A bill signed into law by President Bush last week has rescinded the cap on how many opiate-addicted patients a clinic can treat with medication containing the chemical buprenorphine. While the immediate effects of the law in the Boise area are slight, local doctors and advocates say the potential for change has them feeling hopeful.
Buprenorphine was approved in late 2002 by the Food and Drug Administration as an opiate-dependence treatment, and has been proven to be less addictive than the popular treatment methadone in weaning addictions to heroin and painkillers like OxyContin, Percocet and Vicodin. However, two years before its approval, the Drug Addiction Treatment Act of 2000 limited the number of patients a clinic could treat with narcotic treatments containing buprenorphine to 30-regardless of how many doctors on staff were trained to dole out medication. The limit sometimes caused long waits for local addicts, said Grant Belnap, a local doctor who administers the medication Suboxone, which contains buprenorphine.
Currently Idaho has no methadone treatment facilities, and the nearest one to Boise is in Ontario, Oregon. However, three independent practitioners in the Boise area have been federally certified to administer Suboxone. All three took an eight-hour class learning about the drug, its interactions and effects in order to be approved to prescribe Suboxone, and have only been administering it to local addicts for a matter of months.
"It's not a benign treatment," Belnap said of the drug. "You have to know how to use it. It's safer than methadone, since there's no risk of overdose."
Belnap says his patient base consistently runs in the high 20's, and he has capped out with the allotted 30 patients "several times." He said if an individual patient cap were lifted for doctors, he would exceed 30 patients on a regular basis.
"It's a word-of-mouth treatment," he said. "As word gets out, more people come in."
Patrick Dwyer and Kristina Harrington are the two other doctors in town who are certified to administer Suboxone treatments. Harrington, who operates through Omega Mental Health Psychiatry, treats patients in a local hospital and has yet to reach her cap of 30 patients in the nine months she has been prescribing Suboxone. Her partner, Dwyer, started doling Suboxone in an outpatient clinic through Omega last month.
"I've only had a couple of heroin addicts. It's primarily people who get addicted to pain medications either if they have chronic pain or getting supplies over the Internet," Dwyer said. "It's amazing what you can get over the Internet." Belnap and Harrington agree that the majority of their patients seek treatment for painkiller addictions rather than heroine. Belnap estimated the balance to be about 60 percent to 40, painkillers to heroin.
Suboxone is often covered by health insurance plans, including through the hospital where Harrington works, she said. But Dwyer said he wasn't sure whether insurance provided full coverage for the drug in his clinic. The drug is also on the state Medicaid formulary.
All three doctors were unaware of the recent legislation, and as of Friday the news that Congress had unanimously passed the measure and Pres. Bush signed it into law had not gained much national recognition. But given the drug's upside, Harrington said that Suboxone's obscurity isn't likely to last.
"I'm baffled (by) the 30-patient cap on individual doctors," Harrington said. "Initially, it was a somewhat controversial medication, but as people are using it and seeing how well it works, it will become less controversial. It's a lot safer than methadone."
Buprenorphine drugs like Suboxone differ from methadone in that the latter is a full opiate, Belnap said. According to the FDA, Suboxone is less risky, since the buprenorphine is cut with naloxone, which guards against abuse of the drug.
Belnap said Suboxone is a "partial-agonist," which helps patients not feel withdrawal symptoms from opiates. "If opiates or a substance like heroin are a key that fits into a lock that is your chemical receptors in the brain," he said, "it turns the lock and lights up your brain to get the euphoric effect." Suboxone, on the other hand, fits in that same lock, and "turns it just enough to stop cravings and stop withdrawal. So not only does it stop cravings, but it prevents you from using other opiates while on it."
Melanie Curtis, a local rehabilitation coordinator at the Supportive Housing and Innovative Partnerships, said she sees an under-served need in the community when it comes to heroin addiction, but she and her opiate-addicted patients were unaware of this treatment.
"There's an upsurge in heroin use in this area and people have a difficult time finding help," she said. "I definitely think it's understated. Heroin use is a lot higher than what's indicated in the state numbers."
According to numbers from the Department of Health and Welfare, 35 people in Idaho reported they had used heroin during fiscal year 2002-2003, the most recent data available. Those numbers are down from 94 in FY 1999-2000, although the department's substance abuse program manager, Pharis Stranger, admitted the numbers only represented people treated by government-run programs and who listed heroin as their "primary drug."
"This is under-represented, especially with those addicted to prescription drugs," Stranger said. "If they don't come into the public system to get treatment, we are not capturing them in the numbers."
"We definitely have an epidemic that's in crisis proportions," Curtis said of heroin use. "Here we've seen people where their drug of choice may be heroin, but they can't get their hands on it, so (they) will turn to methamphetamine, which is the biggest problem drug here."
Boise doesn't have a detox center, which Curtis said is local addict's most pressing need. Currently, she is spearheading efforts to raise funds for such a facility.
"The key infrastructure is not here for treatment," she said. "We don't have the things we need to start the recovery process. I think that's why they're not seeking help-because they don't think it's out there."