Nicole stepped out of the squad car in front of the Charleston Center wearing nothing but the blue scrubs they had issued her at the hospital.
She was scared, several months pregnant, and underweight as a result of severe morning sickness and more than a decade of battling addiction.
By the time she arrived at the entrance of the publicly run treatment center in downtown Charleston, she had a long history of failed attempts to quit using highly addictive painkillers and the heroin she purchased when those prescriptions weren’t enough.
But each time she was rebuffed by the mind-numbing symptoms of withdrawal: chills, vomiting, aches and the severe dehydration that on one occasion hospitalized her.
“You don’t want to shower. You don’t want to dress. You don’t want to do anything,” said Nicole, 34, who asked to be identified by her middle name because of the continued stigma surrounding addiction.
Her story is familiar.
White and black, poor and upper class, teenage boys and middle-age women, high school dropouts and doctoral degrees. The opioid epidemic hasn’t discriminated.
More than 2 million Americans are estimated to suffer from an addiction to prescription pain pills or heroin. More than 33,000 lives were cut short by related overdoses in 2015, including 565 known fatalities in South Carolina from the Lowcountry to the Upstate.
The toll has only increased since.
In response, the federal government has pumped billions of dollars in aid to states around the country, and in South Carolina, a raft of legislation has been passed in an attempt to curtail the growing health crisis.
Over-prescribing patterns are now more easily recognized. The misuse of legal painkillers is being constricted. And the ability to counteract the overdoses that are occurring in homes, emergency rooms and grocery store parking lots has drastically improved.
What has gotten less attention, addiction experts say, is an ongoing lack of access and affordability to the most effective treatment programs, like the one Nicole walked into last September.
The state is trying to better prepare itself to deal with addiction, but opioid treatment in the Palmetto State is still held back, in part, by the isolation of rural communities, the red tape of public and private insurance providers, and the continued stigmatization of treatment medications.
South Carolina remains one of only 16 states that doesn’t cover methadone, the most clinically researched treatment drug, for opioid addiction under its Medicaid program that serves nearly a quarter of the state’s population. The state Medicaid agency said it was exploring the possibility of covering this drug for addiction treatment in the future.
Meanwhile, the state’s managed care organizations — the private companies that administer health care benefits to two-thirds of all Medicaid beneficiaries in South Carolina — continue to make patients and providers jump through hoops to get coverage for two other approved treatment medications for opioids, addiction treatment providers said.
Many private insurance providers have similar requirements.
Police officers and emergency crews saved more than 6,000 South Carolinians from overdosing last year. Many hospitals are getting better at recognizing addiction and encouraging people to seek treatment. Drug courts are pushing people fighting addiction toward counseling instead of prison.
But unless the physical and financial barriers are lowered for medication-assisted treatment, those efforts are like putting small bandages on a growing wound, addiction experts say.
“It comes close to malpractice to treat someone for an overdose without linking them to care,” said Kathleen Brady, vice president of research at the Medical University of South Carolina and a leader in the field of addiction treatment.
'Mythology' of methadone
Most of Nicole’s days for the past 10 months have started the same way.
She wakes up at around 5 in the morning and piles into the Jeep Cherokee with her fiance and her now 8-month-old son to make the hour-long drive from Colleton County to Charleston.
She drops her partner off at his job and heads to the Charleston Center, where she meets with counselors and drinks her precisely measured dosage of methadone, a synthetic opioid that has been used as a treatment medication for decades.
The dose allows her to function as she slowly weans herself off her long-term addiction. The body-wrenching effects of opioid withdrawal that defeated her so many times before are held at bay. Gone are many of the urges to misuse the prescription painkillers she was first prescribed after a car accident in her early 20s that she later started abusing.
The methadone treatment program Nicole began last year also averted the chance of withdrawal symptoms killing her then-unborn son. It has since given her enough energy to chase her healthy baby boy through their small home near Round O instead of being doubled over in agony.
She hopes to be reunited soon with her two older children, who her grandmother has been raising as she struggles with addiction.
“People have long-term success on methadone,” said Chanda Brown, the director of the Charleston Center, a Charleston County-run substance abuse prevention and treatment program. “They have their families back. They have their careers back. They have their health back. They have their life back.”
But while methadone is often the preferred treatment drug for those suffering from long-term addiction, neither public nor private insurance covers it in South Carolina.
The state’s Medicaid program that insures more than 1 million South Carolinians will cover the methadone if it's prescribed as a pain reliever, but not if it’s used to battle addiction.
In the absence of insurance coverage, federal block grants have been used to cover some patients’ costs, but treatment officials say that pot of money could go a lot further if existing Medicaid recipients could get their care covered.
Now that Nicole’s funding has run out, she is covering the $14 per day it costs for the medication, the medical services and the psychiatric care she receives at the center three times a week. She could be on a similar treatment schedule for quite awhile longer.
A 2016 report from the U.S. Surgeon General cited research that showed patients receiving medication-assisted treatment for more than three years were far less likely to relapse. With less than a year of recovery behind her, the thought of dropping her methadone dosage now frightens Nicole.
There are 19 highly regulated treatment centers in South Carolina allowed to dispense methadone, but most of them are located in more urban areas of the state, including Charleston, Greenville, Myrtle Beach and Columbia. All but the Charleston Center are run by private companies.
Physical distance is often a barrier for those seeking help, said Christine Martin, president of the S.C. Association for the Treatment of Opioid Dependence and the clinical director at another treatment center in North Charleston.
“We have pockets of the state that are well covered,” she said. “But if you get out into the more rural counties, there are definitely parts of the state that are not.”
An even larger problem, treatment officials say, is the amount of misinformation surrounding the science behind methadone treatment and its effects. It’s what Sara Goldsby, the director of the state Department of Alcohol and Other Drug Abuse Services, calls the “mythology” of methadone.
Medical practitioners treating substance abuse agree medication-assisted treatment increases the chances of someone recovering from addiction. But they continue to battle against the public perception that patients are simply trading one drug for another.
There are complaints that methadone is being diverted and abused. Nearly 60 overdose deaths in the state were linked to the drug in 2015. But treatment officials say most of those can be attributed to methadone prescriptions for pain, where patients were given pills to manage their pain instead of the liquid methadone that Nicole receives at the center to treat her addiction.
Even some of the state lawmakers leading the effort to combat addiction in South Carolina have reservations about how long people should remain on methadone. They don’t want it to be a bridge that doesn’t end.
“I’ve experienced medication-assisted treatment in my own family and have my own opinions about how they work,” said Rep. Eric Bedingfield, R-Belton, who is leading a new committee studying issues related to addiction. Still, Bedingfield, who lost his own son to an overdose, recognizes the ultimate goal is to keep people alive.
No other disease besides addiction is questioned in the same way, treatment officials say.
“It’s a medical condition,” said Brown, the director of the Charleston Center. “We don’t tell people with diabetes or people that take medication for hypertension, ‘OK, when are you weaning off that medication?’ ”
Jumping through hoops
Allen Jackson started accepting Medicaid patients for buprenorphine treatment at his private practice in January.
By June, he quit.
The North Charleston physician, who also works at a nearby treatment center, recognized the need for more options for the hundreds of South Carolinians fighting addiction. He thought he would do his part by treating patients with buprenorphine, one of the other opioid treatment drugs that is distributed under the brand name Subutex or Suboxone.
Jackson had heard state Medicaid reimbursements had improved for the drug, which can only be administered by specially trained medical professionals.
Six months in, he’s given up on that effort, frustrated by the endless and sometimes fruitless task of getting prior authorization for the medication from the state’s managed care organizations.
Buprenorphine may be on the list of drugs covered under the state’s Medicaid program, but if a patient's insurance is handled by one of the private care organizations, it doesn’t guarantee coverage. Those companies decide whether the drugs are medically necessary.
In some cases, the managed care companies require people who are suffering from addiction to fail another treatment drug before they’ll approve the prescribed medication, physicians who have worked within the state Medicaid system say.
That means patients may be compelled to revert to their painkillers or heroin, which are becoming more lethal, before their insurance will cover the treatment, possibly threatening lives in the process.
The largest managed care company in the state, Select Health, said in a statement it began covering the generic version of buprenorphine without prior authorization in May, but will only cover the brand name when a patient can't tolerate the generic.
National studies show Jackson is not alone when it comes to shying away from administering buprenorphine, which was supposed to usher in a new era of medication-assisted treatment when Congress passed a law in 2000 allowing the drug to be prescribed at local doctors' offices.
That effort and others since were expected to expand access to medication-assisted treatment, especially in parts of the country that were hours away from the closest methadone treatment centers. But even as the current epidemic has grown, that largely hasn’t happened.
In South Carolina, there are more than 250 physicians licensed to prescribe buprenorphine, but Ed Johnson, a regional manager for the Substance Abuse and Mental Health Services Administration, said many of those doctors aren’t actually treating anybody with the drug and those who are often have a very short list of patients.
Timothy Wingo, a family physician in Mount Pleasant, said he writes prescriptions for buprenorphine for about 12 patients: preachers, lawyers, doctors and laborers.
A minority of those patients, he said, can be a challenge. Some are looking to cheat the system and abuse the medication. Many have other serious health issues as a result of their substance abuse history. He’s under heightened scrutiny by the Drug Enforcement Administration — like all physicians prescribing the medication. But he also thinks the work serves a purpose.
“It can be a very gratifying area of medicine,” he said.
For recovering patients like Nicole, medication-assisted treatment can mean the difference between resuming their life or becoming another trapped victim of the epidemic.
“In a lot of cases, it’s not that people don’t want to quit,” Nicole said, as her son played nearby in his rolling stroller. “People just need that little bit of extra help when they’re going through addiction.”
Mary Katherine Wildeman contributed to this report.