Do Interventions Work?

It has been a while, it seems, since I’ve checked in.  I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.
In the meantime, check out the ‘best of’ page;  I have links there to some of the more popular post.   And for now, I’ll answer a question I received today on ‘TheFix.com’:
Do you believe in intervention of someone who does not ask or desire (to be clean)?
It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within. 

Grandma needs an intervention
More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option. 
For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.
She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.
I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.
So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?
Because true change is very, very difficult. 
Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?
And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.
In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.
But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.
I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!
The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.
The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.
Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

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The Buprenorphine Ceiling Effect

This post is from a couple years ago;  I think it is important for people to have a basic understanding of how buprenorphine removes opioid cravings, so I’m republishing the post.
Note that naloxone has NOTHING to do with the effects of Suboxone.
In this video I explain why the ceiling effect is so important to the effects of buprenorphine for treating opiate dependence.

A true epidemic, with no easy scapegoats

Today an article on the web site Medscape describes the epidemic of opioid dependence in this country.  The article describes what people who work with addiction already know– that use of opioid medications has increased in a way never seen before for any medication.  The article does a good job of presenting the statistics, and puts forward the more obvious conclusions that can be made about the cause of the problem and some possible ways to reduce the magnitude of the problem.  As the article suggests, the databases that have been established in many states to monitor narcotic prescriptions will reduce doctor shopping.  Some experts are calling for special training and certification for doctors who prescribe opioids.  I am surprised that at a time when so many states are recognizing the problem, there are still numerous pain clinics throughout Florida that each pump out thousands of scripts for opioids, seemingly without any effort to stop them.  What’s with Florida, anyway?!

Death rates due to accidental overdose

The largest newspaper in Milwaukee Wisconsin has featured several articles about the local prescription drug problem.  I spoke with the author of the latest front page story about the subject, and tried to explain the complex nature of the problem.  I hoped that he would do the topic justice by writing something deeper than the typical ‘find someone to blame’ article that most papers resort to these days.  I even offered to set him up with a patient of mine who used those Florida-based pain clinics in the past, who ended up on ridiculously-high amounts of pain medication, and still struggles years later to lower his tolerance level.  The patient would have explained that it isn’t just ‘bad doctors.’  He would have explained that sometimes the problem is that a person will have severe pain, and will not be able to say ‘no’ to relief of that pain.  He would have explained that more and more doctors are simply ‘opting out’ of prescribing pain medications;  that if he had the gall to say to his primary care doc that his back hurt, his doc would have cut off the discussion and looked at him suspiciously from that point forward.  Because so many docs won’t deal with the difficulties associated with treating chronic pain, patients are left searching for pain pills in all the wrong places– and left taking them with little or no guidance or supervision.
Unfortunately the Milwaukee Journal-Sentinel writer took the easy way out, and instead of trying to capture the true essence of the problem he wrote a hack piece about ‘pill pushing doctors.’  I don’t personally know any of the docs he pointed out by name in the story– the story he wrote from the safety of behind his desk, where like most reporters he never has to make the tough decisions himself.  I wonder, though, if all of the docs he smeared were ‘bad docs,’ or rather if some of them were struggling with the tough questions that many docs now choose to avoid.  The article featured a photo of a tearful couple who lost a family member to overdose;  their daughter was being treated by one of the pain docs presented in the article as the lowest-of-the-low, a pill-pusher who destroyed the girl’s life.  And my heart goes out to those parents.  I see many people just like them in my practice; parents who have lost a child or who are struggling with the decision whether to put their addict-son or addict-daughter out on the street, or to instead let them live in the basement where they are using every night, where the parents dread looking each morning, into the dark silence, afraid of seeing their worst fear come to pass.
Drug deaths become number one

I don’t know the pain doc smeared in that article, but I do know what it is like to sit in the office with a person crying out in pain, begging for medication to provide relief from that pain. I was an anesthesiologist for ten years, after all, working in a pain clinic of my own.  And when treating someone’s pain, there is no way to get inside that person and determine exactly what the person is experiencing.  Yes, there were many times when I wondered if the pain was REALLY that severe.  There were some things I could try to use to determine whether the patient was ‘faking;’  I could check the respiratory rate, the blood pressure, and try to determine if the tears were real, or came from the drinking water down the hall.  My answer about faking, most of the time, was that the patient was NOT faking.  The patient was experiencing severe pain.  I knew that many people with the same injury would NOT have such severe pain, but for some reason this person DID have severe pain.  Who was I to say differently?  How can any doc listen to a patient describe severe pain, and then look at the patient and say ‘no– you are not in pain.’  Would YOU go to that doctor? 
Are you ready for the complicated article that Tom Kertscher of the Milwaukee Journal Sentinel SHOULD have written?  Those grief-stricken parents in the picture in his article about pill-pushing doctors, who are mourning the loss of their daughter and struggling to assign blame, are blaming the guy who might be the ONE doctor who truly cared, and who tried to help their daughter.  The daughter came to him, looking for help for her pain.  Other doctors turned her away, and told her ‘you DON’T have pain,’ when in reality they didn’t know whether she did or not.  They just knew it was easier to tell her to take a hike, or to say ‘I’m sorry, but I don’t prescribe pain pills,’ or to say ‘my healthcare system won’t let me prescribe them.’  Those doctors who ignored her pain didn’t know if her pain was real or not.  But there was one thing that they DID know– they knew that if they DID empathize with this patient, someone’s daughter, and if she ended up taking too many of the pills one night, they knew that some reporter hack would come ’round and blame them in some one-sided, simpleton-pleasing, ‘gotcha’ article in the Milwaukee Journal Sentinel.  So those docs closed their hearts to the pleadings for pain relief from a patient and kept their licenses for another day.  And the doc who couldn’t say no to her requests for help– who gave in and prescribed pain-relieving medication for the couple’s daughter– ends up being the bad guy.  Go figure.
Deaths rise as prescriptions rise

I have to point out that for non-malignant pain that has no finite endpoint, narcotics are rarely a good answer.  I have had patients say to me ‘I would rather live without pain for today and die next year, than have pain for the next twenty years,’ and to that I have said ‘that is why you need a doctor.  I cannot let you make that choice.’  I recognize that there ARE docs who prescribe pain pills MUCH too easily and loosely, causing a great deal of trouble for the patient in the end.  But they don’t prescribe because they are ‘evil;’  they prescribe because they have a hard time ignoring someone’s pain.  Maybe they need help dealing with confrontation.  Maybe they need to toughen up a little bit.  But they are not ‘evil.’ 
This is a little of the story that SHOULD have been written about the pain pill epidemic.  Then it could go into how people these days want everything to be ‘fixed,’ and that is why everyone takes pain pills.  Or it could say that the bad economy puts so much pressure on people to avoid missing work that they cannot rest an injury, and that is why everyone takes pain pills.  Or it could say that the violence of the inner city or the divorce rates in the suburbs leave people with emotional pain, and THAT is why everyone takes pain pills.   If only every problem had something to blame. 
I’m struggling with closing this post, and it is getting way too late.  I’ll just say one last thing– for those with young kids, keep talking about how horrible this problem is.  Don’t glamorize it, because it is not pretty– just let them know that unlike many things that young people do, taking pain pills incorrectly causes something that lasts a lifetime.  I invite people to check out some of the links in my ‘blogspot’ to see some of the faces of the epidemic, and to share those with your kids as well.
JJ

My Lousy Bedside Manner

I receive about a dozen e-mails each day asking for advice; some are quite long, and while I would love to be more helpful there are days when I don’t have time to even read them, let alone answer– so please understand if I have not gotten back to you. One thing that has also ‘soured’ me a bit on personal communication is that I forget just how messed up addicts ARE– how distorted their world becomes, and how frustrating it is to become involved in trying to help someone who is not yet ready to be helped. I am going to post an exchange I had yesterday and today with one such person… I was way up north this weekend and not connected to the internet, but I received an e-mail on my i-phone and at the time had nothing to keep me from reading it. Having read it, I felt sympathy for the person and gave my honest opinion on the person’s dilemma.
I don’t have time (of course!) to make comments all the way through, and so I will only post the exchange; my goal is not to humiliate the person, as nobody knows the person’s identity. But for those of you who are enjoying some sobriety, the exchange will be useful; you will recognize the self-centeredness and self-pity that prevent sobriety from taking hold. In a treatment center, this person would be given a choice: shut up and listen, or leave and return when you are ready to shut up and listen. She wants support, I suppose– but support will kill her. That is one of the most fatal, and most common, mistakes made by using addicts; that they need ‘support’. That thought allows them to reject all of the calls for change that people take the time to provide. She will keep going from person to person, looking for someone to be ‘supportive’. But the only thing that will sound ‘supportive’ will be advice that keeps her right where she is! ‘Support’ for a using addict is only another form of enabling.
Now, once a person is at a different point of treatment– at a point where she is following instructions, and has gotten past the self-centered ‘terminally unique’ position– a certain amount of support may be useful. But this person is not even in the ballpark for that approach. If she is reading (and I doubt she is, as addicts tend to avoid reading things that stir up awareness of a need for change), I recommend she drop the one-woman pity-party and realize that her life is up to HER, and her alone. If she doesn’t get serious, she will end up just another dead junkie– and for that I am sorry. But I can promise you that me being a bit ‘kinder’ would not have been the answer to keep her alive.
Her Note:
Hi Dr. I am writing to you for help. I am a forty year old female who has been addicted to opiates for twenty years. Eighteen months ago I got clean (mainly from Norco and Fentanyl). I felt wonderful for months and then the pain started again (or my head said it did?) I have a disc protrusion. I went to my psychiatrist (also an addictionologist) who presbcribed suboxone. Now almost a year later I am on 8mg 3x per day for a total of 24mg. I hate this medicine. I am numb just like when I was on vicodin! I cannot go to the bathroom I have severe constipation and have to do a relistor injection every 48hours and take six stool softners and four laxatives to go to the bathroom once a week! I am having rage feelings again just like when took too much vicodin and I am flying off the handle at people, I am angry and numb and I hate everything. I don’t tell my AA friends that I am on subs because I am ashamed of it and I feel like I am still in active addiction. I have tried to get off it and every time I end up back up to 24mg. It does all the things it’s not supposed to do, I crave it just like vicodin. When I was down to 12mg I was unable to stay at that dose, I had to take more, just like vicodin! I know you”ll say that’s not possible but there it is anyway. Some days I take 32mgs and it’s hard to stop myself????? I want to stop this stuff so bad and I can’t and I’m petrified of the side effects and going through withdrawl again. Somehow I convinced myself that I could wean myself off subs with vicodin!! I didn’t taper off the subs (I couldn’t) and yesterday I had had my morning dose (8mg) and then five hours later I got a script from my dentist for Vicodin and stopped the subs and started taking the vicodin and of course now I can’t stop so yesterday I took 4 and a half tablets (7.5mg tablets) and today I’ve taken three already and it’s only 2:00pm. What’s going t happen when I run out of vicodin? Am I going to go into withdrawl anyway? I am so scared right now and I am too ashamed to call anyone, my therapist, my psychiatrist, my sponsor… anyone! Please help me if you can.
My Note:
Hi– thanks for writing. You are not alone in your situation; the bottom line is that Suboxone is only a tool, and if it is not used correctly, people will not do well with it. The person treating you should have ‘reigned in’ that extra use right away by refusing to give early refills; after a couple times of running out early and having withdrawal, you would have learned to keep the dose under control. At this point, I just don’t know if Suboxone is the right med any more for you– you need some way to get your motivation back, so that you will be able to limit yourself. That usually takes a bad experience that gets you to some sort of ‘rock bottom’. Addicts repress the feelings of shame you refer to– the goal of treatment is to keep those feelings from being pushed aside, so that you will remember them when you need to do the right thing for your health. A few suggestions: -read my blog, suboxonetalkzone.com, the post on optimizing absorption of Suboxone– make sure you are getting it in your system in a high-enough concentration. Search on the blog for ‘optimizing absorption’ and you should find it. -the effects of Suboxone peak at about 4 mg per day; everything else is psychological. You want to dose ONCE per day– take 16 mg in the MORNING ONLY– one tab, and then the other. If you get cravings later, you need to distract yourself for 10 minutes, and they will be gone. YOU CANNOT JUST KEEP DOING WHAT YOU WANT TO DO. You have the power to make it work, but perhaps you have a personality where you usually get away with bending the rules. IF YOU WANT TO GET BETTER, YOU CANNOT BEND THE RULES. These things I am suggesting MUST be followed if you want them to work– you cannot do just what YOU want to do, as that is what is destroying you. -Do NOT take extra doses to work or out in your car, etc– give the tabs to someone who cares about you and who is able to say no to you, and have them give them to you each morning– two pills each morning ONLY– no exceptions. If you don’t do that because you don’t want the inconvenience, then there is nothing anyone can do for you– you have to be aware enough of the danger to do what it takes to stay clean. If you dose only in the AM, and distract yourself if you get cravings, eventually the cravings will go away. But you CANNOT take shortcuts, or think you are somehow ‘unique’ and don’t need to follow the rules!
Her Note:
Wow, your bedside manner sucks! I get your point but insulting this addict makes it impossible for me to respect you. I read your arguments with another addict that said you were angry and personalized everything and now I believe it! I’m sorry I asked for your help. Clearly you have your own issues to contend with. I wish you well. Please dont bother responding, I’ll delete anything further you have to say. Peace!
My Final Comment:
People who are getting an understanding of what addiction does to personality will recognize this dynamic. It used to bother me– now I realize it is just addiction. But it does remind me that you really cannot help an addict until the addict is ready to be helped– and if you try, you will often regret ever wasting your time.
JJ

It (gasp!) IS Hard to Stop Suboxone. Here is why.

Yes, you heard it here fir…. fourth…  it is hard to stop Suboxone.  As anyone pausing at this web site knows, it is hard to stop ANY opiate.  There are many forces at work against you when you are tapering off opiates; physical withdrawal, mental withdrawal, cravings for opiates, and the unconscious mental effects of addiction– the conditioning of your mind to see opiates as the solution to all of those uncomfortable feelings.  With all of that going on, it is no wonder that most ‘opiate tapers’ end unsuccessfully, leaving the addict more discouraged than he was before.

Suboxone is clearly different than other opiates, and the differences profoundly influence the tapering process.  I will mention my good friend Brian over at suboxonetaper.com, where he walks through his own experiences and helps a person know what to expect during the taper of Suboxone.  I have mentioned a number of times how the ceiling effect of the drug affects the tapering process;  there is minimal withdrawal going from 16 to 12 to 8 to 4 mg, but then the withdrawal kicks in during the last part of the taper.  This is probably why people leave messages here and there on internet health boards about Suboxone being ‘the worst thing to stop’;  the early stages are a cake-walk, and then the person tapering the drug gets hit with a brick at the end of the process.

What we really could use, to help people taper off Suboxone, is a tablet that is as large as the 8 mg tablet, but that contains less buprenorphine.  It would be helpful to be able to dose people with 1 mg, then 0.5 mg, then 0.25 mg, then 0.125 mg, then off.  Buprenorphine is a very potent drug;  when used for pain relief it came in solution for IV administration in microgram doses, and a dose of 50 micrograms was a potent dose;  the smallest pill form available is 2000 micrograms!  So tapering requires the use of tiny chips of a tablet during the final stages, making accuracy impossible.  In fact, if you wanted to do a proper taper with the drug you would want doses of about 50 micrograms each… and that amount is in one fortieth of one quarter of an eight mg tab.  Do you know anyone with tiny tiny fingers and macroscopic vision?

Since we don’t have a formulation that allows slow, accurate reduction in dose, we are left with doing the best that we can under the circumstances.  I think it is useful, knowing what to expect, so you don’t become too discouraged when hit with the withdrawal at the end.  One thing that seems to be different about Suboxone is that people seem to have less ‘pull’ to take more during the taper.  I don’t know if that is a real difference in the drug, or if it is just that people coming off Suboxone in my practice have taken it long enough for the conditioning that is so prevalent during active use has faded at least to a large extent.  I believe in medicating the taper off Suboxone;  I was criticized on one site for suggesting the medication Vyvanse to deal with the horrible fatigue.  But there is a ‘balance of risks’, and I believe that it is safer to use everything we can to get a person through the taper without re-igniting all of those thoughts and memories of using, even if it means using a stimulant or benzo for a week.

People need to understand that the issue with addiction, and with all of these things related to addiction, is NOT THE DRUG… THE ISSUE IS THE RELATIONSHIP WITH THE DRUG.  Some people hear the word ‘amphetamine’ and they go crazy– ‘that’s addictive!’ they say.  Yes, it is.  So is clonidine, when used in the prison environment.  There are safe ways to use addictive medications;  unfortunately modern medicine demands ten minute appointments, where safe prescribing is an impossibility.  Why do patients keep putting up with it?  Shouldn’t it take longer to figure out your problem and educate you, than it takes to make a hamburger?

The problem with any opiate taper, including Suboxone, is the loss of motivation after a few days of pain, weakness, and depression.  You all tell me– would motivational tapes help?  I have mentioned my web site sober after Sub, where I have tapes describing the state of mind you want to be in…  you can get in that state of mind in a few ways that I know of, including going to meetings.  I am eventually going to have tapes that will hopefully help a person feel support during the four or five days at the end of the taper…  the days when everything appears hopeless and the clock moves in half-time, or even slower.

As for medications, I have been surprised at the effectiveness of gabapentin in relieving the ‘hot flashes’ that are such a pain during withdrawal.  Clonidine is helpful, but it is such a drain on energy that it is sometimes hard to decide if a person is better with or without it.  I tend to recommend it for nighttime use only.  And then there is Vyvanse, an interesting molecule consisting of lysine bound to amphetamine…  it is impossible to abuse, and a short course can really help a person keep working.

For those people who have a problem with the use of a stimulant, picture my patient in the final few days of tapering off Suboxone.  He is tired and discouraged, and despite my encouragements I know that the ‘addict inside’ is now awake, and about to use the self-pity to turn the person away from his good intentions.  That is what happens, by the way– the addict inside the person waits for these opportunities, and once active the addict inside will actually change a person’s insight!  And once it changes, it is impossible to change it back… at least not until there is some negative consequence that wakes the ‘real’ person.  Crazy description, I know…. but addicts will recognize what I am saying.  I strongly recommend all addicts learn to recognize their own ‘addict inside’.  One value of twelve step groups is that you get to hear about everyone’s addict inside, and you learn that the addict inside everyone is the SAME PERSON– the SAME ADDICT.  Watch it in others, and learn about it in yourself.

Where was I…. this patient of mine is on the fence, and I am in danger of losing him.  He won’t go off and relapse, but he will go back to the full dose of Suboxone for another six months before trying again.  So if instead of all that, I can give a week of a stimulant to get his energy and mood up a bit, and help him kick through those last few days… where is the harm?  As it turns out, many opiate addicts have ADD as well;  they were in that common path of poor student identified by the school and the parents, leading to anger, shame, discouragement, and drug use.  And so I have seen a number of patients start reading for enjoyment for the first time in their lives…  pretty cool.

I think I’ve covered the major points:
Yes, it is hard to stop Suboxone… just like anything else.  The ceiling effect results in the withdrawal symptoms being ‘back loaded’– all at the very end of a tapering process.  It is very hard to taper because of the potency of buprenorphine;  a tiny fragment of a tablet of Suboxone contains a very potent amount of buprenorphine, which is usually dosed in micrograms when used to treat pain.  Remember when tapering that stopping 16 mg of buprenorphine is like stopping 30 mg of methadone… and stopping 2 mg of buprenorphine is like stopping… 30 mg of methadone!  THAT is the ceiling effect in action– great for holding addiction in remission, but a pain when it comes to eventually tapering off Suboxone.

One last comment:  tapering off the opiate is the EASY part;  the hard part is not picking back up again.  And that takes a great deal of work over the rest of your life.  Before Suboxone, getting clean literally required changing one’s personality.  I honestly don’t know if people going through a year on Suboxone, learning some things, then tapering the drug will be able to stay clean long term.  I try to offer things that I believe will help, things I picked up through a long residential treatment and years of twelve step immersion.  I really hope I am helping at least some people- not only helping them feel ‘not alone’, but also helping them keep opiates from destroying their lives.  BUT… if you are not doing well, don’t rely on my blog to turn it around.  Do what I did, and open your mind and ask for help at a treatment center.  I will say this again, because if you hear it I will save you tons of money you would otherwise waste:  open your mind before stepping in the door.  Treatment is NOT education– it requires you to change, and to do that you must drop all of your resistance to change.  Avoid thinking that you have the answers; after all, it was your own best thinking that got you to where you are today.