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!

Scam City

When Suboxone first became an option for treating addiction to pain pills back in 2003, some people were excited about having a cure for opioid dependence. Those people were mistaken. It is true that Suboxone has been a huge benefit for treating opioid dependence, but the medication cannot cause the permanent changes in the brain that would be necessary to prevent relapse. Instead, in order for the medication to work, people must do what they do with other medications—keep taking it.

Addiction treatment-- a scam?
Not all scams are so obvious

I recently read an article on another web site that advocated a certain person’s ‘method’ for rapid opioid detox. I went to the primary web site for the developers of that method—pulled to the site in the same way that I am drawn to watch late-night commercials for get-rich-quick schemes or male enhancement products. On the web site I read that they have a new reason to take large sums of money from those addicts fortunate enough to have money, and unfortunate enough to believe their hype— a special, rapid way to change brain function.
We are spending tens of millions of dollars through NIH to understand neuronal ‘plasticity’—the term for the ability of the brain to adapt in response to the environment—and here some guy at a detox clinic has it all figured out!
As I read the web site, I thought about all of the addiction ‘cures’ that I’ve read about over the years, such as the secret blend of amino acids that one program offers (I wrote to the advocates of that treatment to ask how it works, and was told that they would give me the recipe for only $15,000). I thought about my opportunity a year or two ago to review the bill of a person treated at one of those $70,000 per month addiction treatment centers out west somewhere; the bill was padded with one type of therapy after another, with names like ‘mood therapy,’ or ‘PTSD resolution therapy,’ or ‘energy-field releasing therapy.’ The charge for a ‘treatment’? Prices ranged from $700 – $1200… per SESSION, day after day. On many individual days, the person was billed for multiple types of therapy, each costing $1000 or more. Now I know– THAT’S how you get to 70 grand per month!
With all this in mind, I have to wonder– is addiction treatment the last refuge for snake-oil salesmen? Where are the good folks at the FDA when people throw scientific mumbo-jumbo to extract money from desperate people? Maybe I should quit charging the peanuts of a typical private practice—where insurers think an hour is worth a hundred bucks, and the state considers an hour worth $37.50—and instead hang a sign, and make a web site, and offer ‘Selective Cranio- Axial Meningotherapy’ (SCAM) or Bitemporal Sensory (BS) Therapy or Rapid Intentional Pseudo – Olfactory Field Focusing!
I’ve criticized doctors who prescribe Suboxone as well; namely those who take the quick buck to get a person started on Suboxone, then leave the person to find a long-term prescriber on his/her own—knowing that such doctors are impossible to find in many areas.
It is relatively easy to get a person clean for a few weeks. In fact, if anyone desperately wants to get off opioids, bring me $20,000 and I will chain you to the steel post in the center of my basement—and I’ll even throw in meals. The hard part, of course, is keeping you clean AFTER you leave. So for an extra $50,000—the same price charged by many month-long treatment centers—I will provide a couple hours of therapy each day (weekends off of course), and put out an easel for you to draw pictures of traumatic events from your childhood.
Sounds silly, I know—but the truth is even sillier. I bet that the number of long-term cures from MY basement treatment would rival those from any of the methods or programs that I alluded to. From either program—mine or theirs– the long-term relapse rates would be very high.
Fortunately, there IS a long-term treatment for opioid dependence— buprenorphine– that has proven to be safe and effective. The way to make the treatment work is to follow the same principles that are used for a host of other medical conditions: 1. Get a good doctor. 2. Start the right medication. 3. Keep taking the medication. Psychotherapy might be helpful as well, but definitive studies on the value of psychotherapy for Suboxone patients have not yet been done. But we DO know the importance of staying on the medication.
Who knows– you might even save yourself a bundle.

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.

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 2.5, 2.6, and 2.7

My Story (continued)
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!

Eleuthera beach
Eleuthera awaits...

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!
Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup.  Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.
In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket!  I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days!  So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera.  I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well.  Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way.  I eventually learned that both were true—but that and other realizations required further ‘education.’  I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.

Clean Enough, Chapter 1.3: Bias of the book

Introduction
Bias of the book
You will notice the several times throughout the book I take issue with people over what they say about buprenorphine treatment of opiate dependence.  On my web sites I have been told by those who favor ‘total sobriety’ that I am biased in favor of Suboxone.  I don’t know how to best respond to those characterizations.  I have reviewed the studies related to buprenorphine and Suboxone and become sufficiently educated to understand and critically evaluate those studies.  I have experienced opiate dependence for 17 years and experienced treatment failures and treatment successes.  I have experienced relapse and watched friends relapse and in some cases die from addiction.  I have worked for years with addicts in solo practice, in the Veterans Administration setting, in prisons for men and for women, and in residential treatments that do not use Suboxone at all.  After all of these experiences, I have strong opinions over which treatment methods are more effective than others.  Does favoring the more effective method make me ‘biased’?
But my problem with the ‘bias’ accusation is more complicated than choosing winners and losers.  The people who speak of ‘bias’ usually present a choice between Suboxone and ‘being free of drugs’.  We know, and they should know, that being free of drugs is not a real choice. People who are addicted to opiates and who want to stop have always required intensive residential treatment for a period of 90 days or more.  Even with that intensity of treatment, one-year sobriety rates hover around 50%– much lower for 5 years of sobriety.  But opiate addicts who have not yet experienced treatment are living in a fantasyland where the second choice is to just go back to the person they were before their addiction.  If only!!  If the person considering ‘bias’ were to live in the real world, the choices faced by opiate addicts would be Suboxone, 90 days of residential treatment, jails, institutions, or death.  Forced to deal with the truth of the matter, many people would appear ‘biased’ in favor of Suboxone.
The reason addicts adopt a distorted set of choices is because of ‘denial’, the process where the mind refuses to see the horrible reality of a situation, perhaps to protect the mental state of the person carrying that particular mind around.  The result is a bit of insanity that compares active addicts to people drowning in the middle of the ocean.   Floating in the water around them are life jackets– the life jackets representing Suboxone.  The life jackets would hold the people afloat, but they smell bad and look funny.  Plus, there are several people treading water yelling ‘if you put on a life jacket, you aren’t really swimming on your own!!’   So while some people put on the smelly life jackets and live, another group insists on swimming for shore, 1000 miles away, confident that they will make it.  Some people are safely floating in a life jacket, but are made to feel weak and guilty by the swimmers… so they remove them and join the swimmers, setting off on the 1000-mile swim for shore.  In the end, one or two of the swimmers caught a good current and somehow made it to shore alive, but the vast majority of them drowning later that day, a couple miles from the empty life jackets that could have saved them.   I am strongly in favor of life, and of life jackets. 
I receive e-mails asserting that people are better off when they are completely free of narcotic substances.  On that point I completely agree—unless the people have a chronic illness that demands treatment.  When I am feeling sarcastic I will say that an addict living free of substances is a great thing… and so is ‘world peace’!  Heck, I would prefer if a person taking ten medications for heart disease was free of all heart medications and was ‘normal”!  But many people would not survive without their medications.  If one of my patients wants to go off Suboxone, I will share my honest opinion of the person’s odds, and then help him do what he wants to do.  I will point out the risk of relapse, and hold a spot open for some time in case active addiction returns.  One nice thing about Suboxone is that is does allow a ‘trial of sobriety.’  In the days before Suboxone, relapse meant months or years of misery.  But now a person can try sober recovery, and if active use returns he can high-tail it back to the safety of Suboxone.
I hope that you find the information in this book valuable to your understanding of addiction, and helpful in your search for answers for you and your loved ones.

The book

I’ve been writing teasers for a book about buprenorphine for a couple years now.  I keep very busy trying to maintain a solo psychiatry practice, and for awhile there I was running constantly… keepiing the practice going by day and writing nonstop at night.  I’m not sure what possessed me at the time;  I know that I tend to focus more on what I have NOT done than the things I HAVE gotten done, and I really wanted to write a book.  I still do.  But after submitting the product to a number of publishers, I have learned that there is a wide range of publishing arrangements that people work out.  A number of publishers, for example, require ‘new writers’ to make an investment in their own book before the publishers will invest money of their own;  the starting ‘investment’ by the author comes to $3000 to $5000, money that I cannot afford to spend at this point.
I’m realizing, by the way, that I have become pretty open about a number of things on this blog.  I have received a number of nice comments from people ‘out there’ over the years, and I feel like I know the people who are reading.  If you are a newcomer and the situation is freaking you out, I’m sorry.  It freaks me out sometimes too!
Since I have a book that needs a place to go, and a blog that needs material, I might as well share what I have written here– bit by bit.  I invite you to read along, and if you like the story, consider purchasing it in one big hunk at some point in the future when I get my act together!  I will be posting bite-size pieces; maybe one to three pages in length.  The title of the book is ‘Dying to be clean.’  The first chapter is entitled, appropriately enough, ‘Introduction;’ subheadings will be numbered to help keep things in the proper order. Please ask for permission before copying whatever I put here… thanks!
Introduction
1. Why write about buprenorphine?
Three years ago I applied for the DEA waiver to treat opioid dependence using Suboxone.  I knew that the small town in Wisconsin where I live with my family had an ‘opiate problem,’ but I had no idea the extent of the problem, nor how Suboxone treatment would affect my approach to treating addiction in general.  As the medical director of a residential treatment center I believed that residential treatment was necessary when dealing with opioid dependence, and that any maintenance agent would result in a condition akin to a ‘dry drunk’ where the person may not be using, but is miserable about being clean and sober.  The AA joke about a ‘dry drunk’ is that he isn’t drinking—but everybody wishes he was!
But that is not what happened. Instead, when spouses came in with patients during follow-up visits the typical comments were ‘I got my husband back’ or ‘she is the woman I used to know’.  From the addict him/herself I would hear, ‘I feel normal for the first time in my life’.   Patients on Suboxone were nothing like the ‘dry drunks’ that I had come in contact with over the years of attending AA and NA.  Instead of seeing addicts who were clean but miserable, I saw people who were excited to be free of active addiction and who were ready to get back to a happy and productive life.  It seemed that as Suboxone made the obsession to use fade away, the addict’s pre-using habits and interests returned, filling the void that the addiction left behind.
I enjoyed treating opioid dependence with Suboxone. I was reminded of my anesthesia days and the gratefulness of the women after I placed their labor epidurals.  Psychiatry is not a specialty that engenders that kind of gratitude! During my own active opiate addiction I desperately tried to stop using over and over again, only to fail every time.  By the end of my using days I was depressed and demoralized.  I had broken so many promises—to others and to myself.  I stared at my kids’ pictures so many times, thinking surely my love for them would keep me straight, and when it didn’t I felt horrible for letting them down again.  At the time I believed, like most opioid addicts, that there was no way out.  Treatment would mean coming clean about what I was doing—which would destroy my career, and perhaps even take away my freedom.  I now understand that since addiction is as fatal as any cancer, treatment simply must occur, regardless of the consequences—because otherwise there is no life at all.  But to the actively using addict the shame alone appears insurmountable, let alone the career issues.  In result, opioid addicts do not receive treatment unless they are forced to get it.  And for most addicts that occurs only after they have lost almost everything, if it ever occurs at all.
Suboxone changes the dynamics of treatment in a dramatic way.  With Suboxone (or more specifically with buprenorphine, the active ingredient in Suboxone) the typical opioid addict can force his disease into remission over the course of one afternoon!  In a treatment called ‘rapid opioid detox’ the using addict is anesthetized for an entire day and naloxone is injected to precipitate withdrawal.  24 hours later the addict is still shaking as he stumbles toward his ride back home to complete the rest of his detox.  That seriously-flawed detox strategy was the closest to a ‘free ride’ off opioids available ten years ago. Now Suboxone avoids detox almost entirely; the addict leaves the doctor’s office after Suboxone induction and can often return directly to work!  Make no mistake—Suboxone treatment is a ‘remission’ or ‘maintenance’ agent—NOT a cure.  But in many ways traditional, step-based recovery is ‘maintenance treatment’ as well.  Any addict in recovery will tell you that if an addict quits attending meetings, relapse is not far away.  Opioid dependence is a chronic condition that requires chronic treatment, whether that treatment is medication-based or program-based.  And many addicts find medication easier to accept than the dramatic personality changes often required for step programs to induce and maintain sobriety.
And yet the more I worked with Suboxone, the more I became aware of another opinion about Suboxone—an opinion that is much less gracious.  I discovered the ‘Suboxone-haters’; people who gather on internet discussion boards to bash Suboxone and to put down those who use buprenorphine to maintain sobriety.   “It’s just swapping one drug for another!” they say, ignoring the dramatic and positive changes in mood, behavior, and relationships in people who use buprenorphine for treatment of their addiction.  “You’re not really clean!” they say, ignoring their own relapses that occur on a monthly basis.  “It is all a scam by those greedy doctors!” they say, ignoring the fact that few doctors want to prescribe the medication, and that many doctors stop prescribing it after finding that the reimbursement is not worth the work of dealing with such a difficult and frustrating illness.
There is a great deal of misinformation about Suboxone on the internet and in the community, and the misinformation is what fuels the negative attitudes toward buprenorphine.  The shameful result is that young people are dying in my home town and others, at the same time that there is an under-used medication that could have saved them!  Out of a desire to counter the misinformation about Suboxone, I set up an online blog called ‘Suboxone Talk Zone’ where more and more people write to me with comments and questions about Suboxone.
This book is a collection of those questions and comments from the past few years.  These comments from addicts across America capture their desperation from years of active addiction, and show their excitement at the prospect of freedom from the obsession to use.  They show the frustration of addicts struggling to find appropriate and effective treatment.   The comments show the anger of addicts who face retribution in one form or another, first because of their addiction, and then again because of their choice of treatment.  All together, the posts will give the reader an understanding of the process of addiction, the treatment options that are currently available for opioid dependence, and the factors that should—or shouldn’t– influence one’s decision whether or not to use Suboxone for treatment of opioid dependence.

More about counseling and stigma

One of my patients sent me a link to a Kentucky newspaper article that described the recent surge in cases of opioid dependence and treatment with buprenorphine. The article described the increased costs for medicaid programs because of the need to pay for buprenorphine. The reporter said that the problem was that people are being placed on buprenorphine and only ‘maintained,’ instead of receiving ‘definitive treatment’ to fix the problem.
The reporter’s perspective and conclusions are not unusual, but they are, to put it bluntly, a crock– for a couple reasons. The first problem with the story is the reporter’s bias, caused by stigma. I left a comment after the article asking why the reporter wrote about rising costs for buprenorphine, instead of an article about the rising costs for medications for ALL of the many new diagnoses and conditions treated these days? To name a few, we have new medications for bipolar disorder, for elevated cholesterol, for coronary disease, for impotence and ‘low T,’ for diabetes, and for asthma– and all of those medications have resulted in higher costs as well. Why single out buprenorphine?
In fact, opioid dependence has become the second leading cause of death for young adults in many parts of the country, and if you look at the cost of buprenorphine over a denominator consisting of the number of lives saved by the medication, buprenorphine becomes a real bargain! Medications for other fatal diseases, for example chemotherapy for breast cancer, are much more costly than the $5 per day cost for treating opioid dependence. We also spend hundreds of thousands of dollars for EACH victim of a serious motor vehicle accident, and similar amounts for every transplant recipient– even when most transplants eventually fail, just as many addicts eventually relapse. Why is only ONE chronic illness– one with a relatively inexpensive cost per life saved– singled out? Are some lives less valuable than others?
What about the suggestion that buprenorphine is only a band-aid, and avoids ‘definitive treatment?’ I have written about this situation many times, and (thankfully) more and more data lends support to my position. I have struggled with my own opioid dependence for 18 years, and over that period of time have come to know a great many addicts; people who were colleagues, friends, patients, and acquaintenances. I have worked in residential treatment settings, and have referred patients to treatment programs ranging from one month to over a year in length, costing from $4,000 to $70,000 per month. The simple, shocking truth is that for opioid dependence, residential treatment RARELY WORKS. The issue of ‘addiction treatment’ is an incredible, sad, shameful ruse that has been spoon-fed to the lay-public, and even to medical and AODA treatment professionals. On TV, Dr. Drew does his thing with addicts– and yet nobody ever seems to question why his patients KEEP ON USING! We read that Lindsay Lohan just failed another drug test, and people assume she is pathologically stupid– when the truth is that she is only like so many others. She probably has an ignorant doc, pushing her off buprenorphine and blaming her when her ‘treatment program’ failed…. when in reality her DOCTORS failed, and her COUNSELORS failed, by not reading the literature and saying ‘duh– this residential stuff never works!!’ At the residential treatment center where I worked for the past few years, the counselors get excited when the patients look all shiny and clean after six weeks in the program… but completely ignore the fact that almost all of those same patients are using by the end of the next year. And what REALLY angers me is that many of the patients who the counselors consider ‘cured’ end up dead from their addictions… and instead of looking at themselves in the mirror with shame, they blame the ADDICTS for not following the program. That would be fine if a small percentage failed treatment. But when EVERYONE fails, it is the TREATMENT that deserves criticism, NOT the PATIENT.
Sorry for shouting.
Over 600 people taking buprenorphine were followed in a recent study that you can read about here. The study showed more of the same– that patients taken off buprenorphine universally relapse. But the study showed something that I found interesting, but not all that surprising. You see, everyone always loves to say that buprenorphine is fine, but ‘only if there is counseling too.’ I always get a kick out of how many people think ‘counseling’ is a good idea– as long as it is for someone else! This study of people on buprenorphine compared a control group that had a quick med check each week during the study period, with a ‘counseling group’ that had two one-hour sessions per week throughout the period, talking about interpersonal issues, personality problems, trauma and stress in the patients’ lives, and other feel-good issues. Guess what? There was NO DIFFERENCE in relapse rates between the control group and the addicts that received intensive counseling. None. Nada. Zero.
I have stated many times that opioid dependence deserves treatment as a MEDICAL ILLNESS, a chronic illness, a potentially fatal illness that finally has a chronic and effective treatment available. But now that this life-saving treatmennt is finally here, the insurers have the gall to limit access to treatment for only a year?! The newspapers have the gall to whine about the cost of a day’s medication– all of five bucks?!! And AODA counselors and some misinformed doctors have the gall to mislead patients by talking down the medication that will help people, even while knowing that their own meal-ticket/treatment programs are ineffective?!!
It even appears that the docs who ‘get it’ about buprenorphine are not doing what good medical science usually does– which is to keep an open mind about treatments and follow the data, not ‘PC’ assumptions. One assumption has been that addicts are so ‘faulty’ inside that they cannot be treated without ‘counseling;’ that surely they all need counseling to truly get better. Where is that assumption when it comes to treating other illnesses? And now that we have evidence that counseling was of no value in the latest study, will minds be open to change?
One of the study’s authors summed it up like this:  
“Does putting people on a short period of buprenorphine maintenance combined with counseling lead to reductions in relapse? It’s a great idea, and a wonderful hypothesis, because if it does work then this would be a huge win. We would not have to use extended maintenance. Unfortunately, it did not work, but the study needed to be done.”

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.

Anxiety, step-work, and gratitude

One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts.  We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking.  I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking.  But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux;  regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment.  I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps.  I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation.  And once on buprenorphine, addicts quickly lose that desperation.  One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery.  But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy.  The steps have remained as the mainstream treatment for opiate dependence for one reason:  They were all that we had!  The steps saved my life not once, but twice– but they fail for most others.  I got lucky–  maybe having my medical license hanging over my head made the difference.  It is impossible to predict who the lucky ones will be.  All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence.  And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine.  I personally know of several people who died after forced discharge from treatment centers.  Who benefits from that approach to ‘treatment’?  Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided!  Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry.  I tend to wander a bit.  The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth.  Opiate dependence has been treated successfully in a small fraction of addicts.  Yes, the steps CAN work in those who ‘keep coming back’.  But the truth is that people in their 20’s do NOT ‘keep coming back’.  Instead they relapse over and over until everything is gone, and they have become shadows of their former selves.  But then buprenorphine came along.  Buprenorphine is NOT a panacea;  many people fail treatment with buprenorphine as well.  But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence.  But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using.   After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment.  For example, many (MANY) opiate addicts complain of ‘anxiety’.  I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor).  I found that universally, patients who took benzos did WORSE.  They thought they needed them, and even thought they benefited from them.   But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos.  The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board.  I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment.  When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc.  But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh!   People taking buprenorphine are no different than I was;  they are trying to make HUGE changes in how they deal with their feelings.   Of COURSE they will feel all messed up inside!  But the answer is NOT to find another subsstance to reduce those uncomfortable feelings.  The answer can be found instead in many of the principles that make up the twelve steps.  If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting.  I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety.  Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’.  All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs.  And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean.   The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life.  During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago.  She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc.  She was grateful for the positive changes in her relationships as well.  No, things were not perfect– they never are.  But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together.  Not being broke and sick all the time allows a person to start to feel like a contributing member of society.   Being able to go all day without telling her friends or partner a lie has improved her relationships.  Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills.  And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse.  As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined.  No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use.  But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years.  As always, your personal health history is YOUR business;  if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business!  If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery.  You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way.  If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for.  If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift.  With all of the Holiday activities I may be absent for awhile.  My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks.  Back then I thought my life was over– no job, license suspended, anesthesia career effectively over.  I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing.  I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’.  I learned through meetings that EVERYONE with addictions felt that exact same way.  After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir).    Until the play that ended today, I’ve been too busy to participate.  But today I was on the exact same stage where I stood 9 years ago.  Today I reflected on all that has happened since feeling so hopeless back then.  I am grateful that back then I KNEW that I didn’t know anything about how to stay clean.  I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself.  Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ