How Lake County ER doc's medicine, compassion help opioid addicts
Editor's note: This story has been updated to correct the title of Dr. Diane Copeland, clinical psychologist.
The woman came to the Waukegan emergency room complaining of all sorts of pain - something that usually would draw strong painkillers: Opioids.
When those meds were denied, she wouldn't take no for an answer.
Dr. Kenji Oyasu had seen her type before. He pulled up her name on the state's prescription monitoring program; it revealed a list of her drug-seeking behavior, and all the ends to which she'd gone to fuel her opioid addiction, fulfill her strong cravings.
Confronted with this, Oyasu said, "She started crying."
He pulled out his card from Brightside Clinic in Northbrook, the medication-assisted treatment facility he opened to help opioid addicts in May 2015 and said, "I'm the one person who does understand."
All too much.
'Steady state'
Oyasu, 49, started Brightside to address the toughest case he sees as an emergency room doctor at Vista Medical Center in Waukegan - the opioid addict. Opioids include such medications as hydrocodone, oxycodone and fentanyl, which bind to pleasure centers in the brain and reduce the intensity of pain signals, numbing the hurt. They're helpful after surgeries, dental procedures or injuries, but they're addictive and abused by many.
"Either they've overdosed, or they come in drug-seeking," he said. "It's complicated."
For the overdose patients: "The conversation you have with them is 'Hey, don't do that. You almost died,'" Oyasu said. "We know it's not getting through to them."
For the seekers: "You know what's going on there is not that it's a chronic pain issue," he said. "It's an addiction issue."
Yet the treatment for each patient is never the same.
Oyasu and a growing number of doctors and drug addiction experts say a significant part of the answer is medication-assisted treatment.
It's a process of using one of three main medications approved by the FDA to diminish cravings for addictive opioids or block their effects and allow recovering addicts to feel normal.
Oyasu's clinic exclusively prescribes buprenorphine, a partial opioid approved in 2002 that's also part naloxone, the overdose reversal drug. Like methadone, an opioid that has been used to treat addiction for more than 40 years, buprenorphine helps patients not to feel sick, as they would if they were in withdrawal, and not to feel buzzed.
"The goal is to keep you at a steady state so you're not getting high, but you're not getting cravings either," said Susan McKnight, substance abuse program coordinator for the Lake County Health Department, which is expanding its efforts to provide medication-assisted treatment to opioid addicts at the county jail.
While taking the third type of medication, naltrexone, patients are unable to feel the effects of opioids because the medication blocks opioid receptors in the brain so they can't be activated.
Oyasu knows these medications have their doubters and detractors - people who worry prescribing them is replacing one addiction with another. But he also knows science says the meds work.
That's why, after years of seeing addicts of all types flowing into the emergency room, Oyasu knew he had to do something to help. So he chose to prescribe buprenorphine, and he chose to do it in a way that shows compassion.
Induction
At Brightside, it all starts inside a small, Ikea-furnished office, which is one of four at the clinic smartly adorned with bright, modern art.
There, Oyasu explains his clinic's three-step process to patients from as near as neighboring suburbs or as far as neighboring states, sometimes five hours away.
The average age of the 160 patients at Brightside is about 30. Many have been using opioids as long as 15 years. They've tried to stop, but nothing has worked and no clean spell has lasted. Some spent as much as $3,000 a month on drugs, hunting for them for 20 to 40 hours a week. Oyasu always asks.
Later, when his patients reach recovery, he reminds them of everything they've gained.
"Let's celebrate the fact that, now, you're in recovery," he says. "You've got all this time back; you can keep all this money."
But first comes induction.
To begin taking buprenorphine, a patient needs to have been opioid-free for between 24 hours and several days, depending on which substance they've been using. To help patients through that phase, Oyasu will prescribe things to ease withdrawal symptoms - something for anxiety, something for nausea, something for cramps. When the patient arrives, he'll hand out those prescriptions to fill at a pharmacy across the street.
The last prescription will be for buprenorphine, a film or tablet that must be dissolved under the tongue and absorbed into the mouth, not swallowed.
In his second year of running the clinic, Oyasu may prescribe buprenorphine to 100 patients. Next year, he can treat 275, thanks to a recent federal Health and Human Services rule change that increases the maximum patient load for doctors who are Drug Enforcement Agency-certified. Buprenorphine prescribers in their first year of certification can handle only 30 patients, which Oyasu says contributes to a shortage of providers and makes it difficult for patients to get help when they need it.
That's why he employs four other doctors at Brightside and has five more at the ready - so he can scale up his practice to meet increasing demand.
Just the fact someone picks up the phone at Brightside impresses many who've sought treatment there. So does Oyasu's obvious caring for his patients. He's been known to make the occasional home visit when someone is particularly struggling.
That's what he did for Christopher Zucchero, 35, whose parents live near Oyasu's home in Park Ridge.
"He told me, 'Hey, I'm out of options for you right now,'" Zucchero said. "I saw the look on his face and I was like, 'Oh man, I disappointed this guy.' I've disappointed everyone - my wife, my mother and father and everyone else - and he came to the house and was concerned."
Zucchero says he "finally matured" and made the choice to stay sober from a 9-year Vicodin and heroin addiction after Oyasu's intervention at his parents' home.
Stabilization
Once a patient is committed to sticking with buprenorphine treatment, stabilization begins.
"The goal is always to find the lowest dose possible for you to feel normal," Oyasu said. "Our goal is routine. Wake up, brush your teeth, put in your sublingual buprenorphine tablet and go about your day."
The medication is usually covered or subsidized by patients' insurance, be it from the government's Medicaid program or a private company. But for patients such as Zucchero, a Chicago restaurant owner whose medical plan doesn't cover long-term use of the drug, he says it costs $10 for an 8-milligram dose. He takes two a day and says they taste awful.
"But it's better than being dopesick," Zucchero said. "It's better than being in withdrawal, and it's better than being in a weird cycle of addiction."
During the stabilization phase, patients start visiting Brightside monthly to check in with Oyasu and meet with Dr. Diane Copeland, a clinical psychologist who provides the behavioral health counseling aspect of treatment at the clinic. It's not enough to prevent opioid withdrawal and reduce someone's cravings with a medication - complete recovery also requires new ways of thinking and acting.
"You really need someone to coach you into 'This is what you're going to do' because your life is now different," Oyasu says. "It's vitally different."
Maintenance
When weeks stretch into months and recovery becomes more consistent, that's another point when medication-assisted treatment becomes controversial. How long is too long to keep taking meds? When should a patient begin to taper and get weaned off to "true" sobriety?
"I discuss taper with every patient. But I also say we're not going to taper until you are ready," Oyasu says. "Why would we cut them off from a medication that's giving them a good result?"
Buprenorphine, methadone and naltrexone all can be taken long-term without harmful effects, doctors say.
So Chelsea Laliberte, founder of the Arlington Heights anti-heroin nonprofit Live4Lali, says questioning when someone is going to get off the treatment is just another way society unfairly approaches addiction differently from other medical conditions such as heart disease or asthma. She and Oyasu agree: No one would ask a seizure patient or a diabetic when he was going to stop needing his prescribed drugs, so no one should ask an addiction recovery patient that question either.
"You could be on these medications for the rest of your life," Laliberte said. "If it saves your life, fine. Totally worth it."
Two of Oyasu's Brightside patients have tapered off completely and stopped taking medication during the 15 months the clinic has been open. But the maintenance phase can last months to years to a lifetime. Oyasu tells his patients wherever they fall on that spectrum is OK.
"There's a lot of tears that flow in this room," he says. "They (patients) say, 'No one has ever treated me this well before.'"
He tells them they deserve it. Anyone would. After all, they're just a human with a disease - a disease that's chronic and relapsing, misunderstood and often deadly, but nonetheless treatable.
"We're just offering you a resource and we're being nice to you because we get it," he says. "You're not a bad person."
Coming Monday: Woman shares how sometimes-controversial medicine is helping her through a 10-year heroin addiction and 21-year battle with opioids.
Three meds help heroin recovery
Patients who want to try medication-assisted treatment for heroin or opioid addiction can use one of three main FDA-approved prescriptions.
MethadoneCommonly sold as: MethadoneWhat it is: Synthetic opioid used for more than 40 years in heroin addiction treatmentHow it works: Metabolized more slowly than heroin, methadone eliminates opioid withdrawal symptoms and, at higher doses blocks the effects of heroin and other opiatesWho it’s good for: Patients addicted to injecting opioids because it reduces the rate of injection use and risk of transmitting HIVHow to get it: Daily visits to a clinic certified by the Substance Abuse and Mental Health Services Administration and registered with the Drug Enforcement Agency; eventually patients can be deemed stable enough to visit less frequently and receive take-home doses
BuprenorphineCommonly sold as: SuboxoneWhat it is: Part opioid, part opioid overdose reversal drug naloxone; FDA-approved to treat heroin addiction since 2002How it works: Taken as a dissolving pill or film under the tongue, Suboxone suppresses opioid withdrawal symptoms and reduces cravings; a new 6-month implant produces the same effectWho it’s good for: Patients unable to visit a clinic daily for doses of methadone; people in long-term recovery from heroin or opioid addictionHow to get it: Find a doctor who is certified by the Drug Enforcement Agency to prescribe buprenorphine and has not yet hit his/her patient limit; limits recently were increased to 275 patients for doctors in at least their third year of certification
NaltrexoneCommonly sold as: VivitrolWhat it is: Opioid blockerHow it works: A non-addictive opioid antagonist, Vivitrol blocks opioid receptors in the brain so they can’t be activated by other opioids such as heroin; long-lasting; each injection blocks the effect of opioids for a monthWho it’s good for: Patients who have been detoxified from all opioids for 7 to 10 days; patients able to manage cravings and triggers through coping mechanisms and want to avoid relapseHow to get it: Find a doctor, drug treatment center or county health department that offers Vivitrol injections; some jail inmates are being offered Vivitrol upon releaseSource: Office of National Drug Control Policy