Suffolk should offer Suboxone treatment for opioid misuse disorder

New York State has won more than $2 billion from settlements with companies involved in manufacturing, distributing and selling opioids. Suffolk County, where I practice medicine, has already received $25 million of this in grants designed to combat the opioid epidemic and is expected to receive $200 million more over the next two decades.

How is this best spent?

It is tempting to shunt some of this to enforcement. While big-time dealers must be prosecuted for their hubris, impeding the supply of drugs has never been successful, as we have seen from the ineffectiveness of the harsh Rockefeller drug laws of the 1970s to present restrictions on physicians: Beginning in March 2017, all controlled substance prescriptions in New York had to be transmitted electronically, allowing government to monitor our prescribing habits. We get monthly reports of every controlled drug we have ordered, reminding us that we’re under surveillance. Physicians who prescribe “too many” opioids risk prosecution. Most of us cringe every time we prescribe an opioid, despite knowing the patient really needs it.

The result: Fewer opioids are being prescribed, and opioid overdose deaths have increased — by about 68% in New York between 2019 and 2021, according to a November 2022 state comptroller’s report. All that’s changed is that fentanyl and heroin, rather than prescription opioids, are the culprits.

As long as there is demand, supply will always find a way. So what does work?

Medication-assisted recovery (also known as medication-assisted treatment) is by far the most effective way of treating what we now call opioid use disorder. It mitigates the harms of addiction — stealing to pay for drugs, needle-associated diseases, and overdoses — with the goal of ultimately easing patients off opioids. Methadone has traditionally been used for this, with considerable success, and Suffolk maintains several treatment centers with all-inclusive sliding-scale fees as low as $10. But the medication-assisted treatment of choice is now buprenorphine, commonly prescribed as Suboxone. It is safer than methadone, and at least as effective. And while methadone treatment requires almost daily visits during the first year, Suboxone patients are seen once a week at first, and ultimately monthly.

Surprisingly, there are no county-sponsored Suboxone treatment centers on Long Island. The drug must be obtained through private practitioners or facilities. An uninsured patient — or one whose insurance is not accepted, or doesn’t cover Suboxone — will pay, at one facility I called, about $1,000 during the first six months of what will likely be a long-term process. That doesn’t include the actual medication, which will cost at least $200 per month. I have been told by patients that it is much cheaper to obtain Suboxone on the street, despite the dangers.

Flush with opioid settlement money, Suffolk County has no excuse for failing to provide what the respected independent publication Medical Letter recently called “the treatment of choice for most patients with opioid use disorder.” It could be provided through clinics, as methadone is offered, or through vouchers or special insurance to be used in the private sector. Counties have always provided free care for illnesses that threaten the public’s health, like tuberculosis or sexually transmitted disease. Opioid misuse is very much a public health problem, and should be dealt with as such.

While opioid overdose deaths continue upward despite our “best” efforts, only about 10% of those who could benefit are receiving medication assistance. What are we waiting for?