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.
Firsted Posted 1/8/2014