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.
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