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, …
We can now leave naloxone out of the discussion, and focus on the side effects of Suboxone that are caused by buprenorphine.
Side effects are symptoms caused by a given medication that are not part of the therapeutic benefit of that medication. Whether a symptom is a side effect depends on the reason for taking the medication. For example, decreased intestinal motility is the desired effect of opioids used to treat diarrhea, but a bothersome side effect when taking opioids for pain. The term ‘side effect’ is not on the package insert for medication, the symptoms and actions instead referred to as ‘adverse reactions.’ Package inserts also have a section entitled ‘warnings and precautions’ where the most dangerous adverse reactions are listed.
Some medications have a ‘black box warning’ for adverse reactions that are particularly common or particularly dangerous, consisting of a frightening statement at the start of the package insert (enclosed, naturally, by a black box). Black box warnings in psychiatry include the warning for increased suicidal ideation in children and adolescents treated with antidepressants, and the increased risk of death in people with dementia treated with atypical antipsychotics.
Increased risk of cancer or mutations, and effects on fertility or fetal development, are listed in yet another section entitled ‘nonclinical toxicology.’ They are listed as ‘nonclinical’ because the events do not involve the intended physiologic system or pathway targeted by the medication. For example, slowing of intestinal activity by opium …
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 …
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+ …
Several of my patients have warned me about the world ending in a few days, on December 21, 2012. There are variations on the theme, but the basic idea is that the Mayans, who were accomplished mathematicians and astronomers, used an advanced calendar to measure planetary cycles… and that calendar ends at the end of this week. Some patients tell me that the end of the Mayan calendar coincides with predictions by the French seer Nostradamus, although the definitive authority on everything, Wikipedia, holds that Nostradamus did not make such a prediction.
I’ve browsed internet sites about this topic in order to prepare this post and found that there are about as many different versions as there are web sites about the prediction. I suspect that some versions have more adherents than others, and I have no idea which web sites are the most authoritative. I’ve read, though, that the world will end as described in the Book of Revelation in the Bible, or that instead, humanity will be erased, leaving the Earth unscathed. I’ve read that the Earth and Sun will line up in a way that eclipses the energy flowing from the center of the Milky Way Galaxy, causing humanity to die off and be replaced by aliens from outer space.
Like any good prediction, this one has plenty of wiggle-room. Comparisons between our modern calendar and the Mayan calendar require assumptions about how the Mayans determined months and years, …
Lately it seems as if I’ve been hearing more calls to change US marijuana laws. The legalization of marijuana has been a cause for some citizens for decades, and efforts to change marijuana laws have waxed and waned since I was a teenager in the 1970’s. Some people believe that this time around, attitudes are truly changing. A recent Quinnipiac University poll showed that as of November 2012, a majority of US voters favor legalization of the drug for recreational use.
The current status of marijuana laws are confusing, to say the least. Marijuana is regulated at multiple jurisdictional levels, so a person in any one location is subject to state, federal, and sometimes local statutes. These statutes are often at odds with each other, so the legality of marijuana depends largely on the employer of the agent or officer making the arrest.
There are also multiple forms of legality. In November, Colorado and Washington State legalized the possession of up to one ounce of marijuana. Another dozen-or-so states decriminalized marijuana over the past 20 years, so that possession of the drug is punishable by citation, not prison time. Another 20 or so states have laws allowing for the medical use of marijuana, including in some cases provisions to grow marijuana for personal use or for a small number of patients.
By federal law, marijuana continues to be illegal in virtually all settings. The DEA classifies marijuana as ‘Schedule I’, the same status as …