An Addict's Story

I received the following email last week.  I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients.  As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic.  In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication).  At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me [email protected]@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer;  I’ll be adding my thoughts soon!
 

Jerk Counselor

Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention.  This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’
I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness.  I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions.  In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do?  Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

Some Jerks advocate punishing patients who struggle.
This Jerk Counselor

We all know that certain professions attract certain types of people.  Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt.  When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people.  It’s the power trip, I suppose.
This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment.  He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way.  One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room.  But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.
Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position.  In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room.  We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.
The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power.  Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids.  Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.
This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety.  He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.
In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious:  when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts.  On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.
I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric.  I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach.  I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right.  But most of us leave that world behind when we commit to helping people suffering from illness.
What’s This Jerk’s excuse?  Is it that he just doesn’t get it?  Or are there other motives at play?  With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.
Or is it the power trip– that people with difficult addictions are an affront to therapists?  I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die.  I suppose This Jerk would say ‘not my problem!  I did MY job!’
Readers may suspect that this topic irritates me—and they’re right.  Maybe I’ve seen more death, up close, than the typical counselor.  I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery.  I have spent hours with the parents of young patients who died from overdose.  I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child.  Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.
I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior.  People like This Jerk hold power over an individual with an addiction history, but there is power in numbers.  It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle.  It is not appropriate to humiliate a patient in front of others.  If you see that behavior, collect witnesses, and bring it to someone’s attention.  Maybe that ‘someone’ will write a blog post about it!
Doctors in particular should treat patients with ALL diseases—including addiction—with respect.  It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite.  I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.
Would THAT make sense— even to This Jerk?

Relapse in an Era of Buprenorphine

A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.
I drug-test patients who are treated with buprenorphine or Suboxone.  The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble.  It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example.  The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’
The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight.  Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important.  It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high.  On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.
I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.
In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me.  But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.
Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations.  But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.
One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’
After shooting the heroin, Paul immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.
His desire to talk is an amazing thing—and worth noting.  Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician.  In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.
There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients.  I don’t get the logic of those programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!
Paul made an appointment to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues.  Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!
We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it may also feel bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.
Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.
On buprenorphine, relapse doesn’t necessarily cause instant loss of insight.  I don’t mean to minimize relapse, as bad things can always happen.  For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused.  But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.
This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

Clean Enough: An Educational Process

Clean Enough continues:
An Educational Process
I was able to stop using codeine after returning home and to my job in the operating room.  I dodged a bullet– or so it seemed.  I continued to drink wine, beer, and the occasional margarita, but I had convinced myself that drinking was an isolated vice that was necessary given the stress of my job.  Yes, the AA and NA people said that alcohol would take me back to my ‘drug of choice’, but they didn’t understand my special situation, and didn’t know how smart I was.  The scary incident in the Bahamas faded from my memory.  Looking back, it wasn’t that big of a deal.
About ten months later I was having a tough week.  I had a bad cold, I was feeling depressed (my mood always takes a hit when I am sick), and my wife and I were in one of those low stretches that visit most marriages.  Seemingly out of the blue, I thought about how I had stopped the codeine after my vacation months earlier.  Hey– I must have learned to control my use of codeine!  And since I have control, I can take a small amount of codeine for my cold… and perhaps get a tiny bit of euphoria… but then I will stop just like I did before!   That thought—that I now had ‘control’—would be the end of my career as an anesthesiologist.  Similar to the experiences of many other addicts, my relapse was horrible; much worse than my original addiction.  I was like a rat pushing a lever to get food in a lab experiment, using medications from work, shooting up intravenously, and taking doses that I knew could be fatal.  I even injected contents from unlabeled syringes, hoping they contained something to make the sickness go away, and not the paralyzing agents that would have killed me.  Every Friday I brought home enough fentanyl to cover the weekend, but no matter the amount, it was gone by Friday night, leaving me sick from withdrawal every Saturday and Sunday.  At some point I didn’t even care about getting busted. There is a great line in the movie ’28 Days’:  “this is no way to live…. this is a way to die!” 
I was met by a security officer one Saturday morning as I entered the hospital to scrounge the operating rooms for drugs, and he apologized for having to escort me out of the hospital.  The next morning I met with the my wife, a member of my anesthesia group, and the hospital CEO, telling them that I only needed a minor, outpatient ‘tune-up’, since I knew all this recovery stuff already.  But the CEO pointed out the needle marks on my hands and arms, and said that any possibility of working again required residential treatment.  I left the meeting wondering whether to just put all of us out of our misery or to instead go into treatment.  As an aside, I remember that feeling now when I am trying to get a person to enter residential treatment– my aversion to treatment was so strong that suicide seemed a reasonable alternative!  I did choose treatment over death, but not by a long-shot. 
The night before going to treatment I watched my 12-year old daughter play a piano duet, her teacher playing the part that I was supposed to play.  Laura and I had practiced the piece together for weeks, but with my hands shaking and dripping sweat I was in no condition to play.  I have many shameful memories from my ‘using days’, but memories of that night will always be among the worst of them.
I was in severe withdrawal the next morning, too sick to enter the treatment facility, so I spent some time in acute detox in a locked psych ward.  My shoelaces were taken from me so that I couldn’t hang myself.  I was given a room at the end of the hall where I waited for the pain to stop, minutes becoming hours.  Clonidine was ordered, but was to be held for blood pressure below 90. Every time I heard the nurse I tensed my muscles, trying to push my pressure higher, but I was so dehydrated that I couldn’t get my blood pressure high enough for even one dose!  I will point out that people write on the web that ‘Suboxone withdrawal is the worst;’ in detox I could barely walk for the first few days, and for a month or two I was so weak that I became short of breath after walking 100 feet.  Sleep and appetite took a couple months to return.  After experiencing withdrawal many times, and watching many people go through withdrawal from substances including buprenorphine, I can say with complete confidence that buprenorphine withdrawal can be significant, but is NOT as severe as withdrawing from opioid agonists.  Those who say otherwise are being influenced by the fact that current misery always feels worse than ‘remembered misery.’   People withdrawing from buprenorphine go to work every day and complain about how bad they feel; those withdrawing from oxycodone, methadone, heroin, or fentanyl lie in bed and DON’T complain, as they are too sick to write on the internet!
I eventually transferred to the treatment center where I would spend the next three-plus months of my life.  The program consisted of work from sun-up to bedtime, and included individual therapy, group therapy, art therapy, music therapy, experiential therapy, relaxation training and guided imagery, ropes and challenge course, physical training, and twelve step groups.  One irony of treatment is that a person is ready to leave at about the time when he no longer wants to go.  I now see the experience as a wonderful gift to myself.
I had a number of ‘consequences’; I lost my job and my hospital privileges, and I was disciplined by the licensing board.  I was ordered to attend treatment and twelve step meetings for the next five years, and I was subject to random urine testing at a frequency of at least twice per week.  I did as I was told and time went by.  At one point I decided to repaint the interior of our house, and beige walls were replaced by forest green, golden tan, and light burgundy.  I took up running and got in better shape.  I became active in community theater, something I had always wanted to do but now had time for.  I became more involved in the day-to-day lives of my children.
I had been released from residential treatment the day after September 11, 2001, and I found out a few days after the horrible attacks that my best friend from college, Commander Dan Shanower, had been killed at the Pentagon on that day.  My attention to his tragic death led to finding a job with the Transportation Security Administration providing medical clearance for new airport screeners.   That brought in some money, and we sold our vacation cottage to help pay the bills, but I knew that I needed a new career.  I loved being an anesthesiologist, but I knew that most relapses in anesthesiologists came to light when the addict was found dead in a call room.  After significant sober reflection I decided to return to residency—this time in psychiatry, to get back to my early interests in the mind and brain.
Starting over
It was difficult being a lowly resident again, but things could have been worse.  I know doctors with addictions who never made it back to practicing at all.  I have known addicts who died from their addictions.  Those AA bumper sticker slogans often contain true wisdom; my most appropriate bumper sticker reads ‘Gratitude is the Attitude.’  A common recovery phrase is ‘the Chinese symbol for crisis means opportunity.’  I don’t know whether the statement is true, but the sentiment is accurate.  I have seen recovering people do some amazing things, and I hope to be one of them.
My relapse, horrible as it was, resulted in a wealth of opportunity.  I mentioned my participation in Community Theater; circumstances also led to a position as a columnist for the trade journal Psychiatric Times.  I for years had dreamed of teaching but only now do I participate in that dream, teaching addiction and other topics to medical students and residents.  I appear in a weekly radio show about psychiatry and addiction, and I am, of course, writing this book!  None of these things would have happened if not for that fateful day in Eleuthera seven years ago.  I am not saying that my relapse was a good thing—don’t get me wrong about that!  But addiction– and relapse– do not have to be the end of one’s life.  For me, in many ways they were only the beginning.

Clean Enough: Some Distorted Thinking

Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup.  Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.

A horrible relapse in Eleuthera
Eleuthera: not a soul in sight

In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket!  I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days!  So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera.  I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well.  Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way.  I eventually learned that both were true—but that and other realizations required further ‘education.’  I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.

Why do some docs kick patients off buprenorphine?

I often receive e-mails from people that go something like this:  I was addicted to oxycodone and heroin for 5 years, and lost my marriage, several jobs, and the trust of my children.  I was completely broke, and considering suicide.  Then I heard about treatment with buprenorphine and found a doc who prescribed it.  Since then everything has been going much better; I have a job, I’m putting some savings away, and I have been starting to reconcile with my family.  But my doctor says he wants me off Suboxone and is making me taper, and I’m definitely not ready.  I am starting to panic because I know that if I have to go off buprenorphine I’ll only end up using again.  Is there a way to make him keep me on buprenorphine?

Why the rush off buprenorphine? Suboxforum.com
Why the rush?

I have described my approach ad nauseum on this blog.  I look at the ‘givens’:
– Despite everyone’s wish that addicts stop using opioids and ‘get off everything,’ it just doesn’t work that way.  The relapse rate after stopping opioids is very high, whether stopping buprenorphine or any other opioid substance.
– Opioid dependence is a chronic illness that never goes away.  People relapse even after years of sobriety.
– Traditional treatment suffers from very high costs and very low success rates, and requires a large time commitment.  Traditional treatment does NOT offer any ‘long term protection’ against relapse; if a person stops attending meetings, the rate of relapse becomes similar to those who never went through treatment.
– Buprenorphine can hold opioid dependence in remission in motivated addicts.  It is not just a ‘substitution’ of one drug for another, as the ‘obsession’ which is the essence of addiction is reduced, allowing personality to improve and for other interests to return.
– The side effects and risks of taking buprenorphine are not significant, especially when compared with treatments for other life-threatening conditions.
– Even a short relapse can have unpredictably severe consequences, including legal trouble, loss of career, loss of key relationships, and death.
I could go on and on with this list, but you get the idea.  My own conclusion then has been that buprenorphine should be considered a long-term treatment for a long-term condition. 
Why do some doctors insist on a short-term approach?  One reason is simple ignorance, and not understanding the nature of opioid addiction.  Many docs persist in seeing addiction as a ‘choice’, and fall into the same silly thinking that some addicts initially believe, that the main barrier to sobriety is withdrawal.  Addicts who become miserable enough to get through withdrawal quickly learn that the withdrawal is NOT the problem—at least not the MAIN problem—as even after the symptoms go away, the addict relapses. This is maddening to the addict’s loved ones, and some doctors see this situation and become angry at the addict, rather than understanding the nature of addiction.  At least there are now studies showing the high rate of relapse, and hopefully the data will change the behavior of physicians prescribing buprenorphine.
Another reason for short-term prescribing is because the buprenorphine is being used as detox, for entry into a ‘total sobriety’ treatment center.  I won’t get too upset about such a situation, except to point out that such treatment centers commonly mislead patients about their chances.  At the treatment center where I used to work, Nova counseling services in Oshkosh, WI, the counselors would get very excited about patients who looked good on their way out the door.  But nobody seemed to feel any responsibility if that same patient relapsed and returned—or died—six months down the line.  Of course many patients never made it to the end of treatment, getting thrown out early or leaving on their own.  The counselors blamed those failures on the patient—instead of recognizing a failing treatment strategy.  THIS IS A VERY SERIOUS PROBLEM, by the way, with residential, traditional treatment programs—a problem that exists because of stigma about addiction, and a sense that addicts are less deserving of good health than ‘normal people.’  How can I say that?  Think of it this way—what if any other illness was managed in this way?  If heart disease or diabetes simply failed to make people better most of the time, and the doctors routinely blamed the patients for the lack of success, how would THAT fly? 
My biggest concern is that there are motivations to get patients off buprenorphine that come from the requirements placed on physicians who prescribe the medication.  Physicians can treat only 30 patients at a time with buprenorphine.  After a year they can apply to raise that limit to 100 patients.  Ironically there is no limit at all on the number of patients a doctor can treat with opioid agonists!  In a typical practice, patients are seen less often as they become more ‘stable’ on buprenorphine, resulting in a situation like mine– I have about 100 patients who have done well on buprenorphine for some time, many of whom had multiple attempts at ‘traditional treatment’ and some who were on buprenorphine from other docs, who would like to stay on buprenorphine long-term.  That’s fine with me; buprenorphine patients are a small part of my practice.  But if I wanted to make significant income from patients on buprenorphine, I would need to clear out spots for new patients who are seen at greater frequency, and who would pay the initial intake fee. 
In other words, doctors are rewarded for high patient turnover, and the growth and earning power of their practices are limited by the cap on the number of patients they can treat.  I understand the reason for the cap; we don’t want to suddenly have thousands of patients on buprenorphine without adequate treatment and supervision.  But there is always a downside to any regulation, and rapid turnover in some practices is a downside to this particular regulation.
I don’t have any particular advice for people who are being forced off buprenorphine for no fault of their own, other than to seek out a new physician.  Patients who are considering starting buprenorphine may want to ask the doctors in their area about their attitudes toward long-term maintenance.   Hopefully over time at least some of the motivations for pushing people off buprenorphine will become less significant.  For the docs who are doing the pushing, I encourage you to examine your own motivations.  I realize that everybody wants to get back to how they were before becoming addicted to opioids… but it is important to remember that nobody can predict the outcome of a relapse, and some people die.

Is She Still Using?

I have been involved in Q and A with a person in another part of the country, and will share some of our exchange after removing the identifying info. BTW, I receive many e-mails from people and I just don’t have time to answer most of them; I DO provide ‘educational consultation’ (not a ‘medical’ relationship) at a rate of $100 per 30 minutes, and anyone is welcome to set that up by writing to [email protected]
The person below consulted me over her daughter, who is addicted to opiates and on buprenorphine but not doing well. The grown daughter receives some level of support from her parents, who are in that horrible position of trying to pull back to avoid enabling while at the same time fearing that pulling back will cause relapse or worse. The mother has had the impression that her daughter is sedated from buprenorphine, and that the buprenorphine may be making things worse. Mom considered helping daughter pay for ‘rapid opiate detox’ to ‘get off Suboxone’ at one point; I was not a big fan of that idea, as I have seen people do poorly after that approach (in my opinion, GETTING clean is much easier than STAYING clean).
Our exchange:
She is still on suboxone but we are paying for it. her weekly appt last week was on wednesday and she did not bring us her prescription to have it filled until saturday which means she did not have any meds for 3-4 days.
She was like a wild animal when we saw her and told us she has filled it herself. Then finally Saturday she gave us the prescription and told us to fill it for her.
Number one: why would she have waited so long, would this be a sign of a relapse? Number two: can you stop for 4 days and then start up again? Wouldn’t this make you high from it? She is on 16 mg.
She is NOT doing well with Suboxone, could she be using it to subsidize the in-between times or something?
Just can’t figure out why a medicine that is supposed to make her better is making her worse?
Hi XXXX,
I find myself in the position of defending Suboxone– and wish I had something else to suggest. People taking buprenorphine comprise about 20% of my psychiatry practice, and I have not taken a new patient for buprenoprhine treatment for over a year, so I want to make it clear that I am not a ‘Suboxone zealot’. I’m just trying to be frank about what I see with addiction.
I often end up saying things like ‘it isn’t fair to Suboxone.’ When I say that, I am not concerned about ‘fairness’ toward a business plan or marketing strategy; I am speaking of ‘fairness’ in an intellectual sense. Maybe instead of ‘fair’ I should say ‘proper’—I will try that below and see if it helps clarify my point.
Your last comment is an example of why I have the forum and blog, as I hear similar comments frequently— i.e ‘why a drug that is supposed to help making her worse?’ That is NOT an intellectually honest question. SOMETHING ELSE is making your daughter worse, and buprenorphine is keeping her alive. I lived as an addict for 10 years BEFORE Suboxone, and I saw what things were like with only methadone as an option. While there has always been residential treatment, the results of treating opiate dependence with residential treatment have always been poor.
In the past six years, 1200 people died in Milwaukee from overdose. There is nothing special about Milwaukee; recent stories in Time, Newsweek, and elsewhere have highlighted the dramatic increase in overdose deaths from ‘prescription medications,’ largely opiates and benzodiazepines. We do not know what would have happened in your daughter’s case, had she not gone on buprenorphine. She very well might have died by now. She might be in prison. We don’t know—but at any rate it is not PROPER to ‘blame’ buprenorphine, when in fact the medication may have saved her life. The fact that she is still sick is most likely because addiction has many factors and consequences that are impossible to define, let alone treat. I have seen the outcome of untreated opiate dependence too many times. That outcome consists of either death or incarceration. The deaths have been mostly ignored until recently, and I imagine that after this ‘news cycle’ we will return to ignoring them. But the deaths are still there, every day. One result of being a physician who treats opiate dependence is that I now read the obituary section of the newspaper; I sometimes get ‘follow-up’ there on people who had at one time sought help, but for whatever reason had stopped coming to appointments.
To answer the other questions, it is very unusual for a person who is doing things right to forget to fill a prescription for buprenorphine. At first, people in treatment may wait until the last minute, then call in a panic saying they will run out the next day. One of my jobs is to get them living like ‘normal’ people, i.e. planning ahead of time and respecting boundaries, including not expecting me to drop everything because THEY forgot to schedule an appointment. Your daughter should learn to take care of the basics herself, and suffer some degree of consequences should she ‘forget’ to plan ahead. Every addict, of course, has many excuses for not being able to make appointments, call in requests for refills ahead of time, etc… even if the addict is doing nothing all day, and the caretaker is working three jobs! That dynamic must change so that the addict is responsible for herself.
Yes, stopping buprenorphine for 4 days and then restarting it will result in the person ‘feeling’ opiate effects. It is difficult to sort out whether the person is feeling ‘high,’ or just feeling the loss of withdrawal—but there would definitely be relief associated with taking the buprenorphine after 4 days. The goal with buprenorphine is to avoid that cycle of ‘sickness’ and ‘relief’ and to instead feel normal all the time. And ‘normal’ is what the vast majority of my buprenorphine patients describe; they say that they feel nothing with each dose, and that they don’t feel ‘high’ at all. Feeling ‘normal’ is consistent with the chemistry of taking buprenorphine; the person becomes completely tolerant to the effects of the medication and as long as the blood level remains above a certain threshold, there is no sense of something wearing off.
In the case of your daughter, I agree with you—something is not right. She is either using opiate agonists intermittently or she is still very much wrapped up in wanting to ‘feel’ something—or both. There are deficiencies to all testing methods, but she should have a ‘state of the art’ urinalysis at some point when things are irregular. By ‘state of the art,’ I mean a test that is witnessed (most labs can provide this service), that has a chain of custody, and that is analyzed at a certified medical laboratory.
In a case like that of your daughter, it is important now and then to return to basics– does she WANT to live a clean life? What is motivating her to do well, and what is motivating her to do poorly? Are there sufficient consequences for bad behavior? Is SHE the one working the HARDEST on her sobriety? She SHOULD be, by the way… when I see a situation where everyone else is working to help a person stay clean, I know that bad things are coming.
I realize that it is simply horrible, what is happening to you and to your daughter. You are being forced to distance yourself from her so that she will take on more responsibility for herself, and so that you are protected to a small degree from the horror of the current situation and the fear of what could come at any time. That distance is just like any other significant loss. Understand that it isn’t your fault, and you are not alone. I often compare opiate dependence to cancer; both illnesses have consequences far beyond the risk of death. The loss that you are experiencing is similar in some ways to what cancer patients go through, when they see close friends back away out of fear of death and dying.
The one consolation is that for most people, age brings insight. I have many people on buprenorphine who do very well—they take a daily medication as they would for any other chronic illness, and lead happy and productive lives. But I also have a few younger patients who do not do as well—particularly those under age 20. In those cases, the course of illness includes a constant battle to prevent the addiction from going ‘underground,’ i.e. where the addict keeps secrets from the physician, and there are periods of stability and relapse. In such cases I hope that buprenorphine at least allows me to keep the person alive and out of prison (and hopefully employed or in school as well). The addict’s life may still be chaotic, but each day the person is a little closer to age 30—an approximate age when insight seems to have a better chance of taking hold. Hopefully your daughter will gain insight as well as time passes. If she only loses a decade of her life, she still has much to live for.
As always, I’m sorry for what you are going through. Protect yourself first; make sure you are doing all that you can to keep your own sanity intact.
JJ

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.
SD

A Common Mistake

I brought a note from the ‘comments’ section up here because it presents a topic that comes up over and over with opiate dependence and Suboxone.  I am the expert on MedHelp.org’s addiction forum;  I get questions and comments like this one quite frequently on that site– although I have addressed the issue so many times that I think people there know what my opinion will be on the subject.  I will post the comment, and then write my own comments afterward.
I started on the Suboxone in Feb 08 to get off the opiates. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it b/c I had no more insurance and it was very expensive. I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped b/c I ran out of Suboxone. About 3 days after I stopped taking it completely I started withdrawing from the Suboxone. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. Once that began I started doing research on Suboxone withdrawals and people were basically saying that depending how long you were taking the drug that would depend on how long you withdraw b/c Suboxone stays in your system for a long time. So what did I do.. to get rid of the withdrawal feeling I was getting I started taking the opiates again. Then eventually I  got addicted to those again. What I have noticed works with the suboxone is if you take it for about 10-14 days long enough for the opiates to get out of your system and stop taking the Suboxone you wont get sick and you will be successfully detoxed from opiates. Now the hardest part is staying away from the opiates. I am now on my 3rd day of the Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from the opiates by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you all posted and to everyone else doing the same.. GOOD LUCK TO ALL OF YOU!!
I have written about the natural progression of opiate dependence before, but I will review things again for newcomers.  Early in addiction, the addict believes that if he can only get past the physical withdrawal, everything will be fine.  During the first third of an addicts ‘using life’ he is always fighting for that first piece of sobriety– you see these people on message boards all over the internet, comparing tapering plans and different cocktails of amino acids or other worthless regimens to find the one that ‘works’– that gets them through a taper or withdrawal to become opiate-free.  They usually are not interested in meetings or rehab at this point;  they don’t consider themselves to be ‘THAT kind of addict’ who needs that much help– just the right pill to get through the worst of things.  These are the people who often insist that Suboxone be used only short-term, as a bridge to sobriety.  They have no interest in the idea that they have a life-long illness, and will argue that point until blue in the face, even as they continue to use opiates on a daily basis.  Denial is huge during this stage of addiction;  the addict minimizes the impact opiates are having on his relationships, work, and health status.  It is easy to discount all of those things because he considers all of the messes to be temporary and ‘easily corrected’– once he just stops the darn opiates.  He assumes– sometimes for a long time– that the ‘right method’ will come along… eventually.  Hooked?  Not him!
A person enters the second stage of addiction when he has been able to successfully taper of opiates.  From my vantage point of seeing many, many addicts over time, this point is not associated with any particular taper method or amino acid formula, but rather occurs when the person has enough consequences to motivate him through the withdrawal.  More and more bad things pile up until they cannot be repressed and ignored;  job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.  During the first stage, the addict would get to a certain level of withdrawal and say ‘screw this!’ and resume using, but during the second stage the problems are remembered even during bad withdrawal, and the addict stays motivated to be free of opiates.  The taper that eventually works is often the worst one;  the addict just says ‘enough!’ and stops without any plan or preparation.  Or perhaps the consequences lead to a jail cell or being completely broke– again, resulting in sudden and absolute sobriety without the luxury of a taper or meds to reduce the severity of withdrawal.
That’s great, right?  He is finally there– free of those opiates… or so he thinks.  But unfortunately he is about to enter the third and worst stage of opiate addiction– the stage that can last for years and years and that totally demoralizes the individual.  This stage begins with relapse, and it can happen after a week, or it can happen after a year.  The bottom line is that it almost always happens– and that NOBODY thinks it will happen to him.  I hear the comment over and over– ‘no doc– I don’t plan to relapse!’  or ‘I know what you are saying– but you don’t understand the way I am!’  Everyone considers himself too smart for relapse, but I see the AA adage come true over and over:  nobody is too dumb for Recovery but some are too smart for it!  The meaning is that every now and then a person will avoid relapse– and it tends to be a person who has a ‘simple’ outlook on life who didn’t really ‘shine’ in other, more competitive areas.  Someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities.  That person can sometimes simply stop using because he easily accepts the idea that he has lost the fight– that opiates are much stronger than he is, and that he will never figure out how to take them without disaster.
Most people, though, are way too smart for this situation;  as soon as things start going well their minds take off again…  and at some point they return to using.  I’m not going to spend time on all of the triggers for relapse, but maybe I will discuss that another time–  but there are things common to all relapses, including   rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness’ that I mentioned above, where all of the warnings are an issue for OTHER people.  During this third stage, the addict will have repeated episodes of relapse and sobriety;  there is little joy in using since consequences occur much more rapidly now, so more and more time is spent being sick from withdrawal.  This is the stage that most long-time addicts remember, and fear, the most.  In my case, I could stop using every weekend;  I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME–  come Monday I won’t touch ANYTHING!’  And so I was always sick;  the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them.  And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.   As I mentioned earlier, during this stage the addict becomes truly ‘sick and tired’.  This is a dangerous period of time for the addict for a number of reasons;  when the addict uses he feels a great deal of shame, which fuels more using– making use more impulsive and reckless and more likely to cause a fatal overdose.  The addict also becomes depressed– sometimes extremely depressed– and commits suicide, either actively or through just not caring anymore about the risks of taking too much.  The addict sometimes feels such a wave of hopelessness or shame that he needs to do ANYTHING to change how he feels– so he swallows any pill he finds, or shoots up something that he doesn’t even know the actions of–  he just needs SOMETHING!  Even a hammer to the head looks good at this point!
This is the time when traditional treatment has been effective;  the addict is at rock bottom, and he no longer feels confident about any of his own abilities.  He is ready to follow ANYONE or ANYTHING– after all, what does he have to lose?  Life is over anyway– so why not listen?  If the addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a genuine shot at some meaningful sobriety.  If, though, he gets into treatment and quickly makes a girlfriend, or he can tell jokes and be the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is…  there is a strong chance that the treatment will prove worthless.  He needs to hold on to the attitude that he knows nothing, for only that attitude will allow true learning and change to occur.
This is why, in my opinion, young people have lower success rates in treatment.  Young people often feel way too invincible for treatment to take hold.  They also have short memories for painful events;  consequences are quickly forgotten and dangerous self-reliance returns.  The true wonder of AA is that the program designers understood all of this;  the program is all about humility and powerlessness, and consists of a series of steps that, if practiced completely, will take a person to the right frame of mind and keep him there– provided he continues to work the program.  The reason treatment tends to work better for older people is because first, more are at the later stage of addiction when they are truly ‘sick and tired’,  and second, self confidence tends to return a bit more slowly.  Us older folks tend to remember the bad things because we know that some friendships can be lost forever.  Plus it is difficult to feel immortal when one’s body aches each morning!
I’m sorry to pick on the writer of the comment above;  I could do this with many of the comments that I receive from those who plan ‘short term’ use of Suboxone.  In light of what you have read, go back and read the comment again;  see if you can tell the stage of addiction that the person is experiencing.  Again, I get these types of comments over and over, both here and at the other site that I mentioned.  I have watched, over the past 16 years, as addicts (including myself) have gone through the same process.  Every person is convinced that HE is different– only to eventually find that in regard to addiction he is the same as everyone else.  This is why I recommend seeing Suboxone as a long-term medication… or seeing AA or NA as a life-long program.
One final comment… the three stages that I use to describe opiate dependence are ‘mine’;  I have noticed them over the years and they continue to be retold in my patients’ stories, and so they appear entirely obvious to me.  I have not seen the stages spelled out in this way by others, so if at some point others agree with me, let’s name them the ‘junig stages of addiction’.  I accomplished one more of the ‘goals of my life’ a few weeks ago when a guy met me at the airport with my name on a piece of cardboard;  having something named after me would scratch one more thing off the list!

Suboxone is OK– If Used 'Short-Term'?????

For the sake of a good night’s sleep I will share the post I just left with my good friend over at ‘arm-me’ blog– see the blogroll for the link.  The conversation there arose over the recent Suboxone-related deaths in Milwaukee, Wisconsin, and I was responding to a writer who made the bold claim that ‘spiritual based’ treatments were superior to non-spiritual treatments, and that Suboxone is OK but only if used ‘short-term’– a statement oft-read on the internet that is based on… well, based on nothing at all.
My Comments:
I would be interested in the reference for the comment about the ‘higher rate of success for Faith-based addictions programs’. I work and lecture in the field of addiction– and have been dealing with opiate dependence for over 15 years– and I suspect the comment is more anecdotal than ‘proven’.

Twelve step programs save my life twice– in 1993 and after my relapse, in 2001. I now am medical director of a large treatment center that does not use Suboxone; I also treat opiate addiction WITH Suboxone from my office practice. I have lost friends to opiate dependence; I have seen many more deaths of patients who had gone through step-based treatment at some point in their lives. And we all have seen many, many deaths from overdose in people who never went to treatment—which is by far the largest group of opiate addicts. While step-based treatment worked for me, it does NOT work for most addicts. Yes, it COULD work—just like we COULD have ‘world peace’. The truth of addiction, known to all who work in the field, is that addicts do not seek help, particularly residential, spiritual-based, or step-based help—until they are at the end of a series of horrible consequences. Even then, many patients enter treatment centers with tears on their faces, saying they will do ‘anything’ to get clean… only to check out the following morning with resumed cockiness and denial. Even opiate addicts who finish 30 days or more of residential treatment have a low rate of lasting sobriety. The FACT of addiction treatment is that before Suboxone, opiate addicts entered treatment only after losing almost everything, and many died before getting to that point. And the tiny fraction of addicts who do enter treatment have a high rate of relapse, to the point where an opiate addict receiving treatment and never having a relapse is quite rare.

I went through treatment with other doctors—people with a high motivation to succeed as their licenses are on the line, and they are being constantly monitored. Even that group of addicts has a high rate of relapse, and since my treatment in 2001 I have seen a number of my treatment-colleagues fall by the wayside.

Enter Suboxone. My point with the prior comments is that it is not as if we had great treatments already; the existing treatments for addiction are NOT used by the vast majority of addicts, and even when used the techniques only work in a select, lucky few. Suboxone allows the treatment of opiate addicts FAR earlier in the course of their addiction, before the severe consequences that are necessary for the other treatment options. The ‘drug for a drug’ argument is valid only for those ignorant to the actions of Suboxone; buprenorphine, the active substance in Suboxone, attacks the obsession to use DIRECTLY– in essence treating the very nature of addiction itself. To be frank, it is difficult to imagine a better, or more effective medication to treat opiate dependence—even the withdrawal from buprenorphine that some addicts curse is in reality a blessing, as it assures compliance with the medication. Naltrexone, for example, is an opiate blocker that has NO agonist effects and NO withdrawal; it is largely ineffective for opiates (although it does help with alcoholism) in part because it does not reduce the obsession to use, and in part because it can be discontinued easily, allowing relapse.

Similarly, the comment that buprenorphine should be used ‘only short-term’ is a sure sign of a person who does not read the literature, and who does not understand the disease concept of addiction, but rather is stuck in the world of shame-based treatments. Opiate dependence is a chronic, relapsing, fatal condition—why should it not deserve treatment? Why the concern about being ‘clean’, when we don’t demand the diabetics be ‘clean’ from insulin? But the obvious comparisons aside, the simple fact is that short-term use of Suboxone has clearly been shown to be a waste of time—the relapse rate is virtually 100%! And still, people keep repeating the same thing… that Suboxone use should be ‘short term’. I would love to see those addicts in their docs office, being told that they would receive medication for their heart disease for ‘short term only’—after that they would avoid heart attacks through prayer. The success rate for treating coronary disease with prayer is likely similar to the success rate of short-term use of Suboxone for treatment of addiction!

People on Suboxone: I have seen many patients talked off of their medication by someone on the internet or at NA, only to return to my practice, sheepishly, 6 months later—if they survived the experience. I am not being dramatic; they do NOT all survive being talked off their Suboxone. The people on the web who induce guilt in people on Suboxone are true messengers of death; they do not see, or have any idea, of the lives of the people who they have impacted in such negative ways. Go on any health message board and read the posts over time—you will see people writing about their tapers and relapses for YEARS—and others who simply disappear, no doubt after relapsing and assuming THEY did something wrong. I hold the anti-sub zealots responsible; I have yet to personally meet anyone helped by those people, and I know literally 100’s of patients taking Suboxone, free of guilt and shame, enjoying their lives, and grateful to FINALLY have an effective medication for such a horrible disease.

SD/SuboxoneTalkZone