Thursday, June 27, 2013

Suboxone -- A Tool for Persistent Opiate Addiction, Useful but Imperfect

As always, let me begin by reiterating that I am a clinical psychologist and not a medical doctor, biochemist, or active scientist/researcher; most of my perspectives are derived from 30+ years meeting with actual patients. 

Both heroin and painkillers (like Oxycontin, Percocet, Dilaudid, Vicodin, etc) are opiates or opioids (the 2nd term coined to include drugs synthesized rather than derived directly from the poppy plant).  All of these drugs are highly addictive, though they are also powerful agents in reducing pain.  Along with pain reduction, especially when used in larger dosages than necessary, many people experience a kind of euphoria and cushion from the world’s slings and arrows that keeps them coming back for more.  Some physicians perhaps don’t worry enough about the addiction risk when prescribing pain medications.  (Lighter pain meds like Tylenol and ibuprofen are not in this category.)  It is often extremely difficult for people who have become addicted to opiates (some of them originally interested only in pain relief when they began), and the rate of relapse is very high. 

In light of that problem, the notion of a kind of controlled addiction came along years ago in the form of methadone, and in recent years in the form of Suboxone (in which the main ingredient is buprenorphine).  Most individuals I have run across strongly prefer Suboxone, which is administered by prescription in the offices of specially certified physicians, rather than at methadone clinics, which are environments that I’ve never heard described in favorable terms.  The idea is that the Suboxone, which is an opioid, quells cravings for opiates while producing little or no “high,” so a person is in a reasonable frame of mind to go about his or her work and family life.  The whole concept of this kind of controlled addiction falls under the broader category known as Harm Reduction, essentially meaning, “if we can’t get the most desirable outcome, in this case total abstinence, let’s settle for an achievable level of improvement.”   

Since I generally favor whatever helps and doesn’t hurt, I have found Suboxone to be a useful tool.  (I am not a prescriber, but a number of people who have seen me for “talk therapy” have also been on Suboxone.)  I have seen it truly help stabilize their lives of people who are motivated to sustain stable lives which, if not free of drugs, are at least free of drug abuse.  There are also some real problems with Suboxone, and this is far from a complete list: 

(1)  Many individuals find it difficult to ultimately taper and discontinue Suboxone without relapsing.  One hears increasingly of recommendations to remain on Suboxone perpetually.  That may still be the best option for many people, but perhaps not what they had in mind.

(2)  Part of the reason for (1) may possibly be that people are relying on Suboxone as their sole treatment and, in particular, not connecting with sober support networks such as 12-step or other supportive networks and life environments.

(3)  There are way too few certified Suboxone prescribers (under 3% of physicians), and the number of patients that each can treat at a time is limited by law.  As a result, it can be very difficult to find a provider when you’re seeking one, and you can anticipate being placed on a waiting list.  But not if you’re wealthy (see #4).

(4)  For a number of physicians who might be viewed as either entrepreneurial or exploitive, Suboxone provision is a gold mine.  They can decide that each (relatively brief) visit costs hundreds of dollars, and to require self-payment rather than use of health insurance.  (The medication itself may still be covered by insurance.)  If you can afford these kinds of fees, you can get Suboxone in very short order.  Of course, this is only one of many, many examples of the fact that the wealthy get greater access to care (and housing, and lawyers, etc.)  But it can be particularly frustrating to the addict who has reached a threshold of motivation to get off drugs and can’t get a kind of service that might help a lot.