MARSHALLTOWN, Iowa — A newborn had arrived for his checkup, prompting Dr. Nicole Gastala to abandon her half-eaten lunch and brace for the afternoon crush. An older man with diabetes would follow, then a pregnant teenager, a possible case of pneumonia and someone with a rash.
There were also patients on her schedule with a problem most primary care doctors don’t treat: a former construction worker fighting an addiction to opioid painkillers, and a tattooed millennial who had been injecting heroin four times a day.
Opioid overdoses are killing so many Americans that demographers say they are likely behind a striking drop in life expectancy. Yet most of the more than two million people addicted to opioid painkillers, heroin and synthetic fentanyl get no treatment. Dr. Gastala, 33, is trying to help by folding addiction treatment into her everyday family medicine practice. She is one of a small cadre of primary care doctors who regularly prescribe buprenorphine, a medication that helps suppress the cravings and withdrawal symptoms that plague people addicted to opioids. If the country is really going to curb the opioid epidemic, many public health experts say, it will need a lot more Dr. Gastalas.
Science says buprenorphine works: A substantial body of research has found that people who take it are less likely to die and more likely to stay in treatment. It is an opioid itself but relatively weak, activating the brain’s opioid receptors enough to ease cravings, yet not enough to provide a high in people accustomed to stronger drugs. But only about five percent of the nation’s doctors — 43,109 as of last week — are licensed to prescribe it. A new study found that even among people who had overdosed, only 30 percent were provided with buprenorphine or one of the other medications approved for treating opioid addiction, methadone and naltrexone, in the year that followed.
After a rocky start, the Trump administration has gotten on board with addiction medications, which also include methadone and naltrexone. The nation’s top health official, the Health and Human Services secretary, Alex Azar, said recently that trying to recover without them is “like trying to treat an infection without antibiotics.” Last year, Congress temporarily began allowing nurse practitioners and physician assistants to prescribe buprenorphine if they go through extra training, and more than 7,000 have gotten licensed; a bill that passed the House on Friday would let them prescribe it permanently. Still, half the counties in the United States don’t have a single buprenorphine prescriber.
Dr. Gastala has to follow strict federal requirements and live with the possibility that the Drug Enforcement Administration might inspect her office with no warning. Insurers require her to jump through constant hoops to get the medication approved for her patients.
She has found that addiction treatment is incredibly complex work, not least because the patients often have unaddressed mental health problems. She has been crushed when patients drop out of treatment, fearful of reading about one of their deaths in the newspaper and conflicted about whether and when to stop treating someone who continues to use drugs.
“This is not like a newborn exam or a diabetes check or strep,” said Dr. Gastala, who has kind eyes and an emphatic laugh. “It’s very complicated and takes a lot of time and effort, and can feel high risk.”
She added: “It definitely wasn’t comfortable at first.”
A Vital Partner
Early in her busy afternoon Dr. Gastala greeted a new patient: Fallon Steenhoek, who was trying to stop using heroin.
Ms. Steenhoek, 30, had started on Suboxone —the most common formulation of buprenorphine — a month earlier, while staying with her stepfather in Illinois. Now she was back at home and needed a way to keep getting the medication. She had already lost custody of her 10-year-old daughter, and didn’t want to lose her 1-year-old son.
Andrea Storjohann, a nurse case manager who is Dr. Gastala’s vital partner in treating addicted patients, was waiting for her in the exam room. Ms. Storjohann keeps the buprenorphine program running while the doctor multitasks. She gauges each patient’s progress, asking about their highs and lows since their last appointment. She also tests their urine to check for other drugs and that they’re not misusing or diverting the medication. And she makes sure they’re going to therapy, which the program requires. She’s a native of Marshalltown, gently sly and good at winning patients’ trust.
“In the last year, how many times have you used an illegal drug or prescription medicine for a nonmedical reason?” she asked Ms. Steenhoek.
“Like, 300,” came the reply. There was no trace of judgment on the nurse’s face.
The questions continued, a long checklist, including whether Ms. Steenhoek had been the victim of violence or abuse.
“Yeah, I definitely have a history with that,” she whispered
“Was it emotional, physical, sexual, financial?”
Ms. Steenhoek’s face crumpled. “All of it,” she said, starting to cry. “My daughter’s dad was pretty textbook.”
She said she’d been having intense cravings for heroin, and had taken more than her usual dose of Suboxone in desperation one recent night. She looked at the nurse uneasily.
“I’d rather you do that than go use heroin,” Ms. Storjohann reassured her. “How often are you feeling like you’re really on the edge and needing to reach for something else?”
“A couple times a week. I go to meetings and that only takes you so far. I do smoke a lot of cigarettes. I drink a lot of caffeine because that seems to help a lot, too. But you can only do so much.”
Then it was Dr. Gastala’s turn to meet Ms Steenhoek, asking about her support system, how often she went to therapy and whether she had a job. She also wanted to know whether Ms. Steenhoek had been treated for the hepatitis C she had gotten from injecting drugs — not yet, the patient said — and whether she had a longterm goal.
“I just know my main goal is to remain sober and recover all my relationships and have that sense of normalcy in my life,” Ms. Steenhoek said. “That’s what I want more than anything right now.”
Dr. Gastala increased her daily dose to 12 milligrams, from eight.
“If you feel it’s not enough, don’t wait until your next appointment,” she said. “Call us.”
An Unexpected Mission
Dr. Gastala had no interest in treating addiction until she arrived in rural Iowa, but she knew from a young age that she wanted to do work that others might shy away from. She was 6 when her mother, a secretary, died of Hodgkins lymphoma, and the doctors and nurses who cared for her left a profound mark. When she was in medical school in Chicago, her father, an engineer, died of brain cancer, and she decided to spend four months working at a rural clinic for the poor in Bolivia. The experience, she said, propelled her into family medicine.
She came to Marshalltown straight out of residency at the University of Iowa, as a participant in a federal program that would help pay off her medical school loans if she worked for three years in an underserved community. Marshalltown, a city of 27,000, appealed because of its diverse population — a mix of longtime, mostly white residents and Hispanics who started coming in the 1980s to work in the area’s meatpacking plants.
Dr. Gastala was eager to start the type of weight-loss and diabetes prevention programs here that she had organized as a resident in Iowa City. But after arriving in July 2015, she was struck by the number of patients dependent on opioids they’d been prescribed over the years — including at her new practice — for chronic pain.
Iowa is no Ohio or West Virginia in the breadth of its opioid problem; meth addiction remains more common here. Heroin and fentanyl, however, have started to grab hold. Iowa had 206 deaths involving opioids in 2017, according to provisional state data; fatal heroin overdoses more than doubled, to 34.
Marshall County’s addiction treatment agency happened to be across the street from Dr. Gastala’s practice. When she mentioned the problem to the agency’s leaders, they asked her to consider prescribing buprenorphine. At that point, the closest prescribers were an hour’s drive away.
Dr. Gastala helped her practice, Primary Health Care, a community health center, get a federal grant to start a buprenorphine program. She took the eight hours of training required to prescribe it, along with an older colleague. They started in January 2016, and demand has grown steadily since then. Most of their addiction patients get individual or group therapy, or both, at the agency across the street, the Substance Abuse Treatment Unit of Central Iowa.
Dr. Gastala had learned almost nothing during her four years of medical school and three years of residency about addiction or how to treat it. She taught herself from articles and books; by talking to a Veterans Administration doctor in Iowa City who prescribes buprenorphine; and from monthly video conferences that a health center in Connecticut holds with primary care doctors around the country who are taking on addiction treatment.
Innately cautious, her instincts clashed with what the doctors leading the video sessions believed — that the overall goal of buprenorphine treatment was preventing deaths, even if it sometimes meant allowing patients to stay in treatment despite continuing to use illicit drugs.
“I thought the goal was zero inconsistent drug screens,” Dr. Gastala said during a 2016 session, sounding exasperated. “I don’t know what to do; I just don’t know.”
Dr. Marwan Haddad, who was leading the session that day from Middletown, Conn., reminded her that addiction was a chronic, relapsing disease.
“I don’t expect my patients, the moment I give them Suboxone, to say, ‘I got the miracle pill and my life is going to fall into place and I’ll stay off drugs completely,’ ” Dr. Haddad said. “If they are decreasing injection and use, you’ve moved them along to a safer place in many ways, even if it’s not completely gone.”
Dr. Gastala said she has undergone “a complete evolution” since then.
“I had to learn how to have a more open mind and just be O.K. with meeting patients where they’re at,” she said. “A lot of our nurses and staff have also grown and been more empathetic than in the very beginning, when it was more like, ‘Oh, you messed up? Then you’re done.’ ”
Another challenge is more logistical: How to fit addiction treatment into a busy primary care practice. Dr. Gastala does it by double-booking her buprenorphine patients; Ms. Storjohann, the nurse, conducts most of each appointment, with Dr. Gastala popping in at the end.
The appointments are not moneymakers; the modest income they bring in helps pay Ms. Storjohann’s salary. A separate grant provides initial doses of Suboxone for patients whose insurance (usually Medicaid) hasn’t approved it yet.
Those donated doses often have to last weeks. To get the required “prior authorization,” Ms. Storjohann has to provide insurers with proof that the patient is getting frequent urine tests and that nobody is prescribing narcotics or anti-anxiety drugs. Insurers sometimes limit daily doses and require reauthorization as often as every three months.
“You can write hydrocodone or Percocet and you have no hoops to jump through,” Dr. Gastala said. “With the Suboxone, there are still a lot of hoops.”
Lost to Treatment
Of the 60 patients Dr. Gastala’s practice has treated with Suboxone, 40 are “inactive” at this point, generally meaning they relapsed, found another treatment provider or tapered off the medication successfully, she said. Eleven of the 40 simply disappeared.
“We always try to reach out and call them,” Dr. Gastala said, “but sometimes they don’t call back and you don’t know why.”
In her experience, the patients who do best have strong family support, a permanent place to live and, often, a job. Melinda Karam is one of them; she started on Suboxone last September and has stuck with it but for one relapse around the holidays. The only cravings she has now are in dreams.
“Dreams about using are normal,” Ms. Storjohann reassured her during a recent visit.
That day, she also saw Tammie Mellies, 42, slouched and looking despondent.
Ms. Mellies had come to see her in early February about an addiction to hydrocodone, but disappeared afterward. It turned out a judge had sent her to an inpatient treatment center about an hour away. The center had started her on Suboxone, discharged her after three days and referred her back to Dr. Gastala.
Ms. Mellies was still struggling. The dose she was on, eight milligrams daily, hadn’t diminished her cravings enough.
“Addiction just sucks,” she said softly.
Dr. Gastala gave her a week’s prescription for the higher dose. “We’ll see you back in a week,” Ms. Storjohann said.
Ms. Mellies returned once but then disappeared again. When Ms. Storjohann called to check on her, she said she had decided to stop taking Suboxone. Her name went on the inactive list.
Dr. Gastala initially planned to require patients to taper off Suboxone after two years at the most, believing that if patients’ lives had stabilized, they wouldn’t need it anymore. But she has softened her stance. Most of her patients are terrified of coming off the medication and having their cravings roar back, no matter how well they’re doing.
Andrea Steen, who started on Suboxone in 2016 after becoming addicted to Vicodin she stole from her disabled husband, is one who hopes to stay on it for the rest of her life.
“I would die with it if it was up to me,” she said during a visit with Ms. Storjohann.
Ms. Steen said she sometimes clashes with other recovering addicts who buy into the notion that buprenorphine is just another opioid, a crutch.
“In my 12-step program there’s one member, her and her husband say it’s just like taking heroin,” Ms. Steen said. “Well, do your research. I’ve done mine.”
“A lot of people say Narcotics Anonymous has saved their life,” she added. “In a meeting, I said, ‘I love Narcotics Anonymous but it’s the Suboxone that’s saved my life.’ And it’s the truth.”
It was Thursday, and as usual, Dr. Gastala was the last to leave the office, around 8 p.m. She climbed into her Subaru and set out for Iowa City, where her husband, a radiologist, is completing a fellowship.
After he finishes his training this summer, they are moving home to Chicago. She has accepted a job at another community health center, and will continue treating addiction.
By then, two nurse practitioners at the Marshalltown clinic will be licensed to prescribe buprenorphine, taking over her caseload and, she hopes, allowing it to grow. Primary Health Care, which already offered buprenorphine at a clinic in Des Moines, now also offers it at a clinic in Ames. And doctors from Sioux City, Iowa City, the Quad Cities and Cedar Rapids have sought Dr. Gastala’s advice on starting buprenorphine programs.
Fallon Steenhoek, the patient who was struggling to stop using heroin, remains in Newton, a 45-minute drive from Marshalltown, keeping a video log of her recovery and hoping the expansion of buprenorphine prescribers will reach her there. She relapsed one afternoon in April after finding an old bag of heroin in her garage, but being on Suboxone, she felt sick, not high.
She called Dr. Gastala’s office a few hours later to report what happened.
Ms. Storjohann, the nurse, told her, “‘Fallon, the important part is you came back from it,’” Ms. Steenhoek recalled. Until she has a closer option, she plans to continue driving to Marshalltown.