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:
To sum it up briefly: Some really bad research was used to convince docs that there was an ‘emergency’ need for more potent opioids to treat chronic pain, and that when used properly, these new, more potent opioids presented little or no danger that the user would become addicted.
That turned out to be BS. Surprise.
The result: We’re in a drug epidemic with no South American cartels or Afghan drug lords to vilify. And with some elements in Big Pharma, and some docs, figuring how to get rich off it.
Right– that’s the same combo that got us here.
It’s my belief that many physicians, even the uncommonly brilliant and passionate ones, can have a major blind spot when it comes to the meds they prescribe. Somehow, they convince themselves that a medication is safe if they prescribe it.
It’s worth pointing out that they, also, are not making recovery arguments for maintenance.
Buprenorphine was developed as a safer alternative to methadone for treating heroin and painkiller addiction, a take-home medication that could be prescribed by doctors in offices rather than dispensed daily in clinics. But in some areas a de facto clinic scene, unregulated, has developed, and it has a split personality — nonprofit treatment programs versus moneymaking enterprises built by individual doctors, some with troubled records.
The Times profiles two practices [emphasis mine]:
The New York Times has visited and tracked the patients of two of the largest buprenorphine programs in this region, where addiction rates are high, for-profit clinics have proliferated, doctors go in and out of business and the black market is thriving.
Dr. Clark’s hectic, cluttered office in suburban Pittsburgh is an entrepreneurial venture with heart where the rumpled doctor dresses in sweatsuits, the boundary between patients and employees is razor thin, the requirements are minimal and the tolerance for missteps is maximal.
“I know on the surface it might look like a pill mill,” he said. “We’re seeing a fair number of patients, and they’re primarily receiving a prescription. But if you look deeper, you’ll see that we don’t use the medication in a vacuum. We encourage, we support, we don’t judge. There’s a kind of love.”
Sixty miles away, the more formal, structured treatment center at West Virginia University in Morgantown sits atop a hill, ensconced in a hospital complex and presided over by Dr. Carl R. Sullivan III, a career addictionologist who wears a white lab coat and stands professorially at the front of a classroom when he meets his patients in groups: “Are you clean? How many meetings have you been to?” he asks them.
Dr. Sullivan, 61, primarily treated alcoholism until “a spectacular explosion of prescription opioid drugs” starting around 2000. He considered opioid addiction “a hopeless disease,” with patients leaving rehab and then relapsing and sometimes dying, until he started prescribing Suboxone, the brand-name drug whose main ingredient is buprenorphine, as a maintenance therapy in 2004.
A little more on Dr. Carter:
“As you know, my pharmacist thinks you’re pretty much a joke, and he’s not filling your prescriptions,” one patient, James Markeley, said recently.
. . .
His troubles did not end with sobriety, though.
Pennsylvania suspended him for a month in 2010 because he failed to submit to three unannounced drug tests while on vacation. Ohio revoked his license in 2011 because he forged signatures verifying his attendance at 12-step meetings.
Both doctors are concerned about corruption in the business.
Dr. Sullivan is skeptical of the buprenorphine “empires” in Pittsburgh — though not of Dr. Clark specifically, whom he does not know — believing that they feed the black market and tar the medication’s reputation. Dr. Clark, in turn, is skeptical of “ivory tower” addiction programs with rigid rules and of doctors who, in his view, collude with the pharmaceutical industry.
“Big Pharma is in it for the super profits; we should be in it for the patients,” said Dr. Clark, who nonetheless became a buprenorphine doctor partly because he needed to dig himself out of a financial hole.
One more example of the financial incentives. This is Dr. Clark discussing one of his staff physicians:
“He told me he was feeling some heat in his area and needed to get out of town for a while,” Dr. Clark said.
After filing for bankruptcy protection with $1.5 million in debt early this year, the internist quit in May to run his own buprenorphine practice, saying he needed to make money fast, Dr. Clark said.
For its part, Reckitt Benckiser recruited Sullivan (who believes opiate addiction to have been hopeless before Suboxone) as a paid advocate and courted the shady Clark to prescribe, while also giving dark warnings about prescribing generics:
[Dr. Sullivan] became a paid treatment advocate for the manufacturer, Reckitt Benckiser, delivering, he estimated, 75 talks at $500 each. But, he said, “If the company didn’t pay me a nickel, I’d still promote Suboxone because in 2013, it’s the best thing that’s happened for the opioid addict.”
. . .
In 2008, a Reckitt Benckiser representative approached Dr. Clark at a children’s hospital, saying: “There’s this great medicine, Suboxone. Why not get certified? It doesn’t take much, and it’s a nice thing to add to your practice,” he said.
. . .
[Dr. Clark] said a Reckitt Benckiser representative cautioned him that he was courting trouble with the authorities by prescribing generic buprenorphine and not Suboxone.
…last week, UK pharma firm GlaxoSmithKline admitted that Chinese doctors were bribed by its execs with cash and sexual favours in return for prescribing the company’s drugs. That coincided with rival AstraZeneca having its Shanghai office raided by police – all of which is jolly inconvenient, as Astra faces the City this week to unveil its interim results.
Some investors ponder whether bribery is a wider problem than has yet emerged, and if Chinese authorities are deliberately targeting foreign firms.
Maybe, but critics of the UK companies also point to GSK’s $3bn fine last year for bribing US doctors, plus Astra’s indictment in Serbia on similar charges, as well as an admission in its annual report about “investigating indications of inappropriate conduct in certain countries, including China”.
In a related post, Alan Frances argues that congress needs to fix the U. S. mental health system.
Third, Big Pharma needs to be tamed — just as twenty years ago, Congress tamed Big Tobacco. Drug company marketing consists of nothing more than misleading disease mongering — selling diagnoses to peddle pills to people who don’t need them. If it has the political will to take the following steps, Congress can easily end Pharma’s hijacking of medical care. No more direct-to-consumer advertising of drugs — a privilege Pharma enjoys only in the US. No more misleading marketing to doctors cloaked in the sheep’s clothing of ‘education’. No more financial contributions turning consumer advocacy groups into extenders of company lobbying. No more ‘research’ guided by the marketing efforts to enhance patent life and stretch indications, rather than aiming for real breakthroughs. No more ghost written papers by thought leaders who mouth party line. No more monopoly pricing power because government is prohibited from bargaining. And no more revolving door politicians drifting back and forth from government to cushy Pharma jobs.
Seventh, Congress should attend to the catastrophe that more people now die from overdoses of prescription than street drugs. High flying prescribers need to be brought to ground with strict monitoring, professional discipline, and public shaming. And real-time computerized control could contain loose drug dispensing. If Visa can put an advance stop on a suspicious $100 purchase, we can develop a proactive check that a prescription makes sense before filling it. Cooperative FDA and DEA scrutiny of drug company marketing practices and distribution methods would reduce the current free availability of lethal narcotics. We are fighting a drug war against the cartels that we cannot possibly win and haven’t yet begun a war against the inappropriate use of prescription drugs that we could not possibly lose.
Also a couple of points on Pharma’s diagnostic fuel.
On the DSM:
First, the diagnostic system in psychiatry is broken and can’t be fixed internally by the American Psychiatric Association — which currently holds the monopoly. DSM-5 has fanned the flames of diagnostic inflation with definitions that turn everyday life problems into mental disorder — harming the misidentified ‘patients’ and costing the economy billions of dollars. Psychiatric diagnosis has become too important (in decisions determining workman’s comp, disability, VA benefits, school services, custody, criminal responsibility, preventive detention, and the ability to adopt a child, fly a plane, or buy a gun) to be left to one small professional association
Psychiatric diagnosis is too much a part of public policy to be left exclusively in the hands of the psychiatrists. Experts in psychiatry have no expertise in how their diagnostic decisions will affect public health, public welfare, the allocation of resources, and the health of the economy. Congress should set up an agency to ensure much more careful vetting of risks and benefits.
On inflated prevelance estimates:
Sixth, Congress should investigate the CDC’s fatally flawed method for determining rates of mental disorder. CDC has a systematic bias toward over-estimating the disorder rates in the healthy and ignoring the needs of the really sick. Its data gathering relies on telephone contacts conducted by lay interviewers who cannot possibly distinguish clinically significant mental disorder from everyday symptoms that are part of the human condition. The wild instability and elasticity of the reported prevalences is proof positive they should be discounted; not taken as credible indication our society is getting sicker. Epidemiological attention should focus instead on the extent and correlates of the more severe mental disorders currently being neglected.