The spread of a “wonder drug” — one that could be instrumental in Ohio’s campaign against heroin and prescription painkiller addiction — is threatened by its own potential for abuse.Nearly 1,800 Ohioans — or 18 percent more than the year before — were participating in a buprenorphine program at a substance abuse treatment centers on a single day in 2012, according to new data from the federal government. Data from the Ohio State Board of Pharmacy show that prescriptions for the drug at least doubled from 2010 to 2012 in 29 of Ohio’s 88 counties.
Buprenorphine is a medication — often sold under the brand name Suboxone — that prevents symptoms of withdrawal from opioids. That includes street drugs such as heroin or prescription painkillers such as OxyContin and Vicodin.
More than half of Shepherd Hill’s opiate-dependent patients are treated with a regimen that includes Suboxone, according to Dr. Richard Whitney, medical director and addiction expert at the private rehabilitation facility in Newark.
Patients who take Suboxone are more willing to participate in the other facets of their treatment, such as counseling and education, and abstain from drug use, Whitney said.
People who complete treatment with Suboxone, he said, “get their children back, go back to work again, they stay out of jail. They have no cravings to go back and use drugs again. Those cases are not obvious. They don’t make the news. They simply get back into the mainstream of life and do very well.”
Potential for abuse
The reason Suboxone works is because it gives the addict just a little bit of what their body tells them they need. But it also can be used to get high. That creates the potential for misuse, especially when it’s provided by prescription to a population that has a demonstrated history of drug abuse.
Detective Kris Kimble, who handles prescription drug cases for the Central Ohio Drug Enforcement Task Force, said there were “hardly any cases” involving Suboxone in 2010 when he started in his current position. Last year, Kimble seized 2,062 doses of the drug, mostly in Licking County but also in Muskingum, Coshocton, Perry and Knox counties.
“Every heroin addict … either they have the package with (Suboxone) strips or a legitimate prescription,” he said. An 8-milligram Suboxone pill on the street costs $10, he said, while a dose of heroin costs $10 to $20.
That market for misuse has raised some alarms, according to Orman Hall, director of the Governor’s Cabinet Opiate Action Team.
“I think there are professionals in our state, criminal justice and treatment professionals, that are troubled by the diversion of Suboxone, who might not have had those concerns three or four years ago,” he said.
Ohio has been trying to crack down on the supply of opiates, but to stem demand robust medication-assisted treatment opportunities need to be available for addicts, Hall said. The latest figures from the Ohio Department of Health show prescription opioids were named on 1,154 death certificates in Ohio in 2011. Ohio Attorney General Mike DeWine said on Wednesday that 800 Ohioans died from heroin overdoses last year.
Whitney points out that the high from Suboxone is far milder than that of the drugs the patient is trying to kick and that the likelihood of overdose, especially death, is far lower.
“Suboxone is unquestionably a breakthrough drug with a documented clear ability to help patients reduce their cravings and get into sustained recovery,” Whitney said. “It has dramatically more benefits that downsides and the overwhelming majority of people who are opposed to the use of Suboxone simply don’t have all the information.”
Watching the doctors
In 2000, Congress relaxed rules governing the prescribing of opioids to treat addictions to heroin or prescription painkillers, creating a key distinction between methadone, which has been used to treat heroin addiction since the 1960s, and buprenorphine. Methadone is almost exclusively dispensed at treatment centers and consumed on-site. Buprenorphine, however, is also a prescription medication, meaning the patient can take the drug themselves outside close supervision.
Licensed physicians who take an eight-hour training course can apply for a waiver that allows them to prescribe Suboxone to as many as 30 patients in the first year, and up to 100 after that, said Dr. Melinda Campopiano, a medical officer with the U.S. Substance Abuse and Mental Health Services Administration.
As of last week, 48 treatment programs and 555 doctors were permitted to prescribe buprenorphine in Ohio, according to the administration.The law does not specifically require doctors to follow up on whether a patient is regularly attending 12-step classes or meeting with a behavioral health professional, Campopiano said, but there is an ethical obligation to do so.“(Doctors) are required to make sure this person gets the help they need,” she said, “just the same way if you sent somebody to a cardiologist you would find out if they went and if they didn’t you would find out why.”A spokeswoman for the State Medical Board of Ohio said the board provided guidelines for medication-assisted treatment after the congressional changes and that they are working to develop rules specific to buprenorphine.There’s a possibility that something akin to a smaller model “pill mill” — clinics where unscrupulous doctors trade prescriptions for cash — could arise, or has already, using Suboxone.“There are, unfortunately, a number of physicians who can take a relatively short eight-hour online course and be able to prescribe Suboxone legally,” Whitney said. “In today’s environment this can be a relatively lucrative source of income.”There are likely many more doctors who aren’t employing Suboxone maliciously, but just aren’t following up as closely as they should, Hall said.
He said the state needs to root out any unscrupulous prescribers, but they need to be mindful not to discourage well-meaning doctors who want to incorporate Suboxone treatment into their practice.“As significant as the opiate problem is in our state, it’s unrealistic to think that we’ll have the capacity to accommodate everyone through the public treatment providers,” he said.