The Drug Policy Digest
Sunday, August 17, 2003
New York Times Article Lauds Potential of Buprenorphine in Treatment of Heroin Addiction and Other Dependencies
2000 Physicians Already Using the "New" Treatment
In an August 11th New York Times piece entitled New Drug Promises Shift in Treatment for Heroin Addicts by Richard Perez-Pena, the article discusses addicts who take buprenorphine, a drug "newly approved" by federal regulators (it's been at least ten months, now) to treat addiction to heroin and other opiates, including addiction to prescription drugs like Vicodin and OxyContin.
According to the Times, experts and addicts say it has several advantages over methadone, and the most important may be that a patient can get a supply, not merely a dose, with a visit to a doctor and pharmacy.
Like methadone, buprenorphine (pronounced byoo-pre-NOR-feen) is addictive, but the risk of overdose is much lower. Unlike methadone, buprenorphine will not give an addict more than a mild high no matter how large the dose, and it cannot be combined with opiates or other narcotics to get higher still. Users suffer fewer unpleasant side effects, and milder withdrawal symptoms when they stop taking it.
Other highlights of the article:
* The relative ease with which a supply of buprenorphine can be obtained is a radical departure from the use of methadone, which is tightly controlled by federal law and can be given only one daily dose at a time, in licensed clinics where space is limited. Experts say the advent of buprenorphine could triple the number of people in treatment for heroin addiction.
* Some experts see the change as more evolutionary than revolutionary, warning that much remains to be learned about buprenorphine, and that methadone, too, was once seen as a wonder drug. But they are enthusiastic, saying that since doctors began prescribing buprenorphine in October, the experience has been overwhelmingly positive.
* New York City has an estimated 200,000 heroin addicts, and only 38,000 methadone program slots. Nationally, there are 800,000 to one million heroin addicts and about 180,000 methadone clinic spaces, and addicts outside major cities often live nowhere near clinics. Experts say that for every heroin addict, there are two people addicted to prescription opiates, drugs like oxycodone, hydrocodone, codeine and morphine, and that buprenorphine can be effective for them, as well.
* Buprenorphine will not work for all addicts, and will not completely replace methadone. Some people simply will not respond well to it, which is true of almost any drug.
* Buprenorphine has been used as a painkiller for many years, and a few researchers, including Dr. Kleber, were permitted to make limited use of it for addiction treatment. In general, though, for decades federal law has prohibited use of any drug but methadone for heroin addiction.
* After a long lobbying campaign by treatment advocates, Congress loosened the law in 2000, and last October, the Food and Drug Administration ruled that doctors could prescribe buprenorphine in their offices for addiction treatment. To prescribe it, a doctor must first take an eight-hour course and register with the federal Drug Enforcement Administration. Because buprenorphine is addictive and has a potential black market, federal law prohibits a doctor from prescribing to more than 30 patients at a time.
* Since October, about 2,000 doctors nationally have been cleared to prescribe buprenorphine for drug treatment, including 218 in New York State and 62 in New Jersey. People in the drug treatment field say there are no more than a few thousand people around the country taking buprenorphine.
* New York State has decided that Medicaid, the health plan for the poor, will cover buprenorphine, but most states and most private insurance plans do not. Doctors say the retail cost is $5 to $10 a day.
* France allowed general practitioners to prescribe buprenorphine in 1996, and has reported a sharp drop in fatal overdoses. New York City alone has about 200 heroin overdose deaths each year.
* Buprenorphine latches onto the same receptors in the brain as heroin, methadone and other opiates, but more aggressively and effectively. A person already on buprenorphine who took another opiate would feel no effect, because the second drug would be unable to push the buprenorphine out of the way and latch on. Buprenorphine stays in the system longer, so many people can take it every other day, rather than every day.
* Buprenorphine is also unlike the others in having a "ceiling effect;" that is, beyond a certain dosage, taking more does not make the person any higher, or depress breathing any more. That reduces the risk of both abuse and overdose.
The withdrawal from buprenorphine ("bupe" as the article refers to it) is less serious than coming off of heroin or methadone.
Buprenorphine's debut as a treatment modality for addiction may have an important significant symbolic value, since it is the first opiate in decades that has been approved to be prescribed or administered in a physician's office. Many of us can recall when this was a criminal offense and doctors were imprisoned for trying to assist addicts.
Click Here to find a physician near you who is approved to use buprenorphine as an adjunct to recovery. There are about 175 such doctors in California as of August 2003.
Read the complete article here. Physicians interested in obtaining certification for using buprenorphine in their practice should see the Health and Human Services Buprenorphine site for information on training and waivers. Note that, like methadone, buprenorphine remains available for use in treating pain and other symptoms associated with organic disease processes. It may not be used for addiction treatment without special physician certification and a DEA endorsement to one's current DEA license. SPECIAL NOTE: Buprenorphine is *NOT* a Schedule V (exempt) controlled substance as stated in some parts of the DEA website. It is currently a Schedule III drug and all rules pertaining to the prescribing of these medications apply to this drug, in addition to the special provisions for using it as a treatment for addiction.
For more information about this medication and its use in addiction treatment, see The Australian Drug Foundation (ADF) web site for details.
Saturday, August 16, 2003
Kicking the (Heroin) Habit in Myanmar (Burma)
Country Moves Away from Opium and Heroin to Gambling and Prostitution - This is Progress?
In a recent article in The Los Angeles Times, "Myanmar Tries to Kick Its Habit" by Mitchell Koss, the author describes a forthcoming (this winter) documentary on the Golden Triangle by Mitchell Koss and Laura Ling will be presented this winter by the National Asian American Telecommunications Association.
In the late 1980s, the government of Myanmar ceded a region where a fifth of the country's opium is produced, dubbed Special Region #2, to the United Wa State Army. The area was granted autonomy in exchange for an end to its decades-long war against the Burmese majority to the south.
Our army guide took us to a newly opened "casino," a rough barn-like structure where the gamblers ran away when he walked up to a table. He then led us to a shed-like karaoke bar staffed by very young women imported from across the border in China. There, my colleague, encouraged by our enthusiastic host, sang John Lennon's "Imagine."
Our real reason for wanting to see the region, though, was to check out a U.N.-run voluntary opium-reduction program being run in several hundred Special Region #2 villages, funded in large part by the United States. Farmers here traditionally grow opium for cash to buy food because they usually can't grow enough food for a whole year. Everywhere, fields of largely white flowers climbed the steep sides of the green mountains.
Once, in the mountains above Neiva, Colombia, in February 1999, I was caught by insurgents from the Revolutionary Armed Forces of Colombia while filming poppy fields for a documentary and was lucky to be let go with a warning. But in Special Region #2, the opium harvesters are not camera-shy. Barefoot women, some of them teenagers with babies on their backs, laboriously scored the poppy buds to draw out the opium gum, while others scraped the dried opium off buds that had been cut the day before. But unlike opium or coca farmers I've seen in Colombia and Bolivia — where an illicit crop can bring enough wealth to buy a pickup truck and a satellite dish — the average Golden Triangle family makes only $200 per year from its opium, according to the United Nations.
As I watched the women harvesting opium, I noticed that one woman's baby was covered with scabs; another's was going blind from conjunctivitis — "pinkeye," a common illness here but one that's easily cured with antibiotics. In Special Region #2, it is a common cause of blindness. The Wa have little access to health care or medication, other than opium. Indeed, smoking opium to alleviate malaria, TB or any of the other endemic diseases results in a high rate of addiction in the villages.
The region's extreme poverty is summarized by what passes for progress. The U.N. took us to a couple of model villages where the newest innovations were pit toilets and clothes for children.
On market day in the newly electrified town of Mong Pawk, we watched villagers bring their opium to Chinese women sitting by small scales. The opium buyers were a little more camera-shy and wouldn't answer questions. But the U.N. told us that a kilo of opium in Myanmar fetches only $120, about a fifth of what an ounce of high-quality Vancouver-grown marijuana — "B.C. Bud" — can retail for in New York City.
From the Mong Pawk market, the opium goes global. The distance separating Special Region #2 from Yunnan province, China, across the river, is literally a stone's throw (I made it on my sixth try). According to the U.N., in the early 1990s, globalization gave rise to mainland Chinese organized crime syndicates that challenged the supremacy of the old Hong Kong/Taiwan smuggling groups, just as Shanghai now challenges Hong Kong as a business capital. When mainland Chinese syndicates began turning Myanmar's opium into heroin and smuggling it out, 60% of the drug began crossing China. And some of it began staying there.
About the time heroin began crossing over, so did HIV. In the Mong Pawk market we watched as U.N. workers demonstrated how to put a condom on a model penis (ignored by the passing karaoke girls). Some studies estimate that Myanmar has the second-highest HIV rate in Asia, after Cambodia. So now China, with 1 million to 2 million intravenous heroin users, is facing the possibility of 10 million HIV cases by the end of the decade.
On the journey back out of Special Region #2, we stopped for the night in the city of Mong Lar, in the adjoining Special Region #4. Compared to where we'd just been, Mong Lar looked like a metropolis. It has eliminated opium production. Taking advantage of the nearness to China, Mong Lar has switched from opium to large casinos. Unlike the makeshift Wa casinos, Mong Lar's gambling palaces light up the night sky and draw thousands of Chinese visitors. Around the casinos are streets of brothels staffed by young women from all over China.
Suddenly, it all clicked. We understood why the Wa leaders had taken us to those would-be casinos and karaoke bars — they were showing how they planned to get rid of opium. They want to go into the tourism business.
Perhaps the Wa would try harder to stay in the opium business if it were more lucrative. They seem lately to be embracing methamphetamine production. In that, they are like many residents of California, who risk long federal prison sentences to maintain our state's status as the Golden Triangle of illegal methamphetamine production.
But the U.N. is hoping that eventually Myanmar's leg of the Golden Triangle will become more like Thailand's leg, where opium production is largely a thing of the past. It cautions that this is still a distant goal. But according to its survey released this June, poppy cultivation in Myanmar is down 24% from last year, and down 60% from 1996.
Unfortunately for the world, the global market still offers plenty of other sources of opium. The defeat of the Taliban in Afghanistan ended that group's ban on opium production, and now the Afghans have regained the No. 1 spot in world opium production. And according to the Drug Enforcement Administration, most of the heroin used in the U.S. now comes from Colombia and Mexico.
Read the entire article on the Los Angeles Times site or here.
Friday, August 01, 2003
Look Out For Bears; And Opium Fields !
Report Says There's Opium in Those Hills!
Press reports say that a hiker discovered 40,000 lavender-hued opium poppies growing in the Sierra National Forest, south of Yosemite. The plants, enough to yield 40 lbs. of raw opium, were in a clearing on a 3,000-ft.-high slope scorched by a forest fire two years ago.
Three men in camouflage outfits were in the process of scoring the poppy pods and squeezing out the raw opium for harvest when they were surprised by law-enforcement personnel. They fled into the woods and, although one "Asian" man was briefly detained after authorities found him with scratches on his face and a "brown substance" on his hands, nobody was arrested.
A new, domestic, source of materials for heroin manufacture? Not likely, say those interviewed. The area where the plants were found is about 40 miles from Fresno where smoking opium is said to still be prevalent among the area's Southeast Asian immigrant population.
Nothing truly new, opium cultivation is simple -- it is the California State Flower, after all. Actually, there are over 200 different species of poppy and the "opium poppy" (papaver somniferum) is illegal to grow anywhere in the United States, although vast quantities of opium are imported for medical purposes and as many as 108 nations are known to be growing the poppy for one purpose or another. India, for one, produces at least 46, 000 tons of the poppy seed alone. Opium is also a strategic material -- stockpiled in the event of war -- painkillers are going to be in high demand if, for example, North Korea lobs one of those "low yield" A-Bombs at California.
In April of this year, two Iowa University students were arrested after police found (among other proscribed items) 100 poppy pods that had been allegedly grown in their domicile.
Given that the 40 pounds of raw opium contains only about 0.4 to 0.9 percent morphine (the "active ingredient"), the best a heroin producer could yield from this crop would be less than half a pound of heroin. A nice chunk of change, but heroin is too easy to smuggle into the United States to make this a likely source of competition for the Mexican and Colombian brands.
Despite its illegal status, it is not at all unusual to find papaver somniferum seeds onbagelss and other pastry. In addition, the seeds and even the seed pods can be purchased from various quasi-legal sources in the United States. And, no, I won't tell you where.