Some use opioid treatment drug to get high

A treatment drug widely-prescribed to help Medicaid recipients get off opioids is being manipulated, sold on the street and used as barter in area jails, according to addiction treatment advocates.

“The tragic result is that many addicts are selling their Suboxone script, using part of the cash as a monthly stipend and then purchasing much less expensive heroin or some other drug of choice,” said Burt Dhira, owner of Phoenix Recovery Centers with locations in Dublin and Newark.

Suboxone is the most-widely prescribed treatment option for addicts to safely withdraw from opioids. But it has become controversial. The thin strips that dissolve on the tongue are seen as too easy to divert and misuse, causing groups like the Ohio Addiction Treatment Council to argue for Medicaid to pay for other treatment options.

Suboxone is a combination of the opioid buprenorphine and the opioid-blocker naloxone. By minimizing the effect of the naloxone, dealers have been able to add to the local drug supply.

Suboxone strips are purchased by drug dealers for as much as $1,200 for a one-month supply, Dhira said, and sold on Dayton-area streets for $10 to $15 a pop. Often the sellers are addicts on Medicaid who got a Suboxone prescription from their local treatment clinic, he said.

As a result, drug dealers are profiting off Medicaid, which is funded by state and federal tax dollars, according to Dhira.

More than a quarter of the addicts interviewed for a study by the University of Kentucky’s Center on Drug and Alcohol Research said they’d sold, traded or given away the Suboxone they were prescribed.

Most people who are using Suboxone without a prescription are doing so to self-medicate and avoid withdrawal, medical professionals say.

Medicaid’s preferred list

Push-back from the medical, treatment and law enforcement communities about Suboxone led to changes in the state’s 2018 Medicaid preferred drug list.

The list specifies which medicines are automatically covered by Medicaid and which ones require prior authorization from a doctor. The list was initially drafted to make Suboxone the exclusive preferred treatment addiction treatment, which was a huge potential boon to the company that makes it.

That struck some treatment experts as odd because Attorney General Mike DeWine and 41 other attorneys general across the country are suing Suboxone-maker Indivior for allegedly driving up profits by illegally delaying the entry of a generic drug into the market.

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Suboxone is still on the preferred list, but another treatment drug — Zubsolv — was added earlier this month. Although Zubsolv is similar to Suboxone, it is sold in a pill form that law enforcement officials say is more difficult to conceal.

Dhira called the move is a step in the right direction, but he’d like to see all FDA-approved treatment options covered by Medicaid without prior authorization. Medicaid pays for about half of all medication assisted addiction treatment in Ohio.

“One treatment is not good for all in this fight that takes the lives of nearly 80 Ohioans every week,” he said.

Manipulating treatment drugs to remove their opioid-blocking properties is dangerous, doctors say, particularly when they are combined with other street drugs.

"It can be diverted and used by people with opioid use disorder the same as any other opioid," said Dr. Michael Dohn, Medical Director of Public Health Dayton & Montgomery County's outpatient drug addiction treatment center.

“The evidence seems to be that it’s not that good of a replacement (for heroin or other opioids),” he said, but it’s better than nothing for someone in withdrawal.

And, he said, users risk overdosing if they double or triple up on the dosage to get the same effect as a normal opioid high.

Jail tricks

The staff at the Greene County Jail have seen a lot of tricks over the years from inmates trying to smuggle drugs into the facility.

During the crack epidemic it was sewing crack rocks into the hem of clothing sent by family members. More recently it was drugs hidden in body cavities. But since the jail installed body scanners to combat contraband, smugglers have had to get even more creative.

“The problem is not the drug, it’s the addiction,” Jail Administrator Maj. Kirk Keller said. “There are people that are going to try to relieve that addiction through any means.”

Suboxone became the drug of choice in the jails because it could be hidden under a postage stamp or in the seam of an envelope on a letter to an inmate, Keller said.

Now, the Greene County Jail won’t accept mail unless it has metered or embossed postage — stamped on at the post office — and no stickers of any kind are allowed. All mail is carefully inspected looking for anything that could be concealing a Suboxone strip, he said.

Already, someone made at least one attempt to skirt the new system. Last week, an envelope arrived marked as legal correspondence, which limits how much scrutiny jail staff can have. There was a tip off, though: The local lawyer whose name appeared on the envelope has been dead for years.

When the envelope was held up to a ceiling light, a small thin Suboxone square was visible under one of the sealed ends, Keller said.

“They think of a lot of creative ways,” he said of the jail population.

High demand

One reason there is such high demand for Suboxone in jails, Dhira said, is because many addicts are forced to detox cold turkey when they become incarcerated.

Jail medical staff can prescribe treatments, but Medicaid and most insurance plans won’t pay for them once someone becomes incarcerated. The entire cost of treatment falls to the county at that point.

“Once you come to jail (Medicaid) doesn’t pay for anything,” said Karen Hall, director of medical services at the Greene County Jail.

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In order for patients to get Vivitrol — a shot that blocks drug cravings for a month — through one of the county’s treatment programs, inmates are taken off-site by probation officers, she said. Others are monitored each shift to see how severe their withdrawal symptoms are and a doctor can be called in to prescribe something if needed.

Pregnant inmates get a drug called Subutex, which does not contain naloxone, because it’s bad for their babies and withdrawal puts too much stress on the fetus.

The other drug added to the preferred list for 2018, Zubsolv, is a tablet that dissolves under the tongue and is also a combination of buprenorphine and naloxone. The body is able to more effectively use the buprenorphine in Zubsolv, according to addiction experts, so the tablets contain a lower dose of active ingredients and it is harder to abuse. It's also harder to smuggle into a jail because it looks like a small pill.

There are three other drugs that Medicaid will cover for medication assisted addiction treatment, but they require a prior authorization from a doctor.

Dohn said doctors who treat addicts should limit prescriptions for addiction treatment drugs to just what the patient needs and than pay close attention to how often they return for refills.

“It’s writing the prescription and making sure you’ve got the right dose for the patient,” he said.

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Suboxone vs. Zubsolv

The two drugs on the 2018 Medicaid preferred list for treating opioid dependence are similar but treatment experts say Suboxone is easier to abuse while Zubsolv dissolves faster and is better absorbed by the body.

Suboxone

Active ingredients: buprenorphine and naloxone

Form: sub-lingual film

Maximum dose authorized by Medicaid: 16 mg

Flavor: Citrus

Zubsolv

Active ingredients: buprenorphine and naloxone

Form: sub-lingual tablet

Maximum dose authorized by Medicaid: 11.4 mg

Flavor: Mint

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