The December three-part series in the Baltimore Sun on buprenorphine, the drug approved by the Federal Drug Administration in 2002 for heroin addiction, compromised clarity and balance by burying key facts about the drug’s use and effectiveness and further exaggerated its potential abuse. Ostensibly motivated by a concern that potential abuse of buprenorphine was not well known by the public, the Sun ultimately produced a series that experts in the U.S. and France found to be extremely misleading.
Sun readers who are aware that Baltimore City, after careful planning, has added buprenorphine to its treatment modalities for heroin addiction must have been confused. But researchers, practitioners and funders (including the Open Society Institute-Baltimore) engaged in building a high-quality, evidence-based system of treatment in Baltimore, were truly irritated. Rather than explore the complexities of treating a chronic disease such as heroin addiction with buprenorphine, the Sun used the trappings of rigorous investigation—a team of reporters, international comparison, lengthy articles—to concoct an impending epidemic of treatment abuse.
Sensational headlines kicked-off the Sun’s campaign, followed by “reporting” that generally characterized heroin-dependent individuals–and even their physicians–as willful schemers. The result: an interested reader, let alone a casual reader, was highly likely to come away from the series believing that buprenorphine is not an effective treatment for heroin-dependent individuals in Baltimore or elsewhere, that the drug is generally being abused, and that buprenorphine treatment substitutes one high for another. Only a very careful reading of the series, ideally coupled with other sources of evidence-based information, would give the public a sense of the limited scale of the Sun’s charges of abuse. The Sun squandered a valuable opportunity to examine and educate the public about the challenges of treating chronic diseases–and the particular challenges of treating individuals who use other illicit drugs while being treated for heroin addiction. Reporting on abuses of treatment protocols is important but only meaningful if put in an informed context.
Therefore, my audacious idea is that the Baltimore Sun conduct its investigative reporting in a balanced, rigorous and evidence-based manner and rectify mistakes, when they occur, in a manner that readily gives the public access to the facts.
In an area as complicated as addiction, the Sun has a potentially important role in presenting what we know from research and from practice about buprenorphine and about the behavior of people suffering from the chronic disease of heroin addiction.
When experts in the field immediately wrote to the Sun about its various reporting mistakes and misleading statements, the paper choose not to print any of the letters until days after the series appeared, when many people were already distracted by the holidays. While the public editor of the Sun may think this approach meets journalism standards, we believe that Sun readership deserves a higher standard of reporting.
What follows is a sample of letters that were submitted to the Baltimore Sun, re-printed here in the original, unedited versions:
Submitted to the Baltimore Sun by Rebecca Ruggles, Director of Special Projects, Mid-Atlantic Association of Community Health Centers:
The Sun’s series of articles on buprenorphine was a shocker. But unlike the readers you were probably trying to attract, I was shocked not by the anecdotes of abuse and street sales that you chose to highlight, but by your stooping to this kind of sensational journalism.
Monday’s article leading off with a French physician describing himself as a drug dealer took a quip and misinterpreted it. That’s an insult to the many physicians who are trying to prescribe responsibly. Sunday’s article titillated readers with stories of drug stings and overdose deaths, while omitting to quote patients succeeding in treatment.
I expect the Baltimore Sun to be more intelligent than this. These articles play all the cheap cards that will keep people reading for lurid details of the sad and depraved lives of drug addicts.
The truth is buprenorphine (suboxone) is one of the safest and most effective treatments we have for a disease that is life threatening. Lives are being saved by this new medication; people are being restored to productive work and healthy relationships by receiving it. It is not a miracle drug. It is an important addition to our arsenal of weapons in the fight against a deadly disease.
The incidence of abuse and diversion of suboxone is small compared to what has already happened with prescription opiates such as oxycontin. The overdose potential with buprenorphine is negligible compared to that of methadone, which was our only medication in the United States for opiate dependence until 6 years ago.
I’m not saying that your coverage should avoid the difficult questions of drug safety and narcotic diversion. But these issues can be raised in a manner that avoids stigmatizing the disease and its treatment. Deep in these articles are references to the difficulties of balancing public health impacts – and the fact that there is no risk-free strategy. Then the articles quickly return to emphasizing instances of harm, instead of the science and the data, the weighing of risks and benefits.
That is journalistic choice – what to lead with, what to bury. That’s what I find so disappointing. There was a clear alternative – a way the Sun could have raised these issues to juxtapose the benefits and the risks – and to help readers understand the complexities of the public health challenge of treating addiction. You decided instead to go for shock value.
—
Submitted to the Sun by Alex Wodak, MD, Alcohol and Drug Service, St. Vincent’s Hospital, Sydney, Australia:
Buprenorphine is an effective, safe and cost-effective treatment for heroin dependence. In 2005, the World Health Organisation included buprenorphine in its Essential Drugs List. In the same year, the World Health Organisation, UNAIDS and the United Nations Drug Control Programme jointly endorsed buprenorphine as an important and effective treatment for heroin dependence.
The recent series of articles in your paper sensationalises and trivializes the difficulties of providing pharmacological drug treatment to heroin users with inadequate funding and limited community support. What is most needed from the media covering the complexities of illicit drug use and its important public health and public order consequences is what was lacking from your series: a sense of balance.
The USA has by far the highest rate of AIDS per capita in the industrialized world, three to four times higher than the next country (Spain). The grossly inadequate strategies to prevent HIV spreading among and from injecting drug users in the USA is largely to blame for this terrible legacy that is being passed on to unborn generations of Americans. Buprenorphine treatment has an important role to play in helping to keep HIV under control in the USA as it does now in over 40 other countries world wide.
Injecting drug users are somebody’s son or daughter, brother or sister. They are often someone’s mom or dad. Health care workers are obliged to provide treatment to injecting drug users based on evidence. As someone who has visited scores of countries attempting to assist HIV control among injecting drug users and a frequent visitor to the USA (including visiting Baltimore several times), I trust that this newspaper will soon return to this subject but to provide instead a properly balanced coverage of the issues raised.
—
Submitted to the Baltimore Sun by Christopher Welsh, MD, Professor at the University of Maryland School of Medicine:
In the Sun’s recent series of articles on buprenorphine, the many positive aspects of buprenorphine seem to have been lost in the overwhelming focus on its negatives.
The first and most important of these positive aspects is the number of studies that have shown how effective the medication is at helping people stop using heroin and prescription pain killers.
The diversion of buprenorphine, although an issue, must be put in the context of the illicit sale of other medications – for instance, there is even a black market for antibiotics and asthma inhalers.
As for safety issues, in the United States, there is little evidence that buprenorphine causes or even has a substantial contribution to the reported “buprenorphine-related deaths,” and there are no cases of deaths related solely to buprenorphine – unlike the more than 1,000 deaths per year as a result of heroin and other prescription painkillers.
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Submitted to the Baltimore Sun by Diana Morris, Director, Open Society Institute-Baltimore:
Your series this week on the abuses of buprenorphine (The Bupe Fix, December 16, 2007) distorts the true picture of an extremely promising therapy for heroin addiction.
If you knew someone who had diabetes and mixed insulin with alcohol or another drug, would you tell that person not to take insulin? If you knew someone with hypertension who combined blood pressure medicine with other drugs, would you tell that person to give up the blood pressure medicine? Of course not! You would reinforce the old rule that people shouldn’t mix drugs.
Addiction is a chronic medical condition much like diabetes or hypertension. Given the high societal costs of addition, the U.S. embraced buprenorphine as an effective treatment for heroin addiction, after carefully examining the experience of France and other countries.
A number of extraordinary controls guide the use of buprenorphine in the U.S. To prescribe buprenorphine, doctors go through an eight-hour certification course and are instructed to tell patients not to mix drugs, without their guidance. The addition of naloxone to buprenorphine in the U.S. significantly decreases its potential for abuse. As a result, buprenorphine is extremely safe when used properly.
Two years ago, the federal government made it easier for doctors to prescribe buprenorphine – with strict rules. Doctors can only prescribe it initially to 30 patients – and after a year to 100 patients. The Drug Enforcement Administration, with which all doctors prescribing buprenorphine are registered, ensures that doctors do not provide multiple prescriptions to a single patient.
The main point is that thousands of people in the U.S. use buprenorphine appropriately and therefore safely. It has helped them turn around their lives. In the process, it has saved the public all the negative health consequences and costs of heroin addiction, from HIV transmission and emergency room visits to property crime and incarceration. The Sun should also cover these successful stories, as buprenorphine is a powerful treatment for the devastation caused by heroin addiction.
I’m the Sun editor who oversaw the ‘bupe’ series in December. For the record, the series has been praised as well as criticized. NO ONE has disputed key findings, among them:
1.Diversion is growing as bupe becomes more widely available by prescription. Reckitt Benckiser’s own advisory committee acknowledges this.
2.Bupe can and is being abused. Naloxone — and Reckitt Benckiser acknowledges this — is not as much of a deterrent to snorting and injection as had been hoped.
3.Eight hours of training is inadequate for doctors inexperienced in addiction treatment.
4.The price of the drug — and of doctor’s office fees — is a major obstacle to treatment.
5.Congress did not take these issues into consideration when it laid the legal foundation for widespread prescribing of bupe.
Sincerely,
John Fairhall
Assistant Managing Editor
I am a RN, specialty is psychiatry, as well as the mother of a heroin addict. My son was on “bupe”- and it was NOT successful. The doctor my son saw was very expensive, my son did not have insurance, he was unemployable, he came to live with us to “try one more time to get it”- all the expenses were out of pocket-our pocket, and we are not wealthy- we went into debt to try to help.
The drug seemed to be effective for a short time, but then he needed more, as well as there was no counseling, he “checked in” w/ the receptionist, got his rx and was gone in 15 minutes, we had a doctors fee, and to pay for the rx. I tried to get assistance from the pharmaceutic co- but they AND the doctor made it next to impossible- they based my son’s needs on OUR income- my son was 29 at the time. The system has you going in circles, and there is NOT assistance in getting the treatment needed. I feel that bupe CAN be a good RESOURCE- however it should be rxd along with mandatory counseling, mandatory invovlement in a 12 step recovery program, life assistance skill training, community service, and job training. I work with addicts- it is not about the drug- it is what causes them to use- then go back and con’t to use- if they do not change – nothing changes and eventually they will use again- it may not be heroin at first- it may be abuse of the bupe- as I have seen over and over, as well as seeing how methodone is abused. I feel that in order to “stop the cycle” there must be a “whole person change” – not a drug just to ease the cravings. Believe me, my husband and I have tried everything with our son for a long, long time- nothing has been effective, in fact he is out using again, and we no longer have a relationship with him. I feel he was “unsuccessful with the “bupe” because it was too easy- it just made the cravings go away for awhile, and he did not choose to change other aspects of himself and his life. I have learned thur my personal as well as professional life that you cannot change anyone or make them want it- it must come from within, and by getting new and better drugs for treatment may seem to be the “cure”- however- I feel that the “whole picture” must be addressed not just one aspect. If I appear passionate about this- I am- this is the first time I have responsed to an article, but it just “hit me” and I am someone who has been involved and sees the damage done, people need to see the whole picture. There are doctors that are precribing bupe- and using it for a “quick buck”- as well as people getting it and abusing it. The “picture” is not simple- and there is not a simple answer.
In a city with a high rate of heroin addiction, we need to examine all modes of treatment. As Chris explains above, her son had a negative experience because the treatment was not accompanied by a therapeutic approach. Anti craving medication is an important tool as part of a comprehensive approach to behaviour change, thinking and living. There is no magic bullet for treating addiction; there is no one size fits all. It requires work on the part of the addict and the family to change their behaviours too. New anti craving meds are in development and the treatment industry is certainly looking at their role as an adjunct to other modalities. Treatment works. The longer people stay in therapeutic treatment, the better the outcome. None of this dialogue should blur that truth. Prescription abuse by teenagers that mimics heroin has increased dramatically in the last few years. We will need all the tools at our disposal to help addicts lead productive substance free lives.
Terry M Rubenstein
Secretary Hazelden Foundation
Executive Vice President
Joseph and Harvey Meyerhoff Family Charitable Funds
Chris and Terry Rubenstein make very good points, which we made the heart of part 3 of the series: Congress and the gov’t authorized the medicine, bupe, but did nothing to equip doctors and patients with the services — and training and financial resources — critical to successful addiction treatment. Baltimore’s program, e.g., tries to overcome these problems, with taxpayer-supported services, but that program is not the way most addicts in Maryland and the U.S. will receive bupe-assisted treatment.
Mr. Fairhall claimed in his posting that Congress did nothing to equip doctors and patients with the services, training and funding they need to ensure that addiction treatment is a success. I disagree.
For the first time in the history of the US, Congress requires doctors to undergo additional training (beyond the 4 years of medical school and usual 3 years of residency training) in order to prescribe a particular medication (buprenorphine). The Sun has no basis on which to contend that this training is inadequate, let alone necessary. Sadly, the training requirement has been one of the obstacles which prevent doctors from prescribing this effective medication. Thus, less than 2% of Maryland’s doctors have signed up on the federal website as being permitted to prescribe and most heroin-addicted patients in the US and in Maryland are not in treatment.
It is a common misconception that buprenorphine (or methadone for that matter) is not effective unless it is accompanied by counseling.
Rigorous research conducted in Baltimore and elsewhere has demonstrated that these medications, even when provided without counseling, signicantly reduce heroin use, crime and HIV-risk behavior. They work by blocking the euphoric effects of heroin (not merely by reducing craving). While other supportive services are often beneficial for many, they are not necessary to obtain signficant improvements. Furthermore, patients receiving buprenorphine treatment in the community can seek counseling or other support in addition to the care provided in the physician’s office. In summary, Congress didn’t need to provide additional services because they already exist in the public and private sector and are not even always necessary for effective treatment.
Indeed, throughout the world, buprenorphine is provided successfully by primary care physicians. These physicians in the UK, France, Australia and elsewhere are not required to obtain any additional training. They provide treatment without additional supportive services. Yet they achieve excellent results for the public health and for their patients.
Mr. Fairhall and I do agree that more treatment funding (federal, state and local) is needed for all types of effective addiction treatment (with and without medication). Until we provide sufficient funding to permit the majority of our addicted population to receive treatment, we will continue to suffer (and pay for)the consequences of addiction.
Finally, I would be delighted, if asked, to submit an op-ed piece to respectfully dispute the editor’s original posting of what he considered to be the five key findings of the Sun Series.
Yours truly,
Robert Schwartz, M.D.
Friends Research Institute
Medical Director
and
Open Society Institute-Baltimore
Senior Fellow
The Sun’s assistant managing editor, John Fairhall, lists a series of “key findings” from the paper’s recent series on buprenorphine that he maintains “No One has disputed.” To begin, I would list a different set of key findings: 1) buprenorphine is clinically proven to be an effective treatment for heroin and other opioid addiction; 2) expanded access to buprenorphine treatment, including through primary care physicians, has significant public health benefits; 3) buprenorphine has a superior safety profile compared to other available treatments for heroin and other opioid addiction; and, 4) given the pervasiveness and high social and economic cost of untreated heroin addiction in Baltimore and elsewhere, there is great need for the expansion of effective addiction treatments such as buprenorphine.
Unfortunately, many of the Sun’s statements were wrong or misleading, including some of the “key findings” set forth by Mr. Fairhall:
1) The Sun claims that buprenorphine diversion in the US is growing as the number of prescriptions for it grows. This statement is misleading. Problems associated with any medication will increase as more of it is prescribed. Buprenorphine is no exception. The fact that the amount of buprenorphine diversion increased from zero prior to its approval to some small amount is true. However, by any objective measure, the problems associated with diversion of buprenorphine are so small that the government is unable to measure them against the problems associated with prescription medications or heroin. The latter include over 1.4 million annual emergency room visits for the misuse or abuse of illicit drugs and medications, an estimated 300,000 US inmates with heroin addiction, a mortality rate for heroin-addicted people from 6 to 20 times higher than their non-addicted peers, over 240,000 AIDS cases in the US due to injection drug use, and costs associated with heroin addiction in excess of $20 billion per year. No approach to addiction treatment is perfect. However, the benefits of buprenorphine treatment far outweigh the risks to individual patients, their families and the community.
2) The Sun claims that buprenorphine can and is being abused and that naloxone is not as much of a deterrent to snorting and injection as had been hoped. This is also misleading. Most heroin-addicted people who misuse buprenorphine do so to relieve heroin withdrawal symptoms, not to get “high.” Reports indicate that this misuse of the medication leads some people into actual treatment. Paradoxically, this is an unintended, positive outcome, as the vast majority of heroin-addicted Americans are not in treatment. The shortage of drug abuse treatment availability unfortunately leads some individuals to obtain medications (some far more dangerous than buprenorphine) to “treat” themselves. The remedy to this treatment shortage is to expand (not to limit) access. It was anticipated that some people would use illegally obtained buprenorphine to get “high.” People in the thralls of alcohol or drug addiction do many self-destructive behaviors. Drug policy and treatment experts are examining these data and are considering changes in the naloxone content of the tablet to reduce the likelihood of abuse further. This is appropriate and shows that the system of monitoring is working.
3) The Sun claims that eight hours of training is inadequate for doctors inexperienced in addiction treatment. There is no basis for this claim. Physicians are trained in medical school for four years and for three or four additional years in residency programs. This training prepares physicians to recognize heroin addiction and to learn pharmacology. It equips them with the skills they need to prescribe the hundreds of new medications that come out on the market after their initial training is complete. The Physician Desk Reference has over 3,530 pages, three of which are devoted to buprenrophine. Yet, buprenorphine is the only medication in the history of the US that requires any additional training, despite buprenorphine’s superior safety profile compared to many other medications. Further, the eight-hour training program was developed carefully by addiction treatment experts from the major US professional societies.
Indeed, these training requirements are widely recognized as a barrier to the expansion of treatment. For example, less than 2% of Maryland’s physicians are listed on the federal website as being approved to prescribe buprenorphine. Experience in Australia, France and the U.K. (among many other countries) indicates that primary care physicians do not require this special training. Expanded access to buprenorphine treatment provided by physicians (without special training) in France has helped that country to experience a 50% reduction in HIV infections among drug addicted people, a 78% drop in overdose deaths and a significant decrease in drug-related crime.
4) The Sun claims that the price of the drug – and of doctor’s office fees — is a major obstacle to treatment. This is quite true. A key ingredient in France’s success story is that all its citizens have health care and medication coverage.
5) The Sun claims that Congress did not take these issues into consideration when it laid the legal foundation for widespread prescribing of buprenorphine. This is not true. Legislation permitting physicians to prescribe buprenorphine took five years for Congress to enact, underwent many revisions, and ultimately won wide, bi-partisan support. The relevant federal departments, including the FDA, NIDA, the DEA and SAMHSA, had significant input into the legislation, as did many of the major medical and substance abuse professional groups. The prevention of diversion was a key consideration all along. In fact, the legislation passed by Congress included extraordinary and unprecedented protections. Buprenrophine, as a result, is the only medication in the US that requires a physician to: (1) undergo special training; (2) register with both SAMHSA and the DEA for special buprenorphine prescribing privileges; (3) and limit the number of patients treated per physician to 30 in the first year and up to 100 in their second year (out of the usual caseload that a physician has of 1,500 patients).
John Fairhall has embarassed a fine newspaper by producing a series of articles on buprenorphine that is biased, misleading, and sensationalistic. His efforts make the Baltimore Sun look like a cheap tabloid.
Even his self-defense, given in the face of rather blistering criticism, is misleading and/or false. He claims five “undisputed” key findings of his series. They are all wrong or misleading; as such, we dispute them all:
1. “Diversion of buprenorphine is growing.” All prescription medications are diverted to unprescribed uses to some degree. Buprenorphine wasn’t on the market until recently. Until then, it couldn’t be diverted. Now it can, therefore it is, in small amounts. The legitimate question is whether there is a substantial, problematic amount of diversion going on. There is no evidence of a significant problem of buprenorphine diversion in the US. His assertion is misleading.
2. “Buprenorphine is being abused; naloxone hasn’t prevented this as much as was hoped.” Hoped? We all hope for world peace. Failing to achieve a hope isn’t news. Bupe does get abused on occasion, so does Tylenol. So does Ex-Lax. As far as anyone can tell, abuse of Ex-Lax by young women wanting to remain thin is a far bigger problem than what is going on with buprenorphine. Will John Fairhall be producing a three-part expose of Ex-Lax?
3. “Eight hours of training isn’t enough.” Compared to what? The ZERO hours required for prescribing morphine or cancer chemotherapy agents? The zero hours for performing any particular surgery? Only buprenorphine, among all medications, has a particular training requirement enshrined in federal law. Professional and state regulations guide legitimate practice. The federal training requirement is a peculiar, unique, unnecessary, and excessive requirement. It is eight hours more than enough.
4. “The price of the drug and the associated doctor fees are an obstacle to treatment.” The context is healthcare in America. The price of any and all drugs, and any and all doctor fees, are an obstacle to treatment of all diseases. This applies to cancer, heart disease, all mental health problems, everything. There is absolutely nothing unique here in regards to buprenorphine or addiction. His assertion is misleading.
5. “Congress did not take these issues into consideration when it laid the legal foundation for widespread prescribing of bupe.” Since “these issues” are false, exaggerated, misleading, or obvious, there’s no evidence that Congress failed to take any of them into appropriate consideration.
John Fairhall owes his newspaper, its readers, and his profession an apology, not additional distorted assertions.
Steve Coulter, MD
SteveMDFP -at- gmail -dot- com
Buprenorphine: The Little Orange Pill That Offers Hope to Many
Meena R. Abraham, DrPH and Martin P. Wasserman, MD
Would anyone with sound body and mind willingly risk their health and well-being for a high? Live every minute of every day trying to survive from one fix to the next?
Opiate addiction ranks as one of the most debilitating illnesses in the world with high health care and societal costs. Addicts often have higher rates of infectious diseases and other co-occurring morbidities – oftentimes their behavior results in destroyed families, increased crime rates and destabilized communities, all of which create a major burden on our local community and nation as a whole.
In the eyes of the medical community, opiate addiction is a health issue that often requires a long-term approach, analogous to managing high blood pressure or diabetes. It is a chronic medical disorder that has both physical and behavioral traits. Its underlying cause stems from changes in the brain that result from chronic use of opiate drugs.
Medical and psychosocial treatments have been found to limit these adverse effects while improving a person’s day-to-day functioning. The lack of common knowledge and awareness about addiction among health care professionals, policymakers, and the public has resulted in limited access to effective treatment for many individuals whose lives could literally be saved.
The Drug Addiction Treatment Act of 2000, revolutionized treatment for opiate addiction by bringing it back into the mainstream medical setting for the first time in more than 85 years. The centerpiece of this new treatment approach is buprenorphine, which was approved by the FDA in 2002, and is prescribed in a form with decreased potential for abuse, called Suboxoneâ.
Recently, readers of The Baltimore Sun were exposed to a series about buprenorphine, a relatively new treatment modality for opiate addiction that can be administered directly by physicians in the office setting. These readers, however, may have been left confused about some important facts about this drug and how it is used in treatment.
What’s so special about buprenorphine? It has been studied extensively in a number of countries and in the United States, and has been found to be safe and effective in allowing patients to stop using opiates while experiencing reduced opioid cravings and withdrawal symptoms. Many addicts shun getting the help they need because of the stigma associated with entering a treatment program. Patients can receive treatment with buprenorphine through a prescription obtained in the privacy of their doctor’s office. Most addicts, as indicated above, have additional medical problems, which can be treated by their physician together with their addiction.
Maryland ranks among the top five states in the nation with the highest heroin addiction rates, having double the percentage of primary heroin abuse problems compared to the nation as a whole. Despite the great and increasing rate of opiate addiction in Maryland, less than 25 percent of those who need treatment are actually receiving it due to insufficient resources, limited access to treatment services, the stigma associated with enrolling in treatment, and under-diagnosis of the problem.
Buprenorphine provides an avenue for allowing more persons to be treated for this problem, and it does so in the traditional physician-patient relationship. Although heroin has been the most commonly recognized opiate drug that is abused, prescription analgesics, such as hydrocodone and oxycodone, have become an increasingly growing problem. A report from the Drug Abuse Warning Network (DAWN) states that the incidence of emergency department visits related to prescription pain medications (e.g., Oxycontin, Demerol, Vicodin) had more than doubled between 1994 and 2001.
Over 300 physicians have currently completed the certification process and are able to prescribe buprenorphine in Maryland. These doctors have been through a special training program and must meet certain requirements to provide office-based treatment, including the capacity to make referrals to appropriate counseling services. But only about 50 percent of them are actually prescribing this medication and actually treating addicted patients. And usually they manage fewer than 30 patients at a time; which means that often it is difficult for patients to locate a prescribing physician.
Is buprenorphine treatment perfect? No. Will there be a small number of addicts who abuse it? Of course. But the overwhelming opinion of the medical and public health community is that buprenorphine is one of the best treatment options for treating opiate addiction. The challenge in buprenorphine treatment is not to limit it, but rather to expand its availability. We need to encourage more, rather than fewer, physicians to become eligible to prescribe buprenorphine so that additional individuals in need can and will access treatment.
Since 2003, the Center for a Healthy Maryland, an affiliate of MedChi, The Maryland State Medical Society, has been at the forefront of attempts to expand treatment capacity by educating and supporting physicians in providing office-based treatment for opiate addiction. Even with the proviso that this treatment is demanding of their time and resources, physicians have been very positive about the opportunity that office-based practice offers addicts for recovery. Some were surprised at how effective it has been for their patients, while others cautioned that it is not a magic bullet for everyone, but offers one more tool for physicians and addicts to use in the process of recovery.
Opiate addiction is not a run-of-the-mill health care issue. It is one of the most daunting public health challenges of our time. And, as with any health issue, success in winning the battle comes slowly. But progress, at least for now, has occurred with the additional treatment modality offered by buprenorphine, the little orange pill.
Let the public not be confused. This drug is safe and effective and certainly provides much more in personal and community benefit than it costs by the actions of the very few offenders who would abuse this drug, as well as the others that have formed the pattern of their lives.
The writers are, respectively, the Executive Directors of the Center for a Healthy Maryland and of MedChi, The Maryland State Medical Society.
OK, now I’m just starting to feel bad for The Sun…
Dear Editor,
Yes, buprenorphine ‘works’ predictably when used along the same lines as in published research. Virtually every study used doses which were supervised and within ‘programs’ parallel to typical methadone treatment.
It is possible that some addicts will do well with a simple prescription for weeks or even months of opioid medication. The majority will find it difficult to find the right dose which may vary from 2mg to 32mg daily. Addicts coming into treatment usually need help with a lot more than just finding the right dose.
I have been treating addictions in my medical practice in Sydney, Australia for over 20 years and find this drug is an excellent alternative to methadone – although it does not suit everyone. As in most research reports, we use daily supervision in new and unstable patients so the scope for diversion, injecting, etc is relatively low.
The ‘noble experiment’ engineered by the FDA in America has uncertain outcomes, some of which are being described in your article. Is this the first time a drug has been approved in America without a body of research to back up the protocols approved? Unsupervised, office based opioid prescription for addiction has not been properly trialed in America or anywhere else to my knowledge. The combination drug with naloxone has still not been shown to be equivalent, safe or as effective as the pure drug which has been around for over 20 years. The manufacturer has banned its use in pregnancy.
Andrew Byrne .. Addictions Physician, Sydney, Australia. http://www.redfernclinic.com/
I thank you OSI for offering a place for a spirited debate of a news article published in a newspaper.
I also, welcome the comments of the editor from the Sun. We need debate of issues. I sincerely request that you focus your attention with the ideas in this blog.
Our nation depends on educated informed discussion.
Sun News paper please act as a watch dog to inform people in a fair and balanced method or parish from lack of subscriber readership.
Again, thank you all, for engaging in spirited debate of serious issues,
Though I am not as informed as you, i enjoy reading your views.
Thank you OSI… Keep on, keepin on!
As a physician who prescribes buprenorphine, I am adding my voice to the chorus of disapointment and disbelief at The Sun’s shoddy one-sided reporting. It bears repeating that the series never summarized the peer-reviewed literature which methodically demonstrated buprenorphine’s effectiveness in controlled studies of large numbers of addicts, but instead relied on anecdotes. The article was a drumbeat of breathless bad news without perspective, with no attempt to compare benefits vs. risks. It was as if someone printed a sensationalistic report about aspirin’s side effects by recounting anecdotes, with no mention of the benefits or the real issues, and packaging it like some sort of expose.
The only response to the avalanche of criticism of this series would be to acknowledge errors and take steps to repair the damage. Instead, Assistant Managing Editor John Fairhall who oversaw the series, chose to say that “NO ONE has disputed the key findings”: that diversion is growing as bupe becomes more widely prescribed (of course), that Bupe is being abused (of course), that physicina training is inadequate and the price is too high. Since Mr. Fairhall did nothing to address the actual criticisms, his remarks just serve to further infuriate health professionals, i.e. people with actual knowledge of the issue, who see client after client whose lives are being saved by this treatment, (which has risks and benefits like all treatments).