First, let me say this about conflicts of interest regarding buprenorphine taper, because it’s going to come up. I receive no money of any kind from any maker of buprenorphine. I was on speaker panels for both RBP and Orexo in the past but have not been for over a year. I get no consideration from any pharmaceutical company.
Ms Roberts asked in her piece in The Fix “Why is there no official medical protocol to detox people off Suboxone?” I’d like to answer that question.
The question seems to suppose that getting off buprenorphine after being maintained on it for opioid dependence is entirely about medical withdrawal management. It is not. What happens when most people get off of buprenorphine is that the medication that was suppressing the symptoms of addiction is going away, and those symptoms return. This is separate and distinct from withdrawal symptoms, but most people don’t make this distinction.
What are these symptoms? They are symptoms of low dopamine tone in the midbrain. Well more than half of the patients who have ever come to see me for addiction treatment tell me they’ve had these symptoms since before their first drug use, and it was the relief of these symptoms that was, at least in part, what made the drug so useful. An incomplete list of them are: not enjoying things as much as others who are experiencing the same thing (relative anhedonia), poor memory, poor focus, irritability, and difficulty making attachments to others. If these things start to return along with withdrawal symptoms, it’s easy to think the whole thing is from withdrawal.
So there will never be a single protocol for tapering buprenorphine, because in most people, the taper will have to be customized with additional specific treatments for the original symptoms. Agonism of the mu receptor, even partial agonism like buprenorphine, causes additional tonic release of dopamine, and this makes people with low dopamine feel better, even if their original problem wasn’t at the mu receptor or within the opioid system. I’ve seen many patients who weren’t able to get off that last 2mg until we added specific medication for the pre-existing symptoms.
In addition to the quest for a specific protocol, Ms Roberts seems to imply that the pharmaceutical companies coopted the government in some nefarious plan to make buprenorphine. In a less paranoid world some might say that the people at NIDA and SAMHSA saw the rise in opioid use over the last two decades and worked for a solution to increased cases of opioid dependence that they could implement because they had no control over the DEA approval of more and more full opioid agonists or what doctors did with them. There were a lot of people over the last 40 years that saw problems with the national focus on pain, and the use of full opioid agonists for chronic pain, and foresaw that there would be a great increase in addiction involving opioids.
Ms Roberts rightly points out that every full opioid agonist that was brought to market as a solution to the addictive potential of other full opioid agonists failed. But she also accepts the underlying assumption of the attempt. In Medicine, when a treatment doesn’t work for a diagnosis that it’s supposed to work for, we check our underlying assumptions about the diagnosis and the adequacy of the treatment. The serial failures never prompted anyone to question just who it was “getting addicted to opioids.” The problem was that the underlying assumption that normal people are the ones who largely get into trouble is incorrect. It’s not the formulations that need to be addiction-proof, it’s the doctors that need to know how to recognize the risk factors and symptoms of the illness before they give the drugs. This lack of understanding of addiction as an illness has caused a huge amount of trouble, harm, and failed policy over the years.
The same assumption underlies the failure to understand how and why people get off of buprenorphine. It isn’t a dose problem, it’s that people taking buprenorphine are taking it for different reasons, and if those reasons aren’t known and included in the care plan, the withdrawal management plan won’t likely work as well as if they had.
Finally, Ms Roberts offered her own partial solution. She talked to four doctors who found that daily cardio helped. There didn’t seem to be a check of their records to see if patients not helped by daily cardio left their practice and weren’t counted. Could it be that daily cardio helps with some people? Of course. But my point is that we need to stop saying that anything works in everyone. We don’t need a specific protocol for buprenorphine withdrawal regardless of the inclusion of exercise, diet or flower picking. What we need is a change in our societal attitude that people with addiction were once normal and can be so again easily and permanently and that everyone needs the same thing.
This attitude also leads to another complaint of Ms Roberts’, that many doctors only take cash for buprenorphine treatment and charge an exorbitant amount. Let’s do a little thought experiment. Would those doctors be able to do that, to demand high prices, if buprenorphine treatment was freely available? I think not. In fact, I think it is the fact that no matter how skilled the physician, no matter how much they know about the neurobiology of addiction, no matter how well they individualize care, no matter what credential they have, they are all held to the same 100 patient limit that a cash loving doctor with no care for addiction treatment can have if he takes an 8 hour course. There is an unintended feedback loop here. The intent was to keep diversion from happening. It was felt to be necessary because of the very history Ms Roberts points out about the new introduction of opioids that are supposed to be safe in everyone. So rather than create policy that fostered individualization by physicians they set a 100 patient limit. That limit increased the value of the service, allowed people to demand cash, and created a larger market for diversion. Now we have people in Washington trying to solve a problem that they caused, but don’t know they caused. If they reversed the original cause, they wouldn’t have another problem to solve.
Ms Roberts’ piece does the disservice of continuing to confuse addiction and dependence. It suggests that people who want to stop their buprenorphine treatment are desperate, and suggests that this desperation comes, in part, from the drug company’s unwillingness to make 1mg doses. I have not found the 2mg minimum dose to be too large. A new dose won’t help; a specific protocol won’t help; another law won’t help. What we need is to see that addiction is a medical illness, free up those who know how to treat it, and stop making policy that makes things worse.