The "Bupe" Fix

There's a new narcotic on the street in Baltimore and other communities - and taxpayers helped put it there. The hexagonal orange pills some users call "bupe" are championed as an exceptional treatment for heroin and pain-pill addicts. Federal officials have spent millions of dollars to help create and promote buprenorphine, and are encouraging thousands of private doctors to prescribe it.

But making buprenorphine widely available has also made it easy for patients to sell the narcotic illegally, leading to growing abuse, an investigation by The Sun found. Some people have died after misusing it with other drugs.

Heroin addicts hardened by years on city streets, and youthful buyers in suburban and rural areas, are using it to get high - sometimes in dangerous combination with other substances - and to tide them over when they can't obtain heroin or other narcotics.

The drug, mainly prescribed in a form called Suboxone, is intended to be dissolved under the tongue. But some abusers are crushing the pills to snort or inject buprenorphine, a dangerous practice that medical experts believed could be deterred by a chemical safeguard in Suboxone.

Federal officials didn't anticipate such abuses when they joined forces with Reckitt Benckiser Pharmaceuticals Inc., a newly formed Richmond, Va.-based subsidiary of a British company, and spent at least $26 million to bring Suboxone to market. With congressional approval, officials began rolling it out in 2003 as the centerpiece of a bold experiment to steer addiction treatment from restrictive clinics to doctors' offices.

Suboxone holds the promise of treating addiction as a chronic health condition, like treating diabetes with insulin. The pills relieve addicts' cravings for opiates and the sickness that comes on when they stop using them. Many say the drug makes them feel "normal."

Sen. Carl Levin, a Michigan Democrat, referred to Suboxone last year as a "miracle drug" as Congress increased how many addicts physicians can treat with it. In Maryland, health officials swiftly embraced Suboxone as a major new treatment for heroin addiction, one of Baltimore's most vexing and debilitating public health problems.

Yet Suboxone is starting to cause some of the very problems it was created to solve. Illegal sales and abuse remain far below other abused narcotics but are on the rise, especially where the drug is most heavily prescribed. Among the newspaper's findings:

• Some patients sell a portion of their take-home pills to raise cash or buy drugs, including heroin, according to police and health officials in several states. In some cases, taxpayers are subsidizing some of this illicit trade through the Medicaid health care plan, which in Baltimore pays many addicts' Suboxone bills, often at a cost of $300 or more a month.

• The street trade has flared in New England, which has the nation's highest rate of Suboxone prescribing. In the Boston suburb of Quincy, Suboxone is "popping up everywhere," a detective said. In Baltimore, the pills sometimes called "Stop Signs" and "Subbies" have been sold near Lexington Market, Oldtown Mall and elsewhere.

• Reckitt Benckiser told the newspaper that it knew of 13 deaths since 2005 related to taking buprenorphine with other substances. The Sun identified two deaths in Vermont that the company didn't know about. One was a 30-year-old Vermont construction worker; the other was a man who worked at a ski resort. There is uncertainty about the total number of deaths, because most medical examiners, including Maryland's, have no standard test for detecting buprenorphine in overdose cases.

• Suboxone's failure to deliver on one of its major selling points - that addicts wouldn't inject it - is raising concern among doctors who prescribe the drug. In October, an advisory panel that helps Reckitt Benckiser track misuse of Suboxone said that it might ask the company to consider changing the drug's formula.

Rolley E. Johnson, vice president for scientific and regulatory affairs for Reckitt Benckiser, said that some degree of abuse is inevitable. "Anything that has opioid-like effects, which buprenorphine does, can and will be abused by those people seeking that effect," said Johnson, a former Johns Hopkins buprenorphine researcher.

The company wants the public to have realistic expectations. Spokeswoman Harriet Ullman said: "We cringe every time we hear people say Suboxone is a miracle or a magic bullet. No drug is."

The drug's benefits

Suboxone's benefits are still being assessed as more addicts receive it. Experts in addiction and doctors who prescribe it say that the drug is extremely effective in helping stabilize addicts as they go through the counseling, rehabilitation and training they often need to turn their lives around.

Suboxone works for people "who are sick and tired of the ravages of addiction," said Dr. H. Westley Clarke of the federal Substance Abuse and Mental Health Services Administration.

Only small numbers of patients are peddling their medicine illegally, said Clarke, director of the agency's Center for Substance Abuse Treatment, which oversees the buprenorphine program. "Diversion doesn't appear to be substantial at this point," he said of the illegal selling, adding, "It's hard to design a system that's 100 percent foolproof."

The dangers posed by heroin and other opiates led governments in at least 40 countries to adopt buprenorphine treatment. American officials have generally followed the system in France, which for more than a decade has encouraged private doctors to prescribe the drug.

While estimates vary, U.S. officials believe that 1.7 million Americans are addicted to opiates, and about 67,000 of them are Marylanders. Heroin addiction is a particular problem in Baltimore, where state officials estimate 30,000 addicts need treatment.

Suboxone does not block desire for cocaine, and so it cannot be used to treat the thousands of addicts who use that drug primarily.

For decades, methadone has been the primary medical treatment for addiction to heroin and other opiates. But its misuse by addicts and patients who take it to relieve pain has been linked to thousands of overdose deaths. To stem abuses, methadone clinics initially require addicts to appear daily for their doses.

Buprenorphine is safer. Although like methadone it can suppress breathing, the drug has a "ceiling effect" that limits the danger of overdose even as more is consumed. That effect diminishes if the drug is taken with tranquilizers or alcohol, according to the company. Death can result in such cases.

Officials of the National Institute on Drug Abuse helped persuade Congress that buprenorphine is so safe that addicts could be prescribed it to take home and use without supervision. Nationwide, about 6,500 doctors are prescribing the drug to roughly 170,000 patients. And the numbers are increasing.

In New England

So are illegal sales. Nowhere is that clearer than in New England, where Reckitt Benckiser's own surveys show that illicit sales by patients are a problem. From sparsely populated Vermont to Cape Cod and suburban Boston, the drug is winding up in the wrong hands.

Chad Bessette, a 30-year-old construction worker, was one such person.

Six feet 2 inches tall and 190 pounds, he was an adventurous young man who moved to Colorado shortly after graduating from Fairfax High School in northern Vermont to work on a ranch as a horse roper.

He returned to Vermont and worked construction during the day in Burlington, partying in the city's bars at night and crashing at his father and stepmother's house.

"Chad liked to drink. That was his thing," said his father, Art Bessette. "But when he had to work, he'd get up and go right to work."

But on the morning of April 23, 2006, after a night of heavy drinking at a bachelor party, Bessette didn't wake up.

The medical examiner initially found in Bessette's body a high level of alcohol and a muscle relaxer, cyclobenzaprine, but did not determine a cause of death. After learning from Bessette's family that he had taken someone's buprenorphine pill that night, the examiner ordered a test that detected the substance.

Bessette died from "acute intoxication - combined effects of ethanol, Cyclobenzaprine (Flexeril) and Buprenorphine," the death certificate reads. The family wants answers from police about how their son got the pill, but state police will say only that the matter is under investigation.

Dr. Todd Mandel, medical director of Vermont's substance abuse agency and adviser to Reckitt Benckiser on misuse issues, said he believes Suboxone can help many addicts. But he's concerned about the effects of illegal sales. "I don't want the initiative to backfire," he said.

"But I have to worry."

Doctors in New England have turned to Suboxone partly to cope with widespread prescription drug abuse. In some areas, there are few methadone clinics.

People who buy it on the street experience different effects. Most say buprenorphine doesn't provide the high that heroin does, but it can be a potent alternative. Others use it to stave off withdrawal sickness when the heroin or pain-pill supply runs out, or when they want to take a break from those drugs.

Clayton Gilbert, director of Evergreen Substance Abuse Services in Rutland, Vt., said, "Bupe is turning into the in thing to be on. ... Almost like a fad."

Patients obtain extra Suboxone from doctors by complaining they need a higher dose to satisfy their cravings, said Gilbert, whose center has treated about 200 people with the drug. They also plead for large quantities of the pills to take at home, creating the potential to sell some.

Dr. Mark Logan of Rutland said 102 of his 139 Suboxone patients first obtained it on the street. Many sell pills that Medicaid pays for, creating a financial incentive to stay on it, he said. One man he had kicked out of treatment for selling his dose wept because he was relying on the income.

Logan is among doctors who randomly call in patients to count their pills. Patients who have been selling them - and therefore would come up short - pay someone to lend them replacement pills at a cost of $5 a day. In Rutland, the scheme is called "rent-a-bupe."

Abuse is "very prevalent," said Thomas Zarvis, 53, of Rutland, who used to pay up to $20 to buy a Suboxone pill illegally and who is now taking it legally in treatment. "I know one guy who snorts it all the time."

Doctors say some patients experiment with Suboxone by adjusting doses or taking it with other drugs.

John J. Lakus III, 37, of Walden, Vt., the ski resort maintenance worker, died Aug. 9, 2006, from "drug (cocaine, buprenorphine) intoxication," medical examiner records show.

Lakus' sister, Dawn Tanko, said he began Suboxone treatment for abuse of painkillers, a condition of his probation from an assault conviction.

Police near Boston say that the drug appeals to a wide variety of abusers, some in their late teens or early twenties, and that authorities are making more arrests as illegal sales increase.

"We're seeing it as a drug of abuse," said Detective Patrick P. Glynn of the Quincy Police Department, which made seven arrests in October for selling or possessing Suboxone without a prescription.

In Worcester, a reporter accompanying police in October witnessed three undercover buys of Suboxone within an hour near a rooming house known to authorities as a hotbed of drug dealing.

One of the buys occurred after an informant tipped police about a man driving a van and shouting out the window, "I've got Suboxone for sale!"

Lt. Timothy J. O'Connor, the leader of Worcester's vice squad, joked: "It's like a Red Sox game: 'Peanuts! Peanuts!'"

Police set up a buy in a nearby park, where they arrested the man. He had a prescription for Suboxone, police said, and had offered the entire contents of a pill bottle.

Some illicit use has led to injuries to children in Massachusetts. Harvard toxicologist Dr. Edward W. Boyer documented nine instances in which toddlers had swallowed buprenorphine over the past two years. In six of the cases, he said, the pills that sent them to the hospital for treatment had been illegally obtained by parents or relatives.

In Maryland

Maryland is seeing more problems as the prescribing of buprenorphine increases. Slightly more than 400 doctors have signed up to treat addicts with the drug; the number of patients is not publicly known. The state and Baltimore City are investing millions of dollars in expanding access.

Irvin Feagin, a 36-year-old recovering heroin addict from West Baltimore, first bought Suboxone on city streets last year for about $5 per pill. He sought it to make it through the "rough spots" that arose when he couldn't buy heroin.

"The days I couldn't get $10 or $20 for heroin, I'd get bupe," Feagin said.

Baltimore Sun