Nurse Bruce Baginski uses a breathalyzer on a patient before giving them their dose of methadone at Zuckerberg San Francisco General’s Opiate Treatment Outpatient Program. (Laura Klivans/KQED)
Each morning when Tomás wakes up, he opens his nightstand drawer and takes his medications: a drug for high blood pressure, pain relievers for his sciatica and a light pink pill.
The 68-year-old places the pill under his tongue and waits for it to dissolve.
"It has a typical medicinal taste to it," Tomás said. "It's just slightly bitter."
The medication is buprenorphine. It's a prescription drug that curbs the cravings that come from opioid addiction. When dosed correctly, it won't produce a high.
Tomás is one of a growing number of Californians with prescriptions for buprenorphine, one of the FDA-approved drugs that is part of medication-assisted treatment (MAT) for opioid addiction. MAT combines those medications with counseling and is considered the most effective way to treat opioid addiction.
While the opioid crisis has not hit California as hard as some of the Eastern states, roughly 2,000 Californians die each year of an opioid overdose.
In a bid to combat this, California's Department of Health Care Services (DHCS) has invested $265 million since 2017 to increase access to medication-assisted treatment throughout the state.
Tomás' story offers a window into what America's opioid crisis may look like in the future: people on medication to treat their addiction for years, or even for the rest of their lives.
'I Can Control This'
Tomás was once addicted to heroin, and preferred only his first name be used in this article. He owns a landscaping business and is concerned that current or future clients may peg him as untrustworthy if they learn about his past.
He started using heroin at 18, when he was in the Army during the Vietnam War. He was stationed in Germany.
"I didn't think much of it at the time, thinking I can control this, this won't be a problem," Tomás said. "That when I get out of the service I'll just put this behind me."
But things didn't pan out that way, and Tomás continued seeking out and using heroin. He said he hit bottom in the 1980s when he was back living in the U.S.
"I was a dealer-addict," Tomás said. He lived in San Francisco's Mission District, "in one of those fleabag hotels. I had a girlfriend who was a working girl. We slung dope, and did a lot of dope."
He said that life was dangerous and lonely, and eventually he wanted something different.
"I just woke up to my surroundings one morning and realized, this isn’t the way to live," he said.
Tomás got clean with the help of methadone, another medication for opioid addiction. Eventually, though, he chose to stop taking it. He liked the idea of being free of any medications, and he said the methadone made him sleepy and turned his thinking a bit cloudy.
Going off that medication was a risky move. Research shows that people who are not on medication-assisted treatment are overwhelmingly more likely to relapse within a year than people who are on it.
But Tomás made it past a year. In fact, he made it longer than two decades without medication-assisted treatment, which addiction specialists say is rare.
Tomás' sobriety ended, however, when he developed a painful cyst on his spine. One weekend he ran out of the pain medication his doctor had prescribed.
"I said, 'I can't be in this pain, I gotta go do something,' " he said. "That's when I went back to doing heroin again."
'Addiction Is Like Diabetes'
Tomás' relapse — or anyone's for that matter — is not surprising to most addiction doctors. That's because they see addiction as a chronic disease requiring ongoing treatment.
"Addiction is like diabetes," said Dr. Keith Humphreys, a professor of psychiatry and behavioral sciences at Stanford University.
"It's not something that we can cure or eliminate, and it has to be managed over time by the person," Humphreys said. "Just as most people who take insulin will need it for the rest of their lives, most people who are, say, addicted to heroin will need medication for the rest of their lives."
Humphreys said that when someone uses opioids again and again, the structure of their brain changes. Therefore it's the work of years and not months for someone to stop using medication for their opioid addiction. It may be best to continue taking the medication indefinitely, he said.
"The fact that it started from voluntary use does not mean that it's reversible. There are plenty of things, plenty of diseases that we get through our behavior that we have to accept as an enduring condition of ourselves," Humphreys said.
There are myriad challenges to keeping patients on medications long term, however: The treatment takes time and money. Patients also face stigma from their families, their communities and from our culture as a whole.
"One of the most dangerous risks to our patients' health is stigma," said Dr. Soraya Azari, an associate clinical professor at the UCSF School of Medicine.
Azari said patients also blame themselves. "They think that this medicine is just using more drugs, and they think that [addiction] isn't a medical condition, that it's just a bad choice," Azari said. "That's patients' self-stigma."
Two out of the three FDA-approved medications for opioid addiction are opioids (methadone and buprenorphine), and some patients worry they're substituting one opioid for another.
There are side effects to the medications, too: changes in energy, GI issues, increased sleepiness. But "all those risks are way lower than the risk of injecting heroin," said Humphreys.
Studies show that people with opioid addiction are up to five times more likely to die of an overdose if they stop maintenance treatment.
Where Treatment Begins
Ramona Gaines stands behind a glass window and welcomes person after person to the Opiate Treatment Outpatient Program (OTOP) at Zuckerberg San Francisco General Hospital. She knows the names of most of the 300-400 patients she sees each day. This is one place where treatment starts.
While the OTOP program at Zuckerberg is not funded directly by the state's recent investment in opioid treatment, other similar clinics are.
All patients who show up are here to "dose," i.e., to take their medication for their addiction. They wait briefly in a waiting room until called up to one of three windows, where a nurse will check in with them and then give them their dose of either methadone, in red liquid form, or bupenorphine, a pill.
Some patients will access additional services, depending on the day and their circumstances. They often meet one-on-one with their counselors to address the issues underlying their opioid use; homelessness and trauma are common.
Most people come here every single day. Since the medications are themselves opioids, they're tightly regulated. After regular visits and clean urine samples, though, patients can graduate to taking their doses at home. Eventually, they may even transition out of the clinic and get their medications from their primary care doctor.
That's what happened to Tomás: After he relapsed in 2011, he came to this clinic.
"The concern there was very sincere," he said. He found it inspiring and motivating.
Through counseling, he looked back on what he'd done with his life — his business, his friendships. And he realized, "It would be very, very stupid of me to let all that go for chasing the euphoria of any opioid," he said.
Tomás has been on buprenorphine consistently for more than eight years. He said that someday he would like to get off it again. He doesn't like feeling like he's dependent on something.
Maybe he will get off the buprenorphine, maybe he won't. But for now, he's got his daily pills right there in his nightstand.