In ‘Addiction Treatment with a Dark Side’, Deborah Sontag of the New York Times shared her observations of the clinical use of buprenorphine for treating opioid dependence, warts and all. Readers of the Talk Zone know my bias—that buprenorphine/Suboxone is one of the only effective treatments for opioid dependence, and many patients are best-served by long-term, perhaps life-long treatment with buprenorphine. But I read the article the article with interest because I know that Ms. Sontag ‘did her homework’, including visiting a number of practices, speaking with a number of patients, and reviewing hundreds of studies about buprenorphine and Suboxone over the course of many months.
From my perspective, the article overstates the diversion problem. In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment. I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.
With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion. Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone. The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year. The total number of deaths linked …
The forces of nature appear intent on reversing mankind’s progress toward better health. An example is the ever-increasing resistance of bacteria to antibiotics. A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans. In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.
Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ’modern.’ Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases. There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.
Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts. The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic. As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that …
I’m always impressed by the power of our ‘unconscious.’ I realize that people have a range of models for conceptualizing how our minds work; my own combination of education, analysis, and observation has led to an understanding that ‘works for me.’
My conscious mind works in series, holding one or two thoughts at a time and proceeding in a somewhat-linear fashion. The unconscious, on the other hand, is an amalgam of countless processes that never end, epiphenomena of the constant barrage of sensations, emotions, and memories that are sorted, compared, associated, and recorded.
At least that’s how I see it.
The unconscious is not something that can be figured out, no matter how much insight a person may develop. During treatment for addiction I thought that if I could discover my unconscious motivations for using, my desire to use would cease. I don’t see it that way now. Even after more than a decade of sobriety, I am aware that my unconscious mind remains intertwined with the addictive parts of my personality, forever inseparable.
My unconscious mind protects me from unpleasant emotions. Some insights are deemed, by whatever determines my conscious experience, as too painful. But even when I’m not allowed to have a certain awareness, I can sometimes infer what is going on beneath the surface using the clues evident in my behavior.
For example, I’ve been struggling to write for several weeks now, since my dad’s death. I don’t know for certain what unconscious thought or emotion is getting in …
My dad passed away two days ago, one day after his 89th birthday. It doesn’t feel quite right to post something so personal. But it feels more wrong to write about anything else.
Writing was a source of tension between us in some ways. My perspectives on myself, my parents, and my upbringing have changed over the years, and I tried to share my observations with my dad in several short essays centered around memories from my childhood. The efforts were a mistake. I learned that insight develops in each of us at different rates and in different directions, and my ‘aha’ moments—realizations about how my dad shaped my development— felt to him like criticism. I don’t think he fully realized that I accepted him, loved him, and respected him.
As for my ‘aha moments’, I don’t assume that my realizations and insights are accurate. As my perceptions change over the years, I try to remain open to two alternate explanations for those changes—that with age I’ve learned, through wisdom, to see things more accurately, or that with age my thought process is becoming more rigid and any newfound ‘insight’ is an illusion, a product of that rigidity.
My dad was an intellectual, who read more books about philosophy and theology each year of his adult life than I’ve read in my lifetime. So when our understandings of the world differed, I had to at least consider that my own judgment was off, rather than assume that old age impacted …
I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.
My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin. Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.
I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication. As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap. They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.
But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment. I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges. To be blunt, young people don’t do as well on Suboxone or buprenorphine as their …
A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine. I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest. Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications. If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation. Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’ Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter. I know that buprenorphine saves lives, beyond a doubt. I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats. I notice how quickly people complain about others ‘on buprenorphine’, without taking the …
A late post tonight, since my new exercise program has pushed my blogging back by an hour or so each night. My suspicions about exercise were correct, by the way; it is much easier to suggest exercise to other people than it is to actually exercise. I’ve been at it since the beginning of the year, and I at least feel a bit less hypocritical.
While I’m on the topic… I’ve received many comments over the years from people complaining that they’ve been taking Suboxone or buprenorphine for X many years, and they have no energy, they feel stressed, they have gained weight, they don’t sleep well or they sleep TOO well… and concluding that all of the problems are from Suboxone.
The problems are the result of other things, including things that tend to occur naturally as our lives become less chaotic and more outwardly-secure. The problems I mentioned above, for example, come from inactivity. They come from thinking that we’ve ‘paid our dues’ at the age of 30, and it’s time to coast in life. They come from failing to seek out challenges, and from failing to do our best to tackle those challenges. They come from letting out minds be idle, smoking pot or watching American Idol instead of responding to the naggings sense of boredom that ideally pushes people to join basketball, tennis, or bowling leagues.
Our minds and bodies are capable of SO much. I (honestly) am not a network TV viewer, but I love the contrast of ‘before and after’ scenes …
There have been a number of events over the past couple weeks that have been ‘game changers’ in the efforts by Reckitt Benckiser to hang onto their profitable treatment for opioid dependence, Suboxone. Reckitt Benckiser (RB) had asked the FDA to deny any future generic drugs based on Suboxone tabs because of deaths of several chldren, who might have confused the tabs for candy.
The FDA gave RB’s comments some thought and then discarded them, even stating that the efforts by RB might have been unlawful anticompetetive marketing. The FDA wrote that they were referring their concerns about unlawful marketing to the FTC.
The FDA went on to approve two generic versions of Suboxone, or more properly, buprenorphine/naloxone tablets. It will be interesting to see whether insurers and medicaid agencies go back to covering tabs (generic tabs), or whether they will continue to waste money on the heavily-marketed Suboxone’film.’
Just in case that isn’t enough drama for one week, the FDA announced that they will be holding hearings to determine whether to approve a buprenorphine implant called Probuphine.. I’d love to share details about the product, but at this point I don’t have further information. The manufacturers of Probuphine are hoping that the medication will be used to treat opioid dependence. On the surface, a number of advantages are apparent about such a product; one would expect a lower risk of diversion, for example, and better compliance.
NOT mentioned at this point, is whether the implant could help people who would like to discontinue Suboxone. Many …
A recent exchange with a reader:
I have been on buprenorphine for 5 yrs. Recently my doctor stated that my u/a t looked like I have been ‘loading my meds.’ He said my levels where ‘backwards’ and that would happen if I took just a few doses just before my appt. My doc had me come back in two weeks to go over my next u/a, and again it came back funky. So my doc starts having me take my meds in front of the nurses on a daily basis. Two weeks later with supervised u/a’s, my urine comes back the same. My doc looked perplexed but kind of ignored the results like I was still doing something to mess with the results. I had to come in again for another urine test and it finally came back normal. My numbers were fine after that, and all was good until last week.
I went to my normal monthly check up and the u/a showed NO buprenorphine in my system. My doc looked at me like I am the biggest liar. I am perplexed. I am taking my meds daily. I don’t know what is going on and I need to figure it out soon before my doc kicks me out of the program. What could be wrong with the test, that is says that I have no buprenorphine in my body?
There are several directions we could go with this issue. One aspect is whether it is always fair …
In a recent Google search about Suboxone and pregnancy, one of the top links included the frightening statement that Suboxone and buprenorphine have been linked to SIDS or sudden infant death syndrome, commonly called ‘crib death.’
The statement was from a health forum where a woman wrote about taking Suboxone during pregnancy. She wrote that her child went through opioid withdrawal after delivery, recovered, and then died two months later from SIDS. She then claims that her doctors told her that Suboxone was a possible reason for her child’s death.
I don’t know if the woman’s story is true. If it is, I hope my comments do not cause her pain, and I’m sorry for her loss. But someone should comment on the information, given the number of young women on Suboxone who become pregnant and frantically search the internet for reassurance that their baby will be OK. I know that pregnant women in my practice lose a great deal of sleep because of guilt over taking buprenorphine. I am not a SIDS specialist, obstetrician, or pediatrician, and I do not actively follow the SIDS literature. But I have done some reading to prepare for this post, and I’ll do my best to address the issue.
While the causes of SIDS are not completely understood, a number of factors have been associated with sudden infant death, including maternal age and socioeconomic status (higher rates in infants of poorer, younger mothers), maternal smoking, air pollution, …