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!

Help for Heroin Addiction

A couple comments for regular readers…  first, watch for an upcoming change to a new name.  For years I’ve debated whether to adopt a name centered on ‘buprenorphine’, rather than the more-recognizable ‘Suboxone’.  I believe that time has come.   Second, I’m going to ‘reset’ with some introductory comments about the proper approach to treating heroin addiction, intended for those who are seeking help – starting with this post.
I’m addicted to heroin.  Which treatment should I use?
I’ve treated heroin addiction in a range of settings, including abstinence-based programs and medication-assisted treatment with buprenorphine, naltrexone, and methadone. My education prepared me for this type of work, and my personal background created empathy for people engaged in the struggle to leave opioids behind.
The first barrier to success is on you. Are you ready to leave opioids behind? How ready? Are you so ready that you will be able to end relationships with people who use? Are you ready to stop other substances, especially cocaine and benzodiazepines? You will find help during treatment and you don’t have to take these steps entirely on your own. But you must at least have the desire to get there.
If you’re ready, the next step is deciding the treatment that is likely to help you. Many people see abstinence-based treatment as a ‘gold standard’ – the ultimate way to escape opioids. Unfortunately, that belief has fueled many deaths over the past ten years, as desperate people paid large sums of money for themselves or loved ones expecting programs to alter personality over the course of three months. It doesn’t work that way for most people!
During several years working in abstinence-based programs, I helped fix people who were broken by addiction. After a couple months, people left treatment with healthier bodies, cleaner complexions, and better hair. But over 90% of those people returned to opioid use, some within a few days. Some of them died because of their new lack of tolerance to opioids. In each case, counselors said the same thing: ‘he/she didn’t really want it’. But I remembered that they DID ‘want it’ when they were in treatment. In fact, some were considered star patients! At some point we must hold treatments responsible if they fail over 90% of the time.
My perspective changed. Now I wonder, why does anyone expects those treatments to work? A person is removed from a life of scrambling and drug connections and poverty, placed in a box and shined up for a few months, then put right back in the same using world and expected to act differently?
I eventually learned about medications that treat opioid addiction. I realized that opioid addiction truly is a medical illness that should be treated like any medical illness. Think about it – we treat high blood pressure, asthma, and diabetes over time. We don’t cure any of them. In fact, the only illnesses that we can cure are infectious diseases, and even that accomplishment is fading as organisms develop resistance to current medications. Given that we can’t really cure anything, why do we expect anyone to cure addiction – in 12 weeks?!
Medication-based treatments for addiction represent a transition to normalcy. Doctors and nurses were removed from treating addictive disorders decades ago because of historical events that I’ll eventually write about. Clearly, it’s time for health professionals to take a role in treating addiction. In the next article I’ll discuss the medications currently available, and the reasons that one might work better than another for certain individuals.
In the meantime please check out my youtube videos under the name ‘Suboxdoc’, where I discuss the use of medications, primarily buprenorphine, for treating addiction to heroin and other opioids.

Brandeis and CDC Wrong on Buprenorphine PDMP Data

I’ll share an interesting story about the data used for the prescription drug database in Wisconsin and other states.  I’ve been holding back on writing about this issue in hopes that the reason for the story would be corrected, and I would have no story to tell.  But that hasn’t happened.
A new law in Wisconsin requires all prescribers to check the prescription drug database when prescribing any controlled substance.  I’m surprised that no privacy advocates have complained about the database, which tells prescribers about the controlled substances used by their patients over the past 5 years, the pharmacies their patients used, and any suspicions of law enforcement about their patient in regard to controlled substances.  The database, or PDMP, is a significant tool for preventing doctor-shopping and diversion.  But the PDMP provides a great deal of information about activities by patients that they rightfully believed to be private just a few years ago.
But this story isn’t about privacy.  I’ll leave that for another day.  This story is about the information provided by experts at the CDC, the top health agency in the world, about buprenorphine.  A mountain of nonsense about buprenorphine permeates healthcare, law enforcement agencies, and addiction treatment programs.  But one could optimistically expect the CDC to get it right.  Right?
When a prescriber follows the new law and looks up a patient on the PDMP, the web page includes a graph that displays the patient’s use of opioids over the past three months, displayed as the oral morphine equivalence.   The graph has a blue line on the graph that represents 50 mg of oral morphine per day, and a red line that represents 90 mg of morphine per day.  Another line represents the patient’s daily opioid dose, and the entire graph is shaded red during the time that the patient also used benzodiazepines.  Neat!
For most patients, the red and blue lines are clearly visible, and the patient’s opioid use is displayed in relation to those lines.  But for patients on buprenorphine, the red and blue lines are pushed against the bottom of the graph by the line that shows the patient’s opioid usage.  Why?  Because according to the PDMP, a patient on 16 mg of a buprenorphine medication is taking the equivalent of 900 mg of morphine per day!
Anyone with a basic understanding of buprenorphine knows about the ceiling effect of the drug.  Unlike with opioid agonists, the opioid potency of addiction-sized dosages of buprenorphine cannot be directly extrapolated from the potency at lower dosages.  With oxycodone, 10 mg of the drug is ten times stronger than 1 mg of the drug.  With buprenorphine, 2 mg of the drug is about as potent as 8 mg, which is about as potent as 24 mg.  The PDMP, though, shows 16 mg of buprenorphine to be 16 times stronger than 1 mg of buprenorphine.
When I noticed the error in the data I emailed the people who developed the Wisconsin PDMP.  They responded and wrote that they appreciated the information, but Brandeis University provided the data about opioid dose equivalency, so Brandeis was responsible for the accuracy (or lack of accuracy) of the data.
So I wrote to the folks at Brandeis who provided the information for Wisconsin and other states’ PDMPs.  They responded that THEIR information comes from the CDC, and so the CDC was ultimately responsible for the dosage conversion data.  They also said that doctors shouldn’t use the information for opioid dose conversions, and there was no danger to that effect because of the fine print at the bottom telling doctors to avoid using the information in that way.
I wrote to the CDC, cc’ing everyone and their cousins to make certain that the right person received my email.  I wrote, respectfully, what I’ve written here—that the information about buprenorphine failed to take the ceiling effect into account, and that the misinformation could potentially lead to patient harm, if a doctor did what doctors tend to do, i.e. use the most readily available information about dose equivalency and trust that information, especially if it comes from an official site like their state’s Prescription Drug Database.
The CDC replied with a form-email.  Given that a genuine response takes about one minute, I can’t believe that the person who received my email saved a significant amount of time by searching out that reply, but I suppose we citizens would become spoiled if the government responded personally!  The form email thanked me for my interest in the CDC, and provided a link where I could read more about the great work they do.
I admit that I get worked up about things sometimes. And yes, I was annoyed to get a form email providing a link to more information from the CDC, after writing to correct their wrong information.  So I sent an email expressing that annoyance to everyone in the story up to this point.  I’m sure that at least a few of the people in the ‘to’ box had a good laugh, and I suspect that I annoyed a few more.  Whatever.
A couple weeks later I noticed a new paragraph under the dose-equivalence graph, telling doctors to avoid using the opioid dose-conversion information to actually convert opioid dosages.  The small print at the bottom of the page was made larger, and placed higher in the page, directly below the display of morphine equivalents.  I don’t know if the change had anything to do with my emails or was only a coincidence.
But then yesterday I received an email from one of my patients, after he consulted with his surgeon about an upcoming operation.  The patient wrote about that doctor, paraphrasing a bit: “she showed me a graph that said my tolerance is equal to 900 mg of morphine.  I don’t know what that means exactly but she will need to give me a high dose of pain medicine without killing me.”  I eventually spoke with that doctor. Guess where the graph came from?!
This the punchline by the way, in case you’re skimming the story.  The patient wrote that his doctor used the PDMP to convert the amount of morphine he would need after surgery, in spite of the ‘warning’ on the web site.  What a shock!
I shared my patient’s email with the people at the WI PDMP, Brandeis University, and the CDC, letting them know that even though they added a paragraph to their data telling doctors that their data was nonsense, doctors STILL used that data in a way that could kill somebody.
Should they be proud of that misplaced trust?  I have no idea.  But why don’t they just USE THE CORRECT DATA??!!

Where’s the Buprenorphine asked Mr. Obvious? Thanks, CDC!

A quick note tonight, hopefully with a longer post to follow this weekend…
I’ve been frustrated by the people behind the Wisconsin PDMP, or Prescription Drug Monitoring Program, for their mistakes related to buprenorphine. Whoever came up with the numbers made a rookie error when calculating the equivalent morphine dose of patients taking buprenorphine products. The error is easy to notice by anyone who works with the drug, but apparently difficult to grasp by anyone with the power to correct the database figures.
Those people include, by the way, the folks at Brandeis University who give the numbers to Wisconsin, and the people at the CDC who give them to Brandeis. I’ve written to all of them; the bright folks at the CDC skimmed my explanation of their error and responded with a form-email that provides a link to where I can get ‘answers to my questions’.
Thanks, CDC!
In short, the people doing the calculation take a low dose of buprenorphine– say 200 micrograms– and extrapolate out in a straight line to 16 mg, ignoring the ceiling effect of partial agonists like buprenorphine. The calculation causes the PDMP to display a graph showing that people on buprenorphine are on the equivalent of 1200 mg of morphine. Any physician who sees that data (and all WI physicians are required by law to use the PDMP effective April 1) will think that the buprenorphine patient needing post-op pain is on THAT dose of opioids. Talk about an April Fool’s joke– nothing like hypoxia in the recovery room to brighten everyone’s mood! Don’t worry though– in their email they pointed out the disclaimer in fine print that the site shouldn’t actually be used to compare or convert opioid doses.
Then why make the calculation and show the graph, asks Mr. Obvious?!
This is getting longer than I intended… Another annoying State tidbit is the series of letters to Wisconsin physicians warning about the severe risk of harm from prescribing benzodiazepines to patients on buprenorphine. I’ve written to those folks as well, pointing out that combinations of benzodiazepines with opioid agonists are much, much, much more dangerous than with buprenorphine. I’ve explained how somehow, sometime long ago, the phrase ‘buprenorphine can only cause death in adults if given to someone without opioid tolerance AND combined with a second respiratory depressant, to which the person also lacks tolerance’ (a true statement) was changed to ‘buprenorphine is dangerous when combined with benzodiazepines’ (mostly ‘fake news’).
I haven’t written as many letters over this second issue because I’m no big fan of benzodiazepines. But both issues annoy me greatly, maybe because the errors of logic in both cases are SO obvious. Even for government work!!
Speaking of government work, the Milwaukee County Common Council released figures about the surge in overdose deaths, including a breakdown by ethnicity, age, county region, and drugs found at autopsy. Mr. Obvious has a question for the people writing to doctors to tell them about the SEVERE risks from buprenorphine: ‘What drug is NOT on the list of the 8 most-common drugs found in toxicology tests of overdose patients?’ A hint: It starts with a ‘B’!

This Suboxone Doesn’t Work!

Today on SuboxForum people were writing about their experiences with different buprenorphine formulations.  Doctors occasionally have patients who prefer brand medications over generics, but buprenorphine patients push brand-loyalty to a different level.  The current thread includes references to povidone and crospovidone, compounds included in most medications to improve bioavailability.  Some forum members suggested that their buprenorphine product wasn’t working because of the presence of crospovidone or povidone.  Others shared their experiences with different formulations of buprenorphine and questioned whether buprenorphine products are interchangeable, and  whether buprenorphine was always just buprenorphine, or whether some people respond better to one product or another.
My comments, including my observations about patient tolerance of specific buprenorphine products, are posted below.
Just to get some things straight about povidone and crospovidone (which is just another synthetic formulation of povidone),  both compounds are NEVER absorbed, by anyone.   They are part of a group of compounds called ‘excipients’, and are included in many medications to help with their absorption.  They act as ‘disintegrants’– meaning they allow the medication to ‘unclump’ and dissolve in liquids, such as saliva or intestinal secretions.
Molecules tend to clump together, sometimes into crystals, sometimes into other shapes.  A pile of powdered molecules molded, packed, and dried into pill form wouldn’t dissolve in the GI tract if not for povidone or other disintegrants.  I remember reading somewhere about cheap vitamins that could be found in the stool, looking much the same as they did when they were swallowed.  Not sure who admitted to doing the research for that article..
Buprenorphine IS buprenorphine.  Period.  The absorption isn’t affected much by excipients, because nobody ever complains that their Suboxone or buprenorphine won’t dissolve.  Povidone or crospovidone are also added to increase the volume, because an 8 mg tab of buprenorphine would be the size of 100 or so grains of salt.  Excipients like povidone and crospovidone also help some drugs dissolve, especially drugs that are fatty and don’t usually dissolve well in water-based solutions.   This last purpose does NOT apply to buprenorphine, since buprenorphine is very water-soluble.  Zubsolv is supposedly absorbed more efficiently in part because it dissolves very quickly, and maybe that is due to excipients.
I realize that when I write ‘bupe is bupe’ it sounds like I don’t believe those who complain about their medication.  But honest, I work with people over this issue every day…  I have an equal mix of people who insist Suboxone doesn’t work for them and people who insist ONLY Suboxone works for them.    Today I was reading TIP 43–  a guide about medication-assisted treatment put out by SAMHSA and the Feds that is over 300 pages long, very well-cited– in a section that cited studies about the psychological triggers for withdrawal symptoms.  TIP 43 and other TIPs can be downloaded for free… just Google them.  TIP 43 is primarily about methadone, but some of the information applies to methadone and buprenorphine.  The pertinent section was around page 100, if I remember correctly.
The TIP information mirrored what I see in my practice.  For years, I’ve noticed that patients will complain about withdrawal symptoms even at times when their buprenorphine levels are at their highest.  Patients also report that their withdrawal symptoms go away ‘right away’ after dosing, when in fact buprenorphine levels won’t increase significantly for 45-60 minutes.  People who have been addicted to opioids may remember how even severe withdrawal mysteriously disappeared as soon as oxycodone tabs were sitting on the table in front of them.   The bottom lline– withdrawal experiences are remembered, and those memories are ‘replayed’ in response to triggers or other memories.
In my experience as a prescriber, I’ve come to believe that patients with an open mind will learn to tolerate any type of buprenorphine (the exception being the 1 patient I’ve met who developed hives from meds with naloxone– hives that appeared consistently on three distinct occasions).  But withdrawal symptoms seem to be triggered, in many people, by the expectation of withdrawal symptoms.  So someone convinced he will never tolerate Zubsolv, Bunavail, or Suboxone Film will probably never tolerate those medications.
As for buprenorphine, it IS just buprenorphine.  Molecules with a certain name and structure are always identical to each other.  They are not ‘crafted’ products like bookcases or tables;  some buprenorphine molecules aren’t made with a quality inferior to other buprenorphine molecules.  And once a molecule is in solution, I don’t see much role for excipients.  Of course a tablet or strip could contain too much or too little active drug, but that is an FDA issue, not an excipient issue.

Obama’s Lousy Suboxone Offer

I was reading more about Obama’s executive order over at Dr. Burson’s blog.  I guess she is a ‘competitor’ in the blogging world, but I have to admit that her blog has a lot more detail about the issue than I do.  If you haven’t been there yet, check it out.  Keep coming back here too of course!
She wrote recently about the rules that would be required by the Feds, in order for them t o allow us the ‘right’ to treat people with buprenorphine.   I wrote to Dr. Burson after reading her post that she is providing the facts, and I can’t help but provide the emotion.  And after reading the baggage tied up with the ‘right’ to treat heroin addicts, I am.. ‘pissed’!  I realize that isn’t a word that doctors should use.  But honestly… I just don’t have another one!
Dr. Burson wrote that according to the current proposal, Doctors begging the Federal Government to treat another 100 addiction patients must 1. Use electronic medical records; 2. Accept insurance for the treatment; and 3. Require counseling of patients treated with buprenorphine products.  There were other requirements as well, but these were the three that I remember for irritating me the most.
Dr. Burson goes through her reactions to the requirements, and mine are mostly the same.  As a solo psychiatrist, I don’t see the value of electronic records.  Many of my patients don’t WANT their addiction treatment in a database. They know the stigma that they face already every time they go to the pharmacy.  Some of them work for employers who would discriminate against people once-addicted to opioids.  Some of them know they would be accused of ‘impairment’ for taking buprenorphine.  Those of us who prescribe buprenorphine know that they are not impaired– and that they’ve worked at jobs for years with no problems should speak volumes.  BUT IT WON’T.  We all know that ‘impairment’ can be in the eye of the beholder– and once someone thinks it is there, it IS there.  Once accused, how do you prove you’re not impaired?
I realize that at first glance, accepting insurance sounds like a good deal.  But now, I am able to see at most 2 patients per hour.  I have accepted insurance in the past, and that’s a completely different business.  Insurance companies reimburse psychiatrists at a rate that anticipates seeing 4-5 patients per hour.  Medicaid reimburses far below that, expecting doctors to make up the difference through commercially insured patients.  But that doesn’t work when treating addiction, where the large majority of patients are on Medicaid.  The only way it works is if the doctor works for a network where knee replacements and MRI scans subsidize addiction treatment, or where care is ‘mass produced’ by a team that minimizes the time doctors spend with patients.
I LIKE seeing two patients per hour.  The Obama team says if that is the case, I can’t see more than 100 patients, no matter how much my home town needs my services..  How ironic… if I spend less time per patient, I can have MORE patients.
I’ve written about the counseling issue before.  The requirement is a nod toward the huge counseling/rehab industry that has tried to block medication-assisted treatment at every turn.  Shouldn’t something as personal as counseling be decided by each individual patient?  Is there any other illness that requires counseling in order for patients to receive medication?  Of course diabetics would benefit from nutritional counseling– but would we consider withholding insulin without it?!
Who will decide, by the way, if the counseling is adequate?  Will the doctor stop your medication if you miss too many sessions?  What if you have nothing to talk about– so you still have to go? How many times? What type of ‘counseling’ counts?  Can a person get a massage and call it ‘counseling’?  If I get my ears candled, is that good enough? Group therapy?  Music therapy?  I saw recently that Madison WI has practices offering ‘float therapy’– is that OK? What about equine therapy?
I think you get my point.
As I mentioned in an earlier post, the TREAT Act would have increased the cap and allowed doctors to decide the best course of action for each patient.  The doctor remained in charge of patient care– sort of like ‘if you like your health insurance, you can keep it.‘  President Obama stepped in front of the TREAT Act to offer something different.  I can almost hear him saying with a Bronx accent… ‘how can you turn down dis’ deal?’
With all the heroin deaths, he’s putting forward ‘an offer you can’t refuse’.   No thanks…. I’ll stay at 100.

Obama and the TREAT Act

I just read an article in the Daily Beast that reads like a better version of something I would write about the value of medication-assisted treatment of opioid dependence.  I appreciate Christopher Moraff telling a story that has been untold far too long, and I hope the story raises questions across the country.
But I have something else on my mind that deserves a story of its own.  I am just a small-town psychiatrist in the Midwest, of course, and so I could be missing something.  I watch Veep and House of Cards, but I assume that the political games in those shows are grossly exaggerated.  I’ll offer a bit of background… but if you already understand why people opposed to increasing the buprenorphine cap are idiots, just skip the next few paragraphs.
The Recover Enhancement for Addiction Treatment Act, a.k.a. TREAT Act, is a Bill with bipartisan support written in response to the epidemic of opioid dependence in the US.  If enacted into law, the TREAT Act (among other things) would increase number of patients that a physician can treat with buprenorphine from 100 to 500 and allow nurse practitioners and other ‘mid-level prescribers’ to treat opioid dependence with buprenorphine medications. For newcomers, treatment professionals debate the wisdom of raising the cap on the number of patients treated by each practioner.  Some people argue against medication treatment entirely and claim that abstinence is the only legitimate goal when treating addiction, despite the fact that abstinence-based treatments rarely work.  ‘Rarely’ is in the eye of the beholder, I guess– but even the most optimistic promoters of abstinence-based treatments claim they fail only 70% of the time– within ONE YEAR.   Other addiction docs advocate using medications that dramatically cut death rates, in concert with counseling.  They demand the counseling despite no evidence– none– that counseling improves outcomes in medication-assisted treatments.  But arguing against counseling is like arguing against… milk, I guess.  Who can argue against milk?
Then there are the extremists like me who argue that addiction is an illness that should be treated like any other illnesses and managed with medications, sometimes over the course of a person’s life.  Maybe counseling is indicated, and maybe not– but the need for counseling should not stand in the way of obtaining a life-sustaining medication.  After all, do we withhold insulin from diabetics who don’t receive nutritional counseling?  We extremists point out that there is no ‘cap’ on patients who are prescribed opioid agonists– the type of practice that started this epidemic in the first place.  We point out that literally no deaths have been caused by buprenorphine in patients who were prescribed the medication.  In all of medicine, THAT is the medication that needs a ‘cap’?  Doctors can treat unlimited numbers of patients with cancers, pain disorders, or complicated surgical procedures, but can’t handle more than 100 of THESE patients?!
I don’t see the point of the other groups, so I won’t try to explain their thought processes– accept one example.  Some docs are Boarded in Addiction Medicine– a secondary certification that can be obtained after certification in primary care or psychiatry.  Full disclosure– I am not Board Certified in Addiction Medicine.  I am Board Certified in Anesthesiology and in Psychiatry, and I worked with narcotics as a pain physician and anesthesiologist for ten years.  And I have a PhD in neurochemistry.  From my perspective, I have enough things on the wall. But the docs who DID get boarded in addiction medicine are angry that they get nothing special for their efforts.  The law that created buprenorphine treatment was intended to increase addiction treatment by primary care practitioners.  But that’s sour grapes to the addiction docs, who want the sole right to treat more than 100 patients.  Never mind that 30,000 people die from overdose each year, and buprenorphine could save many of them.  The addiction-boarded docs are angry that they aren’t given special privileges.  Isn’t THAT a problem!
What does all of this have to do with President Obama?  A bipartisan group of members of Congress of worked on the Treat Act over the past 8 months.  Professional societies have come to compromises over the Bill.  According to Schoolhouse Rock, Congress creates laws and then if passed, the President signs them into law.  The President often pulls opposing factions together, encouraging them to get a Bill to his/her desk.  For most of President Obama’s term, about 20,000-30,000 young Americans have died each year– far more than the total number of Americans killed by war, terrorism, hurricanes, and other natural disasters combined.    Until a month ago, I’ve heard absolutely nothing from the US President– no calls to action, no pressure on lawmakers, no requests to call our congresspersons.  But as the TREAT Act was introduced in the Senate, President Obama announced that he will raise the cap by Executive Order.  A supporter of the President would say (I know, because I’ve heard them) that the important thing is that it got done– so who cares how it happened?
Readers of this blog know that I pretty-much dislike everybody… so it is no surprise that I’m not happy.  We have the TREAT Act sitting in Congress, needing a simple majority to be sent to the President’s desk and signed into law.  During an epidemic of overdose deaths, the support would not be difficult to find for most Presidents, even with an ‘obstructionist Congress’, as our President likes to call them.  A change in the law would be relatively PERMANENT, unlike an Executive order– which can be changed with a new President, or with a new set of political calculations by the same President.   And an Executive Order to change rules at HHS requires hearings for citizen comments, which take more time– time when more patients will die.  Shouldn’t President Obama have used the operations that other Presidents used for far-more controversial issues, and changed the law?  This temporary, delayed Presidential action will get kudos from articles like the one in the Daily Beast.  And Obama gets TV time and headlines to describe how he addressed the opioid epidemic, on his own– in spite of a ‘obstructionist Congress.’
What irks me the most, though, is that an Executive Order didn’t need to take seven years.  By 2010 the overdose epidemic was well-underway, and had already killed a couple hundred thousand young people.  Did President Obama need to wait until the TREAT Act was almost at his doorstep before taking ANY action to stem the surge in overdose deaths?  From the sidelines it looks like the deaths themselves didn’t provoke a response.  But the threat of bipartisan action during an election year?  I guess that’s another story!

Prince Missed Suboxone Lifeboat by 12 Hours

One of the links from this page connects to the ‘OD Report‘.  I set up the connection to highlight the epidemic of overdose deaths, not to sensationalize the issue.  But the Prince story is sensational and tragic at the same time. And the connection to buprenorphine only magnifies the tragic circumstances that are wrapped around the use of a potentially-life-saving medication.
I read some time ago about Prince’s chronic pain problems, primarily involving his hips and secondary to years of dancing in high-heeled shoes.  Shortly after his death, TMZ reported that Prince’s plane made an emergency stop in Moline Illinois on his way home from Atlanta.  They reported that he received Narcan at the airport after landing, and then was treated and released at the hospital before flying home to Minneapolis.  TMZ later reported that Prince was taking large amounts of prescription opioids that contributed to his death.
The OD Report contains newsfeeds about opioid overdose.  An article published today describes the circumstances surrounding the discovery of Prince’s body by Andrw Kornfeld, the son of an addiction doc from Mill Valley, California.   According to the article, an emergency addiction treatment plan was arranged with a program called ‘Recovery Without Walls’ based in Mill Valley, California.   The physician who founded and medically directs that program, Dr. Howard Kornfeld, was not able to make it to Prince and instead sent his son, Andrew Kornfeld, a premed student who worked as a ‘spokesman’ for Recovery Without Walls.
Here is where it gets interesting…  Andrew Kornfeld travelled to Prince’s home with a small supply of buprenorphine.  The intent of the people involved cannot be known, of course, but one could surmise that the buprenorphine was provided in order to get Prince started on the medication.  Andrew Kornfeld was the person who reportedly called 911 after he arrived at Paisley Park, prompting security personel to summon the singer and eventually find his body in an elevator.
Putting aside for a moment the legal and ethical lapses of a premed student delivering buprenorphine to a person in another state. one thing is clear:  Had Prince taken the two tablets of buprenorphine found with Andrew Kornfeld, he would never have died from opioids– unless, at some point, he decided to stop taking the medication.  If you have trouble believing that simple fact, then I suggest you do some more research about buprenorphine treatment.  You’ll find that while 30,000 people die each year from opioids without buprenorphine in their bloodstream, only 40 die with buprenorphine in their system– and almost all of those people died from other agonists, and would have lived if more buprenorphine was present.
It is almost impossible to die from opioids if a person is taking buprenorphine or the combination drug, buprenorphine/naloxone.
I don’t know how the media will interpret the story, or who society will hold at fault.  From my perspective, the story is tragic in how predictable things played out.  Prince had the resources to determine the truth about opioid dependence– i.e. that abstinence-based programs rarely work, especially for patients with chronic pain.  He likely learned that his options included 1. a stay in rehab, including a painful withdrawal, followed by a high risk of relapse, or 2. finding a doctor to treat his chronic pain and opioid dependence using buprenorphine or a buprenorphine/naloxone combination medication (as they are essentially identical), which would almost immediately place his ‘opioid problem’ in remission.   It is not clear how much of his problem was ‘addiction’, and how much was ‘pain treatment plus tolerance.’  The difference between the two conditions is often in the eye of the diagnosing physician.  But the good news for such patients is that is doesn’t really matter.  Buprenorphine products provide almost immediate resolution for pain patients tolerant to opioid agonists, removing cravings and providing relief from withdrawal.
In a sane world, Prince would have called the doctor down the street to get started on buprenorphine immediately.  But doctors who prescribe the medication are hard to find, and the few doctors who do prescribe the medication are stuck at the 100-patient cap, waiting for President Obama to make good on his promise to change the rules so that more people can be treated.
Instead, the 100-patient limit remains in place– and patients desperate for help search throughout the country for doctors with openings.  I myself receive several emails and calls every single day from people across the country who are begging for help.  I tell them the same thing I would have told Prince:  I’m stuck at the cap.  I wish I could help.

Addiction Treatment Has it ALL WRONG

Today on SuboxForum members discussed how long they have been treated with buprenorphine medications.  Most agreed that buprenorphine turned their lives around, and most are afraid they will eventually be pushed off the medication.  Most buprenorphine patients described a reprieve from a horrible illness when they discovered buprenorphine.  But most have new fears that they never anticipated– that their physician will die or retire, that politicians will place arbitrary limits on buprenorphine treatment, or that insurers will limit coverage for the medication that saved there lives.
I joined the discussion with the following comment:
I give lectures now and then about ‘Addiction, the Medical Illness.’  Once a person thinks through the topic several times with an open mind, the right approach to treating addiction becomes obvious.    After all, doctors ‘manage’ all illnesses save for a few bacterial diseases, and even those will become at best ‘managed’, as greater resistance develops in most bacteria.  We doctors rarely cure illnesses.  We manage illness.
The public’s attitudes toward treating addiction differ from treatments for other diseases.  Avoiding effective medications isn’t  a goal for other illnesses.  In fact, in most cases doctors refer to skipping medication negatively, as ‘noncompliance.’  There are religious orders that don’t believe in medication including Christian Scientists… and there are religions with specific beliefs, e.g. Scientology, that don’t believe in psychiatry, or Jehovah’s Witnesses who don’t accept blood products. I assume that attitudes toward addiction developed over the years when no medical treatments effectively treated addiction.  Doctors and laypersons came to see addiction as untreatable, and the only survivors people who found their rock bottom and in rare cases, saved themselves.  And since nobody could fix addiction, and the only chance at life was to find ‘recovery’, a nebulous concept based on spirituality, adherence to a group identity, and correction of ‘personality defects.’
What an obnoxious attitude– that people with addictions have ‘personality defects’!  Even most of the docs and therapists who ‘get it’ about medication insist that no patient will heal until we ‘fix the underlying cause of his/her addiction’.  What a bunch of crap…  as if all of those people out there WITHOUT addictions have GOOD personalities, and all of those people who got stuck on opioids (mostly because of bad doctors by the way) have BAD personalities.  I call BULL!  Opioids are powerfully-addictive substances, and a percentage of people  exposed to them, regardless of character, become addicted.  My personality was apparently good enough to get a PhD, get married, save a drowning woman, have a family, go to medical school and graduate at the top of my class with multiple honors, become an anesthesiologist and get elected president of my anesthesia group an unprecedented 3 times.  But taking cough medicine that grew into an addiction to fentanyl means I have ‘personality defects’??!!
I’m sure everyone has his/her own story.  But we’ve all heard so often that we have some broken screw at the base of our brains that we’ve started believing it.  And the mistreatment by doctors and pharmacists (and reporters and media and society in general) perpetuates that shame among all of us.
The truth is that our ADDICTIONS caused us to do things that were wrong.  We developed an intense desire to find chemicals because of the activation of addictive centers in our brains.  And THAT caused our ‘character’ problems.
I’ve written before about the ‘dynamic nature of character defects’.  Search my name and that term, and you will find the comments- or just click here.  The character problems so obvious in using addicts are driven by the obsession to find and use opioids.  When you treat that obsession with buprenorphine, those ‘character defects’ disappear.  I’ve seen the process unfold over and over, in patient after patient.  Some doctors perpetuate character problems by treating patients like criminals, and ANY person will develop character problems if treated poorly long enough.  In that way, the defects can become a self-fulfilling prophecy.
The character defect argument is the whole reason for counseling.  But get this– there have been several studies that looked at abstinence after discontinuation of buprenorphine after one year, with or without counseling.   And the counseling group did WORSE in those studies!  Of course, everyone interprets those studies by saying that ‘the counseling must not have been done right’ or it was not intense enough, rather than accept the data with an open mind, as any good scientist would.
Vivitrol (i.e. depot injections of naltrexone) are the biggest example of treatment based on flawed ideology.  The treatment rests on the idea that if we block receptors and counsel the heck out of people, we can fix their character defects and their addictions so they won’t use when Vivitrol is removed.  The travesty is that nobody will look at the results of this vast experiment, mostly played out in drug courts.  When you think about it, we have a long history of experimenting on people caught in the criminal justice system.  Studies in Australia showed a 12-fold higher death rate in addicts maintained on naltrexone and ‘counseled’ compared to people maintained on methadone.   When the people forced onto Vivitrol by the legal system start to die, will anyone keep track?
Deaths after residential treatment are common, but nobody keeps track of them.  So I’m not holding my breath for outcome data from the failures of drug courts!
Every serious chronic illness warrants chronic medical treatment, save one.   All healthcare professionals will say, some reluctantly, that addiction is a disease.   It is time to start TREATING IT LIKE ONE.

Subox Docs: Analyze This!

People on buprenorphine or Suboxone often write to me with complaints about lab testing.  I received an email last week that mirrors my personal experience with lab testing companies.
Here is what it said:
Dr. Junig:
I thought you might find this interesting. I continue to see (name withheld) for addiction treatment using buprenorphine. I see the doctor every three months, and I’m prescribed a low dose of Suboxone film (below 4 mg per day). I recently got an insurance denial for over $2000 in lab charges, for ONE urine test! Evidently someone sent my tests to (lab name withheld for patient privacy) who billed for 23 tests!  This is on a test that was negative for any substances other than the proper amount of buprenorphine.   This is like a license to print money! The same thing happened three or four years ago with (a National lab provider), but that was ‘only’ $600 and it eventually got written off. I have no idea if (withheld) will come after me– but there is no way I’ll pay them a dime.
Is there any wonder health costs are so out of control? How can a company get away with this? I have a feeling this is just routine and someone on the staff sent it by mistake as after the first incident with the other lab.   My doctor doesn’t usually send my tests into a lab, but instead just does the immune point-of-care test in the office.
Have you heard of charges this high? Just thought I’d pass it to you in case it’s good info for a blog post. Talk about crazy–  How in the hell, even seeing a doctor 4 times a year, could I remain in recovery on buprenorphine with total annual costs near $12,000?  Plus, doing these expensive tests on negative samples?  I can maybe see on a positive result – but negative?  This is so wrong.
I wrote this email in response (I’ve edited my remarks for grammar and privacy):
I wrote about this issue a couple of years ago, and I understand your anger.  I used the same lab company a few years ago for about a month, after their salesperson promised they would never charge anything beyond what insurance paid.  But they did charge some patients, and then other patients complained that one lab test used up their entire annual mental health coverage!   Now I only use point-of-care tests (which cost $3 each), unless there is a clear reason for confirmatory testing.
(Note—Wisconsin health insurers used to commonly limit mental health expenses to two or three thousand dollars.  Now, because of mental health parity laws, insurers must provide the same coverage for mental health expenses, including drug testing, as they do for other types of healthcare.  I guess it’s good that the care is no longer treated differently… but one very ugly result has been an explosion in lab testing costs—which increase EVERYONE’S insurance rates).
Back to my email:
In the past few years representatives from two pain clinics asked for meetings, and told me the same thing: that insurers were tightening payments for ‘injections’ by paying only for injections that actually worked (what a concept!).  The pain clinics now make more money from lab testing than from their bogus injections.  The problem?  Insurance would only cover one urine test per month unless an addiction doc was on staff, which would allow them to do unlimited numbers of tests.  They said that lab companies set up turn-key operations for docs providing equipment, technicians, billing codes, etc—and they could bill over $1000 for a test that used $4 in raw materials.   Even Medicaid paid over $500 for one urine test!
I would love to blow the whistle on this garbage, but every agency seems to have the attitude that doctors need to test people more, not less—no matter the cost.  Talk about a situation ripe for abuse!
Comments:
Opioid agonists are a Godsend to patients with severe pain, whether the pain is acute or chronic.  Opioid agonists are also highly-abused, so some degree of monitoring is appropriate.  I wonder about the motives of some doctors, who prescribe ever-increasing doses of potent opioids, and then suddenly stop prescribing when a urine test shows traces of THC.  Those doctors know, or at least should know, that acutely stopping opioids results in severe withdrawal.    About ¾ of my addiction patients turned to street pain pills when a doctor, often the same doc who started them on pain meds, kicked them out of treatment for testing positive for THC or for running out of medicine early after treating a flare-up of their pain.
Even for the sadistic docs who practice that way, it doesn’t take a thousand-dollar test to discover a drug habit.  If society is truly concerned about healthcare costs, is it appropriate to spend $2700 testing for non-existent metabolites of non-existent substances, when one $3 test will detect the presence or absence of cocaine, buprenorphine, oxycodone, hydrocodone, amphetamine, THC, propoxyphene, PCP, heroin, or benzodiazepines?  Is the extra $2697 justified on every routine follow-up visit?  Inexpensive or free measures, such as pill counts or random 3$ point of care tests– are far more useful to determine if someone is selling or sharing a prescription.
Opioid agonists cause tens of thousands of deaths each year, so maybe someone could argue for that type of overkill with those medications. But this degree of drug testing for patients treated with buprenorphine?!   Buprenorphine is identified in fewer than 50 overdose victims per year in the US–  the same number of people killed by lightning.  Even in those few cases, buprenorphine didn’t cause death, but rather was present because the person used a buprenorphine product at some point in the days or weeks before overdose.  In fact, most of those 50 overdose deaths would have been prevented had MORE buprenorphine been present.
I find it bizarre that more and more ‘PA’s’ for buprenorphine products ask the question, ‘are you doing drug testing’?  I’m curious– what do the people who create those forms WANT to happen with their patients?  I’ve thought about writing back…. “Yes, I did drug testing.  He tested positive for marijuana, so I kicked him out of my practice, and he died of a heroin overdose last week.”  Would the insurer see that as a good outcome?  Would I get a pat on the back– “Great job!  That’s some GREAT drug testing you’re doing!”
Why So Much Testing?
When did doctors stop trusting their patients?  Doctors used to provide a confidential refuge for troubled people.  Med school ethics courses questioned whether doctors should take any action that interfered with patient autonomy.  Doctors must go against their patients’ wishes in certain situations, such as cases of child abuse.  But when did we start assuming that people voluntarily seeking treatment were lying?
I wonder why my colleagues are so eager to get behind aggressive testing.  I’ve already suggested one motivator—i.e. greed.  But that doesn’t explain the entire phenomenon, because many docs get just as excited about testing while leaving all the profit for the testing companies.  In those cases I’ve wondered if their willingness to distrust their patients relates to their backgrounds as addiction doctors.
Many addiction docs are psychiatrists, a specialty that attracts the most risk-averse medical students.  Consider the risks that doctors in other specialties accept as a matter of course.  A neurosurgeon speaks with a patient a couple of times, and then opens that person’s skull and removes part of the person’s brain.   Consider the CT surgeon who meets with a patient, reviews the tests, and then splits the sternum to sew grafts into arteries that supply blood to the heart.  Those doctors are entrusted to cut people open, remove diseased tissue, and provide appropriate follow-up care.
But when you talk to addiction docs about drug testing, they all say the same thing:  They have to do the testing ‘or they will lose their license.’   They claim that they don’t have the power or autonomy to decide which patients need to be treated like criminals, and which patients have proven themselves as trustworthy and stable.  They have no choice, they say, other than to test every single patient on every visit.
Then there is the true cynic in me, who wonders of some doctors just ‘get off’ on catching people.  Patients who come in for addiction treatment are in dire straits, and have a lot of work to do.   After living like animals, they are taking on the challenges of giving up their drugs of choice, learning to trust their physicians, giving up self-medicating, and learning to tolerate their emotions.   Many new patients struggle with giving up marijuana, a drug they’ve used to treat withdrawal for years, and a drug associated with mixed signals from a couple states (and from the President).   Kicking a heroin addict out of treatment for smoking marijuana is the worst type of of bullying I can imagine.
I admit that I drug-test patients.  But I don’t use drug tests to kick someone out of my practice, any more than an endocrinologist would stop prescribing insulin for a diabetic patient who can’t stay on a diet.  My patients know that I don’t kick people out for struggling, so I usually hear, at the start of the appointment, if a patient has relapsed.    I’m sure there are docs who think I’m naïve, who believe that patients are getting away with something ‘on my watch’.  But I can live with that.   In return I get to be a doctor who treats people like human beings, not criminals.
If buprenorphine was causing death (it isn’t), serving as a gateway drug (it isn’t), or was used in some nefarious way similar to GHB (it isn’t), I would likely think differently.  But honestly—the docs and DA’s who spout that ‘buprenorphine is just like heroin’ are idiots.  I suggest that they learn a bit of neurochemistry before spreading such nonsense.  In fact, just pay for my travel and I’ll walk you through the science, and show you WHY you’re idiots.
To the doctors who aren’t yet making a profit from lab testing but considering jumping on the bandwagon, reconsider. What type or relationship do you want with your patients?
To the doctors who gave in to the slick sales pitch from a lab company’s salesperson who brought you a nice lunch, and promised to only bill insurance so that ‘nobody loses’, stop kidding yourself.  You are a big part of the problem.
And to the docs who make money from treating all patient like liars, driving up insurance rates for the rest of us…  Shame on you.