1 By Anna Merlan Wednesday, Oct Pablo Iglesias Five months ago, Chris resolved that it was finally time to get clean. Internist Dana Jane Saltzman is one of the 1,600 doctors in New York state authorized to prescribe Suboxone. Suboxone is "not being used in the context we've seen it to kick a habit or even to replace a narcotic dependence. It's just a way to control your habit a little bit better." Sort of. The 34-year-old Brooklyn real estate broker (who declined to be identified by his real name; "Chris" is a pseudonym) had begun using heroin and quit once before, in his late teens. But family problems and a few tough months caused him to relapse, and soon he was snorting the drug two or three times a week. After nearly a year of using, the days between doses started to get dicey, and Chris got worried. On the off days, he says, "I was never myself. I was irritable, exhausted, had no motivation or desire to do things I once enjoyed doing. I wasn't happy." So, in between bags of heroin, Chris scored Suboxone, a prescription painkiller used to treat opiate addiction. He'd use it when he was making a halfhearted attempt to get sober, or when he just didn't want to feel bad between bags. Thanks to its main ingredient, buprenorphine hydrochloride, Suboxone eliminated the agonizing heroin withdrawal, the "three days of complete hell" he had to go through every time he tried not to use.
2 Addiction researcher Adam Bisaga says, You wouldn t get as high as with heroin.... But you d still feel somewhat Chris didn't get Suboxone through a doctor, at first. He didn't have to. It was easier and quicker to buy the drug from a friend who had a prescription and lots of leftovers, which he was willing to sell to Chris for $5 a pop. "Subs," as people often shorthand the drug, come in paper-thin strips, a lot like the Listerine kind, that melt under the tongue. Chris's friend took half of a twomilligram strip each day and sold the extras to Chris. Eventually, Chris decided he was spending too much money on the subs. He found a physician willing to prescribe him 24 milligrams a day a "totally ridiculous" dose, he says, far too much for one person to take. (According to the drug's manufacturer, U.K. based Reckitt Benckiser, the recommended maintenance dose is anywhere from four to 24 milligrams.) He takes one or two strips each day, two to four milligrams, and sells the rest on Craigslist. "I don't work with everyone," Chris says. "I'm probably more cautious than most." He tries to weed out law enforcement by asking for Facebook or LinkedIn profiles to back up the buyer's identity. "I'm not a fullblown addict. I do have a job. I have a lot to lose." Besides, he adds, "I'd rather sell to someone who wants to get clean, rather than someone who just wants it in between their heroin binges. I'd rather help someone." Special Narcotics Prosecutor Bridget Brennan says dealers carry Suboxone to keep their clientele happy. Other dealers up and down the East Coast who sell buprenorphine take the same tack in their Craigslist sales, positioning themselves as stops on the road to recovery. "If you're trying to kick your diesel habit, then TEXT me asap!" writes one dealer. "Heroin is overwhelming here in New Jersey, so please do the right thing and get on Subutex asap!" "Not LE here," writes another dealer in Soho, using the shorthand for "law enforcement." "Just a guy with a few extras and looking to help someone in need. Please be real about getting clean." "No bs and no le," echoes a poster in upstate Montgomery County. "I'm just trying to help someone who needs to be off of pain medication."
3 The technical term for what Chris and other dealers are doing is "diversion," and it is, as you might guess, illegal. Selling your meds is a class C felony in New York, carrying a minimum of one year and a maximum of 10 in prison. In the case of Suboxone and its generic equivalents, diversion is also increasingly common. Suboxone has been on the market in the U.S. since the late 1990s. Over the past two years, sales have skyrocketed, corresponding to a rise in heroin and (especially) painkiller addiction. The number of pain-pill prescriptions hovered around million in 2010; the National Institute on Drug Abuse estimates that 5 million people in the U.S. abuse painkillers. It's hardly surprising that a drug that can help people get off opiates has become a runaway success. According to IMS Health, a company that collects data about the drugs U.S. doctors prescribe, Suboxone reached $1.4 billion in sales in the first quarter of 2012 nearly 10 times the figure from Seven years ago, Suboxone was the 198th-most commonly prescribed drug in the U.S. Today, it ranks 26th. In 2012, doctors wrote 9.3 million prescriptions for buprenorphine. From January to March of this year, they wrote 2.5 million more. A majority were for Suboxone, which controls about 70 percent of the buprenorphine market. As the legal market for the drug expands, so does the black market pooling underneath. If Chris is too picky, Craigslist drug seekers can do business with 24-year-old Luis, who teams up with a friend with a prescription to sell the drug. Luis, who calls himself a "distributor," is homeless and says he's selling Suboxone to finance his move out of the shelters. That, and a desire to help folks. "People thank me," he says earnestly. "I'm not doing a bad thing. I'm not selling drugs." In her line of work, Bridget Brennan sees and busts a lot of drug dealers. She's immensely skeptical of the notion that anyone buying Suboxone on the street is taking it to get clean. "To me, that seems highly unlikely," she says. "You don't need health insurance to go to a treatment center." Brennan is New York City's Special Narcotics Prosecutor, and her office is responsible for prosecuting drug crimes. It was created by the city's five district attorneys in the 1980s as a way to respond to a new epidemic of heroin and a corresponding citywide increase in violent crimes. Brennan doesn't seem surprised, or especially concerned, to learn that people are using Craigslist to sell their detox meds. She notes that Craigslist drug sales have transpired on and off for years. "Our focus is on more of the major suppliers," she says. "But we do monitor Craigslist, and we do periodic sweeps there." Brennan says that, in her experience, most dealers carry Suboxone as a way to keep their clientele happy; in recent years, her office has busted several drug rings that stock it alongside heroin, Xanax, and Percocet. Addicts buy Suboxone when they can't afford their drug of choice, or when they have a pressing social engagement that requires them not to turn up totally high.
4 "It's not being used in the context we've seen it to kick a habit or even to replace a narcotic dependence," she asserts. "What I've seen is not a real commitment to getting clean, it's just a way to control your habit a little bit better." Mike Laverde agrees. He's a former heroin addict himself, now nine years sober and an intervention specialist with a Chicago company called Family First Intervention. Like Brennan, he sees black-market Suboxone users as just another subspecies of addict. "They think they can take the Suboxone and come off drugs themselves," he says. "But they can't. The problem in the drugs department is them." Without actual treatment, Laverde says, addicts are very likely to fall back into dependence on their drug of choice. That practice toggling back and forth between the drug you like and the drug that helps you avoid withdrawal is known as "bridging." "People cycle on and off, absolutely," says Jose Sanchez, a substance-use counselor at the nonprofit Lower East Side Harm Reduction Center. His clients, Sanchez explains, tell him they carefully plan out their drug use. "They'll stop taking the Suboxone for a couple days, so that by the third day they'll be able to feel that zing of the opiate, whether it's heroin or Oxycontin." It's unlikely they'll ever really get clean that way, he adds. "It certainly could work. But I think to be successful, you need every bit of support you can get" i.e., counseling and a doctor's supervision. When someone self-medicates with Suboxone, Sanchez says, "You really can't judge how well the medicine's working for you. All you know is you feel good that day, and the next day you want to feel just as good." If you wanted to kick an opiate habit the aboveground way, you might visit a doctor like Dana Jane Saltzman, an internist who's also one of the 1,600 doctors in New York State authorized to prescribe Suboxone. Her practice is hidden away in midtown, in a nondescript, five-story building not far from the marquee lights of the Ambassador Theater. She keeps two websites, one for her regular practice, and the other, NYCSuboxone.com, for people looking to get clean. Saltzman's building is a little down at the heels, but her clientele is anything but. Most of her Suboxone patients, she says, are Wall Street guys, "masters of the universe types" who find themselves with a pain-pill addiction and a pressing need to get sober without cutting into their 100-hour workweeks. "I see a lot of young men, very high-functioning, very ambitious and upwardly mobile," Saltzman says. Many of them are prescribed Oxycontin after they sustain sports injuries: shoulders, backs, knees. A client came to see her several weeks ago who'd been on the painkiller for two years before he realized he'd become dependent. Buprenorphine is popular with Saltzman's patients and other opiate addicts for one basic reason: It too is an opiate.
5 "It hits and stimulates the same receptors in the brain that are affected by heroin or methadone," explains Adam Bisaga. He's a professor of clinical psychiatry at Columbia University and an addiction researcher at the New York State Psychiatric Institute. Like other opiates, buprenorphine binds to certain receptors in the brain. It's "stickier" than drugs like heroin, binding to those receptors faster and holding on longer: Morphine has a half-life of about two hours; buprenorphine's is anywhere from 24 to 60 hours. Buprenorphine is also a partial opioid agonist. It doesn't fill up the brain's receptors as completely as heroin or painkillers do, making its effects much more muted than the intense euphoria heroin offers. "It stimulates the receptors, but only to 50 percent," Bisaga explains. "At some point there's a ceiling, and no matter how much you take, you'll never get across that. It's like an electronic block on your gas pedal in a sports car." To further limit its effects, Suboxone contains naloxone, an opiate blocker. The most famous naloxone-containing drug is Narcan, which can treat people during an overdose, and which has no known potential for abuse. Subutex, a Reckitt Benckiser-manufactured formulation that's pure buprenorphine, is more potent and in greater demand on the black market. Saltzman says she won't prescribe it unless a patient has a proven allergy to naloxone. Suboxone's older cousin, methadone, is a full agonist, meaning that its effects, along with its getting-high and overdose potential, are that much stronger. But Suboxone offers users a powerful feature methadone can't match: It's designed to be taken at home, whereas by law methadone is required to be distributed at a clinic. (In New York, methadone patients can get take-home doses, but they're tightly controlled; to get a six-day supply, a patient has to have been in treatment for at least three years.) "You have to go to the clinic every day, and that has a little bit of a reputation," Bisaga says. "Many people don't like the idea." Buprenorphine was introduced as a treatment for opiate addiction in Belgium in 1983, in the form of little orange tablets that were placed under the tongue. Four years later, it was being used in France. Reckitt Benckiser won approval to distribute Suboxone in the U.S. in 1994, although it wasn't released here until At the time, the Food and Drug Administration granted it "orphan" status, which is awarded to drugs that are meant to treat "rare diseases or conditions" and aren't expected to be profitable. Orphan drugs qualify for generous tax credits, and the FDA can't rescind the designation once it's granted. Suboxone retained orphan status until 2009, when the patent for the tablets expired. Several U.S. drugmakers promptly set to work making generic versions, two of which went on the market this past February. That month, analysts projected Reckitt's annual pharmaceuticals profit would take as much as a 4 percent hit.
6 By 2006, Suboxone's abuse potential had become pretty clear: A study of French buprenorphine users found that a lot of them were crushing up their tablets and injecting them. According to the European Opiate Addiction Treatment Association, the same problem soon turned up in England, Ireland, Scotland, New Zealand, Australia, Finland, and the Czech Republic. (A recent report in the daily Prague Post estimates that Subutex accounts for 70 to 80 percent of all drugs sold on the street.) Also in 2006, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) found the same issue cropping up in the U.S., noting that buprenorphine abuse appeared to be "concentrated unevenly in Northeastern and Southeastern regions." Seeing buprenorphine cross the Atlantic came as no surprise to Bisaga. "It's a problem with every drug we have," he says. "It was just a matter of time." Introduce a drug, and soon people will find a way to use it to get high. According to SAMHSA figures, emergency-room visits involving buprenorphine use "increased substantially, from 3,161 in 2005 to 30,135 visits in 2010, as availability of the drug increased." More than half of the people seen at the ER reported that they were using the drug "nonmedically." The researchers who studied French buprenorphine injectors wrote that it seems "pharmacologically impossible" for anyone to get high from the drug. And yet, they say, the addicts did report feeling a "rush" after injecting it, which the researchers chalked up to the placebo effect. The question for drug- and policy-makers alike is how to short-circuit any new drug's potential for getting you high. Adding naloxone to buprenorphine hydrochloride is one way to limit abuse, Bisaga says. Another was to pull the tablets off the market and replace them with a film designed to be impossible to abuse. (According to several pharmacies the Voice contacted, brand-name Suboxone tablets are still available, at least in New York, though Reckitt Benckiser had notified the FDA in February 2012 that it would voluntarily discontinue the tablets. The company said at the time that the pills would be off the market by March 2012 at the latest. Reckitt Benckiser did not respond to several requests for comment for this story.) People still try very hard to make the most of their Suboxone; Internet forums are full of tips and tricks about how to get high off the strips. Some users recommend melting them in water and injecting them, or offer instructions on how to "snort" them. Others insist the would-be stoners are wasting their time, that "bupe" won't ever get you lifted. Bisaga begs to differ. "People who are not in treatment, not taking it every day, can get high." If you take it consistently and correctly, as part of a treatment plan, you probably won't feel any euphoric effects, he says. But taken more sporadically, it's possible: "You wouldn't get as high as with heroin. It's not such a powerful, instant, intense euphoria. But you'd still feel somewhat affected."
7 Some patients in treatment report that the drug has mood-lifting properties. "People often feel good on Suboxone," notes Saltzman, the Suboxone specialist. "Many people say they feel better than they have in their lives." Saltzman has seen the rise of Suboxone abuse firsthand. She has had a license to prescribe it since 2000; in the past few years, the number of patients she suspects are diverting the drug is increasing. "There's a constant wave of diversionary tactics in here," she says. "It's constant and unending. It's just piling up." She tries to weed out the drug-seekers from the people who are genuinely eager to get sober. She requires patients to attend group therapy and one-on-one sessions with a counselor, and she encourages them to enroll in a 12-step program like Narcotics Anonymous. She also drug-tests them every time they come in to have their prescription refilled. "If someone doesn't want to give a urine sample, that's always a bad sign," she says. "That may mean their last prescription was sold on the street." Saltzman is quick to add that most of her patients including the ones who relapse or sell their prescriptions genuinely want to get better. She acknowledges, too, that her treatment is too expensive for many: $400 for the initial visit and $250 for every visit thereafter. The medication itself is covered by insurance, but the office visits aren't. That's by design, Saltzman says. Otherwise "we'd have lines out the door. It would be a whole different thing. Making people pay is about getting their full attention. It's very intense work, and it's not at all like primary care." (By law, Suboxone doctors can only treat a maximum of 100 patients.) A couple of low-cost clinics in the city don't charge for the initial visit, but most Suboxone doctors' rates are as steep as Saltzman's. As for the price of the drug itself, at a CVS pharmacy, the estimated price for an uninsured person to get 30 days' worth of Suboxone tablets is $295. At Duane Reade, it's $315. At Rite Aid, it's $283. Insurance brings down the price substantially: United Healthcare's rate is $60 ($25 for the generic). Blue Cross Blue Shield's is about $40; Aetna's, $75. Chris, the real estate broker and Craigslist dealer, routinely gets s from people who say the price is what prevents them from procuring the drug legally. "im interested in yr add," a recent would-be buyer wrote. "recently lost insurance, and the cost of a doctor/script is just too much fr me right now. very serious about getting off, without getting too sick to work. Im a professional honest guy with a family you can look me up on facebook, just search [redacted] in new york, there is a drawing of a rabbit as my main photo. Please keep it discreet and profess. and i will do the same." Motive and legality aside, how harmful is "bridging" with Suboxone? Every dose of buprenorphine is a dose of heroin (or the like) not taken. And a person is far less likely to die
8 from using buprenorphine. According to Joshua Lee, a professor at New York University Medical Center and an attending physician at Bellevue Hospital, buprenorphine has "less overdose potential" than methadone. In particular, it's less likely to cause "respiratory depression" the physical state when breathing becomes so shallow as to no longer provide the body with oxygen. "As doctors prescribing it, we're very concerned with this," Lee says of black-market use. "And we discourage people from doing that. But from a public-health, harm-reduction standpoint, we acknowledge that diversion of buprenorphine seems different than diversion of oxycodone, say, or Xanax." "So many people who cannot afford the medications from legitimate sources are basically buying it on the street to treat themselves," offers Bisaga, the Columbia professor and addiction researcher. "I don't think these people are doing it to get high although certainly there are people like that. I think most of them are just trying to get treated at low cost, which is obviously a tragedy. Most developed countries in the world have free treatment for drug addicts and this is no longer an issue." A few months after he began selling his prescription on Craigslist, Chris has decided to stop for good. "I pulled all my ads down," he says. Chris is muscular and pale, and he looks exhausted. He's wearing a V-neck sweater and jeans, and carrying a shoulder bag that looks like something a doctor making house calls might use. He says he saw "many, many" people in the few months he was selling including attorneys, fellow real estate brokers, and even one addiction counselor. Chris says he got himself off Suboxone, a process he describes as "brutal." He did it by transitioning to the painkiller Percocet, then weaning himself off that. The experience of detoxing left Chris with mixed feelings about Suboxone. "On the one hand, it is a good thing," he says. "It keeps people from stealing and robbing and overdosing. But it really just masks the issue: the addiction. From heroin withdrawals, you move onto Suboxone, and then you have to go through those withdrawals. It's something that's going to happen, but a lot of us choose to prolong it." In the longer term, he adds, the drug also made him feel "like total shit." "My girl always says I couldn't even formulate sentences," he explains. "I was not articulate. I couldn't fuck her, excuse my language. I was just totally like a zombie. And then my feet were constantly uncomfortable. I couldn't sleep without it. My eyeballs would turn into like these huge dishes, big pupils like Mickey Mouse." To his dismay, Chris realized that he initially felt even worse when trying to pull back on the Suboxone than when he experienced heroin withdrawal. "You're exhausted for a very long time. It takes forever to get out of your system," he says.
9 He believes now that his doctor didn't adequately warn him that the detox drug had the potential to be addictive, nor about its "sticky" properties. "The doctor I was seeing it was literally five or 10 minutes he sits there and gives his typical speech about how bad drugs are, et cetera, and then he writes a scrip, and I'm gone. He gets paid, I go fill it, and that's it." Saltzman says some Suboxone doctors operate as little more than drug mills. "I had one of them get arrested right in front of me on 57th Street the other day," she says. In part, she goes on, the problem may have to do with how Suboxone doctors get their licenses. Ten years ago, in order to be able to prescribe the drug, she was required to complete a two-day class at Mount Sinai Hospital. These days, she says, "it's an Internet course that takes a couple of hours." Chris also was disturbed to hear his doctor tell him that he might have to use buprenorphine for the rest of his life. "It made me feel like a loser," he says. Adam Bisaga takes a different view. "This is the push that they hear from [12-step programs]," the Columbia professor says. "That recovery with medication is something inferior. That you're not truly in recovery until you take nothing. It's not science. It's just ideology from a 12-step movement that makes them vulnerable to relapse." (Responds a spokesman for Narcotics Anonymous: "The experience of NA members is that being clean means complete abstinence from all mood- and mind-altering drugs. That said, NA welcomes everyone. Ultimately, we're not in the business of telling people blanket statements about whether they're clean or not.") "On the other hand," Bisaga adds, "you do hear the stories of the pharmaceutical industry pushing people to stay on as much medication as possible. Depending on where you stand in this conversation, you can hear arguments on both sides. We rely on science and effective treatments, and we'd like patients to make informed decisions on their future." Saltzman says some of her patients are, for all practical purposes, on the drug permanently, but she doesn't encourage it. "I don't like that idea. It's not a healthy way to live," she says. "To me it speaks to someone not wanting to look at themselves." Chris gazes out a window and rubs his legs, which sometimes still hurt. "At some point," he says, "you have to pay the piper. There's no easy way out with opiate addiction." Asked how long he's been clean, he smiles, looking both proud and more tired. "Two weeks," he says.