OPIOID CRISIS MEDICAL CURES ARE CURRENCY FOR FENTANYL ON THE STREET? WHO KNEW?

If the neurobiological and clinical rationales and evidence for “safer supply” were ever valid, why must safer, failed buprenorphine and methadone now be replaced by more potent opioids?

by Clark Miller

Published February 3, 2024

From an editorial in the Ontario, Canada Toronto Sun – 

Toronto Sun editorial headline

A four-month investigation by columnist Adam Zivo with our sister paper, the National Post, suggests the federal government’s “safer supply” program meant to wean addicts off the deadly opioid fentanyl, is having the opposite effect.

In interviews with 20 health-care experts, including 14 specializing in addiction medicine, Zivo was told many addicts are selling on the black market the free drugs they are given to reduce their dependency on fentanyl, to buy more fentanyl.

Compounding the problem is that this has caused the street price of the opioid they are given as a substitute— mainly hydromorphone — another powerful opioid, although nowhere near as potent as fentanyl — to plummet down to a few dollars per tablet.

The lower street price for hydromorphone because of the increased supply, Zivo reports in, “Drug fail: The Liberal government’s ‘safer supply’ is fuelling a new opioid crisis” has led to a wave of hydromorphone addiction across the country, particularly among the young.

The problem is that while hydromorphone is five to 10 times more powerful than morphine, it doesn’t eliminate the craving for many addicted to fentanyl, which is 50 to 100 times more potent than morphine.

But hydromorphone can be deadly for novice drug users, particularly when hydromorphone tablets, intended for oral consumption, are crushed for intravenous injection, potentially leading to excruciating and disfiguring infections and in some cases, paralysis.

Does that seem oddly familiar? 

It will for anyone who has been paying attention to longstanding accounts of the “bupe” economy – of the lethal role of America’s gold standard proven cure buprenorphine in street economies of illicit opioid use, overdose and deaths mounting year-by-year, bupe serving as free, medically dispensed commodity, consumable, and currency including for fentanyl. See descriptions here, and here, and here (scroll down to “The bupe economy”).

Here are the pieces Zivo wrote based on his interviews and the investigations. 

Let’s go back to the Toronto Sun piece. 

A four-month investigation by columnist Adam Zivo with our sister paper, the National Post, suggests the federal government’s “safer supply” program meant to wean addicts off the deadly opioid fentanyl, is having the opposite effect.

In rationale, branding, and intent, Canada’s safer supply program is no different than the medical provision of “safer” substitute opioids in the U.S., Canada, and elsewhere begun decades ago, before fentanyl, and with predictable effects of worsening a lethal opioid crisis

The conclusion seems inescapable – that the New Safer Supply, of medically dispensed more potent, more powerfully mood-altering opioids morphine and hydromorphone constitutes desperate acknowledgment of the failure and harms of safer supply, of opioid substitute treatment, OST (aka MAT, MOUD). 

In interviews with 20 health-care experts, including 14 specializing in addiction medicine, Zivo was told many addicts are selling on the black market the free drugs they are given to reduce their dependency on fentanyl, to buy more fentanyl.

Those warnings, red flags, reports are similar to those available a decade ago, and earlier, from front-line healthcare workers in the crisis and those impacted directly by American Medicine’s use of buprenorphine in OST. 

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 – 

Compounding the problem is that this has caused the street price of the opioid they are given as a substitute— mainly hydromorphone — another powerful opioid, although nowhere near as potent as fentanyl — to plummet down to a few dollars per tablet.

The lower street price for hydromorphone because of the increased supply, Zivo reports in, “Drug fail: The Liberal government’s ‘safer supply’ is fuelling a new opioid crisis” has led to a wave of hydromorphone addiction across the country, particularly among the young.

Same for buprenorphine, “bupe”, “subs” on the street – it’s cheap and everywhere, partly thanks to Medicaid expansion, which, in effect, dispensed free bupe, more recently under relaxed safety standards, predictably worsening the lethal crisis by multiple measures

Buprenorphine is less valuable as a drug of abuse than hydromophone, a more potent and easily abused opioid, unless combined with a benzodiazepine, a common and potentially dangerous practice. Bupe drives mounting lethality in the opioid crisis by other means and uses

Bupe’s main value is as a free, medically distributed currency to be exchanged for cash or illicit opioids on the street, “real dope”, its unique qualities contributing to its value and exchange potential. 

 – 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.

The problem is that while hydromorphone is five to 10 times more powerful than morphine, it doesn’t eliminate the craving for many addicted to fentanyl, which is 50 to 100 times more potent than morphine.

Yes, that’s the problem. The problem underlying the decades-long “safer supply” of buprenorphine and methadone driving an increasingly lethal crisis, now with the more potent opioids morphine and hydromorphone. 

The opioids supplied, without there ever having been  a body of research supporting safety and benefit from the begining, do not meet the untreated needs of users desperately compelled to experience the relief from psychic pain and anguish that their more potent street opioids provide them, opioids easily obtained with the currency of their free, medically dispensed opioids. Their publicly financed vouchers.  

That desperately needed relief from the psychic pain that drove their dependene on opioids has never been treated, the effective psychological, mental health and psychosocial treatments and supports never offered to them. They don’t exist, displaced by cronyism employment systems and lethal medical interventions the entirely non-medical condition of compulsive substance use. 

Yes. 

It is actually that simple, that lethal, and that fucked up. 

You thought they had somehow become competent and ethical, and were telling you the truth this time?

The Sun editorial included an objection to concerns expressed about safer supply outcomes by Canada’s Prime Minister – 

Prime Minister Justin Trudeau defended the program when Conservative leader Pierre Poilievre accused the government of contributing to opioid deaths, based on the report, saying “the evidence is clear, harm reduction saves lives, some 46,000 overdoses have been reversed since 2017 … We will continue to trust the science.”

And the Prime Minister’s understanding of the evidence and “the science” was corrected by an astute commentator – 

comment on the Troonto Sun editorial

[The commentator may have in mind the potentially debilitating effects of a near-lethal overdose, rather than due to use of naloxone.]

Naloxone distribution and use to save opioid overdose subjects from lethal outcomes have increased dramatically in the U.S. and in Canada. Ignoring the obviously confounding effects of these reversals on trends or comparisons for opioid overdose deaths is a common way that the public is lied to about the efficacy of opioid substitution treatment (OST aka MAT, MOUD, now “safer supply”) as demonstrated for MAT program claims in the U.S.  and as we will see for claims made for safer supply in British Columbia in the upcoming post, OPIOID CRISIS: “SAFER SUPPLY” IS AS LETHAL AS EVER. 

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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