City moves to expand drug treatment access

October 04, 2006|By John Fritze | John Fritze,Sun reporter

Hoping to make a revolutionary treatment more available for heroin users, Baltimore officials are taking the unusual step of subsidizing a training program that could more than double the number of physicians permitted to prescribe a new medication to cure opiate addiction.

Buprenorphine, commonly referred to as "bupe," is being used in place of methadone to wean addicts off heroin because it can be taken at home, is less prone to abuse and is easier to discontinue when the patient is ready. But fewer than 90 physicians in Baltimore have completed the eight-hour training course required to prescribe the drug.

"In a city like Baltimore, where we have a lot of doctors, this really offers a potential for a major expansion of access to care," the city's health commissioner, Dr. Joshua Sharfstein, said of the training initiative. "Getting doctors trained is just incredibly important."

Approved by the Food and Drug Administration in 2002, buprenorphine has been slow to reach patients in Baltimore, where by most estimates thousands are addicted to heroin. To reduce the risk of misuse, the federal government requires eight hours of training and also limits individual physicians to no more than 30 buprenorphine patients at any one time.

Mayor Martin O'Malley's administration is expected to officially announce the program this morning after the city Board of Estimates votes on a $10,000 contract with Clinical Tools Inc. to cover the cost of training the first 100 doctors. The North Carolina-based company will provide the training, at no charge to the doctors, through an Internet-based program.

The money is part of a $250,000 appropriation made from last year's city budget surplus that Sharfstein said will be used to subsidize training, help patients find primary-care doctors and, in some cases, pay for the cost of the drug. Sharfstein said he expects the program to begin this fall and hopes the initiative will eventually train any doctor who requests it - potentially hundreds of physicians.

Other cities, including New York, have provided funding to subsidize the training. Howard County used foundation money to help coordinate training last year, but only seven physicians expressed an interest. Several national experts said it is relatively unusual for local governments to pick up the cost, and Baltimore's program appears to be considerably more ambitious than what has been attempted in Maryland or elsewhere.

In addition to the benefits provided by its chemical composition, physicians said, a main advantage of the drug is that it allows patients to treat their addiction through a primary-care doctor rather than by visiting a methadone clinic. Not only is methadone treatment often stigmatized, it also brings the user into regular contact with other drug addicts - an association that some believe can tempt patients into relapse.

Sharfstein said Baltimore treats about 4,500 people a day with methadone and believes that about 1,000 residents are being treated with buprenorphine. He said the city Health Department's goal is to treat 10,000 patients with the new drug.

Dr. Michael Fingerhood, an internist at Johns Hopkins Bayview Medical Center, said he has used buprenorphine successfully for about three years. Five doctors prescribing the drug in his office see just over 100 patients, he said, and the drug tends to be less sedating while still effective at limiting cravings. The duration and frequency of use, he said, depends on the patient.

"In the primary-care setting, I think that you do build trust. It's a good feeling on both sides, for both the provider and patients," Fingerhood said. "It's truly a drug that can change people's lives."

Buprenorphine is manufactured by the British company Reckitt Benckiser and sold under the brand name Suboxone. Most patients take a 16-milligram dose of the drug after detoxification, health officials said. The cost is $8.48 per dose.

Until last year, group practices - including health clinics, teaching hospitals and large managed-care organizations - were limited to 30 "bupe" patients each, meaning the Johns Hopkins Hospital, for instance, was permitted to prescribe it to only 30 people at any one time. That restriction was lifted, and now the limit applies to individual doctors.

Since then, the number of doctors who have taken the training has remained relatively low. The Substance Abuse and Mental Health Services Administration, part of the U.S. Department of Health and Human Services, lists 190 physicians that are prescribing buprenorphine in Maryland, with 84 in Baltimore, though local officials said they believe the numbers may be higher.

Several experts said doctors might be uncomfortable - or, at best, unfamiliar - with treating patients with a drug addiction, especially given the chance for relapse. But others said primary-care doctors can take a more holistic approach to treating the problem than methadone clinics.

"A lot of physicians have zero training in this, and they're concerned that they're not going to be up to the task," said Frank Vocci of the National Institute on Drug Abuse. "But physicians really do have power when they sit down and talk with [patients]. There's something therapeutic about sitting down with someone that's very powerful."

In some cases, buprenorphine training is performed in classrooms, but the city's model uses a Web-based program that lets doctors start and stop the course at their leisure. Mary Metcalf, director of continuing education for Clinical Tools, said 100 physicians have used the system nationwide and another 50 are now in training.

"For a city government to step in ... to try to get all the care providers trained is just remarkable," said Metcalf, adding that Baltimore is the only local government that has hired the firm.

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