NEW DRUG TREATS THE NEW FACE OF ADDICTION

And for the First Time, Help Comes From the Doctor's Office, Not the
Methadone Clinic

The swans that winter near David Alexander's home depend on the
couple of hundred pounds or so of goose feed he scatters each day.
Only a third of the cygnets, the baby swans, live through their first
harsh Connecticut winter.

Like the toughest cygnets, Alexander, 56, is a survivor. After years
of battling an addiction to painkillers that were prescribed for
numerous injuries he suffered while racing motorcycles, Alexander no
longer craves the narcotics.

His salvation, says the certified wildlife rehabilitator who hopes to
open his own nature center someday, is a drug called buprenorphine.
"It saved my life," says Alexander, a West Haven resident who has
been taking "bupe" since enrolling in a study 31/2 years ago. "And
I'm not being dramatic."

Buprenorphine is the first medication available from the doctor's
office for treating addiction to opioids, which are narcotic
painkillers and heroin. Methadone, the only other drug used to treat
opioid addiction, is available only at methadone clinics.

Instead of having to go to a clinic every day to drink methadone,
patients can get a buprenorphine prescription filled at their local
pharmacy and let the tiny, six-sided orange pills dissolve under
their tongues in the privacy of their own homes.

Launched in early 2003, buprenorphine arrived at an opportune time as
growing numbers of Americans are becoming addicted to painkillers.
The face of opioid addiction is no longer just the stereotypical
street junkie. As the demographics of addiction have changed, so have
the demographics of addiction treatment, thanks to buprenorphine.

"People who would never come into a methadone clinic, because it is
both degrading and stigmatized, will come to a private physician's
office. They could have a cold for all anybody knows," says Charles
Schuster, head of the Substance Abuse Clinical Research Division at
Wayne State University in Detroit.

A study published in July in the journal Drug and Alcohol Dependence
appears to back up Schuster. Yale researchers compared 96 patients
starting buprenorphine treatment with 94 starting treatment at a
local methadone clinic. Buprenorphine patients were three times more
likely to work full time and about a third less likely to have tried methadone.

"The results suggest that office-based treatment of opioid dependence
is associated with new types of patients entering into treatment,"
the researchers said.

Any doctor who completes an eight-hour training session and receives
government clearance can prescribe buprenorphine. Since the drug's
U.S. launch in early 2003, about 150,000 to 200,000 Americans have
taken it -- still only a tiny fraction of the more than 31/2 million
Americans who are addicted to prescription opioids or heroin.

Like methadone, buprenorphine is itself an opioid painkiller. But
buprenorphine's effects are weaker than those of other narcotics. It
decreases cravings for opioids and suppresses opioid withdrawal
symptoms without causing feelings of euphoria.

Taking more buprenorphine than prescribed does not make users feel
high, so it has a relatively low potential for abuse. And only when
combined with alcohol, tranquilizers or sedatives has buprenorphine
led to fatal overdoses, the Food and Drug Administration says.

Although just as effective as moderate doses of methadone,
buprenorphine may not be as effective as higher doses of methadone.
So methadone might still be the treatment of choice for people with a
long-standing addiction.

Buprenorphine is sold by Reckitt Benckiser as Subutex and Suboxone.
Subutex contains only buprenorphine and is given for the first few
days of treatment. Suboxone combines buprenorphine and naloxone,
which, by blocking opioids' effects, guards against abuse. It is
prescribed for maintenance.

To enlighten other doctors, David Fiellin and Lynn Sullivan,
co-authors of the Yale study comparing methadone and buprenorphine
patients, asked Nick Carrano to accompany them when they lectured
hospital staff about addiction treatment.

" 'You are the perfect person to break the stereotype of who people
think is a heroin addict,' " Carrano says Fiellin, an associate
professor of internal medicine, told him.

Since 1999, Carrano, 27, has worked at the same dental lab as his
mother, with whom he lives in North Haven, Conn. He began smoking
marijuana daily in high school. "No big deal," he rationalized. "Some
people are on antidepressants. This is what I do."

Then someone gave him part of a morphine pill. "Wow, I really like
the way this makes me feel. I hope I never have the opportunity to
try heroin, because I probably would like it," Carrano recalls thinking.

That opportunity presented itself when he was 21. He went on to snort
heroin once every week or two for a year. "As long as you're not
stupid about it, maybe you can keep it under control," he thought.

But then he started snorting it every day at lunchtime. Three weeks
later, he realized he had become addicted. "The joke's on me," he
thought. "You never expect it to happen to you."

He could no longer keep his heroin use a secret from his mother and
his boss. "I definitely realized very early on that I had a serious
problem," he says.

Carrano tried stopping on his own and with the help of outpatient
rehab programs, but he always returned to heroin. When he sought
treatment at a methadone clinic, Carrano says, he was told his short
history of addiction made him a candidate for buprenorphine. He
enrolled in his first trial at Yale in April 2002 and has been taking
buprenorphine ever since. "Right away, it made me feel better."

He also has been seeing a psychotherapist, who is helping him deal
with the loss of his father at age 9, an event, he says, "that
basically sent me on the path I went down."

At first, Carrano says, he figured he would need buprenorphine only
for a couple of years. He has tapered down his daily dose from 24
milligrams to 6, but stopping is no longer a priority.

"To me, my life is so improved. It's not even worth the risk," Carrano says.

According to Reckitt Benckiser, some people need buprenorphine for
only a few weeks; others need it for years. Sullivan, an associate
professor of medicine, compares treating addiction with buprenorphine
to treating diabetes with insulin.

"I'm a firm believer in maintenance therapy," Sullivan says. "This is
a medication, not a drug."

Like Carrano, Lauren Nugent, 36, says she never thought she would
become addicted to drugs.

"I didn't take drugs in high school," says Nugent, who lives in West
Haven, Conn. "I was a cheerleader for nine years. I had a normal upbringing."

But right around the time she was married in 1999, Nugent says, she
realized she had become addicted to the Percocet and Vicodin doctors
prescribed after her numerous surgeries for severe endometriosis.

"When I did realize it, I was trying to get pregnant," Nugent says.
"I thought, 'Boy, I'm in big trouble. If I get pregnant, when I get
pregnant, how am I going to get through nine months without taking anything?' "

She didn't. When she finally became pregnant, Nugent says, she did
cut way back on painkillers, but she supplemented them with nighttime
cough and cold remedies. By the time her daughter, now 5, was born,
her husband was on to her. The empty cough medicine bottles and pill
containers tipped him off.

After she delivered, Nugent says, she increased her use of
painkillers, obtained at walk-in clinics and hospitals. Her baby had
been born healthy, but Nugent's drug use left her unable to care for
her. Her husband was on the verge of filing for divorce. Nugent says
she tried inpatient and outpatient rehab programs, but they didn't
work for her. Then she found buprenorphine.

Since May 2004, Nugent has been taking buprenorphine under the care
of Waterbury, Conn., addiction specialist Mark Kraus. She visits his
office every three weeks for a checkup and a prescription.

"I have absolutely no thoughts of going back to drugs," says Nugent,
proud that she was able to host her large, close family for
Thanksgiving dinner. "At one point, I had taken methadone to try to
get my life back. It was just like another drug for me. With the
buprenorphine, I feel like a whole, normal person."

More than 9,000 U.S. doctors have had buprenorphine training, and
about 6,900 have been certified to prescribe it by the federal
Substance Abuse and Mental Health Services Administration, or SAMHSA,
says Robert Lubran, director of pharmacologic therapies for the agency.

Vermont, which has one of the country's highest rates of illicit drug
use, has by far the most doctors per capita who can prescribe
buprenorphine, Lubran says. About 18 doctors per 100,000 Vermonters
can prescribe it. By comparison, only about five doctors per 100,000
New Yorkers can.

Psychiatrists make up the largest segment of buprenorphine
prescribers, but a variety of other specialists, including
gastroenterologists and family practice doctors, also have received
permission to prescribe it.

Scott Prince, a Wilkes-Barre, Pa., family-practice doctor, was
certified in June to prescribe buprenorphine. About half of the
patients he treats were addicted to heroin, half to prescription painkillers.

Prince says many of his colleagues are reluctant to treat addiction.
"They're afraid of that type of patient being in their office, but
they don't understand. That type of patient is in their office already."

Prince's waiting list of more than 300 buprenorphine candidates
attests to both the shortage of prescribers and the limits placed on
them. To encourage more doctors to prescribe buprenorphine, the
American Society of Addiction Medicine has set up a nationwide
mentoring network. Doctors who are new to treating addiction can get
support from a mentor via phone, e-mail or in their office.

Even if the number of prescribers quadrupled, it would still fall
short, because no one can treat more than 30 patients. Still, 30
patients per prescriber is an improvement over the original 2000 law
that opened the door to addiction treatment in doctors' offices.

To avoid creating prescription mills for a drug that could be abused
or sold on the street, the law originally limited the number of
patients per practice, no matter how large, to 30.

Although the number of buprenorphine doses dispensed in the USA
increased from 1.9 million in 2003 to 14.9 million in the first eight
months of 2005, it pales compared with methadone, says Nicholas
Reuter, a senior public health adviser in Lubran's division. In 2002,
nearly 250 million methadone doses were dispensed, Reuter says.

SAMHSA has not seen much abuse or diversion, which is use of the drug
by someone for whom it was not prescribed, Lubran says.

"It could be we're not seeing it yet," he says. "But all the
indicators we're looking at tell us abuse and diversion are
relatively low. I think it's important that we're monitoring it."

Surveys of people entering drug rehab have found few mentions of
buprenorphine being sold on the street, says Schuster, a former head
of the National Institute on Drug Abuse, who is under contract with
Reckitt Benckiser to conduct FDA-required post-marketing surveillance
of buprenorphine.

Surveys of prescribers report that about a quarter say they know of
buprenorphine use by people who did not have prescriptions. But
misuse comes to light mainly because those who obtained buprenorphine
illegally are so impressed with its effect on cravings that they seek
treatment, he says.

Doctors who prescribe buprenorphine say the reward is great.

"There are just not that many things you do that so dramatically
change peoples' lives," says Yale's Sullivan, who has treated David
Alexander and Nick Carrano. "They recoup their lives, their families,
their jobs, their self-esteem."

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ABOUT THIS REPORT

USA TODAY and HBO are collaborating on a special report on drug and
alcohol addiction. This story is part of that project, which will
include future stories in USA TODAY and a three-hour HBO public
service special scheduled to air in January 2007. We will explore the
latest research into addiction, how addiction affects lives and
communities, and cutting-edge treatments. co