I wish I had more time to devote to this topic right now, but I am on my way to a short vacation… so I will not be available by e-mail for at least a few days.  Everyone is pacing around the house right now, waiting for me to finish with ‘that stupid computer’.
I had to to write, though, because of a horrible incident in Milwaukee a couple days ago that took the life of a 15-year-old girl named Maddie Kiefer.  According to news stories, she snuck out from her house in Whitefish Bay, one of Milwaukee’s’nicer’ suburbs– by nicer meaning a place where the houses are kept up, many children grow up with two parents, and the public schools send a high proportion of students to colleges.  The suburb lies just north of Milwaukee, and along with other northern suburbs has seen a significant increase in heroin use by young people over the past 5-10 years.  I live another hour or so to the north, and we are seeing more and more heroin ‘up here’ as well;  the opiate addicts that I treat used to report taking oxycodone mostly, followed by methadone, then fentanyl;  now I am hearing histories of heroin use almost as often as oxycodone.
Most people know about some vague danger of combining Suboxone with ‘benzos’ like Xanax (alprazolam);  the risk is respiratory depression, which can kill a person– and is usually the cause of death in overdose of opiates.  Opiates desensitize the brain’s response to carbon dioxide, causing the person to breathe at a slower rate and allow carbon dioxide to build up.  The high level of carbon dioxide isn’t fatal, but if a person breathes slow enough, or stops breathing altogether, the oxygen level eventually falls… and the low oxygen level either makes the brain stop working– including ceasing the urge to breathe entirely– or the low oxygen level triggers a cardiac arrhythmia that halts the flow of blood, which then affects the brain, causing unconsciousness, apnea (no breathing), and death.
A couple quick points:  Suboxone and benzos are a dangerous combination particularly if a person is naive to both.  If a person is opiate-tolerant, for example is addicted to opiates, then the risk of death from such a combination is very low.  In any case, the risk of Suboxone plus benzos is MUCH LOWER than the risk of combining a benzo with a full opiate agonist, like oxycodone or methadone!  There is nothing especially dangerous about Suboxone in this regard;  in fact, it is much safer than a full agonist.
I suspect that the teen killed in Milwaukee was not used to opiates;  in such a alcase Suboxone alone would almost never be fatal… unless combined with other respiratory depressants, such as alcohol or benzodiazepines.  The story of her death is horrible– it displays the utter lack of concern for others that takes over the soul of a person addicted to opiates.  I will not make any excuse for a person who dumps someone in a driveway who needs life-saving assistance– but I understand how people get that way.  Many opiate addicts do things that are similarly devoid of conscience– and that is behind the ‘split’ that occurs with addiction, where the addict represses the horror of who they have become, and carries a fake outside personna that is cocky, glib, annoying, and easily recognizable to those who understand addiction.
When I talk about tapering, I assume people are working with a physician;  I do not condone the practice of buying Suboxone on the street or sharing it with friends or ‘loved ones’– even out of concern for them.  When people treat themselves, they are fooling themselves;  the addict is firmly in control and there is minimal chance that the person will recover.  People who share or sell Suboxone with others deserve to be incarcerated.  Period.


cward1983 · March 10, 2009 at 2:10 pm

Although I understand your stance on how suboxone should never be shared between friends or with someone who is not under the direct supervision of a doctor I must ask what would you do in this situation?
A year ago I was seeing a psychiastrist whom my sister had seen before me for other issues who I went to see due to my opiate addiction. He started me on suboxone and we formulated out a plan to start with 3 months of treatment to stop the opiate cravings and get my life back on track and if neccasary, stay on suboxone longer if needed.
2 months into treatment my doctor lost his license to legal issues which I had no prior knowledge of and he could no longer treat me or prescribe suboxone to me. There was NO protection from this. I was on my own and there were no suboxone doctors in the entire area which could even see me for a good 3 weeks time for an appointment to get started. I had no choice but to suffer the w/d or ask friends for help for the time being until I found a new doctor. I eventually found a doctor i was comforable with and who didnt charge an outrageous price to restart treatment and I’ve just this last week come off of suboxone (day 8 without it)after a gradual taper. My point is that during the time it took me to get the money for another doctor downpayment to restart treatment (this ended up taking about 2 months) I was on my own and my friends were my only source of staying on course or falling back into opiate use.
I would just like to know, what steps could someone take to prevent a similar situation taking place with a doctor? I know you can never condone the sharing of suboxone between friends because of your position as a doctor and the need to protect yourself and your patients but other than sharing for the time I would almost assuredly have suffered through W/D and fell back into use during that time (and asking a addict who has been through opiate W/D to go through it again is like asking someone to take a hammer to their hand and repeatedly bash their bones, it really can be that painful. So my question is how would you deal with such a situation?

SuboxDoc · March 10, 2009 at 3:52 pm

Yes, that is a horrible situation- I received a somewhat similar note from a person who was recently kicked out of a program for a positive UA for Ambien. I will write a bit about that in tonight’s post– but as far as how I would deal with your situation, I would likely do whatever I needed to do to stay clean… and I will leave my comment at that.
My comments about sharing were not in response to a situation like yours, but rather a response to the many requests for advice that I get from people who have never been to a doctor at all. There are people out there who use ‘subs’ like they would use any other opiate, but thinking that going on Suboxone will somehow help them get off opiates for good! I want people to realize that it doesn’t work that way; Suboxone is a tool that is one part of getting away from opiate dependence. If you just borrow 4 from a friend and write and say ‘how should I use these to kick opiates’, I have no advice for you accept to toss them in the toilet and make an appointment from someone who has treated patients with Suboxone for awhile, who knows what he/she is doing.
As for this writer– the one thing I would say is to avoid being ‘penny wise and pound foolish’. You mention looking for a doc who had reasonable fees– I have had several patients who came back to my practice after dropping out a year earlier because they ‘couldn’t afford treatment’. I asked them to try to total up what they had spent on opiates since dropping out of treatment… and in all cases, they would have saved a ton of money by sticking around!

Wade72 · March 14, 2009 at 10:48 pm

I work for a residential drug and alcohol rehabilitation centre in Thailand. Several years ago in Thailand, the news story was not totally truthful I am sure, a young man purchased Suboxone on the street level and died from it. Being this is Thailand there was no full report and truthful information is not always easily acquired here. Regardless, the young mans father happened to be a government minister and due to the incident Suboxone is now an illegal drug in Thailand.
Or so that is the story I have heard on why it is un-available. Unfortunately it is a blanket policy so even the people it could help can not get it now. As I mentioned above we never get the full story in English so I am not 100% sure of my information. Reading the doctors comments I would imagine there were other factors involved, but this does stress the point about not taking any medications except under the strict supervision of an appropriately qualified physician.

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