have decreased by 47 percent over the last two years, according to Dr. Douglas Griffin, chief medical officer.
“So we’ve dropped it almost 50 percent,” he said. “I think it can continue to drop down significantly.”
Similarly, Essentia Health now has 5,600 chronic opioid patients — using for three months or more — less than half of the 12,000 four years ago. A breakdown for Essentia’s west region, which includes Fargo, was unavailable.
“So it’s come down fairly markedly and continues to go down,” said Dr. Joseph Bianco, a physician who oversees Essentia’s efforts to reduce opioid prescriptions. “We’re still working on reducing total opioid use, safe prescribing practices.”
Besides weaning patients from opioids with medication-assisted therapy, doctors at Sanford, Essentia and elsewhere try to use other treatments for pain, including physical therapy, acupuncture and counseling.
“There’s a whole plethora of things depending on what the pain trigger is,” Bianco said. “Part of our work is making that accessible to our patients.”
Because opioid addicts are so prone to relapse — the cravings powerful, the withdrawal symptoms painful — many patients, as Moran found, have much greater success with medication-assisted treatment.
One form is methadone, but the drug can only be given in special, stand-alone clinics, and therefore is not widely available, especially in rural areas. Suboxone, on the other hand, is available in primary care clinics, as long as the prescriber has received the required training.
“It’s really heartening to have another tool to offer patients who are really suffering,” said Christine Harsell, a nurse practitioner and chief medical officer of Valley Community Health Centers. “It helps the patient buy time.”
The drug is administered in the clinic, so the provider can observe the patient’s response. Patients abstain from opioids before receiving treatment.
Harsell has seen patients make a dramatic turnaround in their battles against addiction with the help of the drug, a form of medication-assisted treatment for addiction.
“It’s a complete 180,” she said. “It’s quite amazing.”
At her clinic, Harsell has treated patients whose lives have been upended by their addiction to opioids, including patients living on the street, shooting up heroin.
Because buprenorphine curbs their craving for a high and suppresses their painful withdrawal symptoms, patients are much more successful in weaning themselves off opioids, enabling them to function better in their work and relationships, Harsell and other prescribers said.
Prescribing buprenorphine goes hand in hand with getting the patients into counseling.
Harsell received the required training through an initiative called Project ECHO, a partnership involving the University of North Dakota School of Medicine and Blue Cross Blue Shield of North Dakota.
The program brings expertise via interactive video to far-flung clinics, whose providers otherwise would find it difficult to obtain the training, said Dr. Lisa Faust, a psychiatrist and senior medical director for Blue Cross Blue Shield of North Dakota.
The idea is to put specialized knowledge in the hands of primary care physicians, physician assistants and nurse practitioners, “front line” health providers. Experts also provide ongoing support, including recommendations for handling patient problems.
“I personally call it the teach a man to fish and have his back model,” she said. “It is very well suited for rural clinics,” whose patients find it more difficult to access specialized care.
The death rate for addicts not receiving medication-assisted treatment is double the rate of those prescribed buprenorphine and other drugs, Faust said.
“We have cancer drugs that don’t work that well,” she said. “It’s not a magic bullet,” but medication-assisted treatment can get addicts on the path to recovery. It is used in combination with counseling and other recovery resources to help addicts resolve the issues that led to their addiction.
In 2016, the most recent figures available, North Dakota had 54 drug overdose deaths, or 7.6 deaths per 100,000 persons, according to the National Institute on Drug Abuse. Although roughly half the national rate of 13.3 deaths per 100,000, the rate is up sharply from 4.5 in 2014, a rise the institute called “concerning.”
Once licensed, physicians, physicians assistants and nurse practitioners can prescribe opioid painkillers, said Benjamin Bucher, a nurse practitioner who heads Towner County Medical Center in Cando.
But those same providers, he said, need to take time for the training course and obtain a waiver from the Drug Enforcement Agency in order to prescribe buprenorphine.
The government and the American Society of Addiction Medicine consider medication-assisted treatment to be the best practice in treating opioid addiction, but so far only a small minority of primary care providers are equipped to provide that care, Faust said.
Sanford and Essentia are working to expand the number of prescribers who are trained to treat with drugs like Suboxone, a process Griffin and Bianco said will take several years.
“We’re really exploring how we can increase these addiction services,” Griffin said. “We’re exploring what options we have internally to address it across our whole footprint.”
Although Moran credits Suboxone with helping him quit opioids — “it saved my life,” he says repeatedly — he stressed the importance of working through the issues that cause or aggravate addiction.
His advice to fellow addicts who seek medication-assisted treatment: “Just don’t think once you’re on Suboxone you’re OK.”
In Moran’s case, he found help from a 12-step program as well as counseling. “I’m still using that,” he said, adding that he knows 12-step programs aren’t for everyone. “As long as you’re doing something to better yourself and figure out who you are.”
He learned that he suffered from depression and also had attention deficit hyperactivity disorder, previously undiagnosed conditions he had sought to treat with illicit drugs.
“I didn’t know there was anything wrong in my life,” he said. “I just knew how I felt.”
Moran is grateful that, in his case, medication-assisted treatment came along after he had “hit bottom,” including years of homelessness, and was ready to commit to going clean.
“We have to get to that point,” he said, “where we’re ready to stop.”