Out to change attitudes about buprenorphine

The contradictions in the practice world that Jeffrey T. Junig, MD, PhD, inhabits offer a sharp reminder of the addiction community's divisions over medication treatments.

In his private medical practice in Wisconsin, Fond du Lac Psychiatry, Junig has remained right at the 100-patient federal limit for buprenorphine patients ever since the maximum was increased, and he says demand for the medication is so great that at any time he could easily maintain a 50-patient waiting list. Yet at the residential and outpatient addiction treatment facility where he serves as medical director, Nova Counseling Services in Oshkosh, buprenorphine treatment is not being used at all, and the center's counselors look warily at the medication.

“Our counselors do not like Suboxone,” says Junig. “They don't know anything about its good side.” While he says these professionals equate buprenorphine to a second long-term dependence for the opiate addict, they don't harbor a similar attitude toward a drug such as the anti-alcohol medication naltrexone, which he says they see as a safety device.

Believing a few years ago that buprenorphine would prove to be a “huge medication” in the field, Junig set out to educate others about this tool in the fight against opiate misuse. He originally wanted to target practitioners with his information, but ultimately decided to communicate with patients and their families directly. For the past three years he has produced a blog at https://www.suboxonetalkzone.com and has sponsored a discussion site at https://www.suboxforum.com; he comments on research and practice developments and reminds readers not to engage in “which is better” debates about treatment options.

His posts are frank, engaging and often humorous, and make no secret of Junig's firsthand experience with opiate addiction. He became addicted to codeine as a young physician in 1993, then relapsed after seven years of sobriety. He says that both times the 12 Steps helped saved his life, but he doesn't believe 12-Step treatment works for everyone and says some counselors can tend to sabotage life-saving efforts.

Junig says, “Sometimes the main topic the counselor wants to discuss with the patient is, ‘When are we going to get you off Suboxone?’”

Need for education

Junig believes education about buprenorphine and about opiate addiction in general is most critical at a time when more physicians are promising in contracts with health systems not to prescribe any opiates at all, because of concerns over abuse.

He makes sure to point out that his sites are in no way affiliated with the manufacturer of Suboxone and the other buprenorphine formulation, Subutex. He actually prefers citing “bupe” instead of the brand name as the keyword for his sites, but he also knows that on the street, individuals look under the name “Suboxone” in Internet searches.

Junig says he conducted a few educational sessions for Suboxone manufacturer Reckitt Benckiser in the past, mostly for non-physicians, but says he has found it difficult to establish a rapport with the company. A look at some of his online writings might offer a clue as to why. Junig hardly could be called “corporate” in the way he presents his topics.

In a recent post about drug testing to detect buprenorphine, he recalled an uncomfortable moment he experienced with an employer before his relapse. Every two years in his reappointment review he routinely would be asked if he had a chronic illness that affected his ability to care for patients.

“I knew what the question was getting at-but to my way of thinking, as a person who had been clean for several years and who was never planning on using again, the correct answer was clearly no, I had no illness that affected my care of patients,” Junig wrote. “But when I relapsed in the year 2000 the hospital made much of my answers to that question, reporting to the board that among my other (much more significant) transgressions, I lied on my reappointment packets. I was going to defend myself by saying it depends on what the meaning of ‘is’ is, but someone else used that excuse before I could use it!”

In a recent comment to counteract talk that addicts move to a second addiction when using buprenorphine, Junig wrote, “An addict who is properly treated with buprenorphine loses the obsession for opiates-something that is amazing to witness at the first follow-up appointment, when the addict sometimes cries over how wonderful it is to be freed from the obsession to use.” For those who still bemoan the need for long-term maintenance with the medication, he says the medication should be long-term, adding, “It beats death.”

In fact, Junig believes the field also should see 12-Step treatment or other non-medication options as long-term maintenance therapies as well, in that the conventional wisdom states that a recovering addict who stops attending meetings is likely heading to relapse.

What has Junig believing in long-term use of buprenorphine are the disappointing outcomes in general for opiate addicts in other forms of treatment, in terms of return to use. In his own practice, he often sees that the best option for the patient is to stay on buprenorphine indefinitely, and he asks in his forums for examples of individuals who were able to taper off long-term use of the drug and subsequently stay clean.

He states bluntly in a written description of his practice's protocol, “There may be some value in tapering a properly motivated patient off buprenorphine and seeing if the person can remain clean. It must be recognized, though, that a certain proportion of patients will die as a consequence of relapse during these efforts.”

He adds that because he finds it difficult to locate like-minded counselors who could work with him on a treatment team, he himself counsels patients as part of their buprenorphine management. One of the points he stresses to them is that the anxiety they often report is in many cases a manifestation of the cravings that can persist for long periods in opiate addicts.

Making progress

Junig says he has found in general that his patients in their 30s and 40s have done better with buprenorphine than younger patients have, although he believes that even for the younger group the medication can be useful until something else can take hold. He says none of the four patients in his practice who have died from an opiate overdose or a suicide were on Suboxone. “I wish I had put them all on Suboxone,” he now says.

His forum site received more than 52,000 page impressions in January, and about one-third of that number of impressions were registered at the blog site. He subsidizes his efforts through sales of relatively inexpensive education aids. A popular selection at present is the $9.99 recording “How Long Are You Going to Take That Stuff?”, which patients have described as a useful tool for opening communication with their loved ones. Junig hopes that little by little he is helping to change attitudes about what he considers a productive medication.

“There are people out there who really get angry about Suboxone,” he says. “Some call me a drug pusher.”