The Great Suboxone Debate - Page 2

By Jennifer Matesa 04/13/11

When it was first released in 2002, Suboxone was hailed as a major advance over methadone. But millions of scrips later, critics charge that the seductive opiate "cure" is causing its own epidemic of addiction. 

Bupe: detox breakthrough, but what about maintenance therapy? Photo via

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I’ve never read any addiction professional declare otherwise: buprenorphine can be a life-saver, especially for people on huge doses of pure pharma drugs. As I was. I’d graduated from Vicodin to plain hydrocodone to morphine to Oxycontin; for the final three years, I was on at least 100 mcg/hr of fentanyl—about the equivalent of 400 to 500mg of morphine. And I couldn’t quit. I might not be here today if it weren’t for Suboxone.

But like so many other drugs, the data the manufacturer showed the FDA for approval of Suboxone told only part of the story. Most clinical trials are small, short-term, and selective, so once the drug is marketed—and Big Pharma is nothing if not a marketing juggernaut—its long-term effects in large numbers of people begin to show the drug’s true colors. As was the case with OxyContin, Suboxone is widely promoted by doctors as being nonaddictive, but the experience of many addicts proves otherwise: bupe can be harder to kick than methadone—and methadone is a beast to kick. At the high doses many physicians prescribe—8 to 24 mg—some say it’s almost impossible to do without professional help.

Meanwhile bupe sales continue to skyrocket. In 2002, some 20,000 US patients were being prescribed the drug; by 2009, that number was 640,000. The Guardian reported last year that Reckitt Benckiser, the maker of Subutex and Suboxone, saw its pharma earnings shoot up by more than sixfold between 2004 and 2009, largely thanks to US sales of the drugs. "Buprenorphine is now the 41st most prescribed drug in the US. Five years ago, it was 196th," Scanlan says. "It's a money machine."

While studying anesthesiology, Scanlan became addicted to fentanyl—the strongest prescription painkiller available—and he detoxed in the 2000s using Subutex. He’s frank about attending the 12-step meetings he was introduced to during the program he entered to save his medical career. “I want people to understand I know what they’re going through,” he says. “You want to lead by example. I want them to say, ‘I want to do what you did.’” One thing he did was to make a point of not taking bupe for longer than three weeks, on the advice of his detox doctor. “Or else I’d be dealing with a whole different problem,” he says.

“I’ve seen what long-term Suboxone does,” says Scanlan, who switched his specialty to psychiatry in order to help other addicts kick prescription drugs. “People come in with endocrine problems—thyroid dysfunction, low testosterone,” which kills sex drive, “and hair loss. Tooth loss with Suboxone,” which is orange-flavored and is usually dissolved under the tongue.

Scanlan’s big concern: bupe’s 37-hour half-life, which makes the drug build up in the body when dosed every day. “Look at it this way,” he says. “If I maintained you on oxycodone, and every day I gave you one milligram more, you’d never complain, right?”

One treatment model for Suboxone is as maintenance—to keep patients on the drug for months or even years while their brain chemistry, which has been severely damaged by heroin or opiate addiction, heals. But Scanlan is a fierce opponent of such long-term bupe use. “There’s no way your brain chemistry can heal while on buprenorphine,” he says. “You’re continuing to give someone a narcotic.”

Buprenorphine is estimated to be 25 to 45 times as powerful as morphine. Scanlan says patients who want to get off the 8 to 16 mg levels physicians typically prescribe must taper very slowly because of the drug’s half-life. “When I hear that amount,” he says, “I think, ‘This is going to take a year.’” Addicts who are used to detoxing from heroin can be in for a rude surprise when they try to kick a bupe addiction—the lack of energy and the depression can overwhelm.

Most people, including doctors, don’t understand bupe’s strength, Scanlan says. He has noticed that at long-term doses of even 2 mg, bupe can block almost all of a person’s emotions. “They say to me after they’re off for a while, ‘Wow, I’m really having a full range of feelings,’” he says.

“There’s a saying in recovery communities: ‘No one needs serenity as much as a drunk.’ While they’re using, they get used to the chaos,” says Dr. Jeffrey Junig, a psychiatrist in Fond du Lac, Wisc., and assistant clinical professor of psychiatry at the Medical College of Wisconsin. In his private practice, Junig treats opiate addiction with bupe maintenance; his client base is always at the federal limit of 100, and he has a constant waiting list. His theory about loss of feelings on bupe: Addicts who sober up miss the chaos, the dramatic rollercoaster ride of using, and the comparative boredom of being on bupe—a facsimile of reality—makes them think they’re having no feelings. In fact, there is some evidence that bupe may be an effective antidepressant—opiates have, of course, been used forever to lift mood—but only one small study has been conducted (seven out of 10 patients with drug-resistant depression responded positively). 

Junig’s YouTube videos, blog, and public forum about the drug make him a high-profile booster of bupe maintenance on a mission to counter what he calls the drug's enormous stigma. His advocacy of bupe maintenance is based on “the least worst” logic. Most of his patients who have tried to detox off, he says, return to legal or illegal drug use. Worst of all, some OD. “I want addiction to be treated like every other chronic fatal illness,” he says. “We put people through treatment, they clean up, they come out looking good, we all congratulate ourselves—and then six months later, the patient dies,” he says. “And no one cares about this. There’s no review of what we might have done better, the way there would be if the patient died of a heart attack, for example.”

When patients take buprenorphine, he says, they quit stealing and lying, they become employable. “Especially if they’re over 40, they do well,” he says. “It’s like they’re taking their blood-pressure pill.” Is his solution to put addicts on bupe forever? “Not necessarily forever,” he says. “Every person I see, going off Suboxone is part of the discussion.” But he says that when a client wants to taper off, he tells them frankly that the odds are against them because studies show 100% of opiate addicts relapse after detox. 

Asked for citations for these 100% studies, he says, “I don’t have them at my fingertips. Actually, it’s based on a lot of personal experience. I don’t know if people at treatment centers would even argue this point. They would tell you that with people addicted to opiates in particular, they tend to go through treatment over and over and over."

"There has been virtually no research on persons dependent on prescription opioids, in spite of the increase in prescription opioid abuse and in the numbers of persons entering treatment for addiction to prescription opioids," Dr. Roger Weiss said at the 2010 American Psychiatric Association annual meeting. Weiss, a professor of psychiatry at Harvard Medical School and chief of the Division of Alcohol and Drug Abuse at McLean Hospital, outside Boston, was presenting a study he conducted designed to figure out how to manage patients when they refuse care in drug-abuse treatment programs. He found that of 653 prescription-opioid addicts, those who were given bupe and then tapered off over nine months, without any other intervention, consistently went back to drugs.

I asked Scanlan about this study. He said that 100 percent of his patients who detox off bupe and work a program of recovery, which may be the 12 steps or some other spiritual-fitness approach, stay sober—but not everyone wants to work that hard.

Junig disagrees. "The people who try abstinence, they’re like the starfish on the beach. There aren’t many of them.”

Is Junig perhaps one of those starfish? Like Scanlan, Junig was also an anesthesiologist; by the mid-1990s he was prescribing himself codeine cough syrup and drinking so much of it that he hid the bottles in his car—until his wife found out. Junig went through a 90-day inpatient treatment program. Since a 2000 relapse, he says he’s been sober.

What does he do to stay straight? “I don’t talk about this to anybody," he says, although he does allow that he has participated in NA and AA. But he says he doesn’t think they’re necessary for many people on long-term bupe. “There are no cravings [on buprenorphine] because nothing is ever wearing off,” he says. “The result is that people feel completely different, very quickly. It is not about the blocking of withdrawal,” he emphasizes.

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Jennifer Matesa is a Voice Award Fellow at the federal Substance Abuse and Mental Health Services Administration and is the author of the blog Guinevere Gets Sober. She is the author of several books, including the non-fiction, The Recovering Body, about physical and spiritual fitness for living clean and sober. You can find Jennifer on Linkedin or follow her on Twitter.