Success, setbacks in France

By Erika Niedowski Sun foreign reporter

December 17, 2007

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PARIS - Dr. Jean-Pierre Aubert considers himself not only a general practitioner but a dealer of sorts.

From his second-floor office up a winding staircase in an apartment building near the Sacre-Coeur Basilica, the doctor prescribes a drug called buprenorphine to 200 patients as a way to treat opiate addiction.

He is not an addiction expert. He does not screen patients to ensure that they, in fact, are opiate-dependent and need treatment. He concedes that some of them might misuse the medicine, including by injection. And he acknowledges that some of the pills he prescribes might end up the stuff of street sales.

Getting addicts in the door is what matters. Even patients who initially show up seeking the drug to get a fix, he said, might progress into proper treatment.

"I'm a legal dealer," he said. "But being a legal dealer, I can help them with many, many other health issues."

Aubert, along with 20,000 other doctors prescribing the medication in France, embodies the revolutionary approach the country adopted 11 years ago in its fight against drug use and the public health problems that accompany it. The French system encourages physicians unfamiliar with addiction to prescribe buprenorphine and trusts patients to use it properly.

In many ways, the plan has worked. The medication, which dampens the craving for opiates, has helped to drive down overdose deaths and contain the spread of HIV/AIDS among injectors. Schering-Plough, the company that sells it in France, terms it a "tremendous success story."

But the French experience also has a down side, one the United States largely overlooked when it followed a similar path by giving private doctors authority to prescribe buprenorphine to addicts.

Buprenorphine, available in France in a formulation called Subutex, has proved addictive for many and has been widely abused. Pills that addicts legally take home are being sold illegally, just like heroin.

Similar problems have begun to emerge in the United States. Street sales are increasing, leading to growing abuse of the drug, a Sun investigation found. American addicts are also injecting buprenorphine, even though U.S. officials took the precaution of approving a form of the drug, Suboxone, with a chemical intended to deter injection. It is the only difference between the two formulations.

With the longest experience in using buprenorphine to treat addiction, France provides the clearest picture of the implications of making such a powerful opiate widely available.

Buprenorphine has become an entry drug for people who haven't used opiates before, a re-entry drug for former addicts, and a factor in more than 100 deaths since 1996 when taken in combination with other substances, according to researchers and public health authorities.

The drug has created a quandary that no one seemed to anticipate: how to get patients off it. Many stay in treatment for years, including some who want to quit, prompting criticism that substitution therapy doesn't address the underlying problem of opiate dependence.

Buprenorphine has been widely sold on the streets of France, and well beyond. A report by the French Monitoring Center for Drugs and Drug Addiction found that a fifth to a quarter of all buprenorphine sold was being illegally diverted. Pills originating in France are being smuggled to places as far-flung as the nation of Georgia and the Indian Ocean island of Mauritius.

"It's overprescribed, and it's too easily prescribed, without any control," said Dr. Agnes Lafforgue, who helps recovering addicts at a treatment and assistance center in Toulouse, a university city in southwest France.

She questions treating longtime heroin injectors with Subutex, for fear they will inject it, too, and worries about its addictive qualities. She said she has "practically never" successfully weaned a patient off it, despite having done so many times with methadone.

"It's a scandal the way Subutex has been introduced in France," she said.

Aubert and other doctors concede it is easy for a patient to get multiple buprenorphine prescriptions from multiple doctors, and sell the pills. Yet he maintains that such sales don't make the treatment program a failure, as it connects addicts with the health care system and provides them what he considers a safer drug. The government shares that view.

Good medicine involves a sometimes precarious balance for which there is no textbook guide. With every course of treatment they prescribe, physicians have to weigh potential benefits against the possibility of harm. The introduction of buprenorphine treatment in France - and elsewhere - raised that issue: how to properly balance widespread access to the drug, getting as many addicts as possible into treatment, with adequate control.