Tapering off Buprenorphine or Suboxone, Pt 2

In the last post we discussed some of the misconceptions about tapering off opioids. Today we will discuss a couple basic principles, and then describe the approach I recommend for my patients tapering off buprenorphine.
Opioids act at receptors that normally bind endorphins, which are released by neurons in response to a range of stimuli including trauma and rewarding behaviors such as eating a good meal or using addictive drugs. Endorphin pathways elevate mood, reduce sensation of pain, and impact urine production, immune function, intestinal motility, and other bodily functions. Endorphin pathways have a certain baseline activity or ‘opioid tone’ that is directly related to opioid tolerance. When opioid stimulation is greater than one’s tolerance, opioid tone is increased. When opioid stimulation drops below one’s tolerance, opioid tone is reduced, causing withdrawal symptoms.

The goal of any taper off opioids is to recover original or native opioid tolerance. Some people focus on getting rid of the opioid, and even use substances or behaviors to ‘flush buprenorphine from the body’. Products marketed as detox agents have minimal impact on the clearance of buprenorphine or other substances. And even if they could increase the rate of clearance, they would only make detox harder by increasing the severity of withdrawal symptoms. The relatively slow metabolism and clearance of buprenorphine provides a cushion by slowing the loss of opioid tone.

Prolonged use of any opioid changes opioid receptors. The changes are not fully understood but include a decrease in number of receptors and changes in binding properties that reduce receptor sensitivity to opioids, including endogenous opioids (endorphins). Recovery from a state of tolerance takes 2-3 months, and is initiated by reduced opioid tone. Withdrawal symptoms reflect the reduced opioid tone that provokes eventual recovery of native tolerance.

Recovery of native tolerance is the rate-limiting step when tapering off any opioid, including buprenorphine. When the dose of buprenorphine is reduced, the amount of buprenorphine at opioid receptors decreases over the next 5 days and then stabilizes at a lower level. In response, opioid tone (the summation of current flow through opioid receptors) drops below normal. If the dose of buprenorphine is maintained at that level, opioid tone will recover to normal in about 2-3 months. If buprenorphine is suddenly and completely discontinued, opioid tone will decrease to very low levels and cause severe withdrawal that lasts for 2-3 months. If buprenorphine dose decreases more slowly, opioid tone will decrease more slowly, lessening the severity of withdrawal. But it still takes 2-3 months for opioid tone to return to normal. So for any taper, patients must decide whether to decrease their dose quickly and be done in 2-3 months, at the cost of greater withdrawal, or instead to taper more slowly to reduce the severity of withdrawal.

The relationship between buprenorphine dose and opioid activity is linear up to about 2-6 mg. Beyond that point further increases in dose have less impact on opioid tone. The reverse occurs when tapering, so that opioid tone decreases only slightly as dose is reduced from 16 mg per day to 4 mg per day. The non-linear dose/response relationship allows for rapid decreases in dose early in the taper process with limited or no physical withdrawal symptoms. Since the early challenge is mostly psychological, I use the early part of a taper to help assess whether a patient is truly ready to take on the tapering process.

I like to have patients lead the way in tapering off buprenorphine. I’ve found that if I lead and reduce the amount of prescribed buprenorphine for the next month, patients often fail to make reductions and end up out of medication before the end of the month. So instead I ask patients to tell me when they are certain that they are ready to stay at the lower dose.
During a taper, I recommend dosing buprenorphine twice per day. Patients start by removing 2 mg from the evening dose. After at least two weeks 2 mg can be removed from the morning dose. This sequence is repeated at intervals of at least 2 weeks until the total dose is 4 mg per day. In my experience patients who get to that point are usually in a good mental position to begin the second, more difficult part of the taper.

Most people will be able to continue working when opioid dose is reduced by 5% or less every 2 weeks, or 10% every month. That number is a good general guideline when deciding how fast to taper. Suboxone film makes tapering relatively easy. Patients purchase a weekly med organizer, and start the week by opening and stacking 7 films. A scissors or razor is used to cut a millimeter from the end of the stack, and one film is placed in each compartment of the organizer for that day’s dose. When the patient is comfortable with that dose, slightly more is removed for the next week. The process continues every 2-4 weeks, eventually changing to the 2 mg films. I recommend that patients continue tapering until the dose is 300 micrograms (0.3 mg) per day or less before stopping buprenorphine completely. It is fairly easy to guesstimate where to cut the film in order to reduce by 10%; just measure half, then half of that, then half of that.

Buprenorphine tablets, of course, are much harder to divide. Zubsolv did people a favor by coming out with a range of doses, and hopefully other brand and generic manufacturers will eventually follow suit. For now I usually have patients use the tablets to taper as far as possible, using the 2 mg tablets in the lower dose range, and then pay the extra cost for the film for the final month or so. A 12 mg film can be divided into 24 half-milligram pieces without too much effort, so the cost doesn’t have to be prohibitive.

I have had many patients taper successfully off buprenorphine. Fear is common and normal for a number of reasons, but the fear usually gives way to a sense of confidence and optimism when a taper is done correctly.
Things to keep in mind:

  • Be patient. Tapering by too much, or too quickly, causes withdrawal symptoms that lead to ‘yo-yos’ in dose.
  • Buprenorphine products are very potent. A sliver of Suboxone Film may contain enough buprenorphine to harm or kill an animal or small child. Take care to divide the medication in a well-lit setting, and clean up very carefully.
  • Buprenorphine is used to treat pain in microgram doses. If you jump from 1 mg, you will have considerable withdrawal symptoms.
  • If you are still running out of medication early, it is not time to taper off the medication.
  • People on buprenorphine for a year or less have rates of relapse over 90%. In my experience patients are more successful tapering off buprenorphine if they have been on the medication for 2-5 years or more.
  • If you struggle in tapering down to 8 mg, consider going back to your stable dose, waiting 6 months, and trying again.
  • People addicted to opioids often substitute other drugs for their drug of choice. Do not start a new addictive substance in order to get off buprenorphine.

Good luck!

Tapering Off Buprenorphine or Suboxone pt. 1

Many patients taking buprenorphine live in fear of a dark world around the corner where they will have to taper off the medication. They see horror stories on YouTube posted by people who, for some reason, abruptly stopped the medication and kept a video log of their experiences. My own patients sometimes ask, nervously, if I plan to retire some day. Some have asked what they should do if I ever, say, drop dead.

It needn’t be all that bad. Yes, sudden discontinuation of a typical dose of buprenorphine will result in withdrawal symptoms. But if you taper correctly, your body will slowly reset your tolerance without putting you through the wringer. In this post I’ll describe my typical approach to helping a person through that process. But first we should correct some of the misconceptions about buprenorphine and opioid dependence.

It does NOT get harder and harder to stop buprenorphine the longer you take the medication. I have heard that idea over and over in one form or another, and I presume it comes from the experience people have with active addiction where use tends to grow with time, and other facets of life gradually fade away. But the opposite occurs in patients treated with maintenance agents like buprenorphine or methadone, where use of the medication does not trigger a reward or relieve the ‘punishment’ of withdrawal. The conditioning that occurred during active addiction is slowly extinguished, and most people gradually lose the desire to use opioids. I’ve witnessed this process literally hundreds of times over the past 12 years in patients on buprenorphine or methadone. Patients of successful treatment also develop interests and accomplishments that help them avoid returning to opioids. And after a few years away from ‘using friends’, people no longer see themselves as part of the using scene. Patients get to a point where they have too much to lose to get close to that world again.

Opioid withdrawal has physical and psychological dimensions. During short-term detoxes, minor physical symptoms trigger fears that magnify the perception of those symptoms. A bead of sweat on the neck signals that hot flashes, diarrhea, and depression are on the way. Patients who have been away from the cycle of using and withdrawal don’t seem to have as many emotions about their physical symptoms. I see the change very clearly in methadone-assisted treatment, where the minor withdrawal at the end of the day is a big deal to people starting treatment, but a minor inconvenience in patients tapering off methadone after several years of treatment.

Does buprenorphine ‘get in your bones’? YES, of course! Bones are living tissue, so anything in the bloodstream gets in the bones. Glucose gets in your bones. Aspirin gets in your bones. But so what? When you taper off buprenorphine, the buprenorphine in your body will be metabolized and removed. It does not accumulate or stay in bones or other tissues beyond what occurs with other fat-soluble molecules.

Is buprenorphine or Suboxone ‘the hardest opioid to stop’? No. The brain keeps no record of the molecules that pushed opioid tolerance higher. The challenge during a taper is that opioid receptors have become down-regulated by opioid stimulation, resulting in reduced endorphin tone as the opioid is removed. Opioids that leave the body quickly tend to have more-intense discontinuation effects than those that leave more slowly because the latter mimics a taper, where opioid activity decreases over time. The longer half-life of buprenorphine also slightly extends the total period of withdrawal by a few days.

I’ve heard people claim that ‘heroin was much easier to stop’, and rather than tell people what they should think I’ll let them have their opinions on the issue. But that opinion is not supported by studies comparing withdrawal from different opioids. Usually the claim is followed by the comment that ‘with heroin I was fine after 4 days’ or something along that line. But it takes longer for tolerance to reset, after ANY opioid. I suspect that perception comes from the severity of early heroin withdrawal, making subsequent weeks easier by comparison. Again, the brain doesn’t care which opioid you used to take; it only cares that the opioid stimulation that was there is now gone.

In a few days I’ll share the approach I recommend to patients tapering off buprenorphine.

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:

  1. 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.
  2. 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’.
  3. No use of intoxicants, especially for treating mood or anxiety—i.e. the ability to live ‘life on life’s terms.’
  4. 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.
  5. No history of depression or anxiety.  Not always controllable, unfortunately.
  6. Stable job, stable finances, and stable relationship, and preferably one or two hobbies.
  7. Complete loss of using contacts, and NO immediate access to opioids (no spouse on pain pills or Xanax;  no dealer calling every few days).
  8. Absence of a chronic pain condition- or acceptance that one will have to tolerate one’s pain.
  9. Being on a regular exercise schedule.
  10. 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.

A New Way to Stop Suboxone?

Originally Posted 10/27/2013
I usually have my wife/business partner review my posts and provide her opinion whether my arguments are sound.  For the record, she tells me that this post is technical and boring.  I disagree, but we aren’t planning to separate over the issue.  A valid criticism, I think, is that I’m doing a lot of guessing and wondering in this post.  This post is an example of the things I waste time wondering about.   I try to avoid writing things that are somewhat speculative, but I wanted to give it a shot for two reasons.  First, because there may actually be something to the idea I am about to describe.  But more important, I wish to point out some of the many ideas in the addiction world worth exploring…. And I hope that pharma continues to search for answers (i.e. spend money) in this area of medicine.
So I’ve been thinking more about ALKS 5461, the Alkermes pipeline medication that is a combination of buprenorphine and ALKS 33, which is a mu opioid antagonist also called Samidorphan with the structure shown at the left. ALKS 5461 is being developed by Alkermes for the treatment of major depression.  I don’t know much about the clinical actions of ALKS 33, (a proprietary molecule), except that it comes from a family of drugs that bind with high affinity and specificity to mu or other opioid receptors.  Samidorphan, a mu receptor antagonist, allows investigation of buprenorphine’s potential therapeutic effects at kappa and delta opioid receptors by blocking effects at the mu receptor.  Drugs with actions at other opioid receptors have be developed, and in some case patented.Until recently, theories about depression revolved around abnormalities in brain monoamine pathways or deficiencies of monoamine neurotransmitters.  Monoamines include serotonin, melatonin, and the catecholamines (noradrenaline, dopamine, and adrenaline). Most modern antidepressants act at serotonin or catecholamine receptors or reuptake sites. The new Alkermes medication ALKS 5461 is the first serious effort that I am aware of to treat depression from the opioid perspective.
Our brains contain natural opioids called endorphins and enkephalins.  Endorphins and enkephalins are neurotransmitters in pathways with a wide range of actions, including blocking pain and raising mood during injury or sexual activity. Pain pills such as oxycodone displace endorphins and hijack the natural endorphin pathways, providing euphoria without the trouble of buying flowers.  Of course, a relationship with self-administered opioids always becomes more destructive than even the most codependent partnership!
As an aside, when I presented for addiction treatment 13 years ago I told the addictionologist about my background in neurochemistry, and went on to explain that I was fairly certain that I suffered from a deficiency of natural opioids.  That doctor got a kick out of my story, and I would enjoy a sense of justification if my hypothesis someday proved to be correct.
When one considers using treating depression with buprenorphine, the obvious deal-breaker is the same issue that has prevented every other serious consideration of treating depression with opioids, namely the development of tolerance at the mu opioid receptor.  Because of tolerance, anyone who finds relief from depression with buprenorphine would be cursed by the need for eventual withdrawal, as well as other consequences of opioid dependence. I assume that Samidorphan is added to ALKS 5461 to prevent mu activation and tolerance.  Beyond partial agonist effects at the mu receptor, buprenorphine antagonizes (blocks) delta and kappa opioid receptors.  These blocking actions are not subject to tolerance, and may provide avenues for treating pain and/or depression.
Depression causes significant morbidity throughout the world, so there are huge profit incentives for new antidepressant medications. Addiction creates a large market as well, but companies rarely go as far out on a limb for addiction products as they do for other diseases. The need for new antidepressants is acute, but in an alternate universe where pain and addiction treatment take priority, Samidorphan and related opioid molecules might have a number of benefits. I’ve posted, for example, about my experience treating severe chronic pain by combining buprenorphine with an opioid agonist.  I expect the combination to be exploited eventually given the need for effective pain treatments, perhaps using an analog of Samidorphan.
Doctors use buprenorphine to treat opioid dependence.  The goal of buprenorphine treatment is to block the cycle of use and reward for some period of time, and to allow patients to create support systems, establish self-sufficiency, regain self-esteem, and practice living ‘life on life’s terms.’  The amount of time that it takes to accomplish these goals likely varies depending on the individual’s premorbid function, life experiences, insight, genetics, and other factors, but studies suggest that a year is not long enough to make meaningful headway.   It is possible that for some people, opioid dependence is a relatively permanent condition that is best controlled with life-long maintenance treatment.   But for those who would like to try to maintain sobriety off buprenorphine, the tapering process reignites the circuits that were set up by the initial addiction, causing cravings, withdrawal, and the constant obsession to delay the taper and resume the prior day’s dose of opioid.
If ALKS 33 has a long half-life and blocks buprenorphine in a dose-dependent manner, I could picture an alternate strategy for stopping buprenorphine where the antagonist (ALKS 33) is introduced to buprenorphine patients at a gradually-increasing dose.  The goal would be to eventually have the person on a daily dose of Samidorphan sufficient to block all of buprenorphine’s effects at the mu receptor, at which point the person could discontinue buprenorphine without withdrawal.  I suspect that the patient would experience withdrawal in response to each increase in dose of Samidorphan, although withdrawal would be reduced by introducing the drug at a measured pace.
What is the value in tapering in such a ‘reversed’ way?  Why would adding an antagonist be preferable to the current process, i.e. simply reducing the dose of buprenorphine over time?  The answer comes from an understanding of the nature of addiction.  A person stopping buprenorphine by gradually adding Samidorphan would face the decision once per day, whether to take the next dose of Samidorphan.  Compare that once-per-day decision to the current method of tapering buprenorphine, where the person must decide, thousands of times per day, to NOT take more buprenorphine.  I would expect that deciding to take an antagonist once per day would be more likely to succeed then CONSTANTLY deciding NOT to take buprenorphine all day long, throughout all of life’s ups and downs—times when the patient was conditioned to take opioids.
We will learn more about Alkermes new medication in coming months. I hope that someone in a power position will consider some of the other diseases that might respond to these interesting chemicals, including opioid dependence.

Making People Stop

Below is an e-mail that I changed just enough to hide the person’s identity. Every week, I receive messages that describe similar situations.
My husband has struggled GREATLY with substance abuse since in his 20’s; he is now in his mid-40’s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose. Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.
From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake! It’s not like if he stops this med he could ‘just’ have depression; he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.
If this is what it takes for him to live a normal life then why not? When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough.
My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.
Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.
Anyone who reads this blog knows that I agree with most of the opinions expressed in the email. I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.
More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease. The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point. We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.
To address a couple points in the message: the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile. Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe. Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’
The situation described in the message is, in my opinion, the result of several factors. First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma. Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’ I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is a more fitting ‘treatment’ than a pill that makes things better.
I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense. The risk of any medication must be compared against the risk of not using that medication. As the message states, we know the risk of ‘not treating’ the woman’s husband! Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient. As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers. So does it make any sense to withhold buprenorphine out of safety concerns?!
There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to. Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’ Some doctors want to maintain high patient turnover in order to keep money coming in, since practices are ‘capped’ at 100 patients per certified physician.
Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’ They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative. They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough. I understand the thought, as that is the type of treatment experience that I went through. But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life. During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance. Some of them– too many of them–died.
I won’t get into the specifics of treatment; I’ll leave that to her husband’s doctor to work out. But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.
To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.