First Published 8/31/2013
One reply to my last post said I go ‘on and on’ about things that could be said with fewer words. I asked the person to send me his/her version, and I hope he does—not to prove anything, but because I appreciate the chance to learn. He wrote that his problem is the opposite– that he can’t write 90-minute screenplays because he gets to the point too quickly. Maybe we should be partners!
I suspect that my writing style comes from my days submitting research findings to basic science journals, where each individual comment must be supported by data or by citation. I’ll try to get to the point more quickly.
In the last post I made two points: 1. Discounts demanded from insurers for front-line services (office visits) create challenges for independent primary care practices that don’t have other sources of revenue, particularly revenue from procedures, and 2. Physicians employed by health systems are less likely to prescribe buprenorphine for treatment of opioid dependence than are small, independent practices.
The result is a shortage of doctors prescribing buprenorphine. This shortage leads to a number of other problems, the most visible (to those who care to notice) being a large number of heroin-related deaths. But other consequences are apparent for those who connect the dots. Wisconsin and other Midwest states contain large, predominately-rural areas where buprenorphine and Suboxone are only available as illicit substances. People addicted to opioids choose ‘self-treatment’ with Suboxone, purchased from the same person who deals heroin. The high cost of buprenorphine and Suboxone encourages people to take very small pieces Suboxone tablets or film; just enough to prevent withdrawal. But the unique pharmacodynamics of buprenorphine that block opioid cravings (the basis for buprenorphine’s efficacy) rely on taking a dosage high enough to maintain blood levels of buprenorphine above the medication’s ‘ceiling effect.’
In other words, small fragments of Suboxone or buprenorphine, taken sublingually, yield the same subjective experience as opioid agonists taken orally.
But this is the tip of a very large iceberg. In areas where buprenorphine/Suboxone is only available illicitly, the scarcity and cost of the medication leads heroin users to take other steps to reduce the costs of ‘self-treatment’. Remember that with sublingual dosing only a third of the buprenorphine enters the systemic bloodstream. Even less reaches the circulation if the drug is swallowed. But 100% reaches the circulation when heroin addicts use the Suboxone or buprenorphine the way they use heroin—by needle. The opioid blocker naloxone is added to create Suboxone, but my new patients have reported injecting Suboxone and buprenorphine, and finding no significant difference between the two.
The people who studied in HS Biology realize that the portal vein does not drain the end of the intestinal tract—meaning that drugs or substances entering ‘backwards’ are not subject to ‘first pass effect’ that destroys oral buprenorphine. This leads to another way to reduce the cost of ‘self-treatment’, referred to as ‘plugging.’ And there’s really nothing more that I want to say about that. Gross.
No matter how clean the marketing, a medication that is injected, ‘plugged’, or sold by heroin dealers will eventually get a black eye. I’ve written about guilt by association, and how patients doing everything right to end an addiction started by their pain doctor feel denigrated for taking Suboxone or buprenorphine exactly as prescribed. We’ve heard about part of Eastern Europe where the black eye to buprenorphine treatment led to political blindness, resulting in the replacement of ‘dreaded buprenorphine’ by a yellow chemical nicknamed ‘Krokodil’. Right now, the primary problem in my region is the potential blurring of lines between treatment and ‘self-treatment’, which is just another form of opioid dependence. I recently began treating a young woman who had been taking illicit Suboxone/buprenorphine, each day, for over 4 years, without any use of opioid agonists. She probably would not be driving a couple hours to see me for each appointment, had the withdrawal symptoms of her newborn not prompted the investigation by social services.
To the person who reviewed my last post— my lack of terseness is showing. I intended to conclude this post today, but when we look more closely, the unintended consequences go on and on. To summarize so far: That the shortage of buprenorphine-certified providers makes buprenorphine/Suboxone a scarce commodity. Buprenorphine has unique effects when taken properly, and the elimination of the obsession to use opioids is a Godsend for many people that cannot be obtained from ANY other substance. While some politicians and regulators see a world where too many doctors put Suboxone and buprenorphine on the streets, the unintended consequence of having too FEW providers has been to fuel the misuse and diversion of a potentially life-saving medication.
In part one, I promised a bit of drama over the Affordable Care Act. I’m getting there. But given that this is a holiday weekend, you will have to wait a few days for part 3!
Addendum: I’m adding comments from a member of the LinkedIn discussion board, from Shaun Shelly, Addictions Specialist at Hope House in Cape Town, South Africa. He points out how the blurring lines between abuse and treatment erode confidence in buprenorphine as a treatment strategy:
Great piece, and I look forward to you going “on and on” a bit more! I see the same in the South African setting where we have only one recently started (last week!) trial state funded OMT program. But all our patients know where they can buy scripts from doctors at R50(US$5) a pop. There is no requirement for special buprenorphine training in order to prescribe. Honestly, these doctors are little more than dealers with titles – these are the same guys who are giving long-term repeat scripts for benzos. And the dealers I know also supply bupe.
The real problem is, as you state, that the self-administration is at best sporadic and sub-optimal. This has the effect of many patients saying Bupe doesn’t work, and when we refer them for medically assisted detox they aren’t interested (Bupe is only funded by the state and many medical aids for 7 day detox). Hopefully sanity will prevail and we will get some decent OMT programs in place.
I have the same experience with some injectors – they report a lemon taste in the mouth but little else negative.