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Contraband highs: Suboxone strips introduce challenges for corrections.

Prescription drug abuse and misuse has surpassed illicit drug abuse nationally, (1) while somehow, a misconception exists that prescription drugs are safer because they are legally prescribed by a health care provider. (2) More deaths, however, occur each year as a result of prescription drug overdoses than from overdoses of other illegal drugs. (3)

The most commonly abused prescription drugs are opioids, which are narcotic painkillers. Prescription opioid medications include morphine, oxycodone, hydrocodone and fentanyl, among others, and are frequently combined with drugs like Tylenol or Ibuprofen. Because cancer and surgical patients with severe pain sometimes cannot swallow pills or liquid medication, manufacturers have created unique delivery systems that do not require swallowing, like patches, ointments or even lollipops.

While effective at alleviating severe pain, opioids also cause side effects. These include an addictive and euphoric "high," especially when taken in high doses. Opioid use can also cause pinpoint (constricted) pupils, severe constipation and decreased respiratory rate. The cause of death in most opioid overdoses is due to a lack of oxygen to the brain, caused by suppressed breathing.

Due to their high risk of abuse, misuse and diversion, opioids are classified as Schedule II Controlled Substances under the Drug Enforcement Agency's (DEA) Controlled Substances Act. This means they require special handling and inventory control throughout the pharmaceutical supply chain. Schedule I opioids, such as heroin, are illegal and highly addictive with no recognized medical use.

Controlling opioid dependence

Suboxone is a prescription drug used to treat opioid dependence. (4) Doctors prescribe Suboxone, or its generic equivalent, to patients who are addicted to legal or illegal opioids. Suboxone contains two active ingredients: buprenorphine and naloxone. Buprenorphine is a relatively weak "mixed" opioid agonist, and naloxone, also known by the brand name Narcan, is an opioid-reversal agent, or antagonist. Naloxone is not well-absorbed when taken by mouth, but when injected, it overcomes and halts any opioid effects, inducing immediate withdrawal. It is the drug commonly used by police and emergency medical services to save the lives of overdosed individuals by kicking the opioid drug off the receptors in the brain and getting patients breathing again.

Buprenorphine--with the trade name of Subutex or the street name of "Bupe"--was first developed as a pain reliever, with similar potency to morphine. It had pain-relieving effects, but unlike other opioids, had only a minimal euphoria, making it attractive for use on patients with addiction. Since the effect of the drug could be amplified if injected intravenously or snorted, naloxone was added to Suboxone to discourage this misuse.

Nalaxone, also known by the trade name Narcan, is an opioidreversal agent. Nalaxone is not well-absorbed when taken by mouth, but when injected, it overcomes and halts any opioid effects, inducing immediate withdrawal. It is the drug commonly used by police and emergency medical services to save the lives of individuals who have overdosed on opioids by kicking the drug off the receptors in the brain and getting patients breathing again. Naloxone should be a part of an institution's medical emergency kit.

These drugs serve dual purposes for patients with addiction. Buprenorphine stimulates the opioid receptors to mitigate withdrawal symptoms and ovoid cravings, while naloxone stops the high, discouraging users from using other opioids and from snorting or dissolving and injecting the drug intravenously.

In 2002, the FDA approved Suboxone for opioid dependence in the U.S. (5) It has been an effective alternative to methadone, another common drug abuse treatment, while avoiding some of the side effects, negative social stigma and addictive characteristics of that drug. Suboxone use has surpassed methadone, as patients can be seen as outpatients in primary care and do not need to go to a methadone clinic. (6)

However, Suboxone provides a unique challenge to the correctional environment. This challenge lies in its formulation, i.e., how the medication is delivered. Originally, it was marketed as a beige-orange, sublingual tablet (dissolved under the tongue), shaped like a stop sign and about the size of three dimes stacked on top of each other. However, the candy-like appearance and citrus flavor resulted in many poisonings and several deaths of children who accidentally ingested them. (7)

In response, the manufacturer discontinued the tablets and reformulated the product into individually wrapped limeflavored sublingual strips, much like a breath mint strip. The foil/ polyester wrapper for each strip is designed to be child-resistant and difficult to rip open. Once out of the package, the strip, about one centimeter by two centimeters, can be cut into different sizes so a patient can ultimately taper off the drug with a doctor's guidance.

Confiscating and detecting the drug

These thin, nearly translucent, rectangular orange strips are smaller than a paperclip and are imprinted with an identifying code in white text. "N2" refers to the dosage form with 2 milligrams of buprenorphine; "N8" refers to the strip containing 8 milligrams of buprenorphine and is more common. Once removed from the external packaging, their small size allows them to be easily and nearly imperceptibly hidden behind postage stamps, in the folds of envelopes, in the binding seam or between pages of books, in the glue seams of large envelopes, or between layers of cardstock.

Demand for Suboxone in correctional facilities has increased by word-of-mouth, owing to its pain relief and euphoric properties, the fact that many routine urine drug screening tests do not detect buprenorphine use, and the perceived ease of introduction. Increased education and awareness among officers working in the mailroom has prevented attempted introductions from reaching the inmate population, with diligent screening of incoming mail. The strips may appear faintly or not at all on simple X-rays.

In an article for The Daily Beast, former inmate Daniel Genis declares that Suboxone has replaced heroin as the drug of choice in prisons, (8) due in part to it being relatively inexpensive and easy to sneak in. He reports that Suboxone was diluted with water and snorted. It was even introduced into the prison as the orange coloring on children's "watercolor" artwork sent to inmates, and confirms several of the introduction methods previously mentioned. He states that one strip can be split among up to eight inmates, providing each with a day-long high.

Inmates may contact relatives or friends on the outside who are being treated for drug addiction, or may have contacts involved in pharmacy robberies or pharmaceutical diversion from the supply chain. Suboxone is known by the street names of Saboxin, Sobos, Bupe, Box or Boxies, Oranges, and Sub or Subs. The tablets were known as Stops or Stop Signs, a nickname that may persist despite their discontinuation. Careful monitoring of inmate communications, and especially inmate mail, will help prevent the introduction of contraband Suboxone to the inmate population.

Suboxone strips may be found in the possession of inmates or during cell shake downs, wrapped in paper or plastic wrap. They may also be hidden behind prescription vial or other labels. When our staff confiscated Suboxone, we required they photograph it for an incident report. Included in the incident report is a memorandum from a pharmacist that identifies the drug and confirms that the inmate was not authorized to possess it. The incident report is then processed through the disciplinary hearing process. In some cases, additional reports have been submitted to the Federal Bureau of Investigations, DEA or FDA. Consultation with health services staff, especially a pharmacist, is recommended for all incidents involving prescription drugs.

Suboxone, although used to treat patients with drug addiction, can itself be addictive and harmful to inmates, many of whom are predisposed to addictive behaviors or have addiction histories. It can cause undesired side effects, sedation and changes in behavior. It may interfere with performance of work duties and can interact with other drugs and exacerbate existing medical conditions.

It is also not recommended for use in pregnancy. Inmates seeking even the relatively mild high or pain relief it provides may also attempt to snort or inject the drug, unaware of the naloxone component, which can cause withdrawal symptoms, such as agitation, anxiety, insomnia, nausea and vomiting.

It would be wise to educate staff members and inmates about the signs and symptoms of opioid intoxication and withdrawal, so they can respond appropriately. Institutions with a high incidence of Suboxone misuse could also consider adding a buprenorphine component to their existing urine drug-screening programs.

Suboxone sublingual strips contribute to the illicit drug economy in correctional facilities that results in violence and management difficulties. Facilities should put forth efforts to make staff--especially mail room, custody and medical staff--aware of this particular drug and how its formulation allows for insidious and creative methods of introduction into the correctional environment.

ENDNOTES

(1) Edlund, M. J., Forman-Hoffman, V. L., Winder, C. R., Heller, D. C., Kroutil, L. A., Lipari, R. N., & Colpe, L. J. (2015). Opioid abuse and depression in adolescents: Results from the National Survey on Drug Use and Health. Drug and Alcohol Dependence, 152, 131-138.

(2) Daniulaityte, R., Falck, R., & Carlson, R. G. (2012). "I'm not afraid of those ones just 'cause they've been prescribed": Perceptions of risk among illicit users of pharmaceutical opioids. International Journal of Drug Policy, 23(5), 374-384.

(3) Paulozzi, L. J. (2012). Prescription drug overdoses: A review. Journal of Safety Research, 43(4), 283-289.

(4) Reckitt Benckiser Pharmaceuticals Inc. (2014). SUBOXONE (CIII): Package insert. Richmond, VA: Reckitt Benckiser Pharmaceuticals Inc.

(5) Ibid.

(6) Svrluga, S. (2015, Jan. 13). The drug Suboxone could combat the heroin epidemic. So why is it so hard to get? The Washington Post. Retrieved from www.washingtonpost.com/ local/a-drug-called-suboxone-couldcombat-the-heroin-epidemic-so-why-isit-so-hard-to-get/ 2015/01/13/4135d08c-812eHe4-9f38-95al87e4clf7_story.html

(7) Press Release. (2012, Sept. 25). Reckitt Benckiser Pharmaceuticals Inc. submits citizen petition to U.S. FDA requesting action to mitigate risk of pediatric exposure with opioid dependence treatment company voluntarily discontinues the supply of suboxone tables (buprenorphine and naloxone sublingual tablets [CIII]) in the United States. Reckitt Benckiser Pharmaceuticals Inc.

(8) Genis, D. (2014, July 17). This antiheroin drug is now king in the jailhouse drug trade. The Daily Beast. Retrieved from www.thedailybeast.com/ articles/2014/07/17/suboxone-is-now-kingin-the-jaiIhouse-drug-trade.html

Quinn Bott is a pharmacist and officer in the U.S. Public Health Service and worked in the Federal Bureau of Prisons for three years. He now attends medical school at the Uniformed Services University of Health Sciences in Bethesda, Maryland.
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Title Annotation:A View From the Line
Author:Bott, Quinn
Publication:Corrections Today
Date:Nov 1, 2016
Words:1720
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