Therapy without a prescription: buprenorphine/naloxone diversion and the therapeutic assemblage in Taiwan

Abstract

Buprenorphine/naloxone (B/N) therapy is a prescription pharmacotherapy for opioid dependence. For certain health service providers, when B/N escapes supervision and diverts into the hands of people for whom it is unintended, it can pose serious risks even if it may still have therapeutic benefits. The line between therapy and diversion is thus a problematic one. By qualitatively analysing archival review and in‐depth interviews, this study uses the concept of a therapeutic assemblage to understand the relationships among government, knowledge, and professionals that surround the regulation of B/N in Taiwan. The therapeutic assemblage is characterised by the partitioning of administration, the loose regulation of prescription, the exclusion of addiction treatment from National Health Insurance (NHI), and the materiality and technicality of therapies. These elements contribute to the therapeutic assemblage's different territorial modes as reflected in the substance schedules that allow for diversion. This is the first grounded work in Asia that empirically examines and theoretically explains the diversion of B/N from an assemblage perspective. It suggests establishing new associations by incorporating addiction treatment into NHI. Lastly, it addresses the analytic purchase of the assemblage approach in unveiling and problematising unintended outcomes of an intervention.

Bridging the Macro-micro Divide: A Qualitative Meta-synthesis on the Perspectives and Experiences of Health Care Providers on the Extramedical Use and Diversion of Buprenorphine

“…Some studies noted an increase in extramedical use and the distribution of buprenorphine through clinics which were known to overprescribe and overdispense. These clinics were seen as undermining the legitimacy of addictions medicine and creating a negative impression of OAT among the general public, other actors working with addiction and substance dependence, and political decision makers 34,40 . Some participants noted that these views on extramedical use made it difficult for some treatment facilities to secure operational resources 40 .…”

“…Nine articles discussed more control and monitoring at the individual patient level to limit the supply of buprenorphine as a solution to extramedical use 32,33,35,37–39,41,44,46 . Two studies noted changing accessibility to buprenorphine at a system level as a solution to extramedical use 34,39 …”

“…Although most of the driving factors for extramedical use described above were at the systems level, most of the proposed solutions by providers were at the individual level in the form of prescribing changes and monitoring 32,33,35,37,39,44,46 . Providers in only 2 studies identified system-level changes around buprenorphine accessibility as possible solutions to extramedical use 34,39 …”

“…Some providers in Sweden and the United States described extramedical buprenorphine use as a facilitator of addiction 36,40,46,47 . Extramedical use was seen as “merely substituting one drug for another instead of instilling a new way of life” and then serving as a gateway to heavier drug use 34,40 . (p605) Buprenorphine was seen as a potent narcotic with attractive features for new drug users.…”

“…34 In these same countries, extramedical buprenorphine use was also thought to jeopardize the credibility and legitimacy of OAT. 34,35,40,47 Some studies noted an increase in extramedical use and the distribution of buprenorphine through clinics which were known to overprescribe and overdispense. These clinics were seen as undermining the legitimacy of addictions medicine and creating a negative impression of OAT among the general public, other actors working with addiction and substance dependence, and political decision makers.…”