A complex epidemic of opioid addictions

The Sun recently reported that the federal government would grant a request of $17 million to expand treatment for opioid addiction in Maryland ("Maryland could get $17 million for opioid treatment as part of White House funding request," June 14).

Yet only two weeks prior, the Maryland Department of Health and Mental Hygiene's Medicaid Pharmacy Program removed a popular opioid treatment option from its preferred drug list.

Suboxone (a combination µ-receptor antagonist and partial µ-receptor agonist) dissolving film would be replaced by a sublingual pill, Zubsolv, the Swedish pharmaceutical company Orexo's version of the tablet originally development by Reckitt Benckiser Pharmaceuticals.

In response, Deborah Agus, the executive director of Behavioral Health Leadership Institute in Baltimore, Leonard Feldman, an associate professor of Internal Medicine and Pediatrics at the Johns Hopkins School of Medicine, and Scott Nolen, the Director of the Open Society Institute-Baltimore's Drug Addiction Treatment Program, wrote an Op-Ed challenging the decision, asserting that the removal of the sublingual film would severely constrain treatment options for individuals most in need.

On July 1, Van T. Mitchell of the Maryland Department of Health and Mental Hygiene and Steve T. Moyer of the Maryland Public Safety and Correctional Services defended the decision, citing the traffic of sublingual film strips in jails and prisons and the sharp increase in opioid related deaths as justification.

If addiction is a vicious cycle, so too is the anxiety that surrounds treatment. Nearly a decade ago, The Sun investigated the adoption of buprenorphine as an alternative to methadone. It reported leakage of the drug into illicit markets based on anecdotes from police officials and offered examples from other cities where buprenorphine had been recently introduced.

The conclusion was that Suboxone (buprenorphine and naloxone) presented a new danger, but the reports failed to distinguish the abuse potential associated with naloxone-combined drugs (primarily used in Baltimore) compared to drugs consisting of buprenorphine.

In a sharply worded letter to the editor responding to claims of the reporters, Joshua Sharfstein, then Baltimore City's health commissioner, and Peter Luongo, director of the Maryland Alcohol and Drug Abuse Administration, argued that the low abuse potential of these drugs offered the potential to do more good than harm.

Since then the average of monthly buprenorphine prescriptions increased to 11,132 in 2015. At the same time, last year 1,259 fatal opioid overdoses occurred in Maryland, a 21 percent increase over previous year. Nationally, overdose deaths involving prescription opioids have quadrupled since 1999 and heroin-related overdose deaths have more than tripled since 2010.

The consequences of addiction for individuals, families, and communities are real. And yet the epidemic of opioid abuse is not one but many interlaced epidemics of prescription opioid abuse, saturated consumer markets and pain mills, epidemics of poverty and violence, and mass incarceration that sustains the protracted epidemic of heroin abuse, along with seemingly new threats such as fentanyl abuse.

Just as methadone would combat heroin in the late twentieth century, pharmacotherapies such as buprenorphine will continue to combat opioid abuse in forms new and old. If these epidemics are indeed interwoven, then it is no wonder that the binary between categories of licit and illicit, addict and patient, and hope and danger muddle conversations about programs for effective treatment. Though they are conflated in debate, drugs for treatment, those that find their way into markets of abuse and those with high potential for fatal overdose remain distinct more often than not.

This is not an argument for nuance; it is a call for facticity. Buprenorphine-naloxone combination drugs are not the same as buprenorphine alone or other agonist therapies, and they are certainly not chemically or socioeconomically synonymous with heroin.

When we consider the form of opioid, the routes through which drugs are taken, and the markets through which these drugs pass, we find that opioids do indeed discriminate and are discriminated by users.

However, the concern here about the decision to eliminate a buprenorphine-naloxone sublingual film from the Maryland Medicaid preferred drug list is not so much a concern about the traffic in pharmaceuticals but the traffic in confusion and fear.

Clinicians, researchers and policymakers should take care to clarify the pharmacokinetic properties of these specific drug combinations, making their molecular and therapeutic specificity a priority, and crucially, making clear the wide-ranging abuse potential and social reality of these drugs lest we allow a market in fear surrounding treatment to flourish.

Todd Meyers

The writer is associate professor of anthropology and director of the Center for Society, Health and Medicine at New York University-Shanghai.

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