Thanks!

Every now and then I will receive a donation fo the site. I don’t receive any support other than Google adsense revenue, which as most webmasters know brings in only a couple bucks per day with a web site this size. So donations are very much appreciated. Today I received a donation in the mail, in the form of a money order. There was no return address, so I have no way to thank the person– other than through this post. Thanks!
I AM looking for a way to pay for upgrades for the blog and for the forum; I am looking at funding opportunities through NIDA, SAMHSA, or pharmaceutical companies, but to date have not formally applied for a grant. If a reader would like to be listed on a ‘supporters’ page, either by name or by listing the name of a business, please send me an e-mail at [email protected] . If I ever do receive support from pharma or other industries, the support will be disclosed openly.

Tapering off methadone– bupe or no bupe?

A quickie question from a youtube viewer:
hiya– Wondering if you could tell me if this is a good idea. I’m almost at the end of my taper from methadone from having addiction to oxycontin. been on methadone coming up on 2 years and I’m taking 8 mg a day. and was thinking of asking my doctor to switch me over to Suboxone when i get down to 2 mg, use suboxone 2 or 3 months to help with the methadone withdrawal, and then taper off the Suboxone.
My doctor brought up Suboxone to me whe n i was at 30mg, but I didnt know anything about it, so I dismiised it. Now i hear its a better treatment. Any advice would be helpful. I want off methadone very bad, I’m just nervous about what comes at the end. I have to continue working– cant take much time off work– and cant afford to lose my job. I was hoping Suboxone might be the answer for me.
My subtle answer:
OH MY GOD, NO!! If you are at 8 mg, you are in the home stretch!! Bupe would be like going back to 30-40 mg of methadone– and bupe is very hard to taper because of the odd ceiling effect and high potency. Some day we will have a neat way to use buprenorphine as a tapering tool; things that would help would be a much lower amount of buprenorphine in a pill that is the same size or even larger, or perhaps an injectable product that slowly dissolves, allowing the blood level of buprenorphine to slowly decrease. But using what is available today, you would need to take a tiny, tiny fraction of a Suboxone tablet in order to take a dose equivalent to only 8– let alone 2– mg of methadone. You would literally need to take about one hundredth of a tablet! Remember that buprenorphine is a ‘microgram’ medication; a dose of 50 micrograms is quite potent, and one tablet contains 8000 micrograms!
I will frequently mention that it is a mistake when people assume that the tapering is the hard part. Yes, it is very hard– but the hardest part is staying clean AFTER the taper is done. I suspect that is what is going on in your mind now; you have done so much good work and come so far, that the ‘addict inside’ is suggesting that you deserve a break at this point. You DO deserve a break– but you just cannot have one. At least not THAT kind of break– and as you know, it wouldn’t even be a break for very long anyway. If you took a quarter of a tab of Suboxone, you would get a significant opiate ‘buzz’ from it, and then you would feel horrible– you would feel trapped, guilty, ashamed… and as the effect wore off, the withdrawal would seem worse than it has felt for months. You would have a very strong desire to take another piece of Suboxone, and then you would be ‘on Suboxone’– and back at the tolerance level that you were at weeks ago. All that work would be for nothing!!
Don’t get me wrong– I believe that most people are best off just staying on buprenorphine. And if you cannot stay clean, then by all means consider using buprenorphine long-term. But if your intent is to get off opiates completely, taking it now would be a huge step backward.
As for worrying about ‘what happens at the end’– there is no big drop-off at the end of a methadone taper. With buprenorphine, there often IS such an effect because people ‘jump’ from 1 or 2 mg when they still have significant tolerance level. But when you are down to 2 mg per day of methadone, you are home free as far as withdrawal goes. In fact, you are pretty close right now at 8 mg of methadone per day.
I have to plug my ‘product’– a set of recordings that includes a recording about staying sober after Suboxone. The tapes are at a site appropriately called ‘sober after Sub’. But I can share the ‘gist’ of it: You want to fill in the empty space once occupied by all that addiction activity– find a new hobby, get another job, fall in love (don’t get married or have kids for a year or so), get interested in school– something. Start exercising and taking an interest in your physical health. Challenge yourself as much as possible to do the RIGHT things (don’t learn how to surf on the hood of a car– learn how to surf for real). Do things you never saw yourself doing. Staying clean involves CHANGE– and change is very hard to do, because everything that you do that is true ‘change’ will feel uncomfortable and awkward. Never act in a play? Then act in a play. Consider yourself athletic? Then do more reading. Use paper? Then start using plastic!
And most important, respect the rules that everybody else respects but that addicts tend to think are ‘bogus’ and don’t apply to them. If the medicine bottle says ‘take one tablet’, take one tablet– unless you call your doctor at an appropriate time and explain why you think you need two of them. And if the doctor says no, you do what the doctor says. Always. In AA they talk about ‘rigorous honesty’– knowing that addicts and alcoholics are all BS, all the time. DON’T LIE– and if you do, apologize and get back to honest behavior. Relapse occurs WAY before the using resumes; it starts when the addict starts cutting corners again, and starts thinking that he or she is ‘special’. After all, ‘special’ people are the ones who get to do what THEY want, and using is entirely self-centered.
Enough lecturing… You are rocking, so don’t lose your momentum. Check the folks out on Subox Forum and tell them how you are feeling; maybe help some others follow in your footsteps. Be proud of the work you have done.
Take care, and good luck,
JJ

Reckitt-Benckiser's 'Here to Help' Program– What do you think?

Reckitt-Benckiser, the first (but surely not last) manufacturer of orally dissolvable buprenorphine sold under the brand names Suboxone and Subutex, has been aggressively pushing doctors to refer addicts taking buprenorphine into a program called ‘Here to Help’ that they promote as something that will keep patients compliant with buprenorphine maintenance. Regular readers of STZ know that I have not been impressed by Reckitt-Benckiser over the years, and so I’m not going to just jump on the ‘here to help’ bandwagon unless I see value in the program for my patients. I have referred SOME patients to the program, but the feedback I have received has not been positive. Patients have told me that they receive confusing or conflicting information, or that the person on the phone seemed ‘scripted’ and not responsive to the person’s specific needs, or that the information they were given assumed a knowledge level below what the patients already had.
Why am I unhappy with R-B, you ask? If you go on the web site of any pharmaceutical company– from the smallest, like Dey Pharmaceuticals, distributor of the MAOI patch called Emsam, to the large companies such as Pfizer– you will find a section with procedures and applications for grant support for unrestricted educational programs, investigator-initiated trials, or other purposes. Little Dey Pharma has released tens of millions of dollars for community educational projects. Pfizer provides hundreds of millions of dollars for similar purposes. But try to find a similar web site for Reckitt-Benckiser (the Suboxone division) — let alone any contact info for grant applications! I have tried for several years to simply get the name of a person to speak to about financial support to expand my efforts, and the result is always the same? I will receive a phone number of a low-level sales manager who tells me ‘he (she) will look into it and get back to me.’ I’m still waiting. I would like to apply for assistance for what I do best– educate addicts about opiate dependence, and educate physicians about how addicts feel about treatment and about what their doctors are missing. I would also like to create a program to address the internalized shame that most addicts on buprenorphine continue to struggle with, no matter how long they are away from active using. I won’t go into specifics here, but there are so many things that could be done—that SHOULD be done. I know some of the things the company spends money on; I resent that they do not see the value in my efforts. And I am annoyed that they don’t even have an application process that would allow them to at least pretend that they are interested!
There are so many ways to become involved with buprenorphine; there are organizations like SAMHSA and CSAT and others that provide education and research into the use of buprenorphine. I was a ‘mentor’ for physicians with new buprenorphine practices for a short time and I have considered becoming active in SAMHSA or the other agencies. But if find those types of organizations to be inefficient compared to what I can do speaking to addicts directly, through the blog or forum. I also know where my strengths lie, and where they don’t. I do not do well as a ‘consensus builder’, for example—such people must be careful about what they say, whereas I tend to say what I am thinking. If a meeting is running long because someone is repeating how much he/she wants to do the right thing for all of these poor addicts, I am the person who will stand up and say ‘y’know, that is a given—and this is all a massive waste of time.’ And then for some reason I won’t get invited back again! Those meetings are not for me. My favorite recovery ‘saying’ is ‘a good man knows his limitations’—and that is one of my limitations. My strength comes from the fact that I understand how opiate addicts feel, and how they think. I always seem to know what an opiate addict is going to say next. On the other hand, I never have any idea what a government bureaucrat is going to say, or what I should say when speaking to one!
I suspect that R-B would like me to get on board the Here to Help message. But I have reservations about the program. I suspect, for example, that it is primarily being supported by R-B in the hopes of somehow using it to maintain their ‘brand’ over buprenorphine. If that is their intention, good luck to them– it is going to need some awesome content to keep people buying Suboxone for $8 when generic Subutex is selling for $2.55 at Walgreens!
Today I received a brochure describing the results of a ‘study’ that claims that patients in the ‘Here to Help’ program had improved compliance as measured by maintaining appropriate use of prescribed buprenorphine. As some of you may know I got my PhD in Neurochemistry doing basic science research and I have served as a Peer Reviewer for Academic Psychiatry for a number of years, so I know how to evaluate whether a study is ‘sound’ or is instead misleading. Even in the material that I received today, R-B refers to the findings as coming from a ‘quasi-study design’—so they at least apparently recognize that the findings are biased. I participated in the data collection for the study, actually; those of us who participated would invite new patients to participate, and the patients who accepted the invitations would then be randomized so that one group would get the ‘here to help’ info and the other group would not. R-B found that the here to help group had better compliance and fewer drop-outs than the other group. One problem I have is that I don’t know what they did for the ‘non-study’ group. For example if they told the non-here to help group ‘Suboxone will kill you if you keep taking it’, then the difference in compliance would be meaningless! I’m sure they didn’t say that, but what DID they say?
Second, there was no way to ‘blind’ the study on either side—both the addict and the phone person knew which group the study person was in. We like studies to be ‘double-blind’, and this one was not even single-blind.
Finally, participation in the study was voluntary, and we don’t know anything about the factors that caused some people to enroll and others to avoid enrolling. Let me explain how that bias could have affected the results. Patients were paid to participate in the study, so I would guess that the addicts who were unemployed were more likely to participate. Likewise, the addicts who were, say, executives from a high-profile company or physicians or attorneys would be less likely to participate, as they would be more concerned about disclosure of their status as addicts. So at best, the ‘here to help’ study looked at a specific subset of addicts—those who were interested in making $100 by talking on the phone for a half hour. Would the here to help program be of any value for a person who is still working, making good money, who has not suffered many consequences yet? We don’t know.
So… I am interested in your feedback. Have any of you used the ‘Here to Help’ program? If so, what do you think about it? If you have NOT used it, why not? Did your doc tell you about it? Leave your answers in the comments section—you do NOT have to leave a real name, and I will not use your e-mail for anything (it does not get displayed in your comment either). Your comment won’t show up immediately; for spam purposes I will approve the messages as I receive them. But here is your chance to let RB how you feel about that program—or about anything else, for that matter. Will you use the generic, or stick with the brand? Why or why not? Leave your comments and I will be sure to send them at least as far up the chain as I can reach!
Finally, I continue to ask for your support. I note that our forum is over 1500 registered members strong and growing; the older forum supported by R-B has about 200 registered members. You must know that your presence just warms my heart! If you have some money to spare and want to join me in my efforts (a pipe-dream of mine!), let me know and we will truly do some good things out there. Lest anyone thinks I’m getting rich from this, I have received 3 donations of $50 over the past few years, and a few of $5-$10. That’s it. And that’s fine—I just don’t want y’all to think I’m cleaning up with this blog. Maybe I should start posting each donation—leave a comment if you have an opinion on that as well! If I help you out or if you care to support my typing away on the blog, or help with the self-publishing of my eventual ‘big book,’ a small financial donation is always greatly appreciated.
The main thing you can do to support me is to spread the word. Send my links to anyone you know who takes buprenorphine– links for the blog, and for the forum too. Better yet, print out the link and give it to your doctor and tell him that you like it (if you do!).
Got all that? I suppose I could have just typed ‘what do you all think about the here to help program’ and gone to bed an hour ago! As always, thanks for reading. And I wish you all the best at keeping the scourge at bay.
JJ

Chat with me

On Wednesday, 4/29 I will be at suboxforum.com for ‘live chat’ from 7:00-8:00 PM, US Central Time. If you are out and about on the internet, stop by and say hi. I don’t have a specific topic, so if you have any questions for me, bring them along. Just go to the bottom of the page at SuboxForum.com and click on the button that says ‘click to join chat’. If you haven’t registered, you will have to do that first– but there is no charge. You can edit the preferences for your account so that you will either receive or not receive e-mails that I send out; I have sent out 3 mass e-mails in 3 years, so you won’t get flooded with them! I am thinking that I will use the e-mail function to send out announcements before similar chat sessions in the future, say if I get a ‘special guest’ or have a specific topic to talk about. I will NOT give or sell your e-mail addresses to someone else; doing so would go against my principles, plus I would have no idea how to find someone who would even want them!
I hope to see you there. One last thing… we have never tested the chat function out before. So if it doesn’t work– if you go there and click on it and find yourself in a room all by yourself– I’m really sorry! I have tested the ‘click’ button, and that works great… I just haven’t ever tried to go there when someone else was available to chat with me! Again that’s Wednesday, two days from tonight, at 7-8 PM Central time.

CHAT now on SuboxForum.com

My computer-genius friend JJ has added chat to SuboxForum.com; Someone go over there and try it and see if it works! I just tried it myself, and it works fine when I was chatting one-on-one with myself…
All of this is a work in progress. If anyone has ideas for the blog or forum or anything else, please let me know– [email protected] is my ‘idea line’. You will note the RSS feed at the bottom of Subox Forum; you can use that to follow the new posts using Outlook or Google Reader or any of the other newsreaders out there. There are also now RSS feeds directly from this blog and from other blogs to the forum, allowing the easy posting of comments to the blog posts or to other comments.
Stay tuned: there are still a few ideas up our sleeves… but in the meantime consider clicking on the chat section and leaving it open when you are on the site– that way it will let other people know you are there in case someone wants to say ‘hi’.
SD