Suboxone Talk Zone: A Suboxone Blog http://suboxonetalkzone.com Questions and Answers about Opioid Dependence and Buprenorphine Wed, 26 Nov 2014 05:14:56 +0000 en-US hourly 1 Killing the Suboxone Gift Horse with Naltrexone http://suboxonetalkzone.com/killing-the-suboxone-gift-horse-with-naltrexone/ http://suboxonetalkzone.com/killing-the-suboxone-gift-horse-with-naltrexone/#comments Wed, 26 Nov 2014 00:40:03 +0000 http://suboxonetalkzone.com/?p=4651 First Posted 11/14/2013

I received an email update today with important news from the world of psychiatry and addiction.  The email highlighted a study from the October issue of Jama Psychiatry, entitled ‘A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers’.  The study compared relapse rates in opioid addicts who were tapered off buprenorphine at different rates.  The study considered success as being free of opioid use and taking naltrexone, an orally-active opioid antagonist, after 12 weeks.  The study found that 50% of the people tapered off buprenorphine over 4 weeks were abstinent and taking naltrexone.  That compared to 21% and 17% of success in patients tapered over 1 or 2 weeks, respectively.

I’m sorry, but who cares?

Regular readers of my blog know my opinion about buprenorphine.  (Newcomers please note that by buprenorphine I mean buprenorphine, Suboxone, or Zubsolv, since they all work in identical fashion).  Most people who work in the addiction field agree that addiction is a life-long illness.  Most people who have worked in the field for a few years or more know that relapse is a common feature of opioid dependence.  I believe that anyone claiming to ‘cure’ opioid dependence through use of a plant, root, amino acid, vitamin, hypnosis, accu-pressure point, or 90-day program is either misinformed, pathologically optimistic, lying, or blinded by profit motives.

Opioid dependence is associated with a high rate of death and morbidity. Beyond buprenorphine, the only reliable intervention for treating opioid dependence is methadone maintenance, if ‘reliable’ is defined as ‘likely to be successful.’  I realize there are hundreds if not thousands of residential treatment facilities throughout the US that advertise ‘freedom from addiction’; some even offering freedom from ‘addiction’ to buprenorphine.  These claims are made, and apparently believed, even with one-year relapse rates greater than 90% in opioid addicts treated without medication.  In the real world of ‘Suboxone Talk Zone’, I have to burst a few bubbles about ‘sending someone to treatment.’    For opioid dependence, treatment without medication yields long-term sobriety in only a small minority of patients.

Yet many healthcare professionals continue to chase after the golden goose of abstinent recovery.  Makes me wonder if laetrile would still be around with better marketing!

Before buprenorphine, opioid dependence was an oft-fatal illness that in most people responded only to the administration of opioid agonists at frequent intervals, with no patient autonomy and the threat of discharge if anything prevented on-time arrival at the early-morning line-up.  In 2003, along came buprenorphine— a prescription medication with a reasonable generic cost (finally), with few or no long-term risks and tolerable side effects, that eliminates cravings and prevents illicit opioid use in 50% of an average study population of opioid addicts who are allowed to continue their medication.  So why, exactly, are we excited by the prospect of changing from buprenorphine to a medication that carries the risk of hepatic necrosis?

Are people on naltrexone better off than people taking buprenorphine?  One would hope so, given that 50%-83% of people in the current study went back to active using while trying to make the switch!  Patients on naltrexone still have the problem of blocked mu receptors during emergency surgery.  Having blocked opioid receptors is an even larger problem for many educated addicts than their doctors realize, that goes something like this: ‘I stopped opioid agonists, but now I have to block my endorphins too?!

Why not just keep stable buprenorphine patients on buprenorphine?

The argument for naltrexone over buprenorphine comes down to two issues.  The first is the quasi-spiritual attitude that people are in an inferior form of treatment if their mu receptors are bound by even a partial agonist—no matter that those receptors have developed complete tolerance to the agonist effects of the drug.

The second argument focuses on diversion.  Buprenorphine is sold on the street, particularly in areas where there are no doctors certified to prescribe the medication.  People divert buprenorphine in a number of ways, ranging from efforts to get high, to use ‘in between’, to attempts at self-treatment.  But should risk of diversion reduce the legitimate use of a medication that has saved thousands of lives? Is it logical to throw the bupe-baby out with the bath water when deaths from buprenorphine are less common than deaths from acetaminophen?

I expect that the risk of diversion decreases over time in patients treated with buprenorphine.  Patients in long-term, stable treatment are more likely  employed and insured, with less financial incentive to sell controlled substances and more to lose for doing so.  Most of my stable patients develop insight into the damage caused by addiction, and have no interest in getting someone else caught in the same trap.  Most of the patients I’ve treated over time have severed their connections with the using world.  And most of them are grateful for a second (or tenth) chance at life; grateful enough to avoid risking everything by selling drugs.

Even if diversion could be blamed, in part, on stable buprenorphine patients, why is addiction treated differently than other diseases?  Diversion of opioid agonists is a greater problem than diversion of buprenorphine, both by sheer volume and by the damage from diversion, yet the FDA just approved another potent mu agonist in Zohydro—a drug with far greater diversion potential than buprenorphine or Suboxone.  If diversion doesn’t disqualify the pain meds used for strained backs, bumps, and bruises, why should diversion derail one of the only effective treatments for a disease that is killing thousands of young people?  Heck, pseudoephedrine is sold from pharmacies with a signature; the dangers of methamphetamine didn’t eliminate our collective concern for people with stuffy noses!

If we take diversion out of the argument—for example by deciding that the 300-odd deaths from buprenorphine diversion don’t warrant removing an effective treatment for a disease that has become the leading cause of death in young adults— the push off buprenorphine makes little sense.  I suspect that the people advocating ‘progressing’ from buprenorphine to naltrexone do not envision patients treated indefinitely with naltrexone either, but rather see naltrexone patients as somehow ‘closer’ to abstinence than buprenorphine patients.  From a neurochemical standpoint, what is the difference between being fully tolerant to a partial agonist vs. taking an antagonist?  For relapse-prevention, advantage goes to buprenorphine, since ‘effective relapse’ to opioid agonists requires buprenorphine patients to first go through days of withdrawal.  Naltrexone patients on the other hand can miss the morning’s naltrexone, and later that night relapse using mu receptors that are even hyper-sensitive to agonists.

As for arguments that patients on buprenorphine are impaired, I would love to see my attorney-patients take part in THAT debate.  Concerns of impairment have come from poorly designed studies where buprenorphine groups consisted of patients with no tolerance to the medication. I suspect that medical reporters too often read the abstract and skim the ‘materials and methods’—let alone the statistics!

If ‘success’ consists of moving to naltrexone—a medication that many real-world addicts reject–   how long is naltrexone continued, and what happens when it is stopped?  Do people go back to heroin again?  If not, why not? The cycle of ‘use, treat, cease treatment, use, and repeat’ should be a black box warning on naltrexone— as soon as they finish stamping the warning on the steps of every residential treatment center.

I’ve been accused of being too long-winded.  The short version for those who skipped to the bottom:  buprenorphine-based medications offer an effective, tolerable, long-term treatment for a chronic, life-long disorder.  How many people will die in their quest—or their doctor’s quest—for ‘abstinent recovery’ with or without naltrexone?  Emphasis on naltrexone is just one more example of looking the gift horse of buprenorphine treatment in the mouth.

Sigmon SC, Dunn KE, Saulsgiver K, Patrick ME, Badger GJ, Heil SH, et al. A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers. JAMA Psychiatry. Oct 23 2013;

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Pregnant Taking Suboxone: Should Social Services be Involved? http://suboxonetalkzone.com/pregnant-taking-suboxone-should-social-services-be-involved/ http://suboxonetalkzone.com/pregnant-taking-suboxone-should-social-services-be-involved/#comments Mon, 24 Nov 2014 18:15:52 +0000 http://suboxonetalkzone.com/?p=4500 First Posted 11/4/2013

I recently saw a new patient who described treating her own opioid dependence with diverted Suboxone.  She sheepishly described reading everything she could find about buprenorphine and meticulously using half of her friend’s medication to avoid other opioids, without fail, for four years. She would likely be treating herself now, if she hadn’t become pregnant and  told her OB and a hospital nurse what she was doing.  Her disclosure prompted a call to CPS, leading to the assignment of a caseworker and the threat to remove her baby from her home.  CPS eventually allowed her to keep her baby providing that she stop using medication illegally—prompting her to call my office.

My first reaction was that everything worked out well, and justice had been served.  But since the visit I’ve thought about some of the inconsistencies in how HIPAA is applied, and in the general attitude toward doctor/patient confidentiality.

I’ve also given thought to how things could have worked out, had my patient count been at 100 rather than 99.  There are not many buprenorphine-certified prescribers in my area, and she very likely would have been unable to find a doctor if my practice was full.  Had that been the case, what would have happened?  Would CPS have backed off and told her to go back to doing what she had been doing?  More likely she would have been given the choice of stopping buprenorphine or going to the methadone/buprenorphine clinic an hour’s drive away.    In the latter case, how would that work, exactly, traveling an hour at 6 AM each day as the single mother of a newborn infant?

I suspect that if my practice had been full she would have stopped buprenorphine or Suboxone, and joined the ranks of either the 4% of people who remain clean after stopping buprenorphine or the 96% who relapse within a year.  Would anyone at CPS have noticed which group she became part of?

Her case is an example of how complicated the ‘diversion’ issue has become.  And perhaps I’m paranoid, but I feel the need to say that I am against diversion of buprenorphine.  I’m saying so because I know the righteous attitudes of some physicians who claim to be more careful than others.  So to avoid confusion…. diversion is bad.  I’m on THAT side.

But death is bad too.  And breaking patient confidentiality is bad.  My new patient is someone’s daughter, and I found myself wondering what I would have recommended had she been MY daughter?  What would the reader recommend for his/her daughter?  She is 22 years old.  She became addicted to opioids at 16, when her best friend shared Vicodin that she found in her mother’s medicine cabinet.  By 18 had tried to quit a number of times on her own and with the help of meetings.  She failed intensive outpatient and residential treatment, like the vast majority of patients who take those paths, before her parents asked her to move out.

She tried calling numbers on the NAABT and SAMHSA databases but found that all listed practices within an hour’s drive were full, or more often were out of the ‘Suboxone business.’  She went on methadone for a few months but had trouble making the 50 mile drive to the clinic in the middle of January—an understandable problem for people who know the area.

At some point she met someone who agreed to share a prescription of Suboxone, splitting the script if she picked up most of the cost.  Compared to a buck per mg for oxycodone, she thought she found a bargain.

I’m usually able to let go of conflict in such cases by arguing for the common good, or by pointing out the things that she should have done to avoid her current problems.  But those positions are more difficult when one imagines the hypothetical case of a son or daughter.

I was going to make a number of points, but it is getting late, the Packers lost, and I’m in the mood to just call it a night.  I was going to ask whether or not her isolated case truly threatens the ‘public good.’  I was going to ask if it is appropriate to call CPS about someone who has done all that she can to create a better environment for her baby.  I was going to ask if breaking her confidence for the good of the child would be a bit paternalistic by modern medical standards.  I was going to ask if there are different types of ‘diversion’, and if self-treatment, in the absence of any other option, should always be condemned?

But I think I’ll just leave it here, and ask people to imagine their own daughter in the situation that I described.  Would you be angry that she met someone who shared Suboxone?  I know that some will claim that there must be other options— an argument that I’ve already heard from several people claiming the doctor did the right thing to turn her in.  But if there were any options I didn’t mention, I am not aware of them.

What would you have recommended for your child?  Things worked out this time, but I have a waiting list of 90 people who are looking for a doctor who prescribes buprenorphine, and I had just discharged a patient the day before her call.  Nobody was out there making certain that after the call to CPS, she would find a reasonable option.  With that in mind, how was the call to CPS consistent with the thought of ‘first, do no harm?’

A few comments from the original post:

WisdomQ:

What is a pregnant woman taking buprenorphine supposed to do? Stop being addicted to opioid’s for 11 months?

A 2010 study (http://www.nih.gov/news/health/dec2010/nida-09.htm) found bupe to be less problematic than methadone. Perhaps the most powerful tool is to never tell the child about it unless the child starts to abuse opioid’s on their own; considering the power of suggestion.

Tic:

This patient had been diverting suboxone for four years. I doubt that she was looking for a provider for four years without any success.

Me:

I don’t know what things are like in your area, but patients in northern Wisconsin have no access to buprenorphine-certified physicians. Some are listed– but they are all people who either signed up but never actually prescribed buprenorphine, or who shut down that aspect of their practice.

I’ve been at the 100-patient limit since shortly after the limit went from 30 to 100. My waiting list has 90 patients. Note that I do no accept any insurance panels– not just for the 30% of my practice that comes for addictive disorders, but for all patients– but patients wanting buprenorphine have no choice (the other patients choose to see me because I provide much longer appointments, guarantee to start on time, provide easy access, etc). There were two other docs in the county that at least prescribed the medication; one left a year ago, leaving one person.

Even in areas where there are more doctors, many doctors arbitrarily discharge patients after one year (or Medicaid in a state may stop covering the medication after one year). Studies show 94% relapse rate in people treated with buprenorphine for a year– i.e. the medication is best considered as similar to most other medications, as a TREATMENT, not a CURE. There are also practices who abandon the people who struggle the most– a cruel way of practicing medicine that is unique to addiction. So again, I imagine there are places where a patient has been kicked out of the practice of the only provider, perhaps for taking a benzodiazepine– instead of seeing the illicit use as one more aspect of her ILLNESS that deserves better treatment. Perhaps you consider it fair to give a 17-y-o woman one chance– and if she fails, tough luck—- and if that is the case, I hope you’re not someone’s doctor.

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A New Way to Stop Suboxone? http://suboxonetalkzone.com/a-new-way-to-stop-suboxone/ http://suboxonetalkzone.com/a-new-way-to-stop-suboxone/#comments Sun, 23 Nov 2014 19:13:20 +0000 http://suboxonetalkzone.com/?p=4381 Originally Posted 10/27/2013

I usually have my wife/business partner review my posts and provide her opinion whether my arguments are sound.  For the record, she tells me that this post is technical and boring.  I disagree, but we aren’t planning to separate over the issue.  A valid criticism, I think, is that I’m doing a lot of guessing and wondering in this post.  This post is an example of the things I waste time wondering about.   I try to avoid writing things that are somewhat speculative, but I wanted to give it a shot for two reasons.  First, because there may actually be something to the idea I am about to describe.  But more important, I wish to point out some of the many ideas in the addiction world worth exploring…. And I hope that pharma continues to search for answers (i.e. spend money) in this area of medicine.

So I’ve been thinking more about ALKS 5461, the Alkermes pipeline medication that is a combination of buprenorphine and ALKS 33, which is a mu opioid antagonist also called Samidorphan with the structure shown at the left. ALKS 5461 is being developed by Alkermes for the treatment of major depression.  I don’t know much about the clinical actions of ALKS 33, (a proprietary molecule), except that it comes from a family of drugs that bind with high affinity and specificity to mu or other opioid receptors.  Samidorphan, a mu receptor antagonist, allows investigation of buprenorphine’s potential therapeutic effects at kappa and delta opioid receptors by blocking effects at the mu receptor.  Drugs with actions at other opioid receptors have be developed, and in some case patented.Until recently, theories about depression revolved around abnormalities in brain monoamine pathways or deficiencies of monoamine neurotransmitters.  Monoamines include serotonin, melatonin, and the catecholamines (noradrenaline, dopamine, and adrenaline). Most modern antidepressants act at serotonin or catecholamine receptors or reuptake sites. The new Alkermes medication ALKS 5461 is the first serious effort that I am aware of to treat depression from the opioid perspective.

Our brains contain natural opioids called endorphins and enkephalins.  Endorphins and enkephalins are neurotransmitters in pathways with a wide range of actions, including blocking pain and raising mood during injury or sexual activity. Pain pills such as oxycodone displace endorphins and hijack the natural endorphin pathways, providing euphoria without the trouble of buying flowers.  Of course, a relationship with self-administered opioids always becomes more destructive than even the most codependent partnership!

As an aside, when I presented for addiction treatment 13 years ago I told the addictionologist about my background in neurochemistry, and went on to explain that I was fairly certain that I suffered from a deficiency of natural opioids.  That doctor got a kick out of my story, and I would enjoy a sense of justification if my hypothesis someday proved to be correct.

When one considers using treating depression with buprenorphine, the obvious deal-breaker is the same issue that has prevented every other serious consideration of treating depression with opioids, namely the development of tolerance at the mu opioid receptor.  Because of tolerance, anyone who finds relief from depression with buprenorphine would be cursed by the need for eventual withdrawal, as well as other consequences of opioid dependence. I assume that Samidorphan is added to ALKS 5461 to prevent mu activation and tolerance.  Beyond partial agonist effects at the mu receptor, buprenorphine antagonizes (blocks) delta and kappa opioid receptors.  These blocking actions are not subject to tolerance, and may provide avenues for treating pain and/or depression.

Depression causes significant morbidity throughout the world, so there are huge profit incentives for new antidepressant medications. Addiction creates a large market as well, but companies rarely go as far out on a limb for addiction products as they do for other diseases. The need for new antidepressants is acute, but in an alternate universe where pain and addiction treatment take priority, Samidorphan and related opioid molecules might have a number of benefits. I’ve posted, for example, about my experience treating severe chronic pain by combining buprenorphine with an opioid agonist.  I expect the combination to be exploited eventually given the need for effective pain treatments, perhaps using an analog of Samidorphan.

Doctors use buprenorphine to treat opioid dependence.  The goal of buprenorphine treatment is to block the cycle of use and reward for some period of time, and to allow patients to create support systems, establish self-sufficiency, regain self-esteem, and practice living ‘life on life’s terms.’  The amount of time that it takes to accomplish these goals likely varies depending on the individual’s premorbid function, life experiences, insight, genetics, and other factors, but studies suggest that a year is not long enough to make meaningful headway.   It is possible that for some people, opioid dependence is a relatively permanent condition that is best controlled with life-long maintenance treatment.   But for those who would like to try to maintain sobriety off buprenorphine, the tapering process reignites the circuits that were set up by the initial addiction, causing cravings, withdrawal, and the constant obsession to delay the taper and resume the prior day’s dose of opioid.

If ALKS 33 has a long half-life and blocks buprenorphine in a dose-dependent manner, I could picture an alternate strategy for stopping buprenorphine where the antagonist (ALKS 33) is introduced to buprenorphine patients at a gradually-increasing dose.  The goal would be to eventually have the person on a daily dose of Samidorphan sufficient to block all of buprenorphine’s effects at the mu receptor, at which point the person could discontinue buprenorphine without withdrawal.  I suspect that the patient would experience withdrawal in response to each increase in dose of Samidorphan, although withdrawal would be reduced by introducing the drug at a measured pace.

What is the value in tapering in such a ‘reversed’ way?  Why would adding an antagonist be preferable to the current process, i.e. simply reducing the dose of buprenorphine over time?  The answer comes from an understanding of the nature of addiction.  A person stopping buprenorphine by gradually adding Samidorphan would face the decision once per day, whether to take the next dose of Samidorphan.  Compare that once-per-day decision to the current method of tapering buprenorphine, where the person must decide, thousands of times per day, to NOT take more buprenorphine.  I would expect that deciding to take an antagonist once per day would be more likely to succeed then CONSTANTLY deciding NOT to take buprenorphine all day long, throughout all of life’s ups and downs—times when the patient was conditioned to take opioids.

We will learn more about Alkermes new medication in coming months. I hope that someone in a power position will consider some of the other diseases that might respond to these interesting chemicals, including opioid dependence.

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Suboxone Patient Needs Surgery, Refused Pain Control http://suboxonetalkzone.com/suboxone-patient-needs-surgery-refused-pain-control/ http://suboxonetalkzone.com/suboxone-patient-needs-surgery-refused-pain-control/#comments Sat, 22 Nov 2014 17:49:49 +0000 http://suboxonetalkzone.com/?p=4233 First Posted 10/21/2013

I have received MANY messages over the years from patients on buprenorphine/naloxone (Suboxone) who required surgery, but whose doctors refused to provide post-op analgesia.  Those of you not on Suboxone– can you imagine having surgery, and being told that ‘it is too much hassle to give you any medicine for pain relief’?

Below is a comment to my last post, followed by my suggestion.  I am usually not a fan of getting medical boards stirred up over other doctors’ business, but this type of situation is RIDICULOUS, and must be stopped.

The comment:

I’m scared to death!!  I have been on Suboxone for over a year.  Previous to  that, I was on it for a couple of years before stopping its use.  At that time I  developed some gall stones and presented to the ER in pain I can not even begin  to explain.  Ultimately the stone passed but I need to have the gall bladder  removed.  I figured this was a good time to maybe get off of Suboxone.  I knew I  would be getting some standard opiates after surgery to manage pain so I thought  it could manage the Suboxone withdrawal as well.

It was an awful experience and I eventually resumed Suboxone.  It has been a  little over a year now back on.  About 8-12 mg/day.  So about a couple of months  ago, I needed shoulder surgery.  Here we go again.  I tapered back on the sub  and went through with the labrum repair.   I did discuss it with my  psychiatrist but he basically said he wanted NOTHING to do with the acute  pain management portion of this surgery.  And I actually experienced very little  pain post-surgery and went almost immediately back on  sub.

Now I have had complications mainly from scar tissue.  Tremendous pain.  My  ortho recommended a surgical manipulation to clean out the scar tissue.  So I  went along and although the post surgical pain was much worse this time, I got  through it OK and back on sub.  Now I need to to go back to my psychiatrist for  a refill on the sub.  But, because I did not discuss THIS event with him (I  already knew he didn’t want anything to do with it) he said he would not refill  or treat me anymore.  So now I am one year in on Suboxone and being told to take  a flying you know what because of surgery I needed.  I just feel that if I’m on  Suboxone, I am at the mercy of whomever is treating me.  It is like blackmail.  

My response:

Shoulder surgery can be one of the most painful operations to endure.  If patients have inadequate pain relief after surgery, they risk developing scar tissue formation because of inadequate movement and physical therapy.  In other words, you second shoulder surgery might have been required BECAUSE you didn’t get pain meds after the first surgery.

Even if that is not exactly the case, people on Suboxone deserve pain relief after surgery.  Can any of you non-Suboxone patients imagine having a surgeon say ‘you will need pain meds after surgery, but it is too much hassle so I’m not going to give you any’?

I suggest sending a letter to your medical licensing board and saying something like this:

I am prescribed buprenorphine/naloxone, an FDA-indicated treatment for opioid dependence, by Dr. Whatever.   That doctor is certified to prescribe buprenorphine and Suboxone, and so should be aware of the proper way to treat post-operative pain in patients on that medication (as described inthis article).  I realize that there is a certain stigma for addiction even for those of us trying to do the right thing with appropriate medication— but refusing to treat post-operative pain is not consistent with the Hippocratic Oath.  Because my doctor simply refused to ‘get involved’ with treating my surgical pain, I was forced to endure the pain of surgery without any significant postoperative pain control– a level of care that would not be tolerate even for a family pet.   I wish to speak to someone at the board about the postoperative care that I did not receive.

Will it help?  I have no idea.  But the ONLY way things will change is if enough people start to complain.  Good luck.

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DA Asks ‘Why Still On Suboxone?’ http://suboxonetalkzone.com/da-asks-why-still-on-suboxone/ http://suboxonetalkzone.com/da-asks-why-still-on-suboxone/#comments Fri, 21 Nov 2014 03:00:50 +0000 http://suboxonetalkzone.com/?p=3991 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.

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Suboxone Detox is a Sucker’s Bet http://suboxonetalkzone.com/suboxone-detox-is-a-suckers-bet/ http://suboxonetalkzone.com/suboxone-detox-is-a-suckers-bet/#comments Fri, 21 Nov 2014 01:45:47 +0000 http://suboxonetalkzone.com/?p=3982 First Posted 10/6/2013

I attended the US Psychiatric and Mental Health Congress meeting last week and actually attended the meetings (the event was held in Las Vegas), but I was disappointed by the absence of lectures about addiction.  There are other mental health groups geared more toward addiction, but one would think that psychiatry would maintain a strong presence in the field.  This was my first time at the annual meeting for this group, and so I can’t say that I’m witnessing a trend away from addiction by psychiatry—which would be a real shame.

At any rate, I had a very busy Friday and Saturday catching up with the office work I put off for a few days. So today I had to cram in a lot of non-work activities, to make sure that my life remains well-balanced.  That meant watching the entire Packer game, going to the movie ‘Gravity’ complete with 3-D glasses, and then catching the latest episode of Homeland, where psychiatrists continue to gain a bad name.  Thorazine injection, anyone?

So I’m beat…  but I’ve been intending to write something for the past couple weeks, and I think I can knock it off fairly quickly.  Readers know that I get many emails from across the country describing atrocious behavior by physicians.  The latest scam?  It appears that everyone with a medical clinic has a secret recipe for tapering off Suboxone.

I received an email from a person who wanted to stop Suboxone/buprenorphine for months, if not years.  For people who don’t know my attitude, I tend to believe my own eyes, and also what the research shows—that over 9 out of 10 of the people who stop buprenorphine are using opioids again within one year.  When people moan that ‘it is hard to stop buprenorphine’, I remind them that the reason they are TAKING buprenorphine is because they were unable to stop opioids.  Why would they expect that to change?  Oh- I know— counseling!  That’s the line from all of the addiction insiders—that patients take buprenorphine and do ‘counseling’, and the addiction goes away.

There are two scientific findings that keep trickling out these days that are driving some people crazy— and I admit to a bit of amusement with each headline.  The first set of findings concern the troubling lack of global warming over the past 8 years—including the recent headlines that polar icecaps, predicted by Gore et al. to be completely gone by now, have grown by almost a third in the past year.  The other interesting findings are the several studies that failed to demonstrate an increase in sobriety in buprenorphine patients engaged in ‘counseling.’    There is real danger for people who borrow science just in order to hide behind It for an argument or two; they risk getting caught naked when the science moves in an unexpected direction!

Anyway, the person wrote to tell me that after multiple failed efforts to taper off buprenorphine on her own, she had gone to a rapid-detox clinic that promised to ‘heal’ her receptors over a few days. The $7 grand was spent, and I had no desire to ruin whatever placebo effect she would gain from the silly cocktail of nutritional supplements she purchased.  So I told her that I hoped she felt better soon, not adding that she will feel better at about the same time she would have felt better without the rapid detox and nutritional supplements.

She wrote again a week later, struggling from withdrawal, and then again a few days after that to say that she went back on buprenorphine.  But the good news was that she found a different doctor who SPECIALIZES in getting people off buprenorphine.

A few days later she wrote to tell me about the hundreds of dollars the visit cost— and asked if his taper schedule appeared reasonable.  ‘He’s your doctor’, I explained, trying to sound neutral.  I shared my belief, though, that it was a conflict of interest for doctors to sell nutrient products that they themselves prescribed, and that opioid receptors are able to return to health without the addition of trace nutrients.

A week later she wrote about yet another specialist, who this time took $800 to tell her to take 3 mg for a few days, then 2 mg for a few days, then 1 mg for a few days.  She said she had to go back for another appointment for him to tell her what to do after that.

I know it sounds like I’m joking, but sadly, I’m not.  More sadly, I’ve read similar messages a number of times over the past few years.  I’ve stated that I would try to point out things I write that are based on science, vs. things based on personal experience, vs. what I’ve witnessed as a clinician.  What I’m about to say is based on all three.

I had my own nightmare withdrawal from potent opioids when I was in treatment 13 years ago.  I lost 30 pounds from my already-skinny frame at that time, having no appetite and without taking nutrient supplements.   But my withdrawal ended and my receptors healed in about 6-8 week, just as in every opioid addict who I’ve assisted through detoxification.  And when I’ve seen people go away for rapid detox, they complain about feeling lousy— the same amount of complaining over the same lousiness—for the same 6-8 weeks.  One would think that all of this would be enough to outrage the FDA, who usually get irritated at stories about high-cost, low-yield medical procedures.  But once again, the truth is even worse.  For those who do manage to white-knuckle through 6-8 weeks of withdrawal, guess how many are still clean a year later?  Wanna bet?

As for the warming of the planet, I’ll continue to read the science with an open mind.  Maybe Gore will be right in the long run, which would be bad for the planet but good for those who give out Nobel Prizes.  But we know one thing for certain now; that asserting the ice caps would be gone by 2014 was a sucker’s bet.  And the same is true about promises for a rapid or gentle path through opioid withdrawal.

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