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 …
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, low birth weight, season of birth (higher in infants born in the winter), too high or too low room temperature, male sex, history of premature birth, and bottle feeding (instead of breastfeeding).
One of the biggest risk factors is the easiest to correct: sleeping position. The incidence of SIDS is thought to be about twice as high for babies who are placed prone (face-down). Since 1992, when 4895 deaths were attributed to SIDS in the US, a public relations campaign to encourage parents to place infants on their backs may have reduced the incidence of SIDS by 50%. I write ‘may …
Please review my prior post, as my comments will refer to an email in that post.
There are many directions that we could take as we review that message. My overall impression, as I read the letter, was of a person struggling to accept the reality of his condition. Over and over, the person repeated the same behavior, starting Suboxone, stopping, and thinking this time will be different.
One thing I’ve learned as a psychiatrist, more than anything, is that change is difficult, and rare. The writer ends with the thought that maybe this time will REALLY be different. I have no idea if it will be, and for his sake, I hope it is… but unfortunately, the odds are that history will repeat itself.
I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy.
When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness.
I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
I have been struggling with Part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.
As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner.
Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—an outdated and toxic medication—which likely contributed to the charges, but the story creates a chilling atmosphere, regardless.
Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.
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 relapsed in 2000 after seven years of sobriety, and my attachment to opioids progressed much more rapidly than during my initial addiction. I wrote a post a number of months ago that described ‘living on two levels,’ and that was my experience at the time—as if one part of my personality was frantically taking ever-increasing doses of dangerous narcotics while the other part, horrified, looked on.
Eventually my behavior caught the attention of enough people that I was confronted about my addiction. I had been trying to stop using on my own for several months, but I argued over the need for residential treatment. I remember sitting with the hospital CEO, babbling that I would be able to straighten myself up on my own if I had a few weeks of sick-time, and his response: ‘Jeff, you have needle marks on your hands!’
I’ve shared my opinion that traditional treatment methods for opioid dependence—i.e. residential, usually step-based treatments—are a waste of limited resources. I’ve written that relatively few opioid addicts successfully complete such treatments. And many of those who ‘clean up well’ after two or three months die from relapse and overdose, months or years down the line.
Those who disagree with me sometimes pointedly ask “if getting clean without Suboxone is impossible, how did YOU do it?!” My usual answer is that my situation was and is very unique, and it would be misleading to compare my experience to that of most people. But in case someone uses my experience to justify a similar path as mine, i.e. through residential treatment, I’ll expand on my answer.
I have several blogs and forums, all part of the mission to educate people about opioid dependence and buprenorphine. Because of my online presence I am frequently contacted by reporters or journalists, and asked to provide my opinion about some aspect of opioid dependence. The requests have become more frequent over the past year, suggesting that either my name recognition has increased, or that there is greater awareness—finally—that an epidemic of opioid dependence is killing people in large numbers.
Among those who contact me are people who are ‘anti-Suboxone.’ Some people are very heated in their arguments against the medication. I run the addiction forum for another large health-related web site, and a couple years ago my presence on that site provoked ‘hate e-mail’ from readers, who accused me of being ‘just another drug pusher’ for my advocacy for buprenorphine!
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.