I’ve been discouraged by the number of people who write to this blog indicating that they abuse Suboxone by snorting or injecting. I know that’s a small number of people, compared to the thousands that have used Suboxone to get their lives back, and who are in excellent recovery, but it still depresses me.
What should the addiction medicine community do? What should the government do, if anything? What about law enforcement?
In this country, most law enforcement people see abuse of Suboxone the same as any other street drug. For them, it’s usually black and white. If it’s not prescribed for you, or if you’re using it in a way that’s not prescribed, it’s a crime for which you should be prosecuted.
Harm reduction proponents see the situation wholly differently. Since Suboxone is usually safer than other illicit opioids (note I said safer, not safe), even when it’s misused, why not allow the illicit use? In fact, why not hand out Suboxone tablets to anyone proven to be an opioid addict? If the addict snorts or shoots Suboxone, at least he’s not shooting heroin, a much more dangerous drug. True, that person is susceptible to medical complications from injecting and snorting, but this would be true for any other opioid. And some studies indicate that most of the illicit Suboxone is bought by addicts either self-medicating in order to stay out of withdrawal, or giving the medication a try before making the financial commitment to go to a doctor’s office for a legitimate prescription.
In a purely scientific world, I would agree with the harm reductionists. But that’s not the world we live in. We should be sensitive and alert to political forces that would like to annihilate our present freedom to prescribe Suboxone from a doctor’s office. Doctors – and their patients – have to be good stewards of this freedom, by taking whatever measures are appropriate to keep Suboxone out of the hands of illicit users.
So what can doctors do to reduce Suboxone diversion?
- Tablet counts and film counts. When I get a new patient, I have in my monitoring agreement that I will occasionally call them to go to their pharmacy (Some patients drive up to forty minutes one way to see me, so it’s more convenient to go to their pharmacy than to my office. Most pharmacists are happy to help.) for medication counts. If the count is short, either the patient is taking more medication than prescribed, or diverting it. Decreased diversion is the drug manufacturer’s big selling point for the films, rather than the tablets. They say that since each box has a lot number, if a patient has sold or given away some of their films, they can’t just buy replacement films to replenish before their count, like can be done with tablets. The lot numbers have to match. I can see where in theory that can be true…but I can also think of some ways to easily get around that, which I won’t post here.
- Urine drug screens to make sure buprenorphine is present in the urine. Screening should be done anyway, to check for other drug use. Doctors doing urine drug screens should, of course, have buprenorphine on their test panel. In the past this was an expensive test, but not at present. My on-site test kits cost less than $10 when bought in bulk, and test for buprenorphine, methadone, opiates, oxycodone, THC, cocaine, methamphetamine, and benzodiazepines. (I have individual test cassettes for other drugs, when indicated.) Obviously, if there’s no buprenorphine in the urine, we have a problem.
- Check the prescription monitoring program in your state. If the patient is getting prescriptions for other opioids, like morphine or oxycodone, it’s possible the patient stops Suboxone and uses these opioids between doctor visits. The other possibility is that they sell these other opioids, also not an acceptable situation, since it fuels other addicts’ addictions.
What can patients do to help keep Suboxone away from illicit users?
- Don’t share your medication. Even if someone you care about is in withdrawal, help him to get care from a legitimate source. Don’t endanger him and yourself by sharing medication. And of course…don’t sell your medication. Duh.
- Make sure you keep your Suboxone in a lock box, or other safe place. Not only will this keep your medication away from children, but also from addicts looking for opioids. Many patients new to recovery haven’t yet cut off ties with all drug users, and other addict “friends” may be looking for medication.
- If you know of a Suboxone patient who’s selling medication, tell their doctor. You don’t have to call the police to get them into legal hot water, but you should do all you can to stop the illegal sale of any prescription medication. After all, a patient selling Suboxone is endangering your right to get convenient, office-based treatment.
- Family members: please call your loved one’s doctor if any part of their Suboxone prescription is being sold or given away to other people. Because of confidentiality, we may not even be able to confirm that your loved one is a patient, but we can always take information from you. We may do pill counts or other things to confirm what you are telling us, and then take action.
What are the possible consequences of continued diversion of Suboxone? Some authorities are talking about changing the DATA 2000 law. Others are clamoring for buprenorphine to be re-scheduled into a schedule II opioid, which would disqualify it under DATA 2000 for use in an office. It would still be available at an opioid treatment program. And many OTPs (opioid treatment programs) do now offer buprenorphine.
I advocate for continued availability of office-based buprenorphine treatment, but now I believe some patients should start at an OTP, and transfer to office-based program only if they do well. Some patients are so strongly addicted to other drugs that they don’t do well in office-based treatment.
I now work at a wonderful opioid treatment program that offers both buprenorphine and methadone upon admission. I’ve switched a few selected patients to my office-based practice. This means I see them and write a prescription for them to fill at a pharmacy, no longer chaining them to daily OTP dosing. I still see them at regular intervals, usually every one to two weeks. These patients can still contract with the OTP for individual counseling and drug testing. This allows the OTP to have a wider variety of treatment options for their patients, gives me a stable patient, and gives patients who are doing well more freedom and treatment at a lower cost. Win, win, win.
I hope more OTPs will begin to offer buprenorphine as a real option to methadone, so that patients who don’t do well in office-based programs can still be on buprenorphine. And I hope they direct the stable patients to office-based programs.
Posted by Jason on October 19, 2011 at 6:30 pm
Great article. I think after all these years, Suboxone is still misunderstood, especially on the legal side of things. I’m 42 never been in jail. I was pulled over for a trafiic violation 2 yrs ago and the officer saw my pill bottle on my console..a pill bottle that only holds max 2 pills and very cool I might add. I learned my lesson. She asked me what was in there and I told her Suboxone. What is it for, she asked. Opiate addiction, I said. Oh boy, here comes two more squad cars, handcuffs, and in the back of her car. She got on the radio described the pill (before films) and asked where my prescription was. I told her it was at home, but told her I had a suboxone emergency card with my doctor’s info in my wallet. A long story longer, I was charged for felony possession of Naloxone (not Sub or Buprenorphine!) 36 hours in jail, 13 months later and 3 court appearances, i was exhonerated. It was a nightmare and at one point the judge said I could get 1 year in prison and I should get an atty.. There needs to be some assistance with the law enforcement to 1. be able to look up and see if a person has a valid prescription, and 2 to let them have their suboxone in jail. I was given 5 librium (sp?) pills by the jail nurse and slept through almost everything, but I now find out that was dangerous? maybe not. Anyway, keep your prescription bottles with you!
Posted by janaburson on October 19, 2011 at 8:14 pm
That is dreadful!!! It’s sad when police give people such a hard time for being in recovery!!! Educating law enforcement people feels like rolling a boulder up an endless hill…
Posted by Sam on October 19, 2011 at 6:32 pm
Hopefully probuphine, the Buprenorphine implant, will get approved by the FDA. It will address the diversion problem of both tablets and films. It will also make it much more convenient to get the drug, as the implants (under the skin) deliver the drug for 6 months.
Posted by janaburson on October 19, 2011 at 8:15 pm
Yes! I think without a doubt it will change the whole face of buprenorphine treatment.
Posted by Kelly Collins (@kharpercollins) on December 1, 2011 at 1:34 pm
I was under the impression when Suboxone was used for recovering addicts but I read over and over that many of them have been on it for years. That’s not recovery it’s a substitute. I hear doctors say that they are tapering off their patients but don’t see it. My family member seems to be in worse condition then when he started it. We’ve called the doctor office expressing great concern but she still keeps writing the scripts instead of correcting the problem. At this rate we are all afraid of losing our loved one to this vicious cycle of abuse. Any tips?
Posted by janaburson on December 1, 2011 at 10:35 pm
It sounds like your family member isn’t doing well, abusing the Suboxone and other drugs. In such case you’ve done what you can by telling her doctor what you see.
However, if you’re opposed to your relative staying on Suboxone even when they are doing well, you need more information about Suboxone.
Opioid withdrawal is often about more than just the acute withdrawal which lasts for days to weeks. In many opioid addicts, their bodies stop making their own endorphins. These are opioid-like chemicals made by our bodies that give us a feeling of well-being. Some addicts can have a low-grade withdrawal lasts for months. It’s difficult to tolerate this fatigue, depression and sluggishness, so relapses are frequent.
We use Suboxone (and methadone) because it’s a long-acting opioid that replaces the endorphins the addict’s body should be making. At the proper dose, patients on Suboxone should feel normal, not high or intoxicated. There are some addicts with such bad addiction that they aren’t able to take the Suboxone as prescribed, so a different form of treatment is indicated. This seems to be the case for your loved one.
For patients who take Suboxone as prescribed, it allows them to feel normal physically and allows them to concentrate on getting their lives back. This takes time, and it takes time to get needed counseling to prevent relapse.
Some patients do so well that they don’t want to risk a relapse by coming off the Suboxone.his is the group that appears to be doing the best in research studies. But some addicts are able to slowly taper Suboxone and successfully remain off all opioids. So it depends on what’s right for the patient. The decision to stay on or taper off Suboxone should be made by the patient and by their prescribing physician. Another complicating factor is chronic pain. If a non-opioid way to manage chronic pain can’t be found, Suboxone may be the best option to manage the difficult combination of addiction and chronic pain.
Posted by Scruf2 on July 20, 2012 at 3:18 pm
The abuse of suboxone starts with the guidelines for prescription that doctors learn to be certified. The web course training has induction involving 16 to 24mg the very first day. Then the stabilization phase is 6 to 8 weeks where this dose is maintained.
No room for the low dose/ short term patient – Who will be gone in 30-60 days if they are able to stop drugs after help with W/D.
It is assumed all are to stay on the drug. Tapering is not taught in any way that would work. AT $500 a month compare 2 months of treatment with a patient who stays 5 years. It is 30 times more profitable to addict the patient to the
“cure”.
And the early statements that Suboxone is easy to taper — are not true it seems.
Visiting the sites on line such as Suboxone Talk Zone and reading the posts on quitting indicate it is very very hard.
The medical establishment is not using this drug to detox — even when it should be done. All patients are addicted and maintained in this new profitable system.
At the same time low income people who need help get none, and detox centers are stopped from using it when they need it.
What happened to “do no harm”?
Posted by janaburson on July 22, 2012 at 8:28 pm
*deep sigh*
Stopping opioids is a small part of the problem. The bigger problem is relapse back to opioid use. Suboxone clearly works better as a maintenance drug for most – not all – people. We’ve seen this in study after study. In the Kakko study, which compared a quick taper with maintenance, both groups got fairly intense psychosocial therapy. At the end, none of the quick taper patients were still in treatment. And 20% of them were dead of opioid overdose after they left treatment.
Dead addicts don’t recover. Let’s use medication if it means keeping folks alive.