Suboxone Replacements

I’ve written about the need for competition in the market for opioid dependence treatment medications.  Reckitt Benckiser had a monopoly with Suboxone, and then Suboxone film.  Readers know that I’ve also questioned some of the methods that RB used to hold onto that monopoly, including spreading fear about the use of other formulations and asserting a moral imperative to use Suboxone Film so not to expose small children to the risk of overdose.

We finally have the competition that has lowered the price for other medications.  Buprenorphine/naloxone is manufactured by several generic companies.  Plain buprenorphine, formerly known as Subutex, provides an inexpensive alternative.  Manufacturers of buprenorphine/naloxone argue that the rate of diversion is greater for buprenorphine alone than for ‘generic Suboxone,’ but comparisons of diversion using crime-data or toxicology surveys ignore the significant confounding variable that invalidates such conclusions.  Specifically, plain buprenorphine is almost exclusively prescribed to non-insured patients, whereas Suboxone film is almost exclusively prescribed to insured patients.   We would expect a higher rate of diversion in the population of patients who are uninsured, more often unemployed, and at the lower end of the socio-economic spectrum.  One common form of diversion occurs when patients share a script in return for payment for the entire prescription—i.e. ‘if you pay for them, I’ll give you half of them.’   That type of diversion is not an issue when a script is covered by insurance.

My point isn’t to argue that people use plain buprenorphine, but instead only to point out some of the flaws in the conclusions made by people who have the power to regulate medications.  Maybe plain buprenorphine is diverted more than buprenorphine/naloxone if all else is equal.  But maybe the difference in diversion is accounted for by the different patient populations for each medication.

And then there is Zubsolv, a combination of buprenorphine and naloxone that is absorbed more efficiently than Suboxone film—providing both medications are taken the same way.  Placed under the tongue, a bit less than 6 mg of buprenorphine in Zubsolv creates the same blood levels of buprenorphine as 8 mg of buprenorphine in Suboxone film.    But what if patients ignore the advice on the package insert, and spread the buprenorphine-containing saliva from either medication throughout the mouth?  Will the amount of buprenorphine in Zubsolv create the same blood levels as the buprenorphine in Suboxone Film?

But these are small issues.  The big issue will be the price-point of Zubsolv vs. generic Suboxone and Suboxone film.  I recently learned that CVS-Caremark, a major mail-order prescription drug insurance provider, will replace Suboxone film with Zubsolv on their formulary as of January, 2014.  I also see more insurers covering plain buprenorphine, apparently similar to me in being unsold on the margin of safety that naloxone adds to buprenorphine— or perhaps just not concerned about any difference in safety.

This is all good news, right?  We still have a little bit of capitalistic spirit in this country—so in theory, the makers of Suboxone will put their heads together and build a better mousetrap for less money, which will then force the good people at Orexo to do the same.   Of course, Reckitt Benckiser is based in the UK, a country made up of people whose ancestors chose not to risk everything to seek fortune in the New World.  And Orexo is based in Sweden– a beautiful country, but hardly a bastion of capitalism….

And now we hear the rumor that RB, upset over the appearance of generic competition, is thinking about picking up their ball and going home—depending on how much money someone is willing to pay for their old uniforms.  C’mon, RB–  I remember your science people asserting that Reckitt-Benckiser will be THE addiction drug company of this century!   You hit one or two bumps in the road and decide to run back to cleaning products, condoms, and rat poison?

Capitalism only works if everyone stays in the game.  I’ve given RB a hard time now and then, but count me as someone who hopes they’ll lick their wounds and put their money where their product is- or was.

Not to be selfish, but I’ve put a lot of time and effort into the SEO for SUBOXONE talk zone and SUBOX forum.  I do have a couple ‘bupe’ domain names… but I’m not ready to start all over from scratch!

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