It is humorous when companies do what Reckitt-Benckiser recently did– make a small change in their product, then trash the old product in favor of the new, more expensive product. “The OLD formulation is GARBAGE! It poses huge risks! It is reckless and irresponsible to prescribe that tablet (the one that we’ve been marketing for years, that is…)” Is buprenorphine film a step forward or marketing gimmick?
For people who are confused, here is what happened…. Reckitt-Benckiser, the makers of Suboxone and Subutex, used to have a stranglehold on the market for buprenorphine. Profits poured in from selling buprenorphine at ridiculous prices; $6 per tablet in the Midwest for Suboxone, and over $11 per tablet for Subutex. The prices were particularly obnoxious given that the company didn’t invent buprenorphine– in fact, buprenorphine has been around for 30 years, and could be purchased cheaply in bulk quantities. All that RB did was come up with a sublingual formulation, and from that point forward they were essentially printing money. Suddenly a cleaning product company is raking in the big bucks!
Of course at some point, patents expire. Companies often sue to stretch out patents– and profits– as far as possible, but at some point the party comes to an end, and such is now the case with Reckitt-Benckiser and Suboxone. The generic version of Subutex costs as little as $2.80 in my area; RB has been stemming the bleeding from that generic by warning doctors that patients will dissolve and inject buprenorphine if naloxone is not mixed in– something that is exceedingly rare, given the long half-life of the medication, the aversion that most addicts have for needles, and the fact that most diversion of buprenorphine is by people seeking a way to stop using– not by people looking for a ‘buzz.’
More recently Teva, a large manufacturer of branded and generic medications, received approval for their version of sublingual buprenorphine. I have not seen it in pharmacies in the Midwest, at least not yet, but it will be more difficult for RB to deal with this form of buprenorphine– which will essentially be the same as branded Suboxone, only cheaper.
Some states, including Wisconsin, REQUIRE pharmacists to substitute less-expensive generics unless specifically blocked by the prescriber. Insurers, both private and government, also require use of generics in the absence of a compelling reason to use the branded product. That means that to get brand Suboxone, doctors will have to fill out paperwork explaining their reason for requesting the brand. Doctors, of course, hate paperwork, and so I anticipate a huge shift to the generic product once it appears in pharmacies.
RB, then, is in a pickle. So some marketing guy gets the idea to put buprenorphine in a listerine-style breath strip, sell it indiviually packaged, and tell everyone that individual tablets of Suboxone are a huge risk to the public. They tell us that little kids put them in their mouths, that the packaging isn’t safe enough, or that the tablets absorb moisture, making their sublingual dissolution rate unpredictable. Better use the strips intead, they say.
I tried one of the strips– one that was a ‘dummy strip’ that did not contain buprenorphine. The instructions are to put it under your tongue, but as I have written here many times, there is nothing special about the under-the-tongue space, and they can be put on top of the tongue if that is easier; the point is to get the molecule in contact with the mucous membranes that line the mouth. I like the idea of the strip in theory; the absorption of buprenorphine is driven by the concentration gradient of the molecule, and the film helps deliver a highly concentrated dose of buprenorphine to the surface of the oral mucosa.
The film could also conceivably be cut into small pieces using an exacto knife, to help with tapering the drug. But in practice, the film was unpleasant to use. It was thicker than I expected, sort of like a cross between a Listerine strip and a gummy worm. It took longer to dissolve than I expected, and the taste was nasty.
So what is the conclusion? Is the strip a leap forward in safety and convenience? Or is it just an attempt to hang onto a brand? I suppose that answer depends on how you see the world, and how you see a cleaning products company from the UK that struck it big on the backs of US opioid addicts.
10 Comments
Jay · September 29, 2010 at 6:26 pm
The first thing that came to my mind was how much easier tapering would be with the film. I for one am looking forward to trying it and will talk to my doc about it at my next apt. I would like Dr. Junig to comment on Purdue’s switch from oxy oc to oxy op. Does he think it will create a huge heroin demand in the US? Will patients who can not or will not make the switch be switched to Roxy IR or something else? A good friend of mine who was on the OC’s got sick on the OP’s and so she is being switched to methadone. I told her I didn’t think that was a good move but I’m not a doc. Opinions anyone?
cdelic · September 30, 2010 at 12:08 pm
Is the teva version subutex or suboxone S.Beck M.D.
tic · September 30, 2010 at 12:25 pm
If the strip is supposed to taste better than the tablet, the tablet must be terrible. I am not having any difficulty with acceptance of the film strip with the $75 off coupon every month through March 2011. After that, I suspect most patients will go with whatever is less expensive.
I have not heard any fear mongering comments over use of the tablet from my suboxone pharmaceutical rep. at all. All he says is that the film disolves faster than the tablet and 60% of patients say it doesn’t taste as bad.
armme · October 30, 2010 at 8:09 am
If patients CAN choose the cheapest formulation becomes the question. During a presentation from a rep from RB promoting the Suboxone Film I was told that any patient not wanting to make the switch “must be up to something” because why wouldn’t they want the film unless their intention was to SNORT the pill! In other words reps are going to doctors and convincing them if they want to stop patients from abuse of bupe (which, as Dr.J pointed out is RARE to begin with) and stop the bad publicity in the media then they HAVE to switch their patients over to the film–because any patient who wants to stay on the tablet has a sneaky alterior motive that has nothing to do with saving money. YEAH, right. He also made it seem as though all patients on Suboxone would be switched immediately to the film because for doctors to do anything else would be “irresponsable”.
They also said each packet of film has an ID number, which he SAID would help during medication call back counts. What he doesn’t say is that the only way this would work is if the filling pharmacy was willing to take up pharmacist time and computer space to run a database which would track which packets went to each patient. The chances that a pharmacy is going to take on that responsibility without compensation are slim.
shan673 · February 21, 2011 at 3:05 pm
I have actually taken the film and the tabs and to be honest I agree with what the company is saying. I, personally, feel a lot better taking the film, the tabs seem to make me feel very drowsy and kind of like crap, where I don’t get that feeling with taking the film, not to mention the film tastes better, dissolves faster and they don’t break, crumble, etc. The only slight pain is the packaging and having to cut them if you only want a half or quarter instead of the whole strip. I would definitely take the film over the tabs any day but that’s my preference, anyway the reason I was responding to the above post was because of my agreeing with the company about the comparison between the film and the tabs, the cost is by far better with the film, my pharmacy charged me $11.99 per tablet where I can get 10 film for $17.89, that is by far better for the times my insurance doesn’t cover my meds, my doctor is adamant about everyone switching to the film because abuse is high in my area, to the point where people not only shoot the Subutex they shoot the Suboxone also, and if they are not shooting it they are selling, trading, etc, etc, it has become an epidemic in my area right along with heroine, oxy’s and whatever other opiates people are doing now a days and it is ruining the freedom and ease people like me have with getting Suboxone, I have been on the tabs for 8 years and have been clean for 8 years with no problems but now my insurance wants me to go to drug & alcohol counseling, get prior authorizations, go to the doctor every month instead of every three, which is a pain in the a** since I already went through all the counseling and everything else but now I have to suffer because of the actions of others, I hope the film does crack down on all of the excess so I can go back to just taking my meds without all the bullsh*t
shawnsbruno · April 11, 2011 at 8:57 am
Did Reckitt-Benckiser tell you how easy it is to put the film on a spoon, add water, heat up ,and then inject with a needle. Now that could be a big problem!!!
SuboxDoc · April 16, 2011 at 4:26 pm
Frankly, they don’t tell me anything. But I would think that buprenorphine has limitations as an IV drug of abuse- at least compared to heron or oxycodone. Buprenorphine has very similar kinetics whether taken transmucosally or intravenously. The long half-life of buprenorphine would make the person develop a tolerance after a few uses– and then the person would have to go through withdrawal for a week or two before being able to get ‘high’ again. I can see how a person could inject it for a ‘high’ once or twice–but after that, the person would be ‘on maintenance’, making further abuse unrewarding.
Quarter-Wit · July 5, 2011 at 12:37 am
Although I agree with most of what you have said in this article, I must note that Suboxone tablets (and Subutex to a slightly greater extent) are “abused” routinely. I know some people that are “maintained” on Suboxone just like “legitimate” users yet they often snort the pills, not so much to get super-high but to “feel good”. They prefer the pills because of this. Also, in theory, one should be able to dissolve the buprenorphine out of the films just like with the tablets in order to make an injectable solution. In fact, it might even be easier and more efficient, with the resulting solution having less colloidal character (undissolved particles), to “shoot” the films. The only thing that the pills prevent is snorting. Even so I can imagine several ways that might be effective in rendering the films powder-like.
I definitely believe that the reason the films are being pushed so hard is because of money and expiring patents. The only thing they are effective at preventing at this point in time is snorting (which is comparatively rare). In fact, since the films can probably be readily injected with just a little bit of effort and cannot be snorted, they might actually encourage intravenous use since the abuser will often take the easiest and quickest route to instant gratification. Personally, I’ve never understood the appeal of injecting or snorting Suboxone (probably because I’ve never tried it) when simply dissolving it under one’s tongue gives comparable effects. For many, I think it’s just the act of snorting or IVing that they’re addicted to.
SuboxDoc · July 5, 2011 at 6:00 pm
I am less concerned about abuse of Suboxone than some people; the abuse is, frankly, self-defeating, as the long half-life and tolerance only ends up putting abusers ‘on Suboxone’, where they are unable to get a ‘high’ from their actions. Some people can probably hold things where their tolerance doesn’t escalate, and use infrequently enough so that each use provides a lift– but that in itself is a means of reducing the compulsion to use opioids.
I agree that many people enjoy the act of snorting an even injecting. It is interesting that even such experiences that are unpleasant initially, can be conditioned as positive experiences if associated with the euphoria from opioids.
Finally, I may be cynical, but I see nothing but commercial opportunism in the development of the film, and I believe that the company that has reaped such huge rewards from Suboxone would be better to spend their R and D money on things that would truly help opioid addicts– such as larger, lower-dose tablets to aid tapering off the medication. Is it just me who wonders why they don’t make it easier to STOP their medication? Or am I asking too much?
tearj3rker · November 13, 2011 at 4:56 am
Another great article SuboxDoc.
I also found it difficult to get high from the full agonists after a while. When I was using heroin, my tolerance got so high that it didn’t matter how much I used, the only way to feel an effect was to mix it with other depressants (xanax usually).
Someone here did mention IV use of Suboxone. I injected a 4mg Subutex pill I was given many years ago early in my addiction, micron filtered , and I did feel a bit stoned for a little while. It wasn’t as intense as heroin, but it did have some appeal in lasting the whole day through. But I couldn’t use any more heroin, so I left it alone for a while.
My doc prescribed me the film for the first time a couple of weeks ago. And I can see just by looking at it, how much easier it is to inject than the pills. The big turn off of IV pills is all the binders, the need to filter them (preferably) with micron filter. But I’ve seen so many people IV milky claggy pill solutions that are so poorly filtered they have to force it out the needle. Today it makes me sick to remember.
These film strips on the other hand have far less binders, and would dissolve a lot quicker / more easily, both in the mouth and in the spoon. Why the prescribing doctors in my country, where nearly all people on the Subox / methadone programs were / are IV addicts, can’t see this … They seem to believe the film is harder to abuse? That the tablets are the ones people want to divert, and my preference for the tablets has even made my pharmacist distrustful of me.
Last time I saw my prescribing doctor, I told him I was worried that Suboxone tablets would cease to be manufactured / prescribed, because of these misnomers about their abuse potential. He said that my concerns were valid, and left it at that. He also said that 4 other patients who tried the film gave bad reports and switched back. He said he would talk to RB about it. Now I’ve read what the reps are telling doctors, I hope he won’t come back sceptical of my motives, which are pure.
I’ve accepted a lot of things about marketing and capitalism. And even warmed to a lot of it. But seeing these practices happening in something like health care always hits a nerve, especially when it influences a doctor’s decisions, and his / her trust in their clients.