Note to Patient: Dude, Don't 'F' This Up!

A very common pattern of relapse, right before your very eyes. I care about this person, and hope that he makes the right decision.  As always, names are blocked to protect the innocent…
An E-mail message from a long-time patient on Suboxone:
Hello , I’m just writing to follow up on my call that i placed last night.  As i said i am working from the office not home for the next few weeks and email might be the best way to talk. You can always call XXXX and advised him of anything.  As i said Monday a week ago i believe it was i had an accident in the shower and knocked out one of my front teeth.  Apart from being very painful it is rather a hit to you self confidence.  I did not want to take pain med’s. Obviously you know why. So all i knew to do was take more of my suboxone.  It seems to have helped some.  XXXX is lending me the money to get it fixed next week but because of doubling my dose i will run out of my meds before mine arrives from (the pharmacy).  If you will or can call in a week or 2 week supply who know what might happen w/ (the pharmacy) this time hopefully nothing…. That would be good. Because i want to avoid pain meds at all cost. (A new pharmacy) on (address) would be easiest. Please respond.

A quick note:

Not the point I intend to make, but I will point out the reference to the ‘call last night’.  This is a common ‘tell’ in psychiatry, addiction, and medicine in general;  if a patient is doing something that they recognize on some level to be ‘fishy’ or a ‘violation of an agreement’, he/she will call at a time when the doc will not answer– like at 2 AM– and describe the situation as they want it to be perceived, without fear of the doc asking questions that expose the violation.  I have learned to pay attention to the ‘late-night, just wanted to tell you’ phone call, and they almost always fit this pattern.  Sometimes if I am in the office working late (I am often there until 10 PM) I will answer– and the person will hang up and call later to leave the message!

But there is more to this story.  My office-mate wrote this reply at my request:

Hi XXXX,

Sorry to hear about your fall, I hope you are starting to feel better.  I talked to Dr. Junig about an early refill of your suboxone, and he is unable to do that.  You should not take more of the medication than directed by Dr. Junig.  Our policy states there will be no early refills under any circumstances.  I have attached a copy of our office policy for your reference.

Sincerely, XXXX

Note– I will attach a copy of the pertinent sections of our office policies at the end of this post for reference.  Read on for the patient’s reply:

Hi I do understand Dr. Junig’s position on this.  But I had to ask , in light of my history w/ pain med’s, and did the only thing i could think of. I am sorry to have increased the dosage w/o consulting him first and please tell him so.  However with an exposed nerve i will have to seek the only alternative, which will be pain med’s. until the situation is dealt with.

Thanks again,

XXXX

Hmmmm…….. Those of you who know me, or those of you who have found or are finding insight into how addiction works– do you know what I am thinking, and what I am about to say?  Think about the process of what is going on— not the specific facts, but the general pattern.  Think about your own similar situations, as every opiate addict has had this type of a discussion at some time– perhaps many times.  Think about it, then read my response:

XXXX,

I talked to YYYY about what is going on with you; I asked her to send you a copy of the policies for people on Suboxone, and she had already done that. Understand that the policies are in place just for my benefit; they are policies that are necessary when treating addictive disorders. One problem with addiction is that it changes one’s view of the world, leading the person to always find ways around the rules, ways to manipulate the rules, reasons why the rules shouldn’t apply in this specific case, etc. The policies are quite easy to deal with; they only cause problems when a person is in trouble and backsliding. Your current situation is a perfect example of how the policies are intended to work, and why they are in place. Even without reading them, you know how things are in any treatment arena; you certainly knew, or should have known, that I wouldn’t agree with just doubling up on your dose of Suboxone. First of all there is no reason to do so; I have described many times how the effect of buprenorphine peaks at about 2 mg, so a person taking even 8 mg is already taking 4 times what it takes to get the maximum effect. More importantly though, part of getting over addiction is following instructions on medication vials to the ‘T’. We are no longer playing doctor with ourselves; we are recognizing that we are like everyone else—we follow the directions of people treating us.

Suboxone is an amazing medication, but it is used in harmful ways on the street. In the wrong hands and when taken the wrong way, it is just another psychotropic drug! With its long half-life and unique properties, it should never be taken in response to symptoms—that defeats the purpose and turns it into something else. Instead it should be taken once per day, in the morning. Any thoughts of taking it at other times should be seen for what they are—addictive thinking that should be handled by firm resolve, by distraction and redirection, or through meditations on powerlessness if in a 12-step program.

More worrisome, though, is your follow-up letter where you say essentially ‘OK then—just so you know, I might now have to take narcotics!’ Adding the message between the lines, you are saying ‘if I use, it is YOUR fault!’ This is a classic pattern of relapse— and something that you have set in process, probably with the unconscious intent to use being decided weeks ago. The process, in case you don’t see it, is as follows: the addict comes across something that looks like an excuse to use (most addicts recognize that feeling every time they trip—the thought ‘cool—maybe I’ll break my leg and have to take narcotics!). The excuse if often a poor one, but as the addict thinks about it denial takes over and the excuse eventually seems reasonable through their distorted vision. The leads to what is initially a small rule violation; a ‘testing of the waters’. If the person controlling the use (a prescriber or monitoring agency) makes exceptions for the addict the next violation is a little bigger, and so on. If the prescriber holds fast to the rules (as I am doing), the addict uses that to his advantage, now citing the rules that are in place to enforce sobriety as justification for using!

I have seen this pattern many times before, and have likely engaged in it back in my own using days. It will not work that way with me; the policy clearly says that repeated violations are reason for termination—simple as that. When that happens, I really miss the person I have been working with, but there is nothing else I can do! The policies are easy to live with—all you needed to do was contact me after your injury, and I probably would have prescribed opiates as needed to treat your pain, providing you took them EXACTLY as prescribed. Instead you did not tell me; you treated yourself for two weeks, something that you know is not consistent with recovering from addiction. Now you are threatening to take other pain pills. That would tell me that you are committed not to staying on the road to recovery, but instead are intent on using. In that case, you cease to be a Suboxone patient—you instead become a person who has to find a new level of desperation by suffering consequences… again.

I strongly recommend that you get back on track; when an illness flares up, the patient needs to reassess their course of treatment. What that means in this case is that you need to take steps to regain the recovering path—either by scheduling an appointment with me ASAP to discuss the situation, or by finding whatever path suits you—AA, NA, residential treatment, a different Suboxone program, etc. YYYY knows the situation as well, and understands how addiction works also—she experienced it with me, and has been amazed to see the process over and over in our patients. Like me, she is always amazed at how a person’s insight will change as the ‘addict inside’ takes control. Like me, she is impressed by how identical the process is from one addict to the next.

I do have appointment time available—I have time today at 2:00, 2:30, or 3:00. I have some times open tomorrow as well. I hope to hear from you—YYYY will not be answering phones today until after about 12:30, but she always checks messages.

Take care XXXX,

JJ

I truly hope to hear from this patient– he is a good guy, but like all of us he has a horrible illness.

The policies I referred to:

Pertinent scheduling policies:

I would like my practice to feel friendly and inviting for my patients. I would also like appointments to start on time, so that patients have the full amount of time that they need and expect. Finally, the treatment of some psychiatric disorders (primarily the addictions) calls for the placing of boundaries. The following policies are intended to help with these issues.

For patients taking controlled substances, including pain medication, Suboxone, or benzodiazepines, refills will not be provided if an appointment is missed, even if this results in discomfort for the patient. Remember that we are scheduling several weeks out, and so a missed appointment will likely result in several weeks without medication. It is your responsibility to take whatever steps are necessary to remember and make your appointment. There are no exceptions to this policy.

Pertinent prescription policies:

Plan ahead when refills are needed. All refills require advance notice of at least two business days. Refill requests will be denied if the patient has not kept follow-up appointments.

Prescription refill requests should be made during office hours, by telephone call to the main office number. Leave a message if your call is not answered. Refills will not be provided on weekends.

CHANGES OF MEDICATIONS OR CHANGES IN DOSAGE, FREQUENCY, OR STRENGTH OF MEDICATION WILL ONLY BE MADE AT APPOINTMENTS. Please do not call or e-mail to change medication between appointments– take what is directed, and we will discuss changes at the next appointment. Many medications must build up levels in the body before becoming active. Minor side effects are common, but almost always resolve in two to three days.

Controlled substances:

Refills for controlled substances are subject to separate policy, but the main points will be described here. Please review the policies that relate to suboxone and/or stimulants at the end of this document if you are prescribed either medication. Controlled substances must be taken according to direction. Early refills will not be provided for any reason, and medications that are lost or stolen will not be replaced. The only exception is in the case of stolen medication; a replacement MIGHT be provided, at our discretion only, if a police report is presented that describes the medication and the theft. Please invest in a sturdy safe that is secured to the floor, and do not share the combination with anyone. ANY ILLEGAL ACTIVITY INCLUDING SELLING OR GIVING AWAY CONTROLLED SUBSTANCES (EVEN TO A SPOUSE OR OTHER RELATIVE), OR ANY ALTERATION OF A PRESCRIPTION, WILL RESULT IN THE DISCHARGE OF THE PATIENT FROM THE PRACTICE. HAVING YOUR MEDICATION STOLEN MAY RESULT IN YOUR DISCHARGE FROM THE PRACTICE IF IT IS EVIDENT THAT MEASURES WERE NOT TAKEN TO SAFEGUARD THE MEDICATION FROM THEFT.

General Philosophy Regarding Addictive Medications:

When I prescribe a controlled substance, I trust that the patient takes sufficient care of the medication. In accepting a controlled substance prescription you are agreeing to take whatever steps are necessary to prevent the medication from falling into the wrong hands. One methadone tablet can kill a curious child. When a patient ‘loses’ medication, the withdrawal they will go through is the least of my worries; I am concerned about the final destination of every lost pill, as each pill contains the danger of a loaded weapon. Deaths due to narcotic overdose are very common. ANY RELIABLE INFORMATION THAT A PATIENT IS DEALING MEDICATION THAT I PRESCRIBED WILL BE TURNED OVER TO THE PD FOR INVESTIGATION. I WILL COOPERATE FULLY IN ANY INVESTIGATION OF DRUG DEALING OR PRESCRIPTION FRAUD. IF YOU RECEIVE CONTROLLED SUBSTANCES FROM ME, USE THE MEDICATION AS DIRECTED, WITHOUT EXCEPTION.

Miscellaneous:

Any of the following can result in termination of treatment:

-Abusive or profane language directed at other patients or at workers in the office.

-Any physically threatening behavior, or threatening telephone messages or e-mails.

-Unpaid balances older than 60 days.

-Coming to the office with or without an appointment under the influence of illegal substances, or in possession of illegal or non-prescribed controlled substances.

-Any fraudulent behavior related to payments or discounts including misrepresentation of insurance status for the sake of receiving discounted treatment.

I believe that these policies are necessary to avoid misunderstandings and to facilitate care. As a psychiatrist, I understand that there may be conflicts that arise from time to time even in the best therapeutic relationships. If you are angry, I strongly encourage you to take a deep breath and talk to me about the issue. Thank you for your understanding and for your cooperation.

Help!!!!

I received an e-mail asking for help some time ago– I no longer have the original e-mail, but I do have my comments in response to the e-mail.  I will post them because there were a number of teaching points that came up in the letter.   Specifically, my first though with the message was how typical it was;  opiate addiction always leads to the same place, and addicts have the same series of ideas and thought patterns, the same desperate attempts to find a way out of the hell that is active opiate addiction. In the letter the addict tries to run things and to address things scientifically and medically.  It reminded me of my own desperate struggles when I read every article on addiction that I could find, thinking it would help me.  It didn’t, by the way.  Note the AA saying that ‘nobody is too dumb for recovery… but some people are too smart for it.  The message:
I am hoping for some help! I have tried suboxone several times, never my own script but aquired through other addicts.
This never works by the way.  One cannot treat addiction through addictive behavior.  There are no ‘shortcuts’ to getting better.  Yes, Suboxone is a bit of a shortcut itself, but it must be used as a medical tool– just one part of the treatment process.  A person going on Suboxone must embark on a new life that includes ALWAYS following directions for prescriptions.  Always.  No more ‘I’m different than other people– I need more than most people’.  No more ‘I know what I really need better than the doctor does’.  If an addict going onto Suboxone doesn’t know these things, the doctor must educate him.  Suboxone is different, but if an addict uses it without direction it is just another abused drug.  Watch what happens:
The first time 3 yrs ago it was a miracle i felt wonderful but I only had enough to do a 5 day detox, at this time i was taking vicodin and occasional oxy. Of course I ended up back on the pills due to paws which at the time I had no education regarding thid part of addiction nor have i ever heard of it.I thought if this is what being sober is than I cant stand it due to lack of energy, constant fatigue and depression.
‘PAWS’ is ‘Post acute withdrawal syndrome’ by the way.  I wouldn’t consider this to be ‘paws’ though, as it is too early to fit into that category.  Acute withdrawal from opiates takes weeks, not days.  Acute methadone withdrawal can go on for months.  ‘Paws’ comes on after withdrawal ends, and often after a pleasant honeymoon period when the addict thinks he is out of the woods.  Then things start going downhill… reality sets in and the addict realizes that while it is great that he is getting help, nobody else really cares– his wife is still pissed at him, his credit card companies still want their money, or the hepatitis he caught from the needle is going to be a life-threatening illness.  So paws consists in part of mood and anxiety symptoms.  The person still isn’t sleeping, and appetite hasn’t returned…  muscles are deconditioned… and the cravings set in.  All of this can be considered part of paws– a ‘syndrome’ by the way…  in medicine, when something is called a ‘syndrome’ it is usually something that is poorly understood and poorly defined.  Such is the case with ‘paws’– people who use the term often are talking about different things.

I’ll also add that this person didn’t relapse because of ‘paws’. He/she didn’t relapse at all.  He never stopped using– he just played around with a new drug for awhile.  This is NOT just semantics; there is nothing in the story that looks anything like sobriety.  Not yet anyway.
My 2nd attempt was after becoming very addicted to oxy’s I am a proffesional and I am working towards a degree in the health care field si I know I cant continue to live this way. This time i got enough to last me until I could get my own, well heres what happened I was fine until I realized that I could still get high when i felt like it I was taking 4mgs a day of sub and then towards the evening I would do an oxy 80 or 2 I thought o.k. I can do this occasionally and feel no pain when I dont want to WRONG I sonn was using oxies every day while dosing every other day on the suboxone and when I tried to stop this and just use the sub I was horribly sick for wks also I began suffering from horrible depression.
Again, all of this is just playing with drugs.  No commitment to a changed life;  no asking for help from someone else.  I will throw in that people who work in health care are difficult to treat, as they try to treat themselves rather than let themselves be treated.
Now i have chose to quit the suboxone thinking it was causing my horrible depression WRONG again it has been 3 weeks and   horribly depressed so heres my plan I know now more than I ever did in my life that this has to stiop I have to get clean I am willing to do anything to get it together without turning back meetings, prayer, church anything to get out of this hell i am living! I want to try the suboxone again right this time. I am going to get a hotel room and try and wait the whole 24hrs and then take the suboxone. My question is do you think that this time it will work? I mean do you think I messed it up while abusing opiates while on it for about 4 months? I am trying to make sure i keep my dose low on opiates now well as low as i can tollerate so I have a better chance of having a better outcome when starting the suboxone this time. I have never been more serious in my life I have researched this for weeks and one thing I dont understand is why I was able to use while on suboxone without the blocking effects I know i was feeling the oxys.
The reason is because you were on a subtherapeutic dose of Suboxone, and you probably were not taking it completely correctly.  The effects at the receptor are all about competition;  a high dose of a potent opiate will out-compete a low dose of buprenorphine, particularly if it is not taken correctly.
This is my last chance or i will end up at the methadone clinic and I definately don’t want that please tell me how I can make this work after playing so many games with my sobriety and the suboxone. PLEASE HELP ME FIGURE THIS OUT!!!!!!!!!H
Nothing to figure out.  In treatment people often say KISS:  keep it simple, s..s..stanley.   Getting clean is not about working ‘harder’.  It is about being treated.  It is about letting go and stopping the constant running of the show.  I don’t know if Suboxone is going to work at this point– I know it won’t if you just do the same thing again, taking it on your own without a prescription, treating yourself.  You must understand that the addict is in charge of your mind;  you cannot out-think the addict on your own.  You have access to your conscious mind;  the addict has that but also has access to all of your unconscious mind.  The addict knows all of your weaknesses;  all of your deepest secrets and fears.  How do you expect to take that on?
When people start Suboxone there is a lot more going on than just blocking receptors;  they are making a commitment to a new life.  In my experience once that person starts using, he quickly is right back to the same old thing– trying to use willpower, which is useless with opiate addiction.
My recommendation is to get help from someone who has experience treating addiction, and to do everything you can to stop treating yourself. The best, state of the art treatment out there is all around you– that being AA and NA.  But it doesn’t work to try to ‘use’ AA or NA.  Rather to get better you need to let go and recognize that you are lost.  Stop digging.  Skip the Suboxone and instead go to a meeting every day.  Recognize your powerlessness over opiates, and recognize that they are poison for you, and let them go.  Some lucky people will just ‘get it’ all of a sudden– I was that lucky my first time around, but not the second.  It takes utter desperation, and with a leap of faith a person simply says ‘I am done fighting’.
It is hard to explain, but I think I have said enough for it to be figured out if you are ready, and truly desperate.
Let it go.  You can’t take opiates anymore.  You can rest now, because the fight is over.  You lost, but that’s OK.  It’s done.
SD
Suboxone Talk Zone

Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at Subox.info, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
SD
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I'm Not Like 'Those People'

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