In their story about buprenorphine, Suboxone, and opioid dependence, the Brattleboro Reformer gets it about 60% right. They describe the shortage of physicians certified to treat addicts with buprenorphine, correctly identifying most of the diversion of buprenorphine as desperate attempts at self-treatment. They lose points, though, for allowing an ill-informed legislator to suggest getting rid of buprenorphine altogether, without pointing to the example of Georgia, the former USSR republic, where the ban on buprenorphine resulted in the birth of krokodil, a nightmare drug now found in parts of the US.
The story makes a big deal of the costs spent on buprenorphine by state medicaid agencies, but fails to identify the reasons for such high costs—and the simple measures that would lower them. For years, state medicaids have insisted that all covered patients take Suboxone Film, the most expensive form of buprenorphine, costing over $8 per dose. Claims that the film is harder to abuse rely on faulty science and false assumptions. If state medicaids allowed treatment of opioid dependence using generic buprenorphine, costs would be reduced by 75%– not taking into account volume discounts.
That Suboxone film and generic buprenorphine are identical from an abuse standpoint requires a fresh look at the data by people who understand neurochemistry, and who understand the scientific method. Given the costs involved, one would think that at least one state would find SOMEBODY willing to do that work. Government payers that demand expensive, Suboxone Film over cheap buprenorphine are being ripped off—or at least their taxpayers are!
Life and Death
The story also focuses on ‘diversion’—a concept the story’s writer admits is complicated. What if, instead of ‘diversion’, the story wrote about a much simpler concept—life vs. death? Deaths related to buprenorphine are exceedingly rare, because of the ceiling effect of the drug that in most cases prevents overdose. If, at some point, buprenorphine becomes a ‘gateway drug’ that turns people who are opioid-naïve into new addicts, the diversion problem would take on greater importance. But since diversion consists mostly of addicts seeking respite from active addiction, the problem has less significance. The significance of diversion decreases even more, if our primary concern about addiction is the soaring death rate from overdose among young people. Buprenorphine diversion has little to do with death rates—at least not in the way most stories suggest.
Few people die when buprenorphine is part of the cocktail of drugs in their bloodstream. Heroin addicts who have used buprenorphine within the past few days are less likely to die by overdose, because of the potent blocking effects of buprenorphine. I remember the story, years ago, of a man arrested for handing out Suboxone tablets to addicts on the street. I am not that guy, and I work to stem diversion—in part because of the possibility that buprenorphine diversion will become the rallying cry of a short-sighted politician. But in fact, all of the evidence suggests that in most cases, greater use of buprenorphine, legitimate or not, reduces the number of deaths from overdose.
If a study proved that areas with the highest buprenorphine diversion rates had the lowest overdose death rates, would the fight against diversion be as important? Why? Every person who is part of buprenorphine diversion task force should examine this issue. Or is saving lives NOT our bottom-line goal?
I’ve written in the past about the reasons why limited numbers of doctors become certified to prescribe buprenorphine. One primary reason, from what I hear from physicians, is the requirement to agree to random DEA inspections, without cause, in order to treat addiction with buprenorphine. Doctors avoid areas of medicine where politicians instruct them how to treat patients. If politicians make rules about medical practice, such as limiting doses of medications, requiring certain interventions (psychotherapy and med counts), or deciding who is worthy of treatment and for how long, then doctors will avoid that area of medicine. And since much of the diversion occurs because opioid addicts cannot find certified physicians, the diversion issue will be…. reduced? Really? On what planet?
A quick example of why doctors are better at deciding treatment strategies than politicians is the call to require indefinite counseling in ALL patients taking buprenorphine. Physicians, hopefully, realize that treatment strategies should be supported by research. Physicians, hopefully, are more likely to ask the obvious questions, such as ‘since there is so little evidence that counseling, even in addicts desperate for help, does anything to improve outcome, is it reasonable to anticipate benefit from FORCED counseling?
A larger break from logic is the focus on buprenorphine prescribers rather than pain clinics. Since buprenorphine is rarely found as a contributor to overdose deaths, but oxycodone, alprazolam, and clonazepam ARE frequent contributors to death, where are the calls for alprazolam and oxycodone pill counts? Or are anxious or chronic pain patients more difficult to burden with regulations than drug addicts? Why are the loudest calls for regulation aimed at the drug least-likely to kill people? Would someone, after reading the Brattleboro article, find it surprising that the number of deaths in the US related to buprenorphine over ten years—about 400—be lower than the number of deaths caused by acetaminophen EACH (one) year?
I understand that these issues are complicated, and fueled by emotions. That’s why we elect people to serve in the American Society for Addiction Medicine (ASAM) and other agencies, to make certain that decisions about addiction treatment are based in fact, not emotion. But where the heck ARE the people we elected? How is it that article after article presents inflammatory and misleading rhetoric, and those elected to set things straight have nothing to say? Opioid dependence is a leading killer of young people in the US. If this issue isn’t at the centerpiece of every addiction society’s charter, what is?