Bob gets bad news at the doctor.
Bob was on his way to the doctor to find out how his lab testing results turned out. He was a bit nervous, because of the way the doctor spoke to him on the phone.
When Bob arrived at the doctor’s office, he waited nervously in the waiting room, and was then brought in to sit at a desk, across from his doctor. The doctor looked at Bob for a while, then glanced down at the report in front of him.
“Bob, I have some bad news for you. It turns out that you have a rare form of cancer.”
Bob felt sick to his stomach when he heard those words. He wondered how long he had to live.
The doctor continued, “This cancer can be very aggressive. If we do nothing, there is an 80% chance that you will not make it beyond a year.”
The doctor explains to Bob that there’s hope.
“Fortunately, there is a treatment regimen that can be very effective if you are able to follow it.”
Bob quickly sat up, suddenly alert, and responded, “Of course I am going to do the treatment. What do I have to do? How long can I live if I stick to the treatment regimen?”
Bob’s doctor had a worried look on his face. “The problem is that, while the regimen is effective, only about 10 to 20% of people stick with it. It involves a difficult regimen of diet and exercise. You are going to have to stop eating all carbs and follow a specific, high intensity cardio workout for two hours, every single day.”
The doctor continued, “I am going to send you to an institution for a month, where you will be trained in following the diet and exercise program by certified instructors who have themselves completed the same program. After that, you will continue with support meetings. As long as you are able to stick with it, the cancer will remain in remission.”
Bob started to get worried. What if he failed? The idea of changing his lifestyle was not appealing. Why did this have to happen to him? It didn’t seem fair.
Bob then said to the doctor, “There must be another solution. I can’t imagine giving up my lifestyle and changing everything like that. I can already tell you that I don’t think I can do it.”
The doctor didn’t respond right away. Bob wondered what he would say. Would the doctor reprimand him for being weak?
Bob knew that it was wrong to say that he couldn’t follow the diet and exercise program. If he wanted to live, he was just going to have to accept that his life would change completely from here on out.
The doctor offers another solution.
When the doctor finally spoke, Bob was surprised by what he had to say. “Bob, there is another option. If you are interested, there is medication to treat this very aggressive cancer. You will have to take it every day, for at least a year or two.”
Bob wanted to know more. “Why didn’t you tell me this before? Will I still have to do the extreme diet and exercise program?”
The doctor said, “I would still recommend healthy eating and some daily exercise, but generally, your life will not have to change at all otherwise.”
Bob was shocked. “So I don’t have to check in to the institution for a month, I don’t have to go to meetings, and I don’t have to give up pizza, burgers, popcorn, chips, cake, and hanging out with friends and family? We can eat dinner together every night without my having to follow a special menu? I can just go on with normal life and still survive the cancer?”
The doctor held up his hand. “Wait, Bob. There is something I should tell you. It’s true that you can take this daily medication and live your normal life without having to worry, but there is a downside. When you stop taking the medication after a year or two, you are going to feel very sick. In fact, you could feel sick for up to a few months, or even a bit longer.”
Bob thought about this. “What if I just kept taking the medication?”
The doctor replied, “That’s an option. There is actually no harm in continuing it. The medication will protect you from the cancer as long as you take it.”
Bob weighs his options and makes a decision.
After a few minutes of thought, Bob had made up his mind. “I want to take the medicine and live my life without making major changes that I might not be able to keep up with. If I decide to stop taking it, I’ll deal with the sickness.”
Bob’s doctor then told him, “You don’t understand. You are going to feel really sick for a while and you may even wish you never took the medicine in the first place. You may even hate me for letting you get started with it. The withdrawal sickness isn’t dangerous, it is just very uncomfortable.”
Bob replied, “You’re saying that you can successfully treat my cancer with proven medication, but you’re telling me that I might not want to take it at all because I might get sick in a couple of years if I decide to stop taking it? Do you realize how crazy that sounds?”
The doctor shuffled some papers on his desk and ran his hand through his hair. “Bob, the diet and exercise coaches have a lot of influence when it comes to treating this particular cancer. They do not believe in doctors treating this cancer with medication.”
He went on, “I know it sounds strange, but when it comes to this medical condition, there is a long tradition of allowing diet and exercise coaches to have the final say in what is best for our patients.”
The doctor gives Bob some unusual advice.
The doctor continued, “I can prescribe the medication to you, but you may be surprised how many people out there, workout coaches especially, are going to tell you that you are making a mistake. You may want to keep things about your medical treatment private.”
Bob was getting frustrated. “So, I shouldn’t tell anyone that my doctor can successfully treat my cancer? Since when did exercise coaches tell doctors how to treat cancer? Life threatening illness should be treated with the latest treatments made available by medical science.”
He kept going. “I want to live my life. I want to go to work every day and I want to come home to my family. I do not want to work out two hours every single night and then not be able to eat dinner with my wife and kids. I will deal with the withdrawal sickness, if and when it comes up in the future.”
“My children are young and I want to enjoy these precious years with them,” Bob said. “I am doing very well at work and I want to continue in my progress. I can’t afford to take off a month to go to your training institution.”
Bob’s doctor smiled. “I think you made the right decision. I just had to be certain that you understood the risks and alternatives. Here is your prescription. We will meet on a monthly basis to track your progress.”
Opioid addiction is a deadly condition and as serious as cancer.
The story of Bob is fiction. I tell it to show the dilemma that doctors face when we prescribe Suboxone and similar medications that contain buprenorphine for opioid addiction. The cancer is opioid addiction, the institution and the support meetings are rehab and the 12 steps, and the daily medication is Suboxone.
While this is not a perfect analogy, and the percentages in it were invented along with Bob, the comparison is a fair one. Opioid addiction can be as deadly as an aggressive cancer. With heroin or fentanyl, any dose can be the one that stops a person’s breathing.
If someone near you has taken an opioid and cannot be woken, or is not breathing normally, call 911 and give naloxone if you have it. If you are in crisis or thinking about suicide, call or text 988, the Suicide and Crisis Lifeline.
Suboxone is an effective treatment. It is not a “replacement drug.”
Treatment with Suboxone is known as medication-assisted treatment, or MAT. Suboxone is used here as a name for all of the medications that contain buprenorphine, which the Food and Drug Administration (FDA) approved for opioid addiction in 2002.
When patients take Suboxone as directed at an adequate dosage, they generally do not experience drug cravings, withdrawal sickness, or the brain fog associated with opioid use. Yet, the usual objection is that the patient is simply replacing one drug with another. Physical dependence is not addiction.
Dependence means that the body has adapted to a medication and will react if it is stopped too quickly. Addiction is craving, compulsion, and continued use in spite of harm. In fact, many patients report that when they taper off of Suboxone after an adequate period of treatment, they feel withdrawal sickness, yet they do not tend to feel opioid cravings.
Unfortunately, non-medical institutions have had the final say.
Many adherents of 12-step programs, and many leaders in the rehab industry, do not believe in using medication to treat addiction. In the story, they are the diet and exercise coaches.
Many people have difficulty working an abstinence-only program fully enough for it to be effective for them. With opioids, that is dangerous, because a single return to use can be fatal. While a patient who finds support in meetings should feel free to keep going, a fellowship is not a medical board.
The result is that some doctors hesitate to offer buprenorphine, or they offer it with an apology. It is time for us, as doctors, to stop hesitating. Rather than worrying endlessly over the withdrawal associated with Suboxone treatment, we should focus on its life-saving properties.
Is the withdrawal as bad as Bob’s doctor made it sound?
Bob’s doctor was right to warn him. A patient deserves to hear about dependence and withdrawal at the first visit, along with a plan for stopping and the right to say no.
The Suboxone prescribing information says that buprenorphine produces physical dependence, with withdrawal if it is stopped abruptly or tapered rapidly. It also describes that withdrawal as typically milder than withdrawal from a full agonist.
Where Bob’s doctor went wrong was in treating months of sickness as a fixed feature of the medication. What he was describing was mostly the taper.
At the usual treatment doses, buprenorphine already occupies most of the opioid receptors, so a reduction near the top of the range may hardly be noticed. Near the bottom, a reduction of the same size removes a far larger share of what is left.
So, the reductions should get smaller as the dose gets smaller, with time for the body to settle at each step. The Maudsley Deprescribing Guidelines describe this pattern, known as hyperbolic tapering, for other medications that cause physical dependence. That guidance was not written for Suboxone, and applying it to buprenorphine rests on clinical experience. There is more about how to taper off of Suboxone in another article.
A long-acting injection can do similar work at the very end. According to the Sublocade prescribing information, buprenorphine can remain detectable for a year or longer after the last injection, and any withdrawal would be expected to be delayed. Some patients report that the slow fade makes the ending more tolerable, which is the idea behind the Sublocade taper.
None of this is a schedule to copy from an article. Work with your prescriber on every step. Handled this way, the withdrawal is usually a nuisance. The untreated disease is what kills.
Taper or maintenance? Which is better?
Is it best to stay on Suboxone long-term, or to do a Suboxone taper for a week or two and be done with it? Many detox programs do the entire taper within one to two weeks. The reasoning is that Suboxone is also an opioid, so the patient should be finished before the body becomes dependent.
Unfortunately, a person who arrives after months or years of opioid use is already physically dependent. A two-week taper is not treatment. It ends before the brain has had time to heal, cravings come back, and the risk of going back to deadly opioids is high.
By staying on a stable dose for at least several months to a year, and often longer, you have time to work on yourself and to distance yourself from the drugs that threatened your life. The Suboxone prescribing information sets no maximum duration for maintenance, and it says that patients may require treatment indefinitely.
It is clear to me that maintenance is the better, safer option. Maintenance gives you time to heal.
When you take your medication as directed, you are in recovery.
When it comes to Suboxone, some members of spiritual fellowships feel that they have a right to make medical decisions on your behalf. This is dangerous.
Do not let anyone tell you that you are not in recovery because you take medication. If you are prescribed medication for a medical condition and you take it as directed, you are in recovery. You do not have to prove or explain that to anyone.
Talk to your doctor. Do not quit your treatment because street “experts” think you should. They are welcome to an opinion. They are not welcome to practice medicine without a license.
When it comes to MAT, there are several options available.
Fortunately, several medications use buprenorphine as the key ingredient. The sublingual treatments, taken daily under the tongue, include Suboxone films, ZubSolv tablets, and generic films and tablets.
There are also two extended-release injections, given under the skin by a medical professional. Sublocade is monthly, and Brixadi comes in weekly and monthly forms. I can advise on Sublocade and Brixadi in a consultation.
Bunavail, Probuphine, and the Subutex brand have been discontinued in the United States, although generic buprenorphine tablets remain available.
Now is the best time to get started.
If you are using street drugs, such as heroin and fentanyl, or misusing pain medications, now is the best time to talk to a doctor about medication-assisted treatment. You may be able to go to work, come home to your family, and eat dinner with them tonight.
If you start taking Suboxone, you do not have to take it for life. When the time is right for you, you can taper and eventually stop. Yet, you should not stop seeing your doctor, because opioid addiction, like cancer, can recur.
In my practice, buprenorphine films and tablets are prescribed by telemedicine for new patients in Florida. The first doses are taken at home with phone support, and when fentanyl is involved, I start with a low-dose induction if it is needed. Visits are monthly, or weekly when needed, there are no mandatory group meetings, and the patient decides whether the goal is long-term maintenance or an eventual slow taper.
To talk about starting, continuing, or tapering buprenorphine treatment, contact me through the contact form.
This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
