For some patients looking to break their addiction to heroin or prescription painkillers, there's a drug out there that works. It’s called Suboxone, but government regulations and individual doctors have made it difficult to get, which is leading many to buy it illegally.
A lot of people using Suboxone for the first time don’t get it at a doctor’s office.
"I took it when I couldn’t find drugs," said a 32-year-old personal caregiver from Danbury who didn't want WNPR to use her name. "I was, actually, buying it off the street -- and I did that for, God, almost a year."
Following a knee surgery, she started using, and eventually abusing, prescription opiates like Percocet. She bought Suboxone illegally for months before getting it legally at her doctor’s office in New Haven.
Suboxone is used to mitigate opioid withdrawal symptoms. A lot of people use it illegally before finally getting a prescription.
She credited Suboxone and her doctor for helping her successfully treat her opioid dependency.
"You can’t just say, 'I can’t do this anymore. It’s ruining my life.' You really have to dedicate yourself to this," she said. "Because even a drug like Suboxone isn’t going to fix you. It’s you."
Jeanette Tetrault, a doctor at the Yale University School of Medicine who prescribes Suboxone, said this woman’s story isn’t unique.
Lots of patients who come to Tetrault seeking Suboxone treatment have heard about the drug, and many have used it illegally.
"It’s not to get high," Tetrault said. "It’s really to ward off withdrawal symptoms -- that is what fuels opioid addiction in a lot of cases. There’s the initial seeking of the euphoria from using opioids, but for most patients who develop true opioid addiction and opioid use disorder, they tell me they continue to use opioids to maintain."
Addiction doctors say treating behavioral issues is the most important thing about Suboxone treatment.
Suboxone is a partial opioid, a combination of two drugs: buprenorphine and naloxone. When used in the absence of other drugs, its chemistry makes it a hard drug to overdose.
In medicine, Suboxone is used to mitigate opioid withdrawal symptoms. The drug allows some patients day-to-day functionality, which lets them build family members or a job back into their life.
"You can do all those things now, which is what makes Suboxone so attractive on the street," said Stephen Holt, co-director of the Addiction Recovery Clinic at Yale-New Haven Hospital. "But it's just a Band-Aid."
Holt said that as far as street drugs go, it’s “extremely common” for his patients to have used Suboxone illegally before coming to him to get a prescription.
"It’s helping the chemical issue," he said. "But you’re in no way engaging the behavioral issue -- the psychological issues that led you to start using these medications in the first place."
As to that part about behavioral issues, addiction doctors say that’s the most important thing about Suboxone treatment. Holt said it’s also part of the reason why it’s so hard to get Suboxone legally in a place like New Haven.
For starters, to prescribe Suboxone, Jeanette Tetrault said doctors must complete an eight-hour training program. They then need to get a federal waiver.
"Initially, a physician can only prescribe to 30 patients through that DEA waiver," she said. "After a year of experience prescribing to patients, one can then apply to increase their waiver numbers to be able to prescribe to 100 patients at a time."
President Barack Obama has proposed raising that prescriber cap to 200 patients, but some doctors have said they’re stretched thin as it is -- that it’s a lot of work to manage and care for 30 Suboxone patients, let alone 100 or 200.
That work includes urine toxicology tests to make sure Suboxone patients are using the drug correctly and not selling it on the street. They also require regular follow-up visits and therapy. Time-consuming stuff for doctors and their staff, which means not everyone who has a prescriber waiver fully uses it, and that many patients who want Suboxone simply can’t get it.
"You’re going to have this sort of tiered system where many of the private providers within greater New Haven, or in Connecticut, are selectively taking on patients who are the most straightforward to care for," Holt said. "The least complex."
Like patients without other psychiatric illnesses, or patients with more money. Holt said it’s common for many private psychiatrists and physicians who are licensed to dispense Suboxone to charge a cash-only fee up front that isn’t covered by private insurance. Jeanette Tetrault said that’s problematic.
"There’s very few other chronic diseases that you would say, 'Oh well, you know what -- let’s just bypass insurance and pay me $500 to treat your hypertension or diabetes,'" Tetrault said.
And as some clinics turn away patients who might benefit from Suboxone, but can't foot those up-front costs, Tetrault said Suboxone prescribers need to be more critical of their own ethics and prescribing practices -- as the public health issue of opioid abuse continues.