First Posted 9/25/2013
Because of this blog, I frequently receive emails from people describing outrageous behavior by pharmacists. I don’ intend to argue that pharmacists as a group are any more annoying than doctors, nurses, or plumbers for that matter. Every specialty has practitioners who do their best to provide safe and effective services…. and practitioners who are always out for themselves, with much greater interest in ‘CYA’ than helping someone in a difficult situation.
I’ve written about the problems with abuse and diversion of buprenorphine and Suboxone in Northern Wisconsin and the Upper Peninsula of Michigan. Like much of the Midwest, there are few if any buprenorphine-certified physicians in that area. But one corner of Michigan, patients lucky enough to make it through a long waiting list are faced with another problem; price-gouging by pharmacies, and policies based on false assumptions.
People knowledgeable about buprenorphine and Suboxone know that Suboxone and buprenorphine are virtually the same medication. People who inject both drugs in studies will give higher average ‘liking scores’ for buprenorphine, but there is considerable overlap between the two medications. Patients in my practice who admit to injecting Suboxone or buprenorphine (to make it last longer) before they could find a certified doctor claim that they found no difference between the two medications. I’ve described other reasons why adding naloxone to buprenorphine is more of a marketing ploy than a deterrent to diversion. For example, naloxone lasts about an hour in the bloodstream, whereas buprenorphine lasts for days, and the high-affinity binding of buprenorphine is not significantly impacted by the comparatively-weaker drug, naloxone.
The standard narrative, that holds that Suboxone is ‘safer’ than buprenorphine, relies on false assumptions. Many people who should know better believe that naloxone provides some measure of safety in people who don’t inject the medication— that the naloxone ‘blocks euphoria’ or that the naloxone ‘provides the ceiling effect.’ This is, off course, hogwash (do they use that term outside of the Midwest?).
The importance of naloxone is so low that the standard of care in pregnant women is to prescribe ONLY buprenorphine based on the argument that it makes no sense to expose a fetus to an extra medication (naloxone), when that medication doesn’t do anything. The natural question is ‘why expose ANYONE to an extra medication, when that medication doesn’t do anything?’
Opioid dependence is a potentially-fatal condition. People trying to rebuild their lives, after active addiction, frequently begin from a position of unemployment and poverty— and no health insurance. If lucky enough to find a physician who prescribes Suboxone or buprenorphine, their access is severely impacted by the cost of the medication. If their doctor prescribes Suboxone film, they will pay over $500 per month out of pocket. If their doctor instead prescribes buprenorphine, the cost drops to $135—saving almost 75%. But if that patient lives in remote Michigan and wanders into Snyder Drugs, the cost for the same amount of buprenorphine is over $450. I assume that Snyder Drugs has access to US Mail, UPS, FedEx, and all the other delivery methods available in Wisconsin (i.e. they do not rely on bobsleds). We often hear of criminal charges against people who gouge prices for generators during storms. Given that the current epidemic of opioid dependence has killed for more people than the typical hurricane, is it reasonable for a drugstore to mark up life-saving medications by 200%?
It gets worse. Snyder Drugs has a policy that forbids filling prescriptions for men for buprenorphine, but allows filling of the same prescriptions for women—pregnant or not—based on their conviction that men are more likely to divert buprenorphine than women. Men prescribed buprenorphine must drive hours to find a pharmacy that will fill their legal, legitimate prescription; several hours to avoid gouging altogether.
I realize that the UP has a diversion problem, as does most of the country. But does Snyder Drugs and similar stores make the problem better, or worse? Patients in that area, having no buprenorphine-certified physicians, engage in ‘self-treatment’, a form of diversion that probably makes life more bearable than active heroin addiction. When patients finally find a legitimate prescriber, what is the impact of pricing the drug higher than patients can afford? Does the increase in price make it more or less likely that the patient will sell a portion of the prescription? Does the increase in price make it more or less likely that the patient will inject the medication in order to make one tab last four times as long?
And for people living in the UP—is it legal for a pharmacy to discriminate by gender?
There are many regulations governing the treatment of opioid dependence with buprenorphine at the state and federal level. Adding pharmacy-by-pharmacy policies and regulations, that treat people with addictions differently than people with other illnesses, only add confusion—and might be breaking the law.