A newspaper exposes the damage from buprenorphine. But did it end up hurting addicts and misleading readers by misrepresenting the case for addiction medication and harm reduction?
As The Wire brings a fictional version of the Baltimore Sun to life, the real paper recently "exposed" abuse of the new addiction medication, buprenorphine. But as it turns out, HBO's dramatic series does a far better job of examining the complexities of addiction than what appeared to have the factual power of a real journalistic investigation.
The Wire has followed drug addiction in unsparing forensic detail. In the third season, for example, a high-ranking police officer essentially "legalized" drugs in one part of the city, after first offering better housing to non-drug-using residents. He made a deal with the dealers: no violence, no arrests for selling in what becomes known as "Hamsterdam," after the Dutch city which pioneered the quasi-legalization of marijuana. This had the intended result of localizing drug crime to a small area and freeing residents elsewhere from drug-related crossfires. But Hamsterdam becomes a hellish nightmare, where wraith-like addicts overdose and spread HIV because no health services like treatment or clean needles are available.
The Wire recognizes the enormous difficulties faced by those who try to fight addiction, where there are few quick fixes and where every solution also poses additional problems. The shows' writers and producers understand that there is always a trade-off between risks and benefits and that aiming for perfect policies often produces more "collateral damage" than working with the resources which are actually available.
The Sun, however, fell into a point of view regarding one of the best new tools we have for fighting addiction best summed up in the following paragraph:
[Buprenorphine's] wide availability is starting to create some of the problems it was meant to solve. An investigation by The Sun has found that patients are selling their prescriptions illegally, creating a new drug of abuse that some people are injecting to get high.
Noting, only in passing, that where the drug has been widely prescribed, HIV infections and overdose deaths have declined by half or more, the series stresses, instead, that there are many instances where addicts have obtained it on the street. Using story after story of street abuse and sales, it presents a bleak picture of a drug that has actually done exactly what it is supposed to do when it is provided medically: reduce harm related to opioid misuse.
The Sun seems to see such harm reduction as failure: To the reporters, the existence of any level of misuse is cause for concern, and perhaps, increased regulation. It doesn't much matter whether buprenorphine saves lives, reduces infections and increases functioning - all that counts are that some addicts are still injecting and getting high and some prescriptions are still being sold.
In the Sun's article about the use of the drug in France, for example, the writer buries research showing that the introduction of buprenorphine saved 3,500 lives by reducing the number of overdoses, and was associated with a 50% drop in HIV infection rates and a 79% drop in overdose deaths. We only learn this on the third page of four, online. And these numbers are cited only after a discussion of buprenorphine-related deaths, of which there were 167 over nine years.
Moreover, all of these deaths were a result of polypharmacy, meaning that buprenorphine was mixed with other drugs, so it's far from clear whether the buprenorphine itself was responsible. In this light, one must wonder about the kind of news judgment that regards 167 deaths as more important than 3,500 lives saved.
The same story also examines trafficking in the drug, saying that "illegal sales persist despite enforcement efforts." But decades of enforcement efforts have never eliminated illegal sales of any opioid drug anywhere, medical or illicit, even with the tightest possible controls, such as never allowing patients to take the drug home.
And the story doesn't even mention that rising use of buprenorphine in France-- it is now prescribed to 70% of opioid addicts-- was linked with a 75% drop in drug-related crime.
Double standards
This result of such reporting is that addiction treatment is held to a higher standard than any other type of medical care: If the same measuring stick were used for cancer treatment, virtually every current therapy could be seen as an utter failure because none of them work 100% of the time and many can have deadly side effects. If a chemotherapy drug saved 3,500 lives and failed in only 167 cases (and in those, it was used incorrectly), would it make sense to treat the results as an exposé rather than a success ?
Deaths which are due to medical error [reg required] or the side effects from medications used correctly are the third leading cause of death in the U.S., second only to heart disease and cancer. In this context, why is an addiction medication expected to have no risks and only benefits?
What the series also misses completely is that the regulatory scheme for buprenorphine was designed, explicitly, to avoid the over-regulation that has plagued methadone treatment. Legislators and regulators looked at the data on methadone, which actually is much more dangerous than buprenophine, and realized that despite its dangers, the way that it is regulated in the U.S. doesn't make much sense.
Recognizing that politics stands in the way of loosening controls on methadone, they decided to start fresh with a new medication, one that happens to be safer.
Methadone is still the most effective known treatment for opioid addiction, according to the Institute of Medicine and the National Institutes of Health, and yet it is not available to most of the addicts who could benefit from it. Methadone remains more effective than buprenorphine for long-term addicts. This is because buprenorphine, when used in high doses, causes opioid withdrawal, not relief from it, so patients who need such doses don't benefit.
This "ceiling effect" makes buprenorphine safer than methadone and dramatically reduces overdose risk-- but it also limits its usefulness among long-term, hardcore addicts.
Given this, regulators realized that looser controls on buprenorphine could help more addicts access at least some form of maintenance without creating the expense, regulatory overload and the "NIMBY" nightmare of situating clinics that keeps methadone from reaching most opioid addicts.
What the Sun utterly fails to recognize here is the human cost of seemingly benign regulations like limiting distribution of these drugs to special clinics and requiring that the addicts visit daily.
For one, think about trying to hold down a job while having to make daily, sometimes lengthy visits to a clinic - a clinic typically located in a bad neighborhood that is usually open for only a few, fixed hours and that often makes you wait for your dose. You cannot go on a business trip, let alone a vacation. You cannot come in early or work late if you will miss clinic hours and you are literally tied to this daily visit no matter what else happens in your life or you will rapidly become ill.
Such restrictions reduce the likelihood of addicts seeking treatment and succeeding at it if they do enter: Success in recovery is linked with employment (something you'd think everyone would want to encourage anyway).
This is why allowing general practitioners to prescribe buprenorphine and let addicts take it home like any other prescription improves the odds of recovery. It also allows more addicts to get treatment, period.
Does this pared-down distribution system also mean that the drug is more likely to be sold to others? Yes; however, that too can be seen as harm reduction: those who take street buprenorphine are taking a drug of known purity and dose and with less risk of overdose than from heroin or methadone. Allowing a market in a less harmful drug can help dry up sales for the more harmful substances.
The Sun notes that injecting the tablets can be dangerous and can lead to amputations, but it doesn't mention that reformulating the drug could reduce this harm, too.
Mauritius v France: One drug, two policies, two outcomes
There are other similar failures to understand harm reduction throughout the series. For example, in a piece on buprenorphine abuse in Mauritius, the Sun says:
Officials at [Mauritius'] National Agency for the Treatment and Rehabilitation of Substance Abusers oppose the [clean needle] program, saying the distribution of needles is tantamount to distributing drugs, and does not reduce harm but propagate it.
The Sun doesn't mention that research on needle exchange overwhelmingly refutes this view: Every single scientific body that has ever looked at the research has concluded that needle exchange reduces HIV risk, increases treatment entry by addicts and does not increase IV drug use.
In fact, the HIV epidemic in Mauritius, for which the Sun indicts smuggled buprenorphine, is much better explained by a failure to provide maintenance prescriptions and needle exchange. Buprenorphine and needle exchange are illegal in Mauritius and HIV rates have gone up while addiction thrives. In France, legal buprenorphine produced a 50% drop in HIV. Same drug, different policies. The only places where buprenorphine has resulted in increased rather than decreased harm are where it is illegal or heavily restricted.
Two of the leading French researchers interviewed by the Sun wrote to the paper to protest the misrepresentation of the research: "We were dismayed that the major public health benefits of French policy were not properly reflected. We feel that the response by The Sun's public editor to the criticism of the series by several leading public health professionals demonstrates a continuing disregard for the evidence."
Addiction is not physical dependence
Further, the whole series misconstrues the fundamental logic behind opioid maintenance, portraying ongoing buprenorphine prescribing (as opposed to short-term use) as an approach that "merely substitutes one narcotic for another." It attributes this view to "critics" - but it seems that the Sun has bought the criticism. Take the line, "recovering addicts also worry about becoming hooked on buprenorphine." This implies that continuing on maintenance is not really recovery but "being hooked."
But methadone and buprenorphine are safe for long-term use - a fact the Sun doesn't emphasize. Research on methadone-maintenance patients finds that they are not impaired and can even drive safely so long as they are on a steady dose. Buprenorphine is even less likely to cause impairment.
This means that a person can be in complete recovery from addiction - in a stable job, supporting and loving a family, not taking any non-prescribed medications, appearing no different from anyone else - and still take methadone or buprenorphine. Addiction is not physical dependence on a drug. If it was, we'd have to consider all diabetics as "insulin addicts" and people who need antidepressants long-term as "antidepressant junkies."
Instead, psychiatry defines addiction as compulsive use of a drug despite negative consequences. If the use isn't compulsive and the consequences are positive, the addiction has been resolved even if the physical dependence remains.
By failing to recognize this, the article misrepresents long-term use of buprenorphine as a problem, not the solution envisioned by those who support it. The reporting implies that staying on the drug is a failure and is just as bad as compulsive use of illegal drugs. One can agree or disagree with this perspective; but not explaining it doesn't do justice to the argument of the drugs' proponents.
While the public editor cited letters to the paper that raised some of these issues, he dismissed them with the same reasoning that produced the problems with the series in the first place, concluding, "In my view, this series showed there is no magic bullet to defeat heroin addiction and it is a comprehensive effort to rebuild lives and communities that will be required."
No addiction expert on any side of the debate would disagree with that; but that doesn't mean the series adequately covered the risks and benefits of the medication.
If the Baltimore Sun is ideologically opposed to maintenance and harm reduction, it should say so explicitly-- and if it is going to be fair when it covers these issues, it should also adequately represent the data that supports these policies and the reasoning behind them.
This series did not do this, giving readers little insight into the nature of the fundamental disagreements between harm reductionists and proponents of the war on drugs.
If the Sun is not ideologically opposed to maintenance and harm reduction, it clearly needs to examine the fuzzy thinking that underlies this series: if it wants to take the position that reducing overdose and HIV deaths is not worth the risk of some diversion, it should do so openly and let readers make up their own minds about whether they agree with this philosophy. Meanwhile, for those able to handle nuance, there's still The Wire.
--- [updated and cross-posted from stats.org]