Advocates, researchers push for better access to Suboxone

PHILADELPHIA — It’s a refrain dealers chant every day up and down Kensington Avenue in northeast Philadelphia, the city’s largest drug marketplace: “Subs, subs, subs!”

They’re referring to Suboxone, one of the brand names for the opioid-based addiction treatment medicine buprenorphine, prescribed by physicians and shown to produce more lasting recovery from opioid addiction than abstinence-based therapy. As with so many prescription medications, there’s a robust black market for it.

But drug users, advocates and researchers say many people aren’t buying buprenorphine to get high. Rather, they’re using it to protect themselves from overdoses, to get through the pain of withdrawal, or even to engineer their own do-it-yourself addiction treatment.

With more than 1,000 people per year dying of overdoses in Philadelphia — the worst big-city opioid crisis in the nation — city and state officials have scrambled to help more people get into treatment programs. They’ve eliminated ID requirements and insurance pre-authorizations and even launched mobile treatment centers where doctors can prescribe buprenorphine to patients on the street.

Yet entering treatment can still be difficult and daunting for some drug users. For those without Medicaid or generous health insurance benefits, treatment is costly.

Buprenorphine is an opioid. But it’s a partial opioid agonist, not a full agonist, such as heroin or methadone, another addiction treatment drug. Like the full agonists, for people who aren’t used to opioids, it can be used to achieve a pleasurable high — and it can cause respiratory depression, according to the federal Substance Abuse and Mental Health Services Administration.

Because buprenorphine is a partial agonist, the effects — and the risks of overdose — are much weaker. For people who are already used to taking opioids, buprenorphine blunts the powerful cravings and pain of withdrawal that send people in addiction in search of stronger opioids.

The brand-name drug Suboxone combines buprenorphine with naloxone, the overdose-reversal drug, which cuts down the potential for misuse. The naloxone blocks the effects of the opioid if Suboxone is injected or snorted. Other brand names such as Subutex and Butrans contain only buprenorphine. Generic Suboxone retails for up to $160 for 14 doses at pharmacies. Generic Subutex can cost up to $128 for 14 doses. On the street, a single Suboxone strip sells for about $15, and cheaper in bulk.

Approved for clinical use in October 2002 by the Food and Drug Administration, buprenorphine is generally prescribed as part of a treatment regimen with counseling and behavioral therapies, and the drug can be taken at home — unlike methadone, which has to be dispensed daily from a specially licensed clinic.

However, physicians must have special certification to prescribe buprenorphine — even though they don’t need this extra level of training to dole out the opioid painkillers that got many people addicted.

And in Pennsylvania, despite the state Health Department’s efforts to help more people access buprenorphine, a number of lawmakers have proposed even more restrictions around its prescribing, precisely because it ends up on the black market so often.

Because buprenorphine carries a significantly lower overdose risk than prescription pain pills such as oxycodone or illicit drugs such as heroin and fentanyl, advocates say it can be a form of “harm reduction” — a way to make addiction less dangerous to those who are struggling to stay in recovery or aren’t quite ready for treatment.

At the very least, it can keep withdrawal symptoms at bay so people don’t resort to drugs of unknown origin.

Researchers who interviewed 20 drug users in Allegheny and Dauphin counties last year found that nearly all of the study’s participants had bought buprenorphine off the street to get through withdrawal when heroin was unavailable — or when they didn’t want to use heroin.

To that end, a handful of prosecutors around the country have stopped prosecuting people for illegal possession of buprenorphine without a prescription. Last week, Philadelphia District Attorney Larry Krasner became the latest.