“Subs. Who needs subs?” a woman called out quietly near the intersection of Kensington and Allegheny avenues on a recent afternoon. She had to be careful. This district, on the northern fringe of the city’s so-called “Badlands,” is clustered with loosely organized crews hawking pharmaceuticals from Percocet to Adderall. Drawing attention could get her banned from the corner, or possibly worse.

Like many people who are dependent on opioids in Philadelphia, the woman was freelancing—likely selling off the last of her own prescription for the popular opioid substitution medication for money to purchase heroin/fentanyl. It’s something I’ve seen countless others do during my time covering the overdose crisis.

A passer-by inquired how much. “Five dollars,” came the reply. The man kept walking. “Wait, wait,” the woman said. “Give me three.”

And with that, the man acquired his Suboxone at less than half the retail price of a customer paying in cash at their local pharmacy.

Three years ago, I reported for the Daily Beast on how Suboxone’s maker, Indivior, was engaging in a complex patent-hopping scheme to keep cheaper generic versions of the drug from hitting market. But after a rebuke by the Food and Drug Administration and a court defeat, pharmacies finally began stocking off-brand buprenorphine-naloxone formulations early last year. At least four manufacturers now produce sublingual strips of generic “Suboxone,” and many others produce a pill version.

Meanwhile, diverted “subs,” as they are still universally known on the street, are all over Kensington, where the sublingual orange-flavored strips typically sell for $10 a piece, equal to the cash price of the drug at pharmacy chains like CVS or RiteAid. (The pills, which are less desirable because they’re harder to split and reportedly make the mouth water, generally sell for half the price of a strip on the illicit market).

For many harm reduction advocates, ready access to Suboxone or equivalents, legal or not, is a good thing.

Subs are now the most commonly sold pharmaceutical here. And unlike Xanax or Percocet, which are often counterfeit pressed pills that sometimes contain fentanyl, all of the subs on the streets are diverted from legal channels.

For many harm reduction advocates who witnessed Philadelphia’s overdose rate skyrocket with the introduction of fentanyl, ready access to Suboxone or equivalents, legal or not, is a good thing. Jeff Deeney, a former social worker for Philadelphia’s drug court, goes so far as to suggest simply giving it away.

“They should put a free vending machine of the stuff right there at K&A,” he told me, referring to the well known intersection.

That’s not likely to happen anytime soon. But at the end of January, the harm reduction community won a significant victory when District Attorney Larry Krasner announced he would no longer prosecute mere possession of buprenorphine without a prescription.

“Buprenorphine-based medications are primarily used to treat opioid substance abuse, and are recommended by medical professionals including the US Surgeon General for people with opioid use disorder, including those who are pregnant,” said Krasner in a statement announcing the policy shift. “This policy is consistent with other, thoughtful jurisdictions’ efforts to prevent fatal overdoses and to reduce harm from America’s opioid crisis.”

Under the new guidelines, pending criminal cases in which mere possession of medications that contain buprenorphine is charged will be revisited. If the case contains no other charge, it will be withdrawn, according to a press release from Krasner’s office. Selling the drug will still be considered a crime, however.

What’s not entirely clear is how many people will benefit from the new policy. “The only Suboxone arrests I can recall over the last year have been in relation to sales, not possession, and included other drugs,” Chief Thomas Nestel, who heads the Philadelphia’s Transit Police, told Filter.

The layout of Kensington, which is bisected by the city’s elevated train line, sees subs often hawked at or near one of transit stops along Kensington Avenue, meaning that Nestel’s officers are in close proximity to the illicit subs market.

Nestel is a pragmatist when it comes to drugs, so I was not surprised that he seemed on board with the new policy. “The DA notified me of the decision before it was put in place and gave me the opportunity to discuss it with him,” he said. “Everyone in law enforcement is trying to come up with ways to reduce overdose deaths and successfully address the opioid crisis.”

Unsurprisingly, some doctors are less enthusiastic about Krasner’s decision. “Suboxone is an opioid, it’s abusable. People will like the feeling and chase a stronger high,” said “Dr. B,” a Suboxone prescriber who spoke to Filter on the condition that he not be named due to concerns about his employer. “I personally believe it will become the new gateway drug to stronger opioids.”

The counter-point is that far riskier opioids are already available to anyone who wants them. But ascertaining just who is buying diverted subs—which cost twice as much as a bag of heroin in Kensington, despite packing a fraction of its punch—is difficult.

Several street-level sources have told me that subs’ illicit availability has made “chipping” (using heroin only occasionally and filling in with burprenorphine) possible for them for the first time. Others carry a strip or two with them to ease the symptoms of withdrawal in jail (or turn a quick profit for the commissary) in the event they are arrested. A single 8 mg strip of Suboxone costs as much as $80 in county jail, and is typically cut into tiny pieces to maximize return.

Then there are people who are uninsured or poor and simple can’t afford the $250-350 intake fee to begin Suboxone treatment, or the $150 required for each monthly visit. (This seems like a good place to point out that under federal regulations, Suboxone patients qualify for five refills of the Schedule III controlled substance. But of the dozens of people I know or have spoken to who are prescribed the drug, I’ve yet to meet an individual who gets even one refill).

One thing seems certain though, given the sheer abundance of the drug on the street: Many people who have a prescription for Suboxone, who may get it free through county medical assistance or at a reduced cost through the Obamacare exchange, are not taking it.

There’s a fairly simple explanation for this.

“I’ve been doing this a long time but I have to tell you the fentanyl has changed the game,” said Dr. B. “It’s made it hard to induce patients and even harder to keep them. You have to be very cautious.”

Put simply, Suboxone—a partial agonist with a dosage ceiling of three strips a day—is no match for the amalgam of powerful fentanyl derivatives sold as heroin on North Phily’s street corners. It doesn’t “hold” people who are used to these high opioid doses.

Dr. B said that some of his colleagues now provide tramadol along with buprenorphine to ease the transition. He prefers to start with methadone and go from that to Suboxone—if the patient still wants it. Some Suboxone patients self-supplement with K2 or meth. But many Suboxone patients I’ve spoken with find that co-prescribed benzodiazepines help not only to mitigate withdrawal symptoms, but to provide the mood-elevating effects that help to retain people in treatment.

“Buprenorphine with benzos taken as prescribed is pretty innocuous. And if the alternative is buying pressed pills on the street, well…”

Mixing benzos with opioids can be dangerous. But unfortunately there is a pervasive belief that prescribed combinations with Suboxone or methadone are inevitably dangerous. In fact, the Food and Drug Administration issued a 2017 memo to addiction doctors cautioning them about withholding benzos from patients on burprenorphine or methadone. Some programs even dispense benzos themselves, along with a patient’s dose of methadone or Suboxone.

Dr. B told me that when one of his methadone patients repeatedly tests positive for benzos, he switches them to Suboxone. “As a partial agonist, buprenorphine with benzos taken as prescribed is pretty innocuous,” he said. “And if the alternative is buying pressed pills on the street, well…”

The widespread belief that MAT is simply about addressing the mechanics of physical withdrawal, and that it’s not supposed to feel good is damaging. Allowing people to feel good while on MAT is a key element in treatment retention. Denying people the medications they need to feel right causes people to drop out and return to adulterated street drugs, and many are no longer with us as a result.

Until we get this right, we’ll continue to suffer more needless deaths. In the meantime, the street presence of diverted subs may help many people to use fewer riskier drugs, and is nothing to fear.

Photo of a view under the Market-Frankford line on Kensington Avenue in Philadelphia by Dasprevailz via Wikimedia Commons/Public Domain.