With the passage of the Federal legislation, DATA (Drug Addiction Treatment Act) in 2000, physicians were now allowed to utilize Schedule III, IV & V narcotics to treat opioid dependence. This was a major improvement over the past, in which the only medication that was allowed for such treatment was methadone, as required by the Methadone Control Act of 1973. For the first time in almost 30 years, physicians could now treat opioid addicts in the privacy and comfort of their private offices, rather than methadone clinics. Also, patients could receive prescriptions for buprenorphine, marketed as Suboxone and Subutex, once a month, rather than being required to go to a clinic to receive their medication on a daily basis. DATA 2000 also specified buprenorphine as the only medication from these classes that would have opioid dependence as an approved indication for its use. Physicians were required to take an eight-hour course in prescribing buprenorphine and then apply for a waiver by the DEA before they could utilize this medication to treat opioid dependent patients. The great advantage of buprenorphine over methadone is that buprenorphine, when properly prescribed, obliterates withdrawal and craving, while at the same time it does not cause any mood-alteration (feeling “high”) in nearly every patient.
Subutex contains buprenorphine, while Suboxone contains buprenorphine plus naloxone, a medication that is used to block opioids from working if the medication is injected. The naloxone is not active when the pill is absorbed in the mouth, as it is designed to be given. (An alternative form, Suboxone Sublingual Film, which is an even safer formulation than the tablets, is now available.) This means that Suboxone cannot be crushed and injected without running the risk of throwing the user into severe withdrawal from any opioids, such as heroin or Vicodin, to which they are already tolerant. It is this combination drug that makes Suboxone an ideal medication for outpatient office use, since it cannot be diverted to the street for the purpose of getting high.
Suboxone is being diverted to the street, however. The reason for this is paradoxically written into the DATA 2000 law, even in its revised form. The original law limited physician’s offices, even the largest clinics, to a total of 30 patients receiving buprenorphine to treat opioid dependence at any one time. A subsequent revision changed this limit to apply to individual physicians rather than offices or facilities, but it still was too restrictive, because the demand for the medication was so much greater than the legitimate supply, and the number of physicians who made the effort to become approved (waivered) to prescribe was limited. A further revision allowed physicians to treat up to 100 patients at a time, so long as the physician had been waivered for one year and could state that there is enough demand to justify such an increase in the number of patients . Yet, because the law as it is currently written still does not meet the demand for Suboxone, the medication is being procured on the street by persons who want to get off opioids, or just avoid withdrawal when their supply of other drugs has temporarily run out. Such unsupervised use, needless to say, is not only illegal, but also dangerous. But that’s never bothered addicted persons before, has it.
Some will say that a person who is on buprenorphine is not really in recovery, because he or she is still using a drug. While this is pharmacologically correct, the clinical reality is that the buprenorphine-supported patient is freed from withdrawal and craving, while at the same time he or she does not experience mood-alteration, or the feeling of getting “high” from the medication. This allows the patient to focus on life improvement, including attending 12-step meetings and devoting time and energy to family, work, and doing the next right thing.
I once held the philosophy of total and complete abstinence being required for recovery from addiction. But with the advance of medical science, and the positive experiences that I’ve had in prescribing buprenorphine for my patients, I have come to see this medication as being helpful, not harmful, to recovery. I’ve been in the practice of addiction medicine long enough to remember how members of 12-step fellowships and the staff of many treatment centers that utilized 12-step process and philosophy were against the use of anti-depressants, and how dangerous it was when some patients were advised to discontinue these medications. That changed with the advent of the selective serotonin reuptake inhibitor (SSRI) class of antidepressant which had many fewer side effects than the traditional antidepressants of the time, especially drowsiness. The introduction of buprenorphine into the small arsenal of medications that are approved to treat addiction is similar: It helps the patient in early recovery to focus less on the co-occurring problems of withdrawal and craving, and more on the work of early recovery. This can only serve to increase recovery rates for the opioid dependent patient. And isn’t that what we’re all trying to accomplish, after all?