At Clinics, Tumultuous Lives and Turbulent Care (En)

The Double-Edged Drug

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Amanda Rogers, 32, became addicted to painkillers after being prescribed methadone to treat her fibromyalgia. Leslye Davis/The New York Times

PITTSBURGH — The patient is an addict. His doctor is an addict, too. Over the last decade, both men hit their own versions of rock bottom. For the patient, it was the concrete floor of a jail where he writhed in withdrawal. For the doctor, it was the food stamp office where, his career as a child psychiatrist in tatters, he ashamedly sought help.

Then they both found buprenorphine, the patient as a user, the doctor as a prescriber. And because of that drug, an opioid used to treat opioid addiction, they both rebounded, even thrived.

The patient, Todd Smith, 27, who had developed a painkiller addiction because of a kidney disorder and — “I ain’t gonna lie” — moved on to mainlining heroin, built a life with solidity: a car, a townhouse, a job as a mine safety inspector, a live-in fiancée and “knees worn out from praying.”

The doctor, Allan W. Clark, 52, despite losing his Ohio medical license and being on probation in Pennsylvania for eight years, built a buprenorphine business so bustling that five doctors now work under him. His South Hills Recovery Project, tucked behind a 7-Eleven and beneath a hair salon, vibrates with the hubbub of the 600 addicts treated there.

Over the last couple of years, their fates have entwined, with Mr. Smith dependent on “Doc” for the treatment that keeps him stable at an out-of-pocket cost of $7,200 a year and Dr. Clark on “Smitty” and all the other cash-paying patients whose recovery he champions with an us-against-the-world fervor. They have shared, too, a keen awareness that their stability could be precarious.

“In recovery, you’re constantly facing down your demons and dealing with the echoes of your past,” Dr. Clark said. “But in the crazy world of buprenorphine, where this medicine that saves lives is harder to get and afford than the drugs that ruin lives, you’re battling outside forces, too.”

It is indeed a crazy world, or at least a vibrant, volatile subculture of people who see “bupe” as a lifeline, often difficult to reach, in an era when drug deaths outnumber those from car crashes. They scramble to find legitimate, affordable treatment even as buprenorphine is increasingly available on the street, with rising indicators of misuse and abuse tainting its reputation.

Buprenorphine was developed as a safer alternative to methadone for treating heroin and painkiller addiction, a take-home medication that could be prescribed by doctors in offices rather than dispensed daily in clinics. But in some areas a de facto clinic scene, unregulated, has developed, and it has a split personality — nonprofit treatment programs versus moneymaking enterprises built by individual doctors, some with troubled records.

The clinics serve as a crossroads where the tumultuous lives of recovering addicts converge and collide with a turbulent treatment environment.

Since March, The New York Times has visited and tracked the patients of two of the largest buprenorphine programs in this region, where addiction rates are high, for-profit clinics have proliferated, doctors go in and out of business and the black market is thriving.

Dr. Clark’s hectic, cluttered office in suburban Pittsburgh is an entrepreneurial venture with heart where the rumpled doctor dresses in sweatsuits, the boundary between patients and employees is razor thin, the requirements are minimal and the tolerance for missteps is maximal.

“I know on the surface it might look like a pill mill,” he said. “We’re seeing a fair number of patients, and they’re primarily receiving a prescription. But if you look deeper, you’ll see that we don’t use the medication in a vacuum. We encourage, we support, we don’t judge. There’s a kind of love.”

Sixty miles away, the more formal, structured treatment center at West Virginia University in Morgantown sits atop a hill, ensconced in a hospital complex and presided over by Dr. Carl R. Sullivan III, a career addictionologist who wears a white lab coat and stands professorially at the front of a classroom when he meets his patients in groups: “Are you clean? How many meetings have you been to?” he asks them.

Dr. Allan Clark’s chaotic, cluttered office in suburban Pittsburgh contrasts sharply with the institutional environment of Dr. Sullivan’s treatment program in West Virginia.	Leslye Davis/The New York Times

Dr. Sullivan, 61, primarily treated alcoholism until “a spectacular explosion of prescription opioid drugs” starting around 2000. He considered opioid addiction “a hopeless disease,” with patients leaving rehab and then relapsing and sometimes dying, until he started prescribing Suboxone, the brand-name drug whose main ingredient is buprenorphine, as a maintenance therapy in 2004.

He became a paid treatment advocate for the manufacturer, Reckitt Benckiser, delivering, he estimated, 75 talks at $500 each. But, he said, “If the company didn’t pay me a nickel, I’d still promote Suboxone because in 2013, it’s the best thing that’s happened for the opioid addict.”

Dr. Sullivan is skeptical of the buprenorphine “empires” in Pittsburgh — though not of Dr. Clark specifically, whom he does not know — believing that they feed the black market and tar the medication’s reputation. Dr. Clark, in turn, is skeptical of “ivory tower” addiction programs with rigid rules and of doctors who, in his view, collude with the pharmaceutical industry.

“Big Pharma is in it for the super profits; we should be in it for the patients,” said Dr. Clark, who nonetheless became a buprenorphine doctor partly because he needed to dig himself out of a financial hole.

An Unlikely Savior

Tall and lumbering, his balding head covered by a plaid cap, Mr. Smith strode into Dr. Clark’s office last spring with the familiarity of a clinic V.I.P., somebody whose urine is so consistently clean that he does not need to have his “pee tests” observed.

“Hey, Smitty, good to see you, my friend,” Dr. Clark said, propping his sneakered feet on his desk and swigging from his habitual can of Red Bull. By his side, a harness whip, a gift from a patient, sat beneath the framed diplomas hanging crookedly on the wall.

“Hey, Doc,” Mr. Smith said, settling his 270-pound frame into an armchair. He had hurried back from a job building windmills in Alaska just in time to get his next month’s prescription: four 8-milligram tablets a day, the highest dose recommended, that stave off withdrawal, eliminate his cravings for heroin, keep his mood balanced and alleviate his chronic pain.

Growing up in the hilltop town of Meyersdale — “Pennsylvania’s High Point” — Mr. Smith had aspired to follow his grandfather into the family business. “All I wanted to do was towing, in my Pap’s footsteps,” he said.

Todd Smith, 27, stood on a gravel road leading to the farm in Meyersdale, Pa., where he worked as a young man. Mr. Smith is one of Dr. Clark’s patients in addiction treatment. “I still hate myself for it, for the way I was,” he said. Leslye Davis/The New York Times

A rare kidney condition, treated with surgery and potent painkillers, knocked him off course. After several years, he told his doctor that he wanted to wean himself off the pills.

He said: “The doctor stopped dead like I had my pants on backward, and said, ‘You’re admitting you’re addicted?’ I said, ‘Well, it ain’t no news flash.’ ” The doctor ripped up his prescription and threw it in the air.

Mr. Smith spent the next week “dope sick,” shivering, sweating and vomiting. A friend proposed a solution: heroin, cheap and easy to find. “Things started going south,” Mr. Smith said. Then his grandfather died, and he learned that the towing business would be sold.

“I went clean off my rocker,” he said. To finance his habit, he burned through $12,000 in savings and finally drove off to sell the contents of his gun safe, including weapons of disputed ownership. A police officer was waiting when he returned to arrest him for theft. Agonizing on that jailhouse floor, he promised himself he would never use again.

A week later, essentially under house arrest in the custody of his father, a corrections officer, he called Dr. Clark’s office, crying.

“He saved my life,” Mr. Smith said.

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Video | :22 Mr. Smith on his need for his medication. Leslye Davis/The New York Times

That was two years ago. In his session last spring, Mr. Smith told his unlikely savior: “I’m sort of pissed at you. I hear you’ve been shooting Airsoft without me.” (The game involves fake guns and pellets.)

“Yeah, sorry, buddy,” the doctor said. “I know you’d be into that. What we all do in getting better is to switch to different ways of getting our ya-yas out, right?”

They talked motorcycles. The doctor drives a Harley-Davidson Fat Boy. Mr. Smith fantasizes about “barreling down the highway on a Big Dog” but is in too much debt to buy one. “You know how it is,” he said.

Dr. Clark nodded. “I thought losing my credit was the worst thing in the world, but it was the best thing in the world because now I’m living on a cash basis,” he said. “Credit is a big scam, man. It uses our addictive nature against us: ‘I want it now. I want it now.’ “

Mr. Smith loves it when Dr. Clark talks to him addict to addict. “I’ve heard patients say he ain’t no better than we are or he’s just in it for the money,” he said. “But I think being an addict makes him a better doctor. He’s been in our shoes.”

Defending the Disparaged

With tattoos commemorating his recovery, Dr. Clark runs the office with his girlfriend, Natalie Tombs, also a recovering addict. Emotive and animated, Ms. Tombs has festooned the walls with inspirational messages on butterflies and hearts and signs warning against sharing, trading or selling medication: “ANY PATIENT CAN BE SUBJECTED TO RANDOM PILL COUNTS.”

The couple portray themselves as the defenders of a disparaged segment of society with which they commiserate. Their patients see them that way, too.

“As you know, my pharmacist thinks you’re pretty much a joke, and he’s not filling your prescriptions,” one patient, James Markeley, said recently. “I brought one in, handed it to him and said, ‘How long will it be?’ He said, ‘It won’t be.’ “

Dr. Clark giggled. “What’d he say again?” he said. “I’m an old hippie? I like that one.”

It was not always so.

A graduate of the University of Cincinnati College of Medicine, Dr. Clark did a fellowship in child psychiatry at Yale, served as an Air Force doctor in Germany and then took a job at a Pennsylvania hospital.

In the late 1990s, unhappy and overwhelmed by his patient load, he prescribed himself Adderall, a stimulant. His mood improved, and he focused better. But he kept taking more to get the same effect. After two years, he was a wreck.

Dr. Clark checked himself into a rehabilitation program in 1999.

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Video | :17 Dr. Clark discussing how his experience with addiction helps him relate to patients. Leslye Davis/The New York Times

“I had to cold-turkey it,” he said. “Withdrawal from amphetamines is different. It’s much more tolerable than from opioids. After detox, though, the obsession and craving for the drug are similar. The relapse rates are similar. The triggers are similar. I had to learn to manage stress better, to rest better, to improve my self-esteem.”

Dr. Clark also had to meet the demands of Pennsylvania’s physician recovery program: therapy as well as five 12-step meetings and two random urine screens a week.

After a few sober years, he relapsed when his marriage was breaking up. He wrote himself a prescription for painkillers in his son’s name. His wife notified his program advocate.

“Just how much pain is your son in?” the advocate asked.

In 2002, a second residential program gave him a diagnosis of depression and narcissistic personality disorder — he disagreed — and discharged him early with a poor prognosis. He agreed to take a reprieve from practicing medicine in Pennsylvania; Ohio suspended his license.

Deeply in debt, Dr. Clark was reduced to collecting food stamps until Pennsylvania let him return to medicine as a prison doctor in 2003.

That same year, after a positive drug test, Dr. Clark entered his third treatment program and promised himself it would be his last. He has been sober since, he said.

His troubles did not end with sobriety, though.

Pennsylvania suspended him for a month in 2010 because he failed to submit to three unannounced drug tests while on vacation. Ohio revoked his license in 2011 because he forged signatures verifying his attendance at 12-step meetings.

In 2008, a Reckitt Benckiser representative approached Dr. Clark at a children’s hospital, saying: “There’s this great medicine, Suboxone. Why not get certified? It doesn’t take much, and it’s a nice thing to add to your practice,” he said.

Dr. Clark devised a treatment program based on federal guidelines, except he tailored it to what his working-class patients could afford. He mostly prescribed generic buprenorphine rather than the higher-priced Suboxone, which has an additive meant to deter abuse and is favored, though not mandated, by the guidelines.

And he established monthly, rather than more frequent, office visits unless patients violated the rules. He decided to “cut out the middleman” by declining to accept insurance and set his fee at $150 a visit, with a couples’ price of $100 a person.

“I made sure my price was the lowest of any of the clinics, and that’s why people liked us in the beginning,” he said. “Many of my competitors were gouging them.”

With his caseload limited to 100 by law, Dr. Clark quickly found himself turning away patients and searching for doctors who wanted to supplement their income by working part-time for him.

He hired the walk-in clinic doctor who monitored his urine drug screens, and an alternative medicine specialist who sees patients by Skype from Virginia. He also hired a 53-year-old internist shortly after a 25-year-old woman died of “acute combined drug toxicity” at the internist’s home following an evening together at the Wicked Googly bar in Ligonier, Pa.

From 250 miles away in Herndon, Va., Dr. Su Fairchild counseled Janet Vance, a patient at Dr. Clark’s office. Leslye Davis/The New York Times

“He told me he was feeling some heat in his area and needed to get out of town for a while,” Dr. Clark said.

After filing for bankruptcy protection with $1.5 million in debt early this year, the internist quit in May to run his own buprenorphine practice, saying he needed to make money fast, Dr. Clark said.

Dr. Clark scrambled to replace him so his patients would not be abandoned. They often are in this volatile field. Many of Dr. Clark’s patients showed up on his doorstep after the authorities had put their previous doctors out of business.

That happened with both Angela Scotchel, 25, and Amanda Rogers, 32. They are like before and after pictures. Ms. Scotchel, a former basketball star, is relatively fragile in her recovery, while Ms. Rogers appears firmly entrenched in hers despite a tempestuous personal life.

‘A Classy User’

In certain lights, Ms. Rogers, with her long blond hair and cornflower blue eyes, looks like the cheerleader she was, before the people closest to her started dying from drugs and she developed a yearslong habit.

“I never shot up; I always snorted,” she said in March at her home in Toronto, Ohio. “I called myself a classy user. I always made sure the kids were taken care of and the bills were paid first.”

In Steubenville, where Ms. Rogers grew up, drugs were everywhere, and almost everybody in her life was an addict: her mother and stepfather, who suffered fatal overdoses; her younger sisters; her best friend; and her boyfriend.

“That town is like poison,” she said. “I’ve probably lost close to 25 friends in the past 10 years.”

Ms. Rogers took her children, Mackenzie, 8, and Brandon, 2, and her niece and nephew, Lanyah, 6, and Nathan, 8, to Dollar General in Toronto, Ohio, to pick up detergent. Leslye Davis/The New York Times

She was 21 and devastated by her mother’s death when she started seeking solace in the “nerve pills” her mother left behind. She became so dysfunctional that she lost custody of her first child to relatives, she said, then quit the pills, had a second child and sought help for back pain and fibromyalgia from a local doctor.

“I didn’t know he was a pill pusher at the time,” she said of the doctor, who was forced into retirement by the medical authorities in 2010. “He’d get people hooked and then kick them out to hunt for drugs on the street. And once you’re on the street, heroin is cheaper than pills and lasts longer. I loved it.”

Fearful she would end up killing herself, she found a Suboxone doctor she could afford and placed her first tablet under her tongue on Sept. 21, 2009. She has been clean since, she said proudly, despite traumas that tested her resolve.

In June 2012, her younger sister Tiffany was released from a court-mandated, abstinence-based rehabilitation program. She glowed, Ms. Rogers said. But returning to Steubenville, with temptation all around, proved too much for her. Ms. Rogers said, “She was crying and crying, bawling, saying, ‘Mandy, I’m craving.’ “

Within a week, Tiffany was dead at 26 of “acute cardiac and respiratory distress due to opioid abuse and dependency,” her death certificate said.

“When I got that news, it was like with my mom,” Ms. Rogers said. “I just wanted to get in bed and stop trying.”

Ms. Rogers waited for test results at Dr. Clark’s office. Leslye Davis/The New York Times

This time, though, she ran a household filled with the grief and need of her sister’s traumatized children and of her own. So she coped. Then her Suboxone doctor lost his license for excessive narcotics prescribing, and she had to forage for medication on the street until Dr. Clark’s office called in April with an unexpected opening.

Before Ms. Rogers’s first appointment with him, her 2-year-old played boisterously as she described feeling achy and nauseous. Her buprenorphine supply had run out and withdrawal had begun.

“If it wasn’t for my pain, I might tough it out,” she said. “But if I went off the Subs, I’d have to go back on painkillers, and I’m not going back down that road.”

A few hours later, clasping a heart pendant containing a vial of her sister’s ashes, she told Dr. Clark with tearful defiance that she would not let her children or her sister’s children follow in their parents’ and grandparents’ footsteps.

“I want to break that cycle,” she said.

A Basketball Star’s Fall

Angela Scotchel was a first-generation user, but her family clung to her as she self-destructed. For her mother, Connie, that included lying by her side on the nights she overdosed to make sure she did not stop breathing. “You couldn’t call an ambulance every single time,” Connie Scotchel said.

Once a week, Mrs. Scotchel, a small-business owner with her husband, drives her daughter to Dr. Clark’s office outside Pittsburgh from Morgantown to ensure she gets there and uses their hard-earned cash to pay the doctor and buy the medication. At home, Mrs. Scotchel keeps the buprenorphine in a locked safe and dispenses it dose by dose.

In her daily uniform of basketball shorts, Angela looks more like the point guard who used to squat 300 pounds than the scrawny addict who worked for an escort service to pay for her substantial heroin habit.

“I would never do anything like that sober in a million years,” Angela said. “It was always men in their 40s, 50s and 60s, doctors and lawyers. Me being gay, it was especially disgusting. But I didn’t care as long as I got high.”

Angela Scotchel, a patient at Dr. Clark’s clinic, is recovering from a serious heroin addiction. Leslye Davis/The New York Times

During her senior year of high school, playing a rival team in a packed gym, Angela stole a ball right before halftime, tore down the court, leapt for a layup and was smacked down by an opposing player. A hush blanketed the crowd. She had torn an anterior cruciate ligament. And though she recovered to start on a college team, she soon tore another ligament. After two surgeries, she felt she had lost her game. She also developed a taste for painkillers.

“A lot of people said I could go pro, play overseas,” she said. “But I gave it all up for drugs. Every time I used, I hated myself. I felt like I had let everybody down. I wanted to die.”

Over lasagna at their home, her parents talked about how bad things got: the times she disappeared, stole money from them, crashed cars, dangerously mixed heroin and Xanax. “I can’t count the number of times the police and the municipality walked up these steps,” Mrs. Scotchel said. “They assisted us with her overdoses time and time again. I’d have to follow her to the hospital. They’d shackle her. I’d be there all night waiting.”

Putting down her fork, Angela Scotchel cried. “I went from a superstar to this lowdown dirty addict,” she said.

She first tried Suboxone in Dr. Sullivan’s clinic, which is 10 minutes from her home. But it made her ill. She thought she might be allergic to the additive in Suboxone and asked for plain buprenorphine. The clinic said no. She dropped out.

“They lived by the white coat there,” her mother said, “while Dr. Clark is like one of the addicts.”

Angela’s heroin dealer stocked plain buprenorphine, so she tried it. It made her feel great, not sick, she said, so she found a doctor willing to prescribe it last year. After six months, she and her mother arrived at his office to find federal agents in windbreakers.

“We watched the D.E.A. go in and out, and I said, ‘Angela, he’s busted,’ ” Mrs. Scotchel said. “Poor Angela was crying, thinking she was going to get sick again.”

Ms. Scotchel rides to Dr. Clark’s clinic with her mother, Connie. While Angela sees the doctor and receives her buprenorphine prescription, Connie reads in her S.U.V. Leslye Davis/The New York Times

They drove to Dr. Clark’s office, even though they knew his waiting list was long. Seeing how distraught Angela was, the doctor took her on. Early this year, Angela confessed to Dr. Clark that she was injecting her buprenorphine and mixing it with Xanax. He threatened to discharge her unless she stopped immediately. She did.

Mrs. Scotchel insisted that Dr. Clark see her daughter weekly, even though they are uninsured and it adds $3,000 to the yearly cost. The doctor gives her a $20 discount for each Narcotics Anonymous meeting she writes up in her journal.

During her daughter’s appointments, Mrs. Scotchel prefers to wait outside in her Subaru Forester, reading her Bible. “When I go in there, I gawk,” she said. “It should be a reality show.”

Policing Prescriptions

On a typical day last spring, Dr. Clark’s waiting room was a tangle of mothers and babies, interlocked girlfriends and boyfriends, bikers in leather and miners with their names on their shirts. As conversation snippets made clear, they were wrestling with eviction notices and restraining orders, insurance headaches and custody problems, parole officers and abusive spouses.

“If he comes back and says, ‘I’ve got a gun,’ I’ll load up my 12-gauge and it will be war! ” said a patient with purple-streaked hair, mascara dripping down her cheeks.

Another woman, juggling two small children, car keys and a lit cigarette, told the office manager she was broke.

“I just gave you guys my last money, and I’m out of diapers and don’t got gas,” she said. The manager returned $25 to her and told her to get home safely.

Employees wandered about in shorts and flip-flops, shouting, “Can I have a pee cup, please?” Many are recovering addicts themselves, like Thomas Walleck, who staffs the drug testing station, in front of the Wall of Lost Souls — a collage of celebrities who died of overdoses.

At Dr. Clark’s office, patients are encouraged to write down the things they are thankful for. The Wall of Lost Souls, right, has images of celebrities who have died of overdoses.	Leslye Davis/The New York Times

Mr. Walleck, gentle and raspy-voiced, said he led patients to believe that his tests were all powerful so they would be forthright.

“I’ll also tell them Doc has kicked out 180 people for dishonesty; I exaggerate,” he said. “But we got to know if they’re dirty for their own good. And if they admit it, it’s good for the bottom line, too. Because then they have to come back in two weeks, and that’s another $100.”

Monitoring patients is a delicate task. Dr. Clark summons them for surprise pill counts; a sign in his office offers “CASH and FREE VISIT rewards for information leading to the prosecution of those who are engaging in illegal activity regarding their Suboxone/Subutex prescriptions.”

Yet this policing clashes with the doctor’s fierce instinct to take his patients’ side and to confide in them about, say, his own reliance on antidepressants or his girlfriend’s routine of reading recovery books while eating licorice in bed.

Ms. Tombs, the girlfriend, gets frustrated with his penchant for giving his patients second, third and fourth chances. After he wrote a 30-day buprenorphine prescription for a young man who had admitted to dealing cocaine, Ms. Tombs angrily drew 1,000 stick figures to illustrate those on their waiting list.

“I had to sleep in the office for three days,” Dr. Clark said.

Usually the two are united against outside forces: the police who keep a too-watchful eye on their parking lot, the child protection workers who do not consider buprenorphine users drug free, the pharmacists who hassle their patients.

Dr. Clark has frequently felt under siege. He said a Reckitt Benckiser representative cautioned him that he was courting trouble with the authorities by prescribing generic buprenorphine and not Suboxone. Last year, Dr. Clark wrote the Drug Enforcement Administration to ask whether he was indeed tempting fate.

A senior D.E.A. official responded that “what drug to prescribe, what formulation, what quantity” was a doctor’s prerogative.

“It is unfortunate to learn that physicians in Western Pennsylvania have received incorrect information,” the official wrote, “and that such misinformation may potentially be inhibiting legitimate treatment.”

Feeling vindicated, Dr. Clark circulated the letter to pharmacists. But they were concerned, too, about the amounts he was prescribing. While within federal guidelines, his doses were on average twice those of Dr. Sullivan’s.

Many of his patients, having flooded their bodies with potent opioids for years, need high doses, Dr. Clark said. Indeed, he noted, studies have shown higher treatment retention rates for people getting higher doses.

Dr. Sullivan, though, spoke with frustratio