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Duane Baldwin had lost his house. He lost his wife. He lost his two children.
In Baldwin's new makeshift home, a cardboard box deep in the bowels of a building's basement, he had a strategy. If only he could just starve himself to death, he could leave it all behind.
"I'd stop eating for a week, hoping it would happen. I didn't even have enough money to buy enough drugs (to kill myself)," said Baldwin, 51, of Rochester.
That was a couple of years ago, and Baldwin was at the dead end of a trail that had led him from a regular family life to painkillers, heroin addiction, jail and homelessness.
Now he is well-dressed in a blue buttoned-down shirt, pen and eyeglasses neatly tucked into a pocket. His piercing, sky-blue eyes are clear — because he is clean and sober for the first time in more than 15 years.
His salvation lies in a tiny orange pill with the long name that few have heard of.
"I would have never gotten through treatment without buprenorphine," said Baldwin, who is apartment hunting after completing a yearlong drug rehabilitation program at the Open Door Mission.
Buprenorphine, approved by the U.S. Food and Drug Administration in 2002, was expected to be revolutionary: Not only could people addicted to heroin and opium-derived painkillers use it outside a clinic to curb cravings, but also patients couldn't overdose or get high on it.
But most addicts in the Rochester area do not have access to buprenorphine.
Because of a federal law already on the books about narcotic therapy, only 30 people per medical practice can get it — cutting out hundreds who could get treated at large institutions such as Strong Memorial Hospital. And many primary care physicians, who can prescribe the drug by taking an eight-hour course, won't sign up — largely for fear of the kind of patients it might bring to their practices.
But a bill currently in Congress would wipe out the 30-patient rule. And the handful of local doctors who prescribe buprenorphine hope their experience will influence others.
There are no local statistics on the number of opiate addicts in our community. But judging by the more than 200 people in the Rochester area waiting to get the only other widely used drug available, methadone, there is no lack of need.
"If only we can expand the treatment setting to include outpatient and primary care offices, then we're going to help more people," said Dr. George Nasra, medical director of behavioral health in primary care program at Unity Health System.
But even Unity is not prescribing the drug yet.
How it works
Buprenorphine (bue-pre-NOR-feen) is a partial opiate that has been around for years as a painkiller. But it could be administered only intravenously and it usually wasn't strong enough to do the job. It was used to treat addiction in Europe for more than 20 years before the United States approved it in pill form in October 2002. The drug works by binding to receptors in the brain that have become addicted to opiates - binding just enough to stop cravings, but not enough for the person to get high.
For the last 30 or so years, methadone was the only prominent drug treatment available. But methadone is strictly regulated. The drug is highly potent, so someone can get high or overdose on it. Therefore, patients must go to a clinic and take methadone every day - a problem for anyone trying to start work again or for those who live in rural areas.
With buprenorphine, patients can take it in the privacy of their home - thereby avoiding the hassle, and shame, of going to a clinic. But taking buprenorphine is not as simple as popping a pill. Patients also must go through an outpatient program and counseling to prove they are serious about quitting.
The FDA approved another drug, levo-alpha acetyl methadol, in 1993. But prescriptions waned in light of concerns that it caused heart problems.
"(Methadone) is disruptive, it's stigmatizing. It keeps patients in contact with an influx (at the clinics) of actively using people. Those can be triggers to relapse," said Dr. Gary Horwitz, medical director of Westfall Associates, an outpatient drug and alcohol program. Horwitz prescribes buprenorphine.
Doctors disagree about how well buprenorphine works for longtime heroin users. Someone might need methadone doses as high as 200 milligrams a day to stop his cravings, while the maximum dose of buprenorphine is about 32 milligrams a day.
Physicians who prescribe buprenorphine locally say the drug is incredibly effective, particularly for those addicted to opiate-based prescription drugs such as Vicodin and Percocet.
As demand for pain relief increases, so too does users' dependence on the drugs that help them. Painkiller abuse is second only to marijuana abuse in the United States, according to 2002 statistics. And while heroin use has reportedly plateaued, Americans abusing drugs containing the opiate oxycodone (brand name OxyContin) during their lifetime climbed from 11.8 million in 2002 to 13.7 million in 2003.
It took one injury
Duane Baldwin, a graduate of the old Edison high school, has an associate's degree from Rochester Institute of Technology. He had a family and a good job. But everything changed after the machine maintenance worker nearly severed his hand in an accident at employer Star Market Bakery in 1984.
For three years, Baldwin was on Percocet, Tylenol with codeine, morphine — anything to help him cope with painful bone grafts to reconstruct his wrist. But soon, he wasn't just taking them for his wrist.
Baldwin saw multiple doctors or visited emergency rooms to replenish his supply of painkillers. Then in 1989, a co-worker hooked him onto something even stronger — heroin.
"Everything was gone. The pain was gone," Baldwin said.
He went into rehab in 1994, but it would be the first of many times he would try to get clean and fail. Once Baldwin started writing bad checks, it would also be one of many times he spent in jail for minor offenses. His wife left and took his two small children. He also lost the house he was renting on Scottsville Road and all of his belongings.
But somehow he made his way to MainQuest on West Main Street, now DePaul addiction treatment center, which encouraged him to try recovery again. Baldwin got into the Open Door Mission's treatment program and was prescribed buprenorphine by Dr. Joseph Mancini, now a consulting physician at DePaul.
Baldwin eventually learned he was suffering from hepatitis C and a blood disorder called hemochromatosis. He was likely self-medicating with drugs all those years to combat his symptoms. Baldwin is on disability now because of his medical conditions.
Because of the pain from those illnesses, Baldwin said, he would have never been able to quit opiates without a drug replacement. Now, Baldwin just hopes his children might read his story and get in touch with him.
Once his wife left, Baldwin lost touch with where they all went. He hasn't seen his children in four years. But he still wears a large cross around his neck that his daughter, Heather, now 17, got him years ago.
"I want to be on my own. I know I can handle it," said Baldwin. "I just want to start my life over again."
Slow to react
There are 26 doctors in the 585 area code who have received training to prescribe buprenorphine. However, many of those doctors are not prescribing it.
Nasra is one of four doctors at Unity Health System who have had the training but is not prescribing buprenorphine. He said it's a long, bureaucratic process to start prescribing a new treatment within the health system.
Dr. Syed Mustafa, a psychiatrist with Unity, said he got the training because it was offered at a conference he attended. However, he admits he's not comfortable dealing with the addicted population; he thinks some people might not be as serious about quitting as they should be to use the drug.
Another Monroe County doctor, who does prescribe buprenorphine, declined to be named for fear his regular patients would stop coming to his office.
However, most doctors have prescription-drug addicts in their practice but choose to ignore it, said Dr. Norman Wetterau, a family practitioner and buprenorphine prescriber in Nunda, Livingston County.
Nancy Adams, executive director of the Monroe County Medical Society, also supports more physicians being trained.
Many primary care doctors think they aren't qualified to deal with such a population. But drug treatment programs say it would free up slots if some patients' own doctors took over the prescriptions.
"This should be something a doctor in every locale should have a little experience in," said Dr. Paul Updike, medical director of the Pathways methadone clinic in both Buffalo and Rochester. "It's better than nothing."
But what participating doctors hope for most is that the federal government repeals the requirement allowing only 30 people on buprenorphine per practice. The law was enacted five years ago to regulate narcotic use in treating opiate addicts. The bill is currently being considered in both the House and Senate.
If not for the rule, Dr. Gloria Baciewicz, director of Strong Recovery at Strong hospital, said the practice could be treating hundreds of patients. She said Strong Recovery turns away dozens of calls a week because it's already full.
"The benefits to society would be much greater without making it difficult and putting these kind of artificial limits on it," said Horwitz, of Westfall Associates. "I'm close to being full. It's going to be terrible for us to be turning people away."