Doctors in Vermont and across the country are being introduced to a new tool for treating opioid addiction. It’s an implant: four tiny plastic rods, inserted into a patient’s arm, deliver a steady dose of buprenorphine.
The drug counters the craving for heroin or other opioids.
Dr. Patti Fisher of the University of Vermont Medical Center is one of many doctors across Vermont working to address the opioid crisis.
She says she thinks the implant is a great idea.
“This is going to be much easier for providers, and much easier for patients,” Fisher says.
And now, a group of physicians have begun to get trained on how to use the new Probuphine implant.
On a sunny weekend this summer, about a dozen doctors sat inside a hotel conference room and practiced inserting four thin, 1-inch plastic rods into a hunk of raw pork tenderloin – a stand-in for the human arm.
“This is going into the inner part of the upper arm,” explained one of the trainers, a doctor brought in by BRAEBURN Pharmaceuticals, which makes the Probuphine implant. The trainer continued: “I like to tell my students that it’s almost like a piece of spaghetti that’s al dente.”
One of the people taking the training was Dr. Mitch Miller, who works in prisons in Springfield and Windsor. He says inmates with addiction issues who meet certain criteria are allowed to continue on medication-assisted treatment. Currently, that’s a pill or dissolvable strip.
“There are some advantages to the implantable buprenorphine compared with the strips or the pills,” Miller says. “So it’s not clear to me how this is going to pan out, but I felt this was good place to get certified for this procedure and then we’ll see what the future brings.”
One of the biggest concerns for doctors prescribing buprenorphine to any patient is that the drug can get "diverted" – and sold on the street. Dr. Patti Fisher of UVM Medical Center says she doesn’t know how big a problem it is, but that it is a problem.
“I do think some patients are probably on a prescribed 16 milligrams a day and they might take 8 — take one film and sell the other film — and they can sell it for $25 on the street," Fisher says. “I do think it happens, not infrequently.”
Fisher has been working over the past year to get more doctors involved in treating patients who need medication for their addiction.
“I would hope maybe more providers might be willing to prescribe to more patients if it became easier to do so,” says Fisher. “If you were less worried about aberrant behavior, less worried about diversion, less worried about somebody stopping their buprenorphine and then using ... I would think this takes out a lot of the worry.”
Dr. John Brooklyn, who runs the Howard Center's methadone program, went through the steps to get certified on inserting the implant.
But he’s already familiar with how it works. Brooklyn says he was part of some of the studies that tested the implant before it was approved by the FDA.
“So I have patients who have been on the implants that I'm taking care of, and so as soon as it becomes available, they're going to want to go back on implants,” Brooklyn says.
Those are patients, he says, who have regular jobs — working in an office or on a construction site, for example.
For them, the implant is far more convenient than having to make constant visits to the pharmacy. But cost is another issue. When compared to a monthly prescription, Brooklyn says the six-month Probuphine implant is nearly three times more expensive.
“While it's a wonderful treatment,” Brooklyn says, “it's not going to solve much for us in Vermont because we have so many people who are already in treatment. This just offers — for those people who are stable — a situation where they don't have the issue of going to the pharmacy and the embarrassment of having to present and take medicine every day. So it's probably a narrow niche,” he said.
A "narrow niche," for now. But that niche could expand.
Brooklyn and other doctors in Vermont are waiting to see whether — or for how much — the state’s Medicaid program and large health insurers will cover the implant.