Buprenorphine and the Dynamic Nature of Character Defects

Sorry about the re-run—I wrote this several years ago, and I still agree with the concept of ‘dynamic character defects.’ As I read it now, I recognize how things have changed; buprenorphine (Suboxone) has been incorporated into many of the major treatment centers, and even the smallest programs have at least become familiar with the medication.
There still exist some programs where the staff remain ‘anti-Suboxone’, but those places are becoming the exception, and are essentially marginalizing themselves out of the treatment industry.
You may note that I had an attitude of cooperation when I wrote this post, years ago. I suggested that those who prescribe buprenorphine work WITH those treatment centers that were ‘anti-Suboxone;’ that they recognize each others’ strengths. Since then I’ve known several people who were taken in by the anti-sub treatment community, and who eventually died– all the time believing that they were failures at finding sobriety. The shame is not theirs; the shame belongs to those who tricked them, and kept them from the medication that would have saved their lives.
To those treatment centers that do not offer buprenorphine, and that employ counselors who fret about their own jobs to the point of keeping people away from buprenorphine, SHAME ON YOU. Your treatment centers WILL close. And given the high death rate of opioid dependence, I am glad to have such self-centered charlatans out of the industry. Each closing is one less place for people to waste money–while searching for real treatment.
Where was I? Oh yes—my old post about buprenorphine and character defects. This post gets to the issue of the ‘dry drunk’, and why I don’t see that happening with buprenorphine. The post also has implications for the discussion of whether counseling should be a part of EVERY buprenorphine prescription. As always, thanks for reading what I have to say…
I initially had mixed feelings about Suboxone, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the years, because of what I have seen and heard while treating well over 400 patients with buprenorphine in my clinical practice.  At the same time, I acknowledge that while Suboxone has opened a new frontier of treatment for opioid addiction, arguments over the use of Suboxone often split the recovering and treatment communities along opposing battle lines.  The arguments are often fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine and Suboxone can have huge beneficial effects on the lives of opioid addicts.
The active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opioid receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opioid effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response) – relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opioid.
At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach.  People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all.  This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone.  On one hand, good boundaries include the right to keeping one’s private medical information so one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;  they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opioid addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opioid addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opioids than for other substances.  This may be because the ‘high’ from opioid use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opioid use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opioid user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opioid addiction.
Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opioid addicts have a number of such defects.  The dishonesty that occurs during active opioid addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opioid addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opioid addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually his irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opioid addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.  I realize now that I was making the assumption that character defects were relatively static—that they develop slowly over time, and so could only be removed through a great deal of time and hard work.  The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic.  I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opioids as well—the opioid is not the issue, but rather it is the obsession with opioids that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Suboxone removes the obsession to use almost immediately.  The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.  The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.  I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.  I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?  Yes, if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But I see little use in forced or coerced attendance at meetings.  The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.  In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Here are a few common questions (and answers) about Suboxone and Recovery:
-Should Suboxone patients be in a recovery group?
I have reservations about forced attendance, as I question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there clearly is much to be gained from the sense of support that a good group can provide.  Groups also show the addict that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle their own addictive thoughts.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  But for a person taking Suboxone I see the steps as valuable, but not essential.
The use of Suboxone has caused some problems for traditional treatment of opioid dependence, and so many practitioners in traditional AODA treatment programs see Suboxone as at best a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone.  Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Suboxone itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of Suboxone use implies long term use of the drug.  Chronic use of any opioid, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary.  Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opioid addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.  But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out weaknesses.

Strong Enough?

I am moving a post from the comment section up to here, as it sets up a couple points worth making.  As always, I suggest that the writer of the comment check out suboxone.com and naabt.com, two good sources of information about Suboxone.  I also suggest my own ‘product’ for sale on the right, particularly for people who could use an introduction to the concepts involved in choosing between treatment options for opiate dependence.
The comments from the writer:
please email me at [email protected]. I have been using opiates on and off for 12 years with NO issues. July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit. I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break. 20 months later I thought I was strong enough and could handle anything. Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later. If the opiates were not so difficult to get, I probably would NOT quit. That being said, I am starting therapy with a therapist. Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs. But I am asking this entire community along with this doctor here to help me by sending me an email to my email address. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth. Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.
I hope that the writer doesn’t find this too obnoxious, but what I like to do is go through the message part-by-part.  I do this for several reasons.  First, as I frequently point out, opiate dependence is an amazingly-predictable disease.  The progression is virtually identical from person to person, with variation only in the minor details.  Opiate dependence affects the mind of the addict, causing denial among other things.  At the same time, each opiate addict feels ‘terminally unique’ throughout the course of the illness, seeing faults in others, but blind to the same faults in him/herself.  One of the benefits of attending a 12-step group is seeing the pattern unfold in person after person;  this helps the recovering addict understand the progression of addiction and even learn to identify and predict his own ‘triggers’ and ‘addictive thinking’.  I want to do the same with the comments;  to point out examples of classic ‘addictive thinking’ that people can then learn to identify in themselves.  I ask that writer try to avoid taking my comments ‘personally’– I am not trying to insult anyone, as we all are in, or have been in, the exact same place!
One more aside… for people looking for Suboxone treatment in the Midwest, I am now open to new patients and also participating in a study that pays up to $225 for patients who enroll and participate.  My contact info is at Wisconsin Opiate Management Center.  I require at least the first visit, the induction, in person–I can then do telepsychiatry for further visits if people live a distance from my office.
Going through some of the comments:
I have been using opiates on and off for 12 years with NO issue…
I don’t know what to make of this comment.  I do not think that it is possible to take opiates for 12 months without issues, let alone 12 years. I guess it all depends upon what a person means by ‘issues’.  The worst part of opiate dependence, in my opinion, is the most subtle, and the easiest to deny– the effects on personality.  When a person uses any drug of abuse, the person almost always has some inner negative opinion about what they are doing.  Most people have internalized parental messages about d oing drugs, so that even while they make fun of their parents’ being ‘up tight’, there is somewhere inside a small kernel of shame.  Many people also have a ‘work ethic’ somewhere in the back of their minds, and doing drugs is at conflict with that as well.  Some people have personal health standards that using violate.  You get the idea…  the conflicts result in shame, which is a horrible thing to feel– so we repress the feeling and awareness of our shame.  We push the shame deep inside so that we don’t even feel it anymore;  being around other people will sometimes trigger it though, so to keep it from bothering us we put on a fake, cocky exterior.  As time goes on we get better and better at putting up that ‘fake self’, sometimes even losing track of who the ‘real me’ is!  Again,  when we are in that mode it is extremely uncomfortable to be around people who really know us;  I remember being extremely uncomfortable just sitting at the dinner table with my family!  During active use, close relationships with other people are simply impossible– instead we collect a bunch of shallow ‘buddies’ or relationships based solely on physical attraction.
Even if this were not the case, how does a person use opiates ‘on and off’?  The physical dependence and withdrawal are unavoidable– and anyone who has been through several episodes of withdrawal recognizes that they are ‘issues’.  Miserable issues.  Moving on…
July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit.
So at some point during the 12 years, the drugs became the ‘enemy’.  If this person is anything close to typical, the use was an enemy far earlier than the user recognized.  I often speak to family members to verify the story, and close family members ALWAYS noted irritability, distant emotions, preoccupations, etc far earlier than the addict thinks.  We think we cover things up so well!  I should point out in AA and NA this would be  considered a ‘dry drunk’– a person not using but who has not found recovery.  This rarely lasts real long with opiates, although alcoholics can often remain ‘dry’ for years or even a lifetime.  They are usually miserable people– more miserable even than when they were drinking.
I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break.
Always a good idea– drug friends have to either get clean themselves, or go, if a person is going to stay clean for any length of time.
20 months later I thought I was strong enough and could handle anything. D Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later
Opiate dependence will wait.  My relapse didn’t hit for about 8 years, long after I had forgotten about my ‘problem’.  The main point I want to make, though, is about ‘power’.  WILL POWER DOESN’T WORK!  The main reason?  If I can control my use, why should I quit?  Heck, bring them on… I’ll quit tomorrow!  The first step of a 12-step program is POWERLESSNESS– the realization deep inside that the person has no power over the substance.  This realization is sometimes a wonderful event, and the reason for the ‘miracles’ that AA people talk about…  an addict will sometimes suddenly ‘get it’– get the realization that they are powerless.  When that happens, the urge to use will often just disappear, all of a sudden!  It is a neat thing– and it makes sense when you think about it.  I always think about my son, who liked strawberries, but when he found out that the miserable hives were from the strawberries it was quite easy for him to ‘just say no’ to them!
That being said, I am starting therapy with a therapist.
Unfortunately, therapists and psychiatrists have poor records at helping a person stay clean, unless the person is also in some type of group format.  The 12-step group format is the only thing that has stood the test of time– going on 100 years!  The problem with therapy is that it can make a person think that the personal insight will somehow make it OK for them to use.  ‘Now that I know myself, I probably won’t go as crazy with them– and I can use just a tiny, controlled bit.’  It doesn’t work.
Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs…. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth.
I think my spellings are usually correct.  In most states, only MD’s or nurse practitioners can prescribe– not ‘therapists’ for the most part.  And most docs cannot prescribe Suboxone– they need a special waiver from the DEA.  Go to the web sites I mentioned at the top of this post, and they will help you find a prescriber.   As for the basic info, I again point out my recording!!  Or you can just read and read– everything is out there, and those web sites I listed have some good articles on them.
Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.

I don’t understand that last part.  But I wish you well, my friend.  There is a better life out there– that I promise.
SD