Buprenorphine, commonly known as Suboxone, is a drug that stops opioid cravings in people with substance use disorder (SUD) by blocking the opioid receptors in nerve cells. Since being approved by the FDA in 2002, it has been a source of controversy in the recovery community, in large part because it is an opioid-based drug, which is considered by many to be anathema to commonly understood tenets of recovery practice. Critics also complain that the drug can easily be sold on the streets and/or bartered for more opioids.
But as the opioid crisis has worsened, Suboxone has gained widening acceptance, nationwide and Islandwide. Between 2003 and 2013, prescriptions for Suboxone increased from 150,000 to 2.1 million, according to the National Center for Biotechnology Information.
A 2014 study by Cochrane Drugs and Alcohol Group, which examined 31 studies on Suboxone efficacy done between 1992 and 2008, concluded that methadone is the most effective at keeping people in treatment, and that “buprenorphine should be supported as a medication to use in substitution maintenance treatment, where higher doses of methadone cannot be administered or methadone is not tolerated, or simply to provide patient and clinician choice.”
At the Feb. 1 “Destigmatizing Addiction” forum at MVRHS, Department of Public Health commissioner Dr. Monica Bharel strongly endorsed the efficacy of Suboxone in treating SUD.
“Nonfatal overdoses are an ideal time to intervene, in particular with either methadone or buprenorphine treatment,” she said. “The risk of death to people treated with one of these drugs goes down by about half. This is following many, many years of peer review and national data on this topic. This is really powerful information. If we had this information about a blood pressure medicine or a diabetes medicine, it would be used throughout the state, no question. We know these medications work.”
Richie Smith, assistant superintendent of Martha’s Vineyard public schools and a Vineyard House board member, said one of the stated goals of the Martha’s Vineyard Substance Use Disorder Coalition (MVSUDC), organizers of the forum, is “the development of a community approach for Suboxone.” Now, Dr. Charles Silberstein, psychiatrist and substance abuse specialist at Martha’s Vineyard Hospital, Marybeth Dodge, D.O., and Dr. David Gorenberg are the only Island clinicians who can prescribe Suboxone.
To Mr. Smith’s point, New Paths program director and clinical nurse specialist Janet Constantino said at the “Destigmatizing Addiction” forum that Martha’s Vineyard Community Services (MVCS) will soon expand Suboxone availability on the Island. Ms. Constantino and Dr. Dominic Maxwell, medical director at MVCS, are certified to prescribe Suboxone, but await prescriber’s I.D. numbers from the Drug Enforcement Agency (DEA).
“We’re having conversations with the hospital so we can do a Suboxone program, where patients can be prescribed the medication and be referred to the Island Counseling Center, and our New Paths program, where people will be mandated to come once a week,” she said. “You cannot give out Suboxone without requiring treatment; it just doesn’t work.”
Vineyard House, the only sober-living facility on Martha’s Vineyard, will not accept people treated for SUD with Suboxone. Vineyard House policy does not completely prohibit medication-assisted treatment (MAT). Vivitrol (naltrexone), a drug that mitigates alcohol and opioid cravings and is administered by a monthly injection, is permitted.
But the board of directors, which sets policy for Vineyard House, has held firm on Suboxone. In a discussion at the “Destigmatizing Addiction” forum, after Dr. Bharel departed to catch a ferry, Vineyard House directors Jane Seagrave, publisher of the Vineyard Gazette, and Mark Jenkins explained their take on the board’s position.
“Law enforcement has indicated to us that they are seeing an increase in the incidence of Suboxone pills being sold on the street,” Ms. Seagrave said. “We want to be really cognizant of that, and be sure that by adding more prescribers, we’re not adding to the problem.”
Mr. Jenkins said he believes there is a widespread misconception that Suboxone is a “magic pill.”
“It’s not as clear-cut as that,” he said. “It presents challenges in a residential facility that is filled with people with substance use disorder. It is a drug that is used and traded on the streets. There’s a film that’s been introduced that goes on the tongue, but you can look on the Internet and see ways of abusing it. For the moment, in a residential facility that’s filled with people in early recovery, we have decided over the years, and have revisited the issue, that it is simply not appropriate in a situation like ours. We allow Vivitrol, so we’re not opposed in principle to medically assisted recovery. But Suboxone presents its own challenges. For everything that provides enormous benefits, there are also potential downsides. Most important, it’s not the magic solution to our opioid crisis.”
Discussions with several addiction experts since the “Destigmatizing Addiction” forum reveals that Vineyard House policy is not an anomaly, but there are reasons why a change may be in order.
Nationwide challenge
The Times spoke with Dr. Marvin D. Seppala, chief medical officer at Hazelden Betty Ford Foundation in Center City, Minn., and author of “Clinician’s Guide to the Twelve Step Principles” and “Prescription Painkillers: History, Pharmacology and Treatment,” who has served as a board member of the American Society of Addiction Medicine (ASAM).
Dr. Seppala told The Times that while he prescribes Suboxone at Hazelden, placing patients on Suboxone in sober housing is a challenge throughout the country.
“Suboxone was controversial right from the start, because Hazelden is an abstinence-based, 12-step-program-oriented treatment system,” he said.
“Sober houses and those who run them have been very resistant to allowing people with Suboxone in. They often cite logistical concerns because they have very few staff members, and often those staff members are people in early recovery. It’s a legitimate concern; nonetheless, federal regulations require that you can’t bias yourself based on the use of medication in a treatment setting, so the policy is actually breaking federal regulations.”
Dr. Seppala said the 20-bed Hazelden sober-living facility in St. Paul accommodates a small fraction of patients on a Suboxone regimen.
“We use outside sober houses for the majority of the people,” he said. “There’s only one sober house in St. Paul that allows Suboxone to be kept on premises.”
Dr. Seppala said the Hazelden outpatient Suboxone programs, which have been approved by the DEA, require that patients come to a Hazelden facility, or to a pharmacy, on a daily basis to get the medication.
“It’s not ideal, it’s inconvenient; however, it is workable,” he said. “It helps some people find the housing that they need. But some sober-living places won’t let them in regardless. Some pharmacies don’t want to get involved because they’re busy, and if they get 10 or 12 people it becomes a hassle, but some are really committed to helping this population.”
Dr. Seppala agrees that Suboxone is not a panacea, and he echoed the need for a structured program, which includes regular drug screening in addition to active recovery work.
“There are people that abuse it, but it’s very uncommon,” he said. “It tends to be people left to their own devices. If you have the structure necessary to make sure these people are getting the proper treatment, and getting into good long-term recovery, which is really the key for the long run, it can work really well.”
Dr. Seppala said the stigma associated with Suboxone in sober-living facilities can extend to 12-step programs.
“The official position of N.A. (Narcotics Anonymous) is that if you are on Suboxone or methadone, you cannot be in a service position and you cannot speak at a meeting,” he said. “We had a patient go to a meeting last week, and they told him to get out, which in early recovery can be really tough on a person. It’s the exact opposite of what we expect. It’s a lot less likely to happen in A.A., but you never know,” he said.
Dr. Seppala said that the board of directors at Hazelden Betty Ford was also resistant to including Suboxone in its pharmacopeia.
“We showed them information about the crisis, we described how we were going to go about it, and stressed that we were trying to save lives and engage people in their recovery,” he said. “If there are people on the board in recovery, ask them to read the third tradition out of the A.A. “Twelve Steps and Twelve Traditions” book. It describes the decisionmaking when A.A. was first established, and how they were going to exclude all kinds of different people, then they realized that to exclude anyone could be a death sentence. We use that with our staff, with our board, in the recovery community; just as the founders of A.A. realized they had to do everything they can to get people in without restriction, sometimes the decision has to be what’s best for the patient.”
In 2011, the Hazelden directors voted unanimously to approve Suboxone treatment at Hazelden/Betty Ford Clinics.
Closer to home, Ed Glennon, vice president of inpatient services at Gosnold on Cape Cod, said supervised Suboxone dispensing is de rigueur at the five recovery residences that Gosnold oversees.
“We encourage people who come into our sober houses to be on MAT,” he said. “It’s part of the foundation for recovery. For people in early recovery, their chances of staying sober are much higher on MAT. If they’re on Suboxone, or naltrexone, methadone, we encourage that in our facilities.”
Mr. Glennon said Gosnold staff do not take possession of the medications, but they witness the patient taking it every day. “It’s a witnessed administration. We help keep track of it, but we don’t hold it for them.”
He said abuse of the policy has been minimal. “Honestly, we find the people who have the most regressions are usually the people who have alcohol as their primary drug of choice, largely because it’s the most accessible.”
Mr. Glennon said that the majority of sober houses on the Cape have the same policy on MAT as Gosnold.
Vineyard House founder calls for change
Speaking to The Times last week, Dr. Silberstein, a co-founder of Vineyard House and former board member who now serves on the board of advisors, said he sharply disagrees with the Vineyard House Suboxone policy. Dr. Silberstein said that he helped write the original residential criteria in 1997, but he expressed frustration that in light of the proven efficacy of Suboxone since then, the board has remained intractable.
“I was the one of the architects of Vineyard House policy,” Dr. Silberstein said. “It was written before Suboxone was available. Our feeling was that we wanted people who came into treatment to be focused on recovery work from an emotional point of view, and not to have substances that were immediately mood-altering or abusable.”
Dr. Silberstein has been prescribing Suboxone since 2004. He also requires patients to be actively engaged in therapy, and to take urine screens several times a week.
“I agree that it’s not a magic pill for everyone, but it is for some people,” he said. “There’s no question Suboxone saves lives. I see it every day. There are people who need to have their lives stabilized who would benefit from Vineyard House and Suboxone. Recovery also requires therapy, intensive outpatient treatment, and working a program of sobriety. Vineyard House could help provide that.”
Dr. Silberstein acknowledged there would be complications to administering Suboxone to Vineyard House residents.
“You’d have to have a system where people could have it dispensed. Suboxone implants are one option. Maybe a pharmacy does the dispensing. It’s complicated. Could it be done? Absolutely. It’s a matter of will.”
Dr. Silberstein said he hopes that Dr. Bharel’s Feb. 1 visit, with the stated purpose of destigmatizing addiction, will help destigmatize Suboxone at Vineyard House.
“There is strong prejudice against Suboxone among certain people,” he said. “It’s tragic because people are stigmatized and shamed for being on a medication that transforms their lives and allows them to function soberly. I think the [Vineyard House] board needs to have a serious conversation about it. It is tragic, because if Vineyard House did accept people on Suboxone, there are some people who would be alive today who are not alive.”
Speaking to The Times on Wednesday, Mr. Jenkins, past president of the Vineyard House board, remained resolute in his stance against Suboxone, for philosophical reasons and practical reasons.
“From a practical aspect, in a group living situation it’s very difficult to administer,” he said. “From a philosophical standpoint, I feel that people who use Suboxone don’t do anything else to work on their recovery, and as soon as they go off Suboxone, they end up falling back into the old ways of coping. Suboxone is a street drug. Any addict will tell you they can snort it, inject it, drink it. It gets you high. That’s the dirty little secret.”
Mr. Jenkins said conflicts could arise at Vineyard House when one roommate can afford Suboxone treatment, and the other cannot.
“What about the person who can’t afford it? He’s left with abstinence and 12-step meetings. You think he might get a little resentful? You think he might be tempted when he sees it in someone’s gym bag?”
Mr. Jenkins said he’s spoken to many opioid addicts in and out of recovery who also take a dim view of Suboxone. “They say it’s just another drug that makes you sick, that’s expensive and really difficult to get off,” he said. “It’s a street drug.”
Mr. Jenkins said he believes the growth of Suboxone is largely fueled by profit. “I feel there’s a huge amount of money behind Suboxone,” he said. “Look at Big Pharma and how they push so much stuff on us, weight loss drugs and diabetes drugs, and with Suboxone. We’re all so desperate for this stuff to work because it’s our spouses, our kids, our loved ones, but Suboxone is not a magic solution. It’s a big fraud in my view,” he said. “Ten years from now, we’ll be talking about the next thing.”
Ms. Seagrave told The Times on Wednesday that Suboxone has been discussed many times at the monthly Vineyard House board meetings, and she expects it will be a recurring topic.
“We don’t accept substances that are abusable because it creates a risk. That’s the policy at the moment,” she said. “It’s a discussion that comes up all the time because it’s an important issue. There are a lot of different points of view on Suboxone. We’re always looking to get as much information as we can.”
