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.
Tag: how long to take suboxone
How and When to Stop Buprenorphine or Suboxone
First Posted 12/15/2013
People know my bias—that buprenorphine is best-considered a chronic, perhaps life-long treatment for a chronic, life-long disease. That said, I am aware of how many people out there are convinced that they need to be ‘off everything,’ no matter the misery opioids have caused in their lives. I don’t get it; my perspective over the years has been seeing obituaries of patients who were doing great on buprenorphine or Suboxone for years, until well-intentioned relatives convinced them that they weren’t really clean.
But I’ve written all of this before. For those of you who are still intent on stopping buprenorphine, I’ll share my observations after watching hundreds of people stop the medication—some intentionally, and some before going back to H for some crazy reason.
First off—there is NO truth to the idea that ‘the longer you take it, the harder it is to stop.’ The idiots who peddle that line are the same people who are on and off buprenorphine, or perhaps who have run out of doctors willing to see them and now hoping that company will join their misery. The opposite is true. The patients who have done the best are the people who stayed on buprenorphine or Suboxone for at least 2-3 years, and came to a point where they just knew it was time to stop. The ones that have done well—stayed clean—are the ones who made gains during their time on buprenorphine. They got educated. They got promoted. They started families in a responsible manner (i.e fell in love first, and then had the family).
I’ve seen so many people stop Suboxone after 3 months, 8 months, or a year—and what I’ve seen mirrors the studies that show 90% relapse rates within one year of stopping buprenorphine.
I’ve developed a set of indicators that are associated with maintaining abstinence after buprenorphine. In very-rough order of importance, they are:
- Taking buprenorphine once per day or at MOST twice per day, not in response to depression, fatigue, emptiness, insomnia, or urge, but completely ‘by the clock’—as they would take blood pressure medication.
- Having month after month with no extra calls reporting lost or stolen buprenorphine, having no ‘very bad weeks where everything went wrong that forced them to take a little extra’.
- No use of intoxicants, especially for treating mood or anxiety—i.e. the ability to live ‘life on life’s terms.’
- Age over 30. Not sure why—but I have my theories. Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.
- No history of depression or anxiety. Not always controllable, unfortunately.
- Stable job, stable finances, and stable relationship, and preferably one or two hobbies.
- Complete loss of using contacts, and NO immediate access to opioids (no spouse on pain pills or Xanax; no dealer calling every few days).
- Absence of a chronic pain condition- or acceptance that one will have to tolerate one’s pain.
- Being on a regular exercise schedule.
- The recognition that opioids kicked the snot out of them, multiple times—and a strong fear of relapse.
People who lack one or more of these items should strongly re-evaluate a decision to stop buprenorphine. There are other factors—but it is late, so cut me some slack.
When someone wants to stop taking buprenorphine and I’ve educated that person about the numbers and risks, my next step is to ask the person to cut from 16 mg of buprenorphine (if on that much) to 8 mg. That change done correctly will cause no physical withdrawal, but creates enough mental pressure to separate those who are ready from those who are not.
Remember at this point that all of these things are used in my own practice; they are not intended to direct people who are not my patients, but rather to stimulate discussion with your OWN doctor(!)
The method I usually recommend is for the person to go to twice per day dosing—8 mg AM and 8 mg PM, and then change to 8 mg AM and 6 mg PM for two weeks, then to 6 mg/6 mg for two weeks, then 6 mg/4 mg for two weeks, then 4mg/4 mg. If the person can do that without any problems, I am willing to help with the taper.
I usually have patients to make small reductions at their own pace every few weeks. The goal is to move slowly; one common misstep is to make a reduction before arriving at a stable blood level from the last reduction. A dose should be maintained for at least a couple weeks before dropping lower.
Most people benefit from more-frequent dosing during tapering, since the effective half-life of buprenorphine is shortened when blood levels drop below the ‘ceiling level.’ I’ve had some patients claim to do better dosing 3 times per day during tapers. My only concern about dosing that frequently is the risk of returning to conditioned addictive behavior. I suppose the other issue is that more-frequent dosing requires smaller doses, that are more difficult to keep consistent. The 2 mg film is very helpful for tapering at lower levels, can with a razor or hobby-knife.
Patients on buprenorphine for pain treatment can avoid violating the Hamilton Act and progress down a series of Butrans patches—a process that is technically illegal for non-pain patients. The biggest patch releases about 0.5 mg of buprenorphine per day, which seems like a big step from 2 mg of oral buprenorphine until you remember that only 30% of an oral dose is absorbed. So 2 mg of oral buprenorphine yields about 0.7 mg of buprenorphine in the bloodstream—close to the amount delivered by the largest Butrans patch.
It is illegal to taper opioid addicts using Butrans, according to the Harrison Act. I realize that the situation is not fair… but sometimes Presidents create laws, even put their names on them, thinking the law is a good idea… and then the future ends up showing what a bad, bad idea the law was. Just speaking of Harrison, of course…
When patients fail a taper by using opioid agonists or returning to a higher dose of buprenorphine, I suggest they go back to a comfortable dose, and try again in a year. The hardest part of tapering is mental, but the physical symptoms are nothing to sneeze at. When tapered slowly, the physical withdrawal from buprenorphine isn’t all that much worse than having a bad cold. The goal is to stay in the game, hour after hour (after hour).
I recently met with a patient who stopped ‘cold turkey’ from 16 mg, who shared his experience in detail. He worked every day in a factory job, and managed to stay at work throughout the entire process. He swore by the 5-hr energy drinks, and said that they kept him working on the worst of days. His symptoms peaked at 11 days, and at 3 months he felt fully recovered. He carried pictures of his kids, and looked at them every time he felt a hot flash or was stuck on the commode.
I believe that he will do well because he knows that addiction is truly cunning, baffling, and powerful, and understands that he must always be alert for some crazy, cocky idea to enter his thought process. One interesting thing in this particular patient was that the entire time he went through withdrawal, he never experienced cravings. He had been on buprenorphine for a number of years, and just felt ‘done.’
Finally… most of us were brought to addiction by our best ideas. Sobriety requires CHANGE, and change is not comfortable or pleasant. Nobody wants to attend his/her first meeting. And everyone who loves meetings has many, many days when meetings are the last thing they want to do… but they go anyway. THAT is what change is all about.
How long are you going to take that stuff?
I have produced a few educational items, and I sell themt priced at a small fraction of the street cost of one tablet of oxycodone. All proceeds go toward the support of this web site, the forum, and other educational efforts. The most popular item is the e-book called ‘User’s Guide to Buprenorphine.’ You can get a sneak peak at the inside of the book at Amazon. I receive good feedback about the e-book but the most ‘successful’ recording has been the one entitled ‘How long are you going to take that stuff.’ The recording is designed for parents, spouses, or children of opiate addicts who take buprenorphine; especialy for those family members who don’t quite ‘get it,’ who ask the title question every week or so.
I have had several patients tell me that their loved ones changed their tone after listening to the recording, in which I explain the basics of opiate dependence and tell the listener why it is often in a person’s best interest to stay on buprenorphine for an extended period of time. I have also received comments in e-mails from people who had similar success with the recordings. If you have a close friend or loved one who means well, but who just doesn’t understand the point of buprenorphine, consider turning him/her on to the recording. Check out the other recordings as well, and thanks in advance for your support.
JJ
How Long to Take That Stuff?
I ended the ‘85% off’ sale of the recordings listed to the right of the blog; they are also listed at the web page ‘Sober After Suboxone,’ along with some other useful recordings about opiate dependence. I have received good feedback about the recordings, and I think that the ‘how long’ one is the most useful for the people reading this blog; people at other stages of opiate dependence may find other recordings more useful, such as the one that discusses opiate dependence treatment options. The treatment options are NOT just a list of the different options available; they are a list of the options from the perspective of someone (i.e. me) who has dealt with my own opiate addiction for 16 years. They take into consideration the fact that few people will commit to residential treatment, and more importantly they take into account the relapsing nature of opiate dependence in SPITE of residential treatment options.
The ‘how long are you going to take that stuff’ recording is for the people who are always on your case about Suboxone– the people who think you are still getting high, or the people who say you have ‘substituted one addiction for another’ (you haven’t, by the way). I take on these and other issues, such as the fantasy about being ‘clean of all substances’ that comes from NA programs from time to time. I haven’t fully decided on the title of the book I am almost done with, but I like ‘dying to be clean’, as it captures the folly of going off life-sustaining medication to chase after a shame-based goal to be ‘completely clean.’ For parents who keep harping on their children to stop Suboxone, will you feel better when your son or daughter has died from an overdose while trying to avoid the Suboxone that would have kept him or her alive? DROP THE IDEA OF BEING OFF EVERYTHING. Opiate dependence is a horribly fatal illness; if Suboxone is working, count your blessings and appreciate life. Finally, addiction is not the ‘use’, it is the ‘obsession’. Suboxone is unique among opiates in that it addresses the obsession. THAT is what gives you your son or daughter back.
As I said I stopped the 85% off sale, but I did keep a 50% off sale– not actually a sale, but more a permanent 50% price reduction. I hope you will continue to use the recording, either to arm yourself with knowledge or to share the information with others.
As I have said before, consider the $10 purchase as a donation to the cause. I really appreciate those of you who have already purchased one or several of the recordings.
Thanks!
How long to take Suboxone? Seven years?
‘Seven years’ refers to a scrape over on SuboxForum.com with a moderately disturbed woman from Roselle, Illinois… Those of you who haven’t visited are really missing some good action! We also have a new ‘Q and A’ section that I think will be a hit. Please visit and register, but more than that, WRITE! People on Suboxone need to talk to each other so that they don’t feel like isolated members of an ‘underclass’. I tell you– there are more people on Suboxone than you would ever imagine. I can’t remember the exact number, but somewhere around 500,000 people have been treated in the past few years (7 years if you believe our crazy lady from Roselle!). So let’s talk… as you will read below, the stakes are high. There remaines a great deal of ignorance out there, and it would be a shame if ignorance made the rules.
Here is the first question from the new Q and A section:
Hello Suboxdoc, I he a guy friend who has been taking suboxone for years, I read some of these stories where people have been taking it for years as well. First …is it safe to talke for that long? Can you tell me why some doctors would say “NO” to keeping a patient on it for life or what do they call it …a mantenance dose? My friends doc wants to take him off and he tells me he is not ready. He cant seem to find a doctor out here in Chicago that will work with him and tell him ok well keep you on it. I know you would need to know a lot more about my friend “XXX” and cant just guess at what he needs, I am just asking your opinion if you think keeping someone on suboxone for years is ok to do. What is your opinion. I am so glad I found this site, my friend XXX does not have a computer and I want to do as much research for him as I can and give him some positive feedback. Can you refer any doctors to me for him as I read you were out here for a meeting, do you know of any good doctors out here in Chicago? Thank you in advance!
My ‘A’:
First, let me say that this is only my opinion, and that there are other opinions. I DO think that my opinion benefits a bit from being an addict myself– but maybe it is the opposite and my opinion is LESS valid. So… I will leave that issue for you to decide.
While buprenorphine has been around for pain treatment for 30 years, using Suboxone to treat opiate dependence is new. As many people probably noticed, there was initially some hype about using Suboxone for a few months, as a detox tool. three years ago 30% of the scripts were written for long-term use. Now, 70% are for long-term use, or ‘maintenance’. The reason: studies showed that people who took Suboxone for less than 6 months had very high rates of relapse. Another reason, in my opinion, for the change in prescribing pattern was the increase in the patient cap to 100 patients, from 30 patients. I’ll explain:
The law that led to the use of buprenorphine was passed in 2000, and is called ‘DATA 2000’ for those who want to look it up and learn all the specifics. DATA 2000 dreated an exception to the Harrison Act, an 80-y-o law that bans the use of narcotics to treat opiate addiction. DATA 2000 allows the use of DEA schedule III-V meds to treat opiate dependence. In 2003 buprenorphine was moved up to schedule III from schedule V, where it had been for decades, in preparation for greater use of the drug. Finally, in May of 2003 the FDA gave the indication for Suboxone to treat opiate dependence. The initial law said that each doc could have up to 30 patients on buprenorphine at any one time. The docs had to get certified through an 8-hour course and a bunch of paperwork, and a waiting process of several months– a big hassle to a busy practice for just 30 patients! Plus, once a patient is stable there is little revenue generated… creating an incentive to ‘turn over’ patients as quickly as possible (the law of unintended consequences). So… patients were treated, tapered, and discharged, clearing the way for more patients. Never mind that the people who were discharged only relapsed again– unless they were sent straight to residential treatment after the detox was completed.
A year or two ago the law was changed, allowing doctors to have 100 patients after their first year of prescribing Suboxone. This change in the law, and the recognition that long-term treatment yields long-term sobriety, has resulted in more people being on Suboxone long-term. Given what we know about short-term use, I am always a bit suspicious about the motives of docs who use Suboxone short term– either they don’t know the science, or they want more money— again, in my ‘humble’ opinion. What is ironic is that the ‘anti-suboxone’ crowd, like our ‘7years’ friend from last week, think that the long-term docs are ‘evil’, trapping them on Suboxone to make more money! In reality the exact opposite is true. In most parts of the country if you hang a sign saying you are treating with Suboxone you will have 100 patients in two days! If you want to ‘clean up’ and make a ton of money, you treat everyone for a couple weeks of detox– then bring in another 100 patients! The ethical docs– the ones who understand addiction and who are willing to make less money to help people– treat people for the long term. They also have to put up with the head cases like ‘7 years’ harassing them. Those people are amusing, but they can be a bit annoying at times as well.
I believe that we are in the middle of a very important struggle over how addiction will be seen and treated. There is the ‘medical model’– where addiction is an illness as valid and as worthy of treatment of any other illness– and the ‘it’s your fault’ model, where addiction is a ‘spiritual deficiency’ treated through fixing character defects. I used to subscribe to the latter model, in part because it was all we had. But I have met many addicts who were just as ‘spiritually good’ as any non-addict! I mean, really– read what that ‘stone cold sober’ crazy lady wrote, and tell me– does she sound like the person YOU would want to become?!
Your specific question: We do not know of any long-term negative effects from buprenorphine. One problem I have with the nuts who spread the anti-sub stuff is that they are always wrong about everything they say– yet they write things like ‘do your research!’. To a newcomer, it must be horribly confusing. Bottom line: we hae had buprenorphine for thirty years. It is nothing new. It has been used to treat opiate dependence in other countries for 15 years– not as Suboxone, but in liquid form, using ampules and syringes to squirt it into the mouth. There is a long track record, and nothing bad has come up. And again, I have written explanations behind the claims of those who say the withdrawal is worse than that from other opiates; they are wrong about that, and if you want the reasons for their mistake you can read my recent posts on the issue.
I am a fan of long-term treatment. You will read comments like ‘I think Suboxone is fine, but only if used short term’– those comments are always by non-medical people who have no experience with the medication, and who don’t take the time to read the studies and understand the science. An argument CAN be made that a better model would be short-term detox followed by residential treatment… but it is just so darn hard to get a person into residential treatment. It really takes a commitment of 90 days to be effective, and while it can be a wonderful thing, it can also be a total waste of time and money. I believe that Suboxone and residential treatment do not mix, because residential treatment requires some level of desperation, and people on Suboxone are not desperate.
I hope that answers most of your questions… thanks for asking.
SD