My Book

Ah yes…. another post about my book…
Over the past few years, I’ve taken posts from this blog, posts from other sources that I’ve written, some sections of a ‘memoir’ that I have not gotten around to writing… and combined them in a book about addiction. The book does not hold together as well as it should, and it is way too long– so instead of a ‘sit and read’ book it is more like a reference, similar to the blog itself. If you like this blog, you’ll like it; I’ve taken the more important posts and cleaned them up and organized them. I’ve added some new material as well, including a section about my own background. If you have a loved one on Suboxone, or have an interest in the medication yourself, you will know as much about the buprenorphine as anyone should you finish this book– particularly about the use of buprenorphine by addicts, the controversy over buprenorphine, the relationship between buprenorphine and methadone, etc.
There are some chapters that are dated– i.e. where my opinion has changed or softened over the years. I was much more ‘anti-methadone’ when I wrote most of the book; now I see methadone as something that some people simply need in order to survive. I am not a fan of how some clinics are run– but that is a topic that I don’t get into in this book.
Finally, you’ll notice how I have changed over the years; in early posts I would become angry and sarcastic with some writers. In part, that is because I was being attacked on a daily basis by the ‘anti-sub’ movement– which has largely disappeared. But I think I have also aged a bit, and I now tend to pick my battles more carefully.
The book (note- this is an e-book) goes for $14.99, and runs around 250 pages– long enough to occupy most of your summer! Proceeds continue to support this blog, and SuboxForum as well.
Thank you very much, to those of you who purchase it and check it out. I would be most grateful if you would leave comments about it– for me, and also for others– by writing them in response to this post. At some point I will get a page set up, and tranfer this promo and the comments to that page.
The book is called ‘Dying to be Clean’– and can be purchased using the links at the left of this page– or right below this post.
NOTE: Because I don’t want it simply passed around freely at this point, you need a code to open it– and it cannot be printed. The code will be included with the download link. Please understand why I take those actions.
Thanks again,
Jeff J
Buy Now

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night
Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.
On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?
This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.
Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’
The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.
The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.
All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.
My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

Chapter 4, Pt 2: Stages of Addiction

I am always impressed by how similar addiction progresses in one individual versus the next.  The next reader’s comments and my comments afterward demonstrate a pattern that I have observed in one opioid addict after another.  Throughout the book, comments that I receive from others will be italicized.
I started on Suboxone in Feb 08 to get off opioids. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it because I had no more insurance and it was very expensive.
I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped because I ran out of Suboxone. About 3 days after I stopped taking it I started withdrawing. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. So what did I do? To get rid of the withdrawal feeling I was getting I started taking opioids again.
I am now on my 3rd day of Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from opioids by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you posted and to everyone else doing the same… GOOD LUCK TO ALL OF YOU!!
Early in addiction, opioid addicts believe that if they could only get past the physical withdrawal, they would be done with opioids forever.  During this first stage of opioid dependence, addicts are always fighting for that first piece of sobriety.
They hang out with each other on message boards on the internet comparing tapering plans using cocktails of amino acids or other worthless regimens, hoping to find the one that works– that gets them through withdrawal to become opioid-free.  They are not interested in meetings or rehab; they don’t consider themselves to be the kind of addicts who need THAT kind of help.  They insist that Suboxone be used only short-term, as a bridge to total sobriety.  They have no interest in accepting a life-long illness, and argue that they expect to find a ‘cure’ even as they return to opioids again and again.
Denial is huge during this stage of addiction; addicts minimize the damage opioids cause in their relationships, work, and health.  They can discount the damage in part because they consider their addiction temporary and easily corrected– once they just stop the darn opioids.  They assume– often for a long time– that the right tapering method will come along and things will be fine.  Hooked?  Not them!
Addicts enter the second stage of addiction when they have successfully discontinued opioids and made it completely through withdrawal.  From my vantage point of seeing many addicts over time, the point where sobriety is finally achieved is not associated with any particular taper method or amino acid formula, but rather occurs when addicts have had enough consequences to motivate them to tolerate the entire period of withdrawal.
More and more bad things pile up until they cannot be repressed and ignored; job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.
During the first stage, addicts get to a certain level of withdrawal and say ‘enough of this!’ and resume using.  But during the second stage the drug-related problems are remembered throughout the entire length of withdrawal, keeping addicts motivated to get free from opioids.  Often addicts are so sick of using by this time that they don’t even use a taper, but rather just stop at a moment of self-disgust, without any plan or preparation.  Or perhaps the consequences lead to a jail cell, resulting in sudden and absolute sobriety without the luxury of medication to reduce the severity of withdrawal.
That’s great, right?  They are finally free of opioids!  Unfortunately they are about to enter the third and worst stage of opioid addiction– the stage that can last for years and that totally demoralizes addicts.  The stage begins with relapse — after a week or after a year, but the bottom line is that it almost always happens — even though NOBODY thinks it will happen to him.
I hear the comment over and over — ‘don’t worry, doc, I don’t plan to relapse!’ Or ‘I hear what you are saying — but you don’t understand how motivated I am!’ Many addicts consider themselves too smart for relapse, but I see the AA adage come true over and over: nobody is too dumb for Recovery but some are too smart for it!  The meaning is that every now and then a person will avoid relapse — and it tends to be a person who has a simple take on life who didn’t really shine in other, more competitive areas.
The lucky person who finds recovery to be easy is someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities.  That person can sometimes simply stop using because he accepts the idea that he has lost the fight — that opioids are much stronger than he is, and that he will never figure out how to take them without disaster.
But most people are far too smart to find easy sobriety.  As soon as things start going well their minds take off again, and at some point they return to using.  I’m not going to spend time on the triggers for relapse, as we will discuss them another time — but there are things common to all relapses, including  rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness:’ a sense that all of the dangers of relapse apply, for one reason or another, to OTHER people.
During this third stage of opioid dependence, addicts will have repeated episodes of relapse and sobriety.  There is little joy in using, because consequences occur much more rapidly now.  More and more time is spent being sick from withdrawal.  This is the stage that long-time addicts remember and fear the most.
In my case, I could stop using every weekend;  I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME–  come Monday I won’t touch ANYTHING!’  And so I was always sick; the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them.  And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.
As I mentioned earlier, during this stage addicts become truly ‘sick and tired.’  This is a dangerous period of time for addicts for several reasons; when addicts use they feel a great deal of shame, which fuels more using — making use more impulsive and reckless and more likely to cause a fatal overdose.  Addicts in this stage become depressed — sometimes extremely depressed — and commit suicide, either actively or by not caring anymore about the risks of taking too much.
Addicts sometime feel such hopelessness or shame that they will do anything to change how they feel — swallowing any pill they come across, or shooting up unlabeled and unknown liquids — anything!  Even a hammer to the head looks good at this point!
This is the time and level of desperation when traditional treatment has been effective; addicts are at ‘rock bottom,’ and no longer feel confident about any of their own abilities.  They are ready to follow anyone or anything — after all, what do they have to lose?  Life is over anyway — so why not listen?
If an addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a shot at meaningful sobriety. But if he gets into treatment and quickly finds a girlfriend, or if he tells jokes and becomes the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is…  there is a strong chance that the treatment will prove worthless.  To get better, an addict must hold on to the attitude that he knows nothing, for only that attitude will allow change to occur.
The ‘desperation’ issue relates to why, in my opinion, young people have lower success rates in treatment.  Young people often feel too invincible for treatment to take hold.  They also have short memories for painful events; consequences are quickly forgotten and dangerous self-reliance returns.
The true wonder of AA is that the program’s founders understood all of this; the program is about humility and powerlessness, and consists of a series of steps that if practiced completely, will take people to the right frame of mind and keep them there.
The reason treatment tends to work better for older people is because first, more are at the later stage of addiction and are truly ‘sick and tired,’  and second, self-confidence tends to return a bit more slowly after a major blow in us older folks, so we hang onto our desperation a bit longer.  We also tend to remember the bad things that happen because we know that people sometimes die, and that some friendships can be lost forever.  Plus it is difficult to feel immortal when one’s body aches each morning!
In light of what you have read, go back and read the italicized comments from the reader again.  See if you can tell the stage of addiction that the person is experiencing.  I receive similar comments every day by e-mail.  I have watched over the past 16 years as addicts (including myself) repeat these stages over and over again.  Every person is convinced that he is different– only to eventually find that in regard to addiction he is the same as everyone else.
This is why I recommend seeing Suboxone as a long-term medication and seeing AA and NA as life-long programs.  In either case, the natural tendency of the untreated addict will be to relapse and return to the horrible cycle of using and withdrawal.

Dying To Be Clean, Chapter 3; continued

Why buprenorphine?
The partial agonist nature of buprenorphine is behind the usefulness of the drug for treating addiction and chronic pain.  Opioid agonists always cause tolerance, and the tolerance usually causes cravings for more and more drug– no matter whether the drug is being used therapeutically or recreationally.  Tolerance is unavoidable, at least for now (there are some chemicals that may reduce the development of tolerance, but they are not yet on the market). Buprenorphine, on the other hand, initially results in some level of tolerance, but the tolerance stops at a certain level so that cravings do not occur.  The ability of buprenorphine to eliminate cravings for opioids is the basis for its ability to induce remission of opioid dependence.
The Drug Enforcement Agency, or DEA, assigns ‘schedules’ to controlled substances based on the potential for the substance to become a dangerously abused drug.  Substances that are ‘Schedule I’ are considered by the DEA to lack medicinal value, and include marijuana, heroin, Quaaludes, psilocybin mushrooms, and LSD.  The potent opioid medications and most stimulant medications are Schedule II; there are special barriers to the use of Schedule II medications including the need for written prescriptions, no refills allowed, and limits on prescribing to no more than a 90 day supply.  Buprenorphine was classified as a Schedule V substance for a number of years, but was changed to a Schedule III medication around the time that it was approved for use for treatment of opiate dependence.  In spite of the higher classification, buprenorphine remains relatively easy to prescribe for physicians and for patients; prescriptions can be called into pharmacies, and refills are allowed.  In recent years there has been concern over diversion of buprenorphine and selling of buprenorphine ‘on the street’ for upwards of $20 per tablet.  There is some concern by physicians and by patients that the diversion will lead to greater controls placed on the medication; controls that will ultimately become barriers to treatment for some patients.
Remission- Not a ‘cure’
Buprenorphine does not ‘cure’ opioid dependence.  When buprenorphine is discontinued, the stimulation of opioid receptors ceases, the neurons with the receptors stop firing, and the craving for opioids returns. Moreover, since buprenorphine does have some agonist activity, discontinuation results in withdrawal—although the withdrawal is usually less-severe than the withdrawal after discontinuation of opioid agonists.
To consider the proper role for buprenorphine and Suboxone a person must understand the ‘medical model’ of addiction.  For years there has been a discussion over the role of personal responsibility in addiction, and whether addiction should be considered an ‘illness’ or a manifestation of poor character.  I have wrestled with this question myself and have come to a few conclusions.  First, addiction fits any definition of ‘disease’ that a person chooses to use.  Addiction is progressive; there are familial and environmental influences; the course is quite similar between individuals; the progression of the illness is predictable; and recovery from the illness is possible with appropriate treatment.  As for the behavioral component of addiction, most illnesses have a behavioral component.  Many diabetics would be cured by weight loss, and many cases of lung cancer or emphysema would be prevented by stopping smoking.  So from my perspective, addiction is a disease like any other disease.
The classification of addiction as a disease should not be seen as a way to avoid blame or consequences for criminal or immoral behavior that occurs during active addiction.  Every addict is responsible for his or her behavior, regardless of whether the behavior was fueled by addiction!  Moreover addicts have a responsibility to keep their addiction in remission as best as possible through the use of proper treatment.  Some of the ‘anti-recovery’ literature accuses addicts of using the ‘illness’ label to avoid responsibility–  such as ‘I’m not a bad person—I just have a bad addiction’.  To be honest though, the anti-recovery crowd need not worry—that type of excuse never gets a person very far!
One final comment on the disease theory:  Understanding that addiction is a disease is an important part of ‘getting’ treatment—of being one of those who are successfully treated into sobriety.  Understanding the disease nature of addiction allows the addict to accept his powerlessness over the substance, which is the first step in classic twelve step programs. If powerlessness is a disease, the addict can retain a bit of pride during the first step (pride that will be given up later).  On the other hand, if addiction is not a disease but a character flaw, the addict is being asked to own and admit to a huge character defect right at the start of treatment.  Addiction as a ‘character flaw’ also implies that addiction is shameful.  Finally, addiction as a character flaw suggests that a person of ‘good character’ should be able to stop using by simple will power.  But will power does not work for addiction for a number of reasons, the most important reason being that if a person thinks he can control his use, he can stop… TOMORROW!  That is the addict’s mantra; use today, stop tomorrow.  The only real reason to stop using is if a person recognizes the lack of control—and recognizes that using even once will always result in disaster.
Medical management vs. ‘sober recovery’
There is tension between addicts who found sobriety the ‘old fashioned way’ and addicts who choose to use buprenorphine to maintain remission of their addiction.  The tension between groups is unfortunate, and needless.  The people who worked to establish AA groups a century ago were concerned with saving lives.  They were not anti-technology zealots;  there are comments throughout the ‘big book’ of AA pointing out that the twelve steps often placed the obsession to drink into remission, even where attempts by medicine and psychiatry had failed.  But the emphasis in the AA literature is on the promises—on the fact that recovery from active addiction will result in untold benefits to one’s life.  There is no talk of sobriety ‘for sobriety’s sake’;  no discussion about the need to be free of all substances, except from the pragmatic perspective that the use of one intoxicant will often lead back to the use of the person’s drug of choice.  From my perspective, I look forward to a day when addiction is firmly understood to be a predictable disease, with no more shaming stigma than what is currently applied to those with hypertension or heart disease.  In the meantime, I see little value in forced AA attendance for the average patient taking Suboxone.  If a person is motivated to approach the twelve step program through his/her own interest and motivation, I think that is fine.  My only caveat is to be wary of attempts to push you from Suboxone if you are taking that medication, and to exercise good boundaries. Your medical condition and medical history are your business and between you and your doctor— end of story.

Clean Enough, Chapt 3; Primer on Buprenorphine part 2

Physical dependence vs. addiction
Tolerance and withdrawal are signs of ‘physical dependence’ on a substance.  Addiction, on the other hand, is a complicated term that has different meanings in different contexts, but generally refers to an obsession or attachment to a behavior, person, or substance.  Many people mistakenly consider physical dependence and addiction to be the same.  To illustrate the difference, there are many medications that cause physical dependence that are not addictive.  Effexor and Paxil, two common antidepressants, cause physical dependence and have very uncomfortable withdrawal symptoms.  Physical dependence occurs in non-psychiatric medications as well; suddenly stopping some blood pressure medications will cause an upward spike in blood pressure.  Most people are aware of the withdrawal from missing their morning dose of coffee.  Steroids must be tapered when they are discontinued to avoid the risk of hypotension or even shock. 
So what is addiction?  Addiction can be seen in different ways depending on who is looking.  From my perspective (as a psychiatrist), opioid addiction is the mental obsession for opioids.  Addiction is the relationship that the addict has with the drug.  Most people associate ‘addiction’ with a person using large amounts of the substance, but when addiction is understood to be not the taking of the drug but rather the obsession, it is clear that addiction does not even require the presence of the substance to be active.  In fact, addiction is in some ways most active when the substance is NOT present.  I have heard patients say ‘I’m not an alcoholic– I haven’t had a drink in weeks’.  But in AA there is recognition of a condition known as a ‘dry drunk,’ where a person who loves alcohol is not consuming alcohol, but is consciously or unconsciously thirsting like crazy for a drink!  Similarly, an opioid addict may be free of opioids for several days, but will be so obsessed with finding opioids that there is little ability to think about anything else.  So treating addiction requires much more than keeping the person from using drugs.  Successful treatment also includes removing the mental obsession for the substance and removing the relationship with the substance.  I sometimes refer to addiction to a drug as similar to having an unstable boyfriend or girlfriend.  When the realization is finally made that the relationship is toxic, it isn’t enough to stop dating– the phone calls and text messages have to end as well.
Buprenorphine is different
Drugs that bind to receptors can be classified into several categories depending on their effects at those receptors.  At the mu opioid receptor, hydrocodone (Vicodin), oxycodone (Oxycontin, Percocet), methadone, morphine, and meperidine (Demerol) cause increasing stimulation as the concentration of drug is increased. Molecules that have this effect are called ‘agonists.’  Naltrexone and naloxone, on the other hand, block mu receptors without stimulating the receptors.  Molecules with blocking activity are referred to as ‘antagonists’ and are used medically to reverse overdoses or to block opioid effects. Buprenorphine has actions at mu opioid receptors that are between agonist and antagonist molecules, and is classified as a ‘partial agonist’ or ‘agonist-antagonist.’  Buprenorphine stimulates mu receptors to a point, but beyond that point further increases in dose do not cause increased stimulation—the so-called ‘ceiling effect’.  When Suboxone is taken sublingually, the ceiling effect occurs at a buprenorphine dose of about 4 mg.  Beyond this dose buprenorphine becomes an antagonist as well as an agonist, blocking mu receptors and preventing stimulation by other opioids.  This effect of buprenorphine is unique and distinct from the effects of opioid agonists such as methadone.
It is worth pointing out that like many opioids, buprenorphine has effects at opiate receptor subtypes other than the mu receptor.  Buprenorphine is an antagonist at kappa and epsilon receptors, for example.  Actions at other receptors may be responsible for the mood effects of buprenorphine.
Buprenorphine is very potent.  Outside of the United States buprenorphine is used to treat pain in doses as low as 5 micrograms.  A patch formulation of buprenorphine in the UK (BuTrans) releases buprenorphine through the skin at a dose of 5-25 micrograms per hour.   The potency of buprenorphine creates challenges for those who try to taper Suboxone, when they taper down to two mg/day, think that they have made great progress, and assume that the rest of the taper will be a piece of cake.  They instead find that the work of tapering has just begun.

Clean Enough, Chapt. 3: A Primer on Suboxone

What is Suboxone?
Suboxone is the trade name for a medication that contains buprenorphine and naloxone. A similar medication, Subutex, contains buprenorphine without naloxone.  Both are manufactured and sold by Reckitt-Benckiser, a company based in the UK with operations world-wide. Suboxone is FDA indicated for the treatment of opioid dependence.  Both medications are also used ‘off label’ (**see footnote ), or without FDA indication, to treat chronic pain and more controversially,  refractory depression.  Because of longstanding regulations in the United States that prohibit treating opioid dependence with narcotics, a waiver from the DEA is required in order for doctors to prescribe buprenorphine for that indication.  Buprenorphine can be used to treat other conditions, including chronic pain, without special waiver or permission, provided the doctor has current DEA registration for Schedule III medications and a valid state medical license.
The use of buprenorphine to treat opioid dependence in the US was made possible by the Drug Abuse Treatment Act of 2000 (DATA 2000).  In order to become certified to use buprenorphine, a physician must have his/her credentials approved by the DEA and must take an 8-hour course that describes proper uses and regulations related to buprenorphine.  Even after the passage of DATA 2000, the use of buprenorphine for treating opioid dependence was not possible until 2003, when the FDA approved Suboxone for that indication.  Buprenorphine, which had been a Schedule V drug for many years, was moved up to Schedule III by the DEA.  To differentiate the use of microgram doses of buprenorphine for treating pain from the use of milligram doses of buprenorphine for treating opiate dependence, some authors who have written about studies of buprenorphine have used the term ‘high dose buprenorphine’ or HDB for the latter.  I will try to use HDB to refer to the use of buprenorphine in milligram doses, except when the specific brand medication is discussed.
Naloxone is not necessary
The naloxone in Suboxone has no significant action when the medication is used properly, and is not responsible for the ‘ceiling effect’ of Suboxone. Suboxone is taken by dissolving the tablet in the mouth; buprenorphine enters the bloodstream via capillaries that flow just beneath the lining of the oral cavity. To get into the capillaries the dissolved buprenorphine must stick to the surfaces inside the mouth and then diffuse through those surfaces. Naloxone is a large molecule that is less soluble in fatty tissues, and so is less likely to stick to the oral surfaces (cell membranes consist of fatty molecules, so molecules that dissolve in fats pass through the membranes more easily). Since naloxone doesn’t stick to, or pass through, the cell membranes lining the mouth, little or no naloxone enters the bloodstream.  Eventually the non-absorbed molecules are swallowed, and the naloxone and the remaining buprenorphine are absorbed into the bloodstream from the intestine.  The anatomy of the circulatory system has important effects on Suboxone at this point; the blood that drains the small intestine flows into the portal vein, which takes newly-absorbed substances directly to the liver. Some substances—including buprenorphine and naloxone—are destroyed so efficiently by the liver that few molecules survive to enter the general circulation. This phenomenon, the efficient breakdown of an absorbed medication by the liver, is called the ‘first pass effect.’  The first pass effect for buprenorphine makes the medication ineffective if the tablets are swallowed, and the first pass effect for naloxone prevents oral naloxone from reaching the systemic circulation and causing withdrawal.
The reason naloxone was added to Suboxone is probably more theoretical than medical.  Buprenorphine has been used for thirty years as an intravenous pain medication, and so there are concerns over diversion and abuse of the substance.  If Suboxone is injected, the naloxone would be active (injected naloxone bypasses the first pass effect).  Naloxone blocks opioid receptors and is used clinically to reverse opioid effects during overdose, so an addict who dissolves and injects Suboxone will experience withdrawal rather than euphoria. 
I should point out that the withdrawal from naloxone that occurs when Suboxone is injected is completely different from the withdrawal that can occur when Suboxone is taken too soon after opioid use.  In the latter case, called ‘precipitated withdrawal,’ the buprenorphine is responsible for the withdrawal symptoms, NOT.  The mechanism behind precipitated withdrawal will be discussed later in this text.  I should also point out that naloxone is sometimes confused with naltrexone, which is an opioid blocker that is active when taken orally.  Naltrexone is indicated, curiously enough, to reduce cravings for alcohol in alcoholics.  It is sometimes used ‘off label’[1]  in opioid addicts in early sobriety to prevent the possibility of a ‘high’ from opioids; it has this effect by blocking receptors for opioids in the brain.  Naltrexone causes withdrawal in people who have a high tolerance to opioids, even if opioids haven’t been used for weeks.  The brain and nerve cells take up to 8 weeks to return to normal tolerance after stopping opioid agonists, and so naltrexone is generally started only after a prolonged period of sobriety.  The exception is a form of opiate detox called ‘medicated withdrawal’ or ‘rapid opiate detox.’  In this procedure the addict is given an almost-general anesthetic, and then a large dose of intravenous naloxone.  Sometimes a slow-dissolving piece of naloxone is also implanted under the skin to prevent the addict from getting high for weeks following the procedure.  The procedure sounds good in theory, but in reality the procedure costs up to $10,000 and the benefit questionable, both in terms of avoiding misery and maintaining sobriety.
Opiate receptors and opioid effects
The use of HDB for opioid dependence stems from the actions of the drug at opiate receptors.  There are many opiate receptor types and subtypes; mu, kappa, sigma, delta, and others.  The actions of most pain medications, including buprenorphine, occur at mu opiate receptors.  To provide some background, neurons communicate with each other when one neuron releases chemicals called ‘neurotransmitters’, which cross a space or ‘synapse’ and attach to ‘receptors’ on the cell membrane of another neuron.  Endorphins are naturally-occurring chemicals in our brains that act as neurotransmitters.  Endorphins (and smaller molecules called enkephalins) are released during severe trauma, activate mu receptors on neurons, and cause those neurons to block signals from pain receptors.  The teleologic reason for such a system is because during severe injury, pain serves no adaptive advantage, but rather gets in the way of survival of the injured animal.  Pain-fighting chemicals like oxycodone and hydrocodone mimic endorphins, attaching to mu receptors and causing neurons with those receptors to fire at a rate even greater than the firing caused by endorphins.  The extra activity of these neurons causes analgesia, euphoria, relaxation, energy… good feelings for the most part.  When the chemicals leave the receptors the neurons stop firing, and the good feelings go away, and so the person wants to take the pain pills again– and again.
Most parts of our bodies, including neurons, have some ability to repair themselves. The neurons stimulated by endorphins and pain pills recognize that they are firing at an abnormal rate, and make changes to bring the firing rate back down to normal.  They do this by changing the receptors, essentially making the receptors less sensitive to the chemicals that activate them.  It then takes larger levels of chemicals to get the same effect– something called ‘tolerance’.  Over time, the receptors become less and less sensitive in response to increasing doses of pain pills.  That is why patients with chronic pain can end up taking huge doses of pain pills yet get little benefit from them.  A person in this situation must take large doses of pain pills just to get the neurons to fire normally! The person is now ‘physically dependent’ on opioids.  The receptors have become so insensitive that the person’s own endorphins no longer activate them.  And without activation of the receptors, the neurons become quiet, allowing pain input from everywhere to flood the brain.  This situation is experienced as ‘withdrawal’—a miserable state of affairs that opioid addicts learn to avoid at any cost.  As before, the neurons can ‘fix themselves’; they recognize that they are firing at an abnormally slow rate and adjust the receptors, this time making them more sensitive to stimulation.  The sensation of withdrawal will go away when the neurons have made the receptors normal again, so that native endorphins will activate them– a process that takes days, weeks, or even months, depending on a number of factors.
**
The term ‘off label’ refers to the prescribing of medications for purposes other than those approved by the FDA.  A pharmaceutical company will submit evidence to the FDA that a given drug, say ‘drug X’, is effective for treating depression.  If the FDA gives approval, the drug is then ‘indicated’ for that use.  The company can run ads and market the medication for that use, provided they also list the risks of the medication in the commercials—those fast words at the end about how the medication might kill you.  If a few years later drug X is found to cure something else, say baldness, doctors can prescribe the drug to treat baldness without needing any special FDA permission.  This is called ‘off label prescribing’, and is actually very common.

Clean Enough: An Educational Process

Clean Enough continues:
An Educational Process
I was able to stop using codeine after returning home and to my job in the operating room.  I dodged a bullet– or so it seemed.  I continued to drink wine, beer, and the occasional margarita, but I had convinced myself that drinking was an isolated vice that was necessary given the stress of my job.  Yes, the AA and NA people said that alcohol would take me back to my ‘drug of choice’, but they didn’t understand my special situation, and didn’t know how smart I was.  The scary incident in the Bahamas faded from my memory.  Looking back, it wasn’t that big of a deal.
About ten months later I was having a tough week.  I had a bad cold, I was feeling depressed (my mood always takes a hit when I am sick), and my wife and I were in one of those low stretches that visit most marriages.  Seemingly out of the blue, I thought about how I had stopped the codeine after my vacation months earlier.  Hey– I must have learned to control my use of codeine!  And since I have control, I can take a small amount of codeine for my cold… and perhaps get a tiny bit of euphoria… but then I will stop just like I did before!   That thought—that I now had ‘control’—would be the end of my career as an anesthesiologist.  Similar to the experiences of many other addicts, my relapse was horrible; much worse than my original addiction.  I was like a rat pushing a lever to get food in a lab experiment, using medications from work, shooting up intravenously, and taking doses that I knew could be fatal.  I even injected contents from unlabeled syringes, hoping they contained something to make the sickness go away, and not the paralyzing agents that would have killed me.  Every Friday I brought home enough fentanyl to cover the weekend, but no matter the amount, it was gone by Friday night, leaving me sick from withdrawal every Saturday and Sunday.  At some point I didn’t even care about getting busted. There is a great line in the movie ’28 Days’:  “this is no way to live…. this is a way to die!” 
I was met by a security officer one Saturday morning as I entered the hospital to scrounge the operating rooms for drugs, and he apologized for having to escort me out of the hospital.  The next morning I met with the my wife, a member of my anesthesia group, and the hospital CEO, telling them that I only needed a minor, outpatient ‘tune-up’, since I knew all this recovery stuff already.  But the CEO pointed out the needle marks on my hands and arms, and said that any possibility of working again required residential treatment.  I left the meeting wondering whether to just put all of us out of our misery or to instead go into treatment.  As an aside, I remember that feeling now when I am trying to get a person to enter residential treatment– my aversion to treatment was so strong that suicide seemed a reasonable alternative!  I did choose treatment over death, but not by a long-shot. 
The night before going to treatment I watched my 12-year old daughter play a piano duet, her teacher playing the part that I was supposed to play.  Laura and I had practiced the piece together for weeks, but with my hands shaking and dripping sweat I was in no condition to play.  I have many shameful memories from my ‘using days’, but memories of that night will always be among the worst of them.
I was in severe withdrawal the next morning, too sick to enter the treatment facility, so I spent some time in acute detox in a locked psych ward.  My shoelaces were taken from me so that I couldn’t hang myself.  I was given a room at the end of the hall where I waited for the pain to stop, minutes becoming hours.  Clonidine was ordered, but was to be held for blood pressure below 90. Every time I heard the nurse I tensed my muscles, trying to push my pressure higher, but I was so dehydrated that I couldn’t get my blood pressure high enough for even one dose!  I will point out that people write on the web that ‘Suboxone withdrawal is the worst;’ in detox I could barely walk for the first few days, and for a month or two I was so weak that I became short of breath after walking 100 feet.  Sleep and appetite took a couple months to return.  After experiencing withdrawal many times, and watching many people go through withdrawal from substances including buprenorphine, I can say with complete confidence that buprenorphine withdrawal can be significant, but is NOT as severe as withdrawing from opioid agonists.  Those who say otherwise are being influenced by the fact that current misery always feels worse than ‘remembered misery.’   People withdrawing from buprenorphine go to work every day and complain about how bad they feel; those withdrawing from oxycodone, methadone, heroin, or fentanyl lie in bed and DON’T complain, as they are too sick to write on the internet!
I eventually transferred to the treatment center where I would spend the next three-plus months of my life.  The program consisted of work from sun-up to bedtime, and included individual therapy, group therapy, art therapy, music therapy, experiential therapy, relaxation training and guided imagery, ropes and challenge course, physical training, and twelve step groups.  One irony of treatment is that a person is ready to leave at about the time when he no longer wants to go.  I now see the experience as a wonderful gift to myself.
I had a number of ‘consequences’; I lost my job and my hospital privileges, and I was disciplined by the licensing board.  I was ordered to attend treatment and twelve step meetings for the next five years, and I was subject to random urine testing at a frequency of at least twice per week.  I did as I was told and time went by.  At one point I decided to repaint the interior of our house, and beige walls were replaced by forest green, golden tan, and light burgundy.  I took up running and got in better shape.  I became active in community theater, something I had always wanted to do but now had time for.  I became more involved in the day-to-day lives of my children.
I had been released from residential treatment the day after September 11, 2001, and I found out a few days after the horrible attacks that my best friend from college, Commander Dan Shanower, had been killed at the Pentagon on that day.  My attention to his tragic death led to finding a job with the Transportation Security Administration providing medical clearance for new airport screeners.   That brought in some money, and we sold our vacation cottage to help pay the bills, but I knew that I needed a new career.  I loved being an anesthesiologist, but I knew that most relapses in anesthesiologists came to light when the addict was found dead in a call room.  After significant sober reflection I decided to return to residency—this time in psychiatry, to get back to my early interests in the mind and brain.
Starting over
It was difficult being a lowly resident again, but things could have been worse.  I know doctors with addictions who never made it back to practicing at all.  I have known addicts who died from their addictions.  Those AA bumper sticker slogans often contain true wisdom; my most appropriate bumper sticker reads ‘Gratitude is the Attitude.’  A common recovery phrase is ‘the Chinese symbol for crisis means opportunity.’  I don’t know whether the statement is true, but the sentiment is accurate.  I have seen recovering people do some amazing things, and I hope to be one of them.
My relapse, horrible as it was, resulted in a wealth of opportunity.  I mentioned my participation in Community Theater; circumstances also led to a position as a columnist for the trade journal Psychiatric Times.  I for years had dreamed of teaching but only now do I participate in that dream, teaching addiction and other topics to medical students and residents.  I appear in a weekly radio show about psychiatry and addiction, and I am, of course, writing this book!  None of these things would have happened if not for that fateful day in Eleuthera seven years ago.  I am not saying that my relapse was a good thing—don’t get me wrong about that!  But addiction– and relapse– do not have to be the end of one’s life.  For me, in many ways they were only the beginning.

User's Guide to Suboxone

Many of you are familiar with my e-book, ‘User’s Guide to Suboxone,’ that has been available for sale on the web.  The copy that is sold through that site is ‘print-protected’ and copy protected;  a password is required to open the document and it cannot be printed– at least not without a bit of digital trickery. 

e-book about buprenorphine

I was just looking through the book, and realized that it ain’t that bad– I’m no Hemingway, but I think that it contains some good ideas, and the words are spelled correctly.   The chapters are listed at the end of this post.
I plan to upgrade ‘the forum’ in the near future, and part of that process includes raising money for a web designer.  My friend Jim will always be the ‘right-hand guy’ with the programming, but I can only ask for so much free help before feeling guilty!  So if anyone out there has considered making a donation, now is the time…. because a $5 donation will get you a copy of the e-book, User’s Guide to Suboxone, sent as an e-mail attachment that unlike prior forms can be printed.  I do ask that you respect the copyright, and if you want a dozen copies for your treatment center, send me a note to work out a discount– rather than simply making 11 copies.
Instead of automating things this time around, if you want a copy of the printable e-book I’ll have you use the donation button on the right side of this web site.  Just make a donation of $5 or more, and I will use the e-mail address that you use for the PayPal or Google Checkout donation to send the book as an attachment.  I’ll get it out within a day or two.  Proceeds will go to the new SuboxForum– the more I raise, the nicer I hope to make it!  As always, thank you all for your support.
List of Chapters:
A Caution
Introduction
Introducing Buprenorphine
Practical considerations
High Tolerance at Induction
Precipitated Withdrawal
Pain control
Surgery
Pregnancy
Length of Maintenance
Tapering
Other Medications While On Buprenorphine
Other Drugs of Abuse
Benzodiazepines
Other Medications
Buprenorphine Side Effects
Twelve Step Meetings
Future trends

Clean Enough, 2.8 and 2.9

Treating myself
In the spring of 1993 I took codeine cough medicine for a cold.  A few weeks later I was still taking the codeine each evening.  It worked so well; finally I could relax and get some quality sleep!  I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word.  I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated.  I had ALWAYS accomplished what I set out to do!  By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed.  The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings.
I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all!  Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said.  “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.”  I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well?
As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine.  After trying to find will power and failing over and over, I finally ‘got it’; I had no control!  As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day.
I’m cured!
My admission of powerlessness was the start of my sobriety.  I soon found a treatment program that let me enter outpatient treatment, and I also began attending 12-step meetings.  AA and NA became guiding principles in my life, and over the next five years every area of my life improved.  My marriage and family life improved, I became Board Certified, I was elected Chief of our Anesthesia Department, my wife and I had another healthy daughter, we bought a vacation home… what’s not to like?
After five years of avoiding all intoxicating substances and attending AA, there was no doubt in my mind that my problems with addiction and opioids were behind me. Avoiding alcohol was not difficult, because I was never much of a drinker. One afternoon I had some friends over to watch the Green Bay Packers, who had been having a great season. I was serving beer in my home, something that I had avoided for the first several years of my sobriety, but that I began doing after becoming convinced that relapse was not a concern. At some point during the game I asked my wife whether she thought it would be a good idea for me to have a beer. How sneaky– I have since learned that we addicts will do this type of thing on the road to relapse; we set up a situation where we know in advance what the outcome will be—that outcome being the answer that the addict inside our brains wants to hear. We are looking for permission to take a very small chip out of our sobriety. I manipulated my wife into saying what I needed to hear, and a few minutes later I was sipping a beer. From that day forward it was okay to have beer during Packer games. It was then a logical step to enjoy a glass of wine with dinner. I found a wine store run by two retired college Geology professors, and tasting wine from different parts of France became an academic exercise. In fact, I was so inspired by the idea of lifelong learning that I began to enjoy this academic exercise every evening at dinner time. At some point I was introduced to port, a fascinating beverage that has a noble history and just happens to have higher alcohol content. When eating Mexican food, margaritas were, of course, more appropriate. And then I found that there is a huge world out there of aged cognacs, which have a history all their own!  Wow, I was learning a lot!

Clean Enough, chapter 2.3 and 2.4, My story continued

My Story (cont.)
Local hero

Hero for a day in 1979

Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since.  During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks.  I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic!  To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy.  But then I realized that something was fast-approaching in the current.  I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight.  I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling.  I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her.  After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!).  To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”
I am grateful that I was given the opportunity to be a hero.  There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God, for the times when I had little else to feel proud of..
Getting serious
Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York.  After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program.  I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school.  My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.
Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways.  His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after.  After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country.  Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’.   But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.
Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home.  At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.