Another question from a reader:
The current blog brings up the notion of long term use of Bupe or short term detox. You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug. But- what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.
The Suboxone helps with the W/D and just getting through with that is all we want. NA meetings and the like are like being on Mars, it makes no sense. There are no drug cravings at all and the goal is just normal. Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them And now that too is unavailable. This group does not need Suboxone to become a new problem for them. They just want the help. It is not critically important to determine “who” is being treated. The certification training materials seem to brush over this so lightly that there is only one induction method allowed. One that a drug company would love, but not always a patient — pleading, do no harm.
I hear you, and watch for those patients. Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list. The financial motivation for the DOCTOR is to push people through, for that same reason. Of course the drug company gets paid in either case.
The first question is whether buprenorphine even helps in the case you describe. It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills. It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter. But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.
There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year; those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox. But I don’t know where those people would have fallen on the spectrum that you are presenting. I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.
My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else. They describe the process in different terms; instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’ They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.
I agree with your thoughts, and get your point. I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away. Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits. In a sense the pain is remembered, even after the original injury is repaired. The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics….. and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.
Thanks for your comments!
Another question from a reader:
tic · July 21, 2012 at 5:56 am
In my experience, which is limited compared to Dr. J, chronic pain patients without addiction taper opiates without needing much help, and without needing buprenorphine. Patients who cannot taper opiates by gradual dosage reduction almost always turn out to have more addictive behavior than they report on initial evaluation. In either case, patients continue to need some opiate agonist or buprenorphine because medical interventions for chronic painful conditions do not ever seem to be 100% successful.