Anyone who follows the news knows of the epidemic of overdose deaths, particularly across the heartland of the United States. First, oxycodone and Oxycontin were used more and more regularly for treating chronic pain, to a large extent fueled by warnings from Federal health agencies, in the 1990’s, that pain was ‘undertreated.’ After a steep rise in diversion of oxycodone and other pain medications, the Feds instituted ‘REMS’; the requirement that all medications, including opioids, must have a ‘mitigation strategy’ to reduce the dangers associated with use or misuse of the medication.
In response to the requirement for REMS, Purdue changed the formulation of Oxycontin to a non-crushable product. Addicts who were snorting crushed Oxycontin (oxycodone) turned to heroin… which just happened to be flooding the country from Afghanistan, since the Taliban was no longer preventing growth of poppies there. Unforeseen was the tendency of heroin users to inject, rather than snort the medication. Oxycodone was absorbed rapidly across the nasal membranes, decreasing the ‘value’ of intravenous use. But heroin is absorbed more slowly, and oxycodone-users seeking the same effect with heroin found that only intravenous use provided the same rapid onset.
Heroin is not held to the same standard of consistency as pharmaceutical medications. There is no equivalent of the FDA, making sure that a milligram of heroin is a milligram of heroin, and not a half-milligram of baking soda or another adulterant. Use of any opioid causes significant respiratory depression, and use of an unknown quantity of an opioid is a recipe for disaster!
Residential treatment has been the standard of care for addiction for decades. Unfortunately, the relapse rate after residential treatment is over 90%, particulary among younger patients. The sad fact, for those willing to see it, is that we had not had an effective treatment for opioid dependence… until about ten years ago, when a drug called Suboxone was approved by the FDA for treating opioid dependence.
Suboxone will sustain remission when taken appropriately, and studies show that about half of patients who take the medication stay away from other opioids for at least a year. Suboxone consists, essentially, of a chemical called buprenorphine, which acts as a ‘partial agonist’ at the opioid receptor. Patients taking Suboxone become tolerant to those effects, and feel no euphoria or sedation once used to the medication.
Some people argue that those taking Suboxone are not completely ‘sober’, since they are taking a substance with actions at the opioid receptor. I get their point… but I recognize that many young people are dying, and Suboxone will save about half of those who otherwise would die– which amounts to tens of thousands of people. I also know that people on Suboxone look and ‘feel’ as normal as anyone else– and making arguments against the use of Suboxone make little sense, given that we treat many other, less fatal chronic illnesses, using medications with many more risks and side effects.
By law, physicians who wish to treat opioid-addicted patients using buprenorphine or Suboxone require special certification from the DEA, after taking a short course. After certification, a physican can treat up to 30 patients at one time. After one year a physician can ask the DEA to increase that limit to 100 patients.
I became Suboxone ‘certified’ through a process that takes a day or two, but that for whatever reason, most physicians do not complete. As of late 2012, there are only about 5000 doctors in the US who can each have up to 100 patients on Suboxone. That number has decreased in the past couple years.
I write about the shortage of physicians, the occasionally-crappy behavior of the pharmaceutical company that patented and manufactures Suboxone, the side effects and risks of buprenorphine, and various issues related to addiction on my blog, Suboxone Talk Zone. I invite you to meet me there. I also started a forum called SuboxForum, where almost 10,000 people have registered, anonymously and without charge, so that they can discuss the same issues.
These web sites are intended to provide information, but not to diagnose, cure, or treat a specific patient. Anyone with health issues related to addiction or Suboxone should consult with his/her own physician, as I cannot fill that role. Please remember that opioid depenence is a chronic, highly-lethal illness that has killed many thousands of people over the past ten years– none of whom expected to be the next to die. I hope you will join us!