Update, Opioid Crisis – Word from the Street: The Bupe Economy is About Abuse not Self-Treatment

by Clark Miller

January 10, 2019

It would be hard to identify more nakedly and lethally discrepant accounts of reality than those of America’s opioid epidemic and costly medical treatment for it: 1) from the users – on the streets and in prisons – of the pain killer opioid economy fueling the lethal epidemic versus 2) assertions from the medical establishment supplying the addictive and diverted substitute opioids as a medical “fix” for the crisis.

STAT opioid deaths

That medical and “harm-reduction” view – that not just used-as-prescribed but also diverted (“diverted” = medically prescribed opioids that are obtained and used by someone other than the person prescribed to) and used substitute opioids like Suboxone (buprenorphine + naloxone) are providing significant benefit to opioid users as medical “treatment” – is the assertion provided to “Dopesick” author Beth Macy by National Institute of Drug Abuse (NIDA) medical addiction authority and champion of the long-invalidated “hijacked brain” disease model of “addiction”, Nora Volkow. As long as the person is not tapered off “bupe” too soon, the medical “treatment” is generally successful, and buprenorphine that is diverted and allegedly abused, in fact is used by persons in the process of successfully treating themselves for opioid use disorder, to avoid returning to problem opioid use (like heroin) during periods of withdrawal symptoms:

When a person is weaned too soon, his or her relapse feeds the perception that MAT is ineffective, reinforcing unfair and faulty notions about the treatment, said Nora Volkow, the NIDA official, “All studies – every single one of them – show superior outcomes when patients are treated” with maintenance medications such as buprenorphine or methadone, Volkow told me. She pointed out that most patients buying black-market Suboxone are really trying to avoid dopesickness – “and that is so much safer for them than going back to heroin” (from Dopesick, p 222).

As explained by the medical authorities consulted for this recent NPR report

Because of these attributes, few people use buprenorphine to get high. Instead, more people use it to prevent withdrawal and to stay away from other illegal drugs such as heroin and illicit fentanyl.

Some leading addiction experts argue that self-treatment with buprenorphine can save lives because it is used in place of more dangerous substances that are blamed for the continued rise in overdose deaths.

“It was not diverted buprenorphine that’s responsible for our current situation,” says Dr. Zev Schuman-Olivier, an addiction specialist and instructor at Harvard Medical School. “The majority of people are using it in a way that reduces their risk of overdose.”

It may well be, must be actually, that somehow the many Americans trapped in Appalachia’s and America’s lethal opioid epidemic and interviewed or reported on over the course of Macy’s research – the word from the streets and towns in Appalachia – constituted a freakishly biased, unrepresentative sample – because there are no, or essentially no, cases of patients being successfully “weaned off” or experiencing “superior outcomes” using the medical “fix” that U.S. public healthcare resources are essentially exclusively invested in. In Dopesick, there are treatment failures, buprenorphine-dependent patients, and deaths.

Volkow’s confident assertions are repeated by popularizers of the medical and well-funded “harm reduction” industry view, in featured pieces in major media and on social media by medical prescribers of the substitute opioids in opioid substitution treatment (OST), or MAT (medication assisted treatment) programs. Those assertions are authoritative, constructed as informed and credible, and as such, fuel a medical/pharmaceutical industry alliance with the Trump administration, U.S. media, and healthcare institutions to dedicate public healthcare resources to the strategy that results in widespread diversion (below).

Dr. Nora Volkow, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health where "Dr. Volkow’s work has been instrumental in demonstrating that drug addiction is a disease of the human brain."

And why not? If the rapidly expanding provision of the substitute opioid buprenorphine (Subutex, Suboxone) is an evidence-based “fix” for the opioid crisis, with buprenorphine as asserted by Volkow and a healthcare and public policy consensus as a medication with therapeutic gains not just for those it is prescribed to, but also for those it is illicitly diverted to and used by, then it deserves full support, as a medically-endorsed, proven “treatment” for problem and high-risk opioid use driving an increasingly lethal epidemic.

But there are problems.

naloxone

One problem is the science – there is no body of evidence, never has been, to support such beneficial effects (in reducing dependence on opioids, or high-risk opioid use, or overdoses, or overdose deaths, or any other opioid-related measure) instead overwhelming evidence of harm in the forms of diversion for abuse, illicit trade, involvement in high-risk use – and the apparent moderation of lethal opioid-related overdoses accounted for fully by concurrent increases in use of the reviving drug naloxone (Narcan) leaving no reduced OD deaths to be accounted for by OST, and . . .

The other problem, and focus of this post, is that the word on the street – the direct accounts of users, sellers, and direct observers enmeshed in drug use and culture – of use of the prescribed substitute opioids, the medical fix for the opioid problem, is . . . different. Radically different from  the word of medical authorities and their popularizers. Contradictory.

Someone is not telling the truth.

On one point there is little dispute – the potential for buprenorphine, or any other potentially mood-altering substance to be diverted and abused by individuals strongly compelled to gain the desired effects

From the street –

“You can cook anything down.”

From the research literature

The combination of a benzodiazepine with buprenorphine/naloxone (Suboxone in the U.S.) appears to moderate or compensate for any deterrent effects of naloxone in the formulation: “In 2006, the Malaysian government replaced buprenorphine, which was introduced in 2001 [102], with buprenorphine/naloxone to address concerns of buprenorphine misuse and injection [55]. After the transition to buprenorphine/naloxone, there was no reduction in injection risk behaviors among IDUs, but an increase in their use of benzodiazepines [55] (see Table 1). The concomitant use of benzodiazepines has been identified elsewhere, and has been attributed to an increase in euphoric effects of buprenorphine [53] . . .” expanding abuse potential of buprenorphine formulations.

In the Pacific Northwest, my work brings me in regular contact with those consumers, in rural areas hard-hit by the opioid crisis, including in Oregon where public healthcare fund payers are scrambling to control the runaway over-prescription of opioids that created the epidemic – by substituting another addictive opioid, buprenorphine, in OST (MAT) programs.

To the point: everybody knows the medical “fix” opioids are being diverted, misused and abused, – for the euphoric/sedative effects of the drugs – or to avoid pain of withdrawal, “bridging”, until return to illicit, problem use for euphoric/sedative effects – not as “treatment” to escape problem opioid use – and no one seems to mind talking about it.

In a conversation with direct observers or consumers in that “bupe” economy, on the streets and in prisons, Suboxone is affirmed as an integral commodity and currency in that economy of dependent opioid users facing an array of euphoric addictive opioids including heroin (only $20 for a day’s worth) and readily available Suboxone ($100 to stay comfortably high for a day). Interchanging heroin and the bupe prescribed by medical providers is, they say, “going from Scotch to Brandy”.

But why? In prisons Suboxone pills and film – easy to get in – bring top price and are preferred. Packaged and unadulterated, dose, quality and safety are known.

“Every Monday morning they get on the bus and go to #####” to pick up weekly buprenorphine scripts from medical prescribers, bring it back and trade to a dealer for heroin, a preferred injectable and preferred high. Dealers with means can get the sub into a prison where price and profits make those transactions worthwhile.

Huh. That doesn’t sound like a therapeutic use, like “treatment”.

Of course, those accounts of the users of medically prescribed and diverted buprenorphine could be fabrications, lies. Isn’t that what users do? Lie?

In the radically different accounts of the opioid economy driving the lethal opioid crisis, somebody is fabricating, deceiving an American public dying and trapped in a lethal epidemic: either the users on the street, or esteemed members of medical/harm reduction industries and their popularizers.

If there are criminally-disordered behaviors – deception, mendacity, reckless disregard for the safety and welfare of others – driving the opioid crisis, then it is the obligation of all concerned to identify them.

All concerned.

Maybe my sources in the Pacific Northwest are not credible, or exceptions, not representative of any real buprenorphine economy that does not function to provide the OST medications to individuals who are motivated to use bupe to stop use of other opioids, stop problem, high-risk use of drugs, access all needed therapies and supports for recovery, and return to healthy functioning in their communities, just like the medical authorities and their popularizers assure us they are. We have that assurance, after all, by our most respected, knowledgeable, beneficent and trusted institutions – medical, media and governmental.

 

Beth Macy’s “Dopesick” out this year (2018) chronicles first-hand accounts and observations of the users and user’s families in hard hit Appalachia.

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.

Well, it may be argued, that doesn’t prove any misuse ! All or most that diverted buprenorphine is going to motivated illicit opioid users who desperately need it to self-treat their opioid dependence, and who use it responsibly, as medicine to help stop problem use of opioids. We know that because the most trusted and knowledgeable sources – medical authorities – have assured us of that, based on their knowledge of the research and use of that knowledge to protect the public from unsafe use of opioid medications.

STAT opioid deaths

But . . . (Dopesick p 213)

“We have people shooting up Suboxone and abusing it every which way,” Mark Mitchell, the Lebanon police chief, told me. “For a town of just thirty-four hundred to have three Suboxone clinics – that’s absurd”.

Discrepant.

Someone is misinformed. Or misleading vulnerable Americans.

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.

90 percent of Suboxone abused!

That doesn’t seem possible. Must be an exaggeration, or fabrication. Clearly, someone is fabricating.

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.

 

A mass media necessary “truth” that was constructed, the watchdog media now along for their second ride. Just like they did with the opioid pills!, the prescription pain killers  over-prescribed yesterday for the non-medical condition of common chronic pain – constructed as a safe and effective “fix” for chronic pain and generating today’s opioid crisis.

I could be way off, but it appears that the abuse of today’s medical substitute opioid “fix” for the lethal crisis (the crisis created yesterday, by runaway, contraindicated prescription of an addictive opioid fix for the non-medical condition of common chronic pain – against all lines of longstanding evidence indicating against it) is real and widespread, is supplying a medical “fix” economy of abuse, just as users on the street are describing it.

As recently reported in the NY Times, Dayton, Ohio can be added as another outlier, like Plumas County in California, where overdose deaths dropped dramatically after concerted efforts, and use of public healthcare funds to initiate or expand interventions to reduce high-risk opioid use and lethal overdoses, the reduction in 2018 attributed to some combination of reduced carfentanil (a highly potent opioid linked to overdose deaths) on the streets, an intensive campaign to expand traditional substance use treatment programs, and high investment of public funds in expansion of medical prescription of buprenorphine. The headline for the Times piece, dated November 25 of this year, 2018, asks, “Can Others Learn From It?”.

Dayton header NYT

That question was highlighted as critically important, in a new light, with more recent reporting on the opioid problem and public health response in Dayton and Ohio by the Dayton Daily News.

That report – consistent with what we know about diversion and abuse of increasingly prescribed substitute opioids, criminal and unethical medical profession behaviors, and other problems – described misuse of public healthcare funds for ineffective approaches and supporting bupe abuse.

Dayton DN composite 2

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.

Concerns, below, uncovered by the News, disclosed directly by Dayton and Ohio treatment providers and others on the front lines of the crisis, echo early and ongoing warnings from France of treatment failures and deficiencies, diversion and abuse, pointing to overall failure of France’s decades-long opioid substitute experiment to construct provision of substitute opioids like buprenorphine (opioid substitution treatment = OST) as, itself, a form of “treatment” for the complex psychosocial problem of compulsive use of substances, a behavioral symptom of inner psychic distress and distortions.

“The fly-by-night, Medicaid-funded MAT treatment programs that have popped up have terrible track records. They are milking the system and not improving the lives of half the people who need their help because the state isn’t tracking their efficacy,” said Jan Lepore-Jentleson, executive director of East End Community Services. “Treatment programs need to be monitored for effectiveness.”
. . .

 

Other doctors and treatment providers in the area have reported the same story from patients and said they are concerned about the quality of care people are getting when they simply Google Suboxone clinics and find one with walk-in appointments and cash payments.
“It’s often medication without the treatment,” said Wendy Doolittle, CEO of McKinley Hall, a state-certified treatment center in Springfield.

“The prescribing of medication is what got us into this mess,” said Jade Chandler, president of Woodhaven Residential Recovery Center in Dayton, a state-certified facility that uses some MAT for withdrawal management but focuses much more on behavioral therapy.
. . .

It’s unclear how much diversion of Suboxone is happening from those paying cash and those using Medicaid or other insurance providers.
Treatment providers and users surveyed for the most recent Ohio Substance Abuse Monitoring report on drug abuse trends in Dayton said Suboxone is being sold in the parking lot of many clinics in the area for about $20 per 8 mg strip. One treatment provider stated in the report, “There are a lot of shady clinics, and people know where they are, and they know how to get it.”
. . .

A Dayton Daily News report from about a year earlier found that

A treatment drug widely-prescribed to help Medicaid recipients get off opioids is being manipulated, sold on the street and used as barter in area jails, according to addiction treatment advocates.

“The tragic result is that many addicts are selling their Suboxone script, using part of the cash as a monthly stipend and then purchasing much less expensive heroin or some other drug of choice,” said Burt Dhira, owner of Phoenix Recovery Centers with locations in Dublin and Newark.

Suboxone is the most-widely prescribed treatment option for addicts to safely withdraw from opioids. But it has become controversial. The thin strips that dissolve on the tongue are seen as too easy to divert and misuse, causing groups like the Ohio Addiction Treatment Council to argue for Medicaid to pay for other treatment options.

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.”

Elsewhere across the United States

In Kentucky: “Suboxone abuse is huge,” said Karyn Hascal, president of The Healing Place, a Louisville recovery facility where Stearns is being treated. “For some, it’s their primary drug of addiction. They’re choosing it over other drugs.” . . . At first, Stearns melted Suboxone tablets under his tongue. When the dissolvable strips came along, he figured out how to inject them intravenously to get the drug’s effects more quickly. His life spiraled so far out of control that he was kicked out of a homeless shelter for drug use.

Kentucky, where still, in 2017 “some doctors are selling the drug illegally, making the opioid crisis worse.”

Kentucky, where the more the U.S. medical treatment fix is provided, the worse the condition gets –

In New York, by this first person account, Suboxone (bupe/naloxone) is not just a major part of the illicit economy of opioid abuse on the street, but in prison as well, “to be high for a day”.

Not to get clean, or reduce risk, or manage dependence, but “to be high for a day”.

Nationwide, pronounced increases in buprenorphine-involved ED visits points to misuse and high-risk use, rather than use for “treatment”, as does the 59 percent involvement of “additional drugs”.

From results of an 11-state survey, patients in medically-supervised OST (bupe) programs use additional opioids or other drugs of abuse at high rates, constituting misuse, and do not retain in treatment and/or return to other opioid use after medical OST “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.”

In Pennsylvania, from on-the-street reporter Christopher Moraff writing 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.

90 percent of Suboxone abused ?

What about that alarming claim (from an addict, and entirely at odds with assurances from respected American medical authorities on the subject) that in a location in Appalachia 90 percent of all Suboxone was abused.

Based on reports from France, the “proven” model for America’s medical opioid substitute fix for the opioid crisis, that claim may not be less than credible.

– 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%.

shutterstock Suboxone

This is discouraging. It would have been comforting to believe, trusting the best and most authoritative minds and institutions in American medicine and healthcare, that a medical fix (okay, with an addictive, commonly abused opioid drug) would somehow provide the answer, the (perhaps prematurely) celebrated “fix” for the lethal opioid crisis – a crisis generated by another American medical “gold standard”: addictive opioids, with never a body of evidence for effectiveness, for the non-medical condition of common chronic pain.

But perhaps despite all the indications from direct reports of use of the medical “treatment” and associated outcomes establishing abuse and associated problems as the apparent norm, there really are benefits, gains, superior outcomes when patients are treated as Dr. Nora Volkow and others in the medical and media consensus have confidently discerned from the research. Beyond the consistent, widespread evidence outlined in this post and others, there are additional ways we can evaluate that hypothesis.

One way to evaluate that claim is to consider the fact that over past years, nationally, there has been remarkable expansion of medically planned and monitored dispensing of the medical treatment, illustrated graphically with data provided by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA):

If claims of Dr. Volkow, the medical and harm reduction industries, and their popularizers – that the remarkably increasing amounts of prescribed bupe dispersed, whether received directly or by diversion, are used primarily as treatment by motivated patients to reduce high-risk opioid use – are accurate, then necessarily we would be able to measure reduction in high-risk opioid use: e.g. gains in psychosocial functioning, reduced opioid dependence, reduced opioid-related overdoses, and/or reduced OD deaths.

By those measures, there is no evidence for benefit from the medical “treatment” or for diverted buprenorphine being used as self-treatment primarily or significantly:

No evidence of reduced lethal ODs that are not accounted for by use of naloxone which accounts for at least 4000 additional reductions in OD deaths each year

No replicated evidence for other psychosocial gains attributable to OST

No body of evidence from natural, community setting, randomized, controlled clinical trials to support gains from bupe OST as differentiated in controlled trials from other interventions and supports (e.g. increased exposure to naloxone intervention; psychosocial treatments and supports, needle exchange programs)

Instead nationally, as in Kentucky, opioid-related OD deaths, adjusted for known, direct moderation by naloxone use, continue to climb even as the population “dose” of the buprenorphine medical “fix” increases substantially.

Instead, persistently worsening crises, not only opioid, but for vulnerable Americans trapped in worsening public health epidemics of compulsive substance use despite decades and billions of public healthcare dollars diverted to medical fixes.

As outlined in a series of posts including here, the status of the evidence from France, American medical industry and popularizing media model for a promised, branded opioid crisis “fix”, is the same – pointing to predictably failed outcomes attributable to the provision of an addictive opioid drug as a medical “fix” for a non-medical problem.

shutterstock_man with pill

It turns out, after all, that the diversion of pubic heath resources to provide inappropriate medical interventions for non-medical problems predicts harm.

Who knew?

Who could have known?

All of us, actually – if healthcare, research, scientific and professional publication, and oversight systems had been simply performing legally, competently and ethically. If critical thought, critical analysis of research, and ethical reasoning had not been abdicated and overpowered by constructed, useful fictions. And if media had been performing the role of journalism, providing truths available for decades.