Logan of Vermont has limited his patients to people who, among other things, have completed a 28-day detox program and are over 30 years old. "I think it's a much smaller population that we can be successful with," Logan said.

Doctors acknowledge that inexperience can lead to "lax or inappropriate prescribing," according to a survey of physicians done for Reckitt Benckiser. The company's advisory panel has discussed whether doctors should be urged to refrain from prescribing until they know their patients well.

The cost factor
Suboxone's price is another challenge for doctors and patients. The federal Substance Abuse and Mental Health Services Administration said in a March 2006 report that the "high cost of the medication" was a "significant barrier to obtaining and continuing" treatment.

Howard said in his practice the expense "ends up being a pretty big issue. I've had patients who have asked to come off the medication because of costs."

Many of his poor, mostly working-class patients must pay with cash because they don't have insurance.

Spector, the Bel Air internist, said he gives his patients up to two months' worth of refills to help them avoid paying for frequent office visits. Otherwise, he said, "They try to get off of it too soon because they feel pressure financially."

A month's worth of Suboxone can cost $300 or more, depending on dose and the price charged by the pharmacy. That doesn't include doctors' fees and charges for any other treatment. In all, Sharfstein said, a patient under the care of a private physician might pay an average of $500 a month, or $6,000 a year.

But those costs are less than what an addict might have to pay for heroin, Howard and Spector say.

Addiction experts worry that without subsidies, Suboxone could be unaffordable. Chris Kelly, president of the Washington chapter of Advocates for Recovery Through Medicine, termed buprenorphine "methadone for rich people."

Johnson of Reckitt Benckiser said the company has pushed for state Medicaid coverage and broader insurance coverage to widen access. "We don't want to see a two-tiered system," he said.

The company provides the medicine for free to a limited number of patients whose doctors recommend them, according to a spokeswoman.

Baltimore has spent close to $1 million to ensure that patients receive buprenorphine. Another $725,000 has come from a state medical coverage plan for low-income adults across Maryland. Last week, a legislative committee authorized $3 million sought by Gov. Martin O'Malley to help local officials develop their own programs, recruit doctors and cover medication costs.

Sharfstein said that in addition to finding funds, his priority has been recruiting addiction professionals and physicians.

As he put it, he has been the "Johnny Appleseed of getting doctors to prescribe or be interested in buprenorphine."

Now he's lobbying Rep. Elijah E. Cummings of Baltimore to introduce legislation to allow physician assistants, nurse practitioners and doctors in residency to prescribe it for addiction treatment.

"It really is the beginning. We're rushing out," Sharfstein said. "I think it's way too early to declare what we're doing a success, and it's way too early to declare it a failure."

doug.donovan@baltsun.com fred.schulte@baltsun.com