Prince Missed Suboxone Lifeboat by 12 Hours

One of the links from this page connects to the ‘OD Report‘. I set up the connection to highlight the epidemic of overdose deaths, not to sensationalize the issue. But the Prince story is sensational and tragic at the same time. And the connection to buprenorphine only magnifies the tragic circumstances that are wrapped around the use of a potentially-life-saving medication.

I read some time ago about Prince’s chronic pain problems, primarily involving his hips and secondary to years of dancing in high-heeled shoes. Shortly after his death, TMZ reported that Prince’s plane made an emergency stop in Moline Illinois on his way home from Atlanta. They reported that he received Narcan at the airport after landing, and then was treated and released at the hospital before flying home to Minneapolis. TMZ later reported that Prince was taking large amounts of prescription opioids that contributed to his death.

The OD Report contains newsfeeds about opioid overdose. An article published today describes the circumstances surrounding the discovery of Prince’s body by Andrew Kornfeld, the son of an addiction doc from Mill Valley, California. According to the article, an emergency addiction treatment plan was arranged with a program called ‘Recovery Without Walls’ based in Mill Valley, California. The physician who founded and medically directs that program, Dr. Howard Kornfeld, was not able to make it to Prince and instead sent his son, Andrew Kornfeld, a premed student who worked as a ‘spokesman’ for Recovery Without Walls.

Here is where it gets interesting… Andrew Kornfeld travelled to Prince’s home with a small supply of buprenorphine. The intent of the people involved cannot be known, of course, but one could surmise that the buprenorphine was provided in order to get Prince started on the medication. Andrew Kornfeld was the person who reportedly called 911 after he arrived at Paisley Park, prompting security personel to summon the singer and eventually find his body in an elevator.

Putting aside for a moment the legal and ethical lapses of a premed student delivering buprenorphine to a person in another state. one thing is clear: Had Prince taken the two tablets of buprenorphine found with Andrew Kornfeld, he would never have died from opioids– unless, at some point, he decided to stop taking the medication. If you have trouble believing that simple fact, then I suggest you do some more research about buprenorphine treatment. You’ll find that while 30,000 people die each year from opioids without buprenorphine in their bloodstream, only 40 die with buprenorphine in their system– and almost all of those people died from other agonists, and would have lived if more buprenorphine was present.
It is almost impossible to die from opioids if a person is taking buprenorphine or the combination drug, buprenorphine/naloxone.

I don’t know how the media will interpret the story, or who society will hold at fault. From my perspective, the story is tragic in how predictable things played out. Prince had the resources to determine the truth about opioid dependence– i.e. that abstinence-based programs rarely work, especially for patients with chronic pain. He likely learned that his options included 1. a stay in rehab, including a painful withdrawal, followed by a high risk of relapse, or 2. finding a doctor to treat his chronic pain and opioid dependence using buprenorphine or a buprenorphine/naloxone combination medication (as they are essentially identical), which would almost immediately place his ‘opioid problem’ in remission. It is not clear how much of his problem was ‘addiction’, and how much was ‘pain treatment plus tolerance.’ The difference between the two conditions is often in the eye of the diagnosing physician. But the good news for such patients is that is doesn’t really matter. Buprenorphine products provide almost immediate resolution for pain patients tolerant to opioid agonists, removing cravings and providing relief from withdrawal.

In a sane world, Prince would have called the doctor down the street to get started on buprenorphine immediately. But doctors who prescribe the medication are hard to find, and the few doctors who do prescribe the medication are stuck at the 100-patient cap, waiting for President Obama to make good on his promise to change the rules so that more people can be treated.

Instead, the 100-patient limit remains in place– and patients desperate for help search throughout the country for doctors with openings. I myself receive several emails and calls every single day from people across the country who are begging for help. I tell them the same thing I would have told Prince: I’m stuck at the cap. I wish I could help.

Drug Court Organization Lobbied Against Suboxone

For years, people familiar with the benefits of buprenorphine have wondered– who is the idiot standing in the way of increasing access to this life-saving treatment?  One of the idiots was recently identified, when an open-records request by the Huffington Post uncovered a letter to HHS Secretary Sylvia Burwell from West Huddleston, then-CEO of the National Association of Drug Court Professionals.
In the letter, Huddleston wrote that allowing doctors to see more than the current limit allows ‘will result in the expanded use of buprenorphine in a manner that is less responsible and presents greater risk to the health and safety of the individuals and communities we both serve.’   The Huffington Post correctly points out that over 28,000 Americans died from opioid overdose in 2014, when the letter was written.
People familiar with buprenorphine know that the medication virtually eliminates the risk of death by overdose– even when taken incorrectly.  The anti-medication lobby, fueled by the large profits of revolving-door ‘abstinence-based’ treatments, has used fear of diversion of buprenorphine as a weapon against greater access to the medication.  But stories about diversion always fail to mention key facts about buprenorphine– for example that of the 30,000 US opioid overdose deaths last year, only about 40 had buprenorphine identified as one of the drugs in the bloodstream at the time of death.  And of those 30,000 deaths, none were CAUSED by buprenorphine.
There have been overdose deaths that were in-part due to buprenorphine or buprenorphine/naloxone medications (i.e. Suboxone, Bunavail, and Zubsolv).  But such deaths are rare.  In order for buprenorphine to contribute to overdose, the victim must 1. Have a low tolerance to opioids, and 2. Have a low tolerance to a second respiratory depressant, taken around the same time in sufficient amount.   In other words, someone physically dependent on opioids cannot overdose on buprenorphine.  In fact, buprenorphine products would precipitate severe withdrawal if taken by opioid addicts within a few hours of heroin, oxycodone, or other opioid use.
Drug courts in my area tend to avoid medication assisted treatments, with the exception of Vivitrol or IM Naltrexone.  There is no evidence that blocking opioid receptors for a year has any effect on death rates from opioids.  Studies have reported that patients who stay compliant with treatment, who return each month for another injection of naltrexone, don’t waste their money on agonists that would have no effect on them.  But what happens 6-12 months later, when probation ends and those patients are no-longer required to take naltrexone?
I wish I could tell you what happens– but I can’t, because nobody has done the studies to find out.  The cynic in me takes it further, wondering if anyone even cares what happens when people are temporarily maintained on naltrexone and then allowed to stop the medication?  I’ve asked physicians, prosecutors, and law enforcement the same question:  what happens to the person when the naltrexone is discontinued?  In response I usually hear ‘what do you mean?’  Or ‘how would I know, since I don’t see them anymore?’, or ‘I assume they do fine… don’t they?’
I don’t see much concern when I explain that people who stop naltrexone are in a state of ‘reverse tolerance’ making them more susceptible to death by overdose.   So I remind them of the large number of overdose deaths in people who were recently released from a controlled environment, such as residential treatment or incarceration, after tolerance dropped to normal levels.  Maybe I’ll point out the Australian studies that show a 12-fold higher death rate in addicts who were maintained on naltrexone.   But by that time I’ve lost the person’s attention– just as their attention leaves each addict when his/her probation expires.  ‘Not my problem anymore.’
Huddleston is no longer the CEO, but the NADCP continues to express a muddled message about buprenorphine medications.   If you have a minute, you might consider educating the NADCP staff about the value of buprenorphine treatment.
Meanwhile, HHS Secretary Burwell says changes to the cap are coming.  I received 12 calls last week from people looking for help.  I’ll keep telling them to try to be patient.

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!

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.

Double Standard for Buprenorphine at Pharmacies

First Posted 9/25/2013
Because of this blog, I frequently receive emails from people describing outrageous behavior by pharmacists.  I don’ intend to argue that pharmacists as a group are any more annoying than doctors, nurses, or plumbers for that matter.  Every specialty has practitioners who do their best to provide safe and effective services…. and practitioners who are always out for themselves, with much greater interest in ‘CYA’ than helping someone in a difficult situation.
I’ve written about the problems with abuse and diversion of buprenorphine and Suboxone in Northern Wisconsin and the Upper Peninsula of Michigan.  Like much of the Midwest, there are few if any buprenorphine-certified physicians in that area.  But one corner of Michigan, patients lucky enough to make it through a long waiting list are faced with another problem; price-gouging by pharmacies, and policies based on false assumptions.
People knowledgeable about buprenorphine and Suboxone know that Suboxone and buprenorphine are virtually the same medication.  People who inject both drugs in studies will give higher average ‘liking scores’ for buprenorphine, but there is considerable overlap between the two medications.  Patients in my practice who admit to injecting Suboxone or buprenorphine (to make it last longer) before they could find a certified doctor claim that they found no difference between the two medications.   I’ve described other reasons why adding naloxone to buprenorphine is more of a marketing ploy than a deterrent to diversion.  For example, naloxone lasts about an hour in the bloodstream, whereas buprenorphine lasts for days, and the high-affinity binding of buprenorphine is not significantly impacted by the comparatively-weaker drug, naloxone.
The standard narrative, that holds that Suboxone is ‘safer’ than buprenorphine, relies on false assumptions.  Many people who should know better believe that naloxone provides some measure of safety in people who don’t inject the medication— that the naloxone ‘blocks euphoria’ or that the naloxone ‘provides the ceiling effect.’   This is, off course, hogwash (do they use that term outside of the Midwest?).
The importance of naloxone is so low that the standard of care in pregnant women is to prescribe ONLY buprenorphine based on the argument that it makes no sense to expose a fetus to an extra medication (naloxone), when that medication doesn’t do anything.  The natural question is ‘why expose ANYONE to an extra medication, when that medication doesn’t do anything?’
Opioid dependence is a potentially-fatal condition.   People trying to rebuild their lives, after active addiction, frequently begin from a position of unemployment and poverty— and no health insurance.  If lucky enough to find a physician who prescribes Suboxone or buprenorphine, their access is severely impacted by the cost of the medication.  If their doctor prescribes Suboxone film, they will pay over $500 per month out of pocket.  If their doctor instead prescribes buprenorphine, the cost drops to $135—saving almost 75%.  But if that patient lives in remote Michigan and wanders into Snyder Drugs, the cost for the same amount of buprenorphine is over $450. I assume that Snyder Drugs has access to US Mail, UPS, FedEx, and all the other delivery methods available in Wisconsin (i.e. they do not rely on bobsleds).  We often hear of criminal charges against people who gouge prices for generators during storms. Given that the current epidemic of opioid dependence has killed for more people than the typical hurricane, is it reasonable for a drugstore to mark up life-saving medications by 200%?
It gets worse.  Snyder Drugs has a policy that forbids filling prescriptions for men for buprenorphine, but allows filling of the same prescriptions for women—pregnant or not—based on their conviction that men are more likely to divert buprenorphine than women.   Men prescribed buprenorphine must drive hours to find a pharmacy that will fill their legal, legitimate prescription; several hours to avoid gouging altogether.
I realize that the UP has a diversion problem, as does most of the country.  But does Snyder Drugs and similar stores make the problem better, or worse?    Patients in that area, having no buprenorphine-certified physicians, engage in ‘self-treatment’, a form of diversion that probably makes life more bearable than active heroin addiction.   When patients finally find a legitimate prescriber, what is the impact of pricing the drug higher than patients can afford?   Does the increase in price make it more or less likely that the patient will sell a portion of the prescription?  Does the increase in price make it more or less likely that the patient will inject the medication in order to make one tab last four times as long?
And for people living in the UP—is it legal for a pharmacy to discriminate by gender?
There are many regulations governing the treatment of opioid dependence with buprenorphine at the state and federal level.  Adding pharmacy-by-pharmacy policies and regulations, that treat people with addictions differently than people with other illnesses, only add confusion—and might be breaking the law.