A person posted the following after one of my youtube videos about Suboxone:

While SuboxDoc knows what he’s talking about in his videos, not everything he says is always true. Not everyone needs permanent blocker therapy. Everyones willpower varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinance. The easier withdrawals are, the more likely that persons mindset will be “one more can’t hurt”. Pain builds you, it builds character, personality, and maturity.

My thoughts:

I have had my share of bad withdrawals.  So have most opiate addicts who have live with their illness for a few years.  Unfortunately, there is much more to staying sober than remembering the pain of withdrawal.  There is also much more to staying clean than ‘character, personality, and maturity.’

I’m not sure the best way to approach this discussion, but the first thing to do is to dismiss the comment about ‘will power’.  The collective experiences of hundreds of thousands of addicts over the past 75 years have taught most of us that there is one thing we know about addiction: Will power does not work.

I learned this simple fact during a ‘spiritual conversion’ that removed my desire to use, back in 1993. Since then I have tried to approach the issue more scientifically. The first thing I come up with is the realization that if I had will power, I would have no reason NOT to use. I would just go ahead and use today, and stop tomorrow! But I can’t do that—I can’t use today– because I KNOW that I do not have will power over opiates. I KNOW that if I used today, I would never regain control again. I have mentioned my ‘7-year relapse’ before—after 7 or 8 years of sobriety, all the time working in the OR with potent opiates in my hands, I relapsed on some codeine tablets that I found for sale ‘over the counter’ in a little market in the Bahamas. I came back to the US terrified, but didn’t use after getting back to work. But six months later I had a cold, I was tired, and I was stressed…. and I had the sudden thought that I was able to stop when I came back from the Bahamas… so I must have Will Power!! And so I used that day, planning to stop the next day using that wonderful will power that I now had. But the next day I decided to wait, and use the will power the next day. And a month later, I started to wonder just how much will power I really had. Finally after about 5 months, I lost my job, my medical license, my friends, my vacation cottage, 30 pounds of my body weight, my self respect… and I went into treatment, planning on a quick ‘tune-up’, since I had done it all before, and thinking that I had that ‘will power’ to help me out. It ended up taking over three months to stamp out that thought of having ‘will power’. So as far as I am concerned, you are welcome to all the ‘will power’ you want. Take my share too, while you are at it!

From a psychological perspective, I wonder if ‘will power’ keeps us from experiencing the appropriate fear about addiction that is needed to stay clean. Addiction lives in the ‘limbic system’ of the brain—in the primitive part of the brain that controls basic drives. Too often we try to control our addictive behaviors with our higher-order brains, and with reason—but we end up just talking in circles and rationalizing further use! I think the way to take on addiction is to meet it where it lives—in the limbic system. That is a place where animals fight over territory, where mates are chosen, and where we fight to the death—or run like heck to get to safer ground. Will Power involves the higher order brain, and our ‘super-ego’ making the ‘right choices’; powerlessness and fear live in our id, in the lower structures of the brain, and they work to keep us safe—while the higher order parts ponder away. So from my way of thinking, BE AFRAID. Drop the will power. Addiction has killed friends of mine—wouldn’t I be a fool, not to fear it?

Then there is the question… does more severe withdrawal help keep one safer from relapse? The question reminds me of my anesthesia residency in Philadelphia, doing labor epidurals. The nurses wouldn’t let me put a labor epidural in a 14-y-o girl until she suffered for awhile— until she had a bit of what they called ‘punitive labor’. They assumed that the pain would help keep the girl’s legs together for the next few years. But I always wondered about that philosophy. Instead, what if the girl was hooking up too young because she had a rough life, and was always beaten down by one person or another… and getting pregnant was a consequence of a desperate desire to stop the emotional pain? If that was the case, maybe more ‘punitive labor’ would just make her burden a bit heavier, and make another pregnancy MORE likely!

That is where I am with the withdrawal experiences (note– since writing this post I have received a couple e-mails from people who don’t understand the analogy.  Hopefully most people reading this understand what I am saying!)   Beyond this apparently-confusing analogy, I don’t buy the argument that worse withdrawal provides protection from relapse for another reason as well.  People don’t remember ‘pain’ very well.  If you try to remember something painful, you will see my point.  I don’t really remember the pain of my worst withdrawal episodes; I know that the last one, the final detox before treatment in 2001, was pretty horrible… but I don’t ‘feel’ it anymore. And even if I did, would it make me avoid using? Or would it make me think that I was safer, for example make me think that ‘the pain built me up.. . gave me character, personality , and maturity… so I probably am a stronger person now.  In fact I am so strong and full of character that I don’t really need to go to meetings— I can handle it on my own.  In fact, I am such a strong person… that I could probably take some codeine for this darn cough that has been keeping me up… I’m probably strong enough now to take it just once, and then stop… ‘

Tricky business, addiction. See the problem with thinking too much? That is why I choose to stick with fear– when it comes to addiction, fear will keep you safer than will character, in my opinion.  Don’t get me wrong– build your character too!  But don’t think that good character alone will keep you from using.



Christopher · January 29, 2009 at 8:25 am

Will Power. I’m a person with strong will power, but my wife is not. My will has no power to get her help. Twenty years after 3 spinal fusions, she is now a daily methadone user (which I just found out 8 months ago?) for the past six years, to get off Oxycontin for chronic back pain. Since I confronted her about it she has repeatedly said she was getting weaned off of Methadone, and only had to go to the clinic twice a month now. Eight months later, nothing has changed, only getting worse. She is losing her mind, nodding out on her feet sometimes (“Oh, I was just thinking!” she’ll say) forgetting the most simple things and saying the craziest things. I have found Xanax, and Ambien in her purse and flushed them. Apparently local doctors (the ones she hasn’t been to before) have given them to her for depression. These combined with the Methadone makes for a person I can’t stand. Disgusting. Like someone who has been drinking scotch all night.
This is a nightmare, and my 31yr. marriage is about to end unless I have an intervention or something. She says she will do “whatever it takes,” but she’s dosed-up when she says it. She says her life sucks, and she knows Methadone is a wedge that is driven between us, but she is powerless to do the right thing.
I can’t afford Narcanon(?) and really don’t understand all this “agonist” stuff to well. I quit doing drugs at least twenty years ago and don’t even take an aspirin anymore, so I’m a little apprehensive about taking another drug (Suboxone) to get off another one (Methadone). The money she must have spent all this time on something that has convinced her brain she will die without it, she could have had two laser spine corrective surgeries by now. This is absolutely crazy. What’s to prevent a Suboxone user to not also include their Methadone dose as well? Chasing the dragon.
Is Suboxone a way to get off of Methadone?
Man I hope somebody reads this.

stefan · February 1, 2009 at 1:00 pm

I also feel strongly about fear being a strong relapse preventitive .as you say,it is in the limbic part of the brain ,which controls our basic survival instints and drives. great stuff and artiulation. keep the good info.,doc.

cdunn57 · February 8, 2009 at 4:02 pm

I have no idea how to leave a comment to my particular situation.
I have taken Lortab for approximately three years for low back pain. I am three weeks out of a L5-S1 fusion. I am still having pain in my calf, which I am told may be permanent nerve damage.
This morning I woke up WITHOUT PAIN for the first time in three years. My son takes suboxone and he had given me one 4mg tablet a couple of months ago. This morning I took 1/8th of it when I began physical withdrawal symptoms. The withdrawal stopped. It is not 8 hours later and, although I have some muscle soreness in my buttocks, I am not hurting. I want off the Lortabs NOW.
For the first week after surgery it was necessary to take 20 mg percocet every 4 hours. The second week 10mg every 4 hours. Last week I was 30mg total per day. Today I have taken NONE.
Okay. Here are my questions:
What will happen if I take the other 7 doses of suboxone, 1/8th tablet each morning. Is this one week period adequate to stop all opioid withdrawal AND at this minimal dose, what can I expect if I just stop the suboxone on the 9th day.
I am 52, extremely familiar with addiction, having whipped it more than once in my life. I do have the addictive personality, but I have educated myself enough that I have had it under control since I quit EVERYTHING in 1997.
Next question: will Aleve or Tylenol work in the event I have recurrence of the calf and buttock aching…..
My incision is healed, the swelling has completely diminished, I have no pain at the incision site or in my low back PRAISE GOD.
Thank you for your time.
And thank you for your dedication — we are blessed to be a blessing, and this blog is by far the most informative — a blessing to us all.
Our healing has come!!!

SuboxDoc · February 11, 2009 at 7:14 pm

The tablet is probably an 8 mg tab– it only comes in 2 mg (which is a tiny pill) and 8 mg sizes, to my knowledge. The dose of buprenorphine that you have ingested is hard to determine when you are taking small pieces, and because of the ceiling effect, even a very small piece will put a person at the ‘maximum effect’ of Suboxone. So it is hard to know what will happen when you stop the Suboxone.
Understand that going on Suboxone does not REDUCE withdrawal symptoms; it only delays them, or spreads them out. If you have a certain tolerance, it takes a certain amount of misery to get to zero tolerance. I think the net amount of misery will be the same, no matter whether you use Suboxone to taper, or whether you use an agonist; Suboxone has a very long half life, so it leaves the body very slowly, making the withdrawal feel much less severe.

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