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Goals of buprenorphine treatment and generic Suboxone

Posted Jul 22 2010 9:38pm

A question in response to a recent article, and my answer.  My primary point is to address what buprenorphine maintenance CAN do– which is far more than simply ’replace’ opioid agonists.  I recently received a message from an AODA counselor that totally misses the point of buprenorphine;  a message that did what the anti-sub crowd typically does– i.e. present a skewed view of buprenorphine and then tear down that skewed view.  I’m not posting his ‘straw man’ message here, as there is already enough misinformation out there without his contribution. 

Instead I’ll share a different, nicer letter:

Hi– my name is (Julie) and I’m a member of your site however I never post as I usually find answers to my questions.

I too would like to make a donation.

I have been on Suboxone for 3 months. Before that I was on methadone for one year, and tapered down before switching to Suboxone. I am now at one mg per day which I’m doing well with.  How long should I stay at one mg before reducing to 0.5 mg?  And how do I ask for Subutex (since it’s generic) without the doc thinking I’m going to abuse it?  I’ve never been a needle user; sniffing was my thing– oxys but most heroin.    I’m interested in generic buprenorphine because obviously it’s cheaper.

I love your site and have read about the liquid taper and your story. It’s nice to have an addiction psychiatrist who’s been in “our” shoes and who understands addiction.

Also can I mention these drugs you’re talking about to my doctor, BuTrans, Probuphine and proglumide?

Like most addicts the thought of going through withdrawal terrifies me. But I know I can’t stay on this forever. I own a small business and can’t afford to take 3 weeks or more off of work. Also I have prescriptions from a different doc who gives me valium and lorazepam. Will these help with my withdrawals? The diazepam doesn’t seem very strong to me.

Thank you!

Back to me:

Donations are always appreciated– the donation button on the blog site works through PayPal.

The mistake most people make– addicts and their docs– is to stop buprenorphine too early.  Several large studies show very clearly that buprenorphine treatment less than 6-12 months is almost always followed by relapse;  there is now general agreement that buprenorphine should be continued for a year or more, and often indefinitely.  I understand the desire to get off everything, but there is simply no going back to who we were, before we became addicted.  Active addiction permanently changes pathways in our brain, and we cannot erase them any more than we can ‘forget’ how to ride a bike.  What we hope for, during buprenorphine maintenance, is for the pathways that have become engrained in the brain to fade to some extent.  Addicts learn, while using, to constantly gaze inward and focus on how they ‘feel.’  If there are unpleasant sensations or feelings, addicts learn to turn to a chemical to make the feelings go away.  The goal on buprenorphine is for the person to learn the reverse– to stop constantly looking inward and instead direct our minds outward, and to learn to accept life on life’s terms. When we notice unpleasant sensations or feelings, we must learn to tolerate them and ignore them.  Buprenorphine maintenance allows that process to occur– providing it is taken correctly.  If an addict, for example, takes little chips of buprenorphine in response to every unpleasant sensation, that person may as well take an opioid agonist.

Another goal of buprenorphine maintenance is to promote character change. I don’t think that most docs (and certainly few AODA counselors) get this part.  The harm from opioid dependence does not come from ‘taking’ opioids;  the harm comes from the OBSESSION for opioids.  That obsession takes over the addict’s life, replacing interests in work, relationships, hobbies, simple pleasures– everything.  I naively expected a ‘dry drunk’ when I first treated addicts with buprenorphine, but that is not what I discovered.  Instead, I saw that as the obsession for opioids faded away, other interests returned.  It’s almost as if the mind is like a computer hard drive, and has only so much capacity.  If the mind is filled with obsession for opioids, there is no room for other things. I suppose the analogy is a person filling his business computer with porn– so that there is no space, and no time, for what is SUPPOSED to be going on!

One other positive aspect of buprenorphine in regard to character has to do with honesty.  Opioid addicts learn to lie about pretty much everything.  Addicts learn to repress the guilt over those lies and the guilt from their behavior, eventually becoming extremely adept at lying.  All that lying leads to the development of an artificial, shallow personality that allows an addict to put on a fake smile even as life is falling apart.  The fake personality can fool some people, but a fake ‘self’ cannot form real intimate relationships.  So the addict appears happy, giddy, or even goofy… but is intensely alone on the inside.  Eventually that loneliness contributes to the despair that leads, hopefully, to seeking help and recovery.  One reason that taking buprenorphine on the street is foolhardy is because the addict is still leading a life of dishonesty.  The fake veneer remains in place in such cases. The addict fools him/herself by thinking that everything is in order, but deep inside the addict is still separated from society by his lies, and by knowing that he is not who he says he is. With appropriate treatment on the other hand, the addict gains self confidence from knowing that the rest of the world is interacting with his/her true self.  I have testified in court for various purposes, and it always boosts my confidence when I realize that I only need to speak the truth.  If I had to present a version of reality that I was fabricating, I would be a mess!  How much easier to just speak the truth– at least the truth as a person knows it!

Back to your situation… I worry a little that your dose of buprenorphine is too low, but if you going the full 24 hours between doses without withdrawal or cravings, your dose is sufficient.  But I would be in much less of a hurry to get the dose lower.  There is little difference in the opioid tolerance of a person taking 4 mg vs. a person taking 24 mg (because of the ceiling effect).  So the ONLY reason to take such a low dose is for cost considerations– and maybe so that if you needed surgery, it would be a little easier to overcome the block from buprenorphine.

You are free to talk about the things I’ve mentioned with your doctor– about medications to reduce withdrawal symptoms.  Unfortunately, though, it is difficult for people to understand our fear of withdrawal, who have  not experienced it firsthand.  As you know, there are no words that capture the symptoms, so docs think in terms of ‘pain’ or ‘depression;’ neither of which come close to describing the experience of opioid withdrawal.  Society as well has no empathy for THAT type of suffering, instead dismissing it as something brought on by addicts themselves, that on some level they deserve.  Yes, we are VERY far from treating addiction as a disease!!

As for benzos specifically– like Valium (diazepam) and Ativan (lorazepam)– they clearly reduce the misery of withdrawal, but they are themselves almost as addictive as opioids (and probably more addictive in some people).  I support their use for such a purpose only if there are significant measures to make sure that their use stops after a short period of time.  Many, perhaps most, physicians would be reluctant to prescribe them in the setting of opioid withdrawal, and I am not critical of that attitude, as I have seen many patients who have been injured by careless prescribing and use of benzodiazepines.

Finally on the Subutex issue, there is no doubt that the difference between Suboxone and Subutex in reagard to diversion has been overblown.  Most diverted buprenorphine from either formulation is taken sublingually to stave off withdrawal, not intravenously for a ‘high.’  I have wondered aloud if Reckitt-Benckiser perpetuates the misperception purposefully in order to reduce abandonment of brand Suboxone.  Thankfully we now have generic Suboxone from Teva Pharmaceuticals, and hopefully prices for both formulations will fall.  I recently heard about a pharmacy in Appleton, WI that had generic buprenorphine 8 mg tablets for about $2.80 per tablet retail, which is the lowest price I’ve seen for a couple years.  For any physicians reading this, I encourage you to cut your patients some slack if they have no insurance and consider prescribing generics;  I prescribe the generic in such cases and have had no complaints of lower efficacy or other problems.  In Wisconsin most pharmacies do not stock the generic, but they can order it if given a day or two notice.  Although we do NOT yet have the Teva generic available, at least as far as I have heard.

Thank you for your letter.  Please let your doc know about the blog, and particularly about the forum.


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