Suboxone Assisted Treatment Of America
" Let's Celebrate Our Independence"  
July 2008 News-Updates

"Be Ashamed To Die Until You Have Won Some Victory For Humanity"

"Who would believe that a democratic government would pursue for eight decades a failed policy that produced tens of millions of victims and trillions of dollars of illicit profits for drug dealers, cost taxpayers hundreds of billions of dollars, increased crime and destroyed inner cities, fostered widespread corruption and violations of human rights and all with no success in achieving the stated and unattainable objective of a drug free America. " Milton Friedman Winner of 1976 Nobel Prize For Economic Science" 

Strategies To Control Bupe Abuse Outlined 

Dr. Charles Schuster, formerly of National Institute on Drug Abuse, tracks bupe abuse. (Sun photo by Andre' F. Chung / February 22, 2008)

WASHINGTON - Amid growing illegal sales and abuse of buprenorphine, top federal officials outlined yesterday action they might take to curb problems with the addiction-treatment drug, including more precise detection methods, improved training of doctors and stronger warning labels for patients.

 "The issue of diversion has been out there since 2004," said Dr. H. Westley Clark, director of the Center for Substance Abuse Treatment, which oversees the federal government's buprenorphine initiative. "We've been concerned about that, and we will continue to be concerned about that."

 Clark spoke to reporters after a two-day, closed-door summit of experts on buprenorphine, which the government sees as the best medical treatment for hundreds of thousands of people addicted to heroin or painkillers.

Introduced in 2003, the drug known as "bupe" has been subject to increasing misuse and illegal sales as more of it is prescribed by physicians, The Sun reported in a series of articles beginning in December. Some patients sell it on the street; buyers use it to get high or hold off withdrawal symptoms until they can get their next heroin or painkiller hit.

With tens of thousands of opiate addicts in Maryland, Baltimore and state officials are investing millions of dollars in bupe treatment. Experts say it's safer than methadone - the traditional heroin treatment, normally given out under close supervision - and more likely to appeal to addicts because they can get bupe from their doctors.

Though Clark and other officials said they are encouraged that bupe has expanded access to drug treatment, they acknowledged publicly for the first time a need to tighten safeguards over use of the drug, sold mainly under the name Suboxone.
 

Suboxone was developed as a joint project by the National Institute on Drug Abuse and Reckitt Benckiser Pharmaceuticals Inc. of Richmond, Va. An estimated 170,000 addicts are taking it.

Many patients and doctors say that bupe pills are extremely effective in curbing withdrawal sickness and help ease cravings for heroin or prescription opiates.

The Sun's articles identified a variety of problems the government hadn't acknowledged when it approved buprenorphine. Some users crush and inject the drug, a dangerous practice because it can spread diseases. Many experts told the newspaper that an eight-hour training course required for doctors who prescribe bupe is not adequate and that some physicians are contributing to illegal sales of the narcotic substitute by prescribing it too generously.

Dr. David Fiellin, a Yale University professor who directs the Physician Clinical Support System, said that "there are physicians who are practicing outside" the standards of care.

Fiellin said the support system, funded by the government, will work with private medical societies to teach doctors how to properly store the medication and to identify patients who might be misusing or selling the drug.

"There is not an active surveillance system in place to identify physicians who are practicing outside the guidelines," Fiellin said. When they are found, he said, his group will work to report them.

Dr. Charles R. Schuster, a former director of the National Institute on Drug Abuse who tracks abuse of the drug for the manufacturer, agreed. "We have reports from physicians that they know of other physicians not practicing within the standards of care," Schuster said.

The biggest problem, according to Schuster, is that some doctors are prescribing 30-day supplies of the pills to addicts after only a single visit. While that's legal, Schuster said, doctors should become comfortable that a patient is not abusing the drug before prescribing large amounts.

"A small minority of doctors are not practicing good medicine," he said. "That's a problem we need to be concerned with."

Experts and officials identified other problems, including doctors who provide little counseling. An official with the NIDA said studies are showing that buprenorphine works better with pain-pill addicts, not heroin abusers.

Schuster also said he learned at the two-day conference that federal government drug-abuse warning systems were considering ways to add new medications to their watch lists.

"Currently they are designed for detecting the use and abuse of drugs that have been around for quite a while," he said.

Dr. Celia Winchell, a medical officer for the U.S. Food and Drug Administration, which approved Suboxone in late 2002, acknowledged that some abusers are able to crush the pills and inject the drug despite the presence of a chemical intended to deter that.

"Certainly, we're concerned about diversion and abuse," she said.

Winchell said the FDA is evaluating whether to strengthen warnings on the drug labels to "prevent diversion" and alert doctors and patients to adverse effects that accompany misusing it.

"We're exploring if there's anything left unsaid in packaging," Winchell said.

But the government can do little to alter doctors' practices. The Drug Addiction Treatment Act of 2000, which authorized buprenorphine treatment, forbids the government from interfering in private medicine.

Federal regulations allow doctors to prescribe a 30-day supply of buprenorphine and up to five refills, a practice that is far more lenient than in most countries.

Canada, for instance, requires that a patient be in treatment for two months before receiving Suboxone to take unsupervised.

doug.donovan@baltsun.com fred.schulte@baltsun.com

 

"A small minority of doctors are not practicing good medicine," he said. "That's a problem we need to be concerned with."  

Greetings! It's Deborah back with you again with updates.  We definitely agree with the above article. I'm not sure we agree with a "small miniority of doctors " not practicing good medicine.  (LOL) 

There isn't one day that passes we don't hear from someone dissatisfied with their physician. Patients tell us they make an appointment and fill out the required paperwork and then the nurse checks their blood pressue, pulse and listens to their heart. Once she is finished the doctor comes in and asks a few questions and then, they are given a prescription for the medication, (and some have even been told to take it as needed.)  

Many others are too strict with their prescribing.  They send the patient home with barely enough to prevent their withdrawal.  Many patients think maybe the medication is just not working for them.  It is at this point we receive a call from them ...they are having withdrawal symptoms and want to know what they should do?  They don't have any idea if what they are going through is normal or if the medication is simply not working. 

It is evident some of the physicians must not educate the patient.  I'm thankful we have the Internet because at least they are able to "google" Suboxone and locate some information.  We take calls 24 hours every day if you need information. If you can't afford to call us ...just send us an e-mail with your name, number and the best time to call you ...we will touch base with you at our own expense the same day. What about the people without access to the Internet?  What can they do when they can't reach their doctor? 

Believe me, it happens quite frequently!!!  We usually advise them to get in touch with their doctor and let them know what you are feeling.  They try and can't reach him especially if it falls on a week-end.   We step in and provide the information they need and take the time to answer all their questions.  We can't prescribe more of the medication for them but many of them we are able to talk out of returning to the streets.  We take the time to listen  and many times it gives them the courage to hold on until Monday but, I am sure all of them we speak with doesn't make it. 

If any of you have experienced withdrawal symptoms then you know just how agonizing they can be.  It's twice as tough if you are all alone without anyone to give you support and encouragement.  Believe me, it makes all the difference in the world just to know someone is there for you.  It is in this way the doctors have failed their patients. It should be mandatory they provide the counseling which complements the medication.  Most are not providing it for the patients...

I want you to hold the thought about the counseling...because I want to talk with you about it more but if they aren't going to supply counseling they should provide the patient with information about the medication.  They should tke the time before they send you on your way to answer any questions you may have. and/or literature you can read.

We know, because we host a Suboxone Forum, patients are diverting the medication and many are taking it with other medications and/or not as directed.  We know  it is available on the streets and it may not be as deadly as methadone but you can defininitely die once you begin taking it with other medications.

I'm using some posts from our forums.  You can see the patient in the first post has access to Suboxone but it is too much for her to cope with even with insurance...We did offer to help her, but kindly asked her not to post on our forum because diversion made it more difficult on all of us.  It must be nice to have your own supply but it is people like her husband giving the medication a bad name and adding to the stigma and discrimination against us. Don't you agree? Should she not learn to cope like us? We are interested in hearing any comments about the posts. 

  

"Wow! Reading this posts has been a real eye-opener for me.  I've read quite a few posts about how people struggle to find pills or whatever each day while they feel terrible.  

I never had to look for it...My husband has endless prescriptions and would leave me something everyday before he went to work.  It started out long ago (7 yrs or so) as just one -half Norco per day...and recently it was up to 4 or more Norco, Percocet or Oxycontin per day.  Not a huge amount, I know...but when I realized I just couldn't walk away from it, I had to start considering the fact that I'm actually "addicted."

It's always in the house.  Even though I'm taking Suboxone, there's always other stuff around my house. Sometimes he's good about not offering it, but all I have to do is ask, or look for it. 

I mentioned in another post that I was getting Suboxone from my husband who gets it from a relative. (He supplements his supply with Suboxone.)  I know I'd be better off to go through a Doctor who specializes in Suboxone treatment and I do have insurance for the prescription, but I don't know how I would come up with the money for the Doctor visits.  As it is, it's only a $10.00 copay for the tablets once a month or so. It seems like an odd twist, that it's easier and less expensive to get the tablets and stay on them, than to get treatment to stop taking them. 

Okay, I know I'm rambling. I just have so much to process and finally a place to do it. Thank you for this awesome forum...I can see wonderful things are happening here for so many.

Blessings,
(Name Withheld)

 How many days after opiates should you wait before taking Suboxone? Listen to what one girl has to say, do you agree?

Hey girl,I was on methadone 150mg a day,got thrown in jail for 7 days,got out and a friend provided me with buprenorphine,and I haven't never felt better.I had so much methadone built up in my system,it took 7 days just to start feeling withdrawal symptoms. My friend started buprenorphine the day after he dosed, 20mgs of methadone, never felt better.

Buprenorphine is a very different and great maintenance drug. I would recommend you to keep some, methadone 20mg, right up to one day before or two, but you don't have to pay any price of pain, for having a disease.

You can safely take buprenorphine the next day. Doctors are not too informed, mine dosed me with buprenorphine,and I had taken 5 percocets,(10 mg), and he said,"Your starting dose of 2mgs twice a day will kill that percocet buzz, but you will be fine."I was so sure I was going to get so sick,well I didn't and that is my experience."

You will be fine,I am a big time wimp when it comes to even thinking about withdrawal symptoms. I know where your coming from, but you can start buprenorphine 1-2 days after methadone,(5 days, that is  statistical untested assurance from the manufacturer) to make sure that they and the doctor can not be worried that the unthinkable will happen.

Good luck and don't let those wheels inside your head drive you batty.

Sincerely,
(Name Withheld)

 Needs Higher Dose

My biggest issues is that at my dose, 12-mgs/day, I can still use heroin and get its full effects. Even the same day I dose bupe. I unfortunately discovered this about six weeks ago. So I relapsed, as I do (I know I can beat this but I LOVE heroin and it was available - easily, and I decided to try it while on bupe - BIG mistake).

I do not appear to have any significant blockade effect from the buprenorphine. I do have a high tolerance to heroin and was able to easily tolerate about 0.38 - 0.40 grams in one "shot" of fairly decent quality Mexican black tar heroin on several occasions and a full gram in an 18 hour period - granted with a serious level of intoxication - severe nodding and such, but I really liked it (again, BAD).

I think this shows that there is a blockade effect to a point, I hadn't used street opiates - only methadone and buprenorphine from September 2007 - April 2008, so my tolerance should have been quite low and the amount of heroin I used when I relapsed would have certainly killed me IF Buprenorphine didn't provide some measure of blockade/overdose protection.

So the issue for me that is most significant is the lack of the complete blockade I enjoyed when I was taking 200-mgs/day of methadone.

Unfortunately, due to my relocation to Idaho and my severe distaste for the clinics in Colorado and the existence of only one clinic in Idaho I don't reasonably have to option to return to methadone. Not that I want to anyway.

I believe - I must really - that I will not relapse again as I would likely lose my job and career - as the Department Of Transportation tracks positive UAs for people who do what I will be doing in a few weeks as my new job. I will be randomly and post-accident tested as part of my job. I passed the pre-employment UA test despite very low levels of THC and morphine in my urine (detected using a Department Of Transportation immunoassay dip test I obtained from my former MMT ). 

(Name Withheld)

Manager Answers 

  The value of the drug requires adequate dosing to achieve the long half-life and repression of cravings. At doses of less than 8 mg, suboxone becomes more similar to a pure agonist;  one might  as  well  be giving  small  doses of hydrocodone to prevent withdrawal. The average patient takes 12-24mg of Suboxone daily.

The Suboxone Paradigm, Part Two

Traditional treatment of opiate addiction helps only a small number of addicts, and only after severe negative consequences. Even after successful treatment, opiate addiction is characterized by multiple relapses. Suboxone treatment is a dramatic improvement over traditional methods, and allows a new treatment paradigm: Successful treatment by inducing reliable remission of active addiction, using Suboxone.

Suboxone consists of two drugs; buprenorphine and naloxone. The naloxone is irrelevant if the addict uses the medication properly, but if the tablet is dissolved in water and injected the naloxone will cause instant withdrawal. When suboxone is used correctly, the naloxone is destroyed in the liver shortly after uptake from the intestines and has no therapeutic effect.

Buprenorphine is the active substance; it is absorbed under the tongue (and throughout the mouth) but destroyed by the liver if swallowed. There is a formulation of buprenorphine without naloxone called subutex; I have used this formulation when the patient has apparent problems from naloxone, including headaches after dosing with suboxone.

I have also treated addicts who have had gastric bypass, where the first part of the intestine is bypassed and the stomach contents empty into a more distal part of the small intestine. In such cases the naloxone escapes ‘first pass metabolism’, the process with normal anatomy where the drug is taken up by the duodenum and transferred directly to the liver by the portal vein, where it is quickly and completely destroyed. The changes in anatomy with gastric bypass allow naloxone to pass from the distal small intestine to the bloodstream, bypassing the liver and resulting in mild symptoms of withdrawal.

Buprenorphine has a ‘ceiling effect’-the narcotic effect of the drug increases with increasing dose up to about one or two mg, but then the effect plateaus and higher amounts of buprenorphine do not increase narcosis.
The average patient usually takes 12-24 mg of suboxone per day, and quickly becomes tolerant to the effects of buprenorphine (buprenorphine does have significant narcotic potency, but the potency usually pales in comparison to the degree of tolerance found in active opiate addicts).

 The opiate receptors in the brain of the addict become completely bound up with buprenorphine, and the effects of any other opiate medication are blocked. Once the addict is tolerant to the correct dose of suboxone, the buprenorphine that is bound to their opiate receptors reduces cravings and prevents the effects-and so the use—of other opiates. Suboxone is very effective in preventing relapse; the ‘choose to use’ issue is effectively removed by the fact that use would require the addict to go through several days of withdrawal in order to remove the receptor blockade and allow other opiates to have an effect. Given addicts’ attitudes toward withdrawal, the appeal of this ‘choice’ is quite low.

The only real problem with suboxone treatment relates to specificity. With suboxone, the addict stays off opiates, but there is nothing to prevent the substitution of alcohol. On the other hand, naltrexone reduces alcohol cravings by blocking opiate receptors, and it is quite likely that suboxone, through its similar mechanism, will reduce alcohol cravings as well. Such an effect has been reported to me by a number of suboxone patients, but has not been reported in the literature at this point.

The suboxone patients who move from one substance to another will likely require an approach that demands total sobriety. But in the case of pure opiate addiction, suboxone allows treatment without the misery of protracted withdrawal, without the high cost of residential centers, without the stigma and limitations imposed by methadone programs.

As I stated in part one of this article
, I predict that suboxone will eventually be the standard treatment for opiate addiction, and will change the treatment approach for other substance addictions as well. My only reservation with this statement is that it is unclear how the current recovering community will respond to patients treated with suboxone.

 If suboxone patients are rejected by the recovering community, what will be the long-term outcome of their addictions when the substance is removed but the personalities and issues remain untreated?

Is it a given that all addicts have a disease that requires group therapy?

As things stand now, addicts maintained on suboxone are often referred for addiction counseling. But the exact message to deliver with counseling is debatable. In many ways, a patient maintained with suboxone becomes similar to a patient with hypertension treated for life with medication-the underlying problem persists, but the active disease is held in remission. If the uncontrolled use of opiates is effectively treated, is that enough?

Should counseling be focused on removing the shame of having the disease of addiction, and on encouraging the treated addicts to get on with their normal lives? Or should we continue to see addiction as a consequence of a deeper problem or faulty character structure, which requires groups and meetings if one hopes to become ‘normal’?

Unfortunately the use of suboxone runs counter to successful adoption of sobriety through 12-step programs, which in the first step require acceptance of the fact that the addict is powerless over the substance-that there is no amount of will power that will allow the addict to control the deadly effects of the drug. By using suboxone the addict may develop the impression that he/she has control, particularly if suboxone becomes popular on the street for self-medication of withdrawal.

Before suboxone, the only option for opiate addicts was to lose a sufficient number of things-family, employment, freedom, health-to cause them to accept treatment and recovery. Only a small fraction of addicts recovered, and only after significant losses-and relapse rates were high.
Suboxone is an amazing breakthrough; one that for the first time allows treatment of addicts early in the course of their illness, and that reliably induces remission in most patients. There are, however, some factors that have the potential to reduce the effectiveness of suboxone treatment.

First, some insurers demand that the drug be used only short-term, in some cases for only three weeks! This requirement totally misses the nature of addiction, and ignores the known high relapse rate after short-term use of suboxone (and why wouldn’t it be high?). Some physicians use the medication in this short-term way; hopefully the motivations for this ineffective treatment method are not related to the limits placed on the numbers of maintenance patients per physician.

Other physicians will transfer their attitudes toward opiate agonists to the use of suboxone, and place constant downward pressure on the daily dose of suboxone. This approach is not appropriate with suboxone; the value of the drug requires adequate dosing to achieve the long half-life and repression of cravings. At doses of less than 8 mg, suboxone becomes more similar to a pure agonist; one might as well be giving small doses of hydrocodone to prevent withdrawal. There is no reason beyond drug cost to reduce the dose, as tolerance is limited by the ceiling effect that occurs with relatively low doses.

 In other words, higher doses of suboxone do not result in eventual higher degrees of withdrawal. Another issue is that the medication is sometimes prescribed carelessly, without emphasizing the need to dose once per day. Patients left to their own devices will start using the medication multiple times per day as a ‘prn’ medication, and will remain in the same addiction behavior that brought them to treatment.

 Once per day dosing is important because it allows the addictive behavior to be extinguished over time. The frequent dosing does provide a distraction and placebo effect, and so initially patients will have an increase in anxiety when the dosing obsession is removed. But over time the anxiety will fade, and the huge void left by the removal of addictive obsession will allow the development of relationships and other positive character traits that were forced out by their addiction.

Given the time pressures and payment structures of modern medicine, suboxone may eventually replace residential treatment as a more reliable, less costly alternative. I believe that the time has come to replace the ‘recovery’ model with a new ‘remission’ model, which allows treatment of a much higher percentage of users at an earlier stage of disease. With time, will we find analogous agents that provide a low level of intoxication in return for receptor blockade?

While not likely with alcohol, such an outcome is certainly within the bounds of imagination for cocaine, benzodiazepines, and barbiturates. While it is true that daily use of a partial agonist would represent a reversal from our current approach where all intoxicating substances are to be avoided, it is also true that the current approach has no bragging rights based on outcome.Finally, perhaps the adoption of a remission model will lessen the time until opiate and other addictions carry as much moral stigma as hypertension or diabetes-two other diseases that are generally treatable, but that require long-term use of medications.

Jeffrey Junig lives in Fond du Lac, Wisconsin. He has worked as a neuroscientist and as an anesthesiologist, and is a psychiatrist and pain physician in solo, independent practice. Additional information can be found at the web site of his chronic pain and addiction practice, Wisconsin Opiate Management Center, or at Fond du Lac Psychiatry. He is available for patient care, consultations, or educational presentations.

Please send any comments you would like to have posted on the August New-Updates to deborahshrira@gmail.com

Thank you for visiting with us. We provide New-Updates each month to keep you up-to-date.  We hope all of you will see us next month and if you have a success story to share, please take the time to send it to us.  I am going to try and post  all the "Patient's Stories"  I have during the next month.  Please try
and send it to me as soon as possible. You never who you may inspire. 
     
Suboxone Assisted Treatment
501 (c) (3) Non-Profit Organization
368 Johnston Pkwy N.W.
 
Kennesaw, Georgia 30152-4445

 Phone: 770-428-0871 Cellular: 770-527-9119 Emergency:770-428-8769

Deborah Shrira, Editor  
July 2008