Taking Suboxone Long-Term is Wrong!

I’m sorry, those of you who have been reading this site for the past couple years, to go through this once more…   but I have another of THOSE messages, and it has been, what, a few weeks since I discussed the short-term/long-term issue?   Rest assured that I spare you, the reader, more times than not.  I suppose I could tell the writer of the message (the one I am about to share) that he could search the blog for ‘foolish pharmacist’ or any one of a dozen other posts about the topic and spare me from writing and all of you from reading… but he probably wouldn’t do that.   So in my typical fashion I’ll post his message interspersed with my comments.
The message:
I want to add my perspective on Suboxone. I think it is a great medication but ONLY if used in conjuntion with therapy. It is NOT an anti depressant. It is an OPIATE type medication you are putting into your body with an additional ingredient to block the “high” you get from regular narcotics. The mentality of staying on it “for the rest of your life” is NOT good.
Right off the bat, the writer makes a common mistake– which I’ll get to in a minute.  Of course it isn’t an antidepressant– I would hope that every regular reader of the blog knows that.  Yes, it IS an ‘opiate-type medication’– but so what?  I can assure you that the molecules that have little opiate labels hanging on them are no more evil than any other molecule!  Vivitrol and Revia are ‘opiate-type molecules’ as well– both are trade names for naltrexone, for injection or as a pill, respectively, and both indicated for treatment of alcohol dependence.  There is no logical connection between ‘it is an opiate’ and ‘the mentality of staying on it is NOT good’–  your body doesn’t know ‘opiate’ from ‘indole-amine’ or ‘butyrophenones’ from ‘thioxanthenes’–  they are just names of broad categories of molecules.  Don’t get hung up on labels– they don’t mean anything to the human body.  As for the mistake, the main ingredient in Suboxone is buprenorphine, a chemical that has been used for about 30 years as an analgesic with partial-agonist effects at the mu receptor– as you all know.  People who take Suboxone properly do not get ‘high’, and again, mentioning ‘high’ in the message only confuses the issue.  The added ingredient, by the way, is naloxone– a mu receptor antagonist.  ALL of the effects of Suboxone are due to buprenorphine;  naloxone is added to deter parenteral use of Suboxone.  Naloxone has no important effect for the regular use of Suboxone.
Don’t get me wrong, my partner was put on it last July and it pretty much saved his life as far as I’m concerned. HOWEVER, when the doctor put him on it he said it would help “heal his mind” if used in conjunction with therapy and after 3-4 months would begin to taper him off of it. Well, he went on a business trip and accidently left it behind at one of his stops. He had to be without it for about 5 days and it was hell but as soon as he got it back and resumed he was fine. He shared this with the prescribing doctor who IMMEDIATELY said “Well, you need to be on it longer then since you had such a bad experience being off of it.” There was then NO treatment plan made. Doctors seem to have a sense of vagueness about them when they prescribe this NARCOTIC medication as to what the treatment plan is.
That’s a pretty broad statement about us doctors!  I don’t think that doctors who work with addiction and Suboxone are any more ‘vague’ than other doctors;  I read complaints about doctors of all specialties at the forums I write for at medhelp.org and elsewhere.  I do think that medicine in general has gotten away from the interpersonal relationships that were once a significant part of the doctor-patient bond, but that is a general observation and not specific to addiction treatment.  As regular readers know, I am an opiate addict, and have been for the past 16 years;  I know enough about the mindset of other opiate addicts (I often point out examples of how alike we all are!) to wonder about the communication between your partner and his doctor.  We addicts have very selective hearing, particularly early in the treatment process– so I am reluctant to draw too many conclusions from the ‘he said this’ claims of another opiate addict (like me– did I mention that?).  In other words, I don’t know what the doc said, and to be frank if you weren’t there, you don’t know either.  I doubt that your partner does.  I don’t mean to be insulting;  I’m just telling it like it is, based on working with addicts every day for years, on or off Suboxone.
The reason I am writing this is because what I have observed with longer term use is that my partner was constipated DAILY, slept at least 10 hours per night AND took naps. He did not enjoy excercising as he once did and gained weight. He was mellow and sober but at the same time was not himself. He has been tapering off slowly and is down from 4 mg per day to 2 mg per day. He is not constipated daily any longer, now does fast walks with me every day and passes me up just like the old days. For a while I was out walking him and I hate excercise.
You are attributing all of those things to Suboxone?!  How about your hatred of exercise– what is that from?  Your partner was in the process of trying to stop one of the most addictive substances that there is;  opiate addicts LIVE for using opiates!  For an opiate addict there is but one concern in life– how will I avoid getting sick in four hours?  So here we have your partner– a person who is by all practical sense gravely mentally ill (I could easily argue that the loss of insight and near-delusional obsession to use causes ‘insanity’ as great as in any other psychiatric condition!), and in a span of a few weeks to months has had a dramatic change in his life–  suddenly the crutch that occupied his entire mind has been removed… and you are complaining that he doesn’t like exercising enough?
Today I had a patient who recently started Suboxone and now is having panic attacks.  I explained to him that months ago when he was burglarizing homes and stealing from relatives, he had no worries– because all his mind could think of was using.  Now his mind has been freed from the obsession to use– and all of a sudden he has to think about all of the people he harmed, the consequences that he is facing, etc– so of course he is having anxiety and panic!  Heck, he would be crazy not to!
The writer is blaming Suboxone for the partner’s issues– when the blame should be on his addiction!  It is VERY early, and there are so many things going on those first few months that ‘enjoying exercise’ is a bit silly.   He is trying to recover from a fatal illness, for Pete’s sake.  As for the constipation– I’ll give you that.  That is probably from the Suboxone… but I consider it to be a minor side effect for treatment for a fatal condition–  compared to chemotherapy it’s a great deal.
To sum this up there are no guarantees when it comes to sobriety but to preach horrible relapse statistics to anyone deciding to come off of this NARCOTIC medication is WRONG. Now, if this was something more like a Prozac type medication I would probably better support the “rest of your life” mentality of being on this medication.
I’m not sure how we got from the beginning to your conclusion– you basically say that your partner is addicted to opiates, a horrible condition that destroys and often kills those who suffer from it–  he took Suboxone and it ‘saved his life’… but it made him constipated and he slept too much and didn’t like to exercise– so preaching relapse statistics (correct ones, by the way) is WRONG!.  I don’t get the logic.
The writer is missing the point in a way that is all too common.  The writer blames the ‘rest of your life’ situation on SUBOXONE.  But the truth of the matter is that OPIATE ADDICTION is a life-long condition!    Suboxone isn’t the ‘rest of your life’ issue;  the partner’s opiate addiction is!!
Before Suboxone, opiate addicts like me had a life-long condition that had no good treatments.  Yes, there is NA and AA– they ‘work if you work them’, and I have worked them for a long time.  But twelve-step recovery has ALWAYS been for the very few people who are lucky enough to ‘get it’ before dying from the disease of addiction.  And  people in twelve-step recovery tend to relapse over time, and before Suboxone, relapse was often permanent– many addicts could never get back the sobriety that they once had.  Now we have another option.  But neither Suboxone nor step-work are cures.  And to be frank, there is no ‘therapy’ that cures opiate addiction either.  Yes, therapy is indicated for some patients, but some others do very well without significant therapy.  I do see all patients for at least 30 minutes for every appointment, as there are always things to discuss– but I disagree that EVERY patient on Suboxone needs therapy– just as every patient on meds for bipolar disorder doesn’t need therapy.
If anyone is interested in the issue of Suboxone versus ‘traditional recovery, please read my article on the topic.  Just Google ‘Suboxone’ and ‘traditional recovery’ and you will find it very easily.  To the writer– I’m sorry your partner is an opiate addict.  That is a tough life for anyone.  But Suboxone allows many of my patients the chance to live as if they DIDN’T have a fatal illness.  Many of them tell me that they don’t feel like addicts anymore– they feel like ‘regular people’ with just another illness.  And that is a major paradigm change from traditional treatment and therapy, where the point is to get the addict to identify very strongly with the addict label.   I think there is room for both types of treatment.  In fact, after 16 years of being an opiate addict– it’s about time!!
JJ

Long-Term Effects of Suboxone

A note from a reader with a question about Suboxone:

Suboxone has really worked for me in getting off vicodin.But I have been unable to stop taking Suboxone.It occurred to me recently that this may turn into a lifelong dependency.If so, what are the long-term side effects of Suboxone?

Thanks so much,

My Answer:

Suboxone really is best thought of as a long-term, perhaps life-long medication.Your attachment to pain pills will in all likelihood be life-long as well; most people who stop Suboxone are surprised at the cravings for opiates that they have.I don’t think Suboxone increases the cravings at all, but rather it is just so effective at eliminating them that people forget how attached to opiates they once were.I generally recommend that people stay on Suboxone ‘forever’, or until something better comes around– they are much safer on Suboxone, as it helps them avoid an impulsive relapse that can put them in jail, kill them, etc…

We do not know of many long term effects from Suboxone.Long term opiate use in general can lower testosterone levels in men and cause things from that, like reduced sex drive and I suppose even infertility.I assume that buprenorphine will do the same.There are the other short-term side effects that over time become long-term side effects– dry mouth (which long-term can cause an increase in tooth decay), constipation (which could lead to hemorrhoids, diverticulitis, anal fissures or peri-rectal abscess), sweating (which could lead to… problems dating?). The opiate antagonist naltrexone can cause liver damage, and it is related to naloxone, which is a component of Suboxone– in general the naloxone does not get absorbed, and so the chance of liver damage is likely minimal.It may be a good idea to check a set of labs once per year, though, to check the liver, kidneys, thyroid, and blood cell system, just for safety’s sake.

Probably the worst thing about long-term use is that some docs insist upon keeping everyone on Suboxone in endless therapy.I do not think that therapy is generally required, and I do not think that ‘forced therapy’ is very helpful.But it is hard to find a doc who will treat with Suboxone as they would treat with any other treatment for a chronic condition– that is, to prescribe the medication without placing a number of other requirements on the person.

I hope that answers your questions–

Take care,

J