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.

Suboxone Makes Me Fat and Boring and Stupid

Originally posted 3/6/2013
A late post tonight, since my new exercise program has pushed my blogging back by an hour or so each night.  My suspicions about exercise were correct, by the way; it is much easier to suggest exercise to other people than it is to actually exercise.  I’ve been at it since the beginning of the year, and I at least feel a bit less hypocritical.
While I’m on the topic…  I’ve received many comments over the years from people complaining that they’ve been taking Suboxone or buprenorphine for X many years, and they have no energy, they feel stressed, they have gained weight, they don’t sleep well or they sleep TOO well… and concluding that all of the problems are from Suboxone.
Suboxone causes… everything!
They aren’t (from Suboxone).   Not at all.  But I wonder, at this point, if regular readers of my blog know EXACTLY what I’m going to say.  I’m tempted to stop typing and ask people answer so I get a sense of how predictable I’ve become.    But then I’d have to wait and then come back, read, and assess the situation….  I really can’t imagine much positive to come out of THAT experience, so I’ll just finish my thoughts, about the problems that people often blame on Suboxone.
The problems are the result of other things, including things that tend to occur naturally as our lives become less chaotic and more outwardly-secure.  The problems I mentioned above, for example, come from inactivity.  They come from thinking that we’ve ‘paid our dues’ at the age of 30, and it’s time to coast in life.  They come from failing to seek out challenges, and from failing to do our best to tackle those challenges.  They come from letting out minds be idle, smoking pot or watching American Idol  instead of responding to the naggings sense of boredom that ideally pushes people to join basketball, tennis, or bowling leagues.
Our minds and bodies are capable of SO much.  I (honestly) am not a network TV viewer, but I love the contrast of ‘before and after’ scenes on ‘Biggest Loser.’  People magazine (it sits in my waiting room) had a section a while back about people who lost half their body size, by exercise and dieting.  The part I found most interesting was the deeply personal answer that each person had to the question, ‘what was your turning point?’  Each cited an episode of humiliation or shame that lifted the veil of denial, and helped them do what they knew, all along, needed to be done.
We are not all capable of ‘Biggest Loser’ comebacks. But it is important for people to understand that feeling good, physically or mentally, takes work.   That incredible feeling of a ‘sense of accomplishment’ only comes when we accomplish something.  We don’t need to eliminate global hunger or cure cancer; sometimes we just need to shovel the driveway, mow the lawn, or do a crossword puzzle.  I’ve learned, as a psychiatrist, that the people who walk around with smiles on their faces usually did something that made the smile happen.  I’ve learned that ‘feeling happy’ does not just happen for most people.  And I don’t think I’ve ever met a person who answered, when asked about stress, ‘no—I don’t have anxiety.’
Once someone blames Suboxone for their problems, it becomes less likely that the real causes of those problems will become apparent. For example, If I think that my glasses are giving me headaches, I’m less likely to make changes in my diet that might make the headaches better.  Once we have something to blame, our problems become more and more engrained, and the real solutions become less and less evident.
I’m truly sorry if I am coming across as ‘preachy’; understand that I’m just trying to make my way through life like everyone else.  But I now take note of all those people power-walking at 6 AM, and I understand why they do it.  Some of them might be on Suboxone.  Some of them might not be.  But I respect all of them for opening their minds, and for their willingness to do the hard work that brings happiness—or at least points in that general direction.

Does Suboxone Cause SIDS?

Originally posted 1/13/2013
In a recent Google search about Suboxone and pregnancy, one of the top links included the frightening statement that Suboxone and buprenorphine have been linked to SIDS or sudden infant death syndrome, commonly called ‘crib death.’
The statement was from a health forum where a woman wrote about taking Suboxone during pregnancy.  She wrote that her child went through opioid withdrawal after delivery, recovered, and then died two months later from SIDS.  She then claims that her doctors told her that Suboxone was a possible reason for her child’s death.
Suboxone and SIDS?
I don’t know if the woman’s story is true. If it is, I hope my comments do not cause her pain, and I’m sorry for her loss.  But someone should comment on the information, given the number of young women on Suboxone who become pregnant and frantically search the internet for reassurance that their baby will be OK.  I know that pregnant women in my practice lose a great deal of sleep because of guilt over taking buprenorphine.  I am not a SIDS specialist, obstetrician, or pediatrician, and I do not actively follow the SIDS literature.  But I have done some reading to prepare for this post, and I’ll do my best to address the issue.
While the causes of SIDS are not completely understood, a number of factors have been associated with sudden infant death, including maternal age and socioeconomic status (higher rates in infants of poorer, younger mothers), maternal smoking, air pollution, low birth weight, season of birth (higher in infants born in the winter), too high or too low room temperature, male sex, history of premature birth, and bottle feeding (instead of breastfeeding).
One of the biggest risk factors is the easiest to correct: sleeping position. The incidence of SIDS is thought to be about twice as high for babies who are placed prone (face-down).  Since 1992, when 4895 deaths were attributed to SIDS in the US, a public relations campaign to encourage parents to place infants on their backs may have reduced the incidence of SIDS by 50%.  I write ‘may have’ because some experts attribute the decrease to changes in how infant deaths are coded and reported, rather than to a true decrease in cases.
SIDS is a leading cause of death among healthy US infants.  But the actual risk is very low, estimated at about one death from SIDS per 2000 infants.  Deaths from prematurity or from congenital disorders are far more common than SIDS.
When I started this post, I planned to write that the link about buprenorphine causing SIDS was nonsense.  And it may be nonsense.  Realize that it is very difficult to determine the risk factors for things that rarely occur. Only relatively common factors like smoking or prematurity are identified as risks for SIDS in controlled studies.  Unless the connection is very strong (and it isn’t), there are not enough pregnant women on buprenorphine to cause a detectable rise in deaths from SIDS, even in the largest studies.
So what about the link in search engines about SiDS and Suboxone?  From what I can tell, the connection between buprenorphine, Suboxone and SIDS comes from a 2007 study in Finland that prospectively followed 67 women who had babies while prescribed buprenorphine.  In that study, 2 of the 67 infants were reported to have died from SIDS, an incidence of 3%.  A number that high is certainly frightening. But at the same time, an effect that strong would be evident in the larger SIDS studies—- especially those including thousands of women.
A closer look at the Finnish study reveals that the two infants who were thought to have died from SIDS were born to women who were not compliant with the buprenorphine program, i.e. who were using other opioids including heroin.  The associations between SIDS and other risk factors—risk factors that are common among active drug users, such as smoking, low socioeconomic status, low birth weight, and prematurity— confound the results of the study.  Are women struggling with active opioid dependence as likely to know that infants should be placed on their backs? Some SIDS researchers have questioned the numbers from the Finnish study, The forensic uncertainties often associated with SIDS, the significant risk of death associated with co-sleeping, and the challenge of monitoring women who are actively using opioids further confound the Finnish study.
One possible cause of death in SIDS is the accumulation of carbon dioxide in soft blankets or clothing, close to the mouth and nose of a baby sleeping prone (face down).  That cause of death suggests danger for an infant who is for some reason administered opioids, since opioids reduce respiratory response to carbon dioxide.  Opioids are secreted in breast milk, including buprenorphine.  The infants of mothers on Suboxone/Subutex would be tolerant to any buprenorphine in breast milk, since the exposure would be less, if anything, than the exposure during pregnancy.  But mothers who are noncompliant, i.e. intermittently dosing with high-potency opioid agonists, could in theory expose their infants to levels of opioids higher than the infants’ opioid tolerance.  I did not find any reported associations between opioid use, SIDS, and breast feeding.
My take on the data is that the safest situation for any infant is to develop in the womb of a woman who is not drinking alcohol, smoking cigarettes, taking prescription medications, or using illicit opioids.  Out of all of these things, being compliant with a stable dose of buprenorphine or Suboxone likely carries the least amount of risk.  If there was certainty that pregnant women could remain free from opioids after stopping buprenorphine maintenance, then stopping buprenorphine during pregnancy would be a good idea.
But unfortunately, far more women PLAN to remain opioid-free after Suboxone, than actually remain opioid-free.  The intermittent use of illicit opioids, and the malnutrition, cigarette smoking, poor sleep, poverty, needle-sharing, and other risky behaviors that come with opioid dependence create the worst-case-scenario, making the stable use of Suboxone or buprenorphine far safer in comparison to ‘planned abstinence.’
As with everything, there is the world we want, and the world we live in.  I encourage women addicted to opioids to do all in their power to maintain compliance in a Suboxone/buprenorphine program.  I also encourage these women to look forward to a life of doing the ‘next right thing’ for their children— and cutting themselves some slack over taking buprenorphine.  Efforts to stop Suboxone would be better used to avoid alcohol, tobacco, and illicit substances, and to maintain appropriate prenatal care.

Suboxone Side Effects Pt. 2

Originally posted 1/2/2013
We can now leave naloxone out of the discussion, and focus on the side effects of Suboxone that are caused by buprenorphine.
Side effects are symptoms caused by a given medication that are not part of the therapeutic benefit of that medication.  Whether a symptom is a side effect depends on the reason for taking the medication.  For example, decreased intestinal motility is the desired effect of opioids used to treat diarrhea, but a bothersome side effect when taking opioids for pain.  The term ‘side effect’ is not on the package insert for medication, the symptoms and actions instead referred to as ‘adverse reactions.’  Package inserts also have a section entitled ‘warnings and precautions’ where the most dangerous adverse reactions are listed.
Some medications have a ‘black box warning’ for adverse reactions that are particularly common or particularly dangerous, consisting of a frightening statement at the start of the package insert (enclosed, naturally, by a black box). Black box warnings in psychiatry include the warning for increased suicidal ideation in children and adolescents treated with antidepressants, and the increased risk of death in people with dementia treated with atypical antipsychotics.
Increased risk of cancer or mutations, and effects on fertility or fetal development, are listed in yet another section entitled ‘nonclinical toxicology.’  They are listed as ‘nonclinical’ because the events do not involve the intended physiologic system or pathway targeted by the medication.  For example, slowing of intestinal activity by opium is either treatment of diarrhea or unwanted constipation, but in either case the outcome is caused by actions of opioids at opioid receptors.  If the opium molecule happened to bind to DNA and cause cancer, the cancer would be nonclinical toxicology, not a side effect.  Carbamazepine decreases the excitability of neurons to prevent seizures, and the sedation caused by the slowing of neurons is considered an adverse reaction. Carbamazepine impairs fetal development through different actions, considered nonclinical toxicology.
All of these divisions can be picked apart so that division of symptoms to one category or another will appear arbitrary.  The system is not precise, by a long shot.  But it may be helpful to be aware that one person’s ‘adverse reactions’ are another person’s intended therapeutic effect.  Some people find the mood stabilizer quetiapine too sedating;  others find the sedation critical to a good night’s sleep.
Allergic reactions are yet another issue.  To put it simply, medication allergies are not something that the medication does to the body, but rather something that the body (the immune response) does to a medication—and the inflammatory fall-out from that reaction.  While the distinction sounds like splitting hairs, the true nature of a reaction can be important.  Nausea is a common adverse event from the action of opioids, used for pain control, at opioid receptors.  Through intellectual laziness, a patient with nausea from morphine in a hospital is often incorrectly labeled as having a morphine allergy. Because of the bureaucracy of modern medicine, the patient has had a very useful medication removed from the armamentarium of treatment options, in essence forever.  Analogous situations are ‘allergies’ to antibiotics like erythromycin.  Allergies tend to become worse with each medication exposure, whereas adverse reactions often go away over time.
Am I going to need a part 3?
Things actually get pretty simple from here. Buprenorphine, like other opioids, has a range of predictable effects that occur along the dosage spectrum— a spectrum that is relative to the person’s opioid tolerance.  Doses of buprenorphine low on the person’s tolerance spectrum fail to have the desired action of preventing withdrawal.  Doses that are close to a person’s tolerance level have the desired therapeutic effect, i.e. blocking withdrawal and a reduction in cravings for opioids.  Doses in this range commonly cause ‘ileus’, i.e. disruption of the normal movement of the intestine.  Ileus in turn causes a number of symptoms, including constipation, cramping, bloating, loss of appetite, and nausea.  Constipation can lead to increased intestinal pressure, leading to hemorrhoids or diverticular disease.
Apart from ileus, buprenorphine and all opioids have direct actions at the base of the brain, at the ‘area postrema’.  Actions at the area postrema cause nausea as an adverse reaction, or in other cases the desired therapeutic effect of induced vomiting.  Nausea is very common when doses of opioids are taken that are at the upper end of tolerance, making nausea particularly common with potent opioids like buprenorphine.  Impaired coordination, slow reflexes, sedation, slurred speech, and somnolence are also caused by strong opioid effects.  Combinations of these effects are obviously quite dangerous.
Opioids reduce the tone of the ‘gastroesophageal sphincter’, increasing the chance of acid reflux, heartburn, hoarseness, and theoretically even esophageal cancer in severe cases.
Cough suppression by opioids might be a therapeutic benefit, but can be an adverse reaction if gastric contents are aspirated into the lungs.
Opioids reduce the response of the brain’s respiratory centers to carbon dioxide, resulting in less drive to breathe.  Carbon dioxide level therefore goes up, and the rise in CO2 increases brain blood volume and in turn, intracranial pressure.  The increased brain pressure reduces the flow of fresh, oxygenated blood into the brain.  Because of this potentially-disastrous sequence of events, opioids must be used with caution in people with head injuries.
Respiratory depression is a common reason for overdose, but even that adverse event can be a desired therapeutic benefit in some cases, for example in patients who are on a ventilator and triggering the machine to cause hyperventilation.  Respiratory depression is even used therapeutically to reduce ‘air hunger’ in people at the end of their lives, to relieve suffering in patients and patients’ family members who are witnessing the death.
I realize that a simple list of side effects would have been easier to read, but like the proverb says about giving a man a fish, I’m hoping that running through the processes will help people figure out, for themselves, what their medications are doing.
What else…  pruritis or ‘itching’ is a common side effect of potent opioids, that doesn’t respond very well to the usual anti-itching treatments like diphenhydramine or steroids.  All common opioids except meperidine (Demerol) constrict pupils, which often makes daytime vision sharper, but impairs night vision by allowing less light to fall on the retina.
Opioids reduce immune function through a number of physiologic interactions, including the presence of opioid receptors on immune tissue. Opioids can have a range of effects on mood and mood disorders.  All opioids, including buprenorphine, have the potential to reduce testosterone levels in men, which in turn can affect mood, libido, and sexual performance.  Opioids alter the release of vasopressin, changing how much water is conserved by our kidneys—which in some people results in more trips to the bathroom at night.
Buprenorphine and other potent opioids interfere with the initiation of ‘micturition’, i.e peeing, particularly in men who are already struggling from an enlarged prostrate.
I know that I’m missing something, and I invite people to write and help me out.  I also realize, as I write this, that I don’t have a package-insert category for a particularly common worry about Suboxone, that it is hurting one’s teeth.  Such a reaction, were it found to be attributable to Suboxone, would probably be considered nonclinical toxicology, although a recent case report proposed that buprenorphine could increase cavities by reducing the immune response in teeth, which sounds more like an adverse reaction.  In either case, I’ve written about the lack of evidence for tooth damage from Suboxone, but the topic still appears on my forum now and then.
That’s all for now…

Brain Surgery or Suboxone?

Originally posted 12/31/2012
Today I read about the stereotactic brain surgery used to treat opioid dependence in China over the past ten years.   The procedure is relatively straightforward; the patient’s skull is clamped in place while small holes are drilled, guided by computerized, 3-dimensional maps of the brain.  Probes are inserted deeply through brain tissue to the nucleus accumbens, where electric current destroys varying amounts of brain tissue.   Patients are awake and talking during the procedure, so that surgeons know if the probes are too close to brain regions that control speech or other functions.
A large number of ablations for the treatment of addiction were performed in China about ten years ago.  The rapid growth in popularity of the technique, before full knowledge of the risks and long-term effects, led to a ban on the procedures by the Chinese Ministry of Health in 2004.  Still, ablations were performed as part of research studies, with over 1000 people treated by ablation since 2004.
The scientific community outside of China overwhelmingly condemns the technique, and medical journals are pressured to withhold publication of ablation studies.  Human rights advocates claim that such experiments are performed on people who are not fully aware of the risks, or who are pressured to participate in the studies to avoid harsh punishments for drug offenses.  The veracity of the results from ablation studies has also been challenged. Ablation treatment of opioid dependence is in the news lately because of a recent paper describing the five-year follow-up of opioid addicts treated by the procedure.
Neuroscientists distinguish between DBS (deep brain stimulation by electric current) vs. procedures where brain tissue is destroyed.  I’m surprised by the intensity of the distinction, given the similarity of the procedures.  In both cases long probes are passed through brain tissue, risking hemorrhage, stroke, or seizures.  For DBS, wires are left behind and connected to power-packs that release different patterns of electrical current.  In the ablation studies, small areas of tissue at the end of the probes are destroyed, and the probes removed.  If there is a future for addiction treatment using stereotactic brain surgery, DBS is likely to become the procedure of choice, given the preference by the scientific community for non-permanent interventions.
The recent follow-up study found that about half of those treated by ablation of the nucleus accumbens were sober from heroin after five years.  But about a quarter of the patients who had ablation were found to have long-term neuropsychiatric side effects including memory loss, loss of motivation, mood disturbances, and loss of sexual desire.
I found the studies and results interesting in a number of ways.  Throughout the latest paper, the authors point out the severe consequences of opioid dependence and the lack of effective treatment options.  Opioid dependence is noted to be a permanent, progressive, fatal condition, with a prognosis poor enough to warrant drilling holes in the skull and destroying brain tissue.  Even as record numbers of young people die from overdose, I don’t have the sense that US citizens recognize the severity of the problem.
I find it interesting how strongly society’s perceptions influence what are considered appropriate or inappropriate brain procedures. SingularityHub points out the popularity of frontal lobotomies after 1949, when António Egas Moniz won the Nobel Prize for Physiology or Medicine for inventing the procedure.  Over 20,000 lobotomies were performed in the US by 1951, but the procedure was discredited and eventually banned in the US.  Who says the Nobel Prize people always get it right?
The recent study’s introduction points out that the most stringent addiction treatments in China– compulsory detoxification, mandatory labor, education, and skills training for as long as 3 years– have one-year abstinence rate of 44% and 3-year abstinence rates of only 15%.
Drilling holes deep into the brain to destroy the pleasure centers might bring the sobriety rates up to 50%, but at the cost of memory, motivation, and sex drive.
And then there is buprenorphine (brand name Suboxone), a medication that has success rates over 50%, with fewer risks or side effects than drilling holes in the brain– but that remains limited by US law.
Which approach would you prefer for your son or daughter?

Marijuana Laws: Progressive Change or Society's Downfall?

Originally posted 12/8/2012
I’ve been hearing more calls these days to change US marijuana laws (note- Colorado and Washington legalized recreational use of marijuana shortly after this article was originally posted).  Legalizing marijuana has been a cause for some citizens for decades, and efforts to change marijuana laws have waxed and waned since I was a teenager in the 1970’s.  Some people believe that this time around, attitudes are truly changing.  A recentQuinnipiac University poll  showed that as of November 2012, a majority of US voters favor legalization of the drug for recreational use.
The current status of marijuana laws are confusing, to say the least. Marijuana is regulated at multiple jurisdictional levels, so a person in any one location is subject to state, federal, and sometimes local laws.  These laws are often at odds with each other, so the legality of marijuana depends largely on the employer of the agent or officer making the arrest.
There are also multiple forms of legality. In November, Colorado and Washington State legalized possessing up to one ounce of marijuana.  Another dozen-or-so states decriminalized marijuana over the past 20 years, so that possession of the drug is punishable by citation, not prison time.  Another 20 or so states have laws allowing for the medical use of marijuana, including in some cases provisions to grow marijuana for personal use or for a small number of patients.
By Federal law, marijuana use remains illegal in virtually all settings.  The DEA classifies marijuana as ‘Schedule I’, the same status as heavy-hitters like LSD or Heroin.  Smoking marijuana can be reason enough for most employers to terminate employment.  And violation of marijuana laws, even possessing small amounts of marijuana, can result in permanent banishment from federal financial aid programs for higher education.
I have no pressing opinion on this issue.  I don’t have a ‘marijuana problem’, and I never really had a problem with the drug.  I smoked it as a teen, and note that the year of my high school graduation, 1978, was the peak year for marijuana use in this country.  But I never enjoyed smoking pot as much as some people appear to.  I always had things that I wanted to do or accomplish, and smoking marijuana, as I grew older, got in the way of those things.
Marijuana was a much less potent drug in the 1970’s than it is today.  In my teens, people talked about ‘smoking a joint or two.’  Now that the THC content is much greater, people have ‘hits.’  I just realized, by the way, how ‘square’ I sound right now.
It is difficult to know whether perceptions surrounding marijuana are accurate or based in fantasy.   Last night I saw a Facebook post from one of my HS classmates that included a picture of my geography teacher in 1976, wearing extra-long, extra-wide, plaid bell-bottom slacks.  It is hard to remember 1970’s marijuana without remembering all the other silly things that we did in the 1970s, that seem so harmless in retrospect.  On the other hand, I remember the fallout shelters and nuke drills back then, which on paper seem every bit as serious as any ‘fiscal cliff.’   Clearly, dangerous things in the past seem less frightening than dangerous things now.
Is marijuana a ‘gateway drug’ that leads to use of more dangerous substances? Marijuana smokers are more likely to use heavier drugs than are non-marijuana-users, but correlation is not causation.  I’m reluctant to conclude that marijuana use ‘causes’ people to use pain pills or heroin. At the same time, I don’t buy the arguments by some pot smokers that marijuana keeps them sober from alcohol or illicit substances.
My Klout score isn’t so high as to impact the likelihood of legalization of marijuana, but I will share a few thoughts anyway about my clinical experiences and observations:

  • Many of my patients can smoke marijuana without apparent negative impact on their lives.
  • Many patients have shared with me their desire to stop smoking, but are unable to leave the drug behind.
  • The biggest downside of marijuana use from my perspective is the complacency that some users develop.  Some marijuana smokers seem to accept miserable circumstances that they would be more likely to change if forced to endure them without smoking pot.
  • Medical marijuana, at least in some cases, is a system rife for abuse.  I meet patients from neighboring Michigan who are prescribed marijuana to treat pain from cancer and side effects from chemotherapy.  I see other patients prescribed marijuana for headaches, fibromyalgia, anxiety, depression, irritable bowel, Crohn’s disease, and a host of other symptoms and disorders.  For all other medications, the FDA provides guidelines on the proper indications for the drug.  Medical marijuana, however, has been embraced as a panacea for so many symptoms and conditions that it is difficult to accept any specific treatment as ‘clinically indicated.’  The illegal status of marijuana, of course, prevents the FDA from considering the drug as medically indicated for any condition.  So we have the worst of both worlds;  a drug without proper vetting by the FDA, only-legal-enough to allow for use without good clinical study.
  • Proponents of marijuana legalization compare marijuana to alcohol from the perspective of fairness, but when doing so often neglect to consider the huge societal costs from use of alcohol.  Or as your grandma used to say, ‘two wrongs don’t make a right.’

Many young people have been led to believe that the Obama administration is on ‘their side’ in regard to legalizing marijuana.  I wonder, though, if legalization of marijuana will require the lead of a traditional antagonist—as Clinton participated in welfare reform, and Nixon opened relations with China.  In other words, I’m not expecting big changes on the federal level anytime soon.
(Addendum: We have a good experiment underway in two states— let’s follow the data….)

The End of Narcotic Pain Medication?

First posted 11/15/2012
The LA Times ran a very interesting story a few days ago about deaths from overdose of narcotic pain medications.  I strongly encourage readers of this blog to read the story, which discusses the issue from the perspectives of doctors, patients, and family members.
The story reports that a small number of Southern-California doctors wrote prescriptions that have killed a large number of patients. Over the past five years, 17% of the deaths related to prescription-drug overdose–298 people—were linked to only 0.1% of the area’s doctors.  I was not surprised by the findings in the article, as I have read stories from other parts of the US reporting similar statistics.
There is a simple reason for the skewed numbers.  Prescribing opioids for chronic pain is associated with risk of death by overdose.  More and more doctors are avoiding that risk by refusing to treat chronic pain with opioid pain medication.  That means that the few doctors who are willing to prescribe such medications are linked to a higher number of deaths from those medications.
Are the doctors who prescribe narcotic pain medications ‘bad doctors?’  Some doctors would claim that they are.  I have described the doctors in a group called PROP, or Physicians for Responsible Opioid Prescribing, who take the position that almost all opioid treatment of chronic pain is inappropriate.  I understand the point made by those physicians.  Treating chronic pain using opioids carries significant risks.  Complications, including death, are common.  But I have met a number of patients who suffer from severe pain who take issue with doctors who tell them that they are better off without opioid pain medications.  And I’ve noticed myself, from my own rare occasional injury, that it is one thing to talk about the proper treatment for someone else’s pain, and another thing when one’s self, or one’s loved one, suffers from pain.
The skewed numbers also demonstrate the problem with online doctor rating systems that report on the complication rate for one doctor vs. another.   Across the spectrum of patients in need of surgery, for example, are healthier patients with relatively low risk of complications, and sicker patients with higher risk of complications.  If a doctor restricts his/her practice to treating only the healthier (often younger) patients, is he/she a better doctor than the doctor treating the sicker, older patients?  The numbers for the first doctor will surely look better than the numbers for the second doctor!
Some people worry that the efforts to ‘score’ doctors based on outcomes will lead doctors to avoid treating the neediest, highest-risk patients.  As evidence that those concerns are valid, one only need look at the trends in opioid prescribing. If treating certain conditions increases the risk of being called a bad doctor, many doctors will focus their efforts elsewhere.  Doctors are, after all, only human.
Perhaps because of years of academic competition, doctors are less likely to support colleagues under fire than to pile on, like sharks sensing blood in the water.  As a result, the risk of treating chronic pain using opioids goes beyond being called a bad doctor, and can include loss of license and even criminal prosecution.  As much as any doctor wants to relieve a patient’s pain and suffering, watching colleagues go to prison doesn’t do much to incentivize narcotic pain management!
Some healthcare regulators and even some physicians try to make this issue appear simple, by painting patients with chronic pain as drug-seekers at worst, or as ignorant healthcare consumers at best.  But as someone who has worked in the trenches, I know that the issue is not that simple.  Right now, across the US, a number of doctors are listening to patients who are tearfully describing their misery and pleading for help.  As these doctors consider the options for their patients, they think about the comments by President Obama’s President Obama’s drug czar, R. Gil Kerlikowske, about the LA Times findings: “Do I think this has the potential to change the game in the way it’s being looked at and being addressed, both at the state and federal level? Yes, I do.”
If you were a doctor, what would YOU do?

Suboxone and Tooth Decay

Originally posted 10/21/2012
I have received a several emails over the past few years from people who experienced deteriorating dental health while taking buprenorphine or Suboxone.  I also have patients in my practice who have had extensive dental work, and wonder if Suboxone is to blame for their cavities or other problems.
I wrote about this issue several years ago.  At that time I wrote that there was no evidence that sublingual buprenorphine or Suboxone cause or accelerate tooth decay.  After writing the article I received a number of angry emails from people who insisted that I was wrong.
Let’s step back for a moment to highlight the difference between thinking something vs. proving something.  Some people misunderstood my comments about tooth decay and Suboxone, thinking that I was arguing that Suboxone does not harm teeth.  That was not what I wrote.  My point was that as of that time, there was no evidence that Suboxone or buprenorphine caused tooth decay.  When I write about the science of buprenorphine, I try my best to distinguish between what I think is true vs. what was established through scientific study.
I recently met with a patient who has had extensive dental work over the past few years, the same time that she was taking sublingual buprenorphine.  She asked if I thought that the two were related.   I made a few comments (that I’ll be getting to), but also promised her that I would do a literature search, to see whether any connection has since been established.  Ironically, a case report of a woman on Suboxone who required extensive dental work was just published yesterday.  The case report is in the latest issue of The American Journal on Addictions, and the same case is cited in the October 20, 2012 edition of Reactions Weekly.
The world of science is not efficient.  Knowledge moves forward slowly, based on findings amassed from many studies, often repeated multiple times.  Case reports are not intended to prove something.  In fact, case reports are often unusual clinical examples that defy the norm.  They are often published to point out an area that deserves more study.
I cannot copy the case report here because of copyright laws.  But the case described a 35-y-o woman who used oxycodone for about a year at doses up to 160 mg per day, and then went on buprenorphine/naloxone.  After 18 months, her dentist told her that she had extensive decay of 4 molars requiring root canal.  She reportedly had minimal history of dental problems before starting opioids or buprenorphine.
The author of the case report hypothesized that if there is a connection between Suboxone and tooth decay, one reason could be xerostomia, i.e. dry mouth, caused by buprenorphine.  The lack of saliva was my thought, too, as a mediator of any possible effects of buprenorphine on teeth.  Saliva serves an important role in dental health, including rinsing away food particles and acting as a buffer.  The patient in the case report did not report a dry mouth, so the author pointed out that all opioids have some ability to suppress the immune response, and perhaps buprenorphine and/or naloxone reduce the immune response, allowing for greater destruction of teeth by bacteria.
The case report, surprisingly, did not say which buprenorphine product(s) the patient had used, e.g. tablets, film, or generic buprenorphine.
What needs to happen next is for someone to do a case-control study of patients on buprenorphine, to see if they are more or less likely to have tooth decay.  The most valuable study is usually a prospective, randomized clinical trial;  that would not be proper here, since it would not be appropriate to randomize subjects to buprenorphine vs. no buprenorphine.  But a close second would be a case controlled study, where patients on buprenorphine are matched to ‘controls’ with similar characteristics— age, sex, eating habits, income level, education, etc.– and the dental outcomes are followed forward over a number of years.  A less-costly, less-reliable study is one that looks backward, comparing patients on buprenorphine with those not on buprenorphine to see which group has a higher incidence of dental caries.
We are not much better off at this point in our knowledge of whether Suboxone or buprenorphine predispose toward tooth decay.  The case report only mirrors what I see in my practice.  But as I often tell patients, I have other patients who are not on buprenorphine or Suboxone, who have tooth problems.  I also have patients on Suboxone with great teeth.  Hopefully some ambitious PhD candidate will sort through the issue soon.

Treatment? Or Murder?

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.
Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.
I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.
In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even if we tattooed the letter A across their chests, there are addicts who are in need of pain treatment. Are we to decide that every person who has become addicted to pain medication gives up the right to pain treatment?  And we know that many of the patients addicted to opioids became addicted through the course of pain treatment from their physician— so I would expect that on average, patients addicted to opioids would have a higher incidence of chronic pain, and vice versa.
I do not find it reasonable to make patients with addiction histories endure pain that would be treated in other patients.  Father than singling out some patients for ‘special non-treatment,’ we should prepare for the risks from opioids in ALL patients—a set of ‘universal precautions for opioid treatment,’ similar to the way we use a different set of universal precautions to avoid transmission of blood-borne infections.
There are times when doctors have to tolerate being the bad guys.  Some patients have been taught, through careless prescribing, that all pain should be treated with narcotics. Those patients are not happy when told, after paying several hundred dollars, that they do not ‘need’ narcotic pain medication– and so many of their doctors have a hard time saying ‘no.’ After all, doctors studied hard to do well in school, and usually receive praise for what they do. It is much easier to write a prescription and hear ‘thank you’ than to be called an unsympathetic jerk! But doctors are paid the big bucks to tolerate such things, and to keep the long-term health of patients in mind. And for many people with chronic pain, opioids will provide a good month or two, but for the price of many years of misery.
I’ve been told by patients “I don’t care about the risks, doc– I’d rather have three good months and then die, then have twenty years in pain.” I reply, “that’s why these medications require a doctor to consider things very carefully, and a good doctor would not allow someone to make that decision.” I’m sure that some people will be angered by that attitude. But the approach is similar to how we handle many other illnesses, where we encourage patients to tolerate short-term misery for long-term benefits. Many patients would refuse chemotherapy and give up on life if not pushed to move forward. And to depressed patients, suicide can appear a reasonable option. I’m a fan of free will, but I recognize that we don’t always choose our paths through life with full insight.
Even with full knowledge of the reasons to avoid narcotics, some doctors really struggle over withholding opioids.  I find it somewhat ironic that the doctors who are too ‘kind-hearted’—i.e. who want to please patients so much that they cannot deny even that which is bad for them—are the ones who end up getting into trouble.  The Iowa doctor is being sued over several of the deaths, likely by relatives of the patients who pled the hardest for pain pills!  Talk about good deeds not going unpunished!
But there are aspects of the case in Iowa that do not argue well for the doctor. Several of the patients who died were only seen once, but treated with narcotics for years. The DEA requires that patients are prescribed no more than 90 days of narcotic medication at one time (divided on three monthly prescriptions). I presume that patients were picking up scripts every three months, without having appointments each time. Such a practice is not strictly illegal (not that I am aware of, anyway), but the standard of care would be to evaluate patients on potent opioids every three months, or even more frequently. And one news article stated that the doctor had tens of thousands of pain patients. As a full-time practitioner with less than 1000 patients, I wonder how so many patients could be managed by one physician.
When I write about this topic I receive angry comments from some readers. Some attack me personally with comments like “I’m glad I’m not YOUR patient!” or “I hope YOU have to suffer with horrible pain some day!” I realize that this is a very hot topic, and my only intent is to educate and inform, to help people understand what is happening in the minds of physicians. Of course, the care of patients should not be determined by the need for doctors to protect their own interests. But at the same time, it is understandable that doctors are affected by headlines announcing the imprisonment of other doctors facing the same treatment decisions.
Bottom line– there are very good reasons to avoid using opioids for nonmalignant chronic pain. Just giving patients what they want, and ignoring the danger of opioids, will likely result in criminal and civil prosecution. But that reason is secondary to the most important thing– the promise all doctors make to first, do no harm. And patients should realize that their doctors may be withholding narcotics for that reason alone.

Avoiding Precipitated Withdrawal

I received the following question earlier today:
Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.
My thoughts:
My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!
The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.
It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, and considerably increases the risk of death.
If a person is taking a very low dose of an agonist, or taking a weak agonist like hydrocodone, the problem at induction isn’t withdrawal, but rather opioid intoxication, causing respiratory depression and nausea.  Nausea during induction is much more likely to signify relative overdose, NOT withdrawal.  Patients who have nausea and vomiting from buprenorphine or Suboxone should NEVER take a second respiratory depressant or sedative!  When in doubt differentiating between withdrawal and opioid intoxication, the pupils are a good guide.  Withdrawal comes with LARGE pupils.
If a person is taking a very high dose of agonist each day– over 150 mg of oxycodone or methadone, for example— that dose should be tapered down over time, to the equivalent of 40 mg of methadone per day.  Unfortunately, some people cannot carry out or tolerate such a taper.  In those cases, it may be better to have the person in a controlled environment, and wait as long as possible before induction.  Even if tolerance is very high, a person will often do well if off opioids completely for 4-5 days or more.  Of course, that’s easier said than done!
There is a cap on the number of patients that doctors can treat for addiction using buprenorphine.  Doctors can have up to 30 patients at first, and can petition the DEA to increase to 100 patients after a year.  It is frustrating to keep people who are desperate for help on a waiting list— especially when there is no limit on the number of pain patients that a doctor can treat using opioid agonists!
Suboxone relieves withdrawal symptoms when taken properly.  But the main function of buprenorphine/Suboxone is to eliminate the obsession to take opioids, and to allow patients to move forward in life without substances.  People do best if besides Suboxone, they focus on other principles of recovery, determined with their physician or with a counselor.  The point of Suboxone, in my opinion, is to learn to tolerate ‘life on life’s terms.’  That includes dosing at most twice per day, and learning to say ‘no’ to the minor cravings that most people have, even on Suboxone.
I’m glad you are looking for help– and I wish you the best!