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"If someone doesn't want to give a urine sample, that's always a bad sign," she says. "That may mean their last prescription was sold on the street."
Saltzman is quick to add that most of her patients—including the ones who relapse or sell their prescriptions—genuinely want to get better. She acknowledges, too, that her treatment is too expensive for many: $400 for the initial visit and $250 for every visit thereafter. The medication itself is covered by insurance, but the office visits aren't.
That's by design, Saltzman says. Otherwise "we'd have lines out the door. It would be a whole different thing. Making people pay is about getting their full attention. It's very intense work, and it's not at all like primary care." (By law, Suboxone doctors can only treat a maximum of 100 patients.) A couple of low-cost clinics in the city don't charge for the initial visit, but most Suboxone doctors' rates are as steep as Saltzman's.
As for the price of the drug itself, at a CVS pharmacy, the estimated price for an uninsured person to get 30 days' worth of Suboxone tablets is $295. At Duane Reade, it's $315. At Rite Aid, it's $283. Insurance brings down the price substantially: United Healthcare's rate is $60 ($25 for the generic). Blue Cross Blue Shield's is about $40; Aetna's, $75.
Chris, the real estate broker and Craigslist dealer, routinely gets e-mails from people who say the price is what prevents them from procuring the drug legally.
"im interested in yr add," a recent would-be buyer wrote. "recently lost insurance, and the cost of a doctor/script is just too much fr me right now. very serious about getting off, without getting too sick to work. Im a professional honest guy with a family you can look me up on facebook, just search [redacted] in new york, there is a drawing of a rabbit as my main photo. Please keep it discreet and profess. and i will do the same."
Motive and legality aside, how harmful is "bridging" with Suboxone? Every dose of buprenorphine is a dose of heroin (or the like) not taken. And a person is far less likely to die from using buprenorphine. According to Joshua Lee, a professor at New York University Medical Center and an attending physician at Bellevue Hospital, buprenorphine has "less overdose potential" than methadone. In particular, it's less likely to cause "respiratory depression"—the physical state when breathing becomes so shallow as to no longer provide the body with oxygen.
"As doctors prescribing it, we're very concerned with this," Lee says of black-market use. "And we discourage people from doing that. But from a public-health, harm-reduction standpoint, we acknowledge that diversion of buprenorphine seems different than diversion of oxycodone, say, or Xanax."
"So many people who cannot afford the medications from legitimate sources are basically buying it on the street to treat themselves," offers Bisaga, the Columbia professor and addiction researcher. "I don't think these people are doing it to get high—although certainly there are people like that. I think most of them are just trying to get treated at low cost, which is obviously a tragedy. Most developed countries in the world have free treatment for drug addicts and this is no longer an issue."
A few months after he began selling his prescription on Craigslist, Chris has decided to stop for good. "I pulled all my ads down," he says.
Chris is muscular and pale, and he looks exhausted. He's wearing a V-neck sweater and jeans, and carrying a shoulder bag that looks like something a doctor making house calls might use. He says he saw "many, many" people in the few months he was selling—including attorneys, fellow real estate brokers, and even one addiction counselor.
Chris says he got himself off Suboxone, a process he describes as "brutal." He did it by transitioning to the painkiller Percocet, then weaning himself off that.
The experience of detoxing left Chris with mixed feelings about Suboxone. "On the one hand, it is a good thing," he says. "It keeps people from stealing and robbing and overdosing. But it really just masks the issue: the addiction. From heroin withdrawals, you move onto Suboxone, and then you have to go through those withdrawals. It's something that's going to happen, but a lot of us choose to prolong it."
In the longer term, he adds, the drug also made him feel "like total shit."
"My girl always says I couldn't even formulate sentences," he explains. "I was not articulate. I couldn't fuck her, excuse my language. I was just totally like a zombie. And then my feet were constantly uncomfortable. I couldn't sleep without it. My eyeballs would turn into like these huge dishes, big pupils like Mickey Mouse."
To his dismay, Chris realized that he initially felt even worse when trying to pull back on the Suboxone than when he experienced heroin withdrawal. "You're exhausted for a very long time. It takes forever to get out of your system," he says.
He believes now that his doctor didn't adequately warn him that the detox drug had the potential to be addictive, nor about its "sticky" properties. "The doctor I was seeing—it was literally five or 10 minutes—he sits there and gives his typical speech about how bad drugs are, et cetera, and then he writes a scrip, and I'm gone. He gets paid, I go fill it, and that's it."