This time, sobriety feels different, according to Jennie Singer. Besides starting a new round of treatment for her opioid use disorder, Singer was also diagnosed early last year with bipolar disorder and attention deficit disorder. She said the mental health diagnosis was the piece that was missing from her life since she became addicted to opiates in 2004.
Singer graduated from Door County’s Drug Treatment Court in August 2023 and had been sober for more than a year, before she relapsed in October 2023. She was sent to jail in late December 2023 for violating her parole, and got sober in jail before being released in February.
Before this latest relapse and recovery, Singer said no matter what she did, sobriety did not “work” for her. (Knock profiled Singer as part of a series about opioid and methamphetamine addiction in Door County last year.)
“I would never say recovery is easy, because it is not at all,” Singer said. “But this time feels easier than any other time.”
The medical field is expanding to treat substance use disorder, or SUD, with leading addiction medicine specialists and researchers promoting the safety and efficacy of medication assisted treatment for people like Singer. Access to medications that limit withdrawal symptoms and cravings, like methadone, buprenorphine and naloxone, is still limited by regulation and availability, but patients with opioid use disorder in Door County have some local options.
Addiction medicine, integrated
Medication assisted treatment for substance use disorder has been around since the 1960s, when a few medications were FDA-approved for alcoholism and opioid use disorder. For the most part however, American treatment protocol has historically revolved around 12-step programs and behavioral therapy, according to Dr. Randy Brown.
Brown is a leading researcher and advocate for addiction medicine at UW-Madison, and is the founder of the University of Wisconsin’s Addiction Medicine Fellowship Program. Addiction medicine has a host of possibilities, Brown said, but it has taken until the late 90s and early 2000s to gain any traction in the field of addiction.
Standard behavioral treatment for substance use disorder was an isolated system, according to Brown, highly confidential and it prevented communication and cooperation between treatment providers, researchers and patients.
Things mostly continued this way and treatment for substance use disorder was missing from primary care entirely until about 2016, Brown said, when addiction medicine was recognized as a formal field by the American Board of Medical Specialties.
The Accreditation Council on Graduate Medical Education began accrediting addiction medicine programs in 2019, and fellowship programs like the one Brown oversees began training physicians to be eligible to sit for board exams to be certified in the discipline.
And with that, “a multidisciplinary kind of plan for addressing it (substance use disorder) became much more possible,” Brown said.
Dr. Yasmin Hurd would agree. Hurd is an internationally known neuroscientist who is leading research that is shaping the field of addiction medicine. She is the director of the Addiction Institute at Mount Sinai and a professor in the Departments of Psychiatry, Neuroscience and Pharmacology and Systems Therapeutics at the Icahn School of Medicine at Mount Sinai.
“Treatment of SUD needs to be integrated,” she said in a phone interview last year.
Hurd oversees the Rivington House in New York, a behavioral healthcare facility that offers treatment for substance use disorder, mental health and primary care in one place, she said. Not only does integrative care like this have better outcomes for patients, but it helps relieve some of the stigma around the disease.
“SUD patients will be in the same waiting room as someone going to see their primary caregiver for another medical condition. Nobody will be singled out, nobody will know, they will be no different,” Hurd said.
While there is no integrative clinical model exactly like this in Door County, Singer is seeing both a psychiatrist and Dr. Paul Board, who specializes in addiction medicine at Door County Medical Center. Dr. Board is also her primary care provider.
She takes three different prescription medications every day: Suboxone to treat her opioid use disorder, Latuda to treat her bipolar disorder, and Vyvance for attention deficit disorder.
Her doctors communicate and share records. All her service providers know what medications she is taking and her health history. This is the first time she has received health care in this integrative way and it is making a difference in her recovery, she said.
“I am stabilized in all areas and it’s a whole new world,” she said. “It’s like nothing I’ve ever experienced.”
Before receiving integrated treatment for her mental health and substance use disorders, Singer said every time she relapsed, she would pick herself apart, wondering what she was doing wrong.
“What little thing did I forget to do?” she remembered. “I didn’t do my readings in the morning or meditation or whatever.” She said she lived with an omnipresent terror that sobriety just didn’t work for her.
Once she was diagnosed with bipolar disorder and treated for it with the appropriate medication, Singer realized she was doing recovery right, but there was another piece of her that had been “running rampant.” Sobriety actually made her mental health worse, according to Singer, and often she would relapse with opiates when she was experiencing manic mental health symptoms.
“Heroin works really well for treating bipolar mania,” she added.
Medications for opioid use disorder
Research is being done on a variety of medical options for treating substance use disorder, including THC, psilocybin, MDMA and other drugs. There are medications that help treat alcohol use disorder, like acamprosate, disulfiram and naltrexone. Medications available specifically to treat opioid use disorder are methadone, buprenorphine and naloxone.
Singer takes Suboxone, a commercial name for a combination of buprenorphine and naloxone. Buprenorphine is an opioid medication that is considered a partial agonist, meaning it partially fills the brain’s opioid receptors. Naloxone blocks opioid receptors. The combination of the two helps reduce cravings and withdrawal symptoms and puts a limit on euphoria and respiratory depression, meaning less likelihood for overdose.
Methadone, which Singer is not taking now, is a full agonist, meaning it fills the opioid receptors, and there is no ceiling for euphoric effects or respiratory depression, meaning it has the potential for fatal overdose if misused.
Singer has been prescribed all three medications in the past for her opioid use disorder. She was on methadone for four years, starting in 2010, and said it was effective at first, but then she stopped taking it as prescribed and started abusing the drug.
Side effects from methadone were also difficult, Singer said. Weight gain and difficulty breathing were the worst parts for her. After four years, she tried to stop taking methadone.
“It was a hellish experience that was way worse than any heroin withdrawal I’ve ever gotten,” she said. “It was 100 times worse.”
She eventually went back to using heroin to stop the methadone withdrawal symptoms.
Singer has had better luck with Suboxone, which is what she is prescribed now. She takes eight milligrams in the morning and two more in the afternoon. The dosage can be fine tuned to the individual, she said. In Singer’s case, she would have a lot of cravings in the afternoon and evening and the little dose later in the day helped with that.
Side effects and experiences with medications for opioid use disorder vary between individuals and dosages, according to Brown, but in general you do not see as much of a sedative effect with Suboxone or other buprenorphine products.
He said he has heard many patients say that withdrawal from methadone is worse than heroin and lasts longer. A prolonged tapering off period with close monitoring and support is necessary to be successful in weaning off of methadone, he said.
“In many cases it is simply a matter of some folks doing better with one thing over another,” Brown added.
New paths to lasting recovery
Response to treatment and needs of patients with substance use disorder vary widely based on many different factors. For that reason, and because of the urgency of the opioid epidemic, Hurd believes the medical regulation community has a responsibility to fast-track medical research.
In 2017, the federal government declared the opioid epidemic a public health emergency. Hundreds of people die every day from opioids, Hurd said, and the same amount of urgency from the global scientific and medical communities that was applied to the Covid-19 epidemic should be applied to SUD.
“Experimental treatments, reasonable treatments should be worked on and fast tracked,” she said.
Hurd’s lab at Icahn School of Medicine at Mount Sinai is in the second phase of clinical trials studying cannabidiol, a compound from the marijuana plant, for its role in preventing relapse in heroin and cocaine addiction. Additional research by the Hurd lab is focused on understanding how genetics and someone’s environment contribute to substance use disorder and provides neurobiological insight to advanced treatment options.
The interplay between mental health and substance use is specific to the individual, and as in Singer’s case, trying to treat the disorder without treating underlying mental health issues does not usually lead to lasting recovery.
“There are primal vibes among humans, eating when you’re hungry and drinking when you’re thirsty, and seeking relief from intense discomfort,” Brown said. “And controlled substances, generally habit-forming substances, that’s something that they do really well. If you’re experiencing internal discomfort, psychic trauma, you take a decent dose of alcohol, stimulant or opioid and feel better quickly.”
Some of Brown’s research at UW-Madison is focused on medical treatment of trauma and mental illness. In 2019 his department participated in phase three of clinical trials for the use of MDMA to treat post-traumatic stress disorder. MDMA is a component of the street drug Ecstasy.
The link between post-traumatic stress disorder and substance use disorder is well documented. People suffering from trauma are statistically more likely to develop an substance use disorder and treating an individual’s trauma medically, in conjunction with behavioral therapy, may be a form of preventative care for it, according to Brown.
If the medical community could engage in appropriate interventions early enough with trauma and other mental health conditions that co-occur with addiction, he said, it would be doing a better job than just waiting for substance use to develop into a full-blown disorder.
Access to medication assisted treatment varies
Until about two years ago, in order to dispense methadone or buprenorphine, specialist opioid treatment programs had to be formally licensed at the state and federal level and could not be prescribed by a primary care doctor in a mainstream healthcare setting. Methadone is still regulated this way and isolated in separate clinics, but in 2023 primary care physicians were allowed to prescribe buprenorphine and naloxone within their practice.
That does not mean every primary care doctor will provide medication assisted treatment, however, Brown said.
Lack of training is one reason. “Physicians go through four years of medical school, three years of residency, tens of thousands of hours of training, and on average, get fewer than ten hours of formal training in addressing addiction or use disorders,” he said.
Primary care provider shortages are another reason. When administering medication for substance use disorder, initially the provider needs to meet with the patient frequently, Brown said, a hard ask for providers already struggling to meet with all their patients.
Singer sees Dr. Board every six to eight weeks, she said. In the beginning of her treatment she saw him every week and got drug-tested each time. Recently, when she forgot about an appointment and missed it, Singer was required to have a clean drug test before getting her prescription for Subutex refilled.
Separate opioid treatment programs, which can administer methadone, buprenorphine and naloxone, tend to be concentrated in urban areas. The closest one to Door County is in Green Bay. These clinics have high accountability for patients, meaning the patient usually needs to go to the clinic in person every day to receive their medication. Brown said that is a good thing, as methadone is easy to abuse, and it can be difficult to work out appropriate dosage.
However, if one has to travel 45 minutes or more to receive medication assisted treatment, Singer said that can be next to impossible to do for someone in recovery who is trying to rebuild their life. Often those newly in recovery have lost a lot and are not in a stable living or financial situation, or do not have reliable transportation or valid driver’s licenses, according to observations by providers at the Door County Department of Health and Human Services, as Knock reported last year.
Stigma can affect medication assisted treatment success
Stigma around substance use disorder is already a debilitating factor for people with the disease and their families. It affects care providers also, according to Hurd. Treatment centers do not have the same resources compared to a surgical or clinical center, she said, and for most people treating it, it is not a money-making venture.
“The stigma is on every level,” Hurd added, including within the recovery community itself.
Traditional 12-step programs and abstinence-only recovery practitioners and groups can look down on patients who are recovering with the help of medication, Singer said.
The refrain is that you are just substituting one drug for another with medication assisted treatment, Brown said, but the difference is that within the setting of addiction or disorder, substance use is causing dysfunction in relationships, work, education, physical wellbeing and life in general.
“One gets on buprenorphine or methadone,” he said, “number one, they’re less likely to die. And they’re also more likely to have their function enhanced if they’re taking it as prescribed.”
Singer is active in the local recovery community in Door County and has been through several programs. She said 12-step programs have helped her immensely, but there are a number of people in recovery who see medication assisted treatment in black-and-white terms.
“If you’re on MAT, you put a mind- or mood-altering substance into your body, and so you’re not sober,” she said. “That’s how they see that. I totally disagree with that. I couldn’t disagree more.”
Healthy, sober and functioning is how Singer feels on the medications she is taking. She said using drugs under the direction of her trusted healthcare provider is completely different from using street versions of opioids or misusing prescription drugs.
Singer said she is confident enough in her recovery to either avoid the naysayers or tell them she respectfully disagrees with them. However, she cautioned newly sober people whose recovery is in a more vulnerable stage, to be careful who they give information to about their use of medication for substance use disorder.
Medication assisted treatment in sober living
A new sober living home for women opened in October in Door County. Door County HHS is funding the facility and has hired CORE Treatment Services for consulting and operational management of the home.
Clients using medication assisted treatment in their recovery are welcome in the home, and all staff have been trained in dispensation protocols to ensure medications are used safely, according to Stephanie Short. Short is a certified peer specialist and recovery coach, as well as the Community Impact Coordinator for Health with United Way of Door County. She is in recovery for SUD herself, and has been hired by CORE to oversee the Door County sober living facility.
All prescription medications in the home are secured in a lockbox and dispensed according to the directions and needs of each resident by a trained staff member, Short said. This protocol is for safety, rather than out of any mistrust of residents, she added.
The more treatment providers and members of the recovery community that understand the benefits of medication assisted treatment for substance use disorder, the better, Singer said. Knowing there is more than one tool in the toolbox for recovery and being able to receive integrative treatment for her issues gave Singer hope she could be free of substance use disorder symptoms for good.
According to Hurd, part of the stigma surrounding addiction is that many think there is no hope.
“One of the worst phrases is ‘once an addict, always an addict.’ It’s not true; as a neurobiologist I can say it is not true,” Hurd said emphatically. “The human brain, even the adult brain, is plastic—I’ve seen it. Treatments are coming online to help people get their lives back.”
“The integrative model will treat the disease, eliminate stigma and improve our communities, get people back to work, being better parents, better children,” she added. “The diagnosis is not fatal, not permanent and not hopeless.”