Addictions specialists rejoiced in 2003 when the U.S. Food and Drug Administration approved the use of a drug called buprenorphine in the treatment of opiate addiction. Not only is the drug effective--use of buprenorphine decreased the number of heroin overdoses in France by 80 percent between 1994 and 1999--but it's also fairly easy to use. Any doctor who wants to prescribe buprenorphine (or "bupe" as it's referred to by those in the addiction field) can, and patients take the pills on their own at home as they would any other medication ("Wonder Drug," Feature, March 24, 2004). Yet in Baltimore, a city Maryland's Drug Early Warning System estimated contained 45,000 heroin users in 2002 (7 percent of the city population), use of bupe is still growing slowly.
Prior to the introduction of bupe, the only treatment for opiate addiction was methadone. Although methadone doesn't produce the euphoria of heroin, the two drugs otherwise have similar effects. Both strongly activate the same opioid receptor in the brain, and just like with heroin, patients can overdose on methadone, develop physical dependence after continued use, and go through severe withdrawal when they stop using. As a result, methadone is considered a controlled substance regulated by the Drug Enforcement Administration, and is only available at government-regulated substance-abuse clinics in small amounts, just enough to get patients through the day.
Buprenorphine also binds to the opioid receptor, but unlike heroin and methadone, it only activates the receptor partially. It won't get anyone high, but for addicts, it's just enough to relieve the painful withdrawal symptoms that occur when heroin use is stopped. Because bupe doesn't hit the opioid receptors as hard as heroin, it's also practically impossible to overdose when taken on its own. As with many other prescription drugs, complications can occur when people combine drugs, and overdoses have been seen in people on buprenorphine who also take drugs like benzodiazepines.
Because the drug is so safe, patients can get a prescription for a large quantity from a doctor and treat addictions at home. Instead of long lines and hours spent at a methadone clinic every day, recovering addicts can pick up bupe at the local pharmacy along with their toothpaste and toilet paper, with far less hassle and far less stigma.
The downside is that to get access to buprenorphine, patients have to tread into the murky waters of the health-care and pharmaceutical industries. MedChi, the Maryland State Medical Society, found in a study produced in April 2007 that one of the biggest hurdles to getting buprenorphine treatment is cost. For uninsured patients on a standard dose--two to three pills a day--the cost for buprenorphine treatment ranges from $15 to $20 a day.
"The cost if you're not insured can be a problem," says Dr. Chris Welsh, a psychiatrist and addiction specialist at the University of Maryland Medical Center. Even though many of his patients have $100-a-day heroin habits, Welsh says the differences in the economics of acquiring drugs on the street compared to the hospital pharmacy can be difficult to overcome. "For someone who gets money for drugs through stealing or prostitution," Welsh notes, "well, our pharmacy doesn't accept stolen radios or sexual favors, so it's not the same. I had a guy in here an hour ago saying he couldn't take [buprenorphine] because he couldn't pay for it. He said what's the point of continuing to do the things he was doing to get drugs, to pay for this medicine."
Even those with private insurance can encounter difficulty getting their medication. "If someone comes in, in heroin withdrawal, and the pharmacy says this is going to need a 48-hour preauthorization, you're probably not going to see that person ever again," Welsh says. "If someone doesn't get their Nexium, they might have heartburn, but they'll be OK. If someone doesn't get their [buprenorphine], they'll probably go use [heroin] again and risk overdosing."
Even if they don't run into problems paying for buprenorphine, though, addicts can have problems just finding a doctor to prescribe it to them. Physicians interested in prescribing bupe first have to take an eight-hour online course, which can cost up to $200, on the drug from an authorized medical association, such as the American Medical Association. According to the federal Substance Abuse and Mental Health Services Administration, currently 113 physicians are registered as buprenorphine providers in Baltimore City. By law, each of those doctors is allowed to have 100 patients receiving buprenorphine treatment in their care (increased from 30 in 2006), but in reality many physicians will be maxed out in terms of time and energy at far fewer; Welsh estimates that he's just about hit his personal limit at his current 40-odd patients. Many physicians are hesitant to even begin prescribing, in part because of the hassles with insurance, but also because the prospect of suddenly being confronted with heroin addicts in the waiting room can be unsettling.
"Physicians aren't exactly lining up to prescribe this," Welsh says. "Most physicians . . . would rather not treat [heroin-addicted] patients. Growing up in America, we have a pretty moralistic attitude toward addiction compared to other countries. And heroin is at the extreme even with addicts."
In October 2006, Baltimore City allocated $250,000 for a publicly funded buprenorphine treatment initiative run by two quasi-governmental agencies, Baltimore Substance Abuse Systems (BSAS) and Baltimore HealthCare Access (BHCA). Baltimore City Health Commissioner Dr. Joshua Sharfstein, who began the buprenorphine initiative in Baltimore, describes the city program as designed to help both patients and doctors deal with the trials and tribulations of bupe treatment.
"We pay for the [doctor's] training," Sharfstein says. "We send over stable patients and we're running interference with the insurance companies."
Patients enter the treatment program through one of six addiction-treatment centers funded by BSAS, where they receive daily bupe and counseling paid for by the city. While the patient becomes stable on bupe, a social worker from BHCA works on getting them health insurance. Once stabilized and insured, the patient is then paired up with a certified bupe provider in the community. The idea is to keep patients moving through the system, getting them situated with a doctor so that slots in the publicly funded treatment centers are constantly opening up for new patients. As of October, 583 patients have entered the city's buprenorphine program; of these, 106 have already moved to a primary-care provider for treatment.
So far the program has been successful: The retention rate, a common criteria for gauging success in drug treatment programs, is approximately 70 percent, and plenty of patients are looking to enter the program.
"We have limited slots and a waiting list, so we want to free up a slot and move patients," says Vanessa Kuhn, coordinator of BSAS's bupe project. "Word on the street is that bupe is great."
Buprenorphine's growing reputation as a miracle detox pill, combined with its limited accessibility, has led to an obvious conclusion for some: black-market bupe. A recent series in The Sun on buprenorphine reported on troubles in New England with addicts buying bupe on the streets in an attempt to get high. Welsh says some of the patients he sees have managed to get bupe on the streets, but they know they can't get high from it; instead they're trying to treat their addictions on their own. "Some are buying it on the street because they can't get into a program," he says.
The city is hoping to expand the buprenorphine initiative, Sharfstein says.
The city is working to get more physicians certified and hopes to target community physicians who are trained to deal with many of the secondary issues found alongside opiate addiction, such as HIV and mental-health issues, so that patients can get all their health-care needs met by the same clinic. One of the main sources of funding for HIV health-care services, the Ryan White Program, now requires that HIV clinics have registered bupe providers. Sharfstein and others working on the Baltimore buprenorphine initiative are also hoping to connect the bupe program with the city mental-health system. "We're really just at the beginning of this," Sharfstein says.
Organizations like MedChi are also trying to educate doctors in the private sector about bupe in the hopes of increasing the numbers of registered providers throughout the city. Right now, even bupe providers in private practices are often overwhelmed by the demand for the drug.
"Physicians that do a lot of this, I'd say they have more referrals than they can handle," Welsh says. "[Physicians] can potentially get inundated with people once they're on the list."