Regular readers of my blog know that I believe buprenorphine is the most important development for treating addiction during my lifetime. At the same time, my own recovery from opioid dependence began over 20 years ago, long before the use of buprenorphine. I am grateful for the change in my perspective that occurred one desperate afternoon, when I first recognized the uselessness of ‘will power’ for stopping opioids. I was one of the lucky addicts who experienced a ‘spiritual awakening’— the realization that I could not recover through my own power, no matter my education or motivation.
I’ve searched, since then, for a scientific explanation of how acceptance of powerlessness and belief in a higher power removed, almost instantly, an obsession that I couldn’t control before that moment. I recognized the preciousness of my recovery as friends from treatment lost their sobriety. And I learned, at one point, that success in ‘traditional recovery’ requires lifelong attachment to meetings and step work.
Ten years later I was excited by the power of buprenorphine to induce remission of the same obsession. As patients on buprenorphine regained meaningful lives at a pace similar to those who practice traditional recovery, I realized that recovery from addiction and freedom from ‘character defects’ can stem from changes in thought, or from changes in neurochemistry. I realized that one approach isn’t more ‘natural’ than the other, and that both methods require lifelong efforts to prevent relapse to addictive behaviors. I wrote the following, several years ago, to explain what I was seeing.
Recovery in the era of buprenorphine
Most opioid addicts are familiar with Suboxone, a medication that erases cravings for opioids, and when used properly creates a state of remission from active addiction. My initial thoughts about Suboxone were influenced by my own experiences as an addict in traditional recovery. But that opinion has changed over the years, because of what I have seen and heard while treating over 700 patients with buprenorphine in my clinical practice.
Suboxone has opened a new frontier of treatment for opioid addiction, but arguments over the use of Suboxone split …
With all the recent attention over the epidemic of opioid dependence, why do some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products? The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.
The shortage is caused by a number of factors. All doctors train in medical schools, which are primarily located in larger cities. So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts. As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views. Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.
Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine. The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor. But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause. Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge. But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day. The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a …
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 to buprenorphine over the past ten years is about equal to the number of people who die from acetaminophen– EACH year.
Diversion of buprenorphine is a complex issue. Words like ‘diversion’ and ‘overdose’ are loaded with so much emotion that one word seems to tell the whole story. A Google search of Suboxone brings up news reports such as ‘Suboxone found at overdose scene’, or ‘man arrested with cocaine, heroin, and three Suboxone tablets.’ The stories create an ugly image, with buprenorphine/naloxone as one more drug of abuse, found at ‘an increasing rate’, according to other headlines. But a superficial look …
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 used to kill otherwise-healthy people. We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools. Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.
Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness. I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!) Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected …
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 the way, but I’m aware that something has changed. The ideas that arise as potential topics seem unworthy of my attention and uninteresting to readers. I sit down to type, but the words don’t come.
I can guess what might be going on…. maybe on some level I’m angry that he isn’t reading my posts anymore. Maybe I wrote out of efforts to impress him, and now I have nobody to impress. Maybe I’m just hurt or sad at the loss, and the small child in me is refusing to cooperate. It could be any or all of those things, or …
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 older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences. Maybe they haven’t suffered enough consequences. But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.
I always consider each new patient’s history of ‘consequences’. I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with …
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 time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve. For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better. In some cases doctors do the very best they can (or that anybody could do, yet their patients struggle to maintain sobriety. Doctors may be tempted to abandon the problem patients altogether, to avoid being seen …
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 to believe the results of drug tests over the word of our patients. I understand the reasons for testing, but I think that doctors sometimes lose the forest (the patient’s addiction problem) on account of the trees (quantitative testing). This patient has been on buprenorphine for five years; I would hope to have sufficient trust established with patients after that period of time, such that the lab results wouldn’t be seen as the only answer. There can be problems with any laboratory test. Drug tests are one tool– not the ultimate arbiter of truth.
Most people metabolize buprenorphine a certain way, …
Today I read about the stereotactic brain surgery used to treat opioid dependence in China over the past ten years. The procedure is relatively straightforward; the patient’s skull is clamped in place while small holes are drilled, guided by computerized, 3-dimensional maps of the brain. Probes are inserted deeply through brain tissue to the nucleus accumbens, where electric current destroys varying amounts of brain tissue. Patients are awake and talking during the procedure, so that surgeons know if the probes are too close to brain regions that control speech or other functions.
A large number of ablations for the treatment of addiction were performed in China about ten years ago. The rapid growth in popularity of the technique, before full knowledge of the risks and long-term effects, led to a ban on the procedures by the Chinese Ministry of Health in 2004. Still, ablations were performed as part of research studies, with over 1000 people treated by ablation since 2004.
The scientific community outside of China overwhelmingly condemns the technique, and medical journals are pressured to withhold publication of ablation studies. Human rights advocates claim that such experiments are performed on people who are not fully aware of the risks, or who are pressured to participate in the studies to avoid harsh punishments for drug offenses. The veracity of the results from ablation studies has also been challenged. Ablation treatment of opioid dependence is in the news lately because of a recent paper describing the five-year follow-up of opioid addicts treated by the procedure.
Neuroscientists distinguish between DBS (deep brain stimulation by electric current) vs. procedures where brain tissue is destroyed. I’m surprised by the intensity of the distinction, given the similarity of the procedures. In both cases long probes are passed through brain tissue, risking hemorrhage, stroke, or seizures. For DBS, wires are left behind and connected to power-packs that release different patterns of electrical current. In the ablation studies, small areas of tissue at the end of the probes are destroyed, and the probes removed. If there is a …
People who read this blog are aware of the shortage of physicians who can prescribe buprenorphine to treat people addicted to pain pills, even as an epidemic of addiction to heroin and pain pills devastates the heartland of the country. In order to prescribe buprenorphine, physicians take a short course and obtain special certification. To obtain certification, physicians must promise to treat no more than 30 patients at one time, a number that can be increased to 100 patients after one year.
If you only have a few minutes, please take the time to go to the White House web site and add you name to a petition to allow individual doctors to treat more than 100 patients using buprenorphine. The whole process is fast and easy, and only requires your name and email address through this link: http://wh.gov/QR6K
If you have more time, need convincing, or just like hearing a 52-y-o rage against the machine, continue reading my thoughts about limiting treatment for this one health condition.
The reason for the patient cap, according to cap proponents, is to prevent pill-mill practices where patients could obtain narcotic medications without adequate care for their underlying addiction. That concern is reasonable, I suppose, but I often discover that proponents of the cap have other motives to keep the limits in place. For example, one person at a ‘linked in’ group argued that individual physicians don’t provide the all-encompassing care that he provides… to the 800+ patients he ‘counsels’ at the methadone clinic where he works! According to that counselor, all people addicted to opioids need years of counseling—largely from other people with addictions, who after a couple years of school have all the answers.
He would be surprised to see just how well people can do on buprenorphine, a medication that selectively removes craving for opioids. After years of treating and knowing patients on buprenorphine I realized that ‘character defects’ are largely maintained by active craving. Yes– people with antisocial tendencies before and during active addiction have the same antisocial tendencies on buprenorphine. But people who …