Archive for the ‘snorting pills’ Category

Misuse of Suboxone: What Should We Do?

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.

Best Treatments for Addicts who Snort or Inject Suboxone

Suboxone misuse is much more common than I realized, as I’ve learned from people who write comments to this blog. These opioid addicts have described how they snort, inject, and even anally insert the Suboxone that’s meant to treat their addiction.

Not every addict can be treated with Suboxone from a doctor’s office. For some patients, the addiction is too strong, and they are unable to use the Suboxone as instructed. If a patient is injecting or snorting the medication meant to help them, they aren’t in recovery. These addicts need to be referred for another form of treatment. They aren’t being helped with Suboxone, except that perhaps it’s a little safer then other abused opioids, since at least there’s a ceiling on its opioid effects.

 What are the best options for these addicts? 

Most aren’t willing to go to inpatient detox followed by prolonged (one to six months) residential drug rehabilitation. It’s costly, and no one likes to be away from home for that long. However, this form of treatment can be life saving and gives the best chance of drug-free recovery.

Or they could enroll in an opioid treatment program, called OTP for short. In the past these facilities were called methadone clinics, because that was the only medication offered, but now many clinics also use buprenorphine. I’m glad to see this trend. For many patients, buprenorphine is a better drug. Patients tend to feel less medicated, and are less likely to feel any euphoria from buprenorphine. And the clinic gives patients more structure than I can from my office.

At OTP (opioid treatment programs) the patients are seen every day. Most clinics are open at least six or seven days per week. That way, patients can be given an observed dose each day. They won’t be able to misuse their medication, since a nurse places the tablet or film under the tongue, with buprenorphine. Methadone, dispensed as a red liquid, is swallowed each day in the presence of the nurse. Diversion to another person certainly isn’t impossible, but it’s much less likely to occur.

 So to all of the addicts now using Suboxone in unorthodox ways, snorting, injecting, and other ways, tell your doctor what you are doing. You can get your addiction treated by going to a clinic each day. Counseling is built into the opioid treatment program system. Patients there must see their counselors, and many clinics also make group sessions mandatory.

 I’ve become gradually more selective about who I’m willing to treat with Suboxone in my office. I’m more vigilant about medication misuse, since this blog taught me that it happens much more frequently than I previously thought. I now believe that only very stable opioid addicts should be treated in an office setting. Older addicts with jobs, families, and no other addictions appear to do the best in this type of treatment. From now on, if I have openings for new patients, I’m going to screen more rigorously. Many addicts have an addiction that’s too severe to treat with office-based therapy.

Am I Addicted to Prescription Pain Pills?

I am a guest blogger on addictionblog.org, and recently had a well-received article published on that site about how to know if you are addicted. I thought I’d repeat a version of that column here.

 There’s so much confusion about the differences between the disease of addiction to opioid pain pills and mere physical dependency on pain pills. Even some doctors don’t understand the differences, regretfully. Any person who regularly takes opioid pain pills for a period of weeks to months, for whatever reason, will develop a physical dependency to these drugs. That’s a biologic event. But addiction is much more than just the physical process. With addiction, there’s also a psychological component. People with addiction think about the drug often, spend time using and recovering from the drug, and continue to use the drug even though bad things happen. In physical dependency alone, this doesn’t happen.

 Here are a few specific questions that I ask patients, that help me decide if they have the disease of addiction:

  • Do I take more medication than prescribed? Do I take early doses, or extra doses?
  • Do I take medication in ways it’s not intended? For example, do I snort it, or chew it for faster onset? Do I inject it?
  • Do I get medication from friends, family, or acquaintances because I run out of my prescription pills early?
  • Do I become intoxicated, or high, from my medication? Without telling my doctor?
  • Do I drink alcohol with medication, even though the pharmacist advised against this?
  • Do I look forward to my next dose of medication?
  • Do I get impaired from my medication, to the point I’m unable to function normally?
  • Do I take pain medication to treat bad moods, anxiety, or to get to sleep?
  • Do I use street drugs like cocaine, marijuana, or others?
  • Have I driven when under the influence of pills, when I know I shouldn’t be driving?
  • Do I get prescriptions from more than one doctor, without telling them about each other?
  • Do I spend a great deal of time worrying about running out of medication?
  • Do I spend a great deal of time thinking about my medication, and how it makes me feel? 

One “yes” answer to any of these questions is worrisome, though not necessarily diagnostic of addiction. I think of addiction as a continuum, and it’s easier to diagnose with multiple “yes” answers. For example, people taking prescriptions may have a few worrisome symptoms, like taking an extra pill occasionally. Perhaps they did this because of a temporary increase in pain. Without any other symptoms, I probably wouldn’t diagnose addiction. At the other end of the spectrum, if a patient is crushing pills to inject or snort, I feel confident making the diagnosis of addiction.

 Sometimes addiction only becomes apparent over time. This is why doctors need to see patients frequently who are prescribed potentially addicting medication, like pain pill, stimulant, and benzodiazepines.

 If you had one or more “yes” answers to the above questions, please see a doctor who knows something about addiction, because untreated addiction usually gets worse. In fact, it can even be fatal.

Misuse of Suboxone

After I made some posts on this relatively new blog about Suboxone film, including pictures of the film, the number of hits to my blog increased dramatically. But I saw a pattern. I was getting hits from search engines, after people entered phrases that indicated they were looking to either snort or inject Suboxone.

 Over the past thirty days, the number of hits to my website from people entering phrases related to injecting Suboxone is: 138

 Phrases about snorting Suboxone: 114

 Phrases indicating attempt to get high from Suboxone tablets or film: 26

 Maybe not everyone who entered such phrases actually was looking to learn how to misuse the drug. Maybe some of the entries were people merely gathering information. But I suspect most people were addicts trying to get information about the misuse of Suboxone.

 Then I also receive a few posts that I don’t approve for this blog site. Recently I got an interesting post from an IV addict who describes how he separates the buprenorphine from the naloxone before injecting the tablets, but I’m certainly not going to publish that information. True, you may be able to find this information elsewhere on the internet, but not here.

 All of  this is challenging me to re-consider what I believe about Suboxone.

 I prescribe it from my private office, and I’m having misgivings about this. Are my patients injecting or snorting? I don’t think so, but now I wonder if I’m fooling myself.

 Maybe the only safe way to use Suboxone is through opioid treatment programs, where patients have to come each day to get their dose and take it in front of a nurse,  just like we do with methadone. 

Comments?

Who is Snorting Suboxone Tablets or Film?

Lately I’ve been amazed at the traffic my blog site has been getting. Then I look at the statistics, and the increase is from people who put phrases like “inject Suboxone film” and “snort Suboxone film” into search engines. From this information, I’m starting to have the unpleasant suspicion that there are more than just a few people who snort the tablets, and are worried they won’t be able to snort the film.

After examining the film myself, I don’t think it’s “snortable.”

At the risk of sounding like a shill for the drug company (I don’t take or receive money from any drug company in any form or fashion), this film is better than the tablets. I have quite a few patients reporting to me after using the film for the first time, and nearly all prefer the film to the tablets. They say it dissolves quickly, and while it doesn’t necessarily taste any better, it’s gone more quickly so that the unpleasant taste doesn’t linger.

 Patients describe the difference between sitting for fifteen minutes with a mouthful of saliva, trying not to swallow, versus five minutes or less of letting the film dissolve, with minimal saliva formation. Many patients believe they are absorbing more medication. I don’t know if that’s true, but it makes sense. If the tablet causes a large volume of saliva to accumulate, it seems logical that due to the dilution, less medication would be available for absorption.

 However, if the price of the film increases after March, 2011, I don’t know if patients without insurance will stay on it. Many of my patients can barely afford the medication, along with the cost of my office visit and of drug screening. That $75 coupon provided by the drug manufacturer each month has been a big help, but I don’t know what will happen with the price next year. If there’s a generic buprenorphine/naloxone tablet that works well and is cheaper, many of my patients would probably switch again from the film back to a tablet. 

Which brings me again to my concern about snorting (and even injecting) Suboxone tablets. Lately I’ve trolled the various websites and I see references to snorting, even though pharmacologically that makes little sense. I still suspect it’s due to addiction to the act of snorting, which has become such an ingrained habit in some addicts that they feel a compulsion to use all medications in this way. 

Comments from any Suboxone-snorting addicts out there?

The New OxyContin Formulation

Over the last three weeks, at least five of the opioid addicts I’ve admitted to treatment said they wanted help because they couldn’t abuse the new form of OxyContin.

 And I say: Hallelujah! It’s about time!!

 This new tablet, approved by the FDA in April of this year, appeared recently on the black markets of this area, replacing the older, more easily abused OxyContin. The new tablet is bioequivalent to the older tablet, meaning the same amount of oxycodone, the active ingredient, is available to the body when swallowed whole, as it’s meant to be. In other words, the same amount of pain reliever is given to the body. However, it’s more difficult to crush for the purpose of snorting or injecting, because it turns into a gummy ball.

Purdue Pharma, the drug company that makes OxyContin, admits this new formulation isn’t abuse-proof, but hopes it will be more resistant to abuse.

The patients I’ve talked to say the new tablet is a big disappointment. One patient, who usually chews her pill to get a faster high, said it was like trying to chew a jelly bean. Other patients said they could crush the tablet, but got a kind of gelatinous mess that was impossible to snort or inject.

 For pain relief, the opioid in OxyContin lasts much longer when it’s taken as directed and swallowed whole. Addicts prefer to crush and snort or inject because of the quick high they feel with this route of administration. But when used in this way, it leaves the body faster, and the addict usually needs to find more opioid within six to eight hours to avoid withdrawal.

Before I applaud Purdue Pharma for this change, my cynical mind asks a few questions: Why didn’t the company make this change earlier?

In 2002, a Purdue Pharma representative testified before congress, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously. This representative said they expected to have the re-formulated pill on the market within a few years. (1)  But it took eight more years.

Sterling, the drug company that makes Talwin, another opioid pain medication, was able to re-formulate their drug within a few years when they discovered it was being abused frequently. This was in the 1980s, when, presumably, medication technology wasn’t as advanced as today. Sterling added naloxone, an opioid blocker that’s inactive when taken by mouth, but puts an addict into withdrawal when it’s crushed and injected. It worked great. Talwin isn’t a commonly abused drug.

 I’m assuming that Purdue Pharma holds the patent for this new formulation that makes their tablet gummy when crushed. Purdue probably teaches its sales staff to market the new OxyContin as a safer option than older versions, perhaps available in cheaper generics. So did they wait to re-formulate until their patent was ready to expire? I don’t know, but time will tell.

At any rate, this drug is now just a little bit safer, for now. People with addictions are often clever and creative. I won’t be surprised if soon there’s a way to defeat this new technology.

Just think what addicted people could do, if they directed their talent and intelligence in ways that would help and not hurt them. There would be no stopping them.

1. United States Senate. Congressional hearing of the Committee on Health, Education, Labor, and Pensions, on Examining the Effects of the Painkiller OxyContin, 107th Congress, Second Session, February, 2002.

Pain Pill Addiction: Prescription for Hope

Finally, here’s the cover of my book about pain pill addiction and its treatment. It’s available at http://prescriptionforhope.com or you can order it from Amazon, and soon from Barnes and Noble.

My book contains much of what I’ve been blogging about. I wrote the book because there are so few sources of reliable information about the treatment of opioid addiction (pain pills). It seems  that abstinence-based programs don’t like to talk about medication-assisted programs, and some methadone clinics don’t let their patients know about other options. Methadone and buprenorphine can be life-saving when used appropriately, but they have some drawbacks, as well.

There’s not one single right answer for all opioid addicts. Some treatments work for some patients, but no treatment works for all patients. In my book, I present the data supporting treatment methods, so opioid addicts and their families can chose the best course.

If you like this blog, you’ll like my book. I also have a chapter in the book about the unjust stigma patients face when they are treated with medication-assisted methods. It takes a strong person to stay on a treatment that helps them, despite criticism from friends, family, law enforcement, and even unenlightened medical professionals.

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