DRUGS NOVEMBER 19, 2013
Earlier this year, I followed Senator Joe Manchin to town hall meetings with constituents in southern West Virginia to see how voters were reacting to his role in pushing for expanded background checks for gun purchases. What I found, on the whole, was that voters weren’t that exercised about guns. What they wanted to talk about most of all was painkiller drug abuse, which has been wreaking havoc in Appalachia and many other parts of the country (prescription drug abuse is up 36 percent since 2002, according to the federal government, afflicting some 2.5 million Americans) and leading to a rise in heroin usage (doubling over the decade to more than 450,000 users) as authorities try to restrict access to prescription pills. One of the primary concerns the constituents raised with Manchin was the lack of options for opiate addicts seeking treatment. For one thing, they said, local residents had to drive a long ways to get access to buprenorphine.
Haven’t heard of buprenorphine? That means you’re happily sheltered from the hellscape of opiate addiction. But the drug, which goes by the commercial name Suboxone, has emerged over the past decade as the biggest development on the drug treatment front. Made by the British consumer goods company Reckitt Benckiser and approved by the FDA in 2002, the drug has proven remarkably effective as a “maintenance therapy” for opiate addicts. It allays cravings for painkillers or heroin while, crucially, being harder to get a high off of than methadone. That means it can be prescribed for use at home, with no need for traveling daily to a clinic, as addicts must do to legally obtain methadone.
Buprenorphine—bupe for short—has proven so successful at allowing opiate addicts to feel normal and go about their lives that advocates hail it as something of a wonder drug. And the benefits multiply—less painkiller and heroin abuse means less HIV transmission, less hepatitis C, and, yes, fewer fatal overdoses. Check out the recent trends in buprenorphine use and heroin overdoses in Baltimore, which has embraced bupe as a weapon against its deeply entrenched heroin problem. No, correlation does not equal causation—for one thing, Baltimore was over the same period also expanding the use of naloxone, medication used by drug users and EMTs to reverse overdoses as they’re occurring. Still, it’s hard not to draw certain conclusions from these lines displayed in a recent article in the American Journal of Public Health, which echo the plunge in overdoses in France, an early adopter of buprenorphine.
So what’s not to like? Why are we not shipping us much buprenorphine as possible into small towns in Maine and eastern Oregon and eastern Kentucky and all the other places reporting surges in abuse of painkillers and now, increasingly, heroin? Well, partly because bupe has gotten stuck with its own stigma—not as strong as methadone's, but damaging nonetheless. My old newspaper, the Baltimore Sun, ran a very critical series on the drug shortly after I left the paper. My current employer, the New Republic, chimed in not long ago with a piece about the troubles that the country of Georgia has had with a more powerful form of the drug called Subutex. And now, in by far the biggest p.r. blow of all, comes a massive two-day series in the New York Times that casts bupe in a deeply ambivalent light.
The reporter, Deborah Sontag, is to be commended for deep reporting on a realm of American life that is far too easily overlooked. She takes pains to present the complex picture that has emerged since the drug’s debut, with many accounts of opiate addicts who—using their real names, in a sign of remarkable candor—credit bupe with saving their lives, alongside accounts of the complications that have arisen with the spread of the drug, including Reckitt Benckiser’s questionable efforts to keep the market all for itself. But for all of the granular reporting, the overall tone and framing of the pieces is bluntly ominous: “Addiction Treatment With a Dark Side: In Demand in Clinics and on the Street, ‘Bupe’ Can Be a Savior or a Menace” was the headline of the first article; “At Clinics, Troubled Lives and Turbulent Care” was the headline of the second one.
The dark cast of the series, running in the nation’s paper of record, is surely going to make it even harder for buprenorphine to gain acceptance from doctors, regulators and the friends and families of addicts. “If you’re somebody that doesn’t like it already, it’s not going to make you like it. And if you do like it, you may have doubts now,” said Dr. Sharon Stancliff, medical director of the Harm Reduction Coalition in New York and a strong advocate of buprenorphine treatment. “Policy makers will say we need more restrictions, when the science says we need fewer restrictions.”
And that could well only exacerbate the complications described by the article, because so many of those problems grow out of the restrictions on addicts’ access to the drug. When the drug was approved, it came with strict limits—doctors needed to attend lengthy training sessions, they could prescribe to no more than 30 patients at a time, and they needed to provide counseling. The 30-person threshold was later raised to 100, but advocates say that it is still far too hard for many addicts to find prescriptions, not least because the regulations forbid prescriptions by physicians' assistants and nurse practitioners, who are the primary health care providers in many rural areas.
With so many physicians not wanting to go through the hassles of being approved to prescribe the drug—and the attendant hyper-scrutiny from the Drug Enforcement Agency—addicts have increasingly had to turn to the doctors who are less shy about milking the drug for its commercial potential. And not surprisingly, the lack of ready access to buprenorphine has resulted in some addicts buying and selling it on the street, a fact that both the Sun and Times series dwell on considerably.
But this street-selling is not necessarily as foreboding as it’s made to sound. Of course addicts are looking to get their hands on bupe by whatever means they can—it staves off the horror of opiate withdrawal and makes them feel normal. Yes, some addicts go to great lengths to abuse the drug to try to get a high off of it despite its pharmacological limitations, by injecting it or mixing it with other drugs. But this needs to be kept in perspective, too. The Times cites data showing 402 fatal overdoses linked to buprenorphine in the United States reported to the F.D.A. from spring 2003 through September. As the article notes, this pales in comparison with the 2,826 attributed to methadone over roughly the same period and the more than 19,000 fatal overdoses from opioids overall in 2010 alone.
The fact is, there is no silver bullet for the country’s growing opiate addiction problem. And any approach is going to seem tainted, to bourgeois eyes, by the inherently chaotic and desperate nature of the milieu in which opiate addiction is rooted (though not confined to—painkiller abuse has been on the rise in tony suburbs, too). It would be deeply unfortunate if fraught portrayals in the media with decidedly oversimplified, alarmist headlines had the side effect of dulling one of the best tools we have in this fight.