Posts Tagged ‘buprenorphine’

Suboxone, the “Miracle” Drug

The patient quoted in the Suboxone success story, printed in this blog over the last few days, obviously has a healthy recovery on buprenorphine, and plans to continue his present recovery program. He goes regularly to Narcotics Anonymous meetings, has a sponsor, works the twelve steps of recovery, and contributes to NA by sponsoring people and doing other service work. He had such a good outcome, because he didn’t neglect the psychological aspect of his recovery, even after Suboxone took away the physical withdrawal symptoms.

For the patients I treat with buprenorphine, the most challenging part is coaxing, coercing, and cajoling patients to get some sort of counseling. Whether they go to an individual counselor, pastoral counselor, or to 12-step meetings doesn’t matter to me. I’d love to be able to send them to local intensive outpatient treatment centers, but as will be discussed later, most of these centers require the patient be off buprenorphine completely, before they can enter treatment, which can create a curious circle of relapse. Fortunately, I know good counselors, knowledgeable about addiction and its treatments, willing to see my buprenorphine patients. They markedly benefit from this individual counseling, though group settings can give patients insights they won’t get any other way.

When buprenorphine was first released, the addiction treatment community and opioid addicts had very high hopes for this medication. Many patients say, “It’s a miracle,” on their second visit, after they‘ve started the medication. Most patients are surprised they don’t feel high, and don’t have any withdrawal symptoms.

However, it’s really not a miracle drug. It’s still an opioid, and though it’s weaker than other opioids, some patients have extreme difficulty when they try to taper off of this medication. One can read postings on internet message boards that describe the difficulty some patients have.

In my own practice, I’ve had some patients who stopped buprenorphine suddenly, and claim they had no opioid withdrawal symptoms. At the other extreme, I’ve had patients who wean to Suboxone one milligram per day and say they get a terrible withdrawal, if they go a day without even this one milligram. I’ve had many patients who gradually cut their dose on their own, until they take the medication every other day, and gradually stop it.

Patients appear to differ widely in their abilities to taper off buprenorphine. Some patients are dismayed to discover it’s just as hard to taper off of Suboxone, and stay off opioids, as it is to taper off methadone and stay off opioids.

If it’s appropriate to consider tapering a patient off of buprenorphine, best results are seen if the taper is done slowly. In the past, I have informed patients who wished to taper completely off buprenorphine that addiction counseling improves outcomes, and reduces relapse rates, but this may not be true.

Information presented at the American Psychiatric Association’s 2010 conference calls that advice into question. In a study of over six hundred prescription opioid addicts, relapse rates were remarkably high when patients were tapered over the course of one month, after two months of stabilization. (2) The addition of fairly intensive addiction counseling didn’t improve relapse rates. In the treatment as usual group, prescription opioid addicts met weekly with their doctors, and after their taper, ninety-three percent had relapsed within four weeks. Even in the group getting doctor visits plus twice- weekly one hour counseling sessions, ninety-four percent relapsed within the first four weeks after buprenorphine was tapered. This was the largest study done so far, specifically on prescription opioid addicts, as opposed to heroin addicts. The overall message from initial results of this study seems to be that adding fairly intense drug counseling doesn’t improve patient outcomes, if the buprenorphine is tapered off within the first three to four months.

Once a patient is on buprenorphine and doing well, he or she often becomes very reluctant to participate in counseling, or even 12-step meetings. Once patients feel physically back to normal, they begin to minimize the severity of their addiction, and don’t think they need any counseling.

Some patients admit they need counseling, but say they can’t afford it. This is a valid excuse, because counseling sessions can cost around a hundred dollars each. Private counselors usually like to see their patients weekly, so that’s an additional four hundred dollars per month that patients need to pay. Even patients with insurance are allowed only a limited number of sessions. Those without insurance have great difficulty affording counselor fees on top of all the other expenses, like doctors’ visits, drug screens, and medication. Patients have fewer valid excuses for not participating in Narcotics Anonymous or Alcoholics Anonymous, since they’re free, and located in nearly every city or town. I have more patients who will go to these meetings.

1. Amass L, Bickel WK, “A preliminary investigation of outcome following gradual or rapid buprenorphine detoxification” Journal of Addictive Disease, 1994; 13:33-45.
2. Weiss RD, The American Psychiatric Association 2010 Annual Meeting: Symposium 36, presentation 4. Information from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study, May 23, 2010, New Orleans, LA.

Suboxone Patient’s Success Story, continued

XYZ:My brother had enough faith in me that it was worth the risk of starting this business [that he has now] together. I spent hours setting up a company in a ten foot by twenty foot room above my house. My wife and I started on EBay, making and selling [his product], and slowly grew it to the point that, three years later, I’m going to do over two million dollars in sales this year, I’ve got [large company] as a client, I’ve got [large company] as a client, I’m doing stuff locally, in the community now, and can actually give things back to the community.
JB: And you employ people in recovery?
XYZ: Oh, yeah. I employ other addicts I know I can trust. I’ve helped some people out who have been very, very successful and have stayed clean, and I’ve helped some people out who came and went, but at the same time, I gave them a chance. You can only do so much for somebody. They have to kind of want to do it themselves too, right?
JB: Have you ever had any bad experiences in the rooms of Narcotics Anonymous, as far as being on Suboxone, or do you just not talk to anybody about it?
XYZ: To be honest, I don’t broadcast it, obviously, and the only other people I would talk to about it would be somebody else who was an opioid addict, who was struggling, who was in utter misery. The whole withdrawal process…not only does it take a little while, but all that depression, the body [feels bad]. So I’ve shared with those I’ve known fairly well. I share my experience with them. I won’t necessarily tell people I don’t know well that I’m taking buprenorphine, but I will let them know about the medication. Even though the information is on the internet, a lot of it is contradictory.
It’s been great [speaking of Suboxone] for someone like me, who’s been able to put a life back together in recovery. I’d tell anybody, who’s even considering taking Suboxone, if they’re a true opioid pill addict, (I don’t know about heroin, I haven’t been there), once you get to the right level [meaning dose], it took away all of that withdrawal. And if you combine it with going to meetings, you’ll fix your head at the same time. Really. I didn’t have a job, unemployable, my family was…for a white collar guy, I was about as low as I could go, without being on the street.
Fortunately I came from a family that probably wouldn’t let that happen, at that point, but who knows, down the road… I had gotten to my low. And that’s about it, that’s about as much as I could have taken.
It [Suboxone] truly and honestly gave me my entire life back, because it took that away.
JB: What do you say to treatment centers that say, if you’re still taking methadone or Suboxone, you’re not in “real” recovery? What would you say to those people?
XYZ: To me, I look at taking Suboxone like I look at taking high blood pressure medicine, OK? It’s not mind altering, it’s not giving me a buzz, it’s not making…it’s simply fixing something I broke in my body, by abusing the hell out of it, by taking all those pain pills.
I know it’s hard for an average person, who thinks about addicts, “You did it to yourself, too bad, you shouldn’t have done that in the first place,” to be open minded. But you would think the treatment centers, by now, have seen enough damage that people have done to themselves to say, “Here’s something that we have proof that works…..”
I function normally. I get up early in the morning. I have a relationship with my wife now, after all of this, and she trusts me again. Financially, I’ve fixed all my problems, and have gotten better. I have a relationship with my kids. My wife and I were talking about it the other day. If I had to do it all over again, would I do it the way I did it? And the answer is, absolutely yes. As much as it sucked and as bad as it was, I would have still been a nine to five drone out there in corporate America, and never had the chance to do what I do. I go to work…this is dressy for me [indicating that he’s dressed in shorts and a tee shirt]
JB: So life is better now than it was before the addiction?
XYZ: It really is. Tenfold! I’m home for my kids. I wouldn’t have had the courage to have left a hundred thousand dollar a year job to start up a tee-shirt business. I had to do something. Fortunately, I was feeling good enough because of it [Suboxone], to work really hard at it, like I would have if I started it as a kid. At forty years old, to go out and do something like that…
JB: Like a second career.
XYZ: It’s almost like two lives for me. And if you’re happy, nothing else matters. I would have been a miserable, full time manager, out there working for other people and reaping the benefits for them and getting my little paycheck every week and traveling, and not seeing my wife and kids, and not living as well as I do now.
I joke, and say that I work part time now, because when I don’t want to work, I don’t have to work. And when I want to work, I do work. And there are weeks that I do a lot. But then, on Saturday, we’re going to the beach. I rented a beach house Monday through Saturday, with just me and my wife and our two kids. I can spend all my time with them. I could never have taken a vacation with them like that before.
JB: Do you have anything you’d like to tell the people who make drug addiction treatment policy decisions in this nation? Anything you want them to know?
XYZ: I think it’s a really good thing they increased the amount of patients you [meaning doctors prescribing Suboxone] can take on. I’d tell the people who make the laws to find out from the doctors…how did you come up with the one hundred patient limit? What should that number be? And get it to that number, so it could help more people. And if there’s a way to get it cheaper, because the average person can’t afford it.
The main thing I’d tell them is I know it works. I’m pretty proud of what I’ve achieved. And I wouldn’t have been able to do that, had I not had the help of Suboxone. It took me a little while to get over thinking it was a crutch. But at this point, knowing that I’ve got everybody in my corner, they’re understanding what’s going on…it’s a non-issue. It’s like I said, it’s like getting up and taking a high blood pressure medicine.