How long are you going to take that stuff?

I have produced a few educational items, and I sell themt priced at a small fraction of the street cost of one tablet of oxycodone.  All proceeds go toward the support of this web site, the forum, and other educational efforts.  The most popular item is the e-book called ‘User’s Guide to Buprenorphine.’  You can get a sneak peak at the inside of the book at Amazon.  I receive good feedback about the e-book but the most ‘successful’ recording has been the one entitled ‘How long are you going to take that stuff.’  The recording is designed for parents, spouses, or children of opiate addicts who take buprenorphine;  especialy for those family members who don’t quite ‘get it,’ who ask the title question every week or so.
I have had several patients tell me that their loved ones changed their tone after listening to the recording, in which I explain the basics of opiate dependence and tell the listener why it is often in a person’s best interest to stay on buprenorphine for an extended period of time.  I have also received comments in e-mails from people who had similar success with the recordings.  If you have a close friend or loved one who means well, but who just doesn’t understand the point of buprenorphine, consider turning him/her on to the recording.  Check out the other recordings as well, and thanks in advance for your support.
JJ

Is She Still Using?

I have been involved in Q and A with a person in another part of the country, and will share some of our exchange after removing the identifying info. BTW, I receive many e-mails from people and I just don’t have time to answer most of them; I DO provide ‘educational consultation’ (not a ‘medical’ relationship) at a rate of $100 per 30 minutes, and anyone is welcome to set that up by writing to [email protected]
The person below consulted me over her daughter, who is addicted to opiates and on buprenorphine but not doing well. The grown daughter receives some level of support from her parents, who are in that horrible position of trying to pull back to avoid enabling while at the same time fearing that pulling back will cause relapse or worse. The mother has had the impression that her daughter is sedated from buprenorphine, and that the buprenorphine may be making things worse. Mom considered helping daughter pay for ‘rapid opiate detox’ to ‘get off Suboxone’ at one point; I was not a big fan of that idea, as I have seen people do poorly after that approach (in my opinion, GETTING clean is much easier than STAYING clean).
Our exchange:
She is still on suboxone but we are paying for it. her weekly appt last week was on wednesday and she did not bring us her prescription to have it filled until saturday which means she did not have any meds for 3-4 days.
She was like a wild animal when we saw her and told us she has filled it herself. Then finally Saturday she gave us the prescription and told us to fill it for her.
Number one: why would she have waited so long, would this be a sign of a relapse? Number two: can you stop for 4 days and then start up again? Wouldn’t this make you high from it? She is on 16 mg.
She is NOT doing well with Suboxone, could she be using it to subsidize the in-between times or something?
Just can’t figure out why a medicine that is supposed to make her better is making her worse?
Hi XXXX,
I find myself in the position of defending Suboxone– and wish I had something else to suggest. People taking buprenorphine comprise about 20% of my psychiatry practice, and I have not taken a new patient for buprenoprhine treatment for over a year, so I want to make it clear that I am not a ‘Suboxone zealot’. I’m just trying to be frank about what I see with addiction.
I often end up saying things like ‘it isn’t fair to Suboxone.’ When I say that, I am not concerned about ‘fairness’ toward a business plan or marketing strategy; I am speaking of ‘fairness’ in an intellectual sense. Maybe instead of ‘fair’ I should say ‘proper’—I will try that below and see if it helps clarify my point.
Your last comment is an example of why I have the forum and blog, as I hear similar comments frequently— i.e ‘why a drug that is supposed to help making her worse?’ That is NOT an intellectually honest question. SOMETHING ELSE is making your daughter worse, and buprenorphine is keeping her alive. I lived as an addict for 10 years BEFORE Suboxone, and I saw what things were like with only methadone as an option. While there has always been residential treatment, the results of treating opiate dependence with residential treatment have always been poor.
In the past six years, 1200 people died in Milwaukee from overdose. There is nothing special about Milwaukee; recent stories in Time, Newsweek, and elsewhere have highlighted the dramatic increase in overdose deaths from ‘prescription medications,’ largely opiates and benzodiazepines. We do not know what would have happened in your daughter’s case, had she not gone on buprenorphine. She very well might have died by now. She might be in prison. We don’t know—but at any rate it is not PROPER to ‘blame’ buprenorphine, when in fact the medication may have saved her life. The fact that she is still sick is most likely because addiction has many factors and consequences that are impossible to define, let alone treat. I have seen the outcome of untreated opiate dependence too many times. That outcome consists of either death or incarceration. The deaths have been mostly ignored until recently, and I imagine that after this ‘news cycle’ we will return to ignoring them. But the deaths are still there, every day. One result of being a physician who treats opiate dependence is that I now read the obituary section of the newspaper; I sometimes get ‘follow-up’ there on people who had at one time sought help, but for whatever reason had stopped coming to appointments.
To answer the other questions, it is very unusual for a person who is doing things right to forget to fill a prescription for buprenorphine. At first, people in treatment may wait until the last minute, then call in a panic saying they will run out the next day. One of my jobs is to get them living like ‘normal’ people, i.e. planning ahead of time and respecting boundaries, including not expecting me to drop everything because THEY forgot to schedule an appointment. Your daughter should learn to take care of the basics herself, and suffer some degree of consequences should she ‘forget’ to plan ahead. Every addict, of course, has many excuses for not being able to make appointments, call in requests for refills ahead of time, etc… even if the addict is doing nothing all day, and the caretaker is working three jobs! That dynamic must change so that the addict is responsible for herself.
Yes, stopping buprenorphine for 4 days and then restarting it will result in the person ‘feeling’ opiate effects. It is difficult to sort out whether the person is feeling ‘high,’ or just feeling the loss of withdrawal—but there would definitely be relief associated with taking the buprenorphine after 4 days. The goal with buprenorphine is to avoid that cycle of ‘sickness’ and ‘relief’ and to instead feel normal all the time. And ‘normal’ is what the vast majority of my buprenorphine patients describe; they say that they feel nothing with each dose, and that they don’t feel ‘high’ at all. Feeling ‘normal’ is consistent with the chemistry of taking buprenorphine; the person becomes completely tolerant to the effects of the medication and as long as the blood level remains above a certain threshold, there is no sense of something wearing off.
In the case of your daughter, I agree with you—something is not right. She is either using opiate agonists intermittently or she is still very much wrapped up in wanting to ‘feel’ something—or both. There are deficiencies to all testing methods, but she should have a ‘state of the art’ urinalysis at some point when things are irregular. By ‘state of the art,’ I mean a test that is witnessed (most labs can provide this service), that has a chain of custody, and that is analyzed at a certified medical laboratory.
In a case like that of your daughter, it is important now and then to return to basics– does she WANT to live a clean life? What is motivating her to do well, and what is motivating her to do poorly? Are there sufficient consequences for bad behavior? Is SHE the one working the HARDEST on her sobriety? She SHOULD be, by the way… when I see a situation where everyone else is working to help a person stay clean, I know that bad things are coming.
I realize that it is simply horrible, what is happening to you and to your daughter. You are being forced to distance yourself from her so that she will take on more responsibility for herself, and so that you are protected to a small degree from the horror of the current situation and the fear of what could come at any time. That distance is just like any other significant loss. Understand that it isn’t your fault, and you are not alone. I often compare opiate dependence to cancer; both illnesses have consequences far beyond the risk of death. The loss that you are experiencing is similar in some ways to what cancer patients go through, when they see close friends back away out of fear of death and dying.
The one consolation is that for most people, age brings insight. I have many people on buprenorphine who do very well—they take a daily medication as they would for any other chronic illness, and lead happy and productive lives. But I also have a few younger patients who do not do as well—particularly those under age 20. In those cases, the course of illness includes a constant battle to prevent the addiction from going ‘underground,’ i.e. where the addict keeps secrets from the physician, and there are periods of stability and relapse. In such cases I hope that buprenorphine at least allows me to keep the person alive and out of prison (and hopefully employed or in school as well). The addict’s life may still be chaotic, but each day the person is a little closer to age 30—an approximate age when insight seems to have a better chance of taking hold. Hopefully your daughter will gain insight as well as time passes. If she only loses a decade of her life, she still has much to live for.
As always, I’m sorry for what you are going through. Protect yourself first; make sure you are doing all that you can to keep your own sanity intact.
JJ

Buprenorphine and the Dynamic Nature of Character Defects

What follows is a lightly-edited version of one of my posts from a couple years ago.  I still think that this is a good model for understanding the actions of buprenorphine.

Buprenorphine and the Dynamic Nature of Character Defects

‘Suboxone’ and ‘Subutex’ are the trade names for medications that contain buprenorphine, a substance used to treat addiction to pain medications and/or heroin.  Buprenorphine treatment for opiate dependence has been an option in the US since 2003.  Other treatment approaches for opiate dependence have been used for decades but have had limited success.  With a little imagination, treatment approaches can be placed on a continuum depending on the degree to which the treatment demands changes in the personality and behavior of the addict.  Methadone maintenance is often described as a means of ‘harm reduction’ by preventing the behaviors related to the obsession for opiates or by reducing intravenous use of heroin or other substances.  At the other end of the treatment continuum there are the step-based and other Recovery programs.  One limitation of programs that demand personality change is that such change is difficult and rare, and usually only occurs after a significant amount of despair has been experienced by the addict.  Opiate dependence differs from other addictions in the lethality of overdose, and the fatality rate of even early abuse of that class of substances.  Opiate addicts are at significant risk of dying from their addiction before enough desperation has accumulated to motivate personality change.  A second limitation is the high rate of relapse that occurs even after sustained Recovery.  If a ‘changed’ addict stops actively participating in the program that induced the changes, the personality of the addict tends to revert back to the personality that was present during active drug use.
I initially had mixed feelings about buprenorphine treatment of opiate dependence, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the past four years from what I have seen and heard while treating over 400 patients with buprenorphine.  But while buprenorphine has opened a new frontier of treatment for opiate addiction, arguments over the use of buprenorphine often split the recovering and treatment communities along opposing battle lines.  The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine offers huge benefits for the health and lives of opiate addicts.
A unique medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use buprenorphine 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 buprenorphine as having an ’inferior’ form of recovery, or no recovery at all.  This leaves buprenorphine patients to go to Narcotics Anonymous and hide their use of buprenorphine.  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 buprenorphine 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 buprenorphine.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opiates than for other substances.  This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Buprenorphine has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opiate addicts have a number of such ‘defects.’  The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opiate addicts with buprenorphine—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 buprenorphine 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 buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with buprenorphine.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with buprenorphine have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Buprenorphine 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 buprenorphine patients, and more convincingly with the spouses, parents, and children of buprenorphine 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 buprenorphine treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining buprenorphine treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between buprenorphine and traditional recovery becomes clear.  Should people taking buprenorphine 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 buprenorphine do not feel desperate.  In fact, people on buprenorphine often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should buprenorphine 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 buprenorphine I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist that has a long half-life in brain tissue.  This long half-life promotes a relatively constant state of opiate stimulation, reducing opiate cravings between doses.  But while the ceiling effect of the partial agonist buprenorphine results in a stable, unchanging tolerance to the medication, methadone has no such ceiling, and tolerance will always increase with increasing dose of methadone.  This constant increase in tolerance erodes the ability of methadone to satiate cravings for opiates.  A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.  With cravings comes the obsession to use and the associated character defects.  This explains one difference in the subjective experiences of addicts maintained on buprenorphine versus methadone.  Methadone maintenance is also usually experienced as more sedating than the effects from buprenorphine.  There is a valuable role for methadone to play as we try to prevent deaths from opiate dependence, but I see the mechanisms of action of methadone and buprenorphine to be profoundly different.  Methadone is appropriately described as a ‘maintenance agent,’ but I see a more appropriate term for the actions of buprenorphine, as a ‘remission agent.’  This term accounts for the effects of buprenorphine on the obsession for opiates, and the ability of the medication to allow for dissolution of the character defects caused by active addiction.
The downside of buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine 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 buprenorphine.  Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Buprenorphine itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting buprenorphine reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of buprenorphine use implies long term use of the drug.  Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary.  Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not buprenorphine will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on buprenorphine 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 each other’s weaknesses.

Part of my story; part of my book

I’m often asked “hey, what is YOUR story?”  That opens the door to a long, drawn out presentation… or I’ll just say “I have a book about the subject ready to go– do you know any publishers?”  I DO have a book ready to go, by the way…  and I welcome any e-mails from people with ‘industry connections.’  The book is about my story, of course, but is also an attempt to examine ‘addiction’ in a way that provides greater understanding of the condition.  A family member of an opiate addict will understand addiction better after reading the book, for example.  I also talk about Suboxone quite a bit.  In fact, readers of this blog will know how the book goes, as the book is a reflection of this blog.  In some chapters I share comments from other addicts, and use my responses to their letters to make a point or two.  My goal while writing was to discuss opiate addiction and buprenorphine using what I learned about the mind and brain while getting my PhD in Neuroscience, using insights from my experiences as an opiate addict, and using what I have learned as a doctor and psychiatrist.  My perceptions were also influenced by my experiences in residential treatment, aftercare, recovery, working as med director of a treatment center, and my own psychodynamic psychotherapy.
This post is a ‘teaser;’  I will share the first part of chapter one here, and you can finish the chapter at SuboxForum, at this link.   I hope you like it– and  if you know a publisher or book agent, please send me an e-mail–  you can go to my private practice site and just send it from there.

My Story

Nature vs. nurture
I grew up in a small town in Wisconsin, the son of a defense attorney and a teacher. I was the second of four children. I will not get into a drawn out psychodynamic exploration of my upbringing at this time except to note that I firmly believe that the way I ultimately turned out is a result of a combination of genetic, developmental, environmental, and personality factors. There were probably elements of my early life and also genetic factors that predisposed me to become an addict, but I believe that each person can point to similar predispositions. I am the one responsible for how I used the gifts and liabilities that shaped my life.
The nerd
I was a very cheerful young child, but at some point I began to struggle with social interactions. By the time I was in high school I was clueless about fitting in. The things that seemed impossible back then look easy now; why didn’t I simply look at what other kids were wearing and imitate them? That idea never entered my mind, and I cringe when I see pictures of myself at that age. Why did I think any boy should enter a school with embroidered blue jeans?! I did well with the academic aspects of school, always scoring at or near the top of my class with little effort. There was little respect for academic achievement in my rural high school, and I blamed my academic performance for at least some of the harassment directed my way. By the time I was a sophomore I was literally afraid for my own safety on a daily basis. I had several incidents where I was facing bullies, my back against a wall. I was deeply ashamed when the bullying occurred in public, and I certainly didn’t want my parents to know that it was happening. I was physically beat up on two occasions, both times accepting the blows with no effort to fight back or defend myself. The clear message from my father was that real men do not run away from a fight, and so running was not an option. But I didn’t know how to fight back, and was afraid that if I tried I would only be hurt worse, so the outcome of my ‘don’t run’ strategy was not great!
I ‘tried on’ different personalities during my last two years of high school. I became a druggie, growing my hair long and replacing the smile on my face with a look of apathy or disgust. I sported an Afro and used a pick instead of a comb. I smoked pot and drank beer when not in school. The changes worked as intended, and the harassment from other students stopped. But I was still on the ‘outside looking in’. Some people who lack social skills seem to come to terms with their unpopular position and quit trying. That wasn’t me; I continued to try to be one of the popular kids, kissing up, tagging along, and laughing at the stupid comments of ‘jocks’… Yuck! During my senior year I joined the cross-country and track teams, and in retrospect I was fitting in at the time without even realizing it. But by my high school graduation in 1978, the year when marijuana use peaked in the United States, I was a daily pot smoker with a great GPA, little confidence, and no direction in life.
I attended the same liberal arts college that my older brother was attending mainly because that was easier than finding a college that I liked more. I took the courses that were the most interesting and ended up majoring in biology. College came very easy to me because I had a genuine interest in what I was learning. Everything I learned seemed to answer a question that I always wondered about. That is, by the way, is a great way to attend college!
I was in a couple of relationships in college that in retrospect had addictive traits to them. After a difficult breakup during my sophomore year I became very depressed, and afterward spent several months engaged in the heaviest drug use of my life. My fraternity house provided ready access to pot, opium, cocaine, Quaaludes, marijuana, LSD, and hallucinogenic mushrooms. I wonder if I carried so much anger under the surface that I had a ‘death wish’; I have hazy memories of walking on a ledge seven stories up, losing control of a motorcycle and ending up in someone’s front yard without wearing a helmet, and wandering around in tunnels under the streets of Milwaukee after climbing down a manhole. I was lucky to survive those experiences, and I now try to understand similar behavior—extreme risk-taking and impulsivity—in addicts who are patients of my practice.
Local hero
Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since. During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks. I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic! To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy. But then I realized that something was fast-approaching in the current. I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight. I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling. I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her. After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!). To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”
I am grateful that I was given the opportunity to be a hero. There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God.
Getting serious
Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York. After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program. I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school. My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.
Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways. His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after. After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country. Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’. But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.
Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home. At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.

Junig as anesthesiologist at Suboxone Talk Zone
A stage of my life

Treating myself
In the spring of 1993 I took codeine cough medicine for a cold. A few weeks later I was still taking the codeine each evening. It worked so well; finally I could relax and get some quality sleep! I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word. I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated. I had ALWAYS accomplished what I set out to do! By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed. The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings.
I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all! Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said. “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.” I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well?
As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine. After trying to find will power and failing over and over, I finally ‘got it’; I had no control! As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day.
Continue…

Overdose Memorials during an Epidemic

I sometimes get the sense that there is a parallel universe besides this one, and I am not sure which one is real.  In one, the kids grow up safely, and every premature death is cause for alarm that generates immediate effective action by the community.  In the other universe, kids in their teens are dying in ever-increasing numbers, and only their family members and a few close friends react with alarm.  After a few weeks each death is forgotten and life goes on–  for some.  The parents and siblings of the children who lose their lives somehow stumble forward, living the rest of their with the horrible realization of this second universe–  the one that they didn’t know about until it was forced upon them.
My heart goes out to any parent who has found the way to this blog.  If it is not too late, take the situation– the addiction of a child to pain pills- in the most serious way possible.  If you have the resources to move to the middle of nowhere– a place where there is not a significant problem with opiate addiction, if such a place even exists– just go.  Take severe and drastic measures. 
I wanted to share two things that I heard about today.  The first is that there are several ‘sober schools’ in Wisconsin-   Charter high schools for students who have been through addiction treatment.  I figure that it is tough to get a kid to go to such a high school… but in the case of opiate dependence the teen should not be given a choice in the matter.  The risks of death are simply too high for a teenager to comprehend.
The second thing is a web site devoted to preventing prescription pain pill use by teens, with a focus on Florida.  The memorial page— or more accurately pages– are quite moving.

Withdrawal in newborns: Lay off the guilt trip!!

I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction.  I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother.  My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response.  Read on:

There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction.

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about that discomfort—at least not from the baby’s perspective.  I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal.  Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s – babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose.

My points are twofold, and are not intended to encourage more births of physiologically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right.

Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.

Another one?

I have no idea what killed Brittany Murphy.  The press are reporting that she had a ‘heart attack’ at age 32, not fully understanding the difference between a ‘heart attack’– which typically refers to a heart that stops functioning because of an inadequate suppy of oxygen, usually from coronary artery blockage– vs. ‘cardiac arrest’, a garden-variety term used by coroners who must cite a cause of death without an autopsy, reliable history, or lab results.  We ALL die of cardiac arrest in the end.  Opiate addicts usually suffer respiratory failure, either because of a reduced drive to breathe secondary to the effects of opiates at the brainstem, or because of a ‘blocked airway’ caused by stomach contents gettting into the throat and/or trachea.  The respiratory failure ultimately leads to too little oxygen at the heart, causing the heart to either stop beating or to go into an erratic beating pattern called ‘V-Tach’ or ‘V-Fib’, eventually failing to keep blood flowing to the rest of the body– particularly the brain.

Britttany Murphy with USO, July 2009
Britttany Murphy with USO, July 2009

Reports of Brittany’s death have mentioned that ‘prescription medications’ were found at the scene.  The phrase ‘prescription medications’ is usually code for ‘pain pills.’  And since the death rate for opiate addicts is so high, I am going out on a limb in a BIG way.  I am not trying to make a prediction– only to eventually make a point about opiate addiction, admitting that I may be making the point prematurely.
Britttany Murphy was rumored to have an eating disorder and an addiction to cocaine.  I don’t mean to impugn her character, and hopefully anyone who reads my blog understands that addiction is a disease that NOBODY asks for or deserves.  My concept of addiction would include an eating disorder, by the way.  I am sure that readers have a hard time understanding where I draw lines of responsibility;  I often write from a stance requiring ‘personal responsibility,’ so where do I get off, you ask, painting Brittany Murphy as a victim?  My answer is that it is possible to be everything at once.  We are all responsible for maintaining the behavior necessary to keep ourselves alive.  But there are times when we fail– all of us.  And most people who ‘fail’ and as a result become addicted to drugs face penalties constantly from that point forward– very rapidy getting to a point where we have been punished enough.  IF Brittany Murphy died from complications related to addiction, her death would be on top of the many evenings of misery she already endured– waking up early shaking with chills, running to the bathroom with diarrhea, missing parties at the last minute because of being too sick to go, and the demoralization that comes from looking in the mirror each morning and seeing that pathetic, failure of a person looking back.  Sometimes we look at celebrities and picture the moments when flashes are going off and the person is mugging for the cameras.  But from the moment this morning when I heard that Britttany Murphy had died, I felt (again, perhaps incorrectly) as if I know her very well.  I know how she felt each morning.  I know the relief she felt when certain people ‘came through’ for her.  I know how she felt about having a double personality– that all of her fans thought she was this great person, and deep inside she felt like a liar for keeping her secret from them.  I know how she felt when things looked hopeless– when she thought there was no possible way to escape.  I know how she felt when she was alone with the bathroom door closed and locked, wishing that things would just end without ever taking another step outside that safe little space.

If I am wrong, I am sorry– and I am thinking about someone else who is one of thousands of people who think exactly alike about a few deeply-personal things.  If I am right, I’m sorry that the long list got a little longer with the name of someone so obviously special.
JJ

Reckitt-Benckiser's 'Here to Help' Program– What do you think?

Reckitt-Benckiser, the first (but surely not last) manufacturer of orally dissolvable buprenorphine sold under the brand names Suboxone and Subutex, has been aggressively pushing doctors to refer addicts taking buprenorphine into a program called ‘Here to Help’ that they promote as something that will keep patients compliant with buprenorphine maintenance.  Regular readers of STZ know that I have not been impressed by Reckitt-Benckiser over the years, and so I’m not going to just jump on the ‘here to help’ bandwagon unless I see value in the program for my patients.  I have referred SOME patients to the program, but the feedback I have received has not been positive.   Patients have told me that they receive confusing or conflicting information, or that the person on the phone seemed ‘scripted’ and not responsive to the person’s specific needs, or that the information they were given assumed a knowledge level below what the patients already had.
Why am I unhappy with R-B, you ask?  If you go on the web site of any pharmaceutical company– from the smallest, like Dey Pharmaceuticals, distributor of the MAOI patch called Emsam, to the large companies such as Pfizer– you will find a section with procedures and applications for grant support for unrestricted educational programs, investigator-initiated trials, or other purposes.  Little Dey Pharma has released tens of millions of dollars for community educational projects.  Pfizer provides hundreds of millions of dollars for similar purposes.  But try to find a similar web site for Reckitt-Benckiser (the Suboxone division) — let alone any contact info for grant applications!  I have tried for several years to simply get the name of a person to speak to about financial support to expand my efforts, and the result is always the same?  I will receive a phone number of a low-level sales manager who tells me ‘he (she) will look into it and get back to me.’  I’m still waiting.  I would like to apply for assistance for what I do best– educate addicts about opiate dependence, and educate physicians about how addicts feel about treatment and about what their doctors are missing.  I would also like to create a program to address the internalized shame that most addicts on buprenorphine continue to struggle with, no matter how long they are away from active using.  I won’t go into specifics here, but there are so many things that could be done—that SHOULD be done.  I know some of the things the company spends money on; I resent that they do not see the value in my efforts.  And I am annoyed that they don’t even have an application process that would allow them to at least pretend that they are interested!
There are so many ways to become involved with buprenorphine; there are organizations like SAMHSA and CSAT and others that provide education and research into the use of buprenorphine.  I was a ‘mentor’ for physicians with new buprenorphine practices for a short time and I have considered becoming active in SAMHSA or the other agencies.  But if find those types of organizations to be inefficient compared to what I can do speaking to addicts directly, through the blog or forum.  I also know where my strengths lie, and where they don’t.  I do not do well as a ‘consensus builder’, for example—such people must be careful about what they say, whereas I tend to say what I am thinking.  If a meeting is running long because someone is repeating how much he/she wants to do the right thing for all of these poor addicts, I am the person who will stand up and say ‘y’know, that is a given—and this is all a massive waste of time.’  And then for some reason I won’t get invited back again!  Those meetings are not for me.  My favorite recovery ‘saying’ is ‘a good man knows his limitations’—and that is one of my limitations.  My strength comes from the fact that I understand how opiate addicts feel, and how they think.  I always seem to know what an opiate addict is going to say next.  On the other hand, I never have any idea what a government bureaucrat is going to say, or what I should say when speaking to one!
I suspect that R-B would like me to get on board the Here to Help message.  But I have reservations about the program.  I suspect, for example, that it is primarily being supported by R-B in the hopes of somehow using it to maintain their ‘brand’ over buprenorphine.  If that is their intention, good luck to them– it is going to need some awesome content to keep people buying Suboxone for $8 when generic Subutex is selling for $2.55 at Walgreens!
Today I received a brochure describing the results of a ‘study’ that claims that patients in the ‘Here to Help’ program had improved compliance as measured by maintaining appropriate use of prescribed buprenorphine.  As some of you may know I got my PhD in Neurochemistry doing basic science research and I have served as a Peer Reviewer for Academic Psychiatry for a number of years, so I know how to evaluate whether a study is ‘sound’ or is instead misleading. Even in the material that I received today, R-B refers to the findings as coming from a ‘quasi-study design’—so they at least apparently recognize that the findings are biased.  I participated in the data collection for the study, actually;   those of us who participated would invite new patients to participate, and the patients who accepted the invitations would then be randomized so that one group would get the ‘here to help’ info and the other group would not.  R-B found that the here to help group had better compliance and fewer drop-outs than the other group.  One problem I have is that I don’t know what they did for the ‘non-study’ group.  For example if they told the non-here to help group ‘Suboxone will kill you if you keep taking it’, then the difference in compliance would be meaningless!  I’m sure they didn’t say that, but what DID they say?
Second, there was no way to ‘blind’ the study on either side—both the addict and the phone person knew which group the study person was in.  We like studies to be ‘double-blind’, and this one was not even single-blind.
Finally, participation in the study was voluntary, and we don’t know anything about the factors that caused some people to enroll and others to avoid enrolling.  Let me explain how that bias could have affected the results.  Patients were paid to participate in the study, so I would guess that the addicts who were unemployed were more likely to participate.  Likewise, the addicts who were, say, executives from a high-profile company or physicians or attorneys would be less likely to participate, as they would be more concerned about disclosure of their status as addicts.  So at best, the ‘here to help’ study looked at a specific subset of addicts—those who were interested in making $100 by talking on the phone for a half hour.  Would the here to help program be of any value for a person who is still working, making good money, who has not suffered many consequences yet?  We don’t know.
So… I am interested in your feedback.  Have any of you used the ‘Here to Help’ program?  If so, what do you think about it?  If you have NOT used it, why not?  Did your doc tell you about it?  Leave your answers in the comments section—you do NOT have to leave a real name, and I will not use your e-mail for anything (it does not get displayed in your comment either).  Your comment won’t show up immediately; for spam purposes I will approve the messages as I receive them.  But here is your chance to let RB how you feel about that program—or about anything else, for that matter.  Will you use the generic, or stick with the brand?  Why or why not?  Leave your comments and I will be sure to send them at least as far up the chain as I can reach!
Finally, I continue to ask for your support.  I note that our forum is over 1500 registered members strong and growing; the older forum supported by R-B has about 200 registered members.  You must know that your presence just warms my heart!  If you have some money to spare and want to join me in my efforts (a pipe-dream of mine!), let me know and we will truly do some good things out there.  Lest anyone thinks I’m getting rich from this, I have received 3 donations of $50 over the past few years, and a few of $5-$10.  That’s it.  And that’s fine—I just don’t want y’all to think I’m cleaning up with this blog.  Maybe I should start posting each donation—leave a comment if you have an opinion on that as well!  If I help you out or if you care to support my typing away on the blog, or help with the self-publishing of my eventual ‘big book,’ a small financial donation is always greatly appreciated.
The main thing you can do to support me is to spread the word.  Send my links to anyone you know who takes buprenorphine– links for the blog, and for the forum too.  Better yet, print out the link and give it to your doctor and tell him that you like it (if you do!).
Got all that?  I suppose I could have just typed ‘what do you all think about the here to help program’ and gone to bed an hour ago!  As always, thanks for reading.  And I wish you all the best at keeping the scourge at bay.
JJ

SuboxDoc Goes Negative!

I received a couple responses to my youtube videos tonight that are worth responding to.  For people who haven’t stumbled across the videos, you will find them if you go to youtube and search under ‘suboxone’ or ‘suboxdoc’.  They are pretty much the same thing as what you read here—a combination of my experiences in treating opiate dependence using Suboxone, education on the actions of buprenorphine, some of my personal ‘theories’ (maybe ‘opinions’ is a better word) on the relationship between sober recovery and buprenorphine maintenance (what I like to call ‘remission treatment’, to distinguish it from methadone maintenance, which works through a different mechanism), and my thoughts on the different treatment options for opiate dependence.

Blogging in general has been an educational experience.  I was initially surprised by the number of people who send out very angry messages to a person who simply tries to share knowledge and advice!  Just today I received a message accusing me of ‘getting my degree from a crackerjacks box’ for my opinion that ‘Suboxone withdrawal is NOT the worst withdrawal ever.’ I didn’t get it there, by the way.    I don’t know how to take the responses posted a few minutes ago that are tonight’s topic;  I am not sure if they are simple questions, respectful disagreements, or sarcastic comments.  You would think a psychiatrist would know one from the other!  Maybe the person will add more angry comments after my post, and then I’ll know for sure.  Or maybe there will be nice comments.  Whatever…

The comments, from someone going by ‘cbarrett34’ on youtube:

Dr. I’m curious, why do you say that there is no cure for opiate addiction? That doesn’t give people a lot of hope, if a Dr. is telling them there is no cure or hope for you. Basically leads to apathy and more using.

(That one was clearly very nice).

And the whole saying, once an addict, always an addict. That’s not a very positive viewpoint either.

(That one is harder to tell, don’t you think?  I might just be paranoid from that crackerjacks comment)

My answer, which as always is just one opiate addict/pain doc/psychiatrist’s opinion:

My first thought is that staying clean from opiates has nothing to do with ‘apathy’.  Maybe smoking pot has something to do with apathy, but people actively using opiates are some of the most non-apathetic people you will ever see!  There is no time for ‘apathy’ for an actively-using opiate addict;  there is that hit that is required every 4-8 hours to avoid being sick, there is that need to scam someone out of money to score the dope that is needed every 4-8 hours to avoid being sick, there is that need to come  up with a good lie to tell the parents/spouse/cops/PO/boss/kids to explain the lousy behavior over the past few months or years…  being an actively using opiate addict is a lot of work!  There is definitely a negative attitude that develops after months or years of using, but it is nothing like ‘apathy’.

Too Negative?
Too Negative?

My next thought is that I wonder what the writer would prefer—‘positive’ lies or ‘negative’ truth?  The idea that heroin or oxycontin addiction is ‘treatable’ is one of the big lies of society;  it makes for good movies and helps keep money rolling in to detox facilities and treatment centers, but if you think I’m wrong, seek out the numbers yourself!  Pick your own criteria for success– one year sobriety, five year sobriety, whatever.  If you look at people in their 20’s who go through residential treatment, the one year rate is way, way, way below 50%, even if you just use the numbers for people who go voluntarily and complete treatment!  Go out to 5 years and the numbers for opiate dependence are ridiculous- sobriety rates of less than 10%!  The writer sees danger in telling the truth about treatment I suppose because the truth will somehow take away ‘motivation’ and cause apathy.  But I see things exactly the opposite.  In my opinion based on how I thought as an actively using opiate addict, a sense of confidence is the ENEMY of sobriety.  As an addict goes from day to day using, and getting deeper into addiction, he/she comforts himself by saying ‘I’m going to get straightened out eventually’.  If the person knew that most people do NOT recover; that he is getting mired deeper in an incurable disease, maybe he will think about seeking help a bit sooner!  And if everyone knew that opiate dependence is a largely untreatable and surely incurable illness, maybe fewer high school kids would pick up in the first place.  I hear addicts say one thing over and over again:  ‘if I only knew that oc would have done this to me I never would have taken it.’  I don’t know if that is true for all of them, but I think that had the truth been known, at least some of them wouldn’t have started.

As far as the comment about ‘once an addict, always an addict,’ that is something that is not even controversial.  Yes–  at least with opiates, once an addict, always an addict.  About 7 years after getting clean ‘the first time’, I assumed that I was cured—after all I had only used opiates for 8 months or so, and it had been 7 years… I had been to hundreds of AA and NA meetings, I had worked the steps all the way through several times, and I never even thought about using!  I would get so annoyed when my old NA and AA buddies would come up to me if they saw me someplace and say ‘we miss you at the meetings, Jeff!’  I would want to tell them to bug off and leave me alone— I’m cured, after all!  I don’t need that crap.  Once an addict, always an addict…. NO WAY!

Had I listened to them I might have saved myself a great deal of trouble.  But probably not, since addicts pretty much need to find things out for themselves.    That is one of the personality traits of ‘us addicts’—we are independent thinkers who don’t think the rules of others should apply to us.  Those words on the Vicodin bottle about dosing and about the danger of dependence?  Those are just ‘suggestions’!

I wasn’t always a fan of the idea of taking a medication to treat opiate dependence.  Even after looking around me and realizing that all of the people who got clean with me had relapsed, I thought that it was better to have one out of ten people in ‘real’ recovery than have people taking medication!  Then I ended up in a position where I actually knew some of the people who were dying.  At NA or AA meetings people talk about the deaths with a ‘tsk tsk’ attitude, as if the person who died should have known better, or almost had it coming, since she stopped going to meetings.  But once I was a person who stopped going to meetings in spite of knowing better, it became harder to blame the dead person.

I have in my mind the images of four smiling people who desperately wanted to be free from opiates.  I knew all four of them pretty well at some point;  none took Suboxone, and all assumed they were going to be fine without it.  After all, they had all gone through at least part and in two cases entire treatment programs.  Three men and one woman, all less than 25 years old, two with children of their own.  Two died from suicides, presumably in part from the shame of failing to get better.  I wonder if they thought, before they died, that they were losers because treatment didn’t work for them?  The other two died from opiate overdoses, one the first time he used after being clean for several months.  I suspect he figured that he ‘beat the disease’;  that is what most of us think as we relapse.  One time won’t hurt, we tell ourselves;  we are different now.  We have been TREATED, after all!  The final person was a woman who had been resuscitated several times in her life, once after an overdose in a drug-treatment halfway house!   Maybe she had a death wish—some addicts seem to use as if they truly want to destroy themselves—or maybe she thought she was blessed by a guardian angel who eventually slept in one day and wasn’t there when she needed him.

To simply answer the writer’s questions without all the stories, I tell people that there is no cure for opiate addiction because my opinion is the same as that of everyone else who treats or studies opiate addiction—   there is no cure for opiate addiction.  As for ‘hopelessness’, sometimes ‘hope’ is just a campaign slogan.  Sometimes ‘hoping’ keeps a person from recognizing the cold hard facts of a situation and taking responsible action.  In medicine and in life, diseases do not always have cures.  Some diseases are simply not curable, and people die.  Want to have ‘hope’ about opiate dependence?  Then DON’T USE OPIATES.

The good news is that while there is no cure, there is a relatively new approach to addiction that is keeping many people alive who would have otherwise died from their addiction.  There are many diseases without ‘cures’—in fact there are probably many more ‘incurable’ diseases than ‘curable’ ones!  But every opiate addict should know the facts:  that he or she will always be vulnerable to relapse, no matter the amount of ‘treatment’.

Suboxone vs buprenorphine: Time for a name change?

For the past 6 years, Reckitt-Benckiser has sold buprenorphine under the brand names ‘Suboxone’ and ‘Subutex’. Buprenorphine has been sold under other names in the past, notably ‘Temgesic’, which was buprenorphine intended for intravenous use by medical professionals treating pain. Many people, myself included, have been anxiously awaiting a less expensive formulation of buprenorphine– for example a generic product. We could also use a number of new formulations of the drug called ‘Suboxone’; it is very difficult to taper in it’s present form, for example, and a large pill with lower concentrations would be a tremendous help. Even better would be a ‘taper pack’; many medications make taper packs for use in STARTING the medication (e.g. Lamictal), and I suppose they see a pack used to STOP a medication to be counter-productive from a sales standpoint. I would argue, though, that having an easy exit strategy in place would increase the number of addicts whoe would accept treatment with buprenorphine. And if the sales angle isn’t persuasive enough, there is always the fact that a taper pack WOULD MAKE LIFE BETTER FOR PEOPLE! If that is not important to the manufacturer, they could always comfort themselves by cranking up the price of a taper pack to get that one last shot at the patient’s wallet.
I have used the word ‘Suboxone’ in my blog and forum (and also in educational youtube videos) because that is the word that people search for. But I have to think that SOME generic company will pick up buprenorphine as it goes off patent– which I think happens next month. And when that happens, I am sure the R-B people would love to hang on to the ‘brand loyalty’ by keeping people using the word ‘Suboxone’. That is what the makers of Tylenol managed to do– people ask for Tylenol, not for ‘acetominophen’. People ask for Motrin, not ‘ibuprofen’. And people ask for ‘Xanax’, even though the generic ‘alprazolam’ is much less expensive. I have no allegiance to RB or ‘Suboxone.’ If anything I am annoyed with the company; unlike other pharmaceutical companies they are very difficult to reach at the corporate level, and when I have attempted to contact someone within the science division or someone in a position to discuss the issues I describe above, I am told that so and so will call– but they never do. Sniff sniff… On the other hand, I have no problem speaking to various levels of other pharmaceutical companies. I have presumed the reason was because Reckitt-Benckiser is a British cleaning products company and they don’t really have it together. But to a large extent I am tired of carrying water for them, and watching the price go up on Suboxone.
In medicine in general, doctors are encouraged to refer to medications by their generic names or by their chemical names. I strongly recommend we learn to do that with buprenorphine. I am probably shooting myself in the foot a bit since my blog responds very well to the search term ‘Suboxone’, but if we don’t make the change, we will all be advertising a product that will eventually have a less-expensive equivalent product. I recommend the term ‘bupe;’ it is easy enough to say, even easier than Suboxone. In fact, if every person talking about Suboxone changes to the word ‘bupe’, that will reduce use of syllables by 66% for that word– as Obama said last night, imagine the cost savings (in the form of time savings– but time is money!) if we could reduce the number of syllables for ALL words! Pretty soon the average male phone call would take 10 seconds instead of 30 seconds, and the average female phone call would drop to less than 30 minutes!