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Why do some docs kick patients off buprenorphine?

Posted Sep 07 2010 5:16pm

I often receive e-mails from people that go something like this:  I was addicted to oxycodone and heroin for 5 years, and lost my marriage, several jobs, and the trust of my children.  I was completely broke, and considering suicide.  Then I heard about treatment with buprenorphine and found a doc who prescribed it.  Since then everything has been going much better; I have a job, I’m putting some savings away, and I have been starting to reconcile with my family.  But my doctor says he wants me off Suboxone and is making me taper, and I’m definitely not ready.  I am starting to panic because I know that if I have to go off buprenorphine I’ll only end up using again.  Is there a way to make him keep me on buprenorphine?

Why the rush off buprenorphine? Suboxforum.com

Why the rush?

I have described my approach ad nauseum on this blog.  I look at the ‘givens’:

- Despite everyone’s wish that addicts stop using opioids and ‘get off everything,’ it just doesn’t work that way.  The relapse rate after stopping opioids is very high, whether stopping buprenorphine or any other opioid substance.

- Opioid dependence is a chronic illness that never goes away.  People relapse even after years of sobriety.

- Traditional treatment suffers from very high costs and very low success rates, and requires a large time commitment.  Traditional treatment does NOT offer any ‘long term protection’ against relapse; if a person stops attending meetings, the rate of relapse becomes similar to those who never went through treatment.

- Buprenorphine can hold opioid dependence in remission in motivated addicts.  It is not just a ‘substitution’ of one drug for another, as the ‘obsession’ which is the essence of addiction is reduced, allowing personality to improve and for other interests to return.

- The side effects and risks of taking buprenorphine are not significant, especially when compared with treatments for other life-threatening conditions.

- Even a short relapse can have unpredictably severe consequences, including legal trouble, loss of career, loss of key relationships, and death.

I could go on and on with this list, but you get the idea.  My own conclusion then has been that buprenorphine should be considered a long-term treatment for a long-term condition. 

Why do some doctors insist on a short-term approach?  One reason is simple ignorance, and not understanding the nature of opioid addiction.  Many docs persist in seeing addiction as a ‘choice’, and fall into the same silly thinking that some addicts initially believe, that the main barrier to sobriety is withdrawal.  Addicts who become miserable enough to get through withdrawal quickly learn that the withdrawal is NOT the problem—at least not the MAIN problem—as even after the symptoms go away, the addict relapses. This is maddening to the addict’s loved ones, and some doctors see this situation and become angry at the addict, rather than understanding the nature of addiction.  At least there are now studies showing the high rate of relapse, and hopefully the data will change the behavior of physicians prescribing buprenorphine.

Another reason for short-term prescribing is because the buprenorphine is being used as detox, for entry into a ‘total sobriety’ treatment center.  I won’t get too upset about such a situation, except to point out that such treatment centers commonly mislead patients about their chances.  At the treatment center where I used to work, Nova counseling services in Oshkosh, WI, the counselors would get very excited about patients who looked good on their way out the door.  But nobody seemed to feel any responsibility if that same patient relapsed and returned—or died—six months down the line.  Of course many patients never made it to the end of treatment, getting thrown out early or leaving on their own.  The counselors blamed those failures on the patient—instead of recognizing a failing treatment strategy.  THIS IS A VERY SERIOUS PROBLEM, by the way, with residential, traditional treatment programs—a problem that exists because of stigma about addiction, and a sense that addicts are less deserving of good health than ‘normal people.’  How can I say that?  Think of it this way—what if any other illness was managed in this way?  If heart disease or diabetes simply failed to make people better most of the time, and the doctors routinely blamed the patients for the lack of success, how would THAT fly? 

My biggest concern is that there are motivations to get patients off buprenorphine that come from the requirements placed on physicians who prescribe the medication.  Physicians can treat only 30 patients at a time with buprenorphine.  After a year they can apply to raise that limit to 100 patients.  Ironically there is no limit at all on the number of patients a doctor can treat with opioid agonists!  In a typical practice, patients are seen less often as they become more ‘stable’ on buprenorphine, resulting in a situation like mine– I have about 100 patients who have done well on buprenorphine for some time, many of whom had multiple attempts at ‘traditional treatment’ and some who were on buprenorphine from other docs, who would like to stay on buprenorphine long-term.  That’s fine with me; buprenorphine patients are a small part of my practice.  But if I wanted to make significant income from patients on buprenorphine, I would need to clear out spots for new patients who are seen at greater frequency, and who would pay the initial intake fee. 

In other words, doctors are rewarded for high patient turnover, and the growth and earning power of their practices are limited by the cap on the number of patients they can treat.  I understand the reason for the cap; we don’t want to suddenly have thousands of patients on buprenorphine without adequate treatment and supervision.  But there is always a downside to any regulation, and rapid turnover in some practices is a downside to this particular regulation.

I don’t have any particular advice for people who are being forced off buprenorphine for no fault of their own, other than to seek out a new physician.  Patients who are considering starting buprenorphine may want to ask the doctors in their area about their attitudes toward long-term maintenance.   Hopefully over time at least some of the motivations for pushing people off buprenorphine will become less significant.  For the docs who are doing the pushing, I encourage you to examine your own motivations.  I realize that everybody wants to get back to how they were before becoming addicted to opioids… but it is important to remember that nobody can predict the outcome of a relapse, and some people die.


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