Use, abuse of Suboxone explodes in Western Pennsylvania
By Richard Gazarik
Published: Sunday, Aug. 4, 2013, 10:20 p.m.
Only the most potent prescription drugs could ease the blinding, unrelenting pain from injuries Joseph Cabray suffered on a construction job more than two decades ago.
The drugs carried him through the surgeries to repair the crushing damage to his jaw and teeth, then kept him going during the arduous days of healing.
As long as he had the drugs, he could get by.
Then his doctor pulled the plug on the painkillers.
In desperation, Cabray looked to the streets and found heroin.
After many years, numerous failed stabs at rehab and a couple of overdoses that nearly killed him, Cabray, 54, of West Mifflin says he found salvation in a drug called Suboxone, which reduces the harsh withdrawal symptoms experienced when battling addiction to heroin and other opiates.
Since 2011, “I haven't touched heroin. I just stopped wanting it, looking for it. I just didn't want to do it anymore,” he said.
But Cabray's cure has proven to be a curse for some.
The highly effective drug has spawned a lucrative black market in which Suboxone pills sell for as much as $20 each, according to state officials and addiction specialists.
Experts say the market is fueled by a dramatic increase in prescription drug abuse, an alarming rise in heroin addiction and a shortage of physicians trained to deal with addiction.
“That's what's driving the problem,” said Dr. Neal Capretto, medical director of Gateway Rehabilitation Center in Beaver County. “There's such an epidemic of opioid addiction that there's not enough physicians to treat patients.”
Suboxone, hailed as more effective than methadone in treating opiate dependency, is the first addiction drug the Food and Drug Administration has permitted physicians to dispense from offices.
Heroin addiction soared in the 1960s, but its use tapered off because of fears about contracting AIDS through contaminated needles. In recent years, the drug — much cheaper and more pure than in the past — has triggered a new wave of addicts.
In loosening the rules, the FDA wanted to increase access to treatment and remove the stigma many addicts said they felt as they jammed the limited number of methadone clinics approved by the FDA to dispense the drug.
That part of the FDA's 2002 strategy worked, experts say.
Suboxone sales topped $1.4 billion last year, a more-than-tenfold increase from $137 million in 2006, according to the Center for Substance Abuse Research at the University of Maryland.
At the same time, police seizures of the drug nationally increased from 21 in 2003 to more than 8,000 by 2010, the center reported.
“This illegal diversion and street sale has been documented for some time now, and it's occurring across the nation,” said Gary Tennis, Pennsylvania's Secretary of Drug and Alcohol Programs.
Experts worry about the widespread, unsupervised use of the drug.
“This ... never was to be used as a stand-alone treatment. It's meant to be used with counseling methods,” said Peter Luongo, executive director of the Institute for Research, Education and Training in Addiction in Pittsburgh.
Some addicts sell prescribed Suboxone on the street so they can buy heroin. Others buy it illegally to prevent withdrawal symptoms — nausea, vomiting, diarrhea, abdominal cramps — in between heroin use, said Lucy Garrigan, who runs Jade Wellness Center, a Monroeville drug treatment facility.
Insurance covers the drug. Patients on medical assistance pay $4 for a prescription of 60 Suboxone pills, which some sell on the street for a hefty profit, Garrigan said.
At $12 each, 60 2-milligram pills can sell for $720 on the street. A prescription for 8-milligram pills, each with a street value of about $20, could net an addict $1,200.
“You can see the money that can be made. It's a nightmare,” Garrigan said.
By state law, doctors are allowed to treat only 30 addicts the first year they are licensed to prescribe Suboxone. The state raised the cap in the second year to 100 because of overwhelming demand. Any doctor, regardless of medical speciality, can be certified to prescribe the drug, according to regulations.
More than 500 physicians are licensed to prescribe Suboxone in Pennsylvania, according to the Substance Abuse and Mental Health Services Administration. Their specialties range from plastic surgery to pediatrics.
“Suboxone does work. Suboxone has saved many people's lives,” but allowing physicians who aren't addiction specialists to treat addicts with the drug has caused “prescription mills” to spring up across the state, Capretto said.
“Why does a plastic surgeon write prescriptions for Suboxone?” Garrigan said. “Why does an anesthesiologist prescribe Suboxone? Why does a pediatrician?”
It's about money, she said.
Capretto cautions that not all physicians prescribing Suboxone act inappropriately.
“In good medical practice, there's average, there's poor, and there's what I call rogue, where they want to make money. They're out for every dollar they can make,” Capretto said.
“Some physicians are doing it very well,” he said. “Some are doing it OK. I'll just say there's need for improvement.”
Repeated attempts to reach Western Pennsylvania doctors licensed to prescribe Suboxone failed.
In response to a request for comment from the American Medical Association, a spokeswoman sent a statement from the group's CEO, Dr. James L. Madara, who calls for more training in addiction treatment for doctors.
Madara said Suboxone is “very safe when administered on an outpatient basis” and added that “the regulatory process for becoming a prescriber and the patient limits serve as barriers to increase capacity to treat opiate addiction.”
To circumvent the patient cap, physicians sometimes recruit other doctors to act as subcontractors, Capretto said. Some place newspaper ads seeking retired physicians to work for them, he said.
Garrigan said she knows of physicians in other states, hired by local doctors, who use the online video service Skype to interview addicts in Pennsylvania, then fax prescriptions to the patients for a $250 fee.
Capretto said such a brief interaction between a physician and patient is not enough to accurately assess an addict's needs. He said a physician should complete a detailed medical history before prescribing any drug and must gauge the depth of a patient's addiction.
To be certified by the Drug Enforcement Agency to prescribe Suboxone, physicians must complete an eight-hour course, either in person or online.
“Eight hours really isn't enough for physicians to know what he or she needs to know,” Luongo said. “They're not familiar with dosing. They're not familiar with what exactly happens to people.”
In addition to reviewing a patient's medical history, Garrigan said, doctors should require regular urine testing to ensure patients have opiates in their systems and are not looking to obtain Suboxone to sell.
“Suboxone used correctly is a great medication,” she said. “Centers like ours conduct drug tests. You have to make sure they have opiates in their system. Otherwise, they'd come in and use it for other reasons. Medication without the therapy does not work.”
Richard Gazarik is a Trib Total Media staff writer. Reach him at 724-830-6292 or at firstname.lastname@example.org.
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