Bullets don't kill people...

Several articles on the classification of Subutex as a Class A Controlled Drug in the papers today, but this line in particular from this article in Today catches angry doc's eyes:

"(Subutex) manufacturer, Schering-Plough, said it was not aware of any death in Singapore from injection of Subutex alone."

Right.

Ammunition manufacturers are not aware of any deaths from bullets alone; but we all know bullets fit inside guns.

Putting the Genie back...

... into the drug bottle.

Subutex is now a Class A Controlled Drug, and will have to be taken in the presecnce of a doctor or pharmacist.

You can read the full Ministry of Health press release here, and the Channel NewsAsia story here.

According to the CNA story:

"Medical sources tell Channel NewsAsia that some clinics in Singapore have made as much as one million dollars a year by selling Subutex to their patients."

Wow.

Not uniquely Singapore

Someone asked in a letter in Today today:


"Was any study carried out on the effects of Subutex use and abuse in other countries before it was introduced? If so, what were the findings?

If the findings were adverse, why did the authorities go ahead to use it? If the findings were initially not adverse, did the authorities monitor the experience of other countries in the past few years?"


angry doc did a little googling, and it turns out that Georgia (the one in Europe, not the one in America) has a Subutex-abuse problem too.

In fact, so do Finland, Nepal, Sri Lanka, Bangladesh, Britain, Germany, and New Zealand according to the article.

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.

(excerpt)

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.

(excerpt)

"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.

Use and Abuse 3

This newspaper report today gives an idea of the scale of the Subutex problem (emphasis mine):


Govt to tackle the abuse of drug Subutex

WITHIN two weeks, the Government will unveil a strategy to tackle the rising trend of Subutex abuse, which is the only approved drug prescribed to help heroin addicts cope with withdrawal symptoms.

Health Minister Khaw Boon Wan said he was worried by the "Singaporean" problem, with 40 per cent of the estimated 4,000 abusers from the Malay community, and another 40 per cent from the Chinese community. The trend is especially alarming in Dr Khaw's Sembawang constituency, where the issue of Subutex abuse crops up at every residents' meeting.

"The addicts … cause a social nuisance, leaving behind needles after they use them in the toilets and corridors, frightening the neighbours," he said.

Subutex abusers get a "high" by injecting themselves with the dissolved drug. When used correctly, the pill treats heroin withdrawal symptoms such as nausea.

Between 2002 and 2004, the number of Subutex pills prescribed here is estimated to have shot up from 78,764 to 619,472.

Dr Khaw said his office and the Ministry of Home Affairs would come up with a solution that is "complete" rather than "symptomatic".

There has recently been talk about making Subutex a controlled drug so that doctors selling it would be held even more accountable. Anyone caught with the drug without a prescription could face a fine and/or imprisonment.

Last October, the Government sought to tighten supply by making it mandatory that doctors submit details on patients using Subutex. — CHRISTIE LOH


angry doc likes numbers - they fuel his imagination.

The demand for Subutex increased nearly seven times over the course of two years. Now even if all the Subutex prescribed were to heroin addicts using them as prescribed, the sheer increase in the number of heroin addicts would have been a cause for concern. And that's not even counting Subutex that had been brought into the country illegally.

So did the people who knew of the number of Subutex tablets prescribed in the country conclude that the heroin addiction problem must have improved dramatically over those years, judging from the number of addictis who must have been on therapy? If that was indeed their conclusion, did they check with the Central Narcotics Bureau to see if this was consistent with their surveillance of the drug abuse situation in Singapore?

Or did they not know that the drug was being abused at all?

Well, perhaps all that are not important now. What angry doc is more interested in now is the Ministry's "complete" solution to the problem.

Stay tuned. I know I will.

Use and Abuse 2

I did not expect the Central Narcotics Bureau (CNB) to respond the the letter by Dr Soo which we discussed in this post two weeks ago, but they did so in a letter to Today today.


Providing substitute drugs will only prolong addiction

Letter from Dawn Sim
Public Affairs, For Director
Central Narcotics Bureau

WE REFER to the letter "Drug for heroin dependence can turn lives around" by Dr Soo Inn Choong (July 10).

Abusing drugs such as heroin is a deliberate act of taking a psychoactive substance against the law.

Drug addicts must account for their actions and take personal responsibility to stop their undesirable habits which have serious repercussions on their lives, careers and families.

Providing addicts, who are unwilling to take personal responsibility, with a substitute drug merely encourages them to prolong their addiction from one drug to another.

In our experience, rehabilitating drug addicts can only be achieved through a comprehensive programme of treatment through rehabilitation and aftercare. Unless they are compelled to stop and supported to take responsibility for their actions as part of a holistic rehabilitation programme, many will continue to dither and languish in the embrace of one drug or another.

For every case cited by Dr Soo, we know of many others who have thoroughly cleaned themselves from their addictions and lead healthy and productive lives without the need to be under the bondage of any drugs.

It is with this approach that we have managed to keep Singaporeans relatively drug-free. The Central Narcotics Bureau and the Ministry of Health have been monitoring the Subutex situation closely.

The two agencies are also working together to assess if additional measures are needed.


We are presented with two different views of the same 'problem', which likely stems from the fact that the CNB and Dr Soo probably see two rather different groups of addicts in the course of their work - the one with addicts who did not voluntarily seek help, and the other with those who came forward willingly, after the decision to quit.

Dr Soo sees addiction to heroin as 'a disease that should be treated like every other'.

The CNB sees addiction to heroin as 'a deliberate act... against the law'.

Of course, there is no reason why it can't be both.

But Dr Soo also sees Subutex as a medication, and he believes that '(i)n the same way that people with other mental disorders such as schizophrenia or depression need medication, so do those with heroin dependence.'

Whereas the CNB believes the use of Subutex 'merely encourages (addicts) to prolong their addiction from one drug to another'.

Well, these two positions are a little harder to reconcile, but there is no reason why it cannot be the case of the former in some people, and the case of the latter in others. In fact, that is almost certainly the reality, since we know some people quit their heroin addiction with Subutex, and some people abuse Subutex.

Addiction is a complex phenomenon involving many aspects of a person, including genetics, biology and psychology. Add to that the social implications or stigma of the term 'addiction', and the picture gets even more complex. There probably isn't a one-size-fits-all solution to heroin or Subutex addiction, not to mention other forms of addiction. The 'best' solution depends on which spectrum of the 'problem' you have to deal with.

As politically-incorrect as it seems, angry doc tends to agree with the idea that taking personal responsibility is an important step in quitting any addiction (or controlling many chronic medical conditions, for that matter). While we may argue over individual susceptibility to addiction and what the best method of quitting is, I believe one thing all successful 'quitters' must have had in common was the personal decision to quit, and the continued decision to see the rehabilitation process through, be it cold-turkey, or drug-assissted.

Use and Abuse

There is almost always two sides to a story, and this letter from Dr Soo published in Today today tells 'the other side' of the Subutex story:


Drug for heroin dependence can turn lives around
Letter from Dr Soo Ing Choong

I am a general practitioner and have worked to improve the health of my patients for more than 18 years.

Heroin addiction is a national problem. In the same way that people with other mental disorders such as schizophrenia or depression need medication, so do those with heroin dependence.

The health authorities recognised the usefulness of Subutex in treating heroin dependent patients, and approved its use in 2002. Since then, several Ministry of Health guidelines have trained doctors like myself in the proper use of this medication, and effectively stopped doctor-hopping by registering patients under the Cards system (Central Addictions Registry for Drugs Singapore).

Over the year, there have been many reports of people abusing Subutex — the only approved and effective medication for the treatment of heroin dependence. And with every negative media article, dozens of success stories go untold.

For every case of abuse of this medication, there are numerous patients who can return to work and contribute to society, re-establish family relationships and raise their children with love, as they try to break free from their dependence.

I have treated a large number of patients who have turned their loves around to become contributing members of society with the help of this medication. The public needs to understand that heroin dependence is a disease that should be treated like every other.


We've discussed this problem previously, and the subject continues to make the news and medical literature (click here to see the scale of the problem, here to find out about an alternative to Subutex, and here to look at some gross pictures of limbs turned gangrenous from Subutex abuse).

My own suspicion is that even with tighter regulation or even total banning, Subutex-abuse will continue to be a problem as long as it is manufactured, whether legitimately or illegally, if it indeed gives 'even more high' than heroin.

The genie is, as it were, already out of the bottle.

Abusement Park

An interesting letter on the ST Forum today:


Dec 22, 2005
Put a stop to drug merry-go-round

There is a vicious circle of a sizeable number of repeat drug offenders going in and out of rehabilitation and jail. Once out, they are back with their own kind, scouring the island for clinics willing to supply them with sleeping pills, Subutex, codeine cough mixtures and painkillers, and tranquillisers.

Addiction recognises no social or professional barriers. For obvious reasons, there will always be someone willing to supply addicts with drugs if you refuse to. Then the doctors who prescribe 'too freely' get hauled up by the Singapore Medical Council. The addicts then go on an islandwide merry-go-round looking for other drug sources, and the cycle repeats itself without the root cause of the problem being addressed.

Yes, we have the Community Addictions Management Programme (Camp), but how many people know the hotline number or where the so-called 'We Care' centre is? These clinic junkies will not seek help voluntarily and the problem will never be solved unless Camp is more proactive in its efforts.

You get stressed-out executives hooked on Dormicum or Nitrazepam, or hear of people telling you they have accidentally spilled their cough mixtures and need some more. Some even go to the extent of looking after other people's babies, and claiming they cannot sleep because of the crying at night.

The authorities or Central Narcotics Bureau should suggest where doctors can send these hopelessly hooked codeine junkies and stop their perennial merry-go-round game with clinics. Otherwise doctors will get hauled up regularly for prescribing sleeping pills or codeine-based cough mixtures too freely, and the problem never gets solved.

Dr Lim Boon Hee


Dr Lim seems to have identified the problems, but I don’t think the solution he proposes will work.

The primary problem is: “junkies will not seek help voluntarily”. Add to that the fact that “there will always be someone willing to supply addicts with drugs”, what you have is a perfect working relationship that neither party has reasons to break. Those who refuse to prescribe to known or suspected junkies (bearing in mind that ‘under Regulation 19 of the Misuse of Drugs Regulations, a doctor who attends to a person who he considers or has reasonable grounds to suspect is a drug addict shall, within 7 days of the attendance, furnish details of the person to the Director of Medical Services (DMS) and the Director of the Central Narcotics Bureau (CNB).’) will not “get hauled up by the Singapore Medical Council”.

Those who do prescribe ‘too freely’? Well, under the Misuse of Drugs Act, ‘(a)ny person who abets the commission of or who attempts to commit or does any act preparatory to, or in furtherance of, the commission of any offence under this Act shall be guilty of that offence and shall be liable on conviction to the punishment provided for that offence.’

Fact is, doctors know it is wrong to prescribe to addicts, that it is wrong to not inform the authorities (there is even a clause in the Act to protect the informant’s identity), and they know whom to notify.

So I don’t think doctors are innocent victims in this relationship who get hauled up to the Medical Council for no good reason at all. If the addicts are the ones going on a merry-go-round ride, the doctors are the ones collecting admission into the Abusement Park.

Then Jacob gave Esau bread and pottage of lentils;

I’ve been wanting to blog about this issue for a while now; this news article gives me the excuse:


SINGAPORE :

The drug Subutex, which is used to treat heroin addition, may be listed as a controlled substance.

The Health Ministry is discussing with the Health Sciences Authority and Central Narcotics Bureau to make it a criminal offence for anyone to possess the drug without a prescription.

Subutex is fast becoming a drug of choice among former heroin addicts as they regard it as a 'legal fix'.

The pills are often dissolved in water and mixed with sleeping tablets to create a potentially lethal injection.

Demand for the drug on the black market is high, with one pill costing up to $35.

The Health Ministry has conducted an audit on nine private clinics to see if they prescribe the drug too freely, and is currently reviewing the results.

Strict guidelines on the prescription of Subutex were released last month.

These include supervising patients to ensure they take the tablet properly by placing it under their tongue for the first month of treatment.

Doctors found guilty of prescribing the drugs too freely can be fined up to $10,000 and struck off the medical register.

(source)


The problem is not new, and the Ministry had recently issued guidelines on the prescription and use of Subutex.

You have to wonder: who first decided it would be a good idea to pound a tablet, dissolve it in water, and then inject it into his vein?

But the subtext here is this: doctors are prescribing Subutex to people who abuse the drug.

Don’t they know?

Can they really miss the bruised and hardened veins on the arms of the addicts? Or don't they check?

Doesn’t the drug company know that its product is being abused in a manner that harms its abusers?

Why was a drug that has potential for abuse approved for use to treat addiction?

And people ask me why I am angry...


… and he did eat and drink, and rose up, and went his way: thus Esau despised his birthright.