Woody Curry scoffs at the eight-hour requirement.

Curry's a certified addiction counselor who runs Baltimore Station, a 200-bed, two-year residential treatment program that relies on 12-step philosophies, counseling and employment development. He said doctors should have as much experience as counselors, whose certification can require up to eight years of training.

MedChi, the Maryland State Medical Society, provides the training course. While it's available online, many doctors prefer to take it in person. "They have a lot of questions," said Elaine Gisriel, buprenorphine project coordinator for the group's Center for a Healthy Maryland.

A new experience
Treating opiate addicts is a new experience for many doctors. Addiction care had been reserved mostly for methadone clinics, before Suboxone's approval. "It's a revolution really to bring addiction treatment back into the medical mainstream," Gisriel said.

Federal law also requires doctors to recommend additional treatment to their patients, such as counseling.

But the law doesn't require doctors to provide it.

The drug's manufacturer, Reckitt Benckiser Pharmaceuticals Inc. of Richmond, Va., says Suboxone works best when paired with individual or group therapy.

"If we promote treatment, Suboxone will be a success," said Vice President Rolley E. Johnson, a former Johns Hopkins researcher who helped make the scientific case for buprenorphine's benefits in treating addiction. "If we promote Suboxone, treatment can be a failure. We believe that strongly."

Baltimore's system is intended to provide addicts with comprehensive care as they begin Suboxone treatment. That model might also work in other areas of the state, said Dr. Peter Cohen, who is directing Maryland's rollout of buprenorphine.

He's asking county drug councils to devise plans for tailoring treatment to their specific populations. As in Baltimore, patients could transfer to the care of doctors after being stabilized in clinics.

"Buprenorphine is not the miracle drug," Cohen said. "But with really good treatment, you can save a lot of people's lives."

Meanwhile, many addicts are entering treatment directly with private doctors, as federal officials envisioned. Howard said he refers his patients to support groups and other programs but is not sure that's absolutely necessary.

"I try to pick patients who are committed to recovery and that are compliant," he said.

He prescribes Suboxone to patients he has treated for other conditions and makes them sign contracts promising not to abuse other drugs.

At the same time, Howard conducts urine tests to determine compliance. He immediately begins to wean patients off Suboxone if he catches them taking tranquilizers with it. Patients who are caught abusing other substances, such as cocaine, get three chances.

He has 13 patients on Suboxone now, but over the past year he has treated about 35. And nearly 15 have failed urine screens.

Howard's Suboxone mentor is Dr. Michael Hayes, a Baltimore addiction specialist and buprenorphine proponent. In addition to sharing his knowledge of appropriate treatment, he warns of deceit by addicts.

"Let nobody think that all of a sudden heroin addicts become choirboys," said Hayes. He booted two Suboxone patients from his practice after learning they got narcotic pain pills from another doctor - a practice called "doctor shopping."

"It looked like they were selling them," he said. "That was a scam."