A question was asked about the last post that warrants top billing:

“Buprenorphine acts similar to opioid agonists in lower doses, with the same addictive potential as oxycodone or heroin. In higher doses—doses above 8 mg or 8000 micrograms per day—the ‘ceiling effect’ eliminates interest and cravings for the drug.”

I’m not sure I followed this. Can you explain more? What would you think about someone who is taking 1-2mg of Suboxone twice a day without a prescription, and says they want to stay on that dose once they find a prescriber? Are they better off on 8mg or more per day, or would it be ok for a prescriber to keep them at the lower dose? Is the answer the same if they hope to taper off the medication completely within a year (they don’t feel able to do this on their own right now, but hope to be able to when some life circumstances change). Thanks!

This gets a bit complicated, but I’ll do my best.  A couple background issues;  buprenorphine has a ‘ceiling’ to its effect, meaning that beyond a certain dose, increases in dose do not cause greater opioid effect.  That is the mechanism for how buprenorphine blocks cravings. 

I would like to discuss a comment from a reader:

I have been a recovering addict for 12 years. I was addicted primarily to Lortabs (active ingredient is hydrocodone) and Ultram. I was never an extreme user but I was consistently trying to modulate my feelings and feel better. I also have been battling BPD (Borderline Personality Disorder) for a very long time which appears to be my primary issue. I have been married for 17 years and let’s just say our relationship is difficult due to my inability to be present and emotionally and psychologically sound.

As with most other addicts, I distinctly remember the first opioid I took, even though I don’t remember my first sexual experience. The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.

Since I quit using 12 years ago I have only had a few days, yes, days, where I have truly felt good, and that was after intense work with someone for hours and hours at a time to help me get through an intense emotional roller coaster ride. I will feel “normal and happy” for a few hours or maybe a day and then I feel the despair creeping back in. I cut my thumb the other day and the first thought that I had was, I wonder if this injury will be sufficient enough to allow me a Lortab? I just never feel right without an opioid in my system.

I have been researching drugs available to help me. I have tried many different antidepressants which were never helpful. I am wondering about a small dose of Suboxone (maybe 2 mg/day) which I have read may decrease some of the problems associated with BPD. I have been reading that persons with BPD have shown to have an opioid deficit and that 40% of those with BPD are addicts.

I’ve written about the spectrum of medical and scientific opinion (not, unfortunately, always the same thing) over the use of opioids for treatment of chronic pain.  For those who missed the earlier discussion– one that produced a heated response from readers– I invite you to review those posts.

The essence of the issue is that over many years, there has been significant effort to increase patient access to potent opioids.  This effort has come in part from the pharmaceutical industry, but also from organizations that advocate for patients with a wide range of painful conditions, some with connections to pharma, and some without connections to pharma.

There has even been a push to increase opioid prescribing from Federal agencies.  Back in the 1990′s, when I chaired my local hospital’s Department of Anesthesia, we were warned by agencies hired by the hospital that the Joint Commision on Accreditation was focusing on pain control one particular year, and that some hospitals had been cited for insufficient prescribing of pain medications.

Medications - image from Shutterstock

The point missed by the writers of the Bloomberg article, though, is the same point that is missed by many physicians– even by many addictionologists. The dirty secret that RB does not want anyone to realize is that the equivalent of generic Suboxone is already available, in the form of orally-dissolving tablets of buprenorphine.

I recently received the following note from a reader:

I am aware of historical and recent studies where Subutex (a ‘partial agonist’ opioid called buprenorphine) was used very successfully in the treatment of depression. I am wondering if you have experience prescribing it for that, and what the success rate is? Can it be taken long-term? I am battling a very bad depression; what are my options on Subutex? Are you aware of any doctors in Michigan who work with Subutex for depression?

The gentleman raises a number of interesting questions. He also provides a glimpse into the desperation experienced by people with treatment-refractory depression. Patients with that condition describe one painful day after another, waiting endlessly for a ray of light to brighten the darkness.

My last post—the one about changing attitudes toward using opioids to treat chronic, nonmalignant pain– drew angry responses from a couple readers.  One response was a wandering, spiteful paragraph that (among other things) called me ‘unsympathetic’ for describing the changes coming in the near future, even though I have no role in enacting those changes. I see no value in discussing that angry diatribe further – other than to tell the writer ‘don’t shoot the messenger!’

The other post was more thoughtful and deserves a response—as does the post in the comment section by ‘LS.’  Taking that last comment first, I’ll say thank you– for pointing out something I should have been clearer about.  People who are treated for acute pain—caused by surgery, or from injuries like broken bones or contusions—rarely develop addiction to opioids.  I HAVE had patients presenting with opioid dependence who say that their addiction started after getting pain meds after surgery and discovering that they liked them, but the number of those cases compared to the overall number of people with surgeries and injuries is likely to be a small fraction of cases.

Here is the other response to my suggestion that prescribing opioids for chronic pain MAY make things worse:

In my last post I mentioned that one of my patients on buprenorphine had relapsed. Relapse on buprenorphine reminds me of the philosophical cliché, ‘if a tree falls in a forest and nobody hears it, did it make a sound?’ For those not familiar with the cliché, the question and the answers–from standpoints of science, art, and metaphysics—are discussed in great depth, I just discovered, on Wikipedia. I now know more about the question than I will ever need to know!

When a person on buprenorphine maintenance uses opioids, what happens? The answer, depending on perspective, ranges from ‘nothing’ to ‘everything.’ For example, we could focus solely on the effects experienced by the addict. Because of the blocking effects of buprenorphine, an addict may take significant doses of heroin without having any subjective response. One might argue that since the addict experienced no ‘high’ from the use of heroin, he/she didn’t really relapse. Someone else may focus on the intake of chemicals, and consider such use to be a ‘relapse’ whether or not the heroin had a noticeable effect.

While I’m on the subject of rip-offs, I’ll mention an extreme form of ‘detox capitalism’; a process called rapid opioid withdrawal, rapid detox, or ‘the Waismann Method.’

The name of the process supposedly comes from a certain ‘Dr. Waismann’ who helped Israeli soldiers get off opioids after they were treated for various injuries.  It sounds like a pretty exciting history, but to be honest there is nothing in the technique that takes a rocket scientist to figure out.  The basic idea is to precipitate withdrawal using an opioid antagonist— something that is done many times over every day in emergency rooms across the U.S.—but to do it while the person is sedated with non-opioid medications.

On my personal blog about opioid dependence I often respond to specific questions about buprenorphine or addiction.  I would like to invite questions from readers here as well, using the ‘comments’ section.

Specific questions or comments can generate an interesting give and take that in the end becomes quite informative—for all of us, myself included.  Just remember to be careful with disclosure of personal information.  When in doubt, don’t disclose, as information placed on the internet can never be completely removed!

I’ll provide an example of the type of exchange I’m suggesting, using a question that I received a day or two ago.

I have a number of patients under treatment for opioid dependence taking buprenorphine who have become pregnant, deliberately or accidentally, forcing the decision whether to continue on buprenorphine, taper off the medication, or even whether to terminate the pregnancy.

The decision is not made any easier by the large amount of misinformation people are subjected to, or by the shaming attitudes of some family members and even healthcare workers.

I produce a website called SuboxForum in order to provide accurate information and to allow people to ask questions in a non-judgmental setting.  A member of the forum recently wrote that her doctor informed her that a baby born to a woman on buprenorphine would likely be severely deformed, and that she shouldn’t even think of pregnancy until she was off buprenorphine for several months.  And I wonder—who would say such a thing?!