Tuesday, September 24, 2013

Stepping down, slowly, from suboxone

(MyAddiction and Recovery column.)

By Bob Gaydos

Five years ago, hooked on heroin and pain pills, Mary (not her real name) says, “I was depressed, malnourished, angry and I had just gotten out of jail. That was my turning point. I could continue downhill or change my life.”
Mary decided to change her life. Today, she is clean and sober, married, has a son and is attending classes at SUNY Orange. She says she owes much of this change to another drug -- suboxone -- which allowed her to kick the pain pills and heroin. Taking suboxone, which cost $200 a week and was not covered by her health insurance, was still cheaper than the drugs she was using, she says.
Now, she’s at another turning point. She’s weaning herself off suboxone. “I’m scared,” she admits. I feel when I’m on it, I’m safe. I don’t know if it’s the A.A. meetings or suboxone or both.”
Dr. Rodolfo Nazario, who calls suboxone “a miracle drug,” would say both. Nazario says some kind of outpatient program is also necessary to “deal with the psychological part of the disease.” Even then, it’s no easy transition. Despite his decade of treating patients with suboxone, Nazario says he has been able to wean “very few” off it. And, as he and Mary both emphasized, withdrawal from suboxone can be “horrible.” Which may explain Mary’s fear.
She has first-hand experience of using it in other than the prescribed manner. Two years after starting the suboxone treatment, Mary had a craving for heroin. She stopped taking suboxone for three days, then got heroin. She used it for two months, then one night decided to go back on suboxone before being in withdrawal from the heroin. That is not the prescribed method of treatment. “I felt the heroin on one side of my head, suboxone on the other,” she says. “I had seizures, sweating, vomiting, shaking. I was speaking a different language.”
She hasn’t tried that approach again. From 2 1/2 pills a day five years ago, when she first saw Nazario, Mary is down to half a pill (4 milligrams) a day. She’s following doctor’s orders. Thus far, she says, everything has been fine. “I’ve never gotten high from it,” she says. “I’ve heard you can. I don’t know how.”
In fact, the secret of suboxone, according to those who recommend and prescribe it, is that, while it is a morphine-like substance that provides an addict with a feeling of “normalcy,” it’s impossible to get high on it. Now widely prescribed to treat opiod dependence, suboxone is actually two drugs in one delivery system. Buprenorphine does the same thing for the brain that opiates do, thus the feeling of “normalcy.” The second drug, naloxone, prevents the high that comes from the opiods reaching brain receptors. For safety reasons, the delivery system itself has changed from tablets to a film that is placed on the tongue.
While a strong proponent of it, Nazario has no illusions about taking patients off suboxone. He says some patients do not have the willingness to try weaning off the drug. “I try to step them down slowly,” he says. “Some can take more withdrawal than others. We aren’t here to be martyrs anymore. If they don’t have the medicine, they suffer. They need the drug just to get by. I encourage them to try to get off. If they can’t, they can’t. The important thing is, the patient isn’t doing  anything illegal and is performing well.”
“My goal,” says Mary, “is to get off the suboxone, maintain my sobriety, keep going to AA meetings. I consider myself an addict. I don’t drink. I feel fine. No cravings, no side effects. I’ve been doing it very slowly.” Her doctor and people in recovery would say that’s the way to do it. I’ll keep you posted.
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Doctors in New York state must take a special course to be licensed to treat patients with suboxone. When they are accredited, they are limited to 30 suboxone patients in the first year, 100 thereafter.
Dr. Rodolfo Nazario, of Middletown, who has been prescribing suboxone for 10 years,  says, because of the growing abuse of opiod pain killers, especially among young people, “We should be able to treat more.” He says he’s never had 100 patients.
He also is a strong proponent of the new state law that closely monitors prescription of pain medications by doctors. Some of the growing abuse has been attributed to doctors being too willing to prescribe addictive pain medications. “I hate to say it, Nazario offers, “but there are some physicians … I call them licensed drug dealers.”
Nazario also has some harsh words for insurance companies that won’t pay for suboxone treatment, but paid for the Oxycontin and Vicodin: “You make them addicts, but then won’t treat them.”


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