Clean Enough, 2.8 and 2.9

Treating myself
In the spring of 1993 I took codeine cough medicine for a cold.  A few weeks later I was still taking the codeine each evening.  It worked so well; finally I could relax and get some quality sleep!  I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word.  I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated.  I had ALWAYS accomplished what I set out to do!  By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed.  The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings.
I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all!  Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said.  “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.”  I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well?
As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine.  After trying to find will power and failing over and over, I finally ‘got it’; I had no control!  As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day.
I’m cured!
My admission of powerlessness was the start of my sobriety.  I soon found a treatment program that let me enter outpatient treatment, and I also began attending 12-step meetings.  AA and NA became guiding principles in my life, and over the next five years every area of my life improved.  My marriage and family life improved, I became Board Certified, I was elected Chief of our Anesthesia Department, my wife and I had another healthy daughter, we bought a vacation home… what’s not to like?
After five years of avoiding all intoxicating substances and attending AA, there was no doubt in my mind that my problems with addiction and opioids were behind me. Avoiding alcohol was not difficult, because I was never much of a drinker. One afternoon I had some friends over to watch the Green Bay Packers, who had been having a great season. I was serving beer in my home, something that I had avoided for the first several years of my sobriety, but that I began doing after becoming convinced that relapse was not a concern. At some point during the game I asked my wife whether she thought it would be a good idea for me to have a beer. How sneaky– I have since learned that we addicts will do this type of thing on the road to relapse; we set up a situation where we know in advance what the outcome will be—that outcome being the answer that the addict inside our brains wants to hear. We are looking for permission to take a very small chip out of our sobriety. I manipulated my wife into saying what I needed to hear, and a few minutes later I was sipping a beer. From that day forward it was okay to have beer during Packer games. It was then a logical step to enjoy a glass of wine with dinner. I found a wine store run by two retired college Geology professors, and tasting wine from different parts of France became an academic exercise. In fact, I was so inspired by the idea of lifelong learning that I began to enjoy this academic exercise every evening at dinner time. At some point I was introduced to port, a fascinating beverage that has a noble history and just happens to have higher alcohol content. When eating Mexican food, margaritas were, of course, more appropriate. And then I found that there is a huge world out there of aged cognacs, which have a history all their own!  Wow, I was learning a lot!

Are you ANXIOUS? Are you SURE?

I’ve been posting more lately, but I’m hoping to slow down by the end of the holidays to let everyone catch up.   I’ve also mentioned ‘my book’ several times in the past year, promising to myself and to others deadline that comes and go.  I wish I could take a month and work on it full-time, but I don’t see much chance of that happening… so I’ll have to just keep chipping away at it.  I can be a perfectionist and everything can be worded just a little better…  I’m the same way some mornings with my electric razor, until  my wife gets sick of watching me ‘make it perfect’ and takes the razor from me.  I came across an article the other day that described a form of OCD that involves exactly that behavior– so at least I know the nature of my problem! 
I want to thank those of you who responded to the ‘here to help’ post, and please, if anyone else has had positive or negative experiences with the Here to Help program run by Reckitt-Benckiser,  let me know.  You don’t have to report anything ‘profound’– just a general comment or two whether it was helpful, whether you stuck with it, etc.
I have written about benzos a number of times and I still have more to say.  I would hope that everyone is familiar with the danger of respiratory depression when combining benzos and opiates.  Most of the deaths involving buprenorphine that I have reviewed or read about had two things in common.  First, the person took buprenorphine along with a second respiratory depressant– often a benzodiazepine, but alcohol acts at the same receptor sites as benzos and so alcohol has similar dangers.  The other commonality is that the person who died was not ‘tolerant’ to high doses of opiates, benzos, or both.    I do not want to say anything that puts addicts at risk, and I am NOT condoning benzo use, particularly the use of medications that are not prescribed by your addiction doc.  Doing so will eventually destroy you– but for the opiate/benzo combination to kill someone quickly generally requires that the person is not tolerant to one or the other chemical.  THIS IS NOT SOMETHING TO RELY ON TO AVOID DEATH!  Did I make myself clear?   Understand that the danger of combining opiates and benzos is not greater than the risk of combining benzos with opiate agonists.  There is nothing ‘more dangerous’ about buprenorphine EXCEPT the false sense of safety that users may have about buprenorphine.  But other than that false sense of safety, combining a pure opiate agonist with a benzo is MORE dangerous than combining similar potencies of buprenorphine with the same benzo.
I wanted to get that issue out of the way so that I could get to the main danger for addicts on buprenorphine when taking benzos, i.e the long-term effects on sobriety.  Opiate addicts will become actively addicted to other drugs when opiate addiction is prevented if no efforts are made to change.    I have written about my opinion that ‘standard AODA counseling’ is not the best fit for many people.  But that does NOT mean that change is not required.   At the very least the addict must find a way to fill the time spent using, and find a way to tolerate the harsh glare of reality when the mind is not constantly occupied with using, coming down, craving, or regretting the use of opiates.   I have had many patiens go through an initial ‘happy honemoon’ stage, and several months later struggle with all of the feelings that were being held at bay by preoccupation with opiates.   That preoccupation burns off a great deal of emotional energy, and suddenly our minds have plenty of time to worry about OTHER things!   There is also the fact that many of us used to dull our feelings and our reactions to life’s challenges.  So opiate addicts often compain of ‘anxiety’ early in buprenorphine maintenance, as they experience unpleasant feelings that should really be considered plain old cravings rather than an anxiety disorder.  I’ve written about what people say when I ask them to describe their ‘anxiety– they feel edgy, there is nothing to do, they are pacing, restless– they sound more bored than ‘anxious!’   But right now, for the sake of  the argument I will accept that some addicts are having real ‘anxiety.’  This is a big thing to accept, since anxiety is fear, and the people with anxiety are generally not the ones taking on new challenges, but rather tend to be the people who are doing nothing but playing video games all day… so I’m not sure where the ‘fear’ is coming from.  But even so– if that person was in residential treatment (before the days of buprenorphine) and complained of anxiety, every counselor would say ‘poor baby…. how HORRIBLE that you feel so ANXIOUS!  And so UNIQUE–  why, nobody has EVER felt like THAT before!!’
Do you get my point?  Sorry to be such an ass about it, but we are dealing with a fatal illness here.  Before buprenorphine, addicts would avoid narcotics after surgery in efforts to avoid risking relapse– now with buprenorphine, some people want to take the easiest way that they can find.  I will tell you straight up– if you are on the verge of finding stability on buprenorphine, you are extremely blessed.  Many people have died before you from opiate dependence, without the opportunity to improve their odds with buprenorphine.  You must do SOME tough things— and one is to learn to deal with life on life’s terms.  If you cannot do that, your chances for avoiding using–even with buprenorphine– are low.   Yes, for a time you are going to be ‘anxious’, or dysphoric, or whatever you want to call it.  You haven’t dealt with life lately, so of course it will be a tough adjustment!  But what do you expect– that you can just be numb and relaxed the whole time, and everything will just fall into place?
People with cancer deal with extreme pain, nausea, surgeries, deformity of body parts…  YOU must deal with your ‘anxiety.’   Why?  It is hard to explain to people who have not been through residential treatment, where a person at least learns some things about what addiction is all about.  Addiction is complicated, and occurs for many reasons– there is not ‘one reason’ for being and staying an actively using addict.  One reason relevant to the benzo issue, though, is that addicts become very aware of their own physical discomfort– we become ‘big babies’, basically.  Benzos only make this worse;  the addict in early recovery feels uncomfortable about many things, and having a pill to take when things get bad enough only makes the addict look inward even more often to decide whether things are  bad enough to deserve a Klonopin.   Another reason people stay addicted is because of distortions of insight, specifically losing the ability to predict what they will do in the future.  The addict says ‘I will take it only for severe anxiety’, but after a few days the addict finds that there is ALWAYS a reason to take another dose of a benzos.  Addicts didn’t know life was so tough until benzos became available, when suddenly EVERYTHING seems like a severe situation–  snowed in, new coworker, lost job, getting a new job, a first date, a break-up, an NA meeting… ALL of these things are great reasons for Klonopin!!
Another problem for addicts taking benzos is that when addicts take a benzo for ‘anxiety’, they don’t focus on the disappearance of their anxiety– they focus on the appearance of the ‘buzz’ from the benzo.  ‘Normal’ people hate that feeling, and so they find benzos to be too sedating or too impairing.   But addicts LOVE that feeling– any feeling– and so they dose until they feel it– not until the anxiety is gone.  And that extra ‘dosing for feeling,’ combined with the fast tolerance  characteristic of benzos, leads to rapid escalation of dose.  And what a surprise– that dose escalation even occurs in people who say ‘don’t worry doc– I don’t plan to raise the dose.’
I realize I’m expressing anger with this post, but hey, I have to express it somewhere!  Part of my anger comes from the repeated behavior of addicts– behaviors that I resent that will always remain within myself as well.  I realize my anger is for the addiction, not for the person suffering from the addiction… but sometimes I am frustrated by the unwillingness of addicts who are at the edge of relapse to ‘step up’ and face the challenges, and to fight for their lives.  I was also angry at what happened on a TV show this AM as I was getting dressed.   I shouldn’t admit this… but I was watching MTV, the show about the teens who became pregnant and had babies, which is now a show about teen moms… and one of the teen moms went to the doctor and complained of her ‘anxiety’.  She is young, bored, stuck at home with a crying baby… and she has ‘anxiety.’ Some mornings she ‘just lays in bed and doesn’t want to get up.’   What a surprise that she isn’t just thrilled to get up every morning!  She sees a doc (who could pass for a beetle if he had the right markings on his back) and the doc prescribes… Klonopin.  The next morning the baby is fussing and the teen mom holds the baby at arms’ length, passes him to her BF, and says ‘I have to take my Klonopins.’   A close shot of the bottle shows instructions to take ‘one tab twice per day’ (clonazepam has a half-life of about 24 hours, so the level in her body will increase over several days to a high steady-state level).  The next camera shot the next day shows her laying on the couch, yawning, saying that the medication seems to be working.  Her one-yr-old, meanwhile, is… somewhere….  not sure where I left him… 
But at least she isn’t ‘anxious’!
I went off on something that I was only going to mention in passing… so I guess I’ll finish the story I intended to write in a few days.  I want to write about a couple studies that looked at the cognitive effects of buprenorphine, methadone, and benzos.  Thanks for letting me vent…    good luck returning to work tomorrow for those of us lucky enough to be working, and I hope those who are looking find somethng soon.
JJ

Tired and Sick on Suboxone: What Would Junig Do?

I recently receive e-mails or read posts at Suboxone Forum that go something like this:
I used all kinds of pain pills over the past ten years—Vicodin, then oxycodone, methadone, and even fentanyl patches. Then I got into heroin for a year and finally hit my rock bottom. I went to a Suboxone doctor and he put me on 16 mg per day. At first everything was great, but I don’t like the side effects. I get so tired every day. I’m not happy like I used to be. I wake up in the morning and don’t have any energy or excitement for life. I really don’t like what the Suboxone is doing to me and want to stop.
Sometimes it is a little different—the first part is the same, but then the person writes:
I really wanted to stop taking it so that my body is free of chemicals so I stopped. I was real sick for a month and now I don’t feel like myself—I am tired, I feel depressed and angry, and I’m wondering what the Suboxone did to my opiates—am I ruined forever?
I am a psychiatrist, and only about a third of my practice consists of addiction work. I get e-mails at times after people read the blog for my psychiatric practice at www.patienttimes.fdlpsychiatry.com. A typical message will be similar to this:
Dear Dr. Junig (they tend to be more polite to me there),
I used to be a very happy, energetic person. In high school I was outgoing and everybody liked me, and I had tons of friends. The problem? Now I am in my 30’s and I’m never happy anymore. I have worked at the same place for ten years (or maybe, I change jobs every 18 months) and every day I wake up and dread getting out of bed and going to work. I keep telling myself I should exercise, but I never get started actually doing it. I’m single and don’t have any interest in dating (or maybe, I’ve been married to the same person for ten years and sometimes I can’t stand the look of him). I’ve read about vitamin D deficiency and wonder if that is my problem—all I know is that I am getting more and more depressed and tired. My sleep is crappy too. What should I do?

I have an answer to the first two messages, and the third message is a hint. Does anyone know how I would reply to the first two messages? What would I say? If you get my point and describe it correctly in the comments section—either describe the -general point, or write the reply that I would write– by 6 PM Central time tomorrow, Sunday, September 27, I will send you a free copy of my e-book ‘user’s guide to Suboxone’. EVERY person who gets it correct will get a copy. The ONE person who explains my point the best will receive the user’s guide plus a copy of each of these three recordings—stopping Suboxone, how long will you take that stuff, and opiate dependence treatment options. That’s like almost a thousand—or a hundred dollars—something like that. You don’t have to put your real name or e-mail address, but your comment MUST be entered in the comment section after this post. I might have to approve it if you haven’t written a comment before, but that’s OK—it will still count, as long as it is written and submitted by 6 PM. C’mon folks—take a shot!
JJ

Drug Testing, Prescribed Opiates, and Employment

Im in a methadone maintenance program and am currently at 130 and I have pre-employment drug screen coming up in about a month. I wanted to see how low I could get off the methandone and switch to suboxone. if it is not detectable in a drug screen. Also, I have a prescription for methadone can they not hire me because a Dr, prescribes methadone.? Any thoughts, ideas?

My thoughts:
There are laws that prevent a person from being fired because of certain illnesses or disabilities, but those laws are complicated. Drug addiction is a ‘protected disability’, so theoretically you cannot be fired for being a RECOVERING drug addict. On the other hand, you can be fired you for any other reason, or for no reason at all! So except for the occasional boss who is a total idiot who says ‘I don’t like recovering addicts so I am firing you’, disability law is not involved.

In general you cannot be fired for having an illness… unless the illness interferes with your job. A surgeon can be fired for being HIV positive, as there are just some risks of transmitting the virus during surgery that cannot be TOTALLY avoided– an accidental needle stick during a frenzied attempt to get a suture around the splenic artery, for example.  I used to be an anesthesiologist and miss those days– in the situation I’m referring to, a person came in with a ruptured spleen from a car accident. The blood pressure was stable, but in such a case the intra-abdominal pressure is often holding the spleen together, and as soon as the belly is opened the spleen will pour blood into the belly and the patient will crash…  so the anesthesiologist gets several large-bore lines in the patient, hangs fluids and blood through blood-warmers, maybe even get an infusion of a pressor set up and at the ready to maintain the pressure as best one can when there is a large hole in the spleen…    I loved that work but like the HIV-positive surgeon, it just was not the place for me anymore.  How could I keep all of my attention on the patients under my care, when there were buckets of opiates right next to me under my control?  I think that on Suboxone I would be OK– I think the cravings would be treated so that they would not be a distraction– but I understand, and accept, that I would never be able to convince an employer of that fact.   Alas…. I miss that job, but I am surprised by how I enjoy being a psychiatrist in a different way, and the enjoyment grows as each year passes and I get to know my patients more and more.    OK, enough about me– back to the letter:  A person on methadone can be fired, regardless of getting it legally for pain or from an addiction program, if the job requires operating heavy machinery– because taking methadone, other opiates, sedatives, etc are simply not compatible with operating machinery. Yes, you might feel fine, and even be fine– but it would be so easy for an injured party to file a lawsuit and win by saying that ‘the company had a person taking these drugs, and it says right here on the bottle not to operate machinery!!’ So you will never win the ‘right’ to work while taking impairing medication.

As for drug tests, first realize that methadone shows up in tests for a LONG time– for weeks in some cases. Whether Suboxone will show up is hard to predict; it sometimes shows up and sometimes doesn’t, depending on the manufacturer of the test. I have many patients who have undergone drug testing, and none have come up as positive, but I have purchased test kits that have shown buprenorphine as positive for ‘opiates’. The problem is that you have to list your meds at the start of the test, and if you hide it and then it does happen to show, you are in trouble.  One solution to that problem is to say you take Suboxone for chronic pain; that you use it because it causes less CNS effects (sedation, etc) and you want to be ‘super sharp for your job!!’. Of course you would need your doctor to verify that when he is called by your company.

If you are switching to Suboxone, do it sooner rather than later– get the methadone out of you as quick as you can. And in MOST cases, the Suboxone that you would take would not show up in any test. It isn’t the number of panels on the testing kit– it is the manufacturer of the kit, and there are many manufacturers. I have kits with many different panel set-ups– the companies will make whatever collection of tests that I ask for. I have kits that detect buprenorphine (suboxone), or OC, or methadone, or whatever. If a company wants to test for buprenorphine they could get a buprenorphine test strip for about 3 bucks. But the companies know that they would be challenged for ‘snooping’ into your personal medical history, rather than searching for active drug abuse– that is the only reason they don’t test for buprenorphine.

Wouldn’t it be nice if addiction was treated like any other illness, and you could explain to your employer that you ‘caught’ opiate dependence when your doctor prescribed high-potency narcotics for your back pain, and that now you are under treatment…  and for that, you weren’t fired?  Maybe some day.

A Misguided Doctor Mis-guides a Patient

A question from a reader:
I have been taking oxycontin 40mg 4 years and want to quit so went to dr and gave me 12 suboxone 8mg took one 8mg yesterday at 3pm which would be 20 hrs after last oxy i was having serious withdrawals 10minutes after taking the suboxone i felt so nice freezing cold went away and so pleased, it is 10am and still no chills, is it possible the suboxone is out of my system now? should i still follow the dr’s calender?

My Response:
There are at least two points I want to make.  The first is a direct answer to your question:  no, the Suboxone is not out of your system.  You still have considerable withdrawal in front of you, and you are being kept from withdrawal by the long duration of action of the buprenorphine in Suboxone.

You are used to taking 40 mg of Oxycodone;  Suboxone has a ‘ceiling effect’ that occurs at a dose of 2-4 mg, and which is equal to about 60 mg of oxycodone.  So when you took the Suboxone, if felt pleasant– as if you had taken a 72-hour, 60 mg oxycodone tablet.

There is no free lunch;  your tolerance has to come down to zero, and the reduction of tolerance is always associated by symptoms of withdrawal.  You can yank the tolerance down instantly by taking naltrexone, and being very sick for a few days…. or you can taper yourself down over months, and have tiny amounts of withdrawal every day for the whole time.  But the total amount of misery will be the same.  Suboxone will not reduce that misery.  If only that were the case!

Much more important, though, is that taking a few Suboxone is no way to end a four-year addiction to opiates.  People who take Suboxone for a few days, a few weeks, or even a few months tend to relapse back to whatever they were using before the Suboxone.  And why not?  There is nothing therapeutic about Suboxone as far as treating addiction;  it will hold addiction into remission, but will not cure it.  The goal is to take the Suboxone long enough to do a couple things;  the first is to develop some real life changes, some new friends, some hew hobbies, new habits… and get things moving in a positive enough direction that the person cannot imagine going back to the former using world.

The second and more important thing is to ‘extinguish’ the conditioning that has occurred from the use of opiates.  And that takes time– more time than a few months.

I really think that people should plan on taking Suboxone for six to twelve months.  At that point, decide what you want to do… stay on it if you are still at risk of relapse, or if you have no big reason to stop it, as in my opinion it is the safest place for an opiate addict to be.  On the other hand if you really have a thing about being ‘totally clean’ for some reason, or if you are having side effects, consider tapering off Suboxone.  Realize that doing so will put you at risk, particularly during the time you are doing the taper.  That doesn’t mean it is impossible– just that you will need to be smart.  And in my opinion, the smartest thing to remember should you go off Suboxone– is that a ‘clean person’ always knows his limitations.

I guess I started this post with a title about a misguided doctor.  I will admit to being a bit annoyed.  Opiate addiction is a nasty illlness, and this is not the place to play around with things that we know do not work.  Suboxone can be used short-term as part of a tapering process at the start of residential treatment… but giving a few Suboxone tablets to an opiate addict is not going to accomplish anything, and anyone prescribing the medication should know better.

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.

It's the Paradigm, Silly!

I talk quite a bit about the letters from ‘flamers’, but don’t often mention the messages of support from grateful people on Suboxone, and the nice comments from my patients.  I enjoy speaking to patients on Suboxone about the things said for example by the silly pharmacist in the last post, and as I try to explain things I realize that they KNOW– and I can say:  ‘well- you know how it works!  You’ve TAKEN it!’  And they nod their heads with recognition.
The primary purpose of 12-step groups is supposedly to help addicts;  some groups seem more concerned with something other than ‘help’.  Suboxone, as I have said many times, is not perfect… but it is a great step in the right direction.  If we DID have the perfect medication– say a medication that instantly cured addiction– would NA be for it or against it?  Given those comments in the last post, you have to wonder!  Even with the imperfections of Suboxone, we have a medication taken once per day, with relatively few side effects, that instantly virtually eliminates the desire to use opiates, that maintains it’s actions long-term, that has no known serious toxicity…   And the complaint of people is… it is hard to stop.  To which I say… GREAT– BECAUSE WE DON’T WANT PATIENTS TO STOP IT!  One problem with naltrexone ‘treatment’ (among many other problems) is that the addict can (and does) simply stop it, and use the same day– you can’t do that with Suboxone!
People with awareness of the harm done by addiction, who have minds open to to the progress of science, understand the new paradigm for treating opiate dependence.  To elaborate:
Some of the mis-statements of the anti-Suboxone crowd relate to their confusion over ‘addiction’ vs. ‘physical dependence’. Suboxone does cause physical dependence– if you stop it abruptly you will have significant withdrawal, as with other opiates. BUT… ‘addiction’ is a different issue. Psychiatrists think of ‘addiction’ as the ‘mental relationship with the drug’. Suboxone, when taken properly, eliminates ‘addiction’– or at least holds it in remission;  people who take Suboxone clearly notice that their relationship with opiates– their obsession over them– quickly vanishes. Too often people equate ‘recovery’ with the amount of drug taken or NOT taken; a person can be free of alcohol and be in a ‘dry drunk’ and not in ‘recovery’; Similarly, a person can take Suboxone and be in recovery–as ‘good’ of recovery as any other recovery!

It is true that if you stop Suboxone you will have withdrawal. On the other hand, if you take 8-16 mg of Suboxone once per day, in the morning, you will no longer think about opiates, and they will no longer control your life. THAT doesn’t happen with methadone or with other opiates–and frankly it doesn’t happen with NA either.  Rather, it is a function of the partial agonist effects of buprenorphine. This is the ‘new paradigm’ that has impressed and provided hope for the scientists and physicians looking for a way to reduce the harm done by narcotics.

If you look at ‘addiction’ as the ‘mental obsession for the drug’– and I believe that is the appropriate way to look at addiction, as it is the obsession that destroys intimacy with others, leads to criminal behavior, and demoralizes the addict– if you use this definition, I see a strong argument that a ‘Suboxone recovery’ is BETTER than ‘NA recovery’. Why? Because with NA, the relationship with the substance is often still largely present.

Who is more ‘recovered’: the NA addict who talks about his addiction constantly and attends meetings three times per week… or the Suboxone patient who takes a vitamin pill and a Suboxone tablet each morning, and hasn’t had a thought about using for weeks? The NA addict who crosses the street to avoid walking past a bar… or the Suboxone patient who has lunch in the bar without any fear of falling down a slippery slope that leads to using? The NA addict/pharmacist who hovers over blogs about Suboxone and boasts over whose recovery is better, or the Suboxone patient who no longer needs to meet three times per week with such judgmental people?

Keep it real,

SD

Suboxone: a Drug for a Drug?

A common refrain of the anti-Suboxone crowd is that ‘Suboxone is just replacing one drug for another.’  I have one question for the people who write those angry messages:  why do you care so much about people using Suboxone?
Here is my next youtube submission:

New Discoveries After Suboxone, Continued

Coincidentally, just as I posted last night’s post about my excitement for capitalism’s new interest in addiction medication, a very interesting post appeared on Bluelight (a very interesting site about drug use and abuse) about the same general idea– but with a different perspective.  I am going to try to get the person who posted there to do a ‘guest post’ for us here, so that we can have a ‘point/counterpoint’ discussion about the topic.  I may be wrong, but I think the post I’m referring to takes issue with the money made by ‘big pharma’ as they produce these new medications.  I have probably made it clear that I don’t feel that way;  the companies that make our medications take huge risks when they choose to develop a medication, and there would be nobody taking risks if not for some reward at the end.  Besides, all of those profits don’t go to a guy wearing a suit, smoking a cigar– the image that politicians use to pit people against each other during campaigns–  the profits go to everyone with an IRA or pension fund, or anyone lucky enough to still have some mutual fund holdings after the past year or two!
I will copy a couple parts of the post below.  The people at Bluelight are generally quite sophisticated in their drug knowledge, although the opinions expressed there are more the ‘street’ perceptions and attitudes, rather than ‘medical’.  The original post can be found here.
Narcan: The Next Big Thing In Pain Management
They’re going too far.
…It all started with Talwin; a few low-level healthcare workers came up with the T’s & Blues combination, and shooting Pentazocine (which was unscheduled at the time) and Pyribenzamine (a.k.a. Tripellenamine, a common Rx cold/flu anti-Histamine of the day) spread across the country…
…Then it started: Talwin NX. Pentazocine and Naloxone, combined in one pill. To stop intravenous abuse, they said. And it did: only, abuse never stopped, it just switched to oral and insufflation. A new combination was then discovered to be adequately euphoric to abuse: Talwin NX and Ritalin. All was quiet for a couple decades, then Reckitt-Benckiser hit the lottery with their orphan drug Buprenorphine, owning the patents and branding rights for all of the Bupe products. The magic bullet that made this fortune and fame possible? Narcan. Add some, make money…

…Seriously. It worked for T’s & Blues, remember? See, Pentazocine, Buprenorphine, both partial agonists, both have a long history of IV abuse and addiction, Naloxone cured the IV Talwin problem, we will prevent IV abuse of our Buprenorphine product from ever starting by putting the Narcan in first…

..Now that two working examples of narcotic/Narcan combination products are slick deal-makers in the American Big Pharma, Federal agency shakedown game, every other mom & pop pharmaceutical company is jumping on board with a Dope/Narcan product:
OXYTREK
While not Naloxone, it’s still an antagonist, Naltrexone. Brought to us soon by Pain Therapeutics.
Oxycodone + Naltrexone in a pain relief pill.

Quote: Pain Therapeutics’ oxycodone/naltrexone combination, OxyTrek. Factors driving the market rebound will include the premium pricing of these new therapies compared with current options, most of which will be available generically by the time the new drugs are launched.

“Improving on the significant side effects of analgesics is the near-term opportunity for drug developers, as it has been for many years, and a few companies will succeed in providing incremental improvements in safety or tolerability, despite the recent dramatic changes in the regulatory landscape,” said Michelle Grady, therapeutic area director, Pain Management, at Decision Resources, Inc.

Meaning: “We’re gonna make a ton of f***ing money duping the government, the patients and the addicts”

EMBEDA

Morphine + an antagonist (which one is not known yet)

Quote: Alpharma has asked the Food and Drug Administration to approve Embeda as a tamperproof medication for patients with moderate to severe chronic pain. The pills are formulated so that the euphoric effects of morphine are blocked when a patient crushes, dissolves or chews them. Patients often abuse pain pills by grinding them up to snort or inject.

Same old story, add antagonist, dope not so good to dope fiends, no addiction, better pain management results in old people, etc …

…I don’t think I need to add the Pharmaceutical/Industrial Complex commentary on that one. Same story as Suboxone, Talwin NX and soon OxyTrek: Make a mint with a new medication to brand and have exclusive patent rights to, get great publicity and approval from the gov’t / medical authorities for making a less addictive, less abusable, abuse-resistant, etc product. Stock manipulation by slightly altering the best selling product, create a competitor for your own product, make more money on your products by making more money on your products- a brilliant plan…

…So, thats it people. First a trickle, here comes the flood.

Combination Agonist + Antagonist opioid medications are the future, thanks to Big Pharma and the crooked insider-trading-esque laws we have regarding pharmaceutical branding, patents and distribution rights. Don’t worry though, as with every other “less addictive”, “tamper-proof” pill they make, we will all still be able to abuse, shoot, snort, parachute, plug, smoke, and combine these new and yet to be developed pills and formulations.

After all, they’re counting on it, all the way to the f***ing bank.

One medication not mentioned is a new drug on the market called Relistor–  it is an interesting combination from my perspective.  My neurochemistry experiences are behind my fascination with some of these new medications– which are based on our basic understandings of opiates and the brain.  Relistor is essentially naloxone, altered by the attachment of another molecule so that the new molecule doesn’t pass through the ‘blood brain barrier’.  The result is a medication that when injected blocks the effects of opiates on the gut, without affecting opiates in the brain.  The medication is used to treat opiate-induced constipation.

As for the other products, I think that his last line summarizes the writer’s sentiment pretty well– even after I took out a few letters from one of the words!

How Long Can I Take Suboxone?

I noticed this question in the search terms tonight. I would think I have covered this topic, but Then again, perhaps this is one of those things that seems to be a part of so many posts, but yet never gets a post of its own.

How long to take Suboxone?
How long to take Suboxone?

The simple answer, I suppose, is however long your doctor allows you to take it. Wow… talk about unsatisfying answers!! But really, the attitude of your doctor is probably going to be the thing that impacts this decision the most. I frequently receive notes from people that say ‘help—my doc is making me go off Suboxone and I don’t know what to do!’ On one hand, this is not the end of the world; if a person does happen to relapse, at least the person can get right back on Suboxone. But what if the person lives in one of those areas where people who relapse are treated like pariahs by the treatment community? What if the person cannot get back on Suboxone? THAT would be a real shame.
Opiate dependence is a relapsing illness. Yes, ideally people avoid relapse. But it is not a reasonable expectation that nobody will or should relapse. There must be a contingency plan for dealing with people who ‘slip’, providing that there is an understanding that at SOME point the person will run out of options.
In my opinion and in my practice I don’t have an ‘end point’ for Suboxone treatment. There are things that will result in termination of treatment, including illegal behaviors, diversion, ‘lurking’… but I do not taper a person off Suboxone for simply being at it too long. I have some general guidelines that I like to abide by; I think that stopping Suboxone after less than six months is almost always a bad idea, for example. I usually shoot for a six to twelve month period of taking Suboxone; that generally allows enough time for the person to find new friends and start to establish a non-using identity. But I look more at where the person is at, rather than how long the person has been there. I have some patients in their 40s or 50s who have been on a stable dose of Suboxone for several years.


So when you evaluate physicians who prescribe Suboxone, I suggest that you ask about the doctors’ attitudes about the time frame for Suboxone treatment.