Sample bias and unreliable self-reports of users shape distorted results falsified by objective measures and extensive evidence for “bupe” misuse as the norm, fueling the epidemic  

by Clark Miller

Published November 10, 2021; updated December 30, 2022

American Medicine’s authoritative research journal, Journal of the American Medical Association (JAMA) is on a roll.

Of sorts.

In 2017 JAMA featured an endorsement of the “innovative plan” from the FDA to promote use of e-cigarettes to deliver nicotine to users by inhalation as a form of harm reduction. 

That was followed, unfortunately and within months, by an explosive child substance use epidemic, “vaping”, that is established as being linked to stalling or reversal of decades-long, consistent declines in youth cigarette smoking and to new evidence pointing to association with new troubling diabetes trends

girls vaping

Wait . . . what? 

Nicotine and diabetes? That hasn’t been in the nightly news? Or in the conversation your doctor had with you to provide informed consent about vaping as harm reduction?

Whatever! Let’s lighten up. It’s all good. The FDA was, after all, “snuck up on” by vaping. Now they’ve thoroughly evaluated the risks, so we can be sure that the new approvals of e-cigarettes are based on scientific determinations that vaping is safe and effective for cigarette smokers wanting to quit. In any case, America’s watchdog press, with writers who are informed experts on healthcare issues, would have by now exposed any false or misleading information placing public health at risk

What’s that? Okay, alright . . . fair point – that a child nicotine use epidemic and early evidence of vaping as a gateway for adult cigarette use did not give JAMA reviewers or editors pause in publishing the logical, needed – but unfortunately bogus – follow-up, a validating research note on “e-Cigarettes for Smoking Cessation”, pointing to this study, widely celebrated in mass and social media as establishing that vaping of nicotine provides benefits to adults attempting to stop use of nicotine in combustible cigarettes (by “smoking”). Congruently, and in retrospect predictably, that “study” a) did not provide support, at all, for that conclusion, failing to b) due to errors in experimental design and interpretation of the most elementary and fundamental types – errors that would have been evident to any researcher or student with base competence.

That endorsement for vaping in the nation’s leading medical research journal, just like the one two years earlier, would have been taken as compelling and authoritative by suggestible medical providers who routinely encounter youth and adult smokers in primary care and other settings. Licensed medical providers suggestible enough to rely on clinical advice from pill salesmen who generously provided dinners over which they – the pill salesmen – explained the research establishing safety and effectiveness of opioid pain medications for all types of pain.  Suggestible enough to practice according to that clinical advice from pill salesmen against all relevant longstanding evidence of predicted harm that would have been provided in any legitimate medical education. Suggestible enough to then dispense the opioids without providing informed consent based on risk of harm

BELOW – Gross, minimizing distortions in America’s leading medical journal, JAMA, of misuse of doctor-prescribed buprenorphine (Subutex, “subs”, “bupe”) hide objectively measured and extensively reported diversion, abuse, use of bupe as consumable and currency fueling illicit opioid economies and an increasingly lethal opioid crisis.  

And an army of pretend healthcare writers and corporate media pretend journalists in collaboration with American Medicine and eager for a pat on the head did not have to be asked twice to spin results to provide potentially lethal public health misinformation – 

Purely coincidentally, that original research study – posing direct threat to public health by falsely attributing benefit to e-cigarettes (and to nicotine replacement treatment NRT) for smoking cessation – appeared in another authoritative outlet for dissemination of necessary fabrications from America’s Medical/Media collusion, the New England Journal of Medicine, which astute readers will remember as publishing the fake research that was not research at all and proved invaluable to that collusion in manufacturing the lies that predictably generated an increasingly lethal opioid crisis.

That crisis and the corporate media/healthcare collusion’s fix for it aren’t going so well. 

Secretary of Health and Human Services Xavier Becerra said the overdose epidemic has grown so severe that new measures are needed to keep people with addiction alive.

He’s right, of course, by all accounts, especially direct accounts from that expanding world of illicit and high risk opioid use and near death, repeated risk of death. “New measures” beyond the frenzied revivals to reverse potentially lethal opioid overdoses, exhausting first responders all over the country in a perverse and underreported cycle of continued, repeated revivals for opioid users. New measures because the widespread initiation and expansion of provision and community campaigns for use of the OD death reversing drug naloxone has not kept up with overdoses, despite its rapidly expanding use. 

Nothing, it seems, can keep up with the behavior of high-risk opioid use in communities, on the streets, users with knowledge of the risks, seeking out fentanyl. Or keep up with American Medicine’s continued mis-prescription and over-prescription of opioids

Or keep up with the “bupe” economy – the widespread diversion and exchange of doctor-prescribed buprenorphine (Suboxone/Subutex) in that expanding, increasingly lethal world of high risk opioid use, as documented for decades, ‘bupe”, “subs” the common currency, dispensed by medical providers, then traded on the street for “real dope”- heroin, fentanyl, with known risks. 

That brings us to consideration of another, more recent research article published in America’s top medical journal, JAMA – 

DESIGN, SETTING, AND PARTICIPANTS This survey study used nationally representative data on past-year prescription opioid use, misuse, OUD, and motivations for the most recent misuse from the 2015-2019 National Survey on Drug Use and Health (NSDUH). Participants included 214 505 civilian, noninstitutionalized adult NSDUH respondents. Data were collected from January 2015 to December 2019 and analyzed from February 15 to March 15, 2021.

MAIN OUTCOMES AND MEASURES Buprenorphine use, misuse, and OUD. 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.”

Let’s take a look. 

But first, here’s what America’s top, trusted experts on substance use and its treatment had to say about the results – 

Overall, an estimated 1.7 million people reported using buprenorphine as prescribed in the past year, compared with 700,000 people who reported misusing the medication. 

. . . 

Together, these findings highlight the urgent need to expand access to buprenorphine treatment, because receipt of treatment may help reduce buprenorphine misuse, the researchers said. Furthermore, they recommended the development of strategies to better monitor and reduce buprenorphine misuse.

. . . 

“Three-quarters of adults taking buprenorphine do not misuse the drug,” said Wilson Compton, MD, MPE, the deputy director of NIDA and senior author of the study. “Many people with opioid use disorder want help, and as clinicians, we must treat their illness. This study also underscores the urgency of addressing racial and ethnic, health insurance, economic, and geographic disparities in treatment access, to ensure that everyone with opioid use disorder can access this lifesaving medication.”

. . . 

“High quality medical practice requires delivery of safe and effective treatments for health conditions, including substance use disorders. This includes providing lifesaving medications to people suffering from an opioid use disorder,” said NIDA Director Nora D. Volkow, MD. “This study provides further evidence to support the need for expanded access to proven treatment approaches, such as buprenorphine therapy, despite the remaining stigma and prejudice that remains for people with addiction and the medications used to treat it.”

. . . 

Misuse is defined as patients taking medications in a way not recommended by a physician, and can include consuming someone else’s prescription medication, or taking one’s own prescription in larger amounts, more frequent doses or for a longer duration than directed.

So, clearly these results appearing in America’s top medical journal only reinforce the “proven” benefit of this “life-saving” medication. What is needed for continued progress against an increasingly lethal opioid crisis is to dispense more of the treatment. 

And this graphic in the JAMA report only reinforces the point – 

Notice how insignificant use and abuse of American Medicine’s proven treatments for their opioid crisis – Buprenorphine and Methadone – appear compared to other prescribed opioids. 

Except . . . the graphic is a clear, overt distortion of the relevant research question and of the information needed by Americans affected by an increasingly lethal crisis and trusting American healthcare to provide effective responses. And the truth. 

Hydrocodone, Oxycodone, other prescribed opioids are used very frequently and most often for time-limited pain relief – e.g. for surgery or after a tooth extraction. That’s entirely distinct from prescription and use of bupe and methadone – essentially prescribed, in the context of an opioid crisis, for individuals at risk of continued opioid dependence, harms and death. That’s different. And that population is much, much smaller than the number of Americans accessing dental work, surgeries, other conditions resulting in being provided other opioids for pain. That difference in prescribed population size is what the graphic represents, conveys. Masking the important question of to what extent each type of opioid is misused. Certainly not distorting that comparison intentionally. Of course not. 

That’s a troubling, deceptive distortion, because the relevant measure for the much smaller population using bupe or methadone – whose lives depend on effective use and benefit from those medications – is the extent, or percentage, of misuse that represents increased risk versus potential benefit, life versus death. 

And why. 

Here’s what that looks like graphically, taken from the original source of the data – presentation of data from the NSDUH survey (here as results for the 2020 survey) provided in the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) annual report

Huh! That looks different, doesn’t it? Bupe misuse sticks out like a used syringe. Methadone was not reported here, for the 2020 survey. But it was in the graphic, above, for 2019, misuse at 22.2 percent of methadone users. 

Visualize that – methadone misuse at 22.2 percent, out there next to buprenorphine at 26.5 percent on the right side of the bar graph – in the relevant, meaningful, graphic. Bupe and methadone – the opioids increasingly dispensed as “proven” treatments to Americans trapped in a life-threatening epidemic – are clear outliers, their levels of misuse exceeding that for other opioids, misuse about double of other opioids for bupe (Suboxone/Subutex). 

[update 12.30.22]

Here’s what that looks like – 

graphic of opioid misuse

More recent evidence (see also here in full post) from Washington D.C. is clearly invalidating of the suggestion of decreasing misuse of buprenorphine (and methadone). 

The DC Office of the Chief Medical Examiner (OCME) investigated a total of 17071 deaths due to the use of opioids from January 1, 2016 through August 31, 2021. This report examines the presence of opioids (heroin, fentanyl, fentanyl analogs, morphine, prescription opioids and the general category of opiates) in deaths observed at the OCME.

The two primary opioids forming American Medicine’s cure for American Medicine’s opioid crisis – Buprenorphine and Methadone – became comparable to or significantly more involved in lethal overdoses in 2020 and projecting for 2021 will far surpass lethal involvement of all other prescribed opioids recorded in DC. The clear trend is increase over the years 2018 to 2021 (remember that the values for 2021 in Figure 4 are for January through August only) for the two MAT opioids.

These are the predictable results from continued, increasing and less restrictive provision by American Medicine of the prescribed opioids established as fueling America’s increasingly lethal opioid epidemic.

That’s troubling. But not as troubling and not as clearly indicative of serious distortions that underestimate misuse of those opioids, the medical fix for America’s opioid crisis, as are additional distortions and misrepresentations in the JAMA report. 

Let’s consider those. 

Nonparticipation and selection bias

There is an extensive research literature on and longstanding identification and recognition of generalized error and limits to validity, subject to variability across a complex variety of factors, in data and interpretations of substance use derived from self-reports of the substance users. See, for example, here and for a more recent example here. Factors contributing to under- or misreporting include degree to which use and reporting of use (or misuse) is potentially experienced as stigmatizing or with potentially negative outcomes. That could include a user’s belief, even when reporting anonymously, that contributing by reporting misuse to a picture of generalized misuse of a prescribed substance might lead to policy or practice changes resulting in that substance becoming unavailable. It could represent general apprehension or opposition to disclosing personal information that indicates disapproved or disallowed behaviors, especially in the context of general insecurities regarding privacy and provision of information using or to digital information systems.  

The sampling protocol and details of methodology for the NSDUH survey are provided here. There are two stages: an initial screening of randomly selected households, then among households potentially completing surveys, requests to complete the surveys. For completed surveys used in the JAMA report, about 75 percent of selected households were screened in, then of those, about 67 percent of individuals completed surveys. That is, about 50 percent, one-half, of randomly selected households included an individual who would complete a survey. 

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


” 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. 

And in Dayton, Ohio – 

Our investigation shows:

Suboxone, the brand name for one of the treatment drugs, is being sold or traded for other drugs on the streets and in jails at Medicaid’s expense. Suboxone is highly available on Dayton streets and it’s been increasing, according to the most recent Ohio Substance Abuse Monitoring Network report. The drug is coming from legal prescriptions sold illegally on streets.

Cash or self-pay clinics have opened as demand for addiction treatment has increased. They often charge as much as $250 out-of-pocket for an initial visit, services that would be free to the patient if they qualify for Medicaid, and often don’t provide much counseling or other supportive therapies shown to reduce relapse rates.

Clinics or doctors who see fewer than 30 patients at a time don’t have to be state-certified and comply with the stringent standards of those who treat more people and are certified. That also means they aren’t being inspected regularly like the larger providers and the state relies on complaints to police them.

Here’s how and why this misuse of medically prescribed buprenorphine works so well and is so pervasive, from an insider’s observations

In the decade that I spent in the prisons of New York state, you will be shocked to know that I saw a lot of drug use. Ten years ago heroin was king; its availability set the price of things as varied as pilfered chicken legs, blackmarket Newports and blowjobs. But other drugs were always available; the gangsters smoked blunts in the yard, the white guys were all on pills, and the Spanish took MDMA and massaged each other in the showers. But it was always heroin that ruled the market.

The same stuff that had cost me a decade. I was in prison for robbery; it took a year and nine months of heroin addiction to take me from my desk in the publishing world to pulling stick-ups with a pocketknife. I got caught on a fluke and hit hard by the judge. Sentenced to 12 years, I did my minimum of 10 and got out in February this year. Never even heard of Suboxone back then, although I now know that it was available.

And it’s everywhere. Because of a national change in drug policy that encourages moving addicts on the street from methadone to Suboxone, which comes in the form of orange pills or sublingual strips, the prison yards of America are now full of inmates high on the substance, and it’s all over the streets as well.

. . .

Both the pills and the strips find their way into prison. The pills can be brought in by the guards, or smuggled through the visiting room, or even sent in by anyone who owns a canning machine and can print labels. You can get anything into prison with a canning machine and a labeler.

But the most common method is called “boofing,” That means someone (and it’s almost always a woman) fills a balloon up with drugs and passes it to a prisoner she is visiting. He then shoves it up his ass, which is usually pre-lubricated, since we were all strip-searched on the way out. Heroin used to come in the same way, either packed in bundles of wax baggies or as chunks resembling sticks of chalk. But no longer. Economically, there’s just no point in dealing heroin in jail anymore. After all, a dose of Suboxone that can be shared by eight convicts only costs five dollars on my corner in Brooklyn.

On the street, Suboxone is plentiful because it is prescribed, so junkies get their monthly allotment of several dozen doses, pay with a Medicaid card, and sell it off at five dollars a pill or strip to buy a real bag of dope. Seems to me like they are missing the point, but the addiction makes the decision for them.

However, just one of those pills or strips is way too much for a prisoner, whose system is relatively clean because although there are drugs inside, there just isn’t as much. So when the Suboxone reaches the joint, it is cut up into eight doses. Or 10 if the dealer is greedy. Each dose is enough to be high for a day. The price of the dose was two packs of Newports when I left prison in February, so a little over 10 bucks if the packs are bought in the yard on the blackmarket. For years, the urinalysis machines that the Department of Corrections uses tested for cocaine, THC and opiates. In 2012, they had to add a test for buprenorphine.

. . .

Suboxone now comes in little orange strips. As with the pills, it can be cut into eight doses, either used sublingually or mixed with water and snorted. But unlike a pill, a strip can be put under a stamp. In fact, three strips can be put under a big one. According to The New York Times, children’s drawings, with Suboxone used to color in the orange parts, have given the incarcerated father a lovely surprise. Several states have already learned to fear anything orange colored, even insisting on only white envelopes being used for mail so that concealed Suboxone strips can be seen with a light. Some states are now tearing postage off the mail; by federal mandate you cannot prevent a prisoner from receiving letters, but there is no guarantee of privacy.

It’s being called an epidemic, although in fact it’s really just a reaction to federal drug policy and the next step in jailhouse drug dealing. Drugs have been inside of prisons as long as there have been both drugs and prisons; Dostoyevsky was able to buy vodka in The House of the Dead.

Additional direct reports of the bupe economy, with medically prescribed buprenorphine as currency and commodity fueling America’s increasingly lethal opioid epidemic here, here, and here

Without consent 

More fundamentally, validity of self-reports and results for the NSDUH survey and JAMA report requires that users of doctor prescribed buprenorphine had conveyed to them by their medical prescribers direction, instruction, guidance in a meaningful sense on how and how not to safely and effectively use the bupe dispensed to them. 

But unless the state of New Jersey is anomalous, an outlier, compared to the rest of the U.S. in medical practices, then those users dispensed an addictive, commonly misused and diverted opioid were not provided meaningful guidance, were not provided informed consent that included risks of use. That failure to provide adequate warning and discussion of risks to patients being prescribed opioids has been, in effect, a standard of practice in opioid prescribing over the years that the opioid crisis has worsened. 

Those survey questions would have likely seemed confusing or meaningless to any survey respondents who, like 82 percent of New Jersey patients prescribed opioids, did not receive warnings about risks of prescription opioid use. 

Proven benefit of American Medicine’s lifesaving medications

By estimates based on NSDUH survey results, in 2019 2.4 million and in 2020 2.6 million Americans were provided buprenorphine. Those figures are consistent with independent evidence and reports for increases in provision of prescribed bupe over past years and decades, for example here and here. America’s top addiction treatment experts have established that buprenorphine is a “proven treatment approach” and a “lifesaving medicine”. 

This Pew report includes data for bupe provision up through last year, 2020, for Philadelphia and “other large urban jurisdictions” (Seattle; Detroit; New York City; Pittsburg; Las Vegas; Palm Beach County; Minneapolis; Baltimore; San Diego; Charlotte; Chicago; Cleveland; Miami; Los Angeles; Phoenix, Washington). By a more direct measure than newly waivered prescribers, buprenorphine prescriptions increased by 11%. That 11 percent increase is an underestimate of buprenorphine dispensed to the extent that policy and practice intent and efforts to increase numbers of doses per prescription were implemented to compensate for concerns about access to bupe related to early pandemic stay-in-place and other restrictions. 


That evidence and those authoritative, expert assurances predict, actually necessarily require, evidence of benefit in reduction or at least moderation of adverse effects of America’s epidemic of problem opioid use – by reduced high-risk opioid use, reduced overdoses, or reduced deaths due to overdoses – for their veracity to be supported. Conversely, if meaningful measures of high-risk misuse of opioids (non-lethal overdoses; lethal overdoses with effects of naloxone saves factored out; rates of drug injection-related infectious disease) have instead worsened over those years, along with increased provision of the “proven cure”, then those claims are invalidated, falsified, given the lie to

Provision of buprenorphine as a treatment for problem opioids use has increased over pandemic years, as well as over years and decades pre-pandemic. See also here, for reports of those increases on a specific state and locale basis. 

MAT trends with OD death trend

More than 2 million Americans used buprenorphine yearly, over past years, and even the bupe that is diverted, that finds its way to the street, is used therapeutically, as a “life-saving medicine” we are assured by America’s media-constructed “experts” and America’s Medical/Media collusion. 

And the more of that proven treatment that is provided to diseased brains, the more Americans overdose on opioids, and die of overdose, and contract injection-related infectious diseases due to high-risk opioid use, reduction of high-risk use the sole means of efficacy for provided buprenorphine and methadone

That’s not because buprenorphine and methadone and MAT are “proven treatments” or “life-saving medicines” or forms of treatment at all for compulsive opioid use. Those are all lies, just as the media/medical collusion consensus that opioids are safe and effective for use to treat chronic pain were lies. Lies with tragic, lethal effects, killing Americans every day.  

The opioid crisis is worsening, becoming more and more lethal each year, because of the true things about Suboxone and methadone and MAT, the things established by research. Research evaluated and interpreted competently, not spun into lies for protection or gain, lies publicized by insecure children playing at “journalist” or science writer, too frightened and dull to question or think. 

Here’s what we know, what is established –

Just as in generation of American Medicine’s opioid crisis, there has never been evidence to support the medical “treatment” for an entirely non-medical problem, not for chronic pain nor for compulsive opioid use. 

Research distorted and spun to sell the use of medication assisted treatment (MAT) never supported benefit for a variety of reasons involving deficits in the studies and interpretations, primarily related to the confounding effects of concurrent campaigns and use of the opioid overdose death-reversing agent naloxone. 

Naloxone saves, reducing OD deaths, are directly measured, and more than account for any moderation in opioid overdose deaths over past years and decades. 

Buprenorphine and MAT can have benefit only by reducing high-risk opioid use, measured by overdose prevalence; not by OD deaths, confounded by naloxone campaigns; or measured, for example, by incidence of opioid injection-related infectious disease

Evidence (follow links above) for all of those measures consistently falsify presumed benefit from buprenorphine and MAT.

There is no evidence that buprenorphine is commonly used effectively for therapeutic benefit, in or out of treatment programs. Instead the evidence consistently points to doctor-prescribed opioid substitutes Suboxone and methadone serving as consumable or currency in economies of illicit opioid abuse, fueling rather than treating America’s opioid crisis.  

The forces driving America’s lethal opioid, other substance use and mental health epidemics over the COVID pandemic are a continuation those driving lethal epidemics in the years and decades prior to COVID – pathological levels of incompetence, reckless neglect, criminally disordered, compromised and ethically impaired behaviors of America’s most esteemed publicly funded institutions entrusted with the responsibility to protect public health. There are no signs of capacity for change from within those systems, whose control of cultural capital empowers defiance of truth and accountability, as long as they hold power. 

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.

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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A Critical Discourse

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