A big chunk of my writing time in the last couple years has been dedicated to our state’s drug problem. There are many reasons the subject is important to me, not the least of which is because I struggled with substance abuse in my youth. I am grateful to have gone through this period before opioids were so prevalent in Maine.
As one of my astute readers observed in an email, at least with the substances we were using back then, we stood a decent chance of hitting rock bottom before we died from overdose or some other substance use-related cause. This reader lost a son to a heroin overdose several years ago. With prescription opiates — especially fentanyl — and the grade of heroin today, death can come before rock bottom too easily, and we need to do anything and everything we can to change that equation.
People who live to go into recovery can make incredible contributions to their communities and families. Clearly people who die before they get there, can’t.
I’ve been doing considerable writing and research on the subject of increased access to the drug Suboxone, which is used to help some people treat their opioid use disorder. Suboxone is a combination of naxalone (2 mg) and buprenorphine (8 mg), a synthetic opioid.
I’ve received some interesting feedback, including a few people who think I should write more about recovering from opioid addiction without medications — something a couple of my readers have opted to do. I’ve also been receiving feedback that some people think I am overstating the diversion problem. (Diversion is when something prescribed to one person is sold or given to someone else.)
I’d agree with that assessment if I hadn’t sat next to someone a few years ago and listened to a Narcotics Anonymous friend tell him that one of his “Subs” was worth “$100 in county,” referring to county jail. I’d agree if I didn’t have to temporarily stop helping a young man I know with a substance abuse disorder because every time I went to give him a ride, there were always teenage girls hanging/laying around — something I told him I wouldn’t tolerate whether the girls were 18 or not. He was on Suboxone at the time but still using occasionally and dealing to support that use. I don’t know that he was diverting his “subs” as well, but he had admitted doing so in the past, and I have no reason to believe he wasn’t.
I’d be inclined to agree diversion isn’t a problem if I didn’t know for a fact that kids my childrens’ ages are using pieces of Suboxone as a party drug. I’d be inclined to agree if I hadn’t sat in meetings with social services, mental health and medical professionals in the 2000s trying to report to people higher up the ladder that I was worried about people struggling with prescription drug abuse and about all the diversion going on — only to be told the problem couldn’t be as bad as I was saying.
I’d be inclined to agree if the Department of Corrections didn’t report confiscating 500 strips of Suboxone in 2014. Anyone who has ever dealt with contraband situations knows that whatever is confiscated represents only a portion of the whole problem. Even if providers can argue that some amount of this diversion was altruistic, the idea that there are that many strips showing up in our jails means there’s a diversion problem.
That amount of diversion indicates that protocols around the prescribing of Suboxone may need a rewrite. It’s not that I don’t support medication-assisted treatment for people whose providers think it will work, but I don’t know that it’s safe to prescribe in larger, take-home quantities for everyone for whom this treatment is indicated.
People like comparing addiction to cancer, and it’s true both are illnesses that warrant treatment. However not all cancer treatment can happen at home. Maybe not all addiction treatment can happen at home either. It would be nice if treating all diseases was easy, but we’re not there yet in terms of medical advances.
I’ve received comments from people comparing the number of deaths from Suboxone overdose to the number of deaths from acetaminophen (Tylenol) overdose, but there’s a big difference. You can’t get addicted to acetaminophen. You can, however, get addicted to acetaminophen mixed with opiates, like the drug Vicodin, which was a gateway drug for many of the addicts I know who started their addiction with opiates prescribed for actual medical conditions.
I am troubled by the idea that having an open, honest discussion about the pros and cons of medication-assisted treatment is being perceived as being anti-treatment. As a society we need to stop having all-or-nothing discussions, and the subject of medication-assisted treatment is more complicated than all or nothing.
I know given all my research, I still have unanswered questions —
Are current prescribing protocols based on the original marketing premise that Suboxone/buprenorphine is not divertable? Or highly attractive for abuse and diversion? I read a report by an executive from the pharmaceutical company that developed buprenorphine that concluded with the statement that “nalaxone buprenorphine offers significant non-divertable potential in take home situations.”
Experience and a quintupling of Suboxone-related emergency room visits between 2006 and 2011 has shown us that Suboxone is divertable and is attractive for abuse. People in Maine are even being treated for Suboxone addiction. Which brings me to my next question:
If best practice treatment for Suboxone addiction is integrated treatment that involves cognitive behavioral therapy, are providers insisting that clients on Suboxone access these same treatments to minimize the length of time medication-assisted treatment is necessary for as many clients as is possible?
And how closely are we tracking unreported problematic Suboxone use? My research suggests that screening for buprenorphine in toxicology screens varies within states and from state to state.
In a previous post about Suboxone, I encouraged anyone interested to read an article from the New York Times (click here). I wrote that I thought it was the most thorough, balanced, well-researched article I’d ever seen on the subject, and a couple weeks of research later, that claim still stands. If Suboxone is a tool providers want in their kit to fight addiction, policymakers need to insure the tool is used as safely for communities as possible.