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Suboxone's older cousin, methadone, is a full agonist, meaning that its effects, along with its getting-high and overdose potential, are that much stronger. But Suboxone offers users a powerful feature methadone can't match: It's designed to be taken at home, whereas by law methadone is required to be distributed at a clinic. (In New York, methadone patients can get take-home doses, but they're tightly controlled; to get a six-day supply, a patient has to have been in treatment for at least three years.)
"You have to go to the clinic every day, and that has a little bit of a reputation," Bisaga says. "Many people don't like the idea."
Buprenorphine was introduced as a treatment for opiate addiction in Belgium in 1983, in the form of little orange tablets that were placed under the tongue. Four years later, it was being used in France. Reckitt Benckiser won approval to distribute Suboxone in the U.S. in 1994, although it wasn't released here until 2003. At the time, the Food and Drug Administration granted it "orphan" status, which is awarded to drugs that are meant to treat "rare diseases or conditions" and aren't expected to be profitable. Orphan drugs qualify for generous tax credits, and the FDA can't rescind the designation once it's granted.
Suboxone retained orphan status until 2009, when the patent for the tablets expired. Several U.S. drugmakers promptly set to work making generic versions, two of which went on the market this past February. That month, analysts projected Reckitt's annual pharmaceuticals profit would take as much as a 4 percent hit.
By 2006, Suboxone's abuse potential had become pretty clear: A study of French buprenorphine users found that a lot of them were crushing up their tablets and injecting them. According to the European Opiate Addiction Treatment Association, the same problem soon turned up in England, Ireland, Scotland, New Zealand, Australia, Finland, and the Czech Republic. (A recent report in the daily Prague Post estimates that Subutex accounts for 70 to 80 percent of all drugs sold on the street.)
Also in 2006, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) found the same issue cropping up in the U.S., noting that buprenorphine abuse appeared to be "concentrated unevenly in Northeastern and Southeastern regions."
Seeing buprenorphine cross the Atlantic came as no surprise to Bisaga. "It's a problem with every drug we have," he says. "It was just a matter of time."
Introduce a drug, and soon people will find a way to use it to get high.
According to SAMHSA figures, emergency-room visits involving buprenorphine use "increased substantially, from 3,161 in 2005 to 30,135 visits in 2010, as availability of the drug increased." More than half of the people seen at the ER reported that they were using the drug "non-medically."
The researchers who studied French buprenorphine injectors wrote that it seems "pharmacologically impossible" for anyone to get high from the drug. And yet, they say, the addicts did report feeling a "rush" after injecting it, which the researchers chalked up to the placebo effect.
The question for drug- and policy-makers alike is how to short-circuit any new drug's potential for getting you high. Adding naloxone to buprenorphine hydrochloride is one way to limit abuse, Bisaga says. Another was to pull the tablets off the market and replace them with a film designed to be impossible to abuse. (According to several pharmacies the Voice contacted, brand-name Suboxone tablets are still available, at least in New York, though Reckitt Benckiser had notified the FDA in February 2012 that it would voluntarily discontinue the tablets. The company said at the time that the pills would be off the market by March 2012 at the latest. Reckitt Benckiser did not respond to several requests for comment for this story.)
People still try very hard to make the most of their Suboxone; Internet forums are full of tips and tricks about how to get high off the strips. Some users recommend melting them in water and injecting them, or offer instructions on how to "snort" them. Others insist the would-be stoners are wasting their time, that "bupe" won't ever get you lifted.
Bisaga begs to differ. "People who are not in treatment, not taking it every day, can get high." If you take it consistently and correctly, as part of a treatment plan, you probably won't feel any euphoric effects, he says. But taken more sporadically, it's possible: "You wouldn't get as high as with heroin. It's not such a powerful, instant, intense euphoria. But you'd still feel somewhat affected."
Some patients in treatment report that the drug has mood-lifting properties. "People often feel good on Suboxone," notes Saltzman, the Suboxone specialist. "Many people say they feel better than they have in their lives."
Saltzman has seen the rise of Suboxone abuse firsthand. She has had a license to prescribe it since 2000; in the past few years, the number of patients she suspects are diverting the drug is increasing.
"There's a constant wave of diversionary tactics in here," she says. "It's constant and unending. It's just piling up."
She tries to weed out the drug-seekers from the people who are genuinely eager to get sober. She requires patients to attend group therapy and one-on-one sessions with a counselor, and she encourages them to enroll in a 12-step program like Narcotics Anonymous. She also drug-tests them every time they come in to have their prescription refilled.