The Suboxone Scandal: Interview With Emily Dufton

She wrote the definitive book on medication-assisted treatment

Emily Dufton is a Maryland-based drugs historian who appears in my documentary Antagonist (which screens in New York next month!) and steals the show. She’s also the author of a new banger, Addiction, Inc.: Medication-Assisted Treatment and America’s Forgotten War on Drugs, which is the definitive book on medicine for opioid addiction.

It’s got big scoops, most notably about how the company making Suboxone used the same playbook (and even the same salespeople) as Purdue Pharma, the company that got us into this mess.

The book comes out next week and is now available. I talked to her about how Richard Nixon unfairly gets a bad rap, whether or not we should get rid of the methadone clinic system, and why a nonagenarian former drug czar was mean to her.

When you were a young girl, did you dream of being a drugs historian?

Yes. I drew pictures of horses and thought to myself, “Someday I’m going to resurrect the reputation of Richard Nixon’s presidential administration.”

Ha! Nixon certainly does get a bad rap, and when it comes to promoting treatment for drug abuse, rather than just incarceration, he doesn’t get any credit at all.

Right, exactly. We like using Richard Nixon as a punching bag. And I get it; he certainly seemed like an untrustworthy individual. But he was behind the liberalization of American drug policy, so many years after Harry Anslinger created a very prohibitionist world. After the first two years of Nixon’s first term, he actually created a period of detente in the war on drugs. Treatment and rehabilitation programs were more readily available, and there was more federal emphasis on that than law enforcement and arrests. But he never gets any credit. Poor Tricky Dick.

The part of your book I found most illuminating was how the company making Suboxone basically hired the same salespeople that Purdue Pharma used to hawk OxyContin.

They used the exact same people.

As Purdue was coming under legal fire and the threat of heavy lawsuits, it started laying off most of its sales force and its marketing department. Those people all got scooped up by the small pharmaceutical subsidiary of Reckitt Benckiser, a European conglomerate that mostly produced home goods like Lysol cleaner and Woolite.

They brought Suboxone to market in 2003, and it was kind of a commercial flop because they were trying to promote it for the treatment of heroin addiction.

But in 2005, they got a new president from England, and he started targeting the rising prescription opioid epidemic. So they go back to the same doctors who were prescribing OxyContin, and now they start selling them Suboxone.

David Courtright, the great drug historian, came up with this phrase, “Start the fire, sell the hose.” So Purdue and OxyContin started the fire, and then those same salespeople moved over to Reckitt Benckiser and they began selling the hose. It was a self-contained system.

And in order to protect their sales, they basically lied about Suboxone’s safety for children, right?

Yeah, exactly. Now, buprenorphine is a really important medication and a lot of people have benefited from it, and I’m sure even more people could benefit from it if we made it more accessible. But one of the reasons it’s not easily accessible is because the Suboxone distribution system started to look eerily similar to the pill mills that were distributing OxyContin.

Reckitt Benckiser didn’t mind this because they were making, like, a billion dollars a year. Suboxone by 2012 was outselling Adderall and EpiPens and Viagra.

But they were using flawed data. And instead of promoting Suboxone tablets they were promoting a new version, sublingual film strips, because they were threatened by generic competition and wanted to re-up their patent on these new film strips.

So they started playing the exact same games that Purdue was playing with OxyContin about a decade prior. They started promoting the drug as less prone to misuse, as safer, especially if you have children, because film strips were individually wrapped, whereas a bottle full of tablets could look like candy.

But data actually showed that Suboxone film strips were more dangerous for children. So they were product hopping. They were criminally mismarketing the drug.

When Purdue Pharma was prosecuted in 2007, they kind of got off with a slap on the wrist. No one went to jail. But when the Department of Justice took on Reckitt Benckiser and its spin off company Indivior in 2020, that resulted in the largest opioid settlement in American history up to that point. They were charged about $2 billion in penalties, and the former president, who had hired all those laid-off Purdue staff people, spent six months in federal prison. It was a huge deal.

You were tipped off by a Suboxone saleswoman whistleblower named Gail Groves Scott. She was great. How did you track her down?

I believe someone put us in touch. She actually was the salesperson in Allentown, Pennsylvania, where I grew up.

She was very brave to come forward.

She really was. She’s pretty incredible. A lot of people really opened up about their experiences in this book, which I found touching. The generation of people involved in developing the field of medication-assisted treatment are mostly still alive, but we’re losing them rapidly. [Nixon’s first drug czar] Jerome Jaffe is 92, turning 93.

Westhoff, Jaffe, Dufton

It was very kind of you to introduce us so I could interview him for Antagonist. I know he gave you boxes of his archival materials to go through. What was the kookiest thing he did during your time together, and what was the most endearing?

He was very hard on me in the beginning. We first connected in 2018, when I wasn’t really sure what this project was yet. I talked to him on the phone quite a lot, and after our early conversations, I’d hang up the phone and cry because he was so mean to me.

Aww. What was he mean to you about?

He’s very historically rigorous. He’s like, “You’re wrong about this.” He can be very abrasive.

But as I started putting the pieces together and went through all of his papers, his attitude towards me softened. And I think he saw me as someone who really was trying to tell his story as accurately as I could, because for decades he had been smeared for his work in establishing methadone clinics as someone who was tied to, like, narco genocide.

On that subject, your book explores how early methadone clinics were located primarily in Black communities, and how there was a lot of pushback — death threats, even. Do you think it was fair to claim that the government was using methadone to control minorities and suppress crime, rather than to help addicted users?

These were very legitimate concerns in the 1970s. This was following the Tuskegee syphilis study, and was towards the end of forced sterilization of Black women on welfare. There were reasons for these communities to be distrustful.

But today they call methadone the gold standard of treatment, and we know it does work. So that’s the contradiction of methadone’s history.

The methadone clinic system is a really weird system that nobody likes. Right? The neighborhoods don’t like it, the patients don’t like it, the politicians don’t like it. And somehow this exact same system is still operating fifty years later.

Why do you think methadone clinics generally don’t dispense naltrexone? In Antagonist I speculate it’s because naltrexone is not profitable for these clinics.

Right. Methadone clinics are commercial industries rather than actual public health clinics. An actual public health clinic wouldn’t care if naltrexone or Vivitrol wasn’t profitable for them, because the point wouldn’t be profitability.

This is completely tied to the 1981 divestment of methadone by the Reagan administration, which turned the clinics into private companies. It’s like, you can’t ask a cat to be a dog.

I think naltrexone has been really screwed over by methadone clinics. And most private physicians don’t want to treat addiction, so they’re not going to be a prime source for Vivitrol prescriptions either. There’s no one who has really taken the reins and run with it.

Do you think the methadone clinic system should be abolished, in favor of allowing all doctors to prescribe methadone?

It’s worth noting that Suboxone, which for 23 years has made opioid agonist treatment [widely] available, has not been the savior of the opioid epidemic either.

First, few doctors were trained in addiction medicine. Second, few doctors were interested in private addiction treatment. Opioid users were considered “problematic” patients, and disruptive to a general practice.

The only doctors interested in prescribing Suboxone were those with an “entrepreneurial mindset.” In Appalachia, commercial Suboxone clinics mirrored the same pill mills that had brought OxyContin there a decade prior.

So rather than abolishing methadone clinics, I’d like to complement them. What we need is what Jaffe envisioned back in 1971: a nationwide system of multi-modal clinics that offer all forms of addiction treatment (including all three medications), among a suite of other social, behavioral, and public health services. In my ideal world, methadone clinics and private prescribers would complement this system.

My last question: Did you have fun traveling to Switzerland for “research”?

I had a great time. It was my first time there and it was pretty. I saw a lot of clinics and I talked to a lot of people. It was very eye opening.

There’s been a transformation there since the 1980s, when Zurich’s “Needle Park” was globally infamous for its high rates of heroin use and HIV. Now, it’s this quiet, beautiful, calm place.

The Swiss have a real love for public order, and that’s very much on display with their treatment programs. I think they’re a model for what can be achieved when you actually emphasize elements of public health in your response to illicit drug use.

If you give people an option for treatment and make it accessible and available and attractive, they will probably take it, because addiction is actually not a very comfortable life. And most people who are in the throes of chaotic addiction are not very happy about it.

So, giving them an option and an alternative — as I saw in Switzerland and in some really great programs in the U.S., including in St. Louis — is not an impossible dream. It really can be implemented on the ground.