Opioid Analgesia Without Addiction

I don’t have a lot of ‘pull’ with the addiction-related organizations out there.  I’m never been a ‘joiner’, and I tend to notice the problems caused by medical societies over the good things that they supposedly accomplish.    For example PROP, or ‘Physicians for Responsible Opioid Prescribing’, have a specific mission.  Once a group has a mission, any considerations about individual patients go out the window.  PROP has propagated the message that opioids are NEVER beneficial for patients with chronic pain.  Legislators with no knowledge of clinical medicine hear that message, and respond by passing draconian laws that interfere with any considerations of individual patients.  I would guess that the people of PROP pat themselves on the back for encouraging laws that remove physician autonomy.  I’m sure they figure that they are smarter than all the family practice docs out there.  But in reality, they are only destroying the control of doctors over patient care, and handing that care over to politicians.  Way to go, PROP!!

But I digress…

In the same way, the societies that hold meetings about meetings, that elect Secretaries who become Vice Presidents who become Presidents, get to publish the articles that describe clinical protocols.  The doc who spends every day talking with patients has no access to these sources, and little ability to influence those protocols.  Sometimes the societies and organizations get things right… and sometimes they get things wrong.  The latter is the case with post-op pain control in patients on buprenorphine products.

Baby’s Buprenorphine Withdrawal

This morning I responded to a woman at SuboxForum.  Her baby was taken to the NICU for ‘withdrawal’, which is better identified as neonatal abstinence syndrome.  She said that the baby is eating well, but there is concern that the baby sleep only 2 hours at a stretch.  The baby is on morphine, and mom is wondering when they both can go home.  She is kicking herself for not trying to stop buprenorphine before the delivery.  I spent a while responding, so I decided to post my response here as well, in case a mom in a similar situation stops by.  My comments:

I have written a number of posts about neonatal abstinence, and I invite you to read a post in my blog about the guilt you are feeling.

First of all, you did the right thing.  Period.  Every medical specialist, study, or text will say the same thing:  that women addicted to opioids should be maintained on a long-acting opioid until the baby is born.  Traditionally, that opioid was methadone.  But women on methadone who are pregnant often end up on very high doses of that drug– pushing their tolerance to high levels, so that virtually all their newborns have significant withdrawal.   Of course, the babies do fine in the long run— and the experience of withdrawal is not among the worst things that a baby experiences, by far.

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor.  This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year.  But instead of cheering the good news, some doctors used the occasion to rant about diversion.  Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications.  Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low.  Other opioid addicts use buprenorphine in attempts to detox off opioid agonists.  Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal.  But the statistics don’t keep addicts from trying, over and over again.  After all, the belief in personal power over substances is part of the addictive mindset.

Raising the Suboxone Patient Cap

HHS Secretary Sylvia Burwell announced yesterday that the cap on buprenorphine patients would be raised in the near future.  Details were not released, but she emphasized that measures would be taken to increase availability of this life-saving treatment, while at the same time taking caution to prevent misuse of the medication.   Anyone who works with buprenorphine understands the importance of her announcement.  I only hope that her actions are swift, and not overloaded with regulations that reduce practical implementation of whatever increases are allowed.

I have been at the cap for years, unable to accept new patients for buprenorphine treatment.  My office receives 3-4 calls each day on average from people addicted to heroin, begging for help.  Patients on buprenorphine (the active substance in Suboxone) are much less likely to die from overdose than are patients not taking buprenorphine– even in the absence of perfect compliance.  Some doctors, in my opinion, over-emphasize the ‘diversion’ of buprenorphine medications.  At least in my part of the country, ‘diversion’ of buprenorphine amounts to heroin addicts trying to stop heroin, taking ‘street buprenorphine’ because of the absence of legitimate treatment spots.    Of the few new patients I’ve been able to take this year, almost all have histories of using buprenorphine products on their own, without prescriptions.  They are very happy to finally have a reliable source of the medication– and to have the medication covered by their health insurance!