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!

Drug Court Organization Lobbied Against Suboxone

For years, people familiar with the benefits of buprenorphine have wondered– who is the idiot standing in the way of increasing access to this life-saving treatment?  One of the idiots was recently identified, when an open-records request by the Huffington Post uncovered a letter to HHS Secretary Sylvia Burwell from West Huddleston, then-CEO of the National Association of Drug Court Professionals.
In the letter, Huddleston wrote that allowing doctors to see more than the current limit allows ‘will result in the expanded use of buprenorphine in a manner that is less responsible and presents greater risk to the health and safety of the individuals and communities we both serve.’   The Huffington Post correctly points out that over 28,000 Americans died from opioid overdose in 2014, when the letter was written.
People familiar with buprenorphine know that the medication virtually eliminates the risk of death by overdose– even when taken incorrectly.  The anti-medication lobby, fueled by the large profits of revolving-door ‘abstinence-based’ treatments, has used fear of diversion of buprenorphine as a weapon against greater access to the medication.  But stories about diversion always fail to mention key facts about buprenorphine– for example that of the 30,000 US opioid overdose deaths last year, only about 40 had buprenorphine identified as one of the drugs in the bloodstream at the time of death.  And of those 30,000 deaths, none were CAUSED by buprenorphine.
There have been overdose deaths that were in-part due to buprenorphine or buprenorphine/naloxone medications (i.e. Suboxone, Bunavail, and Zubsolv).  But such deaths are rare.  In order for buprenorphine to contribute to overdose, the victim must 1. Have a low tolerance to opioids, and 2. Have a low tolerance to a second respiratory depressant, taken around the same time in sufficient amount.   In other words, someone physically dependent on opioids cannot overdose on buprenorphine.  In fact, buprenorphine products would precipitate severe withdrawal if taken by opioid addicts within a few hours of heroin, oxycodone, or other opioid use.
Drug courts in my area tend to avoid medication assisted treatments, with the exception of Vivitrol or IM Naltrexone.  There is no evidence that blocking opioid receptors for a year has any effect on death rates from opioids.  Studies have reported that patients who stay compliant with treatment, who return each month for another injection of naltrexone, don’t waste their money on agonists that would have no effect on them.  But what happens 6-12 months later, when probation ends and those patients are no-longer required to take naltrexone?
I wish I could tell you what happens– but I can’t, because nobody has done the studies to find out.  The cynic in me takes it further, wondering if anyone even cares what happens when people are temporarily maintained on naltrexone and then allowed to stop the medication?  I’ve asked physicians, prosecutors, and law enforcement the same question:  what happens to the person when the naltrexone is discontinued?  In response I usually hear ‘what do you mean?’  Or ‘how would I know, since I don’t see them anymore?’, or ‘I assume they do fine… don’t they?’
I don’t see much concern when I explain that people who stop naltrexone are in a state of ‘reverse tolerance’ making them more susceptible to death by overdose.   So I remind them of the large number of overdose deaths in people who were recently released from a controlled environment, such as residential treatment or incarceration, after tolerance dropped to normal levels.  Maybe I’ll point out the Australian studies that show a 12-fold higher death rate in addicts who were maintained on naltrexone.   But by that time I’ve lost the person’s attention– just as their attention leaves each addict when his/her probation expires.  ‘Not my problem anymore.’
Huddleston is no longer the CEO, but the NADCP continues to express a muddled message about buprenorphine medications.   If you have a minute, you might consider educating the NADCP staff about the value of buprenorphine treatment.
Meanwhile, HHS Secretary Burwell says changes to the cap are coming.  I received 12 calls last week from people looking for help.  I’ll keep telling them to try to be patient.

Raising the Suboxone Patient Cap

HHS Secretary Sylvia Burwell announced yesterday that the cap on buprenorphine patients would be raised in the near future.  Details were not released, but she emphasized that measures would be taken to increase availability of this life-saving treatment, while at the same time taking caution to prevent misuse of the medication.   Anyone who works with buprenorphine understands the importance of her announcement.  I only hope that her actions are swift, and not overloaded with regulations that reduce practical implementation of whatever increases are allowed.
I have been at the cap for years, unable to accept new patients for buprenorphine treatment.  My office receives 3-4 calls each day on average from people addicted to heroin, begging for help.  Patients on buprenorphine (the active substance in Suboxone) are much less likely to die from overdose than are patients not taking buprenorphine– even in the absence of perfect compliance.  Some doctors, in my opinion, over-emphasize the ‘diversion’ of buprenorphine medications.  At least in my part of the country, ‘diversion’ of buprenorphine amounts to heroin addicts trying to stop heroin, taking ‘street buprenorphine’ because of the absence of legitimate treatment spots.    Of the few new patients I’ve been able to take this year, almost all have histories of using buprenorphine products on their own, without prescriptions.  They are very happy to finally have a reliable source of the medication– and to have the medication covered by their health insurance!
Let’s hope the increase in the cap happens sooner rather than later.  After all, lives are literally hanging in the balance.

Opioid Dependence Treatment with Ibogaine

First Posted 12/28/2013
I’ve always assumed that stories about ibogaine curing opioid dependence were fabricated or exaggerated.  But I’ve read more about ibogaine since the drug popped up on an episode of Homeland.  The scene made me wonder how and when the hoopla over ibogaine began, and why it ended.  After all, people treat addiction with all sorts of things that don’t work—so why ban ibogaine?
In the era of the internet, the answers are easy to find.  Ibogaine was used for religious rites in Africa for at least 200 years.  Since the 1930’s the drug, brand-named Lambarène, was used to treat depression and improve energy in France.   The usefulness of ibogaine for treating opioid addiction was described by Howard Lotsof in 1962.  But Lambarene was removed from the market in the 1960s, when the World Health Assembly classified ibogaine as ‘a substance likely to cause dependency or endanger human health.’  A few years later the DEA moved ibogaine to Schedule I—a class of drugs deemed to have ‘no value as medicine.’ Marijuana is schedule I, by the way.
In lack of formal study, several authors have recorded clinical outcomes after ibogaine treatment in non-standard environments.  Carl Waltenburg wrote about treating addicts with ibogaine in a squatters’ village in Denmark in the early 1980’s. Lotsof described a series of patients treated for addiction in a patent awarded for that use of ibogaine in 1985.  In the 1990’s the NIDA funded research of ibogaine treatment of opioid dependence, but that funding was cut in 1995 when a review of early outcome data revealed the death of a young woman treated with ibogaine.  The woman’s death was not clearly attributed to ibogaine, since her belongings were found to include heroin paraphernalia after her death.  But as we all know, attitudes toward medications in the addiction field are subject to emotion and politics, and the death of a young woman during study of a schedule I drug was all it took for NIDA to pull the grant and spend the money elsewhere.
Reports of the efficacy of ibogaine for treating addiction are interesting, and I encourage readers to dig into discussions about the drug with a healthy dose of skepticism.  Remember that scientific truth never comes from one study, or even from a few studies.  Rather, results must be replicated by a number of scientists, preferably with a wide range of bias and perspectives.  In the 1985 patent application for the use of Ibogaine for opioid dependence, Lotsof summarized impressive findings (which are in the public domain and copied below).  Keep in mind, though, that someone applying for a patent is not going to use the application to report their failures!
It is a principal object of the present invention to provide an improved method for the treatment of opiate addiction.
Another object of the present invention is to provide an improved method for interrupting the physiological and psychological aspects of the heroin addiction syndrome.
Still another object of the present invention is to provide a method of the above nature characterized by its high degree of success, the absence of the great pain and discomfort accompanying earlier treatments, the ease and convenience of application the absence of undesirable or persistent side effects and the persistent effectiveness of the treatment.
The above and other objects of the present invention will become apparent from a reading of the following description which sets forth preferred embodiments thereof.
A feature of the present invention is based on the discovery that an alkaloid of the family Apocynaceae and its therapeutically active derivatives and salts, particularly, ibogaine and its therapeutically active, non-toxic derivatives and salts for example, ibogaine hydrochloride and other non-toxic salts of ibogaine, possess the unexpected unique ability to disrupt the heroin addiction syndrome. Examples of other salts of ibogaine which may be used are ibogaine hydrobromide, and any other non-toxic salt of ibogaine.
For the purpose of definition, the heroin addiction syndrome is meant to consist of all the symptomology demonstrated by addicts in their use of and search for heroin. The interruption of the syndrome was accomplished in five out of seven (71%) of the test subjects who were addicted to heroin. None of the test subjects were seeking to terminate their habits, and all seven were enamored with narcotics.
A single treatment with ibogaine or ibogaine HCl of doses ranging from 6 mg/kg to 19 mg/kg administered orally, disrupted the subject’s use of heroin for about six months.
A treatment lasts about thirty hours during which time ibogaine exerts a stimulant effect. Apparently, an abreactive process is involved during ibogaine therapy but is not noticeable until the patient wakes from natural sleep occurring after primary and secondary effects of ibogaine are diminished. When effective, ibogaine left the addict with no desire to use heroin and no noticeable signs of physical withdrawal. Subjects appeared relaxed, coherent, with a sense of direction and feelings of confidence. 
(Note: abreaction is defined as ‘the release of emotional tension achieved through recalling a repressed traumatic experience.)
Ibogaine was one of five substances we studied. The other four–mescaline, psilocybin, LSD and DMT though different in duration of action and intensity–have similar psychotropic effects that are well documented and will not be discussed here. Ibogaine, unlike the others, is not a euphoriant hallucinogen and did not leave the subjects open to swells of emotion. While under the influence of ibogaine, emotional responses to traumatic repressed thoughts and feelings appeared to be negated.
Another effect of ibogaine administration that was found interesting was that even after twenty-six to thirty hours of wakefulness, subjects slept three to four hours and awoke fully rested. This pattern continued, diminishing slowly, over a three to four month period.
The effects of oral administration of ibogaine are first noticed in fifteen to twenty minutes. Initially, a numbing of the skin is accompanied by an auditory buzzing or oscillating sound. Within twenty-five to thirty-five minutes the auditory transcends across the sensory mechanisms to include the visual: objects appear to vibrate with great intensity. It is at this time that the dream enhancement or hallucinatory effects begin. In many cases an acute stage of nausea follows the hallucinatory phase. The visions end abruptly and the numbness of the skin begins to abate.
This is followed by six to eight hours of a high energy state during which the subjects see “lightening” or flashes of light dance about them. Thoughts which seem to amplify the meaning of the visions seen during the primary phase of ibogaine intoxication continue during this period.
Between twenty-six and thirty-six hours, the level of stimulation diminishes and the test subject falls asleep.
Thus, three stages of ibogaine intoxication have been observed. First, a hallucinatory period lasting for three to four hours during which time the person receiving ibogaine manifests repressed material visually. Second, a high energy period accompanied by flashes of light, the appearance of a vibration to all objects, and the awareness of thoughts appropriate to the visual material seen by the subject. Third, a diminishing energy period free of vibration or light flashes and culminating in sleep.
In the administration of acceptable dosage forms, any one of a variety of preparations may be compounded, for example: capsules, tablets, pills, powders, solutions, etc. In addition to the active agent, there may be present additional substances used in the manufacture of pharmaceutical preparations such as binders, fillers and other inert ingredients.
The entire patent application, including case reports, can be found at the web site of the US Patent Office, or at this site entirely dedicated to ibogaine.
Assignment of a substance to Schedule I creates significant barriers to formal study, at least in the United States.  But US Schedule I status has not prevented the establishment of ibogaine treatment centers in other parts of the world, including Mexico and Canada.  The data pieced together over the years suggests that ibogaine could be a remarkable medication for some people.  But like any medical treatment, there are significant risks to ibogaine treatment.  One particular concern is cerebellar damage in rats treated with doses of ibogaine greater than 100 mg/kg.  Proponents of ibogaine point out that the dose used for treating human opioid dependence is about 50% lower, hardly a reassuring margin of safety.  Best estimates, taken from limited data, suggest an overall fatality rate of 1 in 300 people treated with ibogaine for opioid dependence, with higher death rates in people with certain comorbid conditions.
I’m skeptical of the claims of permanent, positive treatment outcomes from ibogaine.  Addiction to opioids creates a complicated, interconnected collection of physical and psychological dispositions that favor eventual relapse.  I have a hard time believing that one dose of abreactive insight, no matter how profound or intense, can selectively eliminate the desire to use opioids…. while leaving unaffected the desires for all of the normal, good things that humans enjoy.   But then again, opioid dependence is an often-fatal condition.  The significant risks in the risk/reward equation create scenarios where Ibogaine treatment may be appropriate.  I’d be interested in hearing and sharing first-hand accounts from anyone who has been through ibogaine treatment—without need to share your personal identity, of course.

Quantitative Urine Drug Testing and Buprenorphine: Tainted Motives?

First Posted 11/23/2013
As fear of buprenorphine diversion sweeps the nation, some states have passed legislation adding more rules for practices that treat addiction using buprenorphine.    Never mind that buprenorphine is linked to about 400 deaths over ten years, one tenth of the number of deaths from acetaminophen during that same time, and 0.1% of the number of overdose deaths overall.

Many parts of the country have seen a reduction in number of buprenorphine-certified physicians over the past few years.  Many rural areas have no buprenorphine prescribers at all.  The lack of prescribers, combined with the limit of 100 patients per prescriber, leaves opioid addicts with one legitimate treatment option— the early morning line for methadone or buprenorphine at methadone clinics.  I’m not against the clinics, but the need to report each morning is a significant barrier to employment in many patients who would do just as well with a prescription for the medication—and a first-shift job. Their other option is to do what all the news stories have been reporting—use buprenorphine without a doctor’s supervision and attempt to stop heroin or pain pills on their own, aka diversion.

One clue about your own state’s buprenorphine policies is whether your doctor is still prescribing buprenorphine products, or has instead moved to an area of medicine where doctors make decisions according to clinical judgment.  As the number of buprenorphine/naloxone prescribers in my part of the country has decreased, the amount of diversion has increased.  I predict that policies that discourage doctors from treating opioid dependence will increase the number of addicted people trying to treat themselves.

Sometimes it is easy to predict unintended consequences.

Regulatory agencies of at least one state prevent insurers from covering specific, FDA-approved medications.  Other states require doctors to follow specific practice patterns instead of their best clinical judgment.  One example of oversight that demonstrates the folly of lawmakers playing doctor is the push to require ‘quantitative urine testing’ in all patients at frequencies determined at the state capital, rather than by the doctors treating the patients.  The expectation is for quantitative testing to reduce diversion.  Note that 30,000 overdose deaths per year from non-buprenorphine products never prompted such oversight, nor did the well-known ‘pill-mill’ pain clinics that have flourished for the past decade.  But an average of 40 deaths per year related to buprenorphine has demanded action by lawmakers!
There are times when quantitative testing is useful, but I suspect that legislators who voted to require such testing heard only the half of the story told by people with vested interests.  After all, quantitative testing is one of the more lucrative areas in all of healthcare.  Even Medicaid agencies that pay pennies on the dollar for office visits pay generously for testing with the right billing codes.  Turn-key testing businesses can be purchased by entrepreneurial doctors to grow revenue at pain clinics, leasing out testing equipment and training techs in return for a piece of the action.

What legislators SHOULD know:

Quantitative urine tests for standard drugs of abuse in just one patient can cost well over $1000.  Costs over $500 per test are the norm.  The costs are paid by insurers, Medicaid, or patients, increasing insurance premiums and taxes and blocking treatment for some patients.

‘Point of care’ test strips that use immunoassay methodology are sensitive and accurate.  A standard test kit shows the presence/absence of trace amounts of specific opioids (methadone, oxycodone, or heroin/morphine derivatives), amphetamine, benzodiazepines, cannabinoids, cocaine, PCP, barbiturates, and buprenorphine.  Typical test kits give all the results for a total price of $5-$10.

Almost all the decisions related to testing rely on the presence or absence of substances—not the number of nanograms of a substance.   The point is whether a patient used heroin or cocaine—not how many milligrams of heroin or cocaine were used.  Test companies claim that measurement of buprenorphine’s first breakdown product, norbuprenorphine, can determine if a patient took buprenorphine only recently to fool the doctor. But I receive dozens of emails each year from patients with nothing to gain by describing their experience in those cases, swearing that they were taking the medication correctly, and asking how they can prove their truthfulness after what is called ‘flipped levels’ in such testing.  Besides, anyone with knowledge of addiction knows how difficult it would be to pull of such a scam. The scammer’s urine would still contain the drug of abuse, unless we suppose the unlikely scenario where scammers successfully stop all opioids for a week each month and experience withdrawal each time, all for the sake of a script for Suboxone.  Beyond the misery, few addicts would be able to control use of narcotics to that extent.  That’s why they are addicted in the first place!

‘Quantitative urine testing’ measures the concentrations of substances in a patient’s urine.   But urine concentrations of substances are not accurate reflections of blood concentrations of the substances.  The first part of kidneys (the glomeruli) act like sieves with very large pores, spilling gallons of dilute liquid that contains drug metabolites and other molecules.  The largest parts of our kidneys consist of tubules that reabsorb water and reabsorb or secrete other molecules and ions.  When that liquid finally reaches the exit from the kidneys at the ureters, the original filtrate has been concentrated by several orders of magnitude, and has had a range of molecules removed from or secreted into it.  Water reabsorption depends on hydration status, circadian rhythms, diuretic and other medications, stress hormones, diet, and other factors.  As a result, concentration of a substance in the urine is not related to concentration in the blood—let alone to the use of the substance.  Blood levels provide far-more-accurate information, but even blood levels vary from differences in metabolism of substances between individuals.
Quantitative testing tries to overcome the gap between blood and urine levels by using levels of other substances, such as creatinine or urea, to estimate the extent of concentration performed by the kidneys.  But there are enough variables to make the results far from reliable.  But frankly, the inaccuracies don’t really matter—since in most cases the presence or absence of a chemical is the issue, not the concentration.

In an era when costs are a concern, why would states become involved in testing processes that force a dramatic increase in treatment costs?   Doctors who know their patients are in better position to decide when such testing is valuable.   In medical school 25 years ago, I learned about the inefficiency of shotgun approaches to lab testing—that instead of ordering routine chemistry panels for every patient, doctors should decide which specific tests are necessary and order accordingly.  To mandate such expensive testing, someone is deciding ‘yes that’s true, but….’.   The annual climb in the cost of healthcare is largely due to those and other ‘buts.’

The only reason the state would think that they know better—from hundreds of miles away, without meeting the patients—is if they assume that doctors treating addiction don’t care what their patients are doing, or are inept.  But if the same inept doctors are the people interpreting the results of mandated quantitative testing, what does the mandate add, exactly?  And why the selective oversight of doctors who treat addiction, when most of the harm from drug diversion comes from opioid agonists prescribed by doctors who don’t work in the addiction field?

Other mandates include the rules found on standard opioid treatment contracts.  The rules themselves are not unreasonable.   But I take issue with the double standard applied to addiction physicians.  Expensive residential treatment programs have abysmal success rates.  Should they be regulated?   People who have too much plastic surgery look ridiculous—should that be regulated?  Everybody talks about the epidemic of opioid overdose deaths— deaths caused 99.9% of the time by something other than buprenorphine, the most effective treatment for opioid dependence.  But it’s buprenorphine that needs regulating?

DA Asks Why Still On Suboxone?

First Posted 10/13/2013
A person in my practice was stable on Suboxone/buprenorphine for several years, until he developed a painful injury.   During the time the injury was treated, the person experienced significant pain.  I worked with his surgeon to provide adequate pain relief, which for patients on buprenorphine or Suboxone  consists of a high dose of an opioid agonist, to ‘out-compete’ the buprenorphine.
As an aside, an NIH consensus paper from a couple years ago described the proper approach to patients on buprenorphine who require surgery or analgesia after injury.  Their top recommendation?  Have the person ‘hold’ their buprenorphine for a couple weeks before surgery.  That idea sounds reasonable for a moment or two, but anyone with any experience treating opioid dependence knows that whoever came up with the idea has very little experience working with addicts.  Just ‘hold’ the buprenorphine for two weeks?  Gee… OK…..  do you have any HEROIN I can take in the meantime?!  A little oxycodone maybe?  ‘Cause otherwise, the ‘holding’ isn’t going to work so good….
Every now and then I’ll read a recommendation or comment from someone high in addiction-society circles that shows that what it takes to get high in those circles is something other than a good working relationship with people who have suffered with addiction.
Following the tangent a bit further…. I find that reducing the dose of buprenorphine is a better idea;  people find that they can reduce it to 4-8 mg per day without experiencing withdrawal, and in my experience that is enough to allow 15 mg of oxycodone access to the mu receptor.  The other advantage over ‘just holding’ the buprenorphine is that when the agonist is eventually discontinued, the full dose of buprenorphine can be resumed without going through a period of abstinence, yet without precipitating withdrawal.
Back to the story—- the person continued to complain of severe pain, despite using the 3-day supply of oxycodone that I prescribed, all on the first day.  I had him stop by the office, and given his pinpoint pupils, slurred speech, and slowed respiration, I couldn’t provide more agonist without putting his life at risk.
It is always hard to judge the pain tolerance of someone else.  He said that the pain was unbearable;  I suppose it is obnoxious for a doctor to tell a person in that situation ‘your pain isn’t all that bad.’  I don’t think I said those words, but I think that many people who have gone public with histories of opioid dependence feel that medical professionals never take their pain complaints seriously— that they are forever condemned to suffer through more pain than people who’ve never lost control of opioids.  I think that the patient had that attitude, which didn’t help the situation, even though I tried to explain that I wouldn’t give more agonist no matter WHAT his prior history;  he was simply too narcotized.  In retrospect, what should have happened was that his surgeon should have admitted him to an ICU or SICU, for PCA while on oxygen and on pulse oximetry.  But for whatever reason, that did not happen.
Instead, he found his own supply of opioid agonist.  A bit later, he was found unresponsive and not breathing by a friend, who luckily knew how to do CPR.  (the actual story is that his friend was outside his room, and heard a thud as a head hit the floor).  He woke in the ambulance with an intact noggin, thank heavens.  But the police swung by his room to drop off their best wishes, along with a summons to appear for felony drug charges.
Enter me.  The DA had a concern about the case and wanted me to ‘clarify’ something.  The issue– why, after several years, is this guy STILL on buprenorphine?  Why hasn’t he been ‘tapered off’?  Why hasn’t he been definitively treated, rather than just ‘maintained’?
So I spent the day writing an explanation to the DA that I’m hoping they will find helpful.  It occurred to me that since I’ve been asked this very question before, there are likely other people who have wasted a day writing similar explanations, so I figured I’d just put it here—- so that if YOU are ever in the same shoes, you can either print it out, or refer people to my site– whichever works for you.  I tried to block of specifics– like names, etc– but if you find one, please send me an email and let me know so I can take it off.
My Letter:
To Whom It May Concern:
I was asked to describe the medical and treatment history of XXXX, and to explain why he continues to be prescribed buprenorphine/naloxone (brand name Suboxone).  The decision to continue or discontinue buprenorphine is individualized and complicated.  Sometimes the decision is impacted by non-clinical factors. The decisions, and the science behind the decisions, are complicated, and difficult to explain. I will attempt to explain the basic issues faced during buprenorphine treatment in general, and then describe the specific considerations in XXXX’s case.
Those who work with opioid dependence have known for decades that opioid dependence is a lifelong, potentially-fatal illness that is highly-refractory to treat. In the 1970s, methadone clinics were set up as a response to this recognition.  Methadone clinics are even more prevalent today, providing opioid maintenance for patients over the course of years, and often decades.  Long-term treatment of addiction has come and gone under different names over the years. In the 1990’s, many treatment programs adopted the concept of ‘harm reduction’ after recognizing the low success rates of total sobriety programs.  Harm reduction strategies focused less on the number of consecutive sober days, and more on reducing the most harmful aspects of the patient’s addiction.
There are misconceptions among the general public that people with addictions can be sent to residential treatment and freed from opioid dependence, or that counseling alone can stop active addiction. Sadly, these are misconceptions. I have worked extensively in the field of addiction, including serving as medical director of Nova Treatment Center in Oshkosh for several years. During typical residential treatment, counselors discuss ‘planting a seed’, i.e. treat patients with the knowledge that relapse is inevitable, and that patients will likely return for another round of treatment. Is not uncommon for patients from any residential treatment program to relapse on the day of discharge, or die within 24 hours of discharge with a clean bill of health. Those who work with opioid dependence know that sustained remission from opioid dependence is the exception to the rule. The issue is under-researched, but I would estimate that 5% of entrants to residential treatment programs with opioid dependence remain sober a year after discharge.
In 2000, Congress passed DATA 2000, a law allowing for the use of buprenorphine for treatment of opioid dependence. Buprenorphine has considerable safety advantages over methadone, including a ceiling effect that makes overdose less likely. Buprenorphine treatment programs were initially designed to follow one of two paths, using buprenorphine either for detox or as a chronic maintenance agent. Over the past 10 years, numerous studies have shown relapse rates approaching 100% for patients who are simply detoxified using buprenorphine.  Because of the low rate of meaningful sobriety after detox, buprenorphine is rarely used for detox except as part of a longer (usually residential) treatment program.
Buprenorphine is Different
This topic alone could fill chapters, but I will highlight the salient features.  Buprenorphine was used in microgram doses for the past 30 years to treat pain.  Buprenorphine is a ‘partial agonist’, meaning that after a certain amount is taken, additional doses will cause no greater effect.  The goal of treatment is to keep the patient’s blood level above a critical point—the ‘ceiling effect.’  If the blood level remains above that level, the patient will receive a constant amount of mu-opioid-receptor activation, even as the buprenorphine wears off between doses.  The brain becomes completely tolerant to that activity, and the patient ‘feels’ completely normal.  I prefer the term ‘remission therapy’ over maintenance therapy, because a patient taking proper amounts of buprenorphine feels completely normal, as long as they stay on an amount of buprenorphine that keeps them above that ceiling effect.  Dosing efficiency can vary, so that dose ranges between 4 mg per day and 16 mg per day in most patients.
Patients on buprenorphine feel no desire to take other opioids.  Unlike untreated addicts, they do not experience the frantic search for pain pills or heroin every 4 hours that drives much of the illegal behavior associated with addiction.
Studies examining the long-term use of buprenorphine have found that buprenorphine treatment yields sustained remission from opioid use in about 50% of patients maintained on the medication.  Relapse rates are between 94 and 97% within one year of discontinuing buprenorphine, even in patients who were maintained on buprenorphine for over a year. The clinical data has demonstrated very clearly that when buprenorphine is discontinued, 90% or more of patients relapse at some point, usually within one year.
Doctors require additional certification to prescribe buprenorphine for addiction. Doctors who prescribe buprenorphine must counsel or refer to counseling, patients treated with buprenorphine who need additional help. But studies of the the impact of counseling on relapse rates have shown virtually no impact on relapse in groups who are counseled versus those who are not. I believe counseling is an important part of the picture for patients needing guidance toward education and gainful employment.
Some doctors arbitrarily stop buprenorphine or Suboxone at certain intervals of time, for example after one or two years. There are insurance programs that arbitrarily limit coverage to one year or two years, including some state Medicaid programs. These limits are not based on any evidence that people will do better if they stay on buprenorphine for that length of time. In fact, the opposite is true; people do well while maintained on buprenorphine, but generally relapse within a year after buprenorphine is discontinued.  But there are non-clinical motives to remove patients from buprenorphine which I will describe below.
XXXX’s Case
XXXX struggled early into buprenorphine treatment, which is relatively common in young patients. But during recent years he has done well on buprenorphine, avoiding illicit opioids and other substances. As with any illness, the response of an addict to treatment is rarely perfect. Patients with diabetes have flare-ups caused by alterations in diet that they know they should avoid. People with heart disease who are instructed to exercise often fail to follow that advice, and have a second or third heart attack.  Patients with mood disorders will stop their medications, or stop doing the things that they have been told to do to reduce the risk another mood episode.
For patients maintained on Suboxone, painful illnesses or injuries are particularly challenging. When XXXX had ( ), I coordinated care with his urologist. XXXX had a large stone that clearly warranted opioids to manage the pain according to his urologist.  I took over XXXX’s pain management and prescribed oxycodone, the standard practice in such situations.  XXXX complained that the pain was unbearable, but his respiratory rate was depressed by the pain medications to the point that I could not safely prescribe greater amounts of opioids, particularly to someone outside of the hospital.
The active drug in Suboxone, buprenorphine, has both activates and blocks opioid receptors.  When treating pain in patients on buprenorphine, the dosage of buprenorphine is often decreased, to allow other narcotics greater access to receptors in the brain.  At some point, XXXX obtained fentanyl, a very potent pain medication.  The pain that he was experiencing, combined with the reduction in buprenorphine made to allow for greater pain relief, resulted in a situation that he was unable to avoid taking the fentanyl.  I realize that it is difficult for people with addiction to accept the idea that he was ‘unable’ to do the right thing, but addiction is a major problem exactly because of that fact; that some people are unable to avoid taking certain substances in spite of knowing that the substances are causing significant harm to their lives.
I do not believe that XXXX had any interest in getting ‘high’, or feeling a ‘buzz’ from fentanyl.  XXXX believed that he could not tolerate the pain he was experiencing without taking additional narcotic, and the fentanyl was all that was available for him to use.  I also believe that like many people treated for opioid dependence, XXXX believed that he was deliberately under-treated for pain because of his history of addiction—making it all the more difficult for him to tolerate the pain.  XXXX realizes that he was lucky to survive the incident, and he has done well since the ( ), back on his regular dose of buprenorphine.
Should buprenorphine/Suboxone be discontinued?
Going forward XXXX and I will discuss when and whether he should discontinue buprenorphine, as I do with all of my buprenorphine patients. There are multiple factors to take into account before making such a decision, including patient age, stability of patient’s relationships, presence or absence of physical pain, nature of patient’s occupation, intensity of cravings and time since active use, relationships with work colleagues who are actively using, whether any other members of the patient’s household use pain medication, presence or absence of children, sleep and work schedule, etc.  As of now, XXXX is NOT in the position to discontinue buprenorphine.  I do NOT foresee him being an appropriate candidate for discontinuation of buprenorphine in the near future.
My decisions about the continuation/discontinuation of buprenorphine/Suboxone have been shaped over years by discussions with other physicians, and by experiences while treating opioid dependence with buprenorphine.    I have a number of patients who have been treated with Suboxone for many years, as do many other physicians who treat addiction.  Over the years I have had at least six patients who I am aware of, who insisted on their own, or through encouragement from friends, relatives, or doctors, to discontinue Suboxone against my advice.  I read obituaries for each of those patients over the next few years.  Not all patients who chose to stop buprenorphine ended up dying from overdose, but the frequency was high enough that I noticed six cases in the local newspaper over a period of seven years.
As stated earlier, there are factors that encourage discontinuation of Suboxone that are not necessarily in patients’ best interests. The DEA enforces limits on buprenorphine-certified physicians to treat no more than 100 addiction patients at one time. The limit creates financial incentives for doctors to discharge patients after some period of time, since unstable patients are seen more often than stable patients. And the financial incentives for state Medicaid and health insurance companies to place arbitrary limits on buprenorphine treatment are obvious.
With my background and training, I am convinced that I understand opioid dependence about as well as any physician. Opioid dependence is a chronic, relapsing, potentially fatal disorder. I counsel most of my patients on buprenorphine to take the medication appropriately and to get on with their lives, growing in areas that were blunted by their active addictions.  I do not place arbitrary time limits on treatment. I note that opioid dependence is much like every chronic illness, as doctors treat far more illnesses than we cure. We don’t ask how long our patients will take blood pressure medication. We don’t ask how long our patients should take cholesterol-lowering medication. We don’t ask how long those with diabetes should stay on insulin. Only with addiction do we entertain the thought that patients should expect only a limited period of treatment. I have been happy to see those attitudes change over time, as more and more doctors see buprenorphine/Suboxone as long-term treatment.
In regard to XXXX ’s specific case, he was doing well, fully complying with treatment.  He developed ( ), and I consider what followed to be a complication of illness. I understand that a crime was committed. But I believe that after several weeks of severe pain, combined with the lower dose of medication used to treat his addiction, XXXX reached a point of desperation where he was not capable of making the right decision. He has done well since that incident. I believe in holding people accountable, but in XXXX’s case, I do not believe it in anyone’s interest to make a hard-working individual unemployable. I know that XXXX has worked very hard to improve himself over the years, and I believe that he will continue to do the same going forward.

Suboxone Not on the Affordable Care Act FAQ

First Posted 9/15/2013
I’ve written the first two parts of a three-part column about unintended consequences.  Part one described why discounts demanded from insurers for front-line services (e.g. office visits) create challenges for independent primary care practices that don’t have other sources of revenue, particularly revenue from procedures.  Part two explained why physicians employed by health systems are less likely to provide buprenorphine treatment of opioid dependence than are small, independent docs.  The combined effect is that doctors who prescribe buprenorphine are more likely to be independent practitioners who do not participate in insurance panels or Medicaid.
I hinted that I would eventually tie all of this into an unintended consequence of the Affordable Care Act.   I don’t want to debate politics, but a situation arose last week that illustrates the type of problems that arise when a profession, bound by complex regulations accumulated over decades, is crossed with a complicated new law.
Many patients covered by Medicaid choose to pay out-of-pocket for buprenorphine treatment.  In some cases non-Medicaid doctors are the only doctors available, but there may be other reasons for choosing one doctor over another beyond insurance coverage.   Likewise, patients in non-Medicaid insurance programs have the option to see doctors out of their network, if not satisfied with in-network choices.
Some people believe it is unfair for non-Medicaid doctors to see Medicaid patients through ‘private contracting.’   I described some of the factors that shaped the current system in the first two parts of this series.  Buprenorphine-certified physicians tend to be independent practitioners who lack the profit generators of healthcare ‘systems.’   And there is no way to provide the care warranted by opioid dependence— care that prevents diversion, that supports the type of behavior change needed to stem active addiction—for the $30 per 20-minute visit provided by Medicaid.  We can WISH that the numbers added up, but they don’t.  It might be possible to make a practice driven by volume, say if each patient was seen for five minutes by a doctor with roller skates.  But I suspect that high-volume, low-physician-contact practices would result in less sobriety, and more diversion of buprenorphine.
People in Wisconsin who are addicted to heroin and on Medicaid have several choices.  In parts of the state where no doctors prescribe buprenorphine, patients can 1. Stop heroin on their own or through AA/NA;   2. Purchase illicit buprenorphine and engage in ‘self-treatment’ (one type of diversion); 3. Try to find a residential treatment program that accepts Medicaid, and beat the 95% failure rate of such programs; or 4. Go to methadone clinics that are covered by Medicaid (and try to maintain employment around early-morning clinic visits).  Methadone clinics are high-volume practices that CAN function under Medicaid levels of reimbursement; clinics receive $70-$80 per week to see patients in rapid succession each morning. Medicaid even reimburses patients’ travel expenses for methadone maintenance.
In some parts of the state, doctors who prescribe buprenorphine provide another choice. Patients who choose buprenorphine pay up to several hundred dollars per month for buprenorphine treatment— far more than for daily visits for methadone.    But even with that cost, some patients prefer buprenorphine treatment over methadone.  Some patients are poor candidates for daily methadone because of sedation or other side effects.  Some patients can’t comply with methadone dosing schedules, and at the same time re-establish employment and self-sufficiency (and isn’t self-sufficiency the essence of rehabilitation?).  For people who pay over $100 per day for heroin, choosing buprenorphine for $200 per month may be a bargain.  Patients who to stop smoking or get help for other mental health conditions through buprenorphine-certified psychiatrists do even better in the cost equation—not counting the health benefits.
Several weeks ago, many state Medicaid agencies posted statements on their web sites that ‘because of the Affordable Care Act, services and medications prescribed by non-Medicaid physicians will no longer be covered by Medicaid’.  The statement reflected changes in practice mandated by a little-noticed provision of the new law.  Patients on Medicaid who went to pharmacies for buprenorphine refills were told that they would have to pay out of pocket– $300 to over $500, depending on their dose of Suboxone.  The situation was worsened by older Medicaid rules, that for example prevent patients on Medicaid from purchasing medication out-of-pocket, or that prohibit substituting cheaper generic buprenorphine for Suboxone Brand Film.
Patients turned away from pharmacies called their doctors and were told their options; to stop buprenorphine and go into withdrawal, or to search for a pharmacist that might sell Suboxone or buprenorphine for cash, knowing that paying out of pocket might result in permanent loss of Medicaid benefits (not to mention the cost of the medication).  Doctors had decisions as well; whether to enroll in Medicaid—something that many practices simply would not survive—or to stop prescribing to their Medicaid patients, leaving them to go into withdrawal within hours.
Doctors looking for clarification found inconsistent answers.  The Wisconsin Psychiatric Association had no clue that the rule change existed, let alone a solution.  The Wisconsin Medical Society didn’t bother to answer emails.  Officials at the state Medicaid program said ‘those patients can go on methadone, or they can go to doctors who accept Medicaid.’  Attempts to explain the background provided in my two prior posts were answered by the comment that ‘there are plenty of doctors who prescribe buprenorphine and who accept Medicaid.’  I said ‘no, there aren’t.’    They answered ‘yes, there are.’
There aren’t.
After several days of hand-wringing by doctors (and diarrhea, body aches and sneezing by patients), the web page for the Medicaid program of a different state described a solution that had been devised to accommodate the new law.  Doctors could enroll in Medicaid in a ‘limited status’ where they didn’t have to sign a provider agreement, as long as they didn’t expect any payments from Medicaid for those patients.  After all of the confusion, some doctors decided to play it safe by not taking Medicaid patients in the future.
Maybe someone feels better that fewer Medicaid patients are paying out of pocket for buprenorphine treatment.  But I suspect at least some former buprenorphine patients feel worse, after losing their job in order to stand in line for methadone each morning.  Is the country better off, forcing such ‘fairness’ on people unfortunate enough to suffer from opioid dependence?  That’s for someone else to decide… or more accurately, that is a decision that someone already made, that we all have to live with.
Unfortunately there are many situations like this one, where patients’ options or outcomes are impacted by unintentional, unforeseen problems caused by conflicting regulations.  In this case, the consequences (no medication, withdrawal) were more immediate than in some other cases.  But the infinite number of individual circumstances, combined with thousands of regulations, means that there will be a constant stream of cases that fall outside of the FAQ section of the Affordable Care Act.  In the past, finding solutions to for such problems required a call to an insurance company or in rare cases to state agencies.  But now, nobody who is available by phone understands the questions, let alone knows the answers.  And SOLVING a problem requires an Act of Congress.   How is THAT going to work?

New Bupe News Section

Wanted to take a second or two to point out a new section to the blog, called ‘Bupe News’.  You’ll see the link at the tope of the page, along with an ever-growing list of links.  The point, of course, is to keep y’all reading, since Google knows EVERYTHING, including how many seconds each and every one of you spends on this (and every other) web site.  Understand that I don’t GIVE that information;  that information is simply that is there for the taking on the internet.  Even I can see the average time people spend on the site, the order they went to one page or another, etc.    I do not ‘collect data’ about any reader, meaning that I do not have information about who any individual is or isn’t…   but I DO get reports on my collective audience.
Check the page out, along with the other new section, and of course tell me what you think.  Positive suggestions are ALWAYS welcome!
Thank you for hanging with me,  by the way, for some tough I.T. times.  I’ve got about 3/4 of the ‘lost’ posts back, and then I’ll be back to firing off the NEW things I’m angry about, rather than replaying the things that irritated me a year ago!

A Letter from Drug Court

I recently received a note from an area drug court, asking for help tapering one of my patients off buprenorphine. The patient came to me 4 years ago after being treated for a congenital pain condition.  He had been treated with 150 mg of methadone per day, becoming dependent on the medication after taking it for several years.
He did great on buprenorphine for the past four years, but when a buddy offered him some surprisingly-potent heroin he decided to see what all the excitement was about.  He overdosed and almost died, and was charged for heroin possession as he recovered in the hospital.  I’m convinced he would be dead if not for the buprenorphine circulating in his system.
I thought I’d share my conversation between the person taking his case at drug court.  Names have been left out so that I don’t aggravate my patient’s situation:
Hi Dr. Junig,
I am the ZZZZ  County Treatment Drug Court Coordinator and am writing to you in order to get your input and expertise on a taper down plan for XXXX involving his Suboxone.  XXXX began an Intensive Outpatient Program this week with the ZZZZ County Health & Human Services Department.  XXXX’s therapist is YYYYY.  Our understanding is that XXXX currently takes Suboxone three times a day for pain.  Our goal would be for XXXX to be clean and no longer on Suboxone in the future.  Please feel free to contact me or email me regarding this matter.
I appreciate your time.
Thank you.
My Response:
Dear Ms. AAAA,
I will be as helpful as I can.   I ask that you consider my hesitance to endorse the plan, though, after reading my comments below.
Understand that while XXXX  messed up recently, he did well on buprenorphine since 2011.  Before that time, he was taking over 100 mg of methadone per day for pain related to PPPP syndrome, and taking narcotics from physicians before he went on methadone.   I moved him to my AODA group from the pain group since his last appointment, providing a different intensity of observation for abuse of other substances, and requiring him to avoid other substances entirely, including alcohol.
As you know after meeting XXXX, people on buprenorphine are not impaired.  They have complete mu tolerance, and look and feel normal.  They also have an extremely low incidence of death by overdose.   In the past ten years, on average, 40 people per year in the US  have died with buprenorphine in their bloodstream— the same as the number of people who died from lightning strikes (they didn’t die from buprenorphine;  they died from other drugs, and happened to have traces of buprenorphine in their bloodstream).  It is VERY hard to overdose when buprenorphine is in the body; XXXX would certainly be dead had he taken what he did a few months ago, and NOT been on buprenorphine.
The 40 deaths per year on average in people with buprenorphine in their system compares to over 35,000 deaths per year in people who have no buprenorphine in their system.  Because of the very strong protective effect that buprenorphine has against death, I am always reluctant to stop buprenorphine maintenance or pain treatment, as doing so leaves patients unprotected— while relying on traditional AODA treatment, which as you likely know has a very low success rate.
I have had six patient who were forced off buprenorphine or Suboxone by PO’s, drug courts, or family members, who died within a couple years of stopping buprenorphine.    For that reason, I think that XXXX should receive informed consent that if he uses drugs while not on buprenorphine, he will have a much higher risk of death by overdose.  That fact is pretty clear from the data about overdose in the US.
As for the process of tapering, be sure to check out my forum at www.suboxforum.com  where people discuss all sorts of methods, ranging from tapering all the way down to zero, versus stopping ‘cold turkey’.  The best approach in my opinion is to taper relatively quickly down to 4-8 mg per day, as a taper in that dose range causes minimal or no withdrawal symptoms.    From there, I recommend reducing his dose each week by a small amount, i.e. from 4 mg, to 2 mg, to 1 mg per day, dropping each week.  Below 1 mg per day, the specific pharmacodynamics of the drug makes it difficult to taper, because the ceiling effect that allows people to feel relatively even between higher doses becomes irrelevant, as people drop below the ceiling effect and feel sick between dosing.
The best option may be to stop buprenorphine completely when he gets below one mg per day, and put up with the withdrawal for about 6 weeks.  The misery starts to get less severe at about the 3 week mark.   Clonidine is a blood pressure med that reduces the intensity of opioid withdrawal, and I would be happy to prescribe it for him if he sets up an appointment to plan all of this out at some point.
Again, please plan on following his progress after he stops, because I want you, and anyone else who is involved with this approach, to be aware of what usually happens.   I was med director of QQQQ (a long-term residential treatment program) for several years, until I tired of watching people pay $7000, get cleaned up, die from overdose a month after discharge.  I think that XXXX has a less-severe addiction than many people, so I won’t send a real angry letter your way (believe it or not, I sometimes get even more annoying on this topic!).   But I do worry for XXXX’s sake after working with him for the past 4 years.  If my son were ever addicted to opioids, I would sleep much better knowing he was protected from death by taking buprenorphine.
Feel free to write if I can be of help.
Jeff J

Suboxone as Problem, Suboxone as Solution

Originally Posted 3/14/2013
A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine.  I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest.   Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications.  If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation.  Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’  Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter.   I know that buprenorphine saves lives, beyond a doubt.  I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats.  I notice how quickly people complain about others ‘on buprenorphine’, without taking the time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve.  For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better.  In some cases doctors do the very best they can (or that anybody could do), yet their patients struggle to maintain sobriety.  Doctors may be tempted to abandon the problem patients altogether, to avoid being seen as impotent or worse—as ‘part of the problem.’
I know, right now, that three of my patients are struggling with buprenorphine treatment.  Maybe I’m naive and the true number is higher, but I’ll focus on the people who I know, for certain, to be struggling.
The patients I refer to as ‘struggling’ are taking buprenorphine or Suboxone, but taking it imperfectly.  For years they were conditioned by heroin, as the misery of withdrawal was relieved by the poke of a dull needle and the injection of foul liquid, hundreds and thousands of times over.   They are now ‘freed’ by buprenorphine from the need to relieve physical misery, but the urge to penetrate their skin with needles continues. Buprenorphine binds opioid receptors so tightly that heroin or oxycodone, when injected, cause no high or change in sensorium, yet users are still drawn to inject, a status referred to as ‘hooked on the needle’, where the painful piercing by a dull needle fills an otherwise-intolerable emptiness.
Their actions appear insane to people who have never ‘shot up’.  Why would someone risk endocarditis—or worse– through shared needles, when the injection causes no pleasure, and in fact causes pain? The bizarreness of the situation doesn’t, unfortunately, make it less common.  The situation exists.
I tell my patients that the one thing that results in immediate discharge from my practice is sharing or selling medication that I prescribed.  Even in the midst of insanity there must be some absolutes, and from my perspective, an absolute boundary exists where one person’s behavior harms someone else.  A patient who sells a portion of his/her Suboxone to score heroin, or for any reason, has crossed a line.
But what about the person just short of that boundary—the person who is still ‘hooked on the needle’ who is trying, most of the time, to stay off needles and smack but at 3 AM, in a room with other users—a room where he hit the needle hundreds of times before—hits the needle again?
There are plenty of reasons to terminate treatment for such a person.  He shouldn’t have done it, shouldn’t have been there, shouldn’t have been with those people… and many doctors would stop treatment at such a point, even knowing that doing so contributes to another overdose death.
We don’t treat other difficult patients the same way.  Our noncompliant teenage diabetics are given second, third… endless chances to get their insulin right.  People with post-op hemorrhages are rushed back to the OR for more treatment—not tossed to the curb, labeled ‘difficult patients.’
And I know from experience that some people hooked on the needle, in the position I described, can be saved.  For my struggling patient, maybe tonight wasn’t his night.  But tomorrow, the balance between cues, cockiness, and desperation might allow him to say ‘no’.  And with the right sequence of events, and maybe the right words of encouragement, he might put enough days together to make ‘no’ a regular thing.
Or he might not.  Maybe saying ‘yes’ one more time will end any lingering hope that he will pull it together and give life on life’s terms a try.  For this guy on Suboxone, there is still too much disease in the mind and body for any prediction beyond a guess.  And if, at any time, he happens across something larger and purer than he’s ever experienced before, the respiratory depressant effects of whatever he uses may cost him his life.
It is at this scene where I suspect the DA and I would have different opinions.  I’d expect many DA’s, viewing pictures of a cold body with a needle in the arm and a half-full bottle of Suboxone on the bathroom shelf, would say the guy had his chance and lost the right to take medication a long time ago.  I respect the DA’s position, and wouldn’t expect it any other way.  The DA’s doing what he is supposed to do.
But at the same time, I hope the DA understands MY thoughts, reviewing the same pictures.  I’d think that had my patient made it past tonight, he might have strung a few better nights together. And by the odds, I’d know that had I kicked him out of treatment for screwing up the first time, he would have died weeks ago.
Of course I don’t enjoy prescribing a medication for someone who doesn’t take it correctly, despite my strongest warnings and admonishments. But had I simply kicked him out of treatment and THEN read his obituary, I’d wonder if I’d done everything that I’M supposed to do.