A Common Mistake

I brought a note from the ‘comments’ section up here because it presents a topic that comes up over and over with opiate dependence and Suboxone.  I am the expert on MedHelp.org’s addiction forum;  I get questions and comments like this one quite frequently on that site– although I have addressed the issue so many times that I think people there know what my opinion will be on the subject.  I will post the comment, and then write my own comments afterward.
I started on the Suboxone in Feb 08 to get off the opiates. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it b/c I had no more insurance and it was very expensive. I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped b/c I ran out of Suboxone. About 3 days after I stopped taking it completely I started withdrawing from the Suboxone. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. Once that began I started doing research on Suboxone withdrawals and people were basically saying that depending how long you were taking the drug that would depend on how long you withdraw b/c Suboxone stays in your system for a long time. So what did I do.. to get rid of the withdrawal feeling I was getting I started taking the opiates again. Then eventually I  got addicted to those again. What I have noticed works with the suboxone is if you take it for about 10-14 days long enough for the opiates to get out of your system and stop taking the Suboxone you wont get sick and you will be successfully detoxed from opiates. Now the hardest part is staying away from the opiates. I am now on my 3rd day of the Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from the opiates by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you all posted and to everyone else doing the same.. GOOD LUCK TO ALL OF YOU!!
I have written about the natural progression of opiate dependence before, but I will review things again for newcomers.  Early in addiction, the addict believes that if he can only get past the physical withdrawal, everything will be fine.  During the first third of an addicts ‘using life’ he is always fighting for that first piece of sobriety– you see these people on message boards all over the internet, comparing tapering plans and different cocktails of amino acids or other worthless regimens to find the one that ‘works’– that gets them through a taper or withdrawal to become opiate-free.  They usually are not interested in meetings or rehab at this point;  they don’t consider themselves to be ‘THAT kind of addict’ who needs that much help– just the right pill to get through the worst of things.  These are the people who often insist that Suboxone be used only short-term, as a bridge to sobriety.  They have no interest in the idea that they have a life-long illness, and will argue that point until blue in the face, even as they continue to use opiates on a daily basis.  Denial is huge during this stage of addiction;  the addict minimizes the impact opiates are having on his relationships, work, and health status.  It is easy to discount all of those things because he considers all of the messes to be temporary and ‘easily corrected’– once he just stops the darn opiates.  He assumes– sometimes for a long time– that the ‘right method’ will come along… eventually.  Hooked?  Not him!
A person enters the second stage of addiction when he has been able to successfully taper of opiates.  From my vantage point of seeing many, many addicts over time, this point is not associated with any particular taper method or amino acid formula, but rather occurs when the person has enough consequences to motivate him through the withdrawal.  More and more bad things pile up until they cannot be repressed and ignored;  job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.  During the first stage, the addict would get to a certain level of withdrawal and say ‘screw this!’ and resume using, but during the second stage the problems are remembered even during bad withdrawal, and the addict stays motivated to be free of opiates.  The taper that eventually works is often the worst one;  the addict just says ‘enough!’ and stops without any plan or preparation.  Or perhaps the consequences lead to a jail cell or being completely broke– again, resulting in sudden and absolute sobriety without the luxury of a taper or meds to reduce the severity of withdrawal.
That’s great, right?  He is finally there– free of those opiates… or so he thinks.  But unfortunately he is about to enter the third and worst stage of opiate addiction– the stage that can last for years and years and that totally demoralizes the individual.  This stage begins with relapse, and it can happen after a week, or it can happen after a year.  The bottom line is that it almost always happens– and that NOBODY thinks it will happen to him.  I hear the comment over and over– ‘no doc– I don’t plan to relapse!’  or ‘I know what you are saying– but you don’t understand the way I am!’  Everyone considers himself too smart for relapse, but I see the AA adage come true over and over:  nobody is too dumb for Recovery but some are too smart for it!  The meaning is that every now and then a person will avoid relapse– and it tends to be a person who has a ‘simple’ outlook on life who didn’t really ‘shine’ in other, more competitive areas.  Someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities.  That person can sometimes simply stop using because he easily accepts the idea that he has lost the fight– that opiates are much stronger than he is, and that he will never figure out how to take them without disaster.
Most people, though, are way too smart for this situation;  as soon as things start going well their minds take off again…  and at some point they return to using.  I’m not going to spend time on all of the triggers for relapse, but maybe I will discuss that another time–  but there are things common to all relapses, including   rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness’ that I mentioned above, where all of the warnings are an issue for OTHER people.  During this third stage, the addict will have repeated episodes of relapse and sobriety;  there is little joy in using since consequences occur much more rapidly now, so more and more time is spent being sick from withdrawal.  This is the stage that most long-time addicts remember, and fear, the most.  In my case, I could stop using every weekend;  I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME–  come Monday I won’t touch ANYTHING!’  And so I was always sick;  the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them.  And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.   As I mentioned earlier, during this stage the addict becomes truly ‘sick and tired’.  This is a dangerous period of time for the addict for a number of reasons;  when the addict uses he feels a great deal of shame, which fuels more using– making use more impulsive and reckless and more likely to cause a fatal overdose.  The addict also becomes depressed– sometimes extremely depressed– and commits suicide, either actively or through just not caring anymore about the risks of taking too much.  The addict sometimes feels such a wave of hopelessness or shame that he needs to do ANYTHING to change how he feels– so he swallows any pill he finds, or shoots up something that he doesn’t even know the actions of–  he just needs SOMETHING!  Even a hammer to the head looks good at this point!
This is the time when traditional treatment has been effective;  the addict is at rock bottom, and he no longer feels confident about any of his own abilities.  He is ready to follow ANYONE or ANYTHING– after all, what does he have to lose?  Life is over anyway– so why not listen?  If the addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a genuine shot at some meaningful sobriety.  If, though, he gets into treatment and quickly makes a girlfriend, or he can tell jokes and be the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is…  there is a strong chance that the treatment will prove worthless.  He needs to hold on to the attitude that he knows nothing, for only that attitude will allow true learning and change to occur.
This is why, in my opinion, young people have lower success rates in treatment.  Young people often feel way too invincible for treatment to take hold.  They also have short memories for painful events;  consequences are quickly forgotten and dangerous self-reliance returns.  The true wonder of AA is that the program designers understood all of this;  the program is all about humility and powerlessness, and consists of a series of steps that, if practiced completely, will take a person to the right frame of mind and keep him there– provided he continues to work the program.  The reason treatment tends to work better for older people is because first, more are at the later stage of addiction when they are truly ‘sick and tired’,  and second, self confidence tends to return a bit more slowly.  Us older folks tend to remember the bad things because we know that some friendships can be lost forever.  Plus it is difficult to feel immortal when one’s body aches each morning!
I’m sorry to pick on the writer of the comment above;  I could do this with many of the comments that I receive from those who plan ‘short term’ use of Suboxone.  In light of what you have read, go back and read the comment again;  see if you can tell the stage of addiction that the person is experiencing.  Again, I get these types of comments over and over, both here and at the other site that I mentioned.  I have watched, over the past 16 years, as addicts (including myself) have gone through the same process.  Every person is convinced that HE is different– only to eventually find that in regard to addiction he is the same as everyone else.  This is why I recommend seeing Suboxone as a long-term medication… or seeing AA or NA as a life-long program.
One final comment… the three stages that I use to describe opiate dependence are ‘mine’;  I have noticed them over the years and they continue to be retold in my patients’ stories, and so they appear entirely obvious to me.  I have not seen the stages spelled out in this way by others, so if at some point others agree with me, let’s name them the ‘junig stages of addiction’.  I accomplished one more of the ‘goals of my life’ a few weeks ago when a guy met me at the airport with my name on a piece of cardboard;  having something named after me would scratch one more thing off the list!

One thought on “A Common Mistake”

  1. I was doing some thinking today (oh oh), and about people saying that ‘taking suboxone for less than 15 days’ you’d have no withdrawal. Now, maybe I’m wrong, but doesn’t suboxone have a cross tolerance with other opiates/agonists? Of course it does. Now, if you switched from any agonist to suboxone, there would be a cross-tolerance right? Well, then terminating after 10-20 days may reduce symptoms, but I really doubt that there would be no withdrawal, but perhaps different because of buprenorphine’s long half life (less, more prolonged). Do you see what I’m getting at? I just think that taking it for a short period wouldn’t really let you escape the inevitable withdrawal. Doesn’t tolerance=withdrawal?

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