Does Suboxone Cause SIDS?

In a recent Google search about Suboxone and pregnancy, one of the top links included the frightening statement that Suboxone and buprenorphine have been linked to SIDS or sudden infant death syndrome, commonly called ‘crib death.’ The statement was from a health forum where a woman wrote about taking Suboxone during pregnancy.  She wrote that her […]

Suboxone Side Effects pt. 2

We can now leave naloxone out of the discussion, and focus on the side effects of Suboxone that are caused by buprenorphine. Side effects are symptoms caused by a given medication that are not part of the therapeutic benefit of that medication.  Whether a symptom is a side effect depends on the reason for taking […]

Suboxone Side Effects pt 1

Side Effects pt. 1: Impact of Naloxone It has been a while since I’ve written about the more basic aspects of Suboxone treatment for opioid dependence.  I used to check the phrases used to search for Suboxone, and cover those topics one by one.  In that spirit, I’ll spend a little time talking about side […]

Treating Addiction with Brain Surgery

Today I read about the stereotactic brain surgery used to treat opioid dependence in China over the past ten years.   The procedure is relatively straightforward; the patient’s skull is clamped in place while small holes are drilled, guided by computerized, 3-dimensional maps of the brain.  Probes are inserted deeply through brain tissue to the nucleus accumbens, where […]

Withdrawal Symptoms on Suboxone

I struggle with the length of my posts.   I shoot for 1000 words—an amount of reading that most people can knock off in a typical trip to the bathroom— but I find it difficult to limit posts to that size.  So as I have done in the past, I will break this post into a […]

The post Withdrawal Symptoms on Suboxone appeared first on Suboxone Talk Zone: A Suboxone Blog.

Suboxone and Tooth Decay

I have received a several emails over the past few years from people who experienced deteriorating dental health while taking buprenorphine or Suboxone.  I also have patients in my practice who have had extensive dental work, and wonder if Suboxone is to blame for their cavities or other problems.

I wrote about this issue several years ago.  At that time I wrote that there was no evidence that sublingual buprenorphine or Suboxone cause or accelerate tooth decay.  After writing the article I received a number of angry emails from people who insisted that I was wrong.

Let’s step back for a moment to highlight the difference between thinking something vs. proving something.  Some people misunderstood my comments about tooth decay and Suboxone, thinking that I was arguing that Suboxone does not harm teeth.  That was not what I wrote.  My point was that as of that time, there was no evidence that Suboxone or buprenorphine caused tooth decay.  When I write about the science of buprenorphine, I try my best to distinguish between what I think is true vs. what was established through scientific study.

I recently met with a patient who has had extensive dental work over the past few years, the same time that she was taking sublingual buprenorphine.  She asked if I thought that the two were related.   I made a few comments (that I’ll be getting to), but also promised her that I would do a literature search, to see whether any connection has since been established.  Ironically, a case report of a woman on Suboxone who required extensive dental work was just published yesterday.  The case report is in the latest issue of The American Journal on Addictions, and the same case is cited in the October 20, 2012 edition of Reactions Weekly.  This latter citation is a newsletter that follows multiple sources for any report of adverse drug reactions, described in more detail here.

The world of science is not efficient.  Knowledge moves forward slowly, based on findings amassed from many studies, often repeated multiple times.  Case reports are not intended to prove something.  In fact, case reports are often unusual clinical examples that defy the norm.  They are often published to point out an area that deserves more study.

I cannot copy the case report here because of copyright laws.  But the case described a 35-y-o woman who used oxycodone for about a year at doses up to 160 mg per day, and then went on buprenorphine/naloxone.  After 18 months, her dentist told her that she had extensive decay of 4 molars requiring root canal.  She reportedly had minimal history of dental problems before starting opioids or buprenorphine.

The author of the case report hypothesized that if there is a connection between Suboxone and tooth decay, one reason could be xerostomia, i.e. dry mouth, caused by buprenorphine.  The lack of saliva was my thought, too, as a mediator of any possible effects of buprenorphine on teeth.  Saliva serves an important role in dental health, including rinsing away food particles and acting as a buffer.  The patient in the case report did not report a dry mouth, so the author pointed out that all opioids have some ability to suppress the immune response, and perhaps buprenorphine and/or naloxone reduce the immune response, allowing for greater destruction of teeth by bacteria.

The case report, surprisingly, did not say which buprenorphine product(s) the patient had used, e.g. tablets, film, or generic buprenorphine.

What needs to happen next is for someone to do a case-control study of patients on buprenorphine, to see if they are more or less likely to have tooth decay.  The most valuable study is usually a prospective, randomized clinical trial;  that would not be proper here, since it would not be appropriate to randomize subjects to buprenorphine vs. no buprenorphine.  But a close second would be a case controlled study, where patients on buprenorphine are matched to ‘controls’ with similar characteristics— age, sex, eating habits, income level, education, etc.– and the dental outcomes are followed forward over a number of years.  A less-costly, less-reliable study is one that looks backward, comparing patients on buprenorphine with those not on buprenorphine to see which group has a higher incidence of dental caries.

We are not much better off at this point in our knowledge of whether Suboxone or buprenorphine predispose toward tooth decay.  The case report only mirrors what I see in my practice.  But as I often tell patients, I have other patients who are not on buprenorphine or Suboxone, who have tooth problems.  I also have patients on Suboxone with great teeth.  Hopefully some ambitious PhD candidate will sort through the issue soon.

Treatment? Or Murder?

I subscribe to Google news alerts for the phrase ‘overdose deaths.’  Google Alerts are a great way to follow any topic; subscribers receive headlines from newspapers and web sites for certain keywords from around the world. One thing that has become clear from my subscription is that there is no shortage of stories about deaths from opioids! Every day I see one article after the next, as news reporters notice the loss of more and more of their communities’ young people.

Along with the reports of overdoses are stories about doctors who are increasingly being prosecuted for the deaths of their patients. In an earlier post I described the case of Dr. Schneider and his wife, a nurse, who were tied to a number of overdose deaths in Kansas. That case stood out by the sheer number of deaths; the State charged the couple with the deaths of 56 patients. Cases involving fewer patients have become relatively common. The latest case that I’ve read about is a doctor in Iowa, who is accused of causing or contributing to the deaths of 8 people.

I try to present both sides of the argument when I write about this topic. I have been faced with the difficult decision over whether or not to prescribe narcotics many times, and I understand a doctor’s dilemma. The doctor sees a person who is in pain, and knows that there is a pill that will reduce that pain. But the doctor also knows, or SHOULD know, that initiating a prescription for narcotic pain medication always has unintended consequences, no matter how good the intentions of both doctor and patient.

In the Iowa case, the dilemma over narcotic-prescribing is very clear. The prosecution states that the doctor prescribed pain medication to drug addicts.  On the surface, that sounds bad, right? One gets the mental picture of dirty, lazy people, dissolving tablets in a spoon, over a candle, and then injecting the mixture. But reality is much more complicated. Patients with histories of opioid dependence do not always have track marks. And even if we tattooed the letter A across their chests, there are addicts who are in need of pain treatment. Are we to decide that every person who has become addicted to pain medication gives up the right to pain treatment?  And we know that many of the patients addicted to opioids became addicted through the course of pain treatment from their physician— so I would expect that on average, patients addicted to opioids would have a higher incidence of chronic pain, and vice versa.

I do not find it reasonable to make patients with addiction histories endure pain that would be treated in other patients.  Father than singling out some patients for ‘special non-treatment,’ we should prepare for the risks from opioids in ALL patients—a set of ‘universal precautions for opioid treatment,’ similar to the way we use a different set of universal precautions to avoid transmission of blood-borne infections.

There are times when doctors have to tolerate being the bad guys.  Some patients have been taught, through careless prescribing, that all pain should be treated with narcotics. Those patients are not happy when told, after paying several hundred dollars, that they do not ‘need’ narcotic pain medication– and so many of their doctors have a hard time saying ‘no.’ After all, doctors studied hard to do well in school, and usually receive praise for what they do. It is much easier to write a prescription and hear ‘thank you’ than to be called an unsympathetic jerk! But doctors are paid the big bucks to tolerate such things, and to keep the long-term health of patients in mind. And for many people with chronic pain, opioids will provide a good month or two, but for the price of many years of misery.

I’ve been told by patients “I don’t care about the risks, doc– I’d rather have three good months and then die, then have twenty years in pain.” I reply, “that’s why these medications require a doctor to consider things very carefully, and a good doctor would not allow someone to make that decision.” I’m sure that some people will be angered by that attitude. But the approach is similar to how we handle many other illnesses, where we encourage patients to tolerate short-term misery for long-term benefits. Many patients would refuse chemotherapy and give up on life if not pushed to move forward. And to depressed patients, suicide can appear a reasonable option. I’m a fan of free will, but I recognize that we don’t always choose our paths through life with full insight.

Even with full knowledge of the reasons to avoid narcotics, some doctors really struggle over withholding opioids.  I find it somewhat ironic that the doctors who are too ‘kind-hearted’—i.e. who want to please patients so much that they cannot deny even that which is bad for them—are the ones who end up getting into trouble.  The Iowa doctor is being sued over several of the deaths, likely by relatives of the patients who pled the hardest for pain pills!  Talk about good deeds not going unpunished!

But there are aspects of the case in Iowa that do not argue well for the doctor. Several of the patients who died were only seen once, but treated with narcotics for years. The DEA requires that patients are prescribed no more than 90 days of narcotic medication at one time (divided on three monthly prescriptions). I presume that patients were picking up scripts every three months, without having appointments each time. Such a practice is not strictly illegal (not that I am aware of, anyway), but the standard of care would be to evaluate patients on potent opioids every three months, or even more frequently. And one news article stated that the doctor had tens of thousands of pain patients. As a full-time practitioner with less than 1000 patients, I wonder how so many patients could be managed by one physician.

When I write about this topic I receive angry comments from some readers. Some attack me personally with comments like “I’m glad I’m not YOUR patient!” or “I hope YOU have to suffer with horrible pain some day!” I realize that this is a very hot topic, and my only intent is to educate and inform, to help people understand what is happening in the minds of physicians. Of course, the care of patients should not be determined by the need for doctors to protect their own interests. But at the same time, it is understandable that doctors are affected by headlines announcing the imprisonment of other doctors facing the same treatment decisions.

Bottom line– there are very good reasons to avoid using opioids for nonmalignant chronic pain. Just giving patients what they want, and ignoring the danger of opioids, will likely result in criminal and civil prosecution. But that reason is secondary to the most important thing– the promise all doctors make to first, do no harm. And patients should realize that their doctors may be withholding narcotics for that reason alone.

Suboxone Withdrawal in Newborns

One of the top search terms for Suboxone relates to pregnancy, and fear that the baby will experience withdrawal; official name ‘neonatal abstinence syndrome.’  I wrote this post a couple years ago, and I think it is worth reposting. Since the first time around, several studies have shown that withdrawal symptoms occur in about half of babies born to mothers on buprenorphine. The symptoms, when they do occur, tend to be milder than the symptoms in babies born to mothers on methadone or other opioid agonists.

Headlines grasp for attention with words like ‘addicted babies.’ Realize that there are many differences between physiological dependence and addiction to substances. For example, people who take Effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockers, in that discontinuation results in rebound hypertension, but there is no craving for propranolol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs, depression, and very severe shame and guilt. The normal newborn already has such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction!

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about THAT discomfort—at least not from the baby’s perspective! I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal! Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s (!), babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose!

My points are twofold, and are not intended to encourage more births of physiogically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right. Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

Addendum:  Another of my posts, including a response to a mother’s comments and several references, can be found here.

Tough Choice

I have been struggling with part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.

As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner. Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—and outdated and toxic medication—which likely contributed to the charges… but the story creates a chilling atmosphere, regardless. Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.

For those late to the party, we are discussing the best treatment approach for someone who cannot control using opioids, but who for now, at least, has a low opioid tolerance. Starting buprenorphine in such a patient will cause opioid side effects, as described in an email that I received from a woman who was addicted to hydrocodone for four years, who stopped taking hydrocodone for 7 days before induction with buprenorphine.

She wrote:

This Suboxone is making me feel like crap. He has me on 8mg/2mg sublingual 2/day. It’s awful…

She had been taking 20-30 mg of hydrocodone up to 5 times per day, stopping them a week before induction. She continued:

Have had a headache in the base of my skull since starting Sub 4 days ago, nausea, vomiting, sweating a lot, face feels like it’s on fire, can’t taste anything, throat hurts, can’t sleep because my face & eyes itch so bad that I’ve rubbed them raw.

These are classic side-effects of over-narcotization from buprenorphine. A person in this position typically feels better holding the buprenorphine, and when the nausea is eventually gone, taking a greatly reduced dose of the medication. The problem is that if the dose is too low, there is no advantage to buprenorphine over other opioids. The whole point of taking Suboxone is to stay on a blood level HIGHER than the ceiling effect, as that essentially tricks the brain, since the opioid effect stays constant even as the blood level falls.

In a few days, the writer’s tolerance will increase to a level where she can take an entire dose of Suboxone without nausea. And by that time, the medication will greatly reduce the desire to take opioids.

Will she be better off on buprenorphine or Suboxone than she was on hydrocodone? Her tolerance will be higher—meaning greater physical withdrawal if she stops the buprenorphine, than she would have had stopping the hydrocodone.

But on the other hand, she tried to stop taking hydrocodone for several years, and couldn’t. She was taking over 4 grams of acetaminophen per day— the other medication present in Norco besides hydrocodone— which is enough to cause death through liver toxicity. And the ups and downs of hydrocodone addiction create a living Hell that eventually demoralizes the person.

I hear from writers who are angry at their physician for getting them ‘stuck on Suboxone’, saying they should have simply tapered off the hydrocodone instead. My answer is that it is easier to SAY ‘I would have tapered of hydrocodone’ than it is to actually taper and stay off hydrocodone!

A doctor seeing the patient I wrote about in part one, or the person above, would face two options:

1. Cause an incidental ‘high’ by administering buprenorphine, and titrating the dose up to a level that eliminates cravings, or:
2. Use an alternate treatment strategy.

Some doctors would opt for the latter, saying they are not comfortable with deliberately intoxicating patients with opioids—something that is unavoidable when starting a low-tolerance patient on buprenorphine (or Suboxone; note that the naloxone component of the medication is irrelevant to this discussion, as it has no action unless injected).

In such cases people are often referred to step-based or other residential treatment centers. I’ve written some pessimistic opinions about those places, but I’m just trying to be accurate. I realize that there are many people dedicating their lives to treating people with addictions in such places—ranging from free, community-supported programs to $80,000 per month luxury rehabs. As dedicated as those people are, the success rate of such programs remains low, and the risk of fatal overdose is present upon discharge. Most people who have gone through residential treatment relapse. And many people have been through rehab multiple times, yet continue to struggle.

Vivitrol, a monthly, injectable form of naltrexone, has been marketed to fill in this space, as a protection against relapse after residential treatment or after several weeks of detox. But for whatever reason, most people opt to forgo that medication, instead placing misguided faith in their own ability to stay clean. So what usually happens is that people with a lower tolerance to opioids repeatedly go through detox, or repeatedly pay for residential treatment, only to return to using opioids. Tolerance increases over time and eventually they present with a tolerance level where Suboxone seems more appropriate.

Assuming, of course, they live that long.

The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:

When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.

“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”

Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.

Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”

The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.

The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.

The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.

During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.

Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.

After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.

Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.

The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.

Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.

Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.

Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.

He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.

The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.

While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.

For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.

State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.

“I think we’re going back and relearning how to treat pain,” Thompson said.