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The King County Heroin and Prescription Opiate Task Force wrapped up its work in September with a 101-page report recommending policy changes in three key areas: Prevention, treatment, and user health/overdose prevention. Two months have passed, and the task force has more or less gone dormant, but some of the recommendations–which include opening two new supervised drug-consumption facilities, one in Seattle and one in a still-TBD King County city–are happening behind the scenes. Some recommendations, including a new buprenorphine clinic providing medication-assisted treatment for opiate addiction at the downtown public health center, are already underway, while others are still on hold pending cost estimates, funding, and neighborhood buy-in.

Although the most controversial element of the recommendations, by far, has been the supervised consumption sites (one state lawmaker, Republican Sen. Mark Miloscia, has vowed to pass legislation that would preclude the city and county from opening any safe-consumption sites, along with legislation that would ban sanctioned homeless encampments), expanding access to medication-assisted treatment is also harder than it looks. Currently, federal drug law only allows doctors to provide buprenorphine (brand name: Suboxone) to a maximum of 100 patients at a time; doctors who want to prescribe buprenorphine have to go through special training and certification. Currently, according to the task force report, “Treatment capacity for buprenorphine is limited and far exceeded by demand.”

Caleb Banta-Green is a task force member and researcher at the University of Washington’s Alcohol and Drug Abuse Initiative who has studied the impact of the opiate epidemic and advocates for expanded access to medication-assisted treatment with suboxone or methadone. I sat down with him in his U District office the other day to ask some devil’s advocate questions about Suboxone, other addictions that can’t be treated by taking a pill, and the widespread belief that sometimes, you just have to force addicts into treatment.

The C Is for Crank (ECB): Listening to the task force and to city council members, like Sally Bagshaw, who have really dedicated themselves to working on the problem of opiate addiction, you’d think that buprenorphine treatment is the be-all, end-all of addiction treatment. That worries me a little. For one thing, it’s treating an epidemic largely caused by pharmaceutical companies with drugs prescribed by pharmaceutical companies, and they can and do jack up prices (and lie about side effects, as they did with Oxycontin). For another, it might take away pressure to provide funding for things like counseling and other supports that people need to live better lives without drugs. Should I be concerned?

Caleb Banta-Green (CBG): My analogy is always Starbucks. If you think about how so many people are coffee drinkers, well, there’s a lot of opiate users too, and they’re going to want their fix in a bunch of different ways and settings, just like coffee. Some people like espresso, some people like drip. We don’t just have one type of coffee that everyone has to drink in one setting and one way of paying for it. That’s not the way you get customers, and repeat customers, which is what we want when it comes to treatment. But that’s not what we do. We say, “Here it is, come get, and it if it doesn’t work, you’re failing treatment.” It’s like saying, “We’re making a shitty cup of coffee and you’re not drinking it. What’s wrong with you?”

My favorite, most disturbing, inspiring, frustrating thing in that Frontline piece [“Chasing Heroin“] is the woman [Kristina Block]—she was something like 20—and she said to her dad, “I don’t want to use, but I’m not ready for treatment.” And I think treatment with a capital T is what she’s thinking about. Not like, “I don’t want to use and I [would like to] take buprenorphine, which I can take by mouth every 24 hours and not go into withdrawal and not get high.” She’s saying, “I don’t want to deal with the bureaucracy and the counseling and the hassle and the humiliation and the stigma.” That’s a different thing.

ECB: Assuming the county figures out a way to site and fund two supervised consumption sites on a pilot basis, is two years [the length of the proposed pilot program] long enough? I can see a scenario where a facility goes into a neighborhood and has just enough time to piss everyone off and scare them, but not enough time to show meaningful results, which obviously would be less than ideal.

CBG:  I think in two years, if you’re destroying a neighborhood or revitalizing a neighborhood, I think you can have a whiff of it pretty quick. There’s an example in Hamburg or Berlin where they put a [supervised injection facility] next to a park and basically the park looked totally different almost instantaneously, and in fact, drug dealing changed almost instantly because the only people left in the park were the drug dealers. No one was using anymore. So it changed the drug market as well. It can be very dramatic and very sudden.

“When Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible.”

ECB: Leaving aside all the public health measures like emergency room utilization, overdose prevention, and money saved, is there any good way to quantify subjective quality-of-life improvements for the people who use these programs?

CBG:  Do they return to a life that’s worth living? It’s great to keep people alive, but what’s going to make them want to stay alive and have a valuable, meaningful life? And if part of that is a sense of self and identity and worth, I don’t think those are weak outcomes. What is your sense of self? Do you feel valued and respected by other human beings? Those are kind of important things. In fact, they are essential. And it is a public health outcome, because that whole sense of self is related to a person’s mental health and health care and caring for themselves.

ECB: I’ve mentioned some of my reservations about heavy reliance on Suboxone as treatment before: As an opiate drug, it can be both habit-forming and addictive, it puts users’ fate in the hands of drug companies who don’t have a good record being honest with patients about their products, and I’m skeptical of treatments that sound like magic pills because policymakers zero in on the pill as the only solution, abandoning things like long-term therapy and social supports. Can you put my mind at ease about any of that?

CBG: I’m a researcher, not an addiction medicine doctor, but every single addiction medicine doctor who I know is really clear that in their practice with Suboxone, the majority of people who have long-term opiate use disorder do the best being on Suboxone for many years. Suboxone’s only been around for 14 years, so I can’t tell you that it’s 50 years, but I can tell you that the longer the better. And I can tell you that because when Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible. We wasted 10 years of research on that, even though we knew that on methadone maintenance, on average, the longer the better. So we wasted ten years and now we know the same thing’s true for Suboxone. To me, that’s not saying that a person has to be on it for 50 years. The point is, how’s the person functioning? The calendar shouldn’t be the guide for when or whether a person gets off Suboxone. It should be whether they’re functioning.

Opiate use disorder is not the same as alcohol use disorder. The difference is that if you have opiate use disorder, you’ve had it for a long time, you have an endorphin system in your body that is potentially permanently changed. The only way for some people to feel normal—not high, but normal—is to have opiates on those receptors. Most people with opiate use disorder need opiates on the receptors to feel normal. They’re the people who, when they first took opiates, they didn’t get lethargic and nauseated and sleepy. They’re the ones that said, “Oh, I feel normal.” So where’s the issue? If the opiate makes you feel normal and it doesn’t cause euphoria and it doesn’t have side effects and it helps them function, what’s the downside of them being on it?

“If it were my kid who was addicted to opiates, even as an adolescent, I would say, ‘Let’s get this person on Suboxone, and I want them on it until they’re 25.'”

ECB: One downside might be the widely reported side effects.

CBG: Here’s the issue. The side effect of going off of it is that your mortality risk doubles. That’s the side effect I’m worried about—when you’re not on it, your mortality risk doubles. If it were my kid who was addicted to opiates, even as an adolescent, I would say, “Let’s get this person on Suboxone, and I want them on it until they’re 25.” Then we can figure out what’s going on and figure out how they’re doing physically and socially and psychologically. But the overdose risk is so high with opiates, and even more so now with who knows what the fuck’s out there, that pharma raising the price or having some liver side effect that actually has not been found, compared to your overdose risk doubling? For me personally or for a family member of mine, I’m comfortable with that.

ECB: The task force recommended safe consumption sites, rather than safe injection sites, specifically to create a space for users of many different types of drugs, who use them in different ways.  Do you think that aspect will get lost as the county and local jurisdictions hammer out the details of where these facilities are going to be?

CBG: Brad [Finegood, assistant director of King County’s behavioral health and recovery division] has been very clear about trying to make access to all types of drug treatment for everybody, and we need that. And we need to have safe and heathy places for people who are using methamphetamine. We also need to have good treatment, social support, counseling, and all of that. We’re also very  unfortunate in that the treatment solutions for alcohol, methamphetamine, and marijuana are not nearly as good as they are for opiates.

ECB: Why not?

CBG: It’s because we don’t have medications. Also, we have an antidote [for heroin overdoses, naloxone] that lay people can give. We don’t have that for any other drug. And we have treatment medications that work really well. Methamphetamine’s a bitch. If your’e using meth and heroin, it’s really a bitch. We’ve seen a huge increase in methamphetamine deaths over the last decade, mostly because people are starting to combine it with heroin.

ECB: How many people do you think could benefit from medication-assisted treatment in the state?

CBG: There’s about 10,000 people on methadone. There’s probably 15,000 on buprenorphine in the state, based on a state survey. I think we easily have need for 15,000 to 20,000 more people on treatment medications. So there’s a lot of pent-up demand out there, and I also think that the demand is not just for methadone. There’s actually not bad access to methadone right now, but I know there’s a huge unmet need for buprenrophine.

“Why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment?”

ECB: When I talked to Senator Mark Miloscia after our visit to Insite, a prescription-heroin clinic, and other harm reduction programs in Vancouver, he said he was unconvinced by what he saw there and still believed that forcing people into treatment will make them stop using drugs. What is your response to that?

CBG: That comes up all the time, and as a human being, I don’t like the idea of forcing a person to do that. People have free will. But forget that point—the real point is, we don’t have nearly enough treatment access for the people who do want it, and I’d love to deal with [people who don’t want treatment] after we deal with the problem of making sure we have treatment available to the people who do want it. And the way that we know that they want it is that in a state survey, at least 2/3 of people said they want help reducing their use. People don’t want to be using heroin.

But they also don’t want to access the current types of treatment that are available that may be dehumanizing, that may use behavior modification and yell at you, that may call you a bad person, that may tell you that if you don’t believe in God, then you are not trying hard enough. In what other aspect of our lives would we want to be treated that way? So why would a person with substance use disorder want to be told that they’re a lesser person and they get fewer choices? The majority of people who are using don’t want to be using, and they need the right kind of treatment to not use. So why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment? Let’s take care of those thousands and thousands and thousands of people before we go through a surely illegal process of eugenics and forcing people into treatment.