I have heard others talk about methadone zealots who get very emotional about the drug– I figured the people that described them as a bit crazy were exaggerating… I went ahead and approved a couple of the replies to my last post so that people can judge for themselves. They are 100% free of editing– nothing added, nothing removed.

Striking a nerve!

I don’t want to whip out resumes and see who’s is larger, but I do want to establish my credentials and experiences. The posts make many references to ‘experts in the field of addiction’, and as that is exactly what I am, I am not sure who they are referring to. I assume they refer to people like Dr. Michael Miller, President of ASAP, the American Society of Addiction Medicine– down the highway from the city where I live, in Madison Wisconsin. Or the medical researchers who did the work that led to the approval of Suboxone. I would think those people are ‘expert’ enough. I know the work and the stated opinions of those experts– I have personally met and spoken with some of them, and have read editorial opinions and research papers written by others. I can honestly say that I have read pretty much every major study about opiate addiction over the past 8 years– certainly all of the ones that were in the peer-reviewed literature.

As for my credentials, I am a Board Certified Psychiatrist; I am on the faculty of a major medical school where I teach mainly about addiction and addiction treatment; I am a trained Suboxone Treatment Advocate—I have been to meetings with the people who did the original (and later) research in Suboxone; I have met many, many opiate addicts over the years in my recovery activities, as Medical Director of a 50-bed residential treatment center, through my work treating over 150 patients with Suboxone, and through my work in the state prison system where I treat women and men who are incarcerated. I have worked in a methadone clinic for six years.

The comments refer to the molecular actions of methadone; I completed my Ph.D. in neurochemistry in 1986 before I went to med school, and my thesis involved work with brain receptors– characterizing how they bind to their ligands, localizing specific receptors, etc. While my thesis was not on opiate receptors (rather it was on receptors for vasopressin), several of the other scientists in the Center for Brain Research down the hall from my lab were doing the early work with opiate receptors, substance P, and ‘second messenger systems’. It was an exciting time, as that was when our knowledge base expanded in those areas. Anyway, I have a pretty good understanding of molecular issues.

I won’t repeat all of the things that got them so angry, as you can go back to my original post. I will comment on a couple specific things though. First, whenever you come across someone who is so worked up, you have to ask yourself, Why? What fuels the anger? Sometimes a person has an issue with the topic that they are trying to avoid thinking about– you may have heard the phrase ‘thou doth protest too much’ from some Shakespearean source about a person who exaggeratedly denyies something.

Maybe a person has a financial interest at stake,; or maybe the person is afraid of losing access to something he/she needs… I don’t know. Maybe since I have a blog they see me as an ‘authority figure’ and that riles them up. Although it is pretty easy to have a blog these days.

Similarly, I am always a bit suspicious about a person who talks about ‘the experts’ without naming specifics. Zenith mentions a study about IV heroin users doing better with methadone– If I get the reference I will look it up and check it out. I have helped many IV heroin addicts with suboxone without any problem at all, so I am curious. If I don’t write about it, it will be because I was never given the reference and couldn’t find it in my lit search (which I will do after this post).

There is no debate over the molecular actions of buprenorphine and methadone– anyone can find a Merck manual and read for themselves. Methadone is an opiate agonist, just like oxycodone, hydrocodone, hydromorphone, fentanyl, sufentanil, alfentanil, meperidine ,and morphine sulfate… In all cases the primary effect is at the mu class of opiate receptors (some drugs activate other classes of opiate receptors, like ketamine). Buprenorphine is a partial agonist, which gives it unique properties compared to agonists. Tolerance is universal and unavoidable with agonists. There were trials of morphinex a couple years ago that gave hope for a way to limit tolerance… but it didn’t work in humans.

Methadone potency increases linearly with dose; buprenorphine levels off and becomes flat (I have read reports of antagonist actions in high doses, actually causing a ‘bell-shaped’ curve). Methadone is just another agonist– as any opiate addict knows. Buprenorphine is different. That is why a person who is using can take methadone to avoid withdrawal or to get a ‘buzz’, but taking buprenorphine will cause withdrawal if the person hasn’t abstained long enough to reduce the activity of agonists at the receptor– the bupe will displace the heroin, methadone, or oxycodone and block the opiate receptor.

Some of the other stuff gets a bit off-topic… yes, I realize that nothing is for everybody. If a person fails buprenorphine, they may have to go to methadone– including making the drive each morning to the nearest clinic and standing in line for their dose, knowing that if they miss it, it will be a long, long day. Fear of having to do THAT helps keep people taking their Suboxone! I also mentioned the problems with Suboxone and the need for surgery or intermittent narcotic pain treatment.

As far as my comments about the evils of opiates… thanks for reminding me that molecules aren’t people! I was an anesthesiologist for 10 years– I loved the power of being able to instantly remove pain, in surgery, on the OB floor…. and in myself! Every opiate addict will likely need narcotics at some point in life– but those who have learned to stay clean know that those times are dangerous, and that pain medication must be feared. Anybody who wants to go the route of total sobriety from all substances– including methadone and buprenorphine– must learn to fear opiates if they are to stay clean. That is ‘recovery 101’– also the ‘first step’ of a 12-step approach. Powerlessness. And since we addicts are powerless over opiates, and since opiates will always destroy every good thing about us during active addiction, we had better fear them. I will talk about the twelve-step approach sometime– it is the only approach that has ever worked to maintain total sobriety, and has certainly stood the test of time. Other things have come and gone over the years (Google ‘moderation management’ and Audrey Kishline) as people try to find an ‘easier softer way’, but there are none…

As for my hatred of opiates, I lost a career and much more to opiates, and I have known people who are now dead from opiates. So pardon me, but we are talking about ADDICTION here. And in that context, I HATE opiates– I hate them for the friends that they have killed, and for what they have done to my life and to the lives of those who I care about. That is what works for me– I am not into ‘euphoric recall’– talking about the good old days– or even thinking that ‘y’know, opiates THEMSELVES aren’t all that bad’. I will use them if I ever absolutely need to, but I will do my best to hate them the entire time.

Methadone users: chill out!


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