BUPRENORPHINE: Great, but …

Much publicity was given recently to a Senate-sponsored symposium on buprenorphine (e.g., “Senate touts heroin-detox drug,” Aug 4, Detroit Free Press). While it’s great to have another medication available to treat the devastating (and all too often fatal) disease of opiate addiction, there’s no evidence that buprenorphine would or could replace methadone, as much of the coverage suggests. First, some six years after passage of the original law to permit the use of buprenorphine, the estimated unmet need for treatment in America is – very conservatively - about 75% of those in need, the same figure used for decades. Second, the fact that 93% of all patients receiving buprenorphine for opiate dependence are white says a lot about its limited role to date, for whatever constellation of reasons. And yet, the Detroit Free Press quoted unnamed “experts” as saying, “… methadone may still be useful for patients who need pain treatment.” One can only wonder what those experts believe would be “useful” in providing continued life-saving care to the estimated 200,000 patients who, today, receive methadone, let alone to the more than half-million opiate dependent individuals who have no access to any kind of care.

CALL FOR COMMON VOICE SUPPORTING ALL FORMS OF MAINTENANCE TREATMENT:

In its August newsletter, the Tennessee Society of Adidciton Medicine includes the following appeal of the President, Richard Soper, MD:

“At this critical juncture it is time for physicians in Tennessee and nationwide to put aside their personal biases and support the maintenance model for treating opiate addiction. The evidence is clear: maintenance works, both with methadone and buprenorphine. Detoxification, regardless of the method or medication used, results in patients dropping out of treatment and relapsing to drug use. It is irresponsible and dangerous for medical professionals to send mixed messages about what treatment is effective for opiate addiction. Uninformed comments that may keep patients with opiate addiction from receiving effective treatment will cost these patients their lives.”

Right! But attacks by providers of one form of addiction treatment against different modalities is nothing new. Forty years ago (and right up to the present time!) drug-free treatment advocates vilified methadone maintenance and those who provide it. Today those who encourage expansion of buprenorphine treatment commonly state or imply that this medication is “better” than methadone, “less addictive,” “easier to get off,” etc. – claims totally lacking in empirical support. Meanwhile, the gap between need for and availability of treatment (of any and all kinds!) remains as great as ever.

At the very least, everyone should stress up front when they have a vested interest. That goes for manufacturers and providers of buprenorphine no less than for those whose livelihood is linked to delivery of methadone treatment. By expressing as fact “personal biases” both for and against specific treatment approaches professionals disgrace themselves, harm patients who receive care of one sort or another, and make it less likely than ever that the roughly 80% who today are abandoned will ever receive the help they need.

BUPRENORPHINE: GOOD NEWS AND BAD

The headlines say it all. From the US, numerous articles covered a "symposium" convened by Senators Hatch and Levin. A Salt Lake Tribune headline (Aug. 4) was typical of many: "Buprenorphine: Helps addicts by easing craving." From the other side of the world, Global Insight (Aug. 7) headlined, "Subutex to become controlled drug in Singapore" The latter article explained that "heroin addicts who use the drug to kick their habit instead become addicted to Subutex" - an illustration of misunderstanding and false expectations which have plagued methadone maintenance for 40 years.

Vincent P. Dole, MD, Dies at 93 (Aug 2, 2006)

Dr. Dole will be missed. He was a courageous, pioneer in the field of addiction treatment, and his achievements and impact can be seen throughout the world today (see tribute). He was not only a colleague and a mentor, but a dear friend. If you would like to offer a few words in memory of the man and his achievements please do so.

METHADONE PACKAGE INSERT: use as directed, (but make sure your heirs have a good malpractice lawyer available)

An article in the Gazette-Mail (Charleston, West Virginia – July 23) on rising methadone deaths correctly states that this tragedy has been known for several years to be associated with methadone’s use for pain management, rather than for maintenance treatment of addiction. The article notes that the “package insert” – the manufacturer’s advice to doctors and patients that is included with every prescription that's filled – cites a dosage range that is known, unequivocally, to be potentially lethal in non-tolerant patients (up to 10 mg q.3h. or 80 mg within 24 hours). Must we wait for a $100 million award for the death of a patient taking the medication as recommended, and prescribed, before the manufacturer gets the message? That’ll do it, for sure, but how many needless deaths will there be in the interim?