I just got back from Chicago, where I spent the day learning about ‘best practices with Suboxone’ with the people from Reckitt-Benckiser. I feel an obligation to share my experiences with those of you who are so strongly connected to the efforts of R-B —and I am not referring to owning stock in the company. I’m not in the mood to go on forever; meetings with pharmaceutical company people always tire me out and even bring me down a bit—I’m not sure exactly why. I would almost think it would be the opposite, because things look so easy from the perspective of a PowerPoint presentation. Although as I put my psychodynamic background to use, I realize that an opposite reaction makes sense. Tune into my radio show podcast sometime and listen as I talk about psychodynamics; dysphoric feelings often spring from unconscious conflict, and there was likely conflict between what I was watching and hearing during the presentations, and what I was thinking and remembering from my practice.
Those of you expecting a story about conspiracy theories will be disappointed. I had the impression that the company is sincerely motivated to help people with addictions for the right reasons. They made it clear through their actions and plans for the future that they are in addiction treatment for the long haul, even after the patent on Suboxone expires. There are some things about the company that have bothered me, and I was able to ask questions about those concerns. I will share their answers with you as best I can remember.
I spoke with someone Friday evening who has been with RB since 2003, about the lack of general support in the field for Suboxone compared to other new medications. She believed that RB did a good job of introducing Suboxone, and that their results in numbers of doctors trained and patients treated were good. I pointed out that many, perhaps most, ER docs have no idea what Suboxone IS, let alone know how to manage accidental ingestion or overdose. I compared Suboxone to Shire’s Vyvanse, a medication that has been out for just over a year but has 10 times as many sales reps in the state where I practice. If I want a coupon for Vyvanse, a rep drops off a box of them by the end of the day! But we have two reps covering the entire state for Suboxone! The difference in our perceptions was a classic ‘glass half full or half empty’ situation. She said that when she started in the RB pharmacy division, they had 20 US employees—a tiny fraction of the resources in place for product launches from the ‘big players’.
So I asked why they didn’t sell the drug to one of the big guys, so that it could be rolled out with the fanfare and support given to Cialis or Viagra? Another person from the company pointed out that had they done that, they would have had a bigger problem over the shortage of physicians certified to prescribe the medication. And that was a good point. The bottom line is that Suboxone was a truly unique situation; a small company that had no significant US presence, the unusual requirement for special certification for prescribers, a target illness that is complicated by stigma and the risk of diversion by patients… mistakes were probably made, but mistakes are always made. I left the conversation realizing that the company had some unique challenges to overcome, and so far has done pretty well.
A couple other areas of new perspective: on the issue of the high cost (although I often point out that for a fatal illness, the treatment isn’t all that expensive), it was pointed out that if Suboxone was super cheap, say a buck a pill, there would be a much greater profit motive for diversion of the drug. I think that is probably a fair assumption; there would be more Suboxone on the street if it retailed for a buck per pill than there is at five bucks per pill.
I was happy to see how strongly they connected with the disease model of addiction; in my opinion that is the genuine state of affairs, and the natural way to present Suboxone. Suboxone is a chronic medication for a chronic condition, period. I have always figured that it was a mistake that the company initially talked up using Suboxone for short-term detox, and I heard nothing to change my opinion. They mentioned that a few years ago 70% of patients were prescribed Suboxone for short-term use and 30% for maintenance, and now those numbers have reversed and 70% of prescriptions are for long-term maintenance treatment. Those numbers are consistent with my experience.
There will be other buprenorphine preparations in the future, including depot injectables made by RB or by someone else. Also watch for different types of oral products, including designs that reduce the likelihood of accidental exposure in children.
If I had to complain about something, I would say that the corporate presentation just does not seem to mesh well with the reality on the street. I talked to one of the leading developers briefly about the problem with twelve step groups—how there is a vocal anti-Suboxone crowd, who often talk people into stopping their medication or refer to doctors who prescribe the medication as ‘pushers’. He said that Betty Ford had given her blessing to the idea that people on maintenance medications are still ‘in Recovery’. My thought in response was ‘who the heck cares about Betty Ford?’ I would bet that 99% of the NA and 80% of the AA folks in my home town have never heard of her! I do think that the split among the recovering community over buprenorphine is a serious issue that should be dealt with in a formal manner, through communication between people who understand neurochemistry and buprenorphine, with people from the twelve step intergroup organizations.
I also believe that some in the company, and some prescribers, don’t understand what it is like to be an opiate addict. I realize that nobody who is not an addict will truly understand addiction, but I don’t think they get that we are just like they are outside of our addictions. To give an example, the issue came up about the degree of counseling and meetings that should be required of people on Suboxone. I have put forward my thoughts on this issue many times. Many of the docs at the meeting talked about their practice of requiring ALL people on Suboxone to go through intensive outpatient treatment, and/or requiring twelve step attendance as often as every day! They require AA or NA not because of some theoretical basis, but rather because they think that addiction and AA or NA just go together. I did point out my thoughts on the issue, namely that people only ‘get’ twelve step recovery when they have some degree of acute desperation, and people on Suboxone are NOT DESPERATE. I ‘got’ AA quickly the first time I went to treatment, but the second time it took several months before my mind opened sufficiently to truly accept the program. Only people who have had a spiritual awakening themselves will understand what I am talking about, but going to meetings and just sitting through them is not that beneficial. I have been to meetings with people mandated to attend, and those meetings are generally a waste of EVERYBODY’S time. ‘Getting it’ in twelve step recovery is a moving experience that sweeps the addict of his feet, and pulls him by the heartstrings into a new way of thinking and living. I like that saying that ‘insight maketh a bloody entrance’; the insight required to get clean through the steps is bloody indeed! But these docs just sit back and say ‘no meetings, no Suboxone’, and wear their inflexibility as a badge of honor. I have been in that horrible situation as an addict where my opinion didn’t ‘count’, since I was ‘too sick’ to think logically… that is a tough spot, as the harder you argue, the more belligerent you are accused of being.
As for the scientific topics, I was glad to see that I am pretty much on target with my thoughts about dose levels, tapering, receptor actions, etc. Many docs start patients on twice per day dosing and later convert to once per day; I like to start at once per day from the very start, to avoid setting up a pattern that might be hard to break.
All in all, it was an interesting and informative weekend. I will probably make a couple small changes in my practice in light of things that I heard. And as for RB, I left the conference thinking that I will buy a few shares of their stock. They want to be a premiere addiction-related pharmaceutical company, and given the epidemic of opiates and other narcotics in this country and in other countries, the sky’s the limit!
Suboxone Talk Zone


angelo212 · May 10, 2009 at 8:23 pm

“I will probably make a couple small changes in my practice in light of things that I heard”.
Doc, can you share the small changes that you may make in your practice in light of the things you heard? Since I been following you I take everything you say as the final word so if there is things you may hae said in you videos or blog that are different now can you share with us. Thanks Doc.

SuboxDoc · May 10, 2009 at 10:03 pm

Thanks Angelo– that is a fair question. Because of my own addiction experiences and the long time I have been attending meetings, meeting addicts, working as a shrink in the prison system, etc, I feel like I have a pretty good sense of who is being honest with me and who is not. So while I do have the capability to do urine testing in my office, I don’t do them regularly, but rather only when something doesn’t fit right– I have a ‘funny feeling’, or the person reports losing his medication, or comes in looking a bit ‘buzzed’. I believed that testing constantly gets in the way of trust, and that it was better in the long run if the patient believed that I trusted him.
After some comments by other docs at the meeting I remembered when I was being monitored by the state of Wisconsin– for six years!– and I LIKED being tested, because then I had proof that I had been clean. I saw testing as a positive, as it allowed me to BUILD trust. So I might re-assess the frequency that I do testing.
I also have been allowing greater intervals between appointments, mainly because most people do pretty well. But young people DON’T do as well as older people, and after hearing that most of the docs see people more frequently, particularly early in the process, I think I will see people a bit more often early on as well. Some docs insist on seeing the person on days 1, 2, 5, 10, 20… I do not see people that often, and I don’t think it is necessary to see them THAT often– but I might move a bit more frequent than I currently am doing.
The final issue is ADD; I have been extremely happy with the lack of trouble I have seen from Vyvanse in addicts, so I tend to treat ADD in addicts using that medication. Many doctors believe that addicts shouldn’t have stimulants– period. I don’t agree with that stance, but I recognize that if I ever had to defend my practice in court, I might have trouble finding other psychiatrists to say that treating ADD with stimulants is fine. I recognize the need to be careful that patients are on a good, solid foundation before adding something that is potentially addictive. On the other hand, I have seen studies that show fewer relapses in opiate addicts who had their ADD treated with stimulants.
Thanks for your question and support!

texastechstudent · May 16, 2009 at 1:36 am

Too groovy man. I wish you woulda asked them my question about why partial agonists, like bupe tend to antagonize at larger doses. I wonder what they have cooked up for us…
And the line about ‘cheaper drugs mean cheaper street drugs’ I find to be kind of BS. They was suboxone is over rxed and people tend to get by on as little as 2mg or 4mg, means there is PLENTY of suboxone out there among the opiate addict groups. Coupled with the partial agonist/antagonist properties, it is ONLY good for kicking/ORT. I beilive the french began using bupe to treat addiction in the 70s. and the caucus states began using subutext specifically to treat addiction and saw bad IV use, which led to suboxone. I saw what you said about DATA allowing schedule 3-5 drugs used to treat addiciton (maintance type treatment) and that is true, as long as there are studies done with that certain medication regarding maitnance. I read that and got my hopes up about some hydrocodone maitance therapy. Heh. Shit, codeine and tramadol have show great mu agonism potential. Let me get the thread.
Also, I TOTALLY AGREE even mentioning the word ‘high’ when speaking of suboxone just complicates the sitation. I had a discussion with my parents when first deciding what to do about my opiate addiction and I mentioned suboxone maintance. They asked if ‘it gets you high’. I have this thing with my parents if as long as I tell the 100% truth everything will be okay, so I began. ‘Well, i mean, I wouldn’t get high, but I guess some non-opioid addicts could get a good buzz. I mean, they had addiction problems in Georgia (caucuses)’. They said they wouldn’t be involved with me if I got on suboxone. When I relaped after rehab about 5-6 months later, then again 6 months later, they were a bit more receptive to other options. Suboxone depot… sounds cool man. I have seen people litterally CUT OUT their naltrexone implants and end up in the ER. Of course, they COULD have used suboxone to take the edge off, but don’t tell them that. There was a judge up in baltimore that was FORCING people to get the implant by saying ‘You get the implant and 6 months rehab, or 10 years in jail’.
I wonder how that judge would feel if his kid ended up in the er with his implant cut out. Or commited suicide, as we know suicide rates are 3x time higher when treating an alcoholic with vivitrol and the likes, I think the reason they don’t shoot for FDA approval with opioid illness, is because the suicide rates would be even higher. I have already read more than 5 threads on bluelight of someone getting the vivitrol shot and getting kidney stones or appendicidis and coming in BEGGING for pain relief. After they told their doctors about vivitrol it was 800mg ibuprofin and THATS IT. I auctually called vivitrol about it and asked if they recommended any opioid with a higher affinity (suboxone being one I know of offhand, with many other pure agonists avaible. I don’t know any that are FDA approved though) THey said they recommend short acting opioids. Like some ER doctor is going to administer 5mg of fent to bust through the great wall only to sit there and watch you breath for 3 hours to make sure you don’t die. No, the junky scum NEEDS to suffer.
Anyway man, I love your blog and always follow it. If you were in my area, you would be my doctor. Also, make a post advertisting your podcast, I can’t find a link

texastechstudent · May 16, 2009 at 1:39 am

Oh and I heard something about RB reformulating suboxone to make them dissolve quicker to decrease diversion (other countries have dosing setup like methadone). You think they will or think generics will take care of that? I hear generics come in october.

SuboxDoc · May 17, 2009 at 10:34 am

Thanks for the comments, everyone. Mike, I think they are working on something like a listerine strip that comes in an individual packet. I’m not sure if that will help with diversion, but the goal of it is to reduce the chance of exposure to children.

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