It’s a refrain dealers chant every day up and down Philadelphia’s Kensington Avenue, the city’s largest drug marketplace: “Subs — subs — subs!”
They’re referring to Suboxone, one of the brand names for the opioid-based addiction treatment medicine buprenorphine, prescribed by physicians and shown to produce more lasting recovery from opioid addiction than abstinence-based therapy. As with so many prescription medications, there’s a robust black market for it on the avenue.
But drug users, advocates, and researchers say that many people aren’t buying buprenorphine to get high. Rather, they’re using it to protect themselves from overdoses, to get through the pain of withdrawal, or even to engineer their own do-it-yourself addiction treatment.
With more than 1,000 people a year dying of overdoses in Philadelphia — the worst big-city opioid crisis in the nation — city and state officials have scrambled to help more people get into treatment programs. They’ve eliminated ID requirements and insurance pre-authorizations and even launched mobile treatment centers where doctors can prescribe buprenorphine to patients on the street.
Yet entering treatment can still be difficult and daunting for some drug users. For those without Medicaid or generous health insurance benefits, treatment itself is costly.
Cynthia Kerbaugh, of Berlin, Camden County, said she had been doing well for years in a suboxone treatment program, until her insurance stopped covering the medication about a year ago. “Ever since then, I’ve been back on dope,” she said. But she has bought buprenorphine on the street a few times since, with the aim of getting off heroin. “It costs more to go to the doctor,” she said.
How buprenorphine works
Buprenorphine is an opioid. But it’s a partial opioid agonist, not a full agonist, such as heroin or methadone, another addiction treatment drug. Like the full agonists, for people who aren’t used to opioids, it can be used to achieve a pleasurable high — and it can cause respiratory depression, according to the federal Substance Abuse and Mental Health Services Administration.
Because buprenorphine is a partial agonist, though, the effects — and the risks of overdose — are much weaker. For people who are already used to taking opioids, buprenorphine blunts the powerful cravings and pain of withdrawal that send people in addiction in search of stronger opioids.
The brand-name drug Suboxone combines buprenorphine with naloxone, the overdose-reversal drug, which cuts down the potential for misuse: the naloxone blocks the effects of the opioid if Suboxone is injected or snorted. Other brand names such as Subutex and Butrans contain only buprenorphine. Generic Suboxone retails for up to $160 for fourteen 8 mg doses at pharmacies. Generic Subutex can cost up to $128 for 14 doses. On the street, a single Suboxone strip sells for about $15, and cheaper in bulk.
Approved for clinical use in October 2002 by the Food and Drug Administration, buprenorphine is generally prescribed as part of a treatment regimen with counseling and behavioral therapies, and the drug can be taken at home — unlike methadone, which has to be dispensed daily from a specially licensed clinic.
However, physicians must have special certification to prescribe buprenorphine — even though they don’t need this extra level of training to dole out the opioid painkillers that got many people addicted in the first place.
And in Pennsylvania, despite the state Health Department’s efforts to help more people access buprenorphine, a number of lawmakers have proposed — but not yet passed — even more restrictions around its prescribing, precisely because it ends up on the black market so often.
DIY harm reduction
Because buprenorphine carries a significantly lower overdose risk than prescription pain pills such as oxycodone or illicit drugs such as heroin and fentanyl, advocates say it can be a form of “harm reduction” — a way to make addiction less dangerous to those who are struggling to stay in recovery or aren’t quite ready for treatment.
At the very least, it can keep withdrawal symptoms at bay so people don’t resort to drugs of unknown origin.
“It’s certainly much safer than fentanyl,” said Shoshana Aronowitz, referring to the powerful synthetic opioid that has replaced most of the heroin in Philadelphia and largely accounts for the city’s spike in fatal overdoses.
Aronowitz, a nurse practitioner and a postdoctoral fellow in the National Clinical Scholars Program at the University of Pennsylvania, also is a community organizer for the harm-reduction organization Save Our Lives (SOL) Collective.
“People are trying to keep themselves safe, and people want [buprenorphine]," she said. "They need it. Ideally, people would be able to very easily access health care for all their health needs, but we know that people have trouble with that for lots of different reasons.”
Researchers who interviewed 20 drug users in Pennsylvania’s Allegheny and Dauphin Counties last year found that nearly all of the study’s participants had bought buprenorphine off the street to get through withdrawal when heroin was unavailable — or when they didn’t want to use heroin. A “significant minority” of the participants had bought buprenorphine to try to wean themselves off other opioids, the research, published in the International Journal of Drug Policy, found.
To that end, a handful of prosecutors around the country have stopped prosecuting people for illegal possession of buprenorphine without a prescription. Last week, Philadelphia District Attorney Larry Krasner became the latest. (He has largely stopped prosecuting drug possession for personal use in the last several months.)
In 17 years running a drug-treatment program in Burlington, Vt., Tom Dalton, executive director of Vermonters for Criminal Justice Reform, said that he came to view buprenorphine as a “survival drug,” whether purchased on the street or through a prescription.
“We were explaining to people that to the extent you can limit your drug use to buprenorphine, with or without a prescription, you’re vastly improving your chances of survival, your chances to transition into sustained recovery,” he said. “Eventually I thought, Why would we be punishing someone with a criminal code for making a rational choice to move toward safety and recovery?”
Dalton and other advocates began pushing local officials to decriminalize the drug in Chittenden County, Vt. A year after decriminalization, the county reported a 50% drop in fatal overdoses. More research is needed to determine what caused the drop, Dalton said, but he believes decriminalizing buprenorphine had a significant effect. In Philadelphia, officials think that the ready availability of naloxone has helped nudge down fatal overdoses a bit, but much more needs to be done.
People interviewed on the street in Kensington said they had used buprenorphine for a number of reasons. Some, particularly newcomers to drug use who lack tolerance for opioids, or people whose tolerance has decreased after a period of abstinence, can use it to get high, said Jay, a 28-year-old from New Jersey, who declined to use his full name because of privacy concerns.
But many others buy it to get through withdrawal. For people deep in addiction, the goal is to avoid that intense pain — to simply feel normal.
“It helps me not get sick,” said a man who said he went by “El — like the train.” (He, too, declined to give his full name.) He said he wished he had a more reliable supply of buprenorphine, but wasn’t yet ready to enter a demanding treatment program.
Cynthia Kerbaugh was thrilled to hear that Krasner would stop prosecuting the possession of buprenorphine.
“It’s awesome, incredible. It should have been started a long time ago,” she said. “If people are trying to do the right thing, just let them live.”