urine of suboxone pt I just took over.....

[vistaril]

+ benzos, + opiates(dilaudid), no bup.......

someone is getting terminated.

---

Members don't see this ad.

 

[ghost dog]

+ benzos, + opiates(dilaudid), no bup.......

someone is getting terminated.

I don't practice addiction medicine, so I'm intrigued here...could this pt :

1. Be potentially diverting / selling the bup for above meds ?

2. Not taken the bup for 2 - 3 days, and binged on the above ?

I'm assuming (1) is the (far more likely) conclusion being made, and thus termination is the usual protocol in your neck of the woods.

My hat goes off to you for managing such a challenging population. I thought managing chronic pain was challenging - you got me beat!

 

[whopper]

Suboxone has a street value. If you take it, it blocks opioids so abusers often stop taking it.

 

[BS81]

I never quite understood why Suboxone has the street value it has. The only reason I can see is that it doesn't show up on standard urine drug screens as an opiate and it still gives addicts some of that "high" feeling, but then again why don't they just get their own scripts

 

[whopper]

Here's the reason why.

Guess who drug dealers service? Drug addicts. Some addicts want Suboxone, not to get high, but to help get off of an opioid themself or at least live with withdrawal symptoms for the time being.

Several patients, it appears, wean themselves off or are in need of quick cash and sell them to drug dealers. This has been a major point for me in believing that in at least most patients they should not be not providing Suboxone for too too long to patients (9 months+). There is no exact science behind how long someone should be on it and some patients should be on it longer than others, but some patients I've seen, state they should be on it for the rest of their lives without trying the psychotherapeutic recommendations I give them...leading me to suspect that 1) they weaned themselves to a lower dosage of it and are selling the rest or 2) they're in a comfort zone with the Suboxone and don't want to get off of it.

Neither of which are acceptable in the long run. There really is no full-proof way to make sure they're not weaning themselves off of it and selling the rest.

 

[nitemagi]

Here's the reason why.

Guess who drug dealers service? Drug addicts. Some addicts want Suboxone, not to get high, but to help get off of an opioid themself or at least live with withdrawal symptoms for the time being.

Exactly.

 

[Chrismander]

I never quite understood why Suboxone has the street value it has. The only reason I can see is that it doesn't show up on standard urine drug screens as an opiate and it still gives addicts some of that "high" feeling, but then again why don't they just get their own scripts

Man you have HST as your avatar and you don't get it? Suboxone is a perfectly fine drug for the recreational polydrug user. Partial agonist = getting high, at least for an opiate naive brain. Even for the non-tolerant or only barely tolerant brain, I suppose.

Throw in Whopper's idea of using it to self-detox, manage withdrawal symptoms until you can find some heroin, or just to mix it up a bit every now and again, and you got yourself an all-in-one drug with some street value.

**** if anyone really knows I suppose, maybe they just like lemon-lime? Rickett-whatevers needs to come out with a nice line of premium, flavored suboxone...root beer float suboxone or something. Or some wholistic junk, gingseng- or horny goat weed suboxone: one restoreth what the other taketh.

Long story short, no one ever will ever really know why suboxone has such street value. Don't bother to ask the junkies...to misquote HST, half the time they talk in code anyway.

 

[whopper]

Best way to find out is to talk to people who are abusing it.

Suboxone could be abused by opioid-naive people, the method talked about by abusers is insufflating it, and that's a reason why the manufacturer wanted to get rid of the tablets and switch it with the film.

But the high is not as good as other "real" opioids, so yeah it can be abused but they usually go for the other stuff. Kinda like Cogentin. It could be abused, but when the high blows compared to the other stuff out there, they just let it go.

But while that makes it sound safe, no. Drug abusers in withdrawal are willing to do almost anything to get off that including sex-for-drugs, rob people, even kill people. That drug-dealer selling Suboxone isn't exactly beneficent. They could be coercing a 14 year old kid into fellatio so the kid could get Suboxone so the kid could escape withdrawal.

It still has an abuse potential and a street value.

A nurse told me that a few blocks away from where she lives, some shmuck that I'm thinking is a quack built a Suboxone clinic with bright neon letters "SUBOXONE CLINIC". They might've well just put an exclamation point and at some other neon signs you'd see at a strip club like the blond lady on the swing. At least that would've been more honest.

I prescribe Suboxone but I'd like to think I do it to help people. IMHO that means being strict on patients, no dosages over 16 mg unless there's very very good reason, and they can't stay on it indefinitely unless there's good reasoning, and if so taper down to 12 mg. Anyone copping the excuse that it's the only med they know of that'll block opioids and the don't trust themselves, I tell them..."NO" There's Naltrexone. If you're scared of relapsing, then we get you off the Suboxone at some point and get you on Naltrexone.

 

[vistaril]

Best way to find out is to talk to people who are abusing it.

Suboxone could be abused by opioid-naive people, the method talked about by abusers is insufflating it, and that's a reason why the manufacturer wanted to get rid of the tablets and switch it with the film.

But the high is not as good as other "real" opioids, so yeah it can be abused but they usually go for the other stuff. Kinda like Cogentin. It could be abused, but when the high blows compared to the other stuff out there, they just let it go.

But while that makes it sound safe, no. Drug abusers in withdrawal are willing to do almost anything to get off that including sex-for-drugs, rob people, even kill people. That drug-dealer selling Suboxone isn't exactly beneficent. They could be coercing a 14 year old kid into fellatio so the kid could get Suboxone so the kid could escape withdrawal.

It still has an abuse potential and a street value.

A nurse told me that a few blocks away from where she lives, some shmuck that I'm thinking is a quack built a Suboxone clinic with bright neon letters "SUBOXONE CLINIC". They might've well jusLt put an exclamation point and at some other neon signs you'd see at a strip club like the blond lady on the swing. At least that would've been more honest.

I prescribe Suboxone but I'd like to think I do it to help people. IMHO that means being strict on patients, no dosages over 16 mg unless there's very very good reason, and they can't stay on it indefinitely unless there's good reasoning, and if so taper down to 12 mg. Anyone copping the excuse that it's the only med they know of that'll block opioids and the don't trust themselves, I tell them..."NO" There's Naltrexone. If you're scared of relapsing, then we get you off the Suboxone at some point and get you on Naltrexone.

good post.

Most "street" suboxone is used by addicts detoxing themselves. Not always on a grand scale. Someone may buy 6 8mg tabs and split them with very fine cutters into their own taper over 10 days or whatever. So a lot of the street value in suboxone is derived from medical use.

built into the "street value" of suboxone is the office visit fee.....I've heard self pay addicts state that "my suboxone"( 8mg tabs BID) costs them on average 350 a month....this is for the rx and the office visits

 

[whopper]

I have strong reason to believe a few patients tapered down their dosage from 16 to a lower dosage like 8 mg, then sold the rest. If insurance is paying for it, and usually it does, this could land the person a few hundred a month.

The points of suspicion are patients who are stabilized who appear to have no desire to get off of it. Yes, I realize some are mentally obsessed with relapse and fear getting off of it, but I do think out of a group of 100 people that fit this category, there's going to be a portion that are savvy enough to wean themselves off, then get it from the doctor, the insurance pays for it, and now they get a few hundred a month like I mentioned.

If patients are denying triggers to use drugs and won't go down on their dosage, I at first (maybe the first month or two) ask them why politely. If they keep dragging it on, now this becomes complicated because there's no science to how long someone should be on Suboxone. I give them the fact that many insurance companies won't pay for it indefinitely so they need to actively work on conquering their addiction and getting off of it, I also tell them if they feel they're a lifelong addict they need to move to Naltrexone. Beyond that I have no specific answer because there's no hard science on how long someone should be on Suboxone, but in general the longer they're on it the less I like it.

Another point: I sometimes see patients drop unintended information, or they claim to lose a script, demand another, I tell them no, then tell them they're terminated, and then they beg me to take them back, I tell them only if they find the script and show me, and then they come back the same day saying they miraculously found the script. When that happens, I wont' terminate them (yet) but they basically lost a heck of a lot of credibility in my eyes.

I had one patient where someone (other than him) called the office claiming he weaned himself to a low dosage of it and was selling the rest. They refused to ID themself, so I didn't know if it was someone giving real information. I told the patient what happened, and he told me he didn't know what I was talking about. I wanted to terminate him but for all I knew the person calling could've been a crazy ex-girlfriend stalker. He was later arrested for possession of drug paraphernalia. That's when I terminated him.\

In Ohio, you can look up if anyone's been arrested for anything by putting their name into the county's clerk of courts website. We also have an online website that allows me to see if the person has gotten any prescriptions filled out for drugs of abuse. I do that plus the usual drug screens. The guy I mentioned didn't tell me he was arrested so I told him I knew about it, he then told me the charges were dropped, and I told him the website said he was found guilty. He told me it was an error, to which I said, "then get the court to fax me a letter saying their website is in error, until then don't bother to talk to me again."

 

[toothless rufus]

Addiction medicine sounds...very challenging. I don't think I could put up with all the shuckin'-n-jivin' for more than an hour (but guess I'll have to maybe for the required rotation). Which sucks because theoretically its very interesting.

 

[whopper]

It's not that different from forensic psychiatry in some respects. Anyone on my forensic unit IMHO was not mentally ill until they proved to me they were because of the large portion of malingerers.

With Suboxone patients, they better stick to the rules or I'm going to terminate them. I have let a few slip once or twice on things, provided they have an excuse that can be documented (E.g. they couldn't make their meeting because their mother died), of they have several months of good behavior and have one slip-up.

But, and I hate saying it, what I've noticed, and I've found the same with other doctors following the guidelines are 1) you get a new Suboxone patient, 1/2 of them miss their first meeting because during the X amount of days during the call to schedule and the day of, they gave in to the urge to use drugs again and now ran out of the money to pay for it 2) Of the ones that get on Suboxone, in about 95% it works like a charm (I've seen some people get a bad reaction to it to the degree where they cannot take it, in which case I am willing to refund their money though I have every right to not do that because I'm charging for my time and service that was provided), but then out of that 95%, about 1/4 to 1/3 foul-up in the next few months, not because the medication, but because these were very impulsive people to begin with even before they were addicts, and now they're stable, they forget to schedule a meeting, show up to the office and they're acting inappropriately (screaming at someone on the cell-phone in the waiting room), or they have some BS story about how they can't pay for their office visit so please see them for free because they just plopped their money on a Caribbean cruise (no I'm not making that up).

And then if you don't give into their demands they start screaming or something else outlandish, like get a lawyer to demand all their records--but then oddly there's no lawsuit because I figure the lawyer looked at the records and realizes you did nothing wrong, it's their client that screwed up and there's no case.

Some Suboxone doctors I've noticed keep letting their patients fail, and continue them on it, leading me to believe this is the monster-generator that allows drug-dealers to be supplied with Suboxone.

I don't think I could put up with all the shuckin'-n-jivin' for more than an hour

It's not that bad when you got security. When you don't, you need your receptionist to head these people off over the phone so they don't show up and blow up on the office. E.g. In private practice, if we find out someone's arrested, we tell them immediately before they show up to the office that they're terminated so they don't show up to the office and have their meltdown there. At the university, well it's armed to the teeth with guards, so now I feel protected.

I had one lady, who was terminated a few days before, show up to the private practice one day demanding to see me. The receptionist told her to leave or 9-1-1 would be called. She refused to leave and the receptionist called 9-1-1 and then the lady got up and ran out. This crap happens when you provide Suboxone.

There are good Suboxone patients out there, but the portion of those causing office-problems is pretty high. It's ironic because everyone single Suboxone patient I've had, I told them I won't tolerate bad behavior and they laugh as if they'll never do it but a sizeable portion unfortunately does. I make all of them sign a contract that specifies the rules on day one and most of them sign it without even reading it, and when I notice it I make them read it and tell them I'm not going to tolerate any BS.

 

[vistaril]

I have strong reason to believe a few patients tapered down their dosage from 16 to a lower dosage like 8 mg, then sold the rest. If insurance is paying for it, and usually it does, this could land the person a few hundred a month.

."

oh yeah I agree....Insurance wont usually pay for your office visit will it though?

the good thing about suboxone is that you are talking a few hundred.....whereas with the pain med doctors it's a different ballgame. the number of pain patients selling "some"(so they wont go into wdrawl and will still test +) is massive......not sure how the pain docs can fight them.

 

[BS81]

Cheaper opiates to get high on, per many junkie accounts the high isn't that great, and methadone is easier to get on the streets. The fact that it doesn't show up on standard drug screens seems like it's only "benefit". Keeping up with the appointments to get the suboxone just seems like a waste of time when you can easily get better pain pills with better street value from any unsuspecting family doc or pain mill out there. But addicts don't tend to be the most rational people, so who knows.

 

[BS81]

oh yeah I agree....Insurance wont usually pay for your office visit will it though?

the good thing about suboxone is that you are talking a few hundred.....whereas with the pain med doctors it's a different ballgame. the number of pain patients selling "some"(so they wont go into wdrawl and will still test +) is massive......not sure how the pain docs can fight them.

That's the other point - most appointments are cash so it makes it even less "profitable"

 

[whopper]

..Insurance wont usually pay for your office visit will it though?

True, but the local Suboxone rep is telling me some are including it in their insurance coding. I haven't seen it yet and I've asked her to provide me with a list and I haven't gotten one yet.

 

[vistaril]

True, but the local Suboxone rep is telling me some are including it in their insurance coding. I haven't seen it yet and I've asked her to provide me with a list and I haven't gotten one yet.

if that's going to be the trend, that won't be good news for those of us who want to do
part time outpt suboxone cash pay on the side.....

why in the world would insurance companies be including it in coding? That just opens up a can of worms which leads to more suboxone scripts being covered by insurance as well. Surely employers dont pick employee benefit plan options based on who offers freaking suboxone programs(even addiction as a whole isnt given much respect, but one facet of addiction medicine??)

when was it ever in the interest of insurers to take things that were self pay into insured mode?

 

[OldPsychDoc]

I just think I should provide a tiny counter-point: addicts are challenging, but so are brittle diabetics, head injury patients, and rheum patients. Where docs get frustrated is in trying to accomplish a level of sobriety in their patient that the patient is not motivated to achieve for themselves. But when you've taken the time to find out why they want to get sober (this time) and help them figure out what they need to do to get there...well, they'll love you forever. It is a relapsing and remitting illness, just like everything else in psych. Relapses happen, we learn from them, we move on if we can.

I have a small number of suboxone patients who have done well. I've terminated a couple, so it's not like I've never run across any bad behavior. It's a lifesaver and a godsend in the monitored health professional population. (Never know...could be you some day...) I find it tends to work out better with prescription narc addicts who haven't had as much experience with the repertoire of bad behaviors that street opiate addicts have developed to survive. So, to Toothless Rufus and others who have only dealt with the seamier side of things...keep an open mind. There's good stuff out there too.

 

[OldPsychDoc]

if that's going to be the trend, that won't be good news for those of us who want to do
part time outpt suboxone cash pay on the side.....

why in the world would insurance companies be including it in coding? That just opens up a can of worms which leads to more suboxone scripts being covered by insurance as well. Surely employers dont pick employee benefit plan options based on who offers freaking suboxone programs(even addiction as a whole isnt given much respect, but one facet of addiction medicine??)

when was it ever in the interest of insurers to take things that were self pay into insured mode?

Yes, why in the world would any insurer treat it as an FDA-approved prescription medication for an identified disease, thus taking away your opportunity to be a drug-pusher for profit? Why indeed?

Perhaps you can patent your specialized treatment methods for borderline personality disorder and generate some cash flow off of that?

 

[vistaril]

I just think I should provide a tiny counter-point: addicts are challenging, but so are brittle diabetics, head injury patients, and rheum patients. Where docs get frustrated is in trying to accomplish a level of sobriety in their patient that the patient is not motivated to achieve for themselves. But when you've taken the time to find out why they want to get sober (this time) and help them figure out what they need to do to get there...well, they'll love you forever. It is a relapsing and remitting illness, just like everything else in psych. Relapses happen, we learn from them, we move on if we can.

I have a small number of suboxone patients who have done well. I've terminated a couple, so it's not like I've never run across any bad behavior. It's a lifesaver and a godsend in the monitored health professional population. (Never know...could be you some day...) I find it tends to work out better with prescription narc addicts who haven't had as much experience with the repertoire of bad behaviors that street opiate addicts have developed to survive. So, to Toothless Rufus and others who have only dealt with the seamier side of things...keep an open mind. There's good stuff out there too.

??? your state allows people in health professional monitoring programs to be on suboxone? The two states Im most familar with don't.

 

[vistaril]

Yes, why in the world would any insurer treat it as an FDA-approved prescription medication for an identified disease, thus taking away your opportunity to be a drug-pusher for profit? Why indeed?

Perhaps you can patent your specialized treatment methods for borderline personality disorder and generate some cash flow off of that?

.

suboxone is great. but so area lot of things in medicine that arent covered by insurance or medicare/caid.

not even going to address the bpd comment.

 

[OldPsychDoc]

??? your state allows people in health professional monitoring programs to be on suboxone? The two states Im most familar with don't.

There are more things in heaven and earth, Vistarilio,
Than are dreamt of in your philosophy.

 

[nitemagi]

There are more things in heaven and earth, Vistarilio,
Than are dreamt of in your philosophy.

Brilliant.

 

[vistaril]

There are more things in heaven and earth, Vistarilio,
Than are dreamt of in your philosophy.

ummm yeah ok. As for suboxone and health professional programs, are you talking long term suboxone being allowed? I've treated a number of opiate addict nurses, pharmacists, dentists, doctors through an addiction program, and none of them were allowed to be on suboxone and maintain compliance in their states monitoring system.....

 

[nitemagi]

ummm yeah ok. As for suboxone and health professional programs, are you talking long term suboxone being allowed? I've treated a number of opiate addict nurses, pharmacists, dentists, doctors through an addiction program, and none of them were allowed to be on suboxone and maintain compliance in their states monitoring system.....

To be concrete (as appears to be necessary), you make OPD's point exactly. You know your state. You know your hospital. Can't seem to quite grasp that your experience doesn't generalize to the rest of the world.

 

[OldPsychDoc]

ummm yeah ok. As for suboxone and health professional programs, are you talking long term suboxone being allowed? I've treated a number of opiate addict nurses, pharmacists, dentists, doctors through an addiction program, and none of them were allowed to be on suboxone and maintain compliance in their states monitoring system.....

I guess I'm just fortunate to have trained in and practiced in 2 states that are more interested in recovery and treatment than in stigma and punishment.

 

[vistaril]

To be concrete (as appears to be necessary), you make OPD's point exactly. You know your state. You know your hospital. Can't seem to quite grasp that your experience doesn't generalize to the rest of the world.

the standard for most professional monitoring programs are to not allow suboxone long term.....I cant speak to how many states(and more importantly how many programs/types and in what circumstances) it is allowed.

 

[vistaril]

I guess I'm just fortunate to have trained in and practiced in 2 states that are more interested in recovery and treatment than in stigma and punishment.

maintenance on suboxone is not recovery.

 

[OldPsychDoc]

maintenance on suboxone is not recovery.

 

[billypilgrim37]

maintenance on suboxone is not recovery.

After this *****ic comment, I am officially blocking Vistaril. I can't take it anymore.

 

[whopper]

I agree with OPD's comments despite my previous tone. There are a lot of good Suboxone patients, but there's bad ones as well.

I think a trick to giving this stuff is you have to be strict with those screwing around, but not allow frustration to rub off on the people who are doing well.

About maintenance, it is a step forward, and there are patients where you have to be wary of them being on it for too long. Like I said above, how to handle this becomes grey because there is no exact science on how long they should be on it. I have seen patients be on maintenance for over a year and appear to be sincere and have nothing I find wrong in terms of drug screens, maintaining interviews, etc. I see a group that doesn't want to take any steps forward in terms of getting off of it even afer being on it for months. That group makes me wonder. Like I said, I understand if one's scared to take the next step, but on the other hand someone is supplying the drug dealers.

 

[vistaril]

You're free to your own opinion of course (shrug)

I like suboxone, and have my own license/no for it and use it. Some people require it because they are not capable of true recovery. But if a pt is addicted to opiates and they are on a partial opiate agonist, that's pretty much the definition of "not real recovery"

It also limits peoples options somewhat. If I think I can get an addict of opiates, that's the goal and I'll try to do that. If it's not possible, suboxone is a great idea.

 

[vistaril]

After this *****ic comment, I am officially blocking Vistaril. I can't take it anymore.

I find it laughable that supposed psychiatrists view maintaining someone on a controlled partial opiate agonist is "real recovery"........it *is* treatment, and for a certain population optimal treatment, especially after repeated failures.

I work with a lot of addicts who cannot be on suboxone and work in their profession. I'll put pts on it acutely during detox of course....and for some pts it is a great long term drug.

 

[SomeDoc]

I'm finding some of the points raised here interesting. What defines recovery? Satisfactory social and occupational functioning in the presence of continued maintenance? Sustained and full remission? I think the answer is not as simple as it seems.

 

[F0nzie]

I find it laughable that supposed psychiatrists view maintaining someone on a controlled partial opiate agonist is "real recovery"........it *is* treatment, and for a certain population optimal treatment, especially after repeated failures.

I work with a lot of addicts who cannot be on suboxone and work in their profession. I'll put pts on it acutely during detox of course....and for some pts it is a great long term drug.

"Real recovery"? Are you a patient or a physician?

This is a very high expectation to have from substance dependent patients, whom have been extensively studied and known to suffer from a chronic relapsing and remitting disease. This is why we use the term "remission" and not "recovery". Recovery has an omniscient quality that assume complete resolution, present and future.

By your definition, if someone gets their life back together, stops spending 16 hours a day cheating and stealing drugs, stops injecting themselves with needles contaminated with HIV and Hep C, gets a real job, remains substance free, and is on a partial agonist that does not cause a euphoric high, they are essentially cheating themselves from what you define as a "real recovery".

How terribly sad. Isn't our job to get people's life back together? Not argue over some stupid nuances that overlook potentially life saving interventions? These nuances do give us problems with non-compliant and malingering patients, but that's why we have to be so strict. In an ideal world, we can start using the term "real recovery", maybe, but we're far from it.

 

[vistaril]

"Real recovery"? Are you a patient or a physician?

This is a very high expectation to have from substance dependent patients, whom have been extensively studied and known to suffer from a chronic relapsing and remitting disease. This is why we use the term "remission" and not "recovery". Recovery has an omniscient quality that assume complete resolution, present and future.

By your definition, if someone gets their life back together, stops spending 16 hours a day cheating and stealing drugs, stops injecting themselves with needles contaminated with HIV and Hep C, gets a real job, remains substance free, and is on a partial agonist that does not cause a euphoric high, they are essentially cheating themselves from what you define as a "real recovery".

How terribly sad. Isn't our job to get people's life back together? Not argue over some stupid nuances that overlook potentially life saving interventions? These nuances do give us problems with non-compliant and malingering patients, but that's why we have to be so strict. In an ideal world, we can start using the term "real recovery", maybe, but we're far from it.

You're assuming things about my views on this matter that I did not state, or even imply:

1) Where did you get the idea I believe that person would be "essentially cheating themselves" from real recovery? That's like saying a person with an iq of 75 with schizophrenia is "effectively cheating themselves" from education if they choose to engage in a remedial job training program for people with mental illness rather than go to college.

2) Where did I imply my expectation from hard core addicts is recovery? Another assumption you made.....

3) it is not a "stupid nuance".......it is the difference between sobriety and not having sobriety.

.

 

[vistaril]

I'm finding some of the points raised here interesting. What defines recovery? Satisfactory social and occupational functioning in the presence of continued maintenance? Sustained and full remission? I think the answer is not as simple as it seems.

some in the addiction community argue that simply abstaining from substances is not living recovery. That's a different argument really. Regardless of that, a person with opiate dependence intentionally putting opiates into his body is most certainly not "recovery".......my 4 year old nephew could understand that.

 

[Ceke2002]

I never quite understood why Suboxone has the street value it has. The only reason I can see is that it doesn't show up on standard urine drug screens as an opiate and it still gives addicts some of that "high" feeling, but then again why don't they just get their own scripts

Naltrexone, or at least a dodgy home-based Naltrexone rapid detox used to have a street value where I live. Addicts would hook up with dodgy Doctors, obtain Rohypnol, Clonidine and Naltrexone and then charge $200 to fellow addicts to put them through an 8 hour detox.

 

[ghost dog]

I agree with OPD's comments despite my previous tone. There are a lot of good Suboxone patients, but there's bad ones as well.

I think a trick to giving this stuff is you have to be strict with those screwing around, but not allow frustration to rub off on the people who are doing well.

About maintenance, it is a step forward, and there are patients where you have to be wary of them being on it for too long. Like I said above, how to handle this becomes grey because there is no exact science on how long they should be on it. I have seen patients be on maintenance for over a year and appear to be sincere and have nothing I find wrong in terms of drug screens, maintaining interviews, etc. I see a group that doesn't want to take any steps forward in terms of getting off of it even afer being on it for months. That group makes me wonder. Like I said, I understand if one's scared to take the next step, but on the other hand someone is supplying the drug dealers.

Does this point of view extend to that of methadone, a pure opioid agonist ?

I presume that it would.

 

[OldPsychDoc]

I find it laughable that supposed psychiatrists view maintaining someone on a controlled partial opiate agonist is "real recovery"........it *is* treatment, and for a certain population optimal treatment, especially after repeated failures.

I work with a lot of addicts who cannot be on suboxone and work in their profession. I'll put pts on it acutely during detox of course....and for some pts it is a great long term drug.

This "supposed psychiatrist" (I suppose I am--I have big certificates on my wall from the ABPN stating that I am Board Certified in Psychiatry. And Addiction Psychiatry, for that matter, but go ahead, laugh away...) thinks that you are taking an exceptionally narrow definition of the term "recovery", apparently equated with total abstinence. Frankly, this definition is not subscribed to among the recovery community in my area, where I would say most of the professionals and recovering individuals would define recovery as a long term process toward social and occupational goals, as 'Some Doc' implied above.

Personally, I find it laughable that you presume to determine what is and is not "real" recovery. Once again, you generalize from your own opinions and narrow experience to judge what ought to be for the profession as a whole. And in case you've missed the signals, a fairly wide range of your more senior colleagues is getting rather sick and tired of it.

 

[OldPsychDoc]

Does this point of view extend to that of methadone, a pure opioid agonist ?

I presume that it would.

Methadone is a different animal. I think most docs (and addicts*, for that matter) see it as a last resort. It also has specific licensing requirements for facilities dispensing it for opiate dependence, so it's not something that even an addictionist would be managing from their outpatient office.

*I'm always reminded of the scene from "The Commitments"** where Jimmy Rabbitte is trying to convince a bunch of working-class Irish kids that they should play Soul music:

"Do you not get it, lads? The Irish are the blacks of Europe. And Dubliners are the blacks of Ireland. And the Northside Dubliners are the blacks of Dublin. So say it once, say it loud: I'm black and I'm proud."​

Basically, the alcoholics will tell you "I've never fallen down in the gutter"; the derelicts in the gutter will say "Well, I've never smoked crack"; the crackheads will say "At least I've never shot heroin", and the junkies will say "At least I've never had to be on methadone". Even the stigmatized stigmatize others...

**Awesome movie, BTW--as long as you don't mind 145 F-bombs in 113 minutes!

 

[whopper]

A patient on Suboxone maintenance may indeed been able to regain a constructive life again thanks to it. Is that recovery? Without trying to be political, and trust me I'm not giving this opinion scared to piss people off, it depends.

For many on Suboxone, being successfully on maintenance is the sword of Damocles. Why do I say that? I've seen insurance companies pull the rug out. A person could be quite comfortable with where they are at, and then after 3-12 months on it, insurance companies may choose to stop paying for it. The person may not be able to afford it out of pocket. Further for some, it's actually cheaper to get it off the street than get it legitimately though that entails risks such as being arrested in the process of getting it and patients of mine who used to get it off the street told me sometimes drug dealers would up the price out of nowhere when they see desperation in the customer. E.g "No I'm not going to give you a film for $20, now I want a dick $uck."

As already mentioned, there is a group stable on it that doesn't want to go further. Now here is the place where I feel there's lots of room for argument. Of course it's great they are stabilized and now able to go to work and live a life. The problem here is there's the ethical argument that this stuff costs money and why should a insurance company pay for it indefinitely, especially since it's not declared to be a permanent solution. There's no hard science to say how long someone should be on it.

Then the other problem: how will I know if a patient is weaning themself off of it while trying to still get it from me and sell it? So long as they have clean urine drugs screens, arent' getting arrested and take Suboxone the day of the interview, I won't be able to tell, and like I said, someone is providing it to drug dealers. Suboxone providers IMHO need to give this medication out while weighing the risks the patient may be selling off excess amounts.

That's why I don't like giving it out for too long--> unless a patient is paying for it out of pocket because those people aren't getting it in a cost-effective manner to sell it. As for those on insurance, I've seen insurance companies provide no advance warning (though this is rare) and then stop paying for it, though the majority do give at least a month of advance warning.

My bottom line, if someone wants to be on it for longer than 6-12 months, they have to have good reasoning. I have one patient, for example, that tried to kill himself with opioids even after being on Suboxone for 10 months, he still has triggers to use, and the only reason why I believe he survived is the Suboxone blocked the opioids. He still needs to be on it. I have another person on it for one year and they keep telling me no triggers to use but they don't want the dosage reduced or get off of it and when I ask them why they can't give me an answer. In this category, I make them reduce it to 12 mg a day, the minimum dosage where the person still has full protection from relapse, but aside from this, I start getting more and more heavy with demanding to know why the patient feels they shouldn't lower the dosage.

 

[vistaril]

This "supposed psychiatrist" (I suppose I am--I have big certificates on my wall from the ABPN stating that I am Board Certified in Psychiatry. And Addiction Psychiatry, for that matter, but go ahead, laugh away...) thinks that you are taking an exceptionally narrow definition of the term "recovery", apparently equated with total abstinence. Frankly, this definition is not subscribed to among the recovery community in my area, where I would say most of the professionals and recovering individuals would define recovery as a long term process toward social and occupational goals, as 'Some Doc' implied above.

Personally, I find it laughable that you presume to determine what is and is not "real" recovery. Once again, you generalize from your own opinions and narrow experience to judge what ought to be for the profession as a whole. And in case you've missed the signals, a fairly wide range of your more senior colleagues is getting rather sick and tired of it.

just for kicks I spent time surfing around into different states health care related monitoring sites(I searched for pharm and dent), and suboxone therapy is almost universally not kosher(I say almost because of course I didn't search them all)....

People can label something anything they want. Yes, suboxone helps some become more functional. Yes, suboxone definately has saved some from death by OD. But it's still a harm reduction strategy/treat and they are still on a schedule 2 opiate..and those are the facts

 

[Sneezing]

Whopper I cringe with your statements of avoiding long term suboxone.
-Data shows opiod dependence has a high relapse and maintenance is the best treatment. Methadone is the gold standard and suboxone is a close second for treatment of opiod dependence. Now, if people want to really nit pick its possible to say suboxone can be just as good as methadone if it had the same follow up demands of a methadone clinic.
-If you want to know if someone is taking their suboxone, get a buprenorphine level for qualitative purposes.
-When a person has had the long term sobriety, has the their life back and is functional (working, repaired relationships, forming new relationships, etc). You move into random urine drug tests. Spell it out in your contract for X amount per year. Stick to it. Random urines are more efficacious than scheduled. This is how you get around the anticipation and planning of the same day follow up with urine drop.

-The literature on suboxone diversion is for staving off opiate withdrawal from other full agonists. There is minimal to no abuse for intoxicating purposes.

-To help prevent diversion, prescribe the films. They will soon be fully traceable with tracking numbers on each of the pouches.

-Prescribing films also cuts back on risk of child overdose deaths, as its far harder for a toddler to open one and consume it.

 

[OldPsychDoc]

just for kicks I spent time surfing around into different states health care related monitoring sites(I searched for pharm and dent), and suboxone therapy is almost universally not kosher(I say almost because of course I didn't search them all)....

People can label something anything they want. Yes, suboxone helps some become more functional. Yes, suboxone definately has saved some from death by OD. But it's still a harm reduction strategy/treat and they are still on a schedule 2 opiate..and those are the facts

Schedule 3--just to keep the facts straight.

 

[vistaril]

A patient on Suboxone maintenance may indeed been able to regain a constructive life again thanks to it. Is that recovery? Without trying to be political, and trust me I'm not giving this opinion scared to piss people off, it depends.

For many on Suboxone, being successfully on maintenance is the sword of Damocles. Why do I say that? I've seen insurance companies pull the rug out. A person could be quite comfortable with where they are at, and then after 3-12 months on it, insurance companies may choose to stop paying for it. The person may not be able to afford it out of pocket. Further for some, it's actually cheaper to get it off the street than get it legitimately though that entails risks such as being arrested in the process of getting it and patients of mine who used to get it off the street told me sometimes drug dealers would up the price out of nowhere when they see desperation in the customer. E.g "No I'm not going to give you a film for $20, now I want a dick $uck."

As already mentioned, there is a group stable on it that doesn't want to go further. Now here is the place where I feel there's lots of room for argument. Of course it's great they are stabilized and now able to go to work and live a life. The problem here is there's the ethical argument that this stuff costs money and why should a insurance company pay for it indefinitely, especially since it's not declared to be a permanent solution. There's no hard science to say how long someone should be on it.

Then the other problem: how will I know if a patient is weaning themself off of it while trying to still get it from me and sell it? So long as they have clean urine drugs screens, arent' getting arrested and take Suboxone the day of the interview, I won't be able to tell, and like I said, someone is providing it to drug dealers. Suboxone providers IMHO need to give this medication out while weighing the risks the patient may be selling off excess amounts.

That's why I don't like giving it out for too long--> unless a patient is paying for it out of pocket because those people aren't getting it in a cost-effective manner to sell it. As for those on insurance, I've seen insurance companies provide no advance warning (though this is rare) and then stop paying for it, though the majority do give at least a month of advance warning.

My bottom line, if someone wants to be on it for longer than 6-12 months, they have to have good reasoning. I have one patient, for example, that tried to kill himself with opioids even after being on Suboxone for 10 months, he still has triggers to use, and the only reason why I believe he survived is the Suboxone blocked the opioids. He still needs to be on it. I have another person on it for one year and they keep telling me no triggers to use but they don't want the dosage reduced or get off of it and when I ask them why they can't give me an answer. In this category, I make them reduce it to 12 mg a day, the minimum dosage where the person still has full protection from relapse, but aside from this, I start getting more and more heavy with demanding to know why the patient feels they shouldn't lower the dosage.

excellent points, but I'll speak towards that group that stays at 8 bid forever and won't taper down.....my guess? 3 different types of patients

-using a bit and diverting the rest if they have insurance
-dont want to even take the chance of being even mildly uncomfortable during any sort of taper
-finally, and perhaps most importantly, it's hard to judge exactly what is mild "euphoria" in this pt population. they've had so much stuff in their veins and been through so many detoxs and recovery places that they are pretty much immune to any sort of scale.....I think a lot of chronic suboxone pts do get what they sense to be a nice "feeling" from suboxone. Just how mild it is I can't say for sure.

 

[vistaril]

Whopper I cringe with your statements of avoiding long term suboxone.
-Data shows opiod dependence has a high relapse and maintenance is the best treatment. Methadone is the gold standard and suboxone is a close second for treatment of opiod dependence. Now, if people want to really nit pick its possible to say suboxone can be just as good as methadone if it had the same follow up demands of a methadone clinic.
-If you want to know if someone is taking their suboxone, get a buprenorphine level for qualitative purposes.
-When a person has had the long term sobriety, has the their life back and is functional (working, repaired relationships, forming new relationships, etc). You move into random urine drug tests. Spell it out in your contract for X amount per year. Stick to it. Random urines are more efficacious than scheduled. This is how you get around the anticipation and planning of the same day follow up with urine drop.

-The literature on suboxone diversion is for staving off opiate withdrawal from other full agonists. There is minimal to no abuse for intoxicating purposes.

-To help prevent diversion, prescribe the films. They will soon be fully traceable with tracking numbers on each of the pouches.

-Prescribing films also cuts back on risk of child overdose deaths, as its far harder for a toddler to open one and consume it.

best for who? and under what circumstances? and how long is long term??

those are all the key questions.....

long term suboxone isn't for some people....it's not for the homeless junkie or the 24 yo med student,,,,,for different reasons.

it's a difficult decision for a clinician to make.....personally, I couldn't in good conscience prescribe a long term opiate maintenance med to someone I wasn't sure had no chance to really get off opiates.....

 

[Sneezing]

You start tapering when the patient says they want to try. Otherwise, maintain.

Opiate dependence ruins lives. Costs patients money. Costs the legal system money. Costs the healthcare system money and ultimately costs the tax payer money. Maintenance is and always will be cheaper, so to answer your question it is 'best' for everyone. Unless a patient has full vested interest in tapering, it will likely be another small piece to the puzzle of an impending relapse.

 

[vistaril]

You start tapering when the patient says they want to try. Otherwise, maintain.

Opiate dependence ruins lives. Costs patients money. Costs the legal system money. Costs the healthcare system money and ultimately costs the tax payer money. Maintenance is and always will be cheaper, so to answer your question it is 'best' for everyone. Unless a patient has full vested interest in tapering, it will likely be another small piece to the puzzle of an impending relapse.

oh no it's definately not best for everyone in all circumstances.

opiate dependence is simply a term made up by people to describe people who meet a certain number of criteria agreed upon by other people....

within that group, there is a TON of variance. Not every addict(or even close to it) needs to be on chronic maintenance opiates.......

just because an opiate dependent pt states he wants to remain on 8 bid of suboxone forever doesn't mean he should.....

 

[ghost dog]

A patient on Suboxone maintenance may indeed been able to regain a constructive life again thanks to it. Is that recovery? Without trying to be political, and trust me I'm not giving this opinion scared to piss people off, it depends.

For many on Suboxone, being successfully on maintenance is the sword of Damocles. Why do I say that? I've seen insurance companies pull the rug out. A person could be quite comfortable with where they are at, and then after 3-12 months on it, insurance companies may choose to stop paying for it. The person may not be able to afford it out of pocket. Further for some, it's actually cheaper to get it off the street than get it legitimately though that entails risks such as being arrested in the process of getting it and patients of mine who used to get it off the street told me sometimes drug dealers would up the price out of nowhere when they see desperation in the customer. E.g "No I'm not going to give you a film for $20, now I want a dick $uck."

As already mentioned, there is a group stable on it that doesn't want to go further. Now here is the place where I feel there's lots of room for argument. Of course it's great they are stabilized and now able to go to work and live a life. The problem here is there's the ethical argument that this stuff costs money and why should a insurance company pay for it indefinitely, especially since it's not declared to be a permanent solution. There's no hard science to say how long someone should be on it.

Then the other problem: how will I know if a patient is weaning themself off of it while trying to still get it from me and sell it? So long as they have clean urine drugs screens, arent' getting arrested and take Suboxone the day of the interview, I won't be able to tell, and like I said, someone is providing it to drug dealers. Suboxone providers IMHO need to give this medication out while weighing the risks the patient may be selling off excess amounts.

That's why I don't like giving it out for too long--> unless a patient is paying for it out of pocket because those people aren't getting it in a cost-effective manner to sell it. As for those on insurance, I've seen insurance companies provide no advance warning (though this is rare) and then stop paying for it, though the majority do give at least a month of advance warning.

My bottom line, if someone wants to be on it for longer than 6-12 months, they have to have good reasoning. I have one patient, for example, that tried to kill himself with opioids even after being on Suboxone for 10 months, he still has triggers to use, and the only reason why I believe he survived is the Suboxone blocked the opioids. He still needs to be on it. I have another person on it for one year and they keep telling me no triggers to use but they don't want the dosage reduced or get off of it and when I ask them why they can't give me an answer. In this category, I make them reduce it to 12 mg a day, the minimum dosage where the person still has full protection from relapse, but aside from this, I start getting more and more heavy with demanding to know why the patient feels they shouldn't lower the dosage.

Wouldn't some of the above be an argument for methadone?

Isn't the evidence in regards to outcomes better for methadone ?