Need a Suboxone Doctor? Cap Problems? ACT!

There are ongoing efforts to eliminate the cap on treating people for opioid dependence with buprenorphine or Suboxone.  I don’t know what the odds of success are, but the efforts would benefit from public demand.  If you have had difficulty finding a doctor with room under the cap, write a letter or email that explains just how important the issue is to you, and send it to the address(es) below.
The change requires an Act of Congress, or perhaps an executive order from someone high-placed in the Dept of Health and Human Services.  Consider sending a ‘cc’ to your elected representatives in the Senate or House of Representatives.  I am not excited about using, since they tend to be patsies for Reckitt-Benckiser (I’ve asked to have a link to this blog, or to our 6000-member forum on their web page, but they won’t– but they link to an R-B – supported forum instead– draw your own conclusions).  But this issue is too important even for my own righteous anger to get in the way!
Send comments to the following e-mail or mailing address:
P.O. Box 333
Farmington, CT 06034
Email address:
[email protected]

Opiate dependence treatment options

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

Addiction to heroin and pain pills continues to grow

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

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.

Steve Tyler: Another one of us opiate addicts who isn't cured yet!

Had to mention that I heard that Steve Tyler went in for rehab for ‘pain pill addiction’ related to falling off a stage or some other injury…  Wish I had that ‘falling off the stage’ line when Men’s Health did their story about me!

Steve Tyler enters rehab, but his daughter is a knock-out!
Two wrongs made a 'right'?

I keep thinking that wil all the young people dying from overdoses of opiates (Heroin or oxycodone) and all of the ‘fancy people’ who have died or been destroyed by opiate dependence, why hasn’t the issue become a national crisis?  I bet that 10 times more young people died of opiate dependence in the past year than died from H1N1 virus, but which one gets all the press?  Is it the shame of the victims that keeps it so quiet?  I meet often with parents of children who have died from opiate overdose or suicide related to opiate addiction, and their suffering is every bit as great as the suffering faced by parents who lose children in other ways.  In fact, they probably suffer more, since they have such mixed feelings about sharing the story with others.  They even feel guilty for what happened– no matter how hard they tried to do everything right.
My hope is that the use of buprenorphine will allow opiate dependence to become just another chronic, potentially fatal illness.  I hope that people realize the obvious– that it is not ‘cured’.  That shouldn’t be a big deal, because most other medical illnesses are not cured either.  We MANAGE illness.  This is not Steve Tyler’s first go-round with opiates– and if he is like most addicts it won’t be his last– unless he goes on Suboxone and finds a way to just keep taking it, and to deal with all of the idiots telling him he isn’t ‘clean’ if he keeps taking it!
Mr. Tyler– good luck, dude.  I love your music– all the way back to ‘Toys in the Attic’ when I was about 16 years old.  I don’t know how you lived so long, but I’m glad you found a way– otherwise we would have missed out on Jamie’s Got a Gun and some other fine tunes.   If you are in the decision process over how to go forward, consider taking a chronic medication– buprenorphine– for the chronic illness of opiate dependence. 
Oh– I also don’t know how such a strange looking dude like you put out such a good-looking daughter…  but thanks for that as well!  The world can always use another good looking person.  Just don’t let her mess up her lips with that nasty collagen nonsense!

Clonidine and Opiate Withdrawal

For those of you who like to do some scientific reading, a recent meta-analysis looked at clonidine’s efficacy in reducing the symptoms of opiate withdrawal.  A meta-analysis, by the way, is when someone takes a number of studies that sometimes didn’t reach significant conclusions and combines the numbers, creating a larger study group that sometimes shows significant results that were missed in the smaller study.  There are limitations to such an approach, but it is still a common approach to looking at infrequent things.    The infamous ‘black box warnings’ on SSRIs about suicidal ideation in children came from meta-analysis of old studies of antidepressants.

Alpha2-adrenergic agonists for the management of opioid withdrawal


Monday Morning Anti-Suboxone Quarterback

I spend some time on this post at the forum so I will share it here as well.  First, a post from a person who uses the name ‘Suboxone7yrs’:
I was addicted to vicodin for 10 years popping 50 pills a day of Vicodin ES or NORCO, I then decided enough is enough, went to the ER and they gave me a list of doctors who deal with addiction. I went to see this female doctor who gave me the 3 hour consultation thing, then put me on 32mg of SUBOXONE, she sold me the suboxone out of her office for $5 per pill, rather then paying $8 a pill at a Walgreens I thought ok why not?…Well 5 years later this doctor STILL had me on 32mg of SUBOXONE! She then must have gotten caught because she was no longer in practice, so I found another doctor who was commited to getting me off, it took 2 years and my last dose of 2mg was March 2, 2009. I looked up all over the internet “How long will W/D’s be for this” some said 3 to 5 days some said longer. I am here to tell you I went through withdrawals for 31 LONG A** days and when I tell you this is the hardest thing in life I have ever ever done I an NOT kidding you. I was at the ER 8 times for the CLONODINE patch, I know every one is different but my god, I laid in bed crying…begging for god to take me, it was PURE HELL people PURE HELL!!! Leg twitches AND arm twitches for 31 days straight! Skin crawling, lost 40 pounds from going to the bathroom, weak, vomiting, sweating, depressed like I have never been I couldnt wash my hair for weeks, my best friend had to drive over and wash my hair and do my laundry, your useless!!! I will NEVER EVER recommend to anyone that they go on SUBOXONE even if it’s for 2 dam days. This is just MY STORY and MY OPINION. I am sure it had worked miracles for tons and tons of people but even the doctor couldnt understand why I was withdrawling for SO LONG! 17 years of putting a pill or several pills in my mouth took a blow to my body and I just wish I NEVER EVER would have gotten on SUBOXONE. It was the worst experience of my dam life. I just think about Suboxone and I feel like vomiting. Now I feel all the under lying problems I have that I never felt because I was on Suboxone, like 2 bulging disks in my back that are killing me and I need something, I cant even take a 15 minute walk and I am only 37 years old! I am stuck…dont know what to do? This is ny story and Im stickng to it. I hope others out there have a better road of recovery getting off suboxoxe, all I have to say to them is good luck and hold on tight for the roller coaster road to come!! Piece
Below is my response:
I’m a little disappointed in all you folks, after all the lecturing I do!! I’m kidding– sort of, anyway! I agree that the dose of 32 mg was too high– but the 7 year part is not ‘too long’. ‘Suboxone7years’ is doing what many people do; blaming Suboxone rather than blaming his opiate addiction. We don’t know what would have happened, had the person NOT had Suboxone, but read the history. The person was addicted to opiates for 10 years! My active addiction lasted only 6 months– and that was enough to give me cravings even after 7 years of being totally off medications or substances (i.e. not on Suboxone or anything else– just tons of meetings). So a person who has been on opiates for ten years is SERIOUSLY ADDICTED. After my 6 months of use, I went through treatment that consisted of 3 1/2 months residential (after a week of horrible detox), and then 6 years of aftercare (group twice per week for a few years, then once per week).
I must admit to a bit of skepticism over 7yrs report, just because Suboxone was not available in the US until 2003– so I don’t know how he/she got to 7 yrs of use followed by the time in withdrawal between 2003 and 2009. Yes, DATA2000 was the act that allowed ‘treatment of opiate dependence using opiates on schedule III through V’, but Suboxone was not approved or sold until mid 2003. Maybe ‘7yrs’ means ‘6yrs’– no biggie, as I tend to exaggerate as well.
‘7years’ had 10 years to quit opiates– and then thanks to Suboxone was finally able to get free. And after 7 years of freedom, she complains about 20 or 30 days of withdrawal?! She also blames that on the Suboxone– but you also have to blame it on the 10 years of using before Suboxone! What makes 7 years think that all the withdrawal is just Suboxone’s fault? 7years, let me point out to you that you COULDN’T quit the other drugs– but you COULD quit the Suboxone. What does that tell a logical person about which one is harder to get off?
I have detoxed more than I ever wanted to… and I have seen many, many people go off many things (I’m medical director of a large residential center in addition to my practice). As I have pointed out, I couldn’t walk during my detox! People going off Suboxone tend to go to work and complain about how sick they feel– people going off agonists tend to like in a bed in a detox ward or at home, and they don’t complain– because they are too weak to talk! I’m sorry you felt miserable, 7years, but have you ever ‘jumped’ from 30 mg of methadone? Or come off heroin? You must have at least seen the movies– they call it ‘kickin” because the legs kick constantly. That was MY detox– I lost 30 pounds, and for days I was up around the clock, legs kicking, body shaking and shivering, sweating like crazy, nausea and diarrhea at the same time– after a month I could walk about 50 feet without needing to sit down and rest– and that was a huge improvement!
But none of this even gets to the real issue. 7years, how do you plan to stay clean going forward? Given the time factors I mentioned above, you couldn’t have been clean for more than a couple months so far– opiate dependence is a relapsing condition. Everyone is certain it won’t happen to them, but… it happens to even those who are working a very intensive recovery program. That is why the recommendation, more and more, is to STAY on Suboxone! Yes, if you are a masochist who wants to watch your family get destroyed, go out on the quest for ‘pure sobriety’. But I recommend against it. My own relapse occurred after 7 years of very good recovery– I was ‘all AA and NA’ for years before my relapse. If anyone thought I would return to that life, I’d say they were crazy fools. But you know what? People DID say I was flirting with disaster when I stopped meetings… and they were right.
Now we have Suboxone, so people like 7yrs can enjoy freedom without the work of 90 meetings in 90 days followed by years of aftercare. That is fine– but it isn’t really fair, after enjoying the freedom the medication gave you, to claim that you didn’t really need it, and wish you hadn’t taken it. You very well might be dead or in prison had it not been there. In light of that, a month of feeling sick is a good deal– better than the work I put into my freedom. But your work is just starting, if you are so convinced you will never take Suboxone. Feel free to stop back in a year and boast, if you are still clean– and I hope for your sake that you are. But I often point out that the people who complain about Suboxone are usually people with a few clean months, as those people have themselves fooled into thinking they are all done with addiction… I have put offers out on some of the Subox-hater sites asking for someone with 5 years clean to talk to me– and so far, I haven’t found a soul.