Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor.  This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year.  But instead of cheering the good news, some doctors used the occasion to rant about diversion.  Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications.  Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low.  Other opioid addicts use buprenorphine in attempts to detox off opioid agonists.  Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal.  But the statistics don’t keep addicts from trying, over and over again.  After all, the belief in personal power over substances is part of the addictive mindset.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important.  While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream.  Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream.

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths.  To you doctors:  Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about?  The same number of people die from lightning strikes!  Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths.  FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing.  Getting insurers to treat AIDS was the right thing.  But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids.  When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician.  Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises.  But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine.  In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications.  Such sales are against the law, just as selling Oxycontin or Vicodin is a crime.  But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’.  If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue.  Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine:  With all due respect, you must be doing something wrong.  I have 100 patients right now who tell me, at each visit, that I saved their lives.  I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say!  But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors:  How can you not be excited by a medication that has saved so many of your patients?  If you don’t have such patients, I suggest you give some thought to what you’re doing wrong!  In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug.  I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist.  Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?!  And if the same person injects buprenorphine, the withdrawal will be even more severe!  On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal.  But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine.  This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly.  But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin.

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it.  That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

An Addict's Story

I received the following email last week.  I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients.  As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic.  In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication).  At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me half-a@@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer;  I’ll be adding my thoughts soon!
 

The Buprenorphine Ceiling Effect

This post is from a couple years ago;  I think it is important for people to have a basic understanding of how buprenorphine removes opioid cravings, so I’m republishing the post.
Note that naloxone has NOTHING to do with the effects of Suboxone.
In this video I explain why the ceiling effect is so important to the effects of buprenorphine for treating opiate dependence.

Weezer Ex-Bassist Dies, Suspected Overdose

Written by Daniel Gordon at ThirdAge.com:
Former Weezer bassist Mikey Welsh was found dead in a Chicago hotel room Saturday afternoon, the Chicago Tribune reports.
Raffaello Hotel staff reportedly found the 40-year-old ex-musician on the floor of his room around 1 p.m. Saturday. The Chicago Tribune reported that narcotics are the suspected cause of death.
Chicago Police News Affairs Officer Laura Kubiak told reporters that police are currently conducting a death investigation. An autopsy was scheduled for Sunday, according to the Tribune.

Weezer Former Bassist Mikey Welsh
Weezer Former Bassist Mikey Welsh

Welsh performed with Weezer from 1998-2001. According to Weezer’s Website, he left the band after having a nervous breakdown and reinvented himself as a painter.
In 2002, shortly after leaving Weezer, he told the MetroWest Daily News that he felt the need to move on from music, adding that he was much happier as a painter.
“Music is still an important part of my life, but I really have no desire to actually play it,” he told the Daily News.
A tribute to Welsh on the band’s Website says, “It saddens me and the guys in Weezer so much to say that our beautiful, creative, hilarious and sweet friend Mikey Welsh has passed away at the very young age of 40. A unique talent, a deeply loving friend and father, and a great artist is gone, but we will never forget him. His chapter in the Weezer story (’98 – ’01)
was vital, essential, wild, and amazing.”
Current Weezer bassist Scott Shriner posted a note on his Twitter account saying, “Really bummed about Mikey. My heart goes out to his family and friends. Such a talent… he made a special mark on the world with his art.”
Weezer is playing at the Chicago Riot Fest Sunday, a show Welsh was expected to attend.
The post on Weezer’s site ends by saying, “Mikey was planning on attending this show and we were looking forward to seeing him again. As sad as it is to think about, we know Mikey would never want the rock stopped on his account – quite the contrary in fact. While we wont see him, we know he will be there rocking out with us!”

The REAL Future of Partial Agonist Treatment— Pharma are you Listening?

I just wrote a note to a friend who works in the molecular sciences– she has been studying opioid receptors since the early 1980’s, when things were just getting started on a molecular level.  I’m keeping her name to myself, but I’ll share a few thoughts about what is needed to advance the treatement of opioid dependence– and make a few million dollars along the way (are you listening, RB?)
Hi ——,
(private chit chat that would bore everyone)
Anyway, today I realized what is needed in order to take partial agonist treatment of opioid dependence to the next level.
The problem with buprenorphine is that the ‘ceiling effect’ occurs at a relatively high tolerance level, approximately equal to 40 mg of methadone.  That causes at least two problems.  First, going off Suboxone is a lot of work, as the person still has a great deal of withdrawal to go through.  That may be a good thing early in the process, as it may help keep people on Suboxone, but after a year or so, when people want to try going off the medication, it is a major barrier that opens the floodgates to those old memories of using, etched in the emotions associated with withdrawal.
The second problem with the high ceiling/tolerance level is that surgery is a hassle.  People needing surgery need HIGH amounts of oxycodone to get any analgesia—I usually give 15-30 mg every 4 hours.  Pharmacists shudder to release those doses, and some surgeons and anesthesiologists balk.
The horizontal part of the dose/response curve is the essential part of buprenorphine;  that is what tricks the brain into ‘thinking’ that nothing is wearing off, and in that way eliminating cravings.  But that flat dose/response relationship could occur at lower tolerance levels and still work the same way.
Since I’m wishing for the moon, a series of molecules with progressively lower ceiling levels would be ideal, with the last molecule in the series being Naltrexone.  Although actually, naltrexone doesn’t work—it has NO mu agonism, so there is no tricking of the brain, and no reduction of cravings.  We would want something close to naltrexone, but with a tiny bit of opioid activity that does not vary with dose.
A shorter half-life would also be helpful.  Preparing for surgery requires weeks to get the buprenorphine out of the system.  Of course a shorter half-life means it is easier to get around buprenorphine by people who want to play with agonists, so again, these new molecules would be intended as ‘step down’ meds from early-stage buprenorphine treatment.
Do we know enough about molecular actions at the mu receptor to design molecules with these properties?  Or are we still at the point of making somewhat random changes and assaying the result?  Do you know of any labs doing this type of work?
I figured you’re the person to ask!
Thanks ——–
Jeff

Winehouse

By now, everyone who knows of Amy Winehouse is aware of her tragic death. I’ve always liked her music. So much music these days has been digitally processed and reprocessed, and assaults the senses– I’m thinking of Lady Gaga, for example, whose ‘Edge of Glory’ would be pretty boring in concert if you took away the flashing lights. But Amy Winehouse’s music had an earthy, sultry style that communicated her emotions in a way that words can’t… which is why we even listen to music, at least in my case.
Every now and then I’ll meet a person coming in for help who has an addiction that seems to be almost part of a death wish, as if the person is taking agent after agent with one goal: to eliminate any sense of consciousness or emotion. It is as if life is too painful for the person to tolerate, and the person won’t stop until the brain is finally quiet. I sometimes think that those people would club themselves in the head until they are unconsciousness, if psychotropic drugs were not available! I had that same thought when I read that Amy Winehouse had purchased a grab-bag of drugs including heroin, cocaine, and ketamine in the days before her death.
When I set out to right tonight’s blog I planned on including her picture. But when I went on Google images and searched under her name, I found a number of ‘before and after’ images that demonstrated the horrible toll that drug and alcohol dependence took on her health and physical appearance. The images were so bad that I felt very sad for her and for her family, and I couldn’t bring myself to post them here– as doing so would be ‘piling on’ a horrible tragedy.
I searched around for a suitable tribute, and I think I found one. Her personal, internal battle is apparent in the video, and I’m sorry that she wasn’t able to find a way to tolerate life.
Enjoy the music that she left behind:

Unintended Consequences

I saw a patient from up north earlier today, and we tallked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula.  From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between.  Seems as if it has been that way for a long time now.  And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.  I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation.  And a troubling comment pops up more and more during my discussions with people actively addicted to opioids:  “Now that O-C’s are abuse-proof, we gotta’ use heroin.”
I’ve mentioned the requirement for REMS– Risk Evaluation and Mitigation Strategies– for opioids announced by the FDA about a year ago.  The requirement for REMS on a class-wide basis– a novel use of the FDA’s regulatory powers– places pressure on the manufacturers of opioids to find solutions to the epidemic of opioid dependence. One result has been the development of medications with lower abuse potential, such as the new formulation of oxycontin, which when crushed (a feat by itself) yields a gooey mess that clogs nasal passages and needles if taken by those routes.  But the law of unintended consequences applies to this domain, as one would expect, given the tangled mess of political, societal, and economic forces involved in the epidemic of opioid dependence.  There are many addicts out there, each subject to severe withdrawal in the absence of their daily dose of oxycodone;  what would a reasonable person expect them to do, knowing the intensity of their desire for opioids– and their fear of withdrawal?  Are they just going to stop?
My last patient explained it just fine… and he isn’t even a D.C. social worker.   “Oxycontin or heroin–  it really doesn’t make no difference.  It’s all the same thing– one just isn’t around anymore.”
Unfortunately, he wasn’t referring to heroin.
I do have a question– a genuine question, not a facetious one.  At least in Wisconsin, diverted Oxycontin is often used nasally, and heroin used by needle.  I’m sure that part of  the reason for that different route of use is because heroin has tended (at least until now) to be used later in the course of addiction, and there is a progression to parenteral use of substances over time, as addicts seek more efficient means of using.  My question– are there other reasons that heroin users favor intravenous over nasal use?  To frame the question a bit differently– it appears that the prevention efforts aimed at Oxycontin have caused an increase in the use of heroin.  Did they cause in increase in intravenous drug use as well?

Withdrawal in newborns: Lay off the guilt trip!!

I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction.  I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother.  My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response.  Read on:

There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction.

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about that discomfort—at least not from the baby’s perspective.  I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal.  Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s – babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose.

My points are twofold, and are not intended to encourage more births of physiologically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right.

Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

Sharing Suboxone: W.W.Y.D?

Here is a ‘what would you do’ question: Today I saw a new patient who came in asking to start Suboxone.  She has a significant addiction to heroin– I don’t know heroin doses very well, but she said she uses ‘four bags per day’.  Incidentally, if anyone knows the conversion of that dose to the daily amount of oxycodone, please post in the comments and let me know.  She was in moderate withdrawal, and had not used for over 24 hours– which usually would suggest appropriateness for induction of Suboxone at least from a ‘precipitated withdrawal’ standpoint.  On the other hand, if four bags of heroin is a ridiculously high dose, her tolerance may have been so high that even after 24 hours, withdrawal would be precipitated.
When I have people in this situation I usually suggest going forward;  yes, there is a risk of getting sick… but the person is already pretty sick and can’t get a whole lot sicker.  But more important, a person using those very high doses is literally taking her life in her hands every time she shoots up, and it is very unlikely that she would be able to last another 24 hours without using.  So I typically recommend starting Suboxone and if withdrawal is precipitated, sticking with the Suboxone, dosing each morning as usual–  that way we know that the withdrawal will end within 24-48 hours and things will soon be stabilized.  I do NOT use a ‘higher induction dose’ for people with higher tolerance;  I know that many doctors DO use higher induction doses, but doing so is more a sign of superficial thinking than consistent with an understanding of what happens at the receptor level.  Even only one tablet of Suboxone contains a ‘supra-maximal’ dose of buprenorphine– 8000 micrograms of buprenorphine is sufficient to bind up all of a person’s opiate receptors many times over!
But none of this has anything to do with my question about what you would do.  As I was talking to this person about her use, and about how much Suboxone I was going to prescribe, she argued for more– saying that she had tried Suboxone, and two pills ‘just didn’t do it for her’.  This bothered me a bit;  people who have ‘played’ with Suboxone on the street tend to do poorly in treatment, as Suboxone becomes ‘just another opiate’, rather than a powerful tool that can be used to change a person’s attitudes about using.  As I told her, getting clean takes more than just ‘Suboxone’!  Yes, Suboxone has some unique properties… but if a person comes in thinking that simply taking a pill is going to cure their addiction, they are sorely mistaken.  Understand that opiate dependence is a HORRIBLE illness;  the odds for recovery before Suboxone were very low, and so it is a grave mistake to get cocky about recovering even WITH Suboxone.  And yet so many people, young people in particular, get cocky about their chances… today another patient talked about his plans to taper off Suboxone after a few months, and when I told him that the majority of people who do that simply relapse he said ‘I don’t plan to relapse!’ — as if anybody does!  All addicts have that feeling of being ‘special’;  instead of seeing the experience of others and learning from them, and avoiding misery, addicts believe that THEY are DIFFERENT– they are ‘more special’ than those OTHER people.  But they always find– eventually–  that they aren’t any more ‘special’;  they find that they have the same problems as everyone else.
But this isn’t what I wanted to talk about either.  As this new patient tried to talk me into prescribing a higher dose of Suboxone she said that she got the Suboxone from a guy she knows… a guy who is one of my patients!  Moreover she said that ‘he takes ‘H’ and doesn’t even need the Suboxone;  he just uses it to avoid withdrawal when he doesn’t have ‘H’.’   When she noticed the anger on my face she clammed up, and wouldn’t tell me the name of her friend.
I do not like opiate addiction;  I consider it to be a horrible affliction that takes a toll on the lives of young people greater than any other disease I can think of.  And I have no tolerance for the people who work in the trade of dealing drugs.  I forgive some pretty bad behavior when a person is driven by the obsession for opiates;  I make no moral judgment about those who prostitute themselves or those who steal from grandma.  But for the people who contribute to the addiction of others– who profit from spreading this horrible condition– I have no tolerance at all.  If I knew the name of this person who is giving the Suboxone that I prescribe for him to others, I would do everything in my legal power to have him busted.  I would (and as I think about it I think I will do this) contact the legal affairs dept of the APA– the American Psychiatric Association– and see if there is any protection for breaking confidentiality when a person is dealing.  There is certainly the ability– and the requirement– to break confidentiality if a person is going to engage in something that threatens the well-being of others;  I could certainly argue that sharing Suboxone is ultimately very dangerous for the people who take it.
But I don’t know who the person is– at least not yet.  What would you do about the woman presenting for treatment?  Should I go ahead and start her on Suboxone, even though she is keeping a secret from me, and protecting a person who is taking advantage of my attempts to help him?  Or would you tell her that now that she ‘let the cat out of the bag’, she had to tell me who the person is, before you would treat her?  I realize that the reflex answer is to ‘avoid snitching’, and I have those feelings deep inside as well, left over from my days as a pot-smoking teenager…  but this is a fatal illness, and innocent people die.  I see no excuse for choosing the wrong side of THIS issue;  for keeping secrets that protect those who spread this sh#@ around.
I ended up taking the woman as a patient despite her secret.  But I have some suspicions about the identity of the person she mentioned, and I will be checking urines more frequently for then next couple months.  If anyone reading this is sharing Suboxone with others, please realize that you are playing with fire;  we have had two deaths in Milwaukee in the past month from people taking Suboxone that was not prescribed for them (and mixing it with other substances).  When I worked as a psychiatrist in the womens’ state prison I had a couple patients serving close to ten years each for sharing narcotics that killed the person who took them.  Even if you think you are ‘helping’ someone, you are only preventing the person from getting treatment and increasing the likelihood that they will die from their addiction.  That kind of ‘help’  is ALWAYS the wrong thing to do.
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