Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here.  This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago.  I grew used doctors refusing to treat people addicted to heroin and other opioids.  I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise.  It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices.  I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine.  The comment surprised me, because from here I don’t see the influence.  My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years.  I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things.  I want to write about the little things.  The easiest way to have influence is to write about the things that nobody else writes about.  After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence:  If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way.  I want people to use .  I know I sound like some old guy frustrated by all of the new words and acronyms on social media.  YES, dammit, I AM frustrated by those things!  But communication has become so…. careless in the era of Twitter and texting.  Find an old book and notice the words and phrases used by educated people 100 years ago.  Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends.  Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?)   But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs.  Some large scams benefit from the informal attitudes toward health and medicine;  attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video.  As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term.  Is ‘treat’ the right word?  From my perspective I’d say yes in some cases, and no in others.  Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year.  They said (and I believe them) that they hadn’t used opioid agonists for at least that long.  I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances.  There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances.  Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv.  Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies.  I correct them and tell them that I have a hard time trusting patients who talk that way.  After all, those are street terms.  A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub.  Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing?  Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not.  I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression.  Getting that point across would be enough influence for one day!

Suboxone– nobody's business.

There are plenty of people out there who ‘take issue’ with Suboxone.  Isn’t it odd, when you really think about it?  I mean, we don’t have people arguing about whether someone else should take medicine for their diabetes;  we don’t have people get in the face of cancer patients, and tell them that ‘the chemo is really going to suck!’ So what is it with Suboxone?
Today I came across a web site called ‘drugs.com’, or something along that line.  I posted something in response to a person who wrote something like ‘I’m addicted… help!’ —  I wrote that I had info about Suboxone at my blog and on my recordings– the ones I have shamelessly plugged on this site (another shameless plug– go to soberaftersub.com).  I really though I was giving useful information, but within a few minutes someone reported me for spamming, causing me to be ‘banned’, then to add insult to injury I got a note from some person saying ‘while some people have had help from Suboxone, it has really screwed some people up, so I hope you’re not one of THOSE doctors… ‘   It is in cases like that when I realize that the internet is missing something–  and that someone (maybe Al Gore when he invented it!) should have added a way to just send the ‘f’ word through cyberspace so that it flies out of the other person’s computer and whacks the person on the forehead… WHACK!!– like that.  Do I sound resentful? (sorry).
‘I HOPE you’re not one of THOSE…’   Wow.
I am a bit ornery tonight, as you can tell.  I’m not sure why–  I have been storing up a couple resentments, and I really should do something about that, as resentments are really bad for sobriety.
Anyway… I don’t know whose fault it is– bad doctors, nosy busybodies, self-righteous types– but some people are really screwing up the whole Suboxone thing.  This is an amazing medication, folks– take it from a person who got clean in the days before it was available.  The ‘old way’ of getting clean required first losing everything– house, career, savings… maybe freedom, and maybe even one’s life.    Some people found a ‘rock bottom’ and got into treatment; some fraction of those people stayed long enough to ‘get it’;  some fraction of those people stayed clean for a month; some fraction of those people stayed clean for a year.   Recovery happened for only a few people, and only after great losses.
A patient of mine died last spring;  he was 25 years old, had just found a great job… he wasn’t on Suboxone, mainly because he had only been using for a couple months.  I had him lined up for treatment but then he got the great job, and insisted that ‘I have too much to lose– I would never use now!’.  I tried to explain that it doesn’t work that way– that people relapse when they are doing well, when they get that great job– that is when they get cocky and forget about the misery, and the mind starts spinning…
He was a nice kid.  I have his autopsy report on my desk.  I have another set of photos on the floor near my desk from a different case– another 20-something year old guy who died from opiates.  I have the police photos in that pile, showing him in his parents’ house, in the bedroom where he grew up, but now with a swollen face from the attempts by EMTs to ventilate him, unsuccessfully because he died a few hours earlier while his parents slept in the room next door, or maybe his mom was awake and worried about him from the friends he had been hanging with…

it is terrible, talking to the families afterward– the parents second-guess every decision they ever made, torturing themselves for months, years–    I know death from my anesthesia days in Philadelphia where every night a couple kids were brought in with holes in their chests, bellies, or heads.  I got sick of it there, and I get real sick of it now.  Nothing glamorous about death from opiates– James Morrison fat and blue in the bathtub… Elvis on the floor three feet from the toilet, pants around his ankles… Cobain with his head blown off from a shotgun.  Not cool.
Suboxone has save thousands of lives.  No doubt about it.  No, it is not perfect.  Few medications are perfect.  Want to know a secret about antidepressants?  They barely work.  Just barely.  In almost all clinical trials of antidepressants, about 50% of the placebo group gets better on sugar pills, and about 70% of the treatment group gets better on the medication.  That is it– all of the excitement over Prozac, and we are talking 70% vs 50% recovery.  Compared to that, Suboxone is a true miracle.
Tomorrow I will try to find the time to write about something that I talk about extensively.  Yes, it is on my tapes (that is meant as sort of a joke, and sort of another shameless plug!).  The topic will be about how Suboxone can do much more than many people get out of it.  Many people just use if for the effect on cravings– which is admittedly very dramatic and important.  But there is so much more to addiction.  As an aside, don’t confuse ‘addiction’ with ‘physical dependence’– they are two different things.  People become ‘physically dependent’ on many medications– for example the withdrawal from effexor is horrible!  That is not addiction– addiction is the mental obsession that crowds out everything other part of life, that prevents intimacy with other human beings, that makes life shallow, dry, and miserable.  When people say you have ‘substituted one drug for another’, they are missing the point entirely–  it isn’t about what you are taking.  It is about whether you are still actively obsessing over a substance or not.  Suboxone stops that obsession– THAT is the point.
So tomorrow, or maybe over the weekend, I will talk about how Suboxone does that– and how you can make sure it happens.  Yes, just taking Suboxone will get you halfway there.  But if you recognize the ‘conditioning’ of your brain that has occurred from using, and take Suboxone properly, you can ‘extinguish’ that conditioned pattern of thinking.  THAT is the wonder of Suboxone– and the people that buy it on the street and take little pieces every four hours are missing that point completely.
And the nosy folks who get in your face about Suboxone are clueless about it as well.