Buprenorphine Diversion: Beyond a Superficial Understanding

First Posted 11/19/2013
In ‘Addiction Treatment with a Dark Side’, Deborah Sontag of the New York Times shared her observations of the clinical use of buprenorphine for treating opioid dependence, warts and all. Readers of the Talk Zone know my bias—that buprenorphine/Suboxone is one of the only effective treatments for opioid dependence, and many patients are best-served by long-term, perhaps life-long treatment with buprenorphine. But I read the article the article with interest because I know that Ms. Sontag ‘did her homework’, including visiting a number of practices, speaking with a number of patients, and reviewing hundreds of studies about buprenorphine and Suboxone over the course of many months.

From my perspective, the article overstates the diversion problem. In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment. I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.

With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion. Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone. The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year. The total number of deaths linked to buprenorphine over the past ten years is about equal to the number of people who die from acetaminophen– EACH year.

Diversion of buprenorphine is a complex issue. Words like ‘diversion’ and ‘overdose’ are loaded with so much emotion that one word seems to tell the whole story. A Google search of Suboxone brings up news reports such as ‘Suboxone found at overdose scene’, or ‘man arrested with cocaine, heroin, and three Suboxone tablets.’ The stories create an ugly image, with buprenorphine/naloxone as one more drug of abuse, found at ‘an increasing rate’, according to other headlines. But a superficial look at diversion yields a superficial understanding of the diversion problem.

Take as example a patient has not used illicit substances for 3 years while taking prescribed Suboxone, who relapses to heroin and dies from overdose. News stories will describe a scene littered with needles, heroin, and Suboxone tablets. That description creates a misleading impression of the patient’s history, and a misleading impression of buprenorphine. Even if the story provides more detail, the headline alone will fill the tweet—the ‘news’ of the modern era.

Is the nature of diversion, the reason for diversion, or the consequence of diversion relevant to discussions about the diversion of buprenorphine? If someone tries to hold life together by purchasing street Suboxone in a geographic region void of certified physicians, should that ‘diversion’ be included in the category as the sale of oxycodone?

What if the powerful mu-receptor blocking effects of buprenorphine have positive effects? What if studies found a lower rate of overdose deaths in communities with greater diversion of buprenorphine? Would that be relevant to the diversion discussion?

I do not know of any evidence that diversion of buprenorphine correlates with fewer overdose deaths. But many public health experts predict that encouraging ‘street use’ of naloxone would reduce overdose deaths, so expecting the same from buprenorphine, a stronger and longer-lasting mu antagonist, is not unreasonable.

Patients on buprenorphine awaiting elective surgery discover that the blocking effects of buprenorphine last for weeks. The same patients report that even after several weeks off buprenorphine, significant doses of oxycodone will relieve post-op pain, but won’t provide the ‘euphoria’ oxycodone used to provide. Patients who could never make a week’s script for oxycodone last longer than a day can often control use of opioid agonists after surgery if kept on a small dose of buprenorphine. Considering these findings, it is not unreasonable to wonder if there is a lower risk of death by overdose in people who ‘divert’ buprenorphine. Buprenorphine has a much longer half-life than oxycodone or heroin, so diverted buprenorphine intended for use ‘in between’ acts as a blocker during periods of active heroin use. Is it possible that traces of diverted buprenorphine in the bloodstream saves lives? If so, is that relevant to discussions about diversion?

The worst diversion scenario is if opioid-naïve people take buprenorphine or Suboxone and becoming addicted to opioids as a result, i.e. diverted buprenorphine serving as a gateway drug to opioid dependence. Nobody should take that situation lightly. But stories from the streets bring to mind biological programs where sterile males of an invasive species are released into the wild in effort to eliminate the invasive mosquito, lamprey eel, or fruit fly. What if the spread of buprenorphine functions as an ‘addiction moderator’ where the more buprenorphine in a community, the lower the rate of overdose deaths?

I realize that I am out on a limb— but as the saying goes, that’s where the fruit is. If buprenorphine diversion is investigated in a superficial manner, we will collect nothing but superficial results. The diversion of a medication with the potential to save as many lives as buprenorphine deserves a deeper level of understanding.

Pregnant Taking Suboxone: Should Social Services be Involved?

First Posted 11/4/2013
I recently saw a new patient who described treating her own opioid dependence with diverted Suboxone.  She sheepishly described reading everything she could find about buprenorphine and meticulously using half of her friend’s medication to avoid other opioids, without fail, for four years. She would likely be treating herself now, if she hadn’t become pregnant and  told her OB and a hospital nurse what she was doing.  Her disclosure prompted a call to CPS, leading to the assignment of a caseworker and the threat to remove her baby from her home.  CPS eventually allowed her to keep her baby providing that she stop using medication illegally—prompting her to call my office.
My first reaction was that everything worked out well, and justice had been served.  But since the visit I’ve thought about some of the inconsistencies in how HIPAA is applied, and in the general attitude toward doctor/patient confidentiality.
I’ve also given thought to how things could have worked out, had my patient count been at 100 rather than 99.  There are not many buprenorphine-certified prescribers in my area, and she very likely would have been unable to find a doctor if my practice was full.  Had that been the case, what would have happened?  Would CPS have backed off and told her to go back to doing what she had been doing?  More likely she would have been given the choice of stopping buprenorphine or going to the methadone/buprenorphine clinic an hour’s drive away.    In the latter case, how would that work, exactly, traveling an hour at 6 AM each day as the single mother of a newborn infant?
I suspect that if my practice had been full she would have stopped buprenorphine or Suboxone, and joined the ranks of either the 4% of people who remain clean after stopping buprenorphine or the 96% who relapse within a year.  Would anyone at CPS have noticed which group she became part of?
Her case is an example of how complicated the ‘diversion’ issue has become.  And perhaps I’m paranoid, but I feel the need to say that I am against diversion of buprenorphine.  I’m saying so because I know the righteous attitudes of some physicians who claim to be more careful than others.  So to avoid confusion…. diversion is bad.  I’m on THAT side.
But death is bad too.  And breaking patient confidentiality is bad.  My new patient is someone’s daughter, and I found myself wondering what I would have recommended had she been MY daughter?  What would the reader recommend for his/her daughter?  She is 22 years old.  She became addicted to opioids at 16, when her best friend shared Vicodin that she found in her mother’s medicine cabinet.  By 18 had tried to quit a number of times on her own and with the help of meetings.  She failed intensive outpatient and residential treatment, like the vast majority of patients who take those paths, before her parents asked her to move out.
She tried calling numbers on the NAABT and SAMHSA databases but found that all listed practices within an hour’s drive were full, or more often were out of the ‘Suboxone business.’  She went on methadone for a few months but had trouble making the 50 mile drive to the clinic in the middle of January—an understandable problem for people who know the area.
At some point she met someone who agreed to share a prescription of Suboxone, splitting the script if she picked up most of the cost.  Compared to a buck per mg for oxycodone, she thought she found a bargain.
I’m usually able to let go of conflict in such cases by arguing for the common good, or by pointing out the things that she should have done to avoid her current problems.  But those positions are more difficult when one imagines the hypothetical case of a son or daughter.
I was going to make a number of points, but it is getting late, the Packers lost, and I’m in the mood to just call it a night.  I was going to ask whether or not her isolated case truly threatens the ‘public good.’  I was going to ask if it is appropriate to call CPS about someone who has done all that she can to create a better environment for her baby.  I was going to ask if breaking her confidence for the good of the child would be a bit paternalistic by modern medical standards.  I was going to ask if there are different types of ‘diversion’, and if self-treatment, in the absence of any other option, should always be condemned?
But I think I’ll just leave it here, and ask people to imagine their own daughter in the situation that I described.  Would you be angry that she met someone who shared Suboxone?  I know that some will claim that there must be other options— an argument that I’ve already heard from several people claiming the doctor did the right thing to turn her in.  But if there were any options I didn’t mention, I am not aware of them.
What would you have recommended for your child?  Things worked out this time, but I have a waiting list of 90 people who are looking for a doctor who prescribes buprenorphine, and I had just discharged a patient the day before her call.  Nobody was out there making certain that after the call to CPS, she would find a reasonable option.  With that in mind, how was the call to CPS consistent with the thought of ‘first, do no harm?’
A few comments from the original post:
WisdomQ:
What is a pregnant woman taking buprenorphine supposed to do? Stop being addicted to opioid’s for 11 months?
A 2010 study (http://www.nih.gov/news/health/dec2010/nida-09.htm) found bupe to be less problematic than methadone. Perhaps the most powerful tool is to never tell the child about it unless the child starts to abuse opioid’s on their own; considering the power of suggestion.
Tic:
This patient had been diverting suboxone for four years. I doubt that she was looking for a provider for four years without any success.
Me:
I don’t know what things are like in your area, but patients in northern Wisconsin have no access to buprenorphine-certified physicians. Some are listed– but they are all people who either signed up but never actually prescribed buprenorphine, or who shut down that aspect of their practice.
I’ve been at the 100-patient limit since shortly after the limit went from 30 to 100. My waiting list has 90 patients. Note that I do no accept any insurance panels– not just for the 30% of my practice that comes for addictive disorders, but for all patients– but patients wanting buprenorphine have no choice (the other patients choose to see me because I provide much longer appointments, guarantee to start on time, provide easy access, etc). There were two other docs in the county that at least prescribed the medication; one left a year ago, leaving one person.
Even in areas where there are more doctors, many doctors arbitrarily discharge patients after one year (or Medicaid in a state may stop covering the medication after one year). Studies show 94% relapse rate in people treated with buprenorphine for a year– i.e. the medication is best considered as similar to most other medications, as a TREATMENT, not a CURE. There are also practices who abandon the people who struggle the most– a cruel way of practicing medicine that is unique to addiction. So again, I imagine there are places where a patient has been kicked out of the practice of the only provider, perhaps for taking a benzodiazepine– instead of seeing the illicit use as one more aspect of her ILLNESS that deserves better treatment. Perhaps you consider it fair to give a 17-y-o woman one chance– and if she fails, tough luck—- and if that is the case, I hope you’re not someone’s doctor.

Who Pays For Health Care? (Hint: We ALL Do)

First Published 4/20/2013
I realize that practice patterns differ between practices, even those treating the same condition (opioid dependence) with the same medication (buprenorphine).  Differing patient characteristics result in different regional standards of care, for example.  And some areas have access to services (e.g. group treatments or laboratory testing) that may not be as available somewhere else.
Is Anyone Trying to Reduce Costs?
Physicians also have differing opinions and attitudes toward relapse and personal responsibility.  Some docs are more paternalistic than others. Some are quicker to dump ‘difficult’ patients. For most medical problems, patients are able to find doctors whose practice patterns match their personal preferences.
Shortages of buprenorphine prescribers in some parts of the country force patients onto waiting lists, and to take whatever open space comes along, whether or not they consider the physician to be personable or competent.  I resist finding fault in how other docs run their practices, as I have no way of knowing the considerations that any physician takes in regard to his/her patients.  But I sometimes hear about practice styles that make me wonder if patients need a wider range of options.

Per Capita Healthcare Costs
Per Capita Healthcare Costs

A patient in my buprenorphine program is trying to find treatment for his wife.  I’m at the cap, so I can’t take more patients.  At a recent visit, he described the practice where his wife receives buprenorphine treatment.  I realize that I’m hearing only ‘his side’, but he had little to gain by misleading me…. beyond, I suppose, having an interesting story.
He said that his wife has done well on buprenorphine/Suboxone for over two years.  She hasn’t relapsed or missed appointments, and she hasn’t tested positive for any other psychotropic substances.
She is required to attend weekly psychotherapy sessions with a counselor employed by her physician.  If she misses a psychotherapy appointment, she is subject to discharge from treatment.  Even after two years of doing well, she is required to continue weekly psychotherapy.  She must attend at least one AA or NA meeting per week.  She must see the prescribing physician every month.  And every month she undergoes urine testing.
Her prescriber accepts Medicaid, so her financial burden is not all that high, other than needing to take time off from work five times per month for appointments.  But her husband described the invoices that she receives for charges to Medicaid.  The charges for doctor appointments are significantly discounted, so they make up less than half of the total bill.  But the lab bills add up.
The clinic charges Medicaid a couple hundred dollars for each ‘point of care’ urine test.  Without Medicaid, the charge is paid by the insurer or by patients themselves.  I showed her husband the kits I use that test for the presence or absence of amphetamines, cocaine, buprenorphine, THC, methadone, oxycodone, mixed opioid (e.g. heroin), and PCP.  I purchase the test kits through internet suppliers, complete with collection vials, for about $5 per test— total, for a test that measures simultaneously for all of the substances.  The $5 kits are just as sensitive and accurate as the $200 tests. The only difference is that I do the testing myself in about 3 minutes, rather than send the urine to the lab.
People with ‘indeterminate’ tests at his wife’s clinic— something that he says occurs about 30% of the time— undergo ‘quantitative’ drug testing.  I’ve written about the boondoggle of quantitative urine testing in the past, about why the tests are not an accurate reflection of blood levels of substances.  In short, blood is filter at the kidney through sieve-like structures.  That filtrate goes through a series of tubules where water is re-absorbed in varying amounts, depending on the balance between fluid intake and fluid loss through sweating, respiration, etc.  Because of the varying concentration of urine, the concentration of a drug in the urine is not directly related to the concentration of that drug in the bloodstream.  Further confounding the tests, some substances are specifically transported out of the filtrate, and others are specifically excreted into the filtrate.
Quantitative tests measure the amount of each substance in the patients’ urine, but tell little about the amount of each substance in the bloodstream.  Labs try to correct for concentration effects by measuring the specific gravity and applying a correction factor.  But the resulting value must be taken with a grain of salt (no pun intended) because of the essential flaw in using urine to determine drug levels.
I have used quantitative testing, and I understand the value in knowing, for example, the ratio between excreted buprenorphine and excreted norbuprenorphine, the chief breakdown product.  But in an era of limited resources, I cannot rationalize making a patient, insurer, or taxpayer pay the $800 – $1200 charged for EACH test!
I dropped the quantitative test company that I was using after I learned about their charges.  The reps for the company paid me a visit over lunch, and asked me why it mattered.  ‘Everybody else is using us,’ they said.  ‘Besides— the patient never even sees it.  We just take it from the insurance company, or from Medicaid.  The patients don’t really pay for it.’
Then one of them added a comment that summarizes why healthcare costs are out of control:  ‘I see your point about the problems with the test, but if you don’t use it, you could get in trouble with the state.’
To translate, the $1000 test adds very little information to the $5 test, but the people on state medical boards doesn’t necessarily understand the reasons why the tests are not worth the money, so I should order them just to make sure that I LOOK like I’m doing as much testing as everybody else.
When I was in med school (way back in the mid-1980’s), my professors at the University of Rochester made a big deal about healthcare costs.  We were taught to know the price of tests that we ordered, and to consider the value of each test, in light of the cost. With everybody bemoaning the cost of health care, seems to me that now would be a good time to get back to some of those considerations.

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.

Reckitt Benckiser Citizen Petition for Suboxone: DENIED

Posted 2/23/2013
For those who missed my explanation, I’m adding these old posts to reconstruct the archive.  The site’s database was damaged by something, somehow… New posts coming soon.
Find a copy of the response here, or at this url:www.suboxonetalkzone.com/cpresponse.pdf