Archive for the ‘snorting pills’ Category

Am I Addicted to Prescription Pain Pills?

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

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

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

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

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

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

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

The New OxyContin Formulation

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

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

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

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

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

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

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

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

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

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

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

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

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

Film Review: Suboxone

I had a chance to get more information about the new Suboxone film. I’ve decided I like it. It looks like one of those Listerine breath strips, and dissolves like one, too. When placed under the tongue, it dissolves faster than the tablets, but the taste is apparently about the same. The drug company’s representative brought me an inert (no active drug) film that’s supposed to taste exactly like the real thing. It was orange-flavored and bitterly sweet. While not terrible, it wasn’t tasty. But it was bearable. It dissolved very quickly, an advantage over the tablets.

I was concerned that my patients on 4mg or 12mg couldn’t use these films, as I heard they couldn’t be cut. But the drug company rep said the drug was evenly distributed on the film. Though the company’s official position was the film shouldn’t be cut into halves or fourths, it would probably work.  But she also reminded me that the drug company also says that about the tablets, but my patients use half-tabs frequently with no ill effects.

I don’t see any way the film can be snorted, though some creative and intelligent addict will probably find a way.

The films are contained in individual sealed pouches. Each pouch from the same box has the same number on it, meaning it would be very difficult to “fake” a pill (film) count if the doctor asked a patient to return to the pharmacy to make sure the appropriate amount of medication remains. If films from another box are substituted to make the count right, they will have different numbers. Very clever of the drug company. Oh, and the rep said the film would cost the same as the Suboxone tablet.

The film is available in pharmacies willing to stock it. If you are on Suboxone and want to try the film, be sure to ask your pharmacy to order it a few days before you think you will want to fill a prescription, to make sure they’ll have it.

I hope this delivery form is easier for patients and harder to divert or snort.

New Form of Suboxone: Dissolving Film

Yesterday the FDA approved a new delivery system for the medication buprenorphine. Reckitt Benckiser, the drug company that makes the brands Suboxone (a combination pill of buprenorphine and naloxone) and Subutex (containing only buprenorphine), is now approved to manufacture and sell Suboxone in the form of a thin film that is placed under the tongue to be absorbed. According to early studies, patients think the film tastes better, dissolves more quickly, and is easier to use. I don’t yet have any information on the relative cost of this new film.

Since it was just approved, it’s not likely that a generic form of the film will be available for many years.

 This film of buprenorphine, the active ingredient, can’t be obtained as a generic, and it may be a few weeks before it appears in retail pharmacies.

 I’m hoping the sublingual (under the tongue) film will be harder to snort or inject, because there are reports of addicts misusing the Suboxone and Subutex tablets. And every addict misusing the name brands or the generic of buprenorphine who comes to the attention of law enforcement endangers the existence of the buprenorphine program.

 In the past I worried about prescribing Subutex, the form of the drug that doesn’t contain naloxone, or the newer generic buprenorphine, which also doesn’t contain naloxone. But apparently, some addicts are able to inject Suboxone, and the naloxone in it doesn’t put them into withdrawal. At least, they don’t go into intolerable withdrawal.

 It just shows me again that people are so different in the way they react to medications.

Interview with a Methadone Counselor

I met a skilled drug addiction counselor, previously addicted to heroin, who became abstinent from all drugs, by going to meetings of Narcotics Anonymous. She had been a patient of methadone clinics off and on for many years, prior to getting clean. I met her after she had more than ten years of completely abstinent recovery, yet she happily works at a methadone clinic, helping opioid addicts. I interviewed her because of her personal experience and her striking open-mindedness to different approaches to the treatment of addiction. Here is what she had to say about her experiences with methadone, and her perspective:

JB: Can you please tell me your personal experience of opioid addiction?
RJ: Well, my personal experience began at the age of…probably eighteen….and I was introduced by some people I was hanging out with. I was basically very ignorant about those kinds of things. I wasn’t aware of that kind of stuff going on, ‘cause I was raised in this real small town and just didn’t know this kind of stuff happened.
My first experience was with a Dilaudid. Somebody said we had to go somewhere else to do it, and I really didn’t understand that, because I certainly didn’t know that it would be injected. That was my first experience with a narcotic, with opiates, and….I fell in love!
I loved it. I injected it, and the feeling was…..like none I had ever felt. And even though I did get sick, I thought it was what I was looking for. It was the best feeling in the world.
Obviously, they didn’t tell me about getting sick, [meaning opioid withdrawal] and that after doing it for some days consecutively, when you didn’t have any, you’d get sick. I never will forget the first time I was sick from not having any.
And that lead to a habit that lasted twenty-some years. My experience and my path led me down many roads… with addiction, going back and forth to prison, because I obviously didn’t make enough money to purchase these drugs that I needed to have in my body, to keep from being sick. This lasted for twenty four years. I ended up doing heroin and I liked it, because it tended to be stronger. Morphine I liked a lot, but it wasn’t easily accessible, so I switched over to heroin at some point. Which I liked a lot.
JB: What role did methadone play in your recovery?
RJ: I’ve been in numerous methadone clinics. I typically would get on methadone when I got a charge [meaning legal problems] and I wanted to call myself being in treatment. I never ever got on methadone with any expectations, hopes, or thoughts of changing my life. I got on because it kept me from being sick. And it kept me off the street for a period of time. If I had a charge, I was in treatment and I always thought that would help me in my journeys with the legal systems. That was the part methadone played in my life, it was just to help me get through it.
JB: Did it help you?
RJ: At the time, it did. My problem with methadone was, when I would get on methadone, I would tend to do cocaine, because I could feel the cocaine, and I wasn’t about changing anything. I just wanted temporary fixes in my life. I’d switch to cocaine while I was on methadone. And it [methadone] worked for a time. I never got any take homes, because I continued to test positive for other substances while I was on methadone, but I thought I was doing better, ‘cause I was not doing narcotics. In that aspect it did help.
JB: And you’ve been in recovery from addiction now for how long?
RJ: It will be fifteen years in June.
JB: Wonderful!
KS: Yes, it is wonderful.
JB: And tell me where you work now.
RJ: I work at a methadone treatment facility.
JB: How long have you been working there?
RJ: I’ve been there for almost fourteen years and in this [satellite] clinic for a little over two years, and I’ve been in methadone [as a counselor] for five years.
JB: How do you feel about methadone and what role it should play in the treatment of opioid addiction?
RJ: I believe in methadone. Our [her clinic’s] philosophy certainly is not harm reduction but I believe that’s what it’s about. And I do believe that those people on methadone, and are doing well, have a home, have a life, I think that’s all they aspire to. For them that’s enough, you know, they’re not out ripping and running the roads, they’re not looking for drugs on a daily basis. They come and get their methadone, they go to work, they have a life, they have a family, they have a home, and for them that’s good enough.
JB: Do you think it keeps them from getting completely clean [I purposely chose to use her language to differentiate being in recovery on methadone from being in recovery and completely off all opioids]?
RJ: No. I think they know they have a choice.
JB: OK
RJ: I really believe that a lot of them don’t think that they can ever do anything differently, and I know from personal experience that can be very true. I think that you just get so bogged down in your disease that you don’t see any way out. I think if you can find a place where you can get something legally and you’re not using the street drugs, and you’re not out copping [buying drugs] and you’re working and basically having a life, then that becomes OK, and that becomes good enough.
And addicts by nature are scared of change, and they get in that role and they get comfortable and that’s good enough for them. So I don’t believe they think that they can do any better.
JB: What percentages of your patients have already used street methadone by the time they get to the clinic?
RJ: I’d say seventy-five percent. Very rarely do I do an assessment [on a new patient] that somebody hasn’t already used methadone on the street. Very rarely.
JB: What are your biggest challenges where you work?
RJ: Actually my biggest challenges where I work are internal challenges. Fighting that uphill battle of no consequences for clients. There’s no consequences. We allow them to do basically what they want to do. [She is speaking of her methadone clinic’s style of interaction with patients].
JB: Do you think patients did better when there were a few consequences?
RJ: Oh yeah. Yeah. I mean, when certain clients can continue to have the same behaviors, like use benzos [meaning benzodiazepines like Valium and Xanax] and there are no consequences, certainly they are going to continue doing those behaviors. And those are the things that are challenges now, for us, for me.
I can’t enforce any consequences because we’re not allowed to, because it’s called punishment. The powers that be, they see it as punishment, where I work. Being that I come from living a life of doing the wrong thing always, I’m a big believer in consequences. And I believe that if you don’t have any, you continue to do those things. That’s the kind of stuff, the inadequacies where I work at.
JB: What do you like most about your job?
RJ: (pause) The light…. in somebody’s eyes every now and again. It might not happen much, but now and again the light comes on, and you have that “ah ha” moment. They have it, and you’re like, yes! Or when somebody comes and tells you they have that little spark of hope. Yep. That’s what I like most about my job.
JB: If you could make changes in how opioid addiction is treated, what would you do? If you could tell the people who make the drug laws, what would you recommend? How would you change the system, or would you?
RJ: I don’t know that I would change the system. I think the system works. I think it’s individual facilities that don’t work sometimes. Yeah. I think – methadone’s been around a long time – I mean, obviously it’s worked for a lot of years or it wouldn’t still be in existence. I think methadone maintenance programs work, but each individual facility maybe needs to make changes. You know, that’s just my opinion.
JB: If you were the boss of a methadone treatment center, how would you handle benzodiazepine use by patients?
RJ: They wouldn’t be tolerated. At all.
JB: Why is that?
RJ: Because I think they kill people. I know they kill people.
JB: How about alcohol?
RJ: Alcohol wouldn’t be tolerated either. I mean, obviously you would be given a chance to straighten it and rectify it and clean it up, with help, if you need it. But that would be it. You would get that opportunity and then [if the patient couldn’t stop using alcohol] you would be detoxed from that program. I believe that’s the route to go. We’ve had too many deaths. And there’s nothing to say that it’s not going to continue to happen…so, yeah, if I had a facility it would not be tolerated. There would be zero tolerance, period. There just wouldn’t be any.
JB: What do you say to people that say that’s keeping people out of treatment?
RJ: There are other types of treatment; maybe you need a different level of care. Maybe methadone’s not the answer.
JB: So you don’t think methadone’s the answer for every opioid addict?
RJ: No. No I don’t.
JB: What do you think about people on methadone coming to Narcotics Anonymous?
RJ: I think they have a right to come to Narcotics Anonymous.
JB: Do you think they should share?
RJ: I wish they could share, but I know, there again from personal experience, how methadone is viewed by people in Narcotics Anonymous. And I think that if that person does share [that they are on methadone], they are treated differently.
JB: Do you tell your patients to go to NA?
RJ: I do.
JB: What do you tell them about picking up chips?
RJ: That’s their personal call, because I feel like it is. But then I don’t view methadone as using. See, I look at it as treatment, and somebody taking medication because they’re sick, and trying to get better. So I don’t view that as getting up and doing dope. Therefore if I were on methadone and going to meetings, I’d pick up chips.
JB: Can you think of anything else [you’d like to say]?
RJ: I believe in methadone. I really do. I just believe that it works. I know people who have been on our program for twenty years, and granted, those people will never get off methadone, but they have a life today. And twenty years ago they didn’t have one. They’re not perfect but I’m not either, you know, just ‘cause I don’t use dope any more. But they’re still suffering addicts, just like I am. So I just believe that methadone works, and if you want to make changes in your life, that there are people at every facility who are willing to help you make those changes.

Treatment professionals can also make the mistake of dismissing non-medication treatment of opioid addiction as ineffective, when clearly this is not true. Though treatment with methadone and buprenorphine can provide enormous benefit, so can the other medication-free forms of treatment. And as we have seen, methadone can cause great harm when used inappropriately, and some opioid addicts don’t do well on methadone.
There’s no one best treatment path for every addict. Every evidence-based treatment helps some addicts.

Excerpt from my upcoming book: Pain Pill Addiction: Prescription for Hope

 One doctor makes work for another.  ~English Proverb

 The increase in opioid addiction coincided not only with the movement toward aggressive treatment of chronic pain with opioids, but also with the release of OxyContin by its manufacturer, Purdue Pharma, in 1996. Their other drug for pain, MS Contin, had become well-established in the treatment of severe cancer pain, but this drug was due to come off patent. This meant the other drug companies could then manufacture and sell a generic version of the same drug at a cheaper price. Purdue obviously wanted physicians to switch to their new drug, still under their patent, to maintain their share of this market.

 OxyContin was marketed aggressively to small town family doctors who didn’t have much experience treating chronic pain with powerful opioids, or with identifying and treating pain pill addiction. In rural areas, family doctors had few places they could refer patients who developed problems with their opioid pain medications.  (1)

 The drug company marketed OxyContin as an appropriate treatment for chronic, moderate to severe, non-cancer pain. In the past, such strong opioids were used only for intractable, severe pain. OxyContin was marketed as the pain medicine to “start with and stay with.” OxyContin was even prescribed for such ailments as menstrual cramps, oddly mirroring the misuse of opioids like laudanum and morphine a century earlier.

 Purdue Pharma believed OxyContin was tamper-resistant and less likely to be abused, due to its time release coating. The drug company was still touting this as a selling point in 2001, when addiction medicine doctors all over the country were seeing hundreds of OxyContin addicts. These addicts described how easy it was to moisten the pill, crush it, snort it, inject it, or just file off the coating and chew it.

 Purdue Pharma didn’t do pre-release testing of their new drug, to assess its desirability to addicts seeking to get high. At first, they didn’t have a post-market release system to monitor for signs of abuse and diversion, as other companies have done.  In fact, Purdue Pharma seemed to go out of their way to ignore early warnings and complaints about the drug. Doctors, who tried to warn the drug company about the patients they were seeing who were addicted to OxyContin, were ignored and discounted. (1)

 Purdue Pharma trained its sales representatives to make deceptive statements. Besides telling doctors that the drug was less likely to be abused, the sales representatives also gave false information about the risks of opioid withdrawal after stopping the pill. (2)

 OxyContin became such a commonly known drug to both abusers and the media that the U.S. General Accounting Office (GAO) asked for a report about the promotion of OxyContin by Purdue Pharma, information on factors affecting its abuse and diversion, and recommendations of how to curtail its misuse. This report, released in 2003, stated that by 2001, the sales of OxyContin were over 1 billion dollars per year, making it the most commonly prescribed brand of opioid medication for moderate to severe pain. (2)

 By 2002, prescriptions written for OxyContin for non-cancer pain constituted eighty-five percent of its total sales. The type of non-cancer pain for which it was prescribed included both acute pain, like kidney stones, broken bones, and post-operative pain, and chronic pain like arthritis and fibromyalgia. By 2003, primary care doctors, with little or no experience or training in the treatment of long-term pain, were prescribing about half of all the OxyContin prescriptions written in the country. By 2003, the FDA had cited Purdue Pharma twice, for using misleading information in its promotional advertisements to these doctors. (2)

 The GAO’s report recognized the unique timing of the release of OxyContin. “Fortuitous timing may have contributed to this growth, as the launching of the drug occurred during the national focus on the inadequacy of patient pain treatment and management.” (2, Page 9)

 Purdue Pharma could have re-formulated their pill, to reduce the risk of abuse and addiction. Sterling Drug, manufacturer of the pain medication Talwin, re-formulated their medication, to make it less likely to be abused. The active drug in Talwin is pentazocine, an opioid that had a brief rise in abuse when it was first released in the 1980s. To prevent intravenous injection of their drug, Sterling re-formulated Talwin within a year, adding naloxone, a drug that reverses the effects of opioids. This is the same medication used by doctors to treat opioid overdoses. Naloxone is not absorbed when taken by mouth, because it is inactivated by stomach acid. But when the pentazocine/naloxone pill is ground and injected, it puts addicts into immediate withdrawal, thus making it a much less desirable drug for intravenous addicts. This action by Sterling curtailed the abuse of Talwin/NX, their new product.

 Other manufacturers have taken different precautions, when concerned about the abuse of a prescription drug. For example, the drug Rohypnol, commonly called the date rape drug, is illegal in the U.S., but is legally prescribed in Europe and Latin America. Because they were concerned that the drug was being used illicitly, to facilitate rapes, the manufacturer, Hoffman-LaRoche, re-formulated Rohypnol so that instead of being clear, colorless and tasteless, it becomes milky white when added to any other liquid. This can warn unsuspecting people that something has been added to their drink.

 A Purdue Pharma representative testified before congress in 2002, saying that the company was working on a re-formulation of OxyContin, to make it harder to use intravenously, and that they expected to have the re-formulated pill on the market within a few years. (3)  Eight years later, there still is no such re-formulation of OxyContin. Purdue Pharma said it would take three or four years to reformulate the drug, though Sterling, with Talwin, managed to accomplish this within a year, more than a decade earlier.

 In May of 2007, three officers of Purdue Pharma, a privately held company, pled guilty to misleading the public about the drug’s safety. Their chief executive officer, general counsel, and chief scientific officer pled guilty, as individuals, to misbranding a pharmaceutical. The executives did not serve jail time. Though they plead guilty, they claimed they personally had done nothing wrong, but accepted blame under the premise that an executive is responsible for the acts of the employees working under him. (4) The three executives’ fines totaled 34.5 million dollars, to be paid to Virginia, the state that brought the lawsuit.

 The Purdue Pharma company agreed to pay a fine of $600 million. Though this is one of the largest amounts paid by a drug company for illegal marketing, Purdue made 2.8 billion dollars in sales revenue, from the time of its release in 1996 until 2001 alone.

 To be fair, the drug company and addiction specialists had data that showed the most common opioid to be abused is actually hydrocodone, a short acting opioid, often marketed under the brand names of Vicodin or Lortab. While this is technically correct, the strength of a single hydrocodone pill is usually 5, 7.5, or 10 mg, while OxyContin came in 10, 20, 40, 80, and, for a brief time, 160mg. In addition, hydrocodone is slightly weaker, milligram per milligram, than oxycodone. In other words, the opioid firepower in one OxyContin is much higher than in one hydrocodone, so they are hardly comparable. An addict would need more than eight hydrocodone 5mg pills to equal one OxyContin 40mg.

 This much opioid, packed into one pill, produces a powerful high when it’s released all at once, as it is when the time release coating is removed. Many patients I’ve talked to have said they knew OxyContin would cause problems from the first use. “After that first high, I knew I would keep using. I wanted that feeling,” is an example of a typical quote.

 Since the debacle of OxyContin, Purdue Pharma has donated money towards helping communities treat opioid addicts, and has paid money as ordered by the court. Much of the $600 million award will go to states heavily afflicted by OxyContin addiction. This money will help to establish programs to help prevent and treat opioid addiction.

 OxyContin isn’t a bad or evil drug. It’s just a drug, capable giving great benefit and relief of suffering to those people in serious pain. And it’s also capable of being misused, and can cause great suffering and even death, if not used in the right way.

 1. Barry Meier, Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (Rodale Books, 2003)

2. General Accounting Office OxyContin Abuse and Diversion report GAO-04-110, 2003.

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

4. Washington Times, “Company Admits Painkiller Deceit,” May 11, 2007, accessed online at http://washingtontimes.com/news/2007/may/10/20070510-103237-4952r/prinnt/ on 12/18/2008.

Buprenorphine, Part 2

Changing a patient’s medication from methadone to buprenorphine is trickier than from other opioids, because of methadone’s long duration of action. Patients need to stop the methadone at least seventy-two hours before starting buprenorphine. Since methadone is also a much stronger opioid, the patient should be stable on methadone forty milligrams per day or less. Otherwise, dropping from a higher dose of methadone to buprenorhpine often leaves the patient with feelings of low-grade withdrawal for the first few weeks of buprenorphine.

I’ve had a few strongly motivated patients make the switch from higher doses of methadone than I would recommend, to buprenorphine. One patient was dosing at 70mg of methadone, stopped it for about five days, and then started buprenorphine. He didn’t have a very pleasant first week. I worried it would be too difficult, but he did it. By two weeks he felt pretty good, and he’s done great for the last three years, on a relatively low dose of buprenorphine. Because he also has chronic back pain, he’s decided to stay on buprenorphine as the best solution to both his chronic pain and opioid addiction.

Because buprenorphine is a partial opioid agonist, there’s a ceiling on its effects. This is why it’s now permitted to be prescribed through a doctor’s office, without all the regulations that methadone clinics have. After the buprenorphine dose reaches twenty-four (some say thirty-two) milligrams per day, further increases in the dose have no additional effects. This makes the drug much more resistant to overdoses. However, if mixed with sedatives like benzodiazepines (Xanax, Valium) or alcohol, it can still be fatal.

 Most patients say they “just feel normal,” after taking buprenorphine. When the drug works, many patients have returned to my office on the second visit saying, “It’s a miracle!” They say they feel just like they did before they got addicted. They don’t think about pain pills, don’t feel withdrawal, and don’t feel like they’re medicated. Patients who have been on both methadone and buprenorphine say the methadone is heavier, and they feel medicated, but on buprenorphine they feel lighter.

A dose of buprenorphine can stimulate opioid receptors anywhere from twenty-four to sixty hours, so some patients feel stable when they dose only every other day, though I think overall best results are seen with stable daily dosing. There is no impairment of thought processes or motor function in patients on a stable dose of buprenorphine. These patients can drive, work, and play with no limitations.

I try to temper patients from being overly enthusiastic about buprenorphine. Sometimes patients feel so good on this medication, they don’t realize how much psychological work needs to be done before they can taper and stay off of buprenorphine. Patients feel so good, they minimize their addiction, and are reluctant to get the counseling they need. One of my doctor friends says that the drug’s main problem is that it works so well.

Buprenorphine is ideal for patients with opioid addiction who have lower tolerances, who have relatively stable lives, or who have been using for shorter lengths of time. Buprenorphine is a better drug than methadone for patients who have been addicted less than one year, because methadone is more difficult to stop, once it’s started, for most patients.

 Buprenorphine has the same side effects as other opioids: constipation, sweating, decreased libido (sex drive), and possible weight gain. Usually, these side effects are much less pronounced in patients taking buprenorphine than in patients taking methadone. Unlike methadone, there is no increased risk for fatal heart rhythms, because it doesn’t affect the QT interval. Most patients do complain about the bad taste of the sublingual tablets.

 Buprenorphine doesn’t seem to cause lasting damage to the body, even if it’s continued indefinitely, though elevated liver function tests can be seen in some patients. Liver function blood tests should be checked periodically in patients who are infected with hepatitis C or B.

Buprenorphine can be fatal if taken by children. It can also be fatal in adolescents or adults not accustomed to opioids. Patients should always store their medication safely out of reach, and with a child proof cap. Since buprenorphine is absorbed through the oral mucosa, if a child puts a tablet in his mouth, some can be absorbed, even if the pill is retrieved fairly quickly. Any handling of a Suboxone pill by a child should be viewed as a possible overdose, and the child must be taken to the hospital emergency room immediately.

Why do people snort buprenorphine? I don’t know. I don’t think there’s any difference in the rate of absorption. If anything, buprenorphine probably crosses the thin mucus membranes of the mouth much more quickly than the thicker skin of the nasal mucosa. I suspect people who snort Suboxone and generic buprenorphine are actually more addicted to the act of snorting, rather than getting any true pharmacologic benefit (“high”) from snorting. That’s on my list of things to ask the Suboxone rep to find out for me. Anyone reading this have ideas about why people snort Suboxone?