Dear Palm Beach County: We need to talk about our substance abuse problem.
Relying on Big Pharma that makes MAT ("medication assisted treatment") drugs and the government regulatory agencies (who are in a state of full blown regulatory capture by Big Pharma) to objectively create policy, solutions, and funding to solve our collective problem is no longer an option.
A "rebranding" of addiction medicine is on deck. MAT is being retired to be replaced by MOUD aka Medications for Opiate Use Disorder. The "Assisted" and "Treatment" are being dropped. Big Pharma wants us to believe the MEDICATION is now also the TREATMENT.
Full disclosure: I’m not a lobby or an anti addiction medicine die hard. I am a taxi driver who has been taking dope sick inmate releases home from Palm Beach County Correctional Facility since 2007. I watched opioid epidemic 1.0 blow up at ground zero, the inmate release parking lot at Gunclub jail, and wondered "why isn’t someone doing anything to stop this?" Now I am watching opioid epidemic 2.0 blow up- fueled by the same medication that is touted to stop our drug death problem- Suboxone. I realized I am the "someone". I may not succeed in stopping this train wreck but thats not an excuse to not try. If what I have to say only helps one person it will be well worth it.
To be clear the active ingredient buprenorphine (in suboxone) is an imperative tool in the "war" on addiction. There is a subset of people with opiate issues that can be inducted on to this medication and comfortably stay on it for life. Then there is everyone else.
History: In that late 1990s the plan on deck was to stabilize people on daily methadone, then transition them to 3x weekly ORLAAM (aka LAAM). Months or years down the road if strong recovery was evident the patient would be transitioned to off patent non narcotic naltrexone (active ingredient in VIVITROL 30 day depot shot on the market today).
LAAM was a game changer. It only needed to be taken 3x weekly which would free methadone patients from the daily grind. OTP clinics potentially could have tripled their patient capacity.
Buprenorphine became the "miracle cure" in France. But in 1998, 16 months after high doses of 8-24mg were released & doctors began handing it out like candy 20 people were dead with buprenorphine in their system. A study claimed the connection to high dose buprenorphine and the way it was being handed out like candy was obvious. The study warned France to rethink their policy and warned America to "look before you leap."
As ex White House drug official Charles Okeefe (president of buprenorphine creator Reckitt Coleman/ Benckiser/INDIVIOR) was lobbying ORRIN & BIDEN to pass suboxone buprenorphine monopoly bill DATA2000 to mirror France, suddenly ORLAAM, on the market for years, was cited as having a potentially fatal QT prolongation issue connected to torsades de pointes which is bad news for your heart. There were only 20 drug deaths over YEARS with no direct causal relationship to LAAM proven. Plus the only fatality documentation I could find has cocaine and other drugs in their system.
Although METHADONE had the same QT PROLONGATION issues, HHS put the black box warning beat down on ORLAAM. Roxane Labs was ordered to claim it was a second tier drug AND all of the opiate addicted had to get regular ECG testing done by cash strapped methadone clinic providers. That coupled with DATA2000 suboxone monopoly bill forced Roxane to discontinue ORLAAM.
In 2002 FDA approved suboxone even with clear evidence that buprenorphine was being black market diverted from France all over Europe and that addicts were shooting it up and snorting it. Plus the creator of buprenorphine J Lewis and the DEA warned the FDA the ratio of naloxone to buprenorphine in suboxone was way too low to prevent IV abuse and diversion. The naloxone could not and would not precipitate withdrawal.
INDIVIOR blocked the release of low dose 0.2mg buprenorphine in America which could help opiate replacement therapy patients wean of the suboxone.
The FDA blocked mcg microdose formulas of buprenorphine labeled for PAIN to treat or help patients withdraw from suboxone.
Buprenorphine (suboxone) is a powerful opioid. The MME (medical morphine equivalent) is 30:1. That means 1mg of suboxone = 30mgs of morphine. One 8mg strip of suboxone = 240mgs of morphine. To put that in perspective doctors are sticking MAT patients on 24mgs of suboxone and leaving them there with no taper schedule. There is no profit in taper but lots of black market diversion.
Regulatory captured SAMHSA CDC and HHS have removed buprenorphine (SUBOXONE) from all MME charts. This is frightening as real pain patients who are being cut off their opiate pain medication are being "transitioned" onto buprenorphine and suboxone at stupid high doses.
Buprenorphine and Suboxone have a widely promoted "ceiling effect" aka they are not related to respiratory depression (overdose leading to death) that traditional opiates are. What INDIVIOR doesn't mention is the "ceiling effect" is negated in opiate naive patients. That includes new pain patients. Plus the "high" can be quite intense. So when when your kids best friend says "DUDE! DO I HAVE SOMETHING FOR YOU TO TRY" don't be surprised when you are at your kids funeral while their best friend that supplied the "harmless diverted drug" is in jail waiting for 1st appearance facing a long sentence.
If your kid lives, they may have just developed a new opiate addiction with suboxone as the gateway drug. In Findland it is documented 90% of people reporting to rehab are their for buprenorphine (suboxone) addiction.
Suboxone has replaced heroin as king of the prison drug trade. Yet the FDA still claims its rewards are greater than it's barely regulated risks.
Although Medical Examiners barely test for suboxone buprenorphine (my understanding is a bile tox screen is the gold standard) , in 2016 the Florida Medical Examiners report listed buprenorphine to be the cause of death in 10 cases and related to 43 (poly drug deaths). Yet buprenorphine was left off the drug death pie charts. You don't know what you can't know... right?
It's easy to prescribe suboxone or buprenorphine to a patient for opiate use disorder, addiction, or pain. The problem is barely any one knows how to detox you off this potent narcotic.
The unstudied long term effects of suboxone (buprenorphine) especially at stupid high doses include a zombie like dead to the world lack of feelings at best. If you have clinical depression you might actually need higher doses. If you have clinical anxiety you may need lower doses. Without this pharma knowledge your doctor may start adding adderol, antidepressants and benzodiazepines to your "treatment".
Benzodiazepines are super scary as even in opiate accustomed patients the benzos like Xanax greatly increase risk of respiratory depression (aka overdose leading to death)
When non addict pain patients and the addicted try to taper their suboxone buprenorphine dose they may find their doctors are unwilling to taper them to a lower maintenance dose. Or worse. Have no clue how to completely detox them off the drug.
THIS is NOT GOOD. If you recall 1mg of suboxone = 30mgs of morphine. PLUS the metabolite norbuprenorphine is even stronger. Buprenorphine may be touted as a partial agonist but it high jacks your brain's opiate receptors in a very different way on the back end.
Suboxone is chemically engineered unlike any other opioid to stick to your receptors like white on rice and creates a "long term blockade".
Even a drop at the lowest available dose of only 2mg from 24mgs (Down to 22mg) can feel like diving head first out of a 60 story window (30:1 MME) In some patients.
Worse, the farther you are into taper or detox the slower you have to go with dose reductions. Since INDIVIOR blocked release of the 0.2mg formula in America, and the FDA didn't label microdose BELBUCA BUPRENORPHINE FOR OPIATE USE DISORDER TREATMENT, patients are left with no choice but to slice up the film strips, which of course INDIVIOR recommends you don't do.
Note: INDIVIOR (via HHS CDC SAMHSA CSAT ASAM etc) blocked OTP (FEDERALLY REGULATED CLINICS FOR METHADONE) patients from schedule III take home access (DATA2000) to suboxone from 2003-2013 to bolster cash money $300 per visit DEA waivered suboxone doctor patient flow. Once the regulation was changed in 2013 INDIVIOR positioned suboxone as Medicaid paid drug of choice at the State level by a legal kickback scheme of rebates and discounts to Medicaid. This has blocked access to new lower dose higher bioavailability formulas of suboxone like Zubsolv and Bunavail which would also help with detox, limit exposure to the drug, and slow down black market diversion.
It's counter intuitive, but once patients try to "jump off" suboxone at the lowest 2mg dose they discover they are dealing with a hybrid of a level 10 stalker and the mafia. No matter how hard you try to leave ... you can't.
Patients describe it as "the worst detox ever" and "10x WORSE than heroin detox". And while the cold turkey hellish detox off heroin can last a couple weeks, the detox off suboxone buprenorphine can last months, even a year. And for the majority of the demographic taking a sabbatical from work to try and tough it out isnt an option.
Best case scenario you have a patient who resigns themselves to the fact they are trapped on 2mgs of suboxone for life.
Worse case scenario #1
Coupled with the fact there is no taper or detox protocol training from the CDC HHS or SAMHSA, the patient decides to do a "controlled" suboxone detox using HEROIN.
Worse case scenario #2:
Add in the demographic who discovered early on the naloxone ingredient in Suboxone was a joke. They can either stay on 2mgs of Suboxone everyday while still doing HEROIN staving off withdrawal or they can (as well) sell off the lions share of their 24mg suboxone script for HEROIN and keep just enough to stave off withdrawal in between heroin acquisitions.
Scenario # 1 is the subset stuck on the perpetual suboxone relapse on heroin suboxone hamster wheel FOR YEARS.
Scenario #2 is the subset who discovered suboxone drove them deeper into their perpetual addiction
I got a glimmer of hope in the last couple weeks giving cab rides to people who flew to Florida specifically because we have rehabs here that would help them detox off suboxone and not FORCE them to get back on it.
Problem is these guys were socio-economically fit and have access to these for profit treatment centers.
What happens to everyone else who access treatment via federal, state, and local grants and funding?
The INDIVIOR Suboxone lobby has been diligent in their efforts to convince regulators and lawmakers that the opiate dependent or addicted have an incurable chronic disease thus must be on Suboxone forever. Much effort has gone into bashing 12 Step RECOVERY and the "FAILED" abstinence treatment model.
And of course since suboxone is the "evidence based" "gold standard" only treatment providers who offer suboxone (SAMHSA just declared detox is not treatment in their latest $1 billion dollar grant money grab) should get government grants and funding.
So where do all those people stuck on the perpetual suboxone heroin suboxone hamster wheel and suboxone deep dive abuse go for help without great private insurance?
Where do all the poly drug addicts, alcoholics, crackheads and methamaphetimine junkies go for treatment?
Solutions (in random order):
1) Tell Dave Aronberg and the Palm Beach County Commissioners that we want quantantive drug testing (levels of buprenorphine and norbuprenorphine checked) for people in sober living and 1/2 way houses to become a mandatory funded "thing." Yale Medical Center documented qualitative drug tests (aka dissolve a little suboxone in clean urine) is not an option for this demographic.
2) Tell Palm Beach County Commissioners to advertise a public health advisory that PREGNANT FEMALES should be on monobuprenorphine NOT suboxone. Besides the fact naloxone in suboxone is a joke INDIVIOR NEVER TESTED FETAL EXPOSURE TO NALOXONE while trying to get regulatory agencies to sign off on it.
3) Tell Palm Beach County Commissioners to schedule an opiate crisis response workshop to include the head and support staff of all agencies with an invitation to all hospitals, treatment providers, and anyone with the power to write a prescription in our county to attend. In advance invite Dr Scanlan of Palm Beach DETOX in Boca to lead the workshop and share his knowledge and research on best suboxone buprenorphine induction, maintenance taper, and detox practices. Have staff present who can help medical professionals with prescription writing power to enlist their services as a SAMSHA and DEA waivered buprenorphine prescriber.
4) Tell Palm Beach County Commissioners to follow the proven Yale Emergency Department model. Have 24/7 Buprenorphine rapid detox and hold over doses available from ALL Palm Beach County Emergency Rooms no questions asked. Why are we waiting for addicts to overdose before offering this service? 6 days of heroin laced with fentanyl and 1 day of buprenorphine ACCESS = 24 hours of overdose harm reduction. PLUS invites an at large addict into the light.
5) Tell Palm Beach County Commissioners that we demand a ZERO TOLERANCE POLICY for intakes at Palm BEACH COUNTY CORRECTIONAL FACILITY aka GUNCLUB to be left to life threatening cold turkey detox off alcohol, benzodiazepines, or opiates. Make rapid detox doses of buprenorphine available to all intakes and the proper detox meds for alcohol and benzodiazepines. Every dope sick inmate release is going to SCORE MORE HEROIN via committing new crime, overdose exposure to fentanyl, exposure to HEP C, and exposure to unsafe sex HIV AIDS and STDS. This could be your kid or someone you know. So blow up the commissioners phones and email inboxes on this one.
6) If you are in the 12 Step RECOVERY community tell your home group to add the WE ARE NOT DOCTORS reading to the meeting opening. While it is bullcrap BIG PHARMA is pushing powerful narcotics as the solution with no treatment support it doesn’t give ANYONE in a 12 STEP FELLOWSHIP the right to play higher power and recommend or shame ANYONE to stop taking doctor prescribed meds, including methadone or buprenorphine. Attraction rather than promotion. If and when a person is ready to come off medication assisted treatment IT’S THEIR DECISION. Hard core detox off any substance, prescribed, legally attainable, or illicit is much easier with a support system already in place.
7) To anyone on medicated assisted treatment YOU ARE UNDER NO OBLIGATION to disclose to a 12 STEP FELLOWSHIP that you are taking doctor prescribed meds. TAKE WHAT YOU NEED OUT OF A MEETING AND LEAVE THE REST. Addicts and Alcoholics are ninjas when it comes to getting their needs met. If it didn’t bother you when 50 people in a row told you to piss off while panhandling at a gas station til you scored a buck- a handful of idiots at a 12 Step Meeting not working their own program should be a cakewalk for you. If you walked in the door and sat in a seat you dearly paid for YOU GOT THIS.
8) Tell Palm Beach County Commissioners, State and Federal regulatory and elected officials NO MORE paying for one medication assisted treatment drug over another.
9) Tell Palm Beach County Commissioners, State, and Federal regulators and elected officials NO MORE forcing treatment providers to force their patients to take mandatory medication assisted treatment drugs with no DETOX AND ABSTINENCE OPTIONS.
10) Tell Palm Beach County Commissioners we want funding for a mobil (RV VAN PRIUS whatever) clean needle exchange program. To the objectors who claim this perpetuates IV drug use so does suboxone. The addicted who were needle users before MAT are either banging their suboxone-Or coke-Or benzos-Or crack-Or Methamaphetimines. SUBOXONE doesn’t stop HEP C, INFECTIVE ENDOCARDITIS, HIV , OR AIDS. But clean needles do. Just sayin.
11) Make non narcotic NALTREXONE available over the counter without a prescription in Palm Beach County making full dose non narcotic MAT easily accessible and affordable. Talk to PBC’s compounding pharmacies about making 0.Xmg and mcg microdoses of naltrexone readily available (naltrexone has a paradoxical effect at ultra low doses- it can be used overlapping full agonist and partial agonist opioids use to ease or elimate withdrawal symptoms for starters)
12) Ask Scripps Florida and Max Planck Institute to spearhead research on microdosing of either buprenorphine or naltrexone while overlapping full and partial agonists like methadone, heroin, suboxone, and pain management opiates to safely induct a patient on, or transition them from one drug to another, or safely detox them off while skipping the prerequisite withdrawal phase. Duke University and researchers in Bern and Basel Switzerland have done research on this and IT WORKS. (See Bernese Method) But it involves generics and cuts out alot of middlemen so the public has to push the envelope on this one.
13) Ask Scripps Florida and Max Planck Institute to spearhead research on 12) but also apply microdosing of buprenorphine or naltrexone to pregnant women while overlapping methadone, heroin, or buprenorphine use shortly before delivery. This has the potential to make NAS and BABIES BORN DOPESICK a distant memory.
How cool would that be?