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.

Drug Court Organization Lobbied Against Suboxone

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

Addiction Recovery Act of 2015

With appreciation to the good folks at BDSI, makers of Bunavail:
Here is the latest news concerning the Comprehensive Addiction Recovery Act of 2015 (aka Heroin Crisis Act):
It has easily passed Committee and is headed to the Senate floor next week.  If approved, the bill is scheduled to go into effect this year. Here are some new highlights:

  • The proposed funding was originally $80 million. It may go to $1.2 billion with a proposal of $600 million in emergency funding (note that this article says ‘billion’, but that is a typo.  Other sources confirm $600 million.
  • Mid-level providers are looking to be added to those who can treat opioid-dependent patients
  • Language addressing regulations around the current marketing, manufacturing and prescribing of prescription opioids (pain meds)

This funding (including any emergency monies) would directly impact every state. Additional federal funding would not only mean additional education and treatment services but could also mean more affordable access to medicated assisted treatment.

Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.
Statistics and numbers don’t tell a story unless put into context, so some simple comparisons help demonstrate the magnitude of the ‘opioid problem.’  My perception is skewed after sitting with so many people affected by addiction, but we seem to have a huge blind spot for one of the leading killers of young people.  Consider the issues our country’s leaders talk about and our news reporters write about.   I think we all know the things that get our President’s undies in a bundle… but did I miss the Presidential Summit on Opioid Dependence?  This would not be the first time that our leaders missed the elephant in the living room, of course— but it may be one of the first times a President has been given a pass after missing this big an elephant for this long.  I’m old enough to remember the media soundly criticizing Reagan for failing to create a sense of urgency over AIDS.  And so I wonder… When is Obama going to express urgency about opioids?  Where is the media criticism of his lack of urgency?   Today he told reporters he ‘will leave everything on the field during his last year in office,’ just before he took off for another Christmas in Hawaii.  Will that time on the field include some concern for people killed by overdose?
I don’t get the impression that our President lies awake all night worrying about overdose deaths.  But maybe he should.  We heard a great deal from Obama about the need to bring troops home from Iraq a few years ago.  And all of the networks kept a running tally of US deaths in Iraq in the lower right corner of the screen during the evening news.   So let’s compare priorities.  Let’s add up all of the deaths of US troops during Iraq II during two administrations of Bush and the 1 and 3/4 Obama administrations.  Let’s add the deaths from the World Trade Center attacks, the recent terrorist attacks in France and California, and the mass shootings at Sandy Hook and Columbine.  How does that number compare to the impact of opioid dependence?
I don’t intend to lessen the honor of fallen military servicemen and women, or downplay the horror experienced by victims of 911 and other violent attacks.   I chose these numbers because the horror of each situation prompted speeches by our leaders, rallies by our citizens, and headlines in National news media.   The speeches and commitments of our President and the coverage by news anchors are supposed to be a reflection of what our citizens care about.
The number of deaths from overdose in 2013 alone– one year– was over four times greater than the complete count of US deaths in Iraq, plus all of the horrible events listed above.   US deaths in the Iraq war?  About 4500.  The Trade Center attacks killed almost 3000 people.   In 2013, over 30,000 US citizens died from overdose.  Surprised?  I was.  On average about 100 people in the US die from overdose every day– day after day.
As I wrote above, I remember the reporters calling out Reagan over AIDS.  Activists claimed that Reagan avoided talking about HIV because of the stigma associated with ‘homosexuals’, the people hit the hardest by the initial outbreak of HIV.   They say that the people who died were ‘second class citizens’ who didn’t have a voice, and it was easier for Reagan to pretend that the problem didn’t exist.  Many people believe that if Reagan spoke about AIDS in his speeches or directed National attention toward the outbreak of the virus, that fewer people would have died.   Maybe those people were right.
If they were, what’s Obama’s excuse?

Bob Geldof’s Attitude

I don’t know much about Bob Geldof.  In fact, the sum of my knowledge of his existence comes from what I read on Wikipedia a few minutes ago.  I stumbled across a headline about his daughter’s tragic death about a year ago.  Apparently he made a comment about her death, and the media exploded in reaction to that comment— that he expected that she would die, given that she was addicted to opioids.  The media refers to his daughter as ‘Peaches’, so apparently she was associated with some measure of notoriety that allows a person to use only one name.   From my review of the headlines I learned that her mother, Paula Yates, also died of a drug overdose about 15 years ago.
Again, I know nothing about Bob Geldof.  The news reports about his comments say that he was appointed an honorary knighthood by Queen Elizabeth II.  He was also described as a ‘man of peace’, who was active in the ‘fathers’ rights movement’.
I’m writing this short post because he was quoted as saying ‘there was nothing that could be done’ about his daughter’s addiction.   As a doc who treats opioid dependence, I believe that his comments would have been accurate 15 years ago, when Peaches’ mother died.  But since about that time, effective tools for treating opioid dependence have been available.  Methadone has been around for decades, of course, but many addicts reject methadone maintenance for a number of reasons— including the hassles associated with maintenance treatments, and the stigma associated with methadone, which is seen by some addicts as a ‘poor man’s treatment’.
But buprenorphine-based medications have been around for over a decade.  Suboxone is the medication most-associated with buprenorphine treatment.  I realize that people addicted to opioids cannot be forced into treatment, but if the ‘sphere of influence’ around an addict— the family, the friends, and the media, for example– favored treatment with buprenorphine, the suffering addict would be more-likely to seek out that treatment.  And the great thing about buprenorphine treatment is that opioid addicts do not need to get it perfect.  If a patient is ambivalent about treatment to the point of taking the medication intermittently, and using heroin intermittently, the chance of that person dying from overdose is greatly reduced.
Over the years I’ve had a number of young patients who were not fully ready to commit to an abstinent lifestyle.  They had sufficient consequences to understand that heroin would kill them if they didn’t seek treatment…  but they still had occasional days or nights when their cravings would lead them to use.    But with buprenorphine in their bloodstream, the effects of heroin and other opioids were blunted, and the risk of death from overdose was greatly-reduced.    I’ve written about how I don’t understand the attitudes of doctors who kick people out of treatment for struggling. Most of the patients who I’ve treated over the years who struggled eventually stopped struggling and left heroin behind.
In these modern times. we don’t have to conclude that ‘nothing can be done’.   We have a solution to opioid dependence in buprenorphine, a medication that reliably prevents overdose even in patients who aren’t fully ready for abstinence.  Understand that I don’t intend to validate bad behavior.  But as a parent, I realize that we need a way to keep our kids alive until they reach a level of maturity where they realize the true nature of the risks they are facing.    I don’t know anything about Bob Geldof, but I disagree with any father’s comment that ‘nothing could have been done’.  If people were more-aware of the escape from addiction provided by buprenorphine, I believe that more people would seek out that escape.
I don’t know Bob Geldof or his daughter.  But it is a shame that neither of them knew about buprenorphine.

What’s Up with Buprenorphine?

I think about a joke my dad used to tell over and over.  A guy is upset because his kid has never talked in his entire life.  He has taken his kid to all the specialists, but nobody has an answer.  Then at his 18th birthday party the kid blurts out “we’re having ham AGAIN?!’    His family breaks out in tears of joy, and eventually his dad asks him why he hasn’t talked for so long. The kid pauses, and then says “up to now, everything was OK.”
A dumb joke… but then again I just saw a PBS show about the life of Joan Rivers, and I was struck by how so many comedians make a living by saying things that are simply disgusting, and passing them off as ‘comedy’.  Joan’s disciples all have the same type of humor… what’s the name of that red-headed woman who did a brief stint on Seinfeld?  Just say something shockingly rude to a crowd who paid to see you, and they laugh.
Got off track.  My point was that I’m sorry for being gone so long, and I wish the reason was because there was nothing to complain about.  Unfortunately, there are still plenty of things to complain about…. the cap on doctors prescribing buprenorphine products, the large number of overdose deaths, the spread of hepatitis C and other blood-borne illnesses, the ignorance of the media and among some DA’s and law enforcement agencies…
Frankly, I took a break from writing because I was tired of being so angry all the time.  But over the past few months, I’ve received daily messages from people suffering from addiction and looking for answers.  I appreciate those of you who continue to stop by the web site and the Forum, and I’ll try to get over my anger and get some new content out here.
I have at least a few things that I’d like to address at this point– but please feel free to help me out by sharing a question, an interesting situation, or anything else that you find interesting.. and I’ll use it as a starting point for a post.  Send me an email, or leave a comment… and I’ll be back!
BTW, hope everyone had a nice summer!

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.

Another Suboxone Argument

It has been awhile since I posted a give and take with a misguided reader. I’ve taken that interval as good news that education is winning over misinformation.
But then I read this comment.  I didn’t fix her typos, as I think they provide insight into her opinion:
My daughter was on Suboxone, because she was a heroin addict, when she could not afford this med, the withdrawal lasted for mnths, and was far worse than I have ever seen her go through Heroin withdrawal. These are a Psyhiatrist facts, I absolutely hate Suboxone, YES peple do get high on Suboxone, Yes they absolutely can and do inject this garbage. This medication may have helped people who were not addicts for pain, or addicts who truly took this drug to remain clean, and that’s o.k BUT NO THE DRUG COMPANIES are not going to put the facts out about this dug, and about the deaths caused from overdosing on this drug using it in combination with other drugs. They will not report the abuse of this drug, and the effects of this drug on the bodies organs or how it causes Bone Marrow depression. THE TRUTH WILL COME OUT NO MATTER HOW THE DRUG COMPANIES AND GOOD OLD DOCS, TRY COVER IT UP. Half these Suboxone Dr’s are addicts themselves, I took my daughter to one who’s pupils were so pinned, he was slurring and could hardly stay awake, HMMM Could it be he was abusing the same drug he was supplying. They had a great plan for getting people on it but none what so ever for getting people off of it. The Truth about Suboxone will come out. It should be used only for detox only taken no more than for 10 days. I am a Drug and ETOH detox Nurse, so I have seen not just with my own child, but with clients who, by the way do abuse the drug sell it on the street, so they can buy heroin. IT’S A MONEY MAKER FOR BIG PHARMA, AND THE MAKER OF THIS DRUG PAID DOCTORS THOUSANDS TO BECOME CERTIFIED TO PUSH THIS POISON. I will get the true facts of this drug, but Do NOT JUST PUSH THE PRETTY SIDE TELL THE TRUTH ABUT THE UGLY AND YES SOMETIMES DEADLY SIDE. DR. My daughter committed suicide January 4th 2015 overdose of heroin, among other substances. She went to heroin again because she started going through post SUBOXONE withdrawal. The withdrawal last weeks to months with post withdrawal. So please do make this sound like a miracle drug that saves lives, it also kills and that truth will come out. I am sick of these companies, hiding the facts! Facts to me because I have lived it and have seen personally the effect of this drug.
I responded as follows:
I wish you were at least partially correct, given that you work in the field, and have the potential to spread such inaccurate information.
Deaths…  in the past ten years there were about 35,000 overdose deaths in the US.  None of those people had buprenorphine in their system when they died.  What number of people had measurable amounts of buprenorphine in their bloodstream when they died from overdose?  40 per year.  Most of those 40 people would be alive if there had been more buprenorphine in their bloodstream– the only exception being the few cases each year where a young child ingested the drug.
Note that 400 people die from Tylenol each year in the US– compared to 40 deaths of people who had buprenorphine in the bloodstream.  It is very hard to die from buprenorphine;  those who die must have little or no opioid tolerance, and must also take a second respiratory depressant that they have little tolerance to.
Bone marrow depression?  Really?  Buprenorphine has been in use for almost 40 years.  It has a better safety profile than most meds out there.
‘Plans for getting people off’?  The whole point of buprenorphine is to provide chronic treatment for a chronic illness.   You apparently want something that instantly changes the brain and erases addiction, but that product is not invented yet– and I wouldn’t hold my breath for it.  Your daughter developed a condition that will last the rest of her life.  She will treat it for the rest of her life.  She can take a medication each day, or she can attend meetings several times per week. The latter approach works, mind you, only in the relatively few people who are moved by the 12-step message.  Both approaches must last for years and years, if not a lifetime.  Many people do well on buprenorphine, but some survive without it.  But if she isn’t attending meetings or doing something with similar intensiy, her prognosis off buprenorphine is not good.
The withdrawal from the partial agonist buprenorphine is less severe than from agonists.  ALL opioid withdrawal lasts for 2-3 months, and is followed by post-acute withdrawal.  On buprenorphine, a person’s tolerance is equal to 40 mg methadone per day.  Realize that heroin addicts typically have tolerance that is several times higher.  Your daughter developed a high tolerance to agonists, and then continued to have a high tolerance on buprenorphine.  Any addict, including your daughter, is facing months of detox.  Buprenorphine delayed the detox, giving her the chance to get her act together first.  Many people are successful with that approach, but some blow the chance and keep up the negative behavior.  Buprenorphine relieves cravings;  it doesn’t fix personalities all by itself.
I suspect that the reason you never saw such bad withdrawal in your daughter coming off heroin is because she could never stop heroin long enough to demonstrate 2 months of withdrawal.  Nobody just stops heroin; they stop for a couple weeks and then use again.  On the other hand, many people taper off buprenorphine, and have the chance to experience the full course of opioid withdrawal.
The cost…  The drug companies make much more money from chemotherapy, anti-hypertensives, pain pills, and other meds.  Reckitt Benckiser, the biggest maker of Suboxone products, recently spun off the drug because of the anticipated losses.  Even if buprenorphine was a blockbuster, though, I have nothing against drug companies being rewarded for the risks they take to develop new meds.  There is no doubt that the efforts to market buprenorphine have saved thousands of lives.
If your daughter sold her buprenorphine to buy heroin, that’s her bad.  Most people do not do that, but some probably do.  Understand that heroin is very addictive, and drives all sorts of bad behaviors– theft, prostitution, robberies, etc.  I guarantee you that selling her prescription of buprenorphine alone did not make enough money to pay for a heroin habit.
There are so many things you have wrong…. ‘the drug companies paid doctors to push this drug’… I’m sorry, but you are clearly a zealot, and I can’t even take you seriously with that argument.  If you know of a single doctor paid to prescribe a drug, call the Feds, as that would be a crime.  There are some doctors paid to WORK for pharma— to give lectures about new drugs, for example.  I have done that in the past for drugs I believed in.  Some people seem to hate it when doctors take any money from pharma, but when they do, it is for work–  for travelling to some cheap motel in the middle of nowhere and giving a talk to a group of doctors.  The work is highly regulated, and just like TV commercials, docs are required to stick to a very narrow script that educates, rather than promotes.
‘Detox’ has been marginalized (thankfully) because of recognition that it does nothing to treat addiction.  Likewise, non-medication treatment has very low success rates, especially if you count everyone who enters the door, instead of blaming those who fail for ‘not wanting it bad enough’.
I’m sorry about your daughter.  But one thing many parents eventually realize is that even when a kid is acting irresponsibly, buprenorphine at least keeps them alive.  Buprenorphine allows people to stay alive, even if their recovery is imperfect.  And relieved of most of the cravings to use, many of those patients eventually get it right.
Back to the present…  I’d like to think that I cleared up some misconceptions.  But two days after my comments, I received a very similar set of comments from the same person—except that most of the words were capitalized.  That is the reason I’ve tired of these types of posts….

Rapid Opioid Detox from Suboxone

First Posted 1/26/2014
I recently answered a post at SuboxForum by a member who asked what to expect from rapid detox from opioids, and specifically from buprenorphine.
My reply:
Several of my current buprenorphine patients have been through rapid detox at some point in their past.  Their stories are so similar that it becomes difficult to distinguish one from the next.   A typical history would go something like this:
“I started pot and alcohol by 16, but discovered pain pills when I was about 17 when I had surgery. My doctor gave me pain pills when I hurt my back, and when he stopped, I started getting them from my aunt’s house. She had cancer so she had tons of them. Then she died, and I was getting them from friends at work until they got more expensive. I switched to heroin a couple years ago.”
I’ll ask, “have you been through treatments?”
“Yep– detoxed 3 times, twice to rehab, once for 30 days and once for 3 months…. I did NA on and off, and was on methadone for a couple years. Oh, and I did rapid detox in Florida 5 years ago.”
I’ll ask, “what is the longest you stayed clean?”
“I was clean most of the time when I was in rehab…  so maybe 2 months?  other than that it would be a few days here or there– usually not more than 3 days.  After rapid detox I stayed clean for 2 months because I didn’t have any money left to buy anything.
I’ll ask, “Have you been on Suboxone before? Any time totally off opioids?”
They’ll say “I was on it for 1 year but I stopped. Not sure if I was ever totally clean… there was always something around.”
I don’t mean to be flippant about relapse, especially given the high rate of death associated with relapse to opioids. But I want to give an idea of how my attitudes about buprenorphine were formed over the years. Patient after patient have provided stories about repeated relapses despite a variety of treatment efforts, including rapid opioid detox.
During my own period of active using in the early 1990′s, desperation drove me to my own ‘rapid detox’, without the anesthesia.  I kicked off my ‘clean time’ with IV naloxone, followed by a couple 50 mg tabs of naltrexone.  I had stopped opioids for several days, so I didn’t expect severe withdrawal…. but was I wrong!  I could walk by the end of day one, just barely, but I remained very sick for a week or two.  I’m sure I would have stayed sick at least a few weeks longer, had I stayed clean….  but as soon as I realized that I had made it through such a nightmare alive, I decided that I must have some awesome will power, and I could always just do that again, if I had to…. so I ‘rewarded’ myself with a bit more controlled using.
Crazy.
As I see it, the problem is that the person who walks out of the door of rapid detox is not all that different from the person who walked in.  Yes, the person had his mu opioid receptors antagonized for a day. But that’s not long enough to get one’s receptors back to normal, not by a long shot. After a day or two of naltrexone, patients still have weeks of withdrawal awaiting them.
What if a person stays on naltrexone for the entire several months that it takes for tolerant opioid receptors to be replaced by new, normally-sensitive opioid receptors? That would be a better option than rapid detox alone, reducing the odds for relapse by blocking receptors during the most intense physical cravings.
But in reality, addiction is much more complicated than physical cravings.    Despite the promises of a new life in ads for detox programs, naltrexone is not fairy dust that changes how a person deals with good and bad news. Most people who seek detox have been conditioned, for years, to use opioid in response to resentments.   So the person who picked up at age 18, 20, 25, and 28 tends to pick up again, unless something makes a real difference in how the person responds to life’s challenges.  For most people, I do not believe that rapid detox makes enough of a difference.