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.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important.  While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream.  Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream!

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths.  To you doctors:  Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about?  The same number of people die from lightning strikes!  Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths.  FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing.  Getting insurers to treat AIDS was the right thing.  But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids.  When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician.  Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises.  But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine.  In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications.  Such sales are against the law, just as selling Oxycontin or Vicodin is a crime.  But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’.  If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue.  Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine:  With all due respect, you must be doing something wrong.  I have 100 patients right now who tell me, at each visit, that I saved their lives.  I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say!  But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors:  How can you not be excited by a medication that has saved so many of your patients?  If you don’t have such patients, I suggest you give some thought to what you’re doing wrong!  In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug.  I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist.  Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?!  And if the same person injects buprenorphine, the withdrawal will be even more severe!  On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal.  But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine.  This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly.  But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin!

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it.  That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!