Tag: Suboxone Forum

Part of my story; part of my book

I’m often asked “hey, what is YOUR story?” That opens the door to a long, drawn out presentation… or I’ll just say “I have a book about the subject ready to go– do you know any publishers?” I DO have a book ready to go, by the way… and I welcome any e-mails from people with ‘industry connections.’ The book is about my story, of course, but is also an attempt to examine ‘addiction’ in a way that provides greater understanding of the condition. A family member of an opiate addict will understand addiction better after reading the book, for example. I also talk about Suboxone quite a bit. In fact, readers of this blog will know how the book goes, as the book is a reflection of this blog. In some chapters I share comments from other addicts, and use my responses to their letters to make a point or two. My goal while writing was to discuss opiate addiction and buprenorphine using what I learned about the mind and brain while getting my PhD in Neuroscience, using insights from my experiences as an opiate addict, and using what I have learned as a doctor and psychiatrist. My perceptions were also influenced by my experiences in residential treatment, aftercare, recovery, working as med director of a treatment center, and my own psychodynamic psychotherapy.
This post is a ‘teaser;’ I will share the first part of chapter one here, and you can finish the chapter at SuboxForum, at this link. I hope you like it– and if you know a publisher or book agent, please send me an e-mail– you can go to my private practice site and just send it from there.

My Story

Nature vs. nurture
I grew up in a small town in Wisconsin, the son of a defense attorney and a teacher. I was the second of four children. I will not get into a drawn out psychodynamic exploration of my upbringing at this time except to note that I firmly believe that the way I ultimately turned out is a result of a combination of genetic, developmental, environmental, and personality factors. There were probably elements of my early life and also genetic factors that predisposed me to become an addict, but I believe that each person can point to similar predispositions. I am the one responsible for how I used the gifts and liabilities that shaped my life.
The nerd
I was a very cheerful young child, but at some point I began to struggle with social interactions. By the time I was in high school I was clueless about fitting in. The things that seemed impossible back then look easy now; why didn’t I simply look at what other kids were wearing and imitate them? That idea never entered my mind, and I cringe when I see pictures of myself at that age. Why did I think any boy should enter a school with embroidered blue jeans?! I did well with the academic aspects of school, always scoring at or near the top of my class with little effort. There was little respect for academic achievement in my rural high school, and I blamed my academic performance for at least some of the harassment directed my way. By the time I was a sophomore I was literally afraid for my own safety on a daily basis. I had several incidents where I was facing bullies, my back against a wall. I was deeply ashamed when the bullying occurred in public, and I certainly didn’t want my parents to know that it was happening. I was physically beat up on two occasions, both times accepting the blows with no effort to fight back or defend myself. The clear message from my father was that real men do not run away from a fight, and so running was not an option. But I didn’t know how to fight back, and was afraid that if I tried I would only be hurt worse, so the outcome of my ‘don’t run’ strategy was not great!
I ‘tried on’ different personalities during my last two years of high school. I became a druggie, growing my hair long and replacing the smile on my face with a look of apathy or disgust. I sported an Afro and used a pick instead of a comb. I smoked pot and drank beer when not in school. The changes worked as intended, and the harassment from other students stopped. But I was still on the ‘outside looking in’. Some people who lack social skills seem to come to terms with their unpopular position and quit trying. That wasn’t me; I continued to try to be one of the popular kids, kissing up, tagging along, and laughing at the stupid comments of ‘jocks’… Yuck! During my senior year I joined the cross-country and track teams, and in retrospect I was fitting in at the time without even realizing it. But by my high school graduation in 1978, the year when marijuana use peaked in the United States, I was a daily pot smoker with a great GPA, little confidence, and no direction in life.
I attended the same liberal arts college that my older brother was attending mainly because that was easier than finding a college that I liked more. I took the courses that were the most interesting and ended up majoring in biology. College came very easy to me because I had a genuine interest in what I was learning. Everything I learned seemed to answer a question that I always wondered about. That is, by the way, is a great way to attend college!
I was in a couple of relationships in college that in retrospect had addictive traits to them. After a difficult breakup during my sophomore year I became very depressed, and afterward spent several months engaged in the heaviest drug use of my life. My fraternity house provided ready access to pot, opium, cocaine, Quaaludes, marijuana, LSD, and hallucinogenic mushrooms. I wonder if I carried so much anger under the surface that I had a ‘death wish’; I have hazy memories of walking on a ledge seven stories up, losing control of a motorcycle and ending up in someone’s front yard without wearing a helmet, and wandering around in tunnels under the streets of Milwaukee after climbing down a manhole. I was lucky to survive those experiences, and I now try to understand similar behavior—extreme risk-taking and impulsivity—in addicts who are patients of my practice.
Local hero
Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since. During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks. I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic! To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy. But then I realized that something was fast-approaching in the current. I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight. I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling. I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her. After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!). To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”
I am grateful that I was given the opportunity to be a hero. There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God.
Getting serious
Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York. After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program. I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school. My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.
Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways. His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after. After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country. Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’. But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.
Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home. At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.

Junig as anesthesiologist at Suboxone Talk Zone
A stage of my life

Treating myself
In the spring of 1993 I took codeine cough medicine for a cold. A few weeks later I was still taking the codeine each evening. It worked so well; finally I could relax and get some quality sleep! I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word. I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated. I had ALWAYS accomplished what I set out to do! By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed. The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings.
I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all! Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said. “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.” I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well?
As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine. After trying to find will power and failing over and over, I finally ‘got it’; I had no control! As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day.
Continue…

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 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

THIS is the last time….

My computer expert ‘JJ’ added something interesting at the forum; now you can comment directly on anything from the blog in a ‘give and take’ fashion. It is at the bottom of the page at suboxforum.com. I also want to thank those who signed up; over 30 new people in the past 24 hours!
One last thing… please don’t hesitate to share your knowledge. The best way to share is to emulate an NA or AA meeting, where one will give advice by describing his OWN experiences. For example instead of saying ‘you should…’ people say ‘I don’t know if this would work for you, but in my case I found that….’ A small distinction, but the sort of thing that makes others more receptive to your ideas.
Again, thanks everyone,
Jeff