Archive for the ‘Suboxone’ Category

Update on Suboxone Films

In the past, I’ve blogged about how some of my patients were having problems with their Suboxone films. When they opened the foil packets, the films were broken into pieces or so fragile they broke when handled. But now over the last two or three months, my patients tell me the films are no longer breaking or fragile, making them easier to use.

I’m glad. The Reckitt Benckiser drug company, manufacturer of Suboxone, wants doctors to switch patients to film because it dissolves faster, is easier to use, is less dangerous to children because the package is so hard to open, and it’s less likely to be snorted. They also say it’s harder to divert and has less value on the black market. And they say tablets are more likely to trigger patients who were addicted to tablets.

There’s validity to much of that, but I believe the biggest reason they want patients to switch is because their patent on the film runs for at least seven more years. Call me cynical.

About half of my patients who tried the film didn’t like it. Nearly all were patients in good recovery, stable for months to years, and if they wanted to tablets rather than the film, I was OK with that. When the film became crumbly, a few more patients wanted to switch back to the tablets.

Now, I’m more enthusiastic about the films. I can prescribe the film with more confidence since they no longer crumble. I prefer to use the films for patients tapering off Suboxone. I know the drug company says the films (and tablets) shouldn’t be cut, but of course everyone has been cutting both. With sharp scissors, the films can be cut into equal and small portions, ideal for a gradual taper of the dose.

I have more success with tapers in patients taking the film. In my next blog, I’ll talk about some of the “recipes” for taper my patients and I have used.

Gray Areas

I have a dilemma. A handful of physicians and physician extenders in my area appear to be skirting the regulations around prescribing buprenorphine (Suboxone, Subutex).  They are helping opioid addicts, but not in a manner I consider to be completely appropriate.

Each Suboxone prescriber can have up to one hundred patients on the medication at any one time, as decreed by law. This regulation was put into effect because some lawmakers were haunted by the specter of Suboxone mills, run with the same lack of professional responsibility that we see in pill mills.

Only physicians can prescribe buprenorphine (Suboxone) to treat addiction. Nurse practitioners and physicians’ assistants, frequently termed physician extenders, can’t get the DEA “X” number that allows them to prescribe buprenorphine (Suboxone) for addiction. Many physician extenders say this isn’t fair, because they prescribe all manner of other opioids. Despite their objections, the law is what it is, and they can’t prescribe Suboxone to treat addiction.

And yet, it appears that some extenders are doing just that. In my area, two physician’s assistants, in separate practices, prescribe Suboxone to patients with addiction. These patients’ charts (I’ve requested records when patients transferred to me) show the provider knows the patients have addiction, but in each case the Suboxone is said to be prescribed for the treatment of “chronic pain.” I don’t doubt these patients have pain, since at least 30% of people with opioid addiction also have chronic pain. So technically, since they say they’re treating pain, they aren’t doing anything that’s prohibited…though the FDA would consider it to be off-label prescribing.

A few doctors who don’t have an “X” number have been doing the same thing – they treat patients with known addiction with Suboxone, but they say they use it for chronic pain. I’ve heard rumors that even doctors with an “X” number treat patients with pain with Suboxone, and don’t count these patients as part of their one hundred allowable patients. This allows them to prescribe Suboxone for more patients, and get around the one hundred patient limit.

I’m conflicted when I see these practices. One the one hand, I’m glad more patients are getting treatment, and this is much better than addicts buying Suboxone off the street. It’s the safest opioid, and in some patients it does treat pain. If it works for the patient, why should I care if some doctors and physician extenders are skirting the regulations, and why should I care if they are getting it for pain or addiction?

Because they appear to prove the lawmakers’ fears are legitimate. If we have providers who can’t or won’t follow the present regulations, how can we expect the government to lift the one hundred patient limit? Government officials and lawmakers start to wonder if medical professionals can be trusted to prescribe buprenorphine safely and appropriately if the one hundred patient limit is raised or lifted, if they see providers outwitting present regulations so that they can treat more patients.

In the interest of full disclosure, I have two patients I treat for pain with Suboxone. I didn’t start either patient, but inherited them from another doctor. In each case, I agree that they don’t have evidence of addiction, but Suboxone has been treating their pain very well. Since it’s working, I’m not going to demand they change medication, but I also count them as part of my one hundred patients, to be on the safe side. I do NOT want to get on the wrong side of the DEA.

In the past, I’ve called a few doctors who were prescribing buprenorphine without an “X” number. Both of them were shocked to discover the special regulations around this medication, so in some cases maybe it’s just lack of knowledge about regulations around treating addiction.

Two other colleagues and I did report a doctor to the medical board who prescribed a month’s worth of methadone for opioid addicts, but that’s different, given the dangers of methadone compared to buprenorphine.

I don’t want to report these doctors and extenders to regulatory bodies, because in the grand scheme of things, they are helping the patient, and technically they are following regulations, I think. Plus, I don’t want to have anyone report me to the medical board in retaliation. No one’s charts are perfect, and even though I feel I’m doing a good job treating patients, many decisions in Addiction Medicine are judgment calls. Good doctors can disagree on many of the issues.

For example, I have a few die-hard pot smokers among my one hundred patients. I see them a little more frequently than patients who don’t smoke, and I make the marijuana use an issue in counseling. I don’t (usually) kick them out of treatment for marijuana use. The data show that if you keep these patients in treatment, there’s a better chance they will, at some point, stop using. But I know many diligent physicians who would dismiss such a patient from treatment, because these doctors feel if they can only have one hundred patients, why not use those precious spots for patients willing to enter into full recovery, forsaking all illicit drugs.

Are they wrong? Am I wrong? No, because as I’ve said before, one person’s harm reduction is another person’s enabling. But if the person reviewing my charts for the medical board thinks I’m enabling, it could spell disaster for me. I don’t want to make that kind of trouble for another provider, or myself.

Also I worry if I confront these buprenorphine prescribers, they’d point out the very real financial incentive I have for wanting them to stop prescribing. If the patient is coming to them, they aren’t coming to the clinic where I work, and this reduces my clinic’s profitability. I’m employed as an independent contractor, so it wouldn’t benefit me directly, but the financial health of the clinic I work for would, indirectly, benefit me.

And yes, I’m petty enough to be miffed that I’m following the rules, and other doctors aren’t, yet they reap the same benefits. I’ve decided it’s human to be miffed about such things, but not healthy to get stuck in “miffness” and thus I’m writing this blog in an effort to release my feelings.

For now, I’ve decided I don’t have to do a thing. I’ll discuss the issue to the North Carolina chapter of the American Society of Addiction Medicine, and let those smart people decide the best course of action, if any.

New Health Care Laws: How Will They Affect Office-based Treatment with Suboxone?

Last week, one of my office-based buprenorphine patients asked me how I thought the new healthcare laws would affect my business. I’ve considered this question with a mix of anxiety and hope. Until we have more details, I’m not certain I’ll like the new changes. And of course since I’m a healthcare provider, I’ll look at changes differently than if I were an insurance executive.

I told my patient that it will be excellent for my patients in buprenorphine (Suboxone, Subutex) treatment who don’t have insurance now, and are paying out of pocket. My patient then remarked that I’ll be much busier, because more pain pill addicts will be able to afford treatment.

“No,” I said, “I can still only have one hundred Suboxone patients at any one time, so I can’t add any new patients.”

My patient was quiet for a moment and said, “So if an addict calls you because he just got insurance to pay for his treatment, you couldn’t see him anyway?”

“That’s right, unless I lost a patient for some reason, and had an open spot for him.”

“So even if addicts get insurance, they can’t use it? That’s crazy. Why does the government have that law?”

I explained to him about the newness of the DATA 2000 Act, and that some lawmakers were skittish about this program from the beginning. They were worried Suboxone “mills” would open, where hundreds of addicts were treated with little physician oversight or precautions.

Lifting that limit would be the easiest way to get more opioid addicts into treatment.

My private practice, where I treat opioid addicts with buprenorphine (Suboxone, Subutex), is a bare bones operation. Because of the one hundred patient limit, I have enough patients to keep me busy for one day per week. On the other days, I work at opioid treatment programs. I enjoy my own office practice because of the autonomy, and because I have some great patients that I’ve known for years. But at my own office, I make far less than half what I make at the opioid treatment programs.

I have the usual fixed overhead of rent, utilities, answering service, internet, etc., and most of the money I take in goes towards that. I have a part-time health care coordinator, who makes appointments for patients, calls them to remind them of appointments, does most of my office drug screens, screens my after-hours calls, handles the filing, copying and other record-keeping tasks, and deals with those pesky pre-authorization requests that insurance companies make. (She and the counselor have decided I ought not to be allowed to talk with the insurance companies, since I often erupt into profanity).Then I have the best LCAS (Licensed Clinical Addiction Specialist) counselor in the world who works with me on Fridays, doing individual counseling (he’s my fiancé). Since I don’t file insurance, but rather give the patient a receipt so they can file it themselves, I avoid that personnel expense.

And I don’t accept Medicaid or Medicare as payment for treatment. I feel guilty for admitting that, but I don’t think I could stay in practice if I accepted what these government programs pay for treatment. When I first opened my own office in 2010, I saw a handful of these patients for free, since trying to file and going through the necessary red tape isn’t worth the pittance these programs pay for an office visit.

So if my uninsured patients get Medicaid, I’ll have to decide how to deal with that problem.

It’s not legal for me to ask patients with Medicaid and/or Medicare to pay for treatment out of their pocket unless I opt out of those programs completely for a period of years. I can’t do that because some of the other treatment facilities that I work for do bill Medicaid.

So do I start taking Medicaid, with all its headaches, red tape and low re-imbursement? I don’t know. I don’t like the thought of it, but it will perhaps become a necessity. It will depend on reimbursement rates. Plus, I’ll be paid even less since I don’t have electronic medical records. Government programs have decreed that doctors without meaningful use electronic medical records will receive less money for Medicaid/Medicare patients than doctors with these programs.

I’m not against electronic medical records. I use them effectively at both of the opioid treatment programs. One program is completely paperless, and I like that much more than I ever thought. But in my small, one hundred patient office, I can’t afford any software for medical records. It’s not practical or feasible

Since I was trained and still am board-certified as an Internal Medicine doctor, I could fill my other days with primary care patients. I was talking to another doctor who was starting her own Suboxone practice, and she was wondering how to get by financially, only practicing Addiction Medicine. She too is a former Internal Medicine doctor. I suggested she could always do some primary care.

“Just shoot me in the head,” she said, summarizing my feeling exactly. I’ve never liked primary care as much as addiction medicine, to put it mildly.

Addicts are easier to deal with, and are often nicer people than the average soccer mom, demanding an antibiotic to treat her viral upper respiratory infection. But my biggest reason for preferring addiction medicine is that addicts get better. I never saw the big changes in health when I worked in primary care, like I do in people treated for addiction. Primary care feels like a step backwards. I don’t want to go back to treating non-compliant diabetics, and overweight people who won’t exercise. I’d prefer to keep my present patients, in whom I see an intense desire to get well.

I’m addicted to seeing the big changes that I see when I work in addiction medicine. I hope the new changes in healthcare will allow me to stay in the business of helping people change. Like the rest of the U.S., I’ll have to wait and see.

Helpful Websites for Patients on Medication-Assisted Treatment of Opioid Addiction

I’ve compiled some of my favorite web sites which deal with the medication-assisted treatment of opioid addiction. There are so many pitiful, ignorant sites on the web, it’s great to go to one of these for some sanity. 

http://www.methadonesupport.org/

This is just what the address suggests: a support site for people being treated with methadone for either addiction or pain. This site has message boards and discussion forums as well as good information for patients and their families. There’s information on pregnancy and methadone, with links to recent studies. There are several advocacy links. One describes current legislative challenges to treatment with methadone.

The forums have some interesting topics. For example, there was a thread with methadone clinic patients writing in to say what they would do if they saw a drug deal at their clinic. Would they notify clinic administrators or ignore it? The answers were interesting.

You can get information about Methadone Anonymous, and locations of current meetings. You can also enter a methadone anonymous chat room each evening between 8 to 9 EST, but you do need to register on the site to participate in meetings and to post on other sections.

This site it a little busy and some of it hasn’t been updated recently, but overall it’s a great site for support and information.

http://buprenorphine.samhsa.gov/

This is the website I give people when they’re trying to find a doctor who prescribes Suboxone. This is the most up-to-date list of Suboxone doctors, but it’s not 100% correct. Sadly, there are some doctors who don’t update their information at this site when they are no longer able to take patients. But besides the names, addresses and phone numbers of Suboxone doctors,, there’s some reliable information on this site about buprenorphine. This may be a site you pull up for a friend or family member who has misgivings about medication-assisted treatments of opioid addiction.

 http://www.methadone.us/

This is the best all-purpose site for information about methadone, information about opioid treatment centers, locations of treatment centers, and answers to FAQs about methadone. It also provides a link to a great blog: mine. I’m proud they carry my blog entries on their site. OK so maybe I’m a little biased, but check it out. It’s an extremely well-maintained site, and kept up to date with interesting and new information.

http://suboxonetalkzone.com/

This is a blog written by Dr. Junig, a physician who is obviously well versed in opioid addiction and its treatment with Suboxone. And it’s much more. He gives a link to his Ebook “User’s Guide to Suboxone.” I haven’t read it, but he says it contains information about situations that commonly arise during treatment with Suboxone, like acute pain management, surgery while on Suboxone, pregnancy on buprenorphine, and other problems. His blog has been around for many years, and I believe Dr. Junig is one of the first doctors to publically advocate for medication-assisted treatment for opioid addiction, and I admire this.

http://store.samhsa.gov/home

If you’re interested in the disease of addiction and recovery from it, you’ve got to go to this website. It’s the government’s publication site, where many pamphlets, booklets, and bulletins are free. Even postage is paid, so go browse at the site. It’s arranged so you can search by topic, by audience (patient, family, health professional, etc.), or by drug. There are even DVDs which are available for a small charge.

http://www.casacolumbia.org

This is the website for the National Center on Addiction and Substance Abuse at Columbia University. There’s great information here, though it’s not specific to medication-assisted treatments with buprenorphine and methadone. This site is packed with information about drug addiction, its treatment, and its costs to society. You can download CASA’s famous white papers about the following topics: “Adolescent Substance Use: America’s #1 Public Health Problem” or “National Survey of American Attitudes on Substance Abuse XV” or “Behind Bars II: Substance Abuse and America’s Prison Population.” These are excellent sources of information, much of it downloadable for free. My personal favorite is “You’ve Got Drugs,” about the ease of obtaining controlled substances over the internet.

CASA funds research of treatments for addiction, and also makes recommendations to policymakers in the country. They also provide information and help exchange of ideas between the government agencies, criminal justice system, service providers and education systems.

http://international.drugabuse.gov

This invaluable website is National Institute on Drug Abuse (NIDA) summary of all the research studies about methadone, upon which our present treatment recommendations are based. If you need to know any facts about methadone treatment, you can probably get them here, along with references to support the information. If you are in medication-assisted treatment with methadone, you need to go to this site. You can download the whole of the Methadone Research Web Guide, and can take it to anyone who is pressuring you to “get off that stuff” to show them the science behind treatment with methadone.

http://www.indro-online.de/

If you travel out of the U.S., go to this website to see what other countries allow regarding buprenorphine or methadone. For example, the website tells travelers to Russia: “Methadone or buprenorphine must not be brought into Russia.” Using medication-assisted treatment with these two opioids isn’t legal in that country, and clearly it’s risky to travel with your prescription medication. The site does go on to say that if you must, travel with a letter from your doctor, translated into Russian.

I’ve referred to this site several times, looking to see what’s required for a patient who traveling out of the U.S. It’s an interesting site to peruse, to see how different countries are. There are tips about necessary phrasing for the doctor’s letter that’s usually required.

Readers, do you have suggestions for other great sites about medication-assisted treatment of opioid addiction?

Crumbing Suboxone Films

Yesterday, a busy day in my office seeing mostly Suboxone patients, I had seven patients mention that the Suboxone films were crumbly when they opened the foil package. I’ve had a patient tell me this last year, and I asked the Reckitt-Benckiser drug rep about it. She said the film should not be crumbling, and that my patients should return defective films to the pharmacy.

It’s odd that patients started mentioning this all on the same day. I wonder if the recent heat wave has anything to do with this crumbling. Maybe the 90-plus degree heat in our area has affected the films while they are being shipped. I don’t know if the drug company has done any testing on films – or tablets – to see what they do when heated.

Beginning when the Suboxone films were first introduced, I had some of my patients say that the films aren’t as strong as the tablets. Initially I wrote this off as resistance to change, but some of these patients were stable and active in counseling. Then I’ve had so many people write comments on this blog, saying the film is weaker. Now there’s this problem with crumbling. I’m not entirely comfortable with prescribing the film, and plan to talk to the drug company to see what they have to say about crumbling films.

I’ll keep you updated.

Drug tests and Suboxone (buprenorphine)

Even some treatment professionals and medical professionals have mistaken ideas about drug testing for buprenorphine.

Because it’s a man-made opioid, buprenorphine won’t show as an opiate on a drug screen. It won’t cross-react with tests for oxycodone or hydrocodone. A specific test for buprenorphine must be done in order to detect its presence. In the past, this test was expensive, but now can be added to a drug test fairly cheaply.

I test for buprenorphine because I need to make sure my patients are taking their medication, and haven’t given it or sold it to someone else. Fortunately, I’ve never had a patient to whom I’m prescribing Suboxone have a urine drug screen that didn’t show the medication.  

My patients ask me if the Suboxone I prescribe for them will show up on employment testing, and I answer no, it’s unlikely. Most employers don’t check for methadone, and are even less likely to check for buprenorphine. Employers won’t know unless you tell them you’re on Suboxone. (Methadone, like Suboxone, has to be tested for on a separate test, and won’t show as an opiate.)

Should you tell them? That’s a question you’ll need to answer for yourself. Ordinarily I’m an advocate of honesty, but because Suboxone is usually prescribed to treat opioid addiction, disclosing this information more or less informs them you’ve had a problem with addiction. Is that your employers business? No, I think not, unless it’s a “safety sensitive” job, and even then it’s often not appropriate to tell your employer.

Drug Tests for Patients on Suboxone or Methadone

“Why do I have to do a drug screen? Don’t you trust me?”

Lately a few of my Suboxone patients seem to be questioning the need for drug screens. Some of them resent the tests, and resent paying for them.

So why do I do drug tests?

  • It’s good medical practice. Like many chronic illnesses, relapses happen. It’s better to detect these as early as possible, to discuss what happened, and if/how we need to change their treatment. If a patient has relapsed to opioids, it may mean that I need to increase the dose of Suboxone, if they were still able to feel an opioid high. If the relapse was to other drugs, it usually means we need to increase the “dose” of addiction counseling.
  • There’s a gold mine of information in relapses. I ask my patient what happened immediately before the relapse. Was she around people who were using drugs? Did she use drugs to try to get rid of an unpleasant emotion? Did she use drugs because she became complacent? The answers can help decide how best to avoid relapses in the future. If a patient is fortunate enough to live through a relapse, she can get information she can’t get any other way.
  • Drug screening benefits the patient by giving them accountability. Some patients are less likely to relapse with accountability. I’ve had patients say that the thought of having to talk about a relapse is enough to keep them from using drugs. This surprises me, but I’m glad.
  • Drug screening also shows them I’m serious about their recovery. I’m not just going through the motions of writing a prescription and getting paid for the visit. I really want my patients to recover and get their lives back.
  • Patients in treatment don’t always tell me when they’ve relapsed. In order for addiction to thrive, lies must be told. Otherwise honest people sometimes tell outrageous lies while they are in the throes of addiction. I see this as part of the disease. It’s not about them. It’s not about me. It’s the addiction.
  • I’m not a human lie detector. In the past, I smugly thought I could tell if someone had relapsed, so drug screens just confirmed what I already knew. After more experience, I know that’s not true.
  • It’s the standard of care. Even if the other reasons aren’t compelling enough to do drug screens, the vaguely increased regulatory oversight of doctors who prescribe Suboxone should induce them do drug screens. I know if my charts are ever audited by the DEA (unlikely), my state’s department of health and human services, or my state’s medical board (more likely), I want to show I’m doing things in the proper manner.
  • I don’t want to prescribe medications that will be diverted to the black market. Some doctors say, with some justification, that buprenorphine is a safer drug than most other illicit opioids, and we should look at black market diversion of buprenorphine as a form of harm reduction. However, governmental types don’t see things that way. The DEA certainly doesn’t. I don’t want to prescribe buprenorphine to people with the criminal intent of selling part or all of it. When I do urine drug screening, if there’s no buprenorphine present, that’s a serious matter. If the patient isn’t using what I prescribe, it’s likely they are selling it. Since such diversion of Suboxone endangers the whole program, it’s essential to stop prescribing for people who sell their medication.

These are my reasons for drug screening. Since I’m not going to stop doing them, addicts who object to screening have had to find new doctors. New opioid addicts who come to my office are told, both verbally and in writing, that I do drug screening. They can make their own decision about whether they want to see me as their doctor or go elsewhere.

Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

  1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
  2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
  3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
  4. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295

 

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.

Great Book About Opioid Addiction!!!

I orginally started this blog to promote the book I wrote about pain pill addiction. As it’s turned out, the blog has been much more popular than the book (it isn’t exactly flying off the shelves), so I’d like to remind blog readers – again – that if you like the blog, you’ll love my book.

You can order it from Barnes & Noble, or Amazon. But I’m selling it for a much-discounted rate of $13.95 on EBay. That’s with shipping included.

http://shop.ebay.com/i.html_from=R40&_trksid=p5197.m570.l1313&_nkw=pain+pill+addiction&_sacat=See-All-Categories

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