Rapid Opioid Rip-Off

While I’m on the subject of rip-offs, I’ll mention an extreme form of ‘detox capitalism’; a process called rapid opioid withdrawal, rapid detox, or ‘the Waismann Method.’
The name of the process supposedly comes from a certain ‘Dr. Waismann’ who helped Israeli soldiers get off opioids after they were treated for various injuries.  It sounds like a pretty exciting history, but to be honest there is nothing in the technique that takes a rocket scientist to figure out.  The basic idea is to precipitate withdrawal using an opioid antagonist— something that is done many times over every day in emergency rooms across the U.S.—but to do it while the person is sedated with non-opioid medications.

Put me out, Doc!

I never expected to admit this back when it occurred, but I had the bright idea of putting myself through ‘rapid opioid detox’ shortly before entering treatment ten years ago, when I was desperately searching for a way to free myself from opioids.
Like any typical addict I wanted to do it entirely by myself, figuring that I knew as much about opioids and medicine as anyone else.  I loaded up on naltrexone (an oral form of naloxone) thinking that the antagonist would block my receptors, lower my tolerance, and prevent me from using for as long as I took the naltrexone.
I simplified things a bit by omitting the sedation—a good idea since there was no other doctor monitoring me, but a bad idea because I experienced about a week of withdrawal condensed into several intensely-miserable hours.  I remember being shocked at just how much sweat my body could produce in such a short time, as liquid beaded on my skin as fast as I could wipe it off!
After the real horrible period—the period that I would have slept through had I come up with $15,000 plus airfare—I remained quite ill for a matter of weeks.  And of course that is what happened, since it takes weeks for tolerant mu receptors to be replaced by new, normal mu receptors.  Until the receptors are replaced, the brain’s endorphin pathways remain quiet, causing hypersensitivity to pain—not to mention diarrhea, restless legs, cramping, gooseflesh, and depression.
There are several variations of rapid detox, but the principles are the same for all of them:
–          The addict is given a strong sedating medication or anesthetic
–          While heavily sedated, the addict is given an intravenous infusion of the opioid antagonist naloxone to precipitate withdrawal.
–          After a period of time that varies with the name of the facility, the addict wakes up;  one day of withdrawal gone, and only two more months of withdrawal to go!
–          The process costs from five to ten thousand to tens of thousands of dollars.
–          Different options are tossed in for different programs, everything short of an extended warranty: amino acid cocktails, ‘vital nutrients,’ or long-term sedatives.
–          In some cases a chip of naltrexone is implanted that slowly releases over weeks, supposedly preventing a high from using—provided the addict doesn’t become desperate and use very high doses of heroin, or dig the implant from his/her body using a fork!
Web sites for the procedure point out that opioid dependence is a relapsing illness and that people who use Suboxone relapse when they stop Suboxone (no argument from me), but go on to claim a 70% one-year sobriety rate after their rapid-detox procedure—without any explanation for how they get better numbers than Suboxone patients.  I have never seen peer-reviewed studies showing such success rates.
Speaking of peer-reviewed studies, I have seen a study of rapid detox showing what is intuitively obvious—that since it takes a number of weeks for the body to adjust to the lack of opioids, one day of sedation avoids only a tiny portion of the misery of withdrawal.  Is it worth ten grand to avoid one day of withdrawal, knowing that several more weeks of withdrawal are yet to come?  I suppose it depends on one’s checking account.
But the bigger issue is the poor long-term outcome for these people—a problem similar to what I described in my post about Sneetches.  Early in the spiral of addiction, addicts and their families are under the mistaken belief that the hardest part of ‘kicking opioids’ is to get through physical withdrawal.
They eventually they learn that they are wrong, and that it is much more difficult and rare to STAY clean than it is to GET clean—but ‘rapid detox’ makes money off their ignorance in the meantime.  Quitting opioids by rapid detox, amino acids, magic crystals, hypnosis, or a host of other expensive, highly-promoted methods reminds me of the story about the guy boasting about how easy it was to quit smoking—so easy that he’s done it over 20 times!

Amino Acid Cocktails and Other Sneetch Stories

Aarghh! (he said, moaning in frustration…)  I realize that it isn’t so much anger that shortens our lives as much as the repression of that anger—so pardon my venting!  I just finished an appointment with a patient who described something that is all too common, and that really makes my blood boil.Detox centers make money
I’ve seen ‘Tom’ in my practice for about three years, since he presented with severe heroin addiction.  He once made good money working in the financial industry, but was reduced by addiction to a shadow of his former self.  He had infections in his arms from using needles, to the point of being in danger of losing one of his arms because of destruction of the limb’s blood supply.  He had tried stopping dozens of times without success, having only several ‘clean days’ in a period of ten years.  He was beyond desperate; he truly believed that he would die from his addiction.  In fact, he believed that he would likely die soon.
Tom did very well with buprenorphine, as do many people in his position.  The people who tend to do the best with buprenorphine from my experience are those who are convinced that they cannot stop using, who are aware of the dangers of their addiction, and who utterly hate their dependence on opioids.  I see younger people have less success, in my opinion because they are less aware that there is such a thing as ‘death,’ and that bad things really do happen to people.
Tom was amazed at the effects of buprenorphine.  For the first time in years he could choose to NOT pick up—a wonderful relief that must seem bizarre to non-addicts.  The first days on buprenorphine are a Godsend to those resigned to the same, miserable obsession, morning after morning and day after day; those who kept shooting or snorting regardless of the shame from broken promises to stay clean– made on the lives of every person they hold dear.
Over time, Tom did well in other ways, besides avoiding heroin.  He returned to long-forgotten hobbies.  He began opening up to his wife again, and they worked to heal the damage wrought by years of lies and secrets.  And little by little he began to feel OK about himself again, as he processed the shame that had become a central part of his personality.
I try to facilitate that process, by the way, by helping recovering addicts understand and believe that their addiction is a disease.  I point out that while they had some role in the start of the disease, people have similar roles in the early stages of many, if not most diseases.  I help them realize that they have been punished enough, and that at some point they have the right to hold their heads high again.  I recommend that they avoid developing too large an ego, as righteous anger is a dangerous trait for any recovering addict.  Instead, they should find the humility that most people find in recovering from any chronic illness, the humility that we all find when we realize that we are mortal beings.  And at the same time they should give themselves a break, make amends where due, and feel a sense of pride for working hard at doing the right thing.
Unfortunately, at some point Tom began to resent the fact that he was taking buprenorphine.  I have read about such resentments from people on my forum and witnessed similar attitudes, albeit at a lesser rate, from patients in my practice.  I don’t understand the attitude, and I know from my observations that the attitude is dangerous for opioid addicts, since the relapse rate in people who stop buprenorphine approaches 100% over the long term.  Of course I understand the desire to be off all medications and go back to a time before the person was addicted—just as I understand the desire for world peace.  I imagine that many patients with heart disease look back fondly to the period before their first heart attack, but I don’t think that they are as likely to resent the coronary stent that saved their lives, or the cholesterol-lowering drugs that add another ten years of time with their grandchildren!
I have literally witnessed cases where parents ‘intervened’ to get a son or daughter off Suboxone, precipitating episodes of relapse with severe consequences—even death in one case that I know of.  What a horrible shame!  That situation, by the way, is the background behind the title of the book that I am slowly sharing here, entitled Clean Enough.
Tom made today’s appointment in order to tell me what had happened.  He caught a flight to one of those places advertised on the internet to ‘get you free from Suboxone.’  He paid about $10,000 to stay in their facility for ten days, much of the time watching movies about the greed of doctors and the pharmaceutical industry, who work together to ‘keep you on the drugs that make them MONEY.”  I pointed out to Tom at this part of the story that in the three years I’ve known him, my total fees have run to less than $2,000—compared to the $10,000 collected by these jokers, not counting the cost of the flights to and from their facility.
The detox center gave Tom a proprietary blend of amino acids and other essential nutrients (I’m thinking of a movie right now where the character stifles a cough that sounds like ‘bullsh%$t!).  The blend was supposed to prevent withdrawal and ‘treat his injured neurons.’  I started to explain that the amino acids and other molecules in such cocktails do not cross the blood-brain barrier, which is only one of several reasons for the lack of any evidence in peer-reviewed literature that such infusions do anything at all. And they didn’t do much for Tom; he said that he felt horrible from the withdrawal that was forced over his last five days there (I typically recommend those who insist on stopping buprenorphine taper the medication over several months).
Tom shared this information with me, and also told me that he was using again, starting the  day he got home.  The detox center has no advice for him now, other than to pony up another $10,000 and try again.  He is wondering if he should go on Suboxone again.
I think of the Dr. Seuss story that my parents read to me about 45 years ago called ‘The Star-Bellied Sneetches.’  An inventor had a machine that put stars on the bellies of Sneetches, silly fictional beings lining in the land of Dr. Seuss.  The Sneetches with stars wore them boastfully until they became passé, when another inventor seized the opportunity and created a machine that removed the stars.  By the end of the story, Sneetches stood in line to go through one machine and then circled back to use the other, as money poured out of both machines.
I treat opioid dependence with buprenorphine because I know, without a doubt, that doing so saves the lives of those who take it appropriately. It angers me that there are people with a machine that ‘undoes’ what I do, and that some people are eager to pay ridiculous sums of money to use it!  The lesson for readers with opioid dependence is summarized by another old story about ‘looking a gift horse in the mouth.’  We finally have something with the potential to give suffering opioid addicts their lives back.  If you are in the position to benefit from buprenorphine, I encourage you to be grateful, find contentment if possible, take your medicine… and get on with life.

Please help me

There are so many people who feel like the person who wrote to me today. I remember that feeling so clearly– that there was no solution– but now I see that there is another life, and that some people will find it. And tragically, some won’t.
There are many different levels of ‘insight’– it isn’t the case that I now ‘have it’ and before I didn’t have it. I will always have blind spots– some large, some small; some short-term, and others that will last a lifetime and that I hope won’t trip me up again. I will do my best to share the insight that I have gained with the person who wrote to me– today, and going forward. I don’t know if I will be able to help or not.
Dr Junig;
It is XX am on Sunday, November 29th, 2009. I am supposed to be at a XXXXX party for XXXX.  I am frozen with fear, I have nothing to say, and I have been drinking my wine to numb the fear.
I so wanted to be the one to break this alcoholism….but find myself as I am aging, becoming my Mother!
Please, if you can, tell me how to get control of my fears and the drinking to numb the fears.
Thank you, in advance, for any help you may have for me.
Sincerely;
XXXX
My reply:
XXXXX,
The first step is to realize that the drinking is not ‘medicine’ for anxiety or help for your fears, but rather that alcoholism is a progressive, predictable disease that makes everyone feel the same way.  The standard pattern is for the alcoholic, or addict, to shift from one state of personality to another, back and forth–  one believing that the problem is not that significant and that it can be ‘fixed’ on one’s own with a little bit more will power, and the second feeling horribly shameful, alone, and hopeless.  The problem that I face as a psychiatrist is that a person will call when at that low state of mind, finally realizing that he/she needs help and will do anything to be free from the misery.  But the next morning, the other personality wakes up and convinces herself that everything is fine—decides to throw all the pills or booze down the drain and do the ‘right thing’ next time.
The truth is that both personalities are wrong.  The trick comes in recognizing that your insight will only keep changing back and forth, back and forth, until you do something to change the pattern.  The progression of addiction causes the person to feel worse and worse until finally getting to a ‘rock bottom’ where there is NO way to kid yourself anymore.  We need to get you to that ‘rock bottom’ sooner if we can, so that you can stop the torture.  The challenge for you is to remember how you are feeling now, or when you wrote this message—and keep THAT memory alive for days, weeks, a lifetime.  I can help you with that, but only if you can manage your part- which is to drop the insistence on seeing it how you have always seen it.  I need you to see the alcohol as the PRIMARY problem—not a consequence of something else, like fear.  You also will need to understand that some medications, especially the Valium/Xanax/Klonopin medications, do the same thing as alcohol.
When we first met I suspected this was going on;  I am, after all, in recovery, and I have had the exact same feelings that you are having now.  I still remember when and where the ‘realization’ came to me that I was seeing things wrong, and that I needed to open my mind to the thought that everything I was thinking needed to be dropped and replaced by a new way of thinking.  The change after that moment was remarkable;  I realized that I needed to do drastic things in order to live, and so when I was told I needed to go to an AA meeting, I simply went—there was nothing to argue about and nothing else to say.  If you can get yourself to THAT point, Deborah, we can do wonders to improve your life.  But even if you are not completely there, consider coming in to discuss the situation.  There IS a better life out there—I promise.  But you can’t find it by doing the same things just a little differently;  if that were the case, you would have found it by now!  Consider dropping EVERYTHING and letting go.  Come in soon if you can.
Take care XXXX,
Jeff J

Clonidine and Opiate Withdrawal

For those of you who like to do some scientific reading, a recent meta-analysis looked at clonidine’s efficacy in reducing the symptoms of opiate withdrawal.  A meta-analysis, by the way, is when someone takes a number of studies that sometimes didn’t reach significant conclusions and combines the numbers, creating a larger study group that sometimes shows significant results that were missed in the smaller study.  There are limitations to such an approach, but it is still a common approach to looking at infrequent things.    The infamous ‘black box warnings’ on SSRIs about suicidal ideation in children came from meta-analysis of old studies of antidepressants.

Alpha2-adrenergic agonists for the management of opioid withdrawal

SuboxDoc

Considering Suboxone in NE Wisconsin? Study Enrollment Ends Soon

I have talked a number of times about the fact that Suboxone is only a part of recovery from opiate dependence.  I have been one of the docs recruiting patients for a study that looks at an additional component of treatment that is provided by telephone.  Patients starting Suboxone for the first time for treatment of opiate dependence, or patients who have taken Suboxone in the past but not for at least three months, are eligible for the study (there are a couple other conditions that are relatively minor).   What’s in it for you?  If you participate for the full six months, you are paid a total of $225 by the organization doing the study.
Recruitment for the study will end at the end of 2008.  So if you are ‘on the fence’ about starting treatment, or waiting until after the holidays, here is a reason to start your new life sooner rather than later.
Besides, I can promise you that you holidays will be much more enjoyable if start now, and give up the miserable life of active opiate addiction.