I have recently witnessed a rash of individuals either on Suboxone (buprenorphine and naloxone) or methadone requesting phentermine for weight loss. After researching this issue with local law enforcement and drug task force officials, I have found that oftentimes the individuals seeking phentermine in addition to Suboxone or methadone are using the phentermine for enhancement or extension of the “high” associated with Suboxone or methadone. Drug addiction is strong in the rural counties where I work, and I feel that all providers need to be aware of the potential for misuse of these drugs in combination. The pain management clinics that I have spoken to are in agreement that the use of these drugs in combination can be harmful.—DIANE PERRY, FNP-BC, Hohenwald Tenn. (215-1)

Is Suboxone a bad drug? It is literally a lifesaver and light-years ahead of methadone in terms of safety and usefulness for narcotic addiction. Regarding chronic pain, a meta-analysis in the July 6 JAMA on narcotics for back pain clearly shows that narcotics have absolutely no proven benefits for either functional recovery or pain relief for back pain and should not be used beyond 1 week. Regarding patients who are on Suboxone for multiple years, yes, possibly they can be safely tapered down and off or onto naltrexone implants if they have worked hard on reducing their relapse risk and are continuing to actively work on their recovery. I am a board-certified addiction psychiatrist who has been working with these patients since Suboxone was invented. However, sometimes you have patients afraid to wean and practitioners who only took a weekend course to write Suboxone and are therefore very undertrained. No one gets high injecting Suboxone (Subutex, maybe). Never prescribe more than 16 mg per day (receptors saturated), and never prescribe refills or more than enough for a patient to get to his or her next appointment.—JOSEPH HAAS, MD, Clearwater, Fla. (215-2)

I work in an opiate treatment clinic where both methadone and Suboxone are used along with addiction counseling. I have seen people improve and get their lives back, get out of the revolving jail door, and get their families and self-worth back, as well as address other health problems (diabetes, hypertension, hepatitis C, skin problems, and dental problems). They are breaking familial patterns in which multiple generations use one or more drugs. I have also dealt with addicts coming into the emergency department without treatment. They suffer. They hurt. We have looked at all sorts of treatment options. Detoxification doesn’t work. Research shows that medication treatment with counseling is effective. What are we measuring as successful treatment? The reality may well be that we will never get those who become addicted to narcotics completely off medication. But, and it sounds trite, do we expect to get diabetics off their medication? We are not treating this and pain management appropriately because we are stuck on political correctness, and we’re afraid of the Drug Enforcement Administration (DEA). And we have too many providers who think they know how to manage pain. A lot of my clients got started because they were over-medicated with pain pills, and then the provider got scared and immediately stopped prescribing. Immediate withdrawal. We need to take a huge step back and look at this problem for what it is, not what it should or shouldn’t be. Then treat it for what it is.—DEBBIE DAVIS, FNP, Spokane, Wash. (215-3)

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Whose brilliant idea was it to limit the availability of pain-managing opiates? Besides my primary care practice, I have worked in a methadone clinic for the past 30 years. I have seen it go from encountering heroin addiction to prescription medication addiction. Now it’s back to heroin. Not only is it difficult for my primary care patients to get their prescription filled, it has caused them to drive all over trying to find a pharmacy to fill 120 Norco 10/325. These patients have chronic debilitating pain. Help us help these patients. Give us tools (nonopiates) that control pain. Until then, why are too many patients suffering? The use of Suboxone is limited. I’ve found that if patients use opiates for pain relief, Suboxone does not work. For opiate addiction, it can work well, except for the expense. It is a very good time to be a heroin dealer. Well done DEA! Educate yourself on addiction!—HEATHER PORTER, PA, Lancaster, Calif. (215-4)

Suboxone and methadone are 2 good medicines that are not used according to the purpose for which they should be prescribed. They are money-makers to nonphysician owners and few physicians. Methadone is political, and Suboxone is headed in the same direction. Both drugs are supposed to be used for detoxification, but as the money rolls the medicine rolls. Where is the rehabilitation? Public assistance rehabilitation typically involves groups of 15 who are corralled in a room with their addicted peers sleeping next to them, and the ones who are awake are listening to the same lectures that are more than 50 years old! In private rehabilitation, you can lower doses gradually and let the addicted person leave and eventually relapse several times without ever receiving rehabilitation. And this is not to mention the polysubstance abuse that eventually takes over after time. I assume that it is because of the other medications, prescribed by clinicians, that contribute to addiction and/or death in these patients. Well, if the political elite were to come to us who are on the front line, we can tell them what works when treating substance abuse. This is only the tip of the iceberg. I had to get it off my mind after 25 years of treating addiction and knowing the pros and cons. I have many successful cases, but too few because of the restriction on treatment regimens. Remember, there are other medicines that treat addiction and the lack of real rehabilitation.—RAYMOND SANCHEZ, PA, New York, N.Y. (215-5)

These are letters from practitioners around the country who want to share their clinical problems and successes, observations and pearls with their colleagues. We invite you to participate. If you have a clinical pearl, submit it here.