Angry Doctor

Friday, August 04, 2006

Good Intentions

As promised, the Ministry has unveiled the first part of its "complete solution" to the Subutex-abuse problem, as reported in Today today. I reproduce the article in full as it provides a rather good summary of the Subutex problem.

The cure that got out of hand
Moves to curb heroin treatment which became an addiction
Tan Hui Leng

It was supposed to treat heroin addiction and, for that reason, was made widely available in Singapore clinics.

Instead, Subutex has become the new drug problem and the Government is now considering listing it as a controlled drug.

"Together with the Ministry of Home Affairs, we are finalising a robust set of measures," said Health Minister Khaw Boon Wan yesterday. "We are proposing to classify buprenorphine (Subutex's chemical name) as a Controlled Drug under the Misuse of Drugs Act, making the illegal import, distribution, possession and consumption of buprenorphine an offence."

This means that those caught carrying or using the drug without a prescription will be flouting the law. It marks a major turnaround for a drug that, when it was introduced in 2002, could be obtained freely on the prescription of any general practitioner.

It worked on the same areas of the brain as heroin, without the addictive effects. The condition was that it should only be taken by dissolving it under the tongue.

Instead, abusers of Subutex crush it with other drugs — such as sleeping pills — and the drug cocktail is then injected into their system for a high sensation.

With about 3,800 Subutex users in Singapore today, there is a concern that there may be more abusers. There may also be a need to look at what to do with those using the drug and whether they will need help.

"The introduction of Subutex is a classic example of a good intention that has led to an unintended detrimental outcome," said Mr Khaw who was at the Berita Harian Achiever of the Year Award."It was a well-meaning decision with the interests of the heroin addicts at heart. But the good intention has unfortunately yielded opposite and unexpected results."

This is because while some heroin addicts appeared to have benefited from Subutex, many others seem to have merely shifted their addiction from heroin to Subutex, he explained. Furthermore, injections significantly raise the risk of spreading infectious diseases.

"This status quo is not acceptable," he added. "Let us tackle this problem fundamentally and nip it before it becomes unmanageable."

Some curbs were introduced last year. Subutex users were registered and told to get their medication only from approved clinics. Doctors who prescribe the drug have to key in patients' details into an online system so that they do not obtain multiple doses by going to different clinics.

One such clinic is run by General Practitioner Dr Chee Weng Sun. He said to make sure his patients are not abusing Subutex, he makes them take it correctly in front of him at the clinic itself, during their first month of treatment. Subsequently, the prescription is on a weekly basis. Follow-up consultations include thorough checks to ensure that there are no injection marks on the patients.

As part of Doctors United Against Drug Abuse, a group lobbying against prescription drug abuse, Dr Chee is hopeful that the new measures would curb Subutex drug abuse. He noted that listing Subutex as a controlled drug would prevent black market trading. Currently, there is nothing to stop anyone from bringing it into Singapore.

But like others, Dr Chee is concerned that completely cutting off access to the drug may impact on recovering drug addicts. Currently, it is seen as the most effective method to reverse heroin addiction.

The Health Minister has also pledged that the authorities "will go all out to help abusers wean off the drug and to lead a drug-free life". A comprehensive rehabilitation programme supervised by a panel of psychiatrists will be set up and implementation details will come next week.

"We all want to wean them off but it's easier said than done," said Dr Chee, who sees 30 Subutex patients a month and has managed to take some of them off the drug.

Noting the high relapse rates for drug abusers – even those who go cold turkey, he said that whatever measure is implemented must ensure that heroin addicts who really need Subutex get them and are treated under supervision. Their doctors should then try to wean them off the drug gradually.

Otherwise, recovering heroin addicts may turn to other drugs, such as sleeping pills. Mr Freddy Wee, assistant director of Breakthrough Missions halfway house, concurred.

"The first thing that the Government should do is to help them quit first, put them in rehabilitation for six months, 12 months, whatever it takes," he said.

"If you don't deal with this than a black market will ensue because drug addicts will do whatever they can to satisfy their cravings."

The report on the Channel News Asia site is also interesting.


Recovering heroin and Subutex addicts like Benedick Wong welcome the stricter controls over Subutex.

He said: "I think to put it as controlled drug is very good. I feel that the Government should control it and the doctors shouldn't prescribe it so freely. It's totally too free. Some doctors tell you, 'don't take it too often, you know, you'll get addicted'. But they'll give it to you. Every two weeks you go, the doctor gives the prescription. So that doctor already knows you're misusing it.

"A normal person won't take sleeping pills, especially Dormicum, you won't consume it this way! The Government and CNB have to keep track. If the doctor keeps prescribing it, they should ask, 'why do you keep prescribing it'. Let the doctor give an explanation."

Dr Lim Boon Hee gives us his view on what the 'explanation' may be in a letter to Today too.


"It is a grim reality that some private clinics will not survive if their main source of income — derived from these former drug addicts who visit them for Subutex, Dormicum or codeine cough mixtures — is cut off by the impending control measures."

Under the Misuse of Drugs Act, controlled drugs are divided into a few classes, each of which carries punishment of varying severity for persons convicted of trafficking or abuse of the drug. It would be interesting to see which class Subutex will be put into.

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  • I am sure some GPs out there are going "The fit is going to hit the shan!!!"

    By Blogger Dr Oz bloke, At August 04, 2006 6:53 pm  

  • It's about time that MOH started doing something! This had already began when the new Minister and DMS started clamping down on certain doctors and a particular chain of clinics for excessive sedative prescription. I totally support their actions.

    To clinics who are gonna close because of all the tightened regulations : too bad ! Sell your multi-million dollar homes and luxury cars. Should cover expenses for a while whilst you try to re-learn clinical skills.

    I totally detest such doctors irregardless of the excuses they give when asked about their prescribing habits. All crap. Most start out like that, in order to survive in the first year. Then the money becomes too easy to earn, and they never get out of the cycle.

    By Anonymous Anonymous, At August 04, 2006 7:14 pm  

  • If TB patients can be subjected to daily observed therapy (DOT), I dont see why drug abusers can't for Subutex.

    By Anonymous Anonymous, At August 06, 2006 1:19 pm  

  • I would hazard a guess that technically, the reasons are:

    1. DOT can be enforced for TB because the Infectious Disease Act provides for it under (again I am guessing here) Part III Section 8, which states that:

    "1) The Director may require any person who is, or is suspected to be, a case or carrier or contact of an infectious disease to submit to medical examination or medical treatment at such times and at such hospital or other place as the Director may determine."

    Subutex abusers (and in fact drug abusers 'in general') are not infectious, and do not come under the Infectious Disease Act.

    2. Subutex is not yet a controlled drug.

    Under the Misuse of Drugs Act, one might make a case for requiring Subutex to be taken under DOT under Part II Section 10B, which states that:

    "The Minister may by regulations make provisions for —

    (c) imposing requirements for the registration of premises used in connection with the import, export, manufacture, processing, storage, distribution or supply of any controlled equipment, controlled material or controlled substance;"

    The Minstry may make it a requirement for the 'supply' of Subutex to be on premises, and in observation of a doctor/nurse, as a precondition to licensing.

    By Blogger angry doc, At August 06, 2006 10:19 pm  

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