Are you ANXIOUS? Are you SURE?

I’ve been posting more lately, but I’m hoping to slow down by the end of the holidays to let everyone catch up.   I’ve also mentioned ‘my book’ several times in the past year, promising to myself and to others deadline that comes and go.  I wish I could take a month and work on it full-time, but I don’t see much chance of that happening… so I’ll have to just keep chipping away at it.  I can be a perfectionist and everything can be worded just a little better…  I’m the same way some mornings with my electric razor, until  my wife gets sick of watching me ‘make it perfect’ and takes the razor from me.  I came across an article the other day that described a form of OCD that involves exactly that behavior– so at least I know the nature of my problem! 
I want to thank those of you who responded to the ‘here to help’ post, and please, if anyone else has had positive or negative experiences with the Here to Help program run by Reckitt-Benckiser,  let me know.  You don’t have to report anything ‘profound’– just a general comment or two whether it was helpful, whether you stuck with it, etc.
I have written about benzos a number of times and I still have more to say.  I would hope that everyone is familiar with the danger of respiratory depression when combining benzos and opiates.  Most of the deaths involving buprenorphine that I have reviewed or read about had two things in common.  First, the person took buprenorphine along with a second respiratory depressant– often a benzodiazepine, but alcohol acts at the same receptor sites as benzos and so alcohol has similar dangers.  The other commonality is that the person who died was not ‘tolerant’ to high doses of opiates, benzos, or both.    I do not want to say anything that puts addicts at risk, and I am NOT condoning benzo use, particularly the use of medications that are not prescribed by your addiction doc.  Doing so will eventually destroy you– but for the opiate/benzo combination to kill someone quickly generally requires that the person is not tolerant to one or the other chemical.  THIS IS NOT SOMETHING TO RELY ON TO AVOID DEATH!  Did I make myself clear?   Understand that the danger of combining opiates and benzos is not greater than the risk of combining benzos with opiate agonists.  There is nothing ‘more dangerous’ about buprenorphine EXCEPT the false sense of safety that users may have about buprenorphine.  But other than that false sense of safety, combining a pure opiate agonist with a benzo is MORE dangerous than combining similar potencies of buprenorphine with the same benzo.
I wanted to get that issue out of the way so that I could get to the main danger for addicts on buprenorphine when taking benzos, i.e the long-term effects on sobriety.  Opiate addicts will become actively addicted to other drugs when opiate addiction is prevented if no efforts are made to change.    I have written about my opinion that ‘standard AODA counseling’ is not the best fit for many people.  But that does NOT mean that change is not required.   At the very least the addict must find a way to fill the time spent using, and find a way to tolerate the harsh glare of reality when the mind is not constantly occupied with using, coming down, craving, or regretting the use of opiates.   I have had many patiens go through an initial ‘happy honemoon’ stage, and several months later struggle with all of the feelings that were being held at bay by preoccupation with opiates.   That preoccupation burns off a great deal of emotional energy, and suddenly our minds have plenty of time to worry about OTHER things!   There is also the fact that many of us used to dull our feelings and our reactions to life’s challenges.  So opiate addicts often compain of ‘anxiety’ early in buprenorphine maintenance, as they experience unpleasant feelings that should really be considered plain old cravings rather than an anxiety disorder.  I’ve written about what people say when I ask them to describe their ‘anxiety– they feel edgy, there is nothing to do, they are pacing, restless– they sound more bored than ‘anxious!’   But right now, for the sake of  the argument I will accept that some addicts are having real ‘anxiety.’  This is a big thing to accept, since anxiety is fear, and the people with anxiety are generally not the ones taking on new challenges, but rather tend to be the people who are doing nothing but playing video games all day… so I’m not sure where the ‘fear’ is coming from.  But even so– if that person was in residential treatment (before the days of buprenorphine) and complained of anxiety, every counselor would say ‘poor baby…. how HORRIBLE that you feel so ANXIOUS!  And so UNIQUE–  why, nobody has EVER felt like THAT before!!’
Do you get my point?  Sorry to be such an ass about it, but we are dealing with a fatal illness here.  Before buprenorphine, addicts would avoid narcotics after surgery in efforts to avoid risking relapse– now with buprenorphine, some people want to take the easiest way that they can find.  I will tell you straight up– if you are on the verge of finding stability on buprenorphine, you are extremely blessed.  Many people have died before you from opiate dependence, without the opportunity to improve their odds with buprenorphine.  You must do SOME tough things— and one is to learn to deal with life on life’s terms.  If you cannot do that, your chances for avoiding using–even with buprenorphine– are low.   Yes, for a time you are going to be ‘anxious’, or dysphoric, or whatever you want to call it.  You haven’t dealt with life lately, so of course it will be a tough adjustment!  But what do you expect– that you can just be numb and relaxed the whole time, and everything will just fall into place?
People with cancer deal with extreme pain, nausea, surgeries, deformity of body parts…  YOU must deal with your ‘anxiety.’   Why?  It is hard to explain to people who have not been through residential treatment, where a person at least learns some things about what addiction is all about.  Addiction is complicated, and occurs for many reasons– there is not ‘one reason’ for being and staying an actively using addict.  One reason relevant to the benzo issue, though, is that addicts become very aware of their own physical discomfort– we become ‘big babies’, basically.  Benzos only make this worse;  the addict in early recovery feels uncomfortable about many things, and having a pill to take when things get bad enough only makes the addict look inward even more often to decide whether things are  bad enough to deserve a Klonopin.   Another reason people stay addicted is because of distortions of insight, specifically losing the ability to predict what they will do in the future.  The addict says ‘I will take it only for severe anxiety’, but after a few days the addict finds that there is ALWAYS a reason to take another dose of a benzos.  Addicts didn’t know life was so tough until benzos became available, when suddenly EVERYTHING seems like a severe situation–  snowed in, new coworker, lost job, getting a new job, a first date, a break-up, an NA meeting… ALL of these things are great reasons for Klonopin!!
Another problem for addicts taking benzos is that when addicts take a benzo for ‘anxiety’, they don’t focus on the disappearance of their anxiety– they focus on the appearance of the ‘buzz’ from the benzo.  ‘Normal’ people hate that feeling, and so they find benzos to be too sedating or too impairing.   But addicts LOVE that feeling– any feeling– and so they dose until they feel it– not until the anxiety is gone.  And that extra ‘dosing for feeling,’ combined with the fast tolerance  characteristic of benzos, leads to rapid escalation of dose.  And what a surprise– that dose escalation even occurs in people who say ‘don’t worry doc– I don’t plan to raise the dose.’
I realize I’m expressing anger with this post, but hey, I have to express it somewhere!  Part of my anger comes from the repeated behavior of addicts– behaviors that I resent that will always remain within myself as well.  I realize my anger is for the addiction, not for the person suffering from the addiction… but sometimes I am frustrated by the unwillingness of addicts who are at the edge of relapse to ‘step up’ and face the challenges, and to fight for their lives.  I was also angry at what happened on a TV show this AM as I was getting dressed.   I shouldn’t admit this… but I was watching MTV, the show about the teens who became pregnant and had babies, which is now a show about teen moms… and one of the teen moms went to the doctor and complained of her ‘anxiety’.  She is young, bored, stuck at home with a crying baby… and she has ‘anxiety.’ Some mornings she ‘just lays in bed and doesn’t want to get up.’   What a surprise that she isn’t just thrilled to get up every morning!  She sees a doc (who could pass for a beetle if he had the right markings on his back) and the doc prescribes… Klonopin.  The next morning the baby is fussing and the teen mom holds the baby at arms’ length, passes him to her BF, and says ‘I have to take my Klonopins.’   A close shot of the bottle shows instructions to take ‘one tab twice per day’ (clonazepam has a half-life of about 24 hours, so the level in her body will increase over several days to a high steady-state level).  The next camera shot the next day shows her laying on the couch, yawning, saying that the medication seems to be working.  Her one-yr-old, meanwhile, is… somewhere….  not sure where I left him… 
But at least she isn’t ‘anxious’!
I went off on something that I was only going to mention in passing… so I guess I’ll finish the story I intended to write in a few days.  I want to write about a couple studies that looked at the cognitive effects of buprenorphine, methadone, and benzos.  Thanks for letting me vent…    good luck returning to work tomorrow for those of us lucky enough to be working, and I hope those who are looking find somethng soon.
JJ

7 thoughts on “Are you ANXIOUS? Are you SURE?”

  1. There is something to be said about opiate addiction and anxiety. But what defines anxiety may be different for different people. In December of 2008, I discovered tramadol…not a ‘serious’ opiate agonist by some hard core users, but it gave me this feeling of well being that I liked. Well, 4 months later, I found myself taking from 22-25 50 mg trams a day. Tolerance has definitely built up. Due to my fear that I may have a seizure at high doses, I found a doctor who was willing to prescribe me suboxone. The doctor prescribed me 30 8/2mg (bup/naloxone) suboxone and 45 .5 mg clonazepams. As soon as I took that first suboxone (4 mg), my cravings for tramadol died instantly. On a side note, suboxone made me so nauseous that I had to get a prescription of Zofran as well. Well, my suboxone treatment ended essentially after I ran out of pills (approx 45 – 50 days). I stopped taking the suboxone, and I felt fine…no cravings whatsoever. For the clonazepams, I took about 20 over the entire treatment episode. After 2 weeks into my sobriety, this weird sensation of adrenaline started to build in my chest. It was very uncomfortable. I was tense and irritable. So, I finished off the remaining clonazepams over a couple weeks, which helped for the time being. And because I got laid off of my job in the middle of my treatment, I didnt have health insurance anymore. So, I went back to the tramadols. At first, once again, it was a wonderful expereince, but eventually, the trams couldn’t quell this debillitating anxiety. So this September, when I became employed (and insured), I went back to the same doc and he prescribed me buprenorphine once again. But because I complained of nausea, he prescribed me Subutex instead. And once again, as soon as I took the Subutex, the anxiety went away and I had no cravings for Tramadol. The Subutex still caused me nausea, so I ordered some generic zofran from an online drugstore (this was actually cheaper than a prescription).I’m currently on the subutex treatment (2 mgs, up to 4 times a day AS NEEDED). I find that whenever I have that tense, adrenaline like feeling coming up…I have to take a sub. The funny thing is, I’m not going through withdrawals. This anxiety is different, and it IS physical…I definitely feel it. Breathing exercises sometimes help, but not always. So, how does one defeat this ailment that I fear? I am a graduate clinical psychology student, so I know certain triggers can lead to people relapsing. My fear of this anxiety could be a precurser of an anxiety disorder, but I’m not certain. From what the article said, it seems to be just a manifestation of the addiction. Any thoughts?
    -Rich

    1. I would suggest being careful with the term ‘anxiety’. Understand that stopping many things, including tramadol, clonazepam, or suboxone, will cause intense dysphoria that has nothing to do with ‘anxiety’. So my first suggestion would be to evaluate how you do off all medication that has an agonist effect. The problem with pure agonists is that you are never at a state where you are completely separate from them– you are always either intoxicated or in withdrawal (except for maybe one short instant where your tolerance and the dose level match up). With buprenorphine, if your dose is above the ceiling level, you are in a ‘stable’ situation where daily changes in plasma level do not change the degree of opiate effect. Of course you don’t get to that point when you are taking small doses of buprenorphine ‘as needed!’ I would recommend getting to a stable, once per day dose of buprenorphine and then seeing what feelings you have after a couple weeks– when you are fully tolerant to the ceiling level of buprenorphine. Otherwise it is impossible to sort out what is causing what.
      Just a word on the side– tramadol withdrawal is uniquely miserable. It cannot be blocked completely in most people by using a mu receptor drug like buprenorphine (buprenorphine also has kappa blocking activity, but that is not relevant here). The effect of stopping tramadol includes a feeling similar to stopping SNRI’s- which would be expected, given the dual mechanism of action of tramadol. I have reduced the discomfort in people to some extent by replacing with an SSRI with a long half life, then tapering (e.g. fluoxetine).

  2. Hi, I work for a market research company that is looking to talk to people who take the generic version of Subutex, Subutex, Suboxone, Methadone. If you or anyone you know may be interested in participating in the study please e-mail [email protected]. The study would be conducted via telephone and only take about 20 minutes. The participants would be mailed a check for $50 for their time. Thanks!

  3. Ii am having real panic attacks. Heart rate goes up. Icant be where I am. Having to use the bathroom freaks me out cars clostrophobic. Temperature of my house. Clothes too binding. At least 20% of my day is pure debilitating anxiety with really scarry attacks coming at night around 300 when I wake up. I am unable to function like this. I’ve been on 16mg subutex daily for 2 weeks. I hate it so much I would prefer withdrawl. I don’t know what to do so I am starting a very slow ween to get away from it. Methadone caused the same panic attacks I had to get off. Nobody believes me and everyone minimizes what I’m going through. I am scared to death and miserable. Really freaking out every day. I have avoided benzos believe me I have a hi tolerence for benzos. I could take two Xanax bars in my addiction. Today I cut a .025 Xanax pill in thirds and it helped I know I can’t continue benzo use but as you can see I’m not trying to get high on them. I just want some relief and the very tiny dose helped. I’ve got bottles of hi dose clonipins laying around but I will not use them. 1/3 of a .025mg zanax was enough to get me through tonights panick attack. I really want subutex to work but I am afraid I can’t go on like this. I’m going to drop 1-2 mg a week and try to get away from them.

  4. Very interesting article. I think a lot about the benzo issue and this was helpful.
    Also, I’m trying to get a social networking site for people who are in recovery for opiate dependence, their families and friends started at junkjunk.ning.com
    I hope some people will join to help me get things started.
    Thanks, Tom

  5. I have tried for a while now to long in here and write a compelling story. HAHA Now I got my chance…haha
    I started taking Percocet 5 or 10 mgs to about 10-15 a day during a seriously stressful time in my life. After my tolerence became higher my frustration grew stronger with having to wait to get more and dealing with the old folks around town. They didnt want the pills but needed the money to get by and I didnt want the money and needed the pills to get by. Eventually I got heroin, which any pill head will do. I prefered banging it to snorting it but the stigma associated with addicts and gettting good freshies on a regular basis led me to my preference. After getting down to borrowing money more often and not paying bills like I should I decided to make that change. I went to the doctor who used to prescribe me some percs and told him I needed some help. He didnt know what to tell me. I cussed him up and down both sides, mainly cause I was withdrawing, i later called to apoligize to him. ha Then a freind of mine told me about this magic little stop sign looking pill. I got the number to his doctor and his receptionist sd “bring in $150 cash and take or do whatever you have got now and we will see you in the morning” this was 1600 hours on a Thursday. I got rid of my $60 bag bought another pill ($20 bag of boy(herion)) and a $20 of blow and thought I would see what all that felt like since I was “quitting” tmw anyways. It felt great best night I had in a while. I just chilled out with a girlfriend of mine an small bottle of liquor and got hammered and talked…very cool night.
    Then i went to the appointment, late. And felt like crap, but not too bad. I knew it would get worse and didnt want to really feel any withdrawals. They dosed me up with two little white things and walked out the room. She sd stay here, like i was fucking leaving HAHA then they cam eback aobut 2 hours later and gave me two more and in about 30-45 minutes i was talking on the phone and walking around. very strange for me. since that moment when I realized I could avoid withdrawals without see my buddy in the hood or the old ladies in the projects I was ready to start over. They gave me my script of Suboxone and that was it. Until about 6 months later. I missed the fun I had and the fun of cruisin around the hood high or hangin out with those people…funny shit they say and think. but after a few times using I was and still am totally done. I like my new life and sobriety, other than the suboxone, still has its stressful moments but I dont need to get high and know gettin a bag or whatever isnt gonna do anything. I encourage anyone that wants to quit pain pills, herion or whatever opiate you are on to get Subs and get off that shit. And if you arent sure you are ready to quit then wait til you are or buy about 10 subs and see how you feel after taking two a day for 5 days. I bet you will want to quit then…I know my story is short but I am tired of typing and I am sure someone will have something to say but I am going to get my script filled now and then Ima go right back to work and be prodictive. RIGHT ON!!!!!!!!!

  6. Point taken. Addicts tend to think incessantly about every micro-moment of their dysphoria ( or potential dysphoria) in excruciating detail, which may paralyze them with fear. Activity and avoidance of boredom have helped me , personally , in this regard.

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