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Old 12-24-2011, 09:38 AM
Ocean Ocean is offline
Join Date: Jun 2008
Location: US Northeast
Posts: 6,784
Default Re: Values Added: Refuted By Facts (Mark Kleiman & Harold Pollack)

Originally Posted by SkepticDoc View Post
Most of my patients were spending between $200-$1,000 a month on narcotics, many times, they were using narcotics just to prevent withdrawal sickness, the average maintenance dose of Suboxone is 12 mg, forty five doses retail cost around $7-$12 each dose, $315-$540 a month, add a routine office visit charge and the medical management is a cost effective and safe alternative. Methadone is a different story, I don't know the finances for that treatment.
Suboxone prescription has become a business, at least here in New Jersey. Physicians who prescribe it charge at least $100-$200 (cash, no insurance accepted) to hand a prescription on a monthly basis. Originally the idea of suboxone was, as far as I know, to taper people off opiates. "Maintenance" is a tricky idea. I personally think that maintenance should only mean slower taper.

I've seen young adults who have been using heroin for 6-12 months, and then go on suboxone and plan to stay on it indefinitely. Why? Their opiate addiction wasn't too established to justify long term use of suboxone. If there are psychological/ psychiatric factors contributing to the addiction, those should be addressed. But, there's no rationale for maintenance when someone has a very short exposure to opiates.

The use, abuse, and dependence on prescription narcotic pain killers and sedatives (benzodiazepines especially) is a major problem. These are actual examples of legal drug use and dependence. Accidental overdoses, and the deleterious effect on quality of life and the profile of side effects from long term use of these medications point at their dangerousness. And we have very little resources directed to preventing this problem or providing treatment. The standard substance abuse programs may not be appropriate for a lot of these patients who have never used any illicit drugs and don't connect well with heroin or cocaine users.

I've been seeing an increasing number of patients who have been maintained on benzodiazepines (Xanax!) by their PCPs for years. Now that there's growing awareness of the problems related to abuse and dependence, those PCPs are referring their patients to psychiatrists to figure out what to do. I've seen quite a number of women in their 80s, who have been taking Xanax for a couple of decades, they are experiencing break through anxiety, but now nothing else works. Xanax has increased their tolerance to other potential measures, both pharmacological or psychotherapeutic. As they get older the risks of cognitive decline, falls and fractures, disorientation, problems with sleep and rebound anxiety related to the use of benzodiazepines increases. At the same time the risks of withdrawal (autonomic instability, seizures, delirium tremens) increases. What to do? Those patients wouldn't be accepted in a regular detox unit due to age and medical problems. An outpatient taper more often than not doesn't work because the patient comes in already symptomatic (anxiety) and the taper will increase even if moderately those symptoms, so they can't tolerate the taper. Most of the time the only expeditious solution is to have them admitted to the hospital by their PCPs, and detoxed under medical supervision. But neither patients nor PCPs are very willing to do it. I usually inform them of their options, make my recommendations and send them back to their PCPs. There's nothing much that I can do as long as they continue taking those drugs.

It's sad and frustrating. One of the worst iatrogenic problems that we have these days.
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