stimulant treatment with suboxone patients

[eaglepsych]

Greetings forum,

I just started a new gig at a community health center (FQHC) and I have inherited a number of suboxone patients on stimulants for adhd (oftentimes patients who have started suboxone, remained clean/engaged with tx, and then dxd with adhd). many seem to be doing fairly well. obviously pill counts and UDS's are employed. would be great to hear from any of you who have experience with such patients. any thoughts? I struggle with the fact that a dx of adhd was made while a pt was on suboxone, but at the same time can see how an untreated adhd pt could well end up opiate dependent. any thoughts on navigating this complicated picture would be greatly appreciated.

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[notdeadyet]

Un- or undertreated ADHD can lead to abuse of all kinds of medications, including opiates. I don't think it's that uncommon to see folks with co-morbid ADHD and opiate dependency.

That said, the one's I've treated have had long standing ADHD diagnoses that preceded the opiate dependency. Are you dealing with patients that have been diagnosed with ADHD while opiate dependent? Were they diagnosed in the absence of evidence provided by third party (schools and the like)? I'd be less comfortable with the diagnosis in that picture.

If you're experiencing a rocky/recent ADHD diagnosis, I would likely continue the treatment plan if there is (as you've mentioned) nothing to indicate abuse. I would wait until they were stabilized on suboxone for a prolonged period of time and out of immediate crisis before making changes. When I did, if I was unable to get collateral supporting a diagnosis of ADHD in the absence of substance abuse, I'd likely very slowly taper them from their stimulants and do it with CBT support to see how they react and tinker accordingly.

Let us know how it works out....

 

[nitemagi]

The older teaching was that treating ADHD might prevent future drug abuse. Nowadays the data seems to be moving in the direction of neither hurts nor helps abuse of other drugs.

 

[eaglepsych]

Thanks NotDeadYet and NiteMagi. I appreciate your responses and respect your opinions from reading many of your posts over the years . Most of these pt's were diagnosed with ADHD after being started on suboxone (thus status-post severe substance use). if I were diagnosing them myself with adhd I would most definitely want collateral, etc. agree that persons on this regimen as of now that I will likely continue stimulant medication pending, most importantly, that the stimulant is making a solid significant improvement in the overall quality of one's life. I've only been working here for 2 months thus I'm interested to see how this evolves.

 

[vistaril]

Greetings forum,

I just started a new gig at a community health center (FQHC) and I have inherited a number of suboxone patients on stimulants for adhd (oftentimes patients who have started suboxone, remained clean/engaged with tx, and then dxd with adhd). many seem to be doing fairly well. obviously pill counts and UDS's are employed. would be great to hear from any of you who have experience with such patients. any thoughts? I struggle with the fact that a dx of adhd was made while a pt was on suboxone, but at the same time can see how an untreated adhd pt could well end up opiate dependent. any thoughts on navigating this complicated picture would be greatly appreciated.

I don't view it as an issue at all.

 

[vistaril]

Un- or undertreated ADHD can lead to abuse of all kinds of medications, including opiates. I don't think it's that uncommon to see folks with co-morbid ADHD and opiate dependency.

That said, the one's I've treated have had long standing ADHD diagnoses that preceded the opiate dependency. Are you dealing with patients that have been diagnosed with ADHD while opiate dependent? Were they diagnosed in the absence of evidence provided by third party (schools and the like)? I'd be less comfortable with the diagnosis in that picture.

If you're experiencing a rocky/recent ADHD diagnosis, I would likely continue the treatment plan if there is (as you've mentioned) nothing to indicate abuse. I would wait until they were stabilized on suboxone for a prolonged period of time and out of immediate crisis before making changes. When I did, if I was unable to get collateral supporting a diagnosis of ADHD in the absence of substance abuse, I'd likely very slowly taper them from their stimulants and do it with CBT support to see how they react and tinker accordingly.

Let us know how it works out....

schools? most of these people(Im guessing) are probably in their 30s and above.

 

[notdeadyet]

schools? most of these people(Im guessing) are probably in their 30s and above.

Exactly. Someone in their 30's or 40's with new onset ADHD in the setting of opiate dependence is something that should be viewed with a critical eye. If there is record that they have actually had academic struggles with evaluations indicating a high likelihood of ADHD back in the day and just never received treatment, it might make that a little easier to swallow.

 

[whopper]

Exactly. Someone in their 30's or 40's with new onset ADHD in the setting of opiate dependence is something that should be viewed with a critical eye. If there is record that they have actually had academic struggles with evaluations indicating a high likelihood of ADHD back in the day and just never received treatment, it might make that a little easier to swallow.

Lots of potential problems in treating the ADHD with a stimulant and not treating it.

Here's what I do.

1) Try a non-stimulant to treat the alleged ADHD. I say alleged because as most of you already know, everyone has symptoms of ADHD (well almost everyone, maybe not Sheldon Cooper) and some have fooled themselves into believing they have it.
2) If the non-stimulant doesn't work after an appropriate trial period (e.g. max dose of buproprion after 1 month), refer for psychological testing and specifically request a TOVA test. There is an EEG based method to diagnose ADHD now but it's only approved in children. Problem with that method is it was just approved and it hasn't proliferated the market yet.
3) If the TOVA test is (+), then I'd be open to giving the patient a stimulant but I emphasize that this only ups the stakes with their drug testing being clean because they are now on two controlled substances.

From my experience, a significant portion of people on Suboxone have ADHD and it isn't surprising when you think about it. What demographic is more likely to have a substance problem? People with ADHD? Correct.

 

[Shikima]

I'll throw a fly in the ointment for a moment, just for sakes of discussion.

But do we know they have ADHD? Being an opiate user increases the likelihood for behavioral mismanagement leading to poor circadian control and Central Sleep Apnea from chronic opiate use, thus placing an effect upon sleep. The effects of chronic sleep deprivation can mimic the symptoms for ADHD, and much like children, wake-up when given a stimulant.

 

[vistaril]

Lots of potential problems in treating the ADHD with a stimulant and not treating it.

Here's what I do.

1) Try a non-stimulant to treat the alleged ADHD. I say alleged because as most of you already know, everyone has symptoms of ADHD (well almost everyone, maybe not Sheldon Cooper) and some have fooled themselves into believing they have it.
2) If the non-stimulant doesn't work after an appropriate trial period (e.g. max dose of buproprion after 1 month), refer for psychological testing and specifically request a TOVA test. There is an EEG based method to diagnose ADHD now but it's only approved in children. Problem with that method is it was just approved and it hasn't proliferated the market yet.
3) If the TOVA test is (+), then I'd be open to giving the patient a stimulant but I emphasize that this only ups the stakes with their drug testing being clean because they are now on two controlled substances.

From my experience, a significant portion of people on Suboxone have ADHD and it isn't surprising when you think about it. What demographic is more likely to have a substance problem? People with ADHD? Correct.

The problem I have with #2 is that it is just too expensive.

 

[whopper]

The problem I have with #2 is that it is just too expensive.

I've noticed the price of the test highly varies in the area with one guy charging $50 but then requiring at least 3 sessions of psychotherapy treatment to hundreds of dollars. Thankfully a psychologist in my department can do them so as long as we accept the insurance it usually only comes to about $50 tops for a patient if not much less.

 

[heyjack70]

I'm thinking of setting up a suboxone clinic

Lots of potential problems in treating the ADHD with a stimulant and not treating it.

Here's what I do.

1) Try a non-stimulant to treat the alleged ADHD. I say alleged because as most of you already know, everyone has symptoms of ADHD (well almost everyone, maybe not Sheldon Cooper) and some have fooled themselves into believing they have it.
2) If the non-stimulant doesn't work after an appropriate trial period (e.g. max dose of buproprion after 1 month), refer for psychological testing and specifically request a TOVA test. There is an EEG based method to diagnose ADHD now but it's only approved in children. Problem with that method is it was just approved and it hasn't proliferated the market yet.
3) If the TOVA test is (+), then I'd be open to giving the patient a stimulant but I emphasize that this only ups the stakes with their drug testing being clean because they are now on two controlled substances.

From my experience, a significant portion of people on Suboxone have ADHD and it isn't surprising when you think about it. What demographic is more likely to have a substance problem? People with ADHD? Correct.

could you clarify the problems with 'not treating it?'

 

[whopper]

I'm thinking of setting up a suboxone clinic


could you clarify the problems with 'not treating it?'

Some data suggests that not treating ADHD makes it harder for such patients to stay clean. Don't treat the ADHD, you're not helping the patient achieve their goal of being drug-free (illicit drugs that is).

One thing I've noticed several doctors do is only provide the Suboxone, as if they have no other treatment responsibility. I don't agree with that. If you treat a patient, you have a doctor-patient relationship established. There's nothing I'm aware of that somehow allows a doctor that prescribes Suboxone to somehow ignore the patient's medical needs.

Granted, we have patients with mulitple problems and we tend to refer the patient to other providers when their problem is not within our own field. Well guesss what? ADHD is under the umbrella of psychiatry. Hard to argue that you treat them with Suboxone but referred them to a different psychiatrist when you already are treating. I see Suboxone providing doctors all the time tell the patient their only job is to provide Suboxone. Nope. I don't see anything that allows for this type of practice and still be ethical (excpt below).

(I have referred patients to other psychiatrists that required more than once a month treatment, e.g. a Suboxone patient that is manic but not hospital-worthy on the argument that while I can treat them, because we don't accept their insurance, I don't want to run up their bill and they should see someone in addition or instead of me if they're going to need to be seen more than monthly).

But, I don't see any repercussions happen to the above doctors, just like I rarely see anything happen to the ones that are defacto drug-dealers and give patients all the Xanax they want.

 

[eaglepsych]

thank you all for your feedback. another question - how many of you have seen a significant number of patients significantly benefit from stimulant treatment while on suboxone?

and then there is this (what I believe to be) real possibility that 20 years from now vyvanse or the like may be used to try and reign in cocaine dependent patients much like flooding communities with suboxone helps to control sequelae of opiate addiction:

http://www.cbsnews.com/8301-204_162-57591202/cocaine-addiction-may-be-cured-by-Ritalin

 

[Sneezing]

Some data suggests that not treating ADHD makes it harder for such patients to stay clean. Don't treat the ADHD, you're not helping the patient achieve their goal of being drug-free (illicit drugs that is).

One thing I've noticed several doctors do is only provide the Suboxone, as if they have no other treatment responsibility. I don't agree with that. If you treat a patient, you have a doctor-patient relationship established. There's nothing I'm aware of that somehow allows a doctor that prescribes Suboxone to somehow ignore the patient's medical needs.

Granted, we have patients with mulitple problems and we tend to refer the patient to other providers when their problem is not within our own field. Well guesss what? ADHD is under the umbrella of psychiatry. Hard to argue that you treat them with Suboxone but referred them to a different psychiatrist when you already are treating. I see Suboxone providing doctors all the time tell the patient their only job is to provide Suboxone. Nope. I don't see anything that allows for this type of practice and still be ethical (excpt below).

(I have referred patients to other psychiatrists that required more than once a month treatment, e.g. a Suboxone patient that is manic but not hospital-worthy on the argument that while I can treat them, because we don't accept their insurance, I don't want to run up their bill and they should see someone in addition or instead of me if they're going to need to be seen more than monthly).

But, I don't see any repercussions happen to the above doctors, just like I rarely see anything happen to the ones that are defacto drug-dealers and give patients all the Xanax they want.

I strongly disagree with your views.

Suboxone treatment agreements should require the cessation and tapering off all addictive substances. Opioid dependence untreated carries risk of an overdose death. I believe sound practice is stopping addictive substances in patients with addictive disorders - this means stimulants, benzos, and GABA sleep agents (ambien/lunesta/sonata).

It is perfectly ethical to have a suboxone only practice (or separate practice). A physician may limit their practice or expand it how they choose, and as long as patients are aware upfront of the practice parameters of a physician its ethical. Noting other conditions, as any physician would do, requires referral.

 

[Armadillos]

Suboxone treatment agreements should require the cessation and tapering off all addictive substances.

Will you prescribe suboxone to a smoker? Seems strange that so many psychiatrists are perfectly willing to essentially completely overlook smoking, but will freak out if someone's PCP prescribes a patient a stimulant for a legitimate, longstanding ADHD diagnosis.

 

[billypilgrim37]

Will you prescribe suboxone to a smoker? Seems strange that so many psychiatrists are perfectly willing to essentially completely overlook smoking, but will freak out if someone's PCP prescribes a patient a stimulant for a legitimate, longstanding ADHD diagnosis.

where did the thumbs up thing go?

 

[notdeadyet]

Will you prescribe suboxone to a smoker? Seems strange that so many psychiatrists are perfectly willing to essentially completely overlook smoking, but will freak out if someone's PCP prescribes a patient a stimulant for a legitimate, longstanding ADHD diagnosis.

Or alcoholics. Can they receive suboxone? And what about caffeine?

I definitely disagree with the idea that someone needs to be off of any addictive substance to be treated on suboxone. I do think it's appropriate to do due diligence to ensure that someone is legitimately prescribed their medication. But I don't think this is a a suboxone prescriber thing, I think it's just good psychiatry. I make sure that my adderall patients were prescribed it appropriately, but I do the same for my patients with long standing prescriptions for benzodiazepines, zolpidem, and pretty much anything they are prescribed. It's just good medicine.

 

[whopper]

Suboxone treatment agreements should require the cessation and tapering off all addictive substances. Opioid dependence untreated carries risk of an overdose death. I believe sound practice is stopping addictive substances in patients with addictive disorders - this means stimulants, benzos, and GABA sleep agents (ambien/lunesta/sonata).

As was mentioned, there is real and hard data showing some medications can help patients get off of illicit substances that are potential substances of abuse. ADHD left untreated could make problems worse.
Heck, Suboxone is an opioid. You want them off of all addictive substances, if your comments are taken literally, take them off the Suboxone.

That said, where is the exact hard-line differs among clinicians, and I'll completely admit has changed compared to the first year I was prescribing this medication. The evidenced-based medicine only teaches us so much. We're going to get cases that don't cleanly fit in the studies. My own opinions on how to administer treatment have changed over the years I've prescribed this medication.

If a clinican had a completely hardline with no other substances no matter what, I wouldn't think they were doing bad practice. I'd disagree, but it'd be a respectful disagreement. Some patient IMHO respond better to doctors putting the rules out in such a manner.

Personally, I allow for stimulants if taken legally, with psychological testing backing they have ADHD with a trial of a nonstimulant first.

As for the Suboxone-only treatment, refer out for everything else, this is something that has never been legally challenged, but it defeats the purpose of being a physician. If you believe treatment should only be one-disorder specific (edit: with only one specific medication given, nothing else), you could have technicians with a few weeks of training give out Suboxone. Methadone clinics IMHO are an exception because they are designed to not have doctors see the patients daily, and yes, they have techs or nurses dispense the medication.

The argument of "we warned you ahead of time that I'm not really treating you as a patient, I'm treating the disorder, so it's alright." Again, never been challenged formally specifically with Suboxone, but I don't agree with that, and I can tell you this. Legally, if you have a doctor patient relationship, well guess what?
You got a doctor patient relationship. You have a fiduciary responsiblity to the patient.

Similar issues have been debated within the APA and AAPL in regards to what constitutes a doctor patient relationship (cause forensic psychiatrists, doing an evaluation for the court is not considered creating a doctor/patient relationship). I'd bet 100% of any doctors on an ethics panel would consider Suboxone treatment as creating a D-P relationship. Cutting yourself off doing what a doctor is supposed to do for a patient, if you specialize in the area where they need help, sounds unethical to me, and is not compatible with a D-P relationship.

Suboxone patients I've had with non-opioid psychiatric problems, I have treated, and offered they go to another doctor only if they needed to be seen more than monthly and we didn't accept their insurance because I wanted them to save money. If they wanted me to treat it all by myself, I would have.

 

[michaelrack]

Will you prescribe suboxone to a smoker? Seems strange that so many psychiatrists are perfectly willing to essentially completely overlook smoking, but will freak out if someone's PCP prescribes a patient a stimulant for a legitimate, longstanding ADHD diagnosis.

Psychiatrists are willing to overlook smoking (and caffeine) because the Feds (DEA) and state medical boards are willing to overlook these. Nobody is going to try and take away your medical license for giving suboxone to a smoker. On the other hand, if a psychiatrist is giving both suboxone and ritalin to a 18 year old female (or male), that woman's parents might report the psychiatrist to the state medical board if they happen to disagree with giving ritalin to a "drug addict", no matter how well ADHD is documented.

 

[notdeadyet]

As was mentioned....

Not sure how it happened, but the quote you were replying to came from Sneezing. The quote (and thinking) was somehow misattributed to me.

 

[whopper]

The argument of "we warned you ahead of time that I'm not really treating you as a patient, I'm treating the disorder, so it's alright."

I need to apologize for writing the above. Despite that it foments what I was thinking, these were not the words used in the discussion and it's an injustice to even infer that's what the author wrote. I still stick to my opinion.
The doctor/patient relationship is too complex to limit it to only giving one specific medication despite the dynamics of what can happen over a duration that could last years and the volumes of evidence showing several possible comorbidities.

 

[michaelrack]

As was mentioned, there is real and hard data showing some medications can help patients get off of illicit substances that are potential substances of abuse. ADHD left untreated could

The argument of "we warned you ahead of time that I'm not really treating you as a patient, I'm treating the disorder, so it's alright." Again, never been challenged formally specifically with Suboxone, but I don't agree with that, and I can tell you this. Legally, if you have a doctor patient relationship, well guess what?
You got a doctor patient relationship. You have a fiduciary responsiblity to the patient.

Similar issues have been debated within the APA and AAPL in regards to what constitutes a doctor patient relationship (cause forensic psychiatrists, doing an evaluation for the court is not considered creating a doctor/patient relationship). I'd bet 100% of any doctors on an ethics panel would consider Suboxone treatment as creating a D-P relationship. Cutting yourself off doing what a doctor is supposed to do for a patient, if you specialize in the area where they need help, sounds unethical to me, and is not compatible with a D-P relationship.

Suboxone patients I've had with non-opioid psychiatric problems, I have treated, and offered they go to another doctor only if they needed to be seen more than monthly and we didn't accept their insurance because I wanted them to save money. If they wanted me to treat it all by myself, I would have.

I agree that it is ridiculous to limit one's practice to one medication. I also agree that suboxone treatment creates a doctor-patient relationship. I disagree that there is some type of legal requirement that a doctor needs to treat a patient's problems within his specialty area. In today's era of hyper-specialization, it is hard to even define legally define the concept. For example, would a cardiac electrophysiologist (who practiced alone) be legally obligated to treat his patient's stable angina?? Or would it be ok if he referred that patient to a general cardiology clinic? I think it would be legally ok for an addiction psychiatrist to refer a patient to a general psychiatrist for evaluation/treatment of adhd (though he should give the general psychiatrist some type of opinion on the use of addictive meds in that particular patient).

 

[SuperSoccer19]

Completely anecdotal, but I found in several ADHD patients who smoke or drink that Adderall has actually helped with cessation. On a few occasions when I started an adult on a stimulant, he/she also reported that their cigarette cravings decreased. I avoid starting stimulants in patients who admit to heavy drinking (or other substance use or even history thereof but my population tends to be a little cleaner), but a few after the fact came out and admitted they had cut back here too. Makes some sense from a pathophysiological perspective--both related to dopamine theories and perhaps better impulse control/perfrontal function. I don't think anyone has done a study on Adderall use's effect on opiate dependence (or even smoking cessation) and the ethics might be very questionable, but based on mechanism of action, perhaps there would be an interesting finding in such a study...or the patient would merely sell the Adderall to buy more heroin.

It seems like a lot of the "suboxone only" clinics I've seen are more out to make money then truely treat the patients. I guess this is the right of the physician to chose to practice this way, but it seems that ethically and to prevent provider splitting that if these locations are run by a qualified psychiatrist or medical provider that treating the whole patient would be more optimal. Then again, I've also written for medications completely not related to psychiatry when I know the patient is not going to see his PCM for his BP medication or Lipitor refill and believe the benefits of my prescribing these outweigh the risks.

 

[vistaril]

I've noticed the price of the test highly varies in the area with one guy charging $50 but then requiring at least 3 sessions of psychotherapy treatment to hundreds of dollars. Thankfully a psychologist in my department can do them so as long as we accept the insurance it usually only comes to about $50 tops for a patient if not much less.

well true, but I'm also concerned about overall costs/costs to the system. My medicaid patients don't have to pay anymore for Latuda than Risperdal(I don't think at least?), but I still think about the overall cost to the system and just how much bang for the buck am I getting there. I'm not saying I would never order testing in such a scenario, but cost is still a factor(even if the pt isnt paying it)

 

[Angel414]

Some data suggests that not treating ADHD makes it harder for such patients to stay clean. Don't treat the ADHD, you're not helping the patient achieve their goal of being drug-free (illicit drugs that is).

One thing I've noticed several doctors do is only provide the Suboxone, as if they have no other treatment responsibility. I don't agree with that. If you treat a patient, you have a doctor-patient relationship established. There's nothing I'm aware of that somehow allows a doctor that prescribes Suboxone to somehow ignore the patient's medical needs.

Granted, we have patients with mulitple problems and we tend to refer the patient to other providers when their problem is not within our own field. Well guesss what? ADHD is under the umbrella of psychiatry. Hard to argue that you treat them with Suboxone but referred them to a different psychiatrist when you already are treating. I see Suboxone providing doctors all the time tell the patient their only job is to provide Suboxone. Nope. I don't see anything that allows for this type of practice and still be ethical (excpt below).

(I have referred patients to other psychiatrists that required more than once a month treatment, e.g. a Suboxone patient that is manic but not hospital-worthy on the argument that while I can treat them, because we don't accept their insurance, I don't want to run up their bill and they should see someone in addition or instead of me if they're going to need to be seen more than monthly).

But, I don't see any repercussions happen to the above doctors, just like I rarely see anything happen to the ones that are defacto drug-dealers and give patients all the Xanax they want.

Thank you SOO much for your post! I was prescribed Clonazepam, Ritalin while on Suboxone maintenance for a good 5 years..Never had 1 problem. Believe it or not, my Dr. picked up without notice to any of his patients and began practicing in CA!! (Orig. from MASS). It has now been about 3 years and I still cannot find a provider who will treat my ADD because of the Suboxone!! I'm going crazy dealing with this disorder without medication. I commend you for your belief. If at all possible, would you or anyone who reads this, be able to assist me with finding a Dr. in the Boston area who would be willing to treat me! I am in desperate need of help. I've called almost all the Therapists on "Psychology Today"..100's..All turned me away! Please continue writing. Someone please help!

 

[whopper]

I was considering perhaps writing an article on the rising phenomenon of doctors that treat only with Suboxone and leave the patient's other problems to the four winds. This is happening quite a bit.

 

[Information Underload]

The older teaching was that treating ADHD might prevent future drug abuse. Nowadays the data seems to be moving in the direction of neither hurts nor helps abuse of other drugs.

Do you have data to support this? See below:

There have been some more equivocal studies, and one showing a deleterious effect:

I happen to prefer Strattera for treatment of ADHD in substance usage if it will work. Not because it's a non-stimulant but because its duration of action is 24-hours long. The problem I see with stimulants is that they wear off, leaving the individual relatively uncovered for a period of time. Often at a time when substance-using individuals tend to relapse--in the evenings. That said, Strattera is not nearly as effective per the data or per clinical experience.

 

[Doctor Bagel]

I was considering perhaps writing an article on the rising phenomenon of doctors that treat only with Suboxone and leave the patient's other problems to the four winds. This is happening quite a bit.

Considering how few suboxone providers are actually psychiatrists, I guess it's not surprising. It's quite easy to get a suboxone waiver.

I guess I'm still not wild about stimulants with suboxone patients, although I can see where it wouldn't necessarily be a 100% no. The poster above getting clonazepam + stimulants + suboxone is pretty concerning imo. I'm not surprised other doctors aren't picking that up.

 

[nitemagi]

Do you have data to support this? See below:

I happen to prefer Strattera for treatment of ADHD in substance usage if it will work. Not because it's a non-stimulant but because its duration of action is 24-hours long. The problem I see with stimulants is that they wear off, leaving the individual relatively uncovered for a period of time. Often at a time when substance-using individuals tend to relapse--in the evenings. That said, Strattera is not nearly as effective per the data or per clinical experience.

Personally I take any research by the Biederman group with a grain of salt.

http://www.ncbi.nlm.nih.gov/pubmed/24090624
http://www.ncbi.nlm.nih.gov/pubmed/24526271
http://www.ncbi.nlm.nih.gov/pubmed/24411652 (no assoc btw early tx and less SUD)
http://www.ncbi.nlm.nih.gov/pubmed/24104557
http://www.ncbi.nlm.nih.gov/pubmed/23754458 (meta-analysis in JAMA psych of 32 years of studies showing no benefit of stim use to prevent SUD)

 

[Addmom]

I realize that the conversation on this topic is years old. But as I read all the comments posted, I felt the need to share my experience dealing with this. I have dealt with ADHD for 23 years. I have gone unmediated with this disease for over 10 years. As a result, I ended up with a sever opioid dependency as a means of self medicating. For the last 7 years, I have been in and out of suboxone treatment, and this is what I have found--a patient receiving treatment for addiction has a very hard time finding a dr that will treat underlying mental health issues associated with their addiction regardless if the patient has substantiated medical history, and even if it poses a threat to their sobriety and compliance in the dr's drug treatment plan. The few doctors I have dealt with have even refused to refer their patients out for mental health while they are being treated with suboxone. To me, this seems unethical. If you have a patient/dr relationship, wether it has been formed through drug treatment or not, and that dr has been made aware of their patients medical needs, then they should feel compelled to either help treat that patient or refer them to someone who can. There is not a mold that every addict fits in. And it's ludicrous to force a patient to choose what disease they can be treated for at one given time.

 

[Shikima]

Public health dept just needs to have a fishbowl with benzos, stims and opiates for people to swing by and grab a handful whenever they need something.

 

[Jules A]

Public health dept just needs to have a fishbowl with benzos, stims and opiates for people to swing by and grab a handful whenever they need something.

Yup because _________(fill in the blank) is the ONLY thing that works for my ________(fill in the blank).

 

[WingedOx]

Public health dept just needs to have a fishbowl with benzos, stims and opiates for people to swing by and grab a handful whenever they need something.

It'd make my life easier and I'd get cursed out less.

I've had a run of patients this winter who are college students in their late 20s asking for a stimulant and a new dx of ADHD but who are only getting 4 hours of sleep per night.

 

[Shikima]

I had one mother cuss my nursing asst out because she sent her son up to the clinic to get a script for adderall. Afterall, she's a nurse and she knows what she's talking about.

 

[HarryMTieboutMD]

Ugh, a patient revives a 3 year old thread and spews a self-aggrandizing diatribe and gets some responses (validation) Of course now I'm part of the problem for responding as well!

 

[smalltownpsych]

I know how popular it is to run down Freud these days, but just because he called it the Id doesn't make the dynamic any different. For many people the limbic system is running the show and it just needs to be fed and the ego merely serves to get those needs met. Of course since he was using cocaine to treat his own depression he was feeling that first hand. For myself, I like to think that there is a higher purpose than pulling the lever like a rat in a cage. The big lie is that treating addiction with addictive substances is a good thing. I get that it decreases mortality to have the government administer and regulate it, but is that really "better". In other words, I really wonder how much it mattters if the shackles are from the drug dealer in the back alley or the suboxone "clinic" paid for by medicaid down the street.

 

[SeniorWrangler]

Even if medication assisted treatment mean being in shackles to your suboxone provider, it's better to have a master who gets paid by your health insurance and provides a safe, reliable product than being at the mercy of drug dealers and having to steal and rob to pay them.

 

[clausewitz2]

Even if medication assisted treatment mean being in shackles to your suboxone provider, it's better to have a master who gets paid by your health insurance and provides a safe, reliable product than being at the mercy of drug dealers and having to steal and rob to pay them.

Yeah, I would sort of lean towards a legal regime that would allow Merck or Pfizer to be manufacturing heroin for precisely this reason. Probably yes, there would be people dependent on these substances than would be otherwise, but good gracious there would be so much less suffering for most people so dependent.

 

[Armadillos]

A big lie is that treating addiction with addictive substances is a good thing. I get that it decreases mortality to have the government administer and regulate it, but is that really "better". In other words, I really wonder how much it mattters if the shackles are from the drug dealer in the back alley or the suboxone "clinic" paid for by medicaid down the street.

Your wondering if its better to be dead than to take suboxone???

 

[smalltownpsych]

Your wondering if its better to be dead than to take suboxone???

Yes, I am being a bit hyperbolic, but I do take freedom and freedom from addiction very seriously. I have had several patients who have been on suboxone, one currently, and I have also worked with patients who are in complete abstinence. The difference I see in actual practice is pretty stark. I don't see very good results in the community when we are treating addiction with medications. I have seen the studies, but I just haven't seen the results in the real world. One reason the controlled studies might "work" is the artificial and likely temporary control of the addictive behavior. Of course, when we compare active addiction to controlled addiction we see decrease in negative effects, but the question is whether or not controlling addiction increases or decreases total sustained remissions. That is a tougher question to answer.

 

[Doctor Bagel]

Yes, I am being a bit hyperbolic, but I do take freedom and freedom from addiction very seriously. I have had several patients who have been on suboxone, one currently, and I have also worked with patients who are in complete abstinence. The difference I see in actual practice is pretty stark. I don't see very good results in the community when we are treating addiction with medications. I have seen the studies, but I just haven't seen the results in the real world. One reason the controlled studies might "work" is the artificial and likely temporary control of the addictive behavior. Of course, when we compare active addiction to controlled addiction we see decrease in negative effects, but the question is whether or not controlling addiction increases or decreases total sustained remissions. That is a tougher question to answer.

I am so ambivalent about suboxone. Enough so that I'm addiction certified but did not get my suboxone waiver until after I finished my training and don't use it. I had maybe (looking at it optimistically) one successful suboxone patient in my suboxone clinic in training. My numbers of total patients were too small to say much, but it was discouraging. On the other hand, I did treat people who seemed to do as well as they could on methadone maintenance although I think part of that was the structure of the maintenance program which is lacking in suboxone programs.

So yeah, suboxone has a role, but it's not this miracle treatment that's going to solve the opioid epidemic. Although maybe I should start cashing in on this waiver and open a suboxone clinic. Easy work if you don't pay attention ...

 

[Jules A]

Yes, I am being a bit hyperbolic, but I do take freedom and freedom from addiction very seriously. I have had several patients who have been on suboxone, one currently, and I have also worked with patients who are in complete abstinence. The difference I see in actual practice is pretty stark. I don't see very good results in the community when we are treating addiction with medications. I have seen the studies, but I just haven't seen the results in the real world. One reason the controlled studies might "work" is the artificial and likely temporary control of the addictive behavior. Of course, when we compare active addiction to controlled addiction we see decrease in negative effects, but the question is whether or not controlling addiction increases or decreases total sustained remissions. That is a tougher question to answer.

In my perfect world buprenorphine would be used short term for perhaps 6mos to a year while significant therapy, 12 step and life changes are initiated leaving methadone for what I personally believe is the very small percentage who will be unable to remain sober without MAT. My goal when prescribing is to improve function and anecdotally I do not see a marked improvement in function or abstinence from illicit substances in my patients on long term bup. I got the waiver but don't see myself doing much with it unless I get in with a drug court program or clinic that shares my philosophy.

 

[Armadillos]

In my perfect world buprenorphine would be used short term for perhaps 6mos to a year while significant therapy, 12 step and life changes are initiated leaving methadone for what I personally believe is the very small percentage who will be unable to remain sober without MAT.

Why would you prefer methadone in those patients?

And what evidence can you point to that it is only a "very small percentage unable to remain sober" without maintenance?[/QUOTE]

 

[Jules A]

Why would you prefer methadone in those patients?

And what evidence can you point to that it is only a "very small percentage unable to remain sober" without maintenance?

Didn't add "evidence" because as I clearly noted several times I was only sharing my personal views and anecdotal experience.