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4 / Therapy and Reason
- University of Washington Press
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73 4 / Therapy and Reason I n December 2007, the Baltimore Sun published a series of feature articles profiling the relatively recent use of buprenorphine to treat opiate addiction in Baltimore.1 The articles spanned the use of the drug in sub-Saharan Africa, France, and a number of cities in the United States in order to contextualize the local impact of the treatment. In addition to offering a short history of the drug and its implementation, The Baltimore Sun reported that the police had seized 24 and a half buprenorphine “pills” from a man selling them along Pennsylvania Avenue on Baltimore’s west side. Self-medication and drug diversion were subjects discussed by the reporters in anonymous “street interviews” conducted throughout the city. The basic narrative of the articles was clear: the therapy was clinically promising but suffered from widespread abuse and misuse. The main concern centered on new markets for the illegal sale of the drug toward non-therapeutic ends: 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.2 A few days after The Baltimore Sun ran the stories, the City Paper, a local alternative weekly, ran a similar story, echoing claims of growing abuse in Maryland.3 Indeed, there were many physicians in Maryland prescribing the drug to treat opiate-dependent patients—at the time, there were slightly more than 400 doctors signed up to prescribe buprenorphine and the prescription volume was the seventh highest in the country.4 Despite the volume , there were few—if any—physicians in the Baltimore area who reported grave concern about patients misusing or selling their prescriptions.5 74 Chapter 4 Responding in Kind The Baltimore Sun articles provoked an immediate response. Rolley E. Johnson , vice president for scientific and regulatory affairs of Reckitt Benckiser Pharmaceuticals, wrote an official letter from the pharmaceutical company responding to the characterization and extent of the problem suggested in the reports, emphasizing the company’s intentions to thwart continued misuse .6 The letter conceded poor surveillance. The company acknowledged incidences of abuse but failed to deepen the discussion of the drug’s abuse potential or how prescribing practices and surveillance might be improved. The aim of the letter was to assure a concerned public that everything was being done to prevent abuse. The drug manufacturer avoided a vehement defense of its product, opting instead to maintain a picture of integrity while promising increased scrutiny of existing mechanisms for surveillance.7 Dr. Joshua M. Sharfstein, the Baltimore Health Commissioner, was considerably less deferential in his response to the articles. In a strongly worded letter to the editor, Sharfstein wrote that the reports worked to “obscure the enormous good that has already come to hundreds of thousands” and ignored the fact that the treatment “saves lives.”8 Even in the face of potential abuse and misuse, the benefits outweighed the problems—and compared historically to the illegal sale and diversion of methadone, buprenorphine’s situation paled.9 Close to the time of the articles, Sharfstein asked the Maryland General Assembly to expand buprenorphine treatment by $5 million. The request was warranted. Only a few months before the publication of the The Baltimore Sun articles, the Maryland State Medical Society produced a study in which they found the biggest hurdle related to effective treatment was not misuse and diversion but cost.10 Nevertheless, the articles appearing in The Baltimore Sun continued to generate concern. Only a few days after the first article in the series had been published, the Maryland State Senate called for a probe into the abuse of buprenorphine. The legislators were concerned about misuse of the drug, though they were equally concerned about the misuse of tax dollars to support what seemed like a problematic form of treatment.11 The claims regarding poor surveillance leading to diversion and the alleged incidences of illegal sale were at the core of the debate. The findings of the Senate probe two months after The Baltimore Sun articles first appeared described the problem of abuse as “serious” and “dangerous,” and suggested that the problem might be largely due to “negligence” on the part of the medical community.12 Therapy and Reason 75 Apprehension about abuse and diversion of buprenorphine was not a new topic; it was there from the beginning. In 1978...