Useful Sites about Medications

I have gone on a bit in the past about web sites that I don’t like.  My primary beef is with the sites where people post medical questions, and anyone with an opinion will tell the person what he should do… but if a person who happens to be a physician posts a reply based on clinical practice or science, the reply is blocked because the site ‘doesn’t allow medical advice’.  Don’t worry– I’m not going to get all fired up again!
I haven’t said much about the sites I like, and so I thought I would mention a couple places every now and then.  This first group of sites are useful or interesting places to read about medications.  I try to stay away from the sites that promote or encourage illegal activity, no matter how otherwise interesting they are…. but erowid.com is just too darn big to ignore.  The site contains everything from drug law to subjective drug experiences.  I don’t like the implied condoning– and almost encouraging– of drug use that comes through pretty clearly on the site.  But the section on psychoactive plants contains information that is hard to find anywhere else, and the artwork contributions are interesting to browse through.
Pharmer.org is a collection of forums about medications and pain treatment.  The pain forums contain the usual, somewhat misleading information– people often seem to write about a fantasy world rather than the world we are forced to live in.  For example, one will read comments like ‘a person with true pain does not have to worry about addiction’, or ‘just reduce the pain pills by one per day, and you’ll be fine’, or ‘stopping oxy is just a matter of will power– you can do it!’  But the site has information not found elsewhere including a collection of pill imprints to identify pills (what is that pill that was in your son’s pocket?), discussions about new medications, and a discussion about medication from online pharmacies, such as whether the Xanax that you purchased from India is really alprazolam.
For medication information, I subscribe to epocrates.  I don’t really recommend it to people who don’t prescribe, as it is expensive and is mainly useful for determining the available dosages, recommended starting doses, insurance formularies, etc.
Bluelight is a very interesting site.  What started out as a site about ecstasy has become a site filled with information and intelligent discussion about psychoactive medication.  The conversations certainly reflect a fascination for psychoactive compounds, but there is zero tolerance for illegal activity, and there is an emphasis on health and safety.  The site also has a unique ‘international’ air about it, and contains separate forums for concerns related to specific countries.
I will mention opiophile.org, but only reluctantly.  The site has some interesting information… but it is buried amid discussions about online pharmacies and illegal (and unsafe) practices.  Please do NOT take information there as healthcare advice.  As an example, I recently read a discussion there about sleeping medication, and there was a strong recommendation for the use of barbiturates– a class of medications that was rightfully tossed out of use by physicians in the 1950’s.  We are not missing anything by not prescribing nembutal anymore!
That’s what I have for now– I’m sure I am leaving sites out, because I somehow lose hours to the internet whenever I go off looking for something there.  I will repeat my caution against ‘pseudo-medical’ sites– sites where you are encouraged to ask questions, but where none of the replies come from actual physicians.  I will put in another plug for MedHelp.org, where there are the community forums, and then there are the ‘expert forums’, where questions are answered by physicians or other healthcare workers with actual experience treating the conditions you are asking about.

Who Can Write for Suboxone?

Tonight’s question:  who can write for Suboxone:
To explain this situation requires a bit of history.  In the early 1900’s, morphine and other opiates were sold as ‘tonics’ (along with other drugs that are now ‘controlled substances’).  In the 1920’s doctors treated addicts by prescribing narcotics to relieve their withdrawal.  Clinics existed with the aim of treating and/or preventing opiate withdrawal.  Public outcry consistent with the attitudes of the time eventually led to the closing of these clinics, and a ban on prescribing opiates to treat opiate withdrawal.  That was the state of affairs until the early 1970’s, when congress passed the law allowing methadone clinics to operate.
Most people don’t realize that doctors are allowed to prescribe pretty much anything for anything.  There are very few rules that regulate medical care;  the way doctors practice is kept in line mostly by physicians’ desire to do help patients, coupled with physicians’ fear of being sued for malpractice.  One confusing issue for patients is ‘FDA indications’ for medications;  a pharmaceutical company will seek FDA indication for a medication so that they can advertise the medication for that use, but doctors can use the medication whether or not it is ‘FDA indicated’.
Buprenorphine is indicated for treatment of opiate dependence.  But this use is at odds with Federal law, which bans the use of opiates to prevent withdrawal.  So in 2000 a law was passed allowing the use of buprenorphine to treat addiction under certain conditions;  doctors had to pass a course and be ‘certified’, and they had to follow certain guidelines, including treating a max of 30 patients the first year and 100 patients after the first year.
But buprenorphine was available long before 2000.  It has always been available in IV form, dissolved in a liquid for injection in microgram dosages.  Reckitt-Benckiser found a way to administer buprenorphine as a dissolvable tablet, and patented the product as Suboxone.  There is nothing to prevent a doctor from prescribing buprenorphine, either in liquid injectable form or in the form of Suboxone, to treat acute or chronic pain.  It is illegal to treat opiate withdrawal with buprenorphine or any other opiate, unless the doctor has a waiver– in which case he can treeat it with buprenorphine.  But there is no law against treating chronic pain with buprenorphine.
Unfortunately, most doctors do not know about all of this, and neither do most pharmacists.  If you are able to talk your doctor into prescribing Suboxone for your chronic pain, you are likely to have a problem with getting your pharmacist to dispense it (especially if your pharmacist works at Walgreens, whose pharmacists seem to have problems with every other script that they fill for my patients).  There has been a suggestion made (not sure where it came from originally) that doctors prescribing Suboxone for pain write across the top of the prescription ‘for pain treatment’– then the pharmacist is supposed to fill the script without needing the ‘x number’ that is used by by doctors with the waiver.
So in summary the answer to the question, who can write for Suboxone, is… anyone with a medical license and a DEA registration for Schedule III narcotics.  But getting your doctor to write for it, and your pharmacist to fill a script for it, is another matter entirely.

Addiction, Pseudo-Addiction, and Dependence

I am now in charge of the ‘expert forums’ for both addiction and chronic pain over at medhelp.org.  I was happy to take the position, as I had battled the folks on the ‘community forum’ in the distant past over Suboxone, and the expert forum allows me a small platform to present the other side of the discussion.  I will say again that I am not ‘wedded’ to Suboxone;  I don’t receive support or ‘kickbacks’ for this blog or for prescribing the medication;  I am motivated only by finding a way to reduce the misery in my patients caused by opiates.
Today was interesting;  I had a patient come in with one of his distant relatives, who happened to be a person I knew from recovery circles from years ago.  The person I knew has been active in twelve step recovery for many years, even running a halfway house for the past ten years or so.  I was impressed, and a bit surprised, that he brought his younger relative to my office;  I suppose I expected him to have some ‘anti-Suboxone’ sentiments, given his active role in AA and NA for so long.  But that wasn’t the case.  To my pleasant surprise, he seemed to agree with my perspective– we both have known people who died from their addictions, and we agreed that twelve step recovery has been, and always will be, reserved for the fortunate few who ‘get it’ and build an active recovery program.  Before Suboxone, maybe 5% would fall into that category… and the rest would suffer consequences over and over again.
Suboxone, he agreed, allows us to treat a much higher percentage of ‘suffering addictes’.  Is their recovery as ‘good’?  If ‘good’ means free of relapses, it is as good or better.  If ‘good’ means having the ability to move one’s life forward, relieved of the constant obsession to use– Suboxone is as good or better.
I hear all of you, by the way– saying ‘there he goes again…’
I am posting something that I posted over there, about the difference between the terms listed above.  Sorry if this is a bit boring;  it is a Thursday, though, so what do you expect?
The Post:
Thank you for pointing out something that is often confused. I will do my best to summarize the differences—I encourage people to do some reading on their own, using the following comments as a starting point.
‘Addiction’ is not a name for a condition listed in the ‘DSM’, the book that psychiatrists use to identify and characterize mental illness.  The condition most people would likely see as most similar would be drug dependence, which is distinguished from drug abuse by physical dependence and other things that are associated with heavier use, and by a pattern of negative consequences related to using.
I think I have already confused everyone.
Addiction is not formally defined by psychiatrists, but when I talk about addiction I am usually referring to the relationship that a person has with a substance or other object of addiction.  If a person wants to stop drinking, but can’t bring himself to throw out the beer he just poured himself… and instead leaves the beer in the glass on the counter all day… he is in a relationship with alcohol.  Opiate addicts think about using constantly—they are enjoying the last dose for only a few minutes before trying to feel if it is still there, or if it is starting to go away… and then if it is going away, how much longer do I have?  What is left?  Do I have any money?  Where can I get some?  Who is holding?  Where can I find him?  Uh oh—is that sweat?  I’m sweating, not good.  Is that my belly making noise?  Better get moving…
You get the idea—life becomes all about using, and not even about the ‘joy’ of using (as if!) but about the need to find the next one, and the one after that.  Addiction takes a great deal of mental energy.  Opiate dependence, or alcohol dependence, or cocaine dependence, are the official terms for ‘addiction’ in the DSM.  If you google DSM criteria for drug dependence you will find the formal criteria that must be met to qualify for the condition.  Drug dependence, or addiction, usually include physical dependence… but not always.  For cocaine for example, the addiction or ‘cocaine dependence’ can be quite severe with very little ‘physical dependence’.  The same is true for alcohol.
Physical dependence is when the body becomes more and more ‘used to’ the substance, so that ‘tolerance’ occurs—meaning larger and larger doses are required to get the same effects.  Tolerance is usually associated with ‘withdrawal’.  Physical dependence is NOT identical to ‘drug dependence’ or to addiction.  You can become physically dependent on non-addictive substances, such as blood pressure medication;  suddenly stopping a beta-blocker will result in ‘rebound hypertension’, which is a form of withdrawal.
‘Pseudo-addiction’ is a more complicated concept, but is probably the most commonly occurring of all of these conditions.  The term refers to a person being prescribed a dose of pain medication that is not sufficient to treat the pain, and in response the patient takes amounts of medication beyond what has been prescribed.  The patient feels guilty for doing so, and exhibits many of the signs of addiction, including feeling ashamed, covering up the use, being less than truthful about the use, and perhaps doctor shopping.  The patient’s doctor learns of this behavior, and responds by reducing the medication, ‘since the patient is addicted’.  This, of course, just makes the patient go to greater extremes to find relief from the pain.
There are so many problems with how narcotics are prescribed; doctors often fear getting in trouble, even when there is no real risk of that happening.  On the other hand, there have been some extreme cases where good doctors have been prosecuted or disciplined for care that turned out to be appropriate, but that attracted the attention of the licensing board for some reason.  I see one pattern over and over… the patient complains of pain, and the doctor writes a script, without spending any time discussing the limitations of the medication and the problems that occur from tolerance.  The patient returns and asks for more, or maybe even runs out early;  the doctor scolds the patient as he/she writes for a higher dose.  As time goes on, the patient gets higher and higher doses, each time suffering a new round of scolding so that he feels as if he is doing something wrong.  At some point the doctor is suddenly angry.  He has been getting more and more nervous inside;  many doctors don’t like confrontation, and so they don’t want to talk openly about what is happening…so they pretend everything is fine.  But when the dose gets to a certain point— or perhaps a pharmacist calls the doc and asks ‘are you sure you want to write for THAT many?’—the doc blows his top!  The patient, meanwhile, doesn’t know what has happened, and what he did wrong.  Suddenly the nurses and other office people are giving the patient funny looks, and the doc ‘isn’t available’ to talk anymore.  Sound familiar?
If I had any ‘pull’, I would have medical schools teach a formal course in prescribing narcotics.  I even think that narcotic prescribing could warrant a new medical specialty.  At one point I had a separate ‘division’ to my practice that I called the ‘Wisconsin Opiate Management Center’, and my goal was to prescribe narcotics the ‘right’ way, using adequate education, treatment contracts, meetings with pharmacists in the case of abuse concerns, etc.  I thought it was a great idea… and I still do.  But most doctors want to run the show themselves, or so it seems, anyway.

Physical Dependence vs. Addiction in Chronic Pain Patients

A question from a reader about taking Suboxone for chronic pain, and about physical dependence vs. addiction:
Thanks for the web page. It gave me a lot of information that I had been searching for. Most of your blog deals with addiction. Will Suboxone work for dependence? I have been on Oxycontin for 7 years due to nerve damage in my back and Fibromyalgia. I have been able to get down to 30 mg per day with the help of RF ablations but unfortunately there aren’t any pain doctors in my area that will take medicare anymore. RFA’s don’t last forever and I’m being forced to increase the Oxycontin again to manage the back pain. The severe cold with snow has made this a very miserable winter which is why I’m looking for a different answer.
From what I’ve read, I don’t believe addiction is as big of a problem as the dependence in my case. I’m using the medication as prescribed and the doctor is working with me and is more than willing to increase the medication if needed. The problem is my life revolves around that once a month prescription. Every time I try to leave the state, it is a major production since the nurses think I’m trying to pull something if I ask to fill my meds early. The doctor trusts me but getting through the technician that handles the refills for the office is like dealing with the Nazi’s…and I’m being kind. I’m not sure that switching to Suboxone will change anything. I’m thinking maybe at least this way I might be able to someday get completely off all this kind of medication. I don’t actually want to increase my medication again and if I understand correctly Suboxone will take some of the pain away.
Any insight would be greatly appreciated.
My Response:
I hear your frustration over the attitudes and hassles associated with opiate treatment.  I find it ironic that many doctors act as if patients are criminals for using the very medications that the doctor prescribed!
You question is a difficult one;  I struggle with deciding the best course of action for patients who are physically dependent on opiates but who haven’t shown signs of addiction.   Just to clarify,  I do think that many pain patients do cross the line without realizing it;  it can be very difficult treating opiate addicts who initially started through legitimate use for pain, as those patients see themselves as ‘unique’—and that feeling of uniqueness gets in the way of the changes that need to occur during the recovery process.  So it is important that you take an honest look at what is happening in your own situation.


Buprenorphine is being studied for use to treat chronic pain, as are other medications (search for ‘oxytrex’ or ‘embeda’).  Partial agonists including buprenorphine (including the medication Suboxone) do offer some advantages over agonists, but have some potential drawbacks as well.  Even a pain patient not ‘addicted’ to opiates would likely notice a profound difference with Suboxone;  the feeling of needing ‘more’ would mostly go away, as would the fear of being without medication.  I use Suboxone for pain patients, and they universally report that in retrospect they see how much the pain medications were controlling their lives, and they are grateful for the change to something that leaves their mind free of those thoughts.  Some people find that their pain lessens—in my opinion because they are out of that cycle of feeling/dosing/feeling that makes up opiate pain treatment.  With Suboxone there is much less risk for ‘dose escalation’; the effect is capped at a level equivalent to 30 mg of methadone, and increases in dose do not provide much more pain relief.
The downsides of Suboxone are related to the benefits;  the ceiling effect that limits dose escalation also limits… dose escalation.  If you really DO need more analgesia, you won’t get it from Suboxone—and you will be blocked from getting it from other medications.  ALTHOUGH—the increase in analgesia from dose escalation is mostly a ruse;  you only become tolerant to the higher dose anyway, so there is little value in being able to increase the dose of oxycodone or other agonists.  Suboxone and other partial agonists present challenges during periods when big increases in analgesia are required, such as after surgery or injury.  Finally, patients taking Suboxone quickly become tolerant to the effects of buprenorphine, so I wonder sometimes whether the medication is truly reducing pain, or whether it is causing a ‘placebo effect’.  ON THE OTHER HAND—a ‘placebo effect’ feels as good as a ‘real’ effect, so the question isn’t that important.  Plus, patients will get tolerant to EVERYTHING—including agonists—and so the tolerance to buprenorphine is not specific to that medication.
A tough call—but in patients who cannot prevent the run-up in dose that occurs with opiate agonists, Suboxone is a better choice.  There is no future in being on runaway doses of oxycodone;  those situations will always end badly eventually.  I believe that for those patients, Suboxone restores a great deal of sanity to the treatment process.  With Suboxone, the patient can free himself/herself from the constant thoughts about pain medicine, and get the person to move forward into the appropriate non-narcotic treatment strategies that are usually the true road to better function.
Good luck!

Newer Recovery Programs?

Addiction is a chronic relapsing condition;  opiate addiction in particular is characterized by cycles of dependence, withdrawal, and relapse.  Treatments to date can be separated into the ‘detox’ stage, the ‘treatment’ stage, and the ‘maintenance’ or ‘relapse prevention’ stage (not to be confused with the term ‘maintenance therapy’ as applied to medications such as methadone).
Twelve step programs have been around for about 75 years;  they are by far the most commonly used programs for early treatment and for long-term relapse prevention.  Over the years a number of other approaches to addiction and alcoholism have come and gone;  Moderation Management, for example, was ‘all the rage’ ten years ago… before founder and proponent Audrey Kishline was incarcerated for vehicular homicide for driving while intoxicated.  So much for Moderation Management!
More recently there have been a number of new approaches to recovery;  some are ‘anti-AA’;  others borrow from AA but attempt to take a more ‘secular’ position.  Some examples:  The Pennsylvania Model; Assisted Recovery or ARCA; Rational Recovery; LifeRing; Smart Recovery…
If anyone has personal experience with any of these programs or other programs, has used the program for recovery from opiate dependence, and has more than three clean years on the program, please share your story with me here, or write to me about your experiences at [email protected]  These other programs are so new– I am trying to determine if they are here to stay, or if they are ‘flashes in the pan of recovery’ like so many before them.  Are there people out there who are actually using them?
If you write, please consider including:
– the duration and severity of your use
– number and nature of prior treatment experiences
– basic philosophy of program;  your personal thoughts on why it is a good program
– number of others that you know in the program, and the general success rate in your opinion
– difference from step-based recovery
– philosophy regarding medication
– anything else you think is relevant
I hope to gather and summarize the information, and will be gathering information from other sources as well;  I hope to eventually share the material here and perhaps elsewhere.  Please specify if you want your name to be associated with the information;  I will quote you if you like;  If you do not specify, I will assume that you wish to remain anonymous.
My hope with this is to help all of us get a better understanding of the real options used to treat opiate dependence.
Thank you,
Jeffrey T Junig MD PhD

Darn That Suboxone!

This guy doesn’t like Suboxone– or the horse it rode in on.  He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone.  It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!).  I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.
His Post:
Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to

2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the

good ole subs that all these Drs are making a fortune off. You must remember

that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought

i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.

There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !

My Response:

Before my answer, a quick comment–  I do like the ‘crooks on wal-street’ remark;  I haven’t seen that ‘play on trademark words’ before.  I am assuming that he was making a joke–  he had to be, right?

OK, here is my response.  As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:

I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.

Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.

There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!

Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…

Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.

Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.

I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.

My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.

If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.

OK… on with life…

Help– I Can't Stop Suboxone!

I am still experimenting a bit with youtube.  They tell me that video is the future of the internet, and who am I to argue?  Tonight’s ten minute video deals with a common video title at youtube, and the title of this post.
So… why is it hard to stop Suboxone?  I resisted the urge to put a ‘duh’ here…  in case you are missing the answer…  one reason is because Suboxone has opiate properties, and stopping it causes withdrawal.  Pretty much anyone who is taking it has demonstrated an inability to stop any other opiates– probably over and over again.  So why would such a person be able to stop Suboxone?
Actually, most opiate addicts that I have gotten to know over the years, myself included, have trouble stopping just about anything– opiates, sleeping pills, antidepressants, ice cream, Cap’n Crunch…   if ‘the addict’ in me likes something, he doesn’t want to give it up!!  I don’t know why, but he is stubborn like that!
I realize that there is physical withdrawal to buprenorphine and not to ice cream… so I would expect Suboxone to be a bit more difficult to stop.  But I have a bit of information to add to our database of information here…  although I realize that some people will not believe what I am about to say.  But I really have no reason to lie;  I’m sure the conspiracy theorists think I am up to something– I got a comment today that said that I ‘push Suboxone to rake in more money than I ever dreamed of’.  One thing I can guarantee, just in case the writer is reading this–  I can dream of a lot more than that!  Darn– where was I?  Oh yes…  a patient of mine who takes Suboxone– he is about 45 or so and used opiates for many years for chronic back pain, and has been on Suboxone for only about a year… he is having a great deal of tooth problems related to trauma years and years ago, and will have the remaining teeth pulled in a few days.  To prepare, he took himself off Suboxone a couple weeks ago by tapering down to 4 mg and then stopping.  I saw him today and he insists he had NO withdrawal at all– ZERO.


This guy has been using opiates for decades and has had withdrawal many, many times, so I would have expected him to suffer a bit going off Suboxone.  On the other hand, he is a tough guy– and I don’t mean that any way but literally.  He could probably have his fingernails pulled off one by one without flinching, and he is not prone to ‘working himself into a frenzy’ over fear of something.  But I was still surprised at his claim– I believe it entirely, but I am surprised.
I did have one young woman as a patient who stopped Suboxone after taking it for several months without telling me ahead of time– she also claimed to have no withdrawal, although in retrospect she said she did feel ‘a little tired’ for a few days.  I have had a number of patients taper off Suboxone and have never had one claim that the experience was worse than oxycodone, vicodin, or methadone– not one.  I read the posts on the internet– ‘the hardest thing to quit EVER!’  I don’t know what to make of them.
OK, enough horsing around.  There is no longer any reason for you to watch the video, unless you want to look deep into my eyes to determine if I am telling the truth.  But here it is anyway– my description of the reason for the phenomenon, ‘I can’t stop Suboxone!’

Addict, Heal Thyself… But Not With Suboxone!

Tonight’s discussion comes from the tail end of a discussion with a relative of a person who is addicted to opiates, and who is doing something that is unfortunately growing in popularity– buying and using Suboxone ‘on the street’.
In my private practice, most of the people who have gone on Suboxone have done very well.  In fact, if I didn’t count the third of my practice that consists of people under 30, the relapse rate would be less than 10%.  The relapse rate is much higher in 20-year-old addicts– in my experience about half stay clean, another 25% bounce in and out of stable maintenance with Suboxone, and 25% are lost to follow-up after about a month.  If you do the math, for the entire practice the relapse rate is between 10% and 20% over a period of one year.  I would guess that out of people who take Suboxone on the street, the numbers are reversed– and 10%-20% of addicts stay clean for a year.
But I’m getting ahead of myself.  The question:
Thank you for the kind words. Just a couple questions. Can you tell me, is it dangerous to take soboxone without medical supervision? Also, can you recommend a good treatment center in our area? Are there any federal funds available for people like him?
Every day I read the headings from the sites I have complained about:  ‘I just scored 60 Suboxone tablets and I want to do this right– someone write and tell me what to do!’.  Then there is the corollary post: ‘Suboxone doesn’t work.  I have tried it over and over (on the street) and it doesn’t do anything for me’.  I don’t know who is the biggest fool– the addict treating himself with addictive medication, or the amateur doctor telling the addicts how to use the non-prescribed addictive medication.  But regardless– they are both fools!
There are a couple problems with unsupervised or ‘non-medical’ use of Suboxone. The best way to point the problems out is to first look at the goals with Suboxone treatment: first, to gain some stability over the chaos of using by suppressing the desire to use, and second, to ‘heal’ the manifestations of active addiction– which are mainly personality effects that I have written about ad nauseum on the blog. The personality effect that I see as most important is the way the addict puts up a fake front to deal with the world, while the ‘real’ person is ashamed, angry, afraid, and hidden away from the world. The result is that to the active addict, everything is an act– he is always working people, manipulating the truth, twisting reality to make it fit– rather than ‘living life on life’s terms’. Over time the addict loses the ability to tell what is real, and what is BS. Being around ‘real’ people, or real relationships, becomes more and more painful, as they serve as reminders of how fake everything has become, and they also force those feelings of shame and fear to come to the surface. The addict loses the ability to tell one feeling from another– every uncomfortable feeling is labeled ‘anxiety’, for example, as that is a reason for even more medication.

When the person goes on Suboxone ‘on the street’, some good things can happen– the use can settle down, for example. But often the addict tries to save money by taking small doses ‘when needed’, rather than getting on a regular daily morning dose. There is not a lot of difference between taking small doses of Suboxone when needed, vs taking vicodin or oxycodone as needed– especially since small doses of Suboxone are below the ‘ceiling dose’ and so they behave like an agonist, not like a partial agonist.

I talk to patients a lot about the ‘conditioning’ that occurs with addiction. I want to ‘extinguish’ the conditioning by making sure they dose only once per day, and automatically, not when they ‘need it’. But even if the person does ALL of this– without medical supervision there is something missing (yes, something more than just the absence of payment to the doctor!). Some of what is missing is subtle, and hard to describe. But two things I can describe… first, every addict thinks he can fix himself. That is a part of addiction itself– the misplaced confidence in self-as-doctor, the feeling of ‘uniqueness’, that nobody understands me but ME… and one thing that I have come to learn about every psychiatric illness but especially addiction is that a person usually cannot make adequate changes in himself without an outsider’s view of things guiding the way. A person will think he is making changes, but he will only change what is acceptable, and won’t even consider or notice what really needs to change. To recover from addiction a

Active addiction requires a 'false front'
Active addiction requires a 'false front'

person needs to live another way, and he only knows one way. And reading isn’t sufficient. Going to meetings with an open mind and willingness to take in new things and willingness to change– that can result in recovery. But an addict counseling himself just won’t work, as tempting as it is to hope for. The second thing is more subtle… by going to someone and getting help an addict is making a commitment to himself of sorts. He is taking a step out of ‘self will’ and isolation, and accepting help from another. Just this simple act alone is part of the recovery process. And a person sitting at home popping a Suboxone purchased from a friend is in a very different place than the same addict sitting in an office, tears on his face, asking for help. Unfortunately the addict with tears on his face may break into a cocky laugh as soon as he steps outside– when I see that, my prognosis for the person drops dramatically, in contrast to the person who spends a few days numb and shaken by how horrible life had become. Just that difference in how people present tells me so much about how they will do– I am constantly trying to find a way to turn the first person into the second person.

I got clean after my relapse in 2001 at what is probably one of the better treatment centers in the country. It is ‘open ended’, meaning that they keep you until they think you are better. I was a slow learner, and there for over three months. The state sends docs, dentists, pharmacists, nurses… people with licenses… to that program, and they get the same from several neighboring states. But it costs a mint– I was an anesthesiologist back then, and I sold our vacation cottage to pay for treatment and to pay the bills. I should mention that what makes the place good isn’t the ropes course, the art therapy, the old buildings, etc… they just have several real good counselors, and they are very strict in their rules. There is no wiggle room at all, and that is a good thing. There are other good places around the area that aren’t quite as costly, like XXXXXXXXXXXX… they have some great counselors as well. The thing is, it depends so much on the attitude of the addict. My first time in treatment was at a miserable place, as an outpatient, surrounded by court ordered patients… but I was so sick of being addicted that I attended many meetings and ate up every bit of recovery I could find, and it worked for ten years… even after catching my counselor at a bar (I was going into a restaurant) with a fellow patient who wasn’t his wife (yes, he had one of those at home). I see addicts who aren’t ready for recovery go into a fabulous treatment experience, at dad’s expense, and complain that the food isn’t good, the beds are hard, the counselors are too mean… a person who really wants treatment doesn’t complain about those things!!

Finally, there is something to the idea that a person does better in treatment if he/she has some stake in it.  This applies to so many areas in life, by the way–  I remember being angry at the kids in my college who were attending practically for free, who blew off classes regularly and eventually dropped out.  On a separate, perhaps controversial note, this is why I am against the idea of ‘free college education for all’.  In my never-humble opinion, that would be a disaster, as so many more kids would go ‘just for the heck of it’, diluting the experience for those who are working to be there– and grateful for the opportunity.  No, I’m not saying to take away financial aid!!  Just that people seem to get more out of something that they work for.  And recovery is no different.

SD

Naltrexone Implant vs Suboxone: Mano a Mano!

I am going to share an interaction with a person who wrote to me about using the Naltrexone implant. I am always a bit suspicious about the motivations of people who want comments posted about a different type of treatment, or who come with pot-shots against Suboxone. I don’t go to methadone clinic sites or ads for rapid opiate detox and hound people for their choice of treatment—even though I don’t agree with their choices. But the point of my blog is to educate people (that better be the point, as it certainly isn’t a money-maker!), so I will share the material and let people decide what is right for themselves. I did make some comments at the end of the discussion—the owner of the blog gets the last word!– because there were some things written about Suboxone and Naltrexone that I don’t agree with, based in some cases on the literature, and in other cases on personal experience.
The message about Naltrexone:
I just wanted to add a thought to the doctor’s paragraph about Naltrexone and how it could be used as a tool to help in recovery but it can’t because it doesn’t last in the body for long. I want to tell everyone about the Naltrexone implant. It has been around for a long time but not many doctors have the knowledge of it. I detoxed off heroin six years ago and went onto the Naltrexone implant for twelve months. The implant lasts about 8 weeks and then you have to go back for another. I have to tell you that it was the best twelve months in my whole life. I wish everyone knew about it. I had a great doctor that was a recovering addict and really understood what it takes to be clean and stay clean. I would suggest ANYONE that wants to really be clean…STOP hiding behind Suboxone and get to a doctor that knows how to detox you and put you on something NON ADDICTING like the implant.

Naltrexone vs Suboxone
Naltrexone vs Suboxone

My Reply to the Writer:
Thank you for your comments. I will add your perspective, but will also discuss the problems with the Naltrexone implant that have kept it from becoming more popular.  I’m glad it worked for you, but for many who have it implanted (usually as part of a rapid opiate detox weekend) there have been significant complications.  There is the liver damage from Naltrexone of course, but that is not the only issue.  I have met addicts who dug the implants from their belly or arm out of desperation to get ‘high’; there also have been several documented suicides in patients after rapid opiate detox and Naltrexone implantation.
As a board certified anesthesiologist, one of my initial plans after getting clean was to set up a rapid opiate detox place with a friend who was an internist.  After research of the literature I learned that the medical community sees rapid detox mostly as a gimmick that pays well but that does little to ease the suffering of addicts.
I also take issue with your comment about ‘hiding behind Suboxone’.   Most people would see the implantation of Naltrexone to be at least as significant an undertaking as taking a Suboxone tablet once per day. I’m not sure which person is actually ‘hiding’.

The Writer’s Response:

I completely understand your thoughts about the implant.  I do know about these types of cases and they are unfortunate.  However, because I took that step and did my best to use it correctly as a tool in my recovery, while working VERY VERY hard with a counselor, it worked for me.  Since then, I have devoted a lot of time to speak with other addicts about it and have “sponsored” hundreds and hundreds through this option and I have seen more people stay in recovery longer because of it.  I also was part of a Naltrexone implant study over the course of 12 months to see if people on the implant really achieve longer sobriety than someone on the oral form and even the injectable.  As far as liver damage, case studies show no liver damage within the first 12 months of staying on Naltrexone.  If that was the case, then I truly believe Vivitrol would not have been FDA approved for alcoholism (and they are more prone to have liver damage than an opiate addict).
I went through a rapid detox but with sedation….no anesthesia.  I have been through both and the sedation detox was SO much easier and more comfortable process to go through.  The doctor was great (he too was a board certified anesthesiologist) and I was awake through most of it to learn a lot about the process of which my brain and body was going through.
However…there are still several addiction specialists that can offer a detox (no anesthesia or sedation) on an outpatient basis and still complete it with the Naltrexone implant on the last day.  There are usually several options to offer a patient to help them even get through the tough time.
And with the Suboxone…there are truly people who need to be on it; pain management, people who are NOT ready to be clean, etc.  But there are some who did NOT know enough information about it, took the advice of their “MD” and then now are having a hard time getting off it and have no idea what to do.  I am “sponsoring” a woman now who is a school teacher in AZ….she called me this week and is so upset that her MD keeps writing her scripts for Suboxone, then she talked with him and told him she wanted to stop, and he doesn’t know how to get her through it…..because is in NOT an addiction specialist.  She is only on 2mg per day but she cannot get off of it.  I sent her to a specialist who will detox her in 5-8 days comfortably and then put her on the Naltrexone implant……it will take away her cravings, temptations, and provide her that “safety net” during the first 2 months of her recovery.  She knows it won’t be easy to be dependent for 2 years and all of a sudden not be dependent, but she is so excited to have the “opportunity” that she was never offered before.
I hope you will consider posting my blog…..it may help some and it may not.  But, addiction is non-predictable anyway and there is never a guarantee.  Thanks for the good work you are doing…..look forward to reading more stories.

Suboxone vs Naltrexone
Suboxone vs Naltrexone

My Last Word:

I appreciate the writer sticking with the discussion; too often a discussion will degenerate into name-calling, as I mentioned in my prior post.
I am not aware of anyone using the Naltrexone implant in my part of the country (the upper Midwest). I know that there are places in Florida that advertise heavily on the internet, and I do have one current patient who had rapid detox in Florida and the implant several years ago. He now takes Suboxone.  I will admit to some real stupid behavior on my part, borne from desperation:  on three occasions during my active using days I performed unmedicated rapid opiate detox… on myself!  On one of the occasions I injected the contents of an unlabelled syringe– something that often results in a dead anesthesiologist– but which in this case resulted in an anesthesiologist who only felt dead.  The unlabelled material turned out to be naloxone.  It was when I recognized this level of addiction– and this level of dangerousness– that I decided to leave anesthesiology behind and do another residency.
The other two occasions were equally stupid.  Again, understand that I hated being addicted to opiates from day one;  I took naltrexone tablets (which unlike naloxone are active orally) thinking that the block would set me free.  The first time, I was in a meeting with my partners after I took about 100 mg of naltrexone;  by 60 minutes I had to run from the meeting, much like a disgusting scene in the movie Trainspotting (I won’t say more, but those of you who have seen the film likely know the scene I am referring to).  The last time was late in my active addiction at a time when I was truly going crazy, and I don’t remember the event very well. Yuck.
Back to the writer’s comments– I don’t agree with the idea that Suboxone is for ‘pain patients’ and ‘people who are not ready to be clean’. People taking Suboxone are as ‘clean’ as a person on Naltrexone in my opinion; in both cases the person feels ‘normal’. There is no ‘high’ or any other subjective opiate effect associated with proper use of Suboxone. In fact, I have concerns when I start Suboxone in a patient having significant pain, knowing that the use of opiate agonists will be impossible on Suboxone and that tolerance develops to the agonist effects of buprenorphine.
As I have said in other posts, I see buprenorphine to be in line with Naltrexone, but an improvement upon it. I have not seen evidence that buprenorphine reduces opiate cravings; in my experience the cravings on Naltrexone were if anything more severe. Yes, Naltrexone reduces cravings for alcohol, but that is a completely separate effect. On the other hand, buprenorphine clearly does reduce opiate cravings, very effectively.
Everyone will have his/her own way of seeing things. Here is mine: Naltrexone provides assistance with sobriety by assuring the addict that use would not result in intoxication; the addict therefore can tell himself, as a last-resort measure to avoid use, that ‘even if I did use, nothing would happen’. In my model, ‘addiction’ consists of the mental obsession to use. Since Naltrexone doesn’t treat cravings, it doesn’t treat the ‘obsession’—it doesn’t treat ‘addiction’. So a person taking Naltrexone is truly in a ‘dry drunk’; the obsession to use is STILL there, and so active involvement in a 12-step program is necessary to regain a sense of freedom from substances. I think this is why rapid opiate detox and Naltrexone implantation has sometimes resulted in disaster; an addict stumbles out of a hotel after rapid detox, blocked from using, but still obsessed with opiates—without any exposure or experience with a recovery program (again, the steps are the ‘gold standard’ here). So the blocked addict is miserable—and sometimes digs out the implant, or worse.
ON THE OTHER HAND… and as I have written about many times, buprenorphine gets to the heart of addiction—the obsession to use. A person taking buprenorphine (in Suboxone) is relieved of the obsession, and so in my mind is not in a ‘dry drunk’. For that reason I see twelve step meetings as less of an issue in patients taking buprenorphine. This is a tough point, so I will word it another way: the meetings are necessary with Naltrexone implants in order to stop the obsession (which meetings stop through the adoption of powerlessness and a higher power); Buprenorphine ITSELF stops the obsession in patients taking Suboxone. This leads to my frequent caveat– if a person stops buprenorphine, he needs to take up meetings—or the cravings and obsession will eventually return.
One final comment: there are currently trials underway for a buprenorphine implant, Probuphine, owned by Titan Pharmaceuticals. I have tried to make contact with people at that company on a number of occasions but cannot get a response; if you have contacts with anyone there, please contact me at [email protected]

Tapering Suboxone

I am placing a new link in the Blogroll to a site that discusses tapering Suboxone.  I want to be clear that in my opinion, an opiate addict’s safest place is on Suboxone.  Many opiate addicts also find that on Suboxone they experience less mood variability, less irritability, and less anxiety;  I wonder if those symptoms represent forms of craving for those individuals.
I don’t see a ‘disease theory of addiction’;  rather I see very clearly that opiate dependence IS A DISEASE  (maybe we need to run a campaign:  It’s a disease, stupid!).  For hypertension, people take their medication and spend no time worrying about whether they are ‘living a life free from beta-blockers’.  Seeing that the people who judge addicts as ‘weak’ are idiots, I don’t understand the push to ‘get off Suboxone’.
If you are having side effects from Suboxone, please talk to your doctor.  If you are having random urges to stop Suboxone, at least consider the possibility that on some level you are setting things up to use again… and talk to your doctor.  If you have taken Suboxone for a long-enough period of time to make new, non-using friends, to lose all of the phone numbers, to get a good job, to come to terms with the family issues caused by your addiction– and if you can take Suboxone once per day without giving in to urges to take a bit more or to dose twice per day– AND if you have a plan to replace Suboxone with a recovery program– then maybe you are ready to taper off Suboxone.  In that case… talk to your doctor!!
I will of course put in a plug for a tape that I made, that discusses when and how to stop Suboxone– it is for sale on the right side of this page, or at SoberAfterSub.com.
If you are making a sound decision based on some good, sober thinking, check out the web page SuboxoneTaper.com.  It is relatively new, but I like the attitude of the writer– admittedly because he seems to think and write like me!  He comes across as cocky and angry… and I realize that I write like that as well.  Let there be no mistake– I have connections to some other web sites out there, but I have no connection to this one, and I don’t know the writer.  So if he suddenly gets in trouble for selling a Senate seat, I had nothing to do with it and I have nothing to say about it!!