Questions, Excuses, Krokodil

I’ve been in more of a chatty mood lately, as regular readers have likely noticed.  I find it interesting that weeks will pass when I have little or nothing to say… and at other times, I have all sorts of random thoughts to discuss.
Excuses first– I’ve been tinkering with ads for the past few days, and I apologize to those of you who tried to read a post while I was activating and deactivating Wordpress plug-ins.  After experimenting with different colors I’ve decided that basic grayscale is the best.  For those who don’t blog, ‘plug-ins’ are small, add-on programs that add a range of functions to a blog.  There are literally thousands of them out there;  some free, some for a small charge.  A couple dozen plug-ins are designed to add the code for Google Adsense to a blog, with a range of features including adding ads randomly to old posts, etc.  I’ve found that some work better than others; a couple of them really messed up the other blog functions, causing the top banner to appear at the bottom and vice versa.  I THINK I have things working OK now;  if you are having trouble, please send me an email (drj at Suboxonetalkzone dot com) and tell me the nature of the problen, and the browser and operating system you are using.  Thanks!
Another neat feature of WordPress is that you can review a number of different statistics for a blog, including the keyword that each viewer searched for before arriving at the site.  I see certain questions posted over and over;  I presume those questions are about things that come up often in the lives of people on Suboxone.  I used to do ‘questions and answers’ on a regular basis;  I’ll try to get back to those now and then, using the most popular queries as starting points.
Yesterday, several people searched for phrases related to buprenorphine and workplace drug testing.  I’ve received a number of questions by email about that same topic.  People wonder if Suboxone (buprenorphine) shows up in drug testing, and whether they should disclose that they take the medication before the test.  This is a very tough issue.  I believe that people who take Suboxone properly are NOT impaired by the medication.  There was an article from the Mayo Clinic Proceedings recently that claimed that people ARE impaired by Suboxone, and therefore certain occupations– notably physicians and nurses– should not work at those jobs, if taking Suboxone.
There were at least two things that made their conclusions… ridiculous.  First, the authors wrote that doctors’ work is so uniquely difficult, that it challenges gray matter so much more heavily than other occupations, that doctors should avoid buprenorphine treatment.  To that, I say that a recovering anesthesiologist taking Suboxone is much safer than a recovering anesthesiologist, holding fentanyl in his/her hand, not on Suboxone!  Even if you take away the risk that the non-Suboxone doctor is using, one must consider the effects of cravings on vigilance.  I’ll take the doc on Suboxone, who is placing all of his attention on ME, over the guy reciting the serenity prayer to himself and pondering the decision over what can be ‘changed’ and what can’t!  Of course, that’s just me…
I was also impressed by the ego of the writers, who think that a pediatrician or radiologist has greater need for an ‘unmedicated brain’ than a jet pilot, or a welder ten stories up, or a long-haul trucker, or a nuclear physicist. Yes– doctor jobs are ‘uniquely’ difficult!  (add sarcasm here).
The conclusions were deeply flawed in other ways.  To determine the effects of Suboxone on performance, they looked at studies that gave people opioid agonists or buprenorphine, and concluded that the effects were similar.  I mean really– people who are not on Suboxone regularly, without a tolerance to opioids, taking buprenorphine?  OF COURSE the people were messed up!  Suboxone has potent opioid effects;  there is no argument to that point.  But the unique ceiling effects of buprenorphine allow the subjective effects to go away, as tolerance is established.  That’s the whole point of Suboxone treatment!
I’m off on a tangent, right?  Back  to drug testing…  I do not think that people on Suboxone, who take it properly, are impaired in any way.  So I do not believe that people should have to disclose their treatment, and their history, to their potential employers.  But my opinions on the matter are irrelevant, unless the new/old President-elect appoints me as Attorney General… and odds are not in favor of that happening.
I can say that I’ve received 20-30 emails over the years, asking about employee drug testing.  In each case I asked the writer to follow-up and let me know what happened.  Some ended up disclosing that they were on Suboxone, and most did not.  To date, nobody has written back to say that they were denied the job over the issue.  I therefore conclude that most employers are ignoring buprenorphine, at least at this point.  That’s the best answer I have;  I can’t recommend any specific course of action.
Finally… today I came across an old post on my forum about a drug that was sweeping across Russia last year, called Krokodil.  The drug apparently is made from over-the-counter codeine tablets, in a process that creates a cheap concoction of opioids in a toxic sludge.  Users of the drug describe withdrawal more severe than opioid withdrawal, that includes seizures.  And within days of starting a habit, users slough off large sections of skin and other tissue from their arms, legs, torso– even from the face.  Not for the faint of heart— if you search the name of the drug under Google Images, you will find horrifying photographs of the damage inflicted on people addicted to the substance.
If anyone really thinks that drug addiction is a ‘choice,’ please tell me what, exactly, those tragic people were thinking.

Urine drug testing for buprenorphine (in Suboxone)

I will introduce this topic by typing my response to a reader who asked whether buprenorphine, the active ingredient in Suboxone, shows up in urine drug tests.  More specifically he asked whether companies have the ability to test for buprenorphine.  I will end the post with a question… so please stick around to the end!

Suboxone drug test
Typical 10-panel urine dipstick test

There are tests out there—multi-panel dipstick tests– that react ‘positive’ to Suboxone in the opiate panel.  Or at least there used to be;  I used to see that reaction with a brand  of tests I no longer remember, that I used several years ago.  For the past couple years, every dipstick brand that I have purchased has responded ‘negative’ to buprenorphine (or naloxone for that matter) as an ‘opiate,’ and positive in the ‘buprenorphine’ column (i.e. so I know that the urine truly contained buprenorphine).  I pay more for dipstick tests that have a separate panel for buprenorphine, but yes, that test is available if a company wants it.  From what I have heard from owners of companies or from people privy to the inner workings of companies, some businesses will do a dipstick first, and then send only positive samples to a lab for more formal testing in case a firing is challenged in court.  They do the dipstick first because it is MUCH cheaper-  $5 for a dipstick test, and several hundred for a laboratory test for several substances.  It costs more for each test at the lab, so companies will only have the lab test for the substance of concern.
I assume that it comes down to the attitude of the company, but there may be issues that I am not aware of.  I assume that some HR folks know what bupe is, and deliberately choose not to test for it, believing that it is a medication in most cases and not a drug of abuse.  I’m sure there is a company somewhere that tests for bupe to catch any sign of even ‘prior’ addiction, but that has not been the experience of the people who have written to me.  I have not heard from anyone who tested positive for buprenorphine in a random test—but I will put the question on my blog and see what comes up!
So there is my question:  has anyone tested positive for buprenorphine in the workplace?  Has anyone tested negative who takes buprenorphine? Please share your responses in the comment section below, so that I will have more than guesses for people who write.  My attitude, for what it is worth, is that your medication list is your own business, providing that the medication does not influence your ability to perform your job.  But I realize that the answer to the question can be complicated.  For example, I was first treated for opiate dependence in 1993, and was completely ‘clean and sober’ for many years, active in 12-step Recovery and regularly attending meetings.  Every two years I received a re-appointment packet at the hospital where I worked, and one question was ‘Do you have a chronic illness that affects your ability to care for patients?’  I knew what the question was getting at— but to my way of thinking, as a person who had been clean for several years and who was never planning on using again, the correct answer was clearly ‘no, I had no illness that affected my care of patients.’   But when I relapsed in the year 2000 the hospital made much of my answers to that question, reporting to the Board that among my other (much more significant) transgressions, I lied on my re-appointment packets.  I was going to defend myself by saying ‘it depends on what the meaning of ‘is’ is…’  but someone else used that excuse before I could use it!!
The problem people face with workplace drug testing– at least something that would be considered a problem for those sympathetic to people on buprenorphine– is that people are often asked to provide a list of the medications they are taking BEFORE the test.  If not for that question, they could go take the test and explain themselves in the event of a positive result.  But if asked about medications beforehand, the worker must decide whether to disclose a history of addiction to an employer who may be overly judgmental, or keep the medication use private and risk being accused of lying.
To those who are going to write that ‘taking buprenorphine is impairing a person and therefore the person must put the info out there,’ I will say in advance that my patients on buprenorphine, who take the medication properly, are NOT impaired by any definition of the word.  They are completely tolerant to the mu receptor effects and are getting no ‘opiate effect’ from the medication.  I will also point out the double standard applied to addiction.  A person with a history of epilepsy is at risk for losing consciousness while operating a crane from a seizure.  A person with diabetes is at risk for the same from a hypoglycemic reaction.  Someone with heart diseast could drop dead of a lethal arrhythmia while driving a school bus filled with children.  Should opiate addicts who are doing the ‘right thing’ and keeping their addiction in remission be forever identified as ‘addicts’ to employers?
As always, thanks for your comments;  please also be sure to join the forum if you have not already.  You will note that when leaving a comment, it will take a day or so to get read and approved;  I do that because there are people who have nothing better to do, apparently, than respond that I am ‘a little bitch’ or call me some other name– for reasons that are not always entirely clear!   When I read such comments I always get a mental image of Mr T. saying ‘I pity the fool!’  (then I think of the scene in Pee Wee Herman’s Big Adventure where Mr. T. says ‘I pity the fool… who doesn’t eat my cereal!)  I guess you really have to be there.