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August 11, 2003 New Drug Promises Shift in Treatment for Heroin Addicts By RICHARD P�REZ-PE�A Alex is still a 34-year-old recovering addict, trying to measure what he lost to heroin. He is still building a new life in Manhattan, repairing frayed relationships and an interrupted career in the entertainment industry. He is still reliant on a substitute drug to get him through the day. But three months ago, he switched substitutes, and his life changed for the better. Alex � he told his story on the condition that his full name not be used � stopped taking methadone, since the 1960's the standard treatment for people trying to quit heroin. Instead, he takes buprenorphine, a drug newly approved by federal regulators to treat addiction to heroin and other opiates, including prescription drugs. For many addicts, though not all, buprenorphine does what methadone does, blocking the addict's craving for a high, but experts and addicts say it has several advantages over the older drug, and the most important may be that a patient can get a supply, not merely a dose, with a visit to a doctor and pharmacy. Like methadone, buprenorphine (pronounced byoo-pre-NOR-feen) is addictive, but the risk of overdose is much lower. Unlike methadone, buprenorphine will not give an addict more than a mild high no matter how large the dose, and it cannot be combined with opiates or other narcotics to get higher still. Users suffer fewer unpleasant side effects, and milder withdrawal symptoms when they stop taking it. Alex said methadone, which he took for five years, allowed him to finish college and resume working, but that buprenorphine was a big improvement. "I'm more clear-headed than I've been in years," he said. "I feel better physically. For the first time in a long time, I can see myself getting off everything in a way that's not going to rip a hole in my life and leave me only partially functioning." The relative ease with which a supply of buprenorphine can be obtained is a radical departure from the use of methadone, which is tightly controlled by federal law and can be given only one daily dose at a time, in licensed clinics where space is limited. Experts say the advent of buprenorphine could triple the number of people in serious treatment for heroin addiction. "My hope and my expectation is that buprenorphine will revolutionize heroin treatment in the United States," said Dr. Herbert D. Kleber, a professor at Columbia University's College of Physicians and Surgeons and a leading authority on heroin and buprenorphine, who was deputy director of the Office of National Drug Control Policy in the first Bush administration. Other experts see the change as more evolutionary than revolutionary, warning that much remains to be learned about buprenorphine, and that methadone, too, was once seen as a wonder drug. But they are enthusiastic, saying that since doctors began prescribing buprenorphine in October, the experience has been overwhelmingly positive. "Buprenorphine is no panacea," said Dr. Lawrence Brown Jr., president of the American Society of Addiction Medicine, and an associate professor at Weill Medical College of Cornell University. "But it is a fantastic opportunity for us. We need to encourage more physicians who are outside addiction medicine to take up this treatment." For many addicts, merely not having to go to a methadone clinic is an enormous advantage. "A lot of middle-class people are just not going to walk into a methadone clinic and stand in line every day," Alex said. "You're standing in line there with the same group of addicts every day, a lot of them talking about how they're going to get high. It's not a good head to be in if you're serious about quitting." He said he lived with constant worry that the methadone would jeopardize his job: the fuzzy-headed feeling it often induced might overtake him in the afternoon, his reliance on the clinic's hours might interfere with his work, a colleague might discover his routine. "With bupe, all of that's gone." New York City has an estimated 200,000 heroin addicts, and only 38,000 methadone program slots. Nationally, there are 800,000 to one million heroin addicts and about 180,000 methadone clinic spaces, and addicts outside major cities often live nowhere near clinics. Experts say that for every heroin addict, there are two people addicted to prescription opiates, drugs like oxycodone, hydrocodone, codeine and morphine, and that buprenorphine can be effective for them, as well. New York City's Department of Health and Mental Hygiene has embraced buprenorphine, urging doctors to learn about it and begin prescribing it. "We're looking at being able to increase the number of people in treatment to 100,000 by 2010," said Dr. Lloyd I. Sederer, executive deputy commissioner for mental hygiene. Last week, the department and the federal Center for Substance Abuse Treatment, part of the Department of Health and Human Services, held a forum in Manhattan to educate about 150 doctors and drug counselors about buprenorphine. Speakers included New York and New Jersey state officials, who spoke approvingly of the new treatment. Buprenorphine will not work for all addicts, and will not completely replace methadone. Some people simply will not respond well to it, which is true of almost any drug. Dr. Kleber said that half the people on methadone take such large doses that they could not change to buprenorphine without going through painful withdrawal. Some will be able to wean themselves to moderate doses and then switch, he said, and some will not. He said heroin users should be able to switch to buprenorphine, regardless of their doses. Jerry, 39, an addict living in Brooklyn, said he lowered his methadone dose by almost half, then moved to buprenorphine in June, transitions he described as "a little rocky, but not bad." Like Alex, Jerry, a building maintenance worker who insisted that his last name not be used, said he found that low doses of methadone lasted a little less than 24 hours, so he would awake every morning nauseous from the early stages of withdrawal. "On bupe, my head's good and my stomach's good," he said. Buprenorphine has been used as a painkiller for many years, and a few researchers, including Dr. Kleber, were permitted to make limited use of it for addiction treatment. In general, though, for decades federal law has prohibited use of any drug but methadone for heroin addiction. After a long lobbying campaign by treatment advocates, Congress loosened the law in 2000, and last October, the Food and Drug Administration ruled that doctors could prescribe buprenorphine in their offices for addiction treatment. To prescribe it, a doctor must first take an eight-hour course and register with the federal Drug Enforcement Administration. Because buprenorphine is addictive and has a potential black market, federal law prohibits a doctor from prescribing to more than 30 patients at a time. Still, even with those limits, in theory there are more than enough family doctors and psychiatrists in the country to treat all those who seek treatment. Since October, about 2,000 doctors nationally have been cleared to prescribe buprenorphine for drug treatment, including 218 in New York State and 62 in New Jersey, according to Dr. H. Westley Clark, director of the federal substance abuse center. People in the drug treatment field say there are no more than a few thousand people around the country taking buprenorphine. New York State has decided that Medicaid, the health plan for the poor, will cover buprenorphine, but most states and most private insurance plans do not. Doctors say the retail cost is $5 to $10 a day. Advocates say buprenorphine should be given as part of a wider array of support services, including counseling. Dr. Kleber said Columbia planned to open the nation's first center to help addicts make the transition from methadone to buprenorphine, and then refer them to doctors for long-term maintenance. France allowed general practitioners to prescribe buprenorphine in 1996, and has reported a sharp drop in fatal overdoses. New York City alone has about 200 heroin overdose deaths each year. Buprenorphine latches onto the same receptors in the brain as heroin, methadone and other opiates, but more aggressively and effectively. A person already on buprenorphine who took another opiate would feel no effect, because the second drug would be unable to push the buprenorphine out of the way and latch on. Buprenorphine stays in the system longer, so many people can take it every other day, rather than every day. Buprenorphine is also unlike the others in having a "ceiling effect;" that is, beyond a certain dosage, taking more does not make the person any higher, or depress breathing any more. That reduces the risk of both abuse and overdose. There is another advantage. "The withdrawal from bupe is much easier and faster than that from either methadone or heroin, so it's easier to get off it," Dr. Kleber said. "I think it's going to become the preferred drug not only for getting people off heroin, but for withdrawing them from drugs entirely." Copyright 2003 The New York Times Company http://www.nytimes.com/2003/08/11/health/11HERO.html?pagewanted=print&position= __________________________________ Do you Yahoo!? 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