The December three-part series in the Baltimore Sun on buprenorphine, the drug approved by the Federal Drug Administration in 2002 for heroin addiction, compromised clarity and balance by burying key facts about the drug’s use and effectiveness and further exaggerated its potential abuse. Ostensibly motivated by a concern that potential abuse of buprenorphine was not well known by the public, the Sun ultimately produced a series that experts in the U.S. and France found to be extremely misleading.
Sun readers who are aware that Baltimore City, after careful planning, has added buprenorphine to its treatment modalities for heroin addiction must have been confused. But researchers, practitioners and funders (including the Open Society Institute-Baltimore) engaged in building a high-quality, evidence-based system of treatment in Baltimore, were truly irritated. Rather than explore the complexities of treating a chronic disease such as heroin addiction with buprenorphine, the Sun used the trappings of rigorous investigation—a team of reporters, international comparison, lengthy articles—to concoct an impending epidemic of treatment abuse.
Sensational headlines kicked-off the Sun’s campaign, followed by “reporting” that generally characterized heroin-dependent individuals–and even their physicians–as willful schemers. The result: an interested reader, let alone a casual reader, was highly likely to come away from the series believing that buprenorphine is not an effective treatment for heroin-dependent individuals in Baltimore or elsewhere, that the drug is generally being abused, and that buprenorphine treatment substitutes one high for another. Only a very careful reading of the series, ideally coupled with other sources of evidence-based information, would give the public a sense of the limited scale of the Sun’s charges of abuse. The Sun squandered a valuable opportunity to examine and educate the public about the challenges of treating chronic diseases–and the particular challenges of treating individuals who use other illicit drugs while being treated for heroin addiction. Reporting on abuses of treatment protocols is important but only meaningful if put in an informed context.
Therefore, my audacious idea is that the Baltimore Sun conduct its investigative reporting in a balanced, rigorous and evidence-based manner and rectify mistakes, when they occur, in a manner that readily gives the public access to the facts.
In an area as complicated as addiction, the Sun has a potentially important role in presenting what we know from research and from practice about buprenorphine and about the behavior of people suffering from the chronic disease of heroin addiction.
When experts in the field immediately wrote to the Sun about its various reporting mistakes and misleading statements, the paper choose not to print any of the letters until days after the series appeared, when many people were already distracted by the holidays. While the public editor of the Sun may think this approach meets journalism standards, we believe that Sun readership deserves a higher standard of reporting.
What follows is a sample of letters that were submitted to the Baltimore Sun, re-printed here in the original, unedited versions:
Submitted to the Baltimore Sun by Rebecca Ruggles, Director of Special Projects, Mid-Atlantic Association of Community Health Centers:
The Sun’s series of articles on buprenorphine was a shocker. But unlike the readers you were probably trying to attract, I was shocked not by the anecdotes of abuse and street sales that you chose to highlight, but by your stooping to this kind of sensational journalism.
Monday’s article leading off with a French physician describing himself as a drug dealer took a quip and misinterpreted it. That’s an insult to the many physicians who are trying to prescribe responsibly. Sunday’s article titillated readers with stories of drug stings and overdose deaths, while omitting to quote patients succeeding in treatment.
I expect the Baltimore Sun to be more intelligent than this. These articles play all the cheap cards that will keep people reading for lurid details of the sad and depraved lives of drug addicts.
The truth is buprenorphine (suboxone) is one of the safest and most effective treatments we have for a disease that is life threatening. Lives are being saved by this new medication; people are being restored to productive work and healthy relationships by receiving it. It is not a miracle drug. It is an important addition to our arsenal of weapons in the fight against a deadly disease.
The incidence of abuse and diversion of suboxone is small compared to what has already happened with prescription opiates such as oxycontin. The overdose potential with buprenorphine is negligible compared to that of methadone, which was our only medication in the United States for opiate dependence until 6 years ago.
I’m not saying that your coverage should avoid the difficult questions of drug safety and narcotic diversion. But these issues can be raised in a manner that avoids stigmatizing the disease and its treatment. Deep in these articles are references to the difficulties of balancing public health impacts – and the fact that there is no risk-free strategy. Then the articles quickly return to emphasizing instances of harm, instead of the science and the data, the weighing of risks and benefits.
That is journalistic choice – what to lead with, what to bury. That’s what I find so disappointing. There was a clear alternative – a way the Sun could have raised these issues to juxtapose the benefits and the risks – and to help readers understand the complexities of the public health challenge of treating addiction. You decided instead to go for shock value.
Submitted to the Sun by Alex Wodak, MD, Alcohol and Drug Service, St. Vincent’s Hospital, Sydney, Australia:
Buprenorphine is an effective, safe and cost-effective treatment for heroin dependence. In 2005, the World Health Organisation included buprenorphine in its Essential Drugs List. In the same year, the World Health Organisation, UNAIDS and the United Nations Drug Control Programme jointly endorsed buprenorphine as an important and effective treatment for heroin dependence.
The recent series of articles in your paper sensationalises and trivializes the difficulties of providing pharmacological drug treatment to heroin users with inadequate funding and limited community support. What is most needed from the media covering the complexities of illicit drug use and its important public health and public order consequences is what was lacking from your series: a sense of balance.
The USA has by far the highest rate of AIDS per capita in the industrialized world, three to four times higher than the next country (Spain). The grossly inadequate strategies to prevent HIV spreading among and from injecting drug users in the USA is largely to blame for this terrible legacy that is being passed on to unborn generations of Americans. Buprenorphine treatment has an important role to play in helping to keep HIV under control in the USA as it does now in over 40 other countries world wide.
Injecting drug users are somebody’s son or daughter, brother or sister. They are often someone’s mom or dad. Health care workers are obliged to provide treatment to injecting drug users based on evidence. As someone who has visited scores of countries attempting to assist HIV control among injecting drug users and a frequent visitor to the USA (including visiting Baltimore several times), I trust that this newspaper will soon return to this subject but to provide instead a properly balanced coverage of the issues raised.
Submitted to the Baltimore Sun by Christopher Welsh, MD, Professor at the University of Maryland School of Medicine:
In the Sun’s recent series of articles on buprenorphine, the many positive aspects of buprenorphine seem to have been lost in the overwhelming focus on its negatives.
The first and most important of these positive aspects is the number of studies that have shown how effective the medication is at helping people stop using heroin and prescription pain killers.
The diversion of buprenorphine, although an issue, must be put in the context of the illicit sale of other medications – for instance, there is even a black market for antibiotics and asthma inhalers.
As for safety issues, in the United States, there is little evidence that buprenorphine causes or even has a substantial contribution to the reported “buprenorphine-related deaths,” and there are no cases of deaths related solely to buprenorphine – unlike the more than 1,000 deaths per year as a result of heroin and other prescription painkillers.
Submitted to the Baltimore Sun by Diana Morris, Director, Open Society Institute-Baltimore:
Your series this week on the abuses of buprenorphine (The Bupe Fix, December 16, 2007) distorts the true picture of an extremely promising therapy for heroin addiction.
If you knew someone who had diabetes and mixed insulin with alcohol or another drug, would you tell that person not to take insulin? If you knew someone with hypertension who combined blood pressure medicine with other drugs, would you tell that person to give up the blood pressure medicine? Of course not! You would reinforce the old rule that people shouldn’t mix drugs.
Addiction is a chronic medical condition much like diabetes or hypertension. Given the high societal costs of addition, the U.S. embraced buprenorphine as an effective treatment for heroin addiction, after carefully examining the experience of France and other countries.
A number of extraordinary controls guide the use of buprenorphine in the U.S. To prescribe buprenorphine, doctors go through an eight-hour certification course and are instructed to tell patients not to mix drugs, without their guidance. The addition of naloxone to buprenorphine in the U.S. significantly decreases its potential for abuse. As a result, buprenorphine is extremely safe when used properly.
Two years ago, the federal government made it easier for doctors to prescribe buprenorphine – with strict rules. Doctors can only prescribe it initially to 30 patients – and after a year to 100 patients. The Drug Enforcement Administration, with which all doctors prescribing buprenorphine are registered, ensures that doctors do not provide multiple prescriptions to a single patient.
The main point is that thousands of people in the U.S. use buprenorphine appropriately and therefore safely. It has helped them turn around their lives. In the process, it has saved the public all the negative health consequences and costs of heroin addiction, from HIV transmission and emergency room visits to property crime and incarceration. The Sun should also cover these successful stories, as buprenorphine is a powerful treatment for the devastation caused by heroin addiction.