Are There Too Many ‘Suboxone Experts’?

Every day I receive several comments from self-identified ‘Suboxone experts’ who repeat the same comments over and over again. I am tempted to post a few here, and then pick them apart piece-by-piece, but I am afraid that somebody will pop in, read them out of context, and think that I am agreeing with something that I actually take issue with. The comments are generally something like this: You are wrong. You are replacing one drug for another. Suboxone is the same as methadone. Suboxone is the worst thing in the world to get off of. You should check your facts. Trust me doc—you don’t know what you are talking about.’ Then they often add something like ‘have a nice recovery’, or ‘may you rot in hell’, or ‘if you get defensive that only proves that you are wrong’ (my personal favorite).

Other times I will get comments from amateur pharmacologists, using long chemical terminology (note to writers: if you want to impress someone by using the big words, at least look them up to get the spelling correct!). Tonight I read comments where a person had taken the potency-comparison chart for buprenorphine—the one that says that 1 mg of bupe is as potent as 15 mg of methadone—and projected it out to predict that a certain dose of bupe would be appropriate for a higher dose of methadone. In other words, if 1 mg of bupe is as potent as 15 mg of methadone, ‘that means that 10 mg of bupe is needed for 150 mg of methadone’. This is just plain incorrect; bupe has a ‘ceiling effect’ that is responsible for its usefulness for addiction, and the writer was assuming ‘linear kinetics’. In reality, 1 mg of bupe equals 15 mg of methadone; 2 mg of bupe equals 30 mg of methadone, and 4 mg, or 8 mg, or 16 mg of bupe also equal… you guessed it… 30 mg of methadone!

I want to tell people that there is a huge body of literature out there about addiction, about buprenorphine, about Suboxone… Understand that addiction is a world-wide problem that kills millions of people each year! Millions, if not billions of dollars have been poured into addiction research over the past 20 years. There are many peer-reviewed journals that deal only with addiction. There are hundreds of academic centers that do research into addiction. There are dozens of meetings each year, where scientists with MDs, PhDs, and other degrees discuss the current research findings. For Suboxone to be approved, the pros and cons of the drug had to be studied over and over in research costing millions of dollars. DATA 2000 had to get approved by Congress for Pete’s sake!

The world’s best minds have already thought all of this through. But more than that, studies have been done, looking at what happens in the various treatment scenarios. The ideas about the use of Suboxone have been knocked back and forth for years—over ten years. As for my own comments, I feel a bit obnoxious explaining my credentials over and over, but I do it to try to explain that I’m not just coming up with things off the top of my head because they ‘seem right’… I’m reporting on what we KNOW. We know the ideal dose of various antidepressants because of studies looking at the effects of different dosages. And we know that the withdrawal syndrome after stopping Suboxone are less severe, in humans and in animals, than the withdrawal from methadone or oxycodone—from studies investigating the withdrawal symptoms from various opiates. We also have clinical impression—the accumulated experiences from doctors treating addicts. Today I wrote back to a particularly annoying ‘expert’, ‘do you really believe that Hazelden and all the other treatment centers that use Suboxone as a tapering agent, because it is easier to come off of, are wrong—and YOU are RIGHT?!’

Yes, I realize I am getting a bit ‘pissy’ over this. But people die from opiate addiction! Young people, old people, men, women… they die in part because they don’t get expert help. Instead they try to fix it themselves, or listen to the comments on the internet that they happen to come across. I remember a guy in med school who always thought he was right, even when he was completely wrong. I remember thinking, ‘that is a dangerous way for a doctor to think’. As I have said before, a good man knows his limitations. And when dealing with something that is life-threatening, the stakes of ignorance are very high.

For people looking for information or advice, please try to check the credentials of any person making claims about Suboxone. Some people are so smug about their own ‘sober recovery’ that they take pleasure in cutting down others who found help a different way. Some people mean well, but they can’t help making up the science ‘as it should be’ rather than as it really is—an example would be me writing that ‘the different colors of a rainbow are from each raindrop shining a different colored light from the sky’—sounds almost logical, but it isn’t anything like what really happens (light waves refracted from different relative viewing angles, specifically). A general tip—when someone starts talking about dopamine levels and endorphins being depleted, they are almost always making it up as they go along. Do levels of endorphins go up or down during chronic opiate dependence? I don’t know!! I would have to check the literature. I could make up a neat story about why they go up or down… but it wouldn’t be accurate or true. It is always more complicated than a ‘story’ would suggest!

I need to get to bed at a reasonable time for a change. Keep it real!!