Buprenorphine and the Dynamic Nature of Character Defects

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

Buprenorphine Availability and Diversion

Since I began using buprenorphine to treat opioid dependence in my psychiatry practice, I’ve learned quite a bit about what works and what doesn’t work. Buprenorphine is an amazing medication when used properly, and undoubtedly saves thousands of lives each year.
Even when used improperly, buprenorphine has life-saving properties. Addicts who take buprenorphine illicitly, but above a threshold dose and frequency, will become tolerant to the effects of the drug, and will be largely protected from overdose. There is little appreciation for this part of the story, which is understandable. We cannot expect society to embrace the illicit use of a substance. Buprenorphine is, after all, an opioid, with some abuse potential. There are appropriate efforts underway to reduce the diversion of buprenorphine; efforts that I wholeheartedly agree with. But some forms of diversion are worse than others. And a close look at the experiences of opioid addicts suggests that efforts to control buprenorphine may actually increase diversion of the drug. I should emphasize that my opinion on this subject is ‘anecdotal,’ not scientific. But I receive many, many e-mails from opioid addicts across the country, and their stories are the basis for my comments.
The most damaging form of buprenorphine diversion occurs when opioid-naïve people take the drug. Buprenorphine is a microgram drug in a milligram tablet. People who chip off a quarter of a Suboxone tablet are handling 2000 micrograms of a very potent opioid. That amount of buprenorphine alone won’t usually kill a person. But if combined with a second respiratory depressant, death is possible—perhaps even likely in opioid-naïve people. This type of diversion—the use of buprenorphine by opioid-naïve people, or by people not yet addicted to opioids—should be the focus of efforts to prevent diversion.
Another type of diversion occurs when desperate opioid addicts seek out buprenorphine to ‘treat themselves’ for their addiction. Opioid addicts choose this route, over going to a doctor for legitimate treatment, for a number of reasons. Some may be on the fence between quitting vs. continuing active use of opioid agonists. Some are caught up in the struggle to simply get by each day, and don’t have the presence of mind to seek out treatment providers. Some don’t have enough money to pay for treatment—although as I have written in the past, they would almost surely come out ahead financially in the long run by getting treatment. And finally, in some cases there are no doctors in their area who prescribe buprenorphine or who have openings under the ‘cap.’
I do not intend to legitimize this type of diversion, i.e. self-treatment by people with opioid dependence. But we should be honest and accurate with assessments of the current status of buprenorphine treatment. It is clear that opioid addicts who find and use buprenorphine are far better off than those who don’t. If there is no legitimate treatment available, I have a hard time condemning someone who finds and uses buprenorphine, as that behavior will greatly increase their odds of survival. If someone I loved became addicted to opioids, my first thought would be to get that person on buprenorphine as quickly as possible. Taking buprenorphine regularly would lower the risk of overdose, reduce the risk of impulsive behavior related to cravings, and immediately place the addiction in remission, blocking the imprint of addictive behavior on the brain—the conditioning that at some point turns chemical dependence into a lifelong disease.
Counseling—cure or crock?
Much is made of the need for counseling in addition to buprenorphine. Again, I agree with the need for counseling in some cases, particularly in young people, or those with polysubstance dependence. But I take issue with practitioners who require that every patient engage in weekly group therapy for an indefinite period of time. From the stories I’ve received, it seems that no thought is given to the type of therapy, the education of the ‘therapist,’ or even whether or not the type of therapy is consistent with the use of buprenorphine! Instead there is a blind assumption that therapy is inherently good, without any effort to determine whether or not the therapy improves outcomes. I am amused when I read studies that show no significant effect of counseling on outcome, but then conclude that counseling is a good idea– in spite of the findings of the study. I see wisdom in the requirement for certification to prescribe buprenorphine that counseling services be available, rather than mandating counseling in all cases. Some practitioners appear to miss the distinction.
Psychotherapy is not ALWAYS good. I’ve witnessed situations where the prescribing physician is emphasizing the need for long-term buprenorphine maintenance, while the counselor the patients are required to see encourages the patients to ‘get off Suboxone.’ Even in better situations, it is difficult to determine the efficiency of psychotherapy, if someone even took the time to consider that issue—which nobody seems to do. People have written me about all sorts of requirements that they face, including weekly doctor appointments without any drop in frequency over time, or daily 12-step-group attendance for as long as they are on buprenorphine. The latter is another example of the folly of simply demanding something just for the sake of doing so. I’ve written in the past about why 12-step programs are less appropriate for people on buprenorphine; the steps are best accepted by people who are desperate, and buprenorphine eliminates desperation almost immediately. From my own experiences as doctor and as addict, we should consider treating with either buprenorphine or the steps— not both. Some physicians may disagree with my perspective, but I hope they are at least weighing in their minds the reasons for their treatment approaches.
When one understands the mechanism of action of buprenorphine—the simple but elegant way that a partial agonist tricks the brain by eliminating any change in opioid effect—one can understand why in some cases, remission from addiction will occur with medication alone, without need for counseling.
Not enough docs
I recently had to ask several patients to find new physicians, because of issues related to state licensing. They are all struggling to find people who will treat them. In a couple cases there are no doctors within a 2-hour radius with openings for buprenorphine patients because of the ‘cap.’ I respect the cap, and I’ve taken on very few new cases in the last couple years because of it. But patients on buprenorphine for long-term maintenance do very well after a year or two, and were it not for the cap I could easily care for twice as many patients. I find it strange that a pain doc can prescribe oxycodone to a thousand patients without need for any special certificate, yet buprenorphine treatment programs are capped at 100 patients.
Beyond the shortage of doctors, the doctors who do have openings in some cases appear to take advantage of the situation. If a patient has been stable on buprenorphine for two years, is it reasonable to require a month of intensive outpatient treatment in the doctor’s own facility? Is it reasonable to charge over $300 for each visit—and require visits every two weeks, indefinitely?
I see no action by any addiction society to address this type of issue. And as an addict, this lack of action feels discriminatory. Shouldn’t the societies (ASAM, SAMHSA) be advocating for the rights of patients with the disease of addiction? Isn’t access to treatment a fundamental issue for patients?
There are a number of efforts in place to limit the prescribing of buprenorphine. In many ways the medication is regulated more closely than schedule II opioids. And prescriptions for buprenorphine seem to carry greater stigma at the local pharmacy than do prescriptions for oxycodone. The efforts to prevent diversion are in place—but where are the efforts to increase the availability of treatment? And how much of the second type of diversion that I described above could be prevented by increasing access to reasonable treatment?
I have been a physician for over 20 years. Rarely in the field of medicine does something come along with such potential to save lives. Given the epidemic of opioid dependence, shouldn’t someone, somewhere, be writing legislation that makes such treatment more available?

Buprenorphine Down Under

Much thanks to a doc in Australia for recent comments:

Rats that can jump

From one Doc to another (I’m in Australia). You may be interested (or possibly know) how we do things here. Basically, addicts can register at any Dr who’s completed a programme and is then authorised to prescribe what we call Schedule 100 drugs: mainly buprenorphine and methadone. Almost all these Dr’s ‘bulk bill’ ie. are free for the patient. Once prescribed, the patient turns up at a chemist (who’s set up to dispense S100 drugs) daily and receives their dose. After 2-3 months of stability ‘takeaways’ may be authorised by the Dr: up to 3-4 a week. In general terms there is almost NO prescribing of 30 day bottles here – Px need too see the pharmacist daily and their Dr at least once a month. This is free for the patient, however most pharmacies will charge a couple of dollars a day to dispense, and keep patient’s skin in the game. The provision of the drugs themselves is free. ie. done by the Dept. of Health. So..all in all our systems is quite different in that it’s a) pretty much cost-free to the patient and b) requires regular attendance at a pharmacy ie. daily or almost daily.
In terms of prescribing: Dr’s over here are far less ‘go my own way’ than the US (I have found anyway). There is established practice, and you leave yourself wide open to criticism from your peers if you vary from that. In the case of suboxone, the established standard is to keep patients on suboxone for as long as possible, if not permanently. We are under no pressure to ween addicts off suboxone/methadone, and in general I actively discourage it, except for a very few motivated individuals with stable lives eg. other healthcare workers. A Dr that promoted leaving a programme would face a barrage of criticism, and possibly be reported by his/her peers. This is great in one way, but bad in others: the individual’s healthcare can’t be overly tailored.
So…that’s buprenorphine et al in Australia…hope you and your readers find it interesting, and keep up the outstanding work of this blog!
Thanks Doc— for the info, and for the kind words. I’m sure that people will find things to prefer in either the US or Australian approach to buprenorphine. I’ll offer my own comparison, for what it is worth… starting with things I prefer about the US approach. In the US, all doctors with the ability to prescribe controlled substances can prescribe buprenorphine, although most are not aware of that ability. Buprenorphine is really just another pain medication when used to treat pain, whether given as a sublingual tablet, transdermal skin patch, or (eventually, hopefully) a depot injectable product. The regulation comes into play only when buprenorphine (or ANY narcotic) is used for addiction. No opioid can be prescribed or administered to prevent withdrawal or to treat addiction, except in the case of methadone (by formal methadone programs) or by buprenorphine-certified physicians prescribing buprenorphine. In the US there are no formal limits on the number of days of buprenorphine prescribed at one time, and no formal regulation of the frequency of doctor visits.  Like in most areas of medicine, the only guide is the ‘standard of care,’ something that varies from region to region and that hopefully evolves in the correct manner as science adds to our knowledge.  I’ll mention this evolution in a moment in regard to the length of treatment.  I would not be happy with the requirement that patients present on a daily basis;  at some point I believe that even addicts deserve to be treated like regular people!  You’ve probably read my comparisons of addiction to other diseases;  I realize that addicts have a reduction in their insight at times of active use, but I have many patients who are doing very well, who do fine with quarterly visits. Those patients receive a month supply of medication at one time, and can pick up refills each month for up to 90 days before another appointment.  I reserve such situations for people who have done well– i.e. no relapse, erratic use of buprenorphine, or other irregularities for at least a year– and I strongly encourage patients to come in sooner if they have any problems.
Doctors certified to prescribe buprenorphine for addiction must have the ability to refer for counseling, but patients are not all required to attend counseling. On one hand this allows for flexibility, but on the other hand it creates a situation where the doc has the power to force patients to attend counseling (even in the doc’s own clinic) in order to get buprenorphine, a potential conflict of interest.
The cost issue issue has arguments on both sides.  On one hand, there are many people in our country struggling to get by, especially right now.  But on the other hand, people tend to pay for what they value– and value what they pay for.  I am not real sympathetic toward people who spend $1000 per week on oxycodone, and then refuse to pay a fraction of that amount for treatment.  In a free system I’m sure there are people who abuse the benefit, going in and out of treatment without getting to a point of desperation that might produce a firmer commitment.  On the other hand, making buprenorphine more available to addicts is going to reduce mortality– and it is hard to argue with something that results in more lives saved.
I am particularly interested in your comments about long-term maintenance.  The Australian approach appears to be much more ‘intelligent’ in that respect.  There has been SOME evolution in the US, as study after study shows virtually 100% relapse after discontinuation of buprenorphine.  But there is a buck to be made by the detox centers, whether ‘rapid detox’ for 10-20 grand, inpatient detox for days to weeks, or several months of residential treatment that claim to make people ‘completely clean.’   The attitude among most people, physicians and lay people, is that buprenorphine should eventually be discontinued.  I disagree with that attitude and believe it to be the result of ignorance and a disregard for reality– as I have shared a number of times.  By my thinking it seems so clear;  opioid dependence is a chronic disease that finally has a long-term treatment. 
Thank you very much for sharing your experiences, and for describing how another country manages this difficult issue.    G’day. Mate!

More about counseling and stigma

One of my patients sent me a link to a Kentucky newspaper article that described the recent surge in cases of opioid dependence and treatment with buprenorphine. The article described the increased costs for medicaid programs because of the need to pay for buprenorphine. The reporter said that the problem was that people are being placed on buprenorphine and only ‘maintained,’ instead of receiving ‘definitive treatment’ to fix the problem.
The reporter’s perspective and conclusions are not unusual, but they are, to put it bluntly, a crock– for a couple reasons. The first problem with the story is the reporter’s bias, caused by stigma. I left a comment after the article asking why the reporter wrote about rising costs for buprenorphine, instead of an article about the rising costs for medications for ALL of the many new diagnoses and conditions treated these days? To name a few, we have new medications for bipolar disorder, for elevated cholesterol, for coronary disease, for impotence and ‘low T,’ for diabetes, and for asthma– and all of those medications have resulted in higher costs as well. Why single out buprenorphine?
In fact, opioid dependence has become the second leading cause of death for young adults in many parts of the country, and if you look at the cost of buprenorphine over a denominator consisting of the number of lives saved by the medication, buprenorphine becomes a real bargain! Medications for other fatal diseases, for example chemotherapy for breast cancer, are much more costly than the $5 per day cost for treating opioid dependence. We also spend hundreds of thousands of dollars for EACH victim of a serious motor vehicle accident, and similar amounts for every transplant recipient– even when most transplants eventually fail, just as many addicts eventually relapse. Why is only ONE chronic illness– one with a relatively inexpensive cost per life saved– singled out? Are some lives less valuable than others?
What about the suggestion that buprenorphine is only a band-aid, and avoids ‘definitive treatment?’ I have written about this situation many times, and (thankfully) more and more data lends support to my position. I have struggled with my own opioid dependence for 18 years, and over that period of time have come to know a great many addicts; people who were colleagues, friends, patients, and acquaintenances. I have worked in residential treatment settings, and have referred patients to treatment programs ranging from one month to over a year in length, costing from $4,000 to $70,000 per month. The simple, shocking truth is that for opioid dependence, residential treatment RARELY WORKS. The issue of ‘addiction treatment’ is an incredible, sad, shameful ruse that has been spoon-fed to the lay-public, and even to medical and AODA treatment professionals. On TV, Dr. Drew does his thing with addicts– and yet nobody ever seems to question why his patients KEEP ON USING! We read that Lindsay Lohan just failed another drug test, and people assume she is pathologically stupid– when the truth is that she is only like so many others. She probably has an ignorant doc, pushing her off buprenorphine and blaming her when her ‘treatment program’ failed…. when in reality her DOCTORS failed, and her COUNSELORS failed, by not reading the literature and saying ‘duh– this residential stuff never works!!’ At the residential treatment center where I worked for the past few years, the counselors get excited when the patients look all shiny and clean after six weeks in the program… but completely ignore the fact that almost all of those same patients are using by the end of the next year. And what REALLY angers me is that many of the patients who the counselors consider ‘cured’ end up dead from their addictions… and instead of looking at themselves in the mirror with shame, they blame the ADDICTS for not following the program. That would be fine if a small percentage failed treatment. But when EVERYONE fails, it is the TREATMENT that deserves criticism, NOT the PATIENT.
Sorry for shouting.
Over 600 people taking buprenorphine were followed in a recent study that you can read about here. The study showed more of the same– that patients taken off buprenorphine universally relapse. But the study showed something that I found interesting, but not all that surprising. You see, everyone always loves to say that buprenorphine is fine, but ‘only if there is counseling too.’ I always get a kick out of how many people think ‘counseling’ is a good idea– as long as it is for someone else! This study of people on buprenorphine compared a control group that had a quick med check each week during the study period, with a ‘counseling group’ that had two one-hour sessions per week throughout the period, talking about interpersonal issues, personality problems, trauma and stress in the patients’ lives, and other feel-good issues. Guess what? There was NO DIFFERENCE in relapse rates between the control group and the addicts that received intensive counseling. None. Nada. Zero.
I have stated many times that opioid dependence deserves treatment as a MEDICAL ILLNESS, a chronic illness, a potentially fatal illness that finally has a chronic and effective treatment available. But now that this life-saving treatmennt is finally here, the insurers have the gall to limit access to treatment for only a year?! The newspapers have the gall to whine about the cost of a day’s medication– all of five bucks?!! And AODA counselors and some misinformed doctors have the gall to mislead patients by talking down the medication that will help people, even while knowing that their own meal-ticket/treatment programs are ineffective?!!
It even appears that the docs who ‘get it’ about buprenorphine are not doing what good medical science usually does– which is to keep an open mind about treatments and follow the data, not ‘PC’ assumptions. One assumption has been that addicts are so ‘faulty’ inside that they cannot be treated without ‘counseling;’ that surely they all need counseling to truly get better. Where is that assumption when it comes to treating other illnesses? And now that we have evidence that counseling was of no value in the latest study, will minds be open to change?
One of the study’s authors summed it up like this:  
“Does putting people on a short period of buprenorphine maintenance combined with counseling lead to reductions in relapse? It’s a great idea, and a wonderful hypothesis, because if it does work then this would be a huge win. We would not have to use extended maintenance. Unfortunately, it did not work, but the study needed to be done.”

Counseling: Good for Addiction?

When a person asks for help with some issue in his/her life, a safe and relatively common answer is to suggest ‘counseling’. Trouble with your marriage? Get counseling. Depressed? Take an SSRI, sure, but get some counseling too. Kids acting up? Send them for counseling. Wondering about the meaning of life? Lose your job? Have a flight get cancelled? Try some counseling!
What about all of this counseling? Does it do any good? There seems to be this assumption that any counseling is good counseling—but why would that be? The standards for providing ‘counseling’ vary by state, and in some states pretty much anyone can hang a shingle to be a ‘counselor’… What are we talking about when we say ‘get counseling’? What if we take the word ‘counseling’ and change it to a different word with the same meaning—do we still feel the same way? For example, by counseling, I think most people mean interacting with another person, and receiving feedback in the form of interpretation, clarification, or advice. How would you feel about the idea that if your kids are acting up, you should send them to a stranger and have the stranger give them advice? Sound good?
In reality there is no shortage of bad advice out there, so why is there an assumption that advice is OK, as long as someone is calling it ‘counseling’? One could say that there is the assumption that a ‘counselor’ has had training, and therefore the advice will be better than the random advice one typically receives from strangers. But we all know bad doctors, and the standards to become a doctor are incredibly stringent compared to those for counseling! Not to mention that there are some real goofy things that pass for counseling, particularly the closer you get to California!
There is one thing about counseling that does guarantee a certain degree of safety– any recommendation to undergo counseling is usually ignored! But in all seriousness, the people who are referred for counseling are often vulnerable, and so the issue of whether to blindly send them for advice from strangers does deserve some consideration.
There are, of course, different types of counseling. The ‘counseling’ done by advanced-degree practitioners, such as psychiatrists and psychologists, is generally referred to as ‘therapy’ rather than counseling. Therapy can be broken down into different types, and some conditions are more responsive to one type of therapy than another. Therapy is often described along a continuum, from supportive therapy on one end to expressive therapy on the other. Supportive therapy would be the appropriate approach for a person undergoing trauma or significant stressors, at a breaking point; expressive therapy would be the choice for a person who wants to develop better insight into how his/her mind works. During psychotherapy in my office, I tend to move back and forth on the continuum depending on how the patient is doing; when the person is struggling the therapy moves in the supportive direction.

What is supportive vs. expressive therapy? This is hard to explain in a short article, but supportive therapy is aimed at strengthening the person’s defense mechanisms—as those defenses are what keep us sane during times of stress. Expressive therapy, on the other hand, is aimed at questioning assumptions, digging up repressed content, challenging long-held impressions of relationships, etc. If a person is already under a great deal of stress, and then undertakes frequent sessions of expressive therapy (like psycho-analysis 4 days per week), he will often get worse, even to the point of psychosis.
Looking at it this way, undergoing therapy during active addiction at first seems to suggest some contradictions. During addiction the addict is very ‘stressed out’—so wouldn’t that suggest that ‘supportive therapy’ be the best? I would say no, absolutely not—when treating addiction, I WANT the person to question the assumptions and rationalizations that keep the person using. So does that mean that expressive, psychodynamic psychotherapy would be a good idea? To that I would also say no! The problem is that the using addict is so full of crap that psychodynamic therapy is generally a waste of everyone’s time. Anyone who knows an addict knows the shallowness of emotion during active use; crying for help as if from the depths of the soul one minute, and then laughing it all off a few minutes later.
There are other problems with therapy during addiction, even in recovery. A psychiatrist may see addiction in a way that runs counter to the view of an addictionologist. Specifically, psychiatrists often see addiction as a symptom of something or a consequence of something; addictionologists on the other hand see addiction as a primary disorder, that may be the cause of psychiatric symptoms or illness. To one, addiction is a chicken, to the other, an egg!
The addictionologist worries that the addict in therapy will start to find reasons for what he is doing, when the reasons aren’t the issue—the point is to just stop doing it! I get this image of two extremes among my patients; both have a month of sobriety and it is time to be working full time, and one says ‘OK’ and starts filling out applications without even thinking about the nature of the job, and the other sits for weeks talking about how it ‘feels’ to go back to work, wondering why it feels this way, wondering if other people feel this way, wondering if he will always feel this way… Usually I explode and say ‘JUST GET AN F-ING JOB ALREADY—WHAT THE F**K!! I’m SOOOO empathic!! I like the addictionologist approach in this setting, including the ‘as if’ approach that I have mentioned before. You don’t feel like working? That is OK—just act as if you DO feel like working, and get to work. You feel tired? Act as if you don’t feel tired. To a tired, nonworking person this sounds harsh—but I am only trying to help. And whether you believe it or not, I will help you more by this approach, than by sympathizing with how tired you feel.
This gets to the issue of the harm that the wrong therapy, or the wrong therapist, can do to a patient. If we have a person in treatment who is struggling—nobody is laughing at the cocky, stupid jokes; everyone is calling the person on his ‘stuff’, and he is getting close to that place where he drops the cocky attitude and brings his genuine self to the treatment scene… If at that point, a sensitive, kind therapist came on the scene and started making little ‘poor baby’ faces with the person, that could completely destroy the treatment. Addiction treatment is pretty cool stuff, and pretty challenging– it takes a person who can distinguish the real person and the BS person, and use the BS person’s own words back on him to try to break though the cocky front… this is the work of a good addiction counselor. There are plenty of counselors who think they are treating addiction by providing education and support, maybe also enforcing boundaries… but the great counselors who every treatment center wishes they had are the ones who are addicts themselves, who hate addiction and who come to work ready to rumble every day. It is a game in a way—or a chess match. Knowing how hard to push, and when to push a bit harder, and then knowing when to shift gears and reel in the newly-opened mind. It is tiring work, and given that we are literally talking about saving lives, the pay is not near good enough.
I just mentioned how a ‘softie’ can screw everything up, but there are other dangers to therapy for those in recovery from addictions. All of us in recovery have what I like to think of as ‘the addict inside.’ The addict is there for one reason—to get us to use. The addict is crafty, or as they say in AA, cunning, baffling, and powerful. The addict inside has advantages over our sober selves; the addict has access to all of our minds, including our unconscious, where our fears, lusts, prejudices, hatreds, and other powerful forces reside. The addict can use these unconscious feelings to push us to do things that may ultimately destroy us. But our sober selves have our own advantages; we get to control our arms and our legs. Sure, the addict inside can push us up down, left, right, into using once we are in a dirty bar at 3 AM… but our legs can carry our sorry heads to the edge of the bed at 10 PM and then drop us there, so that we can’t get near that bar! The problem with therapy is that is does at least two things to strengthen the ‘addict inside’. First, the addict LOVES to talk; you start up that therapy, and the addict gets to start up with all the BS, and given free rein the addict will win over logic every time. The second thing is that the addict will use confidence of our sober selves to the addict’s advantage, like this: ‘I see it now! I used because I was teased on the playground, and that created this pain in my heart that never went away—so I needed a pain killer, and I took one, to ease the pain—a form of self-treatment!’. Sounds pretty logical… but you have just told the addict in you about a big weakness. The next time you are in a situation that is somehow similar to being teased at the playground, the addict will be ready to tell you about how much you hurt, and about how good it would feel to medicate the pain, and about how much you deserve to be medicated. And even more– and this is similar to what ultimately led to my own relapse that destroyed my anesthesia career– you are now a smart guy! You had that therapy, dude! You are da’ MAN! Now you get it, don’t you see—just take a little bit this time—no, a TINY bit!! Just enough to medicate, to take the edge off, then stop!
I haven’t addressed how the Suboxone issue may play into all of this. I guess I would say that Suboxone lessens the risks just a bit; the ‘addict inside’ is a bit less powerful when the cravings are muted by Suboxone. But I have seen plenty of addicts go from stability on Suboxone back to ‘self medication’ and ‘playing’, and in some cases this folly is fueled by too much ‘self analysis’– which is really code for ‘rationalization’.
I am not totally down on therapy for addiction. Just don’t kid yourself. One of my favorite lines from the movies is still number one, a couple decades after when the movie came out—Clint Eastwood saying ‘A good man knows his limitations’. This is important advice to any addict who would like to stay clean. Know your limitations. Having psychotherapy—even real good psychotherapy that truly adds insight—doesn’t make you any safer—if anything, it increases the risk that you will talk rings around yourself some day and get into more trouble. Another saying—nobody is too dumb for recovery, but some unfortunates are too smart for it.
The best form of therapy by far for addiction is group therapy with other addicts, preferably with a range of sober time including a few ‘old-timers’. And that happens to be an AA or NA meeting. Similar groups set up in treatment centers can work quite well also. Continuing the ‘addict inside’ analogy, everyone in the group has the same addict inside, and now everyone in the group contributes to identifying the addict, calling it out, and helping each other identify the addictive thinking and addictive behaviors that are the tools of the addict inside.
Heavy stuff for Super Bowl Sunday. Anyone who picks the winning team AND the point spread gets a free copy of my soon-to-be-released book, Suboxone, and Addicts Guide, containing an organized version of the information in this blog I must receipt your e-mail by the end of halftime for it to count! To be honest, I’m just curious to see if anyone manages to even make a guess!
Jeffrey T Junig MD PhD
AKA SuboxDoc