Registration

People who try to post have noticed that I now ask for registration in order to post.  I hate to do this, but the world of Suboxone treatment is pretty crazy… and I want to have some measure of control over the information that comes through my blog.  I want to clarify my thoughts on the issue though– because people control what is posted for many reasons, including what I consider the wrong reasons– as I’ll get into…
I subscribe to Google alerts for Suboxone, buprenorphine, addiction, etc… plus I receive e-mails from many other addiction-related sites.  I get all these messages because I really should know   what is going on in the Suboxone world if I am going to call myself ‘SuboxDoc’.  Sometimes I will read a plea for help from a different site– perhaps Sober Recovery, or Drugs.com, or even ‘Sub Sux’ (yes, there is such a site).  In response I see tons of wrong answers– clearly wrong answers–  and I want to help!  Understand that opiate addiction is a fatal illness, as fatal as any cancer… so wrong answers are… not good!  But if I post something I know to be true, based on years of being a physician, my PhD work, my work as a med school professor of addiction topics or as a trained ‘treatment advocate, or my 16 years of personal dealings with my own addiction…  my answer will just be another guess in the garbage pile of guesses and opinions. (note to self– addicts like myself all want to think we are special;  I have to watch myself when I start presenting myself as an expert on any topic.  I have stopped sharing my ‘expertise’ on many topics– political ones in particular– as I came to realize that there are no ‘right’ answers to many issues.  There are many things I’m NOT good at–  I’m not much of an athlete, for example.  But addiction has become, unfortunately, something I am becoming expert at.  Why couldn’t I be an expert at something like injecting collagen into the lips of beautiful rich people?).
When I know a way to help, I want to post my real credentials… and my blog name.  Most sites around the internet allow posts to include a signature that has the nickname and the person’s blog or home site– check it out and you will see that.  But the places I mentioned above don’t allow that–I assume because they worry about people finding better sources of information and drifting away. But what kind of system is that?  People aren’t idiots– they will find the other sites eventually… but some people need the right information NOW!  But Drugs.com, sober recovery, and a couple others don’t allow any reference to my own blog, no even just the title in my signature– they call it ‘spamming’, even if I am posting good information and trying to help someone.  I am annoyed by the ‘spamming’ accusation– coming from sites that are paid large sums of money from drug companies and other sources.  It irritates me– does it show?
So I don’t post my blog name.  Of course, you all are still welcome to refer people my way– the sites take issue with my ‘self-promotion’, but they generally do allow people to tell other people about web sites and sources of information.  I want more readers, primarily because it motivates me to write when I feel like many people are reading what I write.  Yes, I would also like to make money off the blog, as I have mentioned many times!  But so far, that is not working.  You will notice that I have changed the appearance several times, including just yesterday…  the dark theme with ads up and down the sides wasn’t ‘doing it’.  Can you believe that despite averaging 200 hits per day, I haven’t gotten a dime in revenue from the ads? (actually I did make 8 bucks one day… from my own order for domains from godaddy.com!) The Google Adwords bring in about 25 cents per day on average, … so don’t think that if you refer to me, I’ll be raking it in!   As I have said many times, I am very grateful for donations of ANY size, even just a couple bucks… but donations are quite rare at least in my experience.
So please don’t confuse my asking for registration with those practices.  If you want to put your blog’s name in your post, go ahead.  If you really want to make me happy, put a link to me on YOUR blog… and if there is interest I will put up an area on the blog for readers’ blogs, and put your link up as well.
So why do I have people register in order to post?  Two main reasons.  The first is because I do occasionally put my name out there on sites where my position is unpopular, and I don’t want people who have no interest other than destroying me to have free access to post on my blog.  If a person writes a comment that I don’t agree with but that doesn’t insult me and my family (!), I will let it through– although I may take issue with the parts I disagree with.  I don’t put up the daily messages that wrongly say that ‘suboxone is the worst thing in the world to withdraw from’, or that wrongly say that ‘suboxone is doing brain damage’, or that wrongly state that ‘people on Suboxone aren’t ‘recovering’ because they are still taking a drug’, or finally that make the incorrect ‘substituting one drug for another’ argument.  I have addressed each of these issues in multiple posts, so I won’t go into them now– but I likely will again at some point.  I don’t put them up simply because that is incorrect information that already has too great a presence on the web.  The third example I listed has an opinion component, but the others are simply wrong, based on scientific fact.  And throwing out that kind of garbage isn’t what I want this blog to do.
The second reason for registration is because if you share an e-mail address with me (and you can simply make up any address through hotmail, yahoo, or wherever) I have a way to get in touch with people who have interest in the area of opiate dependence.  I would never sell e-mail addresses– do people even buy them?  And have no plans to use them.  But if I find out that there is a great study that is looking for patients on Suboxone,  or if I ever have a huge celebration for people on Suboxone, I could use the addresses to send out an announcement!
In any case, thank you for your understanding.  I hope that asking for registration won’t keep you from participating with the blog.

Suboxone and other medications; Xanax?

Q/A with a person from suboxforum.com:
I have a question regarding suboxone and i cant figure out how to post comments so i figured i would email to see if i can get my questions answered that way.
1) I know that suboxone has some kind of ceiling effect to where if you take too much it is either pointless or does the opposite, Is this true?
2) I am prescribed to xanax and zoloft as well.Will my anxiety medicine or my depression medicine (xanax/zoloft) not work with me being on suboxone? Does it block out benzos like xanax and valium and soma? Or does it just block opiates?
3) My boyfriend is on suboxone as well but I worry that he is abusing it? Can he get high off taking more than his prescribed amount or is it absolutely impossible to get high off suboxone alone?

My Response:
Hi–
I encourage you to keep fiddling with the site, using the username and password below– you can change the password on the site if you like. That way you can participate in the discussions. But for now…
Yes, Suboxone has a ‘ceiling’ at a dose of about 4 mg, assuming it is being taken correctly (it has to be absorbed through the mouth; whatever is swallowed is destroyed and inactive). Above about 4 mg there is no more opiate effect; at very high doses (above 40 mg) it starts to ‘block itself’ and have even less effect, so a person can cause withdrawal by taking a real large amount.
The active ingredient in Suboxone is buprenorphine; buprenorphine selectively activates and blocks the mu opiate receptor and will not interfere with xanax or other benzos, and will not interact with soma. BUT… buprenorphine will cause respiratory depression in people who do not have a high opiate tolerance, at least until the person gets used to Suboxone (after a few days). Benzos also depress respiration and there have been deaths from the combination of Suboxone and benzos in people who are naive to one or both of the drugs. Also, Xanax and other benzos cause tolerance even faster than opiates do; the first-line treatment for anxiety is serotonin (an SSRI) and benzos are best avoided by people with addictions. Benzos will reduce anxiety, at least for a few weeks, but they are very addictive in their own way, and the withdrawal from them can be fatal. The early withdrawal consists of severe anxiety, which patients often misinterpret as their own ‘anxiety disorder’, for which they think they need more benzos… and the cycle continues. All of us opiate addicts are too focused on how we ‘feel’, and benzos only reinforce turning our attention inward, when what we really should be doing is trying to ignore how we feel and instead focus on things ‘outside’ of us. You can tell, I’m sure, that I don’t like benzos. But patients sure love their benzos– patients get more attached to their benzos than to any other med in my experience, and it is very hard to get a person to give them up.
As for your boyfriend, a person can get high off suboxone if he/she takes it only intermittently and never becomes tolerant to it. That would be very difficult for most addicts to do, as the person would have to take it and then come down, wait a few days, and take it again. Most opiate addicts would not be able to ‘come down’– they would just keep taking it. I cannot imagine how a person could get a high with regular use, as tolerance would prevent it. BUT… I have had Suboxone patients who (unfortunately) took oxycodone or another agonist while taking Suboxone; they had no effect from the agonist but they still could not stop taking it. It appears silly on the surface, taking something so expensive like oxy and getting no effect, yet not being able to stop. But opiate addiction is complex– it is more than just taking something because it feels good. In fact most addicts will admit that they have not had a ‘high’ in years, but they still have to keep using. Using ‘serves many masters’, and each person may have a different master. For example, a person who is actively using becomes completely absorbed in the drug– finding it, playing with it, using it, worrying about finding it again… Some people after starting Suboxone have a great deal of anxiety– the way I see it is that suddenly they don’t have the obsession with opiates occupying their minds, so they are free to worry about the other things in their lives. One reason for their use, then, is to reduce anxiety… and perhaps that is what is going on with the people I know who are on suboxone but are still using. By the way, I do not keep people in such a state– I may give the person who uses one more chance, maybe with a higher dose of Suboxone, but if he/she can’t stay clean (and after crossing that line, most do not stay clean) then methadone or residential treatment is their only hope.
I am going to answer your question ‘publicly’ but I will take away your e-mail info. Please continue to visit the site, and post when you get it figured out!

Why Not Just Take Narcotics for my Chronic Pain?

I received a letter today– a person discussing the use of opiates by a family member with chronic pain.  I was not sure if the letter was asking questions about my opinions, or was instead arguing that my ideas were off-base.  In either case it is worth publishing, as several topics are discussed.  As per usual, the names were blocked to keep things confidential.
Here it is, with my answers:
Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN.
Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.
If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.
I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.
For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.
Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?
We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.
What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.
Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.
Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.
There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.
So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading
I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.
OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.
That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

J