Wasting Resources on Suboxone

Readers of this blog know that I have often questioned whether there is any clinical difference between Suboxone and generic buprenorphine.  Naloxone is an opioid-blocking chemical added to buprenorphine, supposedly in order to reduce intravenous diversion of the medication.  The combination of buprenorphine plus naloxone is branded as Suboxone. I’ve pointed out over the years […]

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 […]

Take Action!

People who read this blog are aware of the shortage of physicians who can prescribe buprenorphine to treat people addicted to pain pills, even as an epidemic of addiction to heroin and pain pills devastates the heartland of the country.  In order to prescribe buprenorphine, physicians take a short course and obtain special certification.  To obtain certification, […]

Buprenorphine Guide

I have a couple pages around the web that offer a guide to buprenorphine for a small charge.   People who are interested can get a free copy simply by visiting the forum at this link.  The link takes you to a page at SuboxForum where the guide can be downloaded;  note the instructions on that page about the […]

Suboxone-Certified Doctor Directories

I recently added a new link to the menu at the top of this blog, for sites that connect patients with buprenorphine or Suboxone-certified doctors.  The link will take you to a ‘meta-directory’ that lists a number of doctor-finder sites, where you can search for a physician based on location and other variables.  Some of the sites […]

The post Suboxone-Certified Doctor Directories 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.

Reckitt Benckiser is Smarter Than I Thought

Regarding a prior post, I carefully read through the entire Citizens Petition’ filed with the FDA by Reckitt-Benckiser.  I have a better understanding of what, exactly, was accomplished by that action by the manufacturer of Suboxone. The document explains that the company hired an independent group, RADARS (Researched Abuse, Diversion, and Addiction-Related Surveillance), to investigate the […]

Find a Suboxone Doctor

Every day, someone writes to ask for help in finding a buprenorphine-certified physician.  Apparently, the distribution of certified physicians is not uniform; in some parts of the country there is competition among providers, and in other areas there are no certified physicians at all.  I assume that Wisconsin is somewhere in the middle. There are doctors in the area, but most are full.  My own practice has had a wait-list of over 50 patients for the past few years.

There are several resources for finding buprenorphine-certified doctors.  I’ll plug my forum, SuboxForum, as one such place.  The Forum has close to 10,000 registered members, and visitor traffic is much higher, since registration is not required to read posts.  I do not share or sell registration info, and you can register with fake information, if the idea of giving a name creeps you out.  Feel free to visit and ask if anyone knows of open docs in your area.

There are several doctor-finding sites.  I recommend Suboxone-Directory as a first stop.    At NAABT, you can enter some information about yourself, and certified docs in your area will be notified that you are looking for help.  They then respond to you, through the web site, if they consider you to be a good match.  Finally, there are physician search engines at Suboxone.com and at Suboxonedoctors.com.

Many of us hope that the cap on patients will be raised or eliminated at some point.  There is no doubt that the cap is killing many more patients, than it is helping by preventing abuse of Suboxone.  And how bizarre, given that doctors can prescribe opioid agonists to unlimited numbers of patients!  But the cap is set by Federal law, so changing it takes more than just an administrator’s decision.

I hope these sites are helpful.

Avoiding Precipitated Withdrawal

I received the following question earlier today:

Hello Dr. Junig, I am opiate dependent or rather an opiate addict. I want to seek treatment because I can’t continue this life style. I have questions about treatment. Do I have to be in full withdrawals when I go to see a doctor? Is it true that most doctors probably won’t see me because they have too many patients already? I know Suboxone works for my withdrawals. I’ve stuck in this rollercoaster for at least four years and now I know it’s time for me to seek help.

My thoughts:

My comments, as always, are intended to increase general knowledge about buprenorphine and to promote discussion between patients and their doctors.  They are not intended to take the place of a relationship with a ‘real’ doctor!

The appropriate waiting period before starting Suboxone– ‘induction’– depends on the person’s opioid tolerance, and on the specific opioid that the person has been taking.  An opioid-free delay before induction reduces the amount of opioid agonist bound to the receptor, and lowers tolerance to some extent.  Starting Suboxone or buprenorphine is likely to cause precipitated withdrawal when either 1. There is agonist binding at the mu receptor, or 2. There is very high opioid tolerance.

It is hard to give exact guidelines, as every person reacts a bit differently.  But in general, people match up well for Suboxone induction if they are taking about 60-80 mg of oxycodone equivalents per day.  Someone on that amount of agonist, who waits over 12 hours, will generally do well at induction, unless the person has been taking methadone.  In that case, a longer waiting period is beneficial.  How long?  As long as possible, and at least a few days.  Even so, the transition from methadone to buprenorphine is difficult, often causing headaches or minor withdrawal symptoms for several days.  The best response to precipitated withdrawal is to take the prescribed dose of Suboxone/buprenorphine each day, without trying to overcome the symptoms by taking more of an agonist or extra Suboxone.  Doing so only lengthens the period of withdrawal, and considerably increases the risk of death.

If a person is taking a very low dose of an agonist, or taking a weak agonist like hydrocodone, the problem at induction isn’t withdrawal, but rather opioid intoxication, causing respiratory depression and nausea.  Nausea during induction is much more likely to signify relative overdose, NOT withdrawal.  Patients who have nausea and vomiting from buprenorphine or Suboxone should NEVER take a second respiratory depressant or sedative!  When in doubt differentiating between withdrawal and opioid intoxication, the pupils are a good guide.  Withdrawal comes with LARGE pupils.

If a person is taking a very high dose of agonist each day– over 150 mg of oxycodone or methadone, for example— that dose should be tapered down over time, to the equivalent of 40 mg of methadone per day.  Unfortunately, some people cannot carry out or tolerate such a taper.  In those cases, it may be better to have the person in a controlled environment, and wait as long as possible before induction.  Even if tolerance is very high, a person will often do well if off opioids completely for 4-5 days or more.  Of course, that’s easier said than done!

There is a cap on the number of patients that doctors can treat for addiction using buprenorphine.  Doctors can have up to 30 patients at first, and can petition the DEA to increase to 100 patients after a year.  It is frustrating to keep people who are desperate for help on a waiting list— especially when there is no limit on the number of pain patients that a doctor can treat using opioid agonists!

Suboxone relieves withdrawal symptoms when taken properly.  But the main function of buprenorphine/Suboxone is to eliminate the obsession to take opioids, and to allow patients to move forward in life without substances.  People do best if besides Suboxone, they focus on other principles of recovery, determined with their physician or with a counselor.  The point of Suboxone, in my opinion, is to learn to tolerate ‘life on life’s terms.’  That includes dosing at most twice per day, and learning to say ‘no’ to the minor cravings that most people have, even on Suboxone.

I’m glad you are looking for help– and I wish you the best!