Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.
Statistics and numbers don’t tell a story unless put into context, so some simple comparisons help demonstrate the magnitude of the ‘opioid problem.’  My perception is skewed after sitting with so many people affected by addiction, but we seem to have a huge blind spot for one of the leading killers of young people.  Consider the issues our country’s leaders talk about and our news reporters write about.   I think we all know the things that get our President’s undies in a bundle… but did I miss the Presidential Summit on Opioid Dependence?  This would not be the first time that our leaders missed the elephant in the living room, of course— but it may be one of the first times a President has been given a pass after missing this big an elephant for this long.  I’m old enough to remember the media soundly criticizing Reagan for failing to create a sense of urgency over AIDS.  And so I wonder… When is Obama going to express urgency about opioids?  Where is the media criticism of his lack of urgency?   Today he told reporters he ‘will leave everything on the field during his last year in office,’ just before he took off for another Christmas in Hawaii.  Will that time on the field include some concern for people killed by overdose?
I don’t get the impression that our President lies awake all night worrying about overdose deaths.  But maybe he should.  We heard a great deal from Obama about the need to bring troops home from Iraq a few years ago.  And all of the networks kept a running tally of US deaths in Iraq in the lower right corner of the screen during the evening news.   So let’s compare priorities.  Let’s add up all of the deaths of US troops during Iraq II during two administrations of Bush and the 1 and 3/4 Obama administrations.  Let’s add the deaths from the World Trade Center attacks, the recent terrorist attacks in France and California, and the mass shootings at Sandy Hook and Columbine.  How does that number compare to the impact of opioid dependence?
I don’t intend to lessen the honor of fallen military servicemen and women, or downplay the horror experienced by victims of 911 and other violent attacks.   I chose these numbers because the horror of each situation prompted speeches by our leaders, rallies by our citizens, and headlines in National news media.   The speeches and commitments of our President and the coverage by news anchors are supposed to be a reflection of what our citizens care about.
The number of deaths from overdose in 2013 alone– one year– was over four times greater than the complete count of US deaths in Iraq, plus all of the horrible events listed above.   US deaths in the Iraq war?  About 4500.  The Trade Center attacks killed almost 3000 people.   In 2013, over 30,000 US citizens died from overdose.  Surprised?  I was.  On average about 100 people in the US die from overdose every day– day after day.
As I wrote above, I remember the reporters calling out Reagan over AIDS.  Activists claimed that Reagan avoided talking about HIV because of the stigma associated with ‘homosexuals’, the people hit the hardest by the initial outbreak of HIV.   They say that the people who died were ‘second class citizens’ who didn’t have a voice, and it was easier for Reagan to pretend that the problem didn’t exist.  Many people believe that if Reagan spoke about AIDS in his speeches or directed National attention toward the outbreak of the virus, that fewer people would have died.   Maybe those people were right.
If they were, what’s Obama’s excuse?

Short-Timers

Another question from a reader:
The current blog brings up the notion of long term use of Bupe or short term detox.  You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug.  But-  what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.  
 The Suboxone helps with the W/D and just getting through with that is all we want.  NA meetings and the like are like being on Mars, it makes no sense.  There are no drug cravings at all and the goal is just normal.  Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them  And now that too is unavailable.  This group does not need Suboxone to become a new problem for them.  They just want the help.  It is not critically  important to determine “who” is being treated.  The certification training materials seem to brush over this so lightly that there is only one induction method allowed.  One that a drug company would love, but not always a patient —  pleading, do no harm.
My Thoughts:
I hear you, and watch for those patients.  Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list.   The financial motivation for the DOCTOR is to push people through, for that same reason.  Of course the drug company gets paid in either case.
The first question is whether buprenorphine even helps in the case you describe.   It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills.  It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter.  But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.
There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year;  those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox.  But I don’t know where those people would have fallen on the spectrum that you are presenting.  I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.
My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else.  They describe the process in different terms;  instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’  They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.
I agree with your thoughts, and get your point.  I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away.  Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits.  In a sense the pain is remembered, even after the original injury is repaired.  The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics…..  and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.
Thanks for your comments!

Mean Streak

I guess I do get irritable sometimes…  but I’m getting better at controlling my anger as I get older.  One cool thing about a blog is that I can go back and see what I wrote years ago.  In this case, I was looking for a post about telling the difference  between opioid toxicity (from taking too much) versus opioid withdrawal. In that post I suggested looking at the size of the pupils.  The name of the post, in case anyone is interested, is called ‘abres los ojos’— the name of an old Penelope Cruz movie and spanish for ‘open your eyes.’ 

Penelope Cruz sounds very cool, by the way, when she whispers ‘abres los ojos…’ as you can hear at the beginning of the movie trailer.  The movie was remade and called ‘Vanilla Sky’– again with Penelope Cruz, but this time with her speaking in English.
Am I the only one who cares about this stuff?!
The post BEFORE that one was from a time– 2009– when people often wrote to tell me how misguided I was for recommeding buprenoprhine.  Those comments, at a time when so many young people were dying from overdose, would really get to me.  I’ll share the exchange, for old time’s sake.  For people who enjoyed my older, feisty posts, they are still out there– you just need to keep hitting the ‘earlier posts’ button!
The post:
This guy doesn’t like Suboxone– or the horse it rode in on.  He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone.  It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!).  I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.
Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to 2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the good ole subs that all these Drs are making a fortune off. You must remember that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.
There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !
My Response:
Before my answer, a quick comment–  I do like the ‘crooks on wal-street’ remark;  I haven’t seen that ‘play on trademark words’ before.  I am assuming that he was making a joke–  he had to be, right?
OK, here is my response.  As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:
I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.
Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.
There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!
Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…
Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.
Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.
I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.
My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.
If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.
Back to the present…
Phew.  Makes me tired just remembering those days.  Since then the number of deaths have only gone up, but at least there is a better acceptance for treating opioid dependence using effective medications— at least for people ready to accept that help.

Brattleboro Vermont To Addicts: Stay Stoned!

I was stunned to see this story about the town of Brattleboro, a town in Vermont with a name famous for the rats that grew up there.
As an aside, my PhD thesis involved working with vasopressin receptors in the brain, and that is why I’m familiar with Brattleboro rats– a species of rat that spontaneously mutated and lost the ability to make vasopressin.
One would think that inhabitants of a town made famous over a rat would be on their best behavior.  But they behaved worse than their namesakes at a meeting intended to get the OK for a clinic to treat people using Suboxone.  I’ll let you read the article, while I get back to what I was doing when I stumbled across the article.  What a bunch of…
Ah, forget it.

Consequences Section

Weeks ago I posted a few new ideas—things like a memorial wall for victims of opioid dependence, and a ‘wall of shame’ for doctors who are known for reckless prescribing of opioids.  I mentioned these ideas over at SuboxForum as well.
I received good feedback from readers here, and from members there.  Sometimes the best feedback is the hardest to hear;  I’ll get excited about a certain plan of action, and like anyone, I don’t like it when someone rains on my parade.
One of my addiction docs from years ago was big on ‘sober thinking.’  Back then, it seemed as if anything I came up with that pushed the boundaries was in need of more ‘sober thinking.’  I wondered if ‘sober thinking’ was simply code for ‘I don’t want to say yes to your idea, and maybe that was the case in SOME instances.  But I now recognize a part of myself that acts quickly, impulsively, with great optimism, and with little regard for risks.  ‘Sober thinking’ is simply letting an idea sit in one’s mind for a few days or even weeks, and keeping a truly open mind to the comments that one receives about the idea.

Prison is a better consequence to heroin addiction
Beats Death--- Barely

I won’t spell out who wrote to me, but I’ll thank the people who did—who risked my ire by giving their honest opinions.  I mentioned a memorial page;  some people pointed out that a memorial on an addiction-related web page may add to the pain and shame felt by family members.  As for my ‘doctor wall of shame’, I was reminded that every story has two sides, and it may be more useful to simply provide referenced information that would allow readers to make up their minds without my own coloring of the facts.  I want to thank the people who wrote, and let them know that they made a difference—and the site will be better because of their efforts.
Instead of the earlier ideas, I added what I am calling the ‘consequences’ page.  The page will contain news stories identified to Google as having ‘drug overdose’ in their tags.  The information will be replaced every 24 hours or so.  I experimented with a couple different intervals and found that no day went by without a significant amount of news under that tag—a rather compelling statistic!
Click on ‘consequences’ to check it out, and let me know what you think!

Endorphin Deficiency Syndrome and Buprenorphine

Every now and then I receive an e-mail  or comment that is sufficiently long to warrant a post of it’s own.  Below is the comment without interruption;  a bit lower I repeat parts of the comment, interspersed with my own responses.  I hope you find it interesting.
The comment:
I am a strange case: vegetarian, healthy, Pilates instructor, good-looking– NEVER A DRUG ADDICT — but i had a secret-  I was badly depressed for years- treatment resistant to over 30 meds, only some helped to a point… I did extensive research into the brain and opiate systems and i wondered if it was possible my endorphin system may be the culprit ( check this primer: http://www.prohibitionkills.blogspot.com/)
 I was desperate enough to try out opiates as a final solution ( and I monitored myself- I have brakes yet I was always scared of tolerance– and forever afraid to keep on that track) then i found my holy grail… i learned about Suboxone’s other use-  ( and it is now being studied for depression)
I was forced to lie to get on Suboxone, i pretended i was an Oxycontin addict etc.. i know that is wrong, but i was trying to save my life ( i was already at the point of suicide attempts)…not only did i get better, i brought my  mother in who was also treatment resistant and she was made better also within a week when even ECT failed her and messed up her brain for a good year…..she still takes what i took- 1mg in morning, 1mg in afternoon ( we both sensed that was when we needed a second dose not uncommon believe it or not for other depression sufferers that noticed a drop in the afternoon that Suboxone was again needed)
Anyway she is doing great on it to this day…saved her.
Me after intense meditation for one month- seriously no joke – i sensed i was ready to go off it.
 i do everything the hard way- so i went cold turkey off my 2mg a day after being on it for 5 years.
lucky for me- no depression- although the withdrawal did a real number on me– i was so sick from flu and withdrawal , horrible coughing, sore throat, dizzy and weak i wound up at the ER – thought i had H1N1. lol !  I was bed-ridden for almost 2 weeks; i ate nothing for a whole week but soups.
it was NO walk in the park, i was so weak i could not brush the tangles from my hair, even talk much to anyone. and the sweats were out of this world.
i am now at one month and 2 weeks.  i still feel  kind of weak and sickly, swollen glands, and sometimes a sore throat a little, my face is pale and i have huge dark circles under my eyes… the sweats have almost stopped….but my pupils still dilate… when i exercise i tend to feel worse not better — why is that?  
but my real question is this:  why does it make me look so pale and dark circles- ??? is it the interrupted sleep?? or low blood pressure or vitamin deficiencies?? Anemia – i take lots of vitamins and 3 iron pills a night (always did as a vegetarian).   i only wake up once or twice a night and i take a quarter of sleeping pill – unfortunately- every night still- otherwise i will be up forever..
And is there any nutritional things i can do to make me look less ghastly??  i look like a heroin addict and feel like people will see me that way as i can’t keep saying i have a flu forever !! ! What puts color back in the face ??
* before u lecture me about my terrible lie to the Suboxone doctor ( i think he knows anyway as he had to fudge my notes to make me a worse addict than  i claimed)  but u know what?? When i was in ER , and could hardly walk straight from my flu + withdrawal–i told the doctor while i felt like i was dying – that even then…  i was so happy i took Suboxone – it cured me and my mom FROM A LIFETIME of DEPRESSION. 
there IS NO withdrawal that is worth depression, let alone years of it, so please don’t lecture me on what i did, i saved 2 peoples’ lives by lying and i would do it again in a heartbeat…( in fact i was so angry when i found they have a cure for treatment resistant depression i tried in vain to contact media sources to publish a story on it- but who would touch that??)
edie
Wow.  I am exhausted.  I’m not sure why- but some comments take so much energy to get through—and this was one of those comments.  Is it just me? 

First things first: Never hesitate to call drug addiction hotlines for help in drug emergency cases.

Some of my answers will likely come across as harsh, and for that I apologize in advance.  I don’t wish Edie any bad will, but my comments will probably show that I think she has gotten a bit carried away with some of her ideas.  Besides, some of the readers LIKE it when I get obnoxious.  Admit it!
My responses—for those of you who still have some energy left:
I am a strange case: vegetarian, healthy, Pilates instructor, good-looking– NEVER A DRUG ADDICT — but i had a secret-  I was badly depressed for years- treatment resistant to over 30 meds, only some helped to a point… I did extensive research into the brain and opiate systems and i wondered if it was possible my endorphin system may be the culprit (check this primer: http://www.prohibitionkills.blogspot.com/)
Most of my friends are drug addicts.  Most are not good-looking.  They all eat meat—lots of it—and laugh at people in Pilates classes.  And they AREN’T depressed.  I’m not drawing any conclusions—just pointing out an inverse correlation with an ‘n’ of about 6.  I’m also suspicious of the ’30 meds’ comment;  it would take a lifetime to give 30 meds adequate trials, even if there were 30 different meds for depression.  But I exaggerate too, so no big deal.
The primer is interesting, mainly for the collection of links to articles about the effects of opioids on mood and depression.  Edie describes doing ‘extensive research into the brain and opiate systems.’  I don’t know exactly what she did, but the long treatise at the url above is in no way scholarly, but rather is a collection of scattered, mostly-minor studies and comments with many, many incorrect statements, all intended to make the reader believe that there is a unique type of depression caused by deficiencies in the body’s endorphins.  I hardly know where to start—but the article, for example, claims that Effexor (venlafaxine) is a good antidepressant in part because of its similarity to the actions of tramadol— and that implies that venlafaxine effects the endogenous opioid system.  This is all nonsense.  Venlafaxine is an SNRI.  Tramadol has effects on norepinephrine reuptake as well.  But tramadol has entirely SEPARATE effects on the mu receptor that are NOT shared by venlafaxine.
The comments about acupuncture… there are a host of studies that show a failure of opioid antagonists to block the analgesia produce by acupuncture—evidence for an effect that does NOT involve endogenous opioids (which are blocked by naltrexone).
I honestly could go on and on and on… we know the mechanism of capsaicin on the release of substance P;  the effects are a very long shot from thinking that using (or eating!) capsaicin will somehow increase a person’s endorphins.  The writer describes a type of patient—a combination of cluster B traits from the DSM, along with assorted personality traits like ‘crying easily.’  Evidently somebody wrote a book.  Understand that the current distinctions between mood disorders, while not perfect, are based on hundreds of studies and years of input from psychiatry thought leaders—who then have their opinions examined and tossed around by more thought leaders.  Comparing the list of symptoms for ‘endorphin deficiency syndrome’ in the article with the longstanding and scientifically-validated diagnoses from the DSM is like someone writing a poem off the top of his head and saying it belongs in the Bible.
The problem is that there is such a thing as REAL science.  I actually DID study neurochemistry and neuroscience during my work for my PhD, and despite that four years of intensive labwork, lectures with distinguished scientists, searching through literature to write and defend my 150-page thesis—despite ALL of that and then my medical school training—I learned about a tiny, tiny bit of how the brain works.  The actions of receptors, neurotransmitters, and their relationships to mood and other subjective states encompasses a vast amount of knowledge, much of which contradicts itself from one study to the next.  One cannot extract a few studies out of ten thousand and use them to draw conclusions.  I’m searching for an analogy… it is like measuring the temperature during one minute from one hour of one day, in a town in Southern Wisconsin, and saying that you therefore understand the climate of the US—and that the US is a rainy and cold place.  You would be ignoring all of the other towns, times, and temperatures—and thinking that your point about the US was still valid.
I’m never going to finish this…
I learned about Suboxone’s other use-  ( and it is now being studied for depression)
I do recommend that people periodically check www.clinicaltrials.gov to see the interesting studies involving buprenorphine.  I would expect other partial agonists to appear on the scene in due course.
I was forced to lie to get on Suboxone, i pretended i was an Oxycontin addict etc.. i know that is wrong, but i was trying to save my life
I’m sorry to interrupt, but this sure sounds like something an addict would say, doesn’t it?  Nobody can be ‘forced to lie;’  we CHOOSE to lie because we like what the lie does for us.  Maybe it was justified… but ‘forced’?  C’mon.
i am now at one month and 2 weeks.  i still feel  kind of weak and sickly, swollen glands, and sometimes a sore throat a little, my face is pale and i have huge dark circles under my eyes… the sweats have almost stopped….but my pupils still dilate
So much for being good looking!  Sorry—just another bitter, bad-looking bald guy…
why does it make me look so pale and dark circles- ??? is it the interrupted sleep?? or low blood pressure or vitamin deficiencies?? Anemia – i take lots of vitamins and 3 iron pills a night (always did as a vegetarian).  
Shoot—I was just going to suggest a good T-Bone, medium rare.  But seriously, the dark circles can be caused by tiny hemorrhages around capillaries, which tend to be very fragile under the eyes… and the pallor of the skin from vasoconstriction in that part of the body—which is part of opioid withdrawal, along with the ‘goose flesh’ that is so common. 
And is there any nutritional things i can do to make me look less ghastly??  i look like a heroin addict and feel like people will see me that way
There you go again, dissing addicts!  I’m sorry, but heroin addict don’t all look the same, and they don’t  all look ‘ghastly.’  I have patients in my practice who were opioid addicts—some oxycodone, some heroin, most whichever was around— who look like the other people they work with on the job as teachers, carpenters, attorneys, nurses, and CEOs.   And no—the thing that will make you look and feel better is TIME.
* before u lecture me about my terrible lie to the Suboxone doctor
Oops—did that already!
please don’t lecture me on what i did, i saved 2 peoples’ lives by lying and i would do it again in a heartbeat…( in fact i was so angry when i found they have a cure for treatment resistant depression….
I NEVER lecture people, but I don’t know if you would get the Nobel prize in Medicine for what you did—although didn’t Al Gore get it for something already anyway?
I’ll stop here.   There is no conspiracy, and buprenorphine is not a ‘cure’ for treatment resistant depression.  Yes, it does seem to improve mood for SOME people.  But there are big downsides—for example the state that you currently are in.  You may be positive that you are not an addict, but I’m not;  your lie to get yourself on buprenorphine for a while MAY have placed something in you that you cannot yet see, that you will regret some day.  If, in five years, you are free of depression and also free of opioids, then it appears that at least in YOUR case, the experiment worked.  But frankly, the odds are against you.  You will tell me all of the reasons why you are different, and special, and why you will never use again…. But I suspect that if the depression returns, you will have a hard time avoiding another lie for another trial of opioids.  If you can’t get buprenorphine but instead buy opioids on the street, you are looking pretty similar to every other opioid addict—ghastly or not.
I have written about this topic before, and included links to some of the things linked on the url that Edie provided.  My bottom line?  If a person has a history of depression and is an opioid addict, there is one more reason to stay on buprenorphine long-term.  But I would have to think very long before conditioning a person to crave opioids—which is essentially what Edie has done.  As my treatment-roommate said (about regretting making porno movies with his wife while using), ‘there are some things that we learn, that we cannot unlearn.’    The warm, fuzzy feeling provided by opioids is one of those unlearnable things, and the lesson comes at a steep price—especially in a person who is prone to episodes of depression that only respond to opioids!
I hope I wasn’t too rough, Edie—I do wish you the best.

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.

Unintended Consequences

I saw a patient from up north earlier today, and we tallked about the economy in his part of Wisconsin and in the Michigan Upper Peninsula.  From what he had to say, things are the ‘same old same old;’ i.e. jobs are few and far-between.  Seems as if it has been that way for a long time now.  And it’s hard to imagine any industry doing well enough in the current economy to make a dramatic change up there.
One change that HAS become apparent over the past year is the increased availability of heroin, now easily found in small towns throughout the upper Midwest.  I’ve seen the same trend closer to my practice, where heroin use has grown from a Milwaukee phenomenon to just another high school temptation.  And a troubling comment pops up more and more during my discussions with people actively addicted to opioids:  “Now that O-C’s are abuse-proof, we gotta’ use heroin.”
I’ve mentioned the requirement for REMS– Risk Evaluation and Mitigation Strategies– for opioids announced by the FDA about a year ago.  The requirement for REMS on a class-wide basis– a novel use of the FDA’s regulatory powers– places pressure on the manufacturers of opioids to find solutions to the epidemic of opioid dependence. One result has been the development of medications with lower abuse potential, such as the new formulation of oxycontin, which when crushed (a feat by itself) yields a gooey mess that clogs nasal passages and needles if taken by those routes.  But the law of unintended consequences applies to this domain, as one would expect, given the tangled mess of political, societal, and economic forces involved in the epidemic of opioid dependence.  There are many addicts out there, each subject to severe withdrawal in the absence of their daily dose of oxycodone;  what would a reasonable person expect them to do, knowing the intensity of their desire for opioids– and their fear of withdrawal?  Are they just going to stop?
My last patient explained it just fine… and he isn’t even a D.C. social worker.   “Oxycontin or heroin–  it really doesn’t make no difference.  It’s all the same thing– one just isn’t around anymore.”
Unfortunately, he wasn’t referring to heroin.
I do have a question– a genuine question, not a facetious one.  At least in Wisconsin, diverted Oxycontin is often used nasally, and heroin used by needle.  I’m sure that part of  the reason for that different route of use is because heroin has tended (at least until now) to be used later in the course of addiction, and there is a progression to parenteral use of substances over time, as addicts seek more efficient means of using.  My question– are there other reasons that heroin users favor intravenous over nasal use?  To frame the question a bit differently– it appears that the prevention efforts aimed at Oxycontin have caused an increase in the use of heroin.  Did they cause in increase in intravenous drug use as well?

A true epidemic, with no easy scapegoats

Today an article on the web site Medscape describes the epidemic of opioid dependence in this country.  The article describes what people who work with addiction already know– that use of opioid medications has increased in a way never seen before for any medication.  The article does a good job of presenting the statistics, and puts forward the more obvious conclusions that can be made about the cause of the problem and some possible ways to reduce the magnitude of the problem.  As the article suggests, the databases that have been established in many states to monitor narcotic prescriptions will reduce doctor shopping.  Some experts are calling for special training and certification for doctors who prescribe opioids.  I am surprised that at a time when so many states are recognizing the problem, there are still numerous pain clinics throughout Florida that each pump out thousands of scripts for opioids, seemingly without any effort to stop them.  What’s with Florida, anyway?!

Death rates due to accidental overdose

The largest newspaper in Milwaukee Wisconsin has featured several articles about the local prescription drug problem.  I spoke with the author of the latest front page story about the subject, and tried to explain the complex nature of the problem.  I hoped that he would do the topic justice by writing something deeper than the typical ‘find someone to blame’ article that most papers resort to these days.  I even offered to set him up with a patient of mine who used those Florida-based pain clinics in the past, who ended up on ridiculously-high amounts of pain medication, and still struggles years later to lower his tolerance level.  The patient would have explained that it isn’t just ‘bad doctors.’  He would have explained that sometimes the problem is that a person will have severe pain, and will not be able to say ‘no’ to relief of that pain.  He would have explained that more and more doctors are simply ‘opting out’ of prescribing pain medications;  that if he had the gall to say to his primary care doc that his back hurt, his doc would have cut off the discussion and looked at him suspiciously from that point forward.  Because so many docs won’t deal with the difficulties associated with treating chronic pain, patients are left searching for pain pills in all the wrong places– and left taking them with little or no guidance or supervision.
Unfortunately the Milwaukee Journal-Sentinel writer took the easy way out, and instead of trying to capture the true essence of the problem he wrote a hack piece about ‘pill pushing doctors.’  I don’t personally know any of the docs he pointed out by name in the story– the story he wrote from the safety of behind his desk, where like most reporters he never has to make the tough decisions himself.  I wonder, though, if all of the docs he smeared were ‘bad docs,’ or rather if some of them were struggling with the tough questions that many docs now choose to avoid.  The article featured a photo of a tearful couple who lost a family member to overdose;  their daughter was being treated by one of the pain docs presented in the article as the lowest-of-the-low, a pill-pusher who destroyed the girl’s life.  And my heart goes out to those parents.  I see many people just like them in my practice; parents who have lost a child or who are struggling with the decision whether to put their addict-son or addict-daughter out on the street, or to instead let them live in the basement where they are using every night, where the parents dread looking each morning, into the dark silence, afraid of seeing their worst fear come to pass.
Drug deaths become number one

I don’t know the pain doc smeared in that article, but I do know what it is like to sit in the office with a person crying out in pain, begging for medication to provide relief from that pain. I was an anesthesiologist for ten years, after all, working in a pain clinic of my own.  And when treating someone’s pain, there is no way to get inside that person and determine exactly what the person is experiencing.  Yes, there were many times when I wondered if the pain was REALLY that severe.  There were some things I could try to use to determine whether the patient was ‘faking;’  I could check the respiratory rate, the blood pressure, and try to determine if the tears were real, or came from the drinking water down the hall.  My answer about faking, most of the time, was that the patient was NOT faking.  The patient was experiencing severe pain.  I knew that many people with the same injury would NOT have such severe pain, but for some reason this person DID have severe pain.  Who was I to say differently?  How can any doc listen to a patient describe severe pain, and then look at the patient and say ‘no– you are not in pain.’  Would YOU go to that doctor? 
Are you ready for the complicated article that Tom Kertscher of the Milwaukee Journal Sentinel SHOULD have written?  Those grief-stricken parents in the picture in his article about pill-pushing doctors, who are mourning the loss of their daughter and struggling to assign blame, are blaming the guy who might be the ONE doctor who truly cared, and who tried to help their daughter.  The daughter came to him, looking for help for her pain.  Other doctors turned her away, and told her ‘you DON’T have pain,’ when in reality they didn’t know whether she did or not.  They just knew it was easier to tell her to take a hike, or to say ‘I’m sorry, but I don’t prescribe pain pills,’ or to say ‘my healthcare system won’t let me prescribe them.’  Those doctors who ignored her pain didn’t know if her pain was real or not.  But there was one thing that they DID know– they knew that if they DID empathize with this patient, someone’s daughter, and if she ended up taking too many of the pills one night, they knew that some reporter hack would come ’round and blame them in some one-sided, simpleton-pleasing, ‘gotcha’ article in the Milwaukee Journal Sentinel.  So those docs closed their hearts to the pleadings for pain relief from a patient and kept their licenses for another day.  And the doc who couldn’t say no to her requests for help– who gave in and prescribed pain-relieving medication for the couple’s daughter– ends up being the bad guy.  Go figure.
Deaths rise as prescriptions rise

I have to point out that for non-malignant pain that has no finite endpoint, narcotics are rarely a good answer.  I have had patients say to me ‘I would rather live without pain for today and die next year, than have pain for the next twenty years,’ and to that I have said ‘that is why you need a doctor.  I cannot let you make that choice.’  I recognize that there ARE docs who prescribe pain pills MUCH too easily and loosely, causing a great deal of trouble for the patient in the end.  But they don’t prescribe because they are ‘evil;’  they prescribe because they have a hard time ignoring someone’s pain.  Maybe they need help dealing with confrontation.  Maybe they need to toughen up a little bit.  But they are not ‘evil.’ 
This is a little of the story that SHOULD have been written about the pain pill epidemic.  Then it could go into how people these days want everything to be ‘fixed,’ and that is why everyone takes pain pills.  Or it could say that the bad economy puts so much pressure on people to avoid missing work that they cannot rest an injury, and that is why everyone takes pain pills.  Or it could say that the violence of the inner city or the divorce rates in the suburbs leave people with emotional pain, and THAT is why everyone takes pain pills.   If only every problem had something to blame. 
I’m struggling with closing this post, and it is getting way too late.  I’ll just say one last thing– for those with young kids, keep talking about how horrible this problem is.  Don’t glamorize it, because it is not pretty– just let them know that unlike many things that young people do, taking pain pills incorrectly causes something that lasts a lifetime.  I invite people to check out some of the links in my ‘blogspot’ to see some of the faces of the epidemic, and to share those with your kids as well.
JJ

The point of addiction treatment

I worked for several years as the medical director of a residential treatment center in Wisconsin, leaving the position several weeks ago.   On my last evening in the place I took a moment to look around and think about how addiction treatment has changed in the past decade.  I looked at the pictures of the patients in their charts, who were mostly in their late teens or early 20’s.  The most common class of ‘drugs of choice’ were opioids, including oxycodone, heroin, methadone, morphine, and hydrocodone.  I thought about the different but similar program that I attended ten years ago, filled mostly with addicts and alcoholics in their 30’s and older.  I wonder if Bill W would have come up with the same twelve steps, had his target been not 50-year-old alcoholics, but teenage heroin addicts!

On the walls around me were posted sheets of paper, and on them were lists of ideas from a brain-storming session about how to remain competitive in the modern era of addiction treatment.   I scanned the 20-some pages for mention of buprenorphine, and found the medication mentioned only once, under ‘challenges.’  On the other hand there a number of ideas related to marketing, endowment funding, and public image.  What I saw in that room essentially summarized the problems with traditional treatment in an era of buprenorphine.  It also validated my decision that it was time to move on.

When I was an anesthesiologist I went through a period of frustration over the American Heart Association’s ACLS treatment guidelines, or more specifically over how they were implemented by the hospital where I worked.  The guidelines provide easy-to-remember steps to use when treating victims of cardiac arrest.  As an anesthesiologist, my education and training taught me to think ‘physiologically;’ if my patient on the OR table went into cardiac arrest, my training allowed me to quickly decide the likely cause, the appropriate medication for that problem, and the proper dose of medication based on body composition, patient age, other medications, medical history, fluid balance, etc.  ACLS guidelines were not initially devised for anesthesiologists, but for paramedics and other medical professionals who had less critical care training and experience.  To keep things simple enough to remember, the ACLS guidelines provide general medication and dose recommendations based on averages, not tailored to specific conditions or patients.  The dose of epinephrine listed in the protocol is 1 mg, whether the patient is a 20-y-o male athlete or a 95-y-o woman.  That dose may or may not be appropriate for either a 20-y-o or a 95-y-o–  but it is certainly not the correct dose for both!  But that’s OK, because we were just talking ‘guidelines,’ not hard and fast rules.

The problem began when nursing educators started teaching ACLS classes not only to paramedics, but to physicians as well.  I attended those classes—I had to, just as most physicians who are part of networks are required to do every three years.  In most courses I attended, physicians who asked about optimizing doses based on patient characteristics were told to stick to the algorithm so that people didn’t get confused.  The result, of course, was to dumb down the classes, and to dumb down the people taking the classes.  The issue comes down to whether to trust that individual doctors will be able to think and get it RIGHT, or to assume that they will get it wrong and therefore give them easy-to-memorize instructions.  I could go off and extrapolate to modern society as a whole, but I’ll try to control myself!  The problem with telling docs to avoid thinking and to instead just follow the protocols is that the guidelines are SO generalized that they almost guarantee failure.

Successful resuscitations are relatively uncommon, making it difficult to come up with treatment guidelines that are clearly good or clearly bad.  Over the years, ACLS guidelines have changed in drastic ways.  Some interventions recommended as beneficial were later found to make things worse.  It is hard enough to decide if standardized, dumbed-down guidelines are beneficial, so you can imagine how hard it would be to determine if a single doctor’s care was good or bad.

What I took issue with was the push for consistency, and the effect of that push on patient care.  After a cardiac arrest and resuscitation in the hospital, the chart was reviewed by quality assurance and by a committee that included the people who taught the ACLS courses.  No problem so far.  But if a doctor deviated from the ACLS protocol, things got silly.  The doctor would be asked to provide reasons for deviating from protocol, including support from the literature for the deviation.  But the literature focuses on whether the ACLS protocols themselves are of any value, so there are few studies of non-ACLS approaches.  There are no studies of the effects of using 750 micrograms of epinephrine instead of 1 mg in a cardiac arrest in a 54-y-o man on beta-blockers, having hernia surgery, who is slightly dehydrated and has a history of mitral stenosis!

Initially the ACLS protocols were designed to help people with less knowledge of physiology provide adequate treatment.   But over time, the protocols became the final authority on treatment.  So if a patient with an intelligent physician has a heart attack in the cath lab, the doc now has to make a decision.  Is the doctor going to give medications and doses of medication specifically geared toward this one patient—and then be hung out to dry by the hospital QA department (which is run by nurse educators who don’t understand this issue)?  Or should the doctor just turn his brain off and follow the ACLS protocols, guaranteeing that there won’t be any calls for explanations?  The irony is that a doctor who never successfully resuscitates a patient will never run into trouble, provided that the ACLS algorithms are followed—he/she may even get an award!  But the doc who saves an occasional patient by THINKING and figuring out the perfect treatment is likely to run into all kinds of trouble!  If you were the patient with that smart doctor, and you were facing low odds of survival, would you rather have the standardized, one-size-fits-all approach that rarely works?  Or would you want your doc to risk getting written up by using the new medication that he read about that he thinks would fit your condition, but that isn’t on the protocol sheet?

How do we get back to addiction treatment?  About 100 years ago some people came up with the twelve steps.  I don’t know the history of early AA as well as many, but the steps were devised for the patients of the time, who were mainly middle-aged alcoholics, mostly Caucasian, and mostly male.  The steps have stood the test of time, and are now applied to many different substance addictions, and even to non-substance disorders such as eating disorders and pathological gambling.  Do they work for those conditions?  Sometimes.  Like cardiac arrests, the conditions treated by the twelve steps tend to have very low success rates for ALL treatment strategies, so the steps don’t have to work very well to be as good as anything else.  I have great respect for the twelve steps, but some have imparted them almost magical qualities that can be used to fix anything!

Some addiction treatment centers are fixated on the steps not as a treatment tool but as a special entity, so that they seem to favor ‘purity of sobriety’ over saving lives.  As a fan of the steps myself, I too see ‘sobriety’ in a biased way, making it all the more difficult to describe this concept.  Bear with me—maybe my point will be clearer if I ask a few questions.  I encourage you to come up with your own answers, and to discuss this topic at the forum.

What is the point of treatment?  When a patient enters a treatment program, how should them measure success?  If everyone is hugging each other and going to meetings at the end of 30, 60, or 90 days, is that enough?  If 85% of those ‘successful treatments’ are using after one year, should the treatment center feel good about the job they are doing?

At the forum, we try to avoid discussions about ‘who is more clean’ because there really is no answer to the question.  Today I surfed past a silly TV program where the Real Housewives of New Jersey were divided into two groups, arguing with each other over who was meaner, who lied first, who said what to who… all shouting over each other.  Do they really think that one side will ‘win?’  That’s how I feel about ‘who is more recovered’ arguments.  And I am gratified that most of the discussions at the forum show far more class and intelligence than that particular topic!  My questions here are not intended to go down that path; these questions are to make the point that there are bigger issues than ‘whose recovery is better.’
Which of the following outcomes should a treatment center prefer?  Patient A leaves treatment totally free of all substances after 30 days of a 30-day program. He enters a halfway house and leaves after 90 days, still clean.  After six months he stops attending meetings.  Three months later his friend from his home town pays him a visit, and after drinking a few beers and taking a couple 80’s for old time’s sake he dies in his sleep.  Patient B leaves treatment after 21 of 30 days and against the counselors’ advice finds a doc who prescribes buprenorphine.  After a month on buprenorphine he takes a couple 80’s with an old friend, and doesn’t feel anything from taking them.  The next month he takes an extra buprenorphine tab every now and then, so that he runs out early.  He doesn’t call his doc, and instead gets sick for a day or two at the end of the month.  He even takes some methadone to ‘treat’ the withdrawal, but it doesn’t really do anything.  After four months he has talked to his doc about these things several times, and is starting to get used to—and enjoy–not feeling high.  At eight months an old friend visits and gives him a couple 80’s.  He knows that they won’t do anything, so he passes on them.  Or maybe he is having a rough day and he gives in one last time—but they don’t do anything.

I am not implying that a patient necessarily does better with buprenorphine (although I do think that it is the case that patients do better with buprenorphine!).  My point is to show two types of ‘recovery,’ and to ask, which patient of the two is doing better?  MY answer is that the second person is better off, because he is ALIVE.  I would think that most people would agree—that it is better to be alive than dead.  But some of the attitudes I have witnessed among traditional counselors make me think that they are so intent on a twisted version of ‘perfection’ that they would feel better about the first patient!  I was speaking with the CEO of a hospital recently who said that if hospitals had a 15% success rate for other diseases, they would be viewed as dismal failures.  But in recovery, there seems to be an attitude that the failure rate is acceptable—as long as someone lives.  I hope that buprenorphine prompts movement toward a new paradigm where it is no longer acceptable, accepted, or ‘a given’ that many people die.

The steps were designed, in my view, with the help of divine intervention.  They sometimes offer the gift of sobriety to a suffering alcoholic who has reached rock bottom.   There have been attempts to use them to achieve sobriety from other substances, including opioids, and they sometimes help a desperate opioid addict.  But it is much more difficult, and rare, for a teenage opioid addict to accept ‘powerlessness’ than for a jaundiced, middle-aged alcoholic to do the same.  Like the ACLS algorithms, the steps are a ‘one-size fits all’ approach to treatment.  Like the algorithms, they can be a valuable tool.  But for both the algorithms and the steps, the point should NOT be on the purity of the treatment approach; the point should be whether lives are being saved, and whether an imperfect approach that uses out-of-the-box thinking might save a few more.

The REAL challenge facing traditional treatment centers will be to let go of their old ideas of ‘perfect sobriety’ and to use the treatment tools that have the best chance of keeping addicts alive.  Doing so should not be that difficult;  all they need  do is look at the faces of the young addicts entering their programs, and ask themselves, honestly, how many will be alive after a few years?  The honest counselors at traditional, non-buprenorphine programs should be humbled, and even ashamed, by what they know about those numbers.