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!

An Addict's Story

I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic. In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication). At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me [email protected]@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer; I’ll be adding my thoughts soon!
 

The Buprenorphine Ceiling Effect

This post is from a couple years ago; I think it is important for people to have a basic understanding of how buprenorphine removes opioid cravings, so I’m republishing the post.
Note that naloxone has NOTHING to do with the effects of Suboxone.
In this video I explain why the ceiling effect is so important to the effects of buprenorphine for treating opiate dependence.

Weezer Ex-Bassist Dies, Suspected Overdose

Written by Daniel Gordon at ThirdAge.com:
Former Weezer bassist Mikey Welsh was found dead in a Chicago hotel room Saturday afternoon, the Chicago Tribune reports.
Raffaello Hotel staff reportedly found the 40-year-old ex-musician on the floor of his room around 1 p.m. Saturday. The Chicago Tribune reported that narcotics are the suspected cause of death.
Chicago Police News Affairs Officer Laura Kubiak told reporters that police are currently conducting a death investigation. An autopsy was scheduled for Sunday, according to the Tribune.

Weezer Former Bassist Mikey Welsh
Weezer Former Bassist Mikey Welsh

Welsh performed with Weezer from 1998-2001. According to Weezer’s Website, he left the band after having a nervous breakdown and reinvented himself as a painter.
In 2002, shortly after leaving Weezer, he told the MetroWest Daily News that he felt the need to move on from music, adding that he was much happier as a painter.
“Music is still an important part of my life, but I really have no desire to actually play it,” he told the Daily News.
A tribute to Welsh on the band’s Website says, “It saddens me and the guys in Weezer so much to say that our beautiful, creative, hilarious and sweet friend Mikey Welsh has passed away at the very young age of 40. A unique talent, a deeply loving friend and father, and a great artist is gone, but we will never forget him. His chapter in the Weezer story (’98 – ’01)
was vital, essential, wild, and amazing.”
Current Weezer bassist Scott Shriner posted a note on his Twitter account saying, “Really bummed about Mikey. My heart goes out to his family and friends. Such a talent… he made a special mark on the world with his art.”
Weezer is playing at the Chicago Riot Fest Sunday, a show Welsh was expected to attend.
The post on Weezer’s site ends by saying, “Mikey was planning on attending this show and we were looking forward to seeing him again. As sad as it is to think about, we know Mikey would never want the rock stopped on his account – quite the contrary in fact. While we wont see him, we know he will be there rocking out with us!”

The REAL Future of Partial Agonist Treatment— Pharma are you Listening?

I just wrote a note to a friend who works in the molecular sciences– she has been studying opioid receptors since the early 1980’s, when things were just getting started on a molecular level. I’m keeping her name to myself, but I’ll share a few thoughts about what is needed to advance the treatement of opioid dependence– and make a few million dollars along the way (are you listening, RB?)
Hi ——,
(private chit chat that would bore everyone)
Anyway, today I realized what is needed in order to take partial agonist treatment of opioid dependence to the next level.
The problem with buprenorphine is that the ‘ceiling effect’ occurs at a relatively high tolerance level, approximately equal to 40 mg of methadone. That causes at least two problems. First, going off Suboxone is a lot of work, as the person still has a great deal of withdrawal to go through. That may be a good thing early in the process, as it may help keep people on Suboxone, but after a year or so, when people want to try going off the medication, it is a major barrier that opens the floodgates to those old memories of using, etched in the emotions associated with withdrawal.
The second problem with the high ceiling/tolerance level is that surgery is a hassle. People needing surgery need HIGH amounts of oxycodone to get any analgesia—I usually give 15-30 mg every 4 hours. Pharmacists shudder to release those doses, and some surgeons and anesthesiologists balk.
The horizontal part of the dose/response curve is the essential part of buprenorphine; that is what tricks the brain into ‘thinking’ that nothing is wearing off, and in that way eliminating cravings. But that flat dose/response relationship could occur at lower tolerance levels and still work the same way.
Since I’m wishing for the moon, a series of molecules with progressively lower ceiling levels would be ideal, with the last molecule in the series being Naltrexone. Although actually, naltrexone doesn’t work—it has NO mu agonism, so there is no tricking of the brain, and no reduction of cravings. We would want something close to naltrexone, but with a tiny bit of opioid activity that does not vary with dose.
A shorter half-life would also be helpful. Preparing for surgery requires weeks to get the buprenorphine out of the system. Of course a shorter half-life means it is easier to get around buprenorphine by people who want to play with agonists, so again, these new molecules would be intended as ‘step down’ meds from early-stage buprenorphine treatment.
Do we know enough about molecular actions at the mu receptor to design molecules with these properties? Or are we still at the point of making somewhat random changes and assaying the result? Do you know of any labs doing this type of work?
I figured you’re the person to ask!
Thanks ——–
Jeff