How Long Should I Take Suboxone?

The length of time a person stays on Suboxone, i.e. buprenorphine treatment, has become a needlessly-heated issue.  Readers of my blog, SuboxoneTalkZone, likely know my opinions on the topic.

I recently met with the parents of one of my buprenorphine patients who were frustrated over their son’s ‘lack of progress.’  They complained that he has been on Suboxone for three years, and wondered when I would finally get him off the medication.  They pointed out how sick he gets when he forgets to have the medication refilled, saying that he is just as ‘dependent’ as he was when he was taking heroin.

I am glad, at such times, that I don’t have to search my conscience to determine whether my treatment plan has a financial incentive.  In short, it doesn’t.  If anything, my financial incentive would be to get everyone off buprenorphine as quickly as possible.  I have a long waiting list of people who are hoping for a spot in treatment.  And since new patients usually need a higher level of care, bringing in new patients results in more ‘business.’  Because of the 100-patient cap, the portion of my practice taken up by people on Suboxone has become a small, relatively-stable group of patients.

But I know the statistics for people who suffer from opioid dependence, before or after residential treatment.  The rate of relapse is high, as is the fatality rate. Everyone— doctors, patients, and family members alike– wishes that spending a certain amount of time on Suboxone would somehow reduce the rate of relapse.  But the facts suggest otherwise;  that regardless of the length of time a person takes Suboxone or buprenorphine, the risk of relapse after stopping the medication remains high.

The frustration over the relapsing nature of the illness is unique to addiction. Nobody would expect a diabetic to cease needing insulin after several years.  Nobody expects coronary disease, hypertention, or elevated cholesterol to simply ‘go away’ after a few years of medication.  Even other psychiatric conditions, such as bipolar illness or depression, are not expected to resolve after a couple years on mood stabilizers or SSRIs.  And the unfortunate truth is that addictive illnesses are similar to non-addictive illnesses.  Most illnesses, including addiction, tend to recur over time.

I shared my thoughts with the parents of my patient, explaining that I am always willing to take a fresh look at the treatment options.  The chance of long-term sobriety after other treatments, for example residential treatment costing 50-100 times more than a year if his current treatment approach, is low– on the order of 5%.  And the rate of complications during active heroin addiction, including felony charges, brain damage, hepatitis, and death, is frighteningly high.  If they know of a better approach at this point, I’m all ears– and ready to make the referral.

I didn’t share the other thought in the back of my mind– that their son was pretty darn lucky, to have access to a medication that probably played a major role in keeping him alive and out of prison for the past three years.

Why Limit Care?

My personal practice receives several calls per week by people asking for help in treating their addiction to pain medications or heroin, or often both.  As people seeking treatment usually discover, each physician is capped at the total number of patients who can be treated with buprenorphine at any one time.  During the first year of buprenorphine certification, physicians can have up to 30 patients under treatment at one time.  After a year, a physician can apply to have the number increased to 100.

I have been at 100 patients for years, and I have relatively slow turnover, since I am an advocate for long-term treatment using buprenorphine.  My wait-list has about 60 names, although when a spot opens up and I start calling people on the list, many of the numbers have been disconnected.  Opioid dependence tends to do that to telephone accounts, either through poverty or death.

Why would we limit the treatment spots for such a lethal condition?  I know HOW it happened, but I’ve no idea WHY.   In order to allow for maintenance treatment for opioid dependence, Congress had to pass a law called DATA 2000 to make an exception to the Harrison Act– an old rule that forbids prescribing opioids for opioid dependence.  Congress through in the patient cap, assumedly out of caution, but in part, I know, because they COULD.  Lawmakers have no ability to control the amount of oxycodone that prescribers release into a community, but since buprenorphine required their permission, they made certain that their permission carried strings.

Proponents for the cap claim that one physician can adequately treat only 100 patients at one time, a ridiculous claim.  Most of my patients are entirely stable, going about their lives in stable jobs and relationships.  Many are by far the easiest patients to manage in my psychiatric practice.  Beyond that, there is no cap on the number of patients that a doctor can have on hydrocodone, oxycodone, oxymorphone, alprazolam, clonazepam….  does anyone really think that patients on buprenorphine are MORE difficlut to manage than THOSE patients?!

The cynic in me wonders if those behind residential treatment programs make up part of the push against increasing the cap.  I have no evidence for that being the case, but I know that successful management of opioid dependence using buprenorphine reduces the number of patients who attend $50,000 per month programs with very low success rates.  I hope my cynicism is wrongly-placed, as everyone in the treatment world should have an interest in keeping people with addictions alive.

There are many reasons to eliminate the cap.  But the one reason is simple:  people are dying because they can’t find a doctor.  Isn’t that reason enough?