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Taking Issue   |    
Office-Based Buprenorphine Offers a Second Chance
Lloyd I. Sederer, M.D.; Andrew Kolodny, M.D.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.7.743
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Heroin addiction is on the rise among our nation's youths. In 1990 an estimated 5,000 youths between the ages of 12 and 17 years were using heroin. By 2000 that number had risen to 40,000. More than 80 percent of the estimated one million first-time users of heroin or other opiates in the United States are under the age of 26 years. Many of these young people will struggle with opiate addiction throughout their lives. They will have serious health problems and difficulty maintaining jobs. Without treatment thousands of lives will be destroyed.

In the 1960s we witnessed a similar rise in heroin addiction. Methadone was then introduced as an effective treatment. However, methadone has been a source of controversy since its debut. Congress and state legislatures imposed onerous regulations that have limited the appeal of methadone treatment, even though the Institute of Medicine concluded that methadone is one of the most effective treatments for heroin addiction and the National Institutes of Health recommended that it be less regulated.

Even though methadone treatment will continue to play an important role in heroin addiction, a new treatment is now available. The federal government recently approved a drug called buprenorphine. Like methadone, buprenorphine reduces the craving for opiates and permits productive living. But buprenorphine has a ceiling effect, which means there is less likelihood of abuse or of an overdose. Buprenorphine is prescribed in a doctor's office, is dispensed in local pharmacies, and can be taken at home as a sublingual pill.

In New York City, where one-fifth of the nation's heroin users reside, we are working to treat tens of thousands of individuals with buprenorphine over the next five years in primary care practices, city jails, HIV/AIDS clinics, and specialty substance abuse services.

As with other medical therapies, treatment with buprenorphine will cost money and raise questions about whether we can afford it and who should pay for it. Remarkably, many health care payers, including Medicaid programs in some states, still refuse to pay for methadone—even though overwhelming evidence exists that methadone treatment saves money by enabling people with a heroin addiction to hold jobs, steer clear of criminal activity, and avoid diseases, such as HIV.

Insurers should cover buprenorphine treatment, just as they cover treatments for other chronic illnesses. Stigmatization, isolation, and neglect have helped perpetuate costly social problems. With buprenorphine we have an opportunity to engage tens of thousands of people in a cost-effective treatment. Let's get it right this time.

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