Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.
But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.
This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that.
Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people.
Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication.
And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.
Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.
Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years. (1,2)
If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals.
Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.
My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.
I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction?
- Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
- McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.