Addicted to a Treatment for Addiction

May 29, 2016 · 29 comments
Dirk (Albany, NY)
First of all, suboxone saved my son's life. My question is - is the black market out there so people can get using suboxone to get high - or because it can be so hard to obtain and people are using it so they don't take heroin? Since heroin is so easy to obtain, unless the suboxone high is so much better than heroin - it would seem to me to be the the latter rather than the former.
Jim Rosenthal (Annapolis, MD)
There's no reason to believe that treatment for opiate addiction, when supervised by the government, will work any better than any other of their programs.

People got off opiates for years before Suboxone, methadone, Subutex came along. They can still do it. What we need is far fewer physicians prescribing opiates to begin with.
s einstein (Jerusalem)
This article is another example of the use of coded language which describes, but does not adequately explain, and even can mislead. Overloaded terms: “addiction” (a value-laden process, outcome, concept, definition, recently consensualized new disease-“substance use disorder,” stakeholder mantra, which remains politicalized ); “dependence” (a lesser sin and flaw which can be redeemed by good “habits”), addiction- “treatment” ( an ideologically-driven, multidimensional, process, over time, using selected goals, techniques, sites, etc. by “therapists” whose clinical ability, quality, experience and outcomes are rarely, if ever noted, in which generalizable evidence is rarely used to decide, for a specific person, if the planned treatment is: indicated, contra-indicated, irrelevant or even potentially harmful; “MATs” ( an oxymoron, when one considers WATs-word assisted treatment); “abstinence” (a focused behavior, life style, adaptation, value, stakeholder concept and goal…remember Prohibition… which overlooks additional recent viable goals given interacting, critical internal and external conditions - harm reduction, quality of life, wellbeing and conflict resolution-each with its own criteria for success and failure. The “natural recovery” literature indicates that many people can CEASE without any treatment. Many can’t. Obesity? What would enable the judge to “abstain” from his beliefs about treating drug users, who represent a diverse population of PEOPLE?
Karl (SouthWest)
The evidence is quite clear. Suboxone saves lives...but is frequently diverted/abused. In fact, Suboxone is now the 3rd most diverted drug in the Us. In many European countries, where there are far fewer prescribing restrictions, Suboxone addiction is even more problematic. A recent study from Kentucky found a significant amount of illicit use, including a surprising amount of IV use.

So how do we balance the benefits of Suboxone vs the risks of diversion? The simplest way is to encourage the use of medications like Suboxone that are much more difficult to abuse.

Probuphine was approved this past week as an implantable, 6-month dose of the active ingredient in Suboxone, buprenorphine. It is not available yet, but may be appropriate for those at high risk for diversion/abuse. The downside is the cost (Over $4K and the fact that many will get the 6-month shot and completely ignore any counselinng).

Currently Bunavail is a version of Suboxone that should be more heavily utilized. Once again, it has the identical ingedients, but is designed in a way that offers two key features to deter abuse:
- It provides improved absorption, so each dose requires on 4 mg of buprenorphine vs 8 mg in Suboxone (aka less drug to abuse)
- It is house in a gel matrix which makes injection a very bad idea, as one is essentially injecting glue.
Recently Tennessee Medicaid switched from Suboxone to Bunavail and noticed what appears to be a multi-million dollar savings by minimizing diversion.
Stephen J Johnston (Jacksonville Fl.)
There were hundreds of thousands of Civil War veterans, who could not kick the habit of morphine, after their physical wounds had healed. Then the Bayer people, who became famous for Bayer Aspirin, discovered that a slight shift in the molecular structure of Morphine could produce heroin, which it was found could miraculously cure dope sickness in Civil War Veterans. Then miracle of miracles Morphine addiction was cured. Well we all know how that turned out.

All that a dedicated alcoholic, whose passion is vodka, needs to do today to beat the system is to confess to her doctor that she is cross addicted to opiates and alcohol, and suboxone and antabuse may be prescribed. The lucky alcoholic will get a new high, and possibly a benzo like Klonopin to act as a chaser, Then all that is necessary to function as a reasonably normal sentient being is a case of Red Bull.

Under this regime of drugs and stimulants there is no chance that twelve steps will be climbed nor will the"Patient" ever resolve the underlying issues, if any.

Not only is American drug policy idiotic, but the rehab industry is out of control. Does the rehab system ever scan the brain of addicts to identify brain damage. Heck no. That is expensive.

Drug prohibition is an abysmal failure, and we need to return to an arrangement where issues of drugs and drug dependence are strictly between doctors and patients, with Physician drug pushers driven out of business, and back to their country of origin.
Steven A. King, M.D. (Philadelphia)
The issues of using buprenorphine for opioid use disorders are not as clear cut as the author appears to be making them.
Some of what Judge Moore believes is true and some of what Drs. Volkow and Kolodny say is misleading.
As a physician who specializes in pain management, I know that there are a not insignificant number patients prescribed opioids for legitimate pain complaints who end up abusing and becoming addicted to these, and although it is often reported that we've only become recently aware of this in fact there is research going back 25 years demonstrating this.
However, there are no studies showing that either buprenorphine or methadone are appropriate treatments for these patients. As these both provide analgesia equal to the other opioids, if these were the proper treatment for these patients then it would make sense to make them the first line opioids for pain as we would be prescribing the appropriate treatment for the problem at the same time we were prescribing the cause of the problem.
John Smith (Cherry Hill NJ)
FACT VS FICTION The historical belief of the value of a sound mind in a sound body is incorrect, as there has been a paradigm shift. The mind/body dichotomy has been eliminated, since the brain has been shown to be part of the body whose functions are eligible for medical treatment on a par with diseases of any other organ. There are many people who require ongoing anti-depression medication to treat the illness. By the same token, it is illogical that some people in the justice system are entitled to ongoing medical treatment for drug dependency just like a diabetic requires ongoing, lifelong medication. The costs to society are far lower when government clinics can dispense formerly illegal substancess and save money on the war against drugs.
Dr Van Nostrand (Chelsea)
There's only one unspoken truth here: these addicts were not given the opportunity to heal with a consistent non-criminalized supply of Buprenorphine. Chasing it makes addicts. End of story. Want to end the drug epidemic overnight? Make Buprenorphine over the counter. The essay is also full of feel-good BS about getting clean for one second as the end of addiction.

Buprenorphine is lifesaving. Regular use is also exceeding boring. It doesn't get you high after a few months regular use, at all, snorting or otherwise. It stops cravings and -- to move away from the contemptible anecdotal as substitute for science that this essay stinks of -- corrects issues with the endogenous opiate system.

"President Obama’s proposed 2017 budget includes $1 billion for the expansion of M.A.T." Because he's not an uneducated zealot giving meals out of the "basement of his church".

“Overwhelming evidence shows that Suboxone improves outcomes in people with opioid-use disorders,” said Dr. Nora Volkow." Why doesn't the essay start there? "I’ve encountered zero climate-change deniers among the M.A.T. critics" Does the author understand what an analogy is? The writer of this article should be crippled with shame for corrupting addiction science with the worlds most myopic lens. Fake science, what-little-I've-seen-is-the-only-truth garbage like this doesn't need to see the light of day. Church basement -- yeah right.
saram.nor (indiana)
Agreed...
Jeff Hunter (Western NC)
As the parent of a 34 year old heroin addict, I can sadly attest to the truths laid bare in this article.

While the black market & abuse is bad enough, the price of Suboxone is ridiculously expensive. There's a clear opportunity for congressional intervention in the so-called free-market. (I'm not holding my breath) In any other industry, this would be referred to as price gouging. Sadly, the exorbitant cost of the drug adds to crime stats as addicts steal, pawn, prostitute themselves, and basically do whatever they need to do in order to get the drug that staves off withdrawal, or paradoxically, feeds the addiction. The do-nothing Congress needs to get off the dime and enact some sensible legislation before an entire generation is lost to this scourge. It's already too late for millions of young people. Congress, are you listening?
Patty (NJ)
The vast majority of Pharma companies are not in the opiate business. Stop with the broad brush!
Publisher (Seattle)
Yeah -- the vast majority gouge with cancer drugs and auto-immune drugs. Big Pharma is Greed, Greed, Greed.
Molly (Middle of Nowhere)
Big Pharma, regardless of the drug they're producing, has no problem contributing to the ever increasing costs of medical care in this country. All of it has become big, booming business rather than the conscientious and concerned practice of healing it once was. They will not negotiate prices in this country, protected by Congress, as they do in single payer countries, charging the highest prices here they can get.

"First do no harm." should be expected equally of Big Pharma as it is to our physicians.
Anne C (Washington, DC)
There is nothing else for these young people to do. The drugs take away the anger and depression they feel because of their reduced possibilities for a productive life. The daily ritual of looking for drugs, wheedling money from relatives, petty thievery, etc. fills the days with something to do. This leads to short painful lives, with devastating consequences on on surviving family.

I saw a similar phenomenon in the former Soviet Union after the break-up. Factory towns collapsed. They had been built out of whole cloth in the 1950s-1960s around a factory that made sense in the Soviet system, but not in a capitalistic one. Overnight, purposeful communities lost the engine that kept them going. The middle aged and old drank, the young did drugs. The death rate (including from AIDS) skyrocketed.
Don't know what has happened there since and Vladimir Putin is certainly not going to allow honest coverage. I suspect that most have died, from one thing or another, far before their time. I am afraid that is what will happen in our depressed areas, too.
Molly (Middle of Nowhere)
"The daily ritual of looking for drugs, wheedling money from relatives, petty thievery, etc. fills the days with something to do."

Trust me when I say, we don't do this, but it's far from some way just to kill time. Generally, we used to call around to friends and family seeing if anyone had any leftovers and spending the day lethargically laying around because we had no strength at all.
Subash Thapa (Albany, Australia)
I don't understand why should a judges belief be held to regard in treating a person with addiction problem. Shouldn't that be the job of a psychiatrist? No disrespect to the judge, I agree that abstinence and counselling would be the ideal solution to recovery, but haven't we already learned by now that ideal doesn't necessarily work.
Isn't there a better way of prescribing Suboxone so that one person doesn't end up buying boxes of it running around town. I don't see the difference between a drug paddler and Suboxone clinics if both of them are only in it for the profit. Sure the Clinics can't stop people from abusing it,but there has to be a proper way to screen it so that there isn't a black market for that substance.
Addiction is a very complicated issue, and there is no 100% method to a road to recovery. You can be abstinent, going to counselling, and taking medications. But all it takes to get back on the cycle is for you to have that one bad day where you lose control for that one split moment.
Molly (Middle of Nowhere)
As of today, I am after three days through withdrawal symptoms from opioids. However, my husband who suffers from chronic back pain and arthritis, has been lying in bed since yesterday, with a clonidine patch given to him by his pain management physician, along with only 15 hydrocodone. He is awaiting his appointment from the referral to a suboxone clinic, and we're hoping his employer is informed and understanding, so he will still have a job and benefits to pay for it.

He was taking the generic form of both Opana ER and IR, similar to Oxycontin, I believe, for nearly five years due to his severe chronic pain issues. He began having addiction issues with them and I no longer know the man I married. He doesn't live here anymore. I'm hoping the suboxone will help him, and I wanted to share this article with him, but there is one reason I won't - it describes how to abuse it. He is a 19 year successfully sober alcoholic, which we accomplished together on our own after he nearly died of alcohol poisoning. So I already know the receptors in his brain are geared to the reward cycles of narcotics, which caused him to over use his pain meds, as well as the fact that they don't really last the 12 hours as prescribed, hence the Opana IR for break through pain.

Our lives have revolved around nothing but these pills for five years. Even though he needs them to work and function, they have taken all the joy out of our lives, replaced it with misery. Beware the doctors pushing these.
Azalea Lover (Atlanta GA)
As a nurse who was worked in a hospital caring for heart patients who also worked in a residential center for substance abusers, I can tell you addiction treatment centers have revolving doors. Whether inpatient or outpatient, addicts generally are ordered into treatment by courts or brought for treatment by desperate families. The addict stays for the time ordered by the court, or leaves after speaking all the right words to the counselors/physicians/families.

And they come right back.

The true addict will use any drug, by any route (nasal, oral, IV). and will state repeatedly "I want to quit". But too often, what the addict means is, "I want someone to work magic so that I no longer use drugs".

Once in a while, there's a success: an addict who gets free of drugs or alcohol and doesn't return for continuing treatment. Counselors celebrate that success........hoping it continues for that patient.

With alcoholics, AA is the only method that works in the long run. With drugs, it's the will of the addict that works.

And to quote one WASP 30-something man: "Why would I want to use methadone or Suboxone? Why would I want to stop using one drug and start using another drug? I don't want to use ANY drug."
Molly (Middle of Nowhere)
Azalea Lover, as a nurse you should also be aware of how these drugs change the receptors in the brain, and how those already susceptible to addiction are also harmed by these drugs. It's a matter of their individual physiology, not necessarily their own will. Wanting something with all one's heart doesn't mean it will happen. The deaths caused by this national epidemic bear witness to that.

http://www.theguardian.com/society/ng-interactive/2016/may/25/opioid-epi...

I recall a very old commercial against drug abuse that stated: "No one says, "I want to grow up to be a junkie."

My husband and I are two very intelligent and ethical adults who had 13 years of a wonderful marriage before these pills were introduced into our lives, eventually ripping it completely apart.

Is it possible that you became desensitized to the plight of these people? Please consider this situation from the place of those of us struggling to overcome this. It's not something we did to ourselves.

http://www.businessinsider.com/porter-and-jick-letter-launched-the-opioi...
Steve (New York)
You conveniently fail to mention that many people in AA have also used antabuse or naloxone to help keep them from drinking.
Azalea Lover (Atlanta GA)
Molly, life is all about choices, and I know many people who made the choice to use legal and/or illegal drugs, including relatives and friends.

The best man at my wedding drove his new sporty car too fast, missed a curve, and rolled his car over numerous times. Fractured spine - neck and chest; fractured pelvis; other fractures. Tough recovery. At one point, while he was using narcotic pain meds, his doctor told him, "You have two choices: become an addict or switch to ibuprofen or acetaminophen". He quit the narcotic med, started walking every day, returned to work, continues to walk every day.

My father was an alcoholic, binge-type, for most of my life. He finally quit, at 60 years of age. One of my generation became addicted to narcotics, switched to methadone, died 3 years ago. Two of her three children became addicts. One quit, cold turkey; one is in a treatment center now.

Everyone's brain has the same receptors. People make their own choices: start with marijuana, move on to hydrocode, possibly other drugs. Some quit. Some don't quit.

The difference is in the individual: the drugs don't make anyone choose them, or make them choose to continue taking the drugs that ruin their lives. We make our own choices.
Scott Fortune (Florida)
Suboxone is addictive. People do all the illegal and unsavory things to get it that people, addicts, do to get opioids. A family member was paying $400 a month for Suboxone. And that was with a prescription.
We have an opioid epidemic. I take AA meetings weekly to treatment centers. The residents are lawyers, salespeople, truckers, veterans, firemen, doctors, teachers... They are young and old, black and white. From age 19 to 80. All men.
Most of them are there because of oxycodone. A 76-year old veteran was using his social security check to buy "Roxies" so that he could sell them and thereby afford to maintain his addiction.
It is heartbreaking. It's as if there are no longer any "good people" in charge of, or regulating, the drug companies. No responsible people holding elective office. It's like the Wild West.
Molly (Middle of Nowhere)
Thank you, Scott. That's exactly how it feels to those of us struggling to rid ourselves of these insidious drugs and get back to a normal life.
Erin (Chicago)
The black market for suboxone exists because of the DEA regulations that keep it and authorized prescribers in chronically short supply. This aspect of the story is an artificial state of affairs that could easily be remedied. Suboxone is safer, more effective and more humanely administered than methadone and should be available through safe, legal, affordable means to everyone who needs it. That's not an article of faith -- it's called evidence-based practice.
Molly (Middle of Nowhere)
One of the new bills introduced in Congress recently allows for more physicians licensed to provide suboxone to patients, but if I remember correctly, the number is small, around 200 nationally.

On one hand I feel that none of these clinics should ever be permitted to operate on a cash basis alone without a prescription required. That it's one fatal mistake that should be rectified. But on the other I think of all of those who have no access to healthcare who need the help, too. I don't know the answer to this problem.
Rima Regas (Southern California)
It is really sad, when one takes stock of what's happened since the start of the 'War on Drugs.' Millions in jail due to racist criminal justice policy and millions addicted to legal and illegal drugs, some of which are now being legalized. Now, the pushers continue to have their way, after having caused what will likely turn out to be the biggest stunt a pusher has ever pulled: the Oxycontin epidemic. The response to the epidemic is to offer immediate relief. But is it really relief?

When one looks at the trail of money and corruption in all this, it leads right to former FDA alums and Big Pharma (see my essay later tonight: http://wp.me/p2KJ3H-2gN.) The LA Times' investigative reports tells a story of corruption and the pushing of a drug that should never have been allowed to be prescribed as it has been. Now, there is a device that will push a substance that is supposed to wean addicts off of opioids and, most likely, will mirror the abuse of the drug it is supposed to wean the victims of.

Will we break free of the strangle hold of money, politics, and corruption any time soon? We badly need to. Millions of lives are being ruined.

---

www.rimaregas.com
Rima Regas (Southern California)
The Los Angeles Times piece I mention above is this one. http://static.latimes.com/oxycontin-part1/
Molly (Middle of Nowhere)
Thank you, Rima, for this link. I have read it and have contacted the reporters to ask them to investigate Opana and the generics, as well.

I always very much appreciate the information and insight you share.
Dr Van Nostrand (Chelsea)
A subset of the human race has deficiencies with dopamine and other endophines that are corrected by the sap provided by the opium poppy. Everything you're saying is shrill and meaningless conspiracy theory without any relevant neurochemistry.