Suboxone and Dr. Patrick Fay

Even the offer of a splendid dinner in one of Vancouver's finest restaurants, the Market, in the Shangri la Hotel, isn't likely to get me out for an evening of learning after a normal grueling 10 hour work day so common to Canadian physicians.  As an addiction psychiatrist having family physician, specialist, subspecialist and more subspecialist certification, and an even unhealthier proclivity for extensive self learning,  I am usually finding in my own practice that the rate limitting steps in health care management are the stupidity and hostility of overpaid, under educated,  beaurocratic thugs with position authority and purse strings.  My rich patients can get the health care they need here or overseas but increasingly those most in need are targetted alongside their care givers for chronic abuse.
That said, Dr. Patrick Fay of Orchard Treatment Centre is not only a leading authority in addiction medicine but one of the most respected clinicians I personally know. Having had the honour of treating patients who have known him I've had the privilege to hear of his empathy and compassion as a human from those patients  as well as see the genius in his medical management with patients who frankly were most unlikely to make it. Dr. Gary Horvath another leader in the treatment of opiate dependent patients encouraged me to come out if only to have the pleasure of bantering with my addiction medicine specialist colleagues,  Dr. David Tsung and Dr. Leszek Kalinowski.  In addition to these two racanteurs I was delighted to finally meet  Dr. (George) Djordges Kljacic, a most highly regarded clinician and the author of The Art and Wisdom of Healthy Living. http://www.amazon.ca/Art-Wisdom-Healthy-Living/dp/1467033138. Across the table I saw Allison, Olive and Sean, the administrative and counselling staff of Doc Side Medical Clinic,  also present.
Sarah Hardy, the representative of Reckitt Benckiser Pharmaceuticals was a surprise.  I thought she was a Vogue model and shocked to have her speak to me till my mind overrode my eyes and accepted that this must truly be one of those unfortunate women of brains whose beauty confuses the average male, not that I was such a human.  She welcomed me and immediately began talking science, mu receptors, k receptors and partial agonists till my mind  was spinning. When the waitress offered me a glass of wine I gladly took a cup of coffee instead.


Dr. Patrick Fay's presentation on Suboxone was excellent, not just for the more academic overview of addiction and the place of buprenorphine in the treatment of opioid dependent patients but also for his extensive clinical experience.  Buprenorphone is the active opiate ingredient in Suboxone. Compared with the full agonist methadone which is also used for the treatment of opioid dependent patients, buprenophone is a partial agonist so has 'ceiling effect',  a decided limit to it's potential for abuse.  The genius of Suboxone is that it is coupled in a 4:1 ratio with Naloxone, the opioid antagonist.  Suboxone is taken sublingually which allows buprenorphine to be released without naloxone. However if it is injected the naloxone counteracts the effects, making the medication even safer from being abused IV.
Dr. Patrick Fay had excellent slides showing the 'disease' of addictiton. He distinguished addiction by the classic 3 'c's, loss of control, continuance despite negative consequence, and a compulsion to persist despite this. He briefly discussed the  MRI studies showing impairment in glucose utilization in the frontal lobes, associated with higher reasoning, and delaying gratification,  as well as discussing the impairment of the nuclear accumbens, the emotional reward centre of the brain. (http://en.wikipedia.org/wiki/Nucleus_accumbens).
Where he shone though was in detailing carefully for us clinicians how he himself began patients on suboxone.  He described the use of the COWS, Clinical Opiate Withdrawal Scale (www.naabt.org/documents/cows_induction_flow_sheet.pdf.,
Then he went on to say that though the guidelines suggest a number of 10 before starting he himself tended to prefer a number of 12. He began by giving the patient 2 mg then tended to give 8 or even more mg through that first day. He saw the patient usually three times  that first day and told the patients they needed to have that day off and a friend available to be with them.  He admitted that headache was a side effect that he'd seen but in the large numbers of patients he'd treated he'd only had one  stop because of persisting headache. He'd also had to stop one patient from going onto buprenorphine maintenance because they developed a variety of odd pains. Withdrawal syndrome was the principal concern because buprenorphine has such strong affinity to the mu opioid receptor that it displaces other opiates. When transfering a methadone maintenance patient to suboxone he reduces the methadone to roughly 30 mg a day before making the switch.
He had used suboxone extensively in young people 18 to 25 and preferred to include the parents in the care if the patients were living at home.  He found that this family approach to addiction therapy resulted in even better results. While some of his patients have been switched in the detox and treatment facilities he has at the Orchard Treatment Centre on Bowen Island the majority of his patients have been started on suboxone in the community. He himself has a clinic where he does just this on Commercial Avenue in Vancouver.  As well as young people he found those who appeared to most benefit from suboxone were those who were snorting opioids, those using opioids such as morphine or oxycontins as opposed to heroin, and those whose methadone usage was under 100 mg a day. He said that there was a belief in the community that it was easier to get off buprenorphine but that he himself had found that it was still difficult for patients to stop that last 2 mg a day.  Suboxone maintenance patients were commonly able to take their medications weekly and were seen monthly relieving them the need of daily visits to a pharmacy for witnessed injestion.  He used suboxone for detox and for maintenance of patients with very good patient report and success long term.
Overall he found that he had the best results with patients who recognised that  addiction was more than just the drug abuse but that it affected, sometimes prominently while other times subtly, their thinking and relationships as well. Addiction specialist, Rabbi Dr. Twerski has written an superb book, called "Addictive Thinking",  detailing this essentially neurological disease process.   Follow up in groups such as AA, NA, Smart Recovery,  and Cognitive Behavioural Therapy  were all associated with better long term protection from relapse. He quoted Dr. Marc Gallanter's (http://en.wikipedia.org/wiki/Marc_Galanter_(psychiatrist) research on the efficacy of 12 step programs in long term recovery.
Dr. Fay concluded his presentation with his own complex case studies of patients who really were truly extraordinary for their successful long term recovery from what was clearly a life threatening illness with near death experiences.
Dr. Fay was very optimistic about suboxone and it's benefits but certainly didn't see it as a replacement for methadone. He was clear in the need to combine the right patient with the right treatment in what has traditionally been the most successful approach to all medical treatements to date. He was insistent that addiction patients be treated fairly and with the dignity that anyone suffering a chronic disease deserves.
His presentation was excellent and well worth the time.  To prescribe suboxone now in British Columbia the physician must already have been certified as a methadone prescribing doctor and in addition complete  online educational modules at www.suboxonecme.ca.  I did this when I worked in the United States and remember the process as reasonable and relatively straight forward. Sarah told me that it usually takes about 6 hours total.  There is now also public funding for suboxone for selected patients for whom methadone is contraindicated.
sarah.hardy@reckittbenckiser.com is a great resource.  Dr. Patrick Fay's presentation was well worth the effort, even after a long day.