Congress Acts on Opioid Dependence (ugh)

I won’t weigh in on the upcoming election, for fear of being barraged with insulting tweets by one candidate or ‘offed’ by the other.  But the current opioid dependence crisis provides a great chance to learn whether you stand on the side of ‘limited government’ or the alternative.
The TREAT Act takes 5 minutes to read, that would have increased the cap on buprenorphine patients.  President Obama undermined the TREAT Act by announcing his own plans to raise the cap soon after the TREAT Act was presented in the Senate.  After 7 years without mentioning heroin or opioid addiction, it’s hard to believe Obama’s actions were a coincidence.   Only a master politician can ignore 200,000 deaths, and then claim to solve the problem single-handedly despite a do-nothing Congress!
As I wrote earlier, few doctors will make use of Obama’s lousy offer.  Today Congress approved a bipartisan bill that will reportedly signed ‘begrudgingly’  by President Obama– who complained that the Bill ‘doesn’t go far enough.’  I wonder how many pages HIS Bill would be.
I invite readers to check out the language of the TREAT Act in regard to the buprenorphine cap– and then read the language of the ‘Comprehensive Addiction and Recovery Act of 2016‘.  And then, please, tell me how many patients doctors will be able to treat with buprenorphine.  The new law will provide treatment authority for nurse practitioners and physician assistants– I think.  How?  When?  How many?  I see a number of details that are left to the HHS Secretary–  a post that changes a couple times during a 4-year Presidential term.
How do we set up practices based on rules that change every couple years?!
I’m no political scientist, so I’m just reading the Bill and trying to figure it out– and I encourage you to do the same.  Myself, I prefer the language of the TREAT Act, but hopefully the attorneys will get this new thing figured out and let us know how many people we get to help with buprenorphine.

Leadership on Opioids

Anyone who proposes an easy solution to the overdose epidemic is either a simpleton or a politician.  But far too many people entrusted with the power and responsibility to set priorities decry the number of overdose deaths, then stigmatize and demonize every effort to save lives.   “Suboxone can be diverted.”   “Someone might drive impaired after methadone.”  “Needle exchange programs attract drug dealers.”    Meanwhile the number of deaths from overdose make clear that current solutions are not working.  Small community newspapers have story after story about the increasing number of deaths, but the silence in Washington is deafening.    I picture a cruise ship leaving  one after another drowning passenger in it’s wake, while the ship’s captain dines at the captain’s table, pausing between bites to tell dinner guests that all is well.
Statistics and numbers don’t tell a story unless put into context, so some simple comparisons help demonstrate the magnitude of the ‘opioid problem.’  My perception is skewed after sitting with so many people affected by addiction, but we seem to have a huge blind spot for one of the leading killers of young people.  Consider the issues our country’s leaders talk about and our news reporters write about.   I think we all know the things that get our President’s undies in a bundle… but did I miss the Presidential Summit on Opioid Dependence?  This would not be the first time that our leaders missed the elephant in the living room, of course— but it may be one of the first times a President has been given a pass after missing this big an elephant for this long.  I’m old enough to remember the media soundly criticizing Reagan for failing to create a sense of urgency over AIDS.  And so I wonder… When is Obama going to express urgency about opioids?  Where is the media criticism of his lack of urgency?   Today he told reporters he ‘will leave everything on the field during his last year in office,’ just before he took off for another Christmas in Hawaii.  Will that time on the field include some concern for people killed by overdose?
I don’t get the impression that our President lies awake all night worrying about overdose deaths.  But maybe he should.  We heard a great deal from Obama about the need to bring troops home from Iraq a few years ago.  And all of the networks kept a running tally of US deaths in Iraq in the lower right corner of the screen during the evening news.   So let’s compare priorities.  Let’s add up all of the deaths of US troops during Iraq II during two administrations of Bush and the 1 and 3/4 Obama administrations.  Let’s add the deaths from the World Trade Center attacks, the recent terrorist attacks in France and California, and the mass shootings at Sandy Hook and Columbine.  How does that number compare to the impact of opioid dependence?
I don’t intend to lessen the honor of fallen military servicemen and women, or downplay the horror experienced by victims of 911 and other violent attacks.   I chose these numbers because the horror of each situation prompted speeches by our leaders, rallies by our citizens, and headlines in National news media.   The speeches and commitments of our President and the coverage by news anchors are supposed to be a reflection of what our citizens care about.
The number of deaths from overdose in 2013 alone– one year– was over four times greater than the complete count of US deaths in Iraq, plus all of the horrible events listed above.   US deaths in the Iraq war?  About 4500.  The Trade Center attacks killed almost 3000 people.   In 2013, over 30,000 US citizens died from overdose.  Surprised?  I was.  On average about 100 people in the US die from overdose every day– day after day.
As I wrote above, I remember the reporters calling out Reagan over AIDS.  Activists claimed that Reagan avoided talking about HIV because of the stigma associated with ‘homosexuals’, the people hit the hardest by the initial outbreak of HIV.   They say that the people who died were ‘second class citizens’ who didn’t have a voice, and it was easier for Reagan to pretend that the problem didn’t exist.  Many people believe that if Reagan spoke about AIDS in his speeches or directed National attention toward the outbreak of the virus, that fewer people would have died.   Maybe those people were right.
If they were, what’s Obama’s excuse?

Kratom, Recovery, Elections

I received a question about Kratom, and searched for a earlier post about that plant/substance. That post came shortly after Obama’s inauguration, after someone wrote to compare his experience at that event to his experience taking opioids. Funny how every ‘high’ has its own ‘morning after!’
That Post:
On a message board called ‘opiophile’, a person wrote about being a long-term opiate addict, then taking methadone for a couple of years, then going on Suboxone for a couple of years. He eventually stopped Suboxone, and had a miserable period of withdrawal… which never, by his recollection, ever totally went away. He works for the Democratic Party (not secret info– it was in his post) and eventually used opiate agonists again (hydrocodone and oxycodone)… during his time in DC for the Obama inauguration. He described how wonderful he felt, experiencing the opiate sensations while at the same time ‘being part of history’.
He returned to normal, boring, miserable life… until discovering a source for ‘Kratom’. Kratom is a plant imported from Thailand that has opiate and other effects; like many other ‘exotics’ it has not yet been scheduled as illegal by the DEA. My understanding is that it is hard to find in pure form, and is expensive… there is also the risk of ingesting something (maybe toxic) that was substituted for what you think you are using.
In his post, the person asked if he is ‘clean’– whatever that means. I don’t mean to be difficult here– I just mean that being ‘clean’ is different to different people. Some people consider themselves ‘clean’ as long as they avoid their ‘drug of choice’…. the use of marijuana not a concern as long as they are depriving themselves of the Oxycontin that they REALLY want! I don’t agree with that definition, but I can see the point of at least avoiding the things that are the most likely to cause problems.
He also asked if he was running the risk of returning to the same problems that have been a part of his life for many years. I think the answer to that question is obvious to everyone reading this blog! As for my other thoughts, I copied them below.
My Reply:
Kratom contains chemicals that includes mu receptor agonists– the chemicals do not show up (yet) in drug screens, but taking them is no different from activating mu receptors with anything else, legal or illegal. And the fact that Kratom is a plant should not make you think it is somehow ‘different’; if the chemicals in Kratom prove safe enough, they will eventually be extracted, identified, manufactured, and marketed in pill form– and will likely be DEA scheduled at that point.
Please read my article on the relationship between Suboxone and traditional recovery. I am aware of the anger some people have toward buprenorphine, but I think your case is the best argument for Suboxone that one can make.
You have had this endless malaise off opiates, and you seem to blame Suboxone (or if you don’t, I know that many people do– they use opiates for years, then go on Suboxone, then when they stop Suboxone they blame it for endless withdrawal symptoms). But the brain doesn’t work like that; tolerance occurs from agonist or partial agonist stimulation of a receptor, and the tolerance is reversible– at least on the ‘neuronal’ level. There is no reason that one drug, say buprenorphine, would cause a more ‘permanent’ state of tolerance than another drug.
I HAVE seen people with an almost permanent state of opiate withdrawal; I have not seen this so much in relation to specific drugs, as to their degree of ‘addiction’. Listening to your experience with opiates, one thing is clear– opiates are a huge part of your life. Even watching your dream candidate be inaugurated is not ‘enough’ of a kick in life; you wanted more. In fact, by your description, I don’t know which would have been a bigger bummer– seeing someone else getting into the Presidency or being deprived of that ‘buzz’! I’m not taking ‘pot shots’ here–I’m trying to add some insight, and I hope you take it as intended. The ‘person’ that you have become… PERHAPS that person just cannot exist without some level of mu receptor activation. Perhaps that whole ‘psyche’ requires the pleasant warm fogginess of an opiate– and without that, the psyche is miserable. If that is the case, of course you will be miserable off opiates— whether the missing opiates are heroin, methadone, Kratom, or Suboxone. The problem is that at least with the first three of these agents, there is no way to take them without ever-increasing tolerance, which eventually leads to cravings, compulsive use, and greater misery.
We know without a doubt that SOME addicts do recover, most often by using a 12 step program. How do THEY do it? I see the answer as consistent with the idea of a ‘psyche’ that needs opiates vs one that doesn’t need opiates. People who ‘get’ the 12 step programs can live without opiates because they have become completely different people. Treating addiction, we know that a person who simply sees the treatment as ‘education’ is not going to do well; people really need to change who they ARE– completely!
To put it into math form: Person ‘A’ plus opiates = an intact person; Person ‘A’ minus opiates = a miserable person; Person ‘A’ + NA = Person ‘B’ = an intact person. Maybe this last bit was a bit over the top… but hopefully you see my point.
I realize that some people will just never ‘get’ NA or AA; the question is, can those people ever be happy without exogenous opiates? I should add that there are other recovery programs out there that do, or intend to do, something like AA and NA, without the religious dimension– I am including them in the same way as AA and NA, although I don’t know as much about them. But knowing what I know about addiction and recovery, I doubt ANY program will make an addict ‘intact’ through education alone; in all cases I would expect the need for that person to change in a significant way.
In my opinion, the answer to the question is ‘no’– that a using addict, minus the object of use, without personality change, will always be miserable. Enter Suboxone… or more accurately, buprenorphine… and there now is a fourth option besides ‘sober recovery’, using (and misery), and ‘dry misery’. Buprenorphine provides a way to occupy mu receptors at a static level of tolerance, therefore preventing the misery that comes with chronic active addiction. And it allows a person to feel ‘intact’ without the need to change to a different person.
Buprenorphine fits well with the ‘disease model’ of addiction; the idea that an addict needs chronic medical treatment, and that if the treatment ceases, the addiction becomes uncontrolled, resulting in either active use or in your case, miserable ‘sobriety’. As for those who are ‘purists’– who think that every addict needs to get off everything and live by the 12 steps– I am glad that works for you, and others likely will envy you. But note that many, if not MOST, opiate addicts in recovery will relapse at some point in life– maybe multiple times. Recovery programs are not ‘permanent’; they need ongoing attention and activity, or they tend to wear off. There is no ‘cure’ for addiction; we ‘maintain’ addicts either through recovery programs, or now, through medication.
One last comment– I do know a person who was stable on Kratom for several years until suddenly going into status epilepticus with grand mal seizures over breakfast one day, in front of his wife and children. An extended work-up showed damage to multiple organ systems that seem to now be getting better after a couple of years. The studies never determined whether the organ damage came from the Kratom itself, or from some additive or pesticide used in Thailand. Use foreign substances at your own (substantial) risk!
JJ
Suboxone Talk Zone (dot com)

Clean Enough

In regard to my last post
There are many directions that we could take as we review that message. My overall impression, as I read the letter, was of a person struggling to accept the reality of his condition. Over and over, the person repeated the same behavior, starting Suboxone, stopping, and thinking this time will be different.
One thing I’ve learned as a psychiatrist, more than anything, is that change is difficult, and rare. The writer ends with the thought that maybe this time will REALLY be different. I have no idea if it will be, and for his sake, I hope it is… but unfortunately, the odds are that history will repeat itself.
Why, then, bother taking Suboxone—if everything just goes back to how it was? The problem is not that Suboxone ‘doesn’t work’; the problem is in the expectations of some of those who take or prescribe the medication. The active part of Suboxone—buprenorphine—is not a cure for addiction, but rather is a very useful tool. Buprenorphine is a chemical that essentially tricks the mu opioid receptor. Because of the ceiling effect—at higher drug levels, effects at the receptor remain constant as drug concentrations vary—the receptors function as if nothing is ‘coming on’ or ‘wearing off.’ That, in turn, eliminates cravings for the drug, and prevents the ‘reward’ for taking the drug.
Buprenorphine appears to work very well for the writer. When on buprenorphine, he is able to avoid using opioid agonists. The problem comes in the expectation that when buprenorphine is stopped, the condition of opioid dependence will somehow be gone, and will stay gone. That is a completely different matter!
Opioid dependence is a complicated condition that can be viewed from different perspectives; behavioral, neurochemical, social, etc. Some factors that contribute to ongoing addiction are addressed by buprenorphine, but most are not. At one point the writer refers to being ‘stabilized on buprenorphine;’ the best way, I think, to view what happens with the medication.
During active addiction, a person finds that unpleasant emotions, thoughts, or feelings can be blunted by taking a substance. In the long run, the consequences of using a substance become more and more negative, but the active addict cannot see beyond the pressing needs of the moment. These pressing needs become worse, once addicted, because physical withdrawal – including depression, pain, and dread—are added to the other pressures of life. Buprenorphine removes the neurochemical pressure to take opioids—i.e. the constant obsession to improve one’s subjective state.
Hopefully, relieving that obsession allows the patient to change the course of his life; to change social networks, to improve occupational standing, to improve self-discovery and personal insight. If a person insists on stopping buprenorphine, the hope is that there will be enough changes in these other areas, so that the person will somehow be able to avoid responding to the urge to medicate the moment.
I think we are at a point where we need to consider the true nature of addiction. Many treatment programs and physicians and treatment programs have an idealized image of how things should proceed after starting buprenorphine. Patients ‘should’ be able to avoid all other substances, and patients ‘should’ be able to taper off buprenorphine at some point. Through a process known as ‘counseling,’ patients are supposed to develop insight into their thoughts, emotions, and behaviors, so their lives follow a different course when the buprenorphine is eventually discontinued.
But what if patients CAN’T taper off buprenorphine? What if patients eventually relapse, after stopping buprenorphine? What then? Contradictions are apparent, when one looks for them. We know that opioid dependence is a chronic, relapsing condition. We know that relapse is more the rule than the exception. We know that addiction is a process, not an event—and that ‘cure’ is not an accurate concept. Yet program after program requires people to eventually stop buprenorphine. Talk about a set-up for failure!
To truly understand addiction and the role of buprenorphine, one must realize that addiction is a conditioned or learned phenomenon. Parents of teens addicted to opioids will sometimes tell me ‘I just want my daughter back.’ I’ll ask the parent when he last rode a bicycle— and point out that even if the last ride was 20 years ago, he could still ride today. And even if he hasn’t been to his childhood home for 20 years, he could likely drive straight to his front door. THAT’S the challenge of ‘curing’ addiction!
Other thoughts…
About the ‘utilitarian’ approach… the way I suggest we view buprenorphine is the best way to consider other psychiatric medications as well, in my opinion. We don’t think of SSRI’s as ‘curative’ for depression; rather they reduce obsession and worry, contributing to changes that allow recovery from depression. Anticonvulsants do not ‘cure’ bipolar; rather they reduce the likelihood or severity of symptoms of mania. Antipsychotics do not ‘cure’ schizophrenia; they prevent or reduce psychotic symptoms.
About anxiety… does the writer REALLY have it more difficult than others? Maybe– or maybe not. It really doesn’t matter. Most patients who I see for opioid dependence believe they were dealt an unfair hand in life, from an emotional perspective. Most feel that their subjective experiences are more difficult than the experiences of others. Many say that they are ‘shy,’ or that they experience significant depression most of the time. Most say that opioids relieved those uncomfortable emotions or sensations very effectively—at first, anyway—and that is why the addiction started.
Whether our load is truly heavier than someone else’s doesn’t matter, since we only experience our own load. In other words, who would hurt more if his arm was severed, you or me? It doesn’t matter—it hurts both of us ‘enough!’ At the same time, no amount of personal distress logically warrants taking something that only makes things worse. If only addiction was logical!
About being able to choose the course of our lives… ‘Choice’ advocates–people who say that addicts choose to use drugs, and that they should simply choose NOT to use—say that addicts are weak in needing to medicate themselves through life. In reality, there are few discreet ‘choices’ in life. Our behavior flows seamlessly from one thing to the next. ‘Choosing’ consists of a million tiny thoughts, sewn together and spread over a wide range of time. The actual ‘choice’ to use occurs long before a person literally picks up the drug—- in a million subtle decisions and behaviors that the person may or may not have insight into. Avoiding opioids, without the help of buprenorphine, requires constant awareness and engagement of insight. Sober recovery is not effortless, and is not possible for everyone— just as some people cannot avoid depression without using SSRIs, and some diabetics cannot control their blood sugars without using exogenous insulin. There is no shame in having one’s addiction treated!
Comments, as always, are welcome. And to the writer, thank you for sharing your story, and provoking this discussion. I can’t say whether it is time to stop Suboxone, or whether you will ever do well off the medication. But in any case, I encourage you to appreciate life as best you can, and cultivate enough interests so that the buprenorphine issue falls into the background. That, in my opinion, is the best way to use buprenorphine; to allow people to live life as if they had never become addicted, and to learn to tolerate life on life’s terms, as best they can. For some people, maybe that’s ‘clean enough.’

An Addict's Story

I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic. In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication). At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me [email protected]@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer; I’ll be adding my thoughts soon!