Sam Snodgrass, Ph.D., works as an “addiction specialist” — a title he gives himself because he said he has no title — at CATAR Clinic, a treatment program in Arkansas that provides both methadone in an opioid treatment program (OTP) setting and buprenorphine in a clinic setting — patients come in and choose either type of medication-assisted treatment (MAT). “It is patient choice; we try to give them the option,” Snodgrass said. But many prefer buprenorphine because they don’t have to come in six days a week to get their dose for the first 90 days, the way they do, by regulation, for methadone.
The OTP itself is more comprehensive and intensive in care, and many people with opioid use disorders don’t need it, said Snodgrass. “These are family people who have jobs, are relatively stable, and just need something to control their addiction,” he said. If they don’t do well on buprenorphine, then they are switched to methadone in the OTP, he said. And clinically, switching from buprenorphine to methadone is much easier than switching from methadone to buprenorphine.
Snodgrass has a lot of credibility: he was trained as a behavioral pharmacologist with one of the best researchers in the country, but he was addicted to opioids himself. From 1992 to 2007, Snodgrass himself was a methadone patient in an OTP. He was eventually kicked out because he was using benzodiazepines. He went to detox and a six-month inpatient treatment program, and hasn’t used drugs since 2011.
Now 59 years old, Snodgrass said his once-promising career as a behavioral pharmacologist was derailed when the director of the laboratory found out he was stealing drugs. Now, he is happy to be able to help patients who need treatment.
He spent some time discussing his current work and his history in a telephone interview with ADAW last week.
Some patients who have been taking methadone since the program opened in 1994 still come in every day for their methadone doses, said Snodgrass. “They’re not using other opioids,” he said. But methadone, while it prevents any euphoria from opioids, doesn’t affect euphoria from benzodiazepines.
Benzodiazepines are always a concern when patients are taking opioids, whether prescribed methadone or illicit opioids, because of the possibility of respiratory depression and overdose, said Snodgrass. There are also concerns about patients on buprenorphine taking benzodiazepines, but because of the ceiling effect of the buprenorphine, the risk of overdose is less. Benzodiazepines, when combined with opioids or alcohol, can be deadly, he pointed out.
Another issue is access: unlike a single office-based physician, the CATAR buprenorphine program is a clinic, and if the program runs up against the 30- or 100-patient limit, the clinic can simply hire another doctor. It’s better to do that than to put people on a waiting list, said Snodgrass.
Typically, patients at CATAR do home induction with buprenorphine, said Snodgrass. (Patients must be in some withdrawal before their first dose, so home induction is more convenient than telling the patient to return to the office when they are in withdrawal.) For the first week, patients are limited to two doses per day, with one dose being a standard 8 milligrams of buprenorphine. “Some people do need more than that,” said Snodgrass. “I wish they would prescribe more than that, because we lose a lot in the first week.” But if patients last through the first week, they can come back and get their dose adjusted, he said.
The same thing happens in OTPs, which under federal regulations aren’t allowed to give more than 30 milligrams of methadone initially. Considering that most OTP patients are stabilized at more like 100–120 milligrams, this is clearly too low a dose as well, said Snodgrass. “It’s insane,” he said. “You start off giving them an ineffective dose, they go out and get more drugs because of the withdrawal.” This is why the first two weeks of methadone induction are the most dangerous for methadone patients — not because they get too much methadone, but because they don’t get enough, he said.
Snodgrass is opposed to extended-release naltrexone (Vivitrol). “We need a functioning opioid system, to be normal, and Vivitrol shuts that down,” he said. “These people are obsessing about opioids, it does nothing to stop their cravings, and so people go to other drugs to try to find some way to feel normal.” And unless they are required to get the shot every month or go to jail, the compliance rate is low, he said. “They don’t come back, because Vivitrol doesn’t do anything for the craving — they’re miserable, they have trouble eating, they don’t feel right, and they can’t get good feelings that we’re supposed to feel.” Vivitrol blocks the effects of opioids but has no effect on benzodiazepines or, for most people, alcohol.
Snodgrass’ drug use started in 1976 when, as a student at the University of Arkansas at Little Rock, he visited an apartment where people were injecting black tar heroin. He tried it, and for 15 years continued to use heroin only occasionally — twice a week at the most. He went on to get a Ph.D. in psychology, and to work with the highly respected drug researcher Donald E. McMillan, Ph.D., at the University of Arkansas for Medical Sciences. He would still use heroin occasionally, and one day saw a bottle of powdered methadone in the lab. He used it. “That methadone took me away. I was doing it every day, massive shots of it, but I thought ‘I have a Ph.D.; I’m not a loser junkie,’” he said. “I told myself, ‘I can stop when I want to,’ and I believed that up until I couldn’t stop.” He started stealing drugs from the safe, until the thefts were discovered, and then he had to buy drugs on the street. “My work went to hell, because I spent all my time and money getting drugs,” he said. “One day McMillan called me in and shut the door, and said, ‘Let’s talk about your drug problem,’” he said. “That ended my career in behavioral pharmacology.” McMillan and Snodgrass published several important articles together.
When he was kicked out of the methadone program in 2007, he thought he could quit, but instead started injecting OxyContin. A friend had gotten him a job teaching in the psychology department, but by the spring of 2008, he couldn’t teach. “I don’t remember this, but apparently I was nodding out at my desk — that’s how we are in active addiction.” For the next three years he was what he calls a “street junkie” — homeless, living on the street and doing everything he could in terms of drugs to avoid being sick — “just to make it through the day without feeling like the guts were coming out of my body,” he said.
During those three homeless years, he never could come up with the $200 required to enter an OTP. This was before the Affordable Care Act, so Medicaid wasn’t available to men without dependent children.
He has been working at CATAR for almost two years. As for research and university, “that’s over,” he said. “I’ll never get back to it, but I can do what I’m doing now, which is rewarding in itself.” He helps tell patients about the brain and addiction, and he explains that “this is not a choice, not about willpower, and that they need to be on medication to control the symptoms,” he said.
Snodgrass also works with Broken No More, an organization formed by families and friends of people with substance use disorders.
One treatment advocate’s path from behavioral pharmacologist to treatment specialist in a methadone and buprenorphine program included his own addiction and treatment.