First Published 7/23/2013
I hear from the anti-buprenorphine people now and then, less than I used to. I also hear from fans of this blog’s early days, when I routinely lost my temper in response to those people. Their general line was that things on heroin weren’t all that bad, but now, on buprenorphine, things are miserable. Starting buprenorphine somehow removed an opportunity to be clean that they used to have, that they would have used if not for buprenorphine.
They somehow miss the obvious—that they could ALWAYS go back to the heroin addiction that worked so well for them. They’ll say they could stop heroin any time they wanted (you know the joke—‘It is so easy to quit that I quit a hundred times!’), but act as if someone is forcing them to take buprenorphine.
If it is so easy to stop heroin, why not go back to heroin and stop?
For the record, I don’t advise people on buprenorphine to change to heroin. It is difficult to wean off any opioid, including buprenorphine. But I do have patients who have tapered off buprenorphine; something I’ve never witnessed with agonists like oxycodone or heroin (i.e. tapering outside of a controlled environment). Most people who read my blog know that I don’t recommend tapering off buprenorphine for most people, an opinion I’ve come to after seeing many people relapse, and some people die, after stopping buprenorphine.
I received a typical anti-bupe message yesterday; the message and my response are below. There are a few typos that I can’t decipher….
Errors of logic, anyone?
Subutex was the worst mistake I ever made. I was an off and on heroin user for 5 years. I was clean for over a year and relapsed that when I survived Subutex first I was getting it off the streets then my wife ego had the insurance got a script. She was pregnant so the doctor prescribed Subutex. She told her that her brain would never be the same from her opiate use and would need Subutex most likely for the rest of her life. We both were quickly using it IV IT killed our sex life. It made me feel like a woman or something I have no libido at all. I quit using it IV for 9 months then started again which caused me to have a full blown relapse I’m in 12 step recovery. I lost our home shortly after our new born son was born forcing her to move in with her parents and I moved into an sober living house. We are now both trying to taper off this drug that it’s overly prescribed. The doctor put her on 26mg a day mind you we shared but the doctor doesn’t know that. I do believe in short term low dose setting this drug has a therapeutic value. But I believe it’s been designed to get money lost to drug dealers into the pockets of our government. I kicked Heroin and Oxycontin more then once. Getting off Subutex has been the toughest one yet the physical and mental withdraws are horrible. The best bet for addiction treatment is 12 step meetings. All Subutex or Suboxone does is give you a crutch and prolongs actual recovery from the disease of addiction. They don’t tell you about all the terrible side effects behind this medication its marketed as a miracle drug. A wise man once said if it sounds too good to be true then it’s probably not. Rant done hopefully this helps someone. The answer to recovery is the 12 and staying sober 1 day at a time, most important a relationship with a higher power.
My Response:
An interesting comment… You’ve taken heroin for over five years as an ‘off and on user’. You then illegally obtained buprenorphine, and injected it (!)… illegally shared what a physician prescribed for your wife… but it’s all buprenorphine’s fault that you are experiencing problems? Part of the 12 steps that you favor includes taking responsibility for what happens in one’s life, yet I don’t hear a lot of that in your narrative.
I don’t know about ‘miracle drug’, although it probably has saved the lives of both you and your wife, since IV heroin addicts don’t tend to do well beyond 5 years. There is nothing in your history to suggest that your ‘on and off use of heroin’ would have somehow come to an end, had you not changed your drug of choice to buprenorphine. But one aspect of buprenorphine is the ‘ceiling effect’, which makes overdose much less likely.
Likewise, I don’t see a government conspiracy, and I disagree with your comment about ‘low dose use’. Buprenorphine HAS been used in low dosage for treating pain for the past 30 years, but everything about buprenorphine that makes it a good addiction treatment relies on the person taking a dose that assures a high blood level, i.e. above the ceiling level for the drug’s effects. In low doses, buprenorphine acts like any other agonist– i.e. causes the same up/down mood, cravings, and obsessive use pattern.
Your problem is that you became addicted to opioids, and your opioid addiction has cost you a great deal. You misused buprenorphine by injecting it, but luckily for you the drug has certain safety features that helped keep you from overdosing– something heroin doesn’t have. But now you blame buprenorphine for all your problems.
I certainly do not suggest that you do this, but for the sake of making a point—- you could easily go right back to where you were, before you met buprenorphine, if you returned to your addiction to IV heroin. If you started heroin tomorrow, the buprenorphine would be out of your system in a week or so, and… voila….. you would be ‘cured’ from this horrible affliction that you claim to have, i.e. an addiction to buprenorphine. Or are you going to suggest that taking sublingual buprenorphine was somehow WORSE for you than doing what you were doing before finding a doctor, when you were injecting foul solutions of heroin into your veins?! You were FINE with the heroin, but BUPRENORPHINE has ruined your life?
Sorry– I don’t buy it. Most people who stop ANY opioid– buprenorphine, oxycodone, or heroin— end up using again. Buprenorphine, as a partial agonist, relieves cravings in a way that opioid agonists can’t. And taking buprenorphine certainly doesn’t make anything ‘worse’; a person addicted to heroin, who doesn’t like taking buprenorphine, can always go back to heroin! I don’t recommend it, as the overdose risk is very high with heroin, and people on heroin suffer from constant obsessions to take more and more– a life far worse than the person properly taking buprenorphine.
This is where I come in… THESE are the patients I see on a regular basis. The doctors who used to call them ‘good patients’ now call the same people ‘drug addicts.’ And the pain doctors—the ones who create so many addicts—give lectures on ‘how to prescribe opioids.’ I can spare you the need to attend the lecture— the main message is that after you make the patient an addict, you must do everything that you can to separate yourself from the patient before the consequences of that addiction become apparent—so that your hands appear sparkly-clean!
Category: terminal uniqueness
An Addict's Story
I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic. In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication). At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me [email protected]@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer; I’ll be adding my thoughts soon!
Winehouse
By now, everyone who knows of Amy Winehouse is aware of her tragic death. I’ve always liked her music. So much music these days has been digitally processed and reprocessed, and assaults the senses– I’m thinking of Lady Gaga, for example, whose ‘Edge of Glory’ would be pretty boring in concert if you took away the flashing lights. But Amy Winehouse’s music had an earthy, sultry style that communicated her emotions in a way that words can’t… which is why we even listen to music, at least in my case.
Every now and then I’ll meet a person coming in for help who has an addiction that seems to be almost part of a death wish, as if the person is taking agent after agent with one goal: to eliminate any sense of consciousness or emotion. It is as if life is too painful for the person to tolerate, and the person won’t stop until the brain is finally quiet. I sometimes think that those people would club themselves in the head until they are unconsciousness, if psychotropic drugs were not available! I had that same thought when I read that Amy Winehouse had purchased a grab-bag of drugs including heroin, cocaine, and ketamine in the days before her death.
When I set out to right tonight’s blog I planned on including her picture. But when I went on Google images and searched under her name, I found a number of ‘before and after’ images that demonstrated the horrible toll that drug and alcohol dependence took on her health and physical appearance. The images were so bad that I felt very sad for her and for her family, and I couldn’t bring myself to post them here– as doing so would be ‘piling on’ a horrible tragedy.
I searched around for a suitable tribute, and I think I found one. Her personal, internal battle is apparent in the video, and I’m sorry that she wasn’t able to find a way to tolerate life.
Enjoy the music that she left behind:
My Book
Ah yes…. another post about my book…
Over the past few years, I’ve taken posts from this blog, posts from other sources that I’ve written, some sections of a ‘memoir’ that I have not gotten around to writing… and combined them in a book about addiction. The book does not hold together as well as it should, and it is way too long– so instead of a ‘sit and read’ book it is more like a reference, similar to the blog itself. If you like this blog, you’ll like it; I’ve taken the more important posts and cleaned them up and organized them. I’ve added some new material as well, including a section about my own background. If you have a loved one on Suboxone, or have an interest in the medication yourself, you will know as much about the buprenorphine as anyone should you finish this book– particularly about the use of buprenorphine by addicts, the controversy over buprenorphine, the relationship between buprenorphine and methadone, etc.
There are some chapters that are dated– i.e. where my opinion has changed or softened over the years. I was much more ‘anti-methadone’ when I wrote most of the book; now I see methadone as something that some people simply need in order to survive. I am not a fan of how some clinics are run– but that is a topic that I don’t get into in this book.
Finally, you’ll notice how I have changed over the years; in early posts I would become angry and sarcastic with some writers. In part, that is because I was being attacked on a daily basis by the ‘anti-sub’ movement– which has largely disappeared. But I think I have also aged a bit, and I now tend to pick my battles more carefully.
The book (note- this is an e-book) goes for $14.99, and runs around 250 pages– long enough to occupy most of your summer! Proceeds continue to support this blog, and SuboxForum as well.
Thank you very much, to those of you who purchase it and check it out. I would be most grateful if you would leave comments about it– for me, and also for others– by writing them in response to this post. At some point I will get a page set up, and tranfer this promo and the comments to that page.
The book is called ‘Dying to be Clean’– and can be purchased using the links at the left of this page– or right below this post.
NOTE: Because I don’t want it simply passed around freely at this point, you need a code to open it– and it cannot be printed. The code will be included with the download link. Please understand why I take those actions.
Thanks again,
Jeff J
Another one?
I have no idea what killed Brittany Murphy. The press are reporting that she had a ‘heart attack’ at age 32, not fully understanding the difference between a ‘heart attack’– which typically refers to a heart that stops functioning because of an inadequate suppy of oxygen, usually from coronary artery blockage– vs. ‘cardiac arrest’, a garden-variety term used by coroners who must cite a cause of death without an autopsy, reliable history, or lab results. We ALL die of cardiac arrest in the end. Opiate addicts usually suffer respiratory failure, either because of a reduced drive to breathe secondary to the effects of opiates at the brainstem, or because of a ‘blocked airway’ caused by stomach contents gettting into the throat and/or trachea. The respiratory failure ultimately leads to too little oxygen at the heart, causing the heart to either stop beating or to go into an erratic beating pattern called ‘V-Tach’ or ‘V-Fib’, eventually failing to keep blood flowing to the rest of the body– particularly the brain.
Reports of Brittany’s death have mentioned that ‘prescription medications’ were found at the scene. The phrase ‘prescription medications’ is usually code for ‘pain pills.’ And since the death rate for opiate addicts is so high, I am going out on a limb in a BIG way. I am not trying to make a prediction– only to eventually make a point about opiate addiction, admitting that I may be making the point prematurely.
Britttany Murphy was rumored to have an eating disorder and an addiction to cocaine. I don’t mean to impugn her character, and hopefully anyone who reads my blog understands that addiction is a disease that NOBODY asks for or deserves. My concept of addiction would include an eating disorder, by the way. I am sure that readers have a hard time understanding where I draw lines of responsibility; I often write from a stance requiring ‘personal responsibility,’ so where do I get off, you ask, painting Brittany Murphy as a victim? My answer is that it is possible to be everything at once. We are all responsible for maintaining the behavior necessary to keep ourselves alive. But there are times when we fail– all of us. And most people who ‘fail’ and as a result become addicted to drugs face penalties constantly from that point forward– very rapidy getting to a point where we have been punished enough. IF Brittany Murphy died from complications related to addiction, her death would be on top of the many evenings of misery she already endured– waking up early shaking with chills, running to the bathroom with diarrhea, missing parties at the last minute because of being too sick to go, and the demoralization that comes from looking in the mirror each morning and seeing that pathetic, failure of a person looking back. Sometimes we look at celebrities and picture the moments when flashes are going off and the person is mugging for the cameras. But from the moment this morning when I heard that Britttany Murphy had died, I felt (again, perhaps incorrectly) as if I know her very well. I know how she felt each morning. I know the relief she felt when certain people ‘came through’ for her. I know how she felt about having a double personality– that all of her fans thought she was this great person, and deep inside she felt like a liar for keeping her secret from them. I know how she felt when things looked hopeless– when she thought there was no possible way to escape. I know how she felt when she was alone with the bathroom door closed and locked, wishing that things would just end without ever taking another step outside that safe little space.
If I am wrong, I am sorry– and I am thinking about someone else who is one of thousands of people who think exactly alike about a few deeply-personal things. If I am right, I’m sorry that the long list got a little longer with the name of someone so obviously special.
JJ
Anxiety, step-work, and gratitude
One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts. We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking. I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking. But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux; regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment. I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps. I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation. And once on buprenorphine, addicts quickly lose that desperation. One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery. But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy. The steps have remained as the mainstream treatment for opiate dependence for one reason: They were all that we had! The steps saved my life not once, but twice– but they fail for most others. I got lucky– maybe having my medical license hanging over my head made the difference. It is impossible to predict who the lucky ones will be. All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence. And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine. I personally know of several people who died after forced discharge from treatment centers. Who benefits from that approach to ‘treatment’? Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided! Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry. I tend to wander a bit. The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth. Opiate dependence has been treated successfully in a small fraction of addicts. Yes, the steps CAN work in those who ‘keep coming back’. But the truth is that people in their 20’s do NOT ‘keep coming back’. Instead they relapse over and over until everything is gone, and they have become shadows of their former selves. But then buprenorphine came along. Buprenorphine is NOT a panacea; many people fail treatment with buprenorphine as well. But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence. But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using. After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment. For example, many (MANY) opiate addicts complain of ‘anxiety’. I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor). I found that universally, patients who took benzos did WORSE. They thought they needed them, and even thought they benefited from them. But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos. The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board. I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment. When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc. But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh! People taking buprenorphine are no different than I was; they are trying to make HUGE changes in how they deal with their feelings. Of COURSE they will feel all messed up inside! But the answer is NOT to find another subsstance to reduce those uncomfortable feelings. The answer can be found instead in many of the principles that make up the twelve steps. If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting. I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety. Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’. All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs. And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean. The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life. During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago. She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc. She was grateful for the positive changes in her relationships as well. No, things were not perfect– they never are. But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together. Not being broke and sick all the time allows a person to start to feel like a contributing member of society. Being able to go all day without telling her friends or partner a lie has improved her relationships. Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills. And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse. As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined. No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use. But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years. As always, your personal health history is YOUR business; if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business! If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery. You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way. If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for. If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift. With all of the Holiday activities I may be absent for awhile. My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks. Back then I thought my life was over– no job, license suspended, anesthesia career effectively over. I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing. I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’. I learned through meetings that EVERYONE with addictions felt that exact same way. After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir). Until the play that ended today, I’ve been too busy to participate. But today I was on the exact same stage where I stood 9 years ago. Today I reflected on all that has happened since feeling so hopeless back then. I am grateful that back then I KNEW that I didn’t know anything about how to stay clean. I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself. Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ
SuboxDoc Goes Negative!
I received a couple responses to my youtube videos tonight that are worth responding to. For people who haven’t stumbled across the videos, you will find them if you go to youtube and search under ‘suboxone’ or ‘suboxdoc’. They are pretty much the same thing as what you read here—a combination of my experiences in treating opiate dependence using Suboxone, education on the actions of buprenorphine, some of my personal ‘theories’ (maybe ‘opinions’ is a better word) on the relationship between sober recovery and buprenorphine maintenance (what I like to call ‘remission treatment’, to distinguish it from methadone maintenance, which works through a different mechanism), and my thoughts on the different treatment options for opiate dependence.
Blogging in general has been an educational experience. I was initially surprised by the number of people who send out very angry messages to a person who simply tries to share knowledge and advice! Just today I received a message accusing me of ‘getting my degree from a crackerjacks box’ for my opinion that ‘Suboxone withdrawal is NOT the worst withdrawal ever.’ I didn’t get it there, by the way. I don’t know how to take the responses posted a few minutes ago that are tonight’s topic; I am not sure if they are simple questions, respectful disagreements, or sarcastic comments. You would think a psychiatrist would know one from the other! Maybe the person will add more angry comments after my post, and then I’ll know for sure. Or maybe there will be nice comments. Whatever…
The comments, from someone going by ‘cbarrett34’ on youtube:
Dr. I’m curious, why do you say that there is no cure for opiate addiction? That doesn’t give people a lot of hope, if a Dr. is telling them there is no cure or hope for you. Basically leads to apathy and more using.
(That one was clearly very nice).
And the whole saying, once an addict, always an addict. That’s not a very positive viewpoint either.
(That one is harder to tell, don’t you think? I might just be paranoid from that crackerjacks comment)
My answer, which as always is just one opiate addict/pain doc/psychiatrist’s opinion:
My first thought is that staying clean from opiates has nothing to do with ‘apathy’. Maybe smoking pot has something to do with apathy, but people actively using opiates are some of the most non-apathetic people you will ever see! There is no time for ‘apathy’ for an actively-using opiate addict; there is that hit that is required every 4-8 hours to avoid being sick, there is that need to scam someone out of money to score the dope that is needed every 4-8 hours to avoid being sick, there is that need to come up with a good lie to tell the parents/spouse/cops/PO/boss/kids to explain the lousy behavior over the past few months or years… being an actively using opiate addict is a lot of work! There is definitely a negative attitude that develops after months or years of using, but it is nothing like ‘apathy’.
- Too Negative?
My next thought is that I wonder what the writer would prefer—‘positive’ lies or ‘negative’ truth? The idea that heroin or oxycontin addiction is ‘treatable’ is one of the big lies of society; it makes for good movies and helps keep money rolling in to detox facilities and treatment centers, but if you think I’m wrong, seek out the numbers yourself! Pick your own criteria for success– one year sobriety, five year sobriety, whatever. If you look at people in their 20’s who go through residential treatment, the one year rate is way, way, way below 50%, even if you just use the numbers for people who go voluntarily and complete treatment! Go out to 5 years and the numbers for opiate dependence are ridiculous- sobriety rates of less than 10%! The writer sees danger in telling the truth about treatment I suppose because the truth will somehow take away ‘motivation’ and cause apathy. But I see things exactly the opposite. In my opinion based on how I thought as an actively using opiate addict, a sense of confidence is the ENEMY of sobriety. As an addict goes from day to day using, and getting deeper into addiction, he/she comforts himself by saying ‘I’m going to get straightened out eventually’. If the person knew that most people do NOT recover; that he is getting mired deeper in an incurable disease, maybe he will think about seeking help a bit sooner! And if everyone knew that opiate dependence is a largely untreatable and surely incurable illness, maybe fewer high school kids would pick up in the first place. I hear addicts say one thing over and over again: ‘if I only knew that oc would have done this to me I never would have taken it.’ I don’t know if that is true for all of them, but I think that had the truth been known, at least some of them wouldn’t have started.
As far as the comment about ‘once an addict, always an addict,’ that is something that is not even controversial. Yes– at least with opiates, once an addict, always an addict. About 7 years after getting clean ‘the first time’, I assumed that I was cured—after all I had only used opiates for 8 months or so, and it had been 7 years… I had been to hundreds of AA and NA meetings, I had worked the steps all the way through several times, and I never even thought about using! I would get so annoyed when my old NA and AA buddies would come up to me if they saw me someplace and say ‘we miss you at the meetings, Jeff!’ I would want to tell them to bug off and leave me alone— I’m cured, after all! I don’t need that crap. Once an addict, always an addict…. NO WAY!
Had I listened to them I might have saved myself a great deal of trouble. But probably not, since addicts pretty much need to find things out for themselves. That is one of the personality traits of ‘us addicts’—we are independent thinkers who don’t think the rules of others should apply to us. Those words on the Vicodin bottle about dosing and about the danger of dependence? Those are just ‘suggestions’!
I wasn’t always a fan of the idea of taking a medication to treat opiate dependence. Even after looking around me and realizing that all of the people who got clean with me had relapsed, I thought that it was better to have one out of ten people in ‘real’ recovery than have people taking medication! Then I ended up in a position where I actually knew some of the people who were dying. At NA or AA meetings people talk about the deaths with a ‘tsk tsk’ attitude, as if the person who died should have known better, or almost had it coming, since she stopped going to meetings. But once I was a person who stopped going to meetings in spite of knowing better, it became harder to blame the dead person.
I have in my mind the images of four smiling people who desperately wanted to be free from opiates. I knew all four of them pretty well at some point; none took Suboxone, and all assumed they were going to be fine without it. After all, they had all gone through at least part and in two cases entire treatment programs. Three men and one woman, all less than 25 years old, two with children of their own. Two died from suicides, presumably in part from the shame of failing to get better. I wonder if they thought, before they died, that they were losers because treatment didn’t work for them? The other two died from opiate overdoses, one the first time he used after being clean for several months. I suspect he figured that he ‘beat the disease’; that is what most of us think as we relapse. One time won’t hurt, we tell ourselves; we are different now. We have been TREATED, after all! The final person was a woman who had been resuscitated several times in her life, once after an overdose in a drug-treatment halfway house! Maybe she had a death wish—some addicts seem to use as if they truly want to destroy themselves—or maybe she thought she was blessed by a guardian angel who eventually slept in one day and wasn’t there when she needed him.
To simply answer the writer’s questions without all the stories, I tell people that there is no cure for opiate addiction because my opinion is the same as that of everyone else who treats or studies opiate addiction— there is no cure for opiate addiction. As for ‘hopelessness’, sometimes ‘hope’ is just a campaign slogan. Sometimes ‘hoping’ keeps a person from recognizing the cold hard facts of a situation and taking responsible action. In medicine and in life, diseases do not always have cures. Some diseases are simply not curable, and people die. Want to have ‘hope’ about opiate dependence? Then DON’T USE OPIATES.
The good news is that while there is no cure, there is a relatively new approach to addiction that is keeping many people alive who would have otherwise died from their addiction. There are many diseases without ‘cures’—in fact there are probably many more ‘incurable’ diseases than ‘curable’ ones! But every opiate addict should know the facts: that he or she will always be vulnerable to relapse, no matter the amount of ‘treatment’.
My book
Hi all– sorry for the infrequent posting lately. I am trying to finish a book about Suboxone and about addiction, and by the time I finish working in my practice each day I have little time to divide between the blog, the book, and a few other projects. I just told the folks at MedHelp.org that I was leaving the expert forums in addiction and chronic pain; I simply have too many things going on at once. I stay up ’til past midnight every night answering questions, then get up the next day, race to the office ten minutes late (again), pick at the book over my lunch hour, then spend the evening on the computer after gettting home. Another example, by the way, of addictive behavior.
The book will include much of this blog, organized in such a way so that a reader can pick it up and learn about chronic pain and Suboxone, pregnancy and opiate dependence, etc. There will be new info as well; the initial chapter tells ‘my story’ along with some learning points, and all of the things lifted from the blog will be cleaned up, with some sections written ‘more efficiently’ and others elaborated on more extensively. I hope you all will like it.
I have decided to self-publish the book under the label ‘Terminally Unique Publishing’, borrowing a phrase from the Recovery literature. You’ll have to buy the book if you don’t understand the meaning of the phrase! And speaking of buying the book… I ask that you all save up your pennies so that when the book is released, you will help make an impression for Amazon.com. If you like the book I will ask you to leave nice comments. If you don’t like it… maybe you could forget to write the bad reviews for a few days! I would like to get your help with the marketing if possible; I will try to figure out a way for you to make a commission for any sales that originate with you. For example, if you get your doc to put the book on a shelf in his office with purchase info, I think I will be able to set it up so that any purchase from that office would be credited to the person who was responsible for getting it placed there.
Thank you for your patience in the meantime. I am shooting to have my part done by mid-September, then it goes to an independent editor, then cover design, then the printer… then Amazon and other retail outlets… hopefully getting the first copy printed by Halloween.
Wish me luck– and your eventual help will be SO appreciated!
JJ
Success (and Failure) Stories with Suboxone
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I am putting a book together about Suboxone; I realized that with all of the talk about side effects, controversy over ‘real recovery’, and letters from angry pharmacists, I don’t have a section for ‘Success Stories’! Don’t get me wrong– I have received many messages from people telling their stories, grateful for having Suboxone as a treatment option. I just don’t keep those messages; the controversy is the interesting stuff!
I don’t know if I will ever finish the book and get it into print, but if you have an interesting success story please share it with me. I don’t want any identifying information, mainly because I don’t want to worry that someone will lose a job over a story and then sue me! I might also shorten a story a bit. But if you are willing to write about your experiences with treatments including Suboxone, please send them my way. When writing, think about what YOU would find interesting about someone else’s story, and share that.
Y’know… the point of writing this book is to help people decide if Suboxone is the right way to go, and also to share information about the use of Suboxone. I suppose I should have an ‘Unsuccess Stories’ section as well! By now, people should know where I am coming from. I am not impressed by the ‘drug for a drug’ comments; those are stale arguments that miss the point of what buprenorphine does, i.e. eliminate the obsession to use, which is the essence of addiction. Those comments go straight to the recycle bin these days. I am also not impressed by the desire to be ‘off everything’. I consider opiate dependence a condition that requires treatment for life, whether the treatment be the creation of an artificial environment at the opiate receptor using a medication, or the creation of an artificial personality state by going to meetings. I will clarify what I mean about meetings and artificial personality states: when people are involved in the twelve steps and the program is working for them, they are being held in a state of personality that is probably closer to their ‘core’ selves; the BS is stripped away, sarcasm is frowned on, they are encouraged to express their feelings more, etc. But while they may be closer to their ‘true’ core selves, they are being held there by going to meetings– and if they stop the meetings they revert back to the ‘old’ personality state. So going to meetings, in my opinion, is just as ‘artificial’ as taking a medication! I don’t consider it a fair ‘unsuccess story’ if a person complains about being chained to a doctor (it is a fatal illness– get over it!), if a person thinks they have a bad doctor (we don’t judge cancer chemo treatments by the bedside manner of the doc who orders them!), or because Suboxone can be abused (we don’t rule out treatment of surgical pain with narcotics, simply because the opiate agonists are abused!). Finally, I am not moved when a person is not successful when they take Suboxone from the ‘street’, without being treated by a physician who understands addiction.
So what would I consider a valid ‘unsuccess story’? If you truly wanted to get clean, and you did as you were told– and Suboxone failed to keep you clean. If you share that story with me please do your best to describe where the treatment failed. I understand that any relapse will have the moment where the addict ‘does what he has been told not to do’– and I won’t rule out an ‘unsuccess’ on that basis– unless you tell me that from day one you made no effort at all to avoid using! The most helpful story would explain why the failure occurred– cravings were not blocked, for example. Another valid story would be a criticism of the nature of Suboxone treatment, in that it doesn’t place great emphasis on the psychosocial side of things. If you are able to explain why, in your case, a more psychosocial focus would have been helpful, that would be useful information.
Who said I’m not Fair and Balanced?
If you are willing to send me a story, please e-mail it to [email protected] I have no idea if I will receive one or a hundred stories, so I can’t say the odds of your story getting into my book project– assuming I finish the darn thing!
Thanks!!
SD
A Common Mistake
I brought a note from the ‘comments’ section up here because it presents a topic that comes up over and over with opiate dependence and Suboxone. I am the expert on MedHelp.org’s addiction forum; I get questions and comments like this one quite frequently on that site– although I have addressed the issue so many times that I think people there know what my opinion will be on the subject. I will post the comment, and then write my own comments afterward.
I started on the Suboxone in Feb 08 to get off the opiates. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it b/c I had no more insurance and it was very expensive. I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped b/c I ran out of Suboxone. About 3 days after I stopped taking it completely I started withdrawing from the Suboxone. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. Once that began I started doing research on Suboxone withdrawals and people were basically saying that depending how long you were taking the drug that would depend on how long you withdraw b/c Suboxone stays in your system for a long time. So what did I do.. to get rid of the withdrawal feeling I was getting I started taking the opiates again. Then eventually I got addicted to those again. What I have noticed works with the suboxone is if you take it for about 10-14 days long enough for the opiates to get out of your system and stop taking the Suboxone you wont get sick and you will be successfully detoxed from opiates. Now the hardest part is staying away from the opiates. I am now on my 3rd day of the Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from the opiates by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you all posted and to everyone else doing the same.. GOOD LUCK TO ALL OF YOU!!
I have written about the natural progression of opiate dependence before, but I will review things again for newcomers. Early in addiction, the addict believes that if he can only get past the physical withdrawal, everything will be fine. During the first third of an addicts ‘using life’ he is always fighting for that first piece of sobriety– you see these people on message boards all over the internet, comparing tapering plans and different cocktails of amino acids or other worthless regimens to find the one that ‘works’– that gets them through a taper or withdrawal to become opiate-free. They usually are not interested in meetings or rehab at this point; they don’t consider themselves to be ‘THAT kind of addict’ who needs that much help– just the right pill to get through the worst of things. These are the people who often insist that Suboxone be used only short-term, as a bridge to sobriety. They have no interest in the idea that they have a life-long illness, and will argue that point until blue in the face, even as they continue to use opiates on a daily basis. Denial is huge during this stage of addiction; the addict minimizes the impact opiates are having on his relationships, work, and health status. It is easy to discount all of those things because he considers all of the messes to be temporary and ‘easily corrected’– once he just stops the darn opiates. He assumes– sometimes for a long time– that the ‘right method’ will come along… eventually. Hooked? Not him!
A person enters the second stage of addiction when he has been able to successfully taper of opiates. From my vantage point of seeing many, many addicts over time, this point is not associated with any particular taper method or amino acid formula, but rather occurs when the person has enough consequences to motivate him through the withdrawal. More and more bad things pile up until they cannot be repressed and ignored; job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences. During the first stage, the addict would get to a certain level of withdrawal and say ‘screw this!’ and resume using, but during the second stage the problems are remembered even during bad withdrawal, and the addict stays motivated to be free of opiates. The taper that eventually works is often the worst one; the addict just says ‘enough!’ and stops without any plan or preparation. Or perhaps the consequences lead to a jail cell or being completely broke– again, resulting in sudden and absolute sobriety without the luxury of a taper or meds to reduce the severity of withdrawal.
That’s great, right? He is finally there– free of those opiates… or so he thinks. But unfortunately he is about to enter the third and worst stage of opiate addiction– the stage that can last for years and years and that totally demoralizes the individual. This stage begins with relapse, and it can happen after a week, or it can happen after a year. The bottom line is that it almost always happens– and that NOBODY thinks it will happen to him. I hear the comment over and over– ‘no doc– I don’t plan to relapse!’ or ‘I know what you are saying– but you don’t understand the way I am!’ Everyone considers himself too smart for relapse, but I see the AA adage come true over and over: nobody is too dumb for Recovery but some are too smart for it! The meaning is that every now and then a person will avoid relapse– and it tends to be a person who has a ‘simple’ outlook on life who didn’t really ‘shine’ in other, more competitive areas. Someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities. That person can sometimes simply stop using because he easily accepts the idea that he has lost the fight– that opiates are much stronger than he is, and that he will never figure out how to take them without disaster.
Most people, though, are way too smart for this situation; as soon as things start going well their minds take off again… and at some point they return to using. I’m not going to spend time on all of the triggers for relapse, but maybe I will discuss that another time– but there are things common to all relapses, including rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness’ that I mentioned above, where all of the warnings are an issue for OTHER people. During this third stage, the addict will have repeated episodes of relapse and sobriety; there is little joy in using since consequences occur much more rapidly now, so more and more time is spent being sick from withdrawal. This is the stage that most long-time addicts remember, and fear, the most. In my case, I could stop using every weekend; I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME– come Monday I won’t touch ANYTHING!’ And so I was always sick; the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them. And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with. As I mentioned earlier, during this stage the addict becomes truly ‘sick and tired’. This is a dangerous period of time for the addict for a number of reasons; when the addict uses he feels a great deal of shame, which fuels more using– making use more impulsive and reckless and more likely to cause a fatal overdose. The addict also becomes depressed– sometimes extremely depressed– and commits suicide, either actively or through just not caring anymore about the risks of taking too much. The addict sometimes feels such a wave of hopelessness or shame that he needs to do ANYTHING to change how he feels– so he swallows any pill he finds, or shoots up something that he doesn’t even know the actions of– he just needs SOMETHING! Even a hammer to the head looks good at this point!
This is the time when traditional treatment has been effective; the addict is at rock bottom, and he no longer feels confident about any of his own abilities. He is ready to follow ANYONE or ANYTHING– after all, what does he have to lose? Life is over anyway– so why not listen? If the addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a genuine shot at some meaningful sobriety. If, though, he gets into treatment and quickly makes a girlfriend, or he can tell jokes and be the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is… there is a strong chance that the treatment will prove worthless. He needs to hold on to the attitude that he knows nothing, for only that attitude will allow true learning and change to occur.
This is why, in my opinion, young people have lower success rates in treatment. Young people often feel way too invincible for treatment to take hold. They also have short memories for painful events; consequences are quickly forgotten and dangerous self-reliance returns. The true wonder of AA is that the program designers understood all of this; the program is all about humility and powerlessness, and consists of a series of steps that, if practiced completely, will take a person to the right frame of mind and keep him there– provided he continues to work the program. The reason treatment tends to work better for older people is because first, more are at the later stage of addiction when they are truly ‘sick and tired’, and second, self confidence tends to return a bit more slowly. Us older folks tend to remember the bad things because we know that some friendships can be lost forever. Plus it is difficult to feel immortal when one’s body aches each morning!
I’m sorry to pick on the writer of the comment above; I could do this with many of the comments that I receive from those who plan ‘short term’ use of Suboxone. In light of what you have read, go back and read the comment again; see if you can tell the stage of addiction that the person is experiencing. Again, I get these types of comments over and over, both here and at the other site that I mentioned. I have watched, over the past 16 years, as addicts (including myself) have gone through the same process. Every person is convinced that HE is different– only to eventually find that in regard to addiction he is the same as everyone else. This is why I recommend seeing Suboxone as a long-term medication… or seeing AA or NA as a life-long program.
One final comment… the three stages that I use to describe opiate dependence are ‘mine’; I have noticed them over the years and they continue to be retold in my patients’ stories, and so they appear entirely obvious to me. I have not seen the stages spelled out in this way by others, so if at some point others agree with me, let’s name them the ‘junig stages of addiction’. I accomplished one more of the ‘goals of my life’ a few weeks ago when a guy met me at the airport with my name on a piece of cardboard; having something named after me would scratch one more thing off the list!