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February 19, 2014

Buprenorphine: Heaven or Hell?

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Paul King, MD

Parkwood Behavioral Health System, Olive Branch, Mississippi

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Recently, award-winning actor Philip Seymour Hoffman died from an apparent heroin overdose. In January 2014, Governor Peter Shumlin of Vermont devoted his entire State of the State speech to the crisis of heroin and opioid use. The increase in opioid addiction treatment in Vermont alone is 770% since the year 2000. Emergency room visits in the United States related to nonmedical use of opioids rose 183% between 2004 and 2011. The national rate of drug overdose deaths (from illicit, prescription, and OTC drugs) has tripled since 1990. Drug overdose is now the leading cause of accidental death in America among people 25 to 64 years old.

On November 16, 2013, The New York Times printed an article called “Addiction Treatment with a Dark Side.” The article began with two case vignettes. One 38-year-old man had become addicted to opioids after an accident, but he was able to again function by taking the combination of buprenorphine and naloxone. (The opioid buprenorphine is most often used for inpatient detoxification from opiates. The combination of buprenorphine with the narcotic antagonist naloxone is available as Suboxone, Zubsolv, or generic sublingual film or tablets and is indicated for maintenance treatment of opioid dependence. It is “not appropriate as an analgesic” according to the package insert.) In the second vignette, a young recreational drug abuser died from buprenorphine poisoning. The article went on to put a heavy emphasis on doctors who were opening cash-only clinics and profiting immensely from the demand while providing poor monitoring.

The prescribing of buprenorphine drugs is limited to physicians who have successfully completed an 8-hour training course, obtained a DEA number, notified the Secretary of Health and Human Services, treat only a certain number of patients, and see that patients are enrolled in a counseling program. These measures were seen as necessary due to the extreme difficulty in properly managing opiate-dependent patients.

Two primary patterns appear to lead to an opiate use problem. The first pattern is when patients are prescribed short- or long-acting narcotics for the treatment of pain. When the physician determines that the patient has met functional goals such as increased activities, improved mobility, good reports from the physical therapist, and return to work, the drug is tapered off. The patient, on the other hand, has become physically and emotionally dependent on the painkiller. He or she will first buy the pill on the street. Soon the person finds that the street price of hydrocodone or oxycodone is too high. Heroin is cheaper. Once the use of heroin begins, there is no turning back. These individuals often did not have a drug problem before starting the narcotic for pain. These patients often are older and do well in addiction treatment because they want to stop taking the street narcotics and resume a normal life. The other pattern is among recreational drug abusers who usually use benzodiazepines, marijuana, stimulants, and alcohol. These people may have experimented with “bup” (buprenorphine), mixing it with other drugs. This recreational drug use can lead to overdose or death through central nervous system (CNS) depression by several drugs. This population either has a poor work history or does not work at all.

The package insert states clearly: “Buprenorphine can be abused in a similar manner to other opioids. Clinical monitoring appropriate to the patient’s level of stability is essential.” (Many may have comorbid psychiatric conditions.) The insert continues, “Significant respiratory depression and death have occurred in association with buprenorphine, particularly when taken by the intravenous (IV) route in combination with benzodiazepines or other CNS depressants (including alcohol). . . . Chronic administration produces opioid-type physical dependence.”

These warnings and others in the package insert are clear. It is the obligation of the physician to have informed consent as well as a provider/patient agreement. Physicians must limit the amount of medication at the first visit, monitor patients carefully, and provide compulsory psychosocial counseling. Drug screens must be performed to test for multiple drug use. The counseling program can give the patient necessary skills to deal with interpersonal stress. There will always be social and personal triggers for relapse. The goal is to use those skills instead of a chemical to numb unpleasant feelings. Dialectical behavior therapy (DBT) focuses on obtaining those skills.

If the addiction escalates to the point that hospitalization is necessary, it must be clear that “detox” is not treatment. There are many stories in Narcotics Anonymous about using “detox” to decrease the physical dependence and the addict returning to drug use soon after discharge. Hospital detoxification must be followed up with either an outpatient program or residential treatment.

The 12-step recovery program provides what professional treatment cannot—meetings with other addicts who are working on their recovery. Only through attending meetings, obtaining a sponsor, and being active in the 12-step program will the addict obtain the needed fellowship. The program has to replace the drugs, and the feeling that comes from ongoing involvement is truly a spiritual transformation.

It is not fair to the physicians who truly are trying to help their patients to be portrayed as criminals by the media. Most of us truly care about our patients and try to practice by the principals of ethics as reflected in the Hippocratic Oath. The problem at times may be that the patient is in greater control of the treatment than is the physician. Once that happens, there can only be problems, and the situation will continue to escalate.

Physicians need to be extra cautious with patients who have a history of abuse of alcohol, benzodiazepines, or any other CNS depressants. The package inserts for buprenorphine drugs have a section called “Safe Use.” This needs to be read carefully and considered in the medical decision-making.

Financial disclosure:Dr King had no relevant personal financial relationships to report.

Category: Substance Use Disorder
Link to this post: https://legacy.psychiatrist.com/blog/buprenorphine-heaven-or-hell/
Related to Buprenorphine: Heaven or Hell?

11 thoughts on “Buprenorphine: Heaven or Hell?”

  1. An issue for me for is always is the physician actually that ignorant of proper substance abuse treatment, or is simply making money by exploiting an upcoming market. I have unfortunately seen too many ‘treatment programs’, where the physician undercuts the methadone clinic monthly fee, and simply maintains their patients on Suboxone, without any discussion of sobriety. The patients find it much cheaper to pay the doctor for Suboxone than buy Lortab on the street……..
  2. Had Mr. Hoffman had an enlightened addiction physician who insisted he stay on depot Naltrexone maintenance monthly when the high risk signs started in 2012 , he would still be alive today. Medication Assisted Treatment (MAT) comes in 3 flavors: methadone; buprenoprphine/naloxone and depot naltrexone all FDA approved because when used as adjunctive treatment to any recovery method of choice the opioid addicted person has OD/relapse resistance. Abstinence only programs have no such track record in the prevention of death for this diseased of brain/mind.
  3. Neither heaven nor hell. Just a tool like any other. Re discussion of sobriety: how do you define it? My observations are that patients using buprenorphine exhibit behavior that conforms to sobriety yet are often excluded from exactly the groups and activities that claim to be a source of help for those that are addicted. Find a sober living facility that will help patients on buprenorphine or a 12 step group that does not attempt to exclude them.

  4. I have been using Suboxone for 3 years as an out and inpt medication. It is evident that it has become as controversial as Methadone has been. When one sees a person with 14 Rehabs, 19 inpt stays and still craving opiates seems logical to try something different. It could be naltrexone, “bup” or Methadone. In England and some other european countries they also have heroin maintenance. I have not seen much success with the Suboxone “detox” but have seen quite a share of “bup” patient doing better, working on their progress and functioning a whole lot better than before. Are they addicted to “bup”? Yes. Which is then better? Heroin,opioids or “bup”? It seems to be left to individual provider to decide, sometimes with a significant opposition by his/her own staff, seldom by the family members. like with any addiction it is vital to involve the families, educate,educate and send them to AlAnon, recommen books, follow up. The condition is a brain disease, not a short lived whim. In treatment accountability and strict follow up with screens, callbacks and their involvement is the way to help them get out of this quagmire they never thought would come about !.
  5. At least in Oklahoma, any physician with a DEA license can write for buprenorphine for pain control and they do not have to have that special license to do so.
  6. Yikes! The very basics of buprenorphine treatment involve the understanding that patients doing well on burprenorphine are physically dependent, not psychologically addicted. There’s a big difference.
    He says that it’s up to the individual “provider” to decide. Providers work for insurance companies,
    physicians treat patients.
  7. Dr King writes that the 12 step recovery program provides what professional treatment cannot – meetings with other addicts who are working on their recovery. He never heard of group therapy?
    He does write about diabolical (oops – dialectical) behavior therapy and the learning of skills. Many addicts (including many who don’t take to notions like “spiritual” or 12 step programs) benefit from psychological treatments involving the psychological process of identification, not the learning of skills. Dr King talks about the Hippocratic Oath, but when physicians forget that our role involves both the mind and the body, we no longer practice the art of medicine, and become mere medical technicians.
  9. It has changed people’s lives for the better; of course I screen carefully the people I select to give it to; they are carefully monitored on it;
  10. Prehaps the question is—is it preferable to ‘maintain’ a patient on and addictive drug, or try for actual sobriety? Obviously, for choice between the myriad of dangers associated with iv heroin use, and taking Suboxone, I feel is clear. But maintaining that addiction (and profitting from it) is another matter
  11. For outpatient: Suboxone has become a joke. 95% of Suboxone doctors are not addiction certified. Typically it is $150 for a 5 minute appointment once a month with how ever many mg you want – up to 32. Most of the patients take it part of the time, sell some of the rest, and take LOTS of other drugs, many prescribed by the self same doctor in his self allotted 5 minutes. So much for an aid to curbing addicition!

    Addicts love suboxone because it’s free (as long as on SSID for “the bipolar”), and can use it to let down easy from H, D or Roxi, lose their tolerance and then comes a return to whoopy time.

    Methadone was actually a relapse prevention drug as it is hell to quit and you can’t get high. Of course if you combine it with 3 or 4 bars and then you can get way out there. And it’s always easy to find the right doc and get 3 bars a day even if they know you take methadone. Just need the green.

    The days of the good quality OMT are over with the demise of the state funded OTP which used to have zero tolerance for positive UDS.

    On the other hand the days of good quality abstinence oriented treatment for opioid addiction are just starting with Vivtrol, but how many really want abstinence, and can spend the money?

    For inpatient the very things that make it useless as an OP OMT agent (easy to quit) make it great for detox, and for that subutex is actually better tolerated than suboxone. My detox unit uses it quite successfully for this purpose.

    I have been the physician for detox and rehab programs for the last nearly 5 years and the addiction psychiatrist for a large psychiatric unit for about the prior 10 years or so. I see all of the above over and over and over

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