Must-Read Article About Buprenorphine

For about 600 reasons I generally avoid the Huffington Post.  But one of their writers did an absolutely perfect job of describing the need for buprenorphine, and the failure of ‘traditional’ treatments.  The article is entitled Dying to be Free.
The challenge, though, is getting the article into the hands of policy-makers.  It is too late for some areas, where the damage has already been done (I find myself humming the old Pretenders tune about Ohio).  When it comes to buprenorphine, too many DA’s, judges, and politicians seem to develop opinions from inaccurate data, and then cling to those opinions no matter what they learn after the fact.  To put it another way… the idiots will always be idiots.  So if anyone reading this post has a relationship with an open-minded politician, now is the time to share the Huff Po story.

The Overdose Report

I set up a new site today that collects newsfeeds related to the epidemic of opioid dependence and posts links to the articles.  Some of the news stories strike a sensational tone, as opposed to the somber nature of the content— and my intention was not to create a website fashioned after an episode of ‘Cops’.   But there is an epidemic going on, and many of the articles refer to efforts to stem the tide through legislation at the state level throughout the country.  Feel free to check it out…  and I hope it doesn’t come across as insensitive because of the title.
Overdose Report

Children Deserve Pain Treatment Too

I hope that people recognize the tongue-in-cheek nature of the title. After working as a physician in various roles over a period of 20 years, I can state with absolute confidence that the answer to the question is ‘yes’.
I’ve written numerous times about the writer/activist for the Salem-News.com web site, Marianne Skolek. I don’t know if she writes for the print edition as well, but at any rate I somehow was planted on a mailing list that provides constant updates on what she calls the battle against Purdue and ‘big pharma’.
People with a stake in the outcome of this battle may want to stay current, and even see if their Senators are involved in the process. The investigation was launched in early may, by the Senate Committee on Finance, and at this point has asked for documents from several pharmaceutical companies, including Purdue, the manufacturer of oxycontin– a medication that has become the focus for most of the wrath of those affected by opioid dependence. The investigation will include a number of groups whose missions are (or in some cases, were) to advocate for pain relief, including the American Pain Foundation, the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the University of Wisconsin Pain and Policy Studies Group and the Joint Commission.
I consider it part of the human condition, the way we push in one direction for some period of time, and then realize (with surprise!) that we pushed too far, and need to push back. Years ago a  Newsweek article warned that an emerging ice age doomed the Earth. Suggestions for saving the planet included covering the polar ice caps with soot, in order to absorb more of the sun’s precious heat– although the article pointed out that growing seasons had already been severely limited in most parts of the world, and famine was just around the corner.
We all know what happened to THAT disaster. And then last week, Dr. James Lovelock, a leading doomsayer of the global warming movement, pointed out that many of the disastrous outcomes predicted by himself, featured in Al Gore’s movie, um…. haven’t happened… and to the chagrin of many, he wrote that most of the disasters that were predicted are unlikely to occur. Read for yourself. Never before were so many people so disappointed by good news.
I’m running off topic, I know, but it is hard to observe the dramatic swing on pain relief without recognizing the broader pattern. For those confused about the pain isssue, you have reason to be confused. About 15 years ago I worked as an anesthesiologist, when the Joint Commission on Accreditation of Hospitals made their 3-year site visit to our hospital. Hospital administrators hired consultants to find out what THAT year’s big issue was— e.g. hospital acquired infections, patient privacy, rights of those with disabilities…. and found that the hot-button issue was ‘undertreatment of pain.’ Little diagrams were dispensed to every patient room, showing the smiley-face guy with an expression ranging from happy to miserable, in case a person was experiencing pain but unable to speak– allowing the person to point to the appropriate picture instead. Key personnel were told to make it abundantly clear that we all take pain VERY seriously, and we do all in our power to avoid undertreatng because of, for example, fear of addiction. Studies were widely cited that claimed that only 7% of people with true pain become addicted to opioids.
One or two textbooks became the authority on opioid prescribing, introducing a new term– pseudoaddiction– which refers to a condition of drug-seeking behavior caused by under-treating pain, rather than by true addiction.
I know that I have to pull all of this together at some point. The easiest way for me to do that is by directing people to the latest article by Ms. Skolek, where she suggests that doctors have been influenced to promote narcotics because of grants from the pharmaceutical industry. Similar accusations have been made by others, including a series of articles by the Milwaukee Journal Sentinel that accused the University of Wisconsin School of Medicine of promoting opioids in return for millions of dollars.
I respect the efforts of another group I’ve described– PROP, or Physicians for Responsible Opioid Prescribing. Their efforts have been promoted by Ms. Skolek to some extent, and vice versa. I do not know of any formal relationship between PROP and Ms. Skolek. But I hope that PROP’s efforts take a more reasoned approach than the latest article by Skolek, where she compares Purdue Pharma to Adolf Hitler. Why? Because among the many clnical trials by Purdue is one that studies the use of potent opioids like Oxycontin in children and teenagers. Some of the most sobering experiences of my medical training were at Childrens Hospital of Philadelphia, providing care for brave, hairless children, knowing the years of pain that awaited them– if things went well.
I think I’ve provided enough background and links to start interested parties off on their own holiday reading. Yes, there is an epidemic of opioid dependence in this country and elsewhere. There are many reasons for this epidemic, and MOST of the reasons have nothing to do with the marketing tasks used by Purdue decades ago– for which they have paid dearly. While there are clearly areas where opioids are overprescribed, and in some cases grossly overprescribed, it would be a shame if the current swing in regulatory sentiment takes us to the point where doctors are afraid to provide pain relief for people who are suffering. This is already the case in some instances; people labelled as ‘addicts’, no matter the length of their remission, are likely to wait a long time for their first dose of narcotic, should they be unlucky enoough to develop a kidney stone.
I’ve spent a great deal of time and energy defending those poor souls, and discovered, sadly, that most doctors just don’t care about the pain experienced by recovering addicts. But there is a saying, also often referenced to the Holocaust, referring to mistreatment of others being ignored, until eventually similar mistreatment is directed at those who didn’t care about others. There are times when attempts to ‘cure’ go too far. Suggesting that methods of pain relief should not be investigated, clarified, and perfected for children is going a bit too far.

The Problem with Benzodiazepines

Last night I came across a medical student web site that included a link to a post of mine from a couple years ago, that described my feelings about Xanax, Valium, Klonopin, and other benzodiazepines.   The people commenting at that site appreciated my comments, and my comments were ‘seconded’ by other physicians.  Here’s the post again, for those who missed it the first time:
Twelve Things I Hate About Benzodiazepines
Author: J Junig MD PhD


Because of several highly publicized deaths from combining Suboxone with benzodiazepines or “benzos”—a class of sedative medications that includes Xanax and Valium—I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are about to be placed in a difficult position. They will either do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.
The problem is that the non-medical community sees SSRI’s as “antidepressants,” and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. Whereas the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.
Today, I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t do anything, she said—intending to mean that the meds are not potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (ie, amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long-acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.
A related question came to me by e-mail yesterday:
Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it.. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.
The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of the meds by others suggest that she is asking for a benzodiazepine.
Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”
All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.”
1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become anxiety. Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
2. Even if we get it right, her relief will be short-lived due to tolerance. Patients often escalate their dose at some point—no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault—it is simply what these meds do. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks, reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
3. Benzos turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzos upon arrival; several months after the benzos were discontinued, the most amazing thing happened: the anxiety disorders went away!
4. A problem specific to addicts is that they don’t take sedative medications to achieve the absence of anxiety, but rather until they feel relaxed. They are not seeking normalcy; they are seeking relaxation. There is a difference between the two states: one is feeling normal without feeling excessive worry or panic; the other is feeling relaxed, something other than feeling normal. This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a fuzziness that non-addicts often find to be uncomfortable.
5. Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict becomes obsessed with how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
6. Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called “cross addiction.”
7. A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without taking something.
8. Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzos.
9. Benzos have been linked to fetal anomalies and early miscarriage.
10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes the benzo during the day, he or she will be trying to sleep just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzos both day and night, tolerance increases even more quickly.
11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures and worse during withdrawal.
12. Benzodiazepines may calm a truly anxious patient, but they do not generally increase the patient’s function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings.
I do prescribe benzodiazepines, usually for the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist, I often resent the treatment that led to the mess that I try my best to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful. Comments anyone?

Endorphin Deficiency Syndrome and Buprenorphine

Every now and then I receive an e-mail  or comment that is sufficiently long to warrant a post of it’s own.  Below is the comment without interruption;  a bit lower I repeat parts of the comment, interspersed with my own responses.  I hope you find it interesting.
The comment:
I am a strange case: vegetarian, healthy, Pilates instructor, good-looking– NEVER A DRUG ADDICT — but i had a secret-  I was badly depressed for years- treatment resistant to over 30 meds, only some helped to a point… I did extensive research into the brain and opiate systems and i wondered if it was possible my endorphin system may be the culprit ( check this primer: http://www.prohibitionkills.blogspot.com/)
 I was desperate enough to try out opiates as a final solution ( and I monitored myself- I have brakes yet I was always scared of tolerance– and forever afraid to keep on that track) then i found my holy grail… i learned about Suboxone’s other use-  ( and it is now being studied for depression)
I was forced to lie to get on Suboxone, i pretended i was an Oxycontin addict etc.. i know that is wrong, but i was trying to save my life ( i was already at the point of suicide attempts)…not only did i get better, i brought my  mother in who was also treatment resistant and she was made better also within a week when even ECT failed her and messed up her brain for a good year…..she still takes what i took- 1mg in morning, 1mg in afternoon ( we both sensed that was when we needed a second dose not uncommon believe it or not for other depression sufferers that noticed a drop in the afternoon that Suboxone was again needed)
Anyway she is doing great on it to this day…saved her.
Me after intense meditation for one month- seriously no joke – i sensed i was ready to go off it.
 i do everything the hard way- so i went cold turkey off my 2mg a day after being on it for 5 years.
lucky for me- no depression- although the withdrawal did a real number on me– i was so sick from flu and withdrawal , horrible coughing, sore throat, dizzy and weak i wound up at the ER – thought i had H1N1. lol !  I was bed-ridden for almost 2 weeks; i ate nothing for a whole week but soups.
it was NO walk in the park, i was so weak i could not brush the tangles from my hair, even talk much to anyone. and the sweats were out of this world.
i am now at one month and 2 weeks.  i still feel  kind of weak and sickly, swollen glands, and sometimes a sore throat a little, my face is pale and i have huge dark circles under my eyes… the sweats have almost stopped….but my pupils still dilate… when i exercise i tend to feel worse not better — why is that?  
but my real question is this:  why does it make me look so pale and dark circles- ??? is it the interrupted sleep?? or low blood pressure or vitamin deficiencies?? Anemia – i take lots of vitamins and 3 iron pills a night (always did as a vegetarian).   i only wake up once or twice a night and i take a quarter of sleeping pill – unfortunately- every night still- otherwise i will be up forever..
And is there any nutritional things i can do to make me look less ghastly??  i look like a heroin addict and feel like people will see me that way as i can’t keep saying i have a flu forever !! ! What puts color back in the face ??
* before u lecture me about my terrible lie to the Suboxone doctor ( i think he knows anyway as he had to fudge my notes to make me a worse addict than  i claimed)  but u know what?? When i was in ER , and could hardly walk straight from my flu + withdrawal–i told the doctor while i felt like i was dying – that even then…  i was so happy i took Suboxone – it cured me and my mom FROM A LIFETIME of DEPRESSION. 
there IS NO withdrawal that is worth depression, let alone years of it, so please don’t lecture me on what i did, i saved 2 peoples’ lives by lying and i would do it again in a heartbeat…( in fact i was so angry when i found they have a cure for treatment resistant depression i tried in vain to contact media sources to publish a story on it- but who would touch that??)
edie
Wow.  I am exhausted.  I’m not sure why- but some comments take so much energy to get through—and this was one of those comments.  Is it just me? 

First things first: Never hesitate to call drug addiction hotlines for help in drug emergency cases.

Some of my answers will likely come across as harsh, and for that I apologize in advance.  I don’t wish Edie any bad will, but my comments will probably show that I think she has gotten a bit carried away with some of her ideas.  Besides, some of the readers LIKE it when I get obnoxious.  Admit it!
My responses—for those of you who still have some energy left:
I am a strange case: vegetarian, healthy, Pilates instructor, good-looking– NEVER A DRUG ADDICT — but i had a secret-  I was badly depressed for years- treatment resistant to over 30 meds, only some helped to a point… I did extensive research into the brain and opiate systems and i wondered if it was possible my endorphin system may be the culprit (check this primer: http://www.prohibitionkills.blogspot.com/)
Most of my friends are drug addicts.  Most are not good-looking.  They all eat meat—lots of it—and laugh at people in Pilates classes.  And they AREN’T depressed.  I’m not drawing any conclusions—just pointing out an inverse correlation with an ‘n’ of about 6.  I’m also suspicious of the ’30 meds’ comment;  it would take a lifetime to give 30 meds adequate trials, even if there were 30 different meds for depression.  But I exaggerate too, so no big deal.
The primer is interesting, mainly for the collection of links to articles about the effects of opioids on mood and depression.  Edie describes doing ‘extensive research into the brain and opiate systems.’  I don’t know exactly what she did, but the long treatise at the url above is in no way scholarly, but rather is a collection of scattered, mostly-minor studies and comments with many, many incorrect statements, all intended to make the reader believe that there is a unique type of depression caused by deficiencies in the body’s endorphins.  I hardly know where to start—but the article, for example, claims that Effexor (venlafaxine) is a good antidepressant in part because of its similarity to the actions of tramadol— and that implies that venlafaxine effects the endogenous opioid system.  This is all nonsense.  Venlafaxine is an SNRI.  Tramadol has effects on norepinephrine reuptake as well.  But tramadol has entirely SEPARATE effects on the mu receptor that are NOT shared by venlafaxine.
The comments about acupuncture… there are a host of studies that show a failure of opioid antagonists to block the analgesia produce by acupuncture—evidence for an effect that does NOT involve endogenous opioids (which are blocked by naltrexone).
I honestly could go on and on and on… we know the mechanism of capsaicin on the release of substance P;  the effects are a very long shot from thinking that using (or eating!) capsaicin will somehow increase a person’s endorphins.  The writer describes a type of patient—a combination of cluster B traits from the DSM, along with assorted personality traits like ‘crying easily.’  Evidently somebody wrote a book.  Understand that the current distinctions between mood disorders, while not perfect, are based on hundreds of studies and years of input from psychiatry thought leaders—who then have their opinions examined and tossed around by more thought leaders.  Comparing the list of symptoms for ‘endorphin deficiency syndrome’ in the article with the longstanding and scientifically-validated diagnoses from the DSM is like someone writing a poem off the top of his head and saying it belongs in the Bible.
The problem is that there is such a thing as REAL science.  I actually DID study neurochemistry and neuroscience during my work for my PhD, and despite that four years of intensive labwork, lectures with distinguished scientists, searching through literature to write and defend my 150-page thesis—despite ALL of that and then my medical school training—I learned about a tiny, tiny bit of how the brain works.  The actions of receptors, neurotransmitters, and their relationships to mood and other subjective states encompasses a vast amount of knowledge, much of which contradicts itself from one study to the next.  One cannot extract a few studies out of ten thousand and use them to draw conclusions.  I’m searching for an analogy… it is like measuring the temperature during one minute from one hour of one day, in a town in Southern Wisconsin, and saying that you therefore understand the climate of the US—and that the US is a rainy and cold place.  You would be ignoring all of the other towns, times, and temperatures—and thinking that your point about the US was still valid.
I’m never going to finish this…
I learned about Suboxone’s other use-  ( and it is now being studied for depression)
I do recommend that people periodically check www.clinicaltrials.gov to see the interesting studies involving buprenorphine.  I would expect other partial agonists to appear on the scene in due course.
I was forced to lie to get on Suboxone, i pretended i was an Oxycontin addict etc.. i know that is wrong, but i was trying to save my life
I’m sorry to interrupt, but this sure sounds like something an addict would say, doesn’t it?  Nobody can be ‘forced to lie;’  we CHOOSE to lie because we like what the lie does for us.  Maybe it was justified… but ‘forced’?  C’mon.
i am now at one month and 2 weeks.  i still feel  kind of weak and sickly, swollen glands, and sometimes a sore throat a little, my face is pale and i have huge dark circles under my eyes… the sweats have almost stopped….but my pupils still dilate
So much for being good looking!  Sorry—just another bitter, bad-looking bald guy…
why does it make me look so pale and dark circles- ??? is it the interrupted sleep?? or low blood pressure or vitamin deficiencies?? Anemia – i take lots of vitamins and 3 iron pills a night (always did as a vegetarian).  
Shoot—I was just going to suggest a good T-Bone, medium rare.  But seriously, the dark circles can be caused by tiny hemorrhages around capillaries, which tend to be very fragile under the eyes… and the pallor of the skin from vasoconstriction in that part of the body—which is part of opioid withdrawal, along with the ‘goose flesh’ that is so common. 
And is there any nutritional things i can do to make me look less ghastly??  i look like a heroin addict and feel like people will see me that way
There you go again, dissing addicts!  I’m sorry, but heroin addict don’t all look the same, and they don’t  all look ‘ghastly.’  I have patients in my practice who were opioid addicts—some oxycodone, some heroin, most whichever was around— who look like the other people they work with on the job as teachers, carpenters, attorneys, nurses, and CEOs.   And no—the thing that will make you look and feel better is TIME.
* before u lecture me about my terrible lie to the Suboxone doctor
Oops—did that already!
please don’t lecture me on what i did, i saved 2 peoples’ lives by lying and i would do it again in a heartbeat…( in fact i was so angry when i found they have a cure for treatment resistant depression….
I NEVER lecture people, but I don’t know if you would get the Nobel prize in Medicine for what you did—although didn’t Al Gore get it for something already anyway?
I’ll stop here.   There is no conspiracy, and buprenorphine is not a ‘cure’ for treatment resistant depression.  Yes, it does seem to improve mood for SOME people.  But there are big downsides—for example the state that you currently are in.  You may be positive that you are not an addict, but I’m not;  your lie to get yourself on buprenorphine for a while MAY have placed something in you that you cannot yet see, that you will regret some day.  If, in five years, you are free of depression and also free of opioids, then it appears that at least in YOUR case, the experiment worked.  But frankly, the odds are against you.  You will tell me all of the reasons why you are different, and special, and why you will never use again…. But I suspect that if the depression returns, you will have a hard time avoiding another lie for another trial of opioids.  If you can’t get buprenorphine but instead buy opioids on the street, you are looking pretty similar to every other opioid addict—ghastly or not.
I have written about this topic before, and included links to some of the things linked on the url that Edie provided.  My bottom line?  If a person has a history of depression and is an opioid addict, there is one more reason to stay on buprenorphine long-term.  But I would have to think very long before conditioning a person to crave opioids—which is essentially what Edie has done.  As my treatment-roommate said (about regretting making porno movies with his wife while using), ‘there are some things that we learn, that we cannot unlearn.’    The warm, fuzzy feeling provided by opioids is one of those unlearnable things, and the lesson comes at a steep price—especially in a person who is prone to episodes of depression that only respond to opioids!
I hope I wasn’t too rough, Edie—I do wish you the best.

Do You Prescribe Buprenorphine?

I’m not sure about the make-up of readers of this blog.  I know that there are about 20,000 page views each month, but I don’t know how many are by people addicted to opioids, people taking buprenorphine, family members of addicts, or physicians who prescribe buprenorphine.  If you fall into that latter category– i.e. if you prescribe buprenorphine, or if you prescribe other medications to treat opioid dependence such as Vivitrol or methadone– consider joining the group at linkedin.com called ‘Buprenorphine and other medication-assisted treatment of opiate dependence.’  If you already belong to LinkedIn, you can simply follow this link to join: http://www.linkedin.com/groupRegistration?gid=2710529
I have always resisted separating those who prescribe buprenorphine from those who are prescribed the medication.  I have avoided, for example, placing a ‘doctors’ section’ at SuboxForum, as I don’t want there to be two separate discussions.  Clearly, each group would benefit from the wisdom of the other.  But there are some physicians who want to discuss prescribing habits, techniques, and science with other docs, who are not comfortable discussing some topics in the ‘presence’ of their patients.
Non-docs, please don’t flame me for this decision;  I’ve wrestled with it, and have made this decision, at least for now.   Frankly, the discussions at SuboxForum are far more interesting than anything that has come up so far at the linked in site!    But some docs who prescribe buprenorphine are isolated out there, perhaps even looked down on by their peers for working with addiction– and that is a crying shame.    I want to get those docs some support.  My goal ultimately is to bring the two sides together, so that docs can talk to addicts and realize that they are the same species as the rest of their patients!
Thanks all,
JJ

Medical bias against addiction

I haven’t gone anywhere in case you’re wondering… but I recently started writing a blog on Psych Central, called ‘an epidemic of addiction.’   Please add it to your reading list!  This is my favorite time of year and the time I am most likely going to be outdoors, so watch for posts to pick up a bit as things get colder outside.
I’m probably in the wrong state of mind to be blogging, so consider this more along the line of venting.  I had an encounter with a local physician a couple days ago that left me shaing my head–  I have a solo practice so I have forgotten just how misguided medicine can sometimes be.  I was asked to speak with an orthopedist for a patient who takes buprenorphine, who was having major knee surgery.  The orthopod started the discussion by saying that he is angry that the patient didn’t say at their first meeting that he takes Suboxone– like it should have been spelled out on his forehead, to make certain that he didn’t give the patient some undeserved pat on the back or some measure of kindness.  I explained that people on buprenorphine find often find that they are treated differently by (ahem) those doctors out there who (AHEM) pre-judge people…  And the ortho guy said ‘well, for good reason!’  As I remember the encounter I’m having visions of the song ‘KILL THE BEAST!’ from Beauty and the Beast– I’m sure this particular doc wishes we ALL would just go away…

Is addiction treated like a disease?

Where was I?  Oh yes–  the doc then explained to me just how hard it is for him to treat people on Suboxone.  He explained how the ‘therapeutic window’ is narrower– meaning that the ratio of the dose that treats to the dose that kills is larger.  I tried to explain that it ISN’T– the entire window is HIGHER, but not NARROWER.  You all know that, of course– on buprenorphine your tolerance goes up, and it takes a much larger dose of opioid to get pain relief, and a much, much, much larger dose of opioid to cause death.  I tried to explain that this is not rocket science;  I would taper the person off buprenorphine ahead of time (I usually tell people to take 4 mg of buprenorphine per day for a week before the surgery, then skip it entirely on the day of surgery), and he could simply treat the person as he would anyone who is tolerant to about 60 mg of oxycodone per day.  I still cannot believe the response from him–that ‘nobody around here takes that much oxycodone’– that those are ‘big city problems’ and that there just aren’t people doing that around here. 
Wow. 
He told me that he doesn’t like giving pain pills to ‘these people’ (he knows, by the way, that I am an opioid addict).  Never mind that he is going to be doing a ‘total knee’, where the ends of the femur and tibia are sawed off and replaced with metal pieces.  I explained that proper treatment is to provide a basal amount of narcotic, and then use a larger than normal PCA (patient controlled analgesia) deamand dose.  I explained that fentanyl may work better according to some reports, but he said ‘I never use fentanyl.’  So I explained that he could use morphine, but that it would take at least 5 – 10 mg IV to have ANY effect on pain.  He said that he would never give that much– that he would give less than usual, if anything.
At some point he mentioned that it bothered him that the patient has taken buprenorphine for 8 months– that it bothered him to ‘think that there are people out there walking around on that stuff.’  I told him that in some states, the more progressive and intelligent licensing boards are recognizing that patents on buprenorphine are not impaired, and are treating them like regular people– to which he replied ‘then why don’t we just give alcoholic pilots a 12-pack and let them fly?!’
Wow.  I had a range of feelings after the discussion.  The first thing I did was contact the patient and strongly recommend that he seek surgery elsewhere.  The guy I am talking about is good enough at sawing bones, but is clearly an idiot when it comes to thinking through medical challenges– and my patient deserves to know that.  In a perfect world, someone would recognize that doctors like this one have no business working in the field of medicine.  I used to work with this doc when I was an anesthesiologist and I knew that he was bone-headed (pun intended!), but I had forgotten just how nasty and judgmental he could be.  I am tempted to post his name, but I won’t — it would only bring me even more headaches than I already create for myself!  But if anyone is having orthopedic surgery in Northeast WI, feel free to send me an e-mail and ask.
The main thing I’d like to say though is that I am sorry that the medical profession has those types of people among its memebers.  Those of you who feel like you are suddenly being judged, when your doc finds out that you have struggled with addiction– you are probably NOT going crazy.  Ignorance is alive and well, and the day when addiction is treated like other diseases is still a long ways off.  And that is a real shame.

Withdrawal in newborns: Lay off the guilt trip!!

I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction.  I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother.  My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response.  Read on:

There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction.

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about that discomfort—at least not from the baby’s perspective.  I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal.  Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s – babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose.

My points are twofold, and are not intended to encourage more births of physiologically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right.

Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

How dangerous is opiate dependence?

I frequently point out the lack of outrage over the epidemic of opiate dependence and the consequence of that epidemic.  I live in ‘middle America,’ and sometimes it seems that everyone I know has some connection to opiate dependence– a relative who is an addict, a friend who died, a parent who is in prison.  My perceptions are admittedly distorted by the work that I do, but I don’t know who has the more accurate perceptions; me or the people who seem surprised to hear that most high school kids know where they could get heroin.  Addicts who I treat who come down from the U.P. of Michigan tell me that heroin is very easy to get up there now, even cheaper than oxycodone.  I guess that’s to be expected, given the horrible economic situation up there.  One thing is certain though– SOME people are making money!  In my part of Wisconsin, oxycodone generally sells for 60-80 cents per milligram;  the average user that I see tries to find one or two ’80’s’ per day, ending up with a habit that costs over $100 per day.  Given the number of people actively using, there is a LOT of money going into someone’s pockets!  Of course much of the oxycodone on the street is bought by insurance coverage and then stolen from grandma’s medicine cabinet by her granddaughter, who replaces them with plain tylenol tablets…  but the herion money is probably leaving town, eventually finding its way back to Chicago.  Sorry, Chicago.  We have to blame SOMEBODY.
Many diseases have prominent celebrities who put on pink ribbons and fight for funding.  Not so for opiate dependence, even though the deaths from opiate dependence must rival those from breast cancer.  I’ll have to look at the numbers.  But celebrity opiate addicts tend to end up like Kurt Cobain or Michael Jackson– or slink off to rehab and later proclaim themselves cured.  Anyone who watches knows that there is no cure for opiate dependence, and the celebrity addicts only go back to rehab again as society goes ‘tsk tsk’.  Society doesn’t say ‘tsk tsk’ when someone’s breast cancer comes back.
I found an interesting web site called ‘informationisbeautiful.net’ where information about a variety of topics is presented in visual form.  Below I have a couple images from the site using data from the UK on deaths from overdose of a number of substances.  The images are relevant to the current discussion, as he compares the death rates to the reports about deaths due to the substances in the National media.  At the web site he discusses data collection;  I won’t make conclusions on the data but rather simply let is provide ‘food for thought.’  After viewing the first image be sure to contine to the next image down.
Opiates have the highest death rate of a range of substances.
In the next image he manipulates the data slightly to add a denominator to the information– he provides the number of deaths per user of the substance.  Again, I will let people truly interested in his findings visit his web site to look into whatever assumptions were made and which data sources were used.  I would like to again leave the data without much comment, in part because I don’t really know how to explain the high rate of fatalities among methadone users.  I will point out that use of methadone in the UK may be quite different than in the US, because in the US the medication is prescribed in two ways– as a cheap opiate for chronic pain management, and as a maintenance agent for opiate dependence.  In the latter case, prescriptions for the medication are regulated very closely (actually ‘prescription’ is not even the right word, as addicts must personally pick up their dose of methadone each morning for at least the early part of their management by a particular clinic).  I should also point out that Heroin is a pain medication in the UK that is prescribed by physicians (as well as a ‘black market’ substance), whereas in the US all Heroin is illegal and cannot be prescribed for ANY indication.  Finally, paracetamol is the Brit’s term for acetominophen, or Tylenol.  The graphic:
Methadone deaths per user lead the pack for deaths from substances in the UK.
I do have a couple final comments.  On other blogs or in response to my videos I sometimes come across remarks by people who are ‘anti-suboxone’ that ‘the problem with treating addicts with buprenorphine is that you then can’t get them off buprenorphine, and you have another problem to deal with’– that the addicts are ‘addicted to buprenorphine.’   I find that argument to be faulty for a couple reasons.  First, ‘addiction’ is not so much about the taking of the substance as it is about the obsession with the substance.  An addict who is properly treated with buprenorphine loses the obsession for opiates– something that is amazing to witness at the first follow-up appointment, when the addict sometimes cries over how wonderful it is to be freed from the obsession to use.  So I don’t see buprenorphine as a ‘replacement’, and I don’t see the physical dependence on buprenorphine as ‘addiction’ any more than people taking effexor or propranolol are ‘addicted’ to those medications (which also have withdrawal symtoms of stopped abruptly).   But even beyond that consideration, given the high mortality rate for opiate dependence, when people complain about taking buprenorphine I am always tempted to say ‘compared to what?’   People are DYING from this disease– frankly I don’t CARE if they get dependent on buprenorphine.  I am on the record here over and over with my opinion– that buprenorphine should be a long-term medication.  Use it to keep a person alive during his or her 20’s, and then worry about tapering off– and if the person cannot taper off, so be it!  It beats death.   And any parent of an addict in his or her 20’s knows that a string of ‘sober’ treatment centers and repeated relapses is NOT a great life… assuming the person even manages to stay alive.  We are left with comparing the two options of taking buprenorphine and living or avoiding it– and likely dying.   A pretty easy choice to make in my opinion.    I have to wonder what the people making arguments about ‘the problem with buprenorphine’ think about all of the problems with chemotherapy…   if a person’s child develops leukemia, if you treat him with chemotherapy he may end up sterile, and with an increased risk of a different cancer years later.   Would you recommend avoiding using chemotherapy to save his life now?  What’s the difference?
As always I am interested in your comments here and over on the forum.  We’ll talk again in 2010!
JJ
http://suboxonetalkzone.com

Publishers, Agents, Nonprofit Owners or Accountants

I am in need of some help from the people listed in the title– so if you have connections, help me out.  I am adding this sentence to the front of this post after rambling too long, as I’m afraid that the person I need won’t get to the important part!  If you work in the areas I mentioned or have connections to someone in those areas, please read on.
I’ve talked about some of the goals I have had for this site over the past couple years…  one of my ‘personal issues’ is that like most addicts, I like to take things on by myself and solve problems by myself.  I remember, in fact, my first time in treatment in 1993– an outpatient, 21-session group therapy program– when one of my assignments was to ask another person for help at least once per day.  That was a very difficult thing to do, and I must have gotten better at it because now I am asking for help all the time!  On the other hand, I have some areas of my life where I would never consider asking for help– so maybe I’m not as ‘better’ as I think I am.
Before moving on I should make a quick educational comment about addiction– one reason that addicts do not ask for help earlier is because we know that if we ask for help, there is a possibility that we will have to change for the better and lose our addiction.  And every addict has ambivalence about becoming sober– even at times when we recognize that we are powerless and that our lives have become unmanageable!  There is always some degree of ambivalence.  If you are being ‘stubborn’ about getting help, consider whether you TRULY want to be done with using.   Sometimes a person who can’t find just the right treatment program is really concerned with something else– whether to really give up the secret life of an active addict.  If you are in such a situation, consider whether you are debating the REAL issues, or whether your concern for clean pillows and the ‘right treatment approach’ is just a distraction from a bigger question.
OK…  I am in need of some help.  I have written a pretty good book about addiction;  it is certainly different from what is ‘out there’, as it is personal and at the same time  educational, theoretical and at the same time practical, long and detailed but at the same time broken into bite-sized pieces.  I have patients on buprenorphine who are accountants, attorneys, nurses, businessmen, laborers, government employees… I find that opiate addicts are an incredibly talented bunch.  I figure that if they do OK in life despite having chains around their ankles, they will do wonderful when the chains are removed!  So out of the readers out there, I know there are people who work close to the publishing field– or people who know people in the publishing field.  If that person is YOU, please consider giving me a hand with the book.  I could just self-publish it, and that is what I may end up doing— but I would rather, of course, get the marketing that comes with ‘being published’ so that I can reach a wider audience.
As for the ‘non-profit’ thing– I am aware that of grants from government and private sources for educational projects related to drug addiction, but support is reserved for ‘non-profit groups’.  My efforts with the blog and forum are certainly not profitable– but I do not know how to go about setting up a non-profit agency.  I would like to make the site grow– to get a ‘real’ web designer instead of doing things myself (and I have no education in computer stuff, so in typical addict style I just try to figure it out myself).  When it comes to the IRS, I don’t want to figure it out on my own!  So if you can help–  either by pointing me in the right direction or something more– please let me know.   If you are unemployed, independently wealthy, and experienced in running a nonprofit company, come join me– be the ‘management wing’ and I’ll be the ‘medical wing’!
I realize these are long shots, but I always tell my kids to keep throwing baited hooks in the water.  If nothing else, we’re getting exercise!  If you even just know of someone who might or might not be interested, throw out another hook for me– I appreciate it!
Serious replies (or even funny ones) can write to me at [email protected]
Thanks!