Kentucky doctors have new restrictions for prescribing Suboxone after efforts to curb pill mills created a new cash-for-pills market and a street trade for the drug designed to safely wean addicts from heroin.
"A lot of the pill mills morphed into facilities that dispense these prescriptions" for Suboxone, said Dr. John Langefeld, medical director of the state's department of Medicaid services.
According to state officials, use of buprenorphine, the active ingredient in Suboxone, has increased 241 percent since 2012. And 80 percent of the prescriptions for it were being written by 20 percent of the state's 470 certified prescribers, said Dr. Allen Brenzel, medical director of the state's department of behavioral health.
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Since 2011, 10 doctors have been sanctioned by the Kentucky Board of Medical Licensure because of problems prescribing Suboxone, according to Leanne Diakov, general counsel for the medical-licensing board.
The surge of problems related to the drug is an unintended consequence of efforts to curb abuse of hydrocodone and expand medical insurance coverage.
The first effort was House Bill 1, which Langefeld said has decreased the number of opiate prescriptions overall but didn't address Suboxone or other buprenorphine products specifically. So a growing number of addicts started doctor-shopping and abusing Suboxone and Subutex, both buprenorphine products, he said.
According to a state report, one user obtained prescriptions from nine doctors.
"It was just a great substitute for heroin," said Jeffrey Gibson, a volunteer at the Hope Center recovery program and a recovering addict who abused Suboxone before he got clean. "It was like doing the same thing, really."
Second, substance abuse treatment became a mandated service under the Affordable Care Act, and as more Medicaid patients and others got health insurance coverage, more people obtained prescriptions for buprenorphine, Langefeld said.
Good idea turned bad
Suboxone is designed to provide a safe way for people to wean themselves off heroin and stave off debilitating withdrawal symptoms, Brenzel said. It operates on the same receptors in the brain as heroin and other opiates.
Suboxone is effective in helping people get off heroin when taken in conjunction with therapy and required drug testing, he said. In that way, it mirrors the long-established use of methadone. Under that model, a patient receives a controlled dose of a legal drug as the dose is tapered by a physician for a safe and effective withdrawal.
Suboxone can be an especially good way to help people with an opiate problem who are able to function in everyday life and hold a job, he said. If they are working, Brenzel said, they are more likely to stay out of jail and more likely to keep custody of their children. Suboxone "becomes a bridge drug," Brenzel said.
But what happened is that a minority of Kentucky doctors started to see Suboxone patients on a cash basis, asking for as much as $300 for an office visit that included a prescription for the maximum allowable amount of Suboxone.
Patients often received no therapy or drug testing. Some patients were on the maximum dose indefinitely, he said.
According to the Kentucky Board of Medical Licensure, some doctors prescribed Suboxone along with other opiates, benzodiazepines and other narcotics.
The increased number of prescriptions led to "diversion" of the drug as addicts bought and sold it on the street, he said.
State statistics show that by spring 2014, 6.3 percent of drug seizures by the Kentucky State Police included buprenorphine, up from 2 percent in 2011.
David Shadd, director of programs for Lexington's Hope Center, said clients fill out a form detailing their drug use when they enter the center's recovery program. In a recent survey, 313 of 807 clients entering the recovery program recently said they had abused Suboxone or buprenorphine, he said.
Clients also talked about the difficulty of withdrawing from buprenorphine. One client wrote: "It helped me get off heroin, but I found it hard to get off Suboxone."
The withdrawals are similar, Gibson said. "It's where you can't even move unless you get something in you," he said.
An alert on the home page of the medical licensure board provides a link to Kentucky's new regulations which include a lengthy list of prescribing mandates. Those include more physician education and the requirement that the drug be prescribed only for medically supervised withdrawal and not be given to pregnant women. Patients should also be closely monitored and drug tested.
If those rules are not followed, a doctor can face sanctions or restrictions to his medical license.
Michael Rodman, executive director of the licensure board, said the new regulations codify the best way to prescribe and monitor buprenorphine products.
Brenzel said he hopes the regulations will help. Spending on buprenorphine products for Medicaid patients has doubled from $20 million to $40 million in recent years.
But even as that number rises, there are few indications that Suboxone is helping the majority of people with prescriptions get off and stay off illegal drugs.
"We weren't seeing things move in a positive direction," he said.