November 28th, 2014

The use of buprenorphine (also known by brand name “Suboxone”) in the treatment of addiction is a controversial issue, which has had the unfortunate effect of dividing our addiction treatment community. I find it helpful to categorize the wide range of opinions into three groups.

For some, myself included, buprenorphine has significantly improved our ability to work effectively with patients who are addicted to opioids. We find that patients stay in treatment significantly longer. Importantly, drug overdose deaths among our patients have decreased. When patients take buprenorphine, they describe feeling “normal” rather than “high.”

I have been impressed by how much better patients are able to participate in therapy and do the hard psychological work of recovery. I liken it to anesthesia for surgery. I would prefer to have surgery with anesthesia rather than without it, but having the anesthesia and no surgery would be pointless. Similarly, I regard Suboxone as ancillary – an important support to treatment, but not treatment in itself.

A second group maintains that buprenorphine is so effective that nothing other than the medication is needed for recovery. They view any additional therapy as wasteful and unnecessary.

A third group believes that any apparent improvement seen when patients are taking buprenorphine is dangerously illusory. They argue that the medication perpetuates the addiction and interferes with patients recovering. Physicians in this group are sometimes willing to use Suboxone briefly to manage withdrawal symptoms but oppose its use for any longer period of time.

Prescribing physicians are not the only ones who disagree about this issue. Patients, their friends and relatives, as well as members of the recovery community, also participate in this controversy and fall into all three opinion groups. Narcotics Anonymous (NA), as an organization, has been slow to accept the use of this medication, as they have been with methadone. While they welcome attendance by all, their literature suggests that individual groups make their own decisions. One compromise that has evolved is to allow those taking Suboxone to perform limited-service duties, such as setting up chairs or making coffee, but not to permit them to celebrate anniversaries, lead meetings, or sponsor others.

For Kolmac patients, meaningful participation in the recovery support community is an important part of the recovery process. We expect our patients to make a good faith effort to find a place in that community – part of what William L. White refers to as a “recovery plan” that is broader than a “treatment plan.” Sometimes, however, patients are caught in the middle between me telling them how important I think that it is for them to take buprenorphine and what they hear from NA members.

Our patients resolve this conflict in different ways. Some seek out NA groups or sponsors who are accepting of Suboxone. Others are more comfortable attending Alcoholics Anonymous, even though they are not alcoholics, because AA, as an organization, is clearer than NA in not taking a position about the prescribing of medications.  On the other hand, some patients refuse to start taking the medication or choose to taper off of it at a time that I think is premature.

Into which of these groups do you best fit? I welcome your comments to this post. It’s important that we continue to engage in dialogue about this controversial, but critical, issue.

Next week, I will write about some of the changes that have occurred in the use of Suboxone during the 11 years that it has been available in this country.

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