Louis Morano knows what he needs, and he knows where to get it.
Morano, 29, has done seven stints in rehab for opioid addiction in the past 15 years. So, he has come to a mobile medical clinic parked on a corner of Philadelphia's Kensington neighborhood, in the geographical heart of the city's overdose crisis. People call the mobile clinic the "bupe bus."
Buprenorphine is a drug that curbs cravings and treats the symptoms of withdrawal from opioid addiction. One of the common brand name drugs that contains it, Suboxone, combines the buprenorphine with naloxone.
Combined with cognitive behavioral therapy, buprenorphine is one of the three FDA-approved medicines considered the gold standard for opioid-addiction treatment.
Morano has tried Suboxone before — he used to buy it from a street dealer to help him get through his workday when he couldn't use heroin. It kept the sick feelings of withdrawal at bay. So he has a sense of how it will make him feel, though he has never been prescribed it. He used to think of it as a crutch. But now, he is committed to his recovery, and buprenorphine is key.
"I can't do this anymore," Morano says. He wants the medical support.
The bupe bus is a project of Prevention Point, Philadelphia's only syringe-exchange program, and is part of the city's efforts to expand access to this particular form of medication-assisted treatment for opioid addiction.
Morano is first in line. After a short time, the heavy doors of the bus heave open and Dr. Ben Cocchiaro waves Morano inside, where they squeeze into a tiny exam room. Together, Cocchiaro and Morano discuss how buprenorphine might help Morano's recovery be more successful this time, as well as if he's open to seeing a therapist. Cocchiaro gives Morano instructions on how to take the medication and then calls a pharmacy to authorize a prescription.
To date, much of the research on barriers to buprenorphine access has focused on the fact that there are too few medical providers available to write the prescriptions.
According to federal law, doctors must apply for a special waiver from the federal Substance Abuse and Mental Health Services Administration to prescribe buprenorphine. To get the waiver, a doctor must undergo eight hours of training — and, initially, can prescribe the drug to only a maximum of 30 patients at any one time. Given these constraints, many doctors don't bother.
But, according to people active in addressing the opioid crisis, some pharmacists also prevent many opioid users who need buprenorphine from getting it.
"We can write a bunch of prescriptions for people," says Dan Ventricelli of the Philadelphia College of Pharmacy. "But if they don't have a pharmacy and a pharmacist that's willing to fill that medication for them, fill it consistently and have an open conversation with that patient throughout that treatment process, then we may end up with a bottleneck at the community pharmacy."
Pharmacists frustrated by remedy's street use
There are a number of reasons some pharmacists say they are hesitant.
Just a few blocks away from the bupe bus in Kensington, for example, Richard Ost owns an independent pharmacy. He says his store was one of the first in the neighborhood to stock buprenorphine. But after a while, Ost started noticing that people were not using the medication as directed — they were selling it instead.
Buprenorphine acts as a partial opioid agonist, which means it's a low-grade opioid, in a sense. When taken in pill or tablet form, bupe is unlikely to cause the same feelings of euphoria as heroin would, but it might if it were dissolved and injected. Many people buy it on the street for the same reason Morano did: to keep from going into withdrawal between injecting heroin or fentanyl. Others buy it to try to quit using opioids on their own.
"We started seeing people [sell the drug] in our store in front of us," says Ost. He says it's unethical to dispense a prescription if a patient turns around and sells the drug illegally, rather than uses it. "Once we saw that with a patient, we terminated them as a patient."
Ost explains that the illegal market for Suboxone also means that customers trying to stay sober are continually targeted and tempted.
"So if we were having a lot of people in recovery coming out of our stores," Ost says, "the people who were dealing illicit drugs knew that, and they would be there to talk to them. And they would say, 'Well, I'll give you this' or 'I'll give you that' or 'I'll buy your Suboxone' or 'I'll trade you for this.' "
Eventually, Ost's staff didn't feel safe, he says, and neither did the customers. He understands the value of bupe but says it just wasn't worth it. He has mostly stopped carrying it.
Even pharmacies that aim to stock buprenorphine can have trouble doing so. Limits set by wholesalers require pharmacies to order the drug in small, frequent batches. Though pharmacies can apply for exemptions to order more at a time or have a higher percentage of their total stock be controlled substances, doing so invites a higher level of scrutiny from the wholesaler and, in turn, from the federal Drug Enforcement Administration.
Buprenorphine saves lives
Doctors and pharmacists also receive different education about how long buprenorphine should be prescribed before tapering a patient off the drug. Medical providers sometimes prescribe it for long-term treatment, based on recent SAMHSA guidelines, while pharmacists may view longer courses of treatment as intensifying the risk of long-term dependency.
"It's not even that they're on different pages," says Ventricelli. "It's that they're reading completely different books."
If a patient going through withdrawal can't quickly get buprenorphine, the stakes are high, says Silvana Mazzella, associate executive director at Prevention Point — patients may be more likely to turn back to heroin or fentanyl.
"We're in a situation where if you are in withdrawal, you're sick — you need to get well," she says. "You want help today, and you can't get it through medication-assisted treatment. Unfortunately, you will find it a block away — very quickly and very cheaply."
Doctors with Prevention Point have found a pharmacy near the bupe bus — the Pharmacy of America — that will reliably dispense buprenorphine to their Philadelphia patients.
The head pharmacist there, Anthony Shirley, says he's comfortable filling the scripts because he trusts that the doctors at Prevention Point will write prescriptions only to patients who need the medication. He has heard firsthand from patients who say buprenorphine saved their lives.
"That's something you can't really put a price tag on," Shirley says. For him, the calculation is simple: His store is in an area where lots of people need buprenorphine. That means it's his job to get it to them.
This story is part of a reporting partnership with NPR, WHYY and Kaiser Health News.
RACHEL MARTIN, HOST:
With America in the throes of a drug addiction epidemic, there's been a big push to make a crucial treatment drug easier to get. It's called buprenorphine, and people who take it are more likely to stay in treatment and less likely to die from an overdose. But there's a problem. Pharmacists are the gatekeepers for filling the prescriptions. And as Nina Feldman at WHYY in Philadelphia explains, not all pharmacies want that role.
NINA FELDMAN, BYLINE: Louis Morano was sick of being in and out of rehab. He was a dad now and wanted to be at home more with his son in northeast Philly. This time, he was determined to make his recovery stick.
LOUIS MORANO: My plan is to go and show that, like, I don't want to do this anymore. I can't do this anymore.
FELDMAN: In all his stints in rehab, Morano says he had never been prescribed buprenorphine, a drug that staves off withdrawal symptoms and ongoing cravings. But he had bought it off the street before.
MORANO: I would use it so I wasn't sick while I was at work, and then I would get high after work.
FELDMAN: So he knew the drug would work to curb his cravings. Morano heard he could get a prescription from a bus that housed a mobile medical clinic. It's usually parked on a corner in Kensington, the Philadelphia neighborhood at the center of the opioid epidemic. People there just call it the bupe bus, for buprenorphine.
BEN COCCHIARO: Hello. Dr. Ben Cocchiaro - it's nice to meet you.
FELDMAN: The bus belongs to the syringe exchange Prevention Point. It's one of Philadelphia's latest efforts to help more people get buprenorphine. Doctors with Prevention Point see patients in a tiny, peaceful consult room at the back of the bus. Morano and a doctor talk about what he'll need to make recovery work for him this time. The doctor gives him instructions for taking the drug, and then he calls in the script.
COCCHIARO: Hi, there. It's Ben from the MAT van.
FELDMAN: The bus parks right outside a Walgreens, but Morano's doctor doesn't bother calling it in there. And Morano won't be filling the script at a nearby independent pharmacy either.
Richard Ost, the owner there, says his pharmacy was one of the first in the neighborhood to stock buprenorphine. But after a while, Ost started noticing that people were not using the medication as directed. They were selling it instead.
RICHARD OST: We started seeing people doing it in our store in front of us. Ethically, we should not be dispensing their prescriptions. And once we saw that with a patient, we terminated them as a patient.
FELDMAN: Ost says the illegal market for buprenorphine, also known as Suboxone, didn't just bring unwanted foot traffic. It also meant customers trying to stay sober were being continually targeted and tempted.
OST: So if we were having a lot of people that were in recovery coming out of our stores, the people who were dealing illicit drugs knew that. And they would be there to talk to them. And they would say - well, I'll give you this, or I'll give you that. Or I'll buy your Suboxone, or I'll trade you for this.
FELDMAN: Ost says, eventually, his staff didn't feel safe, and neither did the customers. He understands the value of bupe, but it just wasn't worth it. He's mostly stopped carrying it.
Another problem is that sometimes pharmacists have trouble stocking buprenorphine, even if they want to. Wholesalers set limits on how many controlled substances a pharmacy can order at a time. If you're in a high-needs area like Kensington, you might max out, especially if you stock other prescription opioids. And lots of pharmacists get different information about buprenorphine compared to doctors.
DAN VENTRICELLI: It's not even that they're on different pages; they're reading completely different books.
FELDMAN: Dan Ventricelli is a professor at the Philadelphia College of Pharmacy.
VENTRICELLI: There's this perception in the pharmacy community that if you're using this medication for a year and you haven't started tapering, that you are doing something wrong - or maybe the provider is doing something wrong.
FELDMAN: But lots of doctors prescribe buprenorphine for longer than a year, and that's consistent with recent guidelines. If a pharmacy doesn't have buprenorphine or the pharmacist won't fill it, the stakes are high. Silvana Mazzella of Prevention Point says when it's not available, patients struggle and can turn back to heroin or fentanyl.
SILVANA MAZZELLA: We're in a situation where, if you are in withdrawal, you're sick - you need to get well. You want help today, and you can't get it through medication-assisted treatment. Unfortunately, you will find it a block away - very quickly and very cheaply.
FELDMAN: Doctors with Prevention Point have found a pharmacy that will reliably dispense buprenorphine to their patients. It's called Pharmacy of America.
UNIDENTIFIED PHARMACY EMPLOYEE: Can I have your birthday please?
UNIDENTIFIED PHARMACY CUSTOMER: (Unintelligible) - '78.
UNIDENTIFIED PHARMACY EMPLOYEE: OK. You can sign for me when you're ready.
FELDMAN: Anthony Shirley is head pharmacist there. He says he's comfortable filling the scripts because of his relationship with the doctors at Prevention Point.
ANTHONY SHIRLEY: Trust is an issue. You know? You have to kind of know what their processes are and make sure that, you know, they're not just giving prescriptions to patients that don't need the medication. It's a very controlled environment at Prevention Point.
FELDMAN: He says he tries to connect with the patients, too.
SHIRLEY: I've heard firsthand from patients - that saved my life. You know, that's something that, you know, you can't really put a price tag on.
FELDMAN: Shirley says, for him, it's simple. His store is in an area where lots of people need buprenorphine. That means it's his job to get it to them. For NPR News, I'm Nina Feldman in Philadelphia.
(SOUNDBITE OF WE CAME FROM THE NORTH'S "WHITE SANDS")
MARTIN: This story comes from a reporting partnership between NPR, WHYY and Kaiser Health News. Transcript provided by NPR, Copyright NPR.