This is irritating– a person is stable on suboxone, employed, turning their life around… and their PO from the case over a year ago wants them off ‘that drug suboxone’. Un-F-ing-believable. My letter to the PO:
I treat XXXXXXX for opiate dependence. He and I have arrived at a taper schedule as you requested. I do feel obligated, however, to let you know that tapering off suboxone is not appropriate care for his opiate dependence.
I have no shortage of patients on suboxone– I am always at the 100-patient limit, and there are always people waiting in line if a patient leaves my care (The most common reason for stopping suboxone is pregnancy). I have no financial incentive to keep XXXX on suboxone; if anything I will be paid more for a new patient taking his place. I have a great deal of experience with addiction; I treat some patients with suboxone, and others by different techniques, depending on their personality, addiction/treatment history, and circumstances. I have treated about 150 patients with suboxone over the past two years; other patients were treated by myself in outpatient therapy, or referred to residential treatment.
I remain current with the standard of care for addiction. I am the Medical Director of XXXXXXXX, a residential and outpatient AODA treatment center in Wisconsin. I am Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, where I teach medical students and psychiatry residents. I do the teaching of the addiction section of the mental health/behavior block for medical students. In the case that you do not accept my opinion on the matter, you can easily find ample support for the use of buprenorphine for long-term maintenance of remission of opiate dependence. I suggest starting at ASAM, the American Society for Addiction Medicine: The president of the organization, Dr. Michael Miller, practices in Madison Wisconsin and is a strong advocate for the use of buprenorphine and Suboxone.Despite efforts to educate physicians and the public, there are a number of misconceptions and prejudices about Suboxone. The active ingredient of Suboxone, buprenorphine, has a distinct mechanism of action at the opiate receptor that is unlike the effect of oxycodone or methadone. After two-three days of use a patient on Suboxone feels no effect from the medication– no ‘high’, and no sedation. A patient on Suboxone cannot get an effect from any other opiate. The action of Suboxone that sets it apart is the effective relief of craving for opiates, which in effect induces full remission from active addiction. Patients on Suboxone are relieved of the terrible obsession that keeps them from moving forward in life. My patients include attorneys, physicians, nurses, prison guards, and factory workers, all grateful to have opiate dependence out of their lives.
There are certainly cases where total sobriety is favored over Suboxone. It is important to realize, however, that even with thorough, residential treatment, the relapse rate for opiate dependence remains well over 50%, much higher than that of other substances. Patients who maintain sobriety through 12-step meetings can expect to have cravings for the rest of their lives. I have had a number of patients tell me that traditional recovery kept them clean and feeling like a ‘recovering addict’, whereas suboxone made them feel like a person who was never addicted in the first place. The role of meetings and therapy for patients on suboxone is debatable, as the relief from the obsession to use allows good character to return. Most of my patients are working and doing well in life– as is XXXXXXXX.
The best way to understone Suboxone treatment is to compare it to treatment of hypertension. Like opiate dependence, high blood pressure is in part genetic, and in part caused by behavior (diet, smoking, lack of exercise, e.g.). We cannot ‘fix’ the defect in hypertension– which is a brain abnormality that causes a faulty ‘set-point’ for blood pressure. We instead artificially dilate blood vessels and weaken the pumping of the heart with medication, and the pressure drops. If we stop the medication, the high blood pressure is still there. The medication causes ‘remission’ of the high blood pressure– not a cure. Likewise, opiate dependence is in part familial and in part behavioral. We have no cure– no way to eliminate the obsession to use that characterizes addiction. But we now have a medication that will induce remission of that obsession. The comparison does not stop there– with both hypertension and addiction, we have non-medical ways to treat the diseases, using the power of the mind. For addiction, the person can work hard to drastically change their mind through hours and hours of treatment and life-long meetings. For hypertension, a person can use biofeedback and meditation to control their blood pressure– can you imagine how effective it would be if a patient put the same effort into it that an addict puts into meetings and treatment? Of course, we would never expect a person to go to that effort to control their blood pressure when medication is available… and yet we think of an addict very differently, and consider medication to be the easy way out. Yes, it is hard to get off suboxone…. Just as it is hard to get off some blood pressure medications, which cause ‘rebound hypertension’ when they are stopped.
As I said, XXXXX is prepared to taper off suboxone, as he has no choice. He will have life-long cravings that will at times occupy his mind and make him irritable. He will place himself at risk of relapse, which could land him in prison or even kill him. As his doctor, I have to wonder about the sense of that, particularly when he is being forced to deviate from the standard of care and face these risks because of someone else’s misconceptions and biases. I used to have similar misconceptions when I read the first studies about suboxone– after all, I treated my own opiate dependence by hours and hours of outpatient sessions and meetings, and then after ten years I treated my relapse by over three months away from my family, in residential treatment, followed by hours of groups and more meetings. The treatment was effective, but I lost my career as an anesthesiologist along the way, and almost lost my marriage and my life. And yet I was lucky– many people in the same position don’t survive. Thank goodness we have progressed to a point where almost everyone can be saved, treated to remission, and go on to live productive lives.
Jeffrey T Junig MD PhD
Fond du Lac Psychiatry
Wisconsin Opiate Management Center

1 Comment

Erin · March 25, 2008 at 2:27 pm

I firmly believe that a PO should have no say what-so-ever when it comes to how someone is being medically treated.
If the patient is under a doctor’s care and is keeping up with the guidelines of their treatment…end of story.
Everyone has their opinions about what is an appropriate amount of time that a patient should be in a Suboxone treatment program but the final say comes down to the patient and their physician.

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