Originally Posted 5/11/2013

The forces of nature appear intent on reversing mankind’s progress toward better health.   An example is the ever-increasing resistance of bacteria to antibiotics.  A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans.  In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.

Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’  Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases.  There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.

Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts.  The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic.  As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people.  We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools.  Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.

Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness.  I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!)  Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected to emerge– and have emerged.

As a medical student I learned about ‘non-A non-B hepatitis’, a small concern at the time that has since grown into the identity of ‘Hep C’ (Funny how long it took to come up with THAT name!)   Hepatitis C is a major public health threat, since routine vaccinations for hepatitis B and the surge in IV drug use.
Not all diseases are from non-human entities.   Cancers, for example, arise from errors in our own DNA, either inherited or acquired.  Cures have been found for a few cancers, but like bacteria, cancers have emerged that are resistant to current chemotherapeutic drugs, requiring a constant search for new agents.

Some illnesses are considered ‘lifestyle diseases’ because they are  related to obesity, smoking, pollution, substance use, inactivity, or poor diet— such as hypertension, heart disease, diabetes, cerebrovascular disease, asthma, and COPD.  The model of resistance show by bacteria doesn’t fit in the same way, but many of these illnesses draw public attention as ‘epidemics’ that demand resources, with apathy or cultural phenomena function acting as resistance to those efforts.

Bear with me;  I’m working up to something that I’ve alluded to before.  My point is that like with other illnesses, addiction doesn’t respond to medications– Suboxone and buprenorphine — quite the way it used to.

When Suboxone hit the US market in 2003, large numbers of opioid addicts were scattered across the country, sick and tired of their dependence on opioids.  Heroin was considered a ‘bad drug’ back then even by those with severe addictions, and was rarely encountered by teens and young adults.  Most opioid addicts used hydrocodone or oxycodone, prescribed by doctors or obtained from people with prescriptions.  Heroin was marginalized to those with the most-severe addictions, or used sporadically in combination with other drugs (e.g. speedballing).  Known doses of oxycodone were comparatively safer than heroin, which is stepped on to varying amounts and sometimes laced with deadly fentanyl.  Oxycodone was absorbed through mucous membranes more quickly than heroin, meaning lower motivation to use needles.  So in the early 2000’s, some people addicted to opioids found a way to get by, albeit in state of chronic misery and loneliness after spouses and friends moved away.

Enter Suboxone– a new medication to treat opioid dependence.  Suboxone carried some controversy, as some in the non-medication treatment lobby did their best to tarnish the medication (as in ‘you’re not as clean as I am!).   But despite the tarnish, Suboxone and buprenorphine were medications that were to be prescribed by doctors.  People who for years kept the same horrible secret were given an option that actually worked.  People returning to my office for follow-up had tears of happiness on their faces;  they thought they would never be free from their afflictions, and were grateful as Hell for a chance to return to the living.

Many of those patients have done well for years, in treatment in my practice and others.  Many are still on buprenorphine and grateful to be on buprenorphine, as happy and productive as they’ve ever been in life, with no desire to change.

But then, just as some of us were becoming optimistic about this great new medication, the disease of addiction changed in the direction that all diseases change– for the worse.  The substrate changed; oxycodone was largely removed from the market through well-intentioned anti-diversion efforts that made Oxycontin harder to abuse…  just as the US experienced a large influx of cheap heroin.  And as in the 1960′s, heroin brought out needles– something that many opioid addicts used to take pride in for not considering.

And Suboxone changed.   People on buprenorphine or Suboxone sometimes shared a bit of their medication with friends going through dry spells. Some people on Suboxone or buprenorphine sold portions of their prescriptions.   The image of Suboxone held by active heroin addicts changed from doctor’s medication to a self-directed treatment for withdrawal.  In fact, the perceived roles of patient vs. treatment provider became blurred by needle exchange programs and programs that provide addicts with syringes loaded with naloxone.   Against a confusing backdrop of publicly-provided needles, free syringes pre-loaded with naloxone, and expensive brand film vs. affordable generic buprenorphine, the image of Suboxone turned from orange to gray.

I don’t mean to criticize the well-intentioned efforts to save lives, such as the distribution of naloxone in areas where overdoses have become epidemic.   It’s hard to predict unintended consequences.  But now, new patients consist of 18-y-o heroin addicts who see Suboxone as a tool to provide cover for a few days, when the heroin supply runs dry.  Some see Suboxone as a tool to detox, although the detoxes never accomplish anything at all—the ultimate bridge to nowhere.  The bottom line is that after seeing a few Suboxone tablets ground up, dissolved, cooked, and injected, the medication loses a bit of luster.
And finally, patients themselves have changed.  Opioid addicts in 2013 are often acutely ill from unknown doses, toxic fillers, and dirty needles, presenting to ER’s with antecubital abscesses and hepatitis C.  And despite being very, very sick, many haven’t had enough time to get sick and TIRED.   Being started on Suboxone is less of a bit deal because they’ve BEEN on Suboxone— little chips of it, over and over and over, whenever the heroin ran out.

Gone are the easy buprenorphine patients.  Now we have young, fresh, sick addicts who won’t live long enough to hate their addictions.  Addiction as a disease has adapted to our treatment efforts, and become stronger– and deadlier.  Our side had better keep up the hard work.

Addendum 12/2022: Interesting rereading this 3 years into the COVID pandemic and fentanyl outbreak.


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