The Suboxone Problem No One Is Talking About

The key to effective treatment with Suboxone

On October 21, 2015, President Obama met with people in Charleston, West Virginia and talked with them about the opiate and heroin epidemics. While all of America has been devastated by these drug epidemics, they have particularly ravaged Appalachia and Rust Belt cities; wealthier regions of the country have both more access to healthcare and better treatment options.

The President announced a number of initiatives, including the expansion of buprenorphine and naloxone. Buprenorphine is the chemical that is in Suboxone. It is a semi-synthetic opiate that helps reduce the physical and psychological craving that so often leads newly clean opiate users to relapse. Naloxone is a drug that has come to prominence in the last few years—it can reverse the potentially fatal effects of an overdose. Thousands of law enforcement officials and emergency medical technicians around America now carry it with them and have saved thousands upon thousands of lives.

President Obama ordered that all federally employed healthcare providers must undergo best practice training for prescribing, pain management and how to recognize and educate misuse. On the same day as his speech, the White House issued a press release that more than 40 provider groups pledged to:

  • Have more than 540,000 health care providers complete opioid prescriber training in the next two years;
  • Double the number of physicians certified to prescribe buprenorphine for opioid use disorder treatment, from 30,000 to 60,000 over the next three years;
  • Double the number of providers that prescribe naloxone—a drug that can reverse an opioid overdose;
  • Double the number of health care providers registered with their State Prescription Drug Monitoring Programs in the next two years; and
  • Reach more than 4 million health care providers with awareness messaging on opioid abuse, appropriate prescribing practices, and actions providers can take to be a part of the solution in the next two years.

These are all plans and initiatives that I approve of, but there is a key problem that has not been addressed. Back in 2000, the Drug Abuse Treatment Act (DATA) was written by Senators Orrin Hatch (R-UT), Carl Levin (D-MI) and Joe Biden (D-DE) and signed into law by President Bill Clinton. The intention of the act was to allow primary care providers to engage in addiction treatment. Physicians were required to take an 8 hour course on addiction treatment. Once completed, they could prescribe up to 30 patients with buprenorphine (this number was later increased to 100 and there are current proposals to increase it to 200). The act suggested that buprenorphine treatment be combined with regular urine screenings and counseling.

The key word here is suggested, and it's a terrible flaw.

Thousands of doctors have undergone the training, and a large number of their practices are primarily in the treatment of opiate addiction. This is despite the fact they are not true specialists, but rather regular doctors who took an eight-to-24-hour course on addiction treatment. Many of these doctors do not drug test their patients, nor do they require them to go to counseling. When the clinical trials of buprenorphine were conducted, the patients were given regular drug screens and counseling. The outcomes of the clients were good and this resulted in the passage of the law and the approval by the FDA. But while these newly trained doctors were prescribing buprenorphine to their patients, they were neither drug-testing them nor making them attend counseling, and the effectiveness of this new drug treatment was greatly diminished.

Regular drug testing through urine screens (blood tests are rare) leads to less drug use. It's clear and irrefutable. To be effective, drug tests need to be monitored by another person in the room and they need to be regular and random. There are many studies that demonstrate that counseling has some effectiveness (I am a believer in a combination of individual, group and multi-family counseling). Despite the suggestion by DATA, studies and best practice guidelines by the American Society of Addition Medicine (ASAM—full disclosure, I'm a member), many doctors do not require drug screens or counseling when they are treating their opiate addicted patients.

This has led to the misuse, abuse and diversion of buprenorphine (the New York Times reported on these issues in November of 2014). Over the last decade, buprenorphine has become a dirty word in Twelve Step meetings and many treatment programs. AA and NA meetings are often the last place someone can go and be accepted—to be rejected there is not only wrong, but it can be deadly.

A majority of halfway and recovery houses refuse to accept people that are on buprenorphine. As a result, people in early recovery are often faced with the decision to either:

  • stay on buprenorphine and be homeless or live in a dangerous environment; or,
  • rapidly or immediately quit buprenorphine in order to live in a safe environment and be accepted in the rooms.

People in Twelve Step programs have reacted negatively to buprenorphine because it has not usually been properly used in treatment. They have seen people use other drugs while on Suboxone or used it as a tool to avoid detox during the week before returning to heroin on the weekends. Their experience with it is almost entirely negative. Thousands of people in recovery have attended my professional trainings, and a majority of them do not believe in the efficacy of buprenorphine. I have had to spend much too much time and energy explaining research studies, the evidence that it is quite effective, anecdotes of clients, and the failure of the DATA act in order for them to even consider changing their minds.

All of this can be fixed with a proposal that no one is talking about. Instead of suggesting regular drug screens and regular counseling, a prescription of buprenorphine (or naltrexone or probuphine for that matter) must be accompanied by regular drug screens and counseling. By regular, I mean weekly drug screens and at least one hour of counseling a week (still too minimal in the beginning).

I have brought this up with both Republican and Democratic members of Congress, and they have all told me that "getting new regulations are tough." I smile and ask them to take a look at it and do their best.

Inside, I seethe. This is an issue that can be easily improved upon. The data and studies are clear. We need leadership, and I don't see any politician speaking about this simple measure.

It is time for addiction treatment professionals and advocates to urge politicians to require that drug screens and counseling accompany the prescribing of buprenorphine (and other medication assisted therapies). It will increase the effectiveness of the medication and thereby reduce the stigma associated with it that is rife in the rooms of Twelve Step programs and in treatment centers.

Frank Greenagel is an adjunct professor at the Rutgers School of Social Work. He is also an instructor at the Rutgers Center of Alcohol Studies and a member of the Hazelden in New York Board of Directors. He writes a blog at He conducts trainings, consults for programs, and delivers keynote speeches around the country. He completed a Masters in Public Affairs and Politics in 2015. He rejoined the Army in 2014 as a Behavioral Science Officer.

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