The Suboxone "Solution"

The Fix has a provocative article on the growing use of buprenorphine maintenance. Over the last several years we’ve watched long-term maintenance become the norm and it has been a growing concern at Dawn Farm, particularly as we’ve had growing numbers of people misusing the drug and others seeking help getting detoxed from buprenorphine.

She presents the dilemma for addicts this way:

Should they take buprenorphine, or “bupe,” long term mainly to avoid cravings—and the junkie lifestyle—or heal their bodies by detoxing and staying clean, which is harder and, in certain ways, riskier? Weighing the costs and benefits of each approach is a very personal, even existential, matter, and science can offer only limited advice, since there are no studies of long-term use of buprenorphine in former opiate addicts. We’re pretty much on our own.

Addicts are not alone in wrestling this this dilemma. It has also been a difficult subject within our own community of professional helpers and it’s not going away. While this has been on the minds of many practitioners and addicts, I’ve never seen an article question buprenorphine maintenance.

I have a strong point of view on the subject and believe that the following principles should inform any services for addicts: that drug-free recovery is possible for most opiate addicts and; that drug free treatment of the appropriate duration and intensity should be made available to every every opiate addict.

Also, more than ever, I’m very comfortable with addicts being given their choice of treatment options. I’m convinced most will migrate toward full, drug-free recovery. Addicts hate their addiction and want to be free of it.

So, with my bias made plain, a few important questions leap out to me:

• Is is necessary?
• Is it helpful?
• Is it harmful?
• Is it compatible with other treatments and paths to recovery?

Let’s take these one at a time. Please, keep in mind that, while I have an opinion on the subject, I’m trying to unpack all of this and muddle through it.

Is it necessary?

One group of people is consistently offered care of appropriate intensity and duration with the expectation that they can achieve full recovery—their outcomes are consistently stellar. That group is health professionals. This tells me, that in a broad sense, it’s not necessary.

One of the arguments is that addicts don’t want drug-free recovery:

“The people who try abstinence, they’re like the starfish on the beach. There aren’t many of them.”

As I said before, I think most will migrate toward drug-free recovery. There are two big conditions on this belief. First, that addicts are offered access to quality recovery support and treatment services of adequate intensity and duration. The second is that the helpers they encounter must consistently communicate hope for full recovery.

Overdose prevention also falls into this category:

In France, where the drug was in use for a decade prior to FDA approval, fatal overdoses of heroin and other opiates fell by 80%.

This is a frequently cited argument for buprenorphine maintenance. It’s compelling if you believe that stable recovery is unlikely—we don’t based treatment decisions for health professionals on an expectation of relapse and overdose.

Is it helpful?

I’ll let one of the advocates in the article make this case:

[Junig's] advocacy of bupe maintenance is based on “the least worst” logic. Most of his patients who have tried to detox off, he says, return to legal or illegal drug use. Worst of all, some OD. “I want addiction to be treated like every other chronic fatal illness,” he says. “We put people through treatment, they clean up, they come out looking good, we all congratulate ourselves—and then six months later, the patient dies,” he says. “And no one cares about this. There’s no review of what we might have done better, the way there would be if the patient died of a heart attack, for example.”

When patients take buprenorphine, he says, they quit stealing and lying, they become employable. “Especially if they’re over 40, they do well,” he says. “It’s like they’re taking their blood-pressure pill.”

We’re not seeing suboxone maintenance patients achieving stable recovery. It’s easy to counter that there’s a selection bias in our experience and I’m sure there’s a lot of truth to that, though our outpatient program typically has clients on suboxone maintenance.

Is it harmful?

One critic on the neurobiology of buprenorphine:

Switching from one opiate (heroin, methadone) to another (bupe) does not “heal” the neurological aspect of addiction, which is characterized in part by the phenomenon of tolerance: as long as exogenous opiods are taken, the body decreases its production of endorphins and increases the number of receptors.

…But Scanlan is a fierce opponent of such long-term bupe use. “There’s no way your brain chemistry can heal while on buprenorphine,” he says. “You’re continuing to give someone a narcotic.”

…He has noticed that at long-term doses of even 2 mg, bupe can block almost all of a person’s emotions. “They say to me after they’re off for a while, ‘Wow, I’m really having a full range of feelings,’” he says.

I share this concern and find it very credible, though I just don’t believe we know enough yet about the neurobiology of recovery to speak definitively on the matter.

And, while advocates argue that the drug offers freedom, the author offers her experience of it as diminishing but extending her bondage:

…of course I asked my doctor if I could stay on Suboxone forever. He had no more maintenance slots left. And then, two or three weeks in, still at 6 mg—I was dragging the taper out as long as I could, because I Felt So Well—the affair went sour. My appetites gradually diminished. My voice clogged up again. My attention was constantly dragged back to how I was feeling—and whether it was time for my next dose.

It took me six more weeks to get off Suboxone, and it was during that time I started going to meetings. I probably could have tapered more quickly, but what slowed my descent onto the tarmac was simple: I was afraid of having nothing left to take. I had taken painkillers every morning, to cope, for so many years. Now, fortunately, I don’t have to.

Note that she didn’t start going to meetings until she was close to discontinuing the medication. Is this a good argument against the use of a drug to manage a chronic illness? I don’t know. Large numbers of people on statins or blood pressure medications could control their symptoms with diet and exercise and improve the quality of their lives and global health. Are they less likely to make changes in diet and exercise because their can control some symptoms and reduce risks with a pill? Probably. Should doctors restrict access to these drugs because of this? Probably not. Should doctors settle for for this? I think not.

Is it compatible with other treatments and paths to recovery?

An obvious question is, “Why not bupe AND tradition treatment and recovery support?” I’ve already touched on this and I’m going to take the long way back around.

I’m convinced that the driving force behind much of this is not a conviction that buprenorphine maintenance is the ideal approach. Rather, it’s driven by a resignation to it being the best many practitioners can do—we can’t offer enough monitoring, we can’t offer more than short-term residential or inpatient, we can’t offer community based recovery support services, we can’t offer outpatient treatment of sufficient duration and intensity, we can’t address all of the client’s other problems that will interfere with recovery, etc.

I have two reactions to this. First, I understand the real world constraints most practitioners function within. I can respect choosing a second best option when the best is not available. However, I expect informed consent (If you were a doctor we’d send you to residential treatment and provide and advocacy for access to the best option. I don’t see this happening.

Second, when one thinks about addiction as a chronic illness, we have historically failed on one front and succeeded on another. We failed to conceptualize addiction as a chronic illness and sold treatment in an acute care model with time-limited doses of treatment provided with the expectation of permanent full recovery. We (Actually, mutual aid groups, rather than treatment, deserve the credit for this.) succeeded in creating long-term disease management support for the behavior and lifestyle changes needed to maintain recovery. What practitioner working with cardiac, obesity or type II diabetes patients wouldn’t envy our free, vibrant communities of support that help initiate and maintain these behavior and lifestyle changes over decades? They’d be crazy not to envy this. We’re not starting in the same place as practitioners trying to encourage diet and exercise. We’ve enjoyed considerable success for decades.

This migration to buprenorphine maintenance has not been one of adding a pharmacological tool to this historical strength. Rather it’s been a migration away from this strength. (Read the comments on the article and it becomes clear that neglect of these patients needs and preferences is not a rare experience.)

Clearly, this doesn’t have to be an either/or decision, but practitioners are telling us that buprenorphine clients don’t want the rest of the “recovery lifestyle”. Why is that? Is there something about the drug that reduces motivation to do so? Does it interfere with the experience of the benefits of the lifestyle?

Again, why this push when we have a model that works very, very well?

A solution is to offer clients their choice of treatments and combinations. I know I’ll take what the doctor’s having.