When it was first developed in the 1950s as a treatment for heroin addiction, methadone was hailed as a miracle drug. It was effectively used to reduce or eliminate cravings and withdrawal symptoms in patients addicted to heroin, all with a single daily dose. By the early 1970s, clinics offering Methadone Maintenance Treatment (MMT) were proliferating throughout the United States.
But soon public opinion turned against methadone, and the press began to point out that MMT was simply substituting one addiction for another. It proved extremely difficult to wean patients off of methadone completely, and the vast majority of those who stopped the treatment relapsed into heroin addiction once more. Worse still, it quickly became apparent that this so-called miracle drug was just as abusable as the substance it was supposed to replace. Methadone acquired a street value, and methadone clinics were flooded with drug seekers and addicts with no intention of mastering their dependence.
Today, patients receiving MMT are subject to draconian regulatory measures. In order to receive the treatment, a recovering addict must visit his clinic each and every day to receive his medication. On weekends or holidays, patients are prescribed just enough of the drug to last them until the clinic opens again, usually only two or three days’ worth of pills. In most states, patients must remain compliant daily for a full two years—in Florida it’s five—before they are allowed to receive a prescription for a full month’s supply of methadone.
These measures do reduce the potential for methadone to be abused, but on the other hand, they also allow recovering addicts no opportunity for personal responsibility, no opportunity to re-learn their decision-making process and take control of their lives once more. Rather than being controlled by cravings for heroin, they are managed by government regulations.
But is this no more than an addict deserves?
Heroin is still present in today’s drug scene, but it has now taken a back seat to a new epidemic: prescription pain pill abuse. As opiate addiction becomes an ever-larger problem in our community, controversy also rages about how addicts should be treated—both medically and socially. One major component in this controversy is the use of suboxone and/or subutex to help opiate addicts recover from their dependence. Like methadone, suboxone is similar in chemical makeup to the drugs in question, and like methadone, it also has a high potential for abuse.
Suboxone and subutex both contain buprenorphine, which is also an opiate (a synthetic morphine, to be exact). In essence, buprenorphine is used to suppress the symptoms of withdrawal in patients addicted to opiates such as oxycodone or hydrocodone while having a far less extreme effect on the body. The symptoms of opiate withdrawal are severe and often include anxiety, restlessness, shakes, sweats and/or chills, rapid heart rate, elevated blood pressure, nausea, vomiting and diarrhea, body aches, runny nose, and sneezing.
Suboxone also contains naloxone, a drug that blocks the opiate receptors in the brain in order to lessen or prevent the effects of opiates. It is intended to make it harder for addicts to abuse suboxone for its opiate component. Subutex does not contain the additional drug and is not used in outpatient care except under special circumstances, such as an allergy to naloxone. Though it was originally believed that buprenorphine could not be used to produce a high in an opiate-dependent patient, this has now been disproven, and both suboxone and subutex have gained street value among the addict population.
Suboxone, with its added component of abuse protection, was approved for use in outpatient addiction treatment several years ago. Such treatment, as opposed to an inpatient or residential rehab, reduces the impact of addiction by allowing the patient to maintain their normal life while undergoing treatment.
Cityview spoke with two doctors who work or have worked with suboxone outpatient programs about the effect and efficacy of using one drug to combat addiction to another.
Dr. Curtis Markham is the medical director of Cornerstone of Recovery, an addiction treatment center in Louisville, Tennessee. Though he was at one time involved in using suboxone for outpatient treatment, Dr. Markham and Cornerstone have now discontinued this program.
Dr. Markham continues to use subutex in Cornerstone’s inpatient treatment. Rather than using it over the course of several months, patients at the clinic undergo a five- to 11-day detoxification under 24-hour nursing supervision. Subutex is used in decreasing dosages to help ease the symptoms of withdrawal until the detoxification is complete. Patients still suffer some of the effects of withdrawal after they take their last dose of buprenorphine, Dr. Markham says, but the symptoms are much less severe than they would be if the patient were to undergo a “cold turkey” detox.
Dr. Markham is careful to point out that outpatient suboxone treatment has succeeded somewhat with specific groups of patients, including some of his own who got off and stayed off of opiates. But, for him, the successes were few and far between. The majority of his patients, he says, were found to be positive for other drugs in their regular drug screenings and were dismissed from the program, while many others failed to return for follow-up treatment. There was far less support and accountability for these patients than for those who committed to residential treatment, and the effect of this was made apparent through the high dropout rate.
However, most of his doubts about outpatient suboxone programs, Dr. Markham says, spring from the way they are administered by many doctors. For instance, he has found that many patients who have been treated with suboxone are unaware that the drug they have been taking is actually an opiate and that using it long-term is equivalent to continued opiate dependence. Some doctors also fail to drug-screen their patients regularly or to encourage and require them to attend the therapy or 12-Step meetings that Dr. Markham believes are essential for the true and complete treatment of addiction.
Another concern is that as many as half of his patients are poly-substance dependents, meaning that they will be suffering withdrawal from more than one drug during detox. While opiate withdrawal is miserable, he says, some other forms of withdrawal are much more dangerous and even have the potential to be fatal, and he believes that outpatient programs can often fail to identify or address these additional problems. Still other patients he has treated have been told by doctors that they will have to remain on the treatment for the rest of their lives. Like MMT, this is considered to be a harm-reduction technique, as it allows the patient to live a mostly normal life.
This harm-reduction method is not compatible with Dr. Markham’s abstinence-focused treatment philosophy. “When you’re basically just substituting or replacing one mood-altering drug with another mood-altering drug, that’s not abstinence,” he says. He argues that addiction maintenance caters to our culture’s need for a quick fix, for a pill to take that will “cure” the patient’s addiction. But, Dr. Markham says, remaining on buprenorphine sustains opiate addiction—it does not cure it. Instead, he advocates complete abstinence from all mood-altering substances as the only true cure for the disease of addiction.
Dr. Andrew Sugantharaj of Complete Family Care, an internal and family medicine practice, holds that despite cases of misuse of suboxone, he still believes there is a place for it in the fight against pain-pill abuse. When doctors mis-prescribe the drug or fail to educate their patients and hold them accountable, he says, it doesn’t mean suboxone is wrong. “It doesn’t mean suboxone is evil,” he says. “It means suboxone is a tool that’s being misused.”
Since 2007, Dr. Sugantharaj has been a member of a program that allows him to administer outpatient treatment for opiate addiction to a limited number of patients at his practice. The federally monitored program requires physicians who enroll to have a special DEA number in order to prescribe suboxone to treat patients suffering from narcotic addiction disorder.
In addition to treating the physical effects of addiction with suboxone, the program at Complete Family Care provides recovering addicts with a structure of accountability for their recovery. Dr. Sugantharaj strongly believes that addressing psychological, behavioral, and emotional issues is crucial to the recovery process. Patients are drug tested and thoroughly educated about the process they will undergo prior to signing up for treatment. They come to the clinic every few days or once week at first, later every two weeks. Pill counting, returning the empty packaging for their prescription, a requirement to attend addiction meetings or some form of counseling at least once a week, and regular drug testing help to keep patients accountable as they struggle to return to what Dr. Sugantharaj calls “living clean and sober.” He is also able to provide proof of their compliance to employers or legal professionals if needed, which often helps his patients to keep a job or to regain child visitation rights. Slowly but surely, his patients are able to restore relationships and rebuild their lives while simultaneously working to overcome their addiction.
And beating addiction is what his program is meant to do. He does not encourage or allow his patients to use suboxone for merely maintaining their addiction at a low level. Some patients come to him after having been prescribed suboxone by another doctor for multiple years. There’s no difference, Dr. Sugantharaj tells them, between staying on pain pills for years at a time and staying on suboxone treatment indefinitely—both are opiates. Instead, he prescribes his patients just enough suboxone to keep them out of withdrawal, gradually lowering the dosage over the course of their treatment until the drugs are eliminated. Most people complete the program in six months to a year, perhaps a little more, all while living at home in their regular environment. Many of them, Dr. Sugantharaj says, tell him, “I can’t believe I can feel normal again.”
The success rate for his program, Dr. Sugantharaj estimates, is 60 to 70 percent. He, too, has had problems with getting follow-up with all of his patients. Inevitably, some of them lose sight of the goal and fall back into old habits before completing the treatment. Some, he admits, enter his program for the wrong reasons and try to use it as a source for drugs. He tries to identify those who are insincere early on and remove them for the program to make way for those who are committed to getting clean. But as long as his program is producing viable, useful results, he says, he will continue to use all of the tools available to him to help his patients to defeat addiction and get back in control of their lives.
Cityview found that both of these doctors agree that despite the potential for abuse, suboxone and subutex have a useful purpose in combating addiction. Though their methods differ, they both believe in getting opiates completely out of a patient’s system to the point where they have no dependence upon any drug in their day-to-day lives. Both make it clear that maintenance is not—and never will be—a cure for addiction.
Addiction treatment professionals agree, however, that the most important component in fighting addiction is real intentionality and dedication on the part of the patient suffering from addiction. This, combined with education, support, and a high level of accountability, combats addiction at a deeper level than any medication.