Sentences to ponder

Framing the national drug problem around opioids misses the bigger target. The future of the national drug problem is more drugs used by more drug users – not simply prescription misuse or even opioids but instead globally produced illegal synthetic drugs as is now common in Hong Kong and Southeast Asia. A focus exclusively on opioid use disorders might yield great progress in new treatment developments that are specific to opioids. But few people addicted to opioids do not also use many other drugs in other drug classes. The opioid treatments (for example, buprenorphine, methadone, naltrexone) are irrelevant to these other addictive and problem-generating drugs.

Mark Gold, MD & Robert DuPont, MD

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Sentences to ponder

“Vancouver is a city with a lot of harm-reduction tools in its tool box and, still, we’ve barely slowed the wave of overdoses,” Mr. Robertson said.

Mr. Robertson is Vancouver’s outgoing mayor. He reflected on his experience managing the city through the opioid crisis.

Number of times the article mentions recovery = 0

Number of times the article mentions treatment = 0

Here’s the thought they closed the article with.

“Vancouver’s lesson is that we need more harm reduction, not less.”

(This post, in no way, implies that the presence of harm reduction is the problem. However, the absence of treatment and recovery should trouble anyone who cares about the lives of addicts.)

 

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No matter how cynical you become . . .

No matter how cynical you become, it’s never enough to keep up.

—Lily Tomlin

From the Financial Times:

A billionaire pharmaceuticals executive who has been blamed for spurring the US opioid crisis stands to profit from the epidemic after he patented a new treatment for drug addicts.

Richard Sackler, whose family owns Purdue Pharma, the company behind the notorious painkiller OxyContin, was granted a patent earlier this year for a reformulation of a drug used to wean addicts off opioids.

The invention is a novel form of buprenorphine, a mild opiate that controls drug cravings, which is often given as a substitute to people hooked on heroin or opioid painkillers such as OxyContin.

This is like a conspiracy theory playing out in real life front of us. Oy.

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New study casts doubt about injection site effectiveness

UPDATE: looks like this study has been retracted. I’ll post more, when I know more about why.

UPDATE 2: German Lopez has an update here.

A new meta-analysis of research on supervised injection sites delivers some disappointing conclusions for advocates:

One of the aims of MSICs (Medically Supervised Injection Centres) is to reduce harms associated with injecting illicit drugs such as heroin under unhygienic conditions. The current research suggests that the extent to which these aims have been achieved are at best modest.

How can this be?

Here’s what the authors say:

How can these surprising and sometimes counter-intuitive results be explained? There are at least two potential explanations. First, MSICs have been found to attract the most problematic heroin users . . . Second, MSIC clients might remain part of local injecting subcultures. In other words, they might be obtaining the benefits of MSICs, while at the same time continuing to inject in public and semi-public environments. There is some evidence to support this assumption.

Why is this noteworthy?

Insite, North America’s first MSIC, was opened about 15 years ago.

Over that 15 years, the approach has enjoyed vigorous support from public health, harm reduction advocates, and drug policy experts. There’s been a steady stream of publications to support their effectiveness.

Observers who questioned their effectiveness or whether they were the best use of scarce resources were often met with dismissive responses about science, evidence, empiricism, compassion, and challenges to presumed moralizing impulses.

This reaction has only intensified, despite other potential explanations for reduced disease transmission rates, reasonable questions about whether other approaches might save more lives, acknowledged “slight” drops in mortality rates, the absence of a recovery orientation in the coverage, and increasing OD rates in the region. There’s also been little willingness to discuss their animating beliefs and assumptions.

Why the discrepancy with past studies?

Well, first off, maybe the rhetoric hasn’t matched the actual evidence. Their description of the evidence is more mixed and narrow than you’d expect from coverage:

The results of the current review have shown that MSICs tend to have either a small effect or no effect on outcomes. The findings of the three reviews and one meta-analysis reviewed in the introduction were also mixed. McNeil and Small (2014) concluded that MSICs were effective in minimising client exposure to risk environments. Potier et al. (2014) concluded that MSICs were effective in reducing harm and providing health benefits to clients. MacArthur et al. (2014) concluded that, at best, there was tentative evidence of MSICs reducing IRB, but little or no evidence of MSICs reducing HIV/HCV incidence. Finally, Milloy and Wood (2009) concluded that MSICs were effective in reducing syringe sharing.

German Lopez got reactions from various researchers and ended with this observation from Keith Humphreys:

“If you are an advocate, you could say correctly that if we assume these are effective, we do not have sufficient information to confidently overturn that presumption,” Humphreys said. “But it’s equally true if you took another view — just look at it as a cold, scientific question — you could say we also don’t have the evidence to overturn the presumption that these don’t make any difference.”

Advocacy

That word “advocate” is important. It’s worth stepping back and considering what they advocate for. They are advocating for a philosophy, an approach, and a program.

This gets lost in a lot of these discussions and they get framed as advocates for science, research, evidence, empiricism, and compassion. A problem is that this framing sets up questioners as opposed or indifferent to those things.

Turns out that hasn’t been fair.

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The treatment hustle behind the scenes

So, the other night I posted about cash-only buprenorphine practices.

The next morning I find this in my mail.

Consulting services to help establish turn-key buprenorphine clinics with cash revenue models that use toxicology services to generate revenue and provide aggressive risk management. (It’s worth noting that I also get emails about treatment valuation conferences/services several times a week. That’s not a typo. Treatment valuation, not evaluation.)

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Vaping draws strong support — from bots

Apparently, twitter-bots are targeting more than elections:

Social media accounts run by internet robots may be driving much of the discussion around the health threats posed by e-cigarettes, according to a study led by San Diego State University researchers, who also found most of the automated messages were positive toward vaping.

More than 70 percent of the tweets analyzed in the study appeared to have been put out by robots, also known as bots, whose use to influence public opinion and sell products while posing as real people is coming under increased scrutiny.

Who the heck cam up with the idea of researching robo-tweets about vaping? They stumbled upon it.

The discovery of the apparent bot promotion of vaping was unexpected. The team originally set out to use Twitter data to study the use and perceptions of e-cigarettes in the United States and to understand characteristics of users discussing e-cigarettes.

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Cash only

Outside of very rural areas, I’ve often scratched my head when advocates express concern about access to buprenorphine. I mean, there are a lot of prescribers in most areas.

I had a conversation yesterday that prompted a google search that led me to this. (OBT refers to office-based treatment with buprenorphine.)

Access to OBT in Ohio is far lower than what the 466 listed physicians suggests. Nearly 1 in 5 of those physicians are not active OBT prescribers, and 1 in 2 active prescribers do not accept insurance for OBT. Further research is needed to determine whether practices who do not accept insurance provide care consistent with CSAT guidelines and whether such practice patterns contribute to buprenorphine diversion. [emphasis mine]

50% of prescribers do not accept insurance? (And, Ohio’s a big state, which makes it a lot less likely that there’s a small ‘n’ that skews strangely.)

So what is going on? Why are so many prescribers not accepting insurance?

Since the introduction of office-based therapy (OBT), the number of eligible prescribers has increased from 9000 in 2006 to more than 20 000 in 2012, and the total sales of buprenorphine/naloxone have increased 10-fold to peak at $1.4 billion (28th best-selling prescription drug in the United States).13

Nationally, there is increasing concern that buprenorphine misuse and abuse are on the rise.14 Even the lay press is reporting on buprenorphine abuse.5,6 Concern is increasing over a pattern of excessive doses of buprenorphine being prescribed, either by design or because of exaggeration of withdrawal symptoms by the patients, enabling this abuse phenomenon. There is the obvious risk that physicians can charge high fees for office visits, whereas the patients can divert the excess medication.2,7,8 There is greater concern that practices who do not accept insurance for OBT and require direct payment from patients may be over-represented in this diversion phenomenon.5

This study is important because the news reports expressing concern about this are dismissed as unjustly disparaging, anecdotal, bourgeois stigmatizingfearmongering, and tragically discouraging legitimate prospective prescribers.

50%!

That is not a small problem. That’s not an anecdote. It’s a real story.

A quick search turns up a lot of stories in local media. Here, here and here are a few examples.

It’s striking that the national media is not covering this story when they are putting so much time and coverage into the opioid crisis.

There’s a lot of media and institutional pressure on non-maintenance treatment providers and mutual aid groups to change and integrate maintenance treatments and maintenance patients into their programming, residences, and groups. It’s appropriate to ask questions and encourage people/programs to interrogate themselves. That’s healthy. And, it’s important for us to remember that there are a lot of shady practices among non-maintenance providers.

However, it’s worth asking, why is there so little pressure on maintenance providers to provide recovery housing, social support, and other services to promote recovery and improve quality of life?

At any rate, this also helps shed some light on why there may be access issues when there are a lot of prescribers.

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