Clean Enough: Some Distorted Thinking

Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup. Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.

A horrible relapse in Eleuthera
Eleuthera: not a soul in sight

In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket! I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days! So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera. I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well. Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way. I eventually learned that both were true—but that and other realizations required further ‘education.’ I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.

Clean Enough, Chapter 1.3: Bias of the book

Introduction
Bias of the book
You will notice the several times throughout the book I take issue with people over what they say about buprenorphine treatment of opiate dependence. On my web sites I have been told by those who favor ‘total sobriety’ that I am biased in favor of Suboxone. I don’t know how to best respond to those characterizations. I have reviewed the studies related to buprenorphine and Suboxone and become sufficiently educated to understand and critically evaluate those studies. I have experienced opiate dependence for 17 years and experienced treatment failures and treatment successes. I have experienced relapse and watched friends relapse and in some cases die from addiction. I have worked for years with addicts in solo practice, in the Veterans Administration setting, in prisons for men and for women, and in residential treatments that do not use Suboxone at all. After all of these experiences, I have strong opinions over which treatment methods are more effective than others. Does favoring the more effective method make me ‘biased’?
But my problem with the ‘bias’ accusation is more complicated than choosing winners and losers. The people who speak of ‘bias’ usually present a choice between Suboxone and ‘being free of drugs’. We know, and they should know, that being free of drugs is not a real choice. People who are addicted to opiates and who want to stop have always required intensive residential treatment for a period of 90 days or more. Even with that intensity of treatment, one-year sobriety rates hover around 50%– much lower for 5 years of sobriety. But opiate addicts who have not yet experienced treatment are living in a fantasyland where the second choice is to just go back to the person they were before their addiction. If only!! If the person considering ‘bias’ were to live in the real world, the choices faced by opiate addicts would be Suboxone, 90 days of residential treatment, jails, institutions, or death. Forced to deal with the truth of the matter, many people would appear ‘biased’ in favor of Suboxone.
The reason addicts adopt a distorted set of choices is because of ‘denial’, the process where the mind refuses to see the horrible reality of a situation, perhaps to protect the mental state of the person carrying that particular mind around. The result is a bit of insanity that compares active addicts to people drowning in the middle of the ocean. Floating in the water around them are life jackets– the life jackets representing Suboxone. The life jackets would hold the people afloat, but they smell bad and look funny. Plus, there are several people treading water yelling ‘if you put on a life jacket, you aren’t really swimming on your own!!’ So while some people put on the smelly life jackets and live, another group insists on swimming for shore, 1000 miles away, confident that they will make it. Some people are safely floating in a life jacket, but are made to feel weak and guilty by the swimmers… so they remove them and join the swimmers, setting off on the 1000-mile swim for shore. In the end, one or two of the swimmers caught a good current and somehow made it to shore alive, but the vast majority of them drowning later that day, a couple miles from the empty life jackets that could have saved them. I am strongly in favor of life, and of life jackets.
I receive e-mails asserting that people are better off when they are completely free of narcotic substances. On that point I completely agree—unless the people have a chronic illness that demands treatment. When I am feeling sarcastic I will say that an addict living free of substances is a great thing… and so is ‘world peace’! Heck, I would prefer if a person taking ten medications for heart disease was free of all heart medications and was ‘normal”! But many people would not survive without their medications. If one of my patients wants to go off Suboxone, I will share my honest opinion of the person’s odds, and then help him do what he wants to do. I will point out the risk of relapse, and hold a spot open for some time in case active addiction returns. One nice thing about Suboxone is that is does allow a ‘trial of sobriety.’ In the days before Suboxone, relapse meant months or years of misery. But now a person can try sober recovery, and if active use returns he can high-tail it back to the safety of Suboxone.
I hope that you find the information in this book valuable to your understanding of addiction, and helpful in your search for answers for you and your loved ones.

Why will power doesn’t work

For those of you who prefer watching to reading, here is a video with a few thoughts about why will power is NOT any kind of strategy for staying clean. As I describe, believing in will power is not only unhelpful; it even INCREASES one’s chance for relapse, and serves as a frequent justification for the using that leads to full-blown relapse. Please share comments at SuboxForum.com.

Opiate dependence treatment options

Below is one chapter of my long, long book– the one that I will probably never finish. I wrote this chapter about two years ago, and have not published it anywhere else, at least not that I can remember. It is LONG, but if you are addicted to opiates and considering your options, I hope you will check it out. I invite other addicts and friends of addicts to read it as well, even though it is LONG (did I say that already?). It essentially describes my ‘vision’ for addiction treatment going forward. I am posting it now because I will be attending a summit in DC over the next few days, discussing the use of buprenorphine going forward with other experts in the field. I will bring back word of any new developments and share them here.

Addiction to heroin and pain pills continues to grow

The article:
The advent of HDP (high dose buprenorphine) for treating opiate dependence raises hopes that we are at the verge of an entirely new approach to opiate addiction, and perhaps to other addictions as well. The traditional, step-based approach to drug addiction treats all substances as essentially the same. The problem with addiction isn’t that the addict is ingesting a substance, but rather that the addict has become obsessed with the substance. The effects of this obsession on the addict are in some ways similar to the effects of a toxic, codependent ‘love relationship.’ And while the addict develops this relationship with a specific drug of choice, the drug’s sister, brother, aunt, or uncle can step in and take the place of the drug of choice in a process called ‘cross addiction’. This is one reason why traditional treatment demands sobriety from ALL substances. Most opiate addict may have had no problem with alcohol when opiates are on the menu. But alcohol may surprise the addict by becoming an important ally when the only alternative is ‘life on life’s terms.’
There is another, more complicated reason that traditional treatment of addiction requires sobriety from all substances, not just from the addict’s former drug of choice. All addicts, opiate addicts in particular, over time become hyper-aware of their moods, comfort, and anxiety level. Addicts constantly ‘check in’ somatically, thinking ‘am I OK? Or ‘am I coming down?’ Every bead of sweat portends the pain of withdrawal, and every ache is a reason to use. Addicts become attuned to their schedule of use, as an internal 4-hour clock becomes all-important, and eventually the only thing that matters. There is even something perversely comforting about reducing all of life’s problems to the need to use, as the other challenges of life become secondary. But sobriety and recovery demand that the addict learn to face life on life’s terms, giving up the obsession for symptoms and medications. Sobriety will extinguish the obsession with symptoms over time— sometimes only after a great deal of time. As the obsession fades, the addict takes steps away from relapse. But if the addict uses a new substance that changes that perception and re-directs the addict’s attention inward, even a substance like diphenhydramine that is not addictive, the pattern of somatic attention returns. Many addicts are aware of an ‘addict frame of mind’ and a ‘sober frame of mind;’ any drug that causes the addict to look inward and again focus on somatic symptoms has the potential to trigger the return of the addictive mindset. And once the addictive mindset is back in place, it can be very difficult to find the way back to a mindset of sobriety.
The reader may be asking, I see your point about total sobriety—but isn’t total sobriety required for buprenorphine treatment as well? In my opinion from working with addicts taking and not taking buprenorphine, sobriety from other substances is beneficial during HDB for similar reasons, but there is less at stake. During HDB the addictive mindset interferes with happiness, relationships, and the development of new, healthy interests. But for the addict in traditional treatment a return to an additive mindset can disrupt the avoidance of opiates and result in relapse.
The need for total sobriety probably prevents some addicts from entering treatment. There are other addicts who enter treatment but who cannot maintain sobriety from all substances despite multiple attempts. To widen the appeal and utility of addiction treatment, a variety of treatment models have appeared, including an approach called ‘harm reduction’. Rather than total sobriety, the goal of harm reduction is to reduce the intensity of use, and reduce the harm that inevitably results from heavy or uncontrolled use. By introducing ‘drink counting’ and other behavioral techniques, harm reduction has similarities to cognitive therapy. There are people who do better in one vs. another approach, and there people who could benefit from either approach. Specifically, some people use or drink in an almost nihilistic fashion—every episode of drinking characterized by drinking to total oblivion. I would favor complete sobriety for such individuals, because the cognitive changes made in treatment will likely be obliterated by the first drink. On the other hand, a person with 20 years of an unchanging pattern of drinking facing his first DUI may be a good candidate for a harm reduction approach. In such a case, alcohol is a major part of the addict’s personality, and total sobriety after one offense would be a difficult sell. But education—for example about changes in tolerance with aging, or an introduction to drink counting– may help the person do well for another 20 years.
There are several inherent problems with traditional treatment methods, beginning with the simple observation that relapse rates have always been high. The high relapse rate has implications for addiction that go beyond treatment methods, as explained later in this article. But relapse is a particular problem for programs that are based in ‘character modification’ because when the forces that encourage character change are removed, character tends to return to its prior state. Addicts in traditional recovery tend to see themselves as ‘changed’ by the steps. But at the same time every honest addict recognizes that if the meetings stop, relapse waits around the next corner. Even worse, a ‘truism’ of step-based recovery holds that people who relapse generally return to a state of using that is even worse than where they were when they entered treatment!
Another problem with traditional methods is that many addicts reject out-of-hand the ‘spiritual foundation for the program. Admittedly such ‘rejecting addicts’ do not necessarily know much about this spiritual foundation and don’t likely know what is good for them! But reasonable or not, having spirituality as one aspect of a recovery program is going to prevent the adoption of the program by a number of addicts. Another problem is that traditional addiction treatment methods require significant motivation on the part of the addict–motivation that must be available to addicts over and over throughout their lives, including (and most importantly) at times when addicts are at their very lowest. Finally, some degree of detoxification is often required before traditional treatment, requiring expensive medical services that may be far removed from the treatment center. The cost of detox and the fear of withdrawal become major roadblocks to treatment. Withdrawal uniquely miserable, and difficult to compare to other dysphoric experiences. Physical symptoms include headache, fatigue, nausea and vomiting, abdominal cramping, diarrhea, and muscle spasms of the arms and legs that cause involuntary movements. The withdrawing addict becomes profoundly depressed and anxious. Even if there is no access to drugs, the addict feels a desperate need to use. No description of symptoms can accurately capture the misery experienced by the withdrawing opiate addict. I suspect a ‘kindling’ effect in opiate withdrawal where symptoms become more and more severe each time withdrawal is experienced, so that eventually there is no such thing as ‘mild withdrawal.’ Instead the addict experiences withdrawal as severe as the worst episode endured up to that point, regardless of the degree of tolerance going into the withdrawal episode. Addicts who have suffered through severe, non-medicated withdrawal have a sense of camaraderie akin to that of disaster survivors. But camaraderie is nowhere to be found in the midst of the withdrawal experience, and the addict feels utterly, horribly, alone.
For years there have been alternate addiction treatment models that are less dependent on character modification and more reliant on medication. Opiate maintenance treatment using methadone, or opiate blockade using naltrexone are two approaches that may be used alone or in concert with traditional treatment. Methadone and naltrexone treatments are diametrically opposed to each other in several ways, but have some things in common as well. Methadone maintenance deliberately creates ‘hyper-tolerance’ to opiates by administering the addict increasing daily doses of methadone. The high tolerance that results prevents recreational use of opiates, and the high dose of methadone satiates opiate cravings. But patients in methadone programs often feel trapped because detoxification from high doses of methadone is very difficult, and violating the rules of the clinic (including not paying the bill) results in dose reduction and withdrawal. Some addicts maintained on methadone claim that they always feel ‘high’, no matter their extent of tolerance. And while high doses of methadone will satiate cravings for a time, eventually tolerance catches up and cravings return. Moreover some addicts claim that methadone causes a lack of motivation for self-betterment through education or employment. For decades methadone maintenance was associated with blighted urban areas, where addicts lined up each morning for their daily dose of methadone. There have been more recent attempts to make methadone maintenance mainstream by improving the physical facilities or relocating to less-blighted neighborhoods. But there have been few changes in the regulation of methadone, so methadone maintenance usually requires that addicts add morning dosing to their daily schedules, often acting as a barrier to occupational advancement.
Naltrexone is a molecule that blocks the binding site for opiates, preventing ingested or injected opiates from having psychotropic effects on the addict. The use of naltrexone for treatment of opiate addiction is limited by the requirement for two weeks of sobriety prior to treatment. This period of sobriety is necessary for opiate receptors to normalize to a degree that avoids naltrexone-induced withdrawal. Another problem is that the addict can ‘choose to use’ by simply skipping a day or two of naltrexone. In fact, patients maintained on naltrexone develop a hypersensitivity to opiates, making them subject to dramatic highs during relapse and vulnerable to the associated risk of overdose by respiratory arrest. Naltrexone is administered as daily tablets or as intramuscular, monthly injections, which help reduce the ‘choose to use’ problem. The primary indication for this naltrexone is for alcohol dependence rather than opiate dependence, as naltrexone has been demonstrated to reduce cravings for alcohol. A related form of naltrexone treatment is called ‘rapid opiate detox’, where the addict is anesthetized and given withdrawal-inducing doses of intravenous naloxone. After 8 hours or so, the addict wakes with a slowly-dissolving chip of naltrexone implanted under the skin. This technique has never been very popular because of reports of patient deaths during the procedure, high relapse rates, and several reports of suicide following rapid detox.
Suboxone is a hybrid of methadone and naltrexone treatments, and has a number of features that make it a unique and valuable tool for treatment of opiate addiction. Suboxone consists of two drugs; buprenorphine and naloxone. Regardless of what people on the internet say in message boards, the naloxone is totally irrelevant if the addict uses the medication properly. If the addict dissolves the tablet in water and injects the compound, the naloxone will cause instant withdrawal. When suboxone is used correctly, the naloxone is destroyed in the liver shortly after uptake from the intestines (‘first-pass metabolism’) and has no therapeutic effect. Buprenorphine is the active substance. It is absorbed under the tongue (and throughout the mouth) but inactive if swallowed by mechanisms similar to those for naloxone. There is a formulation of buprenorphine without naloxone, called subutex; I have used this formulation for times when the patient has apparent problems from naloxone, including headaches after dosing with suboxone. I have also treated addicts who have had gastric bypasses, where the first part of the intestine is missed and the stomach contents empty into a more distal part of the small intestine. In such cases the naloxone escapes ‘first pass metabolism’, where with normal anatomy the drug is taken up by the duodenum and transferred directly to the liver by the portal vein, where it is quickly and completely destroyed. After gastric bypass the naloxone can be taken up by portions of the intestine that are not served by the portal system, causing blood levels of naloxone sufficient to cause brief, relatively mild withdrawal symptoms.
Buprenorphine belongs to a class of molecules called ‘partial agonists’ that have both stimulating and blocking effects at their receptor sites. Buprenorphine has potent opiate effects that increase with increasing dose up to about four mg. The opiate effects then reach a plateau, and higher amounts of buprenorphine do not increase narcosis. This ‘ceiling effect’ is the basis for the use of buprenorphine for treatment of opiate dependence. The average addict takes 8-16 mg of buprenorphine per day, and becomes tolerant to the effects of buprenorphine (buprenorphine has significant opiate potency but the opiate effects usually pale in comparison to the degree of tolerance found in active addicts). The addict’s opiate receptors become completely bound with buprenorphine, and the effects of other opiate substances are blocked. At the same time, the bound buprenorphine reduces cravings for other opiates. Buprenorphine is marketed under brand names Suboxone and Subutex. When used properly, buprenorphine is very effective in preventing relapse. Getting an ‘opiate buzz’ requires the addict to first experience several days of withdrawal, in order to rid the receptors of buprenorphine so that other opiates will have an effect. Taking into account addicts’ attitudes toward withdrawal, the appeal of this ‘choice’ is quite low.
Treatment with buprenorphine may be somewhat limited in the case of addiction to multiple substances. For example, an addict may be able to avoid opiates, but remain susceptible to alcoholism. Or as described earlier in this report, addicts may change their attachment from one drug of choice to another. On the other hand, just as naltrexone reduces alcohol cravings, it is possible that buprenorphine, through similar mechanisms, reduces alcohol cravings as well. Addicts treated with buprenorphine who move from one substance to another will likely require an approach that includes total sobriety. But for pure opiate addicts, benefits of buprenorphine include the fact that that only mild withdrawal is required to start treatment, the drug is usually covered by insurers, prescribing restrictions are relatively minor, and there is less stigma associated with maintenance with buprenorphine than with methadone. Insurers should appreciate the simplicity and efficacy of treatment, and would do well to encourage this treatment approach.
I expect that buprenorphine will eventually be the standard treatment for opiate dependence, and will change the treatment approach for other addictions as well. My only reservation to this statement comes from observing the response of the recovering community to patients treated with buprenorphine, which runs from ambivalence to disdain. Some recovering addicts reject recovering addicts taking buprenorphine for not being ‘completely clean.’ Addiction treatment counselors know less about buprenorphine than they should given the utility of the medication. In some cases their focus appears to be more on job security than on the needs of the suffering addict. There are also disagreements over the amount and type of counseling that should be prescribed for addicts taking buprenorphine. From my own experience treating addicts, it is a mistake to assume that addicts taking buprenorphine are in a ‘dry drunk’ in need of a step program; I have found that buprenorphine-maintained addicts make gains in occupational, social, and family domains at rates at least comparable to addicts in step-based recovery. The present standard of care calls for addicts maintained on buprenorphine to be referred for counseling ‘as needed.’ But the message that should be delivered through such counseling is debatable. By one perspective a patient maintained with buprenorphine becomes similar to a patient with hypertension treated for life with medication—the underlying problem persists, but the active disease is held in remission. If the uncontrolled use of opiates is effectively treated, is that enough? Should counseling focus on removing the shame of having the disease of addiction, and encourage addicts to get on with life? Or should addiction be considered a consequence of deeper problems or faulty character structure, requiring group therapy and meetings if one hopes to become ‘normal?’ The use of buprenorphine runs counter to successful adoption of sobriety through step programs, which in the first step require acceptance that the addict is powerless over the substance—that there is no amount of will power that will allow the addict to control the deadly effects of the drug. Buprenorphine may allow the addict to develop an impression that he/she has control, particularly if buprenorphine becomes popular on the street for self-medication of withdrawal.
Physicians and insurers should strive for greater consistency in the use of buprenorphine. Some insurers demand that the drug be used only short-term, in some cases for only three weeks. This requirement discounts the nature of addiction, and ignores the known high relapse rate after short-term use of buprenorphine (why wouldn’t it be high?). Some physicians use the medication short-term as well. Hopefully the motivation for this ineffective treatment method is not related to the limit on the numbers of maintenance patients per physician, but the practice raises the question whether the cap on patients encourages good practice, or bad practice decisions. Some physicians transfer their attitudes toward opiate agonists to the use of buprenorphine, and place constant downward pressure on the daily dose of buprenorphine. Such an approach is not appropriate, as buprenorphine requires adequate dosing to achieve the long half-life and suppression of cravings that make addiction treatment possible. At daily doses below two mg buprenorphine is essentially an agonist, so one might as well be give small doses of hydrocodone rather than buprenorphine! There is no reason beyond cost considerations (which may be practical) to reduce the dose, as tolerance is limited by the ceiling effect of the medication. In other words, at some point higher doses of buprenorphine do not cause greater severity of withdrawal. Another problem is that the medication is sometimes prescribed carelessly, without emphasizing the need to dose only once per day. Addicts left to their own decisions will use the medication multiple times per day as a ‘PRN’ medication, staying in the same somatically-focused, actively-using state of mind that brought them to treatment. Once per day dosing is necessary in order for addictive behavior and addictive thinking to be extinguished over time, and it often takes a great deal of work early in the treatment process to help addicts take buprenorphine properly. Addicts starting buprenorphine may initially experience anxiety as they lose the distraction and placebo effect of frequent drug use. But over time the anxiety will fade, and the void left by the removal of addictive obsession will allow the development of relationships and other positive character traits that were forced out by addiction.
While there are issues to be worked out, the advent of buprenorphine treatment has had a beneficial impact on many who have struggled with the disease of opiate dependence. Treatment based on character change requires desperation before addicts will become willing to change, and for treatment to be effective. And so before buprenorphine, addicts had to lose a great many things—family, employment, freedom, health—before getting better. Only a fraction of addicts recovered, and those only after significant losses—and relapse rates were high. Buprenorphine on the other hand allows treatment of addicts early in the course of their illness, and induces remission in most patients.
Given the time pressures and payment structures of modern medicine, buprenorphine may eventually replace residential treatment as a more reliable, less costly alternative. Is it time to replace the ‘recovery’ model with a new ‘remission’ model, which allows treatment of a much higher percentage of users at an earlier stage of disease? With time, will we find analogous agents that provide a low level of intoxication in return for receptor blockade? While not likely with alcohol, such an outcome is certainly within the bounds of imagination for cocaine, benzodiazepines, and barbiturates. While it is true that daily use of a partial agonist would represent a reversal from our current approach where all intoxicating substances are to be avoided, it is also true that the current approach has no bragging rights based on outcome. And perhaps the adoption of a remission model would lessen the time until opiate and other addictions carry as much moral stigma as hypertension or diabetes—two other diseases that are generally treatable, but that require long-term use of medications.

Does Reckitt-Benckiser have blood on their hands?

Regular readers of this blog know that I am a big fan of buprenorphine treatment of opiate dependence. I used to spend hours arguing with people over whether or not buprenorphine represents “a drug for a drug”, before eventually deciding that those who must be talked into buprenorphine treatment are poor candidates for buprenorphine treatment. I am now less motivated to engage in such discussions, but for those who are interested, my arguments are scattered throughout the archives of the medhelp.org addiction board, the commentary section of my YouTube videos, and in earlier posts to this blog.

The motivation for this current post stems from two recent incidents. The first was the reaction of a group of physicians at a dinner several nights ago, when I was speaking about a different medication. When I mentioned “Suboxone” I heard hissing and other negative reactions from the assembled group of doctors and nurse prescribers. I am the medical director of a residential AODA treatment center that does not use buprenorphine, so I am familiar with the attitudes of non-prescribing counselors– which tend to run against the use of buprenorphine. But the people at this particular dinner were not addiction counselors, but instead were general practitioners from central Wisconsin. After hearing the negative reaction to mention of Suboxone, I deviated from the topic of my lecture to address their reaction. But I soon realized that their opinions were as fixed as those that I ran up against during the arguments described in the first paragraph above. Despite my certainty that buprenorphine has saved thousands of lives, these practitioners see the medication as ‘villain’ rather than ‘hero.’ The assembled physicians see Suboxone as just one more drug of choice for opiate addicts. More disturbing, they see docs who prescribe Suboxone on a par with physicians who overprescribe opiate agonists.

The second incident that motivated this post was the publication of an excellent group of articles in the Milwaukee Journal Sentinel about the epidemic of opiate dependence in Milwaukee County. The article included statistics on the number of deaths by overdose, the vast majority consisting of respiratory arrest caused by opiates. The numbers included deaths from Suboxone taken in combination with other respiratory depressants by people who lacked significant tolerance to opiates. One of the most striking images from the series was a graphic with the deaths color-coded by year, by age of the deceased, and by type of drug. I am well aware of the epidemic of heroin and oxycodone addiction in my part of the country, but I was shocked at the sheer number and ubiquitous nature of deaths by overdose over the past six years.

I am grateful for the availability of buprenorphine in the form of Suboxone, but I wonder how different the current situation might be had a different pharmaceutical company been involved in the U.S. introduction of buprenorphine for the treatment of opiate dependence. Reckitt-Benckiser is a consumer-goods company based in the UK. When Suboxone received FDA approval in 2003, the pharmaceutical wing of the company did not exist in any meaningful form. From the vantage of a Reckitt-Benckiser stockholder, the company did well. They grew their international pharmaceutical division at an amazing pace thanks to the growth of their one product. But when I take a broad look at the current state of affairs, I wonder where we would be if Reckitt-Benckiser had made the decision to team up with one of the bigger players in the pharmaceutical industry. Doing so would have cost them a portion of their profit from Suboxone. But had a company the size of Pfizer, for example, set their sales force on a mission to market Suboxone, I doubt we would have the now-recognized problems with diversion and low physician acceptance. I am also confident that there would have been far fewer deaths by overdose of opiates over the past six years.

I am old enough to have experienced a number of launches of innovative medications, and I have always been one to quickly adopt the newest approaches and medications. But my early use of Suboxone for treating opiate addiction was a unique experience in many ways. I cannot think of any other medication that was (and still is!) as poorly understood by other physicians. I blame some of the lack of knowledge about Suboxone on the stigma of mental health and addiction, but many psychiatric medications with far more complex mechanisms of action—e.g. atypical antipsychotics—have been introduced without the ignorance that is associated with Suboxone. Even in 2007, four years after the release of Suboxone, the vast majority of physicians had not heard of the medication. Doctors have the bad habit of blaming unknown medications for unusual symptoms, so patients often called me after visiting ER’s or after doctor’s appointments where they were told that their symptoms were ‘from the Suboxone.’ One patient returned to the ER after I called the staff and persuaded them to take a second look, explaining that Suboxone does not generally cause fever or chest pain. On his second visit they did a chest x-ray that showed his pneumonia and pleural effusion. I continue to see examples of the same phenomenon today. The ignorance is not confined to emergency care– I frequently receive e-mails from new mothers with horror stories describing bizarre statements by neonatologists, OB nurses, and obstetricians.

A more common problem is described in the following e-mail:

I need help to figure out what’s wrong with me and what to ask my doctor to do about it. I’ve just been through knee surgery to replace my ACL. It was pretty painful but the pain is a bit better now. I’ve been on 16mg Sub for at least five years, although I recently tapered it to 8mgs. This past month I was down to maybe 4mgs/day when I found out my surgery was scheduled. Since I wanted my pain meds to work I immediately cut down even more and called my doc to see if he would give me some pain meds, because the surgeon refused to help me on the grounds that I was on Suboxone and he doesn’t understand it. Unfortunately my doc was out of town. Nobody would help me, everyone said *my* doc was the only one who could, and sorry he’s gone but oh well. This meant i had to get horribly sick the week of my surgery.

I got to see my doc the day before surgery, and he gave me some Norco which helped the w/d symptoms. Then after surgery I had Norco every four hours. Unfortunately after my release the surgeon AGAIN didn’t want anything to do with me. He wrote a script for Norco and told me I’d have to see my own doctor for anything else. The Norco was barely keeping me out of w/d’s, never mind helping my pain. I was waking up every morning with my nose running, sneezing, and my legs dancing. I got hold of my doc and he prescribed me Percocet, on the theory that those last longer. I’m permitted 1 or 2 of them every six hours, to a maximum of 6 per day. This seems to be utterly inadequate but I don’t know why my doctor would prescribe me something utterly inadequate unless he doesn’t think it’s inadequate.

Please, I need some solid experienced information so I can talk to my doctor. I am NOT trying to get a buzz here. All I asked of everyone prior to my surgery was “please treat me fairly given my tolerance level”. I wonder if my doc thinks that he is treating me fairly. But I’m clearly not getting sufficient dosage of opiate, and I don’t know how to present my case, especially over the telephone and via an intermediary nurse. (As yet, he won’t talk to me in person.) If I have to re-induct on the Suboxone and just deal with the pain then I’ll need some medicine to keep me asleep and not dancing until I’m sick enough, but I’m running scared asking for anything at all because everyone is treating me like a junkie.

Because of my blog, I receive messages like this one almost every day. Most doctors have no idea what Suboxone is used for, and how the medication affects the use of other pain medications. Patients are paying for that lack of knowledge with unnecessary pain and hardship. Of course, they are just addicts, right? (Readers should know my sarcasm by now!).

What should have happened?

To describe what could have happened I will use the example of another medication, Vyvanse, which is owned by a different British company called Shire pharmaceuticals. Vyvanse is a clear advance in ADD treatment. Amphetamine was bound to lysine to create an inactive molecule, and the amphetamine is released at a measured pace after Vyvanse is absorbed into the circulation. Shire is a relatively small company, so they paired with the much larger company, GSK, to get the word out about Vyvanse. The result is that thousands of GSK representatives have provided information about Vyvanse to physicians, pharmacies, and hospitals. Had Reckitt-Benckiser done something similar, doctors everywhere would at minimum know the basics about buprenorphine. And more, the treatment of addiction may have been brought into the mainstream where it belongs.

Reckitt-Benckiser eventually came out with a program called ‘Here to Help’ in order to provide education and by their description to improve compliance in addicts taking Suboxone. I was disappointed that the program began a number of years after Suboxone was released, not until the eve of the launch of a generic form of the medication. The timing left the impression that the program was more about maintaining brand loyalty than concern for addicts. The program pales in comparison to the education and outreach provided by major US pharmaceutical companies when they release a new medication. There are comments about the ‘Here to Help’ program associated with an earlier post on this blog, and I have received a number of similarly negative e-mails, including one just today that included these comments:

This “Here to Help” thing is really not very good. I actually signed up as a patient, and the girl was clueless. Every single issue I wanted to talk about, she told me to “Talk to your physician”.

“I feel scared that when I reduce my dose I’ll go nuts”
Talk to your physician

“I feel like I’ll never, ever feel ok again”
Talk to your physician

“I feel shaky before my morning dose”Talk to you….
You get the point.

When I asked how her course of treatment had gone, she told me that they don’t ever talk about their own personal recovery. Oh, well THAT’S helpful, huh?
There are other complaints about the manufacturer of Suboxone even by addicts who appreciate the medication. They resent the fact that so few non-addiction doctors have any knowledge about the medication. Many have fallen victim to what is described in the first e-mail above, and have suffered painful postoperative recoveries. There are complaints about the cost of the medication, once a pricey four dollars per pill and now up to twice that amount. The patient assistance program offered by Reckitt-Benckiser limits support to only 2-4 patients per practice, a limit that is not present for any other medication that I prescribe for psychiatric patients.

Many addict-patients have experienced poor treatment practices as a result of insufficient education for physician prescribers. Buprenorphine should be taken once per day in a dose range of 8-16 mg, but I have had new patients whose prior doctors prescribed much larger doses at much more frequent intervals. In my experience frequent dosing of buprenorphine is much less effective at extinguishing the psychological component of addiction. Instead of eliminating the relationship between ‘feelings’ and ‘using, such patients remain fixated on how they feel and take small doses of buprenorphine multiple times per day in response to imaginary withdrawal symptoms. Their physicians should have been taught about the value of less-frequent dosing by people who understand addiction. I was, by the way, a Reckitt-Benckiser/Suboxone ‘Treatment Advocate’ for several years. My experiences as an opiate addict for 16 years, my PhD in neurochemistry, my 3+ months of residential treatment and 6 years of formal aftercare, the hundreds of AA and NA meetings I have attended, the eight years I spent working in pain clinics as an anesthesiologist, my psychiatric training, my experience treating over 450 patients using buprenorphine, and four years as medical director of a large residential treatment center have all contributed to some level of insight into addiction and addiction treatment. I called and wrote to R-B multiple times asking that they use me to educate other physicians. I was called upon to do so three times in four years. As a comparison, I have been asked to educate groups of prescribers about Vyvanse over ten times in the last month or two alone. Can you imagine the knowledge-state about buprenorphine had similar efforts been made by Reckitt-Benckiser over the past 6 years?!

I have blogged about my frustration trying to find an application for an educational grant from Reckitt-Benckiser that would allow me to apply for funding to expand my educational efforts on the internet. To compare, a visit to the Mallinckrodt Pharmaceuticals website quickly leads to the application for funding educational programs. There are, in fact, several significant web-based educational programs related to the prevention and treatment of addiction supported by unrestricted educational grants from Mallinckrodt, who manufactures methadone among its products. There is a similar online application for grant support on at least every pharmaceutical company that I visited this evening as I prepared to write this post. I have not found such an application for Reckitt-Benckiser. I even spent four years calling, writing, and e-mailing different branches of the company in search of an application for such support. My hopes were raised on two occasions when I was visited by regional sales directors and promised that information about grants would be provided. But after the visits nothing happened, and when I called in an attempt to follow up, I was back to square one, talking to people who claimed to have never heard about my prior contact with the company.

Does this all sound like ‘sour grapes’ over a snub by Reckitt-Benckiser? Perhaps it is, to some extent. I am, after all, only human. But I am not only resentful. I spend a great deal of time reading and responding to e-mails from addicts, parents of addicts, spouses of addicts, and friends of addicts, and I am acutely aware of the suffering caused by opiate dependence. I’ve spoken to many people who were close to addicts who lost their lives to opiate dependence, and I have at least some sense of the suffering that they go through. And I have no doubt much of this suffering could—and should– have been avoided.

I fear that the actions of Reckitt-Benckiser, specifically their close-fisted release of a life-saving medication, have permanently endangered the successful use of buprenorphine for the treatment of opiate dependence. Once doctors start hissing, it becomes extremely difficult to create positive impressions of a medication or of a practice technique. I will, for what it is worth, continue with my own small efforts. And I hope that Reckitt-Benckiser will observe one of the principles that we teach addicts in recovery: Ask for help when help is needed.

How ironic if the success of a medication with the potential for a profoundly positive impact on addiction fell victim to addictive thinking by its own manufacturer!?!

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