New medications sometimes set off a “pendulum effect.” Initially, the benefits are overrated, and the risks are minimized. With time, problems begin to emerge and are overemphasized. Ideally, these swings come back to a middle position and a balanced assessment of benefits and risks is reached. I have watched with dismay as this has occurred with the buprenorphine controversy.
Improvement in treatment results and patient comfort were so substantial that buprenorphine was sometimes hailed in media reports as a “miracle pill.” Over time, however, it became clear that some patients were able to get high on it, diversion for street use occurred, and withdrawal symptoms upon discontinuing its use could be uncomfortable — severely so for some. Further, a small subgroup of physicians began treating as many patients as they could, using a model of charging premium prices, not accepting insurance, and not encouraging concomitant psychosocial treatment
Some addiction treatment programs, especially those with the 12-Step model as a core element, were reluctant to use buprenorphine initially, and the emerging problems intensified their negative opinions. As patients heard word of mouth reports of the difficulties, particularly those related to withdrawal symptoms, they became reluctant to start the medications. Law enforcement agencies became more focused on preventing its use. These issues contributed to the buprenorphine controversy.
I believe that we are now moving toward the balanced center, but wish that it would happen faster. The division within the addiction treatment field may finally be narrowing. The Hazelden Treatment Center – the oldest of the traditional, 12-Step residential programs – has begun offering buprenorphine to some of their patients, with positive results. At least one Narcotics Anonymous meeting now exists; at a community addiction recovery support center in Baltimore named Dee’s Place, where people on buprenorphine are permitted full privileges with other recovering addicts.
At Kolmac, we continue to work to find the best way to use buprenorphine – who should take it, at what dose, and for how long. Currently, we recommend that those who elect to take it remain on it until their lives are stable and they have a solid recovery plan because of the high relapse rate from premature discontinuation. Most of our patients require at least one year to reach this place and are most comfortable when they stop the medication very gradually. Some addicted patients also suffer from concomitant chronic pain, which has led to prescription opioid abuse. For them, buprenorphine is often an effective intervention for both their pain and addiction. A recent study by researchers at Yale supports this conclusion.
I am optimistic that the intensity of the buprenorphine controversy will slowly subside and hope that differences of opinion will be respected, even if we do not reach consensus. Acceptance of addiction as a disease in the non-recovery community is still low enough that those in the recovery community need as much support from one another as possible.
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