The Maryland Public Policy Institute
Opioids are a scourge across the country, but especially so in the Old Line State. According to the most recent available data, 1,468 people died from overdoses between January and September 2016, with well more than 90 percent of them in combination with opioids including heroin, fentanyl and prescriptions such as Vicodin and Percocet.
That figure is even more staggering considering heroin-related deaths have increased by 74 percent from the same period the year before. There also has been a jump in deaths because of the popularity and availability of fentanyl, a synthetic opioid 30 to 50 times stronger than heroin. This substance is now being mixed into street drugs, producing a deadly multiplier effect for users who take too much. Through the third quarter of 2016, there were 738 fentanyl-related deaths in Maryland, compared with 192 in the same period the previous year.
Maryland has been fighting this rise in drug addiction for years, and coordinated efforts between state and federal law enforcement agencies continue to limit the importation of these drugs into our state.
Treatment must be part of the anti-opioid equation. But treatment success rates are abysmal, with the vast majority of addicts who seek recovery relapsing. Eighty percent of heroin addicts never receive treatment, according to the Journal of the American Medical Association.
As a result, many want a more holistic approach that offers treatment outside of the standard Narcotics Anonymous abstinence model.
Enter medically assisted treatments (MATs) such as buprenorphine, which is prescribed to addicts to decrease cravings for opioids and ease the detox and withdrawal symptoms that lead to relapse (and overdose). MATs play a key role in bridging the gap from addiction to treatment. Buprenorphine is an increasingly popular MAT covered by state Medicaid agencies.
But all buprenorphine treatments are not equal. One brand of the drug, Suboxone, has been associated with over-prescription and black-market smuggling. For those reasons, Maryland’s Medicaid department recently removed Suboxone from its preferred drug list, ensuring that public-health officials and addicts have access to effective buprenorphine treatments that aren’t widely abused.
Dispensed in the form of a film strip, Suboxone is easy to take and, problematically, just as easy to divert to illicit markets. Much of the problem lies in the difficulty of customizing dosage levels for Suboxone; doctors are often forced to prescribe dosages that exceed what a patient needs, leading to excess supply in the market. And when an individual has more than he needs, he can cut the extra portion of the film strip off and smuggle it into prisons and jails.
The delivery system of Suboxone has an unintended consequence: It furthers addiction by increasing the public availability of opioids and of money to fuel drug habits, especially in correctional facilities. In effect, the film strip facilitates a black market for the “medicine” because it is so easily concealable, unlike tablets for competing drugs.
Whether inmates were self-treating or just getting high, the strips were finding their way in massive quantities into the state’s prisons and jails.
But after the state’s Medicaid administrator, the Department of Health and Mental Hygiene, cracked down on access to the drug, prison seizures of Suboxone fell by 41 percent.
The maker of Suboxone, Indivior, which allegedly exploits legal loopholes to extract higher prices for the same chemical from the state Medicaid program, is understandably upset.
Suboxone was previously available as a tablet, which was more difficult to smuggle. The drug maker pulled the old version, however, switching to a film strip to game the patent system and extend monopoly protections. That effectively boxed out competition from more efficient, less-divertible treatments. That’s why Maryland’s attorney general joined 42 other attorneys general to sue Indivior for driving up its profits illegally, at direct expense to taxpayers and the addicted.
Meanwhile, other opiate-recovery medicines are available without the dangerous side effect of facilitating a black market in their abuse. Maryland officials stepped in and replaced Suboxone with Zubsolv, a pill-based buprenorphine treatment that comes in dosages tailored to patients’ needs. That means less over-prescription, a more difficult product to smuggle and a drastically reduced black market for MATs in Maryland’s jails.
Other states may well want to follow Maryland’s lead in interdicting a strange but real threat to recovery — the drug that promises a quick cure. This drug may be worse than the disease by perpetuating the cycle of addiction it purports to end.
Marc Kilmer is a senior fellow at the Maryland Public Policy Institute.