WIDER ACCESS TO MEDICINE FOR ADDICTS APPEARS NEAR

Congress Is Poised To Lift Limit On Heroin Substitute

The House of Representatives is expected to pass long-stalled
legislation today that would expand access to a promising medication
for heroin addiction, particularly in cities like Baltimore that have
serious drug problems.

The legislation, which has been approved by the Senate and is
expected to be signed by the president, would lift a key restriction
on the distribution of buprenorphine, an opiate substitute that curbs
cravings for heroin or prescription painkillers and comes with
advantages over the better-known addiction medication,
methadone."It's going to pass," Rep. Elijah E. Cummings, a Baltimore
Democrat and co-sponsor of the bill, said yesterday. "It's very
important for Baltimore. This gives us another method for treating
heroin, one ... that will allow people to remain productive while
trying to overcome their drug addiction. We're looking for every tool
we can find."

Unlike methadone, buprenorphine, which is nicknamed "bupe," can be
taken at home rather than at clinics because it is less prone to
abuse; it leaves some users feeling more clear-headed than methadone
does; and it is easier to wean off of after a few months.

Related Links Sun coverage: An alternative to methadone But many
opiate addicts have had difficulty obtaining buprenorphine, partly
because of restrictions imposed on the medication by Congress when it
voted in 2000 to pave the way for regulatory approval of the drug two
years later. To keep unscrupulous doctors from operating prescription
mills, Congress decreed that neither individual physicians nor group
practices could prescribe the drug to more than 30 patients at a time.

As it was written, though, this limit also applied to other entities
that operate as group practices, like teaching hospitals, community
health clinics, and some large managed-care organizations.

This limit has had a particularly restrictive effect in cities like
Baltimore, where many of the city's thousands of heroin addicts seek
help from teaching hospitals and community health clinics. All of
Johns Hopkins Hospital in East Baltimore can prescribe it to only 30
people. The number of addicts citywide receiving buprenorphine at any
given time has been stuck in the hundreds.

The limit's starkest effect has been on the managed-care organization
Kaiser Permanente, which has 8.2 million members but can prescribe
buprenorphine to only 240 of them.

Members of Congress have said they never intended the limit on group
practices to apply so broadly, and bipartisan legislation was
introduced last year to lift the cap on group practices while leaving
it in place for individual doctors. But the legislation stalled in
the House last year for lack of attention, and its backers worried
that it might languish again this year.

This week, substance abuse specialists cheered word of the imminent
vote in the House, which followed the legislation's approval in the
House Judiciary Committee, where it had been hung up last year.

Dr. Michael Fingerhood, part of a four-person drug-treatment practice
at the Johns Hopkins Bayview Medical Center, said the legislation
would allow the practice to treat 120 people, rather than the 30 they
are now limited to. The practice has had to "pick and choose" among
patients to stay under the cap, he said.

"It'd be great. It's a big difference. This would be absolutely great
news," he said.

In New York City, Health Department official Dr. Andrew Kolodny said
the lifting of the cap would make it much easier for that city to
reach its ambitious goal of treating 60,000 people with buprenorphine
by 2010. Until now, some hospitals have been reluctant to prescribe
the medication because they cannot serve more than 30 people, he said.

"That excuse is now out the window," he said. "This is really exciting."

Substance abuse experts note that other limitations will remain in
place. The medication, which is made by the British company Reckitt
Benckiser, remains too expensive for many addicts, at about $12 per
day. Medicaid covers it in fewer than half of the states, including
Maryland, and only a few Veterans Affairs hospitals dispense it. And
fewer than expected primary care physicians are signing up to become
certified to prescribe the medication, for which a one-day training
course is required.

Because there is a shortage of doctors prescribing the drug, some
buprenorphine advocates say the best way to improve access is to lift
the 30-patient cap on those doctors who are prescribing it. Dr.
Michael Hayes at Maryland General Hospital says substance abuse
specialists like himself can responsibly prescribe the medication to
many more than 30 people at a time.

"The whole thing is just deranged. [The legislation] just isn't aimed
to help the problem as I see it," he said. "If it said that a group
can have as many patients as it can handle, that's one thing, but to
keep the same formula that limits the amount of patients with the
same disease that a physician can see, that's not an improvement."

Other buprenorphine advocates hope support for lifting the cap on
individual doctors might build as word of the medication's benefits
spreads, and as federal authorities find that the potential for abuse
of the drug is minimal. There have been very few reports of diversion
or abuse so far, according to the Drug Enforcement Administration.

"We're excited about this step," said Dr. Charles Schuster, a
substance abuse expert at Wayne State University in Detroit, who
helped write the 2000 law approving the drug's use, "and we'll move
on to the next one shortly."