Discussion
Based on the evidence outlined above, we cannot unambiguously conclude that naloxone is an effective deterrent to parenteral misuse of buprenorphine. At best, naloxone may reduce or delay the subjective “high” users experience, but in the absence of any dramatic effect on abuse liability, this partial blockade of subjective euphoric effects is of dubious clinical value. Epidemiologic studies have documented reductions in parenteral misuse of buprenorphine after introduction of the combination product, but some of this effect this may simply be due to patients hearing from their physician or from others in the medical community that naloxone prevents such misuse. It could be argued that, if it prevents a patient from ever attempting to take a buprenorphine/naloxone product parenterally, the message that naloxone blocks such misuse is of net benefit to the patient regardless of the actual pharmacological efficacy of naloxone in this regard. However, deliberately misleading patients is an ethical violation, even if we think it is in their best interest. This is one reason that, despite their many proven benefits, we do not actually prescribe placebos. The effectiveness of such interventions depends on trust that has been painstakingly cultivated over generations of interactions between the medical community and the public we serve. If information circulating in the recreational drug-using community is in reality more accurate than the information coming from the medical community, it can only be a matter of time before that hard-won trust is eroded. Our patients expect us to be honest and straightforward with them about the risks they face, and especially about the interventions, we recommend. The stakes are too high for us to do anything less.