Tonight’s discussion comes from the tail end of a discussion with a relative of a person who is addicted to opiates, and who is doing something that is unfortunately growing in popularity– buying and using Suboxone ‘on the street’.
In my private practice, most of the people who have gone on Suboxone have done very well.  In fact, if I didn’t count the third of my practice that consists of people under 30, the relapse rate would be less than 10%.  The relapse rate is much higher in 20-year-old addicts– in my experience about half stay clean, another 25% bounce in and out of stable maintenance with Suboxone, and 25% are lost to follow-up after about a month.  If you do the math, for the entire practice the relapse rate is between 10% and 20% over a period of one year.  I would guess that out of people who take Suboxone on the street, the numbers are reversed– and 10%-20% of addicts stay clean for a year.
But I’m getting ahead of myself.  The question:
Thank you for the kind words. Just a couple questions. Can you tell me, is it dangerous to take soboxone without medical supervision? Also, can you recommend a good treatment center in our area? Are there any federal funds available for people like him?
Every day I read the headings from the sites I have complained about:  ‘I just scored 60 Suboxone tablets and I want to do this right– someone write and tell me what to do!’.  Then there is the corollary post: ‘Suboxone doesn’t work.  I have tried it over and over (on the street) and it doesn’t do anything for me’.  I don’t know who is the biggest fool– the addict treating himself with addictive medication, or the amateur doctor telling the addicts how to use the non-prescribed addictive medication.  But regardless– they are both fools!
There are a couple problems with unsupervised or ‘non-medical’ use of Suboxone. The best way to point the problems out is to first look at the goals with Suboxone treatment: first, to gain some stability over the chaos of using by suppressing the desire to use, and second, to ‘heal’ the manifestations of active addiction– which are mainly personality effects that I have written about ad nauseum on the blog. The personality effect that I see as most important is the way the addict puts up a fake front to deal with the world, while the ‘real’ person is ashamed, angry, afraid, and hidden away from the world. The result is that to the active addict, everything is an act– he is always working people, manipulating the truth, twisting reality to make it fit– rather than ‘living life on life’s terms’. Over time the addict loses the ability to tell what is real, and what is BS. Being around ‘real’ people, or real relationships, becomes more and more painful, as they serve as reminders of how fake everything has become, and they also force those feelings of shame and fear to come to the surface. The addict loses the ability to tell one feeling from another– every uncomfortable feeling is labeled ‘anxiety’, for example, as that is a reason for even more medication.

When the person goes on Suboxone ‘on the street’, some good things can happen– the use can settle down, for example. But often the addict tries to save money by taking small doses ‘when needed’, rather than getting on a regular daily morning dose. There is not a lot of difference between taking small doses of Suboxone when needed, vs taking vicodin or oxycodone as needed– especially since small doses of Suboxone are below the ‘ceiling dose’ and so they behave like an agonist, not like a partial agonist.

I talk to patients a lot about the ‘conditioning’ that occurs with addiction. I want to ‘extinguish’ the conditioning by making sure they dose only once per day, and automatically, not when they ‘need it’. But even if the person does ALL of this– without medical supervision there is something missing (yes, something more than just the absence of payment to the doctor!). Some of what is missing is subtle, and hard to describe. But two things I can describe… first, every addict thinks he can fix himself. That is a part of addiction itself– the misplaced confidence in self-as-doctor, the feeling of ‘uniqueness’, that nobody understands me but ME… and one thing that I have come to learn about every psychiatric illness but especially addiction is that a person usually cannot make adequate changes in himself without an outsider’s view of things guiding the way. A person will think he is making changes, but he will only change what is acceptable, and won’t even consider or notice what really needs to change. To recover from addiction a

Active addiction requires a 'false front'

Active addiction requires a 'false front'

person needs to live another way, and he only knows one way. And reading isn’t sufficient. Going to meetings with an open mind and willingness to take in new things and willingness to change– that can result in recovery. But an addict counseling himself just won’t work, as tempting as it is to hope for. The second thing is more subtle… by going to someone and getting help an addict is making a commitment to himself of sorts. He is taking a step out of ‘self will’ and isolation, and accepting help from another. Just this simple act alone is part of the recovery process. And a person sitting at home popping a Suboxone purchased from a friend is in a very different place than the same addict sitting in an office, tears on his face, asking for help. Unfortunately the addict with tears on his face may break into a cocky laugh as soon as he steps outside– when I see that, my prognosis for the person drops dramatically, in contrast to the person who spends a few days numb and shaken by how horrible life had become. Just that difference in how people present tells me so much about how they will do– I am constantly trying to find a way to turn the first person into the second person.

I got clean after my relapse in 2001 at what is probably one of the better treatment centers in the country. It is ‘open ended’, meaning that they keep you until they think you are better. I was a slow learner, and there for over three months. The state sends docs, dentists, pharmacists, nurses… people with licenses… to that program, and they get the same from several neighboring states. But it costs a mint– I was an anesthesiologist back then, and I sold our vacation cottage to pay for treatment and to pay the bills. I should mention that what makes the place good isn’t the ropes course, the art therapy, the old buildings, etc… they just have several real good counselors, and they are very strict in their rules. There is no wiggle room at all, and that is a good thing. There are other good places around the area that aren’t quite as costly, like XXXXXXXXXXXX… they have some great counselors as well. The thing is, it depends so much on the attitude of the addict. My first time in treatment was at a miserable place, as an outpatient, surrounded by court ordered patients… but I was so sick of being addicted that I attended many meetings and ate up every bit of recovery I could find, and it worked for ten years… even after catching my counselor at a bar (I was going into a restaurant) with a fellow patient who wasn’t his wife (yes, he had one of those at home). I see addicts who aren’t ready for recovery go into a fabulous treatment experience, at dad’s expense, and complain that the food isn’t good, the beds are hard, the counselors are too mean… a person who really wants treatment doesn’t complain about those things!!

Finally, there is something to the idea that a person does better in treatment if he/she has some stake in it.  This applies to so many areas in life, by the way–  I remember being angry at the kids in my college who were attending practically for free, who blew off classes regularly and eventually dropped out.  On a separate, perhaps controversial note, this is why I am against the idea of ‘free college education for all’.  In my never-humble opinion, that would be a disaster, as so many more kids would go ‘just for the heck of it’, diluting the experience for those who are working to be there– and grateful for the opportunity.  No, I’m not saying to take away financial aid!!  Just that people seem to get more out of something that they work for.  And recovery is no different.



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