Striking a nerve with Methadone revisited

Bottom line—there is nothing in those references that shows that methadone is preferential to bupe in any circumstance—UNLESS you compare methadone to a subclinical dose of bupe, which is where the quotes came from.

I received several replies from methadone advocates; I am going to highlight portions of their comments and respond to them. But first I would like to make a personal comment to the writer who spoke of her pain treatment with methadone–  and I would like to thank her for her heart-felt letter, and say that I agree taht opiates must be available for adequate analgesia in the case of cancer and other serious illnesses.  I think that the over-use of opiates for chronic back pain and other inappropriate uses are part of the reason why opiate use is ultimately limited in legitimate indications. And that is a shame for everyone– for the cancer patient with pain, for the doc who is investigated for prescribing appropriately, and also for the patient with low back pain who is destroyed by narcotics, all the while thinking they are necessary and helpful.

But in this case I am referring to methadone for addiction ‘maintenance therapy’, and the ‘methadone advocates’ that wrote to complain that I had ‘dissed’ methadone.  In an earlier post I noted the mention of ‘countless experts’ who supported methadone use, and I asked, which experts? Their replies contained references that I will eventually list in case anyone wants to look them up and read them in their entirety—as I did. I have the benefit of access to the online library and search functions of a major medical school—every time I use it I think about working on my thesis in 1986, reading science citation index each morning, writing down references, and then going up and down the back stairs in the ‘stacks’ of the medical library as I searched for the articles, sometimes needing to dig through bins of unshelved books and journals to find the right one… I can now do something at home in 30 minutes that used to take 4 hours at the med center. These efficiencies from the internet hopefully partially make up for the hours wasted on the internet by society… leaving me with some hope for the future of the human race. But I digress…

It is important to look up entire articles and read them from beginning to end; many times a sentence will be quoted by someone to make a point, but taken out of context in a way that completely changes the meaning of the sentence. Sometimes comments will get handed down from article to article like that old ‘telephone operator’ game, where a comment is passed from person to person around a large circle. Again, comments are changed a bit in each ‘generation’ of article until a whole new comment is generated. I would encourage ‘Arm-me’ to do this exercise with the comments that he/she provided; or just read on… I will get to the articles after responding to the more personal comments.

There was an accusation of a ‘financial motive to prescribe bupe’— I have been at the 100-patient max and closed to new patients for months; I recently re-opened for a few more but unfortunately there is no shortage of supply of addicts in my part of the country (although apparently not enough addicts to keep the methadone clinics open, as several have closed). As for ‘researching methadone for the benefit of my patients’, I explained in ridiculous detail in a prior post how my life has ended up devoted to opiate addiction— as both an addict and as a doc treating addicts—and I know methadone pretty well.

As for the scientific articles, here is a portion of one comment, out of several comments made by the methadone advocates: Here is one of the more extensive reviews of 24 clinical studies re: methadone vs. buprenorphine. In fact when they first started prescribing suboxone they told patients on methadone if they didn’t do well on 60-80mg of methadone they “most likely” weren’t going to do well on Suboxone.

I don’t know who Arm-me is referring to by ‘they’. He provided this reference: Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. – Mattick RP – Cochrane Database Syst Rev – 01-JAN-2008(2): CD002207. This references a ‘meta-analysis’; a meta-analysis is done by taking a number of separate studies which often have no significant findings, and adding them all together in order to create something statistically ‘significant’. This type of study is sometimes useful to summarize the findings of other studies, but one has to look at the nature of the collected studies—24 in this case—before drawing conclusions. This meta-analysis, for example, includes studies that predate DATA 2000 (the Act of Congress that legalized the Suboxone program), before which bupe was available only as a chemical dissolved in a liquid— and the use of the drug was very dissimilar to modern use of Suboxone. In the meta-analysis the author referred to ‘low, moderate, and high-dose’ buprenorphine; the ‘low-dose’ studies are irrelevant to current practice, as we now know that it takes 8-16 mg of bupe to suppress cravings. I know I am starting to bore all of you… The other reference was: Am Fam Physician 2006;73:1573–8, 1580: Managing Opioid Addiction with Buprenorphine—it was not a study at all, but rather a review article that is filled with the ‘telephone operator game’ quotes I mentioned earlier. Arm-me listed quotes from this review article, which the review article itself copied from other articles, which had also copied them… I tracked them back and found that they originated from two articles: one in 1997 (before Suboxone was patented) and the other in 2001—which was another garbage meta-analysis. Bottom line—there is nothing in those references that shows that methadone is preferential to bupe in any circumstance—UNLESS you compare methadone to a subclinical dose of bupe, which is where the quotes came from. Yes, it is true that in 1997, methadone in high doses was better than 2 mg of bupe. But no kidding—that is why nobody who knows what they are doing limits bupe to 2 mg. Another of the quotes referred to a study that measured ‘success’ as staying in the study—at a time when Subox was not available and the dosing had to be done at the study center using a liquid form of buprenorphine. Talk about apples and oranges… there is a big difference between going to a med center and waiting to have bupe squirted in your mouth vs dosing with Suboxone at home.

There are some other things about the latter reference supplied by Arm-me-the-methadone-guy that make me wonder about the bias of the article.  The article has a table with a cost-comparison of methadone vs Suboxone; in the comparison the author lists the price of Suboxone as ‘$100 for a 15-day supply of 2 mg’, and methadone as ‘$30 for a 30 day supply not including counseling’.  Suboxone is sold by Wal-Mart for a little over $5 for 8 mg; at the full daily dosage of 16 mg the cost is $300/month.  Why does the author use a 2 mg dose (that nobody uses for maintenance), which implies a much higher cost per mg?  And then the methadone price of $30 for 30 days– how many people out there have a clinic that charges one dollar per day?  In Wisconsin the charge ranges from $10- $15/day!  Either the author is being deceptive, or he doesn’t understand how things are– either case making his opinion a bit suspect a best.

I have to wrap this up… but there were a couple more things written that worked me up a bit.  Arm-me took issue with my comments about AA and NA, suggesting that there is not data to support the efficacy of that approach— but there are plenty of studies supporting the 12-step approach and so I am not sure where such an impression came from. I’ll provide one of the most recent ones and he can use the references in it to track back to others: Witbrodt J. Bond J. Kaskutas LA. Weisner C. Jaeger G. Pating D. Moore C. Day hospital and residential addiction treatment: randomized and nonrandomized managed care clients. Journal of Consulting & Clinical Psychology. 75(6):947-59, 2007.

Ironically my exchange with Arm-me only reinforced my opinion of methadone programs. He ended his message with this bizarre comment in reference to AA and NA: ‘if you can show me studies that prove that utilizing these support groups make your chances of sobriety better than hoping for a spontaneous remission, than I will gladly add the research to my “bookmarks” on mdconsult’. This a comment from a person who presents himself as knowledgeable about addiction—and as a ‘methadone advocate’. In contrast, the training for docs who want to prescribe Suboxone recognizes, teaches, and requires an understanding that medication is only a small part of recovery.

I have seen so many miracles in those who ‘get it’— those who ‘cling to AA as a drowning man seizes a life preserver’ (or something like that—taken from an AA reading)— as have other fortunate people who have been forced to make the tough changes that AA and NA require. That Arm-me would call them ‘support groups’, and then compare their value to ‘hoping for spontaneous remission’, tells me that he knows nothing of ‘recovery’ at all. And now I understand the whole problem here—the source of the tension. In talking to a person on methadone, I am talking to an active, using addict. Maybe the need for dope is temporarily filled—maybe he has even learned to repress the cravings into the unconscious. But the addict BS and loss of insight is still there. But of course, why wouldn’t it still be there?

After all, methadone is just another opiate agonist.

Suboxforum.com

Bitter taste, euphoria, dosing…

From a person new to suboxone:
This is my, well, second day off opiates seeing it is 12:05am where I am. I had a 11 year on and off love affair with opiates. It got worse in the last 6-12 months or so. That feeling of euphoria really gets you and when you don’t have your pills you feel like you are going to die, literally!! I woke up this morning with no more pills. OH BOY was I sick… I found a list of docs who detoxed using subutex and/or suboxone… He did a patient and family history on me… He wrote me a script for six 2mg/0.5 suboxone. His instructions were take two under my tongue immediately… The taste was disguisting. I just took my second 2 and am cringing because of the taste… After 30-60 minutes, I felt wonderful… I was surprised he started me off at 2 and not 8mgs. The 2mgs do just fine. What is funny is that the euphoria you get from opiates, I am getting from this drug. I read up everything possible on the internet about this drug and it is supposed to be the best drug for opiate users. I have been posting a lot and hope you do not mind. I understand addiction and how hard it is so I want to help people. I am just starting my recovery and have a long road ahead, I know this but if more people know about SUB, there would be less addicts. I am making it clear to everyone that you absolutely cannot take any op’s while on Sub. Apparently you will get the worse side effects imaginable…
I deleted the parts that are identifiable or more specific to the individual than necessary here.
Some comments: As for the taste, there are some little tricks that will make suboxone more palatable; try chewing an altoid or another strong mint right before taking the suboxone, you can also try holding an ice cube in your mouth for 5 minutes first, spitting that out, and then taking the suboxone. Just be sure to start the suboxone dose without saliva or water in your mouth– you will produce saliva while you are dosing, and you want a high concentration of buprenorphine in the saliva, which means you want a low volume of liquid. Other people have used listerine strips. Finally, subutex has a different taste– it is bitter, but not ‘fruity’, and some people like it better. It is, though, significantly more expensive. Contrary to misconception out there, you do NOT need the naloxone to get the ‘blockade’ effect at opiate receptors. Subutex has an identical action in almost all patients– the exception being perhaps people who have had a gastric bypass or who have a (very unusual) allergy to naloxone.
For best results start with a ‘dry’ mouth, bite the suboxone with your front teeth to crush it and dissolve it immediately upon putting it in your mouth, then use your tongue to spread the the concentrated, dissolved medication over all surface areas inside your mouth. A couple points: the intact tablet is not doing anything, so holding it under the tongue takes needless time– get it dissolved right away. Second, there is nothing special about the area under your tongue; the medication will get absorbed from all surfaces inside the mouth, so use as much surface area as possible to increase absorption and speed the process. Third, after dosing for 5-10 minutes you can either swallow the saliva or spit it out– if the bitter taste really bothers you, perhaps spitting it out is the better option (also a better option for the rare individual who seems to get headaches from the naloxone in suboxone). Finally, do not drink anything or rinse your mouth with liquid for at least 15 minutes after dosing, as that will remove some of the buprenorphine that you are trying to absorb.
Euphoria… the initial effect of taking buprenorphine will depend to an extent on the individual’s degree of tolerance. A person taking over 80-100 mg of oxycodone per day who waits 24 hours to have moderate withdrawal, and then takes suboxone, will probably feel relief from the withdrawal, but will not feel much of an ‘opiate’ effect. On the other hand a person taking 5 vicodin per day (which contains hydrocodone, a weaker opiate) who waits 24 hours and then takes suboxone will likely have euphoria and other opiate effects– because the ‘opiate agonist’ activity of buprenorphine is stronger than what the person is used to or ‘tolerant’ to. In either case, the person’s opiate receptors will adjust fairly quickly to the potency of buprenorphine, and after a few days both patients will feel ‘normal’ after taking buprenorphine– no withdrawal, no euphoria. That is what makes it such a popular treatment– patients who take it regularly feel ‘normal’. In fact, many people experience life without the constant craving for opiates for the first time in years, and for the first time in years feel like a person who is not an opiate addict.
This leads to a much broader issue that I have talked about before– an issue that is more controversial: what other things should be required of patients taking suboxone? I have heard ‘second hand’ that Dr Miller, the President of ASAM, the American Society for Addiction Medicine, takes the approach that patients on Suboxone should be sober from all other intoxicants and attending group treatment and 12 step programs. I am in agreement on the ‘total sobriety’ issue but not with the second part, for a couple of reasons. Elsewhere in this blog I theorize a bit on the issue of Suboxone and 12-step attendance (I also discuss the issue here: http://fdlpsychiatry.com/subox.info/suboxandrecovery.pdf) but I have some practical concerns as well. First, ‘recovery’ is all about ‘rigorous honesty’, and yet if a person is honest about taking suboxone at an NA meeting he/she will end up being confronted and harassed– so patients are told to be honest about everything except suboxone use– and that is a problem because we are then reinforcing one of the things the addict has been doing for years– hiding the use of an opiate. Second, people on suboxone are different from people who are not on suboxone– they don’t have the constant awareness of the desire for opiates (or the unconscious drive for opiates manifest as irritability), and have an entirely different subjective experience. They don’t ‘feel’ like opiate addicts. Yes, they are still opiate addicts– don’t get me wrong on that. But they don’t feel the same way. And so I don’t know if a 12 step meeting will do anything for them. I know that to buy into recovery a person has to be desperate; not because there is anything wrong with the 12 step message as I think it is a great, universal approach to life that benefits everyone lucky enough to ‘get it’. But to adopt the 12-step way of living, of seeing the world, a person has to change. And change is very, very hard, and very rare. I remember my own first experience with the twelve steps: sick with withdrawal I wandered into a mall bookstore, found a book about AA, and read through the 12 steps. I concentrated for a few minutes, and considered what they said. Later that day, after using, I thought… ‘that didn’t work’. I’m trying to be a bit funny, but my point is that many people think that ‘recovery’ consists of intense education. Those people are eventually frustrated in treatment, as they think they are ‘getting it’ and yet their counselors and peers keep telling them that they are not getting it. In reality, treatment through a 12 step approach requires a deep change of attitude that is very difficult to come by. I like the saying ‘insight maketh a bloody entrance’. True change usually requires a significant period of distress– a rock bottom, a depression, a great deal of personal turmoil… another comment frequently heard in treatment is ‘crisis equals opportunity’, or ‘the Chinese symbol for crisis is the same as for opportunity’– something that I suspect is not actually true, but I could be wrong.
Wow. I talk too much. OK… practical problems to requiring 12 step attendance… My point (in case you zoned out) was that sitting through 12 step meetings, while not in the middle of a personal crisis at least at the start of 12 step exposure, may be a total waste of time. Ditto for attending ‘recovery group therapy’. Those things work for one type of treatment, and I see little reason why they would be helpful for people on Suboxone. An analogy… (wish me luck)… people with hyperthyroidism sometimes have the thyroid gland surgically removed; other times the thyroid is destroyed by taking radioactive iodine. If a person has had the entire thyroid removed, it makes little sense to then make them take radioactive iodine. Wow… that isn’t bad…
On the other hand… people with thyroid cancer have their thyroid surgically removed and then take radioactive iodine just in case some thyroid tumor cells were left behind. Given that opiate addiction is a fatal illness– at least as fatal as any cancer– maybe the more done, the better. I will say that anyone who is on Suboxone who is attending NA or AA or who wants to attend, and who can deal with the privacy issue of taking Suboxone, GREAT! If you can ‘get it’– if you can truly understand your powerlessness over substances and turn your life over to your ‘Higher Power’– you will be better off for doing so. You will also be in the position to get off of suboxone at some point.
I had better close, but will add one last thing. I will save the ‘dosing’ issue for another post, but please stay tuned because it comes up very often and there are some important concerns. But my last point today is that Suboxone does NOT cure opiate addiction, just as atenolol does NOT cure high blood pressure. To be honest, ‘cures’ are rare in medicine– we usually help the body heal itself or provide medication that ‘maintains’ a reduction in symptoms. We don’t fix the faulty blood pressure set point that is the core problem with hypertension– we give meds that artificially force the heart to pump with less force or at a lower rate, or that make the blood vessels open up wider, and that drops the blood pressure. Stop the medication and there often is a situation like ‘withdrawal’ where the blood pressure rebounds higher. Suboxone is an incredible medication– I know what it is like to be trapped by addiction before the days of Suboxone, and I understand why suicide is such a common outcome with addiction– if taken properly Suboxone will put addiction into complete remission, and that is a wonderful advance of science that saves many lives. BUT…. a person who becomes addicted to opiates has only three options: Buprenorphine maintenance for life, 12-step meetings for life, or prison and death.
DO NOT THINK THAT YOU CAN TAKE SUBOXONE FOR AWHILE, DO NO OTHER TYPE OF TREATMENT OR INSIGHT WORK, AND THEN STOP SUBOXONE.
In my next post I will try to talk about what a person on Suboxone CAN do to eventually stop taking the medication. I will also discuss the ever-important dosing question. The ‘sneak preview’ nutshell version is to follow the instructions of your prescribing doctor. Addicts take what they think they need to take– patients take what they are prescribed. You are not an addict anymore– are you?

I'm Not Like 'Those People'

A recent letter and response that addresses the ‘terminal uniqueness’ issue:
Hi and thx for getting back to me. I have never tried anything to get off of these pills. I am not your stereotypical addict. Truth be told I have never been addicted in my life. I feel like such a loser for letting myself get out of control and if it was not for being sick I would have licked this a long time ago! I am not off them right now because I cant. I work hard all day to support my family and there is no time to be down and out. I have also suffered an incredible string of losses over the past two years. What a predicament huh? I lost my wife two years ago, and the story goes on. I have chronic back pain from degenerative discs, but I will deal with that. Will suboxone do anything for me?
My response:
I have a couple things to say that may come across as ‘brutally honest’—don’t take it personally, but rather understand that EVERY person who gets stuck on opiates has a unique story, and we all were reluctant to see ourselves as ‘stereotypical addicts’. There is a term in addiction—‘terminal uniqueness’—that refers to a state of mind that is common with addiction, and which keeps people sick.
A frequent refrain by a person new to a treatment center is ‘I’m not like those people’. The fact of the matter is that one rarely sees a ‘stereotypical addict’ at treatment. What one sees are teachers, dentists, single and married moms, college students, high school students, people with back problems or fibromyalgia, people who have been through terrible tragedies… So try to avoid seeing the things that make you unique. Instead, try to see the things that make you like everyone else—the horrible feeling of being trapped by something, when you have always handled things well up until now. That is how most people who are stuck on opiates feel—trapped, embarrassed, ashamed, angry… and afraid. Others don’t feel anything because they repress all of their feelings and put up a fake, cocky exterior. That is what denial is all about.
J

Is Suboxone At Odds With Traditional Recovery?

By now almost every opiate addict has heard of Suboxone, a medication for opiate dependence that has been around for about ten years. I admit to mixed feelings about Suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery.While Suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines.Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.
An amazing medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach. People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all. This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone. On one hand, good boundaries include the right to keeping one’s private medical information so one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town. The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’. This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time. Opiate addicts have a number of such ‘defects.’The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.I had such an expectation when I first began treating opiate addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user. I realize now that I was making the assumption that character defects were relatively static—that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic. I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking. People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system. The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear—a primitive emotion from the old brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside. The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining suboxone treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?Yes, if they want to.A 12-step program has much to offer an addict, or anyone for that matter. But I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should Suboxone patients be in a recovery group?
I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.But for a person taking Suboxone I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.With cravings comes the obsession to use and the associated character defects.This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.
The downside of Suboxone
Practitioners in traditional AODA treatment programs will see Suboxone as at best a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone. Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug. Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.Finally, the remission model of Suboxone use implies long term use of the drug.Chronic use of any opiate, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary. Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.But for now, the treatment community would be best served by recognizing each others’ strengths, rather than pointing out weaknesses.
This article can be reproduced freely as long as the following attribution is included:
The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin.  Read more about suboxone at SuboxForum.com, AddictionRemission, or at Suboxone Talk Zone. He can be contacted at Fond du Lac Psychiatry.