Three thoughts on the NYT buprenorphine story
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Last week, the New York Times published “The Double Edged Drug,” a two-part series on the addiction treatment medication buprenorphine.  Given that Reckitt Benckiser’s buprenorphine-naloxone combination suboxone is the “the blockbuster drug most people have never heard of” that surpassed “well-known medications like Viagra and Adderall” and “generated $1.55 billion in United States sales last year,” it’s high time serious news outlets took a closer look at its use to treat addiction.

Part 1, “Addiction Treatment with a Dark Side,” lays out suboxone’s clinical and commercial successes alongside its abuse by addicted patients and profit-driven doctors

Part 2, “At Clinics, Tumultuous Lives and Turbulent Care,” focuses on treatment experiences, highlighting two clinics within 100 miles of Pittsburgh, and some of the obstacles people face in legally obtaining buprenorphine.

You can’t get through a paragraph without bumping into the “double edged” theme.  From the outset, author Deborah Sontag contrasts two patients–one who found recovery through buprenorphine and another who overdosed and died on it.  And in the second article, she points to the double edged circumstances of two prescribing doctors–one in a sweatsuit, the other in a white lab coat, both professing a desire to help patients, both financially incentivized to prescribe suboxone. 

All of these double edges may well lead readers to conclude that “This whole situation is a big old mess,” which is, in fact, the quote Sontag chooses as the last line of part one.

And as the articles (and the comment section) demonstrate, the use of buprenorphine to treat addiction and prevent substance use-related harms is messy.  Interlacing text and video, the NYT pieces illustrate those complexities skillfully.  Here are three points to keep in mind as you read:

1) Medication-assisted treatment reduces overdose deaths.

2) It is necessary and good that buprenorphine treatment is investigated and reported on.

3) Drugs are double edged.

Medication-assisted treatment reduces overdose deaths.  Buprenorphine prevents more overdoses than it causes. Although buprenorphine has contributed to many thousands of ER visits in the past ten years (the number increased nearly ten-fold from 2005-2010), a buprenorphine overdose death is relatively rare.  For example, the NYT cites a Reckitt study of 2,380 buprenorphine overdoses in young children, which “found that 587 had to be hospitalized in intensive care units and that four died.”  Buprenorphine overdose deaths pale in comparison to overdose deaths from opioid analgesics (almost 20,000 in 2010…100 people every day).  Appreciating the scale of the difference is important.

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SAMHSA Toolkit, 2013

What’s more, as Dr. Andrew Kolodny points out in the NYT, the US opioid overdose epidemic, which has coincided with the availability of office-based buprenorphine, would surely have been worse without it.  With so many friends and family members lost every day to overdose, Americans are mobilizing to tackle this thorny issue: communities are forming coalitions, states are upgrading prescription drug monitoring programs, and parents are learning the word “naloxone.”  Ensuring access to medication-assisted treatment, especially buprenorphine, is recommended in the statewide plan “Overdose Prevention Strategies in Massachussetts” (2012) and SAMHSA’s newly released opioid overdose toolkit, among other documents.

Whether you consider them harm reduction measures or recovery-oriented treatment tools, methadone and buprenorphine reduce opioid-related deaths.  Increasing access to them is an important (and under acknowledged) aspect of a public health response to the overdose epidemic.

It is necessary and good that buprenorphine treatment is investigated and reported on.  An important piece of the NYT series is the revelation that buprenorphine prescribing physicians have higher rates of disciplinary action taken against them for professional violations than non-prescribing doctors.  Nationally, Sontag reports that over 10% of bup prescribers have been sanctioned for professional offenses.  That number, not reported in the research literature (to my knowledge), shines a clearer light on some of the problems with bup treatment on the ground.  The series also reports on buprenorphine advocates’–both individual and orgnaizational–ties to pharmaceutical companies that distribute buprenorphine.  Again, useful information.  With suboxone (and an injectable naltrexone drug called Vivitrol), addiction treatment is interfacing with Big Pharma in new ways.  We ought to pay attention to these relationships.

Turning a blind eye to critical investigations of buprenorphine will not improve patient outcomes and public health.  When major news outlets report on addiction treatment, the conversation expands.  Those with experience in the field have an opportunity to comment and clarify their positions.  Reading the tweets and posts of experts weighing in on the NYT series has been a major learning opportunity for me and many others.

Drugs are double edged.  The NYT series eagerly painted buprenorphine as a two-faced paradox, as “a menace or a savior,” which, as a literary device, perhaps clouded the truth rather than elucidating it.

Paracelsus, father of toxicology Photo: Wikimedia Commons

Paracelsus
Photo: Wikimedia Commons

If the average reader comes away from the series thinking that buprenorphine does as much harm as good, that it’s not worth it, and that we’ve reached an impasse in our treatment of opioid addiction or prevention of opioid overdose, then Sontag got it wrong.  All medications with therapeutic value carry risk. Indeed, the double edge-edness of opioid painkillers themselves helped create this epidemic and the solution is not to do away with them.

One of the fundamental principles of toxicology, put forth by Paracelsus in the 16th century, is that “All things are poison, and nothing is without poison; only the dose permits something not to be poisonous,” often paraphrased nowadays as “the dose makes the poison.”

And most patients do not take prescription drugs as prescribed.

All this is to say that singling out buprenorphine as “the” double edged drug seems an inaccurate and potentially stigmatizing view of it.

Further Reading:

Yes, I’m Annoyed, and You Should Be Too – thoughtful and prolific blogger bemoans the healthcare establishment’s handling of buprenorphine treatment

The Anti-Addiction Pill that’s Big Business for Drug Dealers – NPR’s Planet Money podcast reports on the history of buprenorphine’s development, how government agencies have worked at cross purposes, and how that plays out in legal and illegal economies

New York Times Reax – commentary from another thoughtful and prolific blogger who does not favor buprenorphine maintenance