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Thursday, January 31, 2019

What is Suboxone and how does it work?

Suboxone, a combination medication containing buprenorphine and naloxone, is one of the main medications used for medication-assisted therapy (MAT) for opiate addiction. Use of MATs has been shown to lower the risk of fatal overdoses by approximately 50%. Suboxone works by tightly binding to the same receptors in the brain as other opiates, such as heroin, morphine, and oxycodone. By doing so, it blunts intoxication with these other drugs, it prevents cravings, and it allows many people to transition back from a life of addiction to a life of relative normalcy and safety.

A key goal of many advocates is to make access to Suboxone much more widely available, so that people who are addicted to opiates can readily access it. Good places to start are in the emergency department and in the primary care doctor’s office. More doctors need to become “waivered” to prescribe this medication, which requires some training and a special license. The vast majority of physicians, addiction experts, and advocates agree: Suboxone saves lives.
Common myths about using Suboxone to treat addiction

Unfortunately, within the addiction community and among the public at large, certain myths about Suboxone persist, and these myths add a further barrier to treatment for people suffering from opiate addiction.

Myth #1: You aren’t really in recovery if you’re on Suboxone.

Reality: While it depends on how you define “recovery,” the abstinence-based models that have dominated the past century of addiction care are generally giving way to a more modern conception of recovery that encompasses the use of medications such as Suboxone that regulate your brain chemistry. As addiction is increasingly viewed as a medical condition, Suboxone is viewed as a medication for a chronic condition, such as a person with diabetes needing to take insulin. To say that you aren’t really in recovery if you are on Suboxone is stigmatizing to people who take Suboxone, and it’s not the medical reality of effective addiction treatment.

Myth #2: People frequently abuse Suboxone.

Reality: Suboxone, like any opiate, can be abused. However, because it is only a “partial” agonist of the main opiate receptor (the “mu” receptor), it causes less euphoria than the other opiates such as heroin and oxycodone. In many cases, people may use Suboxone (or “abuse” it, if that is defined as using it illegally) to help themselves manage their withdrawal, or even to get themselves off of heroin.

Myth #3: It’s as easy to overdose on Suboxone as it is to overdose with other opiates.

Reality: It is extremely difficult to overdose on Suboxone alone. It is more difficult to overdose on Suboxone compared to other opiates, because Suboxone is only a partial opiate receptor agonist, so there is a built-in “ceiling” effect. This means there is a limit to how much the opioid receptors are able to be activated by Suboxone, so there isn’t as great a risk of slowed breathing compared with potent opiates such as heroin, oxycodone, or morphine. When people do overdose on Suboxone, it is almost always because they are mixing it with sedatives such as benzodiazepines, medicines that also slow breathing.

Myth #4: Suboxone isn’t treatment for addiction if you aren’t getting therapy along with it.

Reality: In a perfect world, addiction treatment would include MAT and therapy, support groups, housing assistance, and employment support. But that doesn’t mean that one component, in the absence of all of the others, doesn’t constitute valid treatment for addiction. About 10% of people with addiction are getting treatment, so while combination treatment is an admirable goal, it is unrealistic to expect that everyone with an addiction will receive all the aspects of treatment that they need, especially without access to regular healthcare, insurance, or both.

Myth #5: Suboxone should only be taken for a short period of time.

Reality: Expert practitioners have different theories on how long Suboxone treatment should last for, but there is no evidence to support the claim that Suboxone should be taken for a short period of time as opposed to being maintained on it for the long term, just as a person would manage their diabetes with insulin for the long term.

One of the main obstacles to getting lifesaving treatment for addiction is the stigma people face. Fortunately, our society’s perception is slowly starting to transform away from an outdated view of addiction as a moral failing, toward a more realistic, humane view of addiction as a complex disease that needs to be addressed with compassion, as well as modern medical care. Eliminating myths and misinformation about addiction, and supplanting them with up-to-date, evidence-based treatments, is a critical step in the evolution of addiction treatment.
Tonsillectomies are one of the most common surgeries performed on children — but the decision to do one should not be taken lightly.

In 1965, there were about a million tonsillectomies (with or without adenoidectomy, a surgery often done at the same time) performed on children younger than 15 years old. By 2006 that number had dropped by half, and by 2010 it had dropped by half again.

Why the drop? Well, complications are common. In fact, one in five children who have a tonsillectomy has a complication. The most common is breathing difficulty, which can affect one in 10. Bleeding affects one in 20, and can happen days after the surgery, after a child has gone home. While the complications are treatable and death is very rare, it’s clearly an operation that should only be done when truly necessary.

There are two main reasons to do a tonsillectomy, but neither is black and white. Each patient and each situation is different. It’s important to understand the gray area (there is a lot of it) in order to make the best decision.
The first reason for tonsillectomy: obstruction

Tonsils (and adenoids) can grow large enough to block the airway, making it difficult to breathe. This can be especially noticeable when a person is lying down, such as during sleep, when gravity brings the tonsils down onto the airway. This leads to a condition called obstructive sleep apnea (OSA), which can be serious and lead to health and behavioral problems in children.

Snoring during sleep isn’t enough to diagnose OSA. “Apnea” means that the person actually stops breathing — so what parents should listen for is not just snoring but pauses in breathing. It can sound like a choking noise followed by silence. Parents whose children suffer from this often find themselves getting up during the night to adjust their child’s position in bed.

Sometimes the story is so clear (smartphone videos from parents can be very helpful), and the tonsils so large, that the decision to do surgery is straightforward, and the surgery is very helpful. But often it’s not so clear, especially when the tonsils (or adenoids) aren’t that large. When it’s not clear, very often the doctor will order a sleep study, called a polysomnogram (PSG). During this study, the child is monitored during sleep to get a better sense of exactly what is happening.

These studies are very helpful, but they aren’t perfect. Not only are they a measure of just one night, which may or may not be typical, but they don’t always predict whether or not a child will have the health and behavioral problems we worry about, or whether they will get better after surgery. This can be especially true when a child is overweight, as being overweight can cause or worsen apnea, and the apnea may or may not get better with a tonsillectomy. Also, PSGs are expensive and not always widely available. That’s why doctors differ in how often they order PSGs and how they use the results.

There are other ways to manage OSA besides surgery, including continuous positive airway pressure (CPAP) machines and other devices, medications, and positioning. When it’s not clear that a tonsillectomy is needed, when parents prefer not to do it, or there are other reasons not to do it (like known bleeding problems or other medical problems that make surgery risky), these other measures can be tried.
Another reason for tonsillectomy: recurrent infection

Children who are severely affected by recurrent throat infections (more than seven episodes in one year, five in each of two years, or three in each of three years) may be helped by a tonsillectomy. However, just having a sore throat doesn’t count. To meet criteria, there needs to be fever, enlarged lymph nodes, pus on the tonsils, or a positive strep culture — and the child should have been seen and all the details confirmed and documented.

In cases where children are severely affected, tonsillectomy can reduce the number of infections — but when this has been studied, children who don’t get tonsillectomies have fewer infections over time too. That’s the thing: either way, children get better. “Tincture of time,” or just waiting it out, can work too.
Making a decision about tonsillectomy

So if you are thinking that your child might need a tonsillectomy, or if your doctor has suggested one, talk it over carefully with your doctor. Ask lots of questions. Spend some time understanding both the risks and benefits. It’s certainly true that for some children tonsillectomy makes a huge difference, especially those with obstruction — but for many others, just giving it some time, perhaps with some medication or other treatments, can do the trick too.
To screen or not to screen for prostate cancer? This remains an important question. Screening relies on a highly imperfect measure, the prostate-specific antigen (PSA) blood test, which is prone to false-positive results. And with mounting evidence that survival benefits from screening pale in comparison with the harms from overtreatment — particularly incontinence and impotence — the pendulum has steadily swung away from it. Still, screening research continues, in the hopes that some lifesaving benefits may be found.

Now the latest study once again casts doubt on PSA screening as an effective public health tool.

British scientists divided more than 400,000 men between the ages of 50 and 69 into two groups: one was screened for prostate cancer with a single PSA test, and the other wasn’t tested for the disease at all. After an average of 10 years of follow-up, prostate cancer death rates in both groups were nearly identical. Cancer was detected more often in the screened group, but mostly it was low-grade, with a questionable need of treatment.

“This was the largest study of PSA screening to date, and the results don’t support it,” said Dr. Michael J. Barry, a professor of medicine at Harvard Medical School, and author of an editorial accompanying the published study.

Called the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP), the study’s approach of giving men a single PSA test differs from the more traditional strategy of testing men repeatedly every few years. However, prior studies investigating repeated PSA tests have reached similar conclusions. One European study with 162,000 men, for instance, concluded that for every life saved by screening, 27 men would be diagnosed and treated for prostate cancer that wouldn’t have been lethal if left undetected.

During the CAP study, 189,386 men were assigned to screening and 219,439 men were assigned to a non-screening control group. After 10 years on average, 549 of the screened men had died from prostate cancer, compared to 647 men in the control group who hadn’t gotten a PSA test. The number of prostate cancer deaths among the controls was higher, but so was the number of men in that group to begin with. So the researchers adjusted for the different sample sizes with a statistical tweak: they compared death rates in terms of person-years, or the total number of years that men in either group had participated to the study. Analyzed that way, the study revealed 0.30 prostate cancer deaths per 1,000 person-years in the screened group, and 0.31 deaths from prostate cancer per 1,000 person-years in the controls, which amounts to a negligible difference.

Dr. Barry, who was recently a member of the US Preventative Services Task Force, an influential group of independent experts who publicly discourage PSA screening, emphasized that most men who opt for the test get it more than once. And with each additional PSA test, he said, the odds of being diagnosed with prostate cancer grow higher. “But is repeat screening worth the risk of a low-grade cancer diagnosis and all the treatment complications that come with it?” he asked. “It’s hard for us as clinicians to make those decisions for our patients. We need to make them with our patients to determine if they feel those risks are worth taking on.”

Dr. Marc Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor in chief of HarvardProstateKnowledge.org, agreed. “This study adds to the discouraging screening literature, and again, simply does not support screening of asymptomatic individuals,” he said.

Fortunately, Garnick added, men diagnosed with prostate cancer following a PSA test may not have to be treated either in the short or long term. Depending on tumor characteristics, some can opt to have their cancer monitored with active surveillance, which relies on periodic prostate biopsies or MRI to look for new signs that treatment may be necessary. “Hopefully, current research that uses sophisticated genetic testing or biomarkers of prostate cancer may help provide more precise information about those who are likely to most benefit from screening and treatment,” Garnick said. “But we are not there yet.”

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