The opi­oid cri­sis is fu­el­ing a mas­sive smug­gling prob­lem in Mary­land’s jails and pris­ons.

The Washington Post Sunday - - METRO - BY MARC KILMER The writer is a se­nior fel­low at the Mary­land Pub­lic Pol­icy In­sti­tute.

Opi­oids are a scourge across the coun­try, but es­pe­cially so in the Old Line State. Ac­cord­ing to the most re­cent avail­able data, 1,468 peo­ple died from over­doses be­tween Jan­uary and Septem­ber 2016, with well more than 90 per­cent of them in com­bi­na­tion with opi­oids in­clud­ing heroin, fen­tanyl and pre­scrip­tions such as Vi­codin and Per­co­cet.

That fig­ure is even more stag­ger­ing con­sid­er­ing heroin-re­lated deaths have in­creased by 74 per­cent from the same pe­riod the year be­fore. There also has been a jump in deaths be­cause of the pop­u­lar­ity and avail­abil­ity of fen­tanyl, a synthetic opi­oid 30 to 50 times stronger than heroin. This sub­stance is now be­ing mixed into street drugs, pro­duc­ing a deadly mul­ti­plier ef­fect for users who take too much. Through the third quar­ter of 2016, there were 738 fen­tanyl-re­lated deaths in Mary­land, com­pared with 192 in the same pe­riod the pre­vi­ous year.

Mary­land has been fight­ing this rise in drug ad­dic­tion for years, and co­or­di­nated ef­forts be­tween state and fed­eral law en­force­ment agen­cies con­tinue to limit the im­por­ta­tion of these drugs into our state.

Treat­ment must be part of the anti-opi­oid equa­tion. But treat­ment suc­cess rates are abysmal, with the vast ma­jor­ity of ad­dicts who seek re­cov­ery re­laps­ing. Eighty per­cent of heroin ad­dicts never re­ceive treat­ment, ac­cord­ing to the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion.

As a re­sult, many want a more holis­tic ap­proach that of­fers treat­ment out­side of the stan­dard Nar­cotics Anony­mous ab­sti­nence model.

En­ter med­i­cally as­sisted treat­ments (MATs) such as buprenor­phine, which is pre­scribed to ad­dicts to de­crease crav­ings for opi­oids and ease the detox and with­drawal symp­toms that lead to re­lapse (and over­dose). MATs play a key role in bridg­ing the gap from ad­dic­tion to treat­ment. Buprenor­phine is an in­creas­ingly pop­u­lar MAT cov­ered by state Med­i­caid agen­cies.

But all buprenor­phine treat­ments are not equal. One brand of the drug, Subox­one, has been as­so­ci­ated with over-pre­scrip­tion and black-mar­ket smug­gling. For those rea­sons, Mary­land’s Med­i­caid department re­cently re­moved Subox­one from its pre­ferred drug list, en­sur­ing that pub­lic-health of­fi­cials and ad­dicts have ac­cess to ef­fec­tive buprenor­phine treat­ments that aren’t widely abused.

Dis­pensed in the form of a film strip, Subox­one is easy to take and, prob­lem­at­i­cally, just as easy to di­vert to il­licit mar­kets. Much of the prob­lem lies in the dif­fi­culty of cus­tomiz­ing dosage lev­els for Subox­one; doc­tors are of­ten forced to pre­scribe dosages that ex­ceed what a pa­tient needs, lead­ing to ex­cess sup­ply in the mar­ket. And when an in­di­vid­ual has more than he needs, he can cut the ex­tra por­tion of the film strip off and smug­gle it into pris­ons and jails.

The de­liv­ery sys­tem of Subox­one has an un­in­tended con­se­quence: It fur­thers ad­dic­tion by in­creas­ing the pub­lic avail­abil­ity of opi­oids and of money to fuel drug habits, es­pe­cially in cor­rec­tional fa­cil­i­ties. In ef­fect, the film strip fa­cil­i­tates a black mar­ket for the “medicine” be­cause it is so eas­ily con­ceal­able, un­like tablets for com­pet­ing drugs.

Whether in­mates were self-treat­ing or just get­ting high, the strips were find­ing their way in mas­sive quan­ti­ties into the state’s pris­ons and jails.

But af­ter the state’s Med­i­caid ad­min­is­tra­tor, the Department of Health and Men­tal Hy­giene, cracked down on ac­cess to the drug, prison seizures of Subox­one fell by 41 per­cent.

The maker of Subox­one, In­di­v­ior, which al­legedly ex­ploits le­gal loopholes to extract higher prices for the same chem­i­cal from the state Med­i­caid pro­gram, is un­der­stand­ably up­set.

Subox­one was pre­vi­ously avail­able as a tablet, which was more dif­fi­cult to smug­gle. The drug maker pulled the old ver­sion, how­ever, switch­ing to a film strip to game the patent sys­tem and ex­tend monopoly pro­tec­tions. That ef­fec­tively boxed out com­pe­ti­tion from more ef­fi­cient, less-di­vert­ible treat­ments. That’s why Mary­land’s at­tor­ney gen­eral joined 42 other at­tor­neys gen­eral to sue In­di­v­ior for driv­ing up its prof­its il­le­gally, at direct ex­pense to tax­pay­ers and the ad­dicted.

Mean­while, other opi­ate-re­cov­ery medicines are avail­able without the danger­ous side ef­fect of fa­cil­i­tat­ing a black mar­ket in their abuse. Mary­land of­fi­cials stepped in and re­placed Subox­one with Zub­solv, a pill-based buprenor­phine treat­ment that comes in dosages tai­lored to pa­tients’ needs. That means less over-pre­scrip­tion, a more dif­fi­cult product to smug­gle and a dras­ti­cally re­duced black mar­ket for MATs in Mary­land’s jails.

Other states may well want to fol­low Mary­land’s lead in in­ter­dict­ing a strange but real threat to re­cov­ery — the drug that prom­ises a quick cure. This drug may be worse than the dis­ease by per­pet­u­at­ing the cy­cle of ad­dic­tion it pur­ports to end.


Subox­one med­i­ca­tion in pill form.

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