On Wednesday morning at the methadone clinic, patients trickled in carrying large coffees and sometimes their babies. The mirrored building, on a desolate stretch of Fourth Avenue up the hill from the Anchorage jail, has no sign visible from the street.
Patients settled into chairs in the threadbare pink-walled waiting room of the Center for Drug Problems and took a number, like at the DMV. A laminated sign advised the "Patient of the Month" got to skip the line.
One by one, a nurse called them back to take doses of the drug meant to keep them away from the destruction of heroin.
Afterward, one gray-haired client walked out onto Fourth Avenue and put on his motorcycle helmet, hopped on his bike and peeled away. Just then, a young mother with her hair in a ponytail arrived holding her 5-week-old baby. Intake coordinator Paula Valdez rocked him as the baby's mom walked back to swallow her dose in front of the watchful eyes of the nurse.
"He's beautiful," said chief operations officer Jennifer Stukey, gazing at the baby. "He would have been really sick without his mom having this."
Methadone is the oldest and most studied form of treatment for opioid addiction, and the Wednesday morning routine has been going pretty much the same way since the clinic opened in 1974.
But with Alaska now confronting the fallout of a new generation of opioid addicts, the people who run it say demand for their services is high — but methadone is being passed over by policymakers as an effective way to help Alaska's addicts.
"There's certainly a focus on other treatment options besides methadone," said Anna Nelson, the executive director of Fairbanks' Interior AIDS Association, the only other nonprofit clinic that dispenses methadone in the state.
Part of the problem is a durable stigma, said Stukey.
Methadone is a replacement therapy, meaning that at prescribed levels it stimulates the same parts of the brain heroin does without giving the user a high. Some people stay on it for decades. The clinic has a handful of patients who've used methadone since the 1980s.
But it can be dangerous if abused.
Back in the 1960s, in the early days of the treatment, clinics were often found in skid row neighborhoods. They had bars over the windows and a clientele of junkies that diverted methadone back to the streets in a thriving black market. Methadone clinics became known as "juice bars," where addicts could go to get a legal fix with few strings attached.
That's not true anymore, at least in Alaska. But some of the people who work in the methadone field still feel they are on the fringes.
Center for Drug Problems clinical director Ron Greene says he has been sounding the alarm to state officials about a rising opioid crisis for more than a decade.
"No one listened to me," he said.
When the state convened a new Opioid Task Force, he wasn't on the list of members.
"They snubbed us," he said.
Methadone has been part of the task force's conversation, said Kate Burkhart, a facilitator of the Alaska Opioid Policy Task Force who works for the Alaska Department of Health and Human Services. It's part of a broader focus on "medication assisted treatment" the task force has spent "two entire meetings on," she wrote in an email. She also noted that Nelson, the Fairbanks methadone clinic executive director, is a member of the task force.
Inundated, patchwork budgets
The clinic is always inundated with people who want what it can prescribe.
The Center for Drug Problems currently has 157 clients with a waitlist about six weeks long. The waitlist is perpetual and sometimes deadly, said Greene. He has crossed names off because the person died of an overdose.
He's talked to parents so desperate to get their child into treatment they've gone out on the street to buy black-market methadone themselves. Pregnant women jump to the front of the line, and the clinic takes pride in their treatment of expectant mothers. Pictures of patients' babies are featured on a cheery bulletin board outside the bathroom.
The clinic is funded by a mix of federal grants dispersed through the state, Medicaid, private billing and cash payments from patients. To serve more patients, it needs more funding, Stukey said.
The nurse stands behind a fiberglass window with a slot. She pushes out a paper cup full of cherry-red liquid. A young woman in a tank top with back tattoos gulps it down. Another young woman with a long mane of blonde hair and a sullen expression. A man in a cowboy hat.
Stephanie Williams was next in line. She swallowed her dose.
"It tastes gross, to be honest," she said.
A statuesque woman of 51, who walks with a cane, Williams said she had been a prostitute in Anchorage for years to support her heroin habit.
After a cascade of health problems forced her to leave Alaska and move in with family in the Seattle area, she decided it was time to get on a methadone program.
Now, she has a steady place to live in Mountain View and a job as an on-site resident manager for her apartment building, where she says she wards off drug dealers by approaching them with, "Have you accepted Jesus Christ as your personal savior?" She sees a counselor and takes relapse prevention classes. And she's spending time with her sons.
"They don't look at the methadone as using. I'm the straightest they've ever seen me in their life. Mom is back."
Her life is better since she's been on methadone, she said.
"This is like living."
The Center for Drug Problems' clientele is largely people like Williams, who were chronic opioid users — people living on heroin for years or even decades. The average client age is 40. About 70 percent of clients are female. In other states, the opposite is true, with methadone clinics reporting clients are roughly two-thirds male, said Stukey.
Stukey is not sure why more women are seeking methadone treatment in Alaska, but the disparity may have something to do with the clinic's admission preference for pregnant women.
Methadone is considered an old-school replacement therapy, and even its staunchest supporters say there are drawbacks.
One of the biggest barriers is patients must physically travel to a methadone clinic every day to take their dose due to tight federal regulations. That requirement is the reason methadone has the nickname "liquid handcuffs." Stukey says she's had patients drive up from camping trips hundreds of miles away to take their dose.
Over time, take-home doses, or "carries" in the parlance of the clinic, can be earned.
But allowing people to take home methadone can cause problems — the clinic recently suspended all "carry" privileges after Drug Enforcement Agency officers notified them that liquid methadone had begun showing up in the illicit street market. Greene said they didn't know if it was coming from their clinic.
The Center for Drug Problems is no longer the only dispenser of methadone in town — a private, for-profit Tennessee-based company operates Anchorage Treatment Solutions on Fireweed Lane in Midtown. A Phoenix-based company opened a for-profit clinic that dispenses methadone in Wasilla this summer.
But only the nonprofit methadone clinics in Anchorage and Fairbanks can take Medicaid, which 81 percent of patients in Anchorage and 58 percent in Fairbanks use to pay for treatment. Stukey's dream is to see small satellite clinics staffed by a nurse and clinic director in places like Bethel and Juneau. Currently there's no way to get daily methadone in those places.
Recently, politicians and the public have put an emphasis on adding detox services.
That doesn't make sense to Stukey and Greene. Detoxing from heroin is excruciatingly uncomfortable, comparable to a bad flu, but unlike withdrawal from alcohol, it is not lethal. After an addict has detoxed, they face a harsh uphill battle in staying off opioids.
"So you've got a person detoxed, now what do you do with them?" Greene said.
"We do lack detox facilities," said Rosalie Nadeau, the CEO of Akeela, an Anchorage-based nonprofit that offers addiction treatment and mental health services. But in terms of the people most in need of detox for safety reasons, "I'm not worried about heroin. I'm worried about alcoholics," she said.
The tension is between two approaches to addiction: abstinence and replacement therapy, said Nadeau.
Advocates of abstinence say replacement therapy trades an illegal drug for a legal dependency. Supporters of replacement therapy say abstinence usually fails.
Newer replacement therapies, such as Suboxone and Vivitrol, have proven popular with younger addicts. They are dispensed as prescriptions in a doctor's office and don't require daily trips to a clinic. But they too have drawbacks.
Vivitrol, which blunts the brain's receptors to kill cravings and prevent a high if the person uses opioids, can be administered in a monthly shot. It has been called a "magic bullet" for the treatment of users. But it can cost up to $1,200 per month, a cost not always covered by insurance.
Suboxone, which is prescribed as a film that dissolves under the tongue, has a high potential for abuse. And in some communities, it can be hard to find doctors who will prescribe it, said Nelson.
Critics of replacement therapy say medication, whether methadone or Vivitrol, doesn't get to the root cause of why addict abuses drugs in the first place. Rehabilitation and abstinence, they say, are the only ways to truly recover from drug addiction.
That view has its roots in the 12-step world, said Nadeau.
"People are still using the language and ideas of alcoholism in the heroin world."
Part of the argument for methadone, said Nelson, is the structure the medication regimen provides. The clinic in Anchorage and the one in Fairbanks also require counseling sessions.
Medication is never the only answer for a person whose life is in disarray because of drug use, Nelson said.
"It just provides a stable platform from which they can make changes in their lives."
At 10 a.m., a weekly "Cognitive Problem Solving" group led by Greene was supposed to begin.
At 10:05 a.m., Greene walked into a room decorated with posters listing "criminal thinking errors" ("fragmentation," "sentimentality," "failure to consider injury to others") and embroidered Peruvian wall hangings.
Only one woman showed up for the group.
"What is this?" Greene said, chagrined. "I can't believe this."
Methadone isn't perfect, and it isn't right for everyone. But Stukey, Greene and Nelson think more Alaskans like Bill Noblett could benefit from more of it.
Noblett usually rides his bike to the methadone clinic.
The 24-year-old from the Mat-Su and his friends first lifted drugs from their families as teenagers: hydrocodone, Vicodin, Percocet.
"It was so easy to get them it just became a habit," he said.
He moved on to heroin for a better high. Eventually, the lifestyle of being an addict — always on the run from withdrawal sickness — filled his days, damaged his relationships and destroyed his self-esteem.
"You're always talking to people that do drugs. You're always trying to find drugs. You're always trying to find the way out of feeling so terrible," he said.
He got on a waitlist and was admitted to the Center for Drug Problems within a month. His first day was March 15.
The changes in his life have been stark.
Now he wakes up early. He started going to church. He returned to a healthy weight and monitors his blood pressure at the kiosk at Fred Meyer. And he attends counseling sessions at the clinic, having group discussions he's never had before.
"You can finally function in your life," he said.
Some people he knows don't see methadone as "real" treatment. His hope is to save for a vehicle and a place to live of his own. For now he's staying with his grandma in Muldoon.
And someday, he wants to stop taking methadone.
Correction: This story originally misidentified the location of the headquarters of Acadia Healthcare, the company that operates the Anchorage Comprehensive Treatment Center, a for-profit Anchorage methadone clinic. The company is based in Tennessee. Wasilla's methadone clinic is operated by Arizona-based Community Medical Services.
Alaska Dispatch News multimedia journalist Marc Lester contributed reporting to this story.