I have been on Suboxone for 2 years. My addiction was Oxycontin.  I had knee replacement surgery and was successfully able to take pain meds and then get off them and go back to Suboxone. My medical Doc and I noticed that when I restart the Suboxone, I get 2-3 plus pitting edema in my legs, severe enough to require diuretics– and they don’t even work very wel. When I have stopped Suboxone in preparation for surgery, I immediately lose 15 lbs and the edema goes away. My Suboxone Doc says that there are no side efffects. I am 53 and have heart disease, and I know that this extra fluid is not good for my heart. My kidneys are normal. Have you heard other comments of this nature? Is it dose related?  This is a serious situation for me.

Reply:

I have had two or three patients with similar complaints.  To put things into perspective, though, over 5 years I have treated over 400 people with Suboxone or buprenorphine.  One person in particular had very bad edema, that caused a great deal of pain in his legs– so much that he stopped the Suboxone and went back on opioid agonists.  In his case, though, the edema did not lessen on agonists and he still struggles with edema a couple years later.  I don’t know if he had edema before I met him and started Suboxone;  he claimed that the edema was a new development, but I have learned that people sometimes notice things related to their health status that differs from the perspective of an independent observer.  This is why, by the way, I don’t fully jump into agreeing with people who report tooth decay ‘that starts after starting Suboxone.’  I had a patient with that complaint, and to look into things we got a copy of his dental records;  they showed that the decay was well underway years before he took Suboxone, at least according to dental notes and x-rays.  But in his mind, it all started after the Suboxone.  The mind sometimes plays tricks on us.

When I worked as a psychiatrist in the WI prison system, women in the maximum security prison reported leg edema from many different medications.  I never knew what to make of it, to be honest.  Most of the time the medications complained about were easy to replace;  if someone felt that the Seroquel caused edema, we could change it to Risperdal.  If someone complained about Risperdal causing leg edema, we could change it to Seroquel.  It reminded me of the old Dr Seuss story about the Star-Bellied Sneetches.  I strongly recommend the story for those who haven’t read it…

I like to think in terms of mechanisms, and I don’t have a good theoretical mechanism for leg edema from buprenorphine or from naloxone.  The collection of edema in the legs usually comes from an imbalance of the natural forces that should be in equilibrium;  gravity or ‘hydrostatic pressure’ causes fluid to leak out of blood vessels into the interstitial spaces, salts in the plasma and interstitium create ‘osmotic pressure’ that becomes balanced, with a neutral overall effect on fluid movement; and proteins in the plasma cause ‘oncotic pressure’ that draws fluid back into the blood vessels.  Veins in the legs are emptied by the effects of muscles that squeeze them during walking or exercise; one-way valves prevent the blood from moving backward or standing in place during this activity.  Taking all of this into account, edema is favored during immobility, when the legs are ‘dependent’ (not elevated), when protein levels are low from malnutrition or liver failure, or when the valves in leg veins have become damaged by standing too much in life.

Preventing edema involves keeping legs elevated as much as possible, reducing salt intake, wearing support stockings, and sometimes taking diuretics or ‘water pills’ to eliminate extra fluid at the kidneys.    Opioids do have effects on a number of hormones;  there are large protein molecules that are cut into smaller pieces that include endorphin and enkephalins, the brain’s ‘natural opioids’.  Other parts of those same large molecules have effects on fluid balance, among other things– the inter-relationships are complex and not entirely predictable.

I am posting this in case others have noticed similar effects, or in case a good endocrinologist or nephrologist has a pet theory.  Anyone?

A question/answer post for tonight:

As you know, generic Subutex is cheaper than Suboxone. I want my doctor to switch me to Subutex, but I am so afraid to ask him.  Even though my doc is nice to me, what if he is one of those doctors….gets mad at me, and discharges me as a patient?  I can’t do something that could possibily send me back on that old course of life that seems more and more distant every day.

Can my doctor legally prescribe me Subutex rather than Suboxone?  What good reason could he have for not agreeing to, once I show him how much money it will save me?   Also, do doctors make extra money by writing a prescription that is filled at a certain pharmacy?

My reply:

Thanks for your question.  Isn’t it sad that people are afraid that their doctors will cut them off of life-saving treatment?  The writer is not paranoid;  there are practices where patients are treated as ‘guilty’ just for asking questions that make the doc uncomfortable.  Such a situation does NOT foster the open communication that keeps addiction out in the open, where it can be treated properly and effectively.  And such a situation is a far cry from treating addiction as the disease that it is, rather than a character deficiency.

Any doctor who can prescribe Suboxone can also prescribe Subutex.  There is no difference in the actions of the two medications when they are taken properly;  Suboxone contains naloxone, that supposedly reduces IV use of Suboxone.  But studies show that most ‘diversion’ of buprenorphine is for ‘self-treatment’ of opioid dependence– not for the sake of getting an opiate high.  I suspect– but have no proof– that the RB reps encourage docs to think that if they prescribe generic Subutex, their patients will be shooting up in their lobbies.  This keeps docs prescribing brand-name Suboxone– at least until the Teva generic becomes available.

The main reason a doc won’t prescribe the generic then is fear of diversion, which in my opinion is overblown– not  because there is no diversion, but because both Suboxone and Subutex are diverted at an equal rate and used for the same thing– for illicit self-treatment.  Some docs probably avoid the generic to avoid a common problem– if the pharmacy doesn’t have the generic they will substitute the very-expensive, name brand Subutex– often resulting in calls to the doctor for prior authorizations or replacement scripts.  It is currently easier for the doctor to simply write for Suboxone.  Docs should realize, though, that the cost difference is quite significant;  in my part of Wisconsin, generic Subutex is lesss than $3.00 per tab, and Suboxone is over twice as costly.

I have heard of places in Florida (sorry Florida– maybe it happens elsewhere too, but you folks have a reputation for this) where docs provide scripts for pain pills with the condition that people use specific pharmacies.  I am surprised that such an arrangement would be legal;  it is clearly unethical to have such a conflict of interest.  That arrangement would violate Medicare law, but if they avoid Medicare patients, perhaps they can get away with it…  But to answer the question, I have never seen such a situation in my part of the country.  Docs– post anonymously if you are willing– has anyone heard of profiting by prescribing certain medications?

To the writer, I would like to just say ‘ask your doc if he/she will prescribe the generic.’  I can tell you that I would certainly not be ‘offended’ in any way, or think poorly of you.  Of course there is always some value in being polite;  no doctor likes being told what he/she ‘has to prescribe!’   But you know your doc and I don’t.  If your gut says tread cautiously, then tread cautiously.  You could always ask your pharmacist if doctor so and so ever prescribes the generic– although pharmacists tend to treat addicts even  more poorly than doctors do!

For the docs out there, maybe it would be appropriate to ask yourselves, ‘is this MY patient writing to the blog?  And if it is, why is he afraid to talk to me?’

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.

JJ

I AM looking for a way to pay for upgrades for the blog and for the forum;  I am looking at funding opportunities through NIDA, SAMHSA, or pharmaceutical companies, but to date have not formally applied for a grant.  If a reader would like to be listed on a ‘supporters’ page, either by name or by listing the name of a business, please send me an e-mail at support@suboxonetalkzone.com .  If I ever do receive support from pharma or other industries, the support will be disclosed openly.

While remission therapy with buprenorphine will likely become the standard treatment for opioid dependence, there will be some cases where tapering off buprenorphine is appropriate.  The problem in such cases is that the taper process causes withdrawal, which stirs up all of the self-disgust, fear, and shame that predispose an addict toward relapse.  As I have discussed, a long-term injectable formulation (such as Probuphine, currently in the FDA approval process) would be useful for tapering off buprenorphine.  The final piece of the equation would be effective treatments for opioid withdrawal. 

A number of medications are rumored to help reduce the symptoms of opioid withdrawal.  I’ll mention a few of the medications that I have used to treat withdrawal, or that I have read about in scientific studies or case reports.

- Clonidine is the ‘standby’ agent for treating opioid withdrawal.  The medication reduces CNS excitation by effects at alpha-2 adrenergic receptors, causing less release of epinephrine and norepinephrine by central and peripheral nerve terminals.  Symptoms of withdrawal are reduced by about a third, and the primary side effect is sedation.

- Some medications target specific components of withdrawal;  Imodium (generic name loperamide) reduces bowel cramping and diarrhea; benzodiazepines reduce anxiety (but are themselves addictive); ibuprofen and acetaminophen reduce muscle aches and headache; stimulants or wellbutrin reduce fatigue (perhaps for severe symptoms, but use of stimulants would be considered controversial at best).

- Proglumide is an antagonist of two classes of receptors for a gastro-intestinal hormone called ‘cholecystokinin’, or CCK.  Proglumide used to be used in the US and elsewhere to treat gastric ulcers, before more effective medications like histamine blockers were developed (e.g. cimetadine).  There are a number of chemicals structurally related to proglumide that have similar actions, that include enhancing analgesia caused by opioids, treating Parkinsons disease, and enhancing the release of growth hormone.  Proglumide appears to ‘reset’ tolerance to opioids in people who are physically dependent, and also to reduce symptoms of withdrawal.  Proglumide appears to have dropped of the face of the planet;  if you search for the medication you will find it available in chemical supply houses in China, but not available through pharmaceutical companies.  I recently received contact from a person claiming that  proglumide is available through a company based in Pakistan, but I have not yet verified the information.  Stay tuned.

- I recently came across an article with some fairly convincing evidence that symptoms of withdrawal are reduced by the anti-anxiety medication buspirone.  A study found that self-reported withdrawal symptoms of opioid addicts were greatly reduced by treatment with buspirone, which is a pretty safe, inexpensive medication that is not itself addictive.

- Ondantreson is an anti-nausea medication used during chemotherapy and surgery.  I have seen several studies demonstrating a reduction in opioid withdrawal from the medication, which like buspirone is fairly safe and is not addictive.  Ondantreson is, however, more costly.

I have treated patients in withdrawal using gabapentin, specifically to reduce sweating and hot flashes.  I do not know if it works, or if the people who liked it were getting a placebo response.  I have not seen reports in the literature showing this benefit.

- I have mentioned the recent approval of transdermal buprenorphine, called ‘BuTrans.’  This formulation provides a lower range of doses of buprenorphine, in the tens to hundreds of micrograms (one tablet of Suboxone contains 8000 micrograms of buprenorphine).  This lower dosed formulation may find usage for tapering.

Do you have other suggestions for treating opioid withdrawal?  If so, please share them in the comments below or over at SuboxForum.  Of course, these medications must NOT be taken ‘on the street,’ but rather should be discussed with your physician if and when the time comes to taper off buprenorphine.

Thanks all,

JJ

I’ll add, for those who still object to the concept of requiring long-term buprenorphine, that we don’t think twice about ‘remission’ treatment of many other diseases;  we don’t object to treating hypertension, diabetes, or asthma throughout a person’s life, for example.  Where did this idea start that addicts only deserve temporary treatment for their disease?

Michigan is a state with a different approach than that of Wisconsin.  Michigan will cover buprenorphine in general after a prior authorization, but after six months authorization must be sought again.  Up until recently it was difficult to obtain coverage beyond one year.  I have a few patients who have managed to remain covered beyond a year, but doing so requires jumping through several hoops;  the state of Michigan wants to see the results of urine tests and wants to see a ‘plan for discontinuation of buprenorphine,’ for example, before reauthorizing buprenorphine coverage.

Wisconsin has recently made some changes to their generous policies regarding buprenorphine.  While I agree with the philosophy behind the policy changes, the enactment of the policies can work against an addict’s sobriety in some cases.   One of my patients had been filling her script a day or two early each month for about six months.  She received notice that a count of her scripts shows that she should have about 14 extra tablets of Suboxone, because of those early fills.  Ideally the state would be correct;  if she took the exact dose each day (as she should) she would have the extra tablets in a bottle somewhere.  But like some other people, she occasionally takes an extra tablet of buprenorphine.  She may forget whether she took her day’s dose, and take another ‘just to be safe.’  Or she may occasionally succumb to the forces of addiction that create psychological cravings, and on a stressful day imagine that an extra tablet of buprenorphine will make things less stressful.  Of course, taking that extra tablet does almost nothing, as her blood level of buprenorphine is already above the threshold of the ‘ceiling effect.’  But many people succumb to those cravings all the same.  My job as their physician is to help them see what that extra use truly represents– i.e. their addiction– and to help them get their use under control and on schedule.

Wisconsin Medicaid deals with the situation by telling patients that they can have no buprenorphine for the number of extra days that they have accumulated– if they have accumulated 7 day’s worth of early refills, the State makes them do wihout buprenorphine for 7 days before allowing a refill.  You might think ‘that’s OK— I’ll pay cash for a few days.’  But the pharmacy involved would not allow the patient to do even that, saying that ‘if you have the money to buy your own, you shouldn’t be on Medicaid in the first place.’    Wisconsin has taken similar steps in related situations;  a patient (I carry 100 patients) who was struggling received pain pills from the ER for a visit for headaches, and when the State of WI got the bill, they sent a letter to the patient telling her that they would no longer cover buprenorphine for her– ever.  Again, I understand the need for limits and rules, but such a decision literally has life or death ramifications.  Keeping with the disease approach, I see the struggle of this particular patient as I would view a diabetic who eats sweets and needs extra insulin or even hospital admission, or similar to the person with hypertension who struggles with dietary changes or exercise.  All of the diseases mentioned, including addiction, are manifest by occasional relapses or compliance problems by patients.  Onlywith the disease of addiction are compliance problems handled by cutting off access to treatment!

I do understand the need to tighten the control of prescriptions for opioids including buprenorphine, although I question why there are greater efforts to control buprenorphine than there are for opioid agonists like oxycodone.  I have not, for example, heard of prescriptions for oxycodone cut off because a patient used other controlled substances.  Instead, such situations result in a letter to all of the patient’s prescribers notifying  them that the patient is seeing multiple doctors.  The patient is NOT cut off from further coverage for medication, as is the case for buprenorphine.

The bottom line:  if you are taking buprenorphine, every tablet should be guarded closely, kept safe, and fully accounted for.  While I don’t agree with the double standard used by the State or with cutting off coverage for patients who are not yet completely stable, we are in the midst of a serious public health problem with opioid dependence, and the magnitude of the problem raises the bar for everyone to reduce complacency and prevent diversion.

Since then I have tried to look at the twelve steps ‘scientifically;’ to determine the essence of the program that leads to such incredible change in SOME cases.  With the introduction of buprenorphine maintenance, my opinion holds that the only way to live a clean life OFF buprenorphine is to adopt a life based in the steps.  The problem is that finding real ‘change’ through the steps (or through any other program) requires that the person abandon his/her former way of living, and that requires desperation.  And unfortunately, once on buprenorphine, addicts are no longer desperate.  I do not see any solution to this stale-mate situation.  Desperation is needed for change, and buprenorphine eliminates desperation.  So the addict must stay on buprenorphine to avoid using, and to avoid desperation.

The question that comes to mind is whether it is a good idea to stop the buprenorphine, thus bringing on the desperation required to change?  In some cases yes– when the person is using multiple substances and life is careening out of control, I think that buprenorphine might only prolong the agony, and the appropriate action is to stop it and allow the person to feel the consequences of his addiction.  But for pure opioid addicts I have a harder time recommending that they discontinue buprenorphine for the sake of bringing on desperation, because the risk of death during overdose is simply too high.

My philosophy for buprenorphine treatment is to try to add the elements of recovery that I found in the steps– to somehow pass them on to the patient without desperation.  I don’t know if that can be pulled off, but that is what I try to do.

I want to share this interesting story about the mechanism of AA from Wired magazine: http://www.wired.com/magazine/2010/06/ff_alcoholics_anonymous/5/

Death rates due to accidental overdose

The largest newspaper in Milwaukee Wisconsin has featured several articles about the local prescription drug problem.  I spoke with the author of the latest front page story about the subject, and tried to explain the complex nature of the problem.  I hoped that he would do the topic justice by writing something deeper than the typical ‘find someone to blame’ article that most papers resort to these days.  I even offered to set him up with a patient of mine who used those Florida-based pain clinics in the past, who ended up on ridiculously-high amounts of pain medication, and still struggles years later to lower his tolerance level.  The patient would have explained that it isn’t just ‘bad doctors.’  He would have explained that sometimes the problem is that a person will have severe pain, and will not be able to say ‘no’ to relief of that pain.  He would have explained that more and more doctors are simply ‘opting out’ of prescribing pain medications;  that if he had the gall to say to his primary care doc that his back hurt, his doc would have cut off the discussion and looked at him suspiciously from that point forward.  Because so many docs won’t deal with the difficulties associated with treating chronic pain, patients are left searching for pain pills in all the wrong places– and left taking them with little or no guidance or supervision.

Unfortunately the Milwaukee Journal-Sentinel writer took the easy way out, and instead of trying to capture the true essence of the problem he wrote a hack piece about ‘pill pushing doctors.’  I don’t personally know any of the docs he pointed out by name in the story– the story he wrote from the safety of behind his desk, where like most reporters he never has to make the tough decisions himself.  I wonder, though, if all of the docs he smeared were ‘bad docs,’ or rather if some of them were struggling with the tough questions that many docs now choose to avoid.  The article featured a photo of a tearful couple who lost a family member to overdose;  their daughter was being treated by one of the pain docs presented in the article as the lowest-of-the-low, a pill-pusher who destroyed the girl’s life.  And my heart goes out to those parents.  I see many people just like them in my practice; parents who have lost a child or who are struggling with the decision whether to put their addict-son or addict-daughter out on the street, or to instead let them live in the basement where they are using every night, where the parents dread looking each morning, into the dark silence, afraid of seeing their worst fear come to pass.

Drug deaths become number one

I don’t know the pain doc smeared in that article, but I do know what it is like to sit in the office with a person crying out in pain, begging for medication to provide relief from that pain. I was an anesthesiologist for ten years, after all, working in a pain clinic of my own.  And when treating someone’s pain, there is no way to get inside that person and determine exactly what the person is experiencing.  Yes, there were many times when I wondered if the pain was REALLY that severe.  There were some things I could try to use to determine whether the patient was ‘faking;’  I could check the respiratory rate, the blood pressure, and try to determine if the tears were real, or came from the drinking water down the hall.  My answer about faking, most of the time, was that the patient was NOT faking.  The patient was experiencing severe pain.  I knew that many people with the same injury would NOT have such severe pain, but for some reason this person DID have severe pain.  Who was I to say differently?  How can any doc listen to a patient describe severe pain, and then look at the patient and say ‘no– you are not in pain.’  Would YOU go to that doctor? 

Are you ready for the complicated article that Tom Kertscher of the Milwaukee Journal Sentinel SHOULD have written?  Those grief-stricken parents in the picture in his article about pill-pushing doctors, who are mourning the loss of their daughter and struggling to assign blame, are blaming the guy who might be the ONE doctor who truly cared, and who tried to help their daughter.  The daughter came to him, looking for help for her pain.  Other doctors turned her away, and told her ‘you DON’T have pain,’ when in reality they didn’t know whether she did or not.  They just knew it was easier to tell her to take a hike, or to say ‘I’m sorry, but I don’t prescribe pain pills,’ or to say ‘my healthcare system won’t let me prescribe them.’  Those doctors who ignored her pain didn’t know if her pain was real or not.  But there was one thing that they DID know– they knew that if they DID empathize with this patient, someone’s daughter, and if she ended up taking too many of the pills one night, they knew that some reporter hack would come ’round and blame them in some one-sided, simpleton-pleasing, ‘gotcha’ article in the Milwaukee Journal Sentinel.  So those docs closed their hearts to the pleadings for pain relief from a patient and kept their licenses for another day.  And the doc who couldn’t say no to her requests for help– who gave in and prescribed pain-relieving medication for the couple’s daughter– ends up being the bad guy.  Go figure.

Deaths rise as prescriptions rise

I have to point out that for non-malignant pain that has no finite endpoint, narcotics are rarely a good answer.  I have had patients say to me ‘I would rather live without pain for today and die next year, than have pain for the next twenty years,’ and to that I have said ‘that is why you need a doctor.  I cannot let you make that choice.’  I recognize that there ARE docs who prescribe pain pills MUCH too easily and loosely, causing a great deal of trouble for the patient in the end.  But they don’t prescribe because they are ‘evil;’  they prescribe because they have a hard time ignoring someone’s pain.  Maybe they need help dealing with confrontation.  Maybe they need to toughen up a little bit.  But they are not ‘evil.’ 

This is a little of the story that SHOULD have been written about the pain pill epidemic.  Then it could go into how people these days want everything to be ‘fixed,’ and that is why everyone takes pain pills.  Or it could say that the bad economy puts so much pressure on people to avoid missing work that they cannot rest an injury, and that is why everyone takes pain pills.  Or it could say that the violence of the inner city or the divorce rates in the suburbs leave people with emotional pain, and THAT is why everyone takes pain pills.   If only every problem had something to blame. 

I’m struggling with closing this post, and it is getting way too late.  I’ll just say one last thing– for those with young kids, keep talking about how horrible this problem is.  Don’t glamorize it, because it is not pretty– just let them know that unlike many things that young people do, taking pain pills incorrectly causes something that lasts a lifetime.  I invite people to check out some of the links in my ‘blogspot’ to see some of the faces of the epidemic, and to share those with your kids as well.

JJ

Acesulfame Potassium

Well, i’ve been clean with the help of Suboxone for 14 months now. Throughout my treatment I’d been getting tongue blisters and ulcers at least two at a time. I’ve probably had them six to eight different times in this 14 month period. I realized something wasn’t right, and started investigating, trying to figure out what the problem was. I watched the foods I ate and the things I drank. Nothing seemed to work; they just kept coming back. So, the only thing I could think of was the Suboxone.  I read the pamphlet that comes with the medication. The artificial sweetener in Suboxone (Acesulfame K sweetener) is what I am allergic to. I have been allergic to artificial sweeteners my entire life. I had been taking a medicine I’m allergic to for 14 months! I admit, i should have done more research from the start. But I was so desperate for relief that i would have done anything to get rid of withdrawal. I also checked the ingredients in Subutex. It does not contain Acesulfame K sweetener. I went to my next doctor appt. and told my doctor my findings. My doctor was a complete jerk. When I brought up pretty much the only option I had and asked ‘could you switch me to Subutex?’  He said he usually only uses Suboxone but because of my allergy there wasn’t any other choice.  I said ‘will you write the prescription so that i can get the generic just in case Subutex isn’t covered?’  He said, ‘nah I really don’t want you taking generic.’ I said, ‘do you mind going to check and see if you can find out whether Subutex is covered?’ he leaves for a few minutes, comes back and says ‘nope it doesn’t cover it.’ Then he says, ‘ I’ll go ahead and write it so that you can get generic.’ He was very angry. I can only guess it was because the generic is made by another company.I could take this discussion in any of several different directions.  But instead of getting angry tonight at doctors who may have hostility for addicts (or perhaps addicts who perceive something else as hostility–  I wasn’t there, so I don’t know what happened), let’s look at the issue of allergy to the artificial sweetener in Suboxone, and the issue of prescribing brand vs. generic and Suboxone vs. Subutex.  For people who are interested, I took the discussion in an entirely different direction on the forum, where I took Reckitt-Benckiser to task for their limited number of slots in their patient assistance program.

Some background:  Brand Suboxone and Subutex have been the only bupe game in town until last fall, when a generic version of Subutex appeared on the scene.  Access to the medication has been a constant frustration since then, as distribution gets backed up and the price continues to rise– now almost double the initial price of about $2.50 per 8 mg tablet.  People in Wisconsin can generally find the generic by ordering it ahead of time at Walgreens– a company I am loathe to refer people to, but that at least has been able to get the medication.  That is if one of their pharmacists doesn’t decide to tar and feather you and post you on the wall along with those other darn drug addicts!

The generic version of Suboxone entnered the market about a month ago thanks to Teva pharmaceuticals, a large generic company that SHOULD be able to meet demand, but that so far does not have tablets on the shelves in Wisconsin.  The hope of many people, of course, is that the advent of generics will bring down the price of buprenorphine.  That SHOULD happen, provided that doctors don’t fall for whatever anti-generic nonsense is thrown their way by the sales force for Reckitt-Benckiser.

This is the point, by the way, where a company’s ‘true colors’ show.  Reckitt-Benckiser makes a big deal of talking about how they are NOT about the money– they are all about HELPING ADDICTS, and really don’t hardly notice that their company profits continue to surprise to the upside, pushing the stock price higher.  And I’m sure it is completely by accident that the price of Suboxone is so high, and that the high price has gone higher by about 50% over the past two years, at a time when everything else in the world is getting cheaper.  I figure that somebody accidentally moved a decimal point,  just like that crazy day in the stock market a month ago.  They probably THINK that Suboxone sells for $0.60 per tablet, not $6.00!

I’m sorry for sounding annoyed.  My anger stems from my suspicion that RB ISN’T just about saving lives.  Don’t get me wrong– I love capitalism.  But only when ruled by honesty, especially in the healthcare sector.  I have heard and read comments from the sales reps from Reckitt-Benckiser that suggest a concerted plan to tarnish competitors in a way not done by other companies about other generics.  I do not know what happened to their plan for a listerine-strip type of product, individually packaged, but they clearly planned to attack their own formulation just as soon as they got approval for the new product.  But so far, the dissolving SL tablet in a multi-dose vial appears to be just fine!  Watch for that to change. 

Reckitt-Benckiser is also playing up the diversion-potential of Subutex, even though they know that the vast majority of diversion cases consist of addicts self-treating their addiction, taking the tablet by the usual sublingual route– NOT injecting it.  But it protects the sales of Suboxone if the doctors and pharmacists (and DEA) are under the impression that prescribing Subutex is taking a big risk.  Is Subutex ever injected?  Of course.  But only a small fraction of diverted Subutex ends up used that way.  For the most part, Suboxone and Subutex are the same medication– except until recently one had a generic and the other did not.  I even suspect that some RB reps deliberately allow confusion over how Suboxone works– i.e. not explaining that Subutex contains EVERYTHING necessary to treat opioid dependence that is present in Suboxone.  Some docs think that the naloxone in Suboxone adds to the opioid blockade (it does not, when taken sublingual) or reduces cravings (it does not).

I did some reading on the artificial sweetener in Suboxone, and the writer is on the right track– and I hope he is prescribed the medication that he needs, rather than suffer with mouth sores.

I encourage physicians to take all factors into account as they take on this nasty illness.  On one hand, I resist the complaint that ‘I can’t get help because Suboxone is too expensive’ because active using is always much more costly– even before considering the costs to one’s occupation or to one’s relationships.  But physicians have long-relied on generics to increase availability of life-saving medications that otherwise would be beyond reach for many people– particularly during a nasty recession. 

Makers of generic buprenorphine, please continue your good work, and good luck to the new products entering the market– for example Butrans, which was approved a few days ago, and Probuphine, a long-term injectable form of buprenorphine that I suspect will be a great help for the final stage of buprenorphine remission treatment, i.e. stopping treatment with buprenorphine.  Let’s hope the FDA recognizes the demand for that delivery system.

JJ

Of course the remaining problem with any opiate taper is that the person must suffer through some degree of discomfort and craving, while at the same time holding a vial filled with the doses that would make things whole.  Most opioid addicts really struggle at 3 AM under those conditions!.  I’ve been excited about the newer products coming down the pipeline, including the transdermal product Butrans and also an injectable form of buprenorphine called Probuphine.  The latter in particular would be useful for tapering, as the addict could get a slowly-dissolving shot of buprenorphine and then go about life as it wears off, without having a vial of more buprenorphine on the nightstand.  I don’t know if Butrans will have any usefulness for tapering buprenorphine– if it did, such use would be ‘off-label’ as the medication is approved for treatment of pain, NOT for addiction treatment.

Here is the link to the Purdue news release: 

http://www.purduepharma.com/pressroom/news/20100701.htm