Acupuncture in Patients With Carpal Tunnel SyndromeChun-Pai Yang, MD,*w z Ching-Liang Hsieh, MD, PhD,w y Nai-Hwei Wang, MD,JzTsai-Chung Li, PhD,z# Kai-Lin Hwang, MSc, ** Shin-Chieh Yu, MD,* and(P = 0.012). Acupuncture was well tolerated with minimal adverseObjectives: To investigate the eﬃcacy of acupuncture comparedwith steroid treatment in patients with mild-to-moderate carpaltunnel syndr
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Philippebourgois.net2QUALITATIVE HEALTH RESEARCH / January 2001 Buprenorphine:
“Field Trials” of a New Drug
Michael AgarPhilippe BourgoisJohn FrenchOwen Murdoch Buprenorphine is being introduced as a new treatment drug for narcotics addiction in theUnited States. The authors were asked by the National Institute on Drug Abuse to conduct afield trial to determine if buprenorphine might play a role in street markets. Because no streetuse of the drug existed in the United States, the authors used three sources of information: (a)“street readings” of clinical studies, (b) Internet discussion lists, and (c) research in othercountries. By using an emergent style of analysis that relies on replication of patterns acrossdisparate data sources, it was determined that buprenorphine has desirable characteristicsfrom a street addict point of view. An evaluation of the field trial 5 years later evaluates itsaccuracy. BuprenorphineisanewtreatmentdrugforheroinaddictsintheUnitedStates.
Like methadone, it is an opioid agonist; that is, it satisfies the craving for a nar- cotic and prevents the withdrawal syndrome. Unlike methadone, it is also an antag-onist; that is, it reacts against opiates and precipitates withdrawal. According toNavaratnam (1995), the agonist effect operates up to a certain dosage level, at whichpoint the antagonist effect begins to operate.
We were asked by the National Institute on Drug Abuse to find out if buprenor- phine currently played any role in U.S. street drug markets. From the medical andlegal points of view, the question was one of what these fields call the “abuse liabil-ity” of a proposed treatment drug. Would the new treatment medication also turninto a hot street commodity, as it happened with methadone in the 1970s? Few pro-grams used buprenorphine at the time of the study in 1996, so it played no street rolein the United States, at least not among numerous different networks in San Fran-cisco, Baltimore, and Newark. Because few users existed in the United States, wedecided to experiment with the idea of a “field trial” for the drug, as opposed to thetraditional notion of a “clinical trial.” The “field” concept was borrowed from AUTHORS’ NOTE: Report prepared under National Institute on Drug Abuse Medications Develop-
ment Division Purchase Order 263-MD-523831 and National Institute on Drug Abuse Division of Epide-
miology and Prevention Research Contract No. NO1DA-3-5201 (CEWG)—State and Local Epidemiol-
ogy Planning and Information Development. Please address correspondence to Michael Agar, P.O. Box
5804, Takoma Park, MD 20913; email: firstname.lastname@example.org.
QUALITATIVE HEALTH RESEARCH, Vol. 11 No. 1, January 2001 69-84 2001 Sage Publications, Inc.
QUALITATIVE HEALTH RESEARCH / January 2001 cultural anthropology with its emphasis on fieldwork, although field here is useddifferently from that traditional term. The logic of the field trial runs like this: 1. The field is expanded from a focus on a particular human group to any information available on the topic of interest, whether in the United States or in other countries,whether presented in media or a conversation, whether scholarly or popular in nature.
2. The field contains examples of use that vary in set and setting. The researcher’s prob- lem is to locate and organize set/setting information that is already available alongthe lines of the concept of the “natural experiment.” 3. Analysis features emergent search for pattern, a style that is traditional in anthropol- ogy but also found in such areas as complexity theory (Waldorf, 1992) and marketingresearch (Michman, 1994). Validity derives from replication of patterns across dispa-rate sources.
4. The analysis is anchored in a particular perspective from which the patterns are eval- uated. In this case, the perspective will be that of urban American street addicts, apopulation with which we have decades of collective experience.
Our goal, then, is to present a field trial designed to forecast whether bupren- orphine might play a role as a street narcotic in the United States and to estimate thechances that this situation might come about. To accomplish this goal, we will reviewa variety of different field sources and look for emergent patterns that replicateacross this material from a street addict point of view. Our model of that point ofview is derived from prior ethnographic work.
Buprenorphine does have a history in the United States as a medication with a cor-responding literature that evaluates it. This professional literature will be examinedwith a different filter snapped over the lens to give it a “street reading.” How wouldthis literature make buprenorphine sound if one were an opiate addict looking tobuy it in a street market? Even in the technical literature, buprenorphine clearly hassome desirable characteristics from this point of view. From various online litera-ture abstracts, we learn that buprenorphine compares favorably with morphine inthe management of postoperative pain. In fact, the literature suggests longer lastingand more moderate effects.
A clinical study of 6 men with histories of opioid use also adds credibility to the hypothesis (Pickworth, Johnson, Holicky, & Cone, 1993). Those who received intra-venous buprenorphine rather than a placebo reported increased positive responsesto a “feel drug” question and higher scores on scales of liking, good effects, eupho-ria, and apathetic sedation. The authors concluded that buprenorphine has sub-stantial abuse liability when administered intravenously.
Another study, meant to test comparative effects of sublingual versus subcuta- neous use, reported varying degrees of euphoria and little dysphoria and sedationfrom buprenorphine, also noting that “subject liking” was reported by both subjectsand observers (Jasinski, Fudala, & Johnson, 1989). And finally, in what must be oneof the first clinical studies of the drug (Jasinski, Pevnick, & Griffith, 1978), buprenor-phine is described as having potential as a treatment drug because it is acceptable toaddicts, has prolonged action, and produces a low level of physical dependence such that addicts may easily detoxify. Such reasons are, of course, also the reasonswhy buprenorphine would be of interest from a street point of view as well.
Buprenorphine appears, hypothetically, as a longer, gentler “high” when com- pared to morphine. Returning to the abstracts, we learn that buprenorphine also hassome history as an experimental drug for the treatment of opioid addiction in theUnited States. The effects of buprenorphine were evaluated using a rapid dose-induction procedure among 19 heroin-dependent men (Johnson, Cone, Henningfield, &Fudala, 1989). During the first 4 days of transition from heroin to buprenorphine,patients reported significantly elevated ratings of good effects, feelings of overallwell-being, and decreased ratings of overall sickness. Euphoria increased anddysphoria and sedation decreased after buprenorphine administration.
A second study by the same team added that buprenorphine offered greater control of opioid withdrawal symptoms and that between-dose intervals of 48 hourscould be tolerated (Fudala, Jaffe, Dax, & Johnson, 1990). In a later study (Johnson,Jaffe, & Fudala, 1992), 8 mg of buprenorphine per day compared favorably with 60mg of methadone in treating illicit opioid use and maintaining patients in treat-ment. Yet another study showed that buprenorphine doses of 2 mg/day comparedfavorably with 30 mg/day of methadone in a heroin detoxification program (Bickelet al., 1988).
The effects of buprenorphine versus placebo on patterns of operant acquisition of heroin and money were studied in 10 male volunteers with a history of heroinaddiction (Mello, Mendelson, & Kuehnle, 1982). Subjects were maintained on 8mg/day of buprenorphine for 10 days during which they could earn money ($1.50)or heroin (7 or 13.5 mg/injection IV) by responding on a second order schedule ofreinforcement for approximately 90 minutes. Buprenorphine subjects took onlybetween 2% and 31% of the total amount of heroin available, whereas placebo sub-jects took between 93% and 100%.
These studies confirm that buprenorphine might serve as a desirable substitute for heroin. But would it? This is a difficult question to answer when talking aboutthe United States because the drug is not available. In other countries, though,buprenorphine has a different history. By scanning international studies wherebuprenorphine is available, we might get some clues about what could happen inthe United States. What follows is a brief review of some samples of internationalresearch on buprenorphine that we found in the abstracts.
Fifty known drug addicts (median age 28.6 years) admitted to a Marseille Hos- pital in France between June and October 1992 were examined (Arditti et al., 1992).
Buprenorphine was identified in urine in 9 (18%) of them. In another study in Scot-land, the effects of prescribing restrictions on the incidence of buprenorphinehydrochloride (Temgesic) are reported (Stewart, 1991). Three months after the re-strictions were imposed, the rate of abuse dropped but then rose again over the next8 months to nearly prerestriction values. Furthermore, as buprenorphine use declined,other opiate use doubled. The restrictions resulted in only a temporary drop in theavailability of the drug.
In a second study from Scotland, researchers reported that 51% of opioid mis- users in 1988 and 70% in 1990 were receiving prescribed opioids before assessment(Griffin, Peters, & Reid, 1993.) They report that, in the prior month, injectableopioids such as Temgesic (buprenorphine) were significantly more common in 1988than in 1990. Although there are some indications of street use of buprenorphine in QUALITATIVE HEALTH RESEARCH / January 2001 England, the reports are less compelling. One article (Strang, 1991), for instance,describes a pattern of use in which sublingual tablets are crushed and the resultingpowder inhaled. In another study, a description of 150 drug users in a London gen-eral practice indicates only 5 cases of reported buprenorphine use as opposed to 121cases of reported heroin use (Cohen et al., 1992).
Another study from Finland (Hakkarainen & Hoikkala, 1992) reports on a pol- icy debate over buprenorphine. During the 1980s, increasing Temgesic abuse wasnoted, and the drug was classified under the narcotics legislation. The status of thatclassification is under review. Barcelona also reported problem use of buprenor-phine (San, Torrens, Castillo, Porta, & De La Torre, 1993). In studies carried out in1988 and 1990, illicit use at some time was reported by 66% (1988) and 71% (1990) ofpatients in treatment, with respectively 5.9% and 6.1% actually testing positive forthe drug. More than 70% of those with buprenorphine experience reported intrave-nous use. Australia also showed concerns about buprenorphine. One case studydescribes an intravenous buprenorphine addict with a history of injecting 4.5mg/day for a period of 2 months (Quigley, Bredemeyer, & Seow, 1984). Other arti-cles discuss general policy issues around the control of buprenorphine and itspotential liabilities (Lebedevs, 1985; Wodak, 1984).
In a presentation at the 1995 College of Problems on Drug Dependence meeting, Kumar, Mandell, Shakuntala, and Daniels (1995) offered a poster session on bupren-orphine use in Madras, India. Among 250 injecting drug users recruited in an HIVoutreach, 96% had used buprenorphine—74% in the previous 30 days—and 44%were DSM III-defined buprenorphine dependent at the time of the interview.
Dr. Kumar was fortuitously encountered by the senior author at a conference.
He described the history of buprenorphine use in detail. The upshot was that a dra-matic increase in heroin availability created a population of addicts in the 1980s,but later political events and harsher laws resulted in a heroin shortage. Buprenor-phine, manufactured locally in Tamilnadu State, provided an alternative for addicts,and its use rose dramatically. One unfortunate consequence of the shift was thatbuprenorphine—available in ampules—was injected, whereas heroin had beensmoked. When heroin did return to the street market, addicts carried the new prac-tice of injecting with them, with obvious increases in HIV risk.
Information on Bangladesh is contained in a report by Ahmed and Ara (1995).
Their interviews with 30 addicts in treatment reveal the establishment of bupren-orphine as a street drug, beginning in 1992, in response to declining quality and in-creasing cost in the heroin market. All 30 used buprenorphine daily and praised itfor staving off withdrawal, pleasurable effects, and ease of use—it must be injectedless frequently than heroin and its availability in ampules makes for simplerpreparation.
These studies do not directly answer our question of whether buprenorphine might become a commodity with competitive value in the U.S. street market. Butthey do show that buprenorphine has appeared as a street drug in several othercountries—France, Finland, Scotland, England, Spain, Australia, India, Bangla-desh—to one degree or another. The studies support the hypothesis that buprenor-phine is actively sought out and that it is something that addicts in street settings aremotivated to obtain. This positive view of buprenorphine’s effects held by heroinaddicts suggests a potentially successful street “product.” Other studies—interna-tional and U.S. based—add to the possibility of success by showing how buprenor-phine interacts with other street drugs in ways similar to heroin and methadone.
In Scotland, researchers reported that 727 new needle-exchange clients (93% of the total) completed an intake questionnaire in 1992 (Gruer, Cameron, & Elliott,1993). The most common drugs injected were heroin, buprenorphine (Temgesic),and temazepam, injected by 61%, 45%, and 28%, respectively. Most clients regularlyused at least two drugs, typically heroin or buprenorphine and a benzodiazepine.
Another study of a 13-week detoxification program using buprenorphine andbehavioral therapy reported that 89% tested positive for benzodiazapenes and 63%for cocaine at least once during the program (Bickel, Amass, Higgins, Badger, &Esch, 1997).
From a Scientific American article comes a report of buprenorphine featuring both its agonist and antagonist effects (Holloway, 1991). The article notes that Jack H.
Mendelson, who had recently completed a study of 12 heroin and cocaine users tak-ing buprenorphine, suggested that high doses of buprenorphine might enhancecocaine’s effects. Mendelson’s concerns are supported by a clinical study from theConnecticut Mental Health Center (Rosen, Pearsall, McDougle, Price, & Kosten,1993). In a double-blind study of 5 cocaine- and heroin-dependent patients who hadbeen drug free for at least 36 hours, it was found that subject ratings of cocaine’spleasurable effects as well as pulse increases resulting from cocaine use were bothenhanced by buprenorphine. In his dissertation on cocaine use, Erin Brown (1993)notes that the effect of cocaine was “potentiated” by coadministration of buprenor-phine and that the two drugs can act together in a synergistic manner.
These studies echo two common patterns of polydrug use among heroin addicts in the United States. According to the first one, a mix of heroin and cocainecalled a “speedball” is used; in the second pattern, the effects of either heroin ormethadone are boosted with benzodiazapines. The sources just cited suggest thatbuprenorphine fits such patterns in the same way.
The literature shows that buprenorphine’s effects are desirable from a street addict’s point of view, it has already appeared as a street drug in several countries,and it mixes with benzodiazapines and cocaine in ways already established in streetpatterns of heroin and methadone use. In addition, we asked about buprenorphineon an illicit drug listserve as another source of information for this field trial.
John French logged onto a drug discussion group on the Internet and asked about buprenorphine. The three elaborate comments he received in reply echoedthe themes in the literature.
1. You can think of buprenorphine as providing opiate replacement therapy similar to methadone maintenance, but with a somewhat more interesting drug. Buprenor-phine is a mixed opioid agonist/antagonist, meaning that it has some effects that arelike morphine and heroin, and others that block the actions of the drug. It also seemsto bind to opiate receptors in the body for a very long time, so its effects are very longlasting. Basically, buprenorphine is enough like heroin that it doesn’t seem to induce awithdrawal syndrome in someone who is already addicted to morphine, methadoneor heroin. Buprenorphine is also “enough” like heroin that it seems to have a mildeuphoric effect, at least at low doses, so there’s a bit of an incentive for former addictsto use it. Buprenorphine is not very addictive on its own (though it has seen some rec-reational use in areas where it’s freely available). It also blocks the effects of other opi-ates like heroin almost completely, so someone shooting up with heroin while takingbuprenorphine wouldn’t achieve the high they expected.
2. In places like Scotland where the heroin supply is erratic, there is a greater reliance upon various pills. Temgesic grew in popularity because for a while, the medical pro-fession thought that they had little potential for misuse. In fact, because they were QUALITATIVE HEALTH RESEARCH / January 2001 designed to dissolve by being placed under the tongue, it was discovered that they werequite a reasonable tablet to inject as they were not laden with chalk. The strange thingabout Temgesic is that they are an opiate antagonist. This means that if you’ve got asmack habit and you do some Temgesic, you’ll end up in withdrawal. On the otherhand, if you don’t have a habit at all, they have an opiate-like effect. They have becomepopular with injectors who lack access to “real” injectable opiates in places like theOuter Hebrides.
3. There are some trials in the US at the moment I believe. I am working as a physician at a Dutch methadone programme. I started to prescribe Buprenorphine nearly a yearago in some cases: people who want to stop using opiates (it’s easier to quit withbuprenorphine than with methadone) and who don’t want to use any other opiates(it’s not working well together with other opiates). My clients (that’s what patientsare called) are mostly very satisfied. It is a synthetic opiate partly agonist/antagonist.
It’s used as a pain-killer in Holland. It must be available in the US, too.
Thus, Internet comments from those knowledgeable about buprenorphine dove- tail with the reported results, suggested hypotheses, and research questions basedon materials in the literature. If we summarize the different sources of informationreviewed in this section, we get the following field trial results for buprenorphine: 1. Buprenorphine has characteristics that compare favorably with the desirable charac- teristics of morphine, methadone, and heroin. Furthermore, buprenorphine mayhave fewer undesirable characteristics than those drugs.
2. There are indications that buprenorphine use lends itself to polydrug use in ways 3. Buprenorphine can play a role in “habit management”; that is, in situations in which a preferred narcotic is not available, buprenorphine can be used to stave off with-drawal and provide an agonist effect.
4. Buprenorphine may be the preferred narcotic in locations where heroin is not 5. Buprenorphine might have characteristics that lead it to become a preferred narcotic in its own right, even in a market that offers several available options.
At the end of this review, we can say that it is clear that buprenorphine has a potential role to play in the streets. We can forecast a “possible world” within whichbuprenorphine would find a street market in the United States. In fact, we can givean optimistic street reading on buprenorphine based on what we learned, a provi-sional but plausible one, given the material at hand: “Buprenorphine is a nice mel-low high and it lasts a long time. It’s easy to kick, it makes a good speedball, and youcan boost it with benzodiazapines.” The results of this field trial are clear. Could buprenorphine possibly develop into a street drug in the United States? Yes, it could. We return to this question andthe subjunctive verb could in the conclusion.
THE ANTAGONIST MIX
After this field trial began, we learned that a focus on buprenorphine alone wouldno longer answer the question about potential street use. Even as we did this study,interest in the United States was shifting from buprenorphine as a stand-alone treat-ment to a mix of buprenorphine and naloxone, a narcotic antagonist. Even thoughbuprenorphine already has an antagonist effect, that effect—as we have seen—clearly does not discourage street use. Naloxone, supposedly, would beef up the antagonistand make the drug less attractive in the streets. However, such a strategy would alsomake it less attractive with respective implications for recruitment and retention intreatment.
Dr. John Mendelson, who was cited earlier in the literature review, showed us the results of a new study in which buprenorphine was compared with a buprenorphine/naloxone mix during an interview with Agar and Bourgois. According to evalua-tions obtained from 10 subjects, buprenorphine alone was a desirable drug with ahigh street value. But the high user ratings of buprenorphine alone plunged whennaloxone was added. The potential problem with the buprenorphine/naloxone mixlies in the classic problem with antagonists in the past. Their history shows that thefew patients who succeed tend to be of higher socioeconomic status with a priorcommitment to quit their narcotics addiction. It is no surprise that most addicts,when offered something that will make them sick and will never get them high, donot find the offer attractive.
Nonetheless, the focus in future U.S. clinical trials apparently will be on buprenorphine/naloxone mixes. In an interview with Agar, Dr. Richard Resnickpointed out that the addition of naloxone to buprenorphine is meant to prevent itsdiversion into the streets. The sublingual dose of naloxone will not affect thebuprenorphine, but an individual who is addicted to heroin will feel the effects ofwithdrawal. The new mixture will also offer commercial and marketing advantagesfrom the manufacturer’s point of view.
We wonder if possible strategies could be developed in the streets to manage the antagonist component of the new buprenorphine/naloxone mix. Numerousshifts in street pharmacology over the years have been observed as users havechanged drugs, modes of preparation, perception of effects, and styles of use. BothMendelson and Resnick, in interviews with us, argue that this will not occur. How-ever, it will be an important exercise to monitor the “street trials” that will follow theclinical trials if and when buprenorphine/naloxone becomes a widely used treat-ment modality.
THE STREET / TREATMENT BOUNDARY
We would like to make it clear that we came to this study neither to praise nor tobury buprenorphine. Our judgment at the end of this field trial is that buprenor-phine alone appears to be a worthwhile alternative treatment modality to metha-done, at least worthy of further study. However, buprenorphine alone will likelylend itself to street use, as methadone did when it was introduced in the 1970s.
Mendelson, in an interview with Agar and Bourgois, pointed out possible advan- tages of the shift to buprenorphine: (a) Buprenorphine does not have the negative or“loser” image that methadone has acquired over the years; (b) one cannot overdoseon buprenorphine, although frankly we are still wondering about agonist/antagonistinteractions in the context of the normal polydrug street environment; (c)buprenorphine is not as euphoric as methadone, although again the same thing wassaid of methadone when it was first introduced, and the literature reviewed earliersometimes suggests the contrary; and (d) with its longer acting effects, buprenorphine QUALITATIVE HEALTH RESEARCH / January 2001 will be cheaper to administer, requiring a visit to a clinic site every few days insteadof daily.
Resnick, who has experimented with buprenorphine as a treatment modality for some time, argues that the drug has other advantages as well (Resnick & Falk,1987; Resnick et al., 1992; Resnick, Resnick, & Galanter, 1991). Stressing the diversityof the addict population, Resnick finds that buprenorphine may appeal to addictswho will not enter the health care system via methadone treatment or therapeuticcommunities and who are not motivated to use a narcotic antagonist. Such addictsshow a higher level of psychosocial functioning when compared to nonrespondersin his studies. Buprenorphine proves useful in detoxification as well, he adds.
But how do we reconcile an interest in buprenorphine as an alternative treat- ment for heroin addiction—something clearly supported by our two intervieweesand three of the four authors of this article—with our field trial results that showbuprenorphine’s possible future as a street drug? Based on our collective experiencewith methadone maintenance over the years, we would argue that it is not a matterof reconciling a contradiction. Instead, it is a matter of accepting that you cannothave one without the other. An effective maintenance drug will always be interest-ing to the streets as well.
When methadone was first proposed as a maintenance drug in the 1960s, it initi- ated an experiment that had not been tried for decades. Since the closing of the U.S.
morphine clinics in the 1920s, if one wanted treatment, one had to eliminate physi-cal dependence right at the beginning. Treatment started only after detoxification.
Relapse rates after such treatment were uniformly high. With methadone mainte-nance, things changed. Now an addict could enter treatment without first kickingthe habit. In fact, by some program philosophies, one would never have to kick thehabit.
In other words, methadone clouded the boundary between treatment and the streets more than ever before. Now treatment included taking an opiate, rather thanrequiring that opiate use cease before treatment started. Methadone accommodatedan addict’s world and, compared to any other drug-free treatment, made it easierfor him or her to experiment with a “patient” role. Treatment evaluations showed ahigher retention rate for methadone compared with drug-free modalities. But then,the other side of the story is this: If a treatment modality accommodates the streetworld, then the street world can incorporate the treatment modality. Historically,we saw this happen with methadone, as a “medication” from the clinical point ofview also became a commodity in the street markets (Agar, 1977; Agar & Stephens,1975; Preble & Miller, 1977).
When the boundary between street and treatment turns fluid and fuzzy as it did with methadone, the treatment drug is no longer either “medication” or “dope.” Itis both. Buprenorphine is another chemical move in this treatment game. With itswidespread use as a treatment drug in the United States, it will probably develop astreet market here as well. In the next section, in which we discuss in more detail thecurrent buprenorphine situation in France, we will see that it has, in fact, become anexceptionally popular street drug in that country and that it is injected rather thanused sublingually as originally intended.
Interesting and problematic will be the development of buprenorphine/ naloxone mixes. Efforts to use naloxone to build a wall against street use may, bythis logic, recruit fewer addicts and resemble the limited role that antagonists alone have always played. The paradox, again, is this: A medication with powerful andeffective outreach and recruitment into treatment is also a drug with a role to play instreet markets. With apologies to Gunnar Myrdal, we might call this the “Americantreatment dilemma” and simply close by hoping that our field trial clarifies its inevi-table and enduring presence.
A YEAR-2000 UPDATE
Roughly 5 years have passed since we conducted the research on which this articleis based. Since that time, needless to say, the buprenorphine story has continued. Inthis brief update, we first look at some of the recent literature to check whether thefield trial holds up. We searched MedLine with key words buprenorphine, human,and abuse and came up with about 80 abstracts since 1995. After a brief review of thisliterature, we will take a look at the current situation in France, where the liberaliza-tion of prescription laws for sublingual buprenorphine in 1996 increased the streetmarket noticeably. In fact, underground economy sales are so robust that the streetprice of buprenorphine is actually cheaper than the pharmacy price. Finally, we willbriefly look at how buprenorphine has become more of a newsworthy topic in theUnited States. In general, our review of this new material will show that, with a fewminor exceptions, the field trial of 5 years ago was accurate.
In recent years, the professional literature has continued to grow, with many reports evaluating buprenorphine—often by comparison with methadone—andconcluding that the new drug does indeed have a role to play in the treatment of her-oin addiction (see, for example, O’Connor et al., 1996, 1998; Petry, Bickel, & Badger,1999). Some studies now discuss a lower retention rate for buprenorphine whencompared to methadone (Eder et al., 1998; Fischer et al., 1999). There is more recog-nition of the drug’s abuse liability, although articles still neglect street views ofbuprenorphine, and street voices commenting on the drug are absent.
Earlier we argued that one signal of buprenorphine’s desirability from a street point of view was its ability to mix with other drugs in ways similar to heroin andmethadone. By and large, this statement is still supported (see, for example,Schottenfeld, Pakes, & Kosten, 1998). However, the recent literature is more equivo-cal on the mix of buprenorphine and cocaine. In one comparison of methadone andbuprenorphine, it is reported that the buprenorphine treatment sample producedfewer cocaine-positive urines, although the difference was not statistically signifi-cant (Eder et al., 1998). Another study concludes that buprenorphine may be moreeffective than methadone for controlling cocaine abuse (Foltin & Fischman, 1996).
On the other hand, a third study questions the claim that buprenorphine reducescocaine use more than methadone does (Schottenfeld, Pakes, Oliveto, Ziedonis, &Kosten, 1997).
Clearly, the jury is still out on the mix of cocaine and buprenorphine. This con- trasts with our statements that cocaine mixed well with the drug. However, the abil-ity of buprenorphine to blend in with benzodiazapines has held up (Eder et al.,1998). A comparison of buprenorphine and methadone patients showed no dif-ference in use of benzodiazapines or alcohol (Schottenfeld et al., 1998). In theFrench case discussed below, one article actually reports several deaths caused by QUALITATIVE HEALTH RESEARCH / January 2001 buprenorphine/benzodiazapine mixes (Tracqui, Kintz, & Ludes, 1998), and anothersuggests that the two drugs are sometimes coprescribed by physicians (Seyer, Dif,Balthazard, & Sciortino, 1998). Ethnographers and outreach workers present themixing of buprenorphine and benzodiazepines—especially Rohypnol—as a matterof street-based common sense (Kempfer, 1998a, 1998b; A. Lovell, personal commu-nication, May 29, 2000.).
Another part of the field trial based on the 1996 research focused on the future of buprenorphine/naloxone mixes. Several research articles report on this mix duringthe past 5 years, and the news is pretty much as we forecast earlier. Mendelson,whom we interviewed for the original research, reported that a buprenorphine/naloxone combination precipitated withdrawal and was unpleasant and that halfthe subjects could not distinguish between naloxone alone and the mix during thefirst hour of the experiment (Mendelson, Jones, Welm, Brown, & Batki, 1997).
Another study reports that the mix produced opiate withdrawal, and it suggestsexplicitly that this will reduce buprenorphine’s street value (Nath, 1999). Thesestudies describe such outcomes as an advantage, a way to reduce the abuse liabilityof buprenorphine. In our field trial, we argued that, from a street perspective, themix would reduce interest in buprenorphine/naloxone in the street markets, but itwould also reduce interest in the mix as a treatment drug. Indications in the recentliterature suggest that our argument, based on the earlier research, still holds up.
In the 1996 research, we scanned international studies of buprenorphine to see if it had become a street drug in the countries where it was more available. The stud-ies we located suggested that it had, and this conclusion led us to strengthen ourforecast for the future street role of buprenorphine in the United States. For thisupdate, Bourgois, whose professional contacts and language abilities made a lookat recent developments in France possible, contacted colleagues and looked at someliterature. Fortuitously, Anne Lovell, an anthropologist with the University ofToulouse and researcher with INSERM (the French equivalent of the National Insti-tutes of Health), contacted Agar on another matter as we were revising this article,and her detailed suggestions and advice made much of our summary possible.
The street history of buprenorphine in Europe—especially France—teaches us a great deal about the potential appeal of the drug among street addicts. It was ini-tially developed as an injectable painkiller in the United Kingdom in 1978 under thetrade name Temgesic and was soon marketed throughout most of Europe. InFrance, it became relatively widely available in 1987 but solely in injectable form. By1990, its distribution was curtailed due to reports of street abuse, and the injectableform was limited to hospital pharmacies. In 1996, it became widely available throughunrestricted medical prescription from general practitioners in a sublingually admin-istered form known under the trademark Subutex intended exclusively as a substi-tute treatment for heroin addiction. By the year 2000, approximately 58,000 addictswere officially on Subutex maintenance compared to only 7,000 on methadone.
France was the only European country where buprenorphine was so widely andsystematically used in drug treatment (C. Carrandie, personal communication,May 24, 2000; Kempfer, 1998/1999; Lert et al., 1998).
According to ethnographers and outreach workers, a significant number of French maintenance patients resell their prescribed sublingual doses on the street where they are dissolved into syringes by street addicts for injection. Unfortunately,this particular form of sublingual buprenorphine rapidly deteriorates veins andcauses especially virulent abscessing when injected (Kempfer, 1998b, 2000; A. Lovell,personal communication, May 29, 2000). The lack of an ecstatic rush effect frombuprenorphine exacerbates its deleterious effects on the veins of street injectors as itoften provokes a cycle of compulsive repeat injection in a search for the elusive rush.
As with methadone in the United States, the frustrating euphorigenic effects of bu-prenorphine lead to the phenomenon of low-status, multiple-substance abuserswho combine alcohol and benzodiazepines with the treatment drug to try to “boost”its effects (Bourgois, 2000; Kempfer, 2000).
Perhaps the exceptional frequency with which street-based addicts inject sublingual buprenorphine in France can be explained by street market fluxes in her-oin availability. In the late 1990s, street injectors in the Goutte d’Or neighborhood ofParis told Bourgois that they were forced to inject Subutex because of the poor qual-ity of heroin in street markets. Indeed, the artificially low price of Subutex on Parisstreets, approximately 10 francs for an 8 mg dose compared to 100 to 200 francs forthe standard street dose of heroin, may explain the frequency with which street-based heroin addicts were injecting (Kempfer, 2000). A French outreach workerreports that buprenorphine is sold at below pharmacy cost on the street becausedealers access the drug for free as indigent patients by presenting themselves fortreatment to a half-dozen doctors simultaneously (Kempfer, 2000). An ethnogra-pher based in Marseilles confirms that Subutex is an inexpensive alternative to her-oin for street addicts and that it is sometimes called a poor man’s heroin (A. Lovell,personal communication, May 29, 2000.). Nevertheless, it is widely used on thestreets of both cities. In a study of street-recruited heroin injectors in Marseilles, 23%were current Subutex injectors (Lovell, in press). Treatment centers in Paris simi-larly report detoxing addicts who are exclusively injectors of Subutex (C. Carrandie,personal communication, May 24, 2000). Outreach workers and ethnographers alsoreport that some younger addicts have exclusively had careers of Subutex injection(see also Kempfer, 2000), and even nonaddicts will use Subutex as an occasionalparty drug (A. Lovell, personal communication, May 29, 2000.). Of course, a silentmajority of French addicts do use buprenorphine to “normalize” and mainstreamtheir lifestyles, as it was intended (Lovell, in press).
The French scenario of a relatively high street demand for buprenorphine among injectors may be somewhat specific to the culture of French substance abuse,which revolves especially intensively around needle use. This is suggested, forexample, by the fact that a disproportionately high number of crack users in theGoutte d’Or neighborhood that Bourgois visited in the late 1990s insisted on inject-ing crack instead of smoking it (Kempfer, 1998b; Lefort, 1998). The easy accessibilityof buprenorphine by general practitioner prescription in France also contrasts dra-matically with the extremely limited access of addicts to methadone maintenance.
And finally, buprenorphine in France does not have the antagonist mixed in, as theUnited States now plans to do. If it did, injection of the sublingual dose would pre-cipitate withdrawal.
The French case shows—with more depth than the earlier review of the interna- tional literature allowed—how treatment policy, market conditions, and cultural QUALITATIVE HEALTH RESEARCH / January 2001 dynamics might combine to enable a flourishing buprenorphine street scene todevelop. Another interesting change since the earlier research is the degree to whichbuprenorphine has become more of a public topic in the United States, although weanticipated this from the reaction with which an earlier draft of this article wasgreeted by the original sponsors, who saw undesired qualifications around thedevelopment of a promising new treatment drug. However, the senior author wascontacted in early 2000 by the Center for Substance Abuse Treatment of the U.S.
Public Health Service. They had obtained an earlier version of this article and askedif they might use it in their role to regulate buprenorphine-based treatment. We sentthem the manuscript and asked for information that we might use as part of therevision in this update section. Unfortunately, they did not respond.
Buprenorphine has also become “news” for the general public, if a recent article in USA Today is any indication (Leinwand, 2000). A front-page feature is titled “Her-oin’s New Fix and Why It Matters to You.” The feature is rather elaborate, but part ofit discusses buprenorphine, which is one example of a new treatment that is “farmore difficult to abuse than methadone because they are much less addictive”(Leinwand, 2000, p. 1). According to the article, a drug called Suboxone is near FDAapproval—it is a mix of buprenorphine and naloxone. They note that another pill,this one only containing buprenorphine, has already been given to addicts inFrance. A physician and drug expert is quoted as saying buprenorphine has been a“huge success. People can function totally normally and be very alert if it’s properlydosed” (Leinwand, 2000, p. 2). Along with the report on the new treatment drugs,buprenorphine key among them, the article talks about how doctors will be able toprescribe it out of their office so that clinics will not have to be set up in neighbor-hoods. Congress and the Drug Enforcement Agency, says the article, are in supportof the change in treatment drug and prescription practice. However, there are someconcerns in law enforcement that the take-home medication will appear in streetmarkets.
We leave it to the reader, based on the material in this article, to sort through the USA Today feature. It seems striking that the use of buprenorphine for heroin addicttreatment now warrants a feature in a widely read national newspaper. Five yearsago, few people had even heard of the drug, including us when we were first con-tacted about this project, and many of our colleagues in the drug field. Clearly,buprenorphine will now be tried in the United States, so the acid test for our fieldtrial and this update are now at hand. We see no reason to change our forecast. Ifbuprenorphine alone is used, a street market will develop. If heavy doses of antago-nist are mixed with buprenorphine, the mix will enjoy less success in enrolling orholding people in treatment.
At the same time, we feel that maintenance of physically dependent persons is a valuable and humane harm-reduction strategy. The fact that an attractive mainte-nance drug has some street value has to be accepted as part of the deal. Given thatframework, buprenorphine with or without the naloxone mix, as many researcherswe reviewed and interviewed for this article have said, offers an interesting newalternative to methadone that deserves a chance. It is good to remember our Frenchcolleague, cited earlier, who said that a “silent majority” of addicts used buprenor-phine to buy some time to change their lives. However, buprenorphine—like meth-adone before it—is no “magic bullet.” Unrealistic expectations for success that neglect the realities and needs of the streets only yield surprises that could have beenanticipated.
Does buprenorphine possibly have a future in the U.S. street markets? Possibly,without a doubt; probably, it depends.
It depends, first of all, on the results of the street trials that will inevitably follow the clinical trials, whereby street trials we mean actual experiments with the drugconducted by users themselves. Navaratnam (1995), cited earlier in this article, out-lined a picture of buprenorphine’s rising and falling effects in an interview. Overmuch of the curve, cocaine or benzodiazipines might be used to boost the effectswithout triggering the antagonist. As the curve falls, an addict could use heroin ormethadone without fear of pushing the curve into the zone where the antagonisteffect begins. His scenario outlined a hypothetical street trial outcome.
It also depends on the way buprenorphine is introduced. The addition of naloxone to the treatment drug increases the antagonist effect. It remains to be seen how thiswould effect treatment efficacy and street interest. Our prediction is that the mixwill be of less interest in the streets, and it will not draw people into treatment aseffectively, except for the highly motivated or those fleeing the stigma and/or inac-cessibility of methadone. We could be wrong. Buprenorphine might offer enough tosatisfy an addict’s craving, whereas the stronger antagonist might deter use of illicitstreet narcotics. And we might be twice wrong if street trials develop polydrugstrategies to enhance the agonist and reduce the antagonist effect, even with theadded naloxone, although the experts we interviewed argue that this will not be thecase.
And it depends, finally, on market conditions. Methadone was introduced at the time of the Nixon-era crackdown on the Turkey-Lebanon-France-U.S. pipelinethat had delivered heroin to the United States for years. Sharp reductions in quan-tity and quality of heroin together with rapid increases in methadone availabilityled to a shift that placed methadone in a key role in the street markets. Buprenor-phine’s fate will also depend on market conditions, as the example of France showedso well.
Our summary reflects a forecasting effort that departs from traditional clinical trials in several ways. We consulted disparate data from the field and developedscenarios based on conditions that make outcomes more or less probable. Fore-casting is different from traditional science, as recent work shows all too well(Sherden, 1998). At the same time, the forecast is useful in outlining alternative sce-narios—we now know something about what might happen and the conditionsthat are likely to make a difference. We move into the future with an outline maprather than no map at all. Field trials, drawing on multidisciplinary and multi-methodology sources from epidemiology to ethnography and from treatmentresearch and medical anthropology to the field of jurisprudence research, clearlyoffer an alternative and important understanding of drugs and their future thatother approaches do not provide. And with the opportunity to evaluate the mid-1990s field trial 5 years later, we can say that, in this case, the field trial worked rela-tively well.
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Waldorf, M. M. (1992). Complexity: The emerging science at the edge of order and chaos. New York: Simon & Wodak, A. D. (1984). Buprenorphine: New wonder drug or new hazard? Medical Journal of Australia, 140, Michael Agar has worked in the drug field since 1968, most recently on the contextual explanation ofdrug use trends. He also consults and teaches ethnographic/qualitative methods, as reflected in his bookThe Professional Stranger, and works on issues of language-based ethnography, introduced in hisbook Language Shock. Philippe Bourgois, Ph.D., is with the Department of Anthropology, History and Social Medicine in theUniversity of San Francisco’s School of Medicine. He is a cultural anthropologist who studies theinterface of violence, poverty, and substance abuse with a special emphasis on the experience of ethnicdiscrimination among inner-city residents and among Latin American immigrants. He is currentlyconducting fieldwork in the homeless encampments of a network of heroin injectors in San Francisco.
His most recent book, In Search of Respect: Selling Crack in El Barrio (1995, Cambridge), won theMargaret Mead and the C. Wright Mills Prizes. He has published numerous articles on substanceabuse in venues ranging from New York Times Magazine to Social Problems and Culture, Medi-cine and Psychiatry. John French is now semiretired after 30 years with the New Jersey Department of Health, where hislongest and latest tenure was as the director of research for addiction services. His areas of expertiseinclude both quantitative and qualitative methodology, as well as program administration. Owen Murdoch received a master’s degree in anthropology from the University of Maryland. In addi-tion to conducting ethnographic research on trends in drug abuse, he has worked on designing andimplementing HIV-prevention projects in Baltimore, Maryland, and Denver, Colorado. He is currentlypursuing a career in medicine.
Chapter Two Most undergraduate research papers, and many graduate andprofessional research papers as well, are based upon libraryresearch. Library research can proceed smoothly if you follow a se-quence of simple steps. Your ﬁrst task is to decide upon a topic for a paper. This is, in a sense,the most important task because the paper can be no better than thetopic. I have found ﬁve mista