PILL GIVES ADDICTS EXIT FROM DOPE

"It's still a lot cheaper than what they'd pay for a fix on the street."
Jan Campbell, an addiction psychiatrist

When Steven Gutsch recalls first shooting up heroin, nostalgia takes over.

"I fell in love with it," the twitchy 20-year-old says. "Your whole body
feels sooooo good. It's like sex times three."

But even that couldn't compare with what followed: an eternal terror of
getting "dopesick" -- the cramping, vomiting, diarrheic, restless, aching
limbo of opiate withdrawal.

It's like sick times ten.

A little orange pill might free him from the relentless craving and the
fear coming off opiates. Addiction specialists think the drug,
buprenorphine, holds even greater promise for middle-class addicts who
stumble into dependence on prescription painkillers.

If only they could score it.

Tough to abuse and dispensed through monthly prescriptions -- eliminating
daily treks to a methadone clinic -- buprenorphine could spare people from
a life of dope, doctors and addiction specialists said.

Not only does it offer an alternative to methadone -- the current choice of
some 1,200 people in the Kansas City area -- buprenorphine looks especially
promising for people who find themselves hooked on drugs such as OxyContin
or Percocet following surgery or serious injury.

It's people like that, psychiatrists and drug counselors said, who find
standing in line for methadone with street junkies like Gutsch either so
intimidating or so embarrassing that they opt instead to nurture an illegal
habit.

Although buprenorphine provides a dramatic alternative, two years after it
was approved in the United States, the drug just isn't easy to get.

One of the two Kansas City area physicians qualified to prescribe the drug
lost his medical license in December, sending clients scrambling for
someone to renew their prescriptions. Doctors as far away as Wichita and
Garden City, Kan., report calls from Kansas City addicts looking for
buprenorphine.

The closest option appeared to be Jay Kennedy, a physician at Lawrence's
Haskell Health Center, which only treats American Indians.

"I had to turn them all away," Kennedy said.

Federal research found that in 2003, about 200,000 Americans were dependent
on or abused heroin. The same year, 11.7 million people in the country
abused prescription painkillers and about 1.4 million of those people
suffered from dependency.

A recent survey of high school students found that one in 20 seniors had
taken OxyContin in 2004, a 25 percent jump from two years before.

For decades, the sole medical alternative for heroin users or Vicodin
abusers was methadone. The problem always has been that getting it meant
daily trips to a clinic -- a requirement so humiliating or cumbersome that
many addicts choose instead to tend their habits with more abuse.

Federal rules imposed to prevent crooked doctors from acting as
buprenorphine prescription-writing mills have meant that few physicians
hold the power to prescribe the new drug. Those who can prescribe may carry
no more than 30 buprenorphine patients at a time.

Nationally, fewer than 4,800 doctors can prescribe buprenorphine
(BYOO-pruh-NOR-feen, or simply bupe). Just 33 in Missouri and 11 in Kansas
have taken the eight hours of training that qualify them. The federal
Substance Abuse and Mental Health Services Administration complains it
can't recruit enough doctors to get buprenorphine licensing.

"Physicians are a little frightened about taking on opiate addicts," said
Charles Schuster, the former director of the National Institute on Drug
Abuse. "Many people think of addiction as a moral failure instead of a
medical problem."

Cheaper than a fix

Addiction psychiatrist Jan Campbell is the lone Kansas City area doctor
currently capable of handing out the drug, and she is near her limit of
patients. She works at the Veterans Affairs hospital in Leavenworth and on
the University of Kansas Medical Center campus.

Although buprenorphine can cost $200 more per month than methadone,
Campbell said her patients don't seem troubled by price.

"It's still a lot cheaper than what they'd pay for a fix on the street,"
she said.

Made by the British firm Reckitt Benckiser Pharmaceuticals, Suboxone is the
brand name for a mixture of buprenorphine and naloxone. It must be allowed
to dissolve under the tongue, or the body doesn't absorb it. So a child
accidentally swallowing his father's dose is unlikely to be harmed. Because
it includes the opiate antagonist naloxone, addicts who crush the tablets
to snort or inject the drug suffer severe withdrawal symptoms. As addiction
specialists put it, abusing Suboxone is something you only try once.

Because buprenorphine plugs into the same receptors in the brain that
channel heroin-like drugs, there's no added high from taking other opiates
once you've dissolved the little orange pill.

Methadone clinic workers commonly suggest buprenorphine is too weak to work.

"The last two (patients) who left here to do buprenorphine came back
because it didn't work for them," said Lynette Maxwell, the coordinator and
a counselor at DRD Kansas City Medical Clinic at 18th and Charlotte streets.

Psychiatrists and treatment specialists believe buprenorphine holds the
greatest hope for people early in addiction. Still, there's a sense that
methadone clinics oversell the structure they offer.

"There's a sizable majority of patients who can do well with less
supervised care," said David Fiellin, a professor of internal medicine at
Yale University and a buprenorphine researcher. "I don't think anybody
would advocate that people with diabetes should have to go to a doctor's
office on a daily basis for their insulin."

Overcoming the stigma

In fact, many patients simply won't go to a clinic every day.

"Countless numbers of people have died from overdose or HIV and hepatitis C
(from infected needles) when they could have been on methadone," said Edwin
Salsitz, who is licensed to train doctors in the use of buprenorphine and
who has spent years studying methadone at Beth Israel Medical Center in New
York City. "It's the stigma that stops people from signing up for methadone."

In addition to specially certified doctors, federal law also allows
methadone clinics to offer buprenorphine to an unlimited number of patients
- -- as long as they hand out daily dosages on site rather than write monthly
prescriptions. Patrick McAlinney, the physician running the Bridge-Way
Recovery Inc. methadone program in Overland Park, expects to draw a whole
new clientele of patients addicted to prescription painkillers when he
starts offering buprenorphine later this spring.

"It's another way to get help for people who are put off by the stigma of
methadone," McAlinney said.

At the Rodgers South Addiction Treatment Program near 31st Street and
Prospect Avenue, about 300 people rely on syrupy cherry-flavored cups of
methadone to tame their hankering.

Few ask for buprenorphine, and few know it exists. Now the center is on the
verge of adding buprenorphine to its regimen -- aimed at the 20-year-old
OxyContin abuser or the addict looking to work off methadone.

"After their life is stable," said psychiatrist Nora Quiason, "they don't
like to be tethered to the clinic."

For people in rural areas, treatment at an urban methadone clinic simply
isn't practical. "The closest methadone clinic we've got is probably
Wichita" more than 100 miles away, said Garden City psychiatrist Dan
Montgomery.

Gutsch sleeps at a Lawrence homeless shelter and has no way to get to any
of Kansas City's methadone clinics. He strolls the shopping district on
Massachusetts Avenue panhandling money for food and taking the tobacco from
discarded cigarette butts to roll his own.

Trying to support his habit, he bungled a purse snatching and spent more
than two months in jail. He shivered and sweated and puked his way through
withdrawal in jail.

Yet his cravings remain. Gutsch wants to try buprenorphine but can't find a
nearby doctor who can prescribe it.

So he's talking of heading to North Dakota to be with his girlfriend, a
fellow addict who has found one of only two doctors in the Dakotas able to
order the drug. Meantime, the sight of something as commonplace as a
cigarette filter, used by junkies to screen impurities from a fix, can
unleash Gutsch's desire to shoot up.

"I want the urge to use," he said, "to go away."

[Sidebar]

FIRST GLANCE

Buprenorphine was cleared for use in the United States in October 2002,
with strict controls over which doctors may prescribe it.

For more information visit these Web sites: www.buprenorphine.samhsa.gov; www.suboxone.com; www.methadone.org.

Fast facts on buprenorphine

Sometimes can create flulike symptoms of nausea and irritability.

Suboxone can be prescribed by a physician. It is buprenorphine mixed with
naloxone, a drug that will trigger severe drug withdrawal symptoms if
crushed and snorted or injected.

Subutex is pure buprenorphine and can only be given under direct
supervision by a physician. Sometimes used in clinic session for initial
period of withdrawal from heroin.

Considered a Schedule III drug under the federal Controlled Substance Act,
meaning it has less risk of psychological addiction or physical dependency
than drugs such as morphine, methadone and oxycodone.

Only physicians with eight hours of training in the drug's use can write
buprenorphine prescriptions. And a single doctor, or medical practice, may
treat no more than 30 patients on the drug at one time. Methadone clinics
may also dispense single doses of the drug, but they cannot write
prescriptions.