Probuphine: the Injectable Suboxone


Last week, the FDA’s advisory committee voted to approve Titan Pharmaceutical’s Probuphine. This is an implantable form of buprenorphine, a drug more commonly known under the brand names of the sublingual forms Suboxone and Subutex.

Probuphine is a slender rod, as pictured above, containing buprenorphine that is released into the body over time. Probuphine is meant to be inserted a few days after the patient has stabilized on sublingual buprenorphine. Four of the Probuphine rods are inserted under the skin of the inner upper arm in a fan formation, just like birth control implants such as Norplant. Four rods contain 320mg of buprenorphine, released over six months.

Probuphine has been touted as the answer to this country’s problem with Suboxone and Subutex drug diversion. Even though studies show most people who buy Suboxone off the black market use it to stay out of withdrawal and not to get high, many officials are appalled at how the medication, intended to treat opioid addiction, seems to be a new favorite street drug. But implantable Probuphine, for obvious reasons, is highly unlikely to be diverted to anyone besides the patient for whom it was intended. With this implantable form of the medication, pediatric exposures would be practically non-existent.

Safety data of the implants appears acceptable. Even minor surgical procedures can cause infection and bleeding, and these were the main problems with insertion. A fair number of patients also had irritation over the implants, possible from the medication.

But how effective is Probuphine? For me, the study results are underwhelming. It did outperform placebo in double-blind randomized controlled trials, but not as well as I expected. In Titan’s two studies, 40% and 60% of patients given active Probuphine also required supplemental sublingual buprenorphine. If patients continued to require extra sublingual buprenorphine, a fifth Probuphine rod was inserted.

Even worse, 35% of the Probuphine patients did not complete the twenty-four week study, and only 8% of Probuphine patients had 80% or more of their urine drug screens negative for illicit opioids. So the Probuphine did outperform placebo, but not robustly. Only a few of the Probuphine patients were negative for opioids at the end of the study.

The surprisingly low blood levels of buprenorphine produced by Probuphine may have caused these disappointing results. Researchers found that blood levels from four rods of Probuphine gave only 31% of the blood levels of patients dosing with 16mg of sublingual buprenorphine. Many of the patients may have been under-dosed. To get the same blood level, I’m assuming it would take 12 implants, too many to be practical.

The FDA Advisory Committee also mentioned other concerns. Obviously, the doctors implanting the medication need to be trained to do so. In the past, sub dermal implants like Norplant were inserted by doctors with training in surgical procedures, like OB/GYN doctors. With buprenorphine, around 21% of patients are treated by psychiatrists, with little training in surgery. The other doctors treating addiction with buprenorphine tend to be like me – minimal experience with surgical procedures. Titan Pharmaceutical has a plan for teaching doctors how to do this procedure, but is it enough to make us proficient?

Do I want to learn to do this procedure, or would I prefer referring patients to a general surgeon? Would the local surgeons be interested in doing these implants? Who follows the patients afterward?

I have no doubt I could learn how to do the implants if I wanted to. But that’s the question…do I want to? I’ve done minor surgical procedures during my years in primary care, like suturing lacerations, incising and draining pustules and abscesses and the like. But I don’t really enjoy doing that kind of thing. I’m slow at it, tend to be nervous, and I don’t like pus. I’m an accomplished quilt maker and I can handle a needle & thread, but memories of surgery rotations during medical school haunt me.

My surgical rotations weren’t the disaster that my OB rotation was, but that’s not much of a horse race. Actually, I did fine in my OB/GYN rotations as long as I didn’t watch any babies being born, but that was kind of hard to avoid. And I got “Honors” in my two-week rotation in Cardiothoracic Surgery, but not because I was brilliant. I was an idiot savant when it came to holding retractors, largely because I was too scared of the surgeons to move a millimeter. These were prototypic 1980’s cardiothoracic surgeons; they threw things and swore, and called the nurses “honey.” They liked me because they didn’t have to keep telling me to hold still and pull on the retractors. I could stand like a statue, for hours, literally scared stiff.

My other surgery rotations were not much better; I did my general surgery rotation at an urban trauma center in a big Ohio city. On my first day, my resident commanded me to record the history of the trauma victims arriving in the Emergency Department. So I would sidle up to a fresh trauma patient, blood spraying, body parts partially amputated, clear my throat to ask, “Um, can you tell me what happened?” The answers were usually short and colorful. Eventually I learned to ask the EMS workers, and confirm with the patients after they were out of surgery.

I didn’t enjoy that month. I saw young people die in quick and brutal ways, forcing my 24-year old self to realize that I wasn’t immortal. I’ve been a careful driver ever since, and always, always, ALWAYS wear my seatbelt.

So do I want to risk re-activation of my medical school post-traumatic stress disorder?

Titan Pharmaceutical’s answer to the FDA’s demand for a Risk Evaluation and Management Strategy (REMS) for Probuphine includes plans for a closed distribution system. This means that the drug company will only ship Probuphine directly to providers who have been trained to implant the cylinders, and are approved to prescribe buprenorphine. This means I would have to store medication in my office. I’d need a system of accounting for controlled substance medication. I wouldn’t be too hard to implement in my small office, but it’s another bit of work for me, and I don’t like the idea of having controlled substances on the premises.

I assume I would have to buy the implants, and then ask my patient to pay me for the implants, the surgical procedure, and my time and expertise. That’s a big financial risk for a bare-bones operation such as mine. I can only have one hundred buprenorphine patients at any one time, so I keep my overhead very low in order to survive financially. This expense does not fit into my business plan.

If I find a surgeon to implant the Probuphine, there are even more barriers to the process. The REMS says not only would I have to store Probuphine until the implantation procedure, but I also have to be present for the implantation procedure, and also for explantation six months later, when the rods are taken out.

Are you kidding me?? This is not practical in my world. And is the patient going to pay for the time of not one doctor, but two? Would health insurance pay for both doctors’ time? I know the answer to that.

I’ve saved the big question for last: how do you get patients with Probuphine implants to keep counseling appointments? Yes, some patients, hungry for recovery, will go to great lengths to get counseling. And others won’t go at all. With our present system, the prescription for sublingual buprenorphine is the leverage used for counseling. Many doctors won’t continue to prescribe unless the patient goes for counseling. But after a patient gets a Probuphine implant, she can decide she doesn’t need counseling doesn’t want counseling, and what’s the doctor going to do about it? Surely not go dig the implant out of her arm.

Probuphine is a great idea, and may work for some patients. But in the real world, I see problems: limited efficacy, muddled plan for implantation and explantation, financial and reimbursement issues, and no way to leverage patients into counseling. This idea needs more work.

36 responses to this post.

  1. Posted by Benjamin Keith Phelps on March 30, 2013 at 10:37 am

    Wow, Dr Burson! You’ve got this thing well thought out, it would seem – much along the lines of the way I think about issues like this (though obviously, I’m not a doctor & my thinking is about hypothetical ways I’d like to see things dealt with, SOMETIMES ending in my passing the ideas along & even less frequently, seeing them implemented to some extent). Anyway, I do have 1 question about 1 of the points you made: You mentioned not keeping controlled substances in your office unless you make some alterations for safe keeping (which I know is required by law, as well as common sense). Don’t you usually initiate buprenorphine treatment in your office already? And in doing so, aren’t the first few doses (either using Subutex or Suboxone, whichever you prefer in your own practice) given under your direct supervision there? This is merely a curiosity question. I do know that keeping opioids (or any CS’s in your office puts you at a MUCH higher risk of break-ins & plundering patients, etc). Aside from that question, I just want to say that these study results are absolute GARBAGE!! I know they’re at least trying for a positive change in the MAT field, & for that, I commend them greatly! But it sounds like they desperately NEED to jack up the medication level in the rods before using them/releasing them to the public! Those numbers were TERRIBLE. I wouldn’t bother engaging in bupe treatment if I faced having something implanted under my skin (4 of those “somethings”!!), faced abysmal positive outcome odds, & so on & so forth. Don’t get me wrong – I’m not at ALL saying that I must have the tablet or daily form of the drug I take in order to be okay w/taking it… I think the basis for the idea here is great. But the only way I’d partake in it is if I KNOW beyond a shadow of a doubt that it’s going to be the equivalent of taking daily medication. I’ve often wondered why they’ve never even considered (that I know of) doing this w/methadone, since it’s a full agonist & as such, causes EXTREME concern of diversion, misuse, & OD deaths for the people who get hold of it that aren’t tolerant (aren’t in treatment themselves). But with the current takehome system & its SEVERE limitations & all, I’d think it would be spectacular for some people to have this option! Getting takehomes & then having them rescinded for reasons other than non-compliance (like I did when my bike was stolen w/3 takehomes locked under the seat in my lockbox) can send the patient’s ENTIRE LIFE into a tailspin, causing the loss of a full-time job & source of income, major transportation costs/problems (b/c when my bike was stolen, it was all I had for transportation – I didn’t even have a bicycle any longer b/c it was stolen about 5 months prior to that!) The bus in Raleigh no longer stops by the clinic on Sundays, leaving people w/o TH’s w/a HUGE problem that day. Our bus system also no longer gives x-fer passes, so you must pay at LEAST $2 if you have to x-fer buses at all (but at least $2 pays for an entire day, no matter how many x-fers). But back to these rods, you mentioned 12 being too many to be practical… I think 4 is too many to be practical! These things are going in a patient’s body, fanned out, & will, as such, be lumps under their skin. When I was in my addiction, I shot Demerol pills, which don’t dissolve well b/c of fillers & binders. At that time (1996&97), I hadn’t yet figured out how to extract the drug & leave behind the pill, so I just crushed it, dumped it into the top of the syringe (w/the plunger pulled out), added water, & then replaced the plunger. Doing that almost ALWAYS ended up causing the tiny needle (insulin syringe is what I’m talking about here…) to get clogged up w/a chunk of pill, & when I’d find a vein, I’d start to inject, & when it clogged, I’d push harder on the plunger, which would break loose & blow out the vein. PAINFUL, to say the least!!! But now, years & years later, I STILL have those pill chunks, fillers, & binders under my skin from those incidents, leaving painful reminders (not just mentally – they physically hurt – BAD sometimes!) of my active addiction. In particular, I have a couple on the pad of my palms below my thumbs, & when I wash my hands in really cold water & the cold hits them suddenly, those lumps will burst into this horrible pain that literally takes my breath away. I have to shake my hands really hard to try to ease it somehow – though that doesn’t necessarily stop the pain – it only helps it pass. Usually, that takes around 10 seconds or so for it to finally stop. But trust me when I say that 10 seconds of that pain can feel like 2 or 3 minutes! So when I imagine lumps under my skin from little rods, I don’t relish the idea! If it were 1, that would still bother me mentally, but if it’s soft & squishy, I suppose it might not be terrible, so long as it’s a small area it covers. But then if you need 4, that negates what I just said, b/c now you need a big area for them to fit – & then adding in a 5th??? Are you KIDDING ME??? NO WAY! They REALLY need to put more thought into this, come up w/some answers to this, get better results, & then re-submit these for approval. I don’t think success rates like those they published on these warrant releasing this drug for the public AT ALL. That’s my opinion, though.


    • Yes, the results weren’t great.
      These cylinders are small diameter, maybe a little bigger than a pencil lead. And they are meant to be taken back out at six months, so there’s another procedure. There were a small number of “extrusions”…where the implant worked its way through the skin surface. Not good.

      No I do home induction, always have, since 2006, never had a problem. I don’t think many people do in-office induction in their office practices any more. Of course, if you start a patient at an opioid treatment program, by law you have to do observed dosing.
      Many times when a patient comes for her first visit, she won’t be in enough withdrawal to start medication, so what can we do? Ask her to try again the next day? With the freedom office-based practice gives us, I write the prescription, she fills it, and has it on hand to take as soon as she feels she’s in moderate withdrawal. I describe how if she starts it too soon, she’ll have precipitated withdrawal from the medication.

      Nearly all patients have been able to wait to take their first dose, as long as they have the medication in hand, and know they don’t have to get too far into withdrawal and it’s up to them.

      The only case of precipitate withdrawal was in a patient who had been on methadone 70mg and he lied about the amount he’d been using, saying he was using around 30mg per day. He was in withdrawal when he took the first dose, but had been on too much methadone. He had a very unpleasant week, but got through it and stabilized nicely. A few years later he tapered off Suboxone slowly and as far as I know is still off opioids.


      • Posted by Vicki Hunt on March 30, 2013 at 1:17 pm

        Hi Dr. Burson,
        I have a couple questions..first, do your new patients not take their first dose of Suboxone in front of you since the law states you must observe the initial dose?
        Here in Oklahoma, most Sub docs have you come in, they take your hx etc. then they write a script for 1 tablet, the pt. runs to the pharmacy and brings the tablet back to the dr office and then the doc instructs the pt whether to break in half or a quarter and observes and waits til the pt is comfortable.
        Secondly, does probuphine have any naloxone like Suboxone or is it like Subutex which is only buprenorphine?
        Thanks for all you do in the ever changing field of addiction medicine!!

      • Observed dosing is only needed if buprenorphine is prescribed under an opioid treatment program license. In an office based program under my “x” number, I can do home inductions.
        No naloxone in the probuphine.

      • Posted by Benjamin K. Phelps on April 2, 2013 at 8:28 pm

        There would be absolutely ZERO reason to have naloxone in these. Naloxone is only in the tablet to prevent injection of it. With these, there’s no chance of injection or diversion, so it’s just not needed.

  2. Posted by davidM on March 30, 2013 at 7:39 pm

    Thanks for the article. Don’t the drug companies ever learn? I read Pfizer had to pay out over 80 million to settle with patients over Norplant issues such as scarring, nerve damage, etc.

    What if the patient gets booked into jail? Will the jail have to schedule a procedure to remove the rods? If not, will the patient remove the rods his/herself and distribute them?

    Diversion is a problem, but the rods don’t seem like a common sense approach!


    • Posted by Benjamin K. Phelps on April 2, 2013 at 8:31 pm

      Personally, I think it would be GREAT to have the rods in place if I went to jail! Then they CAN’T prevent me from being on maintenance while in there, as they do with methadone AND Suboxone in almost every county in my state. Since my visits to jail never lasted longer than 60 days, there’s a great chance I’d be fine the whole way through! NO WITHDRAWAL IN JAIL!!!!!! Wonderful!


    • Posted by Stop Lying on December 20, 2015 at 12:42 pm

      Please get your facts straight:

      Pfizer Settles Norplant Lawsuits For $29.5 Million
      October 12th, 2011 // 12:48 pm @ jmpickett

      After 17 years of litigation, Pfizer has reached a preliminary agreement to settle a Norplant contraceptive class action lawsuit for $29.5 million, according to Mealey’s Drugs & Devices Report. The lawsuit, which was scheduled to go to trial in Louisiana, was brought by 3,500 to 4,000 women.

      The move comes a decade after Wyeth, which is now owned by Pfizer, halted sales of the controversial implant, which was hailed as a breakthrough in 1991. Norplant consisted of silicone rods that contained hormones, six of which were implanted beneath the skin of the upper arm for up to five years to prevent pregnancy.

      A few years later, however, tens of thousands of women had filed lawsuits claiming Wyeth failed to adequately warn about irregular menstrual bleeding, nausea, headaches and depression. By 1999, Wyeth paid $54 million to settle with 36 women. The Louisiana lawsuits alleged Norplant released too much active ingredient during the first 18 months after insertion, which made the device defective.

      In 2002, a federal court dismissed most of the remaining lawsuits for lack of evidence, although the Louisiana lawsuits lingered. For its part, Pfizer denied the allegations and agreed to settle in order “to put to rest all controversy” and avoid the further expense of going to court, a spokesman tells Mealey’s.


  3. Posted by Vicki Hunt on March 31, 2013 at 6:47 am

    I guess I’m confused. What’s the point of Probuphine and Subutex being approved for opiate addiction if there isn’t naloxone in them. Can Subutex (buprenorphine without naloxone) STILL be prescribed for opiate addiction? And if so, why not the Butrans weekly patch also? Buprenorphine has a long half life and is a strong medication for pain control. So really, what’s the difference in Subutex and methadone? Besides the obvious, they both do have some blocking ability but its the naloxone that made the real difference thus adding Suboxone as a second choice for opiate addiction.


    • The naloxone doesn’t do anything. When used properly, under the tongue, it doesn’t even get absorbed. It was only put into the Suboxone tablet to prevent addicts from crushing it to inject. When injected, the naloxone IS active, and puts addicts into precipitated withdrawal (though as you can read in this blog, there are some addicts who can still inject even Suboxone).
      Buprenorphine, the active ingredient in Probuphine, suboxone, subutex, and Butrans, has a very high affinity for opioid receptors, which gives the blocking effect. In other words, buprenorphine sticks to opioid receptors like glue, more so than oxycodone, hydrocodone, methadone, etc. (Maybe not more than fentanyl) If an addict is taking a maintenance dose of buprenorphine, then uses an illicit opioid, the buprenorphine still stays attached to the receptor and the newer opioid doesn’t have a chance to attach. This is because of buprenorphine’s higher affinity for opioid receptors.
      The idea behind both methadone and buprenorphine is the same; both are long-acting opioids that can be dosed daily and still keep the addict out of withdrawal, usually for longer than 24hours. Short acting opioids make lousy maintenance meds, since they would have to be dosed multiple times per day, making them less attractive as maintenance medications. And both methadone and buprenorphine, when used at high enough doses to occupy most of the opioid receptors, make those receptors unavailable for other opioids and block the high, or euphoria.
      This will be way oversimplified for some purists, but hopefully you get my meaning.
      Butrans may work for opioid addiction, but the FDA hasn’t approved this form, so it’s illegal to use for this purpose in the U.S. No opioids can be prescribed for the purpose of treating addiction unless they are approved by the FDA/DEA for that purpose, and so far there are only two: methadone and sublingual buprenorphine. So if this opioid implant is approved, it will be another option for addiction treatment.
      A doctor who uses any other opioid to treat opioid addiction and withdrawal is committing a crime, ever since the passage of the Harrison Narcotic Act of 1914, and risks legal prosecution. Many doctors are unaware of this.


      • First, I am glad that I found your blog via the Addiction Treatment Forum’s (AT Forum) sharing this particular entry on Probuphine via their Facebook Page! 🙂 If I may ask a question or two in regards to your reply to Vicki Hunt (above)… It has always been my understanding (seemingly incorrect after having read your reply to Ms. Hunt, but, hey, I can admit I don’t know everything & want to know the facts even if that means admitting I have been wrong) that the reason patients needed to “begin acute withdrawal” prior to beginning MAT with Suboxone was due to the fact that if Suboxone is taken while using other opioids, and before the withdrawal from those opioids, it would send the patient into nearly immediate (within 10-20mins) withdrawal. While I still believe that to be true, it is what *causes* this nearly instant withdrawal about which I seem to be unclear… I always thought that the reason this might happen (the patient being thrown into withdrawal if starting treatment using Suboxone before beginning acute withdrawal) to someone was because of the naloxone that is in Suboxone in addition to the buprenorphine. As such, I suppose it has always been believed that for some reason buprenorphine was not affected by naloxone the way that full agonist medications/substances are (maybe I thought that buprenorphine being a partial agonist somehow “prevented” it from being affected by naloxone as agonist medications like methadone, heroin and/or oxycodone, to name a few, are affected). HOWEVER, and please correct me if my understanding is incorrect, it seems that what the case REALLY happens to be is that the naloxone (in Suboxone) is a safeguard against IV misuse of the buprenorphine *alone* and, when taken properly sublingually, doesn’t do anything at all (since it isn’t even absorbed into, or activated within, the body)… What would send the patient into withdrawal if Suboxone is taken prior to the beginning of acute withdrawal from the other opioid(s) of abuse is actually due the buprenorphine *itself* having an affinity for opioid receptors that is higher than other full agonist opioids… And, as such, the high affinity of the buprenorphine itself is what leads to the buprenorphine actually “pushing” or “knocking” the other opioids off of the receptors due to their lower affinity for opioid receptors preventing them from “withstanding” the “attack” of the buprenorphine. So, if THIS is the case (which I think that’s what I’m reading/learning here), then it would stand to reason that both Suboxone AND Subutex (and I’m talking about when they are taken properly) would potentially cause nearly immediate withdrawal in opioid-addicted patients who do not wait for the acute withdrawal from the other opioids of abuse to begin prior to starting medication-assisted treatment with buprenorphine (either with OR without naloxone). Is that correct? That it is the buprenorphine ITSELF that can cause these withdrawals and that the naloxone in the Suboxone doesn’t do ANYTHING at ALL (it isn’t even absorbed/activated in the body) when the medication is taken properly?

        I appreciate your answering my questions and/or “clearing that up” for me! Though I am the Director of NAMA Recovery of Tennessee (the Tenn. state-wide chapter of the National Alliance for Medication Assisted Recovery, formerly the National Alliance of Methadone Advocates), a mental health counselor AND a patient advocate, my experience and the vast majority of my research, reading & knowledge is and has been with/around methadone. I am trying to expand & increase my knowledge and understanding of buprenorphine, and I think that I have had some *key* breakthroughs in understanding this medication better as a result of your blog & the questions/answers contained within. 🙂

        The only other thing that I want to ask, if I may, (for now, anyway, ha ha) is what the implications of buprenorphine for maintenance treatment are considering the “ceiling effect” that has been documented at/around 32mg’s/day. (In other words, the benefits/effects buprenorphine has for/on a patient at 32mg’s/day is the “best it’s gonna get.” 100mg’s of buprenorphine won’t benefit a patient any greater than 32mg’s due to this “ceiling effect.”) It is also documented in a few different, and credible, studies that, though every patient’s metabolism, absorption rate & damage done to their endogenous opiate receptors during active addiction are different, 32mg’s of buprenorphine is *roughly* (on average) equivalent to between 30-40mg’s of methadone in terms of dose effectiveness in treating opioid addiction… Is this why most programs (that are worth their salt) will taper a patient taking methadone down to at *least* 30mg’s (if not less) that wants to switch to buprenorphine prior to switching them over? Furthermore, what are your thoughts on the fact that buprenorphine (as stated fairly clearly in SAMHSA’s TIP 43 on MAT) was originally indicated for opioid addictions of 1 year or less and/or opioid addictions of patients with relatively “low tolerances” (though I’m not sure how one’s tolerance could be measured)? It seems to follow (I’m curious on your thoughts & to know if you agree) that buprenorphine maintenance treatment, while an option that can and has been very effective and restorative for many patients, will only be effective and restorative for a small slice of the opioid addicted population (unlike methadone maintenance treatment which can be effective, assuming the patient is not hindered from stabilizing on their correct dose, for close to 100% of opioid addicted people). I sometimes am frustrated (and worried) by the fact that ALL of the facts & information (including those things which I have just mentioned & asked about) about and around buprenorphine aren’t fully disclosed or explained to opioid addicted patients seeking treatment, and many times I have ended up in advocacy cases involving patients who would have *never* switched their maintenance medication to buprenorphine from methadone had they known all of the facts & info that they, unfortunately, ended up learning by their own personal (and oftentimes torturous) experiences. Sometimes, even more disturbingly, it appears that the healthcare providers/physicians supervising the “transition” between maintenance medications don’t even know all the facts.

        Thank you for letting me write a short novel (ha ha), and I *very* much look forward to reading your response to and thoughts about the questions I have asked & statements I have made here. Keep up the good work; I’ll be following you now! 😉

        In solidarity,
        Zac Talbott, Director & Patient Advocate
        National Alliance for Medication Assisted Recovery
        NAMA-Recovery of Tennessee

        “Together we CAN make a difference!”

      • Thanks for writing! I admire NAMA’s work and you surely have your work cut out for you in Tennessee.

        You are exactly right – the buprenoprhine itself, being a partial and not a full opioid, causes withdrawal in addicts who have been using full opioids, if patients don’t wait until they are in withdrawal to take the buprenorphine.
        You aren’t alone – even some doctors think it’s the naloxone that causes withdrawal, but it’s actually a property of the medication. there’s much misinformation about buprenorphine.

        As for buprenorphine’s effect in opioid addicts with relatively higher tolerances…sometimes it does work. When suboxone first came out, we really thought its place would be for new addicts and low-tolerance addicts, but I’ve been surprised by many addicts using oxycodone 200-300mg per day who’ve stabilized nicely on buprenorphine.
        It’s a funny drug – some patients I would expect to do well on it don’t feel at all well. I think some day we will discover that addicts’ responses to buprenorphine are determined in part at least by genetic make up.

        So I’ve been more encouraging of methadone patients to switch if that’s what they want, because there are some real advantages – better safety, and with that less restrictions on take homes even at OTPs. But I do ask the patient to taper to 40mg or less, miss two days of dosing with methadone and see me the third day, so that it’s been 72 hours since their last methadone, and if they are in at least moderate withdrawal, start the buprenorphine. I’d estimate the patient does well making the switch at least 70% of the time.

        I’m lucky that at both OTPs where I work, we offer both buprenorphine and methadone, which I believe is the state of the art. I’d like for every addict to try buprenorphine first unless they’ve already tried it and it didn’t work for them. Sadly it’s also a financial decision, since it does cost a little more, even for the generic, than methadone. And if bupe doens’t work, it’s easy to switch to methadone – you don’t have to wait any days, just start the methdone the next day, no worries about precipitated withdrawal.

        It’s not a miracle drug, though, and I’m grateful we have methadone to fall back on when bupe doesn’t work. There’s definitely a place for both medications. Which one is best just depends on the patient. It’s another tool we can use.

        thanks for reading!

      • Posted by Benjamin K. Phelps on April 2, 2013 at 10:12 pm

        Zac, I haven’t checked to see if Dr Burson replied to your questions, but I will answer the 1st one briefly: Yes, the naloxone is used against IV misuse, & the buprenorphine is what causes the acute withdrawal if taken while on other opioids or too soon after heroin (before w/drawals start) or methadone, etc. It’s b/c it is a partial agonist, meaning it partially activates the receptor, but not fully. The receptor has been used to being FULLY active, & now it’s getting partial activation, so it’s almost theoretically as though it’s stuck in the middle – halfway between sick & well (but only for the patient that has been on opioids enough to be dependent). If taken when a person is already sick, it will help b/c it once again at least partially activates the receptor. But if your receptors are already in full activation mode, taking it will knock them down part of the way b/c bupe has a stronger attraction & bond to the receptors than the other opioids (except POSSIBLY fentanyl). So I hope I’ve given you some clarity as to how they work. ANY partial agonist or mixed agonist/antagonist will precipitate w/d’s – like Nubain, Talwin (whether it’s the NX form that has naloxone or not, b/c the naloxone here is for the same purpose as with bupe – to prevent IV misuse), Stadol, buprenorphine, etc. That’s the bottom line. So don’t ever let a doctor convince you to take one of those drugs, as you will be in for a really bad day if you let him/her do so.

    • Posted by Benjamin K. Phelps on April 2, 2013 at 8:39 pm

      You are confused. Naloxone has NOTHING to do with treating opioid addiction, as Dr Burson has just pointed out in her post to reply to yours. Naloxone is SOLELY for preventing injection & to a lesser extent, diversion (b/c addicts usually don’t want something they can’t inject when it comes to IV opioid users). But it’s not as if naloxone provides any effect to help us stop using opioids. It’s an opioid ANTAGONIST – meaning it throws the opioids (all/any of them) off of your opioid receptors & puts you in withdrawal – VERY quickly & VERY severely. It’s what is used at the hospital & in ambulances by EMT’s to revive heroin addicts that have OD’d. I’m hoping I’ve helped you understand what it is & what it isn’t with this information.


  4. Posted by Jonathan Novak on April 1, 2013 at 4:20 pm

    Dr. Burson,

    Why did Suboxone perform so poorly in the same clinical trial?

    Why has Suboxone performed so poorly in all of the clinical trials that have been run for it?

    I’m just curious because you’ve pointed out a few times that these numbers for Probuphine are disappointing, but they are the exact same results that helped Suboxone receive FDA approval. What is the reason for the poor clinical results and better real world performance?


  5. Posted by Jonathan Novak on April 1, 2013 at 4:26 pm

    This is from the Suboxone website:

    “Significantly more patients in the 16-mg buprenorphine group had urine samples negative for nonstudy opioids (26.8%) compared with the 1-mg group (8.6%) over a 4-week period (P<.001)"

    They use a 26% negative urine sample rate to actively promote the drug on their own website.

    Are these results not comparable to Probuphine? Yes, it exposes a patient to a lower amount of the drug, but it is just as, if not more, effective.

    I know your an expert in the field, so I would love to hear your take on these numbers.


    • Yes, you are right. After reading your comment, I went back and re-read some of the biggest studies of sublingual buprenorphin. That data is close to data from the studies of Probuphine. It’s a great example of how my work prescribing sublingual buprenorphine can bias my impressions and memory! (Schottenfield, et al, 1997, Archives of General Psychaitry, Fudala et al, NEJM, 2003)
      In one of the biggest studies, about 44% of subjects in a Suboxone study dropped out of treatment at 6 months, and around 50% of the subjects were negative for opioids, and only around 65% were negative at one year. This, of course , is not the same as saying only 8% of patients had 80% or more negatives urine drug careen as seen with Probuphine,So but different measurements were used.
      So you are right – drop- out data isn’t that different, and efficacy isn’t that different, between Probuphine and Suboxone. Still, I have issues with the mechanics of placing the Probuphine and getting patients to come for counseling.


      • Posted by Jonathan Novak on April 3, 2013 at 9:15 am

        Thank you for the response. It’s a good thing that your work with Suboxone has biased your opinion. If the clinical results translated to the real world, Buprenorphine wouldn’t be a viable treatment option. I’m sure that is why they have pharma reps to remind doctors of the difference.

        The procedure is something that each doctor will have to evaluate on their own, but I doubt many of them lack the ability to perform it. I believe they will require an 8 hour training course that has hands on experience with the implant and if a doctor fails to do a procedure within a six month period they will be required to do the training again before they are authorized to use the implant, again.

        My other question has to do with getting patients to attend follow up sessions. One of the things you will notice if you look at the clinical results for Probuphine is that the average patient needs about 8 rescue sublingual Suboxone over the 6 month period. I’m sure the 40% who dropped out of the trials skews that number a bit, but you could easily get away with writing a patient a monthly script for 5-10 Suboxone pills (it doesn’t limit the risk of diversion, but it does significantly reduce the risk. 5-10 pills is significantly less than the 30-60 pills or strips that most patients receive. Plus, they will be less likely to give up their meds if they have such a limited amount). If you give the impression that the patient will need it, then they will most likely feel they need it. From there, that 5-10 pills a month gives you one more aspect of treatment to manage for the patient. As they progress in treatment, they would need less and less of the rescue medication. In a sense, it is a mental tapering down of the drug. They have the implant working, but they lose that “physical dependence” that some people like to point to as a reason for why some people will prefer the pill or strip… If they don’t need the rescue meds then they are probably the type of patient that is going to come back on their own anyways.

        Do you think the need for the rescue medication would be enough of a carrot to get patients to come back for follow up visits? I agree that that is an important part of treatment.

      • I may be wrong but I don’t think many patients would keep follow up visits for a prescription for 5-10 sublingual suboxone. It’s a significant cost for the doctor’s visit and for counseling. Maybe the ones with insurance would be more likely to return. I guess time will tell.
        I don’t think I will take an 8 hour training to learn a surgical proceudre when I’m not all that crazy about doing surgical procedures anyway. the more I consider it, the less it appeals to me. I’m sure there will be some docs eager to learn the procedure.

      • Posted by Jonathan Novak on April 4, 2013 at 10:48 am

        Thanks for your perspective. I think they assume 30-40% of doctors will not use the implant, so you’re probably not alone in your thinking. Is the counseling a mandatory aspect of treatment, or is it something exclusive to psychiatrists who treat addiction?

        While i’ve got you engaged, I was wondering if you would share your opinion on the 30-100 patient limit imposed on addiction specialists. What is your understanding of why such a harsh limit is imposed, do you agree with the limit, and do you think there is any possibility that the limit will one day be removed or expanded (maybe for a treatment like Probuphine or one that improves on it)?

        Also, you mentioned insurance coverage, so I’m assuming you accept it? From your experience, what percentage of doctors accept insurance and why do some doctors refuse to accept it?

        Thanks for taking the time to answer questions. There are so many unique aspects of addiction treatment. Sometimes, it seems like many of those aspects (patient limits, doctors not taking insurance, etc..) hurt the patient population.

      • I think more doctors won’t learn to do the implant than 30-40%.

        All doctors need to have the “ability to refer for counseling.” What exactly that means differs, I think. It’s not exclusive to psychiatrists.

        I insist new patients get some kind of counseling – but I’m flexible about the type. If they have no insurance and limited money, 12-step meetings are still the best deal in town. I have an LPC/ LCAS counselor in my office, so he’s available for all my patients. Some patients see him AND go to 12-step meetings. But if a patient already has a therapist they feel comfortable with, and they are willing to let me talk with the therapist so I can be assured addiction issues are being talked about, I’m OK with that too.

        I’ve inherited 30-40 patients who are on maintenance treatment, been doing well for more than 2 years. Do they still need counseling? That’s the question I wrestle with. Most have had a great deal of counseling at some point along the way. But they have decided they do better staying on Suboxone and I’m OK with that, since it appears patients who do stay on the medication have lower relapse rates. If they are doing well I don’t insist on continued counseling, though some still go, having seen the benefits.

        No. I do NOT accept insurance. I do provide a receipt to patients with diagnosis and CPT codes so that they can file it themselves and be paid back directly by their insurance company. By doing things in this way, I avoid having to hire an additional office worker to do insurance, and my fees are slightly cheaper. About half my patients are self-pay and half have insurance. I’m sick of insurance companies eating up 30% of the cost of healthcare without providing much service in return. If we cut out this bloated middleman the world would be a better place. Excuse me while I wipe some spittle off my face and could you please help me down off this soapbox?

        I don’t like the patient limits. I’d like to be able to treat a few hundred patients in my office, since it’s so hard to keep my office profitable with only 100 patients. Then I’d have enough work to stay open two days a week instead of only one day per week. With so many of my 100 patients doing well, I don’t see them as often as new patients. Great for them, and I’m happy they are doing well…but I make less money from these stable patients, and see them less often.
        I think the patient limits were placed to encourage doctors to treat addicts as a part of primary care. It’s a great idea. But I sincerely hate doing primary care (did it for 8 years and that’s enough) and only want to do addiction medicine, so I also work at OTPs on my other work days.

      • Posted by Jonathan Novak on April 23, 2013 at 9:03 am

        Sorry this is coming so late, but I just wanted to thank you for taking the time to respond to everyone questions in such a detailed manner.

        Also, I came across this early study on Probuphine:

        If you read it, you’ll see that 59% of urine samples came back negative. I think this has to do with the study protocol. Instead of 3 weekly drug tests throughout the entire six months, subjects took twice weekly tests during the 1st month, weekly tests during months 2-3, and twice monthly tests for months 3-6.

        Obviously, this is more of a real world testing regime (though possibly a little more extensive during the first month to three months). I was just wondering if these are similar to the results you see? If so, do you take the results with a grain of salt? Meaning, it is obviously a lot easier to pass a drug test when you only have to take it once every few weeks and you know when you are taking it. I have read a lot about how those addicted to opiates are able to manipulate doctors and make things appear better than they are. Is that always in the back of your mind or do you trust your patients?

        Sorry to ask so many questions, but addiction treatment is such a complex and interesting subject and you are very knowledgeable on the issue. I’d be willing to bet that if they took twice monthly tests the entire time, the results would be higher than 59%. Compared to the 34% seen in the other trial, it is a significant difference and obviously 59% is not a realistic number. Just wondering if that is something you guys think about when you treat patients and if there is anything you do to try and stop it?

        Thanks again for taking the time to answer all of these questions.

      • Posted by Benjamin Keith Phelps on April 23, 2013 at 7:30 pm

        Jonathan, though you didn’t ask me, I will reply to your question about patients knowing when they’ll be tested & whether that makes docs suspicious about the results, etc. My clinic does urine tests w/their random call-backs. Call-backs can occur ANY time. Thus, if you use, you are likely to skate for a time, but not forever, by a long shot. You WILL get burned if you attempt to skate by that type of setup, & you’ll be kicking yourself hard for a long time when you lose a huge chunk of privileges over it, not to mention the fine mess you can get yourself into when you play w/other (non-opioid) drugs while in treatment. I did that w/sleeping pills & ended up completely & entirely dependent physically on them, to the point of horrendous w/d’s if I stopped. It was a total nightmare, & I had nobody to turn to b/c I felt I couldn’t tell the clinic or I’d lose my BIG amount of takehomes (also, they were the ones who started me on the sleeping medicine in good faith. I misused it & ended up in trouble, so it was MY fault!) I couldn’t tell my parents, or they’d accuse my methadone of not working (this is a pet peeve of mine – OTHER drug relapses of the non-opioid type are NOT indicative of MMT not working!! It’s NOT SUPPOSED to work for those drugs, nor has anyone ever claimed it does!) In a nutshell, I made myself feel backed into a corner & I ended up in jail over it for passing fake prescriptions to keep up w/the # I needed. This is different from the urine test question, but is an example of what happens when you dabble w/things that make you feel good. WE CAN’T HANDLE THOSE THINGS. B/c when I feel good w/1 tablet, I know that 2 will probably make me feel even better, & 3 will likely make me feel fantastic! And once I’m up, I don’t want to come down, so to speak (though I prefer “downers” over “uppers”). Once you get used to feeling other than “normal”, then feeling “normal” – & I use that term in quotes b/c normal is a subjective thing, experienced differently by every person, but you know what your normal feels like – won’t be acceptable to you & feels somehow sort of wrong. You get to where you don’t know how you lived w/out feeling differently before. Once you reach this point – which is basically just the same thing as your addiction was before, only now you’re achieving it on top of your MMT – it is only a matter of time before you WILL get caught by your drug screen (even a scheduled one), b/c you WILL reach the point where you can’t seem to get it out of your system long enough to pass the test. I.e. – you’ll know that it takes about 3-4 days to get substance xyz out of your urine for the test, but you won’t be able to last that many days, & you’ll give in & use 2 days before the test b/c you’ll think you can probably drink lots of water & pass the test. And if you manage that, you’ll end up using the day before eventually, thinking this time you’ll REALLY drink lots of water, to be sure. And you may or may not drink all that water, but you WILL eventually get burned on the test, & the bottom line is this: it’s JUST NOT WORTH IT. Not b/c you’ll lose the takehomes, though that’s certainly something worth striving to earn & keep, etc… But b/c of what you’re doing to yourself ALL OVER AGAIN. The big question is this: are you in treatment to get better? Or to continue using & stay sick w/your addiction? If it’s the latter & you just want harm reduction, then that’s certainly your choice to make, but life is SO much easier when you don’t have that monkey on your back day in, day out, 24/7/365. I realize you may not have been asking for your own purposes, & that’s ok – if what I say doesn’t apply, let it fly! I just wanted to comment about how my clinic handles it, & give my thoughts on it. Unfortunately, all too many patients out there don’t care about really getting better, & it makes it so much harder for those of us who are doing what we should, really wanting to do well in treatment. I’m not saying we’re any better than they are, but what I mean is that MMT & Suboxone treatments both are laden w/enough red tape that it prevents thousands & thousands of addicts from seeking treatment at all already, just b/c of the FEAR that bureaucrats have that we’ll misuse the meds & sell them. For them to actually get reports in their hands that their fears have materialized is only that group of patients that doesn’t really care working hard at making things MORE difficult on themselves, but affecting all of us in the process – yet still, they couldn’t care less. I have a problem w/that. But anyway, that’s my rant for the day. :o)

      • I expect many patients to use opioids during the first weeks of treatment. Addiction is a powerful disease and it doesn’t stop overnight. but with fine-tuning of the dose and increased counseling, the people who stay in treatment do great, usually within a few months. After that, it’s rare to have a positive drug screen, at least for opioids. Yes, some patients may falsify, but I think fewer are tempted to do so if I keep a therapeutic environment where relapse is looked at as a problem to be solved together rather than bad behavior which should be punished. If I have a buprenorphine patient who continually uses opioids, even at a maximum dose, I’ve either got to really intensify counseling or refer to an opioid treatment program where they can be treated with the stronger mainenance medication, methadone.

      • Posted by Jonathan Novak on April 23, 2013 at 10:41 pm

        Excellent response Ben! I’m not addicted to any substances and I know that I can’t grasp the concept of what it is like, but your explanation offers a window that I can look through and get an idea.

        I don’t want to comment on what you had to say because I’m not qualified and I don’t want to say something that may come off the wrong way, but it was an informative response from start to finish.

        I wish you all the best in your struggle with staying on the right path. You seem like you have a good understanding of your addiction and that’s a great thing to have.

        Good luck to you and thanks for your response.

      • Posted by Benjamin Keith Phelps on April 24, 2013 at 7:36 pm

        Thanks much, Jonathan! It took a good while to get there, though… I SO wish I could have gotten that kind of grasp you describe much earlier on. But thanks for the compliments!

      • Posted by Benjamin K. Phelps on April 25, 2013 at 6:41 pm

        Dr Burson, what a GREAT reply (the one that started w/you expect to see patients use in the first days of treatment….) Actually, it’s just a GREAT way to look at things that you have. Many, if not most OTPs view drug use as a moral failure of some kind, instead of what it is – it’s not a personal thing where we want to be deviant, or deceive the clinic, or hurt somebody out there… It’s our disease manifesting itself. And I don’t mean to use that as a cop-out; I’m NOT saying that this should be an excuse to go & use, nor am I saying it’s a good excuse to use if you already did relapse. But it is an underlying reason for the action of relapse. There are many times where the person doesn’t do things that s/he should to avoid relapse (i.e. – resisting the urge to accept a prescription for a controlled medication, as I did), & many times where s/he does things s/he shouldn’t to bring it on (i.e. – visiting using friends, etc). It pleases me to hear that you seem to have a solid understanding that relapse should be an opportunity for you to interact w/your patient & work on discovering the problem & correcting it so that relapse doesn’t occur again (hopefully), rather than an opportunity to crack the whip of power yet again to “let this person know who’s in charge here”. Power trips like that almost NEVER work & only result in the patient not trusting the doctor/counselor in future times. I hate to say it, but my clinic does an INCREDIBLY WONDERFUL job of making absolutely SURE that none of their patients EVER tell them the truth or come to them with problems. For example, they usually only allow 5 THs for people w/o employment. So you’ve achieved your maximum 13 THs there, & all has been fine for YEARS. Then one day, you sadly learn of a lay-off where you work, & you’re affected. In great despair, you go to your counselor to talk to him or her about this, b/c you want to do the right thing & not use – you want to handle your stress the right way. When you leave his or her office at my clinic, you leave w/5 THs from now on… not any hope of finding a new job or happiness that you’ve handled your stress the right way. For them, rules are arbitrary & there to be enforced on a blanket basis – there are NO case-by-case instances. So your situation of losing your work will NOT be given any kind of exception, no matter that your compliance has always been perfect, nor that you will likely find work again soon. And if things are like they’ve always gone for me there, you’ll have to EARN those THs back; you won’t get them back the day you get the job. So Dr Burson, I appreciate your viewpoint on the doc-patient relationship. And I understand that you DID NOT say that there will be no accountability, nor am I saying there shouldn’t be any, simply b/c a patient decides to be honest. But there are situations where punishment is not the appropriate response. At least, I think so. And I’m glad that you view this as a reason to send a patient to MMT (if they can’t get clean of opioids on bupe). That’s the RIGHT way to handle that situation! ONLY THEN, if they cannot get clean of opioids & have been given a high enough dose for a long enough time, should any consideration be given to trying a different treatment. And some would say that even then, the patient should be allowed to continue in treatment in hopes that s/he eventually finds his/her footing…..

      • Thank you!!

  6. I am not too sure I can trust a long term implant that would block other pain killers and opiates. What if I am in an accident and I am required to go under surgery. What have they come up with to assure that this Probuphine will not block the effect of other pain killers that would be prescribed.


    • That’s a great issue! I can probably be overridden with enough opioid, but it may be dangerous as an outpatient. As an inpatient with monitoring available, pain could probably be managed, but it’s definitely a consideration.


    • Posted by Benjamin K. Phelps on April 2, 2013 at 10:04 pm

      Pain can still be treated with both methadone & Suboxone/Probuphine. It’s just a matter of having a willing doctor & higher doses that are closer together than usual. Dr Burson is right, though – it would require more monitoring to ensure no adverse reactions &/or deaths in the process if the patient were sent home with pain medication. But this is just as true for methadone & Suboxone patients as it is Probuphine patients. B/c you DON’T want to stop your maintenance medication to be treated for pain by another opioid temporarily – this is NOT a good idea. Since there are incomplete cross-tolerances between all these opioids available for prescribing, you are VERY likely to feel sick, even with high doses of another opioid, such as morphine or Dilaudid if you stop your methadone or Suboxone. The preferred way to treat in this situation is to continue the maintenance medication while giving “rescue doses” of another short acting opioid in a higher dose than usual & closer together than usual.


  7. Posted by kevin on May 7, 2013 at 11:23 pm

    I have an important question Dr, what is a rescue dose?


  8. Posted by Carlos on May 8, 2013 at 1:36 pm

    You aren’t alone – even some doctors think it’s the naloxone that causes withdrawal, but it’s actually a property of the medication. there’s much misinformation about buprenorphine.

    If buprenorphine was the only thing that clinicians have misinformation (and pass it on to patients and the public) about we wouldn’t have such a big problem. What appears to be true is that there quite a bit of misinformation about lots of things in substance use disorder treatment.

    Seems like clinicians believe that their education, license and “years of experience” is sufficient to provide their expert advice and even provide testimony in court. I have never seen so much rubbish been spoke by a PsyD making all kinds of claims without providing one iota of scientific evidence. Hell, which cares about a little petty thing like scientific evidence…. It is expected of all other medical field except in Mental Health and Substance Use Disorder where misdiagnosis runs ramped. Who cares about following standards, just make it sound good and dramatic and that’s the diagnosis your patients get.
    I have a question. How does a patient who is getting abstinence based 12 Step treatment?, after being in treatment over a month and all of his urines test are clean can he/she be diagnosed as Opiate Dependent? The patient is no longer going through withdrawal symptoms. There shouldn’t be any evidence of tolerance anymore given the patient is no longer using. Perhaps when they get a doctorate degree they become functionally illiterate and they forget how to read. I might not have a Doctoral Degree in Clinical Psychology, but at least I know how to read and comprehend what I read.
    What to find out how much quackery and snake oil goes on in the court system? Read “Coping with Psychiatric and Psychological Testimony” written by a Psychologist and Attorney who is attempting to teach attornies how to take out the spooky dust out of psychiatry.


    • Sadly it’s not only mental health that’s full of bad science. It’s in primary care too.

      Your question about opioid dependence… the terms are confusing. One person who uses the term “dependence” may be talking about physical symptoms seen when a person taking opioids stops suddenly. But the DSM IV, the text used to make mental health and substance abuse diagnoses from the symptoms the patient has, uses the term “dependence” to mean “addiction.” Therefore, it is possible for a person in early recovery and out of withdrawal to have a diagnosis of opioid dependency, since that diagnosis is made not only because of tolerance and withdrawal, but also psychological symptoms like history of using opioids despite adverse consequences. There are 4 other criteria of a psychological nature in the DSM-IV. Of course, the DSM V is ready to come out soon. I don’t know if they plan to change criteria and terms.

      So yes, a person with a month of abstinence, with a history of meeting criteria for opioid dependence would have the diagnosis of opioid dependent, in early remission. If the person was on methadone or buprenorphine, the qualifier “on replacement meds” could be added.


  9. Posted by Carlos on March 19, 2014 at 10:02 pm

    I just don’t want to trust it. The lees invention to my body the better. I have already done some damaged via a motorcycle accident some time ago that has come back to hunt me.

    We all due respect we need to be very careful with criteria in the DSM system. In fact part of my beef is that most of the DSM is based of nothing more than some guys that put the pants on just like me vote on who is healthy and who is not. The science is really sketchy. In fact I think they should remove the word statistics from the title. Because the statics I can assure you is much less than what must people think exist in the book. And it is place on the title in order to impress us with number that do not exist. Is rather questionable in a lot of areas. That is no secret, but I think that is much worst than what most people think.

    In fact if you really read the criteria in the DSM V (want a copy? I have a pdf I can pirate to you). Most people in treatment, even those on methadone and buprenorphine do not meet the standards. Aside from all the hoopla we think of ourselves in recovery the impairment does not exist. I mean we can make all kinds of story about how bad we are off, and how badly we behaved.

    There is some psychos out there that truly believe that noone is really healthy. I had one PsyD state that he could diagnosed anyone in 15 minutes. With accent in anyone.

    Psychology does not have the FDA (granted they need to be better watch and they are too concerns on drugs and the pharmaceutical companies. But in psychology there is nothing. Even the professions and the states agencies are horrible at policing themselves.

    I hear what you are saying about the psychological, but there is way to much make believe in it. One quack once told me that because I was an opiate addict at one time equals Impulsive disorder and when one stops using. One still impulsive. I think that is rubbish. There is possibility but it is not always true. I learn in behavior analysis that what one learns or what ever chain paired with any behavior like opiate addiction. Once there is an extinction all of the behavior in the chain also go in extinction. One assumes that all kinds of bad habits exist with it. But that data is more anecdotal than in actuality. One needs to be careful about the stuff they claim in those meetings. Remember people are asked to identify with “the speaker”. Those identifications call also be dangerous. And just because you remember behaving like that once that does not mean a lot of things.

    You see we have to be careful with what I call “Shape Shifting” popular in twelve step groups. For example when the 8th tradition says that “it will never be professional” and you point out all of the gurus and the professionals practicing 12 Step facilitation. They give you some hoarse pup to make you think that is not what it says. It says something or they mean something else. Same thing is true with a lot of stuff in psychology. They come up with exemptions that do not necessarily a good fit.

    Remember psychiatry are the same groups of people and true believer that brought PMS (still exist with different name), Homosexuality, Multiple Personality Disorder (that still around with a different name when the science did not fit the claims. In the DSM II it was a rear condition, but there was an explosion epidemic in the eighties).


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