Subox Docs: Analyze This!

People on buprenorphine or Suboxone often write to me with complaints about lab testing.  I received an email last week that mirrors my personal experience with lab testing companies.

Here is what it said:

Dr. Junig:

I thought you might find this interesting. I continue to see (name withheld) for addiction treatment using buprenorphine. I see the doctor every three months, and I’m prescribed a low dose of Suboxone film (below 4 mg per day). I recently got an insurance denial for over $2000 in lab charges, for ONE urine test! Evidently someone sent my tests to (lab name withheld for patient privacy) who billed for 23 tests!  This is on a test that was negative for any substances other than the proper amount of buprenorphine.   This is like a license to print money! The same thing happened three or four years ago with (a National lab provider), but that was ‘only’ $600 and it eventually got written off. I have no idea if (withheld) will come after me– but there is no way I’ll pay them a dime.

Is there any wonder health costs are so out of control? How can a company get away with this? I have a feeling this is just routine and someone on the staff sent it by mistake as after the first incident with the other lab.   My doctor doesn’t usually send my tests into a lab, but instead just does the immune point-of-care test in the office.

Buprenorphine Depression Drug Stumbles

I’ve written a few optimistic lines about ALKS 5461 as a potential solution for people suffering from refractory major depressive disorder.  Those unfortunate will have to keep waiting.

ALKS 5461 is a product in Alkermes’ pipeline that combines buprenorphine with ALKS 33, or Samidorphan.  The combination drug is purported to ‘stabilize opioid pathways’, which is a very simple explanation for a complicated, poorly-understood system.  The results of two late-stage trials were disappointing, in part– according to Alkermes– because the placebo groups did better than usual.  Beating the placebo is a common problem in trials involving antidepressants, because of the high susceptibility to the placebo effect in the patients in such trials.  Over half of patients get better from taking the sugar pill, so a medication that helps half the patients will not move the needle to signal success.

I receive emails now and then from patients treated with buprenorphine for depression.  If the emails are any measure of reality, buprenorphine is not going to cure the world of depression.  While I occasionally read success stories, I just as often read angry descriptions from people complaining that they were never warned of the difficulty of stopping the medication.   I’ve written before that for that reason, I am reluctant to start buprenorphine for depression alone, in patients who are not already opioid-tolerant.  I have patients who struggled with depression before becoming addicted to opioids, and I believe the drug benefits their mood symptoms.  But I continue to hold back in a couple patients who have very severe depression, who have failed traditional treatments.  The news from Alkermes doesn’t push me in either direction.

Suboxone and Suicide

Today I came across an article about a study that showed a reduction in suicidal ideation caused by buprenorphine.  The dose of buprenorphine used in the study was lower than doses used for treating opioid dependence, ranging from 100-800 micrograms taken sublingually.   Buprenorphine was administered for up to four weeks in the study.

I haven’t read the full text yet, and I’ll have more to say after I do.  There was also a provocative link on the article’s web page leading to an editorial about treating depression with opioids.  My post is a bit premature, but I want readers to be the first to describe these findings at the water cooler tomorrow morning!

Most people reading this blog are already aware that opioids can elevate mood.  In fact, opioids can serve as an answer to all of life’s problems, making life fulfilling and pleasant… for a little while.    Those effects are part of why it is so hard to leave opioids behind.  Opioids bind to receptors for endorphins– called ‘mu opioid receptors’– and activate the same pathways that light up during life’s most pleasurable moments.

But most of the people reading this post have learned the sad, simple truth that the positive effects of opioids carry a steep cost.  Any pleasure provided from mu-receptor stimulation must be paid back by the absence of activity in those same pleasure pathways.  And like any transfer of energy, the process is not 100% efficient.  Most opioid users discover that they eventually lose far more happiness than they ever gained from opioids.

Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.