Buprenorphine Availability and Diversion

Since I began using buprenorphine to treat opioid dependence in my psychiatry practice, I’ve learned quite a bit about what works and what doesn’t work. Buprenorphine is an amazing medication when used properly, and undoubtedly saves thousands of lives each year.
Even when used improperly, buprenorphine has life-saving properties. Addicts who take buprenorphine illicitly, but above a threshold dose and frequency, will become tolerant to the effects of the drug, and will be largely protected from overdose. There is little appreciation for this part of the story, which is understandable. We cannot expect society to embrace the illicit use of a substance. Buprenorphine is, after all, an opioid, with some abuse potential. There are appropriate efforts underway to reduce the diversion of buprenorphine; efforts that I wholeheartedly agree with. But some forms of diversion are worse than others. And a close look at the experiences of opioid addicts suggests that efforts to control buprenorphine may actually increase diversion of the drug. I should emphasize that my opinion on this subject is ‘anecdotal,’ not scientific. But I receive many, many e-mails from opioid addicts across the country, and their stories are the basis for my comments.
The most damaging form of buprenorphine diversion occurs when opioid-naïve people take the drug. Buprenorphine is a microgram drug in a milligram tablet. People who chip off a quarter of a Suboxone tablet are handling 2000 micrograms of a very potent opioid. That amount of buprenorphine alone won’t usually kill a person. But if combined with a second respiratory depressant, death is possible—perhaps even likely in opioid-naïve people. This type of diversion—the use of buprenorphine by opioid-naïve people, or by people not yet addicted to opioids—should be the focus of efforts to prevent diversion.
Another type of diversion occurs when desperate opioid addicts seek out buprenorphine to ‘treat themselves’ for their addiction. Opioid addicts choose this route, over going to a doctor for legitimate treatment, for a number of reasons. Some may be on the fence between quitting vs. continuing active use of opioid agonists. Some are caught up in the struggle to simply get by each day, and don’t have the presence of mind to seek out treatment providers. Some don’t have enough money to pay for treatment—although as I have written in the past, they would almost surely come out ahead financially in the long run by getting treatment. And finally, in some cases there are no doctors in their area who prescribe buprenorphine or who have openings under the ‘cap.’
I do not intend to legitimize this type of diversion, i.e. self-treatment by people with opioid dependence. But we should be honest and accurate with assessments of the current status of buprenorphine treatment. It is clear that opioid addicts who find and use buprenorphine are far better off than those who don’t. If there is no legitimate treatment available, I have a hard time condemning someone who finds and uses buprenorphine, as that behavior will greatly increase their odds of survival. If someone I loved became addicted to opioids, my first thought would be to get that person on buprenorphine as quickly as possible. Taking buprenorphine regularly would lower the risk of overdose, reduce the risk of impulsive behavior related to cravings, and immediately place the addiction in remission, blocking the imprint of addictive behavior on the brain—the conditioning that at some point turns chemical dependence into a lifelong disease.
Counseling—cure or crock?
Much is made of the need for counseling in addition to buprenorphine. Again, I agree with the need for counseling in some cases, particularly in young people, or those with polysubstance dependence. But I take issue with practitioners who require that every patient engage in weekly group therapy for an indefinite period of time. From the stories I’ve received, it seems that no thought is given to the type of therapy, the education of the ‘therapist,’ or even whether or not the type of therapy is consistent with the use of buprenorphine! Instead there is a blind assumption that therapy is inherently good, without any effort to determine whether or not the therapy improves outcomes. I am amused when I read studies that show no significant effect of counseling on outcome, but then conclude that counseling is a good idea– in spite of the findings of the study. I see wisdom in the requirement for certification to prescribe buprenorphine that counseling services be available, rather than mandating counseling in all cases. Some practitioners appear to miss the distinction.
Psychotherapy is not ALWAYS good. I’ve witnessed situations where the prescribing physician is emphasizing the need for long-term buprenorphine maintenance, while the counselor the patients are required to see encourages the patients to ‘get off Suboxone.’ Even in better situations, it is difficult to determine the efficiency of psychotherapy, if someone even took the time to consider that issue—which nobody seems to do. People have written me about all sorts of requirements that they face, including weekly doctor appointments without any drop in frequency over time, or daily 12-step-group attendance for as long as they are on buprenorphine. The latter is another example of the folly of simply demanding something just for the sake of doing so. I’ve written in the past about why 12-step programs are less appropriate for people on buprenorphine; the steps are best accepted by people who are desperate, and buprenorphine eliminates desperation almost immediately. From my own experiences as doctor and as addict, we should consider treating with either buprenorphine or the steps— not both. Some physicians may disagree with my perspective, but I hope they are at least weighing in their minds the reasons for their treatment approaches.
When one understands the mechanism of action of buprenorphine—the simple but elegant way that a partial agonist tricks the brain by eliminating any change in opioid effect—one can understand why in some cases, remission from addiction will occur with medication alone, without need for counseling.
Not enough docs
I recently had to ask several patients to find new physicians, because of issues related to state licensing. They are all struggling to find people who will treat them. In a couple cases there are no doctors within a 2-hour radius with openings for buprenorphine patients because of the ‘cap.’ I respect the cap, and I’ve taken on very few new cases in the last couple years because of it. But patients on buprenorphine for long-term maintenance do very well after a year or two, and were it not for the cap I could easily care for twice as many patients. I find it strange that a pain doc can prescribe oxycodone to a thousand patients without need for any special certificate, yet buprenorphine treatment programs are capped at 100 patients.
Beyond the shortage of doctors, the doctors who do have openings in some cases appear to take advantage of the situation. If a patient has been stable on buprenorphine for two years, is it reasonable to require a month of intensive outpatient treatment in the doctor’s own facility? Is it reasonable to charge over $300 for each visit—and require visits every two weeks, indefinitely?
I see no action by any addiction society to address this type of issue. And as an addict, this lack of action feels discriminatory. Shouldn’t the societies (ASAM, SAMHSA) be advocating for the rights of patients with the disease of addiction? Isn’t access to treatment a fundamental issue for patients?
There are a number of efforts in place to limit the prescribing of buprenorphine. In many ways the medication is regulated more closely than schedule II opioids. And prescriptions for buprenorphine seem to carry greater stigma at the local pharmacy than do prescriptions for oxycodone. The efforts to prevent diversion are in place—but where are the efforts to increase the availability of treatment? And how much of the second type of diversion that I described above could be prevented by increasing access to reasonable treatment?
I have been a physician for over 20 years. Rarely in the field of medicine does something come along with such potential to save lives. Given the epidemic of opioid dependence, shouldn’t someone, somewhere, be writing legislation that makes such treatment more available?