After surgery for extraction of his wisdom teeth at 20, Tsiaras, now 42, became addicted to prescription Percocets doctors gave him for pain, and as the story so often goes, pretty quickly found himself injecting heroin.
He did take methadone for about 11 years and had success with it for the most part, though Tsiaras admits he used heroin off and on during that time. But having to go to a clinic every day while trying to hold down his job at his family’s Philadelphia-based pizza shop, was difficult for him, Tsiaras said.
About two years ago, he decided to detox off of methadone himself and wound up in an emergency room and nearly died. Then Tsiaras lived with his parents for a few months before making his way to Kensington to start using heroin again.
But he also started going to Prevention Point Philadelphia, one of the largest needle exchanges in the country that offers medical and other services, just to hang out. Eventually, a counselor suggested Tsiaras try Suboxone, an opioid replacement drug like methadone but that doesn’t require daily clinic visits.
“Everything started falling into place,” Tsiaras said. He got his Hepatitis C under control. He made amends with his parents and moved back into their Fishtown home. He started working again at the pizza shop.
“I got a life again,” Tsiaras said. “The Suboxone works for me. I don’t have no cravings or nothing.”
The trusted alternative?
Stories like Tsiaras’ alongside an extreme fatal drug overdose rate – the city had just under 1,200 drug-related deaths last year – have motivated Philadelphia to launch a major media campaign with the tagline, “Bupe Works.” Bupe is short for buprenorphine, an FDA-approved partial opioid agonist that can treat addiction to narcotics.
The campaign will place posters along SEPTA’s Market-Frankford Line and Philadelphia bus shelters, as well as two billboards along I-95 and one along Route 1. Pop-up advertisements on social media along with on TV and radio will also be part of the campaign. Some of the ads will be in Spanish.
The goal is not only to reach those who are homeless users out in the open but also the “hidden population” of Philadelphians injecting or taking pills in the privacy of their houses, as well as the bilingual Spanish/English community, Philadelphia Health Commissioner Thomas Farley during a press conference last week.
“What we know is that there is ample evidence to support medication-assisted treatment,” Farley said, adding that it was considered the gold standard for treating opioid use disorder.
The campaign will emphasize buprenorphine or “bupe” for short. But it is really aimed at offering people treatment with any of the medication-assisted treatment (MAT) drugs available, also including methadone, Suboxone, and Vivitrol. People can access treatment by calling 888-545-2600 or go to bupeworks.org to be referred to a provider.
The goal of the campaign is to show “relatable” Philadelphians who attribute their recovery in part to buprenorphine, as well as therapy, said David T. Jones, commissioner of the Department of Behavioral Health and Intellectual disAbility Services.
Buprenorphine is often used alone or as Suboxone, which combines buprenorphine and naloxone. Naloxone precipitates withdrawal if someone crushes Suboxone pills or melts the film form and tries to inject them.
German doctors developed methadone during World War II as an alternative pain killer to morphine. A full agonist that blocks the effects of opioids, methadone comes in the form of a tablet, powder, or liquid. Methadone usually requires daily visits to a clinic.
Naltrexone, also known under the brand name Vivitrol, is a once a month shot that also blocks the effects of heroin and other opioids. But sometimes people shy away from it because they have to detox before beginning Vivitrol treatment.
Right now, these drugs are the only evidence-based treatment for opioid use disorder, usually combined with some sort of therapy.
Stories of success
Peter Kinzie, 31, is proof of how effective MAT can be.
He had been to more than 20 rehab facilities before a doctor finally suggested that he try buprenorphine. Now, seven years later, he is still in recovery and is one of the faces of the city’s campaign.
While he was using heroin, Kinzie had nothing left. His family had disowned him, weary of his stealing and drug use. He was living on the streets of Kensington. Finally, Kinzie decided to try buprenorphine. “I felt like I hadn’t felt in 15 years,” Kinzie said. “I felt amazing. It was a gift. It was just a gift at the end of the day, even today.”
Now Kinzie lives a stable life with his girlfriend in Lancaster, works as a sous-chef, and has reunited with his family.
“I’m very happy they’re doing this,” Kinzie said about the city’s campaign. “A lot of people are dying, and it’s not necessary.”
He added that he agreed to be in some of the ads to try to dispel stigma around substance use disorders, having experienced discriminatory attitudes in 12-step programs because he takes buprenorphine. Typically, 12-step fellowships emphasize abstinence, including MAT drugs in that category.
“I felt like I hadn’t felt in 15 years. I felt amazing. It was a gift. It was just a gift at the end of the day, even today. “I’m very happy they’re doing this, a lot of people are dying, and it’s not necessary.”
– Reformed drug user Peter Kinzie on buprenorphine, designed to treat opioid addiction
But Kinzie is not a bitter person. Instead, he is incredibly grateful.
“I was in that press conference, and in walks the doctor from the rehab who initially put me on bupe,” Kinzie said. “I told him, ‘Thank you. You literally saved my life.’”
Here to help
According to Commissioner Jones, the city currently has 12,000 MAT slots, of which about 3,000 are still available. Of those openings, approximately 1,500-1,800 are for buprenorphine and about 1,000 are for methadone.
Approximately 50,000 to 100,000 city residents use opioids, according to surveys, although exact numbers are hard to pin down, and these figures represent the “tip of a very large iceberg,” according to Farley. Furthermore, Philadelphia had 1,200 drug overdose deaths in 2017, the most of any major city “by far,” Farley said. Even with a slight drop to fewer than 1,200 overdose deaths in 2018, Farley notes that numbers are “still at crisis levels.”
When Farley was the commissioner of New York’s Department of Health and Mental Hygiene until 2014, the city ran a similar MAT advertising campaign. But he says Philadelphia has an even greater need for such a campaign because of the high number of users and drug overdose deaths.
Dr. Joshua Lee, associate professor in the Department of Population Health at New York University Langone Health, has done extensive research about MAT and has worked with many patients in and out of incarceration settings who use buprenorphine, methadone, or Vivitrol. He said a city-wide MAT campaign can be effective because “awareness grows and the ability to treat more and more people grows.”
“It’s a drug we’ve had for many years now,” Lee said about buprenorphine, which received FDA approval in 2002 specifically for treating opioid addiction. “It’s kind of an old story in terms of pharmacology.”
But “the epidemic has gotten worse, and most people never had good access to buprenorphine even in a city like Philly,” Lee said, adding that even with the help of buprenorphine and other MAT drugs, treatment hasn’t been able to keep up with the fentanyl levels present in the heroin supply. Fentanyl is a lethal synthetic opioid 50 to 100 times more potent than morphine.
In general, more doctors should start prescribing buprenorphine to help combat the opioid crisis, Lee said. The problem is that there’s not a lot of motivation to do so because physicians have to go through special training and be certified; they don’t earn more money than they do treating other patients; there’s no special recognition, and they don’t see fewer patients than they do now, Lee said. Also, sometimes a discriminatory attitude toward drug users gets in the way of doctors pursuing MAT.
“They may have preconceptions or experiences…associating heroin use with poorly functioning patients,” Lee said.
Dr. George Woody, emeritus professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania, says that it should be easier for doctors to gain certification to prescribe buprenorphine. It is “more user-friendly, easier to use,” than methadone or Vivitrol, he said.
“I just think it’s a very effective drug,” Woody said. “The medication itself is very helpful and holds onto patients,” giving them a start so they can stabilize their lives, enter counseling, and find housing and jobs if that is an issue.
The bottom line for the city in terms of messaging, Woody said, is that “without medication, the relapse rate is very high, as well as the fatality rate without taking these medications.”
Philadelphia has seen a sixfold increase over the past three years in the number of people with opioid use disorders who are taking some form of MAT. This is encouraging but insufficient, considering the rate at which people are still dying from drug overdoses, Jones said.
Tsiaras said he worries about young users thinking they are getting heroin but instead receiving fentanyl. “They’re playing Russian roulette with three, four bullets missing.”
Tsiaras, himself, didn’t think he’d make it to 42, but he did with the help of MAT. “This is the way to stay clean. There’s no happy ending. It took me so many years to understand that. We need this,” Tsiaras said about the ad campaign.
Asked whether he thought the campaign would actually draw people into treatment, Tsiaras nearly started to cry.
“I feel like if you want to live a good life, a stable life, this [MAT] is the way. I’ve been there, done it all. It [MAT] works.”