A DISCREET WAY TO BEAT ADDICTION

Law Expands Access to Pill That Helps People Hooked On Painkillers and
Other Drugs

A new federal law promises to expand access to a medication that is
transforming the treatment of patients addicted to pain pills and other drugs.

For patients, the drug, called buprenorphine, is convenient and discreet,
unlike the more widely known methadone. Both are mild narcotics that can
help patients ease off of harder drugs. But methadone is more potent and
must be dispensed daily under supervision at drug-treatment clinics, while
buprenorphine is available by prescription at local pharmacies and can be
taken anywhere by dissolving a pill under the tongue.

Doctors who prescribe buprenorphine say this office-based form of rehab
appeals to patients who otherwise would never seek treatment. Some say
their patients are largely professionals -- from bankers to business owners
- -- and their family members, who have developed a dependence on pain pills
or even heroin, but couldn't imagine themselves lining up at a methadone
clinic or entering an in-patient facility. Patients say buprenorphine makes
it possible to live normal lives, including holding down jobs, while
receiving drug treatment.

To date access to buprenorphine has been severely limited. Before the drug
was approved three years ago, Congress passed a waiver to current narcotics
laws, allowing specially trained doctors to prescribe the drug for
individual use. Otherwise it would have to be dispensed in a supervised
clinic, as methadone is. But as a safeguard against overuse, each group
practice or hospital could treat only a maximum of 30 patients. For
instance, health plan Kaiser Permanente's entire 5,400-physician group
practice in Northern California could treat only 30 patients with
buprenorphine.

The new law, signed by President Bush last week, lifts the 30-patient cap
for group practices. From now on, each individual doctor in the same
medical group or hospital can prescribe buprenorphine for up to 30
patients. And advocates for the drug hope even that restriction will be
relaxed eventually as well.

The expanding access to buprenorphine reflects a growing acceptance of
addiction of all kinds as a medical condition, not a moral failing, that
benefits from both medication and counseling. The medical community has
increasingly recognized that asking someone to go cold turkey from drugs,
nicotine or even alcohol may be unrealistic and can have health
consequences. Beginning with methadone, the trend has moved to nicotine
patches and gum to treat smokers. A hallmark of many of these efforts is
that they are accessible to the individual, and don't require clinical
settings or in-patient stays. And there are continuing efforts to develop
new drugs to help smokers, alcoholics and drug abusers quit.

Buprenorphine is designed to ease withdrawal and satisfy cravings without
the rush of abused opioid drugs. It can be used to treat addiction to pain
killers such as Oxycontin, Vicodin or codeine, as well as heroin, and can
be as effective as methadone in most cases, doctors say. Buprenorphine
blocks the intoxicating effect from opioids for days, which doctors say
helps patients resist temptation. Only doctors who've undergone eight hours
of training or have equivalent specialty training can prescribe the drug.

Patients can become dependent on buprenorphine, however, and common side
effects include headache, pain and nausea. But withdrawal symptoms are
usually milder than those associated with methadone, and there is less risk
from an overdose.

At about $10 a day, buprenorphine treatment costs a lot less than the drugs
abused by many people. Oxycontin, for example, may cost an addict $35 to
$85 or more a day on the street. Some 82% of people with commercial health
insurance are covered for buprenorphine, according to data compiled
recently by the drug's maker, Reckitt Benckiser PLC of the U.K.

Abuse of opioid drugs, from Vicodin to heroin, is a common and growing
problem. About 1.4 million people were dependent on prescription pain
relievers in 2003, the most recent year for which estimates from the
federal Substance Abuse and Mental Health Services Administration are
available. Nearly 12 million people used the drugs for nonmedical reasons
that year. Another 189,000 were dependent on heroin, by these estimates,
with 314,000 users nationwide.

A study by assistant professor of medicine Lynn E. Sullivan and colleagues
at Yale University School of Medicine found that patients seeking
office-based buprenorphine treatment were more likely to have jobs, have
fewer years of addiction and be new to treatment than those going to a
traditional methadone clinic. "These are the same patients that have always
been in my office," says Dr. Sullivan, who is also an internist.

James Berman, an internist who specializes in addiction, says his practice
in the prosperous Philadelphia suburb of Haverford, Pa., includes money
managers, bankers and real-estate and construction executives. Dr. Berman,
who is affiliated with the University of Pennsylvania, says among adults
who stick with therapy and buprenorphine, he's had success rates of 85% to
95% since he began using the approach in 2003.

People interested in buprenorphine treatment haven't always been able to
find a doctor to help. Many primary-care doctors have been slow to embrace
buprenorphine because they don't feel qualified to treat drug dependence or
they balk at the idea of having addicts in their waiting rooms. About 5,800
doctors across the country have been cleared to prescribe the drug, but
only 3,400 are listed in a government-run database to help patients find a
local prescriber -- which may reflect a change of heart, a wish to limit
the number of patients or paperwork delays.

Buprenorphine is usually given two or three times a day as an orange pill
called Suboxone that partially blocks the receptors in the brain for drugs
such as Oxycontin that work like opium in the body. Suboxone includes an
ingredient called naloxone to thwart drug abusers who might try to dissolve
the pills and inject concentrated buprenorphine for pleasure. (Subutex, a
buprenorphine-only drug, is usually used only during supervised
detoxification at the beginning of treatment.)

People seeking doctors qualified to prescribe buprenorphine can search a
database maintained by federal government's Substance Abuse and Mental
Health Services Administration, at buprenorphine.samhsa.gov. When calling
for an appointment make sure there's a slot available right away. Starting
treatment quickly, some doctors say, is important for success.

Most of all, make sure there are adequate provisions for counseling.
"Buprenorphine is not a panacea," says Dr. Berman.

At a therapy session early this year, about 20 men, most being treated with
buprenorphine, gathered in Dr. Berman's office to talk about their
struggles with addiction. One man described how difficult his marriage had
become since he stopped using prescription painkillers. His wife had only
known him while he took the pills, which made him easygoing. Now, he told
the group, his wife was discomfited when he had the bad days that are part
of normal life. He had been tempted, he said, to return to pain pills.

Some veterans of the group encouraged him to reach for support, and several
volunteered to talk to him daily.