Angry Doctor

Saturday, December 10, 2005

Then Jacob gave Esau bread and pottage of lentils;

I’ve been wanting to blog about this issue for a while now; this news article gives me the excuse:


The drug Subutex, which is used to treat heroin addition, may be listed as a controlled substance.

The Health Ministry is discussing with the Health Sciences Authority and Central Narcotics Bureau to make it a criminal offence for anyone to possess the drug without a prescription.

Subutex is fast becoming a drug of choice among former heroin addicts as they regard it as a 'legal fix'.

The pills are often dissolved in water and mixed with sleeping tablets to create a potentially lethal injection.

Demand for the drug on the black market is high, with one pill costing up to $35.

The Health Ministry has conducted an audit on nine private clinics to see if they prescribe the drug too freely, and is currently reviewing the results.

Strict guidelines on the prescription of Subutex were released last month.

These include supervising patients to ensure they take the tablet properly by placing it under their tongue for the first month of treatment.

Doctors found guilty of prescribing the drugs too freely can be fined up to $10,000 and struck off the medical register.


The problem is not new, and the Ministry had recently issued guidelines on the prescription and use of Subutex.

You have to wonder: who first decided it would be a good idea to pound a tablet, dissolve it in water, and then inject it into his vein?

But the subtext here is this: doctors are prescribing Subutex to people who abuse the drug.

Don’t they know?

Can they really miss the bruised and hardened veins on the arms of the addicts? Or don't they check?

Doesn’t the drug company know that its product is being abused in a manner that harms its abusers?

Why was a drug that has potential for abuse approved for use to treat addiction?

And people ask me why I am angry...

… and he did eat and drink, and rose up, and went his way: thus Esau despised his birthright.

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  • The interesting thing is this.

    Subutex is prescribed to drug abusers. It's to help them kick the habit.

    Which means that there are over 22,000 "registered" drug abusers in Singapore!

    It looks like despite the death penalty, there is a pretty big drug problem in Singapore.

    And it looks like everybody knows that too.

    By Anonymous Anonymous, At December 10, 2005 9:18 am  

  • as a non-medical professional... i don't feel any anger like Angry Dr... but am v. curious what's go thru' the mind and heart of these drs prescribing these medication...

    on the other hand, these patients know what they are getting into anyway...

    By Anonymous Anonymous, At December 10, 2005 10:49 am  

  • Haha. Reminds me of this line from The Godfather:

    "In my city, we would keep the traffic in the dark people -- the colored. They're animals anyway, so let them lose their souls..."

    A willing victim is still a victim, and does not exempt us from 'first do no harm'.

    By Blogger angry doc, At December 10, 2005 11:00 am  

  • I don't buy the "I can't control the problem that patients sell the drug on the black market" excuse.

    It's an admission that one is aware that there is a problem.

    Subutex is meant to help drug abusers rehabilitate. Not to replace on drug problem with another. But clearly, looking at the way the drug works, it is replacing one problem with another.

    It's as good as saying, I'll help this person quit gambling blackjack, by gambling on Toto.

    What's the point?

    I think the drug companies are also at fault here.

    If I was a doctor who had been prescribing Subutex, I'd stop. I wouldn't be able to sleep at night knowing I'm raking in "drug money".

    In the end I think cold turkey may be the only way to end a drug addiction.

    By Blogger Dr Oz bloke, At December 10, 2005 11:14 am  

  • Hmm... I wonder if quiting-smokers get addicted to nicotine gum instead...

    Subutex is not really very lucrative, but I think is being sold because it is not illegal/controlled, unlike Dormicum/Erimin?

    Selling such drugs attract 'undesirables' to your clinic, who will hover around the area and even 'chope' your parking lot for you. :)

    By Blogger angry doc, At December 10, 2005 11:19 am  

  • why don't they do directly observed therapy with Subutex?
    (or do they already?)

    if they can do it for TB, why not Subutex?

    By Anonymous Anonymous, At December 10, 2005 11:45 am  

  • With regard to all these supposedly "rehab" drugs eg Nicotine gum, Antabuse, Subutex etc..

    How well do they work? Honestly I think the main determinant whether a patient will be successful in kicking his habit is his reasons for doing so and his determination and focus. It is not the drugs that do that.

    Most patients are all looking for magic cures though. Which is why you end up getting problem being replaced by another problem.

    By Anonymous Anonymous, At December 10, 2005 11:46 am  

  • They are trying to make DOT compulsory 'for the first month', but let's see how popular a clinic that implements that becomes. :)

    I must admit addiction is not my area of specialty, but yes, I think if a guy WANTS to smoke, he would just pick up a cigarette rather than nicotine gum.

    By Blogger angry doc, At December 10, 2005 11:54 am  

  • yes seeing so many of these cases in the hospitals... going to become a 'bread and butter' soon!

    regarding the guideline tt prescriptions of subutex got to be logged into a cross-reference system, yeah, good suggestion, but who's the one enforcing it? just the morals of the doctor prescribing the medicine? (not that they lack it, but then, haven't we read abt tax evasions and so on...)

    maybe subuxone would do better?

    nevertheless, i think this problem is here -to stay-. event with DOTS, even with cross-reference to prevent doctor-hopping, even with subuxone... these druggies will do almost anything to get their highs... -> smuggling's going to get more rampant...

    regarding the many comments i hear about these druggies 'knowing what they're doing is wrong but still persisting in it'... that's what drug dependence/addiction is! you just can't control the urges!

    By Anonymous Anonymous, At December 10, 2005 12:16 pm  

  • waaa... such a headache... and the 'best' part is... these patients are really really really good at deceit, rationalising, and appearing contrite, regretful when they get admitted.

    but once they're out, it's back to their old ways! argh!

    By Anonymous Anonymous, At December 10, 2005 12:20 pm  

  • Well then it is exactly what everyone knows. The problem is with the characters of the drug addicts themselves.

    Can medicines make these people into better people? I don't think so.

    Reminds me of what I was asked to do as an MO in SAF and sent "problem" men and asked to "do something about it".

    Is there a place for these "rehab" type "medicines" in the first place?

    It is interesting when you read on the history of these drugs. Heroin for example was used to help patients with morphine and codeine addictions. Morphine was used to treat alcohol addiction. SO it looks like my theory of replacing one problem with another is true.

    By Blogger Dr Oz bloke, At December 10, 2005 12:59 pm  

  • Like I said addiction is not my area, but just some thoughts:

    Nicotine replacement therapy has been shown to work. So far I haven't read of any problem with addiction to nicotine gum, although I have been tempted to get myself some to see how it tastes/feels like...

    Subutex abuse sounds worse than heroin abuse.

    Addiction may be genertically-related. Some people just don't get a high from alcohol/cigarettes/morphine.

    The habit can be kicked. People have kicked the habit. Some do it all by themselves, some need a little help.

    Whatever it is, somehwere along the line they decided to take the first step, and to stay on track.

    And then some try to profit from a fellow human being's sufferings...

    By Blogger angry doc, At December 10, 2005 2:10 pm  

  • interestingly, while i was doing my medicine internship, i came across a couple of subutex abusers.

    wait, that's not the interetsing part.

    the interesting part is that subutex was the first drug of abuse for a handful of them, ie. other than alcohol, they'd never ventured into the realm of addictive drugs before subutex.

    which would mean that druggies out there are savvy enough to know of this "legal" drug of abuse, and are somehow getitng their hands on subutex and peddling it out in society.

    By Anonymous Anonymous, At December 10, 2005 2:48 pm  

  • Now that makes Subutex EVIL.

    By Blogger angry doc, At December 10, 2005 2:51 pm  

  • Exactly why Suboxone (buprenorphine hydrochloride : naloxone = 4:1) should be used instead!

    Interestingly, this combination deters illicit intravenous preparation of the tablet, and will seriously (though only temporarily) debilitate a user if injected.

    By Anonymous Anonymous, At December 10, 2005 6:38 pm  

  • I would have preferred a KCl mix, but your combination works too... :)

    I don't think what SHOULD be done is really the question here.

    The questions are why is it not done and why has it not yet been done?

    If you look at the links I provided in the post, the problem was known more than 2 years ago.

    Why did it take so long before action is being taken?

    By Blogger angry doc, At December 10, 2005 6:48 pm  

  • From Sammys alfresco kopi tiam
    87651.3 in reply to 87651.2

    Hmm I was reading the article again.

    Dr Kwan sells Subutex at $21.40 per tablet. The cost to him is $12.50 per tablet. Each patient gets 7 tablets. Profit earned from each patient is $62.30.

    There were 40 patients on Friday evening. He has a list of 200 patients who come regularly to get Subutex. It was reported that each weekday night he sees 25-40 users. If he sees 40 users each weekday night, that would be 200 users a week which is correct.

    So let's say these 200 come weekly to get Subutex. 200 X $62.30 = $12,460 per week in profits earned. 1 month = $49,840. 1 year = $598,080

    That's a lot of money!

    Interestingly here is the punishment:

    "Any doctors judged to be prescribing these drugs too freely will face the Singapore Medical Council and, if found guilty, may be fined up to $10,000 and struck off the medical register."

    Well if I do this for a couple of years eg 5 years I can make up to 3 million dollars! If after 5 years then get caught, I really wouldn't mind just paying $10,000 and get struck off the register then retire lah.

    Something is not right here.

    By Anonymous Anonymous, At December 10, 2005 8:27 pm  

  • Only the Ministry of Health would know the answer to that.

    Psst! And people make mistakes ;)

    By Anonymous Anonymous, At December 11, 2005 8:30 pm  

  • Maybe the drug should only be used in a rehab center context. How can someone effectively administer rehailitation in an outpatient setting? I mean if they really want to quit, shouldn't the addicts be checking in to some detox hotel to help kick the habit. Anyway it is difficult to treat addiction.

    By Anonymous Anonymous, At December 12, 2005 12:07 am  

  • Reply to Anon 12:07 AM:
    Not sure if the GPs can enlarge their scope of work to include this kind of 'drug rehab'... Generally, our GPs in S'pore are Under-Employed. They can definitely do more than just dispensing panadols and cough syrup...

    By Anonymous Anonymous, At December 12, 2005 8:33 am  

  • I learnt that there is a link up between IMH and one big retail pharmacy chain to dispense a tablet of subutex to their patients. Apparently , the pharmacist at the retail chain would have to crush the tablet before dispensing to the patient. And have to be very careful when crushing the tablet as if a little is spilled, the patient will make hell lot of noise. Rather do without their business.

    By Anonymous Anonymous, At December 14, 2005 8:40 pm  

  • I want to ask why it isn't sufficient to watch them place the tablet under their tongue, but I fear the answer...

    Incidentally, when you buy duty-free beer in the army, the seller is obliged to open the can for you there and then. :)

    By Blogger angry doc, At December 14, 2005 8:44 pm  

  • oh, why not DOT?

    By Anonymous Anonymous, At December 14, 2005 8:47 pm  

  • Because Subutex is administered by dissolving the tablet under the tongue and not swallowed.

    Unless you have the manpower to watch a patient for several minutes after he placed the tablet under his tongue, he can just spit it out again, and dissolve the saliva-tablet mixture in water, and then inject it into his vein...

    Hmm... but then again, how is crushing the tablet supposed to help? They crush the tablet to dissolve it anyway, right?

    By Blogger angry doc, At December 14, 2005 8:52 pm  

  • yeah, I was also wondering on how crushing the tablet will prevent abuse by the patient.

    By Anonymous Anonymous, At December 14, 2005 9:10 pm  

  • I'm a pharmacy student in the US, and I was just wondering if Subutex is the primary drug dispensed for opiate addiction in Singapore. I know many methadone clinics here dispense liquid methadone to avoid the sale of methadone tablets on the black market, etc. . . and I thought that there must be a pharmaceutical preparation using a different salt or ester that would make the buprenorphine difficult to inject. Oxycontin is formulated in such a way that if it is crushed, then an antagonist is released and inactivates the medication--due to widespread drug abuse through snorting. I am just wondering if similar preparations are used in Singapore.

    By Anonymous Anonymous, At January 11, 2006 12:54 pm  

  • Stephanie,

    Like I said addiction is not my specialty, so hopefully the pharmacy students who read this blog can give you the answer.

    Subutex is widely (?) prescribed locally because until recently it is not a controlled drug. Do read the Dec 22 entry for some more on the abuse of Subutex.

    Personally, I suspect no matter how noxious you make the drug, the addicts will still administer it if they can get their fix.

    Thanks for reading.

    By Blogger angry doc, At January 11, 2006 5:56 pm  

  • I asked my pharmaceutics professor and he's asking a specialist on drugs such as those, so I should be able to get back to you shortly. :)

    By Anonymous Anonymous, At January 12, 2006 12:19 pm  

  • Thanks.

    Looks like no one has a ready answer! :)

    By Blogger angry doc, At January 12, 2006 7:39 pm  

  • subutex gives little or no high. as a pescribed user i have come across addicts that have bought them but only to stop their withdrawls. all the other percribed alternatives are much more problematic in terms of abuse and physical and mental addiction. i thought this was common knowledge. if an addict wanted to spend his/her money to get high they would never choose subutex. They would go for any other opiate available, but it would be pointless buying subutex simply to get high. people are buying them on the black market to get well and off opiates, and because they carnt find legal help quick enough to help their pain.

    By Anonymous Anonymous, At February 14, 2006 8:55 pm  

  • When used as prescribed, Subutex is not supposed to give a high.

    But the problem we are discussing is that of people NOT using it as prescribed.

    I have no personal experience, but I suspect the abusers are indeed getting a high from injecting Subutex, or else they would not be subjecting themselves to the pain and complications of doing so.

    By Blogger angry doc, At February 14, 2006 9:14 pm  

  • I feel that any doctors who prescribe Dormicum n Subutex to patients without monitoring them properly are unfit to be a Doctor. Perhaps these doctors need to be hang for trafficking!!!

    By Anonymous Anonymous, At June 27, 2006 8:59 pm  

  • they crush subutex so the desperate few dont spit it out in theit hand and then inject when they get home.suboxones the best-narcaine in it

    By Blogger mangoe, At July 26, 2006 2:23 am  

  • Subutex releases many good people from the hell of methadone and heroin, if it's abused ?!........every opiate/opiod is used/abused. This incredible drug is the way to total abstinence for many,many addicts since it lowers desire for other addictive substances and is much easier to withdraw from than Methadone, Morphine and Heroin. This drug saved my life and I found sobriety as a direct result. I have a few friends with the same facts - Given that virtually all long term Methadone addicts stay addicted for many years '(decades) they only have suffer a day or so of discomfort before trying bupe (subutex). The difference in a patient after subutex treatment is a profound sight to see. Remember how much 'Good' this therapy is giving addicts . No different from heavy drinkers/alcoholics or those with many other mental problems . Sometimes a sense of responsibility ( be strong - just say no ) isn't enough.

    By Anonymous Anonymous, At August 26, 2006 4:57 am  

  • my boyfriend of 5yrs and father of my two girls is a subutex abuser... have been through the crap that goes with heroin with him and thought subutext was a wonder drug and two years into my partner being on subutex I am still finding shot marks and needles in his car. Just goes to show a junkie is a junkie and no matter what support they recieve they will find a way. He ended up in hospital on the weekend due to Sepsis/Infective Endocarditis - very serious condition caused by years of injecting and drug/subutext abuse. He is on his own now. Subutex has its place but more research needs to be done.

    By Anonymous Anonymous, At May 17, 2007 2:25 pm  

  • Without getting into a blow by blow account of my affair, my addiction to opiates started with an oxycontin prescription and ended up with my nose in a bag of heroin. I'm not proud of being an addict, but understand that I did not continue with opiate use to get high, I continued use to avoid debilitating withdrawal symptoms. I used just enough to be able to function in society and keep my professional career from going in the toilet. You cannot work if withdrawing from opiates. You cannot work and support yourself if you are in a rehab center ether. Suboxone was my savior. There are no withdrawal symptoms while taking Suboxone, and it can't get a person "high". It allows a person to stop abusing opiates and return to a drug free state without a cold turkey crash or a stay in a rehab clinic. This is why it is prescribed, people can get treatment for their addiction without a life disrupting rehab stay. I would still be using if it were not for Suboxone. Not all of us want to get "high," some just want to return to normal in the least disruptive way possible. Suboxone made that happen for me.

    By Anonymous Anonymous, At October 14, 2007 12:55 pm  

  • okay for all those who dont know if you use subutex over 4mg you cannot use other opiods this is because and DOCTORS SHOULD KNOW THIS its an opiod agonist, subutex has strange properites, i.e if used in over 4mg it has a blocking effect of all other opiates despite it being an opiod itself this is why it is used to a huge success to wean heroin users off it, when used correctly it works I should know it has changed my life from almost killing myself to being a family man with a ft job

    By Anonymous Anonymous, At November 10, 2007 9:02 am  

  • These comments made me so sad because they were supposedly coming from educated people (doctors). Unfortunately, they have no experience in the field of addiction or they would know it is not a moral dilemna, but an illness - a physical craving and mental obcession, and has nothing to do with "CHARACTER", as the postings suggested. We alcoholics and addicts produce THIQ, synthetic opiate basically, in our brains which makes us different from other people. Suboxone and subutex have helped rescue me from a life of hell of just trying to feel and function normally through polysubstance abuse that started with alcoholism and prescribed pain medication for a back injury. I've been in AA for eight years now, on suboxone for three years and recovering much quicker. I walked around with pain and depression for first several years and after 3-4 months would give up and relapse then try again over and over without progress. Right now i have 15 months TOTAL sobriety on suboxone(and 3 years without abusing opiates of any kind), and my family tells me they never want me to come off suboxone, the change is that significant. A once-a-day pill as opposed to a lifetime of pain and depression, rehabs and suicide attempts is alright by me. The Lord knows I deserve this medicine and the relief and hope for a future that it provides; THAT is why it was made.

    By Anonymous Anonymous, At March 03, 2008 3:05 pm  

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