Laurel to the Baltimore Sun for spotlighting abuse and street sales of buprenorphine, a widely hailed prescription drug for treating opiate addiction, in a series of well-reported articles published late last year. And a mini-dart to the same series for ultimately failing to put the “bupe” problem in proper context (see Editor’s Note, page 9).
As the Sun explained, bupe is a significant advance over methadone, the long-dominant treatment for heroin and painkiller addiction. Methadone provides a stronger high than bupe and can be fatal in an overdose. Suboxone, an FDA-approved form of buprenorphine, forestalls euphoria past a certain dosage and contains an agent, naloxone, intended to trigger withdrawal symptoms when crushed and injected. Most coverage of buprenorphine has touted the drug’s resistance to abuse and its proven effectiveness in combating addiction. The Sun’s three-part series and follow-up articles brought important balance to the bupe story by vigorously raising the issue of street sales and the specter of addicts using “street chemistry” to subvert naloxone to achieve an opiate high.
Reporters Doug Donovan, Fred Schulte, and Erika Niedowski hit the streets to document abuse and diversion in West Baltimore, New England, and France. They discovered that little data exist on bupe’s role in overdose deaths because many medical examiners have no way to detect traces of the drug. The street reporting was the story’s strength. Much of the enthusiasm over buprenorphine is based on its success in research settings, but the reporters searched out patients, doctors, and medical examiners to chronicle its effects in the real world.
The series also investigated the rush in Congress to authorize doctors to prescribe the drug before it received fda approval, raising legitimate questions about public officials playing down the potential for abuse and diversion. Since the series was published, the government and the public-health community have more actively monitored the drug’s problems.
Unfortunately, the tone and structure of the series does the reporters’ excellent work a disservice by unnecessarily marginalizing important context and creating the impression that this complex story of addiction treatment is little more than a taxpayer boondoggle. The first story’s subhead (“Promoted by the U.S. as a treatment for opiate addiction, buprenorphine has become one more item for sale in the illegal drug market”) and lead (“There’s a new narcotic on the street in Baltimore and other communities—and taxpayers helped put it there”) set an adversarial tone that persisted throughout and cast an unflattering light on the drug’s supporters.
Advocates of the drug may have been overly exuberant about bupe’s success in weaning patients off opiates and its resistance to abuse and diversion, but government health officials acknowledged the possibility of at least some such problems, and legislators suggested measures to minimize them. In short, it is unrealistic to expect that there would not be the kinds of problems that the Sun documents.
The series seemed to struggle between two worthy objectives: to make government accountable and to help readers understand an important issue in all its complexity. But it led with the indignant tone that newspapers use to pressure government into action, and bupe’s supporters were often used as defensive “she-said” responses to the erroneous notion that bupe was expected to be a panacea.
With nine thousand words to play with, there is no reason the Sun couldn’t have delivered its important new information and still established early on the complexity of this still-evolving story. For instance, rather than lead with such a heavy and exclusive emphasis on the extent of the abuse and diversion, the reporters could have easily made it clear that the broader bupe story is this: An effective drug behind a revolution in addiction treatment that seeks to move addicts from clinics to doctors’ offices may have been rushed to market without sufficient controls on abuse and diversion.
The series also marginalized a major structural root of the bupe controversy: the dynamics of the “harm reduction” public-health model. This model might tolerate street sales of bupe to addicts in the hope that it will help them fend off withdrawal or cravings for more destructive drugs, such as heroin. This unintended diversion of bupe, the argument goes, might even lead addicts into treatment. This is the more relevant issue for taxpayers, because if public officials are quietly abiding such diversion of a drug covered by Medicaid, they are creating a taxpayer-funded back channel for a public-health model that the federal government rejects in other forms, such as funding for needle-exchange programs.