Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here.  This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago.  I grew used doctors refusing to treat people addicted to heroin and other opioids.  I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise.  It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices.  I feel like I’m the conservative one at those meetings!
I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine.  The comment surprised me, because from here I don’t see the influence.  My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years.  I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.
Those are big things, and anyone reading my blog knows all the big things.  I want to write about the little things.  The easiest way to have influence is to write about the things that nobody else writes about.  After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence:  If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.
On the forum I try to keep things real – not in a cool way, but in a medical or scientific way.  I want people to use .  I know I sound like some old guy frustrated by all of the new words and acronyms on social media.  YES, dammit, I AM frustrated by those things!  But communication has become so…. careless in the era of Twitter and texting.  Find an old book and notice the words and phrases used by educated people 100 years ago.  Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends.  Does anyone communicate in sentences anymore?
I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?)   But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs.  Some large scams benefit from the informal attitudes toward health and medicine;  attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video.  As in ‘I can treat it myself if I can find the medicines somewhere.’
The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term.  Is ‘treat’ the right word?  From my perspective I’d say yes in some cases, and no in others.  Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year.  They said (and I believe them) that they hadn’t used opioid agonists for at least that long.  I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances.  There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances.  Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv.  Those in the second group talk about finding subbies.
I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies.  I correct them and tell them that I have a hard time trusting patients who talk that way.  After all, those are street terms.  A pharmacist doesn’t say ‘here’s your subs!’
So here’s the rub.  Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing?  Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not.  I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.
But I will continue to correct them, and let them know that their words create a certain impression.  Getting that point across would be enough influence for one day!

20 thoughts on “Buprenorphine, Not Subbies”

      1. I do not think you are an “influencer” I think you have the balls to tell the truth about buprenorphine! You don’t blow smoke up people’s ass and you are tolerant and non-judgmental. I think most buprenorphine doctor’s should come to you for some training because the people on the streets using the term subs are probably more educated about the drug than half the physicians that prescribe it..I very much enjoy reading your blog and would give anything if you were my doctor!!

  1. Dr. Junig, i am not praising you for the sake of just praise, but I really take comfort from hearing words from a doctor that is informative, that will actually use words with their patients unlike my doctor who says here is your next script where is your 200.00 and on to the next month. I have really given up on my doctor. He makes me feel like i am just some random number. I have tried to ask him questions and he either lies to me or is so uneducated on suboxone that its insane. Now tell me if this is proper treatment. I had for 23 years been going to my primary care physician I have a disease called Interstitial Cystitis. He wrote me all the morphine and percocet I wanted. So I finally make a decision that I am sick of this opiate ridden life and I want off the rollercoaster so I went to him and had an honest conversation. I told him that I had been abusing the medication and was taking twelve percocet a day and I had heard about suboxone and I was going to start therapy and get off these drugs. Mind you all these years he was charging my medicare and they were paying for my doctors visits and prescriptions. The day I told him the truth and he wrote my first script of suboxone. I had to first pay 400.00 to start and then 200.00 a month to keep coming. I noticed that they accepted no checks or debit cards but all this time he had me on narcotics he used a computer and would send my scripts to the pharmacy. Now with the suboxone they use a little vanilla folder I cannot pay the receptionist i have to pay the lady I see each time after I get back who writes me out a receipt from and old style book that does not have the doctors name or anything on the receipt and now he treats me like I am not important at all. If I were a doctor I would be happy if my patient was abusing the drugs i prescribed if they cam to me for help. And why the old school back alley methods of hand written receipts. And unless i change doses i never see the doctor anymore i see one of his nurses that has worked there for years…To be honest the turn around makes it feel like a back alley method and he lied to me or he is uneducated one I will soon have to have foot surgery I go in and request to see him and I ask him how do I transition from suboxone to pain meds he tells me oh quit taking suboxone for a day and the pain meds will work! I have no medical degree and I know that is not true and it scares the shit out of me cause when my surgeon looks at my treatment plan this man is who they are going to look to to help with my pain treatment. Sorry for the ramble, but i know this is wrong could I get your opinion on this?
    Sincerely,
    David

    1. As I read your comments, I was thinking now that I’ve written about patients I should also write something about doctors who drag down perceptions about buprenorphine! I don’t know why a doctor would have such different practices for buprenorphine than for other types of care. Maybe there is something specific to your state that I don’t know about, but I don’t know any reason for a change in billing and in prescriptions for buprenorphine. It is actually more difficult to prescribe Percocet than buprenorphine; Oxycodone is ‘schedule II’ and requires written scripts, and some states opioids require doctors to keep copies of schedule II prescriptions… where buprenorphine is ‘schedule III’ and can be called in over the phone.
      I can imagine reasons someone might keep things hidden, for example if trying to avoid paying taxes or reporting income. That would be a crime that carries significant penalties, so hopefully there’s some other reason.
      You’re correct about the surgery. I get frustrated about the lack of good guidelines out there for patients on buprenorphine. I have a number of posts about the issue, and you can find them if you go to suboxsearch.com and search the blog with the words ‘post-op pain’ or ‘surgery’. As you know, stopping buprenorphine for a day, or even a week, does little to help. You would still have the higher tolerance caused by buprenorphine and there would still be buprenorphine in your system, blocking opioids. The best way to handle surgical pain from my perspective is to continue the buprenorphine or Suboxone or whatever, and then to give the patient higher doses of oxycodone– around 30 mg instead of 5-10 mg every few hours as needed. That approach has worked every time I’ve used it, although there was one person who had shoulder surgery who really struggled with pain, even after very large doses of oxycodone. There are risks, of course, when using high doses of opioids. But the risks are very straightforward, and easily managed in a hospital by monitoring respiratory rate. A tip about monitoring respiratory rate is to do it without the patient knowing, because if you say you’re measuring it, it will change. So I usually tell the patient I’m measuring the pulse, and then I watch the person breathe while I pretend to feel the pulse. Normal respiratory rate is 16/minute; a person in pain breathes faster, and a narcotized person breathes more slowly.
      When my patients have surgery, I give them guidelines that they can give to the surgeon. You’re welcome to show the guidelines to your doc; maybe it will encourage him to handle things differently. Although I realize that doctors aren’t good learners after med school. Here is what I use: http://suboxonetalkzone.com/surgery.pdf
      One thing about foot surgery that might be helpful: the pain is greatly reduced if you can keep the swelling down. So keep your foot CONSTANTLY elevated during the first 24-48 hours post-op. Ice will reduce inflammation, swelling, and pain too. And finally, the anesthesiologist or surgeon can delay the pain (and prevent the worst of it during the first 12 hours) by doing a block with a long-acting local anesthetic like bupivicaine. If they do a block, though, make sure you still keep it elevated– because otherwise it will really hurt when the block wears off, usually in the middle of the night.
      Good luck – I hope your doc opens his mind about the pain issue!

      1. Dear Dr. Having received your guidance in the past I would like to offer some perspective of why patients on suboxone are treated differently. We are basically hostages to the demands of the DR’s out to make $$$$. Our other option is back to drugs. We are up against a wall and they know it and use these practices to remind us.

        1. I hear you. I think that doctors should do what they can to minimize cost to patients such as reducing frequency of appointments as appropriate, and doing drug testing as indicated, rather than doing $2000 of labwork every month (which frankly is a scam that brings in revenue for some doctors).
          At the same time, people with addictions should realize that their situation is not unique. I had skin cancer, so I pay for regular check-ups with an expensive dermatologist. I have eye issues I won’t go into that require regular appointments with that doctor. And of course any cancer patient is ‘held hostage’ to a host of doctors– and could come up with the same complaint. Half of the country says that healthcare should be ‘free’; of course there is no such thing when doctors pay about a quarter million dollars in order to become doctors (not even counting the value of their time studying).
          Treatment with buprenorphine is usually a good value even when provided at steep cost. I don’t think I’ve met a patient who spent less on illicit opioids than they would spend in any buprenorphine program! Residential treatment costs tens of thousands of dollars, and barely works… methadone treatment costs over $4000 per year for at least 2-3 years.
          And treatment for other potentially-fatal illnesses easily runs over $100 K.
          When you step back an look at the harm to a person’s physical, emotional, and interpersonal health caused by opioid dependence, the costs of treatment are usually more reasonable than treating comparable illness. Perceptions are altered by the free care provided by medicaid, but I pay over $20 K for health insurance that pays nothing until I spend over $10,000, and every other working person under 65 pays those same costs, either on their own or through an employer. I know that about 20 years ago, a 40-minute ACL repair cost about $20,000… makes treatment for addiction look like a good deal.

        2. That’s one way to see it. I’ve ‘been there’ too – my treatment cost $60,000 for the first 90 days then another $60,000 for the next 6 years of group therapy, individual therapy, and drug testing. Sort of ironic that I had to pay that in order to keep practicing medicine – a trade that cost me 12 years of college, med school, and residency plus about $100,000 of debt. The person helping you went through similar training. I’m not sure what you do for a living, but if you paid a hundred thousand dollars and studied for 12 years to be a plumber, would you spend your life fixing pipes for free?
          I believe that doctors should take the patient’s situation into account as much as possible. I try to keep my costs reasonable. But I don’t love the job enough to do it for free – and I would never ask anyone else to do the same.
          I appreciate you reading my blog, but I’m sorry- the idea that your options are to pay doctors or return to drugs is simply incorrect. You have many other choices. You can work a second job to pay for treatment. If you smoke tobacco or pot, you can quit paying for that in order to pay for treatment. Or you can skip buprenorphine and go to 90 meetings in 90 days – or 180 meetings in 180 days.
          If those sound unreasonable, I’m sorry but you’re wrong. I’ve done almost all of them. Any wall you’re feeling behind you is of your own making.

  2. I just have a,quick question…ive been taking Roxy 30s for a,while and I want to get off of them…so I tried methadone because I still have to go to work everyday and I have diarrhea ..body aches and can’t think straight…methadone helps but then I have withdrawels from methadone…so now I have suboxen…ive been taking a quarter of one every day for 3 days now…will I have withdrawels from it,or should I be good if I take it for 3 more days…just a quarter of a pill a day?

    1. I wish it was that easy. First, understand that simply detoxing rarely works. Even a person who goes through several months of treatment has a low chance of remaining free from opioids in the absence of ongoing recovery work, step meetings, etc.
      But from a purely physical perspective, the problem is that the receptors in your body where endorphins act have become altered by the oxycodone, then the methadone, and now the buprenorphine. All of those chemicals act in place of endorphins, activating certain nerve pathways. The nerves adapt by changing the receptors, so that now your endorphins aren’t potent enough. That is called ‘tolerance’.
      That process is repaired when those same pathways stop firing as much – which you feel as ‘withdrawal’. During withdrawal your nerves create new receptors and replace the old, insensitive ones. But that is a long process, taking 2-3 months if you stop opioids completely. Since people don’t like being sick for 2-3 months they often use something to activate those receptors, and then slowly reduce that substance.
      Buprenorphine is a potent medication, and has a ceiling effect. A person on buprenorphine develops about the same tolerance as a person taking 40 mg of methadone per day. But the relationship between dose and strength is not a straight line with buprenorphine. The effect maxes out at about 4-8 mg per day. So if you are taking 4 mg of buprenorphine per day you still have the tolerance of someone on 40 mg of methadone. You’re on 2 mg, which has a little less activity than 4 mg (but more than half the activity).
      Some people use buprenorphine to reduce withdrawal because it leaves the body very slowly. If you stop it now, you will have withdrawal that peaks in about 10 days, and then slowly gets better over the next month or two. If you want to avoid withdrawal you will want to taper slowly over MONTHS. Go to my forum, suboxforum.com, and you’ll get many suggestions about the best way to do that.

  3. Those that use suboxone as it is intended, who rely on it to keep the beast at bay.. have everything to lose from the “subbies” culture. I would not be alive today had it not been for suboxone. It has transformed my life. You are much kinder than I am doc. I do not run in the “subbies” circle but if I did, I’d have a hard time not judging these folks and being mad as hell at them for putting my life at risk. The folks out there that are abusing suboxone, those that are feeding the systemic impression that suboxone is one drug replacing another, are making it harder for those of us who are doing it right. I have lived a lifetime of pain, a lifetime of suffering and those that abuse this drug risk its availability. Abusers of this drug are putting us all at risk. I hope the system is able to recognize that the benefits to society outweigh the risks. I live in fear everyday that they will someday take this drug, and my life as it is today, away. Educate them doc, the thought of going back to that life of misery is horrific.

  4. Hi Dr. Junig
    I messaged you around 6 or so months ago telling you about my ER experience in Pittsburgh while in severe pain and how I swore I’d get off the medication. I took your advice and have been lowering my dose from 24 Mgs. daily to 8. Thank you again for being there for the addicts. we really don’t have mant people in our corner to help us. But this website is a shining beacon of hope for anyone who wants to get clean and lead a drug free lifestyle. There’s a place in Heaven for people like you, I wish you’d open a satellite office in Pgh. I’d be your first patient!!

      1. Its 3:29am and I am suppose to have surgery at 11am in Charlotte today. I was trying to sleep but I have never had surgery while on suboxone. I’ve been on this medication since February of last year and it has kept me focused on living a life worth living. I want to thank you for being so open about how this medication doesn’t effect you being put under. I’m having the lining of my uterus lasered off. It’s a procedure called Novasure. I too am one that doesn’t want to be in pain, but I believe that I will be ok. The doctor doing my surgery says he normally just gives 800 mg Ibuprofen. Its really not what most consider a surgery that causes pain. He informed me that I would experience some discomfort but that’s all.
        I know that pain meds do work while on suboxone , but you must give the patient more than you normally would. I had a tooth pulled while on suboxone and I am always upfront about my medication with my doctors. The dentist gave me narcotics…..quite a few….and it did help. I never lowered my dose or anything I currently take 8mg 2x a day but I only really take 1-1 1/2
        Thank for this info I’m going to be able to sleep now!

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