Tough Choice

I have been struggling with part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.
As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner. Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—and outdated and toxic medication—which likely contributed to the charges… but the story creates a chilling atmosphere, regardless. Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.
For those late to the party, we are discussing the best treatment approach for someone who cannot control using opioids, but who for now, at least, has a low opioid tolerance. Starting buprenorphine in such a patient will cause opioid side effects, as described in an email that I received from a woman who was addicted to hydrocodone for four years, who stopped taking hydrocodone for 7 days before induction with buprenorphine.
She wrote:
This Suboxone is making me feel like crap. He has me on 8mg/2mg sublingual 2/day. It’s awful…
She had been taking 20-30 mg of hydrocodone up to 5 times per day, stopping them a week before induction. She continued:
Have had a headache in the base of my skull since starting Sub 4 days ago, nausea, vomiting, sweating a lot, face feels like it’s on fire, can’t taste anything, throat hurts, can’t sleep because my face & eyes itch so bad that I’ve rubbed them raw.
These are classic side-effects of over-narcotization from buprenorphine. A person in this position typically feels better holding the buprenorphine, and when the nausea is eventually gone, taking a greatly reduced dose of the medication. The problem is that if the dose is too low, there is no advantage to buprenorphine over other opioids. The whole point of taking Suboxone is to stay on a blood level HIGHER than the ceiling effect, as that essentially tricks the brain, since the opioid effect stays constant even as the blood level falls.
In a few days, the writer’s tolerance will increase to a level where she can take an entire dose of Suboxone without nausea. And by that time, the medication will greatly reduce the desire to take opioids.
Will she be better off on buprenorphine or Suboxone than she was on hydrocodone? Her tolerance will be higher—meaning greater physical withdrawal if she stops the buprenorphine, than she would have had stopping the hydrocodone.
But on the other hand, she tried to stop taking hydrocodone for several years, and couldn’t. She was taking over 4 grams of acetaminophen per day— the other medication present in Norco besides hydrocodone— which is enough to cause death through liver toxicity. And the ups and downs of hydrocodone addiction create a living Hell that eventually demoralizes the person.
I hear from writers who are angry at their physician for getting them ‘stuck on Suboxone’, saying they should have simply tapered off the hydrocodone instead. My answer is that it is easier to SAY ‘I would have tapered of hydrocodone’ than it is to actually taper and stay off hydrocodone!
A doctor seeing the patient I wrote about in part one, or the person above, would face two options:
1. Cause an incidental ‘high’ by administering buprenorphine, and titrating the dose up to a level that eliminates cravings, or:
2. Use an alternate treatment strategy.
Some doctors would opt for the latter, saying they are not comfortable with deliberately intoxicating patients with opioids—something that is unavoidable when starting a low-tolerance patient on buprenorphine (or Suboxone; note that the naloxone component of the medication is irrelevant to this discussion, as it has no action unless injected).
In such cases people are often referred to step-based or other residential treatment centers. I’ve written some pessimistic opinions about those places, but I’m just trying to be accurate. I realize that there are many people dedicating their lives to treating people with addictions in such places—ranging from free, community-supported programs to $80,000 per month luxury rehabs. As dedicated as those people are, the success rate of such programs remains low, and the risk of fatal overdose is present upon discharge. Most people who have gone through residential treatment relapse. And many people have been through rehab multiple times, yet continue to struggle.
Vivitrol, a monthly, injectable form of naltrexone, has been marketed to fill in this space, as a protection against relapse after residential treatment or after several weeks of detox. But for whatever reason, most people opt to forgo that medication, instead placing misguided faith in their own ability to stay clean. So what usually happens is that people with a lower tolerance to opioids repeatedly go through detox, or repeatedly pay for residential treatment, only to return to using opioids. Tolerance increases over time and eventually they present with a tolerance level where Suboxone seems more appropriate.
Assuming, of course, they live that long.

Mean Streak

I guess I do get irritable sometimes…  but I’m getting better at controlling my anger as I get older.  One cool thing about a blog is that I can go back and see what I wrote years ago.  In this case, I was looking for a post about telling the difference  between opioid toxicity (from taking too much) versus opioid withdrawal. In that post I suggested looking at the size of the pupils.  The name of the post, in case anyone is interested, is called ‘abres los ojos’— the name of an old Penelope Cruz movie and spanish for ‘open your eyes.’ 

Penelope Cruz sounds very cool, by the way, when she whispers ‘abres los ojos…’ as you can hear at the beginning of the movie trailer.  The movie was remade and called ‘Vanilla Sky’– again with Penelope Cruz, but this time with her speaking in English.
Am I the only one who cares about this stuff?!
The post BEFORE that one was from a time– 2009– when people often wrote to tell me how misguided I was for recommeding buprenoprhine.  Those comments, at a time when so many young people were dying from overdose, would really get to me.  I’ll share the exchange, for old time’s sake.  For people who enjoyed my older, feisty posts, they are still out there– you just need to keep hitting the ‘earlier posts’ button!
The post:
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.
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.
Back to the present…
Phew.  Makes me tired just remembering those days.  Since then the number of deaths have only gone up, but at least there is a better acceptance for treating opioid dependence using effective medications— at least for people ready to accept that help.

Chapter 4: The Disease of Addiction, pt. 1

The universal nature of addictive experience
What I enjoy the most about having a presence on the internet is receiving comments from people from around the world.  The writers describe the same progression of symptoms that characterize opioid dependence, a disease that affects people from all cultures and socioeconomic groups.
I often think about how surprised most ‘normal’ people would be to learn the true extent of what can only be described as an epidemic of opioid use.  Writers, stockbrokers, artists, businessmen, doctors, lawyers, factory workers, photographers, teachers, students, IT professionals, waitresses, realtors, landlords, welders, professors, home-makers, mothers and dads… I have patients with opioid dependence from all of these occupations in my practice alone.  And in each patient, the story is the same…  the initial use, the loss of control, the assumption that the control will come back, the feeling of being ‘different’ from those ‘other people’ who get addicted, the assumption that what happens to other people won’t happen to ME, the repeated failures to control use, the repeated episodes of withdrawal, and the fear deep in the gut that maybe I really AM in trouble after all.  Each addict knows the deep shame that ‘I should have known better.’  Each addict makes a weak effort to blame someone or something else—a lie that even the addict doesn’t fully believe but that he still uses since the alternative– accepting all the blame himself– is intolerable. Each and every addict has done things that he never thought he would do—spending the family Christmas fund on pills, picking the kids up late from school because of a dope deal or from ‘nodding off’ at work, lying to friends, spouse, or children, stealing pain pills or money from family members, and eventually criminal activity and serious consequences that leave the addict thinking, ‘how did I become one of THOSE people?!’ At that point the addict often rationalizes that his constant guilt keeps him from getting clean, but that is just another excuse; he could just as easily say that being sick of hating himself is the reason he MUST get clean.
The first choice is the one that is taken, because for an addict, there is ALWAYS an excuse to use. The family is too distant… or is‘suffocatingly close.’  The weather is too horrible, or too nice.  The house is too empty or too full; my wife is too attractive and flirty, or too unattractive and boring.  There is always an excuse– which really means that there is never an excuse.  I run short on patience when addicts telling their stories get to the excuses; I have heard them all and none of them mean anything.  And yes, I have used many of the same excuses back in my own using days.
For the typical opiate addict, those first few weeks of using felt great.  He/she was stressed over a busy job and the opioids provided extra energy at home.  The spouse and kids were happy about the changes in attitude.  But after a short time the addict began to feel miserable inside (note:  even after years of sobriety I will hear addicts wonder if they can pull it off;  find a way to capture that initial euphoria without the misery that follows.  I can save them much trouble—the answer is ‘no’).  The addict retreats further and further into a world of secret thoughts.  His personality and interests grow smaller and smaller and he puts up a cocky façade, thinking he is fooling everyone. His kids might be the first to notice that something isn’t right, only because they lack the ability to ignore and repress thoughts that are too painful or frightening to acknowledge.
A parent living behind a façade is a set-up for causing borderline personality in the kids;  later when the kids talk to their own therapists they will say that everything seemed OK– there were no beatings, and dad was always happy…  but normal child development doesn’t do well with ‘fake’ personalities.  The kids internalize the growing distance from the addict (dad or mom) as somehow related to them.  To kids, everything relates to themselves… so the distance becomes part of low self esteem, mood swings, cutting, and impulsive behavior that is really borderline personality but that some shrink with 7-minute appointments will misdiagnose as ‘bipolar.’   The kid will be put on Depakote or Seroquel or Zyprexa and will gain 100 pounds, assuring a lifetime of self-consciousness.  It is hard to acknowledge, but our addictions are horrible for our children.
The good news is that sometimes the addict will get miserable enough to take action.  The bad news is that the damage will last a lifetime– not just the addict’s lifetime, but the kids’ lifetimes as well.

Anxiety, step-work, and gratitude

One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts.  We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking.  I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking.  But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux;  regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment.  I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps.  I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation.  And once on buprenorphine, addicts quickly lose that desperation.  One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery.  But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy.  The steps have remained as the mainstream treatment for opiate dependence for one reason:  They were all that we had!  The steps saved my life not once, but twice– but they fail for most others.  I got lucky–  maybe having my medical license hanging over my head made the difference.  It is impossible to predict who the lucky ones will be.  All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence.  And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine.  I personally know of several people who died after forced discharge from treatment centers.  Who benefits from that approach to ‘treatment’?  Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided!  Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry.  I tend to wander a bit.  The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth.  Opiate dependence has been treated successfully in a small fraction of addicts.  Yes, the steps CAN work in those who ‘keep coming back’.  But the truth is that people in their 20’s do NOT ‘keep coming back’.  Instead they relapse over and over until everything is gone, and they have become shadows of their former selves.  But then buprenorphine came along.  Buprenorphine is NOT a panacea;  many people fail treatment with buprenorphine as well.  But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence.  But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using.   After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment.  For example, many (MANY) opiate addicts complain of ‘anxiety’.  I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor).  I found that universally, patients who took benzos did WORSE.  They thought they needed them, and even thought they benefited from them.   But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos.  The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board.  I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment.  When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc.  But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh!   People taking buprenorphine are no different than I was;  they are trying to make HUGE changes in how they deal with their feelings.   Of COURSE they will feel all messed up inside!  But the answer is NOT to find another subsstance to reduce those uncomfortable feelings.  The answer can be found instead in many of the principles that make up the twelve steps.  If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting.  I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety.  Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’.  All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs.  And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean.   The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life.  During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago.  She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc.  She was grateful for the positive changes in her relationships as well.  No, things were not perfect– they never are.  But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together.  Not being broke and sick all the time allows a person to start to feel like a contributing member of society.   Being able to go all day without telling her friends or partner a lie has improved her relationships.  Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills.  And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse.  As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined.  No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use.  But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years.  As always, your personal health history is YOUR business;  if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business!  If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery.  You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way.  If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for.  If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift.  With all of the Holiday activities I may be absent for awhile.  My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks.  Back then I thought my life was over– no job, license suspended, anesthesia career effectively over.  I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing.  I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’.  I learned through meetings that EVERYONE with addictions felt that exact same way.  After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir).    Until the play that ended today, I’ve been too busy to participate.  But today I was on the exact same stage where I stood 9 years ago.  Today I reflected on all that has happened since feeling so hopeless back then.  I am grateful that back then I KNEW that I didn’t know anything about how to stay clean.  I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself.  Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ

Publishers, Agents, Nonprofit Owners or Accountants

I am in need of some help from the people listed in the title– so if you have connections, help me out.  I am adding this sentence to the front of this post after rambling too long, as I’m afraid that the person I need won’t get to the important part!  If you work in the areas I mentioned or have connections to someone in those areas, please read on.
I’ve talked about some of the goals I have had for this site over the past couple years…  one of my ‘personal issues’ is that like most addicts, I like to take things on by myself and solve problems by myself.  I remember, in fact, my first time in treatment in 1993– an outpatient, 21-session group therapy program– when one of my assignments was to ask another person for help at least once per day.  That was a very difficult thing to do, and I must have gotten better at it because now I am asking for help all the time!  On the other hand, I have some areas of my life where I would never consider asking for help– so maybe I’m not as ‘better’ as I think I am.
Before moving on I should make a quick educational comment about addiction– one reason that addicts do not ask for help earlier is because we know that if we ask for help, there is a possibility that we will have to change for the better and lose our addiction.  And every addict has ambivalence about becoming sober– even at times when we recognize that we are powerless and that our lives have become unmanageable!  There is always some degree of ambivalence.  If you are being ‘stubborn’ about getting help, consider whether you TRULY want to be done with using.   Sometimes a person who can’t find just the right treatment program is really concerned with something else– whether to really give up the secret life of an active addict.  If you are in such a situation, consider whether you are debating the REAL issues, or whether your concern for clean pillows and the ‘right treatment approach’ is just a distraction from a bigger question.
OK…  I am in need of some help.  I have written a pretty good book about addiction;  it is certainly different from what is ‘out there’, as it is personal and at the same time  educational, theoretical and at the same time practical, long and detailed but at the same time broken into bite-sized pieces.  I have patients on buprenorphine who are accountants, attorneys, nurses, businessmen, laborers, government employees… I find that opiate addicts are an incredibly talented bunch.  I figure that if they do OK in life despite having chains around their ankles, they will do wonderful when the chains are removed!  So out of the readers out there, I know there are people who work close to the publishing field– or people who know people in the publishing field.  If that person is YOU, please consider giving me a hand with the book.  I could just self-publish it, and that is what I may end up doing— but I would rather, of course, get the marketing that comes with ‘being published’ so that I can reach a wider audience.
As for the ‘non-profit’ thing– I am aware that of grants from government and private sources for educational projects related to drug addiction, but support is reserved for ‘non-profit groups’.  My efforts with the blog and forum are certainly not profitable– but I do not know how to go about setting up a non-profit agency.  I would like to make the site grow– to get a ‘real’ web designer instead of doing things myself (and I have no education in computer stuff, so in typical addict style I just try to figure it out myself).  When it comes to the IRS, I don’t want to figure it out on my own!  So if you can help–  either by pointing me in the right direction or something more– please let me know.   If you are unemployed, independently wealthy, and experienced in running a nonprofit company, come join me– be the ‘management wing’ and I’ll be the ‘medical wing’!
I realize these are long shots, but I always tell my kids to keep throwing baited hooks in the water.  If nothing else, we’re getting exercise!  If you even just know of someone who might or might not be interested, throw out another hook for me– I appreciate it!
Serious replies (or even funny ones) can write to me at [email protected]
Thanks!

How long to take Suboxone? Seven years?

‘Seven years’ refers to a scrape over on SuboxForum.com with a moderately disturbed woman from Roselle, Illinois…  Those of you who haven’t visited are really missing some good action!  We also have a new ‘Q and A’ section that I think will be a hit.  Please visit and register, but more than that, WRITE!  People on Suboxone need to talk to each other so that they don’t feel like isolated members of an ‘underclass’.  I tell you– there are more people on Suboxone than you would ever imagine.  I can’t remember the exact number, but somewhere around 500,000 people have been treated in the past few years (7 years if you believe our crazy lady from Roselle!).  So let’s talk… as you will read below, the stakes are high.  There remaines a great deal of ignorance out there, and it would be a shame if ignorance made the rules.
Here is the first question from the new Q and A section:
Hello Suboxdoc, I he a guy friend who has been taking suboxone for years, I read some of these stories where people have been taking it for years as well. First …is it safe to talke for that long? Can you tell me why some doctors would say “NO” to keeping a patient on it for life or what do they call it …a mantenance dose? My friends doc wants to take him off and he tells me he is not ready. He cant seem to find a doctor out here in Chicago that will work with him and tell him ok well keep you on it. I know you would need to know a lot more about my friend “XXX” and cant just guess at what he needs, I am just asking your opinion if you think keeping someone on suboxone for years is ok to do. What is your opinion. I am so glad I found this site, my friend XXX does not have a computer and I want to do as much research for him as I can and give him some positive feedback. Can you refer any doctors to me for him as I read you were out here for a meeting, do you know of any good doctors out here in Chicago? Thank you in advance!
My ‘A’:
First, let me say that this is only my opinion, and that there are other opinions. I DO think that my opinion benefits a bit from being an addict myself– but maybe it is the opposite and my opinion is LESS valid. So… I will leave that issue for you to decide.
While buprenorphine has been around for pain treatment for 30 years, using Suboxone to treat opiate dependence is new. As many people probably noticed, there was initially some hype about using Suboxone for a few months, as a detox tool. three years ago 30% of the scripts were written for long-term use. Now, 70% are for long-term use, or ‘maintenance’. The reason: studies showed that people who took Suboxone for less than 6 months had very high rates of relapse. Another reason, in my opinion, for the change in prescribing pattern was the increase in the patient cap to 100 patients, from 30 patients. I’ll explain:
The law that led to the use of buprenorphine was passed in 2000, and is called ‘DATA 2000’ for those who want to look it up and learn all the specifics. DATA 2000 dreated an exception to the Harrison Act, an 80-y-o law that bans the use of narcotics to treat opiate addiction. DATA 2000 allows the use of DEA schedule III-V meds to treat opiate dependence. In 2003 buprenorphine was moved up to schedule III from schedule V, where it had been for decades, in preparation for greater use of the drug. Finally, in May of 2003 the FDA gave the indication for Suboxone to treat opiate dependence. The initial law said that each doc could have up to 30 patients on buprenorphine at any one time. The docs had to get certified through an 8-hour course and a bunch of paperwork, and a waiting process of several months– a big hassle to a busy practice for just 30 patients! Plus, once a patient is stable there is little revenue generated… creating an incentive to ‘turn over’ patients as quickly as possible (the law of unintended consequences). So… patients were treated, tapered, and discharged, clearing the way for more patients. Never mind that the people who were discharged only relapsed again– unless they were sent straight to residential treatment after the detox was completed.
A year or two ago the law was changed, allowing doctors to have 100 patients after their first year of prescribing Suboxone. This change in the law, and the recognition that long-term treatment yields long-term sobriety, has resulted in more people being on Suboxone long-term. Given what we know about short-term use, I am always a bit suspicious about the motives of docs who use Suboxone short term– either they don’t know the science, or they want more money— again, in my ‘humble’ opinion. What is ironic is that the ‘anti-suboxone’ crowd, like our ‘7years’ friend from last week, think that the long-term docs are ‘evil’, trapping them on Suboxone to make more money! In reality the exact opposite is true. In most parts of the country if you hang a sign saying you are treating with Suboxone you will have 100 patients in two days! If you want to ‘clean up’ and make a ton of money, you treat everyone for a couple weeks of detox– then bring in another 100 patients! The ethical docs– the ones who understand addiction and who are willing to make less money to help people– treat people for the long term. They also have to put up with the head cases like ‘7 years’ harassing them. Those people are amusing, but they can be a bit annoying at times as well.
I believe that we are in the middle of a very important struggle over how addiction will be seen and treated. There is the ‘medical model’– where addiction is an illness as valid and as worthy of treatment of any other illness– and the ‘it’s your fault’ model, where addiction is a ‘spiritual deficiency’ treated through fixing character defects. I used to subscribe to the latter model, in part because it was all we had. But I have met many addicts who were just as ‘spiritually good’ as any non-addict! I mean, really– read what that ‘stone cold sober’ crazy lady wrote, and tell me– does she sound like the person YOU would want to become?!
Your specific question: We do not know of any long-term negative effects from buprenorphine. One problem I have with the nuts who spread the anti-sub stuff is that they are always wrong about everything they say– yet they write things like ‘do your research!’. To a newcomer, it must be horribly confusing. Bottom line: we hae had buprenorphine for thirty years. It is nothing new. It has been used to treat opiate dependence in other countries for 15 years– not as Suboxone, but in liquid form, using ampules and syringes to squirt it into the mouth. There is a long track record, and nothing bad has come up. And again, I have written explanations behind the claims of those who say the withdrawal is worse than that from other opiates; they are wrong about that, and if you want the reasons for their mistake you can read my recent posts on the issue.
I am a fan of long-term treatment. You will read comments like ‘I think Suboxone is fine, but only if used short term’– those comments are always by non-medical people who have no experience with the medication, and who don’t take the time to read the studies and understand the science. An argument CAN be made that a better model would be short-term detox followed by residential treatment… but it is just so darn hard to get a person into residential treatment. It really takes a commitment of 90 days to be effective, and while it can be a wonderful thing, it can also be a total waste of time and money. I believe that Suboxone and residential treatment do not mix, because residential treatment requires some level of desperation, and people on Suboxone are not desperate.
I hope that answers most of your questions… thanks for asking.
SD

Opiates as the Other Man

This gentleman answered my post about the limits of will power. I feel for him– I moved his post up here because it describes what happens when one partner falls in love with narcotics. As I read the post, about his wife slowly checking out with opiates and then with benzos… addiction makes a person fade away, lost in hazy fog… I had this image of his wife cheating on him, telling him lies about it being over…but going back again to the other man without even having the decency to go to a motel.
Will Power. I’m a person with strong will power, but my wife is not. My will has no power to get her help. Twenty years after 3 spinal fusions, she is now a daily methadone user (which I just found out 8 months ago?) for the past six years, to get off Oxycontin for chronic back pain. Since I confronted her about it she has repeatedly said she was getting weaned off of Methadone, and only had to go to the clinic twice a month now. Eight months later, nothing has changed, only getting worse. She is losing her mind, nodding out on her feet sometimes (“Oh, I was just thinking!” she’ll say) forgetting the most simple things and saying the craziest things. I have found Xanax, and Ambien in her purse and flushed them. Apparently local doctors (the ones she hasn’t been to before) have given them to her for depression. These combined with the Methadone makes for a person I can’t stand. Disgusting. Like someone who has been drinking scotch all night.

This is a nightmare, and my 31yr. marriage is about to end unless I have an intervention or something. She says she will do “whatever it takes,” but she’s dosed-up when she says it. She says her life sucks, and she knows Methadone is a wedge that is driven between us, but she is powerless to do the right thing.

I can’t afford Narcanon(?) and really don’t understand all this “agonist” stuff to well. I quit doing drugs at least twenty years ago and don’t even take an aspirin anymore, so I’m a little apprehensive about taking another drug (Suboxone) to get off another one (Methadone). The money she must have spent all this time on something that has convinced her brain she will die without it, she could have had two laser spine corrective surgeries by now. This is absolutely crazy. What’s to prevent a Suboxone user to not also include their Methadone dose as well? Chasing the dragon.

Is Suboxone a way to get off of Methadone?

Man I hope somebody reads this.
A couple thoughts.
Yes, Suboxone can be a way off methadone.  You will find some disagreement on the web, but since this is my site I can share my observations and opinions.   I have helped a number of people  change from methadone to Suboxone; most of the time those people were happy with the change.  But I don’t get the impression that this gentleman’s wife would be happy.
Methadone is an opiate agonist, and buprenorphine is a partial agonist.  The ceiling effect of buprenorphine allows one to take a sufficient dose to bind up all of the opiate receptors, which results in the loss of cravings for opiates.  To my way of thinking, buprenorphine, by eliminating the obsession to use, treats the heart of addiction itself.  That’s a good thing most of the time;  the person describes feeling much less ‘busy’– suddenly the person has tons of time and empty space in his/her mind to think about other things, such as wondering how one’s partner is doing, wondering about the meaning of life… whatever.
But I don’t get the impression that this gentleman’s wife is into all of that.  Were she to change to Suboxone, she would have time to feel ashamed of herself for what her life has become.  She would have to acknowledge her husband’s anger.  She would have to return to the living. s That would be a dramatic change from her self-obsessed fog.
For the writer, it is obvious that your wife has checked out of the relationship.  Is she still inside that doped up person?  I don’t know.  If you give her an ultimatum– come back to planet earth, or you are out of there– which will she choose?

The Foolish Pharmacist

Today I had a follow-up visit with a patient who takes Suboxone.  She is a 55-y-o married woman;  I remember when I first ‘met’ her during a frantic telephone call to my practice about 5 months ago.  At the time, she was on a high dose of pain medication from her doctor for a variety of ailments, and more worrisome she was on high doses of benzodiazepines– Valium-related medications like Xanax, Klonopin, and Ativan.  As I have mentioned before, benzodiazepine withdrawal can be fatal… but with opiate withdrawal you only wish you were dead!  Anyway, she had been through traditional treatment a number of times;  had attended meetings over the years and worked a program as hard as anyone… and yet she had little sobriety to show for her efforts.  She was crying, afraid, depressed… and for good reason, because from her perspective life appeared to be over.  I have met many people in the same condition over the years, and have been in her condition myself– as have many of the readers of this blog.
A few years ago I would have been afraid for her, and would have given her poor odds for surviving ten years, let alone for finding sobriety or any degree of happiness.  I would have offered her residential treatment, but she would have had trouble coming up with the $4000 required to get in the door to a 30-day center, and the open-ended treatment center where I went years back wouldn’t even be on the table, as costs there run to $30,000 and more for three months of treatment.  Insurers don’t usually pay these bills, as the treatment is considered ‘residential’, and not ‘inpatient’.  I could have offered her psychotherapy– which doesn’t work particularly well for opiate dependence.  I could have recommended NA or AA meetings… something she was already doing.
I set up an appointment, and we discussed the options, including Suboxone.  She warily agreed to give it a try.  Three months later she sat across from me in my office, smiling and grateful.  She was employed for the first time in years;  she was exercising and had lost over 15 pounds;  she was attending NA meetings once or twice per week;  her relationships at home were improving;  most importantly, she felt something that she hadn’t felt for years: that life was worth living. Cost for three months of treatment?  Several hundred dollars after her insurer (the cost for a person without insurance would have been about $1200 for medication and appointments).  She looked great and felt great.  Everyone who knew her was surprised by the sudden change in her demeanor, and most were happy for her.  Most, but not all.
Today she was crying at the start of her appointment.  Everything had fallen apart– ever since she took the advice of the people at NA who told her to ‘get rid of her crutch’ and stop the Suboxone.  The doctor is (gasp!) making TONS of money off you!  You aren’t REALLY sober!  And so she took their advice and stopped.  She had passed through the withdrawal– not the worst she has had– but things kept getting worse.  She was on the verge of losing her job– the job that she was so proud of a month earlier.  She was at odds with her family, and her son had announced plans to ‘write her out of his life’.
During our discussion she told me about the advice she had been given.  I usually attend AA meetings myself, and am not familiar with the NA meetings she attends– and plan to keep it that way!  Taking each other’s inventories, giving medical advice counter to a person’s physician without knowing anything about her history, accusations of ‘inferior recovery’…  what a bunch of self-righteous jerks!  They had taken this trusting woman and turned her into a basket case.  We discussed the difference between ‘honesty’ and ‘inappropriate self-disclosure’; we discussed boundaries.  And we got her back on Suboxone.
A bit later in the day I get the usual message from some idiot– only this time, the idiot is a pharmacist.
His message:
Perhaps you charge differently than my local docs do that prescribe this junk, but they charge $200 to $300 every 2 weeks. Thirty patients times $400 a month is $12000. Sounds like a nice chunk of change to me.
I’m a pharmacist in recovery now for 8 years.
I think Suboxone could have a place in treating addicts if it were prescribed and managed properly and ethically. What I’ve seen doesn’t fall along these lines. What I’ve seen is doctors taking the place of the dope dealers. You get them off narcotics so that they can be on narcotics? OK…? That would be okay if the Suboxone were used for a short period of time and then tapered. I have yet to see anybody get tapered. Why is it necessary to keep these patients on this new narcotic for so long? Put them on it, let the fog clear, point them to some AA/NA meetings, and taper the junk so they can learn to live.
I’ve seen the guys coming in the pharmacy week after week for their Suboxone fix. They’re not changing anything but their dealer. They are living with this false suboxone hope that everything is better. If they are actually taking only Suboxone and not using illicit drugs too, then I’ll admit that could be a step in the right direction. At least they aren’t involved in illegal buy and selling of narcotics.
Why do I care? I care because I am passionate about recovery and guiding people there. I see these people weekly and I hurt for them because they are spinning their wheels by continuing on these narcotics while recovery is available. I care because I hate addiction and what it does to people and their families (I’ve been there), and I don’t want anyone else to be fooled by this so-called opiod treatment. There are better ways to live than being a slave to narcotics, including Suboxone.

Fairly civilized.. but keep reading:

Keep kidding yourself about Suboxone while you rake in the money from these people who don’t know you’re nothing more than a pompous ass pusher with a great degree that’s being wasted by greed. You offer these people an answer that’s not real- a fucking band aid for a gaping wound.
How much do you charge these people to write these prescriptions for them? Is it a regular office fee? Or do you rape them like the con artists around here? Just curious.
Jared Combs
My comments:
I don’t know where this idiot works, but I feel for you folks out there who have to see such a self-pretentious jerk in order to fill a prescription.  I urge you to count your pills closely– someone who thinks on this level– who has such disdain for doctors who prescribe Suboxone– can justify who-knows-what for the ‘good’ of others!
I have talked about all of his ‘cussing points’ over the past year;  I have never met a doc who charges the fees he quotes (I suspect he made the numbers up), and you would hope that a pharmacist would know at least some basic biochemistry– such as the difference between an agonist and a partial agonist.
What bothers me the most, though, is the attitude.  I left out the part of his message where he boasted about his 8 years of recovery and (for some reason) belittled my own– as I have written a number of times, I found recovery through the steps in 1993, relapsed in 2000, and have done well since 2001– but like the others at my meetings I consider myself as ‘sober’ as anyone else in the room!  And yes, I am angry– angry because of patients like the one I saw this morning who listen to idiots like this guy.  Some of those patients die.  An idiot like this pharmacist caused a great deal of pain for a woman in my practice, and that makes me angry.
As for the woman in my practice who has ‘inferior recovery’ according to this guy?  I would put her level of honesty, decency, and respect for others far above his!  If that is the difference between ‘true recovery’ and Suboxone, I know which one I like better!