Tony Heins, MD, is a physician in New Hampshire with a medical practice that is devoted to the treatment of opioid addiction with Suboxone.

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Questions

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Evelyn Corsini, MSW:

What is Suboxone?

Tony Heins, MD: Suboxone is a drug that combines two medications, buprenorphine, an opioid which is a mixed agonist/antagonist at the mu receptor, and naloxone, a pure opioid blocker. It was approved by the FDA in 2002. Suboxone is most often used to safely suppress opioid withdrawal. For best results, all opioids need to be out of the patient’s system before starting Suboxone. The initial dose or doses are given in a monitored setting. Patients start with a low dose that is slowly increased if there are signs of withdrawal. Suboxone is a tablet that is taken under the tongue and can be used at home with proper medical supervision. Like methadone, it can be used for both a detox/taper strategy, or for long- term maintenance as a "harm reduction" drug to treat opioid addiction.

EC: What led you into the field of addiction medicine?

TH: I was trained in Internal Medicine and was in General Practice for ten years. Over time I realized that a significant number of my patients’ complaints (maybe even the majority) involved alcohol, drugs, or nicotine. I decided that I wanted to learn more about addiction. At the time there weren’t fellowship programs as there are now, so I got my training by working in the field: in detoxification centers; methadone programs; residential treatment facilities; and psychiatric hospitals. Over the years, I’ve participated in research and have kept up with the field by talking with colleagues, attending professional meetings, studying for certification/recertification exams, and on-line CME websites.

In 2003, as the medical director for an addiction treatment program, we started Suboxone with a small number of patients who were on a maintenance plan. I set up my own practice in 2004.

EC: Does a physician require special training or licensing in order to prescribe Suboxone?

TH: The use of Suboxone is regulated by the Drug Addiction Treatment Act of 2000 (DATA 2000). This made it possible for qualified physicians to obtain a DEA license waiver allowing them to prescribe and/or dispense approved Schedule III-V medications for the treatment of opioid dependence outside of a hospital or opioid treatment program. To become qualified, if you are not "grandfathered" in by being certified by the American Board of Addiction Medicine or a similar body, a physician needs to complete an 8-hour CME course. You must then meet the DEA, state medical boards, and federal Center for Substance Abuse Treatment (CSAT) regulations, to receive the waiver that adds an ‘X’ to your DEA number. This allows a physician to prescribe Suboxone for addiction treatment. Any physician with a DEA number can prescribe Suboxone off-label to treat chronic pain.

EC: What percent of your patients have a chronic pain condition?

TH: I estimate that 30-40% of my patients have chronic long-standing pain conditions. Some patients, those whose pain has been made worse with long-standing opioid treatment by phenomena such as opioid induced hyperalgesia or allodynia, will significantly improve. For other pain conditions whose physical symptoms might be psychologically intertwined, like the somatoform disorders or fibromyalgia, Suboxone may work well and increase a patient’s functioning.

EC: Is Suboxone your patients’ only therapy?

TH: No. There are multiple components to the treatment program and Suboxone is just one part of it. Patients have to be willing to work with a cognitive behavioral therapist, or with another therapeutic modality, and be engaged in "sober social support", like AA/NA, and stay up with other health preserving behaviors. If they have co-occurring medical or psychiatric considerations, we work with their other health care providers.

EC: Please describe your "ideal patient" - the person you think will benefit most from your program.

TH: I do a very thorough evaluation when I assess a new patient, looking at multiple facets of their life, and only accept the patients who I consider most likely to benefit from the treatment. Suboxone treatment is most effective with the highest functioning “tip of the addiction iceberg.” These are patients with education, skills, sober friends, and not overwhelming life stressors. A large number of these patients will be able to work full time and lead very productive lives with proper treatment.

Patients who relapse while on Suboxone, or who drop out of treatment, may need the additional structure of an outpatient methadone program, an intensive outpatient program, a partial hospitalization program, or even residential treatment.

With Suboxone, patients do not develop tolerance. This is a significant, positive feature, as with stable doses it can be used for long-term maintenance. There are some side effects, as with other opioids, but euphoria is significantly reduced, respiratory depression is much less prominent, constipation still occurs but more often is normalized, and while sexual dysfunction, including hypotestosteronism happens occasionally, many patients report a return to normalcy. Hepatic dysfunction can occur, especially in previously damaged livers, and liver functions should be monitored periodically. There have been reports of overdose deaths, however these have overwhelmingly occurred in poly-drug ingestion situations, especially when combined with benzodiazepines, and often in naïve users. Most obstetricians still recommend methadone for the pregnant addict, and while studies of its use are ongoing in this country, data from abroad suggests a comparable safety profile for methadone and Suboxone. Despite these issues, Suboxone treatment is remarkably safe, certainly safer than not being in treatment.

There is some risk of societal harm by Suboxone diversion, but Suboxone is not considered a “gateway” drug. It has a low street mark-up value - $10.00 per 8 mg/2mg tab versus $8.00 per tab at the pharmacy. The street value derives from its effectiveness in reducing symptoms of “dope-sickness” in regular users who find themselves temporarily without their drugs. Young people who are “experimenting” would be more likely to get sick rather than become euphoric from Suboxone, but this remains a consideration and underscores efforts to keep the pill burden on the street as low as possible.

EC: How do you get referrals and what are barriers to treatment?

TH: The demand for Suboxone treatment far exceeds the supply of practitioners in our area, so I am overwhelmed with referrals. I receive referrals from other physicians and word of mouth. Websites such as www.samhsa.gov, www.suboxone.com, and www.naabt.org, all have physician locator sections, so that a patient can find physicians who offer this treatment in their geographical area.

Health insurance usually does not cover treatment, especially if it’s not for detox. Usually health insurance will cover the cost of the medication and urine testing and other lab tests. However, in my experience, it’s very unusual for patients to find themselves paying more for maintaining their treatment, than they did for maintaining their habit.