Maybe you've noticed the signs. They can be seen at intersections as you drive into Martinsville, through town and as you drive out: “Methadone – Suboxone - $1 a Day” or “Methadone – Suboxone – Medicaid accepted.”
Both signs carry the same phone number, although only the $1-a-day sign features a logo and website address, in small letters on the bottom: ALEF Behavioral.
“Both [methadone and Suboxone] are medications that are used in the treatment of opioid addiction,” said Sharon Buckman, the clinical services director at Piedmont Community Services.
The city of Martinsville is one of the nation's worst for opioid addiction. The presence of signs touting those powerful drugs used to replace the addictive painkillers and ease an addict's path to recovery -- ultimately linked to a clinic in Eden, N.C. -- raised questions about how they came to be there and the propriety of touting cheap paths to medications that Piedmont Community Services says must be taken in conjunction with therapy, peer support and other types of help.
The Bulletin asked the Federal Drug Administration about those signs and received a response from “spokesperson,” who did not provide a name. That spokesperson said the FDA takes promotions for anything having to do with opioids very seriously. The spokesperson said in an email that “the Office of Prescription Drug Promotion proactively flags, monitors and reviews promotional pieces for opioids as one of our highest priorities.”
Those simple yard signs are classified by the FDA as “reminder ads,” which give a medication’s name but not its use.
“The assumption behind reminder ads is that the audience knows what the drug is for and does not need to be told,” the section “Reminder Ad (Correct)” states on the FDA’s prescription drugs website.
When asked about the $1/day signs in Martinsville, the spokesperson did not talk about them specifically but responded about drug advertisements in general, including links to parts of the agency’s website.
“As a regulatory agency, the FDA is committed to ensuring that prescription drug promotion is truthful, balanced and accurately communicated,” the spokesperson said by email.
Federal law does not prohibit drug companies from advertising any kind of prescription drug, “even ones that can cause severe injury, addiction or withdrawal effects. However, companies cannot use reminder promotion for drugs with certain serious risks (drugs with ‘boxed warnings’),” the spokesperson wrote.
According to the FDA’s “Drug Advertising” A Glossary of Terms” on its website, “Boxed warnings” are required in “drugs that have special problems, particularly ones that may lead to death or serious injury.” They are like those lengthy warnings you hear read at the end of ads on television.
Because prescription opioids carry such high risks, the FDA carefully scrutinizes how they are marketed. “The Office of Prescription Drug Promotion proactively flags, monitors and reviews promotional pieces for opioids as one of our highest priorities,” the spokesperson wrote.
The spokesperson sent links to sections of the FDA’s website, which provide details about drug advertisements:
“Prescription Drug Advertising Questions and Answers” states that the FDA does not see ads before the public does. If it believes an ad violates the law, “we send a letter to the drug company asking that the ads be stopped right away.”
The review of “promotional pieces for opioids” is one of the roles of the Office of Prescription Drug Promotion, the FDA spokesperson wrote, and considers monitoring and reviewing “promotional pieces for opioids as one of our highest priorities.”
Last year, Piedmont Community Service helped 1,000 people with substance abuse disorders across its coverage area of Martinsville and the counties of Henry, Patrick and Franklin, Buckman said.
“Both methadone and Suboxone have street value,” Buckman said. “Methadone has the potential for abuse,” although the way to get high off it is “very complicated.”
“Suboxone’s street value is primarily because it can help [stop] withdrawal symptoms” from opioid abuse if an abuser “can’t get their preferred street drug, to prevent getting sick,” she said.
Buckman said overcoming a drug addiction is much more involved than just taking pills.
“Those require a combination of medication, counseling and care coordination and case management,” she said. “Our program also includes peer support from individuals who have training and education, but also … experience in recovery.
“We know that just the pill alone does not usually get results … in long-term recovery.”
How Suboxone is used
PCS has “office-based opioid treatment in all three of its clinics” at 24 Clay Street in Martinsville, 22280 Jeb Stuart Highway in Stuart and 30 Technology Drive in Rocky Mount.
Suboxone is used to reduce cravings for opioids and ease or prevent withdrawal symptoms caused when someone stops taking opioids, Buckman said.
It can be prescribed “by any physician who has completed training by the Substance Abuse and Mental Health Services Administration,” she said. A doctor who takes the free, 8-hour training is granted certificate from the Drug Enforcement Agency to prescribe it.
Nurse practitioners are able to get that certification if they complete 24 hours of training, she said.
Methadone requires a clinic
Methadone “has to be provided by a specialized clinic,” she said. A person using methadone usually has to take that medication at a clinic under supervision, rather than receiving a supply to keep at home.
“There is a potential for abuse with methadone, which is why people have to be observed taking it initially,” she said.
“Methadone clinics operate in the early hours of the morning,” she said. “Family members have to take the person in at 5 p.m. to get their doses. They have to go every day,” until “eventually they get a week’s worth of medications at a time” to take on their own, at home.
Opioid addiction problems are treated with multiple tactics including, as appropriate, licensed and certified counselors, care coordinators “to help people get access to basic needs,” including a primary physician, transportation and housing, peer supporters and Suboxone.
Recuperation time from an opioid addiction varies greatly, she said. The goal of the first 90 days of treatment is “to give people the tools they need, and especially the road map to stay in recovery.”
Some people consider recovery from opioid addiction to be a lifelong process, she said.
“Some clinics try to taper people off Suboxone after a year,” she said. “Other prescribers feel if it helps someone to avoid relapse, it’s OK to use the medication indefinitely.”
A new clinic
Buckman said she had not seen the ads promoting the $1 Suboxone and methadone, but that could be because she does not live in the city and has not been out as much as normal because of the pandemic restrictions. She said she has noticed other lawn signs for a different clinic, Spero Health, which recently opened a clinic in Martinsville and has many signs close to the ALEF signs.
“I did some research” on Spero Health, she said. “It appears to me that they have a track record nationally for putting in place the right services to help someone toward the right recovery. I was happy to see that.”
Buckman said another “national provider” was looking to open an office in Martinsville. That group talked “about the combination, the medication but also the counseling and peer support,” she said.
ALEF Behavioral Health Group
ALEF Behavioral Health Group's website calls the company “a fully-accredited, evidence-based opioid addiction treatment center” that “employs the best mind, body and spirit elements in our addiction treatment.” It says it is fully certified by the federal Substance Abuse and Mental Health Services Administration and is “duly registered” with the Drug Enforcement Administration.
It has a clinic in Eden, N.C., and, “coming soon,” clinics in Chapel Hill, N.C.; Dare County, N.C., High Point, N.C., Lauren’s County, Ga., Myrtle Beach, S.C., and Pulaski County, Ga., according to its website.
When asked in a telephone conversation about the $1/day promotion, ALEF Behavioral therapist Orlando Paz said, “That was a program we had, and we were helping out the community with it, mostly because of when the COVID stuff came in, a lot of people were having a rough time. We dropped it down to 30 days – the price of the prescription went down to $30 for 30 days.”
In comparison, GoodRx.com lists various price options for Suboxone tablets, with the lowest being $35 for 28 days, and for methadone, $9 for 60 10mg tablets.
The $1-a-day promotion at ALEF Behavioral “included your counselor, your intake, no hidden fees, no doctor fees,” Paz said. “Some places you go you have a doctor fee, pay for a prescription and also have to pay for a doctor’s visit.”
In an interview with John Joyce of Triad Business Journal, ALEF Behavioral Group President and CEO Ronald Flack Jr. said that ALEF Behavioral operates “on a self-pay model” and does not accept insurance or Medicare.
Paz said the clinic now accepts Medicaid.
When asked about the $1/day signs, Paz said, “We have taken those signs down pretty much and put up new signs that say we accept Medicaid. If you come in and are still struggling, for the first 30 days we go on and off: week on, week off at $1 a day.”
After that, he did not answer any more questions, saying his is not authorized to speak to the press.
A community in crisis
Southern Virginia long has been recognized as having among the nation’s worst problems for opioid misuse and addiction.
Two doctors who had clinics in Martinsville, Vincent K. Jones and Joel Smithers, were under federal investigation for improperly prescribing opioids. Smithers was sentenced to 40 years in prison and fined in October, and Jones committed suicide last fall.
The city of Martinsville had the nation’s second-highest-per-capita rate for the most opioid pain pills prescribed between 2006 and 2012, based on information in a database maintained by the DEA. That report said 242 pills per person were distributed in Martinsville, exceeded in rate only by another Virginia city – Norton, with 306 pills per person.
“The FDA is committed to ongoing efforts to address this tragic crisis and supports broader initiatives including regulatory, educational, scientific, and collaborative activities from a range of stakeholders,” the FDA spokesperson wrote in the email. “We have maintained that industry has a very important role to play here and we urge companies – from drug manufacturers, to payors and pharmacies – to not only comply with the law and what is required, but ask themselves what more they can be doing to help reverse this public health crisis of abuse, addiction and death from overdose.”
Holly Kozelsky is a writer for the Martinsville Bulletin; contact her at 276-638-8801 ext. 243.