As city includes hard-core addicts, more drop out
Baltimore has doubled the number of people using the medication buprenorphine to shake off heroin addiction but has struggled to keep them in treatment.
As the Baltimore Buprenorphine Initiative has accepted more hard-core drug addicts dealing with complications such as mental illness, more drop out. At the start of the initiative in October 2006, officials had picked mostly highly motivated participants.
The retention rate dropped to 52 percent for the year that ended June 30 compared with 65 percent in fiscal year 2007. That is prompting city health officials to question which patients do best on buprenorphine, sold as Suboxone and widely known as "bupe."
"Who is the right candidate for bupe?" asked Dr. Joshua M. Sharfstein, Baltimore's health commissioner. "It's just really hard to tell." He said officials will examine that issue closely.
The initiative, which cost about $2 million last year, is "continuing to gain momentum," he said. "More clinics are participating. More patients are being treated. More doctors are interested in seeing patients."
The novel program introduces addicts to Suboxone in city-backed clinics that stabilize patients before transferring them into the care of private doctors who have become qualified to prescribe the drug.
The city has streamlined its process of securing health insurance for the mostly low-income participants and added clinics and doctors to expand access.
But the 771 patients who entered the program over the past year are taking longer than the first year's 388 patients to make the transfer because they still abuse drugs other than heroin, such as cocaine.
Some studies have shown that methadone is better for longtime heroin addicts while Suboxone is best for people who are newly addicted or who are hooked on pain pills like OxyContin. Sharfstein hopes that pairing public and private resources will render buprenorphine an effective new weapon to battle heroin addiction.
In 2006, more than 10,000 city residents were admitted to facilities for heroin addiction treatment. Each year more 200 die from overdoses of heroin and other narcotics.
Valarie Clark abused heroin for nearly 20 years. After enrolling in the city initiative nearly two years ago, she has experienced her longest stretch without using heroin.
But her struggles demonstrate the challenge of getting even the best patients - Clark was held up as model before the City Council last summer - to stick with treatment.
Last month, after a dispute in her recovery house, Clark moved out and stopped taking Suboxone, without consulting her doctor or therapist at Total Health Care, the city's largest participating clinic.
She fell into a depression that left her with a choice: heroin or bupe.
"I would have used," said Clark, 52.
But she chose the bupe, starting again with the pills left over from her earlier prescription. "The depression went away and I'm continuing my therapy," she said. "I'm back in the [recovery] house."
A recent report showed that fewer addicts stuck with Suboxone treatment after 90 days than in the first year. The city's goal was to retain 67 percent at least that long. In the period from October 2006 to June 2007, the initiative succeeded in keeping 65 percent that long. But that dropped to just over half in the 12 months ending June 30.
"The retention rate has fallen," Sharfstein said.
One major reason is that the initiative has broadened its reach to take in people who are new to treatment, who suffer from other psychological problems or addictions and who engage in high-risk activities like prostitution.
It also took longer for patients to get off all drugs so they could be transferred out of city-backed clinics into the care of private doctors. Many patients stop using heroin but continue to abuse cocaine, leaving them ineligible to transfer. The city had wanted to transfer patients to the medical system after 90 days. In the first year, it took an average of 155 days. For the year that ended June 30, it took 163 days.
In addition, the initiative's pace of training doctors has lagged. Sharfstein had wanted 100 doctors to receive the federal waiver required to prescribe the pills. So far, 82 have received the clearance after completing an eight-hour training course.
The initiative also made a special effort to recruit more psychiatrists to deal with patients suffering both addiction and other mental illnesses.
"I would characterize this as good progress," Sharfstein said in an e-mail. "While we have not had 100 new waivered doctors yet, I am confident we will get there."
Suboxone's expense remains an issue. Methadone for heroin addiction costs about $8,000 per person over two years, the city reported last year. Suboxone treatment costs nearly twice that and has gotten more expensive.
Wendy Merrick, who directs addiction care at Total Health Care in West Baltimore, said the price per bottle of 30 pills has increased from $107.15 to $111.70.
To help cut costs, the Baltimore Substance Abuse Systems Inc., which manages most of the budgets for nearly all of the participating addiction treatment centers in Baltimore, has started buying in bulk, said Marla Oros, a consultant with BSAS.
The city's first report on its initiative in July 2007 made little mention of efforts to prevent misuse and illegal sales of buprenorphine. In December, The Sun published a three-part series that showed that abuse of Suboxone was on the rise across the nation as its availability increased. The drug was rolled out in 2003 after the federal government allowed doctors to prescribe it from their offices, unlike methadone, which is dispensed from highly regulated clinics.
The latest report devotes an entire section to efforts that the city has taken to minimize misuse of the drug: counting pills, testing urine and monitoring patients when they first start taking the pills. But the report states that "there is no evidence of a significant public health threat from buprenorphine diversion in Baltimore at this time."
A survey of 30 Baltimore physicians conducted by a consultant with the drug's manufacturer, Reckitt Benckiser Pharmaceuticals Inc., found that 67 percent were "aware of buying and selling of Suboxone, a percentage higher than the national average," the report states.
Clark, who was profiled in the series and has returned to treatment at Total Health Care, said she has seen the street demand for Suboxone increase.
"I was just at Lexington Market getting lunch and, wow, it's amazing," said Clark, who first tried Suboxone on the street. "It's almost like people are asking for Suboxone more than other things. The bupes. They ask for bupes."
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