Tapering Suboxone

I am placing a new link in the Blogroll to a site that discusses tapering Suboxone.  I want to be clear that in my opinion, an opiate addict’s safest place is on Suboxone.  Many opiate addicts also find that on Suboxone they experience less mood variability, less irritability, and less anxiety;  I wonder if those symptoms represent forms of craving for those individuals.
I don’t see a ‘disease theory of addiction’;  rather I see very clearly that opiate dependence IS A DISEASE  (maybe we need to run a campaign:  It’s a disease, stupid!).  For hypertension, people take their medication and spend no time worrying about whether they are ‘living a life free from beta-blockers’.  Seeing that the people who judge addicts as ‘weak’ are idiots, I don’t understand the push to ‘get off Suboxone’.
If you are having side effects from Suboxone, please talk to your doctor.  If you are having random urges to stop Suboxone, at least consider the possibility that on some level you are setting things up to use again… and talk to your doctor.  If you have taken Suboxone for a long-enough period of time to make new, non-using friends, to lose all of the phone numbers, to get a good job, to come to terms with the family issues caused by your addiction– and if you can take Suboxone once per day without giving in to urges to take a bit more or to dose twice per day– AND if you have a plan to replace Suboxone with a recovery program– then maybe you are ready to taper off Suboxone.  In that case… talk to your doctor!!
I will of course put in a plug for a tape that I made, that discusses when and how to stop Suboxone– it is for sale on the right side of this page, or at SoberAfterSub.com.
If you are making a sound decision based on some good, sober thinking, check out the web page SuboxoneTaper.com.  It is relatively new, but I like the attitude of the writer– admittedly because he seems to think and write like me!  He comes across as cocky and angry… and I realize that I write like that as well.  Let there be no mistake– I have connections to some other web sites out there, but I have no connection to this one, and I don’t know the writer.  So if he suddenly gets in trouble for selling a Senate seat, I had nothing to do with it and I have nothing to say about it!!

Angry at Suboxone? Why?!

I received a nice message today in a comment section;  I am posting the message and the thoughts that it generated.  The primary topic of this post is the anger that is often directed toward the use of Suboxone.
The nice comment:
Hi Dr. Junig, my name is Jane XXXXXX. I have been reading this blog for a couple hours now, and have been searching the whole site trying to figure out how to email you. So far no such luck, and I hope you don’t mind me writing this to you in the form of a comment on a completely unrelated subject. Anyway, I wanted to thank you, sincerely, for the understanding and insight you’ve provided to so many people, myself included. I’m 19 years old and have been struggling to keep myself clean for the past several months. I’ve battled a heroin addiction since the age of 17, and in a way I feel that it’s grown into my identity as I’ve become an adult. That’s not something very many people can wrap their minds around, which seems to make a lot of the hard work that’s put into staying off of drugs go unnoticed, and unappreciated. I realize that the road to recovery is long, and one that you tread upon from the inside of yourself, not based on the recognition from others. However, I do believe that it helps a great deal to have someone in your corner. Thank you for all your help and for seeing that we aren’t just “addicts”, but people who have lost their way somewhere along the line, and for genuinely caring that we are now on the path to a better life. Please don’t stop helping, you’re doing a wonderful job!

-Jane

My very long-winded answer:

Thank you very much for your nice comments! When a person makes comments, I receive an e-mail with the person’s comment and e-mail address—I always cringe a bit before I open the message, because usually it is usually negative and often nasty and insulting. That makes a note like yours even nicer to read!

I don’t know what fuels the anger of those who write mean things. I suppose some of it comes from the anger that some people have toward anyone who is a self-professed expert on the internet.  But the anger toward Suboxone…  I remember how horrible I felt during my actively-using days; I think of the friends I had from treatment who have since died from their addiction to opiates, knowing that Suboxone would have kept them alive; I see people in my practice who come in completely broken, and in as short a period as a month are human beings again… I would think that all addicts would be thrilled to finally have the pharmaceutical companies interest, whether or not they themselves used Suboxone!  But instead, the addicts who are sober through 12-step programs accuse people on Suboxone of being in ‘lesser recovery’.

I try to let go of resentments, as I myself am a ’12-stepper’ and I know that resentments are a pathway to using… but you probably read my negative remarks about a couple other web sites. There is an ‘institutional’ drive against Suboxone at the two sites I mentioned in my posts; through my alerts from Google I see daily posts from new visitors to those sites, asking about Suboxone; they receive a chorus of replies that are negative and inaccurate. They list side effects that I have never seen in my large practice, and that are often inconsistent with the known actions of buprenorphine (many people don’t realize that buprenorphine has been around for 30 years, and so it isn’t hard to recognize the posts that are simply making things up!). I don’t know what motivates the people there, but they have made it impossible to post accurate information about buprenorphine and Suboxone; they will simply delete posts they don’t like. I received an e-mail from someone at drugs.com that would be funny if not for the misery that results from the practices there—the note started with angry expletives, and finished in a way that might be telling:

My way is the only way!
My way is the only way!

I’ve been clean and working with recovering addicts in my ministry for a long time.  God is pleased with me. I do what I do for His approval not yours.  If you don’t like me I can’t help that.  God bless.  And don’t you dare post my email address or we will have legal issues I assure you. I will turn you over to authorities if you post my email address online.  That is a promise.

Authorities? WHAT authorities? Anyway, you can see why it is so nice to get your kind message!

I suppose I should be at a meeting right now instead of getting worked up again… but I think instead I will make this a post that addresses the issue of anger at Suboxone (note—this is a classic example of addictive behavior— recognizing what one ‘should’ do but instead doing what one ‘wants’ to do. I am an addict, after all. One goal in recovery is to recognize one’s own addictive behavior and correct it) (note to the note: You just read a second example of addictive behavior—intellectualizing the problem as an excuse to avoid the correct behavior! See? Recovery CAN be fun!). The God note above seems to come from a self-righteous person who sees only one way to become clean and sober. I receive many similar letters, but my point with this one is that the person writing it has the power to screen posts at drugs.com— which is why I see that site as potentially dangerous to an addict who is stumbling around looking for help, who may just stop taking his/her Suboxone in response to advice from some nut.

Most of the angry letters come from people who think addicts are weak or lack ‘will power’—who think that ‘addict as a disease’ is still a ‘concept’. Here is one of those messages.. I will leave the misspellings in it so that you get the full sense of the writer’s intelligence!:

I know a lot more about addictions then you think, I was or I should say I am an addict, once an addict always an addict the only difference is if you use or not. I choose not too. Your making excuses, and you get as defensive as the addicts I know there is no magic pill that will cure a drug addict,and if you have people using sub. instead of oxy what is the difference??? Nothing, except an addict can get suboxone from a doctor who thinks he is helping these people who will lie,steal and take down anyone and everyone in their lives to stop the withdrawals and get something wether it be suboxone or what ever is going around their area. No you don’t stop using insulin, but a diabetic has no choice they are diabetics no one offered them the option of would you like to have diabetics or not. Addicts have a choice and they choose to use. There was something troubling them in the first place or they wouldn’t have started using drugs period. Happy well adjusted people don’t use to the point of self destruction. Sure I would love to get a bottle of oxy’s when I am having bad times because they take all the pain away mentally and physically. No problems, just peace. Maybe I’m different then most but when I was taking oxy’s and I noticed I was having withdrawals I threw the rest of my pills away and haven’t touched one in years. So what you are saying is that even after the psychical withdrawals of pain killers the psychological addiction will be with you for ever?? Hmmmmm… That’s where therapy comes into play but then again I don’t know because I haven’t had any problems with drugs. I guess crack addicts should just get diagnosed with a.d.d so they can be a life long member of the addarall club. I know that’s different crack addicts are low lives and they are not the same type of people who use pain killers heard it all before. The truth is the truth if someone is using one drug to stay off another and the drug is an opiate or opiate substitute they are still using. Until a person can stand alone without any drug or substitute and until they can learn to handle life and all the ups and downs straight they will always be at great risk of falling back into their old habits. I have seen it time and time again and I ask why if the withdrawals are so painful do so many people take suboxone for a few months and switch back and forth from sub’s to oxy’s? The pain can’t be as bad as they claim or they wouldn’t go back and forth. That is just stupid and selfish. So anyway I guess I don’t have a clue so good luck to you and your practice.

Do you think he really meant that last part about ‘good luck to my practice’?

I also receive angry letters from people who see Suboxone as a threat to methadone. I try to remain neutral toward methadone; it wouldn’t be my first choice, but if it saves someone’s life, who am I to judge? I DO take issue with comparing buprenorphine and methadone as ‘one and the same’; partial agonists are not the same as agonists. When I hear the comparison, I make the point that if anything, buprenorphine is similar to an antagonist—like Naltrexone. When people leave traditional, step-based treatment programs they are sometimes put on Naltrexone as a ‘safety measure’ so that they know that even if they used, they wouldn’t get ‘high’. I have never heard objection to the use of Naltrexone, even from the most die-hard advocates of ‘total sobriety’. There are a couple problems with Naltrexone; one problem is that the person taking it has cravings for opiates. What if we took Naltrexone and added a small amount of opiate activity—not enough to get ‘high’, but just enough to prevent cravings? Another problem with Naltrexone is that it doesn’t last very long in the body—a person can skip a dose and then use the same day. What if we made Naltrexone longer-acting, so that it stuck around for three days? And what if we made it have a small amount of withdrawal, to make it less likely that the addict would stop taking it? If we did all of these things to Naltrexone—made it treat cravings, made it longer-acting, and made it create withdrawal when discontinued—we would have… Suboxone!

Darn Addicts!
Darn Addicts!

I receive letters from non-addicts;  some are genuinely dumbfounded over a person not being able to stop something that is so obviously self-destructive.  Many of the non-addicts who write clearly have anger left over from dealing with an addicted family member;  if some of those writers had their way,  anyone who meets criteria for ‘addiction’ would be put to death, or at least banished to some miserable place to live with all the other losers of the world.  I receive letters from health professionals in the mental health field who see Suboxone as only a band-aid over a neglected wound;  to those folks I say that Suboxone is always only part of the answer.  But I also point out that while I am a big fan of self-insight, ‘counseling’ has a poor record when it comes to treating addiction.  One-on-one counseling is often used by addicts to self-justify addictive behavior like I mentioned earlier– ‘yes, this is bad, but since I understand myself it will be OK’.  The best counseling or therapy for addicts is group therapy, so that addicts can call each other on their sh#@.

The remaining letters are mostly from addicts who are still in the learning process, ‘collecting research’ as we say at meetings. I see these people in my practice and struggle to help them, which is essentially the work of treating addiction. They still think that once they get past the physical withdrawal, everything will be OK. They want to take Suboxone just for a few weeks as a bridge to sobriety, but they don’t see any need for meetings or other treatment. When I tell them that the physical withdrawal is the EASY part, and that they will almost certainly return to using, they either become angry or tell me that they are ‘different from those people’—that unlike ADDICTS, they used only because of (insert pain, anxiety, depression, loneliness, unemployment, bad spouse, bad boss, bad weather, wrong season, bad parents, or bad children). They tell me that they have ‘fixed’ the problem, so everything will be fine. They don’t yet understand that the addiction is both ‘chicken’ and ‘egg’—that they use because of their problems, but more importantly they have problems because they use! I tell them what happens in ‘late-stage addiction’: the addict hates using so much that he/she will be able to get through withdrawal; while sick, the addict will remember that hatred of using and use the hatred to stay clean… but as soon as the sun comes out and the withdrawal passes, the addict returns in full force and uses again. This stage of addiction is particularly demoralizing (been there, done that) because the addict is almost always sick; it is also a time of intense emotional ups and downs, big hopes and promises to self and others, periods of relief… and then regret, secrecy, broken promises, anger, shame, and disgust. Spouses say “how COULD you?” Addicts feel like they are going crazy. Enter loneliness, self-disgust, despair… no wonder suicide is so common in late-stage addiction.

Before Suboxone, a few of the people who reached the point of despair would find Recovery through treatment and/or the steps. Now, with Suboxone, we can save many, many more addicts, often long before they reach such misery. Is Suboxone perfect? Of course not! What medication is perfect? It did not come with a ‘cure’ attached. Too bad, so sad. But what a huge step forward it represents! And I am thrilled that Suboxone has caught the attention of capitalism, because suddenly the bright minds in Pharma see that there is MONEY to be made treating addiction. Build a better mousetrap—invent BETTER medications! And the company that finds a treatment that gets to the core of addiction will deserve the huge profits that will come their way.

I had better stop and get back to my ‘real’ job! But thank you, Jane, for your nice comments, and for sparking this morning’s post. I wish you all the best in your own recovery.

SD

Listen to me– 'cause I KNOW!

I’m becoming quite the sarcastic one lately but I had to share the Google Alert I got this morning– understand that I don’t get the whole post, just a couple sentences, but it was from soberrecovery.com…

Love them Packers...
Love them Packers...

The title was Suboxone = Devil in Disguise, and it went on to say you people who are saying your taking suboxone and are “clean and sober” are fooling yourself period. I have had many detoxes….
Reminds me of the classic movie ‘Animal House’ (with fellow addict and brilliant comedian John Belushi– click here to see his SNL audition tape) when he says ‘Rats– seven years of college down the drain…’
OK–I’m off to Lambeau Field and the Packer game…
SD

SoberRecovery.com and Drugs.com: Oceans of Misinformation

Another morning of Google Alerts about buprenorphine, and another list of new posts at SoberRecovery.com and Drugs.com about Suboxone.  The posts usually have one thing in common– the writers of the posts are seeking the easy way out from opiate dependence.  They were in a huge mess from their addiction to opiates, they started on Suboxone, life got better… and now they are complaining that they are ‘stuck on Suboxone’, resenting the medication that saved them.  A post today suggests that Suboxone docs have a secret agenda, to keep them addicted to Suboxone– I’m no sure how one draws that conclusion at the same time there are waiting lists for the limited number of docs who are willing to treat opiate addicts, with or without Suboxone!
I have taken on the addicts’ arguments many times over the past year;  it is frustrating arguing with opiate addicts, not because the arguments are intellectually tough, but rather because the arguments are always the same, and it gets tiring writing the same thing over and over again.  And as a recovering opiate addict, I have been in the shoes of the person on the other side of the argument– back when I was using and miserable.  Like all opiate addicts in recovery, I still have that ‘addict inside’ who tosses out the same old lines every now and then– except after being at this for years and years, I have come to identify most of them fairly quickly.  That is the job of the recovering addict, by the way– to learn to identify one’s own BS– one’s own ‘addictive thinking’– and to call one’s self on it as soon as possible, before it leads the addict back to a life of misery.
Add to this that all addicts seek the easy way out of most situations… and that a hallmark of opiate addiction is feeling ‘unique’ from others, so that each addict considers himself or herself to be a ‘special case’–  the result is that instead of taking the time to go to the ‘search’ function of the blog or site and reading the collective wisdom, the addict puts up his/her own post and grabs the advice of the people who are first to respond, assuming that those ‘first responders’ must care the most.
The trite arguments on those sites are mostly ignored by treating professionals and the professional societies;  the general assumption is that people who rely on those forums cannot be helped until they realize that the forums contain mostly nonsense, and move beyond them to get help from genuine treatment professionals.  But opiate dependence is a fatal illness, and it bothers me that those sites– sites like ‘soberrecovery.com’ and ‘drugs.com’– provide such a distraction from the truth of addiction treatment.  They create an environment where every person is an expert– I imagine there are areas where that is a valid format, but when working with fatal illnesses that have denial as a hallmark of their presentation, such sites are surely responsible for the misery and death of many, many people.
I responded to an addict the other day who posted something typical to those sites– the ‘drug replacing a drug’ thing, I think it was…  which I usually answer by describing how addiction is not the ‘drug’, but the relationship with the drug, and how buprenorphine is a partial agonist, and how it suppresses cravings to induce ‘remission’ of addiction, and finally how addiction, like other remembered things, cannot be erased or cured– so an addict can’t just stop Suboxone and expect to remain clean without replacing Suboxone treatment with a 12-step program.  Blah blah blah…  I have written it over and over that I am starting to bore MYSELF, and so I must certainly be boring the other people who read my blog.  Sorry about that, by the way.
When I write my answer I will be one answer in a list of answers from people like ‘druglover’ or ‘soberjim’ or ‘petuniagirl’ or ‘suboxonehater’…. and I have no interest in jockeying for position with people who may or may not have any experience or knowledge about addiction.  So I used to put the name of my blog– but sites like soberrecovery.com and drugs.com are dependent on ad revenue, and they would prefer that the other blogs out there would just go away– so they erase comments if you mention your own blog.  There have been times, though, when I have really felt bad for this person out there who sees ‘soberrecovery’ and thinks (incorrectly) that the people making the site ‘care’– and so I would post a reply with my REAL name– Jeffrey T Junig MD PhD– and with my REAL e-mail address (I’m expecting to be attacked for this post, so I won’t make that one quite as easy– to flame me you will have to click once or twice to get my e-mail address!).  Today I get this message from Soberrecovery.com:
Giving medical advice on the public forums is not allowed.Neither is posting your email address.
Posts containing such will be removed.
Peter

I replied, basically, that it is pretty irresponsible for a site to entertain medical question after medical question, and allow posts from every medical non-expert with medical ‘guesses’, and then block any response from a person who happens to have the training, education, and/or experience to answer the question with some degree of accuracy.  I don’t claim to be an expert on everything– but I write about addiction, especially opiate addiction, because over the course of my life that is where my attention has been (for good and for bad), and if I am an ‘expert’ on anything, it is addiction to opiates.
I must get to the office (where I treat addiction, by the way!).  So I’ll just close with the suggestion to seek out information only from places where the people can list a resume.  You don’t have an electrician fix your plumbing.  You wouldn’t go to the real estate forum to learn how to train your dog.  Ironically, most sites that deal with non-life-threatening issues encourage the posters to list their experience– how messed up that sites like soberrecovery.com and drugs.com block them!  So instead, go to Health Mavens at wellsphere.com, some other site where you know AT LEAST the e-mail address of the person who is counselling you.
Later I will post a summary for many of the questions about Suboxone that come up at the BS sites like soberrecovery.com and drugs.com (yes, I am posting their names a lot, because I want Google searches to provide links like ‘BS sites like soberrecovery.com’).  I also encourage those of you who want to save a life to spread the e-word about the BS at those sites. Yes, I am a bit bitter… but that doesn’t take away the fact that those sites are killing people.
SuboxDoc
Jeffrey T Junig MD PhD

Getting Off Alprazolam (Xanax): The need for Recovery

A comment on my old blog referred to a discussion about the withdrawal from Xanax, or Alprazolam, a short half-life benzodiazepine:
Clonazepam (Klonopin) actually is not the drug of choice used in benzo withdrawal, rather it is diazepam (Valium). Clonazepam It is not a very long-acting drug, with a half-life of only 18-50 hours; diazepam’s half-life is 20-100 hours, with its metabolite hanging around for twice that long.

Absolutely the worst thing about benzo withdrawal (take it from me) is that it never ends. That is why I still take them.

Sadie

My Response:

The ‘drug of choice’ for benzo withdrawal depends on many factors beyond half-life. Diazepam (aka Valium) is absorbed very quickly and so the onset of action is as fast as 20 minutes; this is useful in some situations, but is also thought to contribute to the increased addictiveness of diazeapam over clonazepam (Klonopin). Both drugs stick around long enough to accumulate with repeated dosing; diazepam has active metabolites, making the effective half-life even longer than the pharmacologic half-life. But who cares? In either case the person coming off alprazolam (Xanax) can take the longer-acting benzo four, three, or two times per day– even once per day could be sufficient to prevent seizures with either drug, providing the dose is high enough.

It is very hard for most people to get off Xanax… or any benzo. For that reason, the best medication for alprazolam withdrawal may be a non-benzodiazepine anticonvulsant. I have used valproic acid (Depakote) or phenobarbital in patients for treatment of benzo withdrawal and/or alcohol withdrawal. Pretty much anything that works for alcohol withdrawal will work for benzo withdrawal– which is consistent with the fact that alcohol, benzos, phenobarb, and valproate all have actions at the GABA receptor. Other factors to consider when choosing a medication for benzo withdrawal include liver function– diazepam in particular lasts forever in patients with bad livers. Phenobarb affects the metabolism and plasma levels of many other medications. Valproic acid can cause liver damage and tends to stimulate appetite; is also causes heartburn and nausea in many patients.


The biggest problem with coming off benzos is losing the fuzzy haze that covers life and tolerating the harsh glare of reality. Patients complain of ‘anxiety’– many times they are simply feeling what everyone feels all of the time, but they have lost the ability to tolerate the normal stresses of life. This is where 12-step programs come in; working the steps provides everything that is needed for a person to learn to tolerate reality. After 15 years of going to meetings, I am still amazed at the value contained in the 12 steps. EVERYTHING is there! How to tolerate one’s self; how to deal with others; how to cope with rejection or loneliness; how to begin to understand a purpose for living… the answers to all of these questions– questions faced by most drug addicts on a daily basis– are contained in the steps. I strongly encourage, and invite, people learning to tolerate reality to come to recovery and join the others who are looking for the same thing– and finding it at AA or NA.

SD

Getting off Suboxone, Continued…

Thanks BC for this post and discussion point:
I often wonder what’s up with the people who say that Suboxone w/d is the Worst! Thing! Ever!
Maybe they never really went through w/d’s before, so they don’t have much to compare it to? It seems that some people carp on how long it takes to feel “normal” again, but I wonder what they are doing in terms of self-care.
Many of the websites I see (I subscribe to the same Google alerts as you) say stuff like – Only take Sub for 2 weeks max!!!! Otherwise it will take you six months to get off of it. Which makes no sense to me.
Anyway – I’m trying to taper off because my insurance will only cover Sub for 12 months. They say there is no evidence that it should be used longer than that, which is news to me, but that’s what it is. I could try to appeal, but I want to be prepared to be cut off anyway.
I could just try to pay, as I’m at a low dose now, but I returned to college and between that and certain other chronic-health issues, I just don’t have much money.
I really like reading your blog, because it’s nice to hear the opinion of someone who knows of what he speaks, but you are frankly starting to scare me. Do you know of anyone who has successfully made the transition from Suboxone treatment to “sober recovery”?
My doctor has only had a few patients even get off of Sub, but he says if anyone is a good canidate to make it, it’s me. Somehow I don’t find that terribly comforting. If you have any success stories, would you mind sharing them?
thanks, bc of Diary of a Quitter
My Response:
Hi BC,
Thanks for the nice comments that you have made and for your support.    Some days I feel that I am too ‘invested’ in the debate over Suboxone;  the anti-Suboxone people seem to be getting louder, and at the same time they are getting more stupid.  You may have seen the post today on Google Alerts from Drugs.com:  Should I taper off Suboxone using methadone?  The denial of opiate dependence couldn’t be more obvious!  I went to the site to read the post–  Drugs.com ‘banned me’ but I just use an ‘anonymizer’ and I can post all I want (I was banned for having SuboxoneTalkZone in my signature– I got this strange e-mail from a guy talking about God and his ‘mission’, interspersed with profanities and comments like ‘I’m doing the Lord’s work and you’re Jack Shit’–  must be an interesting church those Drugs.com folks go to…).  Where was I?  Oh–  the guy who asked about tapering off Suboxone using methadone wrote ‘I don’t intend to become addicted to methadone– only to use it for about 7 days’.   Maybe that was MY problem– I should have tried ‘not intending to get addicted’.
I think my comments will only continue to scare you, but I don’t think they should.  The way I look at it, the bottom line is that opiate dependence is a life-long condition. I don’t know if you have read my story, but I was ‘clean’ throughout the 1990’s without sub.  Today I was sitting in an AA meeting as we discussed ‘step 5’, and someone was saying how not completing step 5 will eventually lead to relapse.  I remembered how things were in the 1990’s, before sub; an opiate addict who relapsed was ‘up a creek’ with little hope of getting clean again.  I used to have nightmares that I had relapsed, and that I was heading for death from my addiction.
Now, Suboxone has helped many people, but at the same time it has changed the bottom line.  Opiate dependence no longer has to be fatal;  there is another option.  For people who come from the time of no options, Suboxone is pretty amazing.  But the newer crowd– people getting addicted more recently– don’t have the same gratitude for the medication, and maybe they don’t have the same respect for the danger of opiate dependence.
I have had a few people choose to leave Suboxone– about 6-8 who I can think of, out of about 150 people started on Suboxone in my office.  I don’t know how they are doing long-term, as people who do well tend to disappear (as do people who don’t do well).  I don’t know of anyone who has relapsed from that group, but that doesn’t mean a whole lot.  But if they did relapse I wouldn’t blame the fact that they took Suboxone;  I would blame the fact that they stopped it.  I always tell people who present with opiate dependence that they have a life-long illness that will need life-long treatment.  They can treat it with Suboxone, or they can treat it through the process of changing their personality by working a 12-step program.  There is no cure.
That stinks about your insurer.  We have one local insurer who limits people to two years, but the rest cover people indefinately– at least so far.  Opiate dependence is a disease by any criteria;  I see stopping treatment at 12 months a consequence of stigma.  Can you imagine an insurer saying they will cover insulin, or blood pressure medication, for only 12 months?
I have given a lot of thought to how to get a person ready to stop Suboxone.  I look at the things that were accomplished during my residential treatment, and try to find ways to do the same thing for addicts getting ready to stop Suboxone.  This includes working on boundaries, emphasizing the need to respect ALL directions on prescriptions, working on balance in life that includes exercise, good sleep, good diet, and a support system; identifying ‘triggers’ for using; finding ways to fill one’s time;  having a ‘daily plan’, rather than just ‘bumming around’ day after day…  All of these things were ‘given’ to me in my treatment, and they all helped keep me clean.
Then there is step-work and meetings.  We really know of no other way to keep people clean.  There is so much good information at meetings… I have considered requiring attendence for Suboxone patients but I don’t, in part because people don’t benefit much from meetings that are forced on them.  So instead I try to take the things that are taught through the steps and get people to apply them in their daily lives.  It is hard to say whether that works or not;  it is very hard for people to change, unless they are truly desperate.
For you, I wish you the best with your ongoing recovery, and I have to put in a ‘plug’ for AA and NA.  They did save my life– a couple times.  They take work, but the work pays off– in the same way that it takes exercise to get into shape.  All of the hard things about going to meetings have benefits to them–  tackling the fear of walking in that first time gives the satisfaction that comes with facing our fears, for example.
Suboxone does go generic in 2009, so hopefully it will be cheaper at some point.  Even at its current price, it is much cheaper than using, particularly if you factor in the total costs of using– so if God forbid you find yourself in a relapse, don’t waste any time debating the issue– just get back on some form of buprenorphine.  Watch for ‘probuphine’, an implantable buprenorphine delivery system that is in human testing.
My tape directed at ‘sobriety after Suboxone’ goes into the AA and NA issue in a bit more detail, and talks about what I see as good personality features or bad personality features for going off Suboxone.  If you check it out, be sure to provide some feedback in relation to your experiences.
I wish you the best out there BC.  Please keep in touch– I will watch for you over at your blog.
SuboxDoc

Suboxone's complicated relationship with traditional recovery

By now almost every opiate addict has heard of Suboxone, the amazing medication for opiate dependence that has taken the using world by storm.  I initially had mixed feelings about Suboxone, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the past two years, because of what I have seen and heard while treating well over 100 patients with buprenorphine in my clinical practice.  At the same time, I acknowledge that while Suboxone has opened a new frontier of treatment for opiate addiction, arguments over the use of Suboxone often split the recovering and treatment communities along opposing  battle lines.  The arguments are often fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine and Suboxone can have huge beneficial effects on the lives of opiate addicts.
An amazing medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach.  People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all.  This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone.  On one hand, good boundaries include the right to keeping one’s private medical information so one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;  they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opiates than for other substances.  This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opiate addicts have a number of such ‘defects.’  The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opiate addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.  I realize now that I was making the assumption that character defects were relatively static—that they develop slowly over time, and so could only be removed through a great deal of time and hard work.  The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic.  I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Suboxone removes the obsession to use almost immediately.  The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.  The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.  I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.  I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining Suboxone treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?  Yes, if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But I see little use in forced or coerced attendance at meetings.  The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.  In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should Suboxone patients be in a recovery group?
I have reservations about forced attendance, as I question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there clearly is much to be gained from the sense of support that a good group can provide.  Groups also ‘show’ the addict that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle their own addictive thoughts.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  But for a person taking Suboxone I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is just another opiate agonist.  A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.  With cravings comes the obsession to use and the associated character defects.  This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.
The downside of Suboxone
Practitioners in traditional AODA treatment programs will see Suboxone as at best a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone.  Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Suboxone itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of Suboxone use implies long term use of the drug.  Chronic use of any opiate, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary.  Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.  But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out weaknesses.

I'm Not Like 'Those People'

A recent letter and response that addresses the ‘terminal uniqueness’ issue:
Hi and thx for getting back to me. I have never tried anything to get off of these pills. I am not your stereotypical addict. Truth be told I have never been addicted in my life. I feel like such a loser for letting myself get out of control and if it was not for being sick I would have licked this a long time ago! I am not off them right now because I cant. I work hard all day to support my family and there is no time to be down and out. I have also suffered an incredible string of losses over the past two years. What a predicament huh? I lost my wife two years ago, and the story goes on. I have chronic back pain from degenerative discs, but I will deal with that. Will suboxone do anything for me?
My response:
I have a couple things to say that may come across as ‘brutally honest’—don’t take it personally, but rather understand that EVERY person who gets stuck on opiates has a unique story, and we all were reluctant to see ourselves as ‘stereotypical addicts’. There is a term in addiction—‘terminal uniqueness’—that refers to a state of mind that is common with addiction, and which keeps people sick.
A frequent refrain by a person new to a treatment center is ‘I’m not like those people’. The fact of the matter is that one rarely sees a ‘stereotypical addict’ at treatment. What one sees are teachers, dentists, single and married moms, college students, high school students, people with back problems or fibromyalgia, people who have been through terrible tragedies… So try to avoid seeing the things that make you unique. Instead, try to see the things that make you like everyone else—the horrible feeling of being trapped by something, when you have always handled things well up until now. That is how most people who are stuck on opiates feel—trapped, embarrassed, ashamed, angry… and afraid. Others don’t feel anything because they repress all of their feelings and put up a fake, cocky exterior. That is what denial is all about.
J

Is Suboxone At Odds With Traditional Recovery?

By now almost every opiate addict has heard of Suboxone, a medication for opiate dependence that has been around for about ten years. I admit to mixed feelings about Suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery.While Suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines.Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.
An amazing medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach. People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all. This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone. On one hand, good boundaries include the right to keeping one’s private medical information so one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town. The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’. This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time. Opiate addicts have a number of such ‘defects.’The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.I had such an expectation when I first began treating opiate addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user. I realize now that I was making the assumption that character defects were relatively static—that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic. I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking. People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system. The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear—a primitive emotion from the old brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside. The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining suboxone treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?Yes, if they want to.A 12-step program has much to offer an addict, or anyone for that matter. But I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should Suboxone patients be in a recovery group?
I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.But for a person taking Suboxone I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.With cravings comes the obsession to use and the associated character defects.This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.
The downside of Suboxone
Practitioners in traditional AODA treatment programs will see Suboxone as at best a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone. Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug. Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.Finally, the remission model of Suboxone use implies long term use of the drug.Chronic use of any opiate, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary. Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.But for now, the treatment community would be best served by recognizing each others’ strengths, rather than pointing out weaknesses.
This article can be reproduced freely as long as the following attribution is included:
The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin.  Read more about suboxone at SuboxForum.com, AddictionRemission, or at Suboxone Talk Zone. He can be contacted at Fond du Lac Psychiatry.