Many heroin addicts trying to break the grip of drugs and crime turn to a health center on West Saratoga Street for help. Some come asking for an orange pill they believe might be a "wonder drug" for treating their problems. Nearly 200 have gotten it.
They're among tens of thousands of addicts nationwide being treated with the buprenorphine drug Suboxone. Federal officials promote it as the best hope for overcoming opiate addiction and are encouraging thousands of doctors to prescribe the drug.
"I never understood this whole idea that you could just give people a pill and that that is the answer to drug addiction," she said.
The federal government equipped doctors and patients with little more than a pill when it approved prescribing buprenorphine to opiate addicts. The law doesn't require that doctors provide additional treatment - or receive much training to deal with the complexities of addiction. Nor did lawmakers authorize funds to help patients pay for the drug or additional care, costs that can quickly reach thousands of dollars.
Even with the extra services that a substance abuse clinic offers, Suboxone patients are having a hard time shaking old habits they learned on the streets. Up to a third of Merrick's patients have been caught at one time or another using illegal drugs such as heroin and cocaine. Other city clinics and doctors elsewhere note similar patterns.
Many patients also experience difficulty quitting the medicine, which is a narcotic. They become dependent on its effects or fear succumbing to heroin again. Lengthy use is often the norm with Suboxone, but its price becomes prohibitive the longer the treatment - especially for impoverished heroin addicts.
"It's really tough for those people, no matter what medication you give them," said Dr. Charles P. O'Brien, a University of Pennsylvania psychiatry professor who advises Suboxone's manufacturer on tracking abuse. Habitual drug users need job skills, among other things. "If they've been using heroin for 15 years, how's a treatment program going to turn them into a taxpaying citizen?"
The federal government had that sort of transformation in view when it approved buprenorphine in 2002 amid expectations that the drug would revolutionize addiction treatment with minimal abuse. But its wide availability is starting to create some of the problems it was meant to solve. An investigation by The Sun has found that patients are selling their prescriptions illegally, creating a new drug of abuse that some people are injecting to get high.
Hard-core heroin addicts, like the thousands living in Baltimore, are a difficult population to wean off illegal drugs, as they typically have criminal histories, unstable families and few job skills.
"It was never meant to treat people who live in chaos," said Dr. Erik Garcia, who treats addicts in Worcester, Mass. "It was meant to treat people who have gotten hooked on painkillers who have relatively stable lives. But the need is so huge, it ... outstrips the capabilities of the methadone clinics."
Methadone continues to be seen by many experts as the best replacement medication for heavy-use heroin addicts. Most of the 170,000 people being treated with Suboxone in the United States are pain-pill addicts who often have more resources to help them recover.
But Baltimore Health Commissioner Dr. Joshua M. Sharfstein says he believes heroin addicts also can benefit from Suboxone, especially if they get extra support. He enlisted six addiction treatment clinics to become the first stops for hundreds - and eventually perhaps thousands - of addicts. After being stabilized at the clinics, they can transfer to private physicians.
Vermont and some counties in Pennsylvania are also using a clinic model. But the vast majority of addicts in Maryland and other states aren't taking this more comprehensive route to Suboxone treatment.
Whether they get Suboxone directly from a doctor or at a clinic, addicts face similar challenges.
The clinics in Sharfstein's program have been able to transfer to private doctors only 122 of 653 addicts receiving Suboxone. One reason is that so many keep using drugs. Another is lack of health insurance.
A third to a half of the buprenorphine patients in the clinics have been flunking urine tests, indicating that they have been taking illegal or unauthorized drugs. People treated with Suboxone do no better or worse than addicts on any other type of treatment, clinic directors say.
Merrick said abstaining from illegal drugs is a significant sign that patients are committed to treatment. "If the goal is recovery," she said, "you can't fill the program up with people who don't want that."
It's not just heroin addicts who have trouble staying clean. Dr. Mark Logan of Rutland, Vt. prescribes Suboxone mostly to people addicted to the pain pill OxyContin. He said he had to kick out 45 percent of 139 patients for abusing other substances or selling their Suboxone on the street.