Here is a ‘what would you do’ question: Today I saw a new patient who came in asking to start Suboxone. She has a significant addiction to heroin– I don’t know heroin doses very well, but she said she uses ‘four bags per day’. Incidentally, if anyone knows the conversion of that dose to the daily amount of oxycodone, please post in the comments and let me know. She was in moderate withdrawal, and had not used for over 24 hours– which usually would suggest appropriateness for induction of Suboxone at least from a ‘precipitated withdrawal’ standpoint. On the other hand, if four bags of heroin is a ridiculously high dose, her tolerance may have been so high that even after 24 hours, withdrawal would be precipitated.
When I have people in this situation I usually suggest going forward; yes, there is a risk of getting sick… but the person is already pretty sick and can’t get a whole lot sicker. But more important, a person using those very high doses is literally taking her life in her hands every time she shoots up, and it is very unlikely that she would be able to last another 24 hours without using. So I typically recommend starting Suboxone and if withdrawal is precipitated, sticking with the Suboxone, dosing each morning as usual– that way we know that the withdrawal will end within 24-48 hours and things will soon be stabilized. I do NOT use a ‘higher induction dose’ for people with higher tolerance; I know that many doctors DO use higher induction doses, but doing so is more a sign of superficial thinking than consistent with an understanding of what happens at the receptor level. Even only one tablet of Suboxone contains a ‘supra-maximal’ dose of buprenorphine– 8000 micrograms of buprenorphine is sufficient to bind up all of a person’s opiate receptors many times over!
But none of this has anything to do with my question about what you would do. As I was talking to this person about her use, and about how much Suboxone I was going to prescribe, she argued for more– saying that she had tried Suboxone, and two pills ‘just didn’t do it for her’. This bothered me a bit; people who have ‘played’ with Suboxone on the street tend to do poorly in treatment, as Suboxone becomes ‘just another opiate’, rather than a powerful tool that can be used to change a person’s attitudes about using. As I told her, getting clean takes more than just ‘Suboxone’! Yes, Suboxone has some unique properties… but if a person comes in thinking that simply taking a pill is going to cure their addiction, they are sorely mistaken. Understand that opiate dependence is a HORRIBLE illness; the odds for recovery before Suboxone were very low, and so it is a grave mistake to get cocky about recovering even WITH Suboxone. And yet so many people, young people in particular, get cocky about their chances… today another patient talked about his plans to taper off Suboxone after a few months, and when I told him that the majority of people who do that simply relapse he said ‘I don’t plan to relapse!’ — as if anybody does! All addicts have that feeling of being ‘special’; instead of seeing the experience of others and learning from them, and avoiding misery, addicts believe that THEY are DIFFERENT– they are ‘more special’ than those OTHER people. But they always find– eventually– that they aren’t any more ‘special’; they find that they have the same problems as everyone else.
But this isn’t what I wanted to talk about either. As this new patient tried to talk me into prescribing a higher dose of Suboxone she said that she got the Suboxone from a guy she knows… a guy who is one of my patients! Moreover she said that ‘he takes ‘H’ and doesn’t even need the Suboxone; he just uses it to avoid withdrawal when he doesn’t have ‘H’.’  When she noticed the anger on my face she clammed up, and wouldn’t tell me the name of her friend.
I do not like opiate addiction; I consider it to be a horrible affliction that takes a toll on the lives of young people greater than any other disease I can think of. And I have no tolerance for the people who work in the trade of dealing drugs. I forgive some pretty bad behavior when a person is driven by the obsession for opiates; I make no moral judgment about those who prostitute themselves or those who steal from grandma. But for the people who contribute to the addiction of others– who profit from spreading this horrible condition– I have no tolerance at all. If I knew the name of this person who is giving the Suboxone that I prescribe for him to others, I would do everything in my legal power to have him busted. I would (and as I think about it I think I will do this) contact the legal affairs dept of the APA– the American Psychiatric Association– and see if there is any protection for breaking confidentiality when a person is dealing. There is certainly the ability– and the requirement– to break confidentiality if a person is going to engage in something that threatens the well-being of others; I could certainly argue that sharing Suboxone is ultimately very dangerous for the people who take it.
But I don’t know who the person is– at least not yet. What would you do about the woman presenting for treatment? Should I go ahead and start her on Suboxone, even though she is keeping a secret from me, and protecting a person who is taking advantage of my attempts to help him? Or would you tell her that now that she ‘let the cat out of the bag’, she had to tell me who the person is, before you would treat her? I realize that the reflex answer is to ‘avoid snitching’, and I have those feelings deep inside as well, left over from my days as a pot-smoking teenager… but this is a fatal illness, and innocent people die. I see no excuse for choosing the wrong side of THIS issue; for keeping secrets that protect those who spread this sh#@ around.
I ended up taking the woman as a patient despite her secret. But I have some suspicions about the identity of the person she mentioned, and I will be checking urines more frequently for then next couple months. If anyone reading this is sharing Suboxone with others, please realize that you are playing with fire; we have had two deaths in Milwaukee in the past month from people taking Suboxone that was not prescribed for them (and mixing it with other substances). When I worked as a psychiatrist in the womens’ state prison I had a couple patients serving close to ten years each for sharing narcotics that killed the person who took them. Even if you think you are ‘helping’ someone, you are only preventing the person from getting treatment and increasing the likelihood that they will die from their addiction. That kind of ‘help’ is ALWAYS the wrong thing to do.
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8 Comments
jamez70 · April 10, 2009 at 11:41 pm
The patient demanded more? I’d suspect diversion more than anything. They may be trading/selling it or something or passing it out to friends. Or, he is out and she wanted more so she could give it to him? As you said, diversion is very dangerous and very illegal. You could request a pill count out of the blue, or a tox screen you could order that they could have done anywhere. Most likely if you demanded who diverted to her, she would not tell you and just disappear, but, the offender might disappear as well.
Unfortunately, diversion activity with Suboxone will most likely get it on Schedule II, or they will drop the 100 patient limit to 30 again. If you search the web with Google News and do ‘Suboxone arrest’ you’ll see lots of news articles regarding diversion. Diversion and dealing just ruins it for honest people who are struggling with opiate dependence, because they will all suffer from actions of just a few.
I know nothing about Heroin as I never used it, but I did a search online for you. According to ‘Principles of Pharmacology’ from Google Books, a ‘bag’ is 25mg, but other sources say up to 50mg. So, maybe 25mg at 50% potency worst case? Diamorphine is 1.5x stronger than morphine.. I think you can figure out the rest better than I could. Maybe someone with experience with Heroin would have a better answer.
chadwick · April 11, 2009 at 5:29 am
I just wanted to throw in my two cents. I really hate to compare pain pills to heroin to begin with, but in my expert opinion I would say that a bag of heroin is about the same as a 40 mg. oxycottin.
But I also wanted to make another comment. You shouldn’t judge all people who use suboxone without a prescription. If it wasn’t for suboxone I would be shooting pain pills and heroin to this day. I use between 1 and 2 mg. a day of suboxone. I do not have insurance and I don’t make a lot of money either. I get my pills from a friend that doesn’t use all of her meds. I have called every doctor in this state to try and work something out so I can get my meds legally. Everyone I’ve talked to wants 300 dollars for the first visit and 150 for each additional visit and that doesn’t include the prescription. Look, if anyone fits the profile as a “junky” it’s me. I’ve been to prison 3 times because of my drug use and lost everything I love in this world. And if I get caught buying suboxone on the streets they’ll probably throw away the key this time. I don’t abuse it, I just don’t want to be able to function in society and suboxone has helped me do just that.
So there is my two cents…
johnpal716 · April 11, 2009 at 7:33 am
doc,
here in buffalo suboxone is everywhere. and at NA meetings, where someone will most certainly be stoned to death for admitting taking it, there are a large amount of younger members talking about it, asking for it (not during the meetings of course) and passing it out. MY doctor was very particular with me for the first several months of treatment, having me bring my pills for him to count, asking me to do toxes, attend counseling and meetings, etc. But now after about a year he seems to trust me, and as I’m not doing anything funky with them I suppose I deserve that trust. When I arrived in his office I was anything but trustworthy. I was on day five of withdrawal from 400 mg of oxycontin and 6 mg of xanax a day, stealing from my exboyfriend, lying to everyone….
Do you deny someone the treatment because of the lifestyle they lead as a result of being an addict? By nature we lie, cheat, steal… all for the next one. When I started suboxone this time around I didn’t tell a soul I had tried it a few months prior, legit, in a doctor’s office, and that it didn’t help me. I know now the dosage was too low, the doctor was clearly misinformed in other ways as well, and I used the rest of the script when I couldnt score any oxycontin. but was afraid of being denied treatment so kept it to myself.
I suppose it boggles my mind why your patient would say that, but, in the grips, who knows? My doc took me on, had faith in me.. I have done all the right things and now in three weeks Ill be celebrating a year clean! But I started as a lying piece of garbage who would have lied or back stabbed for more. I was made to follow rules and chose to do so, and have changed.
All you can do now having taken her on is count her pills, make her pee, and if you encounter any static, you know where they’re going!
thanks as always,
jp
angelo212 · April 11, 2009 at 10:51 pm
I do not like opiate addiction; I consider it to be a horrible affliction that takes a toll on the lives of young people greater than any other disease I can think of. And I have no tolerance for the people who work in the trade of dealing drugs. I forgive some pretty bad behavior when a person is driven by the obsession for opiates; I make no moral judgment about those who prostitute themselves or those who steal from grandma. But for the people who contribute to the addiction of others– who profit from spreading this horrible condition– I have no tolerance at all.
Doc, that’s your quote above. You say you will forgive some pretty bad behavior “when a person is driven by the obsession for opiates”. I think you are taking things a little to personal again in that you found out one of your patience is selling his subox. I’m sure there are alot more of your patience selling some of there suboxone to. I understand how a drug dealer makes your warm heart cold to forgiveness in that he is putting peoples lives in danger but, like you said “a person is driven by the obsession of opiates”. I know not all drug dealers are users but the ones who are they are probable doing it to support there obsession to use. I think they are worthy or your forgiveness as the prostitute who does her thing and cathes aids and brings it back to her husband or unborn child who catches it to. Know 3 lives are lost because of her prostitution and her obession to use.
Doctors who perscribe the subox could be blamed also. I live in the inner city (the hood, the ghetto) whatever you want to call it and the doctors don’t care about urines, meetings, pill counting etc. You could be taking 1 pill a day but you just have to ask for 90 a month and he’ll write take 1 pill 3 times a day. So now everyone is getting 90 pills a month doing 30 and selling the other 60. It’s everywhere here in the city I live in.
Anyway I say keep the girl as a patient, count everyones pills and take urines. You will find out who he is but I say give him another chance to. If he really wants to stay clean after you busting him give him a bunch of rules like coming everyday for 2 months to get his subox, urines etc. That obession to use is a bitch and I don’t think locking him up will solve anythink. Give him another chance and if he blows it well then he bought that.
Angelo
mirimar · April 12, 2009 at 9:11 am
While, It is so very true of Addicts being Addicts with regard to selling anything to get extra money. They cannot sell what they don’t have. This I’m afraid falls into your hands Doc. How often do you require patients to see you? Do you dole out meds. for a week? Day? Month? Personally, I can’t see why anyone could need more than one 8mg tab per day. My Dr. says that anymore then that is just simply not needed or required to get Suboxones FULL effects. He won’t prescribe anymore then that and gives out one weeks worth at a time. After the script is filled you bring it to him to dole out every week. 7 per week. Thats all my friend..Anymore isn’t going to happen..He is very strict about this and personally I have to agree with him. Addicts are to used to taking whatever we damm well please. More than one pill a day is one reason why like stated above..People have so many extras to Sell..Get Real People..Talk to the Hand…OK ?….Your the Dr. and a recovering addict..Get Serious with them..They don’t like your Rules..Sorry..You make the Rules..Not Them..
Brianne · April 12, 2009 at 3:43 pm
First of all, I just want to say how much I love your blog. I actually read it in its entirety of the course of 2-days It’s so informative and has given me so much information and has really changed the way I think about my treatment. So thank you!
Okay, now for your questions. I think the best thing you can do in the situation is to make your patients bring in their pill bottles every month to be counted and to also do more drug testing to make sure that they are staying clean. I think it’s a shame that there are so many people out there who don’t take their treatment seriously.
I honestly feel blessed to be in a position to even be able to get treatment with Suboxone. There are so many people out there who don’t have the option because of the cost and either continue to use or use methadone instead.
There is one thing that I vehemently disagree with you on, and that is your stance against people who first try Suboxone without a prescription. I have been on Suboxone going on two weeks, with one of those weeks going to a doctor legitimately.
I had a heavy pill addiction for three years and spent at least a thousand dollars a month between the five doctors I went to per month plus the cost of my prescriptions. I was finally fed up and decided to stop. I quit cold turkey and was in absolute agony the entire time. I had insomnia, night sweats, chills, diarrhea, sneezing, runny nose, watery eyes, aches..I honestly wanted to die. I couldn’t even bring myself to do simple thing like sleep or even bathe.
Prior to stopping, I had looked extensively into Suboxone but quickly came to the conclusion that it wasn’t even an option at that point due to the cost, which is out of reach for many people. So I suffered.
Three days into my withdrawal, I was talking to a friend of mine about what I was going through. And I think I should mention that this time around I told everyone close to me about my addiction that didn’t even know I had a problem (friends, family, fiance) to have support and have that extra push to follow through. Other times when I had tried to stop, I suffered alone because if I failed there would be no one to be disappointed in me.
Come to find out, my friend’s brother in law had tried Suboxone and she was able to procure 2 1/2 eight milligram pills for me. And you know what? I honestly feel like she was my guardian angel. I mean, what are the odds of that happening?
Because of her, I was able to feel like a normal human being again; I was able to finally try the medicine that I had so desperately wanted to try but couldn’t afford and found out how wonderful it was and how much it helped me. It was because of her kindness that I made finding a doctor for treatment happen because I knew firsthand that it would work. If it wasn’t for her, I would have gone back to using. I know this as an undeniable fact.
This also had a trickle down effect. My mom was also using and going through withdrawal because I had decided to stop. We would take turns going to the doctor and sharing pills with each other and since I quit when it was my time to go, she suffered withdrawal as a result.
I point out that she had NO intention of quitting. None, nada. She wanted to stop, but couldn’t-this is what she told me when I decided to stop. After I tried my first dose of Suboxone, I raved to her about what a miracle drug it was and how she should really consider trying it.
Being in the hell of withdrawal and wanting relief, and also the fact that she is my mother and I didn’t want to see her in pain, I gave her half of a pill to reduce her symptoms and so she could see for herself what I was talking about. And you know what? She made it to the doctor even before I did (insurance helps!) and has been clean ever since. As have I.
I guess what I’m trying to say is that in doing something that you consider morally reprehensible, my life was saved, as was the life of someone very important to me.
mattyr9 · April 12, 2009 at 9:03 pm
Hey Dr. Junig,
I’ve been reading your blog for a couple months now and absolutely love it. It is a great place to come for support without the judgment and stigma that comes along with being a suboxone patient in the rooms of NA. I attend meetings regularly but hestitate to mention being treated with suboxone because of the “drug for a drug”, “not truly clean”, “suboxone and methadone are the same thing” arguments that erupt by ignorant and self righteous addicts in the rooms.
Anyway, I have been a suboxone patient for almost 15 months and thought I’d respond to your latest entry since I used and abused both Oxycontin and Heroin. As a previous poster stated it really is difficult to compare oxycodone vs. heroin. Depending on the purity of the heroin, the strength of a bag can vary greatly, but from my experience your “4 bag/day” patient is using roughly the equivalent of an 80 mg/day oxycodone habit. Again, this is a rough estimate as it all depends on how pure the heroin is, it is very difficult to judge a dose (one of the numerous reasons heroin overdoses occur). By the end of my last “run”, I was shooting up to 10 bags of heroin per day or 2 80 mg Oxycontins.
As for the patient demanding a higher dose of suboxone per day, I would simply explain the same things you discuss on the blog (ceiling effect, how the medication binds to receptors, etc.) and truly make her understand that it is not a “magic pill”. When I was in active addiction, I too tried to play doctor to myself with suboxone illegally obtained from friends. Surprise, surprise it never worked, yes even after self medicating with 16 mgs of suboxone. Hence the popular misconception among many active users that “8 mgs doesn’t do anything”. Only under the supervision of my doctor, at a stabilized dose, with counseling and meetings did the suboxone serve its purpose and helped me return to a “normal” life free from the horrors of my addiction.
However, I do not think it is fair to the patient for you to hold back treatment in return for information on the suspected suboxone seller. I would take her on as a patient and continue to monitor the urine of the “suspects” and deal with the “dirty” results as you must. My doctor collects urine at every one of my visits, and I was only getting 7 days of medication for the first 6 months of treatment, followed by 14 days of medication for the next 6 months, and now finally after a year of treatment I get 28 days of medication between each visit. Just my two cents.
dah_sab · April 14, 2009 at 2:31 am
For me, the reflex answer is that withdrawal is the most painful thing, when considering both its physical & mental effects, a person can experience. So my answer is take her on, get her out of withdrawal, and then maybe she’ll be more open to talking about the problems you wrote about.
To me, the key to getting a person on the road to recovery is for the person to separate, in their mind, themselves from the crowd they were hanging out with, shooting up with, etc., so that they no longer think of themselves as ‘that kind of person.’ And not being in withdrawal, and perhaps being very grateful that she is not in withdrawal, may help her to start this separation process and give herself permission to ‘rat’ on whoever she’s working with.
Lots of qualifiers in there, I realize, but we’re talking about addicts here. You wouldn’t be working with them if you didn’t believe you could help them change, so some faith is in order with every patient you see.
And as others have commented, this brings up the larger issue of how incredibly expensive suboxone treatment can be. The clinic I go to is similar to Chadwick’s in that it costs $300 for the first visit and $150 each after that. And they require monthly visits due to govt monitoring. I also see a psychiatrist and therapist regularly and am taking medication (once again) for manic-depression. I am fortunate in that my wife’s vocation pays her well so money was never an issue, but I can only imagine how many people there are who want treatment can’t get it due to cost issues. I sincerely hope President Obama and his new ‘drug’ czar (such a stupidly nicknamed position/office) take steps to make it much easier and more affordable for addicts to get buprenorphine treatment. I believe the reason so much of the drug is seen on the ‘street’ is due to the fact that few people can afford to follow a long course of treatment. The simple fact that the drug is out there, though, shows that addicts know about it, which is a good thing, however small.
Treat this woman. You just might help her. That is enough reason for me. And write your congressional representative and senators as a physician and urge them to expand the buprenorphine program.