A couple of states are scrutinizing the prescribing practices of doctors who treat patients with opiate addictions. Coupled with the dark shadow cast by the perpetrator of the recent Charleston shootings, who had Suboxone in his possession at the time of his arrest, legislators are taking a long, hard look at buprenorphine, the generic name for Suboxone. Should Suboxone treatment be curtailed, should it continue as it has been, or should it be expanded?
Should the Legislators Have a Say?
Substance abuse treatment professionals were dismayed to learn that Tennessee and Kentucky legislators are exploring options to cut back how much Suboxone is prescribed. The legislators attribute an upswing in prescriptions written to drug abuse and not to successful Suboxone treatment.
One aspect of the legislation deals with a different formulation of buprenorphine, used by physicians and pain management clinics to manage pain, which goes by the brand-name Buprenex, a medication injected by a doctor in the office setting. Many vets use it also, for small animals like dogs and cats. Legislators want to limit the use of buprenorphine per the scope identified by the FDA, which is also found in the the medication treatment for opiate addiction treatment. It would no longer be available for pain management.
But in another aspect, the legislators want to limit the dosage for those receiving Suboxone treatment for opiate addiction. It’s true that doses higher than 24 mg daily are rare. Studies have indicated that people who take 24 mg daily or more have a higher likelihood of relapse than those who stick to smaller dosages. But on the other hand, legislators should have no say in how much buprenorphine a physician can prescribe. Only a medical doctor can make a prescribing decision. Legislators are not qualified to make judgments on the issue.
In a related area, the Tennessee legislators want to limit Subutex to pregnant women only. Subutex contains no naltrexone, which is an added ingredient in Suboxone. Subutex is definitely a better option for pregnant women, because it exposes the unborn baby to fewer medicines. Again, only legislators who have gone to medical school and specialized in addiction medicine should have the final word on that.
Yet another issue involves whether people can get high from Suboxone. Legislators believe the addicts who insist that alcohol and benzodiazepines amplify the effects of Suboxone. Perhaps those addicts are actually just responding to the effects of the benzos and alcohol. The buprenorphine contained in Suboxone or Subutex is only a partial agonist, and it binds with the brain’s opioid receptors but there is a ceiling to the effects felt by the person.
The Case For Expanding Suboxone Treatment
There are additional benefits of Suboxone beyond its limits as a partial agonist. It comes with a longer half-life than methadone, which means it leaves the system slowly. Someone addicted to heroin or pain pills never stops looking for his next dose. Those who take buprenorphine for Suboxone treatment are maintained at a safe and steady level for at least 24 hours.
Many people opt for Suboxone treatment over methadone because they can go to the doctor’s office, receive a prescription, and then return periodically for follow-up and additional prescriptions. It’s not like methadone, which requires a trip to a medication-assisted treatment program every day in order to obtain the medication that saves them from cravings and withdrawal symptoms.
There are long waiting lists for Suboxone treatment in many locations. The Internet and newspapers carry many stories of people who went to abstinence-based rehab and relapsed afterward while they were waiting to get into a Suboxone treatment program. Many of them have died waiting.
But Then There Are the Cons…
The reason for the waiting lists is the limit placed on doctors by the Food and Drug Administration. A physician takes a required course in order to become a buprenorphine prescriber, and in the first year following that certification he is limited to 30 patients, no matter how many practice locations he has. Beyond the first year he can treat up to 100 patients at a time. The federal government’s Substance Abuse and Mental Health Services Administration’s intention is for doctors to ensure that their patients then receive behavioral health and vocational counseling services.
Even with the limit of 100 patients, however, it can be a profitable business for a doctor, especially for those who ignore the counseling end of it. With patients paying up to $500 per month—well, you do the math. There are many doctors who receive the certificate to prescribe buprenorphine, and they just hand out prescriptions to the people who line up at their doors. Those patients undoubtedly represent the bulk of persons struggling with addiction issues who relapse and sell their buprenorphine on the street.
Approving Additional Suboxone Treatment Providers
On the bright side, whether or not certain legislators succeed at the state level in limiting doctors’ prescribing options, Senators Edward Markey (D-Massachusetts) and Rand Paul (R-Kentucky) have joined forces across the partisan divide on the federal level. They hope to expand the availability of Suboxone treatment services. The Recovery Enhancement for Addiction Treatment Act would change the limit from 30 to 100 for those physicians who become newly certified to prescribe buprenorphine. Certain nurse practitioners would become eligible to prescribe buprenorphine. And the 100-patient limit would be removed from physicians who become board certified or achieve recognition in addiction treatment.
This may lead many primary care physicians to obtain the certification and prescribe Suboxone within the scope of their private practices. However, SAMHSA as well as CARF, the accrediting body that oversees licensed, certified Suboxone treatment programs, both agree that counseling obtained in addition to medication enhances the quality of recovery for you or for your loved one in treatment. Let’s hope that new regulations will require that prescribers ensure counseling is also in place for their patients. Ultimately, only you, your doctor, and your counselor can make the decisions that are right for you.