"Instead of going to see a dealer, I go to see a doctor."
"The lucky ones only lost maybe a couple of fingers, the unlucky ones lost a leg or an arm," said Schneider, co-director of a drop-in center for addicts in Marseille.
He had anticipated that drug users would inject Subutex, in part because France had experienced a problem with the injection of Temgesic, a low-dose form of buprenorphine also sold by Schering-Plough as an analgesic.
"Nobody could tell me that people would be observant and take it as prescribed, knowing it was as easy to inject as Temgesic," Schneider said. "Injectors will inject, that's why they're injectors. So if we put something on the market that's injectable, we shouldn't be surprised that they do."
The French monitoring center reported in 2004 on Subutex trends. Because of its widespread availability, Subutex was serving as a first opiate for some drug users and a re-entry opiate for some who had previously injected heroin. The report found it to be highly addictive and hard to stop. And it was increasingly being used in dangerous combinations with alcohol, benzodiazepines (such as tranquilizers) and even cocaine.
Subutex was implicated "as a contributing or causal factor" in 136 deaths in France from 1996 to 2000, in combination with benzodiazepines, alcohol or other substances, according to a 2004 article in the American Journal on Addictions. From 2001 to 2005, Subutex was implicated in combination with other substances in 31 deaths, according to government and police reports.
Researchers say that in the early years of buprenorphine prescribing, there was not widespread awareness of the danger of prescribing it with other drugs.
Serge Escots, a family therapist and addiction specialist in Toulouse, did some of the research on the unintended hazards of Subutex use.
"We could see it," he said. But, "If I talked about it, [Subutex proponents] said, 'You're wrong, you're anti-substitution, you're against public health, you want to see AIDS all over the street.'
"You couldn't talk about it. We weren't invited to talk about it. We were only invited to say good things about it," he said.
Subutex's staunchest supporters in and out of government embrace the public health philosophy known as harm reduction. It acknowledges that some addicts can't or won't quit their habits, and emphasizes ways to minimize the dangers.
Buprenorphine has played a major role in addiction treatment that has saved 3,500 lives, experts say. Opiate overdose deaths have declined 79 percent since the drug was introduced, and the HIV infection rate among injection drug users has fallen sharply - from 40 percent in 1996 to 20 percent in 2003.
"The difficulty, the problem, of Subutex is [that] on one side, it has helped enormously," said Xavier Thirion, a buprenorphine proponent who tracks trends for a Marseille-based center on drug dependency research. "On the other hand, we found the misuse. Every policy has advantages and disadvantages. All of public health policy is about balance."
Schering-Plough has aggressively promoted the drug in France, funding the work of harm reduction groups. Company officials say they are aware of the trafficking and misuse. By their estimate, 25 percent of patients use buprenorphine "non-medically," a figure that includes illegal sales and inappropriate practices such as injection and drug sharing. They term that "a small number" and say the benefits of treatment outweigh the risks especially given the level of opiate addiction.
"By all accounts, what you have is a tremendous success story of the benefits of increasing access to therapy - making it available through general practitioners - and the tremendous benefits to the public health of the community," said Leslie Amass of Schering-Plough's Global Medical Affairs Department.
But many general practitioners - who write the vast majority of buprenorphine prescriptions - lack experience in addiction treatment. While some belong to voluntary networks that sponsor occasional education sessions and include specialists trained in addiction medicine, most GPs do not.
According to doctors and addiction experts, some physicians have mistakenly prescribed buprenorphine as a treatment for marijuana use, potentially creating new Subutex addicts. Others have prescribed it in dangerous combinations with sleeping pills and tranquilizers.
Dr. Alain Morel, a psychiatrist at Le Trait d'Union, a drug treatment center in the Parisian suburb of Boulogne, thinks general physicians should be trained, certified and permanently "attached" to a drug clinic to prescribe buprenorphine. Many, he said, "don't do any follow-up, so it's up to the patient to use - or misuse - the drug."