Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here. This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago. I grew used doctors refusing to treat people addicted to heroin and other opioids. I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise. It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices. I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine. The comment surprised me, because from here I don’t see the influence. My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years. I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things. I want to write about the little things. The easiest way to have influence is to write about the things that nobody else writes about. After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence: If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way. I want people to use . I know I sound like some old guy frustrated by all of the new words and acronyms on social media. YES, dammit, I AM frustrated by those things! But communication has become so…. careless in the era of Twitter and texting. Find an old book and notice the words and phrases used by educated people 100 years ago. Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends. Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?) But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs. Some large scams benefit from the informal attitudes toward health and medicine; attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video. As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term. Is ‘treat’ the right word? From my perspective I’d say yes in some cases, and no in others. Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year. They said (and I believe them) that they hadn’t used opioid agonists for at least that long. I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances. There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances. Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv. Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies. I correct them and tell them that I have a hard time trusting patients who talk that way. After all, those are street terms. A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub. Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing? Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not. I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression. Getting that point across would be enough influence for one day!

Help for Heroin Addiction

A couple comments for regular readers… first, watch for an upcoming change to a new name. For years I’ve debated whether to adopt a name centered on ‘buprenorphine’, rather than the more-recognizable ‘Suboxone’. I believe that time has come. Second, I’m going to ‘reset’ with some introductory comments about the proper approach to treating heroin addiction, intended for those who are seeking help – starting with this post.
I’m addicted to heroin. Which treatment should I use?

I’ve treated heroin addiction in a range of settings, including abstinence-based programs and medication-assisted treatment with buprenorphine, naltrexone, and methadone. My education prepared me for this type of work, and my personal background created empathy for people engaged in the struggle to leave opioids behind.

The first barrier to success is on you. Are you ready to leave opioids behind? How ready? Are you so ready that you will be able to end relationships with people who use? Are you ready to stop other substances, especially cocaine and benzodiazepines? You will find help during treatment and you don’t have to take these steps entirely on your own. But you must at least have the desire to get there.

If you’re ready, the next step is deciding the treatment that is likely to help you. Many people see abstinence-based treatment as a ‘gold standard’ – the ultimate way to escape opioids. Unfortunately, that belief has fueled many deaths over the past ten years, as desperate people paid large sums of money for themselves or loved ones expecting programs to alter personality over the course of three months. It doesn’t work that way for most people!
During several years working in abstinence-based programs, I helped fix people who were broken by addiction. After a couple months, people left treatment with healthier bodies, cleaner complexions, and better hair. But over 90% of those people returned to opioid use, some within a few days. Some of them died because of their new lack of tolerance to opioids. In each case, counselors said the same thing: ‘he/she didn’t really want it’. But I remembered that they DID ‘want it’ when they were in treatment. In fact, some were considered star patients! At some point we must hold treatments responsible if they fail over 90% of the time.

My perspective changed. Now I wonder, why does anyone expects those treatments to work? A person is removed from a life of scrambling and drug connections and poverty, placed in a box and shined up for a few months, then put right back in the same using world and expected to act differently?
I eventually learned about medications that treat opioid addiction. I realized that opioid addiction truly is a medical illness that should be treated like any medical illness. Think about it – we treat high blood pressure, asthma, and diabetes over time. We don’t cure any of them. In fact, the only illnesses that we can cure are infectious diseases, and even that accomplishment is fading as organisms develop resistance to current medications. Given that we can’t really cure anything, why do we expect anyone to cure addiction – in 12 weeks?!

Medication-based treatments for addiction represent a transition to normalcy. Doctors and nurses were removed from treating addictive disorders decades ago because of historical events that I’ll eventually write about. Clearly, it’s time for health professionals to take a role in treating addiction. In the next article I’ll discuss the medications currently available, and the reasons that one might work better than another for certain individuals.

In the meantime please check out my youtube videos under the name ‘Suboxdoc’, where I discuss the use of medications, primarily buprenorphine, for treating addiction to heroin and other opioids.

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.

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor. This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year. But instead of cheering the good news, some doctors used the occasion to rant about diversion. Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications. Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low. Other opioid addicts use buprenorphine in attempts to detox off opioid agonists. Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal. But the statistics don’t keep addicts from trying, over and over again. After all, the belief in personal power over substances is part of the addictive mindset.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important. While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream. Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream.

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths. To you doctors: Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about? The same number of people die from lightning strikes! Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths. FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing. Getting insurers to treat AIDS was the right thing. But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids. When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician. Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises. But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine. In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications. Such sales are against the law, just as selling Oxycontin or Vicodin is a crime. But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’. If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue. Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine: With all due respect, you must be doing something wrong. I have 100 patients right now who tell me, at each visit, that I saved their lives. I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say! But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors: How can you not be excited by a medication that has saved so many of your patients? If you don’t have such patients, I suggest you give some thought to what you’re doing wrong! In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug. I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist. Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?! And if the same person injects buprenorphine, the withdrawal will be even more severe! On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal. But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine. This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly. But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin.

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it. That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

Health Privacy at the Pharmacy

First Posted 12/20/2013
In the middle of an already-hectic schedule, my office received a call from a pharmacist at Roundy’s Pharmacy, Sheboygan WI saying that he couldn’t fill a script for oxycodone without the patient’s ICD-9 number.  The ICD-9 is soon to be replaced by ICD-10, a system that applies numbers to every medical illness under the sun.  The numbers are used for billing under Medicare, Medicaid and insurance networks.
The person at my office who answers such calls asked me about the number, and suggested that I leave it at that.  “Pick your battles” she said.  “No need to make enemies on purpose!”
She had a point… but I get frustrated as layer after layer of regulation squeezes the life out of the medical profession.  One more thing to attend to is not a huge deal; the extra 3 minutes that it takes to look up a number for each prescription will simply mean that patients have 3 fewer minutes to ask questions.  But this is just one little example of one script and one pharmacy.  Another pharmacy now requires patient diagnoses to be written on every controlled substance for Medicaid prescriptions.
The greatest frustration isn’t the rules themselves, but that individual pharmacies make up their own rules for their own reasons.  Each pharmacy cites good ideas that led to their new requirements.   But I can’t predict where each patient will fill each script, so someone is added to the office to handle these and similarly-needless calls.  In a clinic with many doctors, the extra employees really add up at some point.  And patients pay higher and higher costs, to support layer upon layer of ‘good ideas.’
I called the pharmacist and asked why he needed the code.  I’ll mention at this point that the patient, a man in his early-60’s, needs an opioid agonist for severe bilateral leg pain that forced him into early retirement.  Nobody—not myself, and not the many other docs who have consulted on his care—have been able to determine the reason for his pain, despite countless tests and imaging studies.  But I’ve known the gentleman for years, and his suffering is genuine.
The Roundy’s pharmacist said that ‘the DEA is all over us, and they require us to ask for it.’  Nice try, I thought to myself.  He was lying.  I asked him to refer me to the web site or register where the law is listed or described, explaining that I’ve never heard of such a rule.  He said that the rule isn’t ACTUALLY a DEA rule—but it probably WILL be.  He said that for now, Roundy’s has a policy that ICD-9 codes are written for any scripts for immediate-release oxycodone.
Is the rule just for oxycodone, I asked?  What about Opana, or fentanyl, or dilaudid?  ‘No—just for oxycodone’ he stated.   ‘Don’t you about the oxycodone problem out there?’
I asked, what about all of the other potent mu agonists on your shelves?  Isn’t it a bit arbitrary, requiring a code for oxycodone and not for even-stronger opioids?   He answered that he worked in Milwaukee, so he has special insight into the drug problem out there.  Oxycodone is abused ‘way out of proportion’, he explained. In fact, ‘you’re the only doctor who has ever had a problem with this.  Don’t you think we should be trying to reduce diversion?’
I asked how requiring an ICD-9 number reduces diversion.  He answered that with what is going on out there, it can’t hurt.  I asked how he knew that the number a doctor wrote on the script was accurate?  Did he have any way of checking to see if the diagnosis was correct, and not just made-up?  Did he know that people interested in obtaining opioids illicitly could use the same internet that I used to make up their own codes? He again pointed out that nobody else complains, and suggested that I have too lax an attitude toward narcotics. At this point I had to get back to my patients, so I gave him the all-important number:  338, Chronic pain. Don’t we all feel a bit safer now?
Beyond the hassle, I am surprised at how little people care about their privacy these days.  I gave the pharmacist the most general code I could, but most ICD codes are far more specific. When I asked the Roundy’s  Pharmacist if he thought it right that everyone who views the script would know a patient’s diagnosis, he acted insulted and said that HE was part of the patient’s health care too—so HE had as much ‘right’ to know the diagnosis as I did.   But it isn’t just the pharmacist; the script will be seen by other pharmacy staff that live in the same small town.  Should the person who collects the script at the Rx drop-off window know that Mr. Jones has cancer of the pancreas before he tells his family? Should the tech who transcribes prescriptions know that Mrs. Jackson has genital warts?
I read today about the lack of security of private data in the US Government’s foray into health insurance—cracks in data protection that would never be accepted from a private corporation.  But even if or when the software gets fixed, I’m amazed how few people are concerned that their diagnostic codes will be floating through the IRS, of all places.  I am amazed that the same country that elected people who passed HIPAA in 1996 would be so open with their health information with both the public and private sector.
I’m getting off-track; there are so many areas where things have changed, and I want to stick with the pharmacist, since he is the person who got me riled up earlier today.  What do readers think?  Do people know that pharmacists are demanding their diagnostic codes?  Do they care?  Are you comfortable standing in line to pay for your medication when the pharmacist says, loud enough for everyone in line to hear, ‘Oh– I see you are treated for opioid addiction!’  Do you think we will swing back to the era where healthcare data was considered intensely private?
And after viewing the attached chart—are you happy with the growing number of healthcare middle managers who add layers and layers of costs, without seeing a single patient?
I’ve had a couple comments— but for some reason the blog stuck them under the wrong post.  I’ll share them here:
Submitted on 2013/12/21 at 10:56 pm
Good Topic Dr. Junig, I personally and because I feel so strongly about my privacy, refuse to even use my company provided insurance. I pay out of pocket for my office visits and meds. I even have my Dr. write the script so the label on the bottle reads that it is taken for pain. I hate nosy people, much less government. I am neither ashamed or proud of my condition, but it is that….”MY” condition that’s most important to me. I will share it with who “I” want and that’s all. When the day comes when I am on medicare or medicaid, I guess my privacy will go out the window.
Submitted on 2013/12/25 at 7:26 pm
Had virtually the same conversation with a pharmacist at Costco, including the lie about it being required by the DEA, patient privacy, verification of the accuracy of the diagnosis and appropriate use of opioids for the condition, and how giving a pharmacist an ICD-9 code prevents misuse or diversion.  Then I realized how pointless the argument was.  Called the patient and advised that he use a different pharmacy, but the patient was without prescription coverage and desperate for the best price.  Called the pharmacist back and gave him the ICD code for lumbago.