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March 15, 2011
by root
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Differences of opinion on Suboxone maintenance

I wanted to reply to Steven Scanlan, MD's article in the November/December 2010 issue regarding the concerns he has with Suboxone maintenance treatment. I am also board-certified in addiction medicine and I have been prescribing Suboxone to my patients since it was first approved. I continue to be amazed that physicians such as Dr. Scanlan continue to misunderstand the disease of addiction.

There is extensive literature documenting the chronic changes to the brains of laboratory animals caused by long-term exposure to opioids. These changes alter the brain's responses to endogenous opioids and tend to lead to chronic dyshedonia. As Dr. Scanlan tosses around ill-defined terms such as “the emotional and spiritual consequences of addiction” and “recovery,” he fails to address the real science, which indicates that opioid maintenance therapy (including both Suboxone and methadone) has been the most successful treatment for opioid dependence over the past 50 years.

Contrary to Dr. Scanlan's assertions that Suboxone blocks 80 percent of a person's feelings and that higher doses make patients feel numb, I and others have found that maintenance Suboxone treatment actually allows people to overcome their chronic dyshedonia and enjoy life for the first time. These patients are not high and they are not numb-they are normal.

Doctors and scientists for hundreds of years have tried to find the reason why people self-medicate, without success. There is no such thing as an “addictive personality,” and multiple attempts to treat presumed underlying disorders that cause a patient to develop an addiction, such as depression, have been woefully unsuccessful.

It is unbelievable that Dr. Scanlan chastises physicians for how they manage their Suboxone patients, while he charges for performing detox procedures that have long been shown to be ineffective. Suboxone detox is ineffective because addiction is a chronic disease, similar to how insulin detox would be ineffective for my diabetic patients.

It is nice that Dr. Scanlan “believes” that individuals on maintenance treatment do not experience the full range of emotions, despite overwhelming evidence to the contrary. I guess I will be spending the rest of my career re-educating and fixing the patients who continue to be misinformed about the nature of their disease and their legitimate treatment options.

Lee Tannenbaum, MD

Bel Air Center for Addictions Bel Air, Md.

Bravo to Dr. Scanlan. Although the clinic where I work doesn't prescribe Suboxone, we treat a number of clients who are taking the drug.

Dr. Scanlan's comments mirror my own observations: Long-term use of Suboxone is most definitely a problem. Getting off Suboxone completely is very uncomfortable (particularly after long-term use), and the discomfort can go on for weeks, even months. That message is not getting out to the addicts.

Thanks again, Dr. Scanlan.

Brian Duffy, LMHC, LADC-I

SMOC Behavioral Health Services Framingham, Mass.

I want to congratulate Addiction Professional on publishing Steven Scanlan, MD's insightful and thought-provoking article. I'd also like to acknowledge Dr. Scanlan's incredible courage and integrity in addressing the current 800-pound gorilla in the room of the opioid addiction treatment community.

It is way past time that we question the magical thinking that permeates the opioid replacement therapy (ORT) community, particularly regarding buprenorphine-based agents such as the buprenorphine-naloxone combination Suboxone. The fuzzy-headed, euphemistic language that is used by many of the ORT advocates, such as “medication-assisted recovery,” is particularly concerning when applied to long-term maintenance therapy.

What needs to be clarified is that buprenorphine is an extraordinarily potent opioid, albeit a partial agonist at the opioid mu receptor. The available buprenorphine-naloxone preparations have significant abuse liability and have a long history of diversion for illicit use. What is most concerning is that much of the pharmaceutical industry-sponsored research routinely exhibits bias in favor of a positive therapeutic effect of its products.

I want to be as clear as possible that I am in favor of opioid addicts receiving ORT in the privacy of their physicians' offices, provided that there has been a clear failure after detoxification and adequate abstinence-based inpatient treatment. I think we all agree on the chronic, progressive nature of chemical dependency, particularly opioid dependence. I am in favor of virtually all risk reduction strategies, including needle exchange and substitution therapies, where abstinence-based approaches have failed to effect a remission. What I believe is important is that we remember our history of pharmacologic optimism in the treatment of opioid dependence and the debris it has left behind.

Again, I'd like to thank Dr. Scanlan for having the ethical fortitude to address this controversial topic honestly.

Art Zwerling, DNP, CRNA, DAAPM

Elkins Park, Pa.

Addiction Professional 2011 March-April;9(2):7