December 22, 2004
Pill Helps Addicts, but Not Here; No Doctors in Spokane Prescribing Drug Suboxone
A pill that helps patients kick their addiction to prescription painkillers is gaining interest from thousands of doctors nationwide.
But no Spokane doctors prescribe Suboxone because none has taken the eight-hour course required by federal law.
That leaves Spokane patients traveling as far as Yakima to find a doctor who can prescribe it.
Suboxone can change lives, according to doctors and patients. With abuse of painkillers such as OxyContin and hydrocodone on the rise nationally and locally, Suboxone offers hope.
"I can pop those pills in my mouth in the morning, and today, I know I'm going to be clean," said Jerry Littlemore Jr. of Spokane, who got hooked on painkillers after he was injured in an accident. "I can't get high because those receptors are blocked. It's freedom. I don't have to deal with that battle in my head."
Only six doctors within reasonable driving distance of Spokane are prescribing Suboxone. Those doctors are in Moses Lake, Ephrata, Yakima, Post Falls, Coeur d'Alene and Sandpoint.
In contrast, 41 doctors west of the Cascades are prescribing Suboxone.
Littlemore travels to Moses Lake to see Dr. David Curnel, who prescribes his Suboxone.
People familiar with the situation say doctors may be avoiding Suboxone because they don't want to acquire a reputation as Spokane's addiction doctor. They may think patients who come to them for Suboxone may drive away their other patients.
Spokane doctors contacted for this story either had not heard of Suboxone or speculated that the hassle of taking a class and dealing with federal regulations has prevented some of their colleagues from signing up.
Meanwhile, there's no shortage of people who could benefit from the treatment.
Spokane's methadone clinic is overwhelmed with painkiller addicts, who now outnumber heroin addicts in the program 2-to-1. Spokane County is seeing a small but growing number of arrests involving prescription drugs.
The Spokane County Sheriff's Department made 44 arrests involving prescription drugs in 2003, up from nine in 1996. The number underestimates the problem because addicts get their pills from doctors, from friends with prescriptions or by faking pain in emergency rooms - methods that don't attract the attention of law enforcement.
But when there is an overdose, law enforcement gets involved.
"I have seen many deaths where OxyContin, hydrocodone and now, most recently, methadone, are a factor," said Sgt. Brad Maskell, a detective with the Kootenai County Sheriff's Department. He's worked on death investigations eight years and started noticing prescription drug deaths four years ago. In September, he investigated three separate deaths involving teenagers overdosing on methadone.
Nationally, drug abuse-related emergency room visits involving prescription painkillers rose 153 percent from 1995 to 2002, according to the federal government's Drug Abuse Warning Network. An estimated 4.7 million Americans are current abusers of prescription painkillers, according to the Office of National Drug Control Policy.
The people who run the Spokane methadone program want local doctors to start prescribing Suboxone.
"It would definitely help us immensely. We wouldn't have to turn anybody away," said Gary Kissel-Nielsen, program manager of the Spokane Regional Health District's methadone program, which can handle up to 250 patients.
"There are a lot of stereotypes of what an addict looks like. In truth, most look like everyone else," Kissel-Nielsen said. "We are seeing a lot more patients that have become addicted through prescription drug use. They were taking their prescriptions as prescribed for a legitimate reason, became addicted, were cut off by their doctor and now are addressing a dependency problem."
Suboxone is regulated under a 4-year-old federal law. The Drug Addiction Treatment Act was written to set rules for office-based treatment using buprenorphine, the active ingredient in Suboxone, which at the time was not yet approved by the U.S. Food and Drug Administration.
The law limits each prescribing doctor to 30 patients at one time. With only six doctors nearby, there are 180 slots in the Inland Northwest for people who want to try Suboxone. Most of those are full.
J.L.R. spent more than 25 years scamming hospital emergency rooms to get the narcotics that fed her addiction. Now 47 years old, the Spokane woman lost her children and husband due to her habit. She asked that only her initials be used in this story to protect her family from embarrassment
In 2003, J.L.R. was among Washington state's top abusers of hospital emergency rooms on a list compiled by the state's Medicaid office. She visited ERs 119 times that year and the state paid $18,154 for her painkillers and other drugs.
When she decided she wanted help quitting narcotics, she considered the methadone clinic. But the 76 slots for Medicaid clients were full. In June, she learned from a social worker about Suboxone. Along with mental health therapy, Suboxone has helped her get off addictive painkillers.
"For the first time in my life, I am happy. I go to bed at night looking forward to getting up in the morning," she said. "This Christmas, I'm getting a tree and decorating it. I don't ever remember feeling this good."
J.L.R. travels from Spokane to Post Falls to see Dr. Michael Carraher, who prescribes Suboxone. Her husband - they separated, but never divorced - wants to help and drives her to appointment.
"By the time (addicted patients) come in, some have lost everything, so they're desperate," Carraher said. About half the patients he's started on Suboxone have stayed clean, a rate he says is good. The drug costs between $85 and $640 per month, depending on dosage.
Suboxone and an alternative formulation called Subutex were approved by the U.S. Food and Drug Administration in 2002. They are the only drugs approved for treatment of opiate dependence that can be prescribed out of a doctor's office. (Methadone pills can be prescribed by doctors, but only for pain relief.)
Suboxone and Subutex are manufactured by Reckitt Benckiser Pharmaceuticals Inc. The company, based in Richmond, Va., is a subsidiary of Reckitt Benckiser PLC, a publicly traded British firm that sells household products such as Lysol. Suboxone and Subutex are manufactured in Hull, England.
Suboxone was developed, first as a painkiller, then as an alternative to methadone, which because of its potential for abuse and overdose, must be dispensed by federally approved clinics. Addicts must visit the methadone clinic every day to get their dose of the pink liquid.
In contrast, Suboxone offers more confidentiality because it is prescribed out of a doctor's office and dispensed by a pharmacy.
"With Suboxone, the patients have the convenience and ease of coming into a confidential setting in the physician's office," said Dr. Kent Vye, the prescriber in Yakima. Vye has had three patients from Spokane come to him for the drug.
"To see somebody whose marriage and employment is on the edge get into recovery, get clean and sober, and get their job and their relationship back, that is gratifying," he said.
HOW IT WORKS
Suboxone and methadone work in similar ways. They both attach to the same brain receptors as heroin and other opiates. Because they occupy the same chemical parking spaces in the brain, they satisfy the craving caused by addiction, stave off withdrawal symptoms and allow an addict to start rebuilding a life.
Because of its chemical properties, Suboxone is harder to abuse than methadone and less likely to cause a deadly overdose. It also doesn't cause as much of a euphoric high as methadone.
Both Suboxone and methadone create physical dependence and use must be tapered gradually to avoid withdrawal symptoms.
Experts differentiate between addiction and physical dependence.
"Addiction is compulsive use despite negative consequences; physical dependence is needing a drug to function," said Maia Szalavitz, co-author of "Recovery Options: The Complete Guide."
"We're all physically dependent on air and water, but not addicted to them. Maintenance replaces addiction and its negative consequences with simple physical dependence, which many people have on antidepressants and blood pressure meds, but that doesn't make them addicts."
People with experience taking Suboxone are posting messages about it on an Internet discussion board ( www.heroin-detox.com).
Much of the conversation is about withdrawal from Suboxone. People describe trouble sleeping, restless legs, intestinal problems, fatigue and feeling lousy as they taper off the drug.
-- "I don't know that I could have quit hydrocodone use on my own. The Suboxone is a very quick-acting replacement that helped me move from one drug to the other. Now the trick will be to taper from it to no opioids."
-- "My doctor tried to start me way too high on sub (Suboxone). He wanted me to take 24 to 32 mgs the first few days. I had read a lot about sub before I started taking it and 'started myself' at 8 mgs a day and was fine. As others have said, 'less is more' with sub. Also, I wish I had only stayed on sub for a couple of weeks instead of a couple of months. By the time I got off sub I was addicted to it and have had a very rough time detoxing."
-- "My daughter used heroin off and on for about four years. For her, Suboxone was a miracle drug. She was on it for about 10 weeks and had absolutely no withdrawals when she stopped taking it. As far as I know, she is still clean."
Methadone will always have its place, addiction experts say.
"People are trying to say that (Suboxone) could replace methadone, but that's like saying Zoloft could replace Prozac. There will always be people for whom certain drugs are better for reasons we don't know yet," said author and recovery expert Szalavitz.
"I was instantly transformed into my old self. It's been a complete miracle for me," said Chris, an Eastern Washington electrician who is using Suboxone to kick a five-year addiction to OxyContin, originally prescribed for pain from a back injury. "My memory is coming back. My energy level is back. I'm a happy person again."
SIDEBARS:1. FAST FACTSPAINKILLER ADDICTION Spokane's methadone clinic is overwhelmed with painkiller addicts, who outnumber heroin addicts in the program 2-to-1. Spokane County is seeing a small but growing number of arrests involving prescription drugs. An estimated 4.7 million Americans are current abusers of prescription painkillers, according to the Office of National Drug Control Policy.2. IDAHO'S MEDICAID OFFERS MORE LEEWAYDr. Kent Vye and other doctors who prescribe Suboxone would like to see Washington state's Medicaid program pay for one year of treatment instead of only six months, the current time limit for patients. Idaho's Medicaid program gives doctors greater leeway in how long they can keep prescribing Suboxone and get reimbursed through Medicaid. One prescription can be refilled for up to a year, if that's the way the doctor writes it. After a year, the doctor could write a new prescription. Idaho Medicaid limits patients to 16 mg a day of Suboxone. Washington has no such limit on daily dosage, but requires Medicaid clients to be in a state-approved drug treatment program in conjunction with Suboxone therapy. Washington state also requires a clean urine test every two weeks for a patient to continue on Suboxone. Idaho's Medicaid program paid for 15 patients to take Suboxone during 2004. Washington's Medicaid program paid for 61 people to use Suboxone in the first six months of this year.3. TO LEARN MORERESOURCES To locate a treatment facility or a doctor who prescribes Suboxone, go to http://buprenorphine.sam hsa.gov/ bwns_locator/. To reach the methadone program at the Spokane Regional Health District, call (509) 324-1420. Doctors can take an online class to qualify to prescribe Suboxone. Find the class at www.aaap.org and click on "buprenorphine." An in-person training session for doctors is scheduled for March 5 in Seattle. See www.docoptin.com.
Carla K. Johnson can be reached at (509) 459-5148, or by e-mail at [email protected]