CITY MOVES TO EXPAND DRUG TREATMENT ACCESS

Hoping to make a revolutionary treatment more available for heroin
users, Baltimore officials are taking the unusual step of subsidizing
a training program that could more than double the number of
physicians permitted to prescribe a new medication to cure opiate addiction.

Buprenorphine, commonly referred to as "bupe," is being used in place
of methadone to wean addicts off heroin because it can be taken at
home, is less prone to abuse and is easier to discontinue when the
patient is ready. But fewer than 90 physicians in Baltimore have
completed the eight-hour training course required to prescribe the
drug."In a city like Baltimore, where we have a lot of doctors, this
really offers a potential for a major expansion of access to care,"
the city's health commissioner, Dr. Joshua Sharfstein, said of the
training initiative. "Getting doctors trained is just incredibly important."

Approved by the Food and Drug Administration in 2002, buprenorphine
has been slow to reach patients in Baltimore, where by most estimates
thousands are addicted to heroin. To reduce the risk of misuse, the
federal government requires eight hours of training and also limits
individual physicians to no more than 30 buprenorphine patients at
any one time.

Mayor Martin O'Malley's administration is expected to officially
announce the program this morning after the city Board of Estimates
votes on a $10,000 contract with Clinical Tools Inc. to cover the
cost of training the first 100 doctors. The North Carolina-based
company will provide the training, at no charge to the doctors,
through an Internet-based program.

The money is part of a $250,000 appropriation made from last year's
city budget surplus that Sharfstein said will be used to subsidize
training, help patients find primary-care doctors and, in some cases,
pay for the cost of the drug. Sharfstein said he expects the program
to begin this fall and hopes the initiative will eventually train any
doctor who requests it - potentially hundreds of physicians.

Other cities, including New York, have provided funding to subsidize
the training. Howard County used foundation money to help coordinate
training last year, but only seven physicians expressed an interest.
Several national experts said it is relatively unusual for local
governments to pick up the cost, and Baltimore's program appears to
be considerably more ambitious than what has been attempted in
Maryland or elsewhere.

In addition to the benefits provided by its chemical composition,
physicians said, a main advantage of the drug is that it allows
patients to treat their addiction through a primary-care doctor
rather than by visiting a methadone clinic. Not only is methadone
treatment often stigmatized, it also brings the user into regular
contact with other drug addicts - an association that some believe
can tempt patients into relapse.

Sharfstein said Baltimore treats about 4,500 people a day with
methadone and believes that about 1,000 residents are being treated
with buprenorphine. He said the city Health Department's goal is to
treat 10,000 patients with the new drug.

Dr. Michael Fingerhood, an internist at Johns Hopkins Bayview Medical
Center, said he has used buprenorphine successfully for about three
years. Five doctors prescribing the drug in his office see just over
100 patients, he said, and the drug tends to be less sedating while
still effective at limiting cravings. The duration and frequency of
use, he said, depends on the patient.

"In the primary-care setting, I think that you do build trust. It's a
good feeling on both sides, for both the provider and patients,"
Fingerhood said. "It's truly a drug that can change people's lives."

Buprenorphine is manufactured by the British company Reckitt
Benckiser and sold under the brand name Suboxone. Most patients take
a 16-milligram dose of the drug after detoxification, health
officials said. The cost is $8.48 per dose.

Until last year, group practices - including health clinics, teaching
hospitals and large managed-care organizations - were limited to 30
"bupe" patients each, meaning the Johns Hopkins Hospital, for
instance, was permitted to prescribe it to only 30 people at any one
time. That restriction was lifted, and now the limit applies to
individual doctors.

Since then, the number of doctors who have taken the training has
remained relatively low. The Substance Abuse and Mental Health
Services Administration, part of the U.S. Department of Health and
Human Services, lists 190 physicians that are prescribing
buprenorphine in Maryland, with 84 in Baltimore, though local
officials said they believe the numbers may be higher.

Several experts said doctors might be uncomfortable - or, at best,
unfamiliar - with treating patients with a drug addiction, especially
given the chance for relapse. But others said primary-care doctors
can take a more holistic approach to treating the problem than
methadone clinics.

"A lot of physicians have zero training in this, and they're
concerned that they're not going to be up to the task," said Frank
Vocci of the National Institute on Drug Abuse. "But physicians really
do have power when they sit down and talk with [patients]. There's
something therapeutic about sitting down with someone that's very powerful."

In some cases, buprenorphine training is performed in classrooms, but
the city's model uses a Web-based program that lets doctors start and
stop the course at their leisure. Mary Metcalf, director of
continuing education for Clinical Tools, said 100 physicians have
used the system nationwide and another 50 are now in training.

"For a city government to step in ... to try to get all the care
providers trained is just remarkable," said Metcalf, adding that
Baltimore is the only local government that has hired the firm.