Donation Button Malfunction

My thanks to a nice reader in Holland, who let me know that my ‘donation’ button was not working– I don’t know how long it has been down, as it isn’t exactly a steady stream of income….  but if you tried to donate, please don’t hesitate to try again!
As for privacy, I have it hooked up to PayPal using a domain name called ‘internetmentality.com’.  Catchy, don’t you think?  The item ‘purchased’ when making a donation should appear on a credit card receipt as either ‘internetmentality.com’ or as ‘STZ Services’.  I’m just now realizing that the name makes a person suspect a connection to sexually transmitted diseases..  Sorry about that!
Thank you, Holland, for your kind help.

Micrograms, Tapering, and the Ubiquitous Nature of Addiction

One thing I enjoy so much about the blog is that I receive comments from people around the world… hello to my new friend in Holland, and California, and New York… I have also mentioned before how the miserable disease of opiate dependence affects people from all jobs and socioeconomic groups. I receive messages from members of the underground world of opiate dependence, and so often I think about how surprised people would be to know what a huge problem this is!  Writers, stockbrokers, artists, businessmen, doctors, lawyers, factory workers, photographers, teachers, students, IT professionals, waitresses, realtors, landlords, welders, professors, home-makers, mothers and dads… I have talked to opiate addicts from all of these occupations, and more.  And in all of them, the stories are the same…  the initial use, the loss of control, the assumption that the control will come back, the feeling of being ‘different’, so that the stuff that happens to ‘other’ people won’t happen to ME, the repeated failures to control use, the repeated episodes of withdrawal,  the occasional fear deep in the gut that maybe I am REALLY in trouble after all… the deep feeling of shame, that ‘I should have known better’, often with some weak effort to blame someone else, which even the addict doesn’t fully believe but which is still used as an excuse, since the alternative– accepting all the blame one’s self– seems intolerable.  The personality effects are identicle;  everyone has done things that he/she never though he would do– women reduced to prostitution, men to burglaries or robberies, and in one person I have met (outside of the prisons) even murder over drugs. He now says that his constant guilt keeps him from getting clean, but I see that as just another excuse; he could just as well say that taking a person’s life is what made him get clean.  You see, there are ALWAYS excuses to use…  the family is too distant… or too close.  The weather is too horrible, or too nice.  My house is too empty or too full;  my wife is too attractive and flirty, or too unattractive and boring.  Always an excuse… which means that there is really never an excuse.  In fact, one of the only times I tend to cut people off from telling their stories is when they get to the excuses;  I have heard them all, and none of them mean anything.  And yes, I have used many of them myself as well.
In all cases the addict started out feeling great;  often he was stressed from a good job and the opiates allowed some extra energy at home, and the wife and kids were happy about the changes.  But the addict starts to feel miserable inside eventually– it is only a matter of time.  And once that happens, the addict retreats further and further inside, getting smaller and smaller, while putting up a facade that he thinks is fooling everyone… but the kids are probably the first to notice that something isn’t right.  This is a classic set-up for borderline personality in the kids;  later when they talk to their therapists they aren’t sure what happened, because everything seemed OK– there were no beatings, and dad was always happy…  but normal child development doesn’t do well with ‘fake’ personalities.  Spouses often don’t notice at first because they engage in the same denial that the addict engages in.  But the kids don’t know how to do ‘denial’, and so they internalize the growing distance from the addict, from dad or mom, as somehow related to them.  To kids, everything relates to to themselves… so the distance becomes part of low self esteem, mood swings, cutting, and impulsive behavior that is really borderline personality but that some idiot will misdiagnose as ‘bipolar’…  the kid will be put on depakote or seroquel or zyprexa, and will gain 100 pounds…
Is anyone still reading?  What a pathetic story!  The good news is that eventually the addict will get miserable enough to take action.  The bad news is that all of the damage will last a lifetime– not just the addict’s lifetime, but the kids’ lifetimes as well.  But with effort, there is still good news, at least in my twisted opinion.  I see all the people out there who have ‘normal’ lives as the real unfortunates.  If it is through hard times and being tested that we grow, and learn about ourselves, what does that say about the people who never have any problems?  Maybe that is part of the meaning behind the Chinese proverb, ‘may you live in interesting times’.  As another aside, I have a feeling that the whole country will therefore be lots smarter after the next few years…
OK.. Micrograms.  This simply refers to the new info that was sent to me by a nice gentleman who I cannot mention by name…  and a topic that I referred to a couple posts ago.  I mentioned that in order to taper off Suboxone, you must think in terms of micrograms, not milligrams.  When you take an 8 mg pill of Suboxone, you are taking a supra-maximal dose of buprenorphine– a dose that is off the scale.  The ‘ceiling’ is way up high, far above the doses that are used clinically for treatment of acute pain.  As I have said, 24 mg, or 4 mg, of Suboxone are both as potent as 30 mg of methadone!  So your taper off Suboxone doesn’t really start until you get below 2000 micrograms per day– or 2 mg, which is a quarter of a pill.  To do a proper taper, you want to think in terms of tapering down from 2000 micrograms to zero, in small steps.
I had an idea of how to do this at about the same time I received the message from the nameless contributor who had done his own tapering studies.  He did what I had finally figured out;  take an 8 mg tablet and dissolve it in a small amount of liquid– water would probably be fine.  You want a small enough volume so that when you put it in your mouth it is concentrated enough to cause absorption of the drug through mucous membranes, but a large enough volume so that it can be measured accurately.  I suggest using a vial that childrens’ medicine comes in– one with a measured eye dropper.  calculate out the concentration of buprenorphine, and then use the dropper to take a measured dose of the liquid each day.  At some point– if you start getting withdrawal by the end of the 24 hour period– you might want to change to dosing every 12 hours (cut each dose in half, of course).  I recommend making a reduction in dose every one or two weeks– if you are still feeling sick from the step a week earlier, don’t make another change until you feel better.  In general, each drop in dose should be a drop of about 10%.  Be sure to keep the mixture refrigerated, and toss it if it develops a foul odor!
If you taper very slowly, you should be able to avoid the vast majority of the withdrawal.  It will take a long time though, so be prepared to keep at it for months.  If, on the other hand, you need clean urine very quickly…. you have little choice but to simply stop, and tell everyone that you have mono again.  (gee… seems like you are ALWAYS getting mono!), 
Maybe you can get away with saying ‘yes, I know… but I have a real good feeling that I’ll probably never get it again’.
As always, I wish you all the best.  Opiate dependence stinks… do what you all can to stay alive, and pat yourselves on the back every now and then.  You probably deserve it– and nobody else is going to!
SD
If you

Counseling: Good for Addiction?

When a person asks for help with some issue in his/her life, a safe and relatively common answer is to suggest ‘counseling’. Trouble with your marriage? Get counseling. Depressed? Take an SSRI, sure, but get some counseling too. Kids acting up? Send them for counseling. Wondering about the meaning of life? Lose your job? Have a flight get cancelled? Try some counseling!
What about all of this counseling? Does it do any good? There seems to be this assumption that any counseling is good counseling—but why would that be? The standards for providing ‘counseling’ vary by state, and in some states pretty much anyone can hang a shingle to be a ‘counselor’… What are we talking about when we say ‘get counseling’? What if we take the word ‘counseling’ and change it to a different word with the same meaning—do we still feel the same way? For example, by counseling, I think most people mean interacting with another person, and receiving feedback in the form of interpretation, clarification, or advice. How would you feel about the idea that if your kids are acting up, you should send them to a stranger and have the stranger give them advice? Sound good?
In reality there is no shortage of bad advice out there, so why is there an assumption that advice is OK, as long as someone is calling it ‘counseling’? One could say that there is the assumption that a ‘counselor’ has had training, and therefore the advice will be better than the random advice one typically receives from strangers. But we all know bad doctors, and the standards to become a doctor are incredibly stringent compared to those for counseling! Not to mention that there are some real goofy things that pass for counseling, particularly the closer you get to California!
There is one thing about counseling that does guarantee a certain degree of safety– any recommendation to undergo counseling is usually ignored! But in all seriousness, the people who are referred for counseling are often vulnerable, and so the issue of whether to blindly send them for advice from strangers does deserve some consideration.
There are, of course, different types of counseling. The ‘counseling’ done by advanced-degree practitioners, such as psychiatrists and psychologists, is generally referred to as ‘therapy’ rather than counseling. Therapy can be broken down into different types, and some conditions are more responsive to one type of therapy than another. Therapy is often described along a continuum, from supportive therapy on one end to expressive therapy on the other. Supportive therapy would be the appropriate approach for a person undergoing trauma or significant stressors, at a breaking point; expressive therapy would be the choice for a person who wants to develop better insight into how his/her mind works. During psychotherapy in my office, I tend to move back and forth on the continuum depending on how the patient is doing; when the person is struggling the therapy moves in the supportive direction.


What is supportive vs. expressive therapy? This is hard to explain in a short article, but supportive therapy is aimed at strengthening the person’s defense mechanisms—as those defenses are what keep us sane during times of stress. Expressive therapy, on the other hand, is aimed at questioning assumptions, digging up repressed content, challenging long-held impressions of relationships, etc. If a person is already under a great deal of stress, and then undertakes frequent sessions of expressive therapy (like psycho-analysis 4 days per week), he will often get worse, even to the point of psychosis.
Looking at it this way, undergoing therapy during active addiction at first seems to suggest some contradictions. During addiction the addict is very ‘stressed out’—so wouldn’t that suggest that ‘supportive therapy’ be the best? I would say no, absolutely not—when treating addiction, I WANT the person to question the assumptions and rationalizations that keep the person using. So does that mean that expressive, psychodynamic psychotherapy would be a good idea? To that I would also say no! The problem is that the using addict is so full of crap that psychodynamic therapy is generally a waste of everyone’s time. Anyone who knows an addict knows the shallowness of emotion during active use; crying for help as if from the depths of the soul one minute, and then laughing it all off a few minutes later.
There are other problems with therapy during addiction, even in recovery. A psychiatrist may see addiction in a way that runs counter to the view of an addictionologist. Specifically, psychiatrists often see addiction as a symptom of something or a consequence of something; addictionologists on the other hand see addiction as a primary disorder, that may be the cause of psychiatric symptoms or illness. To one, addiction is a chicken, to the other, an egg!
The addictionologist worries that the addict in therapy will start to find reasons for what he is doing, when the reasons aren’t the issue—the point is to just stop doing it! I get this image of two extremes among my patients; both have a month of sobriety and it is time to be working full time, and one says ‘OK’ and starts filling out applications without even thinking about the nature of the job, and the other sits for weeks talking about how it ‘feels’ to go back to work, wondering why it feels this way, wondering if other people feel this way, wondering if he will always feel this way… Usually I explode and say ‘JUST GET AN F-ING JOB ALREADY—WHAT THE F**K!! I’m SOOOO empathic!! I like the addictionologist approach in this setting, including the ‘as if’ approach that I have mentioned before. You don’t feel like working? That is OK—just act as if you DO feel like working, and get to work. You feel tired? Act as if you don’t feel tired. To a tired, nonworking person this sounds harsh—but I am only trying to help. And whether you believe it or not, I will help you more by this approach, than by sympathizing with how tired you feel.
This gets to the issue of the harm that the wrong therapy, or the wrong therapist, can do to a patient. If we have a person in treatment who is struggling—nobody is laughing at the cocky, stupid jokes; everyone is calling the person on his ‘stuff’, and he is getting close to that place where he drops the cocky attitude and brings his genuine self to the treatment scene… If at that point, a sensitive, kind therapist came on the scene and started making little ‘poor baby’ faces with the person, that could completely destroy the treatment. Addiction treatment is pretty cool stuff, and pretty challenging– it takes a person who can distinguish the real person and the BS person, and use the BS person’s own words back on him to try to break though the cocky front… this is the work of a good addiction counselor. There are plenty of counselors who think they are treating addiction by providing education and support, maybe also enforcing boundaries… but the great counselors who every treatment center wishes they had are the ones who are addicts themselves, who hate addiction and who come to work ready to rumble every day. It is a game in a way—or a chess match. Knowing how hard to push, and when to push a bit harder, and then knowing when to shift gears and reel in the newly-opened mind. It is tiring work, and given that we are literally talking about saving lives, the pay is not near good enough.
I just mentioned how a ‘softie’ can screw everything up, but there are other dangers to therapy for those in recovery from addictions. All of us in recovery have what I like to think of as ‘the addict inside.’ The addict is there for one reason—to get us to use. The addict is crafty, or as they say in AA, cunning, baffling, and powerful. The addict inside has advantages over our sober selves; the addict has access to all of our minds, including our unconscious, where our fears, lusts, prejudices, hatreds, and other powerful forces reside. The addict can use these unconscious feelings to push us to do things that may ultimately destroy us. But our sober selves have our own advantages; we get to control our arms and our legs. Sure, the addict inside can push us up down, left, right, into using once we are in a dirty bar at 3 AM… but our legs can carry our sorry heads to the edge of the bed at 10 PM and then drop us there, so that we can’t get near that bar! The problem with therapy is that is does at least two things to strengthen the ‘addict inside’. First, the addict LOVES to talk; you start up that therapy, and the addict gets to start up with all the BS, and given free rein the addict will win over logic every time. The second thing is that the addict will use confidence of our sober selves to the addict’s advantage, like this: ‘I see it now! I used because I was teased on the playground, and that created this pain in my heart that never went away—so I needed a pain killer, and I took one, to ease the pain—a form of self-treatment!’. Sounds pretty logical… but you have just told the addict in you about a big weakness. The next time you are in a situation that is somehow similar to being teased at the playground, the addict will be ready to tell you about how much you hurt, and about how good it would feel to medicate the pain, and about how much you deserve to be medicated. And even more– and this is similar to what ultimately led to my own relapse that destroyed my anesthesia career– you are now a smart guy! You had that therapy, dude! You are da’ MAN! Now you get it, don’t you see—just take a little bit this time—no, a TINY bit!! Just enough to medicate, to take the edge off, then stop!
Right.
I haven’t addressed how the Suboxone issue may play into all of this. I guess I would say that Suboxone lessens the risks just a bit; the ‘addict inside’ is a bit less powerful when the cravings are muted by Suboxone. But I have seen plenty of addicts go from stability on Suboxone back to ‘self medication’ and ‘playing’, and in some cases this folly is fueled by too much ‘self analysis’– which is really code for ‘rationalization’.
I am not totally down on therapy for addiction. Just don’t kid yourself. One of my favorite lines from the movies is still number one, a couple decades after when the movie came out—Clint Eastwood saying ‘A good man knows his limitations’. This is important advice to any addict who would like to stay clean. Know your limitations. Having psychotherapy—even real good psychotherapy that truly adds insight—doesn’t make you any safer—if anything, it increases the risk that you will talk rings around yourself some day and get into more trouble. Another saying—nobody is too dumb for recovery, but some unfortunates are too smart for it.
The best form of therapy by far for addiction is group therapy with other addicts, preferably with a range of sober time including a few ‘old-timers’. And that happens to be an AA or NA meeting. Similar groups set up in treatment centers can work quite well also. Continuing the ‘addict inside’ analogy, everyone in the group has the same addict inside, and now everyone in the group contributes to identifying the addict, calling it out, and helping each other identify the addictive thinking and addictive behaviors that are the tools of the addict inside.
Heavy stuff for Super Bowl Sunday. Anyone who picks the winning team AND the point spread gets a free copy of my soon-to-be-released book, Suboxone, and Addicts Guide, containing an organized version of the information in this blog I must receipt your e-mail by the end of halftime for it to count! To be honest, I’m just curious to see if anyone manages to even make a guess!
Jeffrey T Junig MD PhD
AKA SuboxDoc

Addiction and Will Power

A person posted the following after one of my youtube videos about Suboxone:

While SuboxDoc knows what he’s talking about in his videos, not everything he says is always true. Not everyone needs permanent blocker therapy. Everyones willpower varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinance. The easier withdrawals are, the more likely that persons mindset will be “one more can’t hurt”. Pain builds you, it builds character, personality, and maturity.

My thoughts:

I have had my share of bad withdrawals.  So have most opiate addicts who have live with their illness for a few years.  Unfortunately, there is much more to staying sober than remembering the pain of withdrawal.  There is also much more to staying clean than ‘character, personality, and maturity.’

I’m not sure the best way to approach this discussion, but the first thing to do is to dismiss the comment about ‘will power’.  The collective experiences of hundreds of thousands of addicts over the past 75 years have taught most of us that there is one thing we know about addiction: Will power does not work.

I learned this simple fact during a ‘spiritual conversion’ that removed my desire to use, back in 1993. Since then I have tried to approach the issue more scientifically. The first thing I come up with is the realization that if I had will power, I would have no reason NOT to use. I would just go ahead and use today, and stop tomorrow! But I can’t do that—I can’t use today– because I KNOW that I do not have will power over opiates. I KNOW that if I used today, I would never regain control again. I have mentioned my ‘7-year relapse’ before—after 7 or 8 years of sobriety, all the time working in the OR with potent opiates in my hands, I relapsed on some codeine tablets that I found for sale ‘over the counter’ in a little market in the Bahamas. I came back to the US terrified, but didn’t use after getting back to work. But six months later I had a cold, I was tired, and I was stressed…. and I had the sudden thought that I was able to stop when I came back from the Bahamas… so I must have Will Power!! And so I used that day, planning to stop the next day using that wonderful will power that I now had. But the next day I decided to wait, and use the will power the next day. And a month later, I started to wonder just how much will power I really had. Finally after about 5 months, I lost my job, my medical license, my friends, my vacation cottage, 30 pounds of my body weight, my self respect… and I went into treatment, planning on a quick ‘tune-up’, since I had done it all before, and thinking that I had that ‘will power’ to help me out. It ended up taking over three months to stamp out that thought of having ‘will power’. So as far as I am concerned, you are welcome to all the ‘will power’ you want. Take my share too, while you are at it!

From a psychological perspective, I wonder if ‘will power’ keeps us from experiencing the appropriate fear about addiction that is needed to stay clean. Addiction lives in the ‘limbic system’ of the brain—in the primitive part of the brain that controls basic drives. Too often we try to control our addictive behaviors with our higher-order brains, and with reason—but we end up just talking in circles and rationalizing further use! I think the way to take on addiction is to meet it where it lives—in the limbic system. That is a place where animals fight over territory, where mates are chosen, and where we fight to the death—or run like heck to get to safer ground. Will Power involves the higher order brain, and our ‘super-ego’ making the ‘right choices’; powerlessness and fear live in our id, in the lower structures of the brain, and they work to keep us safe—while the higher order parts ponder away. So from my way of thinking, BE AFRAID. Drop the will power. Addiction has killed friends of mine—wouldn’t I be a fool, not to fear it?

Then there is the question… does more severe withdrawal help keep one safer from relapse? The question reminds me of my anesthesia residency in Philadelphia, doing labor epidurals. The nurses wouldn’t let me put a labor epidural in a 14-y-o girl until she suffered for awhile— until she had a bit of what they called ‘punitive labor’. They assumed that the pain would help keep the girl’s legs together for the next few years. But I always wondered about that philosophy. Instead, what if the girl was hooking up too young because she had a rough life, and was always beaten down by one person or another… and getting pregnant was a consequence of a desperate desire to stop the emotional pain? If that was the case, maybe more ‘punitive labor’ would just make her burden a bit heavier, and make another pregnancy MORE likely!


That is where I am with the withdrawal experiences (note– since writing this post I have received a couple e-mails from people who don’t understand the analogy.  Hopefully most people reading this understand what I am saying!)   Beyond this apparently-confusing analogy, I don’t buy the argument that worse withdrawal provides protection from relapse for another reason as well.  People don’t remember ‘pain’ very well.  If you try to remember something painful, you will see my point.  I don’t really remember the pain of my worst withdrawal episodes; I know that the last one, the final detox before treatment in 2001, was pretty horrible… but I don’t ‘feel’ it anymore. And even if I did, would it make me avoid using? Or would it make me think that I was safer, for example make me think that ‘the pain built me up.. . gave me character, personality , and maturity… so I probably am a stronger person now.  In fact I am so strong and full of character that I don’t really need to go to meetings— I can handle it on my own.  In fact, I am such a strong person… that I could probably take some codeine for this darn cough that has been keeping me up… I’m probably strong enough now to take it just once, and then stop… ‘

Tricky business, addiction. See the problem with thinking too much? That is why I choose to stick with fear– when it comes to addiction, fear will keep you safer than will character, in my opinion.  Don’t get me wrong– build your character too!  But don’t think that good character alone will keep you from using.

SD

Addict, Heal Thyself… But Not With Suboxone!

Tonight’s discussion comes from the tail end of a discussion with a relative of a person who is addicted to opiates, and who is doing something that is unfortunately growing in popularity– buying and using Suboxone ‘on the street’.
In my private practice, most of the people who have gone on Suboxone have done very well.  In fact, if I didn’t count the third of my practice that consists of people under 30, the relapse rate would be less than 10%.  The relapse rate is much higher in 20-year-old addicts– in my experience about half stay clean, another 25% bounce in and out of stable maintenance with Suboxone, and 25% are lost to follow-up after about a month.  If you do the math, for the entire practice the relapse rate is between 10% and 20% over a period of one year.  I would guess that out of people who take Suboxone on the street, the numbers are reversed– and 10%-20% of addicts stay clean for a year.
But I’m getting ahead of myself.  The question:
Thank you for the kind words. Just a couple questions. Can you tell me, is it dangerous to take soboxone without medical supervision? Also, can you recommend a good treatment center in our area? Are there any federal funds available for people like him?
Every day I read the headings from the sites I have complained about:  ‘I just scored 60 Suboxone tablets and I want to do this right– someone write and tell me what to do!’.  Then there is the corollary post: ‘Suboxone doesn’t work.  I have tried it over and over (on the street) and it doesn’t do anything for me’.  I don’t know who is the biggest fool– the addict treating himself with addictive medication, or the amateur doctor telling the addicts how to use the non-prescribed addictive medication.  But regardless– they are both fools!
There are a couple problems with unsupervised or ‘non-medical’ use of Suboxone. The best way to point the problems out is to first look at the goals with Suboxone treatment: first, to gain some stability over the chaos of using by suppressing the desire to use, and second, to ‘heal’ the manifestations of active addiction– which are mainly personality effects that I have written about ad nauseum on the blog. The personality effect that I see as most important is the way the addict puts up a fake front to deal with the world, while the ‘real’ person is ashamed, angry, afraid, and hidden away from the world. The result is that to the active addict, everything is an act– he is always working people, manipulating the truth, twisting reality to make it fit– rather than ‘living life on life’s terms’. Over time the addict loses the ability to tell what is real, and what is BS. Being around ‘real’ people, or real relationships, becomes more and more painful, as they serve as reminders of how fake everything has become, and they also force those feelings of shame and fear to come to the surface. The addict loses the ability to tell one feeling from another– every uncomfortable feeling is labeled ‘anxiety’, for example, as that is a reason for even more medication.

When the person goes on Suboxone ‘on the street’, some good things can happen– the use can settle down, for example. But often the addict tries to save money by taking small doses ‘when needed’, rather than getting on a regular daily morning dose. There is not a lot of difference between taking small doses of Suboxone when needed, vs taking vicodin or oxycodone as needed– especially since small doses of Suboxone are below the ‘ceiling dose’ and so they behave like an agonist, not like a partial agonist.

I talk to patients a lot about the ‘conditioning’ that occurs with addiction. I want to ‘extinguish’ the conditioning by making sure they dose only once per day, and automatically, not when they ‘need it’. But even if the person does ALL of this– without medical supervision there is something missing (yes, something more than just the absence of payment to the doctor!). Some of what is missing is subtle, and hard to describe. But two things I can describe… first, every addict thinks he can fix himself. That is a part of addiction itself– the misplaced confidence in self-as-doctor, the feeling of ‘uniqueness’, that nobody understands me but ME… and one thing that I have come to learn about every psychiatric illness but especially addiction is that a person usually cannot make adequate changes in himself without an outsider’s view of things guiding the way. A person will think he is making changes, but he will only change what is acceptable, and won’t even consider or notice what really needs to change. To recover from addiction a

Active addiction requires a 'false front'
Active addiction requires a 'false front'

person needs to live another way, and he only knows one way. And reading isn’t sufficient. Going to meetings with an open mind and willingness to take in new things and willingness to change– that can result in recovery. But an addict counseling himself just won’t work, as tempting as it is to hope for. The second thing is more subtle… by going to someone and getting help an addict is making a commitment to himself of sorts. He is taking a step out of ‘self will’ and isolation, and accepting help from another. Just this simple act alone is part of the recovery process. And a person sitting at home popping a Suboxone purchased from a friend is in a very different place than the same addict sitting in an office, tears on his face, asking for help. Unfortunately the addict with tears on his face may break into a cocky laugh as soon as he steps outside– when I see that, my prognosis for the person drops dramatically, in contrast to the person who spends a few days numb and shaken by how horrible life had become. Just that difference in how people present tells me so much about how they will do– I am constantly trying to find a way to turn the first person into the second person.

I got clean after my relapse in 2001 at what is probably one of the better treatment centers in the country. It is ‘open ended’, meaning that they keep you until they think you are better. I was a slow learner, and there for over three months. The state sends docs, dentists, pharmacists, nurses… people with licenses… to that program, and they get the same from several neighboring states. But it costs a mint– I was an anesthesiologist back then, and I sold our vacation cottage to pay for treatment and to pay the bills. I should mention that what makes the place good isn’t the ropes course, the art therapy, the old buildings, etc… they just have several real good counselors, and they are very strict in their rules. There is no wiggle room at all, and that is a good thing. There are other good places around the area that aren’t quite as costly, like XXXXXXXXXXXX… they have some great counselors as well. The thing is, it depends so much on the attitude of the addict. My first time in treatment was at a miserable place, as an outpatient, surrounded by court ordered patients… but I was so sick of being addicted that I attended many meetings and ate up every bit of recovery I could find, and it worked for ten years… even after catching my counselor at a bar (I was going into a restaurant) with a fellow patient who wasn’t his wife (yes, he had one of those at home). I see addicts who aren’t ready for recovery go into a fabulous treatment experience, at dad’s expense, and complain that the food isn’t good, the beds are hard, the counselors are too mean… a person who really wants treatment doesn’t complain about those things!!

Finally, there is something to the idea that a person does better in treatment if he/she has some stake in it.  This applies to so many areas in life, by the way–  I remember being angry at the kids in my college who were attending practically for free, who blew off classes regularly and eventually dropped out.  On a separate, perhaps controversial note, this is why I am against the idea of ‘free college education for all’.  In my never-humble opinion, that would be a disaster, as so many more kids would go ‘just for the heck of it’, diluting the experience for those who are working to be there– and grateful for the opportunity.  No, I’m not saying to take away financial aid!!  Just that people seem to get more out of something that they work for.  And recovery is no different.

SD

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

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

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.

Strong Enough?

I am moving a post from the comment section up to here, as it sets up a couple points worth making.  As always, I suggest that the writer of the comment check out suboxone.com and naabt.com, two good sources of information about Suboxone.  I also suggest my own ‘product’ for sale on the right, particularly for people who could use an introduction to the concepts involved in choosing between treatment options for opiate dependence.
The comments from the writer:
please email me at [email protected]. I have been using opiates on and off for 12 years with NO issues. July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit. I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break. 20 months later I thought I was strong enough and could handle anything. Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later. If the opiates were not so difficult to get, I probably would NOT quit. That being said, I am starting therapy with a therapist. Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs. But I am asking this entire community along with this doctor here to help me by sending me an email to my email address. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth. Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.
I hope that the writer doesn’t find this too obnoxious, but what I like to do is go through the message part-by-part.  I do this for several reasons.  First, as I frequently point out, opiate dependence is an amazingly-predictable disease.  The progression is virtually identical from person to person, with variation only in the minor details.  Opiate dependence affects the mind of the addict, causing denial among other things.  At the same time, each opiate addict feels ‘terminally unique’ throughout the course of the illness, seeing faults in others, but blind to the same faults in him/herself.  One of the benefits of attending a 12-step group is seeing the pattern unfold in person after person;  this helps the recovering addict understand the progression of addiction and even learn to identify and predict his own ‘triggers’ and ‘addictive thinking’.  I want to do the same with the comments;  to point out examples of classic ‘addictive thinking’ that people can then learn to identify in themselves.  I ask that writer try to avoid taking my comments ‘personally’– I am not trying to insult anyone, as we all are in, or have been in, the exact same place!
One more aside… for people looking for Suboxone treatment in the Midwest, I am now open to new patients and also participating in a study that pays up to $225 for patients who enroll and participate.  My contact info is at Wisconsin Opiate Management Center.  I require at least the first visit, the induction, in person–I can then do telepsychiatry for further visits if people live a distance from my office.
Going through some of the comments:
I have been using opiates on and off for 12 years with NO issue…
I don’t know what to make of this comment.  I do not think that it is possible to take opiates for 12 months without issues, let alone 12 years. I guess it all depends upon what a person means by ‘issues’.  The worst part of opiate dependence, in my opinion, is the most subtle, and the easiest to deny– the effects on personality.  When a person uses any drug of abuse, the person almost always has some inner negative opinion about what they are doing.  Most people have internalized parental messages about d oing drugs, so that even while they make fun of their parents’ being ‘up tight’, there is somewhere inside a small kernel of shame.  Many people also have a ‘work ethic’ somewhere in the back of their minds, and doing drugs is at conflict with that as well.  Some people have personal health standards that using violate.  You get the idea…  the conflicts result in shame, which is a horrible thing to feel– so we repress the feeling and awareness of our shame.  We push the shame deep inside so that we don’t even feel it anymore;  being around other people will sometimes trigger it though, so to keep it from bothering us we put on a fake, cocky exterior.  As time goes on we get better and better at putting up that ‘fake self’, sometimes even losing track of who the ‘real me’ is!  Again,  when we are in that mode it is extremely uncomfortable to be around people who really know us;  I remember being extremely uncomfortable just sitting at the dinner table with my family!  During active use, close relationships with other people are simply impossible– instead we collect a bunch of shallow ‘buddies’ or relationships based solely on physical attraction.
Even if this were not the case, how does a person use opiates ‘on and off’?  The physical dependence and withdrawal are unavoidable– and anyone who has been through several episodes of withdrawal recognizes that they are ‘issues’.  Miserable issues.  Moving on…
July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit.
So at some point during the 12 years, the drugs became the ‘enemy’.  If this person is anything close to typical, the use was an enemy far earlier than the user recognized.  I often speak to family members to verify the story, and close family members ALWAYS noted irritability, distant emotions, preoccupations, etc far earlier than the addict thinks.  We think we cover things up so well!  I should point out in AA and NA this would be  considered a ‘dry drunk’– a person not using but who has not found recovery.  This rarely lasts real long with opiates, although alcoholics can often remain ‘dry’ for years or even a lifetime.  They are usually miserable people– more miserable even than when they were drinking.
I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break.
Always a good idea– drug friends have to either get clean themselves, or go, if a person is going to stay clean for any length of time.
20 months later I thought I was strong enough and could handle anything. D Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later
Opiate dependence will wait.  My relapse didn’t hit for about 8 years, long after I had forgotten about my ‘problem’.  The main point I want to make, though, is about ‘power’.  WILL POWER DOESN’T WORK!  The main reason?  If I can control my use, why should I quit?  Heck, bring them on… I’ll quit tomorrow!  The first step of a 12-step program is POWERLESSNESS– the realization deep inside that the person has no power over the substance.  This realization is sometimes a wonderful event, and the reason for the ‘miracles’ that AA people talk about…  an addict will sometimes suddenly ‘get it’– get the realization that they are powerless.  When that happens, the urge to use will often just disappear, all of a sudden!  It is a neat thing– and it makes sense when you think about it.  I always think about my son, who liked strawberries, but when he found out that the miserable hives were from the strawberries it was quite easy for him to ‘just say no’ to them!
That being said, I am starting therapy with a therapist.
Unfortunately, therapists and psychiatrists have poor records at helping a person stay clean, unless the person is also in some type of group format.  The 12-step group format is the only thing that has stood the test of time– going on 100 years!  The problem with therapy is that it can make a person think that the personal insight will somehow make it OK for them to use.  ‘Now that I know myself, I probably won’t go as crazy with them– and I can use just a tiny, controlled bit.’  It doesn’t work.
Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs…. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth.
I think my spellings are usually correct.  In most states, only MD’s or nurse practitioners can prescribe– not ‘therapists’ for the most part.  And most docs cannot prescribe Suboxone– they need a special waiver from the DEA.  Go to the web sites I mentioned at the top of this post, and they will help you find a prescriber.   As for the basic info, I again point out my recording!!  Or you can just read and read– everything is out there, and those web sites I listed have some good articles on them.
Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.

I don’t understand that last part.  But I wish you well, my friend.  There is a better life out there– that I promise.
SD

Cured of Addiction!

If only!  I’m sorry about the headline– but did it catch your attention?  We all wish we could be cured– and headlines like this one appeal to that wish.  We are easy marks for a person looking to make a buck.  I want to use that fact as a springboard to discuss a couple things.
I recently received a comment accusing me of just such activity– of ‘making a buck’ off people with addictions.  The writer took it a step further stating that all addiction is a matter of choice;  that people addicted to opiates should just decide to stop taking them, and that Suboxone is just a ‘substitute for oxycodone’.  I was not real polite to that person, although I was more polite than I wanted to be… as that is the type of ignorance that literally kills people.  We ALL tried to stop– many, many times.  Anyone who has even a basic understanding of addiction knows that it is much more complicated than that.  The writer stated that she could stop– that her ‘therapy’ helped her deal with her issues and gain the ability to stop using.  I often write that ‘nobody is too dumb to get clean, but some people are too smart’– perhaps she wasn’t ‘smart’ enough to have problems getting clean! (yes, that was needlessly mean).
On the other hand, it isn’t that ‘mean’ when you realize that people die from opiate dependence—often—and what often keeps them from getting help is the thought that they can get things under control on their own. And so they keep trying, and keep hiding their addiction from the people that could help them. Add the shame that the writer would like to instill, and the addiction is forced even further underground. A common recovery saying is ‘secrets keep us sick’; in order to get better, using addicts must expose their addiction to the light of day– to treatment providers, but even more importantly, to themselves.
As for the ‘making a buck’ part… yes, I would like to be paid for my efforts. And yes, my career does exist because people need help with their addictions. But in medicine there are easier ways to make a buck! I treat opiate dependence (among other conditions) because I understand opiate dependence—having lived it. It is a horrible illness that cuts across all segments of society—it tends to hit people who have tons of potential, and has the ability to take away every bit of that potential—that is what keeps me interested in fighting addiction.
Suboxone is not perfect. I would rather have every person with addiction go into 90 days of residential treatment, and attend NA for life. That is the only other option at this point in time. Most addicts will not go to residential treatment until they have lost a great deal, and some never get there—they die first. So we have Suboxone… and it is an amazing advance in treatment options. Even better options will come along—that is my hope, anyway.
The writer also mentioned my tapes! I really thought they would be popular… but they haven’t been. No ‘quick buck’ there! If you, the reader, have suggestions on what you WOULD pay money for that I could sell as an addiction expert, LET ME KNOW! In fact, if you have a great idea for a digital download that would help other addicts and that we could sell on this site, we could work together on it and share in the ‘tons of profit’ I’m supposedly making!
The other half of the ‘money from addiction’ issue can be seen in this comment:
I can’t imagine being on suboxone for 2 years. After about 6 months, I got off it by going to XXXXXXX. It’s a clinic here in XXXXX that uses an all natural approach They use a 10-day amino acid IV infusion that literally dunks your brain in the essential nutrients necessary to repair all the brain damage I caused by using. I started feeling alive again around day 4. I never had any cravings while going through this. Around day 8 or 9, I started feeling like a million bucks! Not high- just healthy. The staff there was amazing and it’s all outpatient. I never missed a day of work. I am amazed at how good I feel- for the first time in my life, I feel healthy. I would definitely recommend it for anybody.
I wish!
First of all, if you used oxy or other opiates you didn’t do ‘brain damage’—the drugs bid reversibly to receptors on neurons and do NOT do permanent damage—at least not to the structure of the brain. If you used tons of ‘X’ you may have done damage—likewise if you were a ‘huffer’—but you won’t fix the damage with ‘essential nutrients’! Addiction causes changes in personality, destroys intimacy, damages self-image, causes depression… and makes any type of ‘spirituality’ impossible, leading to a life that is empty and meaningless. Suboxone can halt progression of addiction and can help keep these things from getting worse… but Recovery requires more than nutrients and amino acids. I won’t go so far as to declare such ‘restorative’ approaches as totally fraudulent… but I am close to such a declaration! There are a few ‘cocktails’ out there for other addictions as well—the docs that peddle them charge tons of money—10 grand and more—for the ‘secret recipe’. None are supported by REAL research—i.e. in the peer reviewed literature—although they claim to have their ‘own’ studies that support their effectiveness.
Understand that there is a process for documenting effective treatments that all reputable scientists use—there HAS to be such a process, as otherwise we wouldn’t know what works and what doesn’t. First of all, knowing about brain (I hate to keep carping my PhD in Neuroscience but I want readers to know that I am speaking from a position of knowledge), it is silly to think that the complicated factors involved in addiction can be addressed by taking nutrients and amino acids—in ANY combination or dose! But playing along… if there is such a solution, knowing the extent of the destruction that addiction causes around the globe, why not put it through the usual proving process, and then sell it either on one’s own or through ‘big pharma’- and save the world while at the same time becoming wealthy? Or if wealth isn’t the issue, give it away! Why not? The reason, of course, is because those miracle cures don’t work. They may provide a placebo-like response—the addict may feel a bit ‘stronger’ if he/she believes in the product. But that will fade over time, and the addiction will return. The people selling the cure will shrug their shoulders (if they are still around—they may have closed shop and retired to an island by then), and say ‘gee, it usually works… you must have a particularly bad case of addiction! Let’s try a double dose—of course it will cost a bit more…’
Addiction stinks. Suboxone is a step forward… but it still stinks. Want off Suboxone? I made the recordings to talk about the issue. There is no quick cure described on the recordings, but there is my best assessment of what is required, how to go forward, who should try and who shouldn’t, etc. Please buy a copy, check it out, and give me feedback. I promise not to get rich!

SD