The epidemic of drug addiction is on the rise, killing dozens of young Mainers every year and leaving scores of others incapable of leading normal lives. It ruins families, divides communities and drains millions of dollars out of the economy.

A promising medication recently has been made available in the United States. People who know about it say it’s safe, remarkably effective, simple to use and has few side effects. With a prescription from your family doctor, you can get it at the corner drugstore.

Here’s the rub – your family doctor probably won’t prescribe it. Your doctor may not be all that interested in treating this disease. In fact, your doctor might prefer you went away and gave your seat in the waiting room to someone with some other, less complicated problem.

Is this any way to respond to an epidemic?

Doctors slow to respond

With the federal Food and Drug Administration’s 2002 approval of the drug buprenorphine, Mainers living with drug addiction should have gained a powerful treatment alternative to personal counseling, behavioral therapy and methadone.

In approving the new drug, federal officials envisioned a nationwide, grass-roots network of community physicians empowered to treat drug-addicted patients right in their offices, a valuable alternative to the highly regulated regional clinics that dispense methadone.

But doctors in Maine and elsewhere have been slow to step up to the plate. Primary care physicians say treating the disease of addiction is a complicated medical specialty, one they’re not equipped to undertake in their general practices. Although federal law requires doctors to attend a daylong training in substance abuse and addiction management before they can prescribe the new drug, some say the training is a major inconvenience and doesn’t provide solid clinical grounding.

Though they’re hesitant to say so, some doctors don’t want their practices to become known as the local drug treatment center, fearful of alienating patients with a waiting room full of the hard-living characters they associate with substance abuse and addiction. And because many addicts rely on Medicaid for their health care but Medicaid pays doctors considerably less than does private insurance, doctors have little financial incentive to take on this practice.

While Maine families stand by in grief and frustration as addiction consumes their loved ones, state and federal health officials, medical leaders and the Congress are ramping up efforts to answer physicians’ concerns and get treatment to the people who so desperately need it, in the communities where they live.

What is it?

Like methadone, buprenorphine – marketed as Suboxone or Subutex – answers the body’s biological need for opiates, allowing addicts to get on with their lives without being high or worrying about getting their next fix. But unlike methadone, buprenorphine treatment is office-based – it can be prescribed at a doctor’s office for a month at a time, eliminating the need for the daily visits methadone users must make to the nearest tightly regulated clinic, which often is not near at all.

People who have used both say that buprenorphine leaves them clear-headed and alert, without the woozy complacency methadone often confers. Buprenorphine has fewer side effects, a much lower street value and a better track record of keeping addicts clean.

Buprenorphine users also are more likely to be able to be weaned off the drug altogether over time, whereas methadone is, in many cases, a lifelong therapy.

Some methadone users, including those who get it from a clinic, take other drugs along with it in order to get high, a lethal practice that has caused a number of deaths in Maine. But Suboxone, buprenorphine’s most popular formulation, includes a dose of a drug called naloxone, which triggers nearly instantaneous sickness in patients who take other narcotics. The effective control of cravings coupled with the sure-bet illness that results from attempts to use drugs recreationally is a uniquely powerful combination for addicts and treatment providers alike.

But for many people, buprenorphine’s vast advantage is its straightforward availability. For addicts who live hours away from the nearest methadone clinic, for those who have relocated to be nearer a methadone clinic, and for those who dread the social stigma of making a daily visit to the methadone clinic, the prospect of filling a normal prescription at their local pharmacy is mind-bogglingly simple.

But physicians across the country have been slow to embrace the new therapy, leaving addicted drug users waiting for access to what some specialists say is the most effective treatment available. Only about two dozen Maine physicians have taken the eight-hour training required to prescribe the medication for their patients. Of those few who are certified, only about half are actually treating patients with it.

According to Gordon Smith, director of the Maine Medical Association, this foot-dragging reflects doctors’ tepid response to the notion that drug addiction can and should be managed by primary care physicians in small community practices. Many Maine doctors have all the patients they can handle without opening their doors to the specialized population of narcotics abusers, he said.

Smith said doctors balk at having to take a day away from their busy practices to fulfill the training requirement for prescribing buprenorphine.

“On the surface, it doesn’t sound like much of an impediment,” he acknowledged, “but I don’t know of any other drug that you need to take a course for.” A federal requirement that limits practices to 30 buprenorphine patients at a time is a further disincentive for doctors to take on the challenges of treating addiction, he said, especially when they’re not keen on it in the first place.

As a group, Smith said, physicians can be as guilty of stereotypical thinking as other people. “There are unfortunately some doctors who feel like they don’t want ‘these people’ in their waiting rooms,” he said.

‘Stunningly effective’

“This is an enormously, stunningly effective drug,” said Dr. Mark Publicker, an addiction specialist at the Mercy Recovery Center in Westbrook. In a recent telephone interview, Publicker said buprenorphine – which has been used successfully to manage narcotic addiction for more than 10 years in some European countries – is now a routine option for clients.

Because Maine doctors have been so slow to respond to the challenge of buprenorphine, Mercy Recovery Center and Acadia Hospital in Bangor are stepping forward to provide training and support to primary care physicians. Acadia held a certification seminar earlier this summer, recruiting about a dozen staff physicians and other doctors from the Bangor area. Mercy is planning a similar event in the fall.

The two hospitals envision creating a support system for physicians who choose to treat patients with buprenorphine. With a referral from a local doctor, the hospitals will bring clients in for an assessment of their suitability for buprenorphine treatment, including an overnight stay if necessary, followed by a week or so of daily counseling and support. Once the clients are stabilized on a dose of buprenorphine, they’ll be discharged back to their primary care physicians for continued treatment.

Southwest Harbor primary care physician Julian Kuffler attended the training at Acadia Hospital. His concerns are typical of many community practitioners, he said. Even though he knows there are a number drug users in the area he serves – even among his current patients – he is wary of developing a reputation for treating addiction.

Kuffler said small-town practices like his haven’t wanted to alarm their communities or open a high-profile public debate by offering substance abuse treatment in their offices. Additionally, treatment of substance abuse and addiction has long been acknowledged as a medical specialty, he said, and some physicians may feel they are underqualified to manage the condition. More specifically, most primary care physicians haven’t been educated about buprenorphine, he said, and don’t understand how to use it effectively.

Kuffler said he was persuaded to add buprenorphine treatment to his services when he learned that he could partner with the Open Door substance abuse program in Ellsworth. When he gets his certification, Kuffler will serve as one of two doctors who prescribe the drug for addicts who are actively engaged in Open Door’s therapeutic counseling and behavior modification program.

Open Door’s executive director, Barbara Royal, said Suboxone has been in cautious use with her clients for more than a year. Clients who have a strong commitment to recovery are required to sign a contract agreeing not to use other drugs or alcohol and to attend daily counseling sessions and regular 12-step meetings. Those who violate the contract are weaned off Suboxone and asked to leave the program until they’re more committed.

Royal, who opposes methadone because of its abuse potential and the long-term nature of the treatment, said buprenorphine has worked well for most of the Open Door clients who have used it, regardless of how old they are or how long they’ve been using narcotics. Despite the drug’s reputation for being more successful with younger, less entrenched addicts, she said, “This is not about age or hard-core. It’s about ‘Are you ready?'”

In Maine, a crying need

Kim Johnson, the director of Maine’s Office of Substance Abuse, said expanding the network of physicians who are willing and able to prescribe buprenorphine is essential to managing the state’s epidemic of drug addiction.

“The methadone clinics are all full, and all the buprenorphine doctors can’t take any more patients,” she said. “There is simply no place left to send an opiate addict who needs medication to get control of his disease. People have to be able to stop craving drugs and feeling sick before they can do the behavioral work.”

Johnson said her office staff has been working to help Acadia Hospital and Mercy Recovery Center secure federal and private funding to help get the support network in place. There is no state money available.

“Basically, our role is begging,” Johnson said.

How many physicians should get certified? “I think every physician should be able to do this,” Johnson said. “They wouldn’t have to treat a lot of patients, but they should be able to treat their own patients, like they treat them for other diseases.”

Gordon Smith of the Maine Medical Association said his organization is looking for ways to encourage physician participation while respecting professional concerns about undertaking to treat a disease many have not studied. Concerns about the “class” of substance abusers need to be addressed: “It is the social issues that are creating most of these barriers,” he said.

“I wish I could say we have a game plan. Clearly there are things we could do” to increase participation, Smith said. “Most doctors would agree that buprenorphine should be available, but the barriers are real.”

Smith added that the issue was “a high priority of the [Maine Medical Association’s] executive committee.”

Buprenorphine is made by Reckitt Benckiser Healthcare, with offices in the United Kingdom and Richmond, Va. The company has partnered with a nonprofit group to release print and broadcast public service announcements featuring former U.S. Surgeon General C. Everett Koop, which will debut later this summer.

Unlike many drug companies that advertise their products on television and in print, Shaun Thaxter, vice president of marketing, said this week that Reckitt Benckiser has decided not to launch a direct-to-consumer ad campaign, at least not until there’s “a strong infrastructure of physicians” who can handle the demand.

And, while Reckitt Benckiser does have clinical representatives who go office to office to educate physicians directly – as is done with many new medications, including, notably, OxyContin, the abuse drug of choice for many Maine addicts – Thaxter said only doctors who already have been certified or otherwise indicated interest will be approached.

While buprenorphine has been slow to take off in all parts of the country, physicians’ reluctance to get certified is especially disturbing in this area, according to Robert Lubran, director of the Division of Pharmacologic Therapies at the Substance Abuse and Mental Health Services Administration in Washington, D.C.

“There is no other part of the country as devastated by narcotic addiction as northern New England,” Lubran said. “There and in Appalachia. It’s really hard to understand.”

Physicians sometimes think like other people, Lubran said, in that people with drug addiction are out of control, involved with the criminal justice system and don’t really want to stop.

“They may also think that treatment isn’t effective,” he said. “Support for new treatments doesn’t happen overnight, but interest [in buprenorphine] is growing.” SAMHSA has funding available to help pay for training, he said.

There is congressional interest in changing the laws governing the use of buprenorphine, Lubron added, including raising or eliminating the cap on the number of patients that can be treated in a single practice. Some states are considering allowing their courts to refer addicted lawbreakers to buprenorphine-supported drug therapy instead of serving jail terms, a move that would put pressure on the medical community to get certified.

Lubron said such external measures might help convince more doctors to take responsibility for treating the spreading epidemic of addiction.

“Really,” he said, “the whole answer is just getting a whole lot more doctors on board.”

Information on buprenorphine, including a list of certified prescribers in Maine, is available online at www.buprenorphine.samhsa.gov or by calling the Maine Office of Substance Abuse Information and Resource Center at (800) 499-0027. Reckitt Benckiser’s Web site is www.opioiddependence.com.