We are facing attacks on buprenorphine. Like many of my fellow addiction physicians, I have received formal notice that the limit on the number of patients to whom I can prescribe buprenorphine has been increased. In addition, our nurse practitioners and physician assistant have begun initiating the procedure so that they can, for the first time, prescribe this medication. This is occurring because buprenorphine has been one of those rare medications that have lived up to the hope that we had for it when it finally became available in this country in 2003. As a consequence, regulations have been revised, and new laws have been to make buprenorphine more accessible at a time when opioid addiction and overdoses continue to pose a significant problem to people in the United States.
On the other hand, preventable problems continue to disrupt the optimal use of this medication. Most recently, the committee that oversees medications for Maryland Medicaid patients threw numerous stable patients into opioid withdrawal this summer by requiring them to change from one formulation of buprenorphine (Suboxone) to a different one (Zubsolv). The decision was based on the notion that these two formulations were equivalent – even though there has been general awareness to the contrary by addiction specialists, who apparently were not consulted about the decision that was an attack on buprenorphine.
What is particularly troubling about the Medicaid decision is that it was made not because of any treatment problem with patients, but rather at the behest of the criminal justice system. Buprenorphine is one of the medications being smuggled into jails and prisons. The Suboxone formulation, which is a plastic film rather than a tablet, is more easily hidden. The irony is that this formulation is more difficult to divert for the purpose of getting high.
Buprenorphine has a deservedly good reputation among both clinicians and addicts as an excellent medication for relieving or eliminating withdrawal symptoms. Its popularity among inmates is an indication that the Maryland criminal justice system does not provide adequate addiction treatment to inmates, including allowing them to suffer painful opioid withdrawal without the benefit of the appropriate medication.
One of the difficult tasks of incarceration is the reduction of recidivism. I would argue that this could be more effectively achieved by providing inmates with treatment for the addiction that leads to criminal acts rather than directing efforts to disrupt the treatment of addicts who are successfully dealing with their disease.