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Suboxone: When a treatment becomes a problem

Marty Olsen, Community Voices • May 5, 2019 at 5:15 AM

As a practicing physician, I daily experience the honor and responsibility of working with patients to earn their trust and help improve their health. Since I care for pregnant women, the stakes are high; the decisions affect not only the patients but also their unborn children. For the last two years, I’ve worked with opioid-addicted pregnant women in an effort to cut their medication dosages and decrease the chances that their newborns will go through drug withdrawal. Drug withdrawal in newborns is called Neonatal Abstinence Syndrome.

Medical Assisted Therapy is an addiction treatment method where patients are given medications to combat the cravings associated with drug withdrawal. The most common form of MAT in East Tennessee is Suboxone. Suboxone is made up of a medication called buprenorphine, the component that provides the relief from withdrawal, and naloxone, the active ingredient in Narcan. Buprenorphine is safer for addiction management than pain pills, but it is an opioid.

MAT can be lifesaving. People who wake up every morning wondering where they will get their next drug fix can now gain control of their lives, interact with their families, have jobs and contribute to their communities. But in Tennessee, nearly 70% of NAS is related to prescribed MAT. This means, in my view, the treatment has become a problem.

I should point out that my primary training is in obstetrics and gynecology. I am not a board-certified expert in addiction medicine. But it seems to me that MAT was designed to help people eventually get off drugs. MAT could be a bridge between drug addiction to illegal medications and eventual return to complete sobriety. When rules were made for doctors to prescribe buprenorphine, the plan likely was for primary care doctors to treat a small number of their own patients after the doctors made diagnoses of opioid addiction in their patients. But that is not what happened. Very few primary care doctors in East Tennessee write for buprenorphine, but instead we have a flourishing Suboxone industry. When I last checked, there were 17 Suboxone clinics in Johnson City alone.

In a 2017 study on the Suboxone clinics then existing in Johnson City, it was found the average cost at that time was $100 a week just for doctor’s fees. After the patient was established with most practices, the patient could then come only once a month for $400 dollars. Patients now tell me that the cost of the clinics now has gone up to around $150 a week in some cases. These practices can be very lucrative.

Certainly my patients have told me about Suboxone doctors they respect who have done the best they can for their patients. But the patients and their families have also talked about doctors who refuse to help patients come off their Suboxone after years of therapy. “They’re just in it for the money,” the patients say about these doctors. It seems some Suboxone clinic patients sell a portion of their medication in order to afford their next visit.

Combatting the opioid epidemic is filled with unintended consequences. For example, patients who suffer from chronic pain now have significant problems accessing the medication that allows them to function. And, in another unintended consequence for East Tennessee and other areas, the presence of pain pills on the streets has now been supplemented with Suboxone on the streets. In reproductive age females at least, Suboxone is now the gateway drug; a gateway drug is the first addictive drug people take in their pathway toward drug addiction.

Buprenorphine, the active ingredient in Suboxone, is 30 times more powerful than morphine. Many readers are probably familiar with Lortab (also called hydrocodone). Lortab is the same strength as morphine. So the commonly prescribed dose of 16 mg a day of Suboxone is equivalent to 48 Lortab 10 mg tablets a day. Readers who have had narcotics after surgery will recognize that this is a whopper of a dose, but this is the dose recommended by the manufacturer.

Suboxone is apparently now the No. 1 prescribed drug in Tennessee, but in spite of this overdose death rates have gone up in Tennessee, so there is no evidence that rising Suboxone prescriptions have decreased overdose deaths.

Once again, remember — Suboxone has had a vast positive impact on the lives of some individual patients. And there are some patients who may well need to be on Suboxone for the rest of their lives. But it is not all patients. Relapse is a true risk for people on Suboxone who want to come off, but let’s recognize that these people have two alternatives: 1) stay on Suboxone the rest of their lives or 2) accept the risk of relapse at a point in their lives when the risk is acceptable.

Like much in healthcare, the effects of Suboxone on population health are complex. In the case of Suboxone, we appropriately consider overdose deaths as an important health care marker, but we also need to look at NAS. We need to look at the economic devastation caused by opioid addiction in communities where new businesses are afraid to relocate for fear too many employees will be addicted to drugs. We need to get Suboxone off the streets to avoid recruiting new addicts which cause the opioid epidemic to continue growing.

We need to remove the stigma from opioid addiction and treat it like the medical problem it is. Patients should be able to use their insurance to cover treatment, not have to spend thousands of dollars a year from their own or family member’s pockets to get addiction care. This also means that primary care doctors should prescribe Suboxone instead of for-profit clinics. To do this, we need to decrease the regulatory burden placed on doctors who prescribe Suboxone to only a few patients; the time doctors and nurses spend on all the paperwork associated with Suboxone prescriptions is wasted time they are not spending with patients. We also need to make sure the proper doses are prescribed, so that only patients who need the equivalent of 48 Lortab 10 mg pills a day are prescribed that much.

For some patients, the opioid epidemic has become the Suboxone epidemic. I encourage steps to ensure Suboxone returns to its designated role as a medication that helps people instead of one more drug that is available for abuse.

Dr. Marty Olsen is an obstetrics and gynecology physician in Johnson City. He has interests in international medicine and in confronting the opioid epidemic.

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