Doctors shy away from prescribing treatment drug

But officials say addicts need it to ease withdrawal

physicians' training set

`Bupe' an alternative to methadone

September 04, 2005|By Melissa Harris | Melissa Harris,SUN STAFF

Howard County health officials plan to train a handful of doctors this fall to prescribe a revolutionary pill that curbs addictions to heroin and popular painkillers and lessens demand for outpatient drug clinics that residents say attract dangerous clients.

Last year, the United Way of Central Maryland mailed pamphlets on the benefits of buprenorphine - known in the medical community as "bupe" - to every doctor in the county, but only seven expressed interest in taking the eight-hour training course needed to prescribe it.

Howard County officials plan to follow up with those seven doctors this fall and ask them to enroll. A grant from the Columbia-based Horizon Foundation will cover the course's $200 fee.

Buprenorphine's primary benefit is that it can be taken at home, giving addicts greater privacy and a more convenient alternative to methadone, which is administered in clinics. But under federal law, a doctor can prescribe bupe only to 30 patients at a time - hence the need to certify more doctors.

"It's easier to get heroin in Baltimore than it is to get bupe," said Cynthia Lipsitz, medical director at the Howard County Health Department. "And it costs more than heroin, too."

Congress recently lifted some restrictions on the use of bupe, which costs $6 to $8 a pill and eventually can be taken as infrequently as once every three days.

Until this year, only one doctor per group practice or hospital could prescribe the drug. Now, multiple doctors at a hospital or in a practice can distribute it, but the 30-patient limit is still in effect.

The eased rules, however, are not luring many converts among physicians who have reservations and biases about bringing drug addicts into their waiting rooms.

Some physicians steer clear of addiction treatments because patients can be manipulative, relapse frequently and suffer from a host of other problems, such as sexual abuse or mental illness, said Dr. Preston Gazaway, who prescribes bupe to patients at the Howard County Health Department.

Dr. Robin Toler, who is on staff at Howard County General Hospital and is about to open 30 bupe treatment slots in her private practice, put it this way: "The doctors really aren't interested in this area of medicine."

Neglecting these patients is a mistake, said Dr. Michael Hayes, a pioneer in bupe treatment and the head of the chemical dependency division at Maryland General Hospital.

"If we would start treating addiction as we would any other chronic illness, the better we would all be," he said. "Addicts suffer terribly from medical neglect, and treatments for them have taken more than 80 years to spread. Doctors have to understand that addicts are regular people, just like anybody else."

Homeless to well-off

Gazaway said his clientele ranges from the homeless to people with six-figure incomes.

He and Toler are two of at least seven doctors known to prescribe bupe in Howard County, according to the federal government's voluntary registry of providers and interviews.

"The problem is a lot bigger in the county than I think doctors realize," said Toler, who was first exposed to addicts at Walter Reed Army Hospital in Washington, where she worked while attending Georgetown University's medical school.

The allure of heroin and such painkillers as OxyContin and Percocet is emotional and physiological.

The opiates bind to the brain's synapses, or signal receptors. When heroin is injected into the body, it sends pleasurable signals, which soon are perceived as normal. A dearth of these signals creates painful cravings, or withdrawal.

Methadone, the addiction treatment of choice for much of the past century, lessens the high but can become addictive. Bupe binds with synapses, too, and can be painful during withdrawal. But it does not trigger the same feelings of pleasure.

Less addictive nature

Bupe can be prescribed because of its less addictive nature, while methadone treatment requires daily visits to government-monitored clinics.

Bupe also makes users feel less groggy than methadone, said one addict, who hopes to soon be able to quit the drug altogether.

It all started with a car accident for one 36-year-old man from Ellicott City, who asked for anonymity out of fear of losing his job. A doctor prescribed him painkillers, including OxyContin and Percocet.

"For a solid two months, life was pretty much a candy shop," he said.

Once the prescriptions ran out, the pain should have been gone, but the withdrawal only worsened it. He turned to heroin, driving Baltimore streets that a friend recommended.

After 2 1/2 years, he turned to a methadone clinic for help.

"There's a stigmatism of having to be somewhere at 5:30 a.m. every single day," he said. "You stand in line and you see these people hunched over who look 59, but they're only 39. And you just say to yourself, `I'm not like these people,' even though I was."

He was drug-free for four months and then relapsed. He turned to bupe and attended a Baltimore program whose participants go from addict to cold turkey in seven days. It didn't work.

Third try

On his third try, he found Lipsitz, whose program is more gradual and comprehensive and includes acupuncture and counseling. He still takes bupe, but for all intents and purposes, he is cured. He has a job that pays more than $60,000 year, a savings account, a pension plan, a new car and his own place.

He said that the first bupe treatment program made him feel part of an "assembly line" but that the drug didn't give him the "hunched over" feeling of methadone.

"I had hoped that I wasn't going to take it anymore last year," he said. "Then we moved it to this fall, but I don't think I'm ready.

"Am I addicted to it? Of course I am, and if I just stopped it, I would hurt. But right now, I'm living a relatively normal life."

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