DA Asks ‘Why Still On Suboxone?’

First Posted 10/13/2013

A person in my practice was stable on Suboxone/buprenorphine for several years, until he developed a painful injury.   During the time the injury was treated, the person experienced significant pain.  I worked with his surgeon to provide adequate pain relief, which for patients on buprenorphine or Suboxone  consists of a high dose of an opioid agonist, to ‘out-compete’ the buprenorphine.

As an aside, an NIH consensus paper from a couple years ago described the proper approach to patients on buprenorphine who require surgery or analgesia after injury.  Their top recommendation?  Have the person ‘hold’ their buprenorphine for a couple weeks before surgery.  That idea sounds reasonable for a moment or two, but anyone with any experience treating opioid dependence knows that whoever came up with the idea has very little experience working with addicts.  Just ‘hold’ the buprenorphine for two weeks?  Gee… OK…..  do you have any HEROIN I can take in the meantime?!  A little oxycodone maybe?  ‘Cause otherwise, the ‘holding’ isn’t going to work so good….

Every now and then I’ll read a recommendation or comment from someone high in addiction-society circles that shows that what it takes to get high in those circles is something other than a good working relationship with people who have suffered with addiction.

Following the tangent a bit further…. I find that reducing the dose of buprenorphine is a better idea;  people find that they can reduce it to 4-8 mg per day without experiencing withdrawal, and in my experience that is enough to allow 15 mg of oxycodone access to the mu receptor.  The other advantage over ‘just holding’ the buprenorphine is that when the agonist is eventually discontinued, the full dose of buprenorphine can be resumed without going through a period of abstinence, yet without precipitating withdrawal.

Back to the story—- the person continued to complain of severe pain, despite using the 3-day supply of oxycodone that I prescribed, all on the first day.  I had him stop by the office, and given his pinpoint pupils, slurred speech, and slowed respiration, I couldn’t provide more agonist without putting his life at risk.

It is always hard to judge the pain tolerance of someone else.  He said that the pain was unbearable;  I suppose it is obnoxious for a doctor to tell a person in that situation ‘your pain isn’t all that bad.’  I don’t think I said those words, but I think that many people who have gone public with histories of opioid dependence feel that medical professionals never take their pain complaints seriously— that they are forever condemned to suffer through more pain than people who’ve never lost control of opioids.  I think that the patient had that attitude, which didn’t help the situation, even though I tried to explain that I wouldn’t give more agonist no matter WHAT his prior history;  he was simply too narcotized.  In retrospect, what should have happened was that his surgeon should have admitted him to an ICU or SICU, for PCA while on oxygen and on pulse oximetry.  But for whatever reason, that did not happen.

Instead, he found his own supply of opioid agonist.  A bit later, he was found unresponsive and not breathing by a friend, who luckily knew how to do CPR.  (the actual story is that his friend was outside his room, and heard a thud as a head hit the floor).  He woke in the ambulance with an intact noggin, thank heavens.  But the police swung by his room to drop off their best wishes, along with a summons to appear for felony drug charges.

Enter me.  The DA had a concern about the case and wanted me to ‘clarify’ something.  The issue– why, after several years, is this guy STILL on buprenorphine?  Why hasn’t he been ‘tapered off’?  Why hasn’t he been definitively treated, rather than just ‘maintained’?

So I spent the day writing an explanation to the DA that I’m hoping they will find helpful.  It occurred to me that since I’ve been asked this very question before, there are likely other people who have wasted a day writing similar explanations, so I figured I’d just put it here—- so that if YOU are ever in the same shoes, you can either print it out, or refer people to my site– whichever works for you.  I tried to block of specifics– like names, etc– but if you find one, please send me an email and let me know so I can take it off.

My Letter:

To Whom It May Concern:

I was asked to describe the medical and treatment history of XXXX, and to explain why he continues to be prescribed buprenorphine/naloxone (brand name Suboxone).  The decision to continue or discontinue buprenorphine is individualized and complicated.  Sometimes the decision is impacted by non-clinical factors. The decisions, and the science behind the decisions, are complicated, and difficult to explain. I will attempt to explain the basic issues faced during buprenorphine treatment in general, and then describe the specific considerations in XXXX’s case.

Background

Those who work with opioid dependence have known for decades that opioid dependence is a lifelong, potentially-fatal illness that is highly-refractory to treat. In the 1970s, methadone clinics were set up as a response to this recognition.  Methadone clinics are even more prevalent today, providing opioid maintenance for patients over the course of years, and often decades.  Long-term treatment of addiction has come and gone under different names over the years. In the 1990’s, many treatment programs adopted the concept of ‘harm reduction’ after recognizing the low success rates of total sobriety programs.  Harm reduction strategies focused less on the number of consecutive sober days, and more on reducing the most harmful aspects of the patient’s addiction.

There are misconceptions among the general public that people with addictions can be sent to residential treatment and freed from opioid dependence, or that counseling alone can stop active addiction. Sadly, these are misconceptions. I have worked extensively in the field of addiction, including serving as medical director of Nova Treatment Center in Oshkosh for several years. During typical residential treatment, counselors discuss ‘planting a seed’, i.e. treat patients with the knowledge that relapse is inevitable, and that patients will likely return for another round of treatment. Is not uncommon for patients from any residential treatment program to relapse on the day of discharge, or die within 24 hours of discharge with a clean bill of health. Those who work with opioid dependence know that sustained remission from opioid dependence is the exception to the rule. The issue is under-researched, but I would estimate that 5% of entrants to residential treatment programs with opioid dependence remain sober a year after discharge.

In 2000, Congress passed DATA 2000, a law allowing for the use of buprenorphine for treatment of opioid dependence. Buprenorphine has considerable safety advantages over methadone, including a ceiling effect that makes overdose less likely. Buprenorphine treatment programs were initially designed to follow one of two paths, using buprenorphine either for detox or as a chronic maintenance agent. Over the past 10 years, numerous studies have shown relapse rates approaching 100% for patients who are simply detoxified using buprenorphine.  Because of the low rate of meaningful sobriety after detox, buprenorphine is rarely used for detox except as part of a longer (usually residential) treatment program.

Buprenorphine is Different

This topic alone could fill chapters, but I will highlight the salient features.  Buprenorphine was used in microgram doses for the past 30 years to treat pain.  Buprenorphine is a ‘partial agonist’, meaning that after a certain amount is taken, additional doses will cause no greater effect.  The goal of treatment is to keep the patient’s blood level above a critical point—the ‘ceiling effect.’  If the blood level remains above that level, the patient will receive a constant amount of mu-opioid-receptor activation, even as the buprenorphine wears off between doses.  The brain becomes completely tolerant to that activity, and the patient ‘feels’ completely normal.  I prefer the term ‘remission therapy’ over maintenance therapy, because a patient taking proper amounts of buprenorphine feels completely normal, as long as they stay on an amount of buprenorphine that keeps them above that ceiling effect.  Dosing efficiency can vary, so that dose ranges between 4 mg per day and 16 mg per day in most patients.

Patients on buprenorphine feel no desire to take other opioids.  Unlike untreated addicts, they do not experience the frantic search for pain pills or heroin every 4 hours that drives much of the illegal behavior associated with addiction.

Studies examining the long-term use of buprenorphine have found that buprenorphine treatment yields sustained remission from opioid use in about 50% of patients maintained on the medication.  Relapse rates are between 94 and 97% within one year of discontinuing buprenorphine, even in patients who were maintained on buprenorphine for over a year. The clinical data has demonstrated very clearly that when buprenorphine is discontinued, 90% or more of patients relapse at some point, usually within one year.

Doctors require additional certification to prescribe buprenorphine for addiction. Doctors who prescribe buprenorphine must counsel or refer to counseling, patients treated with buprenorphine who need additional help. But studies of the the impact of counseling on relapse rates have shown virtually no impact on relapse in groups who are counseled versus those who are not. I believe counseling is an important part of the picture for patients needing guidance toward education and gainful employment.

Some doctors arbitrarily stop buprenorphine or Suboxone at certain intervals of time, for example after one or two years. There are insurance programs that arbitrarily limit coverage to one year or two years, including some state Medicaid programs. These limits are not based on any evidence that people will do better if they stay on buprenorphine for that length of time. In fact, the opposite is true; people do well while maintained on buprenorphine, but generally relapse within a year after buprenorphine is discontinued.  But there are non-clinical motives to remove patients from buprenorphine which I will describe below.

XXXX’s Case

XXXX struggled early into buprenorphine treatment, which is relatively common in young patients. But during recent years he has done well on buprenorphine, avoiding illicit opioids and other substances. As with any illness, the response of an addict to treatment is rarely perfect. Patients with diabetes have flare-ups caused by alterations in diet that they know they should avoid. People with heart disease who are instructed to exercise often fail to follow that advice, and have a second or third heart attack.  Patients with mood disorders will stop their medications, or stop doing the things that they have been told to do to reduce the risk another mood episode.

For patients maintained on Suboxone, painful illnesses or injuries are particularly challenging. When XXXX had ( ), I coordinated care with his urologist. XXXX had a large stone that clearly warranted opioids to manage the pain according to his urologist.  I took over XXXX’s pain management and prescribed oxycodone, the standard practice in such situations.  XXXX complained that the pain was unbearable, but his respiratory rate was depressed by the pain medications to the point that I could not safely prescribe greater amounts of opioids, particularly to someone outside of the hospital.

The active drug in Suboxone, buprenorphine, has both activates and blocks opioid receptors.  When treating pain in patients on buprenorphine, the dosage of buprenorphine is often decreased, to allow other narcotics greater access to receptors in the brain.  At some point, XXXX obtained fentanyl, a very potent pain medication.  The pain that he was experiencing, combined with the reduction in buprenorphine made to allow for greater pain relief, resulted in a situation that he was unable to avoid taking the fentanyl.  I realize that it is difficult for people with addiction to accept the idea that he was ‘unable’ to do the right thing, but addiction is a major problem exactly because of that fact; that some people are unable to avoid taking certain substances in spite of knowing that the substances are causing significant harm to their lives.

I do not believe that XXXX had any interest in getting ‘high’, or feeling a ‘buzz’ from fentanyl.  XXXX believed that he could not tolerate the pain he was experiencing without taking additional narcotic, and the fentanyl was all that was available for him to use.  I also believe that like many people treated for opioid dependence, XXXX believed that he was deliberately under-treated for pain because of his history of addiction—making it all the more difficult for him to tolerate the pain.  XXXX realizes that he was lucky to survive the incident, and he has done well since the ( ), back on his regular dose of buprenorphine.

Should buprenorphine/Suboxone be discontinued?

Going forward XXXX and I will discuss when and whether he should discontinue buprenorphine, as I do with all of my buprenorphine patients. There are multiple factors to take into account before making such a decision, including patient age, stability of patient’s relationships, presence or absence of physical pain, nature of patient’s occupation, intensity of cravings and time since active use, relationships with work colleagues who are actively using, whether any other members of the patient’s household use pain medication, presence or absence of children, sleep and work schedule, etc.  As of now, XXXX is NOT in the position to discontinue buprenorphine.  I do NOT foresee him being an appropriate candidate for discontinuation of buprenorphine in the near future.

My decisions about the continuation/discontinuation of buprenorphine/Suboxone have been shaped over years by discussions with other physicians, and by experiences while treating opioid dependence with buprenorphine.    I have a number of patients who have been treated with Suboxone for many years, as do many other physicians who treat addiction.  Over the years I have had at least six patients who I am aware of, who insisted on their own, or through encouragement from friends, relatives, or doctors, to discontinue Suboxone against my advice.  I read obituaries for each of those patients over the next few years.  Not all patients who chose to stop buprenorphine ended up dying from overdose, but the frequency was high enough that I noticed six cases in the local newspaper over a period of seven years.

As stated earlier, there are factors that encourage discontinuation of Suboxone that are not necessarily in patients’ best interests. The DEA enforces limits on buprenorphine-certified physicians to treat no more than 100 addiction patients at one time. The limit creates financial incentives for doctors to discharge patients after some period of time, since unstable patients are seen more often than stable patients. And the financial incentives for state Medicaid and health insurance companies to place arbitrary limits on buprenorphine treatment are obvious.

With my background and training, I am convinced that I understand opioid dependence about as well as any physician. Opioid dependence is a chronic, relapsing, potentially fatal disorder. I counsel most of my patients on buprenorphine to take the medication appropriately and to get on with their lives, growing in areas that were blunted by their active addictions.  I do not place arbitrary time limits on treatment. I note that opioid dependence is much like every chronic illness, as doctors treat far more illnesses than we cure. We don’t ask how long our patients will take blood pressure medication. We don’t ask how long our patients should take cholesterol-lowering medication. We don’t ask how long those with diabetes should stay on insulin. Only with addiction do we entertain the thought that patients should expect only a limited period of treatment. I have been happy to see those attitudes change over time, as more and more doctors see buprenorphine/Suboxone as long-term treatment.

In regard to XXXX ’s specific case, he was doing well, fully complying with treatment.  He developed ( ), and I consider what followed to be a complication of illness. I understand that a crime was committed. But I believe that after several weeks of severe pain, combined with the lower dose of medication used to treat his addiction, XXXX reached a point of desperation where he was not capable of making the right decision. He has done well since that incident. I believe in holding people accountable, but in XXXX’s case, I do not believe it in anyone’s interest to make a hard-working individual unemployable. I know that XXXX has worked very hard to improve himself over the years, and I believe that he will continue to do the same going forward.