A Dose of Economic Reality

The drug Subutex has helped hundreds of heroin addicts get clean. The treatment, however, has a high pricetag, and is conditioned on psychosocial therapy.

Anna is driving the new car she recently purchased. She grips the steering wheel with pride - this is a dream come true for her. After several traffic lights, she points to the road and says, "this is where I used to work," and quickly covers her teary eyes with sunglasses. "Sometimes even I can't believe how far I've come," she adds after a long pause.

Anna (not her real name), a 25-year-old native of Ukraine, began using heroin when she was 16 years old. "In the neighborhood where I grew up, there were no 'soft' drugs, so that's how I started - straight off with heroin, straight off with shooting up. At the age of 17, I was already using two to three times a week. To pay for the drug, I began selling the gold jewelry my father bought me and objects around the house."

At the age of 18, Anna immigrated to Israel with her mother. At 19, she began working as a prostitute. That situation fast deteriorated. Within two years, Anna had switched from upscale apartments to escort services and, lastly, to the street. "I worked long hours and earned NIS 1,000 a day," she says. "All the money was spent on heroin. I did it to get my fix and help support my mother."

Anna's story sounds like just another addiction story - drug use at an early age, crime and prostitution and an inability to stop using. But Anna managed to escape the cycle: She hasn't used heroin for five years. Instead, she takes a substitute called Subutex (buprenorphine). She receives a prescription from a private clinic for heroin rehabilitation. "I had a client, let's call him Adam, who fell in love with me," she says. "I felt that he was different, upper-class, refined, considerate. He used to tell me, 'you're different, you don't belong here.' He was the one who encouraged me to go into rehab."

Anna tried on her own to wean herself of heroin - to no avail. Adam promised to help. "We moved in together and he fought for me. He began to find out where one could be treated for heroin addiction and put me in private centers. Each time he would pay NIS 3,000-NIS 4,000, but I would give up and start using again." Adam eventually heard of a public center in Jaffa where, in addition to the drug substitute methadone, they used Subutex to help patients. A short time after she began visiting the center and taking Subutex, Anna succeeded, for the first time in her life, to stop using heroin. "This pill changed my life," she says. "I felt a change from day one."

For two months, Anna traveled daily from home (far from Tel Aviv) by bus to the center where she does a urine test and receives her Subutex allotment. "My boyfriend, who saw the immediate change in me, wanted me to get a regular job," she says. "But when you have to come to the distribution station every morning, wait on line and participate in workshops - what workplace is going to accept you? When is there time to work? In the center in Jaffa, they also distribute methadone to hundreds of drug addicts. He was afraid that if I spent the entire day in such an atmosphere, I would never manage to escape this cycle."

Adam found a private clinic for heroin addicts and decided to pay for Anna's Subutex out of pocket. Since then, she has not used heroin and today has a full-time job as a cashier.

The Health Ministry has approved two medical substitutes for heroin: Adolan (methadone) and Subutex. Methadone is a substance that adheres to the same receptors in the brain as heroin, but it erases the effects of the drug. Subutex, in addition to partially imitating the effects of the drug, blocks the absorption of the substance in the receptor. It has been approved for use in Israel since 2002, and the cost in private clinics runs NIS 700-NIS 1,500 a month (depending on the dosage). In addition there are visiting costs of about NIS 250. At Israel's public health centers, Subutex is distributed for NIS 400 a month, but it is not easy to meet the Health Ministry's criteria to be accepted into the group.

The ministry has conditioned the use of the medication on psychosocial therapy. In addition to paying for the drugs, the patient has to pay for one or more sessions with a psychiatrist or a social worker - to the tune of NIS 300-NIS 500 per meeting. The Social Affairs Ministry refuses to pay for this. The pill is taken daily in varying dosages (adapted to each patient's needs), ranging from 4 to 16 milligrams.

"An addict cannot pay such a sum per month for rehabilitation," says Anna. "Without help, I would never have been able to meet these expenses. I don't understand why the government decided that such an effective method should be available for the wealthy alone. After all, if drug addicts stop using drugs, they will begin to function again and work, as made possible by this pill, and everyone will benefit."

Hebetim, the private clinic where Anna is being treated, is located in the heart of Tel Aviv. Henry, 34, is waiting there for a Subutex prescription. Nothing in his appearance or his behavior suggests that he had been addicted to heroin for eight years. "Would you believe that the people here are addicts?" asks the clinic's director, Dr. Sergio Marchevsky. "They come here and enjoy discretion and a respectful attitude: They get a prescription, go to the pharmacy and buy a pill. It's clean, it eliminates stereotypes about addicts and allows them to join society again."

Marchevsky, director of the clinical studies department at the Beer Yaakov Mental Health Center and an addiction therapist, is one of seven psychiatrists permitted to dispense Subutex prescriptions to addicts. He says the private clinic, which has been operating for around a year and has about 200 patients, is generally used by addicts who have tried a wide array of methods to kick heroin in the past, without success. Many are of high socioeconomic status - they hid their addiction all their lives and would never considering reporting to a public clinic.

"The success of the treatment, and the immediate change that takes place in the addicts, should encourage us to make the treatment more accessible, so as to enable everyone to benefit from it," says Marchevsky. "In most of the world, one can get a prescription from his general practitioner. You don't need a psychiatrist for that. There is no scientific justification for having the addict come to a rehabilitation center every morning to receive Subutex according to the model of methadone distribution."

A background paper on the discussion of the effectiveness of drug substitutes, which was submitted to the Knesset Committee on Drug Abuse in 2005, stated: "The length of time Subutex is effective is the same as methadone, but the required dosage is lower (2 mg. Subutex as compared to 30 mg. of methadone). Subutex is safer than methadone (a lower incidence rate of respiratory problems, self-drugging and incidence of death). The use of methadone is problematic: There is a danger of an overdose, and there are patients who take their dosage of methadone to sell it. Methadone is known as a very addictive drug substitute, as opposed to Subutex; the use of methadone does not prevent the use of other drugs, such as stimulants."

But according to Health Ministry criteria, treatment with Subutex is contingent on "a young age, a short history of addiction, high motivation for treatment and a willingness to return to normal life - including the emotional strength for rehabilitation and job rehabilitation."

Although the studies conducted by the Health Ministry in recent years indicate that the rate of success with long-term treatment with Subutex is 89 percent, about 3,000 addicts in the public and government-funded clinics are still being treated with methadone, and only 300 with Subutex.

'I tried everything'

Marchevsky is angry: "If a person does not have the money to pay for pyschosocial therapy in a private clinic, which is the condition dictated by the Health Ministry for receiving the drug, he is supposed to turn to the Social Affairs Ministry. But the ministry does not serve addicts or those who use substitutes - only those who are completely clean. So the addict will have to approach a public center that provides Subutex along with psychosocial therapy, be on a waiting list for three to four months, come to the center every morning, wait his turn, undergo checkups, undergo therapy. Show me who can go to work after all of that."

Iris Mordokovich, the director of addiction treatment service at the Social Affairs Ministry, says in response: "I agree that if that is the condition of the Health Ministry, of course the addicts who purchase the drug privately must receive psychosocial therapy, but we only give therapy to people who are clean of drugs. It's only a shame that whoever defined this policy in law did not inform us. We have no resources, manpower or money to offer such therapy to everyone who purchases Subutex."

Marchevsky's clinic employs four psychiatrists; a social worker; Eitan Sela, the director of the Ilanot Therapeutic Community in the Sharon; and two mentors - Adi and Ronen (not their real names), former addicts who have themselves been successfully treated with Subutex. In addition to the clinic in Tel Aviv, there is also a Kfar Sava branch and recently two branches were opened in Be'er Sheva and Ashdod. The addict is interviewed to ascertain that the medication suits him and to decide on a proper dosage. After that, he has to have withdrawal symptoms before taking a Subutex tablet.

"I started using heroin at the age of 18," says Adi, 38. "At an early age, I went to prison for a short period and I tried everything - private rehabilitation centers, methadone, support groups and even the famous injection at Cite, a rehabilitation center that has since closed, which cost NIS 17,000. After a week I went back to using, nothing helped. From the first time I took Subutex, I became myself again."

Ronen, 48, says that "anyone who manages to stop using feels a pit in his soul, a tremendous emptiness and a feeling of dissatisfaction. With Subutex this phenomenon - which causes addicts to go back to using - does not exist." Ronen, a businessman, was addicted for 20 years and concealed it from everyone. "I was married, a father, and strongly addicted. I worked hard to hide it, even when I woke up in the morning with withdrawal symptoms I would make sure to shave and to keep up a facade. Even my wife didn't know at the time. Today my children are figuring things out, that I used to leave them in the car and go to buy drugs near ATMs in Lod."

A former success story

"Subutex cannot paralyze the addict's urge to return to the drug," emphasizes Ohad (not his real name ), a 27-year-old student. "I started treatment with the pill about five years ago, but I had a few slipups when I used because I missed it." Ohad comes from a well-off family. When his parents discovered he was addicted, they turned to a private clinic. "It was clear that I would never go to a public center and rub shoulders with addicts in order to get methadone," he says. For a long time he was considered a Subutex success story, until he slipped and began using heroin again. "I had to be more calculating. When I studied at a preparatory course I had to find the quietest bathroom, or shoot up in the car. Today I know that Subutex is protecting me, but it's not enough."

Dr. Paula Roshka and Dr. Anatoly Margolis, who head the substance abuse treatment department at the Health Ministry, also point to the effectiveness of Subutex. "Today all the rehabilitation centers in the country use Subutex for the initial withdrawal, because we have discovered that the process is easier," says Roshka. The Health Ministry conducted a study in 2003-2006 among 259 drug addicts treated at rehabilitation centers. It indicates that the addicts treated with Subutex showed a significant improvement in functioning and in quality of life. Another study conducted by the ministry revealed that 85 percent of Subutex users successfully concluded the first stage of institutionalized rehabilitation, while until Subutex was introduced only 50 percent of patients did so.

Why are only 300 people benefiting from Subutex in the public centers, as compared to 3,000 who are being treated with methadone?

Roshka: "Subutex is another treatment method, it doesn't have to cancel out treatment with methadone. You'd be surprised, but there are many people who are not interested in replacing methadone with Subutex. They've become accustomed to it and don't want a change."

Are you aware of the fact that there is a class division in the area of drug rehabilitation?

Margolis: "We allow anyone who wants to open a private clinic in accordance with Health Ministry criteria, to do so. Of course not every addict who doesn't live with family and is dependent on income supplements can pay for the treatment. That is why we allow long-term treatment with Subutex in our public center as well, at an overall cost of NIS 400 a month."

Up until now, only 300 people have benefited from such public treatment.

Margolis: "Our ministry has to protect the public welfare as well, it's impossible to give everyone who comes for a checkup and declares that he has an addiction problem such a pill. At first we allowed widespread use of methadone, and a tremendous trade in it resulted."

Isn't it more economical for the government to support Subutex, which helps people to integrate into society, instead of being supported by the National Insurance Institute?

Margolis: "Yes, but Subutex is an expensive pill. We have budgetary promises that will make it possible to expand its use in the future. But it's important to understand that, relative to other countries, we are very advanced ... The real problem is that when we want to open a public clinic, the local authorities are opposed."