Sums it up nicely.The Great Suboxone Debate
When it was first released in 2002, Suboxone was hailed as a major advance over methadone. But millions of scrips later, critics charge that the seductive opiate "cure" is causing its own epidemic of addiction.
By Jennifer Matesa
Darlene Bryson (not her real name), 33, an office manager in the Texas oil industry, is in a tough spot. Sheâ€™s been taking painkillers since 2008 for rheumatoid arthritis, a related rare skin condition, and chronic back pain. She was prescribed three 7.5 mg Vicodin per day. Eventually she found herself taking 10 or 12. â€œMy Vicodin habit is not always for pain, if you get my drift,â€ she says drily. She especially liked Vicodinâ€”the painkiller hydrocodone with acetaminophenâ€”â€œbecause it slowed my mind down and made me a happy and pleasant person,â€ she says. When I heard this, I wondered to myself at how many other women have told me this story. It was also my own. Vicodin allowed me to â€œfunction.â€
Recently, Darlene told her family doc she was hooked. She was shocked at his response to her honesty: he told her he could no longer treat her and booted her toward a Suboxone program. Darlene also sees a psychiatrist for a mood disorder. â€œHe said that even if I got off Vicodin, I need to be on Suboxone to keep the cravings at bay,â€ she says. But sheâ€™s been reading about Suboxone on the Internet. â€œIâ€™ve heard getting off [Suboxone] will be bad, too,â€ she says. â€œBut if I get off Vicodin, why would I want to get back on another opiate?â€
This is the question many addicts are asking about Suboxone. Should they take buprenorphine, or "bupe," long term mainly to avoid cravingsâ€”and the junkie lifestyleâ€”or heal their bodies by detoxing and staying clean, which is harder and, in certain ways, riskier? Weighing the costs and benefits of each approach is a very personal, even existential, matter, and science can offer only limited advice, since there are no studies of long-term use of buprenorphine in former opiate addicts. Weâ€™re pretty much on our own.
Suboxone is the new kid on the poorly served addiction-treatment block. Its active ingredient, the semi-synthetic opiate buprenorphine, was FDA-approved for addiction detox and drug-replacement therapy in 2002. Among addicts and addiction specialists alike, opinions about â€œbupeâ€ for maintenance therapy are sharply divided. Enthusiasts view long-term buprenorphine treatment as the best available solution not only to the life of crime, unemployment, poverty and dope-sickness led by many addicts, but also to the chronic depression that can follow detox. The opposing camp casts a cold eye on the Suboxone fervor, viewing its prolonged use as potentially devastating and the movement in support of bupe maintenance as a looming disaster in the addiction-treatment field.
There is, however, one thing both sides agree on: the little orange pill is a stellar detox aid. Until buprenorphine hit the scene eight years ago, most people who wanted to kick an addiction to heroin or prescription painkillers had only one option: methadone, a reddish liquid in a little cup dispensed at crowded, dismal special clinics because it is a Schedule 2 drug. But Suboxone (schedule 3) was hailed as the first in a new generation of addiction treatments that would revolutionize recovery, removing patients from detox and rehab centers, long viewed as sponsors of relapse, and into doctorâ€™s offices and a pill-a-day routines. One of the primary advantages of buprenorphine for addiction-treatment is the fact that its partial-agonist quality prevents it from triggering respiratory depressionâ€”and thus overdose. In France, where the drug was in use for a decade prior to FDA approval, fatal overdoses of heroin and other opiates fell by 80%. The first bupe program for recovery from opiate addiction in the US, at Columbia University School of Medicine, recorded an 88% success rate at six monthsâ€”success being no return to street drugs.
â€œBuprenorphine is the most important advance certainly in heroin and opiate treatment if not all addiction treatments in the last 30 years,'' Dr. Alan Leshner, a former director of the National Institutes of Drug Abuse, told The New York Times in 2004. Bupe works its detoxing magic in a more subtle, refined fashion that methadone. It takes the place of heroin and prescription opiates at the brainâ€™s opiate receptors, binding tightly for days at a time and producing sufficient stimulation to cut withdrawal symptoms. Its binding power is stronger than almost any other opioid, so it kicks all other narcotics off the opiate receptorsâ€”they have no effect.
The reality of addiction, however, has so far stymied such revolutionary hopes. For one thing, bupeâ€™s capacity to soothe the devious cravings that pursue addicts long after detox is limited, at best. Switching from one opiate (heroin, methadone) to another (bupe) does not â€œhealâ€ the neurological aspect of addiction, which is characterized in part by the phenomenon of tolerance: as long as exogenous opiods are taken, the body decreases its production of endorphins and increases the number of receptors.
In the US, buprenorphine is usually prescribed in 2 mg and 8 mg tablets. Two generics are on the market: Subutex is bupe-only, and Suboxone contains four parts bupe to one part naloxone, an opioid antagonist designed to prevent addicts from abusing the drug. If crushed and shot or snorted, the manufacturer says, the naloxone will put the user into withdrawal.
â€œThatâ€™s just dishonest advertising,â€ says Dr. Steven Scanlan, a psychiatrist and addiction specialist. Scanlan is the medical director of Palm Beach Outpatient Detox, in the heart of Florida pill-mill countryâ€”where, he says, more than two-thirds of the nationâ€™s oxycodone or â€œOxyâ€ scrips are written. â€œThe naloxone doesnâ€™t prevent you from shooting it. Iâ€™ve talked to dozens of people who have shot or snorted it.â€
Scanlan says he has detoxed thousands of addicts from all sorts of prescription drugs, including benzodiazepines, like Valium and Xanax, and hypnotics like Ambienâ€”and also alcohol. But his specialty is detoxing opiate addicts, and he uses Subutex for the scads of Oxy fiends who come to him in desperation, many with levels of 300 to 600 mg coursing through their bloodstream. â€œBuprenorphine is the most amazing detox tool Iâ€™ve ever seen,â€ he says flatly.
Iâ€™ve never read any addiction professional declare otherwise: buprenorphine can be a life-saver, especially for people on huge doses of pure pharma drugs. As I was. Iâ€™d graduated from Vicodin to plain hydrocodone to morphine to Oxycontin; for the final three years, I was on at least 100 mcg/hr of fentanylâ€”about the equivalent of 400 to 500mg of morphine. And I couldnâ€™t quit. I might not be here today if it werenâ€™t for Suboxone.
But like so many other drugs, the data the manufacturer showed the FDA for approval of Suboxone told only part of the story. Most clinical trials are small, short-term, and selective, so once the drug is marketedâ€”and Big Pharma is nothing if not a marketing juggernautâ€”its long-term effects in large numbers of people begin to show the drugâ€™s true colors. As was the case with OxyContin, Suboxone is widely promoted by doctors as being nonaddictive, but the experience of many addicts proves otherwise: bupe can be harder to kick than methadoneâ€”and methadone is a beast to kick. At the high doses many physicians prescribeâ€”8 to 24 mgâ€”some say itâ€™s almost impossible to do without professional help.
Meanwhile bupe sales continue to skyrocket. In 2002, some 20,000 US patients were being prescribed the drug; by 2009, that number was 640,000. The Guardian reported last year that Reckitt Benckiser, the maker of Subutex and Suboxone, saw its pharma earnings shoot up by more than sixfold between 2004 and 2009, largely thanks to US sales of the drugs. "Buprenorphine is now the 41st most prescribed drug in the US. Five years ago, it was 196th," Scanlan says. "It's a money machine."
While studying anesthesiology, Scanlan became addicted to fentanylâ€”the strongest prescription painkiller availableâ€”and he detoxed in the 2000s using Subutex. Heâ€™s frank about attending the 12-step meetings he was introduced to during the program he entered to save his medical career. â€œI want people to understand I know what theyâ€™re going through,â€ he says. â€œYou want to lead by example. I want them to say, â€˜I want to do what you did.â€™â€ One thing he did was to make a point of not taking bupe for longer than three weeks, on the advice of his detox doctor. â€œOr else Iâ€™d be dealing with a whole different problem,â€ he says.
â€œIâ€™ve seen what long-term Suboxone does,â€ says Scanlan, who switched his specialty to psychiatry in order to help other addicts kick prescription drugs. â€œPeople come in with endocrine problemsâ€”thyroid dysfunction, low testosterone,â€ which kills sex drive, â€œand hair loss. Tooth loss with Suboxone,â€ which is orange-flavored and is usually dissolved under the tongue.
Scanlanâ€™s big concern: bupeâ€™s 37-hour half-life, which makes the drug build up in the body when dosed every day. â€œLook at it this way,â€ he says. â€œIf I maintained you on oxycodone, and every day I gave you one milligram more, youâ€™d never complain, right?â€
One treatment model for Suboxone is as maintenanceâ€”to keep patients on the drug for months or even years while their brain chemistry, which has been severely damaged by heroin or opiate addiction, heals. But Scanlan is a fierce opponent of such long-term bupe use. â€œThereâ€™s no way your brain chemistry can heal while on buprenorphine,â€ he says. â€œYouâ€™re continuing to give someone a narcotic.â€
Buprenorphine is estimated to be 25 to 45 times as powerful as morphine. Scanlan says patients who want to get off the 8 to 16 mg levels physicians typically prescribe must taper very slowly because of the drugâ€™s half-life. â€œWhen I hear that amount,â€ he says, â€œI think, â€˜This is going to take a year.â€™â€ Addicts who are used to detoxing from heroin can be in for a rude surprise when they try to kick a bupe addictionâ€”the lack of energy and the depression can overwhelm.
Most people, including doctors, donâ€™t understand bupeâ€™s strength, Scanlan says. He has noticed that at long-term doses of even 2 mg, bupe can block almost all of a personâ€™s emotions. â€œThey say to me after theyâ€™re off for a while, â€˜Wow, Iâ€™m really having a full range of feelings,â€™â€ he says.
â€œThereâ€™s a saying in recovery communities: â€˜No one needs serenity as much as a drunk.â€™ While theyâ€™re using, they get used to the chaos,â€ says Dr. Jeffrey Junig, a psychiatrist in Fond du Lac, Wisc., and assistant clinical professor of psychiatry at the Medical College of Wisconsin. In his private practice, Junig treats opiate addiction with bupe maintenance; his client base is always at the federal limit of 100, and he has a constant waiting list. His theory about loss of feelings on bupe: Addicts who sober up miss the chaos, the dramatic rollercoaster ride of using, and the comparative boredom of being on bupeâ€”a facsimile of realityâ€”makes them think theyâ€™re having no feelings. In fact, there is some evidence that bupe may be an effective antidepressantâ€”opiates have, of course, been used forever to lift moodâ€”but only one small study has been conducted (seven out of 10 patients with drug-resistant depression responded positively).
Junigâ€™s YouTube videos, blog, and public forum about the drug make him a high-profile booster of bupe maintenance on a mission to counter what he calls the drug's enormous stigma. His advocacy of bupe maintenance is based on â€œthe least worstâ€ logic. Most of his patients who have tried to detox off, he says, return to legal or illegal drug use. Worst of all, some OD. â€œI want addiction to be treated like every other chronic fatal illness,â€ he says. â€œWe put people through treatment, they clean up, they come out looking good, we all congratulate ourselvesâ€”and then six months later, the patient dies,â€ he says. â€œAnd no one cares about this. Thereâ€™s no review of what we might have done better, the way there would be if the patient died of a heart attack, for example.â€
When patients take buprenorphine, he says, they quit stealing and lying, they become employable. â€œEspecially if theyâ€™re over 40, they do well,â€ he says. â€œItâ€™s like theyâ€™re taking their blood-pressure pill.â€ Is his solution to put addicts on bupe forever? â€œNot necessarily forever,â€ he says. â€œEvery person I see, going off Suboxone is part of the discussion.â€ But he says that when a client wants to taper off, he tells them frankly that the odds are against them because studies show 100% of opiate addicts relapse after detox.
Asked for citations for these 100% studies, he says, â€œI donâ€™t have them at my fingertips. Actually, itâ€™s based on a lot of personal experience. I donâ€™t know if people at treatment centers would even argue this point. They would tell you that with people addicted to opiates in particular, they tend to go through treatment over and over and over."
"There has been virtually no research on persons dependent on prescription opioids, in spite of the increase in prescription opioid abuse and in the numbers of persons entering treatment for addiction to prescription opioids," Dr. Roger Weiss said at the 2010 American Psychiatric Association annual meeting. Weiss, a professor of psychiatry at Harvard Medical School and chief of the Division of Alcohol and Drug Abuse at McLean Hospital, outside Boston, was presenting a study he conducted designed to figure out how to manage patients when they refuse care in drug-abuse treatment programs. He found that of 653 prescription-opioid addicts, those who were given bupe and then tapered off over nine months, without any other intervention, consistently went back to drugs.
I asked Scanlan about this study. He said that 100 percent of his patients who detox off bupe and work a program of recovery, which may be the 12 steps or some other spiritual-fitness approach, stay soberâ€”but not everyone wants to work that hard.
Junig disagrees. "The people who try abstinence, theyâ€™re like the starfish on the beach. There arenâ€™t many of them.â€
Is Junig perhaps one of those starfish? Like Scanlan, Junig was also an anesthesiologist; by the mid-1990s he was prescribing himself codeine cough syrup and drinking so much of it that he hid the bottles in his carâ€”until his wife found out. Junig went through a 90-day inpatient treatment program. Since a 2000 relapse, he says heâ€™s been sober.
What does he do to stay straight? â€œI donâ€™t talk about this to anybody," he says, although he does allow that he has participated in NA and AA. But he says he doesnâ€™t think theyâ€™re necessary for many people on long-term bupe. â€œThere are no cravings [on buprenorphine] because nothing is ever wearing off,â€ he says. â€œThe result is that people feel completely different, very quickly. It is not about the blocking of withdrawal,â€ he emphasizes.
Despite radically opposing views, whatâ€™s clear is that each of these physicians is operating out of his own conviction that people with addiction need better treatment than theyâ€™re getting.
Darlene Bryson, for one, simply doesnâ€™t know what to do. She feels caught between her desire to escape the rat-race of addiction and her fear of slavery to cravings. She quit Vicodin cold turkey, but then had a pain flare-up that sent her back to the doctor for Norco, a lower-dose version of Vicodin. She has disciplined herself to stay within the dose of four to six tablets per day, but itâ€™s a struggle. And the Suboxone program would require her to take an entire week off from work for in-office administration of the drug. Shunned by several physicians because of her addiction, yet in need of pain treatment, she hasnâ€™t yet found anyone who canâ€”or willâ€”treat both problems.
â€œIâ€™m having a hard time not being on [Vicodin],â€ she says. â€œI thought I was doing the right thing by telling the truth. Now I just wish Iâ€™d never said anything, and suffered in silence.
Suffering in silence is an unsatisfactory and unfortunate answer. It sucks, frankly. I've done it myself. But until better ways of treating pain are foundâ€”and the social stigma of addiction reducedâ€”itâ€™s an answer many patients will opt for, either off drugs or on. So bupe detox or maintenance, for now, remains a difficult personal decision.
It was a decision I muddled through. In 2008, while continuing to take large doses of fentanyl, I found my way into the care of a knowledgeable and compassionate outpatient detox doctor who uses bupe. I had no idea what I was doing or where I was headedâ€”all I knew was this: Iâ€™d become a slave to the drugs that had once helped me cope with intractable pain, and I couldnâ€™t bust the chains on my own.
After a difficult induction onto Suboxone, I felt better than well. I woke on my third morning in detox to a crystalline Labor Day Weekend. Standing at the back dining room window I marveled that the sun was actually shining on my skin, that the garden smelled gorgeous. â€œThe world is beautiful,â€ I said.
â€œYou havenâ€™t said that in years,â€ my husband said.
I quickly tapered from 14 mg to about 6. Many other things returned that had been diminished for years: my senses of taste and smell; strong appetitesâ€”for food, sex, work, humor, life. Music sounded somehow psychedelically brilliant, and I sang in a clear voice. I laughed, a rich full laugh that I recognized from, it seemed, another life. And I slept well.
So of course I asked my doctor if I could stay on Suboxone forever. He had no more maintenance slots left. And then, two or three weeks in, still at 6 mgâ€”I was dragging the taper out as long as I could, because I Felt So Wellâ€”the affair went sour. My appetites gradually diminished. My voice clogged up again. My attention was constantly dragged back to how I was feelingâ€”and whether it was time for my next dose.
It took me six more weeks to get off Suboxone, and it was during that time I started going to meetings. I probably could have tapered more quickly, but what slowed my descent onto the tarmac was simple: I was afraid of having nothing left to take. I had taken painkillers every morning, to cope, for so many years. Now, fortunately, I donâ€™t have to.
Jennifer Matesa writes about addiction and recovery issues on her blog, Guinevere Gets Sober. She is the author of two nonfiction books about health issues, including the award-winning journal of her pregnancy, Navel-Gazing: The Days and Nights of a Mother in the Making.
This may have been posted before (it's from last year) but I hadn't seen it, so posting just in case.