One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts. We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking. I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking. But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux; regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment. I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps. I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation. And once on buprenorphine, addicts quickly lose that desperation. One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery. But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy. The steps have remained as the mainstream treatment for opiate dependence for one reason: They were all that we had! The steps saved my life not once, but twice– but they fail for most others. I got lucky– maybe having my medical license hanging over my head made the difference. It is impossible to predict who the lucky ones will be. All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence. And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine. I personally know of several people who died after forced discharge from treatment centers. Who benefits from that approach to ‘treatment’? Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided! Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry. I tend to wander a bit. The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth. Opiate dependence has been treated successfully in a small fraction of addicts. Yes, the steps CAN work in those who ‘keep coming back’. But the truth is that people in their 20’s do NOT ‘keep coming back’. Instead they relapse over and over until everything is gone, and they have become shadows of their former selves. But then buprenorphine came along. Buprenorphine is NOT a panacea; many people fail treatment with buprenorphine as well. But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence. But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using. After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment. For example, many (MANY) opiate addicts complain of ‘anxiety’. I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor). I found that universally, patients who took benzos did WORSE. They thought they needed them, and even thought they benefited from them. But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos. The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board. I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment. When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc. But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh! People taking buprenorphine are no different than I was; they are trying to make HUGE changes in how they deal with their feelings. Of COURSE they will feel all messed up inside! But the answer is NOT to find another subsstance to reduce those uncomfortable feelings. The answer can be found instead in many of the principles that make up the twelve steps. If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting. I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety. Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’. All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs. And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean. The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life. During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago. She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc. She was grateful for the positive changes in her relationships as well. No, things were not perfect– they never are. But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together. Not being broke and sick all the time allows a person to start to feel like a contributing member of society. Being able to go all day without telling her friends or partner a lie has improved her relationships. Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills. And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse. As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined. No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use. But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years. As always, your personal health history is YOUR business; if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business! If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery. You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way. If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for. If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift. With all of the Holiday activities I may be absent for awhile. My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks. Back then I thought my life was over– no job, license suspended, anesthesia career effectively over. I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing. I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’. I learned through meetings that EVERYONE with addictions felt that exact same way. After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir). Until the play that ended today, I’ve been too busy to participate. But today I was on the exact same stage where I stood 9 years ago. Today I reflected on all that has happened since feeling so hopeless back then. I am grateful that back then I KNEW that I didn’t know anything about how to stay clean. I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself. Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ
Tag: 12 steps
Getting Off Alprazolam (Xanax): The need for Recovery
A comment on my old blog referred to a discussion about the withdrawal from Xanax, or Alprazolam, a short half-life benzodiazepine:
Clonazepam (Klonopin) actually is not the drug of choice used in benzo withdrawal, rather it is diazepam (Valium). Clonazepam It is not a very long-acting drug, with a half-life of only 18-50 hours; diazepam’s half-life is 20-100 hours, with its metabolite hanging around for twice that long.
Absolutely the worst thing about benzo withdrawal (take it from me) is that it never ends. That is why I still take them.
Sadie
My Response:
The ‘drug of choice’ for benzo withdrawal depends on many factors beyond half-life. Diazepam (aka Valium) is absorbed very quickly and so the onset of action is as fast as 20 minutes; this is useful in some situations, but is also thought to contribute to the increased addictiveness of diazeapam over clonazepam (Klonopin). Both drugs stick around long enough to accumulate with repeated dosing; diazepam has active metabolites, making the effective half-life even longer than the pharmacologic half-life. But who cares? In either case the person coming off alprazolam (Xanax) can take the longer-acting benzo four, three, or two times per day– even once per day could be sufficient to prevent seizures with either drug, providing the dose is high enough.
It is very hard for most people to get off Xanax… or any benzo. For that reason, the best medication for alprazolam withdrawal may be a non-benzodiazepine anticonvulsant. I have used valproic acid (Depakote) or phenobarbital in patients for treatment of benzo withdrawal and/or alcohol withdrawal. Pretty much anything that works for alcohol withdrawal will work for benzo withdrawal– which is consistent with the fact that alcohol, benzos, phenobarb, and valproate all have actions at the GABA receptor. Other factors to consider when choosing a medication for benzo withdrawal include liver function– diazepam in particular lasts forever in patients with bad livers. Phenobarb affects the metabolism and plasma levels of many other medications. Valproic acid can cause liver damage and tends to stimulate appetite; is also causes heartburn and nausea in many patients.
The biggest problem with coming off benzos is losing the fuzzy haze that covers life and tolerating the harsh glare of reality. Patients complain of ‘anxiety’– many times they are simply feeling what everyone feels all of the time, but they have lost the ability to tolerate the normal stresses of life. This is where 12-step programs come in; working the steps provides everything that is needed for a person to learn to tolerate reality. After 15 years of going to meetings, I am still amazed at the value contained in the 12 steps. EVERYTHING is there! How to tolerate one’s self; how to deal with others; how to cope with rejection or loneliness; how to begin to understand a purpose for living… the answers to all of these questions– questions faced by most drug addicts on a daily basis– are contained in the steps. I strongly encourage, and invite, people learning to tolerate reality to come to recovery and join the others who are looking for the same thing– and finding it at AA or NA.
SD
Getting off Suboxone, Continued…
Thanks BC for this post and discussion point:
I often wonder what’s up with the people who say that Suboxone w/d is the Worst! Thing! Ever!
Maybe they never really went through w/d’s before, so they don’t have much to compare it to? It seems that some people carp on how long it takes to feel “normal” again, but I wonder what they are doing in terms of self-care.
Many of the websites I see (I subscribe to the same Google alerts as you) say stuff like – Only take Sub for 2 weeks max!!!! Otherwise it will take you six months to get off of it. Which makes no sense to me.
Anyway – I’m trying to taper off because my insurance will only cover Sub for 12 months. They say there is no evidence that it should be used longer than that, which is news to me, but that’s what it is. I could try to appeal, but I want to be prepared to be cut off anyway.
I could just try to pay, as I’m at a low dose now, but I returned to college and between that and certain other chronic-health issues, I just don’t have much money.
I really like reading your blog, because it’s nice to hear the opinion of someone who knows of what he speaks, but you are frankly starting to scare me. Do you know of anyone who has successfully made the transition from Suboxone treatment to “sober recovery”?
My doctor has only had a few patients even get off of Sub, but he says if anyone is a good canidate to make it, it’s me. Somehow I don’t find that terribly comforting. If you have any success stories, would you mind sharing them?
thanks, bc of Diary of a Quitter
My Response:
Hi BC,
Thanks for the nice comments that you have made and for your support. Some days I feel that I am too ‘invested’ in the debate over Suboxone; the anti-Suboxone people seem to be getting louder, and at the same time they are getting more stupid. You may have seen the post today on Google Alerts from Drugs.com: Should I taper off Suboxone using methadone? The denial of opiate dependence couldn’t be more obvious! I went to the site to read the post– Drugs.com ‘banned me’ but I just use an ‘anonymizer’ and I can post all I want (I was banned for having SuboxoneTalkZone in my signature– I got this strange e-mail from a guy talking about God and his ‘mission’, interspersed with profanities and comments like ‘I’m doing the Lord’s work and you’re Jack Shit’– must be an interesting church those Drugs.com folks go to…). Where was I? Oh– the guy who asked about tapering off Suboxone using methadone wrote ‘I don’t intend to become addicted to methadone– only to use it for about 7 days’. Maybe that was MY problem– I should have tried ‘not intending to get addicted’.
I think my comments will only continue to scare you, but I don’t think they should. The way I look at it, the bottom line is that opiate dependence is a life-long condition. I don’t know if you have read my story, but I was ‘clean’ throughout the 1990’s without sub. Today I was sitting in an AA meeting as we discussed ‘step 5’, and someone was saying how not completing step 5 will eventually lead to relapse. I remembered how things were in the 1990’s, before sub; an opiate addict who relapsed was ‘up a creek’ with little hope of getting clean again. I used to have nightmares that I had relapsed, and that I was heading for death from my addiction.
Now, Suboxone has helped many people, but at the same time it has changed the bottom line. Opiate dependence no longer has to be fatal; there is another option. For people who come from the time of no options, Suboxone is pretty amazing. But the newer crowd– people getting addicted more recently– don’t have the same gratitude for the medication, and maybe they don’t have the same respect for the danger of opiate dependence.
I have had a few people choose to leave Suboxone– about 6-8 who I can think of, out of about 150 people started on Suboxone in my office. I don’t know how they are doing long-term, as people who do well tend to disappear (as do people who don’t do well). I don’t know of anyone who has relapsed from that group, but that doesn’t mean a whole lot. But if they did relapse I wouldn’t blame the fact that they took Suboxone; I would blame the fact that they stopped it. I always tell people who present with opiate dependence that they have a life-long illness that will need life-long treatment. They can treat it with Suboxone, or they can treat it through the process of changing their personality by working a 12-step program. There is no cure.
That stinks about your insurer. We have one local insurer who limits people to two years, but the rest cover people indefinately– at least so far. Opiate dependence is a disease by any criteria; I see stopping treatment at 12 months a consequence of stigma. Can you imagine an insurer saying they will cover insulin, or blood pressure medication, for only 12 months?
I have given a lot of thought to how to get a person ready to stop Suboxone. I look at the things that were accomplished during my residential treatment, and try to find ways to do the same thing for addicts getting ready to stop Suboxone. This includes working on boundaries, emphasizing the need to respect ALL directions on prescriptions, working on balance in life that includes exercise, good sleep, good diet, and a support system; identifying ‘triggers’ for using; finding ways to fill one’s time; having a ‘daily plan’, rather than just ‘bumming around’ day after day… All of these things were ‘given’ to me in my treatment, and they all helped keep me clean.
Then there is step-work and meetings. We really know of no other way to keep people clean. There is so much good information at meetings… I have considered requiring attendence for Suboxone patients but I don’t, in part because people don’t benefit much from meetings that are forced on them. So instead I try to take the things that are taught through the steps and get people to apply them in their daily lives. It is hard to say whether that works or not; it is very hard for people to change, unless they are truly desperate.
For you, I wish you the best with your ongoing recovery, and I have to put in a ‘plug’ for AA and NA. They did save my life– a couple times. They take work, but the work pays off– in the same way that it takes exercise to get into shape. All of the hard things about going to meetings have benefits to them– tackling the fear of walking in that first time gives the satisfaction that comes with facing our fears, for example.
Suboxone does go generic in 2009, so hopefully it will be cheaper at some point. Even at its current price, it is much cheaper than using, particularly if you factor in the total costs of using– so if God forbid you find yourself in a relapse, don’t waste any time debating the issue– just get back on some form of buprenorphine. Watch for ‘probuphine’, an implantable buprenorphine delivery system that is in human testing.
My tape directed at ‘sobriety after Suboxone’ goes into the AA and NA issue in a bit more detail, and talks about what I see as good personality features or bad personality features for going off Suboxone. If you check it out, be sure to provide some feedback in relation to your experiences.
I wish you the best out there BC. Please keep in touch– I will watch for you over at your blog.
SuboxDoc
Methadone, Suboxone, Sweden.
What follows is an edited message from a reader in Sweden, and my response. The original message can be found as a comment to my ‘methadone revisited’ post. I removed a bit of the writer’s sarcasm and corrected a couple typos; as always nothing was added.
Comment: Yes, methadone is a ‘pure’ agonist, but to claim no difference between it and morphine and other short acting agonists is really naive. The sole reason methadone is used is because of it’s different pharmacological profile. You claim that tolerance is as much an issue with methadone as with morphine/heroin, how is it then that patients stay on the same dose for decades?
Response: There are several reasons that methadone is used for maintenance, not one sole reason. First, it is easy to manufacture and so is dirt cheap. Methadone clinics typically mark it up to $10-$15 per day, but when prescribed for pain treatment it is pennies per dose. It does have some unique properties, and yes, those unique properties make it a good maintenance drug; for example it binds extensively to proteins and so has a long half-life when used for long-term maintenance treatment of addiction. Interestingly though, when used for pain treatment it has a shorter ‘effective half-life’ and generally must be given every six hours or so. In other words the half-life of the drug changes with chronic administration. This somewhat unique property is one reason that SOME patients can be maintained on a stable dose for long periods of time. A short exercise will help to understand this point: Google ‘opiate conversion calculator’ and use it to find the dose of oxycodone that is equi-potent to 40 mg of methadone. A good conversion program will ask you to differentiate between acute and chronic methadone. You will see that with chronic use, methadone becomes more potent by a factor of 10 or more. I see this as the main reason for the APPEARANCE of stability of dose with methadone maintenance. Yes, some patients stay on the same dose for years. But that same dose changes potency over time in ways unique to methadone, so that the patient is actually getting a constantly-increasing opiate potency at the receptor level—even as the oral dosage stays the same. This does not occur with other agonists, and certainly does not occur with buprenorphine.
Comment: To claim that a methadone patient is still an active, using addict but someone on Suboxone is in recovery, that’s the biggest load of BS that I’ve seen in a long time. Sure, buprenorphine is only a partial agonist, but there’s still stimulation of opiate receptors going on. People without tolerance get just as high on buprenorphine as they do methadone, and tolerant users don’t get high with neither buprenorphine nor methadone.
Response: People without tolerance are not the issue here, but for the record you are wrong—patients cannot get ‘just as high’ on buprenorphine as with methadone. As an anesthesiologist I used buprenorphine for just that reason—for example, on the labor floor buprenorphine is a safer narcotic because medications given to the mother can cross the placenta and accumulate in the fetus, causing respiratory depression (and arrest) after the birth—a partial agonist like buprenorphine has a maximum effect that preserves respiration, at least as long as no other CNS depressants are present. Similarly a patient without tolerance will not be able to kill himself using only buprenorphine, as the effect will ‘max out’. With methadone, on the other hand, it is quite easy to OD and die, simply from taking a few too many tablets. In fact, a teenager experimenting with methadone for the first time can die from just two or three 10 mg tablets.
As far as whether methadone users are ‘in recovery’ or are in ‘active addiction’, that is a matter of opinion. I see a clear difference between taking methadone, a drug that causes progressive tolerance, and buprenorphine, a drug which allows tolerance to remain static. The ‘shift of tolerance’ is at the heart of addiction—as it shifts upward the addict is high, and as it shifts downward the addict is in withdrawal. Buprenorphine allows tolerance to increase to a level that eliminates the high, sedation, and other drug effects, but then the tolerance becomes fixed. And for reasons not understood, doses higher than the ‘ceiling dose’ eliminate subjective cravings. For people who consider being on methadone to be ‘in recovery’ I would just ask… why? What is the difference between being on methadone and being on oxycodone, other than the dosing frequency? I didn’t intend to take on the entire methadone system, but there are some very intrusive methadone ‘advocates’ out there—they pop into buprenorphine forums and spout opinions, using pseudo-scientific arguments and misquoting articles, causing nothing but confusion and ill will. I suggest they get a blog of their own—maybe then they would feel less need to flame others.
Comment: Having been on both substances myself, I can testify that the only difference I find between the two is that methadone has (for me) the ability to take away my cravings completely whereas buprenorphine didn’t quite do so.
Response: Medication is only part of any recovery program. In my opinion 16 mg of buprenorphine suppresses cravings sufficiently to allow any patient to remain clean. Until a few years ago every single opiate addict in recovery (and not on methadone) was doing it without the help of a medication. The real situation is that a person who uses from ‘cravings while on Suboxone’ is not ready to quit, and (sorry) in my opinion is looking for an excuse to use. Nothing is perfect in life—people with opiate addiction must realize they have a fatal illness, for Pete’s sake!! Cancer patients have to put up with the pain of surgery, severe nausea, hair loss, severe fatigue… if an addict whines over a few ‘cravings’, I suggest they get real and take a good look at where they are at in life, and start being grateful for being alive.
In my prison work I frequently come across patients who are intent on fine-tuning their subjective experience using every med they can get. They think that medication should make them happy, relaxed, content, and filled with self esteem… but in reality medication will do none of those things. Their expectations are completely out of line. I get the same impression from patients who always need a bit more of this or that for cravings. The whole process of that type of ‘treatment’—the focus on symptoms, the need to medicate one’s self, the self-centered demand to feel perfect– is more consistent with addiction than with recovery!
Comment: I got annoyed when you’ve written stuff that is twisting the truth, if not lying, about the treatment that has quite literally saved my life. And calling methadone patients active, using addicts (also something many many doctors would disagree with you on).
Response: There are the ‘many doctors’ again… but seriously, if it works for you, that’s great.
Comment: Why can’t you accept that our treatments are very similar to each other? I know that you in the US can perceive them to be oh so different, since one can be prescribed in an office-setting and the other can’t. I can see that it can lead to a them-and-us-thing, where suboxone can appear “better” or “more refined” or “less dirty” or whatever.
Response: The treatments have similarities and differences. I don’t think one is ‘less dirty’ or ‘more refined’. But the molecular actions of the drugs differ from each other, and so the subjective effects differ. Sorry—that is just a fact.
Comment: I live in Sweden and here we don’t have ‘clinics’ per se, here both buprenorphine and methadone is prescribed in the hospital, and we have to go there to get our meds daily, for the first 6 months and then we get take homes at certain intervals (if we’re clean that is).
Response: That stinks. You are missing out on one of the biggest advantages of Suboxone.
Comment: Here buprenorphine and methadone alike is looked upon with judgment by many many people, since the treatments are so misunderstood. Here buprenorphine (and methadone) patients are called addicts by people who don’t know better.
Response: They ARE addicts– myself included– And will always be addicts. Opiate addiction is not ‘curable’—it can only be managed. I am an addict. But I am not ashamed of that—although I am ashamed of some of my actions during active addiction. It bothers me that the whole concept of ‘recovery’ is absent from methadone programs. A methadone ‘advocate’ made silly remarks a few days ago that showed a complete absence of knowledge of 12 step groups— something that has been an incredible movement throughout the entire world, for almost 100 years!
Comment: You seem to have a little of the mentality that if I can do it, so can you. And I find that a bit strange since then you could easily have become sober without medication at all, since other people have been able to do so. Do you see what I mean? I’m just saying that while suboxone works for a lot of people, it doesn’t work for all, and it’s just naive to think so.
Response: You know what? A common thing said at NA meetings is that ‘if I can do it, so can you’. Yes, I do have ‘that mentality’ as you put it… and I don’t get your objection to that mentality. I don’t understand the rest of that paragraph either—I think we come from totally different perspectives. I believe that EVERYBODY is capable of getting clean without the use of medication. Unfortunately, many addicts will not choose to give up their addictions until they have lost everything. I had to lose a career and a great deal of money before I ‘got it’. I didn’t ‘get it’ with Suboxone; I went away to residential treatment for over three months. I didn’t want to do that, but my back was against the wall and finally there was no other place to hide. Suboxone was not available at that time—at least not in my area, and I had never heard of it (this was in 2001). I had the ‘typical miracle’ of AA, NA, etc… I realized I was powerless, and the urge to use went away. It really is that simple. Unfortunately, addicts will not usually recognize their powerlessness until they have lost everything—buprenorphine allows people to find some peace without having to go that far. But I do worry that their ‘recovery’ does not run as ‘deep’—see my articles on the topic here: http://subox.info/index_files/recovery.htm .
The issue isn’t over who is ‘better’; the issue is whether the recovery will last, and whether the person ends up having a rewarding life. Opiate addiction is a horrible, fatal illness—I have lost friends and patients to it and so the bottom line is that any way that a person keeps clean is OK with me. And so I usually present the options to the patient and let him/her decide which path they will take. Yes I have opinions about methadone—just as others have opinions about Suboxone. From my perspective, it seems that there are ‘methadone people’ who can’t tolerate the opinions of others. And I wonder… is that a ‘recovery’ issue? Part of recovery is learning to accept things we cannot change… like the opinions held by others. Part of recovery is acceptance—the idea of ‘living life on life’s terms’— including the fact that people are going to disagree on some issues. And part of recovery is learning to know one’s self, and to know that one is OK regardless of how other people think… like not getting all flustered if some stranger in another state– who doesn’t even know the person– holds the opinion that his choice of medication isn’t the best. These parts of recovery are what make many people grateful for being an addict. If things are as I suspect, and methadone maintenance patients are not taught how to find these things… that would be a shame.
Suboxforum.com
Subox.info
suboxonetalkzone.com
Bitter taste, euphoria, dosing…
From a person new to suboxone:
This is my, well, second day off opiates seeing it is 12:05am where I am. I had a 11 year on and off love affair with opiates. It got worse in the last 6-12 months or so. That feeling of euphoria really gets you and when you don’t have your pills you feel like you are going to die, literally!! I woke up this morning with no more pills. OH BOY was I sick… I found a list of docs who detoxed using subutex and/or suboxone… He did a patient and family history on me… He wrote me a script for six 2mg/0.5 suboxone. His instructions were take two under my tongue immediately… The taste was disguisting. I just took my second 2 and am cringing because of the taste… After 30-60 minutes, I felt wonderful… I was surprised he started me off at 2 and not 8mgs. The 2mgs do just fine. What is funny is that the euphoria you get from opiates, I am getting from this drug. I read up everything possible on the internet about this drug and it is supposed to be the best drug for opiate users. I have been posting a lot and hope you do not mind. I understand addiction and how hard it is so I want to help people. I am just starting my recovery and have a long road ahead, I know this but if more people know about SUB, there would be less addicts. I am making it clear to everyone that you absolutely cannot take any op’s while on Sub. Apparently you will get the worse side effects imaginable…
I deleted the parts that are identifiable or more specific to the individual than necessary here.
Some comments: As for the taste, there are some little tricks that will make suboxone more palatable; try chewing an altoid or another strong mint right before taking the suboxone, you can also try holding an ice cube in your mouth for 5 minutes first, spitting that out, and then taking the suboxone. Just be sure to start the suboxone dose without saliva or water in your mouth– you will produce saliva while you are dosing, and you want a high concentration of buprenorphine in the saliva, which means you want a low volume of liquid. Other people have used listerine strips. Finally, subutex has a different taste– it is bitter, but not ‘fruity’, and some people like it better. It is, though, significantly more expensive. Contrary to misconception out there, you do NOT need the naloxone to get the ‘blockade’ effect at opiate receptors. Subutex has an identical action in almost all patients– the exception being perhaps people who have had a gastric bypass or who have a (very unusual) allergy to naloxone.
For best results start with a ‘dry’ mouth, bite the suboxone with your front teeth to crush it and dissolve it immediately upon putting it in your mouth, then use your tongue to spread the the concentrated, dissolved medication over all surface areas inside your mouth. A couple points: the intact tablet is not doing anything, so holding it under the tongue takes needless time– get it dissolved right away. Second, there is nothing special about the area under your tongue; the medication will get absorbed from all surfaces inside the mouth, so use as much surface area as possible to increase absorption and speed the process. Third, after dosing for 5-10 minutes you can either swallow the saliva or spit it out– if the bitter taste really bothers you, perhaps spitting it out is the better option (also a better option for the rare individual who seems to get headaches from the naloxone in suboxone). Finally, do not drink anything or rinse your mouth with liquid for at least 15 minutes after dosing, as that will remove some of the buprenorphine that you are trying to absorb.
Euphoria… the initial effect of taking buprenorphine will depend to an extent on the individual’s degree of tolerance. A person taking over 80-100 mg of oxycodone per day who waits 24 hours to have moderate withdrawal, and then takes suboxone, will probably feel relief from the withdrawal, but will not feel much of an ‘opiate’ effect. On the other hand a person taking 5 vicodin per day (which contains hydrocodone, a weaker opiate) who waits 24 hours and then takes suboxone will likely have euphoria and other opiate effects– because the ‘opiate agonist’ activity of buprenorphine is stronger than what the person is used to or ‘tolerant’ to. In either case, the person’s opiate receptors will adjust fairly quickly to the potency of buprenorphine, and after a few days both patients will feel ‘normal’ after taking buprenorphine– no withdrawal, no euphoria. That is what makes it such a popular treatment– patients who take it regularly feel ‘normal’. In fact, many people experience life without the constant craving for opiates for the first time in years, and for the first time in years feel like a person who is not an opiate addict.
This leads to a much broader issue that I have talked about before– an issue that is more controversial: what other things should be required of patients taking suboxone? I have heard ‘second hand’ that Dr Miller, the President of ASAM, the American Society for Addiction Medicine, takes the approach that patients on Suboxone should be sober from all other intoxicants and attending group treatment and 12 step programs. I am in agreement on the ‘total sobriety’ issue but not with the second part, for a couple of reasons. Elsewhere in this blog I theorize a bit on the issue of Suboxone and 12-step attendance (I also discuss the issue here: http://fdlpsychiatry.com/subox.info/suboxandrecovery.pdf) but I have some practical concerns as well. First, ‘recovery’ is all about ‘rigorous honesty’, and yet if a person is honest about taking suboxone at an NA meeting he/she will end up being confronted and harassed– so patients are told to be honest about everything except suboxone use– and that is a problem because we are then reinforcing one of the things the addict has been doing for years– hiding the use of an opiate. Second, people on suboxone are different from people who are not on suboxone– they don’t have the constant awareness of the desire for opiates (or the unconscious drive for opiates manifest as irritability), and have an entirely different subjective experience. They don’t ‘feel’ like opiate addicts. Yes, they are still opiate addicts– don’t get me wrong on that. But they don’t feel the same way. And so I don’t know if a 12 step meeting will do anything for them. I know that to buy into recovery a person has to be desperate; not because there is anything wrong with the 12 step message as I think it is a great, universal approach to life that benefits everyone lucky enough to ‘get it’. But to adopt the 12-step way of living, of seeing the world, a person has to change. And change is very, very hard, and very rare. I remember my own first experience with the twelve steps: sick with withdrawal I wandered into a mall bookstore, found a book about AA, and read through the 12 steps. I concentrated for a few minutes, and considered what they said. Later that day, after using, I thought… ‘that didn’t work’. I’m trying to be a bit funny, but my point is that many people think that ‘recovery’ consists of intense education. Those people are eventually frustrated in treatment, as they think they are ‘getting it’ and yet their counselors and peers keep telling them that they are not getting it. In reality, treatment through a 12 step approach requires a deep change of attitude that is very difficult to come by. I like the saying ‘insight maketh a bloody entrance’. True change usually requires a significant period of distress– a rock bottom, a depression, a great deal of personal turmoil… another comment frequently heard in treatment is ‘crisis equals opportunity’, or ‘the Chinese symbol for crisis is the same as for opportunity’– something that I suspect is not actually true, but I could be wrong.
Wow. I talk too much. OK… practical problems to requiring 12 step attendance… My point (in case you zoned out) was that sitting through 12 step meetings, while not in the middle of a personal crisis at least at the start of 12 step exposure, may be a total waste of time. Ditto for attending ‘recovery group therapy’. Those things work for one type of treatment, and I see little reason why they would be helpful for people on Suboxone. An analogy… (wish me luck)… people with hyperthyroidism sometimes have the thyroid gland surgically removed; other times the thyroid is destroyed by taking radioactive iodine. If a person has had the entire thyroid removed, it makes little sense to then make them take radioactive iodine. Wow… that isn’t bad…
On the other hand… people with thyroid cancer have their thyroid surgically removed and then take radioactive iodine just in case some thyroid tumor cells were left behind. Given that opiate addiction is a fatal illness– at least as fatal as any cancer– maybe the more done, the better. I will say that anyone who is on Suboxone who is attending NA or AA or who wants to attend, and who can deal with the privacy issue of taking Suboxone, GREAT! If you can ‘get it’– if you can truly understand your powerlessness over substances and turn your life over to your ‘Higher Power’– you will be better off for doing so. You will also be in the position to get off of suboxone at some point.
I had better close, but will add one last thing. I will save the ‘dosing’ issue for another post, but please stay tuned because it comes up very often and there are some important concerns. But my last point today is that Suboxone does NOT cure opiate addiction, just as atenolol does NOT cure high blood pressure. To be honest, ‘cures’ are rare in medicine– we usually help the body heal itself or provide medication that ‘maintains’ a reduction in symptoms. We don’t fix the faulty blood pressure set point that is the core problem with hypertension– we give meds that artificially force the heart to pump with less force or at a lower rate, or that make the blood vessels open up wider, and that drops the blood pressure. Stop the medication and there often is a situation like ‘withdrawal’ where the blood pressure rebounds higher. Suboxone is an incredible medication– I know what it is like to be trapped by addiction before the days of Suboxone, and I understand why suicide is such a common outcome with addiction– if taken properly Suboxone will put addiction into complete remission, and that is a wonderful advance of science that saves many lives. BUT…. a person who becomes addicted to opiates has only three options: Buprenorphine maintenance for life, 12-step meetings for life, or prison and death.
DO NOT THINK THAT YOU CAN TAKE SUBOXONE FOR AWHILE, DO NO OTHER TYPE OF TREATMENT OR INSIGHT WORK, AND THEN STOP SUBOXONE.
In my next post I will try to talk about what a person on Suboxone CAN do to eventually stop taking the medication. I will also discuss the ever-important dosing question. The ‘sneak preview’ nutshell version is to follow the instructions of your prescribing doctor. Addicts take what they think they need to take– patients take what they are prescribed. You are not an addict anymore– are you?
Induction, Relapse, Benzo Questions
Some questions about the induction process and my answers:
If I try to just take the oxycodone for a period of time prior to meeting with you would that eliminate some of the problems and complications associated with the transition from methadone to suboxone? If I took only oxycodone for 4 days or 6 days might I be able to go directly to suboxone without that withdrawal period?
Yes, it is helpful to change from methadone to oxycodone for a stretch of time. Methadone is highly protein-bound, and takes forever to leave the body– I like people to be off methadone for at least 4 days, whereas 24 hours off oxycodone is usually sufficient to avoid precipitating withdrawal with suboxone. There is no way to avoid withdrawal completely, however, as a person must be in a bit of withdrawal at the time of suboxone induction. Otherwise the person will get very sick.
Would I be feeling well enough by (specific date) to be physically comfortable enough to be a joy to be around or will I still be suffering? I believe I will need some help just with the driving alone…
Some people start suboxone and go to work later the same day– it depends on the person’s individual ability to handle the withdrawal, and on their tolerance to opiates. A person who takes less than 40 mg of methadone per day (or the equivalent dose of oxycodone) will generally have no problem adjusting to suboxone. I have done inductions on people taking well over 100 mg of methadone per day, and they do OK as long as they have gone without methadone for a few days. If you can change completely to oxycodone and avoid methadone for a few weeks before suboxone, you will do better.
In addition to the methadone I have also been prescribed Clonazopam (a benzodiazepine) that I take with the methadone. I take 3 to 4 mg a day. Can Dr. Junig prescribe me that or a different one and get me tapered off the benzo’s? I really want to be clean and sober as I once was… I stopped going to meetings and I had gone to over a thousand during that time and was pretty darn healthy in all ways; but after I stopped I picked up a drink and eventually narcotics again.
Clonazepam is a dangerous med for anyone with a history of addiction. The tolerance that develops makes the drug helpful only for short-term use, for the most part. I will prescribe it sometimes for a person who is taking the proper medication for anxiety (like prozac or effexor) but who still has breakthrough anxiety, as long as the dose remains stable. 3-4 mg is a high dose, and I would want to try to taper that down a bit if possible.
The part about the meetings is typical. Opiate dependence is a long-term affliction—life-long for most people. People contemplating suboxone have two choices: life-long medication, or life-long meeting attendance. At this point there is no cure. Addicts who stop going to meetings eventually go back to opiates, for the most part. Likewise, it is important for people who stay sober through the 12-steps to avoid all intoxicants. Use of a different drug often results in ‘cross-addiction’ to the different substance, which then often leads back to using the drug of choice.
More Suboxone Information at subox.info.
Is Suboxone At Odds With Traditional Recovery?
By now almost every opiate addict has heard of Suboxone, a medication for opiate dependence that has been around for about ten years. I admit to mixed feelings about Suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery.While Suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines.Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.
An amazing medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate 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 opiate 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 opiate.
Different treatment approaches
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 opiate addiction there would be less need for the two treatment approaches to learn to live with each other.But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate 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 opiate 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 opiate 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 opiate addiction.
Drug obsession and character defects
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. Opiate addicts have a number of such ‘defects.’The dishonesty that occurs during active opiate 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 opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.The opiate 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 their 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 opiate 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 developed 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 opiates as well—the opiate is not the issue, but rather it is the obsession with opiates 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.
The dynamic nature of personality
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.
Combining suboxone treatment and traditional recovery
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.
Other Questions (and answers):
-Should Suboxone patients be in a recovery group?
I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.
-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.
-Where does methadone fit in?
Methadone is an opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.With cravings comes the obsession to use and the associated character defects.This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.
The downside of Suboxone
Practitioners in traditional AODA treatment programs will 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 opiate, 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.
The beginning of the future
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 opiate 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 others’ strengths, rather than pointing out weaknesses.
This article can be reproduced freely as long as the following attribution is included:
The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin. Read more about suboxone at SuboxForum.com, AddictionRemission, or at Suboxone Talk Zone. He can be contacted at Fond du Lac Psychiatry.