I will share a post from 2009. It was one of my first, about 13 years ago, when I first started treating psychiatric conditions. I have always been interested in addiction as well as other conditions, but I resented employers’ efforts to pigeon-hole me because of my ‘history.’ Oh, that cursed history!

As many of you know I was one of the early docs to use buprenorphine meds. It had been out since 2003, but few were prescribing the medication, in part because of the huge backlash from abstinence-based, for-profit treatment programs (like the one that cost me almost $70,000 BEYOND what insurance covered. My opinions were and are slightly controversial these days, especially in regard to ‘support’ for people with addictions who are not seeking treatment. When I wrote this I was working in a maximum security prison for women, and a medium security prison for men. That probably influenced me, as did other things. I received MANY emails back then as I was the ‘addiction guy’ for Medhelp.org. No charge. I enjoyed sharing what I knew.

This site WILL eventually get back to psych and addiction issues. Enjoy a blast from the past!

The title was ‘My Lousy Bedside Manner.’ You will notice that this is just a copy of that one.

I receive about a dozen e-mails each day asking for advice; some are quite long, and while I would love to be more helpful there are days when I don’t have time to even read them, let alone answer– so please understand if I have not gotten back to you. One thing that has also ‘soured’ me a bit on personal communication is that I forget just how messed up addicts ARE– how distorted their world becomes, and how frustrating it is to become involved in trying to help someone who is not yet ready to be helped. I am going to post an exchange I had yesterday and today with one such person… I was way up north this weekend and not connected to the internet, but I received an e-mail on my i-phone and at the time had nothing to keep me from reading it. Having read it, I felt sympathy for the person and gave my honest opinion on the person’s dilemma.

I don’t have time (of course!) to make comments all the way through, and so I will only post the exchange; my goal is not to humiliate the person, as nobody knows the person’s identity. But for those of you who are enjoying some sobriety, the exchange will be useful; you will recognize the self-centeredness and self-pity that prevent sobriety from taking hold. In a treatment center, this person would be given a choice: shut up and listen, or leave and return when you are ready to shut up and listen. She wants support, I suppose– but support will kill her. That is one of the most fatal, and most common, mistakes made by using addicts; that they need ‘support’. That thought allows them to reject all of the calls for change that people take the time to provide. She will keep going from person to person, looking for someone to be ‘supportive’. But the only thing that will sound ‘supportive’ will be advice that keeps her right where she is! ‘Support’ for a using addict is only another form of enabling.

Now, once a person is at a different point of treatment– at a point where she is following instructions, and has gotten past the self-centered ‘terminally unique’ position– a certain amount of support may be useful. But this person is not even in the ballpark for that approach. If she is reading (and I doubt she is, as addicts tend to avoid reading things that stir up awareness of a need for change), I recommend she drop the one-woman pity-party and realize that her life is up to HER, and her alone. If she doesn’t get serious, she will end up just another dead junkie– and for that I am sorry. But I can promise you that me being a bit ‘kinder’ would not have been the answer to keep her alive.

Her Note:

Hi Dr. I am writing to you for help. I am a forty year old female who has been addicted to opiates for twenty years. Eighteen months ago I got clean (mainly from Norco and Fentanyl). I felt wonderful for months and then the pain started again (or my head said it did?) I have a disc protrusion. I went to my psychiatrist (also an addictionologist) who presbcribed suboxone. Now almost a year later I am on 8mg 3x per day for a total of 24mg. I hate this medicine. I am numb just like when I was on vicodin! I cannot go to the bathroom I have severe constipation and have to do a relistor injection every 48hours and take six stool softners and four laxatives to go to the bathroom once a week! I am having rage feelings again just like when took too much vicodin and I am flying off the handle at people, I am angry and numb and I hate everything. I don’t tell my AA friends that I am on subs because I am ashamed of it and I feel like I am still in active addiction. I have tried to get off it and every time I end up back up to 24mg. It does all the things it’s not supposed to do, I crave it just like vicodin. When I was down to 12mg I was unable to stay at that dose, I had to take more, just like vicodin! I know you”ll say that’s not possible but there it is anyway. Some days I take 32mgs and it’s hard to stop myself????? I want to stop this stuff so bad and I can’t and I’m petrified of the side effects and going through withdrawl again. Somehow I convinced myself that I could wean myself off subs with vicodin!! I didn’t taper off the subs (I couldn’t) and yesterday I had had my morning dose (8mg) and then five hours later I got a script from my dentist for Vicodin and stopped the subs and started taking the vicodin and of course now I can’t stop so yesterday I took 4 and a half tablets (7.5mg tablets) and today I’ve taken three already and it’s only 2:00pm. What’s going t happen when I run out of vicodin? Am I going to go into withdrawl anyway? I am so scared right now and I am too ashamed to call anyone, my therapist, my psychiatrist, my sponsor… anyone! Please help me if you can.

My Note:

Hi– thanks for writing. You are not alone in your situation; the bottom line is that Suboxone is only a tool, and if it is not used correctly, people will not do well with it. The person treating you should have ‘reigned in’ that extra use right away by refusing to give early refills; after a couple times of running out early and having withdrawal, you would have learned to keep the dose under control. At this point, I just don’t know if Suboxone is the right med any more for you– you need some way to get your motivation back, so that you will be able to limit yourself. That usually takes a bad experience that gets you to some sort of ‘rock bottom’. Addicts repress the feelings of shame you refer to– the goal of treatment is to keep those feelings from being pushed aside, so that you will remember them when you need to do the right thing for your health. A few suggestions: -read my blog, suboxonetalkzone.com, the post on optimizing absorption of Suboxone– make sure you are getting it in your system in a high-enough concentration. Search on the blog for ‘optimizing absorption’ and you should find it. -the effects of Suboxone peak at about 4 mg per day; everything else is psychological. You want to dose ONCE per day– take 16 mg in the MORNING ONLY– one tab, and then the other. If you get cravings later, you need to distract yourself for 10 minutes, and they will be gone. YOU CANNOT JUST KEEP DOING WHAT YOU WANT TO DO. You have the power to make it work, but perhaps you have a personality where you usually get away with bending the rules. IF YOU WANT TO GET BETTER, YOU CANNOT BEND THE RULES. These things I am suggesting MUST be followed if you want them to work– you cannot do just what YOU want to do, as that is what is destroying you. -Do NOT take extra doses to work or out in your car, etc– give the tabs to someone who cares about you and who is able to say no to you, and have them give them to you each morning– two pills each morning ONLY– no exceptions. If you don’t do that because you don’t want the inconvenience, then there is nothing anyone can do for you– you have to be aware enough of the danger to do what it takes to stay clean. If you dose only in the AM, and distract yourself if you get cravings, eventually the cravings will go away. But you CANNOT take shortcuts, or think you are somehow ‘unique’ and don’t need to follow the rules!

Her Note:
Wow, your bedside manner sucks! I get your point but insulting this addict makes it impossible for me to respect you. I read your arguments with another addict that said you were angry and personalized everything and now I believe it! I’m sorry I asked for your help. Clearly you have your own issues to contend with. I wish you well. Please dont bother responding, I’ll delete anything further you have to say. Peace!

My Final Comment:

People who are getting an understanding of what addiction does to personality will recognize this dynamic. It used to bother me– now I realize it is just addiction. But it does remind me that you really cannot help an addict until the addict is ready to be helped– and if you try, you will often regret ever wasting your time.

2022 Update: I would write differently now. Yes I was angry. I was up north and trying to help but that comes with the business.

Most of my patients are so stable now they really get the chance to discuss these types of things. I also have changed some ideas. And I recommend dosing twice per day and three times only in very rare situations. that extra medication over 4 mg binds additional receptors. it doesn’t provide any more opiate affect but it might reduce cravings.

and I try really really hard to be nice now!


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