More on that Suboxone settlement

I saw some questions about what it means. Here’s a little more context.

  • 2002 – Reckitt Benckiser introduced Suboxone.
  • 2010 – Suboxone’s patent is expiring and Reckitt Benckiser claimed that Suboxone pills present a safety hazard to children and should be pulled off the market while they introduce a new film version with a new patent.
  • 2014 – Reckitt Benckiser spins off Suboxone into a new company called Indivior.

Here’s some reporting on the implications of the settlement:

Reckitt’s settlement only covers allegations dating to the period before Indivior’s 2014 spinoff, Indivior said in a statement. Reckitt was not directly named in the feds’ criminal investigation, and prosecutors are still investigating Indivior’s own marketing of Suboxone. The company was indicted on criminal charges in April.

Fierce Pharma

So . . . that appears to be a wrap for Reckitt Benckiser.

Here’s the latest with Indivior:

The settlement partly clears the cloud of uncertainty over Indivior. The company sliced its 2019 sales forecast in half in May after the federal indictment and lower-than-expected uptake of its branded Suboxone Film. The company teamed up with Novartis’ generics unit Sandoz to roll out an authorized generic earlier this year.

However, Indivior reversed that revised guidance Thursday, announcing Suboxone’s “outperformance” in the second quarter. The company said its projected revenue on the year is now forecast between $670 million and $720 million—a 25% increase over the previous forecast—thanks to its success at preserving market share

Fierce Pharma

UPDATE: This ABC News article does a good job describing the allegations against Reckitt Benckiser.

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Suboxone maker to pay $1.4 billion in largest opioid settlement in US history

From ABC News:

Suboxone maker Reckitt Benckiser Group (RB Group) will pay the U.S. government a record $1.4 billion to end criminal and civil probes into the marketing of its addiction treatment medication, making it the largest settlement related to the opioid crisis in U.S. history, authorities said on Thursday.

This would appear to be tied for the 5th largest pharma settlement ever.

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2/3 of drug deaths?

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A couple of questions

First, we are currently witnessing rapid change / evolution / destabilization of the conceptual boundaries of recovery. How do these changes affect what it means to call a program or system recovery-oriented? What differentiates a recovery-oriented provider from others?


Second, Bill White frequently shares his epiphany that the orientation of research and service providers was on addiction (pathology) and treatment, to the exclusion of recovery. He called for “a fundamental paradigm shift” from a pathology orientation to a recovery orientation.

There has been a notable shift in locus of recovery advocacy efforts toward drug users rather than people in recovery, often framing communities of recovery as problematic. Additionally, the primary goal(s) of service systems are increasingly organized around death prevention and symptom amelioration. While there are real reasons for these shifts, what risks do they pose? How do they affect the risk of returning to a pathology orientation?

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Possible selves

Possible selves interventions

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improving treatment access

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harm reduction

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recovery-oriented harm reduction

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Is calling addiction a disease harmful?

In recent years there’s been a lot of attention and energy devoted to reclassifying addiction from a disease to something else–a “disease” of despair, a lack of social connection, a product of injustice and hardship, a product of deprived environments, a learning disorder, etc.

Now, there’s a recent study getting attention that suggests teaching clients addiction is a disease may be harmful.

Drug addiction is a disease. That has long been the consensus in the medical community, and in recent decades it has filtered down to the general public.

The hope among public-health officials has been that such messaging decreases the moral stigma that traditionally surrounds addiction, and instead will inspire suffering people to stop blaming themselves and get professional help. But newly published research suggests this framework “may have unintended negative consequences.”

The results of a new study suggest that, for many people who need help, “I have a disease” translates to “There’s nothing I can do about it,” or “It’s out of my hands.”


So . . . should we stop talking about it as a disease?

I’d say no, for a couple reasons.

First, it is a disease.

Second, I suspect that the problem is not with addiction being categorized as a disease, it’s the context for that categorization. I’d imagine there are contexts in which it’s harmful and contexts in which it’s helpful.

Off the top of my head, these contexts might revolve around questions like:

  • What treatment outcomes are possible or can be expected for this disease?
  • Who’s responsible for treatment?
  • If the expected outcomes are not achieved, who is responsible for that? And, how should we respond?

What treatment outcomes are possible or can be expected for this disease?

If the patient assumes the prognosis is poor, I’d imagine that diagnosis is likely to have negative consequences, like a loss of agency.

However, I imagine health professionals deal with this situation every day. Patients hear diagnoses like cancer, asthma, or heart disease and assume that the course of their physical well-being is out of their hands.

I hope that, where the prognosis is not poor and active client participation is an essential element to effective treatments, providers have approaches to mitigate the potential loss of agency that may accompany a diagnosis.

What happens if the provider is pessimistic about the prognosis? How does that influence care? How does the provider explain the poor prognosis?

Off the top of my head, I see 4 possible explanations a helper may arrive at:

First, they may conclude that they are not a very good helper. Few providers will give this serious consideration.

Second, they may conclude that we just don’t have good treatments for this disease–the disease is too difficult treat. This is much more common. Whatever the drug crisis of the moment is, that is considered to be particularly difficult to treat. (Crack, then methamphetamine, then opioids.)

Third, they may conclude that the disease is treatable, but the patient is too difficult to treat. They may believe that their clients are too complex, that they don’t want recovery, that they are too chaotic and difficult to engage or retain. This is more common yet. The belief is, “I am competent, we have the knowledge and skills, but these clients won’t/cant cooperate.”

Fourth, they may believe that the disease is treatable but the context makes it impossible to effectively treat the disease. They may believe that these clients can’t be effectively treated because they are too poor, they are homeless, their living environments are too hostile to recovery, they face legal and employment barriers, etc. This may be the most common. With this explanation, like the second and third, the professional experiences a loss of agency.


Who’s responsible for treatment?

Is treatment something that is delivered by a professional who is believe to possess the important knowledge, skills, tools and plan?

Does treatment narrowly focused on pills and procedures? And, is a “good patient” a passive, compliant patient?

Or, is treatment a partnership between the patient and professionals that is based on listening, understanding, shared decision-making, and shared responsibility? Treatment of this kind may involve pills and procedures, but may also involve much more, including behavioral strategies, and interventions to address barriers to treatment.


If the expected outcomes are not achieved, who is responsible for that? And, how should we respond?

When we don’t get the outcome we wanted, who do we ascribe responsibility to?

Is it the patient’s fault for not following the treatment plan? If we share responsibility, there may be some truth to this at times. However, shared responsibility requires that we don’t stop there. If the patient didn’t adequately participate in treatment or didn’t follow the plan, we should consider:

  • Did the patient have sufficient input on the plan?
  • Was the plan aligned with the patient’s goals? (Recognizing that goals often change before and during treatment.)
  • Did we adequately explore and plan for barriers the patient is likely to encounter?
  • Did we approach the patient in a manner that contributed to a loss of agency rather than using approaches then enhance agency?

Do we blame the illness for being too difficult to treat? In this case, we should consider the following:

  • Is the illness really that difficult to treat, or are we unwilling to invest the necessary resources to achieve remission?
  • If there is no silver bullet treatment, informed consent becomes more important. In this case, what combinations might make sense?
  • Is seeking to reduce symptoms and harms while we wait for better treatments the best we can do? If so, do we communicate this to patients?
  • Do combinations of treatments move us closer to, or increase the likelihood

Do we blame the provider?

  • Are they providing treatment in an adequate dose and intensity?
  • Was the treatment of adequate duration?
  • Was the treatment of adequate quality?
  • Is the provider attending to extra-therapeutic factors that are likely to influence outcomes?
  • While some providers are sure to be poor caregivers, others may be under-resourced.

Do we blame the context?

Do we blame the environments that patients are coming from? Where applicable, do we blame criminal justice policy, homelessness, employment opportunities, anomie, health care policy, social determinants of health, etc.?

Of course, all of these things influence what we’re able to do for patients and the outcomes we achieve together. And, of course, many of these needs fall outside the narrow purview of “addiction treatment.”

We can say, “that’s not my system’s/agency’s job” and complain about other systems’ failures to meet or clients’ needs. We can confine our efforts to reimbursable services. That’s a pretty easy position to defend.

While that is an easy position to defend, it indicates the absence of a mission-based commitment to recovery and our patients.

Anecdotally, it appears to be the smaller, community-based programs that develop housing programs (before any funders would considering reimbursement for these services), employment programs, maintain pantries, and provide meaningful linkages with indigenous sources of recovery support.

I routinely encounter patients from corporate providers who received a time-limited, often high-intensity, dose of treatment followed by inadequate continuing care. The continuing care is often a passive referral to an unaffiliated low-intensity outpatient program near their home. (In the worst cases, corporate programs will complain about smaller, community-based programs that do not adapt their services to accommodate the needs of poorly served corporate patients.)

When I’ve reached out on behalf of patients, the help available to them is entirely contingent on funding.


Negative consequences?

If there are negative consequences to receiving a diagnosis of addiction, it’s worth asking whether it’s the diagnosis itself of something else.

Maybe we don’t need to nuance the language for our patients. Maybe we need to do better for our patients.

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Person-first or identity-first?

This article was shared by a friend today.

Several previous posts have spoken to recent attention to language in recovery advocacy. (See here and here.)

I think may have pointed to LGBT+ communities’ use of words like “queer” when questioning whether we should change our own language to reduce the stigma that others harbor toward us.

It appears other groups are wrestling with the same questions.

You may have been taught not to use the word “disabled.” In fact, you may have been taught to use “person-first” language in which you identify the person before their disability (i.e., person with autism, person who uses a wheelchair, individual with cerebral palsy). There is a shift happening towards “identity-first” language in which we claim our disability and center in the terms that we use (i.e, disabled, Deaf, autistic).

Why this shift?

Using identity-first language makes disability a marker of pride. It’s a little bit “in your face,” but that’s the point. Person-first language potentially diminishes a person’s disability identity by adding it on last. Activists from the disabled community have been pushing for identity-first language, some with a social media campaign called #SayTheWord (the word they want you to say is “disabled”).

And, there’s more . . .

. . . shying away from the actual word “disability” is a form of cultural erasure, because it suggests that people with disabilities shouldn’t identify with their disability or form community with others who have shared experiences. Instead, if the larger population embraces the word disability, it sends a message of acceptance and acknowledgement of disability as identity. A disability is something that shapes our lives, and it’s something to be proud of, not ashamed of.

Personally, I think she puts the emphasis in the right place. It’s the culture that needs to change, not the words. (And, even if we’re successful at changing the words we use, the culture will eventually change the meaning of those words.)

However, her message is not a rant against person-first. In fact, she says both should be accepted.

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