Many people looked for a return to normalcy when they pulled the Biden lever in 2020. Since then we changed the English language, encouraged young children to explore their pre-pubertal sexuality through gender-changing hormones or surgery, and committed ourselves to energy sources that, after 20 years of development, currently provide 3% of our energy needs. I will write about those and other issues when I have more time. The word that keeps coming to my mind is ‘hubris’, but if anyone out there has a better word for people who believe 2021 was the year to change the basics of the English language, feel free to email me. Let them rip. Use firstname.lastname@example.org. Realize that I’ll probably include your comments in my next post.
Warren Harding promised normalcy in 1920 and gave the country Prohibition. Seemed like a good idea at the time, but ten years later opinions changed. Thankfully that change didn’t require the regrowth of organs! European opinions of modern norms have changed already. Experts decided that many young people change gender in response to social pressures, so gender-changing hormones and surgery were banned in minor children. Schools have dress codes because children sometimes dress inappropriately… why do those same administrators believe those same kids choose their PERMANENT gender appropriately? How will history will judge this ‘normal’ moment in the US?
But I am writing about Suboxone first, since this is a ‘buprenorphine blog’. I started prescribing buprenorphine in about 2007, 4 years after Reckitt-Benckiser released the medication in the US. Even after 4 years, I was an ‘early promoter’ of the medication and quickly accumulated the 30 patients allowed for doctors during their first year prescribing buprenorphine for opioid use disorders.
I took the required 8-hr course and obtained the waiver. DEA officers made two surprise visits to my office over the next few years, separately interviewed my office manager (and wife) and myself, inspected the premises, and asked to review my charts. No big deal. I ran afoul of their expectations the first time around because Reckitt Benckiser sent Suboxone to my office for two patients enrolled in a ‘patient assistance program’. I kept it in a safe and recorded daily tallies of the medication. The DEA required tallies every 3 months, and I didn’t keep a column or page devoted to ’90 day tallies’ – so I got a warning and that was that.
After a year I applied and received permission to have up to 100 patients on buprenorphine. I reached that limit in about a month, and from that point forward I had a long wait list. A few years ago the limit was extended again, to 275 patients. Need was still huge in Wisconsin, so I filled up quickly. Around the same time nurse practitioners were given the ability to obtain the waiver and prescribe buprenorphine.
A couple weeks ago in these normal tmes, the government removed all limits on precribing buprenorphine. I agree with that decision, but at the same time the government removed all requirements for prescriber training related to buprenorphine. Buprenorphine is a safe medication, but it is also a complicated medication. For example, if a person addicted to opioids takes buprenorphine soon after opioid use, the medication will cause severe withdrawal. If that person waits 24 hours, the risk of precipitated withdrawal is very low as long as the person wasn’t using a long-acting opioid such as methadone. If the person goes through a sober living program and starts buprenorphine after a month, buprenorphine will cause a very strong opioid effect similar to taking 40 mg of oxycontin (8 tablets of Percocet).
I testified in the death of a 15-y-o girl who was killed by a half tab of Suboxone, a low dose of a benzodiazepine, and a small amount of alcohol. I consulted in another case after a young man died in his parents’ basement after starting Suboxone ‘treatment’.
Prescribers must have a good plan for dealing with post-op pain in their patients because normal pain medications will not work. If a prescriber believes a few extra tablets of buprenorphine will help a patient through a knee replacement, he/she will end up with an angry patient who I’ll be happy to testify for in a malpractice suit.
I agree with lifting the cap given the effectiveness of buprenorphine medications when patients use the medication appropriately. But maybe reduce the 8-hr training to 4 hours? Prescribers in my state need 30 hours of continuing education every 2 years anyway, so why not have buprenorphine prescribers use a few of those credits to learn about buprenorphine?
Since COVID, many of the norms that existed for thousands of years — like the English language — were turned upside down. Again, more on that later. But for now, I’ll encourage new buprenorphine prescribers to take a few hours to learn about the medication — even if you don’t have to.