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!

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’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!

Angry at Suboxone? Why?!

I received a nice message today in a comment section;  I am posting the message and the thoughts that it generated.  The primary topic of this post is the anger that is often directed toward the use of Suboxone.
The nice comment:
Hi Dr. Junig, my name is Jane XXXXXX. I have been reading this blog for a couple hours now, and have been searching the whole site trying to figure out how to email you. So far no such luck, and I hope you don’t mind me writing this to you in the form of a comment on a completely unrelated subject. Anyway, I wanted to thank you, sincerely, for the understanding and insight you’ve provided to so many people, myself included. I’m 19 years old and have been struggling to keep myself clean for the past several months. I’ve battled a heroin addiction since the age of 17, and in a way I feel that it’s grown into my identity as I’ve become an adult. That’s not something very many people can wrap their minds around, which seems to make a lot of the hard work that’s put into staying off of drugs go unnoticed, and unappreciated. I realize that the road to recovery is long, and one that you tread upon from the inside of yourself, not based on the recognition from others. However, I do believe that it helps a great deal to have someone in your corner. Thank you for all your help and for seeing that we aren’t just “addicts”, but people who have lost their way somewhere along the line, and for genuinely caring that we are now on the path to a better life. Please don’t stop helping, you’re doing a wonderful job!


My very long-winded answer:

Thank you very much for your nice comments! When a person makes comments, I receive an e-mail with the person’s comment and e-mail address—I always cringe a bit before I open the message, because usually it is usually negative and often nasty and insulting. That makes a note like yours even nicer to read!

I don’t know what fuels the anger of those who write mean things. I suppose some of it comes from the anger that some people have toward anyone who is a self-professed expert on the internet.  But the anger toward Suboxone…  I remember how horrible I felt during my actively-using days; I think of the friends I had from treatment who have since died from their addiction to opiates, knowing that Suboxone would have kept them alive; I see people in my practice who come in completely broken, and in as short a period as a month are human beings again… I would think that all addicts would be thrilled to finally have the pharmaceutical companies interest, whether or not they themselves used Suboxone!  But instead, the addicts who are sober through 12-step programs accuse people on Suboxone of being in ‘lesser recovery’.

I try to let go of resentments, as I myself am a ’12-stepper’ and I know that resentments are a pathway to using… but you probably read my negative remarks about a couple other web sites. There is an ‘institutional’ drive against Suboxone at the two sites I mentioned in my posts; through my alerts from Google I see daily posts from new visitors to those sites, asking about Suboxone; they receive a chorus of replies that are negative and inaccurate. They list side effects that I have never seen in my large practice, and that are often inconsistent with the known actions of buprenorphine (many people don’t realize that buprenorphine has been around for 30 years, and so it isn’t hard to recognize the posts that are simply making things up!). I don’t know what motivates the people there, but they have made it impossible to post accurate information about buprenorphine and Suboxone; they will simply delete posts they don’t like. I received an e-mail from someone at that would be funny if not for the misery that results from the practices there—the note started with angry expletives, and finished in a way that might be telling:

My way is the only way!
My way is the only way!

I’ve been clean and working with recovering addicts in my ministry for a long time.  God is pleased with me. I do what I do for His approval not yours.  If you don’t like me I can’t help that.  God bless.  And don’t you dare post my email address or we will have legal issues I assure you. I will turn you over to authorities if you post my email address online.  That is a promise.

Authorities? WHAT authorities? Anyway, you can see why it is so nice to get your kind message!

I suppose I should be at a meeting right now instead of getting worked up again… but I think instead I will make this a post that addresses the issue of anger at Suboxone (note—this is a classic example of addictive behavior— recognizing what one ‘should’ do but instead doing what one ‘wants’ to do. I am an addict, after all. One goal in recovery is to recognize one’s own addictive behavior and correct it) (note to the note: You just read a second example of addictive behavior—intellectualizing the problem as an excuse to avoid the correct behavior! See? Recovery CAN be fun!). The God note above seems to come from a self-righteous person who sees only one way to become clean and sober. I receive many similar letters, but my point with this one is that the person writing it has the power to screen posts at— which is why I see that site as potentially dangerous to an addict who is stumbling around looking for help, who may just stop taking his/her Suboxone in response to advice from some nut.

Most of the angry letters come from people who think addicts are weak or lack ‘will power’—who think that ‘addict as a disease’ is still a ‘concept’. Here is one of those messages.. I will leave the misspellings in it so that you get the full sense of the writer’s intelligence!:

I know a lot more about addictions then you think, I was or I should say I am an addict, once an addict always an addict the only difference is if you use or not. I choose not too. Your making excuses, and you get as defensive as the addicts I know there is no magic pill that will cure a drug addict,and if you have people using sub. instead of oxy what is the difference??? Nothing, except an addict can get suboxone from a doctor who thinks he is helping these people who will lie,steal and take down anyone and everyone in their lives to stop the withdrawals and get something wether it be suboxone or what ever is going around their area. No you don’t stop using insulin, but a diabetic has no choice they are diabetics no one offered them the option of would you like to have diabetics or not. Addicts have a choice and they choose to use. There was something troubling them in the first place or they wouldn’t have started using drugs period. Happy well adjusted people don’t use to the point of self destruction. Sure I would love to get a bottle of oxy’s when I am having bad times because they take all the pain away mentally and physically. No problems, just peace. Maybe I’m different then most but when I was taking oxy’s and I noticed I was having withdrawals I threw the rest of my pills away and haven’t touched one in years. So what you are saying is that even after the psychical withdrawals of pain killers the psychological addiction will be with you for ever?? Hmmmmm… That’s where therapy comes into play but then again I don’t know because I haven’t had any problems with drugs. I guess crack addicts should just get diagnosed with a.d.d so they can be a life long member of the addarall club. I know that’s different crack addicts are low lives and they are not the same type of people who use pain killers heard it all before. The truth is the truth if someone is using one drug to stay off another and the drug is an opiate or opiate substitute they are still using. Until a person can stand alone without any drug or substitute and until they can learn to handle life and all the ups and downs straight they will always be at great risk of falling back into their old habits. I have seen it time and time again and I ask why if the withdrawals are so painful do so many people take suboxone for a few months and switch back and forth from sub’s to oxy’s? The pain can’t be as bad as they claim or they wouldn’t go back and forth. That is just stupid and selfish. So anyway I guess I don’t have a clue so good luck to you and your practice.

Do you think he really meant that last part about ‘good luck to my practice’?

I also receive angry letters from people who see Suboxone as a threat to methadone. I try to remain neutral toward methadone; it wouldn’t be my first choice, but if it saves someone’s life, who am I to judge? I DO take issue with comparing buprenorphine and methadone as ‘one and the same’; partial agonists are not the same as agonists. When I hear the comparison, I make the point that if anything, buprenorphine is similar to an antagonist—like Naltrexone. When people leave traditional, step-based treatment programs they are sometimes put on Naltrexone as a ‘safety measure’ so that they know that even if they used, they wouldn’t get ‘high’. I have never heard objection to the use of Naltrexone, even from the most die-hard advocates of ‘total sobriety’. There are a couple problems with Naltrexone; one problem is that the person taking it has cravings for opiates. What if we took Naltrexone and added a small amount of opiate activity—not enough to get ‘high’, but just enough to prevent cravings? Another problem with Naltrexone is that it doesn’t last very long in the body—a person can skip a dose and then use the same day. What if we made Naltrexone longer-acting, so that it stuck around for three days? And what if we made it have a small amount of withdrawal, to make it less likely that the addict would stop taking it? If we did all of these things to Naltrexone—made it treat cravings, made it longer-acting, and made it create withdrawal when discontinued—we would have… Suboxone!

Darn Addicts!
Darn Addicts!

I receive letters from non-addicts;  some are genuinely dumbfounded over a person not being able to stop something that is so obviously self-destructive.  Many of the non-addicts who write clearly have anger left over from dealing with an addicted family member;  if some of those writers had their way,  anyone who meets criteria for ‘addiction’ would be put to death, or at least banished to some miserable place to live with all the other losers of the world.  I receive letters from health professionals in the mental health field who see Suboxone as only a band-aid over a neglected wound;  to those folks I say that Suboxone is always only part of the answer.  But I also point out that while I am a big fan of self-insight, ‘counseling’ has a poor record when it comes to treating addiction.  One-on-one counseling is often used by addicts to self-justify addictive behavior like I mentioned earlier– ‘yes, this is bad, but since I understand myself it will be OK’.  The best counseling or therapy for addicts is group therapy, so that addicts can call each other on their sh#@.

The remaining letters are mostly from addicts who are still in the learning process, ‘collecting research’ as we say at meetings. I see these people in my practice and struggle to help them, which is essentially the work of treating addiction. They still think that once they get past the physical withdrawal, everything will be OK. They want to take Suboxone just for a few weeks as a bridge to sobriety, but they don’t see any need for meetings or other treatment. When I tell them that the physical withdrawal is the EASY part, and that they will almost certainly return to using, they either become angry or tell me that they are ‘different from those people’—that unlike ADDICTS, they used only because of (insert pain, anxiety, depression, loneliness, unemployment, bad spouse, bad boss, bad weather, wrong season, bad parents, or bad children). They tell me that they have ‘fixed’ the problem, so everything will be fine. They don’t yet understand that the addiction is both ‘chicken’ and ‘egg’—that they use because of their problems, but more importantly they have problems because they use! I tell them what happens in ‘late-stage addiction’: the addict hates using so much that he/she will be able to get through withdrawal; while sick, the addict will remember that hatred of using and use the hatred to stay clean… but as soon as the sun comes out and the withdrawal passes, the addict returns in full force and uses again. This stage of addiction is particularly demoralizing (been there, done that) because the addict is almost always sick; it is also a time of intense emotional ups and downs, big hopes and promises to self and others, periods of relief… and then regret, secrecy, broken promises, anger, shame, and disgust. Spouses say “how COULD you?” Addicts feel like they are going crazy. Enter loneliness, self-disgust, despair… no wonder suicide is so common in late-stage addiction.

Before Suboxone, a few of the people who reached the point of despair would find Recovery through treatment and/or the steps. Now, with Suboxone, we can save many, many more addicts, often long before they reach such misery. Is Suboxone perfect? Of course not! What medication is perfect? It did not come with a ‘cure’ attached. Too bad, so sad. But what a huge step forward it represents! And I am thrilled that Suboxone has caught the attention of capitalism, because suddenly the bright minds in Pharma see that there is MONEY to be made treating addiction. Build a better mousetrap—invent BETTER medications! And the company that finds a treatment that gets to the core of addiction will deserve the huge profits that will come their way.

I had better stop and get back to my ‘real’ job! But thank you, Jane, for your nice comments, and for sparking this morning’s post. I wish you all the best in your own recovery.


Suboxone and Anesthesia; Suboxone vs. 'Recovery'

Yes, I have changed blog platforms again… hopefully for the last time! I spent the past few days learning to use the self-hosted WordPress platform. After reading the instructions about uploading the program using FTP (no small task for non-techies like me) I went to my GoDaddy hosting account and found that by clicking a couple buttons it automatically installed for me. Since then I have discovered the different WordPress templates available, the widgets, the plug-ins… cool stuff!

But back to Suboxone. One of the questions on today’s keywords was ‘Suboxone vs. Recovery’– I won’t go into that at length now but will direct interested readers to my article at, where I give some thought to the different things that happen to personality when an addict takes Suboxone vs when an addict goes through traditional step-based treatment. The article is on one of the last pages of that web site.
Another keyword question was ‘Suboxone and Anesthesia’.
As you may know I worked as an anesthesiologist for about ten years before my career was skewered by my opiate addiction.  I still miss the job, but it probably wasn’t good for me… I joke that my arms were getting sore from pushing around that wheelbarrow full of money!  It certainly paid very well, but more than that I loved the feeling of power and control that comes with supporting a patient during surgery, or from totally relieving the pain of a woman in labor.  Anesthesiologists are always heroes in the hospital.  Some patients don’t know just how important the anesthesiologist is, but the nurses and surgeons certainly do.  I felt like a cowboy, as I raced in from home to secure the airway of a 13-y-o boy who had hung himself and whose neck anatomy was swollen and distorted… or as I ran down the hall to the operating room just ahead of the stretcher carrying a woman whose uterus had ruptured as she labored with her tenth kid.  I still vividly remember standing in the middle of the road at about two AM, after we saved the mom and baveby in that case.  It was snowing, and the city was asleep and very quiet, and as I looked at the dark windows of the house down the street I thought that I was the luckiest man in the world to have such a job.  A few years later the job was gone, and my feelings of power were challenged every day as I came to terms with all of the changes in my life– I was doing physical exams for a fraction of my old salary, the weekly dinner parties came to a halt (in seven years I haven’t been invited to a single one of the houses that I used to go to on a monthly basis), two close friends were dead (one a surgeon who committed suicide and the other Commander Shanower killed at the Pentagon on 9/11), our vacation cottage that the family loved was sold to pay the bills…
I didn’t intend to go down this path.  These thoughts used to be very painful for me, but now I can reflect and almost smile.  I see people in my practice who are facing changes in their lives, and it is nice to know what the situation feels like so that I can understand them.  I can also say with complete certainty that one cannot predict what the future holds, particularly when one’s view is colored by depression or other psychiatric symptoms.  I can also say that if an addict stays clean and works a recovery program, good things will ALWAYS happen.
Anyone interested in my personal story by the way can watch for a book that I am writing called ‘Terminal Uniqueness’.  I am trying to decide if I should post it on Twitter as I go or just wait until I am done.
Suboxone does not interfere with MOST anesthetics.  An anesthesiologist has a number of choices of general anesthetics (regional anesthetics using local anesthetics injected into areas to make things numb are not affected by Suboxone either).  A couple examples– one can do a ‘gas-based’ anesthetic where inhaled agents cause amnesia and anesthesia, or one can do a ‘balanced anesthetic’ using combinations of opiates and other IV medications, perhaps with smaller amounts of a gaseous agent as well.  Suboxone WILL block the opiate portion of this anesthetic, but there are plenty of other agents to use to replace the opiates.
The main problem comes after the surgery in the recovery room, when Suboxone prevents morphine, demerol, and other medication from controlling the surgical pain.  One of my patients had an emergency C-Section shortly after dosing with Suboxone and it was difficult to get her pain under control.  Eventually she was transferred to the ICU for close monitoring as they gave her huge doses of morphine– which eventually controlled her pain.  Some surgeries will be of a nature where injections of local anesthetic can provide considerable pain relief for up to twelve hours.  This is a particularly good option for procedures on the extremities.  Sometimes an epidural can help a great deal with pain control after abdominal procedures, or even chest procedures.  In cases where opiates need to be used, the dose will usually need to be surprisingly high, at levels where nobody will be comfortable unless the patient is continually monitored for respiratory function in a step-up unit like the ICU.

I have helped six or seven Suboxone patients through the surgical process and for the most part they have done well.  Stopping Suboxone for three days prior to surgery will make pain control much easier after the surgery.  Even if sufficient time has elapsed to get rid of the Subxone, though, the person will still have a much higher tolerance than patients not on Suboxone, so I strongly recommend discussion the fact that you are on Suboxone with your surgeon and your anesthesiologist.  If you don’t, they won’t know what is going on, and won’t be able to take the proper steps to help you.
Like my style?  Consider TelePsychiatry!

I'm Not Like 'Those People'

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