Buprenorphine could end heroin addiction, curb disease, and cut crime. But bureaucrats, doctors, and much of the treatment industry are just saying no. A case study in why the best technology doesn’t always win.
At 28, Joe has become something of an expert at heroin detox – he’s tried it nine times. Between programs, he’s attempted to quit on his own. Once, when the cravings got the best of him, he tried to knock himself out by hitting his head against a brick wall. So late last year, when Joe checked himself into a New York outpost of Phoenix House, the country’s largest residential rehab program, he knew exactly what to expect: the plastic cups of methadone to wear down his dependence, the sedated days and sleepless nights, the chill of the toilet seat, the sickening sight of food. But then a doctor handed him a medication he’d never heard of. Something called buprenorphine – or simply, bupe. No way, Joe thought. No way this little orange pill is going to do the job.
That first day at Phoenix House, Joe remembers, his last heroin high was wearing off. He felt the familiar beads of sweat. Nausea began to creep to his throat. Perfect conditions, his doctor said; bupe works only when patients are in withdrawal. So Joe curled back his tongue, placed the little hexagonal tablet underneath, and waited. He felt it slowly soften to a gritty paste and disappear. It still amazes him how quickly it worked. He didn’t feel high, didn’t feel withdrawal symptoms, didn’t even feel medicated; he just felt better. “It took away the pain,” he says. “It even took away the craving. I had my strength back, and I was eating sooner than I ever had in detox. I got clarity when I took that first pill.” The details of his addiction – kicked out of high school, stripped of a college basketball scholarship, and ultimately sent upstate to prison – already seem like stories from someone else’s life.
Bupe won approval as an addiction treatment in late 2002. Sold by British firm Reckitt Benckiser and prescribed under the brand name Suboxone, bupe is a synthetic opiate that pushes the same buttons as heroin or painkillers like Vicodin, Percocet, or OxyContin, only without the high or any other significant side effects. It frees recovering addicts from cravings and crashes, allowing them to focus on counseling, work, and relationships. “It is the first real innovation in treatment in 40 years,” says Phoenix House medical director Terry Horton.
Before bupe, there was mainly methadone, an amber syrup that offers similar relief from opiate cravings but is highly habit-forming. By law, methadone must be dispensed at special clinics and, for most patients, only in single daily doses. Widely prescribed beginning in the 1970s, methadone was medical science’s first real attack on addiction, and study after study showed it prevented relapses and deaths by overdose. But public opinion swelled against it. Neighborhood groups battled methadone clinics, where patients congregate daily for their meds. Politicians charged that junkies were merely swapping one habit for another. Methadone has been controversial among addicts, too. Some rejected it for producing a powerful sedative effect that makes it difficult for a recovering addict to perform job duties. Others took methadone illegally as a cheap tranquilizer. “People get a methadone habit because it feels like what you were taking before,” says Solinda, a former Wall Street office manager, heroin addict, and occasional methadone abuser who also went through bupe detox at Phoenix House.
Patients on bupe do become physically dependent on the pill – as do people taking medication for most chronic conditions. Suboxone, though, has no strong side effects. Nor can users get high by taking a larger dose – in other words, no inching up from dependence to addiction. Bupe is also safer than methadone – which, like any strong opiate, suppresses breathing if too high a dose is taken – and easier to taper off. And instead of visiting a treatment center every morning or quitting cold turkey, addicts can get a bupe prescription from their regular doctor. This offers real appeal to addicts, particularly white-collar ones, who cringe at the stigma of methadone lines. “You’re just taking medication,” Solinda says. “You don’t feel sick. You don’t feel high. It makes you feel stronger as a person.”
For all these reasons, doctors and mental health professionals expected bupe to take off quickly. But that has not been the case. While Reckitt Benckiser won’t disclose sales data, Shaun Thaxter, vice president of pharmaceutical marketing, says that 5,000 doctors are now prescribing buprenorphine. However, according to two prominent bupe researchers, sources inside the company late last year said only half that number is prescribing either Suboxone or Subutex, a form of pure bupe often used at hospitals for detox. And Herbert Kleber, director of the substance abuse division at Columbia Medical School, says the company told him it had recorded only about 1,500 prescribing doctors nationwide last summer.
Reckitt Benckiser estimates that since bupe was introduced, 100,000 patients in the US have used it, whether in the form of a single dose during detox or in ongoing treatment. But Yale scientist David Fiellin, a longtime bupe researcher, says that medical privacy laws make it impossible for the company to accurately count the number of patients taking the drug. “They can’t know,” he says. A more reliable indicator is the number of prescriptions filled by pharmacies, which are required to report their data to state health agencies. In New York City, home to an estimated 200,000 heroin addicts and perhaps two to three times that many prescription opiate addicts, some 34,000 people were on methadone maintenance throughout 2004, while only about 1,000 people filled a bupe prescription last year. “It’s depressingly few,” says Lloyd Sederer, New York City’s deputy executive commissioner for health and mental hygiene.
So why has bupe’s progress been so sluggish when it’s clearly a superior innovation? There are several reasons. The general practitioners who were meant to write most of the prescriptions have proved ambivalent, at best, about treating addicts. Lawmakers have bungled regulations; at one point, there was even a federal law barring methadone clinics from dispensing bupe, despite their experience and reach within addiction circles. Meanwhile, Reckitt Benckiser has been conservative in marketing the new drug.