Back Pain, Suboxone, Lortabs, Weaning

A question from a patient with back pain:
I am a XX year old female with a history of depression and am currently taking effexor. I injured my back last winter and my dr prescribed me lortab, you know the rest.. I am sick of taking the pills, i end up buying more from a friend. my doctor doesn’t know i am doing this, and i go into SEVERE withdrawl even when i wean down when i know im running out. this is when i found out about suboxone, I researched all about it and got some from a friend and have been taking them in between. I am currently sending out releases to see a psychiatrist that i hear prescribes it. am i a good candidate for suboxone or should i just try to wean myself off of lortab’s. i probably won’t be able to do that. I have taken enough suboxone to know that it works and completely takes my mind off the tab’s. i am also petrified that someone will find out and take my little girl away from me because of this addiction, even though i have a full time professional job,and this has not affected my life whatsoever except financially a burden..
My Answer:
My first point was accidentally left out of my personal reply– your last sentence is certainly not true, and it is important that you take an open-minded, fearless look at the true situation (in AA it is called a ‘fearless moral inventory’). Anyone who is stuck on opiates has become distracted by their plight; the general sequence is that the person becomes more and more afraid but represses the fear and puts on a ‘fake front’ for the world to see. The person often becomes more cocky, more sarcastic, more ‘manic’… as inside the person feels worse and worse. Every addict withdraws from family, even his/her own children. Intimacy cannot exist in the presence of active use. We all think we are fooling people by ‘faking it’, but we are not as good at it as we think. I find it very painful to watch old video tapes from my using days; I am wrestling with the kids and laughing, but I can now see that it was all fake– and pathetic. So the effects are never just financial. Not even mentioning the effects on your happiness, sense of contentment, and self esteem.
It is always tempting to think that maybe you can escape; maybe you have not become a ‘real addict’, maybe you can just stop the lortabs and never look back. But then I think about how things really happen– I think about the literally hundreds of opiate addicts I have known, and I think about my own experiences. In my case I used opiates for about six months in 1993– primarily codeine back then– and then relapsed to codeine followed by stronger opiates in 2001, using for about four months that time around. My period of use was quite short by most standards. But it was plenty long to change my life forever. In my experience, the obsession has never ended, despite seven years since active use.
The great thing about Suboxone is that almost everyone is a ‘good candidate’, provided that the person is truly sick and tired of the opiate mess. Suboxone is amazing in the way it eliminates cravings. Still, people do relapse– mostly younger people in my experience. I think younger people relapse because it is harder for them to realize that bad things really can happen in life– it is easier for them to fool themselves, and harder for them to understand that one can get to a point where there is no escape.
Opiates are a losing strategy for chronic pain– your situation is very common. I blame doctors most of the time, as they know what happens– they just don’t take the time to explain things to people, instead writing scripts that get people out the door. That is fine for acute pain, but for pain lasting more than a few weeks tolerance always develops, and the person has to take more pills to get relief. Psychological factors then start to impact the pain; as tolerance and dependence on opiates increase, the pain becomes less and less likely to go away. It is as if the body is making the back more sore, so that you will take more narcotic. It is more complicated than that, but that is how the pattern ultimately plays out. Again, I have seen this situation many, many times.
Everyone is different in how things play out depending on personality, genetic factors, amount of true tissue damage, history of abuse early in life, presence or absence of mood disorders… and on a factor that is hard to define, but that might be called ‘grit’– a personal desire to do the right thing and persevere, combined with a willingness to listen to the advice and wisdom of others.
In AA there are a number of ‘bumper-sticker slogans’– the appropriate one here is ‘you gotta wanna’. Another is ‘it works if you work it’. If you want Suboxone to work– but also understand that a pill is only part of the equation– you will do well with Suboxone. The people who do poorly are ones who are always disappointed– disappointed that they still have pain, or that the Suboxone doesn’t do everything that they want.
Specifics: I doubt you will be able to just wean yourself off at this point. Nobody can do that once the drug has its hooks into them. I certainly couldn’t. The best you can do for your back is to exercise (carefully), especially strengthening your abs, which are important stabilizers of the spine that many people disregard. Also, understand that most people who take Suboxone ‘on the street’ take too little to get the full benefit of the drug. You want to take 8-16 mg per day, in a single dose in the morning. That will help you to reduce and even eliminate the obsession with opiates. Simply taking Suboxone, particularly taking it 2-4 times per day, does little for a person other than prevent withdrawal. The person remains obsessed with opiates and life does not get better.
Finally, take that fear that you describe and put it where it belongs– on opiates. Staying clean is not about will power; in fact, it is the opposite. Realize that opiates are a real threat to you– even to your family. Be afraid of opiates and realize that you cannot control them– but that they control you. That is the basic realization that causes a ‘miracle’ in some people who go to meetings and suddenly ‘get it’. That sudden realization allowed me to stop using in 1993, before the era of Suboxone. Unfortunately, like most people, I got cocky over the years. It was much more difficult to find my ‘powerlessness’ in 2001 than it had been in 1993, much to my surprise– and to my dismay.
If you cannot find a doctor, I could see you by tele-psychiatry— My rates are posted at http://telemedpsychiatry.com. I wish you the best.