Why we should be careful about increasing access to Suboxone

Our governors in New England are asking for increased access to Suboxone, a pharmaceutical drug used to help opioid and heroin addicts kick their addiction. I’ve written quite a bit about our state’s addiction epidemic because it’s a subject that’s pretty dear to me. Both professionally and personally, I’ve been privy to more than one addict’s story.

I’ve long advocated for a mutli-pronged approach that includes improved treatment access, educational efforts and law enforcement, and I am thrilled that there seems to be consensus among our political leadership in this regard.

Now that they are all on the same page, it’s time for nuance, for a closer look at the treatment systems and protocols that target opiate addiction. In my experience, a closer look isn’t always pretty, but I’ve avoided airing my concerns about these systems and about opiate replacement therapy. In theory, I support the use of opioid replacement drugs like Suboxone and methadone as part of treatment in a very controlled fashion for those who so choose.

By “very controlled fashion” I mean that opioid replacement drugs should be prescribed in a way that guarantees little or no misuse (taking more at a time than prescribed or injecting it) or misappropriation (selling it or sharing it with others).

My experiences with current treatment practices, though, lead me to believe that politicians should be careful what they ask for when increased access to Suboxone is concerned. While serving as a support to addicts, I have personally witnessed that not all Suboxone is being prescribed in a very controlled fashion, and I think we need a greater understanding of our addiction treatment systems and of Suboxone itself before we expand access. We’ve made a similar mistake before, and it’s a big part of how we got to this point of crisis in the first place.

A pharmacist holds the generic version of Suboxone in Gorham in March 2015. (Troy R. Bennett | BDN)

A pharmacist holds the generic version of Suboxone in Gorham in March 2015. (Troy R. Bennett | BDN)

There was a time when political leadership thought it would be a good idea to expand access to prescription medications through MaineCare. This “good idea at the time” has been linked to the growth of the opiate epidemic, in that it made large quantities of prescription medications available, and too many of these medications made their way to the street.

Months ago I wrote a poem about addiction. It was a request to lawmakers to consider the complexity of the epidemic as they move forward. I ended the poem with a cautionary reference to Shakespeare’s “Romeo and Juliet:”

“Think of the wise monk’s words before two lives passed,
Wisely and slow; they stumble that run fast.”

I’d like to reiterate this caution as leaders look to expand access to Suboxone without a thorough understanding of the potential ramifications of such an action. Suboxone is not only a lifesaver for those who use it appropriately, but it is also a highly sought-after street drug. Since September I’ve been trying to get statistics from the Chief Medical Examiner’s Office regarding how often Suboxone is coming up on the toxicology screens of people who die from overdoses, to no avail. Given my experiences with opioid addicts, I’d want to know that statistic before I advocate for more access.

I would also want to know how often Suboxone is coming up on toxicology screens in emergency rooms, other health care settings, and corrections settings. A 2013 New York Times article on Suboxone reported that such data is not readily available, as not all toxicology screens test for it. At the time of the article, the Centers for Disease Control and Prevention was not even tracking Suboxone-related deaths.

The NYT article, “Addiction treatment with a dark side,” is the most balanced, well-researched documentation of the history and pros and cons of Suboxone that I’ve ever seen. (Click here to read it, and I highly recommend anyone interested in this issue takes the time to do so.) Maine is referenced a few times as a hub of opioid activity, and these references include the story of a young man, Miles Malone, from South Berwick who died in 2010 from buprenorphine (Suboxone) poisoning.

The young man who provided Malone with the Suboxone, Shawn Verrill, was sentenced to serve 71 months in prison. Verrill described the night his friend died this way:

“We were just a bunch of friends getting high and hanging out, doing what 20-year-olds do. Then we went to sleep, and Miles never woke up.”

I personally know one young opioid addict whose addiction started with using misappropriated Suboxone occasionally as a party drug — similar to the use described by Verrill. Months passed, and the use got more and more frequent, until a brilliant young man was a full-blown addict riddled by all the negative behaviors that are part of addiction. Fortunately, unlike Malone, he’s alive and is now doing his best to live in sobriety.

Those two stories alone would be enough to keep me from prescribing Suboxone if I were a doctor and unable to control what happened to the prescription after the addict left my office. And those are only two stories. Given the lack of available data, we have no real way of assessing the true scope of the problem.

Off the top of my head, I can think of five addicts I’ve known who admitted to selling their Suboxone because they were broke or because they wanted to use again, but planned to get back on their Suboxone afterwards.

Which isn’t to say that all recovering addicts will misappropriate their opioid replacement drugs or that replacement drugs are not a valuable tool for some seeking recovery. I like the NYT article because it emphasizes that some addicts attribute their successful sobriety to Suboxone. But Malone’s case is a reminder that even one misappropriation can be deadly, so I’ve never been clear on why Suboxone can be prescribed in more than daily amounts.

In my opinion, if it can make a person extremely high, which users have told me Suboxone does if a user doesn’t have a built-up tolerance, it doesn’t belong on the street in large quantities in an uncontrolled fashion.

Period. I don’t care what opioid you are talking about either. Any misappropriation is too much misappropriation because it exponentially spreads addiction, as we learned from the prescription pill problem that brought us to the mess we are in now.

Some recovering addicts will respond to this statement with outrage, declaring they never and would never misappropriate or otherwise misuse their prescriptions by taking too much at once or altering them so the Suboxone is able to be injected.

This is true, especially for addicts who are further along in their recovery. There are recovering addicts who are capable of managing their prescriptions and their lives independently, which is why I’ve been so hesitant to blog about this particular aspect of treatment. Perhaps these addicts should have access to larger supplies of Suboxone. But policy shouldn’t be drafted as if these addicts are representative of all or most addicts seeking recovery unless we know that to be true.

Let me repeat, one misappropriation has the potential to be deadly, which means treatment systems need to develop means to evaluate which addicts are likely to misuse and misappropriate, and which are not. Multiple misappropriations all over the state just insure new generations of addicts coming up through the pipeline — and more potential addicts landing in jail or worse, at the medical examiner’s office.

There’s a courageous young-seeming person who often comments on articles about the addiction epidemic in the BDN. This commenter goes by MJ and has even commented on my blog before. I admire MJ’s hutzpah.

I found MJ’s candor in a recent comment very enlightening. It was actually this comment that prompted me to finally write this post. I’ve been avoiding sharing my feelings about opiate replacement drugs out of respect to addicts and not wanting to be perceived as contributing to the negative discourse about the value of treatment.

Treatment is critical, and opiate replacement can be a part of treatment, but the caliber of the treatment needs to be looked into carefully as we expand access. MJ’s words echoed a disagreement I once had with a clinician treating an addict to whom I was very close. I had told this clinician that getting him off street drugs was the easy part.

Getting him to stop acting like an addict was something completely different. Handing him a week’s worth of Suboxone and making him attend one group a week wasn’t changing any of the behaviors or giving him the skills he needed to cope with life without opiates and other drugs. Just handing him Suboxone wasn’t addressing the fundamental issues that led him down the path of addiction in the first place.

MJ referred to this aspect of treatment as addressing the “addiction mentality.” And I second MJ’s concerns about how primary care providers will be able to deal with this aspect of treating opiate addicts with Suboxone, as well as manage misappropriation and misuse.

I’m attaching that MJ comment to this post; MJ was commenting about an article (click here) discussing increased access to Suboxone. I hope this young person continues in sobriety, and, even more, I hope this person continues to share and develop her or his voice. This person speaks with the clarity of experience.

MJ’s comment:

Soboxne is dangerous especially for addicts as take homes. The amount of stories I’ve heard in my own NA groups of those on Soboxne melting and booting up is a probably 10 out of 22 people. In ONE group. Doctors must understand that the need for physical recovery is a fraction of sobriety. The rest is the ‘Addiction Mentality’ No doctor nor patient should never be on methadone or soboxne for 10-15 years. The long term medical effects outweigh the positive treatment. I’ve been 4 years sober, and finally leaving the clinic in eight days and I feel great! Yet, the experience there wasn’t the help you all assume it is… I am one of few people in its 15 years to properly taper out in success. Success of treatment should be based upon those who can taper out and remain stable not return or stay for 10 years. That’s not working recovery. Though I am sober. Methadone has RUINED my physical health. I’m 98lbs from a strong 135. I urge people to be proactive in recovery. These clinics are privately owned by out of state companies. Their goal, millions. After two years I began noticing ‘myths’ as they call it. I saw doctor after doctor about my health, and all said the same except for the methadone doctors. They claim increased dose, because my body has gotten used to it and I no longer peak. (High you feel 2-4 hrs later) I refused to increase. To me, that’s not what I wanted. The services are awful. Groups are bogus things no real skill group yet free talk among others. In order to remain sober we MUST INCORPORATE more life skills. Stress coping, job skills, actual goals! How is a group named ‘relaxation’ helping addicts address the issues at home? Tuning down lights and playing soft music isn’t crap in the real skills of sobriety! And Soboxne isn’t the best medicine. It’s new. Where methadone has received research since WWII. Soboxne affects on the GI tract is awful painful worse than the DTs! And giving addicts take homes, will only put it on the street for trade of other drugs. I see it ALL THE TIME! Kids be exposed to it from high or irresponsible parents. I worked in a pharmacy for a few years. I was whitness to those who get the Soboxne prescription and I had to report 5 people who were selling it in parking lot, or go to the bathroom and open up numerous strips and get high. I found Soboxne strips on the store floors Atleast 3 out of 7 days. And many, I legally sold syringes to the second they picked up. (In ME you can safely purchase needles with an ID over 18 under clean bill act) If I didn’t take my sobriety into my own hands. I’d still be at a clinic, listening to their BS. Yes, Methadone helped me. But let’s look behind the curtains of the situation in clinical settings…

Patricia Callahan

About Patricia Callahan

Trish is a writer who lives in Augusta. She has worked professionally in education and social services.