This morning, as I read the latest stories about opioid overdose deaths, I was struck by a common thread in most of the tragic stories.  One report after another had phrases like ‘she was in and out of treatment for years’ or ‘he died tragically one month after leaving treatment.’

I often wonder, if we treated opioid dependence as if we were treating any other fatal illness, would the death rate be lower?  What practice measures would result from such an approach?

First, we would remove the veil of low-expectation that keeps us from realizing the ineffectiveness of ‘residential treatment.’  Once the low expectations are gone, huge questions would come to light.  Why does something so ineffective continue to be seen as the gold standard for treating a potentially fatal illness?

We know that opioid dependence is a chronic condition, marked by relapse.  What should be our measure of ‘success,’ when treating opioid dependence?  Is the treatment in a given individual a success, if that person dies within a year?  Within 5 years?  Does cost matter?  Should we expect better results for $50,000 then we would for, say, $2,000?

Expectations for good results with addiction treatment have been lowered over the years by the absence of other options, the assumption, conscious or unconscious, that addiction is more of a choice than a disease, and by an indifference to the loss of people who often turn friends, family, and society against them.  Instead of seeing a loved one destroyed by illness, people see those with addictions as foolish people, hurting themselves.  By the time death by overdose occurs, those close to an addicted person see death as inevitable; even as a blessed relief in some cases.

For decades, the public perception of residential treatment has benefitted from the fact that nothing better was available.  ‘Send him to treatment’ has become a phrase uttered without thinking; a suggestion that implies a great deal, yet offers almost nothing.  Perceptions of such treatments have also benefitted from abdicating responsibility for their failures.  When patient after patient does poorly, those providing such …

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.

Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.

I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.

In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even …

I received the following question earlier today:

Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.

My thoughts:

My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!

The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.

It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, …