My primary concern over use of benzodiazepines is that when used to treat anxiety, they are more likely to aggravate than improve a patient’s symptoms, especially if taken regularly.  Patients develop physical and psychological dependence to benzodiazepines very quickly.  Once physically tolerant, patients experience withdrawal symptoms if doses are missed, and generally interpret the withdrawal symptoms as manifestations of their own anxiety disorder.  The progression from taking alprazolam or clonazepam ‘as needed’ to taking them regularly is as predictable as any other biological process.   And after physical tolerance has developed, symptoms that were once considered manageable become part of an unmanageable ‘anxiety disorder.’

I have learned over the years that the term ‘anxiety’ means different things to different people. The complaint shouldn’t cause doctors to automatically reach for the prescription pad.  When asked to describe his ‘anxiety’ in detail, a patient said ‘I will pace around the house, looking for something to do.  I will turn on the TV and change channels, but there is nothing interesting.  I feel…. restless and bored.  I need to get out of the house, but there is nothing for me to get outside to do.  I’m like a caged animal.  You know— anxiety!’

I responded, ‘you mean you were bored?’

‘No’, he said.  ‘Boredom is when there is something to do that isn’t interesting.  This is just having nothing at all to do.  It makes me uncomfortable.’

There are other types of anxiety, of course.  But this particular patient, after leaving my office empty-handed, received valium, 10 mg, three times per day from his general practice doc.  And I see the same thing happen over and over again.

Even the patients with ‘real’ anxiety, i.e. fear –based dysphoria, are no better off on benzodiazepines than the bored person in the example above.  Benzodiazepines cause amnesia, a function that is useful in the operating room. But amnesia and other cognitive impairments from benzodiazepines prevent people from learning to deal with the source of their fears.  The mental slowing from benzodiazepines also prevents people from learning to tolerate normal fears that we all face in life.  Whatever symptoms of anxiety were present before taking a benzodiazepine will be worse as the drug wears off, as a predictable rebound effect of the medication.  I’ve described other negative effects of benzodiazepines on development, mood, self-image and self-confidence.

In case those issues are not enough, a recent study from the British medical Journal found another problem with taking benzodiazepines; early death.  The precise impact of medications like benzodiazepines on morbidity or mortality is difficult to determine for a number of reasons.  A typical study compares people taking the medications to a control of people who did not use the medications, and statistical measures are used to remove confounding variables.  In other words, statistics are used to subtract the impact of health risks that are more likely in people who take benzodiazepines, but that are not directly related to the medications.  If people taking benzodiazepines are more likely to have psychiatric disorders, then the study population should be compared to people who have the same incidence of psychiatric disorders.  Many factors were taken into consideration for the recent study, including socioeconomic factors, smoking, and age, as well as sleep and anxiety disorders.

The study showed that people taking benzodiazepines have about twice the risk of death as people who do not take benzodiazepines.  If you have a 1% risk of dying in the next five years and you do not take benzodiazepines, your risk of death would be 2% if you did take benzodiazepines.    Studies with this type of design and outcome always generate big headlines, because having TWICE THE RISK OF DEATH is big news.  But on the other hand, two times a small number is still a small number.

Each individual on benzodiazepines, and his/her physician, should take an open-minded look at the role of that class of medications in the person’s treatment.   Stopping benzodiazepines is physically and psychologically challenging, and can cause seizures and death if done too abruptly, so NO person reading this post should try an at-home, cold-turkey detox.  Even slowly tapering off benzodiazepines, under a physician’s care, is usually an arduous process with a number of sleepless nights and irritable days.   The reward, according to patients I have helped off benzodiazepines over the years, can include greater mental clarity, less anxiety, and less fatigue.  But for many people, the odds of successfully stopping benzodiazepines are so low that efforts should instead be focused on preventing dose escalation over time.

Those most likely to benefit from warnings about benzodiazepines are the young people who haven’t yet started them.  Too many doctors are willing to reward the anxiety faced by teenagers with Xanax, three times per day.  Many doctors mistakenly think that SSRI’s are drugs for depression and benzodiazepines are the proper treatment for anxiety. If the normal fears of adolescence demand treatment, an SSRI is the treatment of choice.  Teens taking benzodiazepines attribute their successes to alprazolam, and miss out on the growth in confidence that occurs when anxious situations are learned to be tolerated.  The natural result includes less confidence for social situations, increased tendency to focus on anxiety and somatic symptoms, and a deeply-engrained belief that ‘discomfort’ calls for a pill to make things feel better—a belief that is much easier to establish than to remove.

I’ve searched, since then, for a scientific explanation of how acceptance of powerlessness and belief in a higher power removed, almost instantly, an obsession that I couldn’t control before that moment.  I recognized the preciousness of my recovery as friends from treatment lost their sobriety.  And I learned, at one point, that success in ‘traditional recovery’ requires lifelong attachment to meetings and step work.

Ten years later I was excited by the power of buprenorphine to induce remission of the same obsession. As patients on buprenorphine regained meaningful lives at a pace similar to those who practice traditional recovery, I realized that recovery from addiction and freedom from ‘character defects’ can stem from changes in thought, or from changes in neurochemistry.  I realized that one approach isn’t more ‘natural’ than the other, and that both methods require lifelong efforts to prevent relapse to addictive behaviors.  I wrote the following, several years ago, to explain what I was seeing.

Recovery in the era of buprenorphine

Most opioid addicts are familiar with Suboxone, a medication that erases cravings for opioids, and when used properly creates a state of remission from active addiction.  My initial thoughts about Suboxone were influenced by my own experiences as an addict in traditional recovery.  But that opinion has changed over the years, because of what I have seen and heard while treating over 700 patients with buprenorphine in my clinical practice.

Suboxone has opened a new frontier of treatment for opioid addiction, but arguments over the use of Suboxone split the recovering and treatment communities along opposing battle lines.  The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that Suboxone represents a novel, medical approach to treating addiction.  For the first time, medications are available that allow for freedom from the potentially lethal disease of opioid dependence—a disease that was largely refractory to existing treatment methods.

The active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to deter diversion by the intravenous route.  Another form of the medication, Subutex, consists of buprenorphine without naloxone.  In this article I will use the generic name, buprenorphine, because of the existence of brands of buprenorphine other than Suboxone.  For the purpose of this article, Suboxone and buprenorphine are interchangeable terms.

The unique molecular properties of buprenorphine create an ideal, long-term treatment for opioid dependence.  Partial agonist actions at the mu opioid receptor cause a ‘ceiling effect’ to sublingual doses above about 4 mg, so that larger doses do not increase opiate effects beyond that level.  The high binding affinity and partial agonist effect eliminate cravings for opioids, dispelling the destructive obsession that destroys the personalities of active addicts.  High protein binding and the long half-life allow for once per day dosing, so the addict can break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward), which is the backbone of addictive behavior.  And the ceiling effect and long half-life cause rapid tolerance to buprenorphine, allowing patients to feel ‘normal’ within a few days of starting treatment.

Even properties considered negative by pessimists are benefits to treatment. For example, the discontinuation effects from buprenorphine provide a disincentive to stopping the drug, improving medication compliance. Patients are assured that any attempt to abuse opioids would be futile, reducing thoughts about using.

There are significant differences between the treatment approaches of those who use buprenorphine versus non-medicated, 12-step-based treatments.  People who stay sober through step work sometimes look down on patients taking buprenorphine as having an ’inferior’ form of recovery.  The attitude causes buprenorphine patients attending Narcotics Anonymous to hide their use of buprenorphine.  On one hand, good boundaries include the right to keep one’s private medical information to one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of buprenorphine is at odds with the idea of ’rigorous honesty’. People new to recovery sometimes struggle to overcome the shame society places on ‘drug addicts,’ and are not in good position to deal with even more shame applied by other addicts.

The time has come for a unified treatment approach for opioid dependence.  More medications will be brought forward for treatment of addiction, now that Suboxone has proved profitable. If traditional treatment was effective, we would want to combine compatible aspects of medication-based and traditional treatment programs.  But opiate dependence has been refractory to treatment without medication.  Success rates for long-term sobriety are lower for opiates than for other substances.  One reason may be that the ‘high’ from opiate use is different from the effects of other substances. Users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic.  In comparison opioid users describe feeling content or even ‘normal’, as if gaining something that was always missing. The experience of using rapidly becomes a part of who the person is, rather than something the patient does.

The challenge for practitioners is to find ways to bring the recovering community together, and to use the most effective combination of tools in the struggle against active opiate addiction.

Traditional approach to character defects

Buprenorphine has given us a new paradigm for treatment which is best considered a ‘remission model’.  This model assumes that addiction is a dynamic process.  The traditional view from recovery circles is that addicts have a number of character defects that were either present before the addiction started, or grew out of addictive behavior over time.  Such defects, such as the dishonesty that occurs during active opioid dependence, are common to all substance users.  The addict represses awareness of his/her trapped condition and creates an artificial self that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession to use takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered.  The opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The using addict learns to blame others for his/her own misery.  Eventually, anger and self-centered behavior results in the loss of jobs and relationships.

The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that in the absence of an active recovery program, simple sobriety will create a ‘dry drunk’—a nondrinker with the character defects of an active alcoholic.  I expected the same, when I first began treating opiate addicts with buprenorphine.  I assumed that without involvement in 12-step groups, patients would remain just as miserable and dishonest as active users.  I now realize that I was making an assumption that character defects were relatively static; that they develop slowly over time, and could be removed only through intense step-work.  The most surprising part of my experience treating people with buprenorphine was that character defects were not ‘static’, but instead dynamic, and responsive to treatment with buprenorphine.

The difference between buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program, continues to suffer the conscious and unconscious obsession to drink.   People in AA often say that alcohol isn’t the problem; it is the ‘ism’ that causes the damage.  The same consideration applies to opioid dependence. Opioid use is not as much the issue as the obsession with opioids, for causing misery and despair. Character defects are best considered as features that develop in response to the obsession to use a substance, sustained by the obsession to use.  When obsession to use is removed, whether through working the 12 steps or with buprenorphine, the character defects caused by the obsession to use dissipate.

Fear as motivator

During traditional step-based treatment, the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession through a shift of thinking that allows them to see their powerlessness with their drug of choice.   Other addicts require a great deal of addiction-induced misery to create the change in thinking. But whether fast or slow, the shift in thinking is only effective when it occurs in the neural circuits where addiction lives, i.e. the brain’s limbic system.  The ineffectiveness of higher-order thinking is proven by addicts many times over, as they make promises over pictures of their loved ones and try to summon the will power to stay clean—promises that almost always fail.   On the other hand, addicts find success in surrender and recognition of the futility of the struggle.  The recovering addict views the substance with fear, an emotion encoded by the most primitive brain regions. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use resolves.  Since human nature leans toward independence and freedom, the recognition of powerlessness will fade over time.  So addicts benefit from meetings where newcomers arrive with stories of misery and pain, which reinforce powerlessness.

Buprenorphine and dynamic character defects

My experiences treating patients using buprenorphine have challenged my old perceptions, and led me to see character defects as more dynamic.  Appropriate buprenorphine treatment removes the obsession to use almost immediately.  But instead of creating a ‘dry drunk’, the removal of the obsession to use allows the return of positive character traits that had been pushed aside.  This change in character does not always require rigorous step work. Rather, in many cases the negative traits simply disappear as the obsession to use is relieved.  My opinion grew from experiences with scores of buprenorphine patients, and more importantly with the spouses, parents, and children of buprenorphine patients.  I have seen many instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.

A natural question is why character defects would simply disappear when the obsession to use is lifted?  Shouldn’t such change require a great deal of work?  The answer, I believe, is because the character defects are not the natural, hard-wired personality of the addict, but rather are traits produced by the obsession to use substances, and maintained by that obsession.

Buprenorphine treatment and traditional recovery

When the dynamic relationship between obsession and character defects is understood, the relationship between buprenorphine and traditional recovery becomes apparent.  Should people taking buprenorphine attend NA or AA?  Yes– if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But there is little value in forced or coerced meeting attendance.  The recovery message, including the recognition of powerlessness, requires a level of acceptance born from desperate times, and people on buprenorphine do not feel desperate.  In fact, people on buprenorphine often report that ‘they feel normal for the first time in their lives’.  A person with this state of mind is not going to do the difficult work of personal inventories and personality change unless otherwise motivated by his/her own desire to change.

Desperation plays an important role in personality change, and in traditional treatment is the most important prerequisite to making progress.  Desperation opens the addict’s mind to the reality of his powerlessness. But when recovery from addiction is viewed through the remission model, desperation is less valuable, and may even be counterproductive by interfering with the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943, as there can be little pursuit of higher-order traits when one is fighting for one’s life.

Other Questions (and answers):

-Should buprenorphine patients be in a recovery group?

One can question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there is much to be gained from the sense of support that a good group can provide.  Groups help the addict realize that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle addictive thoughts. New technologies provide additional options for patients on buprenorphine.

-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?

These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  For patients on buprenorphine the steps are useful for personal growth, but not essential.

-How does methadone fit in?

Methadone is an opioid agonist.  Increasing doses of methadone will prevent cravings, but as tolerance inevitably rises, cravings return.  The return of cravings risks the return of associated character defects. But some patients are not able to maintain safe control of prescribed buprenorphine. The daily scheduling, frequent drug testing, and supportive therapy required by methadone maintenance programs provide structure for patients who are not able to manage buprenorphine prescriptions.

Downsides to buprenorphine

Practitioners in traditional AODA treatment programs will see buprenorphine as a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe buprenorphine.  Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time from addiction without committing to long term sobriety.  Buprenorphine can be abused for short periods of time, until tolerance develops to the drug.  Nasal insufflation of buprenorphine results in a faster onset time, without allowing the absorption of the naloxone (that prevents intravenous use).  Finally, the remission model of buprenorphine implies long term use of the drug.  Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary.  Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.

The future

Time will tell whether or not buprenorphine will replace traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opiate addiction has proven to be profitable, and such success will invite research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Someday we will likely look back on buprenorphine as the beginning of new age of addiction treatment.  But for now, the addiction treatment community would be best served by recognizing each approach’s strengths, rather than looking for weaknesses.

Silhouette image available from Shutterstock.

Now THAT’S crazy.  Her recommendations, sadly, will likely be followed in a number of actual patients.  No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.

At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.

Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches.  They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.

Evidence-based medicine encourages practitioners to ignore their own experience, and to instead anchor practice patterns to those supported by peer-reviewed research.  Practitioners should know the difference in predictive value for comments by a mentor, the findings in a case report, and the results of a large, prospective clinical trial.  Practitioners should appreciate the perils of using their knowledge of basic science to extrapolate findings from one set of conditions, to a case where some variables differ.

These distinctions are especially important in an era where insurance companies increasingly try to influence treatment patterns.  For example, there is considerable evidence that Abilify effectively augments the antidepressant effects of SSRIs.  Insurance companies often refuse to cover Abilify, instead demanding substitution with risperidone, a less-expensive medication from the same general class of ‘atypical antipsychotics.’  But there is no good evidence that risperidone provides any benefit for depression.  There are a number of similar situations where insurers require ‘prior authorization’ for the treatment best-supported by clinical evidence.  Many insurers even require a period of treatment failure with a bad medication, before they will consider the best medication. Insurers would argue that they recommend medications that are much less expensive, at the cost of ‘minor’ side effects.  But practitioners who use evidence-based approaches to treatment know that the insurer’s medication selections are influenced by cost to a much greater extent than efficacy.

Back to the original discussion, those who practice evidence-based medicine know that someone who views psychiatry as a ‘gray area’ is someone who didn’t have a strong education in psychiatry or neuroscience, and who doesn’t read much of the psychiatric literature.  To a Board Certified Psychiatrist, the field of endocrinology is a ‘gray area.’  But when treating depression, the psychiatrist knows—or should know– that adding a ‘one milligram sprinkle’ of Abilify has no scientific basis for treating major depressive disorder, whereas a dose between 2 and 15 mg has been effective in controlled, clinical trials. Nothing gray about it.

Patients treated for depression or other psychiatric conditions should be aware of efforts to increase the use of evidence-based medicine in psychiatry.  How does your treatment measure up?  Read more here…

Psychiatrist with patient image available from Shutterstock.

A member of SuboxForum recently wrote that the hospital where her doctor had privileges required that she sign a formal policy about babies born to mothers on buprenorphine.  She was told that her baby must go to the NICU for at least 10 days after delivery, regardless of condition, and she was not allowed to refuse that level of treatment.

Meanwhile, one of my buprenorphine patients came to her appointment last week, five days after the birth of her baby. Mom and baby left the hospital together less than 48 hours after deliver, and she brought the baby to her appointment.   I realize that hospitals discharge patients more quickly these days but her discharge seemed a bit fast, but not because of anything related to buprenorphine.   I just believe that new moms, who are frequently anemic and sleep-deprived, should have a bit more rest before taking on an infant’s schedule.

How can the ‘standard of care’ vary so greatly?  What role does insurance coverage play in decisions about opioid tapers, NICU admissions, and discharge schedules?  After having dozens of patients go through the process uneventfully, without intervention by a neonatologist, I have to wonder if newborns are always positively served by such efforts.

Realize that I respect neonatologists probably more than most people.  As an anesthesiologist, there were times when a baby had to be delivered, whether or not a pediatrician had made it into the hospital.  Doctors in our group  (and in others across the country) argued whether an anesthesiologist had the duty to assist in the resuscitation of the newborn while simultaneously caring for the mother—a difficult decision that resolved as soon as the baby-doctor arrived on the scene.   A good man knows his limitations— and I am not an expert in treating newborns.    But I understand buprenorphine and opioid withdrawal.  After seeing so many babies born to mothers on buprenorphine go home at the normal time, I question the wisdom of using an opioid agonist to taper from a long-half-life, partial agonist.

According to research studies, half of babies born to women on buprenorphine have no objective signs of ‘withdrawal’— a misleading word for the infant’s experience.  I have no doubt that in the typical nursery, neonatal abstinence symptoms are grossly over-diagnosed.  Pointing out neonatal abstinence syndrome is similar to modern-day complaints about global warming, where a phenomenon is blamed for weather that is too cold or too hot, too violent or too calm, or too frozen or too thawed.  Regardless of the presence or absence of climate change, there is nothing scientific about such an approach.  To validate a theory, that theory must be used to make predictions that are then observed–  not the other way around, where every unexpected deviation supports a new version of the theory.  Mothers on buprenorphine describe a similar diagnostic approach to their newborns, where babies who cry are ‘too agitated’, and babies who sleep are ‘too sedated’ (I’m just realizing that climate change is probably too hot a topic, and I should have used ‘the three bears’ instead—and the story about ‘porridge’, whatever that is).

Even in babies who exhibit clear symptoms, do the symptoms warrant ten days in the NICU?  Is a baby distressed by mild neonatal abstinence better off in mom’s lap, nursing with breast milk that has small amounts of buprenorphine, or lying in a plastic incubator under fluorescent lights with multiple IV lines? Some local docs and nurses allow moms on buprenorphine to nurse, a policy that makes tons of sense from an anatomical and developmental perspective.   As the baby’s liver matures, ingested buprenorphine is eventually completely destroyed through first-pass metabolism.  The process allows for a gradual, natural taper, without the misery and cost of IV infusions and monitoring systems.

Decisions about monitoring and length-of-stay revolve around safety.  I question whether the various approaches to buprenorphine abstinence in the newborn are based on informed, intellectual consideration, or are instead are just best guesses by people who don’t care to understand buprenorphine.  Given the 180-degree difference between the approaches of different hospital systems, somebody is doing it wrong.

I’ve complained about how research studies about drug addiction are so-often focused on things like demographics or social policy.  The best approach to treatment of babies born to mothers on buprenorphine should be near the top of someone’s list.  The hard part will be identifying (and following) the conclusions that are derived from science, vs. those that come from concerns about litigation (where the costliest and most-intense treatments always win out).

Baby getting injection image available from Shutterstock.

The shortage is caused by a number of factors.  All doctors train in medical schools, which are primarily located in larger cities.  So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts.  As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views.  Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.

Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine.  The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor.  But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause.  Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge.  But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day. The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a practice without a significant number of non-buprenorphine patients.  And now that most doctors are employees of large health systems, the requirement for inspections is a greater hindrance.  Most major health systems are not as interested in treating addiction— an area of medicine with low reimbursement rates, and patients who are more likely to be impoverished by their illness– as in attracting orthopedic or heart patients, the ‘cash cows’ of modern medicine.  If you were CEO of a multi-physician network, would you permit random DEA inspections of your physicians’ offices in exchange for the ability to treat more patients addicted to drugs including opioids?

I can’t blame those CEOs and physicians for the decisions they make.  The result is a shortage of buprenorphine-certified doctors, and the attraction of businessmen-doctors who find a way to turn buprenorphine treatment into a profitable enterprise, by signing doctors to increase their patient-limit, and seeing as many patients in as short a time as possible.  Other doctors tend to be physicians who enjoy working in the field of addiction because of their own experiences with addiction and recovery.  To those physicians, treating a fatal disease, in a disrespected and stigmatized patients, can be very a very rewarding way to practice medicine.

There are calls to raise the patient cap, or to find other ways to reduce the stigma over opioid dependence that discourages doctors from entering the field of addiction treatment.  But now as more and more states are writing regulations of their own, sometimes through well-motivated but misguided efforts to reduce ‘diversion’, I’m not holding my breath that the shortage will end soon.   And since much diversion consists of people using Suboxone on their own after failing to find a physician, don’t expect state regulations to move the diversion problem in the right direction!

Here is list of Suboxone doctor locator web sites.

Doctor preparing injection image available from Shutterstock.

From my perspective, the article overstates the diversion problem.  In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment.    I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.

With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion.   Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone.  The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year.  The total number of deaths linked to buprenorphine over the past ten years is about equal to the number of people who die from acetaminophen– EACH year.

Diversion of buprenorphine is a complex issue.   Words like ‘diversion’ and ‘overdose’ are loaded with so much emotion that one word seems to tell the whole story.   A Google search of Suboxone brings up news reports such as ‘Suboxone found at overdose scene’, or ‘man arrested with cocaine, heroin, and three Suboxone tablets.’  The stories create an ugly image, with buprenorphine/naloxone as one more drug of abuse, found at ‘an increasing rate’, according to other headlines. But a superficial look at diversion yields a superficial understanding of the diversion problem.

Take as example a patient has not used illicit substances for 3 years while taking prescribed Suboxone, who relapses to heroin and dies from overdose.  News stories will describe a scene littered with needles, heroin, and Suboxone tablets.  That description creates a misleading impression of the patient’s history, and a misleading impression of buprenorphine.  Even if the story provides more detail, the headline alone will fill the tweet—the ‘news’ of the modern era.

Is the nature of diversion, the reason for diversion, or the consequence of diversion relevant to discussions about the diversion of buprenorphine?  If someone tries to hold life together by purchasing street Suboxone in a geographic region void of certified physicians, should that ‘diversion’ be included in the category as the sale of oxycodone?

What if the powerful mu-receptor blocking effects of buprenorphine have positive effects?  What if studies found a lower rate of overdose deaths in communities with greater diversion of buprenorphine?   Would that be relevant to the diversion discussion?

I do not know of any evidence that diversion of buprenorphine correlates with fewer overdose deaths.  But many public health experts predict that encouraging ‘street use’ of naloxone would reduce overdose deaths, so expecting the same from buprenorphine, a stronger and longer-lasting mu antagonist, is not unreasonable.

Patients on buprenorphine awaiting elective surgery discover that the blocking effects of buprenorphine last for weeks.  The same patients report that even after several weeks off buprenorphine, significant doses of oxycodone will relieve post-op pain, but won’t provide the ‘euphoria’ oxycodone used to provide.  Patients who could never make a week’s script for oxycodone last longer than a day can often control use of opioid agonists after surgery if kept on a small dose of buprenorphine.    Considering these findings, it is not unreasonable to wonder if there is a lower risk of death by overdose in people who ‘divert’ buprenorphine.  Buprenorphine has a much longer half-life than oxycodone or heroin, so diverted buprenorphine intended for use ‘in between’ acts as a blocker during periods of active heroin use.  Is it possible that traces of diverted buprenorphine in the bloodstream saves lives?  If so, is that relevant to discussions about diversion?

The worst diversion scenario is if opioid-naïve people take buprenorphine or Suboxone and becoming addicted to opioids as a result, i.e. diverted buprenorphine serving as a gateway drug to opioid dependence.  Nobody should take that situation lightly.  But stories from the streets bring to mind biological programs where sterile males of an invasive species are released into the wild in effort to eliminate the invasive mosquito, lamprey eel, or fruit fly.  What if the spread of buprenorphine functions as an ‘addiction moderator’ where the more buprenorphine in a community, the lower the rate of overdose deaths?

I realize that I am out on a limb— but as the saying goes, that’s where the fruit is.   If buprenorphine diversion is investigated in a superficial manner, we will collect nothing but superficial results.  The nature and impact of diversion of a medication with the potential to save as many lives as buprenorphine deserves a deeper level of understanding.

Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’  Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases.  There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.

Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts.  The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic.  As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people.  We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools.  Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.

Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness.  I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!)  Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected to emerge– and have emerged.

As a medical student I learned about ‘non-A non-B hepatitis’, a small concern at the time that has since grown into the identity of ‘Hep C’ (Funny how long it took to come up with THAT name!)   Hepatitis C is a major public health threat, since routine vaccinations for hepatitis B and the surge in IV drug use.

Not all diseases are from non-human entities.   Cancers, for example, arise from errors in our own DNA, either inherited or acquired.  Cures have been found for a few cancers, but like bacteria, cancers have emerged that are resistant to current chemotherapeutic drugs, requiring a constant search for new agents.

Some illnesses are considered ‘lifestyle diseases’ because they are  related to obesity, smoking, pollution, substance use, inactivity, or poor diet— such as hypertension, heart disease, diabetes, cerebrovascular disease, asthma, and COPD.  The model of resistance show by bacteria doesn’t fit in the same way, but many of these illnesses draw public attention as ‘epidemics’ that demand resources, with apathy or cultural phenomena function acting as resistance to those efforts.

Bear with me;  I’m working up to something that I’ve alluded to before.  My point is that like with other illnesses, addiction doesn’t respond to medications– Suboxone and buprenorphine — quite the way it used to.

When Suboxone hit the US market in 2003, large numbers of opioid addicts were scattered across the country, sick and tired of their dependence on opioids.  Heroin was considered a ‘bad drug’ back then even by those with severe addictions, and was rarely encountered by teens and young adults.  Most opioid addicts used hydrocodone or oxycodone, prescribed by doctors or obtained from people with prescriptions.  Heroin was marginalized to those with the most-severe addictions, or used sporadically in combination with other drugs (e.g. speedballing).  Known doses of oxycodone were comparatively safer than heroin, which is stepped on to varying amounts and sometimes laced with deadly fentanyl.  Oxycodone was absorbed through mucous membranes more quickly than heroin, meaning lower motivation to use needles.  So in the early 2000’s, some people addicted to opioids found a way to get by, albeit in state of chronic misery and loneliness after spouses and friends moved away.

Enter Suboxone– a new medication to treat opioid dependence.  Suboxone carried some controversy, as some in the non-medication treatment lobby did their best to tarnish the medication (as in ‘you’re not as clean as I am!).   But despite the tarnish, Suboxone and buprenorphine were medications that were to be prescribed by doctors.  People who for years kept the same horrible secret were given an option that actually worked.  People returning to my office for follow-up had tears of happiness on their faces;  they thought they would never be free from their afflictions, and were grateful as Hell for a chance to return to the living.

Many of those patients have done well for years, in treatment in my practice and others.  Many are still on buprenorphine and grateful to be on buprenorphine, as happy and productive as they’ve ever been in life, with no desire to change.

But then, just as some of us were becoming optimistic about this great new medication, the disease of addiction changed in the direction that all diseases change– for the worse.  The substrate changed; oxycodone was largely removed from the market through well-intentioned anti-diversion efforts that made Oxycontin harder to abuse…  just as the US experienced a large influx of cheap heroin.  And as in the 1960’s, heroin brought out needles– something that many opioid addicts used to take pride in for not considering.

And Suboxone changed.   People on buprenorphine or Suboxone sometimes shared a bit of their medication with friends going through dry spells. Some people on Suboxone or buprenorphine sold portions of their prescriptions.   The image of Suboxone held by active heroin addicts changed from doctor’s medication to a self-directed treatment for withdrawal.  In fact, the perceived roles of patient vs. treatment provider became blurred by needle exchange programs and programs that provide addicts with syringes loaded with naloxone.   Against a confusing backdrop of publicly-provided needles, free syringes pre-loaded with naloxone, and expensive brand film vs. affordable generic buprenorphine, the image of Suboxone turned from orange to gray.

I don’t mean to criticize the well-intentioned efforts to save lives, such as the distribution of naloxone in areas where overdoses have become epidemic.   It’s hard to predict unintended consequences.  But now, new patients consist of 18-y-o heroin addicts who see Suboxone as a tool to provide cover for a few days, when the heroin supply runs dry.  Some see Suboxone as a tool to detox, although the detoxes never accomplish anything at all—the ultimate bridge to nowhere.  The bottom line is that after seeing a few Suboxone tablets ground up, dissolved, cooked, and injected, the medication loses a bit of luster.

And finally, patients themselves have changed.  Opioid addicts in 2013 are often acutely ill from unknown doses, toxic fillers, and dirty needles, presenting to ER’s with antecubital abscesses and hepatitis C.  And despite being very, very sick, many haven’t had enough time to get sick and TIRED.   Being started on Suboxone is less of a bit deal because they’ve BEEN on Suboxone— little chips of it, over and over and over, whenever the heroin ran out.

Gone are the easy buprenorphine patients.  Now we have young, fresh, sick addicts who won’t live long enough to hate their addictions.  Addiction as a disease has adapted to our treatment efforts, and become stronger– and deadlier.  Our side had better keep up the hard work.

Woman getting injection image available from Shutterstock.

My conscious mind works in series, holding one or two thoughts at a time and proceeding in a somewhat-linear fashion.  The unconscious, on the other hand, is an amalgam of countless processes that never end, epiphenomena of the constant barrage of sensations, emotions, and memories that are sorted, compared, associated, and recorded.

At least that’s how I see it.

The unconscious is not something that can be figured out, no matter how much insight a person may develop. During treatment for addiction I thought that if I could discover my unconscious motivations for using, my desire to use would cease.  I don’t see it that way now.  Even after more than a decade of sobriety, I am aware that my unconscious mind remains intertwined with the addictive parts of my personality, forever inseparable.

My unconscious mind protects me from unpleasant emotions.  Some insights are deemed, by whatever determines my conscious experience, as too painful.  But even when I’m not allowed to have a certain awareness, I can sometimes infer what is going on beneath the surface using the clues evident in my behavior.

For example, I’ve been struggling to write for several weeks now, since my dad’s death.  I don’t know for certain what unconscious thought or emotion is getting in the way, but I’m aware that something has changed.  The ideas that arise as potential topics seem unworthy of my attention and uninteresting to readers.  I sit down to type, but the words don’t come.

I can guess what might be going on….  maybe on some level I’m angry that he isn’t reading my posts anymore.  Maybe I wrote out of efforts to impress him, and now I have nobody to impress.  Maybe I’m just hurt or sad at the loss, and the small child in me is refusing to cooperate.  It could be any or all of those things, or none of them.  The unconscious actively decides what I am not allowed to know, so there are no ‘aha!’ moments of clarity.  Only hints, based on my behavior.

I am writing about the mind today— a topic on which I’m not an expert, and yet the words for the topic are available to me.  But on my usual topic—addiction— I’m just not ‘feeling it.’  Maybe that’s another clue—that the topic of addiction is wrapped up in memories and emotions that are enmeshed with thoughts about my dad.  Maybe writing about addiction is too….. too something.  And sure enough—right now, as I think about writing about addiction, I feel sad.

Something is blocking me;  if I were my psychiatrist, I’d say that I need to allow the painful thoughts to enter my mind, whenever my unconscious decides that I’m ready to know them.  But for whatever reason, I’m just not there yet.  Thanks for being patient.

Unconscious image available from Shutterstock

Writing was a source of tension between us in some ways.  My perspectives on myself, my parents, and my upbringing have changed over the years, and I tried to share my observations with my dad in several short essays centered around memories from my childhood.  The efforts were a mistake.  I learned that insight develops in each of us at different rates and in different directions, and my ‘aha’ moments—realizations about how my dad shaped my development— felt to him like criticism.  I don’t think he fully realized that I accepted him, loved him, and respected him.

As for my ‘aha moments’, I don’t assume that my realizations and insights are accurate.  As my perceptions change over the years, I try to remain open to two alternate explanations for those changes—that with age I’ve learned, through wisdom, to see things more accurately, or that with age my thought process is becoming more rigid and any newfound ‘insight’ is an illusion, a product of that rigidity.

My dad was an intellectual, who read more books about philosophy and theology each year of his adult life than I’ve read in my lifetime.  So when our understandings of the world differed, I had to at least consider that my own judgment was off, rather than assume that old age impacted HIS judgment.

So to sort things through, I wrote.  I honestly thought that with enough effort, we would fully understand how we each see things; not that we would necessarily agree, but that we would fully understand each other’s perspective.  But I eventually decided that at least for us, differences in our individual perspectives ran too deep for us to completely understand each other— no matter how hard we tried.

My dad grew up during the depression, fought in Germany during WWII, became an attorney on the GI Bill, and worked for the Atomic Energy Commission before settling down in private practice and raising a family. He studied Christian theology and practiced daily meditation.  The internet got going when he was about 70, and he had his own blog, email address and Facebook account.

He jogged since the time when people first started jogging, before someone invented ‘running shoes.’  He worked out at the Y throughout his life, even in the weeks before his death.  I worried that the care he took toward his personal health would eventually cause problems, leaving him without a graceful exit from this world.  But he suffered a brain hemorrhage two days before his death, losing consciousness while sitting in a chair, listening to music from his I-Pad.   The next day his children, grandchildren, and wife of 55 years sat at his bedside, shared memories and sang Happy Birthday.  He died a few hours after midnight, never being one to drag things out too long.

I’m sorry if readers find this to be cryptic or overly personal, but I was stuck, and I had to get these things out before I could move on to the usual stuff.  My dad reads my posts, and there were a couple things I needed him to know.

Rainy window photo available from Shutterstock

My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin.  Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.

I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication.  As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap.  They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.

But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment.  I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges.  To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences.  Maybe they haven’t suffered enough consequences.   But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.

I always consider each new patient’s history of ‘consequences’.  I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with opioid dependence.  I note that consequences impact people similarly in some ways, and differently in other ways.  For example, most people have trouble imagining just how bad things are likely to become until they actually get to that degree of severity.  People who’ve never used a needle believe they will never do so, and people who haven’t been arrested can’t see themselves in that position.

But once consequences occur, people react to them in widely different ways.  Some people react to felony charges with horror, while others appear indifferent.    A near overdose might cause warning bells to go off in one person, yet cause little reaction in someone else. One person will be ashamed and humiliated the first time in jail, while another seems to simply adapt, as consequences move from bad to worse.

Are ‘consequences’ the missing piece of the puzzle for patients who don’t do well on buprenorphine?  If so, are the differing reactions that people have to consequences clues to helping poor responders? Should counseling efforts target for elimination those attitudes of ambivalence or indifference toward negative consequences?

In general, shame is viewed as a hindrance toward recovery.  The cycle of shame is well-known by everyone who treats addiction; the idea that ‘shame’ serves as a trigger of using, which in turn generates more shame, and so on.  But when I see a 20-y-o patient who is addicted to heroin shrug off another relapse, I wonder if in some people, a little shame would be a good thing.