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.

STZ Now on Medpedia

Medpedia has been expanding on a number of fronts, with a ‘wiki’ approach to all things medical– including addiction. This blog— Suboxone Talk Zone– will be included in the News and Analysis section of the site; I also hope to submit content and contribute to our knowledge base about opiate dependence going forward.Capture
I invite readers to visit Medpedia and review my thoughts about the relationship between buprenorphine maintenance and traditional recovery. The topic will be important as we sort out whether buprenorphine should be used as a bridge to step-based treatment, as a long-term treatment that stands on it’s own as a treatment for a chronic condition, or a combination of both paradigms.
When it comes to medical information there are many options on the internet, that vary greatly in the quality and independence of their information. Medpedia follows the model of a similar site, where information is honed through the experiences and opinions of contributors. I like what I see so far. Please check them out sometime.
JJ

Another 'Dust-up' with the 'anti' crowd

A couple people have written to me saying that while I sound a bit ‘defensive’ and as if I am taking things personal, they like it when I let my true feelings out– including my anger. If you are one of those people…. read on. I will say, though, that I realize that there are times to maintain one’s composure. I’m not the type of person who will excel in that environment. When I worked in the prisons there were the inmates– people who had great difficulty holding back their anger– and the administrators– the shy, quiet people who would smile and shake your hand and then write you up for acting too ‘aggressively’ and hurting their feelings… or, if they read the manual would say that the work environment was ‘hostile’. Funny– I always felt safer around the inmates than around the administrators!
But that has nothing to do with anything…. accept maybe making a preemptive excuse for my behavior with the following posts. The first post is from a reader/writer who defends the object of my last post. I took his post and moved it from the comments to up here.
The comment: “I have put offers out on some of the Subox-hater sites asking for someone with 5 years clean to talk to me– and so far, I haven’t found a soul.”
Now doc that’s not quite true. Lots of people are clean and sober without your magic pills.
Your arrogance never fails to make me cringe.
“What makes 7 years think that all the withdrawal is just Suboxone’s fault?”
Ummm because it is Suboxone’s fault…clearly. The guy wasn’t withdrawing from narcotics of 7 years ago. Surely you learned that in your PhD training.
I still don’t understand why you think meetings are such a bad thing…as if they were a prison sentence. I happen to enjoy them- Being clean and sober is so much more than just avoiding cravings by popping a couple sublingual pills everyday. It’s just not that simple folks.
Eight years clean and sober…Sub-free.

My response:
Please don’t put words in my mouth. There is nothing ‘magical’ about buprenorphine. I do not call them magical, and I don’t call them a ‘miracle’. I often point out that they do NOT CURE ADDICTION; they induce REMISSION as long as they are taken, if used correctly.
As for your boastful claim, that’s great for you– the 8 years part. It is no guarantee that you will make ten– I felt pretty sure of myself at 7 years, and realized later that even someone as ‘arrogant’ as myself can lose my way. But even if you do remain sober the rest of your life, that puts you solidly in rare company. I am med director of a 50-bed residential center that HATES Suboxone, and never uses it– not even for detox. Suboxone gets in the way there– people think that they will be done with their withdrawal in a few days, and they aren’t. We added two weeks on just for people coming off opiates, including Suboxone. My beef is with those who place blame on Suboxone when they should be taking responsibility for their own addiction. To be frank, if you could read what I write without looking for a reason to disagree with me you would see that everything that I say is geared toward sober recovery. The person who blames 7 years of Suboxone for her misery, while acting like her 10 years of addiction were meaningless, is trying to completely pass the buck. SHE (not he) is an opiate addict; that is the cause of her misery. She wants her misery to be due to Suboxone. All Suboxone did was give her 7 years to avoid the inevitable. For some people, that is a great thing; it can allow the person to save money for definitive treatment, it can allow people to make amends to others and recover marriages. There is nothing lost from taking Suboxone– she was faced with a choice– sober recovery or Suboxone’s easy way out. Like most addicts, she chose the easier, softer way. But it is disingenuous for her to now complain about the choice that SHE made. It is so much easier to blame her past doctor, or Suboxone. She continues to change usernames every day and post the same garbage, and not ONCE has she taken responsibility for her own behavior. Just a question for you: we have on the forum the rules posted that say ‘this is NOT the place to debate the pros and cons of Suboxone. This is a place for people who have made that choice, or a different choice, to discuss Suboxone, methadone, or sober recovery WITHOUT being criticized for their choice.’ She ignores that rule, and interrupts discussions with her vitriol and bile. Is that how you learned ‘good recovery’ works in NA?
I went to, I don’t know– a bunch of meetings during a five, and then another 5 year period. One or two per week– sometimes more. I quote the twelve and twelve all the time. And from a step based recovery perspective, our ‘7 years’ friend is an embarrassment. If you don’t agree with that, then I don’t know what meetings you are going to and enjoying. The idea is to be an example. What is she being an example of, exactly?
I don’t understand a couple of your comments; you said about her withdrawal that ‘it is Suboxone’s fault, clearly’… followed by some sarcastic comment about my PhD in neurochemistry. I stand by my point. She is NOT just coming off Suboxone! Yes, the last 7 years were buprenorphine (as I wrote, 7 is not possible– I sent her a copy of the Federal Register dated May 22, 2003, announcing that Suboxone would soon be available in the US– so whatever you want to think of her, she is exaggerating by at least a year). But she was on 10 years of other opiate agonists before the (4-6) years of buprenorphine. There IS a connection between the length of time on an opiate and the severity of withdrawal, and my point is that all things being equal, coming off ONLY 7 years of Suboxone is less miserable than coming off 10 years of agonists FOLLOWED BY 7 years of Suboxone. The frontal lobes show decreased glucose metabolism during PAWS, which is probably related to the reduced insight and impulsivity that make early sobriety such a dangerous time for relapse. This brain hypofunction is worse after longer opiate use than after shorter use. The dysfunction is not from cell death, but probably from longstanding changes in firing patterns of neurons that become more and more entrained, the longer the aberrant signals are maintained. So as I wrote initially, she is NOT just coming off the buprenorphine; she is coming off the additive effects from 16 plus years of opiate use– the majority of the time using agonists. No PhD needed to understand that– simple addition is all you need to figure it out!
I do not say bad things about meetings. If you read my blog much, you will come across the comment often that AA saved my life– twice. I also have written in many columns that AA is great for those who want to go to meetings. I disagree with forced attendance because in my opinion, AA can be taken two ways; it can be taken in by the casual observer, and maybe some points will be taken in about how addiction progresses and how difficult sobriety can be. But the other way it can be taken in is the ‘life saving way’– the way I took it in the first time quickly, and the way I took it in 7 years later after a great deal of very hard work. To take it in the second way a person has to change his or her personality– and to do that, he must ‘cling to AA the way a drowning man clings to a life preserver’– to paraphrase AA. That second type of experience, in my opinion, does not happen with people on Suboxone. It requires the open mind that comes from DESPERATION– and people on Suboxone are not desperate!
If you read much of what I write, you would know all of this. Like most of the flamers, you pick and choose certain posts or sentences and come to conclusions that completely miss the point of why I write, and what I write about. What I find interesting is the role of ‘insight’; it is impossible for a person on Suboxone to go to AA and have the same ‘insight’ that a person who is sick, in withdrawal, and desperate will have when reading the steps. Similarly, it is impossible for someone like you, proud as a peacock over your sobriety without Suboxone, to have insight into the experience of those who choose medicated recovery. You, and the others who write the same things that you just wrote, have your own blinders on– they just point in a different direction.
I suppose I should point out that you made a comment about MY arrogance, and you close your note with a boast of ‘eight years clean and sober– sub free’. Who is being arrogant?!
Everything that I do– putting up with people like you who call me ‘arrogant’, all while boasting about your OWN superior brand of recovery– is, believe it or not, because I have seen the people harmed by people like you. I have talked to people who went to NA and got badgered off Suboxone– many people are ashamed and very suggestible early on in treatment, so it is easy to lead them astray. That is one reason why twelve step programs caution against taking another’s inventory. And yet, here you are, boasting about how YOU did it. Look at what you wrote: ‘Being clean and sober is so much more than just avoiding cravings by popping a couple sublingual pills everyday. It’s just not that simple folks.’ Sure sounds judgmental and arrogant to me! I see those people after they stop the Suboxone and relapse, and spend 6 grand on drugs, almost die…. (thinking of the latest person this happened to)… And then I get mad and keep writing what I write. And when I get mad I feel free to write what I really think: that stupid jerk ‘recovery-snobs’ like yourself make me HATE NA– not for the program itself, as the program was sound… until too many jerks like you came around. And to you, it is more important to strut around with your 8 years than to truly listen to the pain of other people. Only about 5% of opiate addicts get clean through step programs– a tiny fraction. Many of the rest of them die, you dumb-ass. Some of those people were friends of mine. So either wipe the smug self-proud smile from your face, or take it somewhere else. These people need help, and believe it or not, one size doesn’t fit all. Heck, I imagine I’d have trouble finding anyone who wears YOUR hat size!
I used to wonder why there are people like you who can’t just mind your own business, but have to butt in where you aren’t welcome. Then I realized that you have to come where you aren’t wanted, because you aren’t wanted anywhere! I think of ‘7 years’– she has spent the last three or four days changing her IP address, registering and re-registering, spending hours to get her post on the forum…. and there are a bunch of us moderators who just delete it as soon as she puts it there. What kind of great, solid recovery she must have- spending hours at the computer, making up phony names to get her post up for 30 seconds. And here you are– supposedly living great recovery, and yet after 8 years you are still lurking around blogs intended for people with questions about Suboxone. Sounds like some great recovery you got going there, dude!

A Day With Reckitt-Benckiser

I just got back from Chicago, where I spent the day learning about ‘best practices with Suboxone’ with the people from Reckitt-Benckiser. I feel an obligation to share my experiences with those of you who are so strongly connected to the efforts of R-B —and I am not referring to owning stock in the company. I’m not in the mood to go on forever; meetings with pharmaceutical company people always tire me out and even bring me down a bit—I’m not sure exactly why. I would almost think it would be the opposite, because things look so easy from the perspective of a PowerPoint presentation. Although as I put my psychodynamic background to use, I realize that an opposite reaction makes sense. Tune into my radio show podcast sometime and listen as I talk about psychodynamics; dysphoric feelings often spring from unconscious conflict, and there was likely conflict between what I was watching and hearing during the presentations, and what I was thinking and remembering from my practice.
Those of you expecting a story about conspiracy theories will be disappointed. I had the impression that the company is sincerely motivated to help people with addictions for the right reasons. They made it clear through their actions and plans for the future that they are in addiction treatment for the long haul, even after the patent on Suboxone expires. There are some things about the company that have bothered me, and I was able to ask questions about those concerns. I will share their answers with you as best I can remember.
I spoke with someone Friday evening who has been with RB since 2003, about the lack of general support in the field for Suboxone compared to other new medications. She believed that RB did a good job of introducing Suboxone, and that their results in numbers of doctors trained and patients treated were good. I pointed out that many, perhaps most, ER docs have no idea what Suboxone IS, let alone know how to manage accidental ingestion or overdose. I compared Suboxone to Shire’s Vyvanse, a medication that has been out for just over a year but has 10 times as many sales reps in the state where I practice. If I want a coupon for Vyvanse, a rep drops off a box of them by the end of the day! But we have two reps covering the entire state for Suboxone! The difference in our perceptions was a classic ‘glass half full or half empty’ situation. She said that when she started in the RB pharmacy division, they had 20 US employees—a tiny fraction of the resources in place for product launches from the ‘big players’.
So I asked why they didn’t sell the drug to one of the big guys, so that it could be rolled out with the fanfare and support given to Cialis or Viagra? Another person from the company pointed out that had they done that, they would have had a bigger problem over the shortage of physicians certified to prescribe the medication. And that was a good point. The bottom line is that Suboxone was a truly unique situation; a small company that had no significant US presence, the unusual requirement for special certification for prescribers, a target illness that is complicated by stigma and the risk of diversion by patients… mistakes were probably made, but mistakes are always made. I left the conversation realizing that the company had some unique challenges to overcome, and so far has done pretty well.
A couple other areas of new perspective: on the issue of the high cost (although I often point out that for a fatal illness, the treatment isn’t all that expensive), it was pointed out that if Suboxone was super cheap, say a buck a pill, there would be a much greater profit motive for diversion of the drug. I think that is probably a fair assumption; there would be more Suboxone on the street if it retailed for a buck per pill than there is at five bucks per pill.
I was happy to see how strongly they connected with the disease model of addiction; in my opinion that is the genuine state of affairs, and the natural way to present Suboxone. Suboxone is a chronic medication for a chronic condition, period. I have always figured that it was a mistake that the company initially talked up using Suboxone for short-term detox, and I heard nothing to change my opinion. They mentioned that a few years ago 70% of patients were prescribed Suboxone for short-term use and 30% for maintenance, and now those numbers have reversed and 70% of prescriptions are for long-term maintenance treatment. Those numbers are consistent with my experience.
There will be other buprenorphine preparations in the future, including depot injectables made by RB or by someone else. Also watch for different types of oral products, including designs that reduce the likelihood of accidental exposure in children.
If I had to complain about something, I would say that the corporate presentation just does not seem to mesh well with the reality on the street. I talked to one of the leading developers briefly about the problem with twelve step groups—how there is a vocal anti-Suboxone crowd, who often talk people into stopping their medication or refer to doctors who prescribe the medication as ‘pushers’. He said that Betty Ford had given her blessing to the idea that people on maintenance medications are still ‘in Recovery’. My thought in response was ‘who the heck cares about Betty Ford?’ I would bet that 99% of the NA and 80% of the AA folks in my home town have never heard of her! I do think that the split among the recovering community over buprenorphine is a serious issue that should be dealt with in a formal manner, through communication between people who understand neurochemistry and buprenorphine, with people from the twelve step intergroup organizations.
I also believe that some in the company, and some prescribers, don’t understand what it is like to be an opiate addict. I realize that nobody who is not an addict will truly understand addiction, but I don’t think they get that we are just like they are outside of our addictions. To give an example, the issue came up about the degree of counseling and meetings that should be required of people on Suboxone. I have put forward my thoughts on this issue many times. Many of the docs at the meeting talked about their practice of requiring ALL people on Suboxone to go through intensive outpatient treatment, and/or requiring twelve step attendance as often as every day! They require AA or NA not because of some theoretical basis, but rather because they think that addiction and AA or NA just go together. I did point out my thoughts on the issue, namely that people only ‘get’ twelve step recovery when they have some degree of acute desperation, and people on Suboxone are NOT DESPERATE. I ‘got’ AA quickly the first time I went to treatment, but the second time it took several months before my mind opened sufficiently to truly accept the program. Only people who have had a spiritual awakening themselves will understand what I am talking about, but going to meetings and just sitting through them is not that beneficial. I have been to meetings with people mandated to attend, and those meetings are generally a waste of EVERYBODY’S time. ‘Getting it’ in twelve step recovery is a moving experience that sweeps the addict of his feet, and pulls him by the heartstrings into a new way of thinking and living. I like that saying that ‘insight maketh a bloody entrance’; the insight required to get clean through the steps is bloody indeed! But these docs just sit back and say ‘no meetings, no Suboxone’, and wear their inflexibility as a badge of honor. I have been in that horrible situation as an addict where my opinion didn’t ‘count’, since I was ‘too sick’ to think logically… that is a tough spot, as the harder you argue, the more belligerent you are accused of being.
As for the scientific topics, I was glad to see that I am pretty much on target with my thoughts about dose levels, tapering, receptor actions, etc. Many docs start patients on twice per day dosing and later convert to once per day; I like to start at once per day from the very start, to avoid setting up a pattern that might be hard to break.
All in all, it was an interesting and informative weekend. I will probably make a couple small changes in my practice in light of things that I heard. And as for RB, I left the conference thinking that I will buy a few shares of their stock. They want to be a premiere addiction-related pharmaceutical company, and given the epidemic of opiates and other narcotics in this country and in other countries, the sky’s the limit!
SuboxDoc
Suboxone Talk Zone

A Common Mistake

I brought a note from the ‘comments’ section up here because it presents a topic that comes up over and over with opiate dependence and Suboxone. I am the expert on MedHelp.org’s addiction forum; I get questions and comments like this one quite frequently on that site– although I have addressed the issue so many times that I think people there know what my opinion will be on the subject. I will post the comment, and then write my own comments afterward.
I started on the Suboxone in Feb 08 to get off the opiates. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it b/c I had no more insurance and it was very expensive. I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped b/c I ran out of Suboxone. About 3 days after I stopped taking it completely I started withdrawing from the Suboxone. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. Once that began I started doing research on Suboxone withdrawals and people were basically saying that depending how long you were taking the drug that would depend on how long you withdraw b/c Suboxone stays in your system for a long time. So what did I do.. to get rid of the withdrawal feeling I was getting I started taking the opiates again. Then eventually I got addicted to those again. What I have noticed works with the suboxone is if you take it for about 10-14 days long enough for the opiates to get out of your system and stop taking the Suboxone you wont get sick and you will be successfully detoxed from opiates. Now the hardest part is staying away from the opiates. I am now on my 3rd day of the Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from the opiates by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you all posted and to everyone else doing the same.. GOOD LUCK TO ALL OF YOU!!
I have written about the natural progression of opiate dependence before, but I will review things again for newcomers. Early in addiction, the addict believes that if he can only get past the physical withdrawal, everything will be fine. During the first third of an addicts ‘using life’ he is always fighting for that first piece of sobriety– you see these people on message boards all over the internet, comparing tapering plans and different cocktails of amino acids or other worthless regimens to find the one that ‘works’– that gets them through a taper or withdrawal to become opiate-free. They usually are not interested in meetings or rehab at this point; they don’t consider themselves to be ‘THAT kind of addict’ who needs that much help– just the right pill to get through the worst of things. These are the people who often insist that Suboxone be used only short-term, as a bridge to sobriety. They have no interest in the idea that they have a life-long illness, and will argue that point until blue in the face, even as they continue to use opiates on a daily basis. Denial is huge during this stage of addiction; the addict minimizes the impact opiates are having on his relationships, work, and health status. It is easy to discount all of those things because he considers all of the messes to be temporary and ‘easily corrected’– once he just stops the darn opiates. He assumes– sometimes for a long time– that the ‘right method’ will come along… eventually. Hooked? Not him!
A person enters the second stage of addiction when he has been able to successfully taper of opiates. From my vantage point of seeing many, many addicts over time, this point is not associated with any particular taper method or amino acid formula, but rather occurs when the person has enough consequences to motivate him through the withdrawal. More and more bad things pile up until they cannot be repressed and ignored; job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences. During the first stage, the addict would get to a certain level of withdrawal and say ‘screw this!’ and resume using, but during the second stage the problems are remembered even during bad withdrawal, and the addict stays motivated to be free of opiates. The taper that eventually works is often the worst one; the addict just says ‘enough!’ and stops without any plan or preparation. Or perhaps the consequences lead to a jail cell or being completely broke– again, resulting in sudden and absolute sobriety without the luxury of a taper or meds to reduce the severity of withdrawal.
That’s great, right? He is finally there– free of those opiates… or so he thinks. But unfortunately he is about to enter the third and worst stage of opiate addiction– the stage that can last for years and years and that totally demoralizes the individual. This stage begins with relapse, and it can happen after a week, or it can happen after a year. The bottom line is that it almost always happens– and that NOBODY thinks it will happen to him. I hear the comment over and over– ‘no doc– I don’t plan to relapse!’ or ‘I know what you are saying– but you don’t understand the way I am!’ Everyone considers himself too smart for relapse, but I see the AA adage come true over and over: nobody is too dumb for Recovery but some are too smart for it! The meaning is that every now and then a person will avoid relapse– and it tends to be a person who has a ‘simple’ outlook on life who didn’t really ‘shine’ in other, more competitive areas. Someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities. That person can sometimes simply stop using because he easily accepts the idea that he has lost the fight– that opiates are much stronger than he is, and that he will never figure out how to take them without disaster.
Most people, though, are way too smart for this situation; as soon as things start going well their minds take off again… and at some point they return to using. I’m not going to spend time on all of the triggers for relapse, but maybe I will discuss that another time– but there are things common to all relapses, including rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness’ that I mentioned above, where all of the warnings are an issue for OTHER people. During this third stage, the addict will have repeated episodes of relapse and sobriety; there is little joy in using since consequences occur much more rapidly now, so more and more time is spent being sick from withdrawal. This is the stage that most long-time addicts remember, and fear, the most. In my case, I could stop using every weekend; I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME– come Monday I won’t touch ANYTHING!’ And so I was always sick; the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them. And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with. As I mentioned earlier, during this stage the addict becomes truly ‘sick and tired’. This is a dangerous period of time for the addict for a number of reasons; when the addict uses he feels a great deal of shame, which fuels more using– making use more impulsive and reckless and more likely to cause a fatal overdose. The addict also becomes depressed– sometimes extremely depressed– and commits suicide, either actively or through just not caring anymore about the risks of taking too much. The addict sometimes feels such a wave of hopelessness or shame that he needs to do ANYTHING to change how he feels– so he swallows any pill he finds, or shoots up something that he doesn’t even know the actions of– he just needs SOMETHING! Even a hammer to the head looks good at this point!
This is the time when traditional treatment has been effective; the addict is at rock bottom, and he no longer feels confident about any of his own abilities. He is ready to follow ANYONE or ANYTHING– after all, what does he have to lose? Life is over anyway– so why not listen? If the addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a genuine shot at some meaningful sobriety. If, though, he gets into treatment and quickly makes a girlfriend, or he can tell jokes and be the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is… there is a strong chance that the treatment will prove worthless. He needs to hold on to the attitude that he knows nothing, for only that attitude will allow true learning and change to occur.
This is why, in my opinion, young people have lower success rates in treatment. Young people often feel way too invincible for treatment to take hold. They also have short memories for painful events; consequences are quickly forgotten and dangerous self-reliance returns. The true wonder of AA is that the program designers understood all of this; the program is all about humility and powerlessness, and consists of a series of steps that, if practiced completely, will take a person to the right frame of mind and keep him there– provided he continues to work the program. The reason treatment tends to work better for older people is because first, more are at the later stage of addiction when they are truly ‘sick and tired’, and second, self confidence tends to return a bit more slowly. Us older folks tend to remember the bad things because we know that some friendships can be lost forever. Plus it is difficult to feel immortal when one’s body aches each morning!
I’m sorry to pick on the writer of the comment above; I could do this with many of the comments that I receive from those who plan ‘short term’ use of Suboxone. In light of what you have read, go back and read the comment again; see if you can tell the stage of addiction that the person is experiencing. Again, I get these types of comments over and over, both here and at the other site that I mentioned. I have watched, over the past 16 years, as addicts (including myself) have gone through the same process. Every person is convinced that HE is different– only to eventually find that in regard to addiction he is the same as everyone else. This is why I recommend seeing Suboxone as a long-term medication… or seeing AA or NA as a life-long program.
One final comment… the three stages that I use to describe opiate dependence are ‘mine’; I have noticed them over the years and they continue to be retold in my patients’ stories, and so they appear entirely obvious to me. I have not seen the stages spelled out in this way by others, so if at some point others agree with me, let’s name them the ‘junig stages of addiction’. I accomplished one more of the ‘goals of my life’ a few weeks ago when a guy met me at the airport with my name on a piece of cardboard; having something named after me would scratch one more thing off the list!