The Suboxone Business Fix

I have shared my thoughts about ‘Suboxone Film,’ a product that serves only one purpose:  to block generic competition from entering the Suboxone market.  Below I’ve copied a Bloomberg article that discusses the current nature of the buprenorphine/naloxone business, and the efforts by RB to prevent market penetration by generics– something that would lead to price reductions for healthcare consumers.

Suboxone Doctors act dumb with buprenorphine
Dumb about naloxone?

Unfortunately, the Bloomberg article overlooks the most significant threat to the profits of Reckitt-Benckiser.  This threat is mitigated only by the ignorance of many of the physicians who prescribe Suboxone.  The threat to profits consists of a simple fact that RB does not want anyone to realize:  that the generic equivalent of Suboxone is already available, in the form of orally-dissolving tablets of buprenorphine.

I encourage physicians who doubt my comments to do their own ‘due diligence’ and break out their old pharmacology textbooks.  I have a hard time understanding how people who graduated from accredited medical schools can get things as wrong as they do with this issue.  I sometimes present opinions, but not with this post.  The facts about buprenorphine and naloxone that I’m about to describe are described in any pharmacology textbook— e.g. Goodman and Gilman—and are not in dispute in any way.

Suboxone consists of buprenorphine plus naloxone.  Naloxone is an opioid antagonist that is added to reduce diversion of Suboxone in the form of intravenous injection of a dissolved tablet.  Naloxone is NOT ACTIVE when not injected.  The molecule is poorly absorbed through the oral mucosa because of the molecule’s size and poor lipid-solubility.  Instead, naloxone is swallowed, absorbed from the small intestine, and totally destroyed at the liver before reaching the systemic circulation through a process called ‘first pass metabolism.’

I suspect that some physicians confuse naloxone with the similarly-named substance naltrexone, an opioid antagonist (blocker) that IS orally active. There is NO naltrexone in Suboxone.

All of the beneficial aspects of Suboxone come from the partial agonist buprenorphine.  The ceiling effect of buprenorphine causes a reduction in cravings through a process that I’ve described in earlier posts.  Naloxone, on the other hand, does absolutely nothing to reduce cravings, to increase safety, to reduce euphoria, etc, provided that the medication is not injected.

The confusion surrounding buprenorphine essentially consists of intellectual laziness or intellectual dishonesty by the physicians who prescribe the medication and the pharmacists who dispense it.  I realize that not all doctors are cut out to be ‘physician scientists’ who understand pharmacology in great detail.  But I am particularly disappointed that the large organizations that supposedly oversee the science of addiction treatment have dropped the ball on this issue. I don’t know why groups like ASAM and SAMHSA don’t get it– whether the problem is ignorance, or whether there are mutually beneficial relationships between these organizations and RB that encourage the organizations to foster ignorance among
patients and doctors.  I don’t belong to the organizations primarily for this reason– and I blame ASAM and SAMHSA for the current status of addiction treatment as the ‘no science zone’ of modern medicine.

 A few examples of intellectual laziness: 

Example 1:  Physicians who prescribe Suboxone often say that one shouldn’t use buprenorphine ‘because it doesn’t have the opioid blocker and therefore….’ (add whatever here– it causes euphoria, it is addictive, it isn’t safe– any or all of these comments). The statement is partially correct. Generic buprenorphine does not have the opioid blocker naloxone— but naloxone is irrelevant to the actions of Suboxone!

There are TWO opioid blockers in Suboxone, but only one is clinically relevant—the one that is in both Suboxone and generic buprenorphine.  What is the relevant ‘opioid blocker’ that IS
in both Suboxone and generic buprenorphine?  Buprenorphine!   As a partial agonist, buprenorphine has antagonist properties that are responsible for ALL of the effective clinical properties of Suboxone.

Example 2:  Refusing to consider the cost of medication as a factor that determines access to treatment.  Some docs make ‘fear of diversion’ the only factor in determining what to prescribe.  Discussions with hundreds of opioid addicts over the years have convinced me that buprenorphine is rarely a drug of choice.  Rather, it is used by addicts who are sick and tired and want a break from using without withdrawal, or by addicts who have no money or access to agonists.  In such cases, buprenorphine or Suboxone are equally effective– and equally diverted.  When I ask addicts new to treatment about their injecting habits, I often ask whether they injected buprenorphine or Suboxone.  The typical response is either ‘can you do that?’ or ‘why would I do that, since heroin is cheaper?’

In my area, an 8 mg tab of buprenorphine costs as low as $2.33.  This low cost should be part of the equation for choice of medication, just as it is for other illnesses.  Does anyone doubt that there are some people kept from treatment by a price differential of 300%?!  Is it ethical to fear diversion so greatly that treatment is effectively withheld– for a condition with the fatality rate of opioid dependence?!   I’m sure readers know my answer, especially when there are effective ways to reduce diversion, such as close monitoring of prescribed doses, a ‘no replacement’ policy, and drug testing, among others.

Example 3:  There is some question whether the naloxone in Suboxone does anything to reduce diversion. Buprenorphine patients on my forum  who have injected Suboxone in the past have claimed that they did not experience withdrawal from either Suboxone or buprenorphine, consistent with what I would expect from combining a low-affinity antagonist with a high-affinity partial agonist.

Note: Injecting ANYTHING is in essence taking your life in your hands, and I strongly encourage anyone in such a position to seek treatment immediately.   Really—don’t do it.

Example 4:  Insurers generally refuse to cover generic buprenorphine (the generic form of the RB drug Subutex), even though it is much cheaper than Suboxone.  The one time they WILL cover Subutex or buprenorphine is for women who are pregnant or nursing.  The argument is that we shouldn’t expose the fetus/infant to one more drug (naloxone), since that drug isn’t necessary to the actions of Suboxone.  I agree with the argument, and wonder why it is extended only to the fetus?  Why does mom or dad have to be exposed to an extra substance(naloxone) that isn’t necessary to the actions of Suboxone?

I struggle to understand the insurance issue, as I would expect that someone at some major insurer would know enough about pharmacology to save money on Suboxone by favoring gen
eric buprenorphine.

The ultimate of silliness is that the State of Wisconsin requires that people on Medicaid use only Suboxone FILM.  Getting Abilify for a patient is virtually impossible without first using a variety of older, cheaper medications… but the squishy arguments in favor of Suboxone Film push the med up the formulary chain past an alternative that sells at a fraction of the cost.  The film/Medicaid situation is doubly dubious, as we have the arguments for buprenorphine over Suboxone, and the even less-sound argument for Suboxone Film being favored over the tablet.

RB apparently convinced the state that for Medicaid patients, only the film was safe– and that the film should be required instead of the tablet form of Suboxone, placing future generics at a great disadvantage.  It is especially impressive that RB accomplished this feat after selling a million units of the tablets themselves!  I can picture the person making the point:  ‘the tablet is unsafe…. Starting NOW!’

I’m going to write all night if I don’t wrap this up.  To summarize, the Bloomberg article below describes why RB is winning the battle with generics, but the writers of the article, along with most doctors, miss the bigger issue– that misplaced fears, intellectual laziness, and misinformation have protected Suboxone sales from a much greater foe-– generic buprenorphine.  If doctors, states, and insurers ever get their acts together and prescribe according to science, brand name Suboxone profits will go down the toilet faster than the cleaning products made by RB.

The Bloomberg piece:

Reckitt Benckiser Kicks Heroin Tablet Habit With Film: Retail

By Clementine Fletcher

Reckitt Benckiser Group Plc may be kicking its heroin problem.

After losing U.S. patent protection in 2009 for its Suboxone tablet, designed to help heroin users quit, Reckitt Benckiser has said that the entrance of a generic competitor could erode pharmaceutical sales and profit by 80 percent (note by JJ:  What a shame?!  Consider the benefit of such a price reduction for addicts in need of treatment!).

Reckitt Benckiser, which gets most of its revenue from selling home and personal-care products like Lysol cleaners and Durex condoms, has faced calls to sell the business before a generic comes to market. Instead, the London-based company aims to divert the showdown by switching users to a film form of the drug — one whose last patent doesn’t run out until 2025 (note by JJ:  NOW do you see why they made the film?!)

To get people to make the switch, Reckitt Benckiser is thinking more like a consumer company than a pharmaceutical one. It’s drawing on a marketing technique first pioneered by Coca- Cola Co. more than 100 years ago: coupons. By offering up to $45 a month toward a user’s co-payment in the U.S., the company is making the film version, which looks like a Listerine Pocketpak, close to free. That offers patients who get part of the bill subsidized by health insurance little incentive to transfer to a generic pill once it appears on the market.

“They’ve done a good job of making a silk purse out of a not very compelling situation,” said Martin Deboo, an analyst at Investec Securities Ltd. in London.

Reckitt Benckiser’s shares have risen 55 percent in the last five years, outpacing Unilever and Procter & Gamble Co. Under Chief Executive Officer Bart Becht, who stepped down last month, the company more than doubled sales in a decade. The stock has dropped 3.7 percent this year, compared with Unilever’s 4.7 percent gain and P&G’s 1.2 percent gain.

Drugs Growth

The company is due to report third-quarter results tomorrow and will probably say revenue adjusted for purchases and asset sales rose 7 percent at the drugs division, analysts led by Andy Smith at MF Global in London estimate, compared with a 3.9 percent increase for the rest of the business. Profit likely rose 0.9 percent to 430 million pounds, they said.

The film version of Suboxone, introduced in September 2010, accounted for 41 percent of the drug’s U.S. sales by the end of the first half (note by JJ:  Thanks, Wisconsin Badgercare!). That surpassed the company’s own expectations, Becht said on an Aug. 30 conference call arranged by Sanford C. Bernstein. Becht was succeeded by Rakesh Kapoor, a company veteran.

Generic Delay

The film “has been a phenomenal success,” Becht said, according to a transcript of his remarks. “To make the business completely sustainable, we would like to have a share which is clearly much higher than where we are.” He added that the company aims to grow that share every month.

Right now, time is on his side. Teva Pharmaceuticals Industries Ltd., the world’s biggest maker of generics, began the year saying it might launch a Suboxone copy in 2011. Now the company has backed off, saying it no longer expects the product to win regulatory approval this year.

Biodelivery Sciences International Inc., another drugmaker going after Suboxone, said a study comparing its own version of the drug to a placebo failed to show a statistical difference in the treatment of chronic pain. A test in patients addicted to opioids, which include heroin and codeine, is scheduled to begin
later this year. Titan Pharmaceuticals Inc. on Aug. 31 said it’s preparing to seek approval of an upper-arm implant that would deliver buprenorphine, one of
the active ingredients in Suboxone, directly into the bloodstream (note by JJ:  the ONLY active ingredient in Suboxone!)

‘Massive Benefit’

“This delay has been a massive benefit,” said Andrew Wood, an analyst at Sanford C. Bernstein. “With every day that goes by, RB has an extra day to convert users.” Suboxone is either harder-than-expected to copy or generic-drug makers are having second thoughts about targeting addicts, according to Bernstein.

About 1 million people in the U.S. are addicted to heroin, the National Institute on Drug Abuse estimates. As many as 325,000 people use Suboxone to quit the drug or painkillers, says Pablo Zuanic, an analyst at Liberum Capital in London.

The medicine combines buprenorphine, a painkiller derived from the opium poppy that shares some of its properties, with naloxone, a chemical that blunts
withdrawal symptoms (note by JJ:  This is simply WRONG.  BLATANTLY WRONG.  Really–  an opioid antagonist BLUNTING withdrawal symptoms?  Shame on the writers!). The film sells for about $4.63 to $8.23 a dose at Walgreens stores, according to Liberum, depending on its strength and pack size. That means the strongest dose costs about $247 a month.  (note by JJ—a pharmacy near my practice sells generic buprenorphine dissolvable tabs, 8 mg, for $2.33 per tablet—a medication that works EXACTLY the same way IF NOT INJECTED INTRAVENOUSLY)

More than half of people on Suboxone use private insurance with co-pay, Zuanic says. Reckitt Benckiser offers $45 towards co-pay for the film, he said, meaning an insured patient who’d contribute $50 to the cost of the drug may end up spending $5.

‘Near Zero’

“The actual cash cost for some patients buying the film with private insurance could be near zero,” Zuanic said in a note to clients this month. (note by
JJ:  but we are all paying the cost in higher insurance premiums, and some insurers, notably Humana, have draconian policies that stop covering—forcing instant withdrawal- if a patient receives a prescription for a sleep medication such as Ambien, so many people are left paying cash).

Meantime, Suboxone is only becoming more important to Reckitt Benckiser. The drugs division, whose sales grew five times as quickly as the main business last year, accounted for almost 9 percent of sales and 24 percent of profit, up from 7.6 percent and 20 percent in 2009. Sales a
t the unit will probably rise 12 percent to 829 million pounds ($1.3 billion) this year, according Nomura International Plc estimates.

The maker of French’s mustard is even considering making an injectable Suboxone and developing new products for cocaine, alcohol and cannabis addicts.
The plan has met skepticism.

“We’re quite a long way from having any visibility on these products,” said Julian Hardwick, an analyst at Royal Bank of Scotland Group Plc in London. “Are they products that will work? Which will get approval?”

Prescription drugs are perceived as a bit of a misfit in the home of Vanish stain removers and Finish dishwasher tablets.

Misfit

“Reckitt Benckiser is basically a home and personal-care company with over-the-counter pharmaceuticals,” said Carl Short, an analyst at Standard & Poor’s in London. The drugs unit is “always going to be something that looks like it doesn’t fit with the rest.”

Reckitt Benckiser may look at selling the unit, which Becht himself has said is “not the No. 1 strategic part” of the company, once a generic form of Suboxone reaches pharmacy shelves, analysts said. (note by JJ:  i.e. after all of the profit has been wrung from suffering addicts).  But the company’s marketing savvy, coupled with delays in the launch of a generic, are giving Kapoor time to settle into his new job.

“This is a big job and he is coming in after someone’s done it for some considerable time and very well,” said Julian Chillingworth, who helps manage about 16 billion pounds in shares at Rathbone Brothers Plc, including Reckitt stock. “You wouldn’t want to come in as a CEO into a very successful business and start selling things off on the cheap.”

Not Time

Analyst valuations range from 2 billion pounds to 6.3 billion pounds, according to four estimates compiled by Bloomberg News. Estimates diverge because it’s hard to value the business without knowing how Suboxone sales will resist the generic challenge and whether the shift to film can counter some of that impact.

“Until you get generic competition for the tablet, I think it’s unlikely that prospective buyers would give you the full value for the business,” said Hardwick of RBS. “Now is not the time to sell.”

–With assistance from Naomi Kresge in Berlin. Editors: Celeste Perri, Marthe Fourcade.

 

 

Generic Subutex, aka buprenorphine– what's the dif?

I’ll take a break from the book to post a question and answer with a reader:
My daughter’s doctor recently started prescribing her a pill called only ‘buprenorphine,’ instead of her usual Suboxone. Should I be concerned about the change?
My answer:
You don’t mention the age of your daughter, but your question raises the issue of how involved should a parent be in the treatment of a child?  Perhaps a more general issue is whether anyone should be closely involved in the treatment of someone with opioid dependence?  After all, I frequently write that opioid addiction should be seen as ‘just another disease,’ and it is hard to make the case that people should share the details of their medical histories with others, at least after reaching adulthood.
But opioid dependence, while being a disease, does have some unique qualities—such as the effect of a worsening of the disease, i.e. relapse, on patients’ ability to make sound judgments.  Over time, I typically want patients to become responsible for their own outcomes; adult children of too-involved parents sometimes seem to be stuck in a state of chronic defiance, where the addict seems to think that a relapse is a statement of independence or a reflection on the parents, rather than the addict’s own problem.  But early on, it can be helpful to have someone monitor the addict’s behavior, and even control the buprenorphine.  Just remember that only the addict him/herself can determine, in the long run, whether a buprenorphine program will work—or whether it will just be one more failed treatment method.
Suboxone and Subutex (generic or brand-name) are interchangeable for the most part— except generic buprenorphine is about half the price of brand-name Suboxone  ($3 per tab vs. $6-$7).  The main chemical difference is the naloxone in Suboxone, which is not present in Subutex or generic Subutex (aka buprenorphine HCL).  Naloxone doesn’t cross mucous membranes; lipid soluble molecules like buprenorphine and fentanyl tend to pass through mucous membranes, and water soluble molecules like naloxone and morphine do not.  When a person takes Suboxone properly the naloxone ends up being swallowed, absorbed from the intestine into the ‘portal vein,’ and then completely metabolized at the liver before getting into the systemic circulation by a process called ‘first pass metabolism.’  The features of buprenorphine that make it effective for treating opioid dependence (for example the ‘ceiling effect’) do NOT require naloxone. Naloxone is added to Suboxone for one reason—to prevent intravenous injection of dissolved Suboxone tablets.  If Suboxone is dissolved and injected, the naloxone would enter the circulation, block opioid receptors, and cause an hour or two of withdrawal symptoms. 
There is not a great amount of injecting of Suboxone going on out there, and so for most people, generic buprenorphine is fine.  Some people who don’t completely metabolize the naloxone (because of genetic variants of liver enzymes, or perhaps because of taking cytochrome inhibitors like certain SSRIs) develop dysphoria for an hour or two after a dose of Suboxone, because the naloxone gets into their systemic circulation and causes withdrawal.
All patients who are pregnant are generally put on Subutex (or generic buprenorphine) because the low chance of injecting is not enough reason to expose the fetus to one more chemical.
I don’t know if your daughter is pregnant, but that would be one reason to take the generic.  Or it may be a cost issue, or perhaps she sometimes felt sick after taking her dose of Suboxone.  The theoretical risk from switching would be that she could then inject the buprenorphine, without the risk of withdrawal.  If she DID inject, she would not get ‘high’ from doing so;  the injected buprenorphine would have the same effects as when it is absorbed through the oral mucosa, only more quickly (i.e. zero effects, more quickly!).  Even for people NOT tolerant to buprenorphine, injecting buprenorphine is not generally a great way to get high;  the person develops a tolerance to buprenorphine very quickly, and within a day or two is ‘on’ buprenorphine going forward–  incapable of feeling opioid effects because of mu receptor tolerance, and vulnerable to withdrawal if the buprenorphine is discontinued.
I’ll be back with another installment of the book in a few days.  Thanks, as always, for reading; please share the site with other addicts and with those who love them.
JJ

Can my doc prescribe Subutex? SHOULD he?

Hi all!  Sorry for the lapse in posting… I have been gearing up to blog for Psych Central, an opportunity that I am very excited about, and I have a hard time writing one blog and being excited about a second blog at the same time!  Please be sure to visit my blog at psychcentral.com, called ‘An epidemic of addiction.’ The first few posts will be mostly introducing myself with information that people here already know, so come visit in a couple weeks when I am up to speed.
A question/answer post for tonight:
As you know, generic Subutex is cheaper than Suboxone. I want my doctor to switch me to Subutex, but I am so afraid to ask him.  Even though my doc is nice to me, what if he is one of those doctors….gets mad at me, and discharges me as a patient?  I can’t do something that could possibily send me back on that old course of life that seems more and more distant every day.
Can my doctor legally prescribe me Subutex rather than Suboxone?  What good reason could he have for not agreeing to, once I show him how much money it will save me?   Also, do doctors make extra money by writing a prescription that is filled at a certain pharmacy?
My reply:
Thanks for your question.  Isn’t it sad that people are afraid that their doctors will cut them off of life-saving treatment?  The writer is not paranoid;  there are practices where patients are treated as ‘guilty’ just for asking questions that make the doc uncomfortable.  Such a situation does NOT foster the open communication that keeps addiction out in the open, where it can be treated properly and effectively.  And such a situation is a far cry from treating addiction as the disease that it is, rather than a character deficiency.
Any doctor who can prescribe Suboxone can also prescribe Subutex.  There is no difference in the actions of the two medications when they are taken properly;  Suboxone contains naloxone, that supposedly reduces IV use of Suboxone.  But studies show that most ‘diversion’ of buprenorphine is for ‘self-treatment’ of opioid dependence– not for the sake of getting an opiate high.  I suspect– but have no proof– that the RB reps encourage docs to think that if they prescribe generic Subutex, their patients will be shooting up in their lobbies.  This keeps docs prescribing brand-name Suboxone– at least until the Teva generic becomes available.
The main reason a doc won’t prescribe the generic then is fear of diversion, which in my opinion is overblown– not  because there is no diversion, but because both Suboxone and Subutex are diverted at an equal rate and used for the same thing– for illicit self-treatment.  Some docs probably avoid the generic to avoid a common problem– if the pharmacy doesn’t have the generic they will substitute the very-expensive, name brand Subutex– often resulting in calls to the doctor for prior authorizations or replacement scripts.  It is currently easier for the doctor to simply write for Suboxone.  Docs should realize, though, that the cost difference is quite significant;  in my part of Wisconsin, generic Subutex is lesss than $3.00 per tab, and Suboxone is over twice as costly.
I have heard of places in Florida (sorry Florida– maybe it happens elsewhere too, but you folks have a reputation for this) where docs provide scripts for pain pills with the condition that people use specific pharmacies.  I am surprised that such an arrangement would be legal;  it is clearly unethical to have such a conflict of interest.  That arrangement would violate Medicare law, but if they avoid Medicare patients, perhaps they can get away with it…  But to answer the question, I have never seen such a situation in my part of the country.  Docs– post anonymously if you are willing– has anyone heard of profiting by prescribing certain medications?
To the writer, I would like to just say ‘ask your doc if he/she will prescribe the generic.’  I can tell you that I would certainly not be ‘offended’ in any way, or think poorly of you.  Of course there is always some value in being polite;  no doctor likes being told what he/she ‘has to prescribe!’   But you know your doc and I don’t.  If your gut says tread cautiously, then tread cautiously.  You could always ask your pharmacist if doctor so and so ever prescribes the generic– although pharmacists tend to treat addicts even  more poorly than doctors do!
For the docs out there, maybe it would be appropriate to ask yourselves, ‘is this MY patient writing to the blog?  And if it is, why is he afraid to talk to me?’

Allergic to Suboxone taste additive/sweetener

Something I haven’t yet come across:

Acesulfame Potassium

Well, i’ve been clean with the help of Suboxone for 14 months now. Throughout my treatment I’d been getting tongue blisters and ulcers at least two at a time. I’ve probably had them six to eight different times in this 14 month period. I realized something wasn’t right, and started investigating, trying to figure out what the problem was. I watched the foods I ate and the things I drank. Nothing seemed to work; they just kept coming back. So, the only thing I could think of was the Suboxone.  I read the pamphlet that comes with the medication. The artificial sweetener in Suboxone (Acesulfame K sweetener) is what I am allergic to. I have been allergic to artificial sweeteners my entire life. I had been taking a medicine I’m allergic to for 14 months! I admit, i should have done more research from the start. But I was so desperate for relief that i would have done anything to get rid of withdrawal. I also checked the ingredients in Subutex. It does not contain Acesulfame K sweetener. I went to my next doctor appt. and told my doctor my findings. My doctor was a complete jerk. When I brought up pretty much the only option I had and asked ‘could you switch me to Subutex?’  He said he usually only uses Suboxone but because of my allergy there wasn’t any other choice.  I said ‘will you write the prescription so that i can get the generic just in case Subutex isn’t covered?’  He said, ‘nah I really don’t want you taking generic.’ I said, ‘do you mind going to check and see if you can find out whether Subutex is covered?’ he leaves for a few minutes, comes back and says ‘nope it doesn’t cover it.’ Then he says, ‘ I’ll go ahead and write it so that you can get generic.’ He was very angry. I can only guess it was because the generic is made by another company.I could take this discussion in any of several different directions.  But instead of getting angry tonight at doctors who may have hostility for addicts (or perhaps addicts who perceive something else as hostility–  I wasn’t there, so I don’t know what happened), let’s look at the issue of allergy to the artificial sweetener in Suboxone, and the issue of prescribing brand vs. generic and Suboxone vs. Subutex.  For people who are interested, I took the discussion in an entirely different direction on the forum, where I took Reckitt-Benckiser to task for their limited number of slots in their patient assistance program.
Some background:  Brand Suboxone and Subutex have been the only bupe game in town until last fall, when a generic version of Subutex appeared on the scene.  Access to the medication has been a constant frustration since then, as distribution gets backed up and the price continues to rise– now almost double the initial price of about $2.50 per 8 mg tablet.  People in Wisconsin can generally find the generic by ordering it ahead of time at Walgreens– a company I am loathe to refer people to, but that at least has been able to get the medication.  That is if one of their pharmacists doesn’t decide to tar and feather you and post you on the wall along with those other darn drug addicts!
The generic version of Suboxone entnered the market about a month ago thanks to Teva pharmaceuticals, a large generic company that SHOULD be able to meet demand, but that so far does not have tablets on the shelves in Wisconsin.  The hope of many people, of course, is that the advent of generics will bring down the price of buprenorphine.  That SHOULD happen, provided that doctors don’t fall for whatever anti-generic nonsense is thrown their way by the sales force for Reckitt-Benckiser.
This is the point, by the way, where a company’s ‘true colors’ show.  Reckitt-Benckiser makes a big deal of talking about how they are NOT about the money– they are all about HELPING ADDICTS, and really don’t hardly notice that their company profits continue to surprise to the upside, pushing the stock price higher.  And I’m sure it is completely by accident that the price of Suboxone is so high, and that the high price has gone higher by about 50% over the past two years, at a time when everything else in the world is getting cheaper.  I figure that somebody accidentally moved a decimal point,  just like that crazy day in the stock market a month ago.  They probably THINK that Suboxone sells for $0.60 per tablet, not $6.00!
I’m sorry for sounding annoyed.  My anger stems from my suspicion that RB ISN’T just about saving lives.  Don’t get me wrong– I love capitalism.  But only when ruled by honesty, especially in the healthcare sector.  I have heard and read comments from the sales reps from Reckitt-Benckiser that suggest a concerted plan to tarnish competitors in a way not done by other companies about other generics.  I do not know what happened to their plan for a listerine-strip type of product, individually packaged, but they clearly planned to attack their own formulation just as soon as they got approval for the new product.  But so far, the dissolving SL tablet in a multi-dose vial appears to be just fine!  Watch for that to change. 
Reckitt-Benckiser is also playing up the diversion-potential of Subutex, even though they know that the vast majority of diversion cases consist of addicts self-treating their addiction, taking the tablet by the usual sublingual route– NOT injecting it.  But it protects the sales of Suboxone if the doctors and pharmacists (and DEA) are under the impression that prescribing Subutex is taking a big risk.  Is Subutex ever injected?  Of course.  But only a small fraction of diverted Subutex ends up used that way.  For the most part, Suboxone and Subutex are the same medication– except until recently one had a generic and the other did not.  I even suspect that some RB reps deliberately allow confusion over how Suboxone works– i.e. not explaining that Subutex contains EVERYTHING necessary to treat opioid dependence that is present in Suboxone.  Some docs think that the naloxone in Suboxone adds to the opioid blockade (it does not, when taken sublingual) or reduces cravings (it does not).
I did some reading on the artificial sweetener in Suboxone, and the writer is on the right track– and I hope he is prescribed the medication that he needs, rather than suffer with mouth sores.
I encourage physicians to take all factors into account as they take on this nasty illness.  On one hand, I resist the complaint that ‘I can’t get help because Suboxone is too expensive’ because active using is always much more costly– even before considering the costs to one’s occupation or to one’s relationships.  But physicians have long-relied on generics to increase availability of life-saving medications that otherwise would be beyond reach for many people– particularly during a nasty recession. 
Makers of generic buprenorphine, please continue your good work, and good luck to the new products entering the market– for example Butrans, which was approved a few days ago, and Probuphine, a long-term injectable form of buprenorphine that I suspect will be a great help for the final stage of buprenorphine remission treatment, i.e. stopping treatment with buprenorphine.  Let’s hope the FDA recognizes the demand for that delivery system.
JJ

Saving Suboxone Spit (ick!)

I looked through the search terms that people used today to find my blog and there aren’t many new topics– just the regular old search terms that come up every day: how long to wait after oxy before Suboxone, how long to wait after Suboxone for Oxy, how to get high from Suboxone, how to treat precipitated withdrawal from Suboxone… Except for a pair of searches for ‘saving Suboxone spit.
I have a patient that does exactly that. He takes it the ‘usual way’, then after about ten minutes he spits it into a cup and puts it in the freezer. He then takes it out of the freezer and reuses it the next day, and so on for about 4 days– he claims that it is still effective for him even at that point. I find the idea a bit disgusting, but I think his logic is sound; there probably is a great deal of the original buprenorphine left behind after dosing, and so it makes sense to try to get more of it– at least when the money is tight and so doses are kept low.
On a different topic, many of you probably know that Suboxone is supposed to go generic next year. There are rumors of a number of different buprenorphine products on the horizon– injectables, implants, skin patches… as a conversation starter, have you heard of any new products, or companies that are working on buprenorphine products? What type of product would you like to see? Feel free to comment…