Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here. This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago. I grew used doctors refusing to treat people addicted to heroin and other opioids. I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise. It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices. I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine. The comment surprised me, because from here I don’t see the influence. My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years. I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things. I want to write about the little things. The easiest way to have influence is to write about the things that nobody else writes about. After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence: If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way. I want people to use . I know I sound like some old guy frustrated by all of the new words and acronyms on social media. YES, dammit, I AM frustrated by those things! But communication has become so…. careless in the era of Twitter and texting. Find an old book and notice the words and phrases used by educated people 100 years ago. Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends. Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?) But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs. Some large scams benefit from the informal attitudes toward health and medicine; attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video. As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term. Is ‘treat’ the right word? From my perspective I’d say yes in some cases, and no in others. Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year. They said (and I believe them) that they hadn’t used opioid agonists for at least that long. I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances. There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances. Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv. Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies. I correct them and tell them that I have a hard time trusting patients who talk that way. After all, those are street terms. A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub. Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing? Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not. I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression. Getting that point across would be enough influence for one day!

Addiction Treatment Has it ALL WRONG

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

Clearbrook President Gets it Wrong

A blurb in the buprenorphine newsfeed (see the bupe news link in the header of this page), has the headline ‘Suboxone challenged by Clearbrook President’.  I followed the link, and after reading the ‘article’ I wanted to comment to that president but the person’s name wasn’t included, let alone an email address or comment section.  So I’ll have to comment here instead.
The article was one of those PR notices that anyone can purchase for about 100 bucks, in this case from ‘PR Newswire’.  It’s a quick and easy way to get a headline into Google News, which pulls headlines for certain keywords like ‘Suboxone’ or ‘addiction’.
The Clearbrook president makes the comment that this 180-degree swing to ‘medication assisted treatment’ is a big mistake.  He says that in his 19 years in the industry he has seen ‘thousands’ of people ‘experience sobriety’.   I’ll cut and paste his conclusion:
There is no coming into treatment and getting cured from the disease of Addiction. There is no pill or remedy that will magically make one better. Those looking for a quick fix to addiction and the treatment modality being used by the vast majority of treatment providers today, will be disappointed with the direction our field is taking when this newest solution doesn’t live up to its claims.
A word to the President of Clearbrook:   I’ve worked in the industry too.  But unlike you, I wasn’t satisfied to see a fraction of the patients who present, desperate for help, ‘experience sobriety’– especially when I read the obituaries of many of those patients months or years later.
The president says that ‘no pill or remedy will magically make one better.’  Addiction, for some reason, has always been considered immune to advances in modern medicine.  We all know that addiction is a disease, just like other psychiatric conditions including depression, bipolar, and schizophrenia.  Why is it that even as medicine makes extraordinary advances in all areas of illness, medications for addiction are considered to be ‘magic’?
Those of us who treat patients with medications, particularly buprenorphine, realize that addiction doesn’t respond to ‘magic’.  But I see a lot more hocus pocus in abstinence-based residential treatment programs than in the medications approved by the FDA for treating addiction.  Residential programs charge tens of thousands of dollars for a variety of treatments–  experiential therapy, art therapy, psychodrama, music therapy, etc.– that have no evidence of efficacy for treating opioid dependence.  Abstinence-based treatments have managed to deflect criticism from their failed treatment models by blaming patients for ‘not wanting recovery enough’.
Buprenorphine finally allows the disease of addiction to be treated like other diseases– by doctors and other health professionals, based on sound scientific and pharmacological principles.   Abstinence-based treatment programs have tried to tarnish medication-assisted treatments, but people are finally recognizing the obvious– that traditional, step-based treatments rarely work.
And that’s just not good enough when dealing with a potentially fatal illness like opioid dependence.

Menzies Gets it Wrong

In Opioid Addiction Treatment Should Not Last a Lifetime, Percy Menzies resurrects old theories  to tarnish buprenorphine-based addiction treatment.  Methadone maintenance withstood similar attacks over the decades, and remains the gold standard for the most important aspect of treating opioid dependence:  preventing death.
Menzies begins by claiming that a number of ideas that never had the support of modern medicine are somehow similar to buprenorphine treatment.  Replacing beer with benzodiazepines?  Replacing morphine with alcohol?  Replacing opioids with cocaine?  Where, exactly, did these programs exist, that Menzies claims were precursors for methadone maintenance?
Buprenorphine has unique properties as a partial agonist that allows for effects far beyond ‘replacement’.  The ceiling effect of the drug effectively eliminates the desire to use opioids.  Seeing buprenorphine only as ‘replacement therapy’ misses the point, and ignores the unique pharmacology of the medication.
Highly-regulated clinics dispense methadone for addiction treatment., and other physicians prescribe methadone for chronic pain.  Menzies claims ‘it is an axiom of medicine that drugs with an addiction potential are inappropriate for the treatment of chronic conditions.’  For that reason, he claims, methadone treatment is ‘out of the ambit of mainstream medicine.’ The 250,000-plus US patients who benefit from methadone treatment would be amused by his reasoning.    I suspect that the thousands of patients who experience a lifetime of chronic pain—including veterans with crushed spines and traumatic amputations—would likely NOT be amused by his suggestion that ‘opioids… were never intended to be prescribed forever.’   Those of us who treat chronic pain take our patients as they come—often with addictions and other psychiatric baggage.  Pain doesn’t stop from the presence of addiction, neither does the right for some measure of relief from that pain.
Menzies cites the old stories about Vietnam veterans who returned to the US and gave up heroin, as evidence that prolonged treatment for opioid dependence is unnecessary for current addicts.   But there is no similarity between the two samples in his comparison!  US Servicemen forced into a jungle to engage in lethal combat use heroin for different reasons than do teenagers attending high school.   Beyond the different reasons for using, after returning home, soldiers associated heroin with danger and death!  Of course they were able to stop using!  And that has to do with current addicts… how?
Teens in the US have no mainland to take them back.  Their addiction began in their parents’ basement, and without valid treatment, too often ends in the same place.
Menzies refers to buprenorphine treatment as ‘a conundrum’ that has not had any effect on deaths from opioid dependence—a claim impossible to support without an alternative universe and a time machine.  He claims that buprenorphine treatment is unsafe and plagued by diversion.  In reality, most ‘diversion’ consists of self-treatment by addicts who are unable to find a physician able to take new patients under the Federal cap.  In the worst cases, some addicts keep a tablet of buprenorphine in their pockets to prevent the worst of the withdrawal symptoms if heroin is not available.  But even in these cases, buprenorphine inadvertently treats addicts who take the medication, preventing euphoria from heroin for up to several days and more importantly, preventing death from overdose.
Just look at the numbers.  In the past ten years, about 35,000 people have died from overdose each year in the US with no buprenorphine in their bloodstream.  How many people died WITH buprenorphine in their bloodstream?  About 40.  Even in those cases, buprenorphine was almost never the cause of death.  In fact, in many of those 40 cases, the person’s life would have been saved if MORE buprenorphine had been in the bloodstream because buprenorphine blocks the respiratory depression caused by opioid agonists.
Naltrexone is a pure opioid blocker that some favor for addiction treatment because it has no abuse potential.  Naltrexone compliance is very low when the medication is not injected, and naltrexone injections cost well over $1000 per month.   Naltrexone may have some utility in the case of drug courts, where monthly injections are a required condition of probation.  But even in those circumstances, the success of naltrexone likely benefits the most from another fact about the drug, i.e. that the deaths from naltrexone treatment are hidden on the back end.  Fans of naltrexone focus, optimistically, on its ability to block heroin up to a certain dose, up to a certain length of time after taking the medication.  But Australian studies of naltrexone show death rates ten times higher than with methadone when the drug is discontinued, when patients have been discharged from treatment, and short-term treatment professionals have shifted their attention to the next group of desperate but misguided patients.
The physicians who treat addiction with buprenorphine, on the other hand, follow their patients long term because they see, first-hand, the long-term nature of addiction.  Menzies’ claim that ‘the longer you take it, the harder it is to stop’ has no basis in the science of buprenorphine, or in clinical practice.  Patients often get to a point—after several years—when they are ready to discontinue buprenorphine.  And while buprenorphine has discontinuation symptoms, the severity of those symptoms is less than stopping agonists—and unrelated to the duration of taking buprenorphine.   Until that point in time, buprenorphine effectively interrupts the natural progression of the addiction to misery and death.
The physicians who prescribe buprenorphine and the practitioners at methadone clinics are the only addiction professionals who witness the true, long-term nature of opioid dependence. In contrast, too many addiction practitioners see only the front end of addiction, discharging patients after weeks or months, considering them ‘cured’…  and somehow missing the familiar names in the obituary columns months or years later.

Media Bias Against Suboxone

First Posted 2.8.2014
After Philip Seymour Hoffman’s death, I anticipated a flood of articles describing the ineffectiveness of non-medication treatments for opioid dependence. I assumed the media would finally report on the need for long-term treatment of a long-term illness. Instead we read more articles describing Suboxone (i.e. buprenorphine) as a ‘bad drug’, since Hoffman may have used the drug to reduce withdrawal between heroin binges.
Taking buprenorphine within a few days of using heroin blocks most of heroin’s effects and makes overdose much less likely– a fact rarely reported. Out of about 400,000 overdose deaths over the past ten years, only 400 deaths included buprenorphine as one drug in the fatal mix– a stunning statistic that calls out for more life-sustaining buprenorphine treatment, not less. In most of those cases, death would not occurred had there been more buprenorphine in the victim’s bloodstream.
Vivitrol is the brand name for a monthly, injectable form of naltrexone that appeals to a superficial approach to opioid dependence. Naltrexone advocates focus on the months of abstinence when patients are taking the medication, often during forced compliance mandated by drug courts. Rarely questioned is the long-term effectiveness (or lack thereof) of naltrexone for reducing the morbidity and mortality of opioid dependence.
The uncritical acceptance of naltrexone by some prescribers begs some important questions. If short-term use of a treatment causes an increase in long-term mortality, is the treatment ethical? If patients mandated to receive a course of treatment only relapse and reoffend a year later, is the treatment an efficient use of resources?
Naltrexone appeals to the same people who push abstinence programs that have long-term success rates well below 10%. Current abstinence treatments often center around programs developed in the 1920′s, that ignore the advances in our understanding of neuroscience and addiction since that era. Abstinence programs blame failures on patients rather than recognizing failed treatment approaches. The case of Philip Seymour Hoffman should call out for a new paradigm, where patients are treated with medication that works and continues to work over the years of a person’s life.
Naltrexone is a ‘blocker’—a great thing for the anti-drug attitudes in all of us. But does it matter that people treated with naltrexone die from overdose at a rate 7-fold higher than people on methadone? Proponents of naltrexone ignore the long-term nature of opioid dependence. And whether naltrexone is administered by shot or by tablet, patients inevitably stop taking it. The ‘naltrexone paradigm’ calls for only 6-12 months on the medication, and many patients drop out even sooner, when their probation ends.
Many patients learn from the internet or elsewhere that naltrexone increases their sensitivity to heroin, a ‘reverse tolerance’ effect that makes relapse impossible to resist. The same hypersensitivity causes greater risk of death, making ‘one last time’ a self-fulfilling prophecy.
On the other hand, headlines that decry ‘abuse of buprenorphine’ greatly exceed true harm from buprenorphine. Most buprenorphine abuse consists of self-treatment by addicts who have no access to the medication, because of limits on patient enrollment and regulations that discourage physicians from prescribing the medication. ‘Abuse’ of buprenorphine is far more likely to prevent overdose than to cause harm. Even one dose of 8 mg buprenorphine prevents death for several days by blocking opioid receptors.
Given the safety of buprenorphine, it is hard to justify the use of temporizing measures or ineffective step treatments. Addiction deserves proper medical treatment—not superficial approaches that delay death for a year or so.