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PostPosted: Fri Mar 21, 2008 6:09 pm 
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This type of thing really bothers me... a patient is doing great, working, getting his life back in order, and the PO from a year-old case wants him off suboxone. Read what I wrote to the PO, and comment if you with.

Any similar experiences?
Read On:

I treat XXXXX for opiate dependence. He and I have arrived at a taper schedule as you requested. I do feel obligated, however, to let you know that tapering off suboxone is not appropriate care for his opiate dependence.

I have no shortage of patients on suboxone-- I am always at the 100-patient limit, and there are always people waiting in line if a patient leaves my care (The most common reason for stopping suboxone is pregnancy). I have no financial incentive to keep Nick on suboxone; if anything I will be paid more for a new patient taking his place. I have a great deal of experience with addiction; I treat some patients with suboxone, and others by different techniques, depending on their personality, addiction/treatment history, and circumstances. I have treated about 150 patients with suboxone over the past two years; other patients were treated by myself in outpatient therapy, or referred to residential treatment.

I remain current with the standard of care for addiction. I am the Medical Director of XXXXX Treatment Center, a residential and outpatient AODA treatment center in Wisconsin. I am Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, where I teach medical students and psychiatry residents. I do the teaching of the addiction section of the mental health/behavior block for medical students. In the case that you do not accept my opinion on the matter, you can easily find ample support for the use of buprenorphine for long-term maintenance of remission of opiate dependence. I suggest starting at ASAM, the American Society for Addiction Medicine: http://asam.org. The president of the organization, Dr. Michael Miller, practices in Madison Wisconsin and is a strong advocate for the use of buprenorphine and Suboxone.

Despite efforts to educate physicians and the public, there are a number of misconceptions and prejudices about Suboxone. The active ingredient of Suboxone, buprenorphine, has a distinct mechanism of action at the opiate receptor that is unlike the effect of oxycodone or methadone. After two-three days of use a patient on Suboxone feels no effect from the medication-- no 'high', and no sedation. A patient on Suboxone cannot get an effect from any other opiate. The action of Suboxone that sets it apart is the effective relief of craving for opiates, which in effect induces full remission from active addiction. Patients on Suboxone are relieved of the terrible obsession that keeps them from moving forward in life. My patients include attorneys, physicians, nurses, prison guards, and factory workers, all grateful to have opiate dependence out of their lives.

There are certainly cases where total sobriety is favored over Suboxone. It is important to realize, however, that even with thorough, residential treatment, the relapse rate for opiate dependence remains well over 50%, much higher than that of other substances. Patients who maintain sobriety through 12-step meetings can expect to have cravings for the rest of their lives. I have had a number of patients tell me that traditional recovery kept them clean and feeling like a 'recovering addict', whereas suboxone made them feel like a person who was never addicted in the first place. The role of meetings and therapy for patients on suboxone is debatable, as the relief from the obsession to use allows good character to return. Most of my patients are working and doing well in life-- as is XXXXXXXX.

The best way to understone Suboxone treatment is to compare it to treatment of hypertension. Like opiate dependence, high blood pressure is in part genetic, and in part caused by behavior (diet, smoking, lack of exercise, e.g.). We cannot 'fix' the defect in hypertension-- which is a brain abnormality that causes a faulty 'set-point' for blood pressure. We instead artificially dilate blood vessels and weaken the pumping of the heart with medication, and the pressure drops. If we stop the medication, the high blood pressure is still there. The medication causes 'remission' of the high blood pressure-- not a cure. Likewise, opiate dependence is in part familial and in part behavioral. We have no cure-- no way to eliminate the obsession to use that characterizes addiction. But we now have a medication that will induce remission of that obsession. The comparison does not stop there-- with both hypertension and addiction, we have non-medical ways to treat the diseases, using the power of the mind. For addiction, the person can work hard to drastically change their mind through hours and hours of treatment and life-long meetings. For hypertension, a person can use biofeedback and meditation to control their blood pressure-- can you imagine how effective it would be if a patient put the same effort into it that an addict puts into meetings and treatment? Of course, we would never expect a person to go to that effort to control their blood pressure when medication is available… and yet we think of an addict very differently, and consider medication to be the easy way out. Yes, it is hard to get off suboxone…. Just as it is hard to get off some blood pressure medications, which cause 'rebound hypertension' when they are stopped.

As I said, XXXX is prepared to taper off suboxone, as he has no choice. He will have life-long cravings that will at times occupy his mind and make him irritable. He will place himself at risk of relapse, which could land him in prison or even kill him. As his doctor, I have to wonder about the sense of that, particularly when he is being forced to deviate from the standard of care and face these risks because of someone else's misconceptions and biases. I used to have similar misconceptions when I read the first studies about suboxone-- after all, I treated my own opiate dependence by hours and hours of outpatient sessions and meetings, and then after ten years I treated my relapse by over three months away from my family, in residential treatment, followed by hours of groups and more meetings. The treatment was effective, but I lost my career as an anesthesiologist along the way, and almost lost my marriage and my life. And yet I was lucky-- many people in the same position don't survive. Thank goodness we have progressed to a point where almost everyone can be saved, treated to remission, and go on to live productive lives.


Sincerely,

Jeffrey T Junig MD PhD
Owner, Fond du Lac Psychiatry and Wisconsin Opiate Management Ctr
Asst Clinical Professor of Psychiatry, Medical College of Wisconsin
Psychiatrist, Wisconsin Dept of Corrections[/url]


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 Post subject: What a Bunch of Crap
PostPosted: Mon Mar 24, 2008 1:44 pm 
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Doc I feel your frustration on this one. A parole/probation officer taking someone off suboxone, guess he wants this guy to return to a life of crime and addiction. I do know someone from another forum that was using subutex for recreational purposes, he jumped off at 12mg, though most myself included begged him not to. He supplemented his detox with heroin, which I told him in a nice way, not a good choice. Anyway he has stopped the heroin and the subutex and doesn't want back on either one. I would love to refer him to your site but they suggest we don't put up e mails, and as such this forum is full of take your drug of choice proponents, and don't want your board infected with people making it a negative experience, and making referrals to their own websites. Maybe this is the wrong place to ask, you have made it clear suboxone itself must be used as a tool, but other tools, such as behavior modification, healthy life style, counseling are all part of it too. This young man sounds much better, and is looking for a natural way to finish his withdrawals. I completely understand he needs so much more than that, but I thought I read in one of your posts suboxone was protein bound, since I was withdrawing more from methadone a high protein diet helped me. What could help someone coming off suboxone and having withdrawals? I suspect this person is poor and cannot afford suboxone. Sorry to get so off topic, because I really think suboxone is a wonderful drug, and will save many lives, and yeah it makes me angry that someone in law enforcement tells someone he can't have suboxone, and that sounds very dangerous indeed. Can we write our congressmen or senators or the drug company itself. How do we educate the public? By the way you do a wonderful job on that.

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PostPosted: Fri Apr 24, 2009 11:13 am 
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I am a Health Practioner trying to get my license back after losing it, my job and briefly, my freedom to a hydrcodone addiction.

In my home State they are abstinance only and have forced me off my Suboxone in order to get my license back. Thay have also forced me to pay for extra urine screening for buprenorphine; a double-double standard, if you will. That fact that I have really been stable on the drug is not important. Liability is the issue, since they must protect the public.

I know in Oregon they have made some exceptions.

Essentially they have, in a few rare cases, allowed a physician to practice on suboxone therapy. This was only after demonstrating no cognitive impairment after neuropsych testing and being in good demonstrateable recovery. I cannot post the specific email I am paraphrasing but they state that I must be reinstated in my home state first and in good standing before they would consider me. Which means coming off the suboxone and I'm doing that now. So it's really all a mute point.

Hopefully there will be some more enlightenment on this issue in the future. There is a real need for a good, LARGE, study looking at cognitive ability on stable dosing of Buprenorphine. One study I found gave sober volunteers IV buprenorphine and they measured cognitive function over a short period of time. Guess what they found, cognitive impairment-how stupid is this? Sorry, I ramble.


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PostPosted: Sun May 24, 2009 8:37 pm 
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I realize this topic started a year ago, but I'll give it a shot anyway.
First, great letter!
I'm really curious - after receiving your letter, did the PO go forward with making your patient end his treatment? Somehow I foresee a legal case showing up (if it hasn't already), whereas a judge would have to decide if the PO is out of bounds making such demands.
(It reminds me of when people are made to attend AA/NA. There have been incidents when such was legally challenged (actually legal action was threatened) and they had to rescind that requirement, based on religious reasons. Two very different reasons, I know, but both situations where a PO went overboard.


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PostPosted: Sun May 24, 2009 9:18 pm 
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Why does a PO, who I'm assuming is not a doctor, get to dictate the terms of someone's medical treatment? That is seriously effed up.

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PostPosted: Thu May 28, 2009 2:11 am 
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I have some experience with this issue as I am currently on Probation and have been taking Suboxone. The probation agents will usually ask for a list of meds your are prescribed and currently taking. While I truly believe in most cases that honesty is the best policy there are different ways of approaching your PO about taking Suboxone. First and foremost you need to make it clear that you are under the care of a licensed Psychiatrist and they are treating you with FDA approved medications for your chronic illness. It is ultimately your choice if you want to tell the PO that you are taking Suboxone. What I've done is simply told them that I am under the care of a Psychiatrist and am taking all medications as prescribed. Most PO's will not push you too hard unless you have been having problems with substance abuse while on probation (e.g. positive urine tests). Also another important note is that the majority of urine drug screens used by probation and parole agents do not screen for Suboxone they use the SAMSHA 5 panel test as used for most dot positions in the government. Honestly, the agents are looking for illicit and illegal drugs such as THC, Amphetamines, Heroin, PCP, and sometimes benzos. Buprenorphine is not usually tested for so there would be no positive tests if you must submit to random drug screens.

Personally I would omit my use of Suboxone vs. the chance that I might be forced to stop it all together.
Everyone's situation is different so you have to decide what is best for you. This is just my personal story.
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PostPosted: Mon Jun 08, 2009 2:27 pm 
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Dear Dr. Junig:
Can you please post to us what has happened to Nick's case so far. I do hope best for him.
Thank you.


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PostPosted: Mon Jun 08, 2009 2:45 pm 
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How do PO officers, courts, judges know to send offenders/drug addicts to NA/AA programs (make 90 in 90)?
Same as, how did this PO know what Suboxone was and is demanding his client taper of and come off it completely?
There are no published reports on the success rate of NA/AA, so how do judges know they work?
Well, there are 12 steppers in all jurisdictions of our society. Many if not most treatment programs require that the people who work there (counselors, therapists, techs) are all NA/AA members (12 steppers). And these counselors/therapists/others tell the judges and the courts that the 12 step program works and so to send everyone there. Well, same as in Nicks case I am assuming. The 12 steppers from NA are telling this PO that Suboxone is still using and that Nick is not really clean while on it and it should be used only for a short period of time. And so the PO is doing what he is told (brainwashed) by these 12 steppers. By the way, do you know the suuccess rate of AA/NA? Probably not. I urge you to do some searches on goggle and find out.
Here is a great source: orange-papers.org
These 12 steppers have infiltrated all parts of our addiction rehabilitation services in our society and are dictating how others should recover. They believe that the 12 step model works for everyone (if you relly, really, really work it). Ok, the success rate of AA is 5%. But it is actually 0% because people die in the fellowship who otherwise might not have died if they did not enter AA/NA. Something has to be done to get these 12 steppers out of the role's of dictating innocent people's recoveries.
The Supreme Court and seven other circuit and federal courts have ruled AA/NA (all 12 step-300 of them) to be of religious nature. nick need's to take his case to court and have Doctor's and professionals back up his claim that the PO is not a medical professional and is getting missguided info from 12 steppers. I urge anyone who is in the fellowship (cult) of AA/NA to read orange-papers.org


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PostPosted: Thu Jun 25, 2009 4:48 am 
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The problem is likely not with the parole officer, but the guidelines even he has to follow, which may be from the state department of corrections, or the parole board itself. Change may have to be effected there. Parole officers no longer have the power to revoke parole; only to bring the parolee before a revocation hearing which is normally conducted by the parole board itself... a case of the fox guarding the henhouse. I wish I knew more about your particular state, but I'm surprised that Suboxone is banned for people under supervision.


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PostPosted: Thu Dec 16, 2010 1:56 pm 
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mnpd wrote:
The problem is likely not with the parole officer, but the guidelines even he has to follow, which may be from the state department of corrections, or the parole board itself. Change may have to be effected there. Parole officers no longer have the power to revoke parole; only to bring the parolee before a revocation hearing which is normally conducted by the parole board itself... a case of the fox guarding the henhouse. I wish I knew more about your particular state, but I'm surprised that Suboxone is banned for people under supervision.


I was wondering about that too. It makes me wonder if these people know what they're doing. They think it's the best thing to be done but they're only trying to make things worst for everybody. My sympathy goes out to you Doc, especially to your patient. I hope the decision changes...

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PostPosted: Mon Dec 10, 2012 11:35 pm 
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They are the authority when it comes to their clients.

I have heard many stories from friends in the rooms of NA/AA who were allowed to be on suboxone during probation as long as it followed the law BUT them being addicts, many would relapse because they would always have subs as a "backup" and grew over confident. (Never addressing the true issues of dependency)

I haven't heard of anybody on parole being allowed to be on suboxone (double true for methadone), but that makes sense since a parolee is someone who came straight from prison, where they technically shouldn't have access to suboxone or any substance in the first place (Not saying its impossible, of course it is but you know).An intelligent and truly caring probation officer would know that someone who has been stabilized thanks to suboxone should not be taken off!

You don't have to tell them on the very first meeting either, you can try to get a feel for them and how they stand by asking the right questions, play some head-games with them and figure out where they stand on suboxone.

Speaking solely for myself, when I would get clean I would last 8-10 months and then relapse for 2-4 months and start over. It wasn't until I got on suboxone and used it properly was I able to experience a sobriety for an extended period of time. Not only that, but I wasn't obsessing over opiates all day.

Suboxone may be a crutch, but I'd rather walk with a crutch then not walk at all.


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Fond Du Lac Psychiatry
Dr. Jeffrey Junig, M.D., Ph.D.

  • Board Certified Psychiatrist
  • Asst Clinical Professor, Medical College of Wisconsin

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