Short Term Suboxone

Firsted Posted 1/8/2014
I received an email today containing an angry comment about Suboxone/buprenorphine that I’ve read a number of times before on forums about addiction.  The essence of the comment was that Suboxone has caused tons of problems, including diversion, people stuck on the medication, and buprenorphine abuse. He wrote that the reason for all these problems was because Suboxone was ‘never intended for long-term use’, but rather was originally intended for detox only.
I could address the nonsense of his email by pointing out that the ‘problems’ he listed are infinitely better than the death that results from untreated addiction, but I’ve made that point already in a number of posts. Instead I’ll address his claim that the addiction community has hijacked a medication intended for short-term use and used it, incorrectly, for long-term treatment.
Let’s first presume, for the sake of the argument, that buprenorphine WAS originally intended for detox and not for maintenance, back in the year 2000 when the FDA considered approval of the drug.  That was not the case—but so what if it was? Over the past ten years we’ve gained knowledge about addiction that we didn’t have back then.  Studies that have shown, quite clearly, that use of buprenorphine for a year or less does little to ‘cure’ addiction.  We’ve also gained clinical experience with buprenorphine.  This gain in knowledge is not unique to buprenorphine, or to addiction.  All fields of medicine progress in a non-linear manner, as medications or procedures are honed to perfection over years of trial and error
I remember taking care of people going through autologous bone marrow transplants in the mid-1980’s when I was an intern in medicine.  Back then, bone marrow transplant patients were the sickest patients in the hospital, and many of them died.  I remember one young man in particular who had metastatic testicular cancer. We talked at the same time each night, when I was summoned to inject medications that helped him tolerate the side effects of platelet transfusions. I was moved by what he was doing, subjecting himself to horrible pain and nausea in order to get through a procedure that at the time was rarely successful. He died from a fungal infection during the stage of treatment when his own bone marrow had been destroyed by chemo, but before the transplanted bone marrow grew back to defend against the many organisms in our environment that can kill people who are immunocompromised.
Autologous bone marrow transplants have changed in many ways over the years, including how the marrow is harvested, how the marrow is cleaned of malignant cells, how the marrow is stored and re-introduced, the timing of each step in the process, the meds and techniques used to prevent fatal fungal infections, and the types of cancer appropriate for such treatment.  The current procedure bears little resemblance to the original—which is a good thing.
The same can be said of every aspect of medicine, from liver transplants to laparoscopic surgeries to running ACLS ‘code blues’.   In the latter case, we added calcium.  When we learned that brain damage was made worse by calcium, and we removed calcium.  We added bicarb, and took away bicarb.  It’s interesting to look back over 30 years at the number of things ‘we knew were right’ that proved to be wrong.  That’s how medicine worked—and still works today.
In the same way, if buprenorphine WAS ‘intended for detox’, so what?  We now know that short-term detox yields long-term sobriety in less than 5% of patients.  Even in the residential treatment centers that use buprenorphine only temporarily, to aid detox, success rates are poor.  Like meetings, buprenorphine works when you work it.  Like meetings, its value ends when you stop taking it.
In reality, buprenorphine was never ‘just a detox agent.’  I became certified about three years into the use of Suboxone in the US, and for a short time served as a ‘treatment advocate’, teaching other doctors how to treat patients with Suboxone.   We didn’t set time limits on treatment.  I suppose there were people who had a mystical view of how medication works, who hoped that buprenorphine somehow erased all of the psychopathology that accumulates during active addiction… but there were no official recommendations to use Suboxone only in that way.  Short-term detox was not the ‘intended use’ for Suboxone.
I’m left wondering: Where do these statements come from, that “Suboxone was never intended as a maintenance agent”, or that “it gets in your bones”, or “it is the worst opioid to come off”, or “it made me gain weight”, “it rotted my teeth”, “it is dangerous long-term”, etc.? Is it like the old ‘telephone game’, where stories take gain details as they are passed from person to person?  For that matter, why do some people spend their time trash-talking buprenorphine on sites intended to help people understand buprenorphine?  The forum is often visited by trolls who are obsessed with other people taking buprenorphine. Do people go on forums for illnesses other than addiction, and taunt patients with bogus information?
As I wrote to the angry person earlier today—if you don’t want or need the medication, move on already.  To some, this is serious business.  Surely you must have something better to do.
Addendum: Since this post, attitudes toward buprenorphine seem to have changed to some extent. We have far-fewer people coming to the forum just to attack buprenorphine. I’m hoping the difference is because of a better understanding of the medication, and not because of less use of the medication.

Goals of buprenorphine treatment and generic Suboxone

A question in response to a recent article, and my answer. My primary point is to address what buprenorphine maintenance CAN do– which is far more than simply ‘replace’ opioid agonists. I recently received a message from an AODA counselor that totally misses the point of buprenorphine; a message that did what the anti-sub crowd typically does– i.e. present a skewed view of buprenorphine and then tear down that skewed view. I’m not posting his ‘straw man’ message here, as there is already enough misinformation out there without his contribution.
Instead I’ll share a different, nicer letter:
Hi– my name is (Julie) and I’m a member of your site however I never post as I usually find answers to my questions.
I too would like to make a donation.
I have been on Suboxone for 3 months. Before that I was on methadone for one year, and tapered down before switching to Suboxone. I am now at one mg per day which I’m doing well with. How long should I stay at one mg before reducing to 0.5 mg? And how do I ask for Subutex (since it’s generic) without the doc thinking I’m going to abuse it? I’ve never been a needle user; sniffing was my thing– oxys but most heroin. I’m interested in generic buprenorphine because obviously it’s cheaper.
I love your site and have read about the liquid taper and your story. It’s nice to have an addiction psychiatrist who’s been in “our” shoes and who understands addiction.
Also can I mention these drugs you’re talking about to my doctor, BuTrans, Probuphine and proglumide?
Like most addicts the thought of going through withdrawal terrifies me. But I know I can’t stay on this forever. I own a small business and can’t afford to take 3 weeks or more off of work. Also I have prescriptions from a different doc who gives me valium and lorazepam. Will these help with my withdrawals? The diazepam doesn’t seem very strong to me.
Thank you!
Back to me:
Donations are always appreciated– the donation button on the blog site works through PayPal.
The mistake most people make– addicts and their docs– is to stop buprenorphine too early. Several large studies show very clearly that buprenorphine treatment less than 6-12 months is almost always followed by relapse; there is now general agreement that buprenorphine should be continued for a year or more, and often indefinitely. I understand the desire to get off everything, but there is simply no going back to who we were, before we became addicted. Active addiction permanently changes pathways in our brain, and we cannot erase them any more than we can ‘forget’ how to ride a bike. What we hope for, during buprenorphine maintenance, is for the pathways that have become engrained in the brain to fade to some extent. Addicts learn, while using, to constantly gaze inward and focus on how they ‘feel.’ If there are unpleasant sensations or feelings, addicts learn to turn to a chemical to make the feelings go away. The goal on buprenorphine is for the person to learn the reverse– to stop constantly looking inward and instead direct our minds outward, and to learn to accept life on life’s terms. When we notice unpleasant sensations or feelings, we must learn to tolerate them and ignore them. Buprenorphine maintenance allows that process to occur– providing it is taken correctly. If an addict, for example, takes little chips of buprenorphine in response to every unpleasant sensation, that person may as well take an opioid agonist.
Another goal of buprenorphine maintenance is to promote character change. I don’t think that most docs (and certainly few AODA counselors) get this part. The harm from opioid dependence does not come from ‘taking’ opioids; the harm comes from the OBSESSION for opioids. That obsession takes over the addict’s life, replacing interests in work, relationships, hobbies, simple pleasures– everything. I naively expected a ‘dry drunk’ when I first treated addicts with buprenorphine, but that is not what I discovered. Instead, I saw that as the obsession for opioids faded away, other interests returned. It’s almost as if the mind is like a computer hard drive, and has only so much capacity. If the mind is filled with obsession for opioids, there is no room for other things. I suppose the analogy is a person filling his business computer with porn– so that there is no space, and no time, for what is SUPPOSED to be going on!
One other positive aspect of buprenorphine in regard to character has to do with honesty. Opioid addicts learn to lie about pretty much everything. Addicts learn to repress the guilt over those lies and the guilt from their behavior, eventually becoming extremely adept at lying. All that lying leads to the development of an artificial, shallow personality that allows an addict to put on a fake smile even as life is falling apart. The fake personality can fool some people, but a fake ‘self’ cannot form real intimate relationships. So the addict appears happy, giddy, or even goofy… but is intensely alone on the inside. Eventually that loneliness contributes to the despair that leads, hopefully, to seeking help and recovery. One reason that taking buprenorphine on the street is foolhardy is because the addict is still leading a life of dishonesty. The fake veneer remains in place in such cases. The addict fools him/herself by thinking that everything is in order, but deep inside the addict is still separated from society by his lies, and by knowing that he is not who he says he is. With appropriate treatment on the other hand, the addict gains self confidence from knowing that the rest of the world is interacting with his/her true self. I have testified in court for various purposes, and it always boosts my confidence when I realize that I only need to speak the truth. If I had to present a version of reality that I was fabricating, I would be a mess! How much easier to just speak the truth– at least the truth as a person knows it!
Back to your situation… I worry a little that your dose of buprenorphine is too low, but if you going the full 24 hours between doses without withdrawal or cravings, your dose is sufficient. But I would be in much less of a hurry to get the dose lower. There is little difference in the opioid tolerance of a person taking 4 mg vs. a person taking 24 mg (because of the ceiling effect). So the ONLY reason to take such a low dose is for cost considerations– and maybe so that if you needed surgery, it would be a little easier to overcome the block from buprenorphine.
You are free to talk about the things I’ve mentioned with your doctor– about medications to reduce withdrawal symptoms. Unfortunately, though, it is difficult for people to understand our fear of withdrawal, who have not experienced it firsthand. As you know, there are no words that capture the symptoms, so docs think in terms of ‘pain’ or ‘depression;’ neither of which come close to describing the experience of opioid withdrawal. Society as well has no empathy for THAT type of suffering, instead dismissing it as something brought on by addicts themselves, that on some level they deserve. Yes, we are VERY far from treating addiction as a disease!!
As for benzos specifically– like Valium (diazepam) and Ativan (lorazepam)– they clearly reduce the misery of withdrawal, but they are themselves almost as addictive as opioids (and probably more addictive in some people). I support their use for such a purpose only if there are significant measures to make sure that their use stops after a short period of time. Many, perhaps most, physicians would be reluctant to prescribe them in the setting of opioid withdrawal, and I am not critical of that attitude, as I have seen many patients who have been injured by careless prescribing and use of benzodiazepines.
Finally on the Subutex issue, there is no doubt that the difference between Suboxone and Subutex in reagard to diversion has been overblown. Most diverted buprenorphine from either formulation is taken sublingually to stave off withdrawal, not intravenously for a ‘high.’ I have wondered aloud if Reckitt-Benckiser perpetuates the misperception purposefully in order to reduce abandonment of brand Suboxone. Thankfully we now have generic Suboxone from Teva Pharmaceuticals, and hopefully prices for both formulations will fall. I recently heard about a pharmacy in Appleton, WI that had generic buprenorphine 8 mg tablets for about $2.80 per tablet retail, which is the lowest price I’ve seen for a couple years. For any physicians reading this, I encourage you to cut your patients some slack if they have no insurance and consider prescribing generics; I prescribe the generic in such cases and have had no complaints of lower efficacy or other problems. In Wisconsin most pharmacies do not stock the generic, but they can order it if given a day or two notice. Although we do NOT yet have the Teva generic available, at least as far as I have heard.
Thank you for your letter. Please let your doc know about the blog, and particularly about the forum.