A couple comments for regular readers… first, watch for an upcoming change to a new name. For years I’ve debated whether to adopt a name centered on ‘buprenorphine’, rather than the more-recognizable ‘Suboxone’. I believe that time has come. Second, I’m going to ‘reset’ with some introductory comments about the proper approach to treating heroin addiction, intended for those who are seeking help – starting with this post.
I’m addicted to heroin. Which treatment should I use?
I’ve treated heroin addiction in a range of settings, including abstinence-based programs and medication-assisted treatment with buprenorphine, naltrexone, and methadone. My education prepared me for this type of work, and my personal background created empathy for people engaged in the struggle to leave opioids behind.
The first barrier to success is on you. Are you ready to leave opioids behind? How ready? Are you so ready that you will be able to end relationships with people who use? Are you ready to stop other substances, especially cocaine and benzodiazepines? You will find help during treatment and you don’t have to take these steps entirely on your own. But you must at least have the desire to get there.
If you’re ready, the next step is deciding the treatment that is likely to help you. Many people see abstinence-based treatment as a ‘gold standard’ – the ultimate way to escape opioids. Unfortunately, that belief has fueled many deaths over the past ten years, as desperate people paid large sums of money for themselves or loved ones expecting programs to alter personality over the course of three months. It doesn’t work that way for most people!
During several years working in abstinence-based programs, I helped fix people who were broken by addiction. After a couple months, people left treatment with healthier bodies, cleaner complexions, and better hair. But over 90% of those people returned to opioid use, some within a few days. Some of them died because of their new lack of tolerance to opioids. In each case, counselors said the same thing: ‘he/she didn’t really want it’. But I remembered that they DID ‘want it’ when they were in treatment. In fact, some were considered star patients! At some point we must hold treatments responsible if they fail over 90% of the time.
My perspective changed. Now I wonder, why does anyone expects those treatments to work? A person is removed from a life of scrambling and drug connections and poverty, placed in a box and shined up for a few months, then put right back in the same using world and expected to act differently?
I eventually learned about medications that treat opioid addiction. I realized that opioid addiction truly is a medical illness that should be treated like any medical illness. Think about it – we treat high blood pressure, asthma, and diabetes over time. We don’t cure any of them. In fact, the only illnesses that we can cure are infectious diseases, and even that accomplishment is fading as organisms develop resistance to current medications. Given that we can’t really cure anything, why do we expect anyone to cure addiction – in 12 weeks?!
Medication-based treatments for addiction represent a transition to normalcy. Doctors and nurses were removed from treating addictive disorders decades ago because of historical events that I’ll eventually write about. Clearly, it’s time for health professionals to take a role in treating addiction. In the next article I’ll discuss the medications currently available, and the reasons that one might work better than another for certain individuals.
In the meantime please check out my youtube videos under the name ‘Suboxdoc’, where I discuss the use of medications, primarily buprenorphine, for treating addiction to heroin and other opioids.
10 Comments
Patricia Fisher Tolman · March 27, 2018 at 10:24 am
I know for a fact REHABS are a bunch of crap and a total scam! No one can get clean and shiny and then be thrown back to the wolves and survive. And as far as NA, it’s a bunch of crap also. Kinda like a cult if you ask me for the ones that take it seriously, and for the others, well let’s just say I’ve never met so many tricks and fiends in my life, and I have experience with both of these methods for 25+ years! I tried everything pretty much, and the only thing that worked for me is suboxone and a change of residence, friends, and lifestyle. So don’t waste money on no rehab. I’ve been clean almost 10 years. And yes I’m still on subutex. And also yes, I consider myself clean and sober.
Jeffrey Junig MD PhD · March 27, 2018 at 5:20 pm
Thanks for your comments. At one point I considered asking my patients to take part in a youtube video. The idea was to have them step up to a camera one by one, and say what they used to use, say what they now do for a living, and end it by saying ‘and I take Suboxone.’ The nonsense out there about being ‘impaired’ is entirely wrong, yet the impression permeates society. I never did the video, though, because I realized that simply asking my patients to take part would put pressure on them to do it.
Yes- you are clean and sober(!)
Matt · April 8, 2018 at 11:47 pm
Dr. Junig,
I’m so pleased you’re writing blogs again. I can’t tekl you how much I appreciate the clarity, perspective and facts you provide. I’m not sure you fully understand the positive impact you’ve had on those of us who have chosen Suboxone as our path forwards, but who constantly fight the internal battle of: will the drug kill me? Am I still myself taking this drug? Have I failed? Have I been defeated? Am I normal? Or broken?
Many of us, or maybe I should simply speak for myself, need to regularly visit your site(s) to remind ourselves that we made a smart choice. That we are on the best path (for now) and that there is a voice of reason among the fear mongering.
I still, unfortunately, live in fear that one day I’ll discover my 6mg dose is slowly killing me, or tht combined with my other meds will shut down my vital organs or that I’m being robbed of my personality, my emotions, my spirit. Of course I know logically that none of this is true (right??? Lol)
Anyway – I don’t know what kind of feedback you get beyond people seeking answers. I just thought it important to tell you how meaningful you have been in my ability to take the necessary steps towards a better life.
Jeffrey Junig MD PhD · April 9, 2018 at 4:40 pm
Wow- that’s the nicest comment I’ve ever read, and I really appreciate it. I usually feel like I’m writing out toward the air… and it is really nice to hear that someone is listening. Thanks!
I hope you’ll read my comment in the same way. You know, of course, that I’m a ‘true believer’ in buprenorphine. But honestly, I don’t see a time coming when we’ll discover some long term side effect. Buprenorphine has been around since the 1970’s in one form or another. I want to keep my mind open, and I recognize that higher doses are used in the past 15 years than before that time. But by now, many people have taken buprenorphine for a long time. Other prescribers I’ve met describe practices like mine, where I have around 100 patients who have taken buprenorphine for a number of years – people who have decided that opioids caused enough misery for one lifetime, and then want to just get on with life without the drama of opioid dependence. I don’t know the number of patients treated overall, but as of 2016 there were about 10,000 doctors certified to treat up to 100 patients. We now have tons of data, and no significant problems.
I realize that some people blame buprenorphine for all sorts of things, from memory loss to dulled emotions to chronic fatigue… but those complaints are similar to the complaints that occur with any non-addictive psychiatric medication. I don’t see a connection between buprenorphine and those symptoms, but even if there were a connection I’d see it as a reasonable trade-off.
So drop the fear! Maybe… just maybe… everything is fine, and there’s nothing to worry about– at least in that area! And seriously, thank you for your comments!
Jenn · April 25, 2018 at 1:07 pm
Dr, Junig, Almost 10 years ago I started working at an outpatient one on one treatment agency. I myself have been clean just tad longer than that. Your site has been the only site I continued to visit often. I would read your blogs and much of what you would say would come to be truth. (Watching the generic come out and the Suboxone company push films prior to it and them discontinue all tablets and go to the FDA….I was utterly stunned. I used to think yes its about money but isnt it about saving a life or two even just a little bit?….I’m sad to say I do not think so) But you are the only site I have given out over the past decade! I have come across other sites but nothing proved to be so honest and helpful as yours! My best friend recently came off suboxone and she had been told by her Doctor (from a clinic who only prescribes Methadone and suboxone) for one he didn’t know they came in other mg forms he was giving her 8mg per day telling her to “throw away” the remainder after cutting off the 3mg she was on. But that she should be able to just come off no problem. I told her to please check out your forum and there is a sticky post about the liquefied taper method. She was extremely grateful and she has in fact come off of the medication without troubles with what was written on your forum. THANK YOU to you and everyone who shares on here!
Jeffrey Junig MD PhD · May 21, 2018 at 5:30 pm
Jenn, that’s so nice of you- I haven’t had the time to write as much as I used to, and my site has been pushed deep into the search listings… so I really appreciate your comment. It makes me want to try harder to stay ‘out there’.
Thanks!!
Renee · May 1, 2018 at 7:44 am
ok. This makes a lotta sense and i’m taking it in. I’m sooo pleased to see a professional FINALLY admit that the failure rate for opiate dependence treatment is truly abysmal….definitely around 90 percent or worse. I think we all need to get in line with the reality of the situation. Work harder on prevention, obviously; but also recognize that the millions that are now afflicted may never be restored to perfect function but can be helped to live lives which are better and more free from suffering. I refer here to the very realistic plans which they have in the U.K. and sweden. They fully acknowledge that these many thousands of patients canNOT fully recover but can be comfortably managed by giving them pharmaceutical grade opioid meds at treatment clinics. Treating with other meds is seldom the answer — i don’t think i have to list the many, serious dangers of methadone treatment, or the uncomfortable/ unpleasant/ often unhelpful problems caused by suboxone treatment.
what is known about heroin/ oxy users is that they revert back to those chemicals because they feel so much better on them, with fewer side effects and hassles (found in the methadone program, let’s say).
If people would stop having knee-jerk reactions, stop making decisions based on emotion, ignorance, stigma, etc….. then we could all see that the VERY forward thinking people in the UK are having real success with their opiate treatment clinics. The clients end up feeling quite comfortable, they are then functional, capable of seeking/ getting work, etc…. I also understand that studies over there show that the rates of burglary, violence, etc have dropped dramatically since the “perps” don’t have to BE perps anymore….. they can be a patient receiving treatment. And that is as it should be. At those times when i’ve experienced the misery of opiate withdrawal, some clown somewhere has usually forced his snotty judgment on me that i’m “less than”, “no good “, etc. What i AM is a sick person in need of medical care.
And for the record, finger pointing helps no one. Without knowing my story, you cannot know that all of the blame and shame foisted on me is completely false and unwarranted. I was a very hgh functioning member of society, a medical transcriptionist in a metro-NYC hospital. I had worked since i was 16 yrs old. For 38 yrs, i was a model citizen. Then some old man rammed into my car when we were both doing 50 mph. I’m lucky to be alive. My bones weren’t broken — they were shattered. Soon after surgery and a long hospital stay, i was sent for pain treatment. That dr sent me home with meds that i believe (now) were far too strong. I believe that unethical doctors WANTED to make money off of dependent victims like myself. Being ignorant of this type of med (at that time) i took the pills — huge mistake. He took a functioning member of society and turned me into a drug dependent person. He did not warn me that this stuff would ruin my life. Obviously, had i received a decent warning, i would have run for the hills. Do you want to know the ONE warning he did give me ? “put these pills in a locked location so no one can steal them, they are very valuable.” Gee, wouldn’t a warning about keeping me sober and not ruining my entire life have been just a LITTLE bit more important ? I do want to sue this vicious creep, but will settle for a voodoo curse for now. Hell will be chuck full of all of these doctors. Sure, they got boatloads of money…. off of my back and millions of other’s backs. Only God knows how many of us have writhed in agony trying to get back to our sober lives, only God knows how many of us lost hope and jumped off of bridges. But, in the end, God sees everything and no one can escape their final justice. Being upset is natural, but i do believe that life can change for the better if other countries AND our country just plain realize that the issue is not going to go away and the patients should stop getting spit upon and looked down upon and given good, medical treatment —- just like the patients get at the English treatment centers.
Jeffrey Junig MD PhD · May 21, 2018 at 8:02 pm
I agreed with you until the second paragraph.
It is common for people to see something they like in a different country and picture that here in the US, but without all of the other things that are required in the foreign country. For example people will see something they like about the British Health Service and think we could somehow have the benefit, but without the problems of the BHS — very long wait lists, surgeries routinely cancelled because of lack of beds, and denial of service for the sake of cost control (last year BHS came under fire for refusing surgeries for people who smoke or were overweight, and many procedures are not even considered in patients who are of advanced age). Then there is Sweden, where the basic structure of society is entirely different than in the US. You’re going to bring the 70% tax rates too? How does that happen exactly, given than even a 5% change in rates has profound impact on GDP? You’ll say that we will only bring your opioid agonist program– but are you the person who is going to get all of the changes in law through Congress?
As long as we’re smoking pipe dreams, we may as well dream bigger than agonist clinics!
Your comments about methadone are not accurate. I work in a methadone program in the morning and in my own practice starting in the afternoon, where I provide psychiatric services and buprenorphine treatment. I’ve treated over 800 people with buprenorphine over the past 12 years, and side effects to the medication are rare. In fact, all of the ‘side effects’ of buprenorphine are actually opioid ‘class effects’, like constipation, hot flashes, and sweats. Methadone is recognized around the world– not just in the US– as the best treatment for opioid use disorder, bar none. People with less-severe opioid addictions can make buprenorphine work, but I can tell you from the trenches that methadone is the only option for many. If anyone wants more info about methadone I’ll refer you to TIP 43 from SAMHSA. Google that, and you’ll find it– a 300 page primer on methadone treatment edited by the foremost addictionologists in the world.
I’m not in their league, but the advantages over heroin are obvious. And no, people who leave heroin for methadone are GREATFUL, and not eager to go back. On average, the 400 patients I see for methadone treatment are not the type of people who routinely express gratitude. But I hear, daily, comments like ‘I am so grateful this is here’, or ‘methadone saved my life’. I hear those things ALL THE TIME. And when people are discharged prematurely, say for a big break of the rules, they beg to stay– or immediately get to another program.
Some people struggle with the structure of methadone programs, after living with no structure for years. But they don’t resist getting methadone over heroin!
I don’t know why you feel as you do, but that’s your business. The things you say about addicts are not typical wishes or thoughts. Heroin, fentanyl, morphine, demerol, or whatever other agonist out there provides an up and a down, all within about 8 hours. Sure, a person could dose three times per day, but IV? Are you seriously going to put a central line in these people? Beyond shooting three times per day, the effects are MISERABLE– nodding off for a couple hours, then fretting about the next dose for the next couple hours?
William Clements · July 25, 2018 at 6:26 pm
Just now in Vancouver BC they are offering pure heroin to those addicts who can’t for whatever reason leave heroin for methadone or Bup. I see no problem with giving these individuals what they crave so they can exist or maybe even thrive on their own terms. I see no problem with attaching some port o cath into a vein so they can save their veins. I’m not about to debate who’s medical system is the best but I know for sure it is not the US. There may turn out to be many methods to treat addiction of all kinds. Surely one thing we have learned is that harm reduction must come first. Once the individual is settled on the substance that makes then well and see that the medical profession is there to help them they just might be amenable to the switch to Buprenorphine or methadone. Also, I too am grateful to have found this site. I respect your expertise , clinical and of course personal experience with substance use/abuse.
Jeffrey Junig MD PhD · July 26, 2018 at 4:35 pm
Thanks for your perspective!