Hyped report on “deaths involving buprenorphine” with relaxed prescribing standards is smokescreen for the lethal role of bupe in a worsening epidemic

by Clark Miller

Published January 15, 2024

From a popularizing media source – 

  • During the COVID-19 pandemic, the U.S. government allowed qualified practitioners to remotely prescribe buprenorphine to treat opioid use disorder.
  • A cross-sectional study looked at 74,474 opioid-involved overdose deaths from July 2019 to June 2021.
  • Researchers report that buprenorphine was involved in less than 3% of opioid-involved overdose deaths during this time period.
  • The proportion of opioid-involved overdose deaths involving buprenorphine did not increase when prescription regulations were loosened due to the pandemic.

That’s certainly reassuring. Isn’t it?

And it makes sense. 

It does, doesn’t it?

If loosening access to bupe including by eliminating the need for clinical contact with prescribers (refills provided by phone call) and drug screen testing had been a problem, then that would be reflected by increased frequency of bupe detected in the overdose medical examiner reports, right? The lack of such a consistent or pronounced increase shows that relaxed clinical and safety standards did not have harmful effects. That makes sense, right? Because the way that bupe would contribute to increased high-risk opioid use, overdose and overdose deaths is by contributing significantly – directly and physiologically – to the central nervous system (CNS) depressive effects  and respiratory failure of opioid overdose along with the other opioids consistently found in the blood of the deceased when bupe was detected. Makes sense, right?

Other opioid like the most commonly found (as described in the original JAMA report) other opioid with bupe in the exam results, fentanyl, the illicit opioid of choice over the study period and orders of magnitude more potent and dangerous than bupe, a synthetic opioid formulated to minimize risk of such CNS depressive effects. 

“Buprenorphine involved” is the term used to describe the overdose deaths when fentanyl was present and bupe was detected as well. 

DUH! Like, how else could the gold standard medication be “involved” in an opioid death?

Still making sense? 

Maybe worth exploring more?

As we’ll see, it is the absence of bupe in toxicology and/or drug screen results and what that means that point to its lethal role in the a continuously surging opioid crisis. The lethal criss accelerating with relaxed clinical and safety standards for dispensing of bupe and methadone, not moderating. 

But let’s provide fair consideration to the expert results and interpretations provided, after all, in America’s top medical journal. 

Here’s validation from a popularizing writer, affirming that the spun results in the report sound just like the assurances she has gotten from America’s Top Addiction Experts when she interviews them. 

Beth Macy, a journalist who chronicles the United States’ opioid epidemic in the books “Dopesick” and “Raising Lazarus,” told Medical News Today that the study “is underscored by every interview I’ve done on the opioid crisis.”

Okay, except for anyone who’s actually read Dopesick, that’s not actually the case for every interview “I’ve done on the opioid crisis”. 

From an earlier post – 

And nearly a decade ago, more warning evidence, more signs

of predictable descent into America’s medically-driven opioid crisis, in Appalachia where writer Beth Macy was researching Dopesick –  

But black-market dealing of buprenorphine, especially Subutex, is rampant. And the drug can get you high if you inject or snort it, or take it in combination with benzodiazepines, a sometimes fatal blend (p 213). . .

Operating at clinics often located in strip malls and bearing generic-sounding names, some practitioners defy treatment protocols by not drug-testing their patients or mandating counseling, and by co-prescribing Xanax, Klonopin, and other benzodiazepines – the so-called Cadillac high.

“Their treatment is a video playing in the lobby as a hundred patients walk through to get their meds; it’s insane!” said Missy Carter, the Russell County drug court coordinator who has dealt with widespread abuse among her probationers as well as in her own family. . .

Overprescribing among doctors specializing in addiction treatment was rampant, according to several rural MAT patients I talked to who unpacked how Suboxone [not Subutex] doctors prescribed them twice as much of the drug as they needed, fully knowing they would sell some on the black market so they could afford to return for the next visit. Others traded their prescribed Suboxone for illicit heroin or pills.

In Dopesick, based on her interviews and research, Macy concludes that “Buprenorphine is the third-most-diverted opioid in the country, after oxycodone and hydrocodone.

From Chapter Ten – Liminality:

“People [outside of Appalachia] don’t believe me” said Sarah Melton, a pharmacy professor and statewide patient advocate who helps her husband, Hughes, run Highpower, their Suboxone clinic, which mandates strict urine-screening protocols, with on-site group and individual counseling. Suboxone, with its blocking agent naloxone, “is a wonderful medicine, but we were seeing actual deaths from Subutex here, where people are injecting very high doses of it. And it comes down to these physicians wanting to make so much money just like they did with the opioid pills!”
. . .

Hope Initiative angels like Jamie Waldrop and Janine Underwood were opposed to buprenorphine, because, based on tier son’s experience, it was too easily diverted and abused. Patricia wasn’t initially a fan either, because of the expense and the lack of accountability on the part of Tess’s doctor, whose drug-testing and counseling protocols seemed lax.

She texted me after taking care of a twenty-five-year-old IV Suboxone user at the hospital where she worked who claimed that 90 percent of all Suboxone was abused.

Tess’s experience with trying to access methadone, a substitute opioid with higher risk of abuse and lethal overdose, was not encouraging:
“I’m walking around the methadone clinic parking lot for two hours with a four-day-old baby,” Patricia said. “And it was loaded with addicts. It was a place where Tess’s circle of addicts would become even bigger than it already was.”
. . .

“It’s a broken system,” said Ramsey, the nurse clinician.

Later in Dopesick Macy provides this overview:

“It was in [the] Highpower clinic that several patients had first explained the diversion and abuse of buprenorphine to me . . .” – a credible pattern of epidemiological data collected throughout her research, but of no value to the harm-reduction and medical industries – “a practice harm-reduction proponents elsewhere in the country dismissed every time I brought it up.”

The trusted medical authorities and their popularizers, with the cultural capital to do so, have been constructing and providing a mass media truth more to their interest and liking – that diverted buprenorphine is provided to users motivated and desperate to use it as part of a “gold standard” medical “fix” for the opioid crisis, a medical treatment to stop their problem, high-risk use of illicit opioids.

It’s a lie

Back to our current post – 

But isn’t it possible, mustn’t it be, that things are very different now, that those lethal and failed outcomes have been moderated somehow by the experts managing the response to the opioid crisis? 


That failure and the continuing pervasive, lethal diversion and abuse are described here, and here, and here (scroll down to “The bupe economy”), also here, including the key role for bupe in economies of illicit use of opioids directly causing the OD deaths (fentanyl these days, something else tomorrow) as currency for those street opioids, for “real dope”. It’s not about bupe showing up in the OD reports with the drug(s) that caused the death, it’s bupe’s  absence after being used as publicly funded, medically-provided currency for the cause of death. Street currency obtained by  phone call to or online message to a medical provider. 

But we’re getting ahead of ourselves, more on that later. 

telemedicine by cell phone

It seems that what Beth Macy actually meant to say when she unintentionally misspoke (certainly there are no reasons to believe she would distort her statements related to the opioid crisis) was something close to, Well, if I discount the things I wrote in Dopesick that I got from interviews of the addicts and their families directly affected by the crisis and exposed to available medical care they received, also discount interviews of low-level health care workers providing direct care, and consider only what has been helpfully delivered to me in interviews of America’s top, trusted medical and addiction experts, then, yes,  this study “is underscored by every interview I’ve done on the opioid crisis”. 

She would be simply following journalistic norms and standards of competence by filtering out certain information and allowing that provided by medical and public health constructed “experts” to determine what is accurate and trustworthy in understanding of and determining clinical and policy direction  to protect lives by managing health crises like opioid, depression, other mental health and health crises, including COVID. Who could argue with that?

Back to buprenorphine, “bupe”

Buprenorphine is a synthetic opioid drug with qualities the same or similar to other opioids and some important differences. 

Its inherent biochemical and neurochemical features were from the start part of the branding and selling of bupe to vulnerable compulsive opioid users and the public as a form of treatment or support for stopping  problem opioid use, now for life-long opioid use of bupe or methadone. 

One attribute is high “affinity” or energy of attraction and fit to molecular receptor sites on central nervous system (CNS) nerve cells in the brain, where natural neurotransmitters and molecules of mood-altering substances initiate their desired (and undesired) effects – sedative, euphoric, anesthetic, etc.). That high affinity “outcompetes” other opioid molecules that might be present like those of heroin, or fentanyl. Bupe also has lower “activation” energy once at a receptor site compared to more potent opioids of abuse, thus producing more moderate effects, including potentially dangerous or lethal CNS depressant effects. That, in theory, is the rational for the belief that bupe provided by prescription could constitute a type of treatment for problem, compulsive opioid use, a rationale that in practice with real compulsive opioid users was increasingly disconfirmed from the start, then necessarily protected by lies, with predictable results

Early signs of failure in France and the U.S. led to a new formulation (Suboxone) with the opioid antagonist naloxone added – the drug used to reverse otherwise lethal opioid overdoses by blocking opioid effects, presumably adding a layer of safety and now the standard formulation replacing the pure bupe in Subutex.  

So . . . 

If you are a problem, at-risk illicit opioid user and your intent is to secure and use opioids to get the desperately needed relieving, sedative, euphoric effects you desire, you would take some Suboxone along with your heroin, or fentanyl, or carfentanyl ? 

Right. Only if you wanted to interfere with its desperately desired effects and waste some of the valuable Suboxone currency you may well have traded for your fentanyl and can again next time. Using the Subs with your opioid of choice is about the last thing you would do. 

Suboxone is found in some drug screens of illicit opioid abusers largely due to a primary role of Suboxone in facilitating continuing high-risk heroin or fentanyl abuse – moderating withdrawal symptoms over periods of scarcity, higher risk or a needed break from daily use of “real dope”. With a half life of about 1 to 2 days, Suboxone remains detectable for some 5 to 8 days or more, making its presence in drug screens of high-risk opioid users not unlikely and unrelated to the real risk of lethal overdose posed by the illicit opioid that is orders of magnitude more potent. Such overdoses  and lethal ODs are “buprenorphine involved” not due to any significantly contributing CNS depressant effects, but because the free, increasingly recklessly and unethically, doctor-dispensed Suboxone currency supported continuing high-risk opioid use, its presence or absence in the drug screen irrelevant.   

Why are “Subs” so valuable in economies of illicit opioid and other drug use? 

 – Suboxone strips are a safe, known dose of an opioid for use in “bridging” described above, to moderate unpleasant symptoms of “dopesick” between planned, continuing episodes of use of an illicit opioid, like fentanyl

 – Because of its demand and value, it is a currency – free currency thanks to American Medicine – to exchange for fentanyl, other opioids, other drugs, cash (see “The bupe economy”, here)

 – Combined with a benzodiazepine, “benzo” , the synergistic effect – the opposite as with another opioid – enhances a euphoric high

–  In the nearly eliminated case of risk of required office (or probation) visit with potential for a collected drug sample, Suboxone can be used over a period of bridging or by an associate not abusing opioids to produce urine that can be frozen, stored, then with easily available cheats, used to “spike” and feign a urine drug sample that will be complaint with MAT treatment and criminal justice demands

 – Suboxone, especially as sublingual strips, has been a common form of opioid more easily delivered into prison settings, increasing its demand and value

An opioid-dependent user medically prescribed Suboxone strips  as “treatment” and selling them for cash or in direct trade for other drugs has been common for decades, part of illicit economies of opioid and other drug use that support continuation of abuse of heroin, fentanyl and the increasingly potent and dangerous drugs that will replace them.

new opening of Suboxone clinic

Let’s review

Over a period of continuously mounting opioid overdose deaths, 

 – while escalating naloxone campaigns more than account for any moderation of rate of increase of those deaths, not treatments,

 – while medical provision of the gold standard opioid cure buprenorphine steadily increases,

 – America’s medical/research collusion and compliant, impaired media generate in America’s top medical journal and disseminate a smokescreen, a lie to hide the lethal role of MAT opioids in a worsening lethal epidemic intended to support continued relaxation of safety standards for those failed, prescribed MAT opioids.  

Less obviously and more lethally, any continuation or expansion of use of prescribed buprenorphine and methadone in “medication assisted treatment”, MAT, adds fuel to the lethal crisis, predicts additional  illness and deaths, constitutes continuation of “deaths involving buprenorphine”. 

That’s because there are no medications, drugs, or medical interventions of any type that are treatments or supports for compulsive substance use, an entirely non-medical condition

Every single visit to a medical setting or practitioner with the hope of being provided such treatment, every single lethally deceptive portrayal in mass media and culture of “addiction” as a medically treatable condition predicts additional illness and deaths. 

Like those we see mounting, year by year. 


Suboxone ad on a billboard

Why A Critical Discourse?

Because an uncontrolled epidemic of desperate and deadly use of pain-numbing opioid drugs is just the most visible of America’s lethal crises of drug misuse, suicide, depression, of obesity and sickness, of social illness. Because the matrix of health experts and institutions constructed and identified by mass media as trusted authorities – publicly funded and entrusted to protect public health – instead collude to fabricate false assurances like those that created an opioid crisis, while promising medical cures that never come and can never come, while epidemics worsen. Because the “journalists” responsible for protecting public well-being have failed to fight for truth, traded that duty away for their careers, their abdication and cowardice rewarded daily in corporate news offices, attempts to expose that failure and their fabrications punished.

Open, critical examination, exposure, and deconstruction of their lethal matrix of fabrications is a matter of survival, is cure for mass illness and crisis, demands of us a critical discourse.

Crisis is a necessary condition for a questioning of doxa, but is not in itself a sufficient condition for the production of a critical discourse.

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