Clearbrook President Gets it Wrong

A blurb in the buprenorphine newsfeed (see the bupe news link in the header of this page), has the headline ‘Suboxone challenged by Clearbrook President’.  I followed the link, and after reading the ‘article’ I wanted to comment to that president but the person’s name wasn’t included, let alone an email address or comment section.  So I’ll have to comment here instead.
The article was one of those PR notices that anyone can purchase for about 100 bucks, in this case from ‘PR Newswire’.  It’s a quick and easy way to get a headline into Google News, which pulls headlines for certain keywords like ‘Suboxone’ or ‘addiction’.
The Clearbrook president makes the comment that this 180-degree swing to ‘medication assisted treatment’ is a big mistake.  He says that in his 19 years in the industry he has seen ‘thousands’ of people ‘experience sobriety’.   I’ll cut and paste his conclusion:
There is no coming into treatment and getting cured from the disease of Addiction. There is no pill or remedy that will magically make one better. Those looking for a quick fix to addiction and the treatment modality being used by the vast majority of treatment providers today, will be disappointed with the direction our field is taking when this newest solution doesn’t live up to its claims.
A word to the President of Clearbrook:   I’ve worked in the industry too.  But unlike you, I wasn’t satisfied to see a fraction of the patients who present, desperate for help, ‘experience sobriety’– especially when I read the obituaries of many of those patients months or years later.
The president says that ‘no pill or remedy will magically make one better.’  Addiction, for some reason, has always been considered immune to advances in modern medicine.  We all know that addiction is a disease, just like other psychiatric conditions including depression, bipolar, and schizophrenia.  Why is it that even as medicine makes extraordinary advances in all areas of illness, medications for addiction are considered to be ‘magic’?
Those of us who treat patients with medications, particularly buprenorphine, realize that addiction doesn’t respond to ‘magic’.  But I see a lot more hocus pocus in abstinence-based residential treatment programs than in the medications approved by the FDA for treating addiction.  Residential programs charge tens of thousands of dollars for a variety of treatments–  experiential therapy, art therapy, psychodrama, music therapy, etc.– that have no evidence of efficacy for treating opioid dependence.  Abstinence-based treatments have managed to deflect criticism from their failed treatment models by blaming patients for ‘not wanting recovery enough’.
Buprenorphine finally allows the disease of addiction to be treated like other diseases– by doctors and other health professionals, based on sound scientific and pharmacological principles.   Abstinence-based treatment programs have tried to tarnish medication-assisted treatments, but people are finally recognizing the obvious– that traditional, step-based treatments rarely work.
And that’s just not good enough when dealing with a potentially fatal illness like opioid dependence.

A Save with Suboxone?

I’d like to share a recent email exchange with a reader. The post is long, but there are several interesting aspects to the discussion. I’ve removed the conversational parts, as well as the identifying information.
The initial message:
I was an intravenous heroin user for three years. After treatment I was able to stay clean for 6 months… Well apparently to most people I was not clean because I was on Suboxone, but to me I was clean. People are so very discouraging when you tell them you’re clean and they find out you are on Suboxone. It hurts because of how much hard work you put in. I did well for six months, but then I relapsed and used for 5 days. After a short binge I again stopped, continued Suboxone and used once more for one day alone.
All of these relapses were with my girlfriend, and she used one extra time while I was working. She overdosed all three times she used. Her mother found her the second time in her room almost lifeless, and I was with her the other two times. I acted very quickly, giving her CPR immediately and calling 911 without the least bit of hesitation, as did her mother.
My girlfriend) is not on Suboxone, but I stayed on every day other than the times we used. I am pretty educated about opiates in general and I understand that she overdosed because of her lack of tolerance. I have read something you said before: A person on Suboxone maintenance has the tolerance of someone who takes 100mg of oxycodone a day. I need to know, for the sake of her life, my life or someone else’s life, if ever in a dire, life threatening situation and for some crazy reason 911 isn’t an option, could you melt down a Suboxone strip and inject the overdosed person and use it like Narcan if you absolutely had to? Or do you think I’m nuts for even asking?
One more topic… I obsess over heroin every day. It’s so bad that I sit with a calculator and tell myself, “alright, if I stay clean for these next two years and I finish my degree and start my career making this much salary then I can spend this much a day on heroin and it will total x amount of dollars a year and subtracted from my salary I will still have more than enough to survive.” How sick is that? It’s disgusting. It’s an absolute obsession of the mind. I seriously convince myself that with the right amount of steady income I could actually be a functioning addict.
Thank you so much for your time. I appreciate it so much.
My Reply:
Your email shows the incredible danger associated with use of intravenous opioids. I remember how impressed I was, when I was a resident in anesthesiology, over how the human body is SO strong and restorative, that we can survive and recover from horrible injuries… yet how fragile we are, that a lack of oxygen for only several minutes can cause death. Injecting opioids is a very effective, targeted way to kill a person. Doctors and nurses do not inject narcotics unless the patient is being monitored, usually using a ‘pulse oximeter’ to monitor the level of oxygen in the blood. Yet people with far less training are injecting the same drugs, not only without monitoring, but even in the absence of a non-impaired observer. It is no wonder that there are so many deaths from opioid dependence.
You probably know how I feel about being ‘clean’; people on buprenorphine are clean enough, in my opinion, to be considered sober. People on buprenorphine become fully tolerant to the effects at the mu receptor; there might be very minor effects at the kappa receptor, that may or may not have very minor cognitive effects…. but people take chronic medications for MANY illnesses, and some degree of sedation occurs with most of them, including medications for high blood pressure, migraine headaches, and seizure disorders. Should we consider all of THOSE people to be ‘not really clean’ too?
The question about using Suboxone to reverse overdose is very interesting– and shows that you have a good understanding of what is going on with medications like buprenorphine (in Suboxone).
One of my patients has described how he saved his girlfriend’s life by injecting Suboxone. He says that she was unresponsive and barely breathing, and out of desperation he put an 8 mg tablet of Suboxone in her mouth. When she didn’t respond after a minute or two, he quickly dissolved a tablet of Suboxone and injected it into her arm. He claims that she woke up 30 seconds later.
I’m glad his girlfriend survived, but I do NOT recommend that anyone rely on this approach to save a life. The most appropriate action, of course, is to do whatever one can to find appropriate treatment, and stop accepting the huge risks associated with IV injection of opioids. If a person has overdosed, call 911 immediately. The brain starts to die in about 3 minutes. Some parts of the country have instituted programs that provide naloxone injection kits for people addicted to opioids; injecting a pure antagonist like naloxone (Narcan) is much safer than injecting the partial agonist, buprenorphine.
The outcome after injecting Suboxone depends on a number of factors, including the person’s tolerance level and the presence or absence of other respiratory depressants. If a person has only used opioids– no benzodiazepines or barbiturates or alcohol— then in theory, injecting Suboxone would rescue the person from overdose. Both parts of the medication would contribute to reversing the effects of opioids; the naloxone (to a small extent) and the buprenorphine, which would have most of the effect. The ceiling effect of buprenorphine should prevent respiratory arrest in any person, as long as no other respiratory depressants are around.
But– one CANNOT expect the ceiling effect’s protection in the presence of other respiratory depressants. If other depressants are present, opioid tolerance becomes a big issue. I’ll describe two cases to demonstrate:
– Let’s take the low-tolerance scenario, with a person who has never used opioids or benzodiazepines, who ‘sniffs’ 40 mg of oxycodone and 10 mg of alprazolam. The risk of overdose would be high in that situation. And if, during overdose, someone injected Suboxone, the opioid effects of buprenorphine would be as great, or greater, than the opioid effects of oxycodone— so the person’s condition would likely worsen. (Note that I’m ignoring the effects of naloxone. Naloxone’s clinical effect last only about 20 minutes. That effect might help the person in this scenario, but it is hard to predict whether the naloxone would out-compete the buprenorphine that is also being injected. People who have injected Suboxone in the past tell me that they found are no difference between injecting Suboxone vs. injecting plain buprenorphine. That wouldn’t surprise me, given the high-affinity binding properties of buprenorphine.
– For the high-tolerance case, let’s take someone who is using 150 mg of oxycodone per day, but on this occasion took an amount of heroin equal to 300 mg of oxycodone. Let’s assume that there are no other depressants on board. In this case, injecting buprenorphine would be expected, theoretically, to block the effects of heroin, and not only wake the person, but precipitate withdrawal. Even if other respiratory depressants are on board, the buprenorphine would likely save the person from overdose, because the opioid effects of buprenorphine are significantly BELOW the person’s tolerance level, and below the effects of the heroin that is causing overdose.
Essentially, the high-affinity binding of buprenorphine displaces other opioids, causing an opioid effect equivalent to 60-100 mg of oxycodone. If the person’s tolerance is higher than that, the result will be precipitated withdrawal. If tolerance is lower, the result will be greater opioid intoxication.
I will stress, again, that the thing to do in case of overdose is to call 911. An even better thing to do would be to get help for anyone you know who is injecting heroin, and get help NOW—as the risks of IV drug use are very high, and nobody believes that he/she will be the next person to die. If you are in a situation where someone else is overdosing, and you inject that person with Suboxone or any other substance other than Narcan, you will likely be prosecuted, and convicted, for manslaughter.
The obsession described in your message is typical, and is the hallmark of opioid dependence. In my opinion, we (psychiatrists) should see ‘obsession’ as the primary defect in cases of addiction, as obsession is what destroys personality, undermines self-esteem, and crowds out other interests and interpersonal relationships. As I’ve written before, buprenorphine’s unique properties allow it to reduce or eliminate the obsession for opioids. Buprenorphine, I believe, is an effective, targeted way to treat opioid dependence.
His message back:
Being a psychiatrist, what are your thoughts on that obsessive thinking? I hate meetings and the 12-step programs. I lived in a half-way house for a month and a half that required 3 meetings per day. I agree with you that they create a fabricated sense of happiness and self-worth. Do you recommend staying on Suboxone for an extended period, especially during a time where i am still having these thoughts? And because of the way I feel toward meetings should I seek a psychiatrist and try to explain my thought process in order to try and change it? What would you recommend to someone in my situation who obsesses to that degree, and hypothetically plans his future around heroin?
Me Again:
I have seen SO many people who stopped Suboxone, then relapsed years later and lost a great deal. I’ve seen obituaries of former patients who used to be on Suboxone. If a person can take the medication without too much hassle— i.e. has a doctor who allows ‘remission treatment’ without making the person feel like a second-class citizen– then long-term Suboxone provides for the best chance of doing well in life, in my opinion.
Other than buprenorphine, the best ‘treatment’ for the obsession, in my opinion, is fear. Step programs tap into that fear, by emphasizing powerlessness— the realization that using even one time will definitely, without a doubt, lead to your destruction. Every thought about using should be confronted with that reality— that if you use, you will die. Relapse often starts with the idea that maybe the person can get away with it, maybe just once… so to stay sober, the person must KNOW that there is no way to try it, even once. That is a bummer, but not the end of the world! Humans love to feel powerful, but attendance at meetings helps reinforce the reality, and the value, of powerlessness. I’ve written about my own experiences back in 1993, when the realization of my powerlessness caused my desire to use to suddenly disappear. If only I could have remembered that powerlessness, even as my life got better!
I do not think that psychotherapy is all that helpful for obsessions. In fact, I think that psychotherapy can be dangerous, if it leads to the thought that you have everything figured out— a thought that the addicted personality loves to run with!
The challenge when treating with buprenorphine is to instill and reinforce the knowledge of powerlessness, even while treating the obsession for opioids with a highly-effective medication. The thought process becomes a little more complicated, but not impossible to grasp.

Do Interventions Work?

It has been a while, it seems, since I’ve checked in. I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.
In the meantime, check out the ‘best of’ page; I have links there to some of the more popular post. And for now, I’ll answer a question I received today on ‘TheFix.com’:
Do you believe in intervention of someone who does not ask or desire (to be clean)?
It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions. But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within.

Grandma needs an intervention
More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option.
For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc. Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing. At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior. They set her up at a treatment center, and she is shipped off for 30 days.
She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’ And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.
I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers. It is easy to clean a person up for a month in a closed environment. But in regard to long-term sobriety… residential treatment rarely works. Sorry to say something so horrible—but that emperor, sadly, has no clothes.
So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?
Because true change is very, very difficult.
Besides, she has plenty of reasons to keep things the same. She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough. Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids; what could they possibly tell her that she doesn’t know?
And the major reason she won’t change? For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.
In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem. But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.
But there are other ways to manage an intervention. It would be best if grandma herself decides, at some point, that things must change. How does that happen? First, everyone has to stop enabling her. If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad. If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out; she is left to juggle excuses on her own. If she needs the ER for pain pills, she drives herself—or waits for a cab.
I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy. Nobody does her a favor by keeping her miserable. Realize, though, that we are discussing addiction here; I’m not suggesting that people abandon loved ones struggling with painful conditions!
The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception. Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill; medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous. A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal. If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills. If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.
The point of all of this is to make the person with the problem feel the consequences of their problem. Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict. The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.
Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change. But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

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Making People Stop

Below is an e-mail that I changed just enough to hide the person’s identity. Every week, I receive messages that describe similar situations.
My husband has struggled GREATLY with substance abuse since in his 20’s; he is now in his mid-40’s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose. Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.
From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake! It’s not like if he stops this med he could ‘just’ have depression; he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.
If this is what it takes for him to live a normal life then why not? When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough.
My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.
Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.
Anyone who reads this blog knows that I agree with most of the opinions expressed in the email. I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.
More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease. The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point. We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.
To address a couple points in the message: the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile. Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe. Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’
The situation described in the message is, in my opinion, the result of several factors. First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma. Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’ I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is a more fitting ‘treatment’ than a pill that makes things better.
I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense. The risk of any medication must be compared against the risk of not using that medication. As the message states, we know the risk of ‘not treating’ the woman’s husband! Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient. As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers. So does it make any sense to withhold buprenorphine out of safety concerns?!
There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to. Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’ Some doctors want to maintain high patient turnover in order to keep money coming in, since practices are ‘capped’ at 100 patients per certified physician.
Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’ They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative. They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough. I understand the thought, as that is the type of treatment experience that I went through. But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life. During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance. Some of them– too many of them–died.
I won’t get into the specifics of treatment; I’ll leave that to her husband’s doctor to work out. But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.
To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

Relapse in an Era of Buprenorphine

A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.
I drug-test patients who are treated with buprenorphine or Suboxone. The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble. It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example. The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’
The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight. Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important. It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high. On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.
I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years. I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’ I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.
In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me. But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything. As soon as I relapsed, nobody could be trusted. Nobody would understand me. I was on my own.
Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations. But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.
One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test. In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience. “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house. With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’
After shooting the heroin, Paul immediately felt disappointed in himself. Unlike in the old days, he felt nothing from the heroin. While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.
His desire to talk is an amazing thing—and worth noting. Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician. In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.
There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients. I don’t get the logic of those programs, and I become angry when I think about them. As I’ve said before, if a person relapses, that person NEEDS help—not abandonment! I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness. And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!
Paul made an appointment to talk about his experience. He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future. He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues. Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down. Those are all big issues, I said as I agreed with him. How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!
We talked about the challenge of being ‘someone’– of being proud of one’s self. It feels good to do the right thing– but it may also feel bad. Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.
Before buprenorphine, people struggled with opioid dependence largely on their own. Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict. Many people in AA or NA will say that “AA is a selfish program.” It has to be. When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.
On buprenorphine, relapse doesn’t necessarily cause instant loss of insight. I don’t mean to minimize relapse, as bad things can always happen. For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused. But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.
This assumes, of course, that the person is not simply tossed from treatment for the relapse. In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.