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
Tag: Reckitt-Benckiser
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.
- 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:
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…)”
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.
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
Does Reckitt-Benckiser have blood on their hands?
Regular readers of this blog know that I am a big fan of buprenorphine treatment of opiate dependence. I used to spend hours arguing with people over whether or not buprenorphine represents “a drug for a drug”, before eventually deciding that those who must be talked into buprenorphine treatment are poor candidates for buprenorphine treatment. I am now less motivated to engage in such discussions, but for those who are interested, my arguments are scattered throughout the archives of the medhelp.org addiction board, the commentary section of my YouTube videos, and in earlier posts to this blog.
The motivation for this current post stems from two recent incidents. The first was the reaction of a group of physicians at a dinner several nights ago, when I was speaking about a different medication. When I mentioned “Suboxone” I heard hissing and other negative reactions from the assembled group of doctors and nurse prescribers. I am the medical director of a residential AODA treatment center that does not use buprenorphine, so I am familiar with the attitudes of non-prescribing counselors– which tend to run against the use of buprenorphine. But the people at this particular dinner were not addiction counselors, but instead were general practitioners from central Wisconsin. After hearing the negative reaction to mention of Suboxone, I deviated from the topic of my lecture to address their reaction. But I soon realized that their opinions were as fixed as those that I ran up against during the arguments described in the first paragraph above. Despite my certainty that buprenorphine has saved thousands of lives, these practitioners see the medication as ‘villain’ rather than ‘hero.’ The assembled physicians see Suboxone as just one more drug of choice for opiate addicts. More disturbing, they see docs who prescribe Suboxone on a par with physicians who overprescribe opiate agonists.
The second incident that motivated this post was the publication of an excellent group of articles in the Milwaukee Journal Sentinel about the epidemic of opiate dependence in Milwaukee County. The article included statistics on the number of deaths by overdose, the vast majority consisting of respiratory arrest caused by opiates. The numbers included deaths from Suboxone taken in combination with other respiratory depressants by people who lacked significant tolerance to opiates. One of the most striking images from the series was a graphic with the deaths color-coded by year, by age of the deceased, and by type of drug. I am well aware of the epidemic of heroin and oxycodone addiction in my part of the country, but I was shocked at the sheer number and ubiquitous nature of deaths by overdose over the past six years.
I am grateful for the availability of buprenorphine in the form of Suboxone, but I wonder how different the current situation might be had a different pharmaceutical company been involved in the U.S. introduction of buprenorphine for the treatment of opiate dependence. Reckitt-Benckiser is a consumer-goods company based in the UK. When Suboxone received FDA approval in 2003, the pharmaceutical wing of the company did not exist in any meaningful form. From the vantage of a Reckitt-Benckiser stockholder, the company did well. They grew their international pharmaceutical division at an amazing pace thanks to the growth of their one product. But when I take a broad look at the current state of affairs, I wonder where we would be if Reckitt-Benckiser had made the decision to team up with one of the bigger players in the pharmaceutical industry. Doing so would have cost them a portion of their profit from Suboxone. But had a company the size of Pfizer, for example, set their sales force on a mission to market Suboxone, I doubt we would have the now-recognized problems with diversion and low physician acceptance. I am also confident that there would have been far fewer deaths by overdose of opiates over the past six years.
I am old enough to have experienced a number of launches of innovative medications, and I have always been one to quickly adopt the newest approaches and medications. But my early use of Suboxone for treating opiate addiction was a unique experience in many ways. I cannot think of any other medication that was (and still is!) as poorly understood by other physicians. I blame some of the lack of knowledge about Suboxone on the stigma of mental health and addiction, but many psychiatric medications with far more complex mechanisms of action—e.g. atypical antipsychotics—have been introduced without the ignorance that is associated with Suboxone. Even in 2007, four years after the release of Suboxone, the vast majority of physicians had not heard of the medication. Doctors have the bad habit of blaming unknown medications for unusual symptoms, so patients often called me after visiting ER’s or after doctor’s appointments where they were told that their symptoms were ‘from the Suboxone.’ One patient returned to the ER after I called the staff and persuaded them to take a second look, explaining that Suboxone does not generally cause fever or chest pain. On his second visit they did a chest x-ray that showed his pneumonia and pleural effusion. I continue to see examples of the same phenomenon today. The ignorance is not confined to emergency care– I frequently receive e-mails from new mothers with horror stories describing bizarre statements by neonatologists, OB nurses, and obstetricians.
A more common problem is described in the following e-mail:
I need help to figure out what’s wrong with me and what to ask my doctor to do about it. I’ve just been through knee surgery to replace my ACL. It was pretty painful but the pain is a bit better now. I’ve been on 16mg Sub for at least five years, although I recently tapered it to 8mgs. This past month I was down to maybe 4mgs/day when I found out my surgery was scheduled. Since I wanted my pain meds to work I immediately cut down even more and called my doc to see if he would give me some pain meds, because the surgeon refused to help me on the grounds that I was on Suboxone and he doesn’t understand it. Unfortunately my doc was out of town. Nobody would help me, everyone said *my* doc was the only one who could, and sorry he’s gone but oh well. This meant i had to get horribly sick the week of my surgery.
I got to see my doc the day before surgery, and he gave me some Norco which helped the w/d symptoms. Then after surgery I had Norco every four hours. Unfortunately after my release the surgeon AGAIN didn’t want anything to do with me. He wrote a script for Norco and told me I’d have to see my own doctor for anything else. The Norco was barely keeping me out of w/d’s, never mind helping my pain. I was waking up every morning with my nose running, sneezing, and my legs dancing. I got hold of my doc and he prescribed me Percocet, on the theory that those last longer. I’m permitted 1 or 2 of them every six hours, to a maximum of 6 per day. This seems to be utterly inadequate but I don’t know why my doctor would prescribe me something utterly inadequate unless he doesn’t think it’s inadequate.
Please, I need some solid experienced information so I can talk to my doctor. I am NOT trying to get a buzz here. All I asked of everyone prior to my surgery was “please treat me fairly given my tolerance level”. I wonder if my doc thinks that he is treating me fairly. But I’m clearly not getting sufficient dosage of opiate, and I don’t know how to present my case, especially over the telephone and via an intermediary nurse. (As yet, he won’t talk to me in person.) If I have to re-induct on the Suboxone and just deal with the pain then I’ll need some medicine to keep me asleep and not dancing until I’m sick enough, but I’m running scared asking for anything at all because everyone is treating me like a junkie.
Because of my blog, I receive messages like this one almost every day. Most doctors have no idea what Suboxone is used for, and how the medication affects the use of other pain medications. Patients are paying for that lack of knowledge with unnecessary pain and hardship. Of course, they are just addicts, right? (Readers should know my sarcasm by now!).
What should have happened?
To describe what could have happened I will use the example of another medication, Vyvanse, which is owned by a different British company called Shire pharmaceuticals. Vyvanse is a clear advance in ADD treatment. Amphetamine was bound to lysine to create an inactive molecule, and the amphetamine is released at a measured pace after Vyvanse is absorbed into the circulation. Shire is a relatively small company, so they paired with the much larger company, GSK, to get the word out about Vyvanse. The result is that thousands of GSK representatives have provided information about Vyvanse to physicians, pharmacies, and hospitals. Had Reckitt-Benckiser done something similar, doctors everywhere would at minimum know the basics about buprenorphine. And more, the treatment of addiction may have been brought into the mainstream where it belongs.
Reckitt-Benckiser eventually came out with a program called ‘Here to Help’ in order to provide education and by their description to improve compliance in addicts taking Suboxone. I was disappointed that the program began a number of years after Suboxone was released, not until the eve of the launch of a generic form of the medication. The timing left the impression that the program was more about maintaining brand loyalty than concern for addicts. The program pales in comparison to the education and outreach provided by major US pharmaceutical companies when they release a new medication. There are comments about the ‘Here to Help’ program associated with an earlier post on this blog, and I have received a number of similarly negative e-mails, including one just today that included these comments:
This “Here to Help” thing is really not very good. I actually signed up as a patient, and the girl was clueless. Every single issue I wanted to talk about, she told me to “Talk to your physician”.
“I feel scared that when I reduce my dose I’ll go nuts”
Talk to your physician
“I feel like I’ll never, ever feel ok again”
Talk to your physician
“I feel shaky before my morning dose”Talk to you….
You get the point.
When I asked how her course of treatment had gone, she told me that they don’t ever talk about their own personal recovery. Oh, well THAT’S helpful, huh?
There are other complaints about the manufacturer of Suboxone even by addicts who appreciate the medication. They resent the fact that so few non-addiction doctors have any knowledge about the medication. Many have fallen victim to what is described in the first e-mail above, and have suffered painful postoperative recoveries. There are complaints about the cost of the medication, once a pricey four dollars per pill and now up to twice that amount. The patient assistance program offered by Reckitt-Benckiser limits support to only 2-4 patients per practice, a limit that is not present for any other medication that I prescribe for psychiatric patients.
Many addict-patients have experienced poor treatment practices as a result of insufficient education for physician prescribers. Buprenorphine should be taken once per day in a dose range of 8-16 mg, but I have had new patients whose prior doctors prescribed much larger doses at much more frequent intervals. In my experience frequent dosing of buprenorphine is much less effective at extinguishing the psychological component of addiction. Instead of eliminating the relationship between ‘feelings’ and ‘using, such patients remain fixated on how they feel and take small doses of buprenorphine multiple times per day in response to imaginary withdrawal symptoms. Their physicians should have been taught about the value of less-frequent dosing by people who understand addiction. I was, by the way, a Reckitt-Benckiser/Suboxone ‘Treatment Advocate’ for several years. My experiences as an opiate addict for 16 years, my PhD in neurochemistry, my 3+ months of residential treatment and 6 years of formal aftercare, the hundreds of AA and NA meetings I have attended, the eight years I spent working in pain clinics as an anesthesiologist, my psychiatric training, my experience treating over 450 patients using buprenorphine, and four years as medical director of a large residential treatment center have all contributed to some level of insight into addiction and addiction treatment. I called and wrote to R-B multiple times asking that they use me to educate other physicians. I was called upon to do so three times in four years. As a comparison, I have been asked to educate groups of prescribers about Vyvanse over ten times in the last month or two alone. Can you imagine the knowledge-state about buprenorphine had similar efforts been made by Reckitt-Benckiser over the past 6 years?!
I have blogged about my frustration trying to find an application for an educational grant from Reckitt-Benckiser that would allow me to apply for funding to expand my educational efforts on the internet. To compare, a visit to the Mallinckrodt Pharmaceuticals website quickly leads to the application for funding educational programs. There are, in fact, several significant web-based educational programs related to the prevention and treatment of addiction supported by unrestricted educational grants from Mallinckrodt, who manufactures methadone among its products. There is a similar online application for grant support on at least every pharmaceutical company that I visited this evening as I prepared to write this post. I have not found such an application for Reckitt-Benckiser. I even spent four years calling, writing, and e-mailing different branches of the company in search of an application for such support. My hopes were raised on two occasions when I was visited by regional sales directors and promised that information about grants would be provided. But after the visits nothing happened, and when I called in an attempt to follow up, I was back to square one, talking to people who claimed to have never heard about my prior contact with the company.
Does this all sound like ‘sour grapes’ over a snub by Reckitt-Benckiser? Perhaps it is, to some extent. I am, after all, only human. But I am not only resentful. I spend a great deal of time reading and responding to e-mails from addicts, parents of addicts, spouses of addicts, and friends of addicts, and I am acutely aware of the suffering caused by opiate dependence. I’ve spoken to many people who were close to addicts who lost their lives to opiate dependence, and I have at least some sense of the suffering that they go through. And I have no doubt much of this suffering could—and should– have been avoided.
I fear that the actions of Reckitt-Benckiser, specifically their close-fisted release of a life-saving medication, have permanently endangered the successful use of buprenorphine for the treatment of opiate dependence. Once doctors start hissing, it becomes extremely difficult to create positive impressions of a medication or of a practice technique. I will, for what it is worth, continue with my own small efforts. And I hope that Reckitt-Benckiser will observe one of the principles that we teach addicts in recovery: Ask for help when help is needed.
How ironic if the success of a medication with the potential for a profoundly positive impact on addiction fell victim to addictive thinking by its own manufacturer!?!
Comments? Write below, or join us at Subox Forum!
Reckitt-Benckiser's 'Here to Help' Program– What do you think?
Reckitt-Benckiser, the first (but surely not last) manufacturer of orally dissolvable buprenorphine sold under the brand names Suboxone and Subutex, has been aggressively pushing doctors to refer addicts taking buprenorphine into a program called ‘Here to Help’ that they promote as something that will keep patients compliant with buprenorphine maintenance. Regular readers of STZ know that I have not been impressed by Reckitt-Benckiser over the years, and so I’m not going to just jump on the ‘here to help’ bandwagon unless I see value in the program for my patients. I have referred SOME patients to the program, but the feedback I have received has not been positive. Patients have told me that they receive confusing or conflicting information, or that the person on the phone seemed ‘scripted’ and not responsive to the person’s specific needs, or that the information they were given assumed a knowledge level below what the patients already had.
Why am I unhappy with R-B, you ask? If you go on the web site of any pharmaceutical company– from the smallest, like Dey Pharmaceuticals, distributor of the MAOI patch called Emsam, to the large companies such as Pfizer– you will find a section with procedures and applications for grant support for unrestricted educational programs, investigator-initiated trials, or other purposes. Little Dey Pharma has released tens of millions of dollars for community educational projects. Pfizer provides hundreds of millions of dollars for similar purposes. But try to find a similar web site for Reckitt-Benckiser (the Suboxone division) — let alone any contact info for grant applications! I have tried for several years to simply get the name of a person to speak to about financial support to expand my efforts, and the result is always the same? I will receive a phone number of a low-level sales manager who tells me ‘he (she) will look into it and get back to me.’ I’m still waiting. I would like to apply for assistance for what I do best– educate addicts about opiate dependence, and educate physicians about how addicts feel about treatment and about what their doctors are missing. I would also like to create a program to address the internalized shame that most addicts on buprenorphine continue to struggle with, no matter how long they are away from active using. I won’t go into specifics here, but there are so many things that could be done—that SHOULD be done. I know some of the things the company spends money on; I resent that they do not see the value in my efforts. And I am annoyed that they don’t even have an application process that would allow them to at least pretend that they are interested!
There are so many ways to become involved with buprenorphine; there are organizations like SAMHSA and CSAT and others that provide education and research into the use of buprenorphine. I was a ‘mentor’ for physicians with new buprenorphine practices for a short time and I have considered becoming active in SAMHSA or the other agencies. But if find those types of organizations to be inefficient compared to what I can do speaking to addicts directly, through the blog or forum. I also know where my strengths lie, and where they don’t. I do not do well as a ‘consensus builder’, for example—such people must be careful about what they say, whereas I tend to say what I am thinking. If a meeting is running long because someone is repeating how much he/she wants to do the right thing for all of these poor addicts, I am the person who will stand up and say ‘y’know, that is a given—and this is all a massive waste of time.’ And then for some reason I won’t get invited back again! Those meetings are not for me. My favorite recovery ‘saying’ is ‘a good man knows his limitations’—and that is one of my limitations. My strength comes from the fact that I understand how opiate addicts feel, and how they think. I always seem to know what an opiate addict is going to say next. On the other hand, I never have any idea what a government bureaucrat is going to say, or what I should say when speaking to one!
I suspect that R-B would like me to get on board the Here to Help message. But I have reservations about the program. I suspect, for example, that it is primarily being supported by R-B in the hopes of somehow using it to maintain their ‘brand’ over buprenorphine. If that is their intention, good luck to them– it is going to need some awesome content to keep people buying Suboxone for $8 when generic Subutex is selling for $2.55 at Walgreens!
Today I received a brochure describing the results of a ‘study’ that claims that patients in the ‘Here to Help’ program had improved compliance as measured by maintaining appropriate use of prescribed buprenorphine. As some of you may know I got my PhD in Neurochemistry doing basic science research and I have served as a Peer Reviewer for Academic Psychiatry for a number of years, so I know how to evaluate whether a study is ‘sound’ or is instead misleading. Even in the material that I received today, R-B refers to the findings as coming from a ‘quasi-study design’—so they at least apparently recognize that the findings are biased. I participated in the data collection for the study, actually; those of us who participated would invite new patients to participate, and the patients who accepted the invitations would then be randomized so that one group would get the ‘here to help’ info and the other group would not. R-B found that the here to help group had better compliance and fewer drop-outs than the other group. One problem I have is that I don’t know what they did for the ‘non-study’ group. For example if they told the non-here to help group ‘Suboxone will kill you if you keep taking it’, then the difference in compliance would be meaningless! I’m sure they didn’t say that, but what DID they say?
Second, there was no way to ‘blind’ the study on either side—both the addict and the phone person knew which group the study person was in. We like studies to be ‘double-blind’, and this one was not even single-blind.
Finally, participation in the study was voluntary, and we don’t know anything about the factors that caused some people to enroll and others to avoid enrolling. Let me explain how that bias could have affected the results. Patients were paid to participate in the study, so I would guess that the addicts who were unemployed were more likely to participate. Likewise, the addicts who were, say, executives from a high-profile company or physicians or attorneys would be less likely to participate, as they would be more concerned about disclosure of their status as addicts. So at best, the ‘here to help’ study looked at a specific subset of addicts—those who were interested in making $100 by talking on the phone for a half hour. Would the here to help program be of any value for a person who is still working, making good money, who has not suffered many consequences yet? We don’t know.
So… I am interested in your feedback. Have any of you used the ‘Here to Help’ program? If so, what do you think about it? If you have NOT used it, why not? Did your doc tell you about it? Leave your answers in the comments section—you do NOT have to leave a real name, and I will not use your e-mail for anything (it does not get displayed in your comment either). Your comment won’t show up immediately; for spam purposes I will approve the messages as I receive them. But here is your chance to let RB how you feel about that program—or about anything else, for that matter. Will you use the generic, or stick with the brand? Why or why not? Leave your comments and I will be sure to send them at least as far up the chain as I can reach!
Finally, I continue to ask for your support. I note that our forum is over 1500 registered members strong and growing; the older forum supported by R-B has about 200 registered members. You must know that your presence just warms my heart! If you have some money to spare and want to join me in my efforts (a pipe-dream of mine!), let me know and we will truly do some good things out there. Lest anyone thinks I’m getting rich from this, I have received 3 donations of $50 over the past few years, and a few of $5-$10. That’s it. And that’s fine—I just don’t want y’all to think I’m cleaning up with this blog. Maybe I should start posting each donation—leave a comment if you have an opinion on that as well! If I help you out or if you care to support my typing away on the blog, or help with the self-publishing of my eventual ‘big book,’ a small financial donation is always greatly appreciated.
The main thing you can do to support me is to spread the word. Send my links to anyone you know who takes buprenorphine– links for the blog, and for the forum too. Better yet, print out the link and give it to your doctor and tell him that you like it (if you do!).
Got all that? I suppose I could have just typed ‘what do you all think about the here to help program’ and gone to bed an hour ago! As always, thanks for reading. And I wish you all the best at keeping the scourge at bay.
JJ
More on the generic form of buprenorphine
Hey Doc,
I went to Walgreens early this morning and they had the drug on hand. So, if there is anyone who still has doubts as to the drug being available at local pharmacies- this shows the 2nd largest drugstore chain has it available in its pharmacies.
Note: the writer is referring to a Walgreens in Wisconsin.
The tablets themselves are round and white with the imprint of 54 411 on one side and a blank opposite side. Really the best way to describe them, is that they are identical in every feature (minus the imprint code) as the “512 Generic Percocet” tablets. As for taste and texture I found them to be much easier to tolerate than the fake orange Pez flavor laced with formaldehyde that Suboxone leaves in your mouth for hours. To me it was as if chewing a large aspirin and holding it in my mouth. Yes, it was slightly bitter, but the flavor itself was mainly inert and inoffensive.
Now as for price… Walgreens lists the retail cash price for 60 tablets to be $152.99 which translates to $2.55 x tablet. Less than half of what the name brand cost!!!ee
Note: in Wisconsin, Walgreens has always been the costliest place to purchase Suboxone, with prices up to 50% higher than other pharmacies such as Wal-Mart, Pick N Save, ShopKo, and even the smaller mom and pop pharmacies. I would expect for that reason that the generic could be found for even less money with a bit of calling around.
Hopefully some good news!
-jp
Thanks JP!
A Day With Reckitt-Benckiser
I just got back from Chicago, where I spent the day learning about ‘best practices with Suboxone’ with the people from Reckitt-Benckiser. I feel an obligation to share my experiences with those of you who are so strongly connected to the efforts of R-B —and I am not referring to owning stock in the company. I’m not in the mood to go on forever; meetings with pharmaceutical company people always tire me out and even bring me down a bit—I’m not sure exactly why. I would almost think it would be the opposite, because things look so easy from the perspective of a PowerPoint presentation. Although as I put my psychodynamic background to use, I realize that an opposite reaction makes sense. Tune into my radio show podcast sometime and listen as I talk about psychodynamics; dysphoric feelings often spring from unconscious conflict, and there was likely conflict between what I was watching and hearing during the presentations, and what I was thinking and remembering from my practice.
Those of you expecting a story about conspiracy theories will be disappointed. I had the impression that the company is sincerely motivated to help people with addictions for the right reasons. They made it clear through their actions and plans for the future that they are in addiction treatment for the long haul, even after the patent on Suboxone expires. There are some things about the company that have bothered me, and I was able to ask questions about those concerns. I will share their answers with you as best I can remember.
I spoke with someone Friday evening who has been with RB since 2003, about the lack of general support in the field for Suboxone compared to other new medications. She believed that RB did a good job of introducing Suboxone, and that their results in numbers of doctors trained and patients treated were good. I pointed out that many, perhaps most, ER docs have no idea what Suboxone IS, let alone know how to manage accidental ingestion or overdose. I compared Suboxone to Shire’s Vyvanse, a medication that has been out for just over a year but has 10 times as many sales reps in the state where I practice. If I want a coupon for Vyvanse, a rep drops off a box of them by the end of the day! But we have two reps covering the entire state for Suboxone! The difference in our perceptions was a classic ‘glass half full or half empty’ situation. She said that when she started in the RB pharmacy division, they had 20 US employees—a tiny fraction of the resources in place for product launches from the ‘big players’.
So I asked why they didn’t sell the drug to one of the big guys, so that it could be rolled out with the fanfare and support given to Cialis or Viagra? Another person from the company pointed out that had they done that, they would have had a bigger problem over the shortage of physicians certified to prescribe the medication. And that was a good point. The bottom line is that Suboxone was a truly unique situation; a small company that had no significant US presence, the unusual requirement for special certification for prescribers, a target illness that is complicated by stigma and the risk of diversion by patients… mistakes were probably made, but mistakes are always made. I left the conversation realizing that the company had some unique challenges to overcome, and so far has done pretty well.
A couple other areas of new perspective: on the issue of the high cost (although I often point out that for a fatal illness, the treatment isn’t all that expensive), it was pointed out that if Suboxone was super cheap, say a buck a pill, there would be a much greater profit motive for diversion of the drug. I think that is probably a fair assumption; there would be more Suboxone on the street if it retailed for a buck per pill than there is at five bucks per pill.
I was happy to see how strongly they connected with the disease model of addiction; in my opinion that is the genuine state of affairs, and the natural way to present Suboxone. Suboxone is a chronic medication for a chronic condition, period. I have always figured that it was a mistake that the company initially talked up using Suboxone for short-term detox, and I heard nothing to change my opinion. They mentioned that a few years ago 70% of patients were prescribed Suboxone for short-term use and 30% for maintenance, and now those numbers have reversed and 70% of prescriptions are for long-term maintenance treatment. Those numbers are consistent with my experience.
There will be other buprenorphine preparations in the future, including depot injectables made by RB or by someone else. Also watch for different types of oral products, including designs that reduce the likelihood of accidental exposure in children.
If I had to complain about something, I would say that the corporate presentation just does not seem to mesh well with the reality on the street. I talked to one of the leading developers briefly about the problem with twelve step groups—how there is a vocal anti-Suboxone crowd, who often talk people into stopping their medication or refer to doctors who prescribe the medication as ‘pushers’. He said that Betty Ford had given her blessing to the idea that people on maintenance medications are still ‘in Recovery’. My thought in response was ‘who the heck cares about Betty Ford?’ I would bet that 99% of the NA and 80% of the AA folks in my home town have never heard of her! I do think that the split among the recovering community over buprenorphine is a serious issue that should be dealt with in a formal manner, through communication between people who understand neurochemistry and buprenorphine, with people from the twelve step intergroup organizations.
I also believe that some in the company, and some prescribers, don’t understand what it is like to be an opiate addict. I realize that nobody who is not an addict will truly understand addiction, but I don’t think they get that we are just like they are outside of our addictions. To give an example, the issue came up about the degree of counseling and meetings that should be required of people on Suboxone. I have put forward my thoughts on this issue many times. Many of the docs at the meeting talked about their practice of requiring ALL people on Suboxone to go through intensive outpatient treatment, and/or requiring twelve step attendance as often as every day! They require AA or NA not because of some theoretical basis, but rather because they think that addiction and AA or NA just go together. I did point out my thoughts on the issue, namely that people only ‘get’ twelve step recovery when they have some degree of acute desperation, and people on Suboxone are NOT DESPERATE. I ‘got’ AA quickly the first time I went to treatment, but the second time it took several months before my mind opened sufficiently to truly accept the program. Only people who have had a spiritual awakening themselves will understand what I am talking about, but going to meetings and just sitting through them is not that beneficial. I have been to meetings with people mandated to attend, and those meetings are generally a waste of EVERYBODY’S time. ‘Getting it’ in twelve step recovery is a moving experience that sweeps the addict of his feet, and pulls him by the heartstrings into a new way of thinking and living. I like that saying that ‘insight maketh a bloody entrance’; the insight required to get clean through the steps is bloody indeed! But these docs just sit back and say ‘no meetings, no Suboxone’, and wear their inflexibility as a badge of honor. I have been in that horrible situation as an addict where my opinion didn’t ‘count’, since I was ‘too sick’ to think logically… that is a tough spot, as the harder you argue, the more belligerent you are accused of being.
As for the scientific topics, I was glad to see that I am pretty much on target with my thoughts about dose levels, tapering, receptor actions, etc. Many docs start patients on twice per day dosing and later convert to once per day; I like to start at once per day from the very start, to avoid setting up a pattern that might be hard to break.
All in all, it was an interesting and informative weekend. I will probably make a couple small changes in my practice in light of things that I heard. And as for RB, I left the conference thinking that I will buy a few shares of their stock. They want to be a premiere addiction-related pharmaceutical company, and given the epidemic of opiates and other narcotics in this country and in other countries, the sky’s the limit!
SuboxDoc
Suboxone Talk Zone