Taxpayer dollars are subsidizing the addiction habits of hundreds of Vermonters, and lawmakers are considering legislation to crack down on buprenorphine diversion.
The state last year spent $8.25 million in Medicaid money on buprenorphine, a narcotic prescribed to help Vermonters overcome dependency on opiates.
State officials have no idea how much buprenorphine, known by the brand name Suboxone, is diverted, even as the state funnels more money into the fight against what Gov. Peter Shumlin calls a "full-blown heroin crisis.
The very drug that is supposed to be part of the solution is increasingly becoming a problem as some addicts sell their medication on the street to buy cheaper drugs, such as heroin.
You can buy buprenorphine outside Rite Aid on Cherry Street in Burlington. "Got the bupe?" people ask. "Got the strips?"
Most Vermonters who take "street bupe" aren't after a high, they are tired of chasing pills or heroin, and they are self-medicating with illegally obtained bupe because they can't get medical care.
Waitlists for Suboxone treatment from private doctors can extend six months or even several years. Hundreds of addicts in Vermont are waiting to see a doctor who can prescribe buprenorphine.
The trouble is, addicts can't wait that long. Once they are ready to get clean, they need help right away.
Gordon Wade's addiction cost him his wife, his dog, his job. The 58-year-old from Mount Holly finally got tired of running after that ephemeral bag of heroin. "I was sick of the drugs," he said.
"On the Suboxone, you can function normal," he said.
Though many addicts have a difficult time finding legitimate access to bupe through a doctor, Wade was lucky. He was able to find a doctor after he finished his most recent treatment at Evergreen Substance Abuse Services in Rutland.
What is bupe?
The U.S. Food and Drug Administration in 2002 approved Suboxone and Subutex, the brand names for buprenorphine. The drugs were the first narcotics that could be prescribed for opiate addiction in an office setting.
The FDA made the drugs widely available because there weren't enough methadone clinics to accommodate the number of patients who wanted opiate addiction therapy.
Buprenorphine is an opioid. It contains just enough of the narcotic so addicts won't experience withdrawal. Bupe also contains a blocker so addicts can't get high on another drug simultaneously.
People who take buprenorphine say the psychological effect of knowing they can't get high even if they tried is as powerful as the chemical itself.
Suboxone has a "ceiling." The doses never need to be higher than 16 milligrams, according to Reckitt Benckiser Pharmaceuticals, the manufacturer. It used to come only in hexagonal pills (called "stop signs" on the street) but now is primarily prescribed in strips that dissolve under the tongue. The new packaging was intended to make the drug harder to traffic.
But people who abuse Suboxone, addicts say, sometimes melt the strips and inject them, or dissolve it under the tongue and shoot the saliva.
As early as 2002, FDA officials knew that the drug was addictive and there was a risk that bupe could be trafficked, according to a report from that agency.
Patients began selling the drug illegally in Vermont a few years later, according to a 2006 federal study by the Substance Abuse and Mental Health Services Administration.
In 2012, buprenorphine accounted for half of all illicit substances found in Vermont correctional facilities. In all, 157 contraband items were found that year, according to the DOC.
One 8 milligram pill of Suboxone on the street costs between $25 and $35. A bag of heroin costs about $20. One Suboxone lasts all day, while an addict might require as many as 20 bags of heroin.
The Medicaid co-pay for a two-week supply of buprenorphine is $2, according to the Department of Vermont Health Access.
State officials say buprenorphine treatment costs the state about $400 to $500 per patient per month. The support services that are supposed to accompany medication therapy cost another $500 per month, according to the Alcohol and Drug Abuse Services division of the health department.
After Oxycodone and Ambien, bupe is the most common substance involved in drug diversion investigations, Vermont State Police say.
Shelley Sweet, a former treatment center employee in central Vermont, said it's not uncommon for women to try to become pregnant in order to bump themselves to the top of a waitlist for Medicaid-subsidized treatment. Often those women take half their bupe and give the rest to the baby's father, Sweet said.
Not enough doctors
When Wade and others tell their stories, it's easy to understand the burgeoning street market for buprenorphine. There's often no legitimate way to buy bupe, and addicts are experts in back channels.
Those who do have a doctor often travel across the state - or across New England - to get their prescription.
Tyler Nolan, 22, of Burlington finished treatment at Maple Leaf Farm in Underhill 60 days ago, he said. As he left, the staff found him a buprenorphine doctor -- in New Hampshire.
Starting this week, Medicaid will pay to drive Nolan from Burlington to see a physician in West Lebanon, N.H., every day for two weeks. There he gets a daily dose and counseling. The long-distance recovery plan makes it hard to find a job, he said.
"There needs to be at least 10 to 15 more doctors that can prescribe Suboxone just in Burlington alone, just in Chittenden County and that's absurd. It's absolutely crazy," he said.
Jessica Coleman drives four hours each way from Rutland to Norton, Mass., each month for a 30-day supply of buprenorphine. The 34-year-old takes a pill called Subutex because she is allergic to Suboxone, she said.
The travel time is especially difficult for Coleman, who is going to college and caring for her 18-month-old and 3-year-old. She plans to become a substance abuse counselor.
"To find a doctor in Vermont to prescribe Subutex is impossible, it really is," Coleman said.
In Williston, substance abuse clinician Alice Larned helps addicts who have children. Patients tell her they're ready to get better, ready to be clean. She tells them they're looking at five months on a waitlist.
"I have to say 'I know it's been helpful for you and it's not an option for you because we don't have a prescribing doctor,'" Larned said. "It's just an unfortunate conversation to have to have."
Of her last 30 patients, eight were using illicit buprenorphine, she said. Six were taking the drug to recover from addiction, two were using it to get high.
While Larned's clients wait, they hustle daily for a pill - of one kind or another. But street bupe doesn't come with life skills coaching, she said.
"They're trying to get better and because we don't have legitimate prescribers they still have a foot in the old lifestyle," Larned said.
It's not easy to call a long list of doctors or get into an office if a patient doesn't have a phone, a safe home or transportation, she said.
Coleman's younger sister just got out of jail and treatment and can't find a doctor, she said. It's all Coleman can do not to share her little white pills.
"It's really hard," she said.
Valley Vista, a residential treatment center in Bradford, last month surveyed 22 patients in treatment, nearly all of whom had taken buprenorphine. Of them, only 40 percent obtained the drug from a doctor.
Still, some physicians have no waitlists at all, and it is unclear why there is such discrepancy.
Dr. Fred Rossman, in Morrisville, sees from 90 to 100 addiction patients between his two clinics. He said one or two people are on his waitlist.
Diversion is always a concern, he said, because there will always be a way to game the system.
"I do what I can, but I'm afraid sometimes that it's not enough. You hope that you're helping the majority," he said.
Rossman calls in patients who he suspects could be reselling bupe for random pill counts or urine samples. He terminates treatment for about eight patients a year because they break the rules.
"It's not without conversation, it's not without discussion, it's not without attempts to get mutual understanding why this happens," he said.
Because Rossman's practice is a so-called "spoke," part of the state's new statewide system to treat addiction, a nurse and a social worker work two days a week at his practice. They connect patients to counseling, primary care, transportation and other services, he said.
Treating addicts is not for everyone. It is much more time consuming and complicated than treating other illnesses, he said.
"I hope we're helping, and that's why we all kind of try to do our share," Rossman said.
He said he can name patients who now have jobs as waitresses, contractors and at other local companies.
Ruining it for the rest of us
Patients who are using Suboxone responsibly say people who abuse the system are "ruining it" for those who take their medication responsibly.
Addicts who want to recover from addiction don't want their lives to revolve around pill counts, urine samples and trips to other states to pick up meds.
But Nolan and Coleman said doctors should require more frequent screenings because so many people abuse the system.
Dr. Deborah Richter sees 65 patients at her spoke office, she said, and between one-third and one-half come in having already been taking street bupe, sometimes for as long as a year.
"I know that it's pretty rampant out there," Richter said.
But eventually addicts realize the so-called "street program" is the same daily hustle as chasing pills or heroin, she said. Eventually, your dealer is called in for a pill count and gets busted.
Who's keeping track?
State officials know there aren't enough doctors prescribing buprenorphine. They also know about bupe trafficking and have systems in place to curb it.
It is unclear how effective those systems are.
Medicaid recipients who take bupe can receive two weeks of medication at once and can only pick it up at a single pharmacy. These two measures are meant to deter resale of the drug.
In addition, state regulators must specially approve a doctor's requests to prescribe a patient a dose larger than 16 milligrams, according to the Department of Vermont Health Access.
State officials say they are encouraging more doctors to prescribe buprenorphine because of the long waitlists. They are asking those who already prescribe to accept more patients.
"Like most everything in Vermont, being a small rural state, workforce is a challenge, and this is no different," said Barbara Cimaglio, deputy commissioner of the health department's Alcohol and Drug Abuse Programs.
But some doctors say that several sets of semi-overlapping regulations make it complicated for Vermont doctors to prescribe buprenorphine.
Others say doctors who do prescribe don't get enough training in addiction medicine. At a minimum, a physician must complete eight hours of online training to prescribe buprenorphine.
"It's not going to turn a physician who's probably had very little training around addiction it's not going to turn them into addictions specialists," said Bob Bick, director of mental health and substance abuse services at the HowardCenter.
Only seven physicians in Vermont specialize in addiction medicine, according to the Vermont Board of Medical Practice's online database.
Last year, the state created a "Hub and Spoke" system to streamline its approach to drug addiction treatment. The system links regional centers that specialize in addiction medicine and dispense methadone with primary care physicians who prescribe buprenorphine from their offices.
Spoke doctors, like Rossman, get help from nurses and social workers provided by the state.
But not all buprenorphine-prescribing doctors are spokes. Doctors who prescribe bupe to more than 30 patients must adhere to some medication-assisted treatment regulations but do not get support for staff.
Doctors who are not spokes and fill prescriptions for fewer than 30 patients do not have to follow any regulations.
The hub and spoke system is designed to cut down on abuse and to get patients into all levels of treatment faster, according to Cimaglio.
But nearly everyone agrees that the spokes are the weak link. Doctors prescribe too much bupe, or do not oversee patient care with enough scrutiny, failing to call patients back for pill counts or urine screenings.
"Until physician acceptance of and expansion in medication-assisted therapy becomes more common, there will be challenges meeting the current demand for treatment," according to a Feb. 4 report to the Legislature about Suboxone.
Physicians who prescribe buprenorphine are not required to put their names on a public list of bupe doctors. Thirty-eight physicians and 11 treatment programs in Vermont are on the website of the federal agency that authorizes doctors to prescribe buprenorphine, the Substance Abuse and Mental Health Services Administration. The list, however, includes at least one doctor who has been sanctioned by the state.
In 2006, there were 101 physicians who were licensed to prescribe bupe in Vermont, according to a federal study.
By law, a physician licensed to prescribe buprenorphine can treat as many as 30 patients in the first year. After that a doctor can request to see up to 100, according to federal regulations.
A federal study in 2006 used Vermont as a case study and provided detailed charts about the number of patients receiving buprenorphine. Bupe diversion was occurring, the study found, if infrequently.
State officials at the time said much of that activity was the same kind of "self-medication" that occurs today.
In 2005, Vermont led the nation in consumption of Suboxone and Subutex tablets, with 584 grams per 100,000 people. The national average was 57 grams, the study said. Those numbers were deemed reasonable based on the number of patients.
Oxycodone is the most frequently trafficked prescription drug, state police say. Buprenorphine for the past two years has ranked third, accounting for 11 percent of all diversion cases in 2013.
The Vermont Prescription Monitoring Program, established in 2006, is designed to cut down on prescription drug abuse.
The program requires pharmacists to log all the prescriptions they fill. As of last year, physicians were also required to enroll.
The system mails a quarterly letter to providers with patients who cross a "threshold" for too many prescriptions and pharmacies.
The Vermont Department of Health this year is proposing improvements, including flagging patients who receive opiates from two or more doctors and merging death records with the prescription database, to see if addicts are filling prescriptions from deceased individuals.
In response to growing concerns about diversion, state police in 2010 created a Drug Diversion Unit managed by one trooper. It has since expanded to three officers and last year worked 236 cases, up from 163 the year before.
Doctor shopping is the most common type of case, according to Lt. Kraig LaPorte, who heads the unit. Diversion makes up another quarter of the cases, he said.
"White-collar, blue-collar, doesn't matter what collar they're wearing. It seems to have touched many, many different people," LaPorte said.
State police have investigated a nursing student, a computer tech who works in a Price Chopper pharmacy and a South Burlington doctor who made up a fictitious patient in order to prescribe meds for herself, LaPorte said.
One roadblock to police investigations of diversion cases is the fact that police cannot access the prescription monitoring database, LaPorte said.
Physicians and pharmacists who notice abnormalities in the system are forbidden from calling police except under very specific circumstances. And the database's seven-day lag time makes it hard to track potential diversion quickly, LaPorte said.
The Legislature steps in
Legislators over the past month have been taking testimony about bupe diversion and Tuesday began crafting legislation intended to curb it.
The Senate Judiciary Committee has heard from physicians, treatment centers, prison officials, pharmaceutical reps and others.
"The amount of Suboxone that's being diverted makes me wonder if we should just ban the stuff," Chairman Dick Sears, D-Bennington, said Tuesday.
Last month a probation officer told lawmakers that people get 16 milligrams and sell eight. They inject it or mix it with benzodiazepine to get high.
Tuesday, the committee asked its attorney to draft an amendment about buprenorphine diversion to add to a bill they are considering related to opiates.
The new legislation will require more doctors to provide counseling services to buprenorphine patients. It would also lower the threshold for medication-assisted therapy regulations. Doctors with as few as 10 patients taking bupe would be subject to the state rules.
The committee wants to require out-of-state doctors who accept Vermont Medicaid to log their prescriptions in the Vermont Prescription Monitoring System. Lawmakers say they also want to encourage the pharmaceutical company to create more tamper-resistant packaging.
But Madeleine Mongan, vice president of the Vermont Medical Society, cautioned the committee Tuesday against creating "administrative burden for not much benefit."
Others echoed her concern.
"The challenge is we also don't want to create disincentives for physicians to treat this population because we're also trying to create access," Cimaglio told lawmakers.
Addicted to bupe instead of heroin
Beyond the debate on how to stop Suboxone diversion, doctors and even addicts themselves disagree on the merits of buprenorphine.
Some doctors and treatment programs aim to wean addicts off substances completely. Others say their patients will stay on small maintenance doses of buprenorphine forever.
"It kind of sucks that I have to rely on Suboxone because it kind of feels like I'm substituting one drug for another drug," said Nolan, the 22-year-old recovering addict in Burlington.
Nolan says he is his own worst enemy, and he believes his addiction will never go away. He spends time at the Turning Point Center of Chittenden County, where addicts help each other.
Sometimes he goes to the Act One detox center on Pearl Street in Burlington to see other addicts in detox.
"I go to see pain and agony on people's faces and remind myself I don't want to feel like them," Nolan said.
Coleman, the 34-year-old mother of two toddlers, says, "I'm addicted to this instead of heroin, basically."
Coleman sometimes tries going 24 hours without taking her pill, she said, and she can. But something in the back of her head nags.
"Take it, take it, take it, take it."