Wider access to medicine for addicts appears near

Congress is poised to lift limit on heroin substitute

July 27, 2005|By Alec MacGillis | Alec MacGillis,SUN STAFF

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.

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."

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