Cost of Suboxone

A Reader Writes:
Message:
The State of XXXXXX prescription price list noted Target Pharmacy as the cheapest for Suboxone at $6.99/Suboxone pill, 8mg-2mg, qty. 30. So I started getting my prescriptions filled at Target.
Well, needless to say they raised their prices twice since then and I am now paying $8.158333/Suboxone pill, 8mg-2mg, qty. 30, Nov. 12, 2011.
My question: How can they be alowed to jack their prices up so fast and so high in a short period of time? What can I do? It’s like they pulled a bait and switch on me.
Please write back Dr. Junig
My Reply:
I sympathize with you.  The best thing you can do is have an educated and educatable doctor– someone who has enough humility to recognize when he/she is wrong, and adjust accordingly.  Somebody who recognizes that as physicians, we are constantly sorting through new data, responding clinically to phenomena according to science.  Most importantly, someone who recognizes that in medicine, as in all fields, people make assumptions about things with partial data, and sometimes later learn that their assumptions were wrong.
I realize that is difficult in the current era when people with addictions are considered ‘manipulative’ for simply raising appropriate questions. The truth is also competing with the marketing and persuasion tactics by Reckitt-Benckiser– a company that has found a way to influence policy-makers in government and addiction societies.  I am generally a fan of corporate greed, as I believe that the marketplace is the best stage for ideas to rise or fall (mixing several metaphors, I know!)  But I am appalled by the extent of involvement of Reckitt-Benckiser, the British corporation that makes Suboxone, with physician societies– the groups that are supposed to be advocating for policies that save lives that are being lost to addiction.
The generic tablet of orally-dissolving  buprenorphine, 8 mg, is FDA-indicated for treating opioid dependence.  In Wisconsin, some pharmacies have it for as low as $2.35 per tab;  the more expensive places sell it for $3.00.  It is CLINICALLY IDENTICAL to Suboxone;  the naloxone in Suboxone is not absorbed sublingually (actually, 3%-5% is absorbed, but does nothing clinically), and after being swallowed the naloxone is completely destroyed at the liver by first pass metabolism.
Suboxone is supposedly safer then generic buprenorphine because naloxone supposedly causes withdrawal if injected.  This is the only justification (initially put forth by the folks at Reckitt-Benckiser) for the need for Suboxone.  The justification is flimsy, since many people who would benefit from the lower price of buprenorphine have very little risk of injecting the medication.  But worse, the flimsy justification is a lie. People who have injected Suboxone intravenously (I have met and heard from many of them) report NO withdrawal from naloxone-containing Suboxone.  What’s more, people who wrote to me who have injected both buprenorphine and Suboxone, at different times based based on availability, have all reported the same thing– that the subjective experience from injecting either substance is identical.
I must point out here that there are MANY reasons to avoid injecting any substance– but particularly a substance made to be taken orally.  These compounds contain fillers that destroy the capillary beds of the lungs, where oxygen is absorbed– potentially leading to severe lung damage.  And infection is always a huge risk, when placing poorly-sterilized material directly into the bloodstream.  Please– don’t do it.
Back to taking buprenorphine properly… the high cost of Suboxone is an unfair burden for patients without insurance coverage, when a much cheaper, idential alternative is available.
I am going to remove your name and location, and put up your question on my blog;  you are then welcome to bring a copy of the post to your doctor. You can also tell him/her to read prior posts, where I explain all of this in greater detail.
For Doctors and Insurance Formulary Committees:
I implore you to look into the facts of this situation with an open mind.  I have a PhD in Neurochem, besides 10 years of experience as an anesthesiologist and training and experience in psychiatry.  Some insurers cover buprenorphine;  they are, of course, the smart ones.  Your company can save a great deal of money by simply allowing the generic equivalent to be covered.  States that mandate the use of Suboxone or Suboxone Film could save large sums of money for their taxpayers.  And doctors–  your cash-paying customers could really use the break, especially in this economy.  If you are concerned that a patient is injecting medication, I understand your hesitancy— even though, frankly, it is misplaced, given that BOTH Suboxone and buprenorphine can be injected.  If your patient pays cash, and never injected medication, do you REALLY think that person is going to start injecting buprenorphine– since doing so would not create any effects?  The ‘ceiling effect’ is in place for ANY route of administration, so a patient taking sublingual Suboxone, who injects buprenorphine, will feel… NOTHING.
Give your patient the gift of affordable treatment as a Christmas present.  You may be saving someone’s life.
JJ

The Suboxone Business Fix

I have shared my thoughts about ‘Suboxone Film,’ a product that serves only one purpose:  to block generic competition from entering the Suboxone market.  Below I’ve copied a Bloomberg article that discusses the current nature of the buprenorphine/naloxone business, and the efforts by RB to prevent market penetration by generics– something that would lead to price reductions for healthcare consumers.

Suboxone Doctors act dumb with buprenorphine
Dumb about naloxone?

Unfortunately, the Bloomberg article overlooks the most significant threat to the profits of Reckitt-Benckiser.  This threat is mitigated only by the ignorance of many of the physicians who prescribe Suboxone.  The threat to profits consists of a simple fact that RB does not want anyone to realize:  that the generic equivalent of Suboxone is already available, in the form of orally-dissolving tablets of buprenorphine.

I encourage physicians who doubt my comments to do their own ‘due diligence’ and break out their old pharmacology textbooks.  I have a hard time understanding how people who graduated from accredited medical schools can get things as wrong as they do with this issue.  I sometimes present opinions, but not with this post.  The facts about buprenorphine and naloxone that I’m about to describe are described in any pharmacology textbook— e.g. Goodman and Gilman—and are not in dispute in any way.

Suboxone consists of buprenorphine plus naloxone.  Naloxone is an opioid antagonist that is added to reduce diversion of Suboxone in the form of intravenous injection of a dissolved tablet.  Naloxone is NOT ACTIVE when not injected.  The molecule is poorly absorbed through the oral mucosa because of the molecule’s size and poor lipid-solubility.  Instead, naloxone is swallowed, absorbed from the small intestine, and totally destroyed at the liver before reaching the systemic circulation through a process called ‘first pass metabolism.’

I suspect that some physicians confuse naloxone with the similarly-named substance naltrexone, an opioid antagonist (blocker) that IS orally active. There is NO naltrexone in Suboxone.

All of the beneficial aspects of Suboxone come from the partial agonist buprenorphine.  The ceiling effect of buprenorphine causes a reduction in cravings through a process that I’ve described in earlier posts.  Naloxone, on the other hand, does absolutely nothing to reduce cravings, to increase safety, to reduce euphoria, etc, provided that the medication is not injected.

The confusion surrounding buprenorphine essentially consists of intellectual laziness or intellectual dishonesty by the physicians who prescribe the medication and the pharmacists who dispense it.  I realize that not all doctors are cut out to be ‘physician scientists’ who understand pharmacology in great detail.  But I am particularly disappointed that the large organizations that supposedly oversee the science of addiction treatment have dropped the ball on this issue. I don’t know why groups like ASAM and SAMHSA don’t get it– whether the problem is ignorance, or whether there are mutually beneficial relationships between these organizations and RB that encourage the organizations to foster ignorance among
patients and doctors.  I don’t belong to the organizations primarily for this reason– and I blame ASAM and SAMHSA for the current status of addiction treatment as the ‘no science zone’ of modern medicine.

 A few examples of intellectual laziness: 

Example 1:  Physicians who prescribe Suboxone often say that one shouldn’t use buprenorphine ‘because it doesn’t have the opioid blocker and therefore….’ (add whatever here– it causes euphoria, it is addictive, it isn’t safe– any or all of these comments). The statement is partially correct. Generic buprenorphine does not have the opioid blocker naloxone— but naloxone is irrelevant to the actions of Suboxone!

There are TWO opioid blockers in Suboxone, but only one is clinically relevant—the one that is in both Suboxone and generic buprenorphine.  What is the relevant ‘opioid blocker’ that IS
in both Suboxone and generic buprenorphine?  Buprenorphine!   As a partial agonist, buprenorphine has antagonist properties that are responsible for ALL of the effective clinical properties of Suboxone.

Example 2:  Refusing to consider the cost of medication as a factor that determines access to treatment.  Some docs make ‘fear of diversion’ the only factor in determining what to prescribe.  Discussions with hundreds of opioid addicts over the years have convinced me that buprenorphine is rarely a drug of choice.  Rather, it is used by addicts who are sick and tired and want a break from using without withdrawal, or by addicts who have no money or access to agonists.  In such cases, buprenorphine or Suboxone are equally effective– and equally diverted.  When I ask addicts new to treatment about their injecting habits, I often ask whether they injected buprenorphine or Suboxone.  The typical response is either ‘can you do that?’ or ‘why would I do that, since heroin is cheaper?’

In my area, an 8 mg tab of buprenorphine costs as low as $2.33.  This low cost should be part of the equation for choice of medication, just as it is for other illnesses.  Does anyone doubt that there are some people kept from treatment by a price differential of 300%?!  Is it ethical to fear diversion so greatly that treatment is effectively withheld– for a condition with the fatality rate of opioid dependence?!   I’m sure readers know my answer, especially when there are effective ways to reduce diversion, such as close monitoring of prescribed doses, a ‘no replacement’ policy, and drug testing, among others.

Example 3:  There is some question whether the naloxone in Suboxone does anything to reduce diversion. Buprenorphine patients on my forum  who have injected Suboxone in the past have claimed that they did not experience withdrawal from either Suboxone or buprenorphine, consistent with what I would expect from combining a low-affinity antagonist with a high-affinity partial agonist.

Note: Injecting ANYTHING is in essence taking your life in your hands, and I strongly encourage anyone in such a position to seek treatment immediately.   Really—don’t do it.

Example 4:  Insurers generally refuse to cover generic buprenorphine (the generic form of the RB drug Subutex), even though it is much cheaper than Suboxone.  The one time they WILL cover Subutex or buprenorphine is for women who are pregnant or nursing.  The argument is that we shouldn’t expose the fetus/infant to one more drug (naloxone), since that drug isn’t necessary to the actions of Suboxone.  I agree with the argument, and wonder why it is extended only to the fetus?  Why does mom or dad have to be exposed to an extra substance(naloxone) that isn’t necessary to the actions of Suboxone?

I struggle to understand the insurance issue, as I would expect that someone at some major insurer would know enough about pharmacology to save money on Suboxone by favoring gen
eric buprenorphine.

The ultimate of silliness is that the State of Wisconsin requires that people on Medicaid use only Suboxone FILM.  Getting Abilify for a patient is virtually impossible without first using a variety of older, cheaper medications… but the squishy arguments in favor of Suboxone Film push the med up the formulary chain past an alternative that sells at a fraction of the cost.  The film/Medicaid situation is doubly dubious, as we have the arguments for buprenorphine over Suboxone, and the even less-sound argument for Suboxone Film being favored over the tablet.

RB apparently convinced the state that for Medicaid patients, only the film was safe– and that the film should be required instead of the tablet form of Suboxone, placing future generics at a great disadvantage.  It is especially impressive that RB accomplished this feat after selling a million units of the tablets themselves!  I can picture the person making the point:  ‘the tablet is unsafe…. Starting NOW!’

I’m going to write all night if I don’t wrap this up.  To summarize, the Bloomberg article below describes why RB is winning the battle with generics, but the writers of the article, along with most doctors, miss the bigger issue– that misplaced fears, intellectual laziness, and misinformation have protected Suboxone sales from a much greater foe-– generic buprenorphine.  If doctors, states, and insurers ever get their acts together and prescribe according to science, brand name Suboxone profits will go down the toilet faster than the cleaning products made by RB.

The Bloomberg piece:

Reckitt Benckiser Kicks Heroin Tablet Habit With Film: Retail

By Clementine Fletcher

Reckitt Benckiser Group Plc may be kicking its heroin problem.

After losing U.S. patent protection in 2009 for its Suboxone tablet, designed to help heroin users quit, Reckitt Benckiser has said that the entrance of a generic competitor could erode pharmaceutical sales and profit by 80 percent (note by JJ:  What a shame?!  Consider the benefit of such a price reduction for addicts in need of treatment!).

Reckitt Benckiser, which gets most of its revenue from selling home and personal-care products like Lysol cleaners and Durex condoms, has faced calls to sell the business before a generic comes to market. Instead, the London-based company aims to divert the showdown by switching users to a film form of the drug — one whose last patent doesn’t run out until 2025 (note by JJ:  NOW do you see why they made the film?!)

To get people to make the switch, Reckitt Benckiser is thinking more like a consumer company than a pharmaceutical one. It’s drawing on a marketing technique first pioneered by Coca- Cola Co. more than 100 years ago: coupons. By offering up to $45 a month toward a user’s co-payment in the U.S., the company is making the film version, which looks like a Listerine Pocketpak, close to free. That offers patients who get part of the bill subsidized by health insurance little incentive to transfer to a generic pill once it appears on the market.

“They’ve done a good job of making a silk purse out of a not very compelling situation,” said Martin Deboo, an analyst at Investec Securities Ltd. in London.

Reckitt Benckiser’s shares have risen 55 percent in the last five years, outpacing Unilever and Procter & Gamble Co. Under Chief Executive Officer Bart Becht, who stepped down last month, the company more than doubled sales in a decade. The stock has dropped 3.7 percent this year, compared with Unilever’s 4.7 percent gain and P&G’s 1.2 percent gain.

Drugs Growth

The company is due to report third-quarter results tomorrow and will probably say revenue adjusted for purchases and asset sales rose 7 percent at the drugs division, analysts led by Andy Smith at MF Global in London estimate, compared with a 3.9 percent increase for the rest of the business. Profit likely rose 0.9 percent to 430 million pounds, they said.

The film version of Suboxone, introduced in September 2010, accounted for 41 percent of the drug’s U.S. sales by the end of the first half (note by JJ:  Thanks, Wisconsin Badgercare!). That surpassed the company’s own expectations, Becht said on an Aug. 30 conference call arranged by Sanford C. Bernstein. Becht was succeeded by Rakesh Kapoor, a company veteran.

Generic Delay

The film “has been a phenomenal success,” Becht said, according to a transcript of his remarks. “To make the business completely sustainable, we would like to have a share which is clearly much higher than where we are.” He added that the company aims to grow that share every month.

Right now, time is on his side. Teva Pharmaceuticals Industries Ltd., the world’s biggest maker of generics, began the year saying it might launch a Suboxone copy in 2011. Now the company has backed off, saying it no longer expects the product to win regulatory approval this year.

Biodelivery Sciences International Inc., another drugmaker going after Suboxone, said a study comparing its own version of the drug to a placebo failed to show a statistical difference in the treatment of chronic pain. A test in patients addicted to opioids, which include heroin and codeine, is scheduled to begin
later this year. Titan Pharmaceuticals Inc. on Aug. 31 said it’s preparing to seek approval of an upper-arm implant that would deliver buprenorphine, one of
the active ingredients in Suboxone, directly into the bloodstream (note by JJ:  the ONLY active ingredient in Suboxone!)

‘Massive Benefit’

“This delay has been a massive benefit,” said Andrew Wood, an analyst at Sanford C. Bernstein. “With every day that goes by, RB has an extra day to convert users.” Suboxone is either harder-than-expected to copy or generic-drug makers are having second thoughts about targeting addicts, according to Bernstein.

About 1 million people in the U.S. are addicted to heroin, the National Institute on Drug Abuse estimates. As many as 325,000 people use Suboxone to quit the drug or painkillers, says Pablo Zuanic, an analyst at Liberum Capital in London.

The medicine combines buprenorphine, a painkiller derived from the opium poppy that shares some of its properties, with naloxone, a chemical that blunts
withdrawal symptoms (note by JJ:  This is simply WRONG.  BLATANTLY WRONG.  Really–  an opioid antagonist BLUNTING withdrawal symptoms?  Shame on the writers!). The film sells for about $4.63 to $8.23 a dose at Walgreens stores, according to Liberum, depending on its strength and pack size. That means the strongest dose costs about $247 a month.  (note by JJ—a pharmacy near my practice sells generic buprenorphine dissolvable tabs, 8 mg, for $2.33 per tablet—a medication that works EXACTLY the same way IF NOT INJECTED INTRAVENOUSLY)

More than half of people on Suboxone use private insurance with co-pay, Zuanic says. Reckitt Benckiser offers $45 towards co-pay for the film, he said, meaning an insured patient who’d contribute $50 to the cost of the drug may end up spending $5.

‘Near Zero’

“The actual cash cost for some patients buying the film with private insurance could be near zero,” Zuanic said in a note to clients this month. (note by
JJ:  but we are all paying the cost in higher insurance premiums, and some insurers, notably Humana, have draconian policies that stop covering—forcing instant withdrawal- if a patient receives a prescription for a sleep medication such as Ambien, so many people are left paying cash).

Meantime, Suboxone is only becoming more important to Reckitt Benckiser. The drugs division, whose sales grew five times as quickly as the main business last year, accounted for almost 9 percent of sales and 24 percent of profit, up from 7.6 percent and 20 percent in 2009. Sales a
t the unit will probably rise 12 percent to 829 million pounds ($1.3 billion) this year, according Nomura International Plc estimates.

The maker of French’s mustard is even considering making an injectable Suboxone and developing new products for cocaine, alcohol and cannabis addicts.
The plan has met skepticism.

“We’re quite a long way from having any visibility on these products,” said Julian Hardwick, an analyst at Royal Bank of Scotland Group Plc in London. “Are they products that will work? Which will get approval?”

Prescription drugs are perceived as a bit of a misfit in the home of Vanish stain removers and Finish dishwasher tablets.

Misfit

“Reckitt Benckiser is basically a home and personal-care company with over-the-counter pharmaceuticals,” said Carl Short, an analyst at Standard & Poor’s in London. The drugs unit is “always going to be something that looks like it doesn’t fit with the rest.”

Reckitt Benckiser may look at selling the unit, which Becht himself has said is “not the No. 1 strategic part” of the company, once a generic form of Suboxone reaches pharmacy shelves, analysts said. (note by JJ:  i.e. after all of the profit has been wrung from suffering addicts).  But the company’s marketing savvy, coupled with delays in the launch of a generic, are giving Kapoor time to settle into his new job.

“This is a big job and he is coming in after someone’s done it for some considerable time and very well,” said Julian Chillingworth, who helps manage about 16 billion pounds in shares at Rathbone Brothers Plc, including Reckitt stock. “You wouldn’t want to come in as a CEO into a very successful business and start selling things off on the cheap.”

Not Time

Analyst valuations range from 2 billion pounds to 6.3 billion pounds, according to four estimates compiled by Bloomberg News. Estimates diverge because it’s hard to value the business without knowing how Suboxone sales will resist the generic challenge and whether the shift to film can counter some of that impact.

“Until you get generic competition for the tablet, I think it’s unlikely that prospective buyers would give you the full value for the business,” said Hardwick of RBS. “Now is not the time to sell.”

–With assistance from Naomi Kresge in Berlin. Editors: Celeste Perri, Marthe Fourcade.

 

 

Score One For Reckitt-Benckiser

I received notice today from the area’s Reckitt-Benckiser rep that the company has secured a mini-coup of sorts, requiring state of WI Medicaid subscribers on buprenorphine to use the Suboxone Film formulation. Here is the notice I received:

RB share price vs S & P, Suboxone Talk Zone
Reckitt-Benckiser stock share price since Suboxone vs. S & P 500

Wisconsin State Medicaid has as of December 1st today added Suboxone Sublingual Film as the preferred delivery system. I have attached a file description. Because of some of you large geography and some limited stocking in certain areas. I would suggest you begin prescribing the Film to all your Medicaid patients as soon as possible to insure pharmacy coverage moving forward. All pharmacies can receive for stocking and distribution to your patients with 24 hour notice.
For PA requests for Suboxone tablets, providers are required to indicate clinical information about why the member cannot use Suboxone film and why it is medically necessary that the member received Suboxone tablets instead of Suboxone film.
Ironically, I just completed a survey (not sure who sponsored it) asking my opinion about ‘Suboxone Film’—i.e. whether I think it is an important step forward, whether patients like it, etc. I shared my thoughts- that it is essentially a marketing gimmick, and one that is apparently successful—at least when used on the people who run WI Medicaid.
The supposed advantage of the film is that each dose is wrapped separately in a foil pouch. This in theory makes it more difficult for a child to inadvertently swallow a handful of the tablets. In reality, this is only beneficial if one limits his imagination to a scenario where a bottle of prescription medication is left out and available to a young child, and the child is somehow able to defeat the child-proof features of the cap. I can envision another scenario—mom keeps several packets of Suboxone film in her purse, and her child pulls one out while looking for gum, tears it open, and decides to see what it tastes like. One could argue that there would be LESS exposure to buprenorphine in the case of the film, as only one strip would be opened as opposed to a child swallowing a handful of tablets. But the partial agonist nature of buprenorphine makes the number of tablets irrelevant. One Suboxone tablet or film contains 8000 micrograms of buprenorphine—a huge dose. A child would need to go to the hospital for observation whether one or 10 doses were ingested, and the effects from the medication would likely be the same in either case.
Let’s say I allow, though, that the requirement that people use the film will reduce the risk of accidental ingestion in children by at least some amount. And let’s ignore the fact that we are taking away the choice that patients enjoy with other medications; we are talking about ‘addicts’ after all, right? No need to treat addicts like ‘regular,’ responsible people! And let’s tell the people who don’t like the gooey, slowly-dissolving nature of the film, or the rubbery aftertaste that some have described, that they are just ‘SOL.’ They’re addicts, so again, who cares? And let’s tell the people who complain about their dose blowing away in the wind that they should learn to take it in a more reasonable place.
After we do all those things, what’s the big deal?
The big deal is for Reckitt-Benckiser. The big deal is that the state of Wisconsin won’t allow people on Medicaid to use the almost-tasteless generic formulation of buprenorphine—something that many patients prefer—and that the state won’t save a few million dollars in medication costs. Reckitt-Benckiser had to sacrifice a small amount; they cut 50 cents off the $6 charge for one tablet of Suboxone. But in return, they essentially hold hostage every patient getting medication through public assistance. Talk about an effective marketing campaign! And if they can use the bogus safety argument to fool the State people, who knows—maybe they can get private insurers to fall for it as well. RB has already managed to use fears of IV diversion to push insurers away from approving generic buprenorphine. RB also prevents insurers from placing generic buprenorphine on formularies by keeping brand-name Subutex priced very high (insurers fear that if they approve generic Subutex, some people will end up getting the real, ridiculously-expensive Subutex due to pharmacy shortages of the generic).
The bottom line is that RB has eliminated the forces of ‘market competition’ that would otherwise force the price of buprenorphine downward. If Dell, Gateway, and Sony could use this type of fear-mongering to control the market, we would all be paying fifty grand for a laptop!
And in a field where access is limited by resource costs, the excess profits gained by RB translate into fewer patients treated, one way or the other. And ‘fewer patients treated’ translates into ‘death.’
THAT’S what I meant in an earlier post by ‘blood on their hands,’ by the way. Congratulations, RB, on Suboxone Film.

Buprenorphine Film: Step Forward or Marketing Gimmick?

It i salways 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…)”

buprenorphine film
The orange rectangle is buprenorphine film

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.’ But 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.

Breaking Bad over RB

Remember back when I used to write those ANGRY posts, where I would take people to task for their silly comments about buprenorphine? I remember them. THOSE were the days! I was always ready to go nuclear on anyone who tried to debate whether buprenorphine treatment was ‘good’ or ‘bad.’ C’mon punk– MAKE MY DAY.
I’ve become more circumspect since then (OK, so I had to look the word up– at least I had HEARD of the word before!) I got tired of going to bed with heartburn every night. I also realized that people will do what people want to do. I have no power over them, and don’t WANT power over them. Addicts must find their own truth, and all I can do is provide information when people are ready to ask for it. Live and let live.
I have a weekly radio show, by the way. You can find it on i-tunes by searching for ‘junig’ or ‘shrinkzone.’ The show is on AM, but I recently got a small, monthly FM spot, which is a clear sign that I am moving up in the world. I needed material for the spot, and I came across a book called ‘Positivity.’ The book is going to teach me to replace my negative energy with new, positive thoughts. I’m expecting even less heartburn going forward! Isn’t life GRAND! Plus other good things have been happening. I already mentioned the coverage that these pages received in Addiction Professional. I also hope to be mentioned in the Carlat Report, a very cool source for independent information about the field of psychiatry.

Reckitt-Benckiser at Suboxone Talk Zone
Reckitt-Benckiser?

So imagine my surprise when I received a note from a doctor describing his interaction with some people from Reckitt-Benckiser. He shared with me that his rep mentioned my name, saying I was a former RB treatment advocate who ‘went bad,’ referring to my earlier post about the company having ‘blood on their hands.’ The note went on to say some nice things about the blog and forum, but my head was already spinning with images from my favorite TV show, ‘Breaking Bad,’ with me as the antisocial chemist. Like the guy on that show (and if you have not seen it, I strongly recommend that you rent the first two seasons and then try to find the episodes that you already missed this year), I don’ have the sense to back away from a fight! Instead, I’ll invite new readers to click on the link to the article, and to leave your comments.
I would like to just close on that note, but I feel guilty now about not leaving any recovery ‘tidbits’ for the few people who read this far. How about this: be careful with resentments! I have shared my thoughts about why buprenorphine is more than just a ‘replacement’ for the addict’s drug of choice– that the obsession for opiates that is the essence of addiction crowds out all other parts of a person’s life, creating character defects at the same time, and that buprenorphine removes that obsession, allowing character defects to be replaced by good relationships, healthy interests, and self respect. I have shared what I see to be the reasons why addicts do not become ‘dry drunks’ when taking buprenorphine. But at the same time, I recognize that addicts who take buprenorphine usually miss out on the intense, life-changing experiences that occur during residential treatment.
My problem with residential treatment as the ‘treatment of choice’ is that relatively few people ‘get’ treatment, especially younger addicts, who rarely get to the level of despair necessary to truly ‘get’ step-based recovery. And it isn’t as if we can just sit and wait for that despair to develop, because the fatality rate is just too great for opiate dependence. In other words, too many addicts will die, BEFORE getting to the necessary level of desperation to ‘get’ recovery.
So ideally, a person should go on buprenorphine and THEN do the step work, right? WRONG. It is true that many prescribers of buprenorphine force twelve step attendance, but I wonder how effective that is, beyond serving as a tool to weed out those who are not truly serious about staying clean. ‘Getting’ the steps requires desperation… and once on buprenorphine, addicts are no longer ‘desperate!’ So intead, I try to use the principles of residential or step-based recovery in an individual manner, depending on the specific stumbling blocks of the addict under my care. For a person like me, I might say ‘be careful with resentments.’ Resentments are a short step away from self pity. And from self pity, we can justify all sorts of things that will lead us in the wrong direction.
There– I feel much better now.
JJ