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EPIDEMIC AND LETHAL CURE IN AMERICA’S DECAY – DEATH BY TELEMEDICINE

 

Despite pandemic-forced protections by reduced exposure of substance users to known harms – drug “treatment” and its associated religious subculture – drug abuse, overdose, and deaths have surged, demanding explanation with evidence, not lies

by Clark Miller

Published November 24, 2021

woman at laptop

Prologue 

Nearly a century ago, 1928,

American science and medicine were marshaled by the federal government under the Committee on Problems in Drug Dependence (CPDD) to bring together “the country’s best researchers” to find a nonaddictive pain reliever to solve the increasing problem of opioid abuse.  That work, as described by Sam Quinones in his unflinchingly “True Tale” of America’s lethal opioid epidemic, relied on a staff of psychiatrists, biochemists, physiologists, pharmacologists, and lab technicians with the Addiction Research Center (ARC) at the U.S Narcotic Farm outside of Lexington, Kentucky. It was “the world’s foremost center for addiction research”.

Those biomedical and biochemical researchers were, a century ago, focused on replacement drugs for opium and morphine, with group therapy and farm work added for presumed support. With less than 10 percent of those treated (likely no more than would have stopped use without any of the interventions) overcoming their opioid dependence, their strategies failed – failed to live on to this day: as what is now known as opioid substitution or medication assisted treatment (OST, MAT); as the sham treatment group therapy; and as a disease named “addiction”, a “chronic brain disorder” with medical treatment.

What Quinones did not write about that group of medically and chemically trained researchers experimenting on opioid dependent subjects at the Farm – where “For four decades, heroin and morphine addicts with long sentences would volunteer for studies because they were given dope” – is that none of those “best researchers” were qualified, none were within scope of practice, had the required competence, to research or formulate concepts or treatments for compulsive substance use or common chronic pain, neither remotely a medical condition or disease, or psychiatric condition, both fundamentally psychological, psychosocial, developmental, psychodynamic, mental health issues. The assembled failed experts might as well have been physicists, anatomists, and phrenologists.

Quinones, through “Dreamland”, weaves that doomed, benighted, lethal first step through a predictable American story of incompetence, graft, cowardice, capitalism, group think, and institutional failure including a complicit press, to arrive at America’s intractably lethal opioid and substance use crises. Along the way, forces including American Medicine, insurance industries, and big pharma colluded to create, sell, and maintain a lie – that all pain, including the non-medical condition of common chronic pain, is treatable medically. Central in that lethal campaign to medicalize chronic pain, insightfully described by Quinones, was the emergence of Managed Care – the deformed, antisocial offspring of a coupling of American capitalism with American healthcare practice.

A half century later in France,

public health institutions and professionals began a much larger-scale experiment, no less doomed.  

In likely the world’s least regulated use of high abuse and high dependence potential opioids, medical general practioners were essentially provided unregulated privileges to dispense Subutex and Suboxone beginning around 1995. Early reductions in opioid-related OD deaths are attributable to public health campaigns and increasing use of OD death-reversing naloxone over the same time frame. France began a campaign in the 1980s for use of naloxone, the opioid overdose death-reversing antagonist, and beginning later with increasingly less restricted distribution of buprenorphine (Subutex) by physicians in private practice, without requirements for specialized training or regulatory control.

Reports of misuse, abuse and contribution to lethal epidemics of illicit drug use emerged early.

In France, from this prior post – 

From the start in France, the U.S. and elsewhere the predictable abuse of buprenorphine

(Subutex, Suboxone), a euphoric addictive opioid, quickly became apparent. Congruent evidence of widespread diversion, abuse and trafficking has continued to mount.

 

French subutex was apparently so easily diverted and plentiful that it fueled a subutex abuse epidemic in Georgia. From the piece by Graeme Wood in The New Republic –

“But starting after 2000, you’d see the line jump dramatically, as if stuck in the ass with a syringe. What drove it up was an opiate called buprenorphine—brand name Subutex, street name “subu”—that effectively did not exist in the country before 2000.

At its peak, one in 20 Georgians was on hard drugs, with Subutex driving the epidemic. “It was like a millennium gift for Georgians who wanted to use drugs,” says George Tsereteli, a physician who is a member of Georgian parliament. . .

And now it’s gone: from zero users to hundreds of thousands and back to zero again, in a decade or less. The journey has been torturous, a case study in grotesque consequences and appalling trade-offs—some former Subutex devotees have taken to injecting pills dissolved in gasoline instead—and it shows that, whatever you think the solution to drug abuse is, you’re probably mistaken.”

The widespread diversion and illicit use has not been moderated over the decades of use in France – where (from this 2015 piece) “in recent years, dealers have taken hold of it and are supplying international drug rings. . . estimated that one prescription in four is currently being diverted towards small and large-scale trafficking.”

Part of the problem is that over the decades of unrestricted distribution of an opioid with abuse potential, French health systems have apparently been unable to regulate doctors and pharmacies either willingly engaging in illicit distribution, or not practicing competently and responsibly in ways to prevent buprenorphine use to become dedicated to abuse rather than therapeutic gains, “How can a doctor provide real patient care when dealing with 300 drug addicts? At this stage, all they are doing is renewing prescriptions.”

This 2015 report on French physician adherence to guidelines aimed at protecting patients and the public from diversion and abuse of a widely-prescribed addictive opioid are troubling and appear explanatory:

“We showed that the physicians we interviewed rarely took into account the guidelines regarding buprenorphine prescription. The actual prescribing of Buprenorphine differed from the guidelines.

Only 42% of independent Family Physicians (FPs), working outside the national health care system, had prescribed buprenorphine as a first-time prescription and 40% of FPs do not follow up patients on buprenorphine.

In terms of compliance with the guidelines, 55% of FPs gave theoretical answers that only partially complied with the guidelines.” [despite that] “physicians declared a high rate of participation in continuous addiction therapy training. 38% of FPs and more than 80% of Network or Hospital physicians reported having attended continuous medical training (CMT) in addiction therapy.”

These results from 2011, French physician reports, appear to document a remarkably, perhaps predictably, high level of misuse among patients prescribed substitute opioids that cannot be attributed to opioid-dependent patients diverting or receiving diverted buprenorphine for therapeutic purposes, instead for abuse or misuse (measured as “Misuse (Injection, Sniffing, Dose Fractionation, Modification of Prescribed Doses, and Combination With Psychotropic Agents) as Reported by Physician”). From two treatment “arms” or groups:

Group 1 (880 patients) – percentage of patients with no misuse = 15%.

Group 2 (1289 patients) – percentage of patients with no misuse = 16%.

Excerpts from the Erika Niedowski 2007 Baltimore Sun piece on diversion and abuse of prescribed buprenorphine in France, a decade or so after initiation of the substitute opioid campaign and a decade preceding the current push to implement unrestricted buprenorphine prescribing in the U.S. as the “fix” for the opioid crisis :

Dr. Jean-Pierre Aubert considers himself not only a general practitioner but a dealer of sorts . . .

He is not an addiction expert. He does not screen patients to ensure that they, in fact, are opiate-dependent and need treatment. He concedes that some of them might misuse the medicine, including by injection. And he acknowledges that some of the pills he prescribes might end up the stuff of street sales.
Getting addicts in the door is what matters. Even patients who initially show up seeking the drug to get a fix, he said, might progress into proper treatment.
“I’m a legal dealer,” he said. “But being a legal dealer, I can help them with many, many other health issues.”
Aubert, along with 20,000 other doctors prescribing the medication in France, embodies the revolutionary approach the country adopted 11 years ago in its fight against drug use and the public health problems that accompany it. The French system encourages physicians unfamiliar with addiction to prescribe buprenorphine and trusts patients to use it properly. . .

Schering-Plough, the company that sells it [buprenorphine] in France, terms it a “tremendous success story.”

But the French experience also has a down side, one the United States largely overlooked when it followed a similar path by giving private doctors authority to prescribe buprenorphine to addicts.
Buprenorphine, available in France in a formulation called Subutex, has proved addictive for many and has been widely abused. Pills that addicts legally take home are being sold illegally, just like heroin.
U.S. parallels – Similar problems have begun to emerge in the United States. Street sales are increasing, leading to growing abuse of the drug, a Sun investigation found. American addicts are also injecting buprenorphine, even though U.S. officials took the precaution of approving a form of the drug, Suboxone, with a chemical intended to deter injection. It is the only difference between the two formulations.
With the longest experience in using buprenorphine to treat addiction, France provides the clearest picture of the implications of making such a powerful opiate widely available.
Buprenorphine has become an entry drug for people who haven’t used opiates before, a re-entry drug for former addicts, and a factor in more than 100 deaths since 1996 when taken in combination with other substances, according to researchers and public health authorities.
The drug has created a quandary that no one seemed to anticipate: how to get patients off it. Many stay in treatment for years, including some who want to quit, prompting criticism that substitution therapy doesn’t address the underlying problem of opiate dependence.
Buprenorphine has been widely sold on the streets of France, and well beyond. A report by the French Monitoring Center for Drugs and Drug Addiction found that a fifth to a quarter of all buprenorphine sold was being illegally diverted. Pills originating in France are being smuggled to places as far-flung as the nation of Georgia and the Indian Ocean island of Mauritius.
“It’s overprescribed, and it’s too easily prescribed, without any control,” said Dr. Agnes Lafforgue, who helps recovering addicts at a treatment and assistance center in Toulouse, a university city in southwest France.
She questions treating longtime heroin injectors with Subutex, for fear they will inject it, too, and worries about its addictive qualities. She said she has “practically never” successfully weaned a patient off it, despite having done so many times with methadone.
“It’s a scandal the way Subutex has been introduced in France,” she said. . .

The French monitoring center reported in 2004 on Subutex trends. Because of its widespread availability, Subutex was serving as a first opiate for some drug users and a re-entry opiate for some who had previously injected heroin. The report found it to be highly addictive and hard to stop. And it was increasingly being used in dangerous combinations with alcohol, benzodiazepines (such as tranquilizers) and even cocaine. . .

Schering-Plough has aggressively promoted the drug in France, funding the work of harm reduction groups. . .

Lafforgue, the general practitioner from Toulouse, doesn’t see buprenorphine as a solution to opiate addiction.
“We’ve made drug users addicted to Subutex because it calmed them down,” she said. “We’ve cleaned up the country, but we haven’t solved the problem of drug abuse.”

Is it just French-model subutex, (pure opioid buprenorphine) with abuse potential, the naloxone added to buprenorphine in the U.S.-favored Suboxone formulation protective against abuse? Apparently not. Naloxone’s deterrent effect is active only when injected, and predictably work-arounds have emerged for abuse by other routes of administration and with polypharmacy abuse (for example with benzodiazepines) to enhance effects and overcome antagonist effects of naloxone.

For its reckless efforts, France has remained 5th worst among 20 European nations for high-risk opioid use.

And in the U.S. ? The more miracle medical cure is applied to diseased brains, the more opioid-related deaths have mounted.

As in France, the warning signs and reports came early and persistently, but not enough to learn from, to change course, to prevent deaths.

Two decades ago,

as described in Quinone’s Dreamland, prescribed methadone became less regulated and more frequently dispersed by doctor prescription. From an earlier post on misuse of buprenorphine and methadone in OST (MAT) programs – 

What types of outcomes might we predict from easing patient safety regulations and controls on dispersing of methadone,

an opioid with significantly greater euphoric effect, greater potential for abuse and lethal overdose than buprenorphine?

Here’s one clue, from Quinone’s Dreamland (p 190) –

Generic methadone, for years strictly an addict-maintenance drug, suddenly started killing, too. As media reports of OxyContin abuse and overdoses spread, some doctors began prescribing methadone for pain instead. . . some doctors figured that methadone was an equally long-lasting painkiller. Plus methadone was generic and cheap; insurance companies covered it. Methadone prescriptions more than quadrupled – from under a million in 1999 to 4.4 million in in 2009 nationwide – mostly for headaches and bodily pain.

. . .

As methadone prescriptions rose, so did overdose deaths involving methadone – from 623 in 1999 to 4,706 in 2007.

Nearly a decade ago, 

America’s paper of record described some of the known risks and dangers of provision of bupe in OST programs, the potential for misuse and harm. Along with this piece in the Village voice, included in an earlier post – 

Five months ago, Chris resolved that it was finally time to get clean.
Sort of. . .

After nearly a year of using, the days between doses started to get dicey, and Chris got worried. On the off days, he says, “I was never myself. I was irritable, exhausted, had no motivation or desire to do things I once enjoyed doing. I wasn’t happy.”
So, in between bags of heroin, Chris scored Suboxone, a prescription painkiller used to treat opiate addiction. He’d use it when he was making a halfhearted attempt to get sober, or when he just didn’t want to feel bad between bags. Thanks to its main ingredient, buprenorphine hydrochloride, Suboxone eliminated the agonizing heroin withdrawal, the “three days of complete hell” he had to go through every time he tried not to use. . .

Eventually, Chris decided he was spending too much money on the subs. He found a physician willing to prescribe him 24 milligrams a day—a “totally ridiculous” dose, he says, far too much for one person to take. (According to the drug’s manufacturer, U.K.–based Reckitt Benckiser, the recommended maintenance dose is anywhere from four to 24 milligrams.) He takes one or two strips each day, two to four milligrams, and sells the rest on Craigslist. . .

As the legal market for the drug expands, so does the black market pooling underneath. If Chris is too picky, Craigslist drug seekers can do business with 24-year-old Luis, who teams up with a friend with a prescription to sell the drug. Luis, who calls himself a “distributor,” is homeless and says he’s selling Suboxone to finance his move out of the shelters. That, and a desire to help folks. . .

In her line of work, Bridget Brennan sees—and busts—a lot of drug dealers. She’s immensely skeptical of the notion that anyone buying Suboxone on the street is taking it to get clean.
“To me, that seems highly unlikely,” she says. “You don’t need health insurance to go to a treatment center.”
Brennan is New York City’s Special Narcotics Prosecutor, and her office is responsible for prosecuting drug crimes. It was created by the city’s five district attorneys in the 1980s as a way to respond to a new epidemic of heroin and a corresponding citywide increase in violent crimes. . .

Brennan says that, in her experience, most dealers carry Suboxone as a way to keep their clientele happy; in recent years, her office has busted several drug rings that stock it alongside heroin, Xanax, and Percocet. Addicts buy Suboxone when they can’t afford their drug of choice, or when they have a pressing social engagement that requires them not to turn up totally high.
“It’s not being used in the context we’ve seen it to kick a habit or even to replace a narcotic dependence,” she asserts. “What I’ve seen is not a real commitment to getting clean, it’s just a way to control your habit a little bit better.”
Mike Laverde agrees. He’s a former heroin addict himself, now nine years sober and an intervention specialist with a Chicago company called Family First Intervention. Like Brennan, he sees black-market Suboxone users as just another subspecies of addict.
“They think they can take the Suboxone and come off drugs themselves,” he says. “But they can’t. The problem in the drugs department is them.” Without actual treatment, Laverde says, addicts are very likely to fall back into dependence on their drug of choice. That practice—toggling back and forth between the drug you like and the drug that helps you avoid withdrawal—is known as “bridging.”

“People cycle on and off, absolutely,” says Jose Sanchez, a substance-use counselor at the nonprofit Lower East Side Harm Reduction Center. His clients, Sanchez explains, tell him they carefully plan out their drug use. “They’ll stop taking the Suboxone for a couple days, so that by the third day they’ll be able to feel that zing of the opiate, whether it’s heroin or Oxycontin.”
It’s unlikely they’ll ever really get clean that way, he adds. “It certainly could work. But I think to be successful, you need every bit of support you can get”—i.e., counseling and a doctor’s supervision.
When someone self-medicates with Suboxone, Sanchez says, “You really can’t judge how well the medicine’s working for you. All you know is you feel good that day, and the next day you want to feel just as good.”

If you wanted to kick an opiate habit the aboveground way, you might visit a doctor like Dana Jane Saltzman, an internist who’s also one of the 1,600 doctors in New York State authorized to prescribe Suboxone. Her practice is hidden away in midtown, in a nondescript, five-story building not far from the marquee lights of the Ambassador Theater. She keeps two websites, one for her regular practice, and the other, NYCSuboxone.com, for people looking to get clean.
Buprenorphine is popular with Saltzman’s patients and other opiate addicts for one basic reason: It too is an opiate. . .

By 2006, Suboxone’s abuse potential had become pretty clear: A study of French buprenorphine users found that a lot of them were crushing up their tablets and injecting them. According to the European Opiate Addiction Treatment Association, the same problem soon turned up in England, Ireland, Scotland, New Zealand, Australia, Finland, and the Czech Republic. (A recent report in the daily Prague Post estimates that Subutex accounts for 70 to 80 percent of all drugs sold on the street.)
Also in 2006, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) found the same issue cropping up in the U.S., noting that buprenorphine abuse appeared to be “concentrated unevenly in Northeastern and Southeastern regions.” . . .

Saltzman has seen the rise of Suboxone abuse firsthand. She has had a license to prescribe it since 2000; in the past few years, the number of patients she suspects are diverting the drug is increasing.
“There’s a constant wave of diversionary tactics in here,” she says. “It’s constant and unending. It’s just piling up.” . . .

A few months after he began selling his prescription on Craigslist, Chris has decided to stop for good. “I pulled all my ads down,” he says.
Chris is muscular and pale, and he looks exhausted. He’s wearing a V-neck sweater and jeans, and carrying a shoulder bag that looks like something a doctor making house calls might use. He says he saw “many, many” people in the few months he was selling—including attorneys, fellow real estate brokers, and even one addiction counselor.
Chris says he got himself off Suboxone, a process he describes as “brutal.” He did it by transitioning to the painkiller Percocet, then weaning himself off that.

The experience of detoxing left Chris with mixed feelings about Suboxone. “On the one hand, it is a good thing,” he says. “It keeps people from stealing and robbing and overdosing. But it really just masks the issue: the addiction. From heroin withdrawals, you move onto Suboxone, and then you have to go through those withdrawals. It’s something that’s going to happen, but a lot of us choose to prolong it.”
In the longer term, he adds, the drug also made him feel “like total shit.”
“My girl always says I couldn’t even formulate sentences,” he explains. “I was not articulate. I couldn’t fuck her, excuse my language. I was just totally like a zombie. And then my feet were constantly uncomfortable. I couldn’t sleep without it. My eyeballs would turn into like these huge dishes, big pupils like Mickey Mouse.”
To his dismay, Chris realized that he initially felt even worse when trying to pull back on the Suboxone than when he experienced heroin withdrawal. “You’re exhausted for a very long time. It takes forever to get out of your system,” he says.

He believes now that his doctor didn’t adequately warn him that the detox drug had the potential to be addictive, nor about its “sticky” properties. “The doctor I was seeing—it was literally five or 10 minutes—he sits there and gives his typical speech about how bad drugs are, et cetera, and then he writes a scrip, and I’m gone. He gets paid, I go fill it, and that’s it.”

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

“a practice harm-reduction proponents elsewhere in the country dismissed every time I brought it up.”

– Beth Macy, Dopesick

About 4 years ago in Arizona

a natural experiment emerged, described in this post

But how the treatment program has worked in Arizona, actually, is to have predictably – based on longstanding evidence bearing on OST – increased instead of decreased high-risk opioid use as clearly illustrated by a measure of high risk use: non-lethal opioid-related overdoses – non-lethal overdoses to factor out confounding effects of changes in use of naloxone to prevent OD deaths.

Let’s look at the timeline and epidemiology.

For both non-lethal and lethal opioid-related overdose prevalence, the numbers decrease after the naloxone campaign is implemented, and prior to OST expansion, through October 2017 – that’s when rapid increase in provision of substitute opioids buprenorphine and methadone was initiated.

Then things change. For non-fatal overdoses – a measure of high-risk opioid use – prevalence then shows a steady increase through January of this year, over a period of 13 months.

For lethal opioid overdoses, the picture not much less clear – an increase in deaths over the three months following initial expansion of OST, then highly variable mortality over the following 12 months, with no evident overall decrease in opioid-related overdose deaths over the period following OST expansion.

Persistently and consistently, accumulating evidence

points to lack of benefit from OST (MAT), from methadone, from buprenorphine, instead to diversion, abuse, currency and commodity in increasingly lethal epidemics of illicit and high-risk drug use.

The more iatrogenic deaths mount, the more American Medicine and allied Media double down on the lies, here for example in America’s top medical journal, described in this recent post

The accuracy and validity of survey results requires the assumption that for the 50 percent of originally contacted households not participating and completing surveys, individuals whose accurate reports would have included misuse of their prescribed buprenorphine were no more likely to fail to participate than were individuals who would accurately report no misuse. 

That’s not a reasonable assumption, and there are ways to evaluate how that likely affected validity of results and conclusions. From this study, for example – 

More than two in five people receiving buprenorphine, a drug commonly used to treat opioid addiction, are also given prescriptions for other opioid painkillers – and two-thirds are prescribed opioids after their treatment is complete, a new Johns Hopkins Bloomberg School of Public Health study suggests.

. . . 

For their study, Alexander and his colleagues examined pharmacy claims for more than 38,000 new buprenorphine users who filled prescriptions between 2006 and 2013 in 11 states. They looked at non-buprenorphine opioid prescriptions before, during, and after each patient’s first course of buprenorphine treatment, which typically lasted between one to six months. Even though there are no universally agreed-upon guidelines regarding the optimal length of treatment, most people discontinued buprenorphine within three months.

They found that 43 percent of patients who received buprenorphine filled an opioid prescription during treatment and 67 percent filled an opioid prescription during the 12 months following buprenorphine treatment. Most patients continued to receive similar amounts of opioids before and after buprenorphine treatment.

Because the study data lacked information on patients’ use of illegal opioids like heroin, the results likely underestimate the proportion of patients using opioids during and after buprenorphine treatment. “The statistics are startling,” says Alexander, “but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment.”

That is, in a study using an objective method of evaluating misuse of prescribed bupe – use along with other opioids, defeating the clinical intent of the provision of bupe – and not relying on self-report of users, more than 40 percent misused, a level of misuse that can be confidently assumed to be an underestimate because use of illicit opioids was not measured. 

To summarize on one source of distortion and underestimate of bupe misuse in the JAMA report, attributable to self-reports versus more objective measures of misuse: 

43 percent misuse by objective measure of just one form of misuse (use with other opioids), that 43% almost certainly an underestimate by exclusion of illicit opioids

Versus

” nearly three fourths of adults reporting buprenorphine use did not misuse their prescribed buprenorphine in 2019″ claimed in the JAMA report based on user self-report

It should be noted that even the NSDUH participants answering surveys in good faith may likely not have accurately indicated this type of misuse – of another opioid, a benzodiazepine, or other substance to augment effects of prescribed bupe – due to how poorly the survey questions were constructed: 

Misuse was defined as use “in any way that a doctor [physician] did not direct you to use them, including (1) use without a prescription of your own; (2) use in greater amounts, more often, or longer than you were told to take them; or (3) use in any other way a doctor did not direct you to use them.”

That language could be easily misconstrued, or accurately construed, or intentionally interpreted to intend to ask narrowly about how the doses of bupe were taken, excluding consideration of addition of other substances for euphoric effect. 

An equally or more seriously distorting bias

would have been the exclusion of any respondents experiencing homelessness in the survey. 

That’s correct. There were no homeless individuals surveyed. 

Problem opioid use, homelessness and access to illicit, “street” buprenorphine (“subs”) and methadone are correlated. There may be a lack of formal research on misuse of prescribed bupe among homeless persons, but there are indications from observational reports including this report of medical bupe provision to “unsheltered homeless” persons in Chicago. 

“Of the individuals that are interested in Suboxone, we don’t have success with all of them,” said Wodja. Over the last few months, Wodja and his street medicine team members have surpassed over fifty participants in the Suboxone treatment program. There are many challenges when it comes to tracking the progress of participants, including locating the individuals to make sure they are following the regimen protocols, said Wodja.

Stephan Koruba, a senior nurse practitioner with the street medicine team, estimates that about twenty percent of the Suboxone program participants see it through to the end. But Koruba said that COVID-19 has pushed many to turn to the program, as resources and certain drug supply chains are inconsistent due to the limiting nature of the pandemic.

That’s an 80 percent Suboxone provision failure rate. 

The individuals in that 80 percent failing to maintain benefit from prescribed bupe almost certainly misused their Suboxone in the way they dosed or administered it, by adding other substances for desired effect, and/or most likely by using their bupe as currency for more potent illicit opioids

An alternate explanation might be that the 80 percent not maintaining engagement in the medical suboxone program used the “proven” treatment to free themselves of opioid dependence and move on with their lives, no longer with problem opioid use. 

I wouldn’t bet on that one. Would you? 

The bupe economy

An economy of illicit opioid abuse with medically prescribed buprenorphine serving as currency for more potent opioids is longstanding, extensive and extensively described, and fueling America’s increasingly lethal opioid crisis. Descriptions of this economy are included in previous posts here, here, and here

The HSDUH survey questions are constructed almost as if to avoid eliciting positive responses for this form of misuse. Again –

Misuse was defined as use “in any way that a doctor [physician] did not direct you to use them, including (1) use without a prescription of your own; (2) use in greater amounts, more often, or longer than you were told to take them; or (3) use in any other way a doctor did not direct you to use them.”

That language could be easily misconstrued, or accurately construed, or intentionally interpreted to intend to ask narrowly about how the doses of bupe were taken, excluding consideration of diversion to obtain, for example heroin or fentanyl. 

No, I didn’t use my prescribed bupe at all, I traded it for heroin. 

In Philadelphia

It’s a refrain dealers chant every day up and down Philadelphia’s Kensington Avenue, the city’s largest drug marketplace: “Subs — subs — subs!”

And as reported by NPR – 

Just a few blocks away from the bupe bus in Kensington, for example, Richard Ost owns an independent pharmacy. He says his store was one of the first in the neighborhood to stock buprenorphine. But after a while, Ost started noticing that people were not using the medication as directed — they were selling it instead.

Buprenorphine acts as a partial opioid agonist, which means it’s a low-grade opioid, in a sense. When taken in pill or tablet form, bupe is unlikely to cause the same feelings of euphoria as heroin would, but it might if it were dissolved and injected. Many people buy it on the street for the same reason Morano did: to keep from going into withdrawal between injecting heroin or fentanyl. Others buy it to try to quit using opioids on their own.

“We started seeing people [sell the drug] in our store in front of us,” says Ost. He says it’s unethical to dispense a prescription if a patient turns around and sells the drug illegally, rather than uses it. “Once we saw that with a patient, we terminated them as a patient.”

Ost explains that the illegal market for Suboxone also means that customers trying to stay sober are continually targeted and tempted.

“So if we were having a lot of people in recovery coming out of our stores,” Ost says, “the people who were dealing illicit drugs knew that, and they would be there to talk to them. And they would say, ‘Well, I’ll give you this’ or ‘I’ll give you that’ or ‘I’ll buy your Suboxone’ or ‘I’ll trade you for this.’ “

And from a street reporter, in Filter – 

“During more than a year of reporting on Philadelphia’s drug culture, I’ve met dozens of active heroin users who are being prescribed Suboxone or its generic equivalent. Almost invariably, they sell the drug in order to buy more-powerful fentanyl. Many are also homeless—and housing stability is probably the most critical component of holistic recovery.”

That’s right. Doctor-prescribed buprenorphine as currency to obtain and abuse fentanyl. 

For a more complete description of accumulating evidence documenting OST medically-prescribed opioid misuse, diversion, and use as currency driving lethal opioid economies as the norm see here, here, here, here, here, and here.

New York Times Building

We might reasonably conclude – are in fact compelled to conclude, and to act – that increasing provision of a lethal cure, a fix that is without evidence of benefit and instead fuels lethal epidemics, is a bad idea, a betrayal of public trust, an example of malfeasant and reckless behavior.

We would also predict, with the confidence gained from the historical pattern, that the evasion of culpability for errors of this magnitude would require more and more fabrications, distractions, lies, the concerted collaboration of America’s media/medical alliance.

That’s what we need to take a look at, and will, in a series of posts to follow. There’s a lot to set right, a lot to account for. Most centrally, why opioid overdoses and OD deaths would continue to increase through a pandemic under which high-risk substance users gained protection by reduced exposure to two factors – engagement in drug “treatment” in America and its associated religious subculture –  established as causing harm by predicting continued or return to problem substance use. 

For example, there is the confident assertion

that reduced access to those “supports” – treatment and AA and NA meetings – due to pandemic restrictions has led to problem users being at higher risk than prior to the restrictions, resulting in increased ODs and OD deaths. Because over the decades prior to the pandemic, while Americans with high-risk substance use were increasingly provided treatment as usual (TAU) i.e., “rehab, “addiction treatment”, AA and NA meetings including as mandated by courts and programs, the incidence of ODs and OD deaths were in decline, right? Or at least moderating, slowing, with some signs of efficacy for those vitally needed and effective supports, right? Instead of continuously, rapidly mounting? At rates of increase comparable to over the pandemic? Right? Were users unable to access American “treatment” or AA and NA meetings prior to pandemic conditions as well?  

See how I did that? See how transparent the lies are?

See how this is going to go?

A web of lies always eventually unravels, will inevitably decay.

medical professional behind computer monitors

But what about the assurances, the consensus that Goes Without Saying –

that it’s been the pandemic-forced social isolation, the physical social distancing causing isolation, that has generated acceleration of overdoses and deaths?

Right. Did that ever make sense? On the street, in the camps, in the parks, sitting, huddling, using opioids 6 feet away instead of 4 feet, or 3 feet away? That created significant changes in risk of not being responded to when needed? 2 or 3 feet? What about users who are not homeless, that is they have a home, apartment, a room with a bed somewhere. Pre- and during pandemic, their behavior and location for using would change? If users were going to work before or to treatment centers, is that when they would administer opioids in ways that placed them at risk of overdose? So, whereas pre-pandemic, significantly higher numbers of overdoses could be responded to because users were using in risky ways in those settings – in the office cubicle next to yours, in the treatment group – instead of more private settings where they could use without detection or jeopardizing work or program status, the same settings they would continue to use in during pandemic stay-in-place restrictions? That makes sense?

Fortunately, there’s objective evidence allowing evaluation of these unsupported claims that by repetition and group think became “truth”, became consensus precisely by virtue of their necessity as desperate,  fabricated distractions.

Like this observation serving as objective evidence,

based on data from a regional public health service, chief coroner’s office, and forensic pathology service contributing to the report that examined opioid deaths in 2019 and 2020. Between March 2020 and December of 2019 opioid deaths surged, increasing by about a thousand, compared to the same time period in 2019 — an increase of just over 75 per cent. And, based on the report, “about three-quarters of people die of opioid overdoses alone — a statistic that has not changed during the pandemic”.

“a statistic that has not changed during the pandemic”

Again, from the report, comparing pre-pandemic with pandemic periods, no difference in the proportion of persons dying alone. There were also no differences comparing pre-pandemic period with pandemic in opioid OD deaths occurring in private spaces including private residence; motel, hotel or inn; shelter/supported living; or rooming house. In contrast, more lethal opioid overdoses occurred outdoors during pandemic compared to pre-pandemic.  

And this large, existing body of objective evidence. Consider calls to emergency responders for apparent overdose, with response and administration of naloxone for revival. Think about it just a minute. How frequently are those calls for help made by the opioid user herself or himself in distress – with loss of alertness and attentiveness sufficient to require an EMR overdose response – almost never of course. Made by others, others nearby enough to perceive a user is in need of emergency response. If social isolation is a  explanation for the surge in OD overdose deaths, that would be reflected in a temporal stalling of prevalence of calls to emergency response for apparent overdose, or a decrease, and corresponding closely in time to onset of pandemic social and physical restrictions. Certainly not an increase in numbers of calls for emergency response, representing increases in social detection of opioid users in distress and invalidating the necessary fabrication of social isolation as explanatory.

What do you think that has looked like pre- and during pandemic conditions? There’s plenty of data out there. It’s been available for months and longer.

We’ll be taking a look at that in posts that follow in this series. It doesn’t fit with the consensus manufactured without evidence that pandemic-related social isolation is somehow explanatory for the pronounced increase in opioid overdose deaths beginning in May of 2020.

Here are additional reports –

serving as objective checks on the fabricated, unsupported distractions, reports that we’ll consider and identify a source for.

In a state where opioid-related OD deaths during 2020 increased nearly 40 percent compared to 2019, services like addiction treatment programs were minimally disrupted and continued to allow access to clients needing face-to-face support, “We were closed for a few weeks”, one addiction program staffer reported, then reopened.

One program client interviewed didn’t mind sharing a no doubt common but underreported story – underreported because it does not fit the necessary narrative providing distraction from what the evidence says about surging opioid abuse over the pandemic – that “Covid-19 ultimately helped [her], she said. The isolation kept her from people who weren’t supportive of recovery. At home, her family gave her the right support”.  That account is congruent with what everyone in the treatment industry knows and decline to expose – decline to expose typically out of cowardice and for job security – that the clientele at treatment programs and “support” meetings of the religious subculture AA or NA are about as triggering, dysfunctional and high-risk a social environment as any. They are, by decades of evidence, most likely continuing to engage in problem substance use and/or on a track to return to problem substance use at a probability of about 90 percent. That, of course, is because American “treatment” industries are not treatment at all, instead predict continued use.

That is, as accurately described by the program client, the social and treatment environment in American treatment programs is one of individuals who are not getting well because they are not getting treatment, are in the process of continuing or returning to problem substance use. 

But I digress, where were we? 

Right. In this state, an anomaly, treatment programs largely stayed open, or provided face-to-face access to pre-pandemic services more days and to a significantly greater extent than in other locales. With the same or worse than average result, a 38 percent increase in opioid-related overdose deaths compared to pre-pandemic.

That was in spite of efforts and measures, as claimed by the director of the state’s Alcohol and Drug Abuse Program, that their programs “remained open”, while other state’s programs closed. “As far as the work that we were doing across the state, that never stopped”. One program, for example, “kept its syringe exchange program and low-barrier buprenorphine programs open throughout the pandemic, and [a program staffer] saw a steady number of people use those programs.” In-person services were reduced for a time, but much less so than in other states and programs, “People, all day, every day, would come in and get help with crisis management — substance use crisis, mental health crisis, sometimes criminal justice crisis, and they would just drop in,” she said. Throughout the pandemic, the center allowed people who needed in-person treatment to come in.  Those continued services included enhanced assess to prescribed substitute opioids (“low-barrier MAT”) and peer support.

That doesn’t fit the narrative, the evidence-free fabricated explanations.

 

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.”

– Pierre Bourdieu  Outline of a Theory of Practice (1972)

In Bourdieu’s Theory of Practice, heterodoxy is dissent, challenge to what “goes without saying” – the accepted, constructed doxa, “knowledge”, reality, that goes without saying precisely because it “comes without saying”, without real scrutiny, untested, unquestioned. The function of doxa is not knowledge or truth or promotion of the collective good, but to protect and serve the interests of those with the power, the cultural capital, to create it.

And it Goes Without Saying as well, because it Comes Without Saying – that the heightened anxiety, stress with the onset of an ominous pandemic – with sudden threats to income, potential loss of housing, serious illness – are explanation, of course, for the escalation of high-risk use of opioids and other drugs with associated surges in overdoses and deaths. Everyone knows that.

Except, no.

It turns out, as we’ll see in multiple upcoming posts, that acute, exacerbated anxiety, objectively surveyed, as predicted surged significantly in the weeks prior to lockdowns and other restrictions, then rather quickly returned to baseline by April or May of 2020, before the significant surges in opioid OD deaths began. That result and evidence were predictable, are consistent and from multiple locales and surveys, and follow what we know about anxiety in humans related to lack of knowledge, uncertainty, and novelty of a stressor. 

And it turns out, as we’ll see in multiple upcoming posts in this series, that actual surges in opioid deaths – not by surmise or assumption, but by objective measure, consistently and across locales, nationally – did not occur in the timeline required by the fabricated explanations required to hide what has obviously happened, those fabricated explanations that America’s Media/Medical collusion has manufactured as expert consensus, as truth. Just as they manufactured truth to establish that opioids are safe and effective for pain, all forms of pain, some time ago.

Line of people waiting outside a methadone clinic

As America’s drug-related deaths mount – more than 100,000 the past year – we are increasingly forced to face the causes, to dispute the deceptions, the lies, fueling lethal epidemics.

That’s what we’ll do in upcoming posts.

More to come.

Stay tuned – subscribe at my Substack  Illness and Cure.

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.

Pierre Bourdieu - Outline of a Theory of Practice 1972

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