The point of addiction treatment

I worked for several years as the medical director of a residential treatment center in Wisconsin, leaving the position several weeks ago.   On my last evening in the place I took a moment to look around and think about how addiction treatment has changed in the past decade.  I looked at the pictures of the patients in their charts, who were mostly in their late teens or early 20’s.  The most common class of ‘drugs of choice’ were opioids, including oxycodone, heroin, methadone, morphine, and hydrocodone.  I thought about the different but similar program that I attended ten years ago, filled mostly with addicts and alcoholics in their 30’s and older.  I wonder if Bill W would have come up with the same twelve steps, had his target been not 50-year-old alcoholics, but teenage heroin addicts!

On the walls around me were posted sheets of paper, and on them were lists of ideas from a brain-storming session about how to remain competitive in the modern era of addiction treatment.   I scanned the 20-some pages for mention of buprenorphine, and found the medication mentioned only once, under ‘challenges.’  On the other hand there a number of ideas related to marketing, endowment funding, and public image.  What I saw in that room essentially summarized the problems with traditional treatment in an era of buprenorphine.  It also validated my decision that it was time to move on.

When I was an anesthesiologist I went through a period of frustration over the American Heart Association’s ACLS treatment guidelines, or more specifically over how they were implemented by the hospital where I worked.  The guidelines provide easy-to-remember steps to use when treating victims of cardiac arrest.  As an anesthesiologist, my education and training taught me to think ‘physiologically;’ if my patient on the OR table went into cardiac arrest, my training allowed me to quickly decide the likely cause, the appropriate medication for that problem, and the proper dose of medication based on body composition, patient age, other medications, medical history, fluid balance, etc.  ACLS guidelines were not initially devised for anesthesiologists, but for paramedics and other medical professionals who had less critical care training and experience.  To keep things simple enough to remember, the ACLS guidelines provide general medication and dose recommendations based on averages, not tailored to specific conditions or patients.  The dose of epinephrine listed in the protocol is 1 mg, whether the patient is a 20-y-o male athlete or a 95-y-o woman.  That dose may or may not be appropriate for either a 20-y-o or a 95-y-o–  but it is certainly not the correct dose for both!  But that’s OK, because we were just talking ‘guidelines,’ not hard and fast rules.

The problem began when nursing educators started teaching ACLS classes not only to paramedics, but to physicians as well.  I attended those classes—I had to, just as most physicians who are part of networks are required to do every three years.  In most courses I attended, physicians who asked about optimizing doses based on patient characteristics were told to stick to the algorithm so that people didn’t get confused.  The result, of course, was to dumb down the classes, and to dumb down the people taking the classes.  The issue comes down to whether to trust that individual doctors will be able to think and get it RIGHT, or to assume that they will get it wrong and therefore give them easy-to-memorize instructions.  I could go off and extrapolate to modern society as a whole, but I’ll try to control myself!  The problem with telling docs to avoid thinking and to instead just follow the protocols is that the guidelines are SO generalized that they almost guarantee failure.

Successful resuscitations are relatively uncommon, making it difficult to come up with treatment guidelines that are clearly good or clearly bad.  Over the years, ACLS guidelines have changed in drastic ways.  Some interventions recommended as beneficial were later found to make things worse.  It is hard enough to decide if standardized, dumbed-down guidelines are beneficial, so you can imagine how hard it would be to determine if a single doctor’s care was good or bad.

What I took issue with was the push for consistency, and the effect of that push on patient care.  After a cardiac arrest and resuscitation in the hospital, the chart was reviewed by quality assurance and by a committee that included the people who taught the ACLS courses.  No problem so far.  But if a doctor deviated from the ACLS protocol, things got silly.  The doctor would be asked to provide reasons for deviating from protocol, including support from the literature for the deviation.  But the literature focuses on whether the ACLS protocols themselves are of any value, so there are few studies of non-ACLS approaches.  There are no studies of the effects of using 750 micrograms of epinephrine instead of 1 mg in a cardiac arrest in a 54-y-o man on beta-blockers, having hernia surgery, who is slightly dehydrated and has a history of mitral stenosis!

Initially the ACLS protocols were designed to help people with less knowledge of physiology provide adequate treatment.   But over time, the protocols became the final authority on treatment.  So if a patient with an intelligent physician has a heart attack in the cath lab, the doc now has to make a decision.  Is the doctor going to give medications and doses of medication specifically geared toward this one patient—and then be hung out to dry by the hospital QA department (which is run by nurse educators who don’t understand this issue)?  Or should the doctor just turn his brain off and follow the ACLS protocols, guaranteeing that there won’t be any calls for explanations?  The irony is that a doctor who never successfully resuscitates a patient will never run into trouble, provided that the ACLS algorithms are followed—he/she may even get an award!  But the doc who saves an occasional patient by THINKING and figuring out the perfect treatment is likely to run into all kinds of trouble!  If you were the patient with that smart doctor, and you were facing low odds of survival, would you rather have the standardized, one-size-fits-all approach that rarely works?  Or would you want your doc to risk getting written up by using the new medication that he read about that he thinks would fit your condition, but that isn’t on the protocol sheet?

How do we get back to addiction treatment?  About 100 years ago some people came up with the twelve steps.  I don’t know the history of early AA as well as many, but the steps were devised for the patients of the time, who were mainly middle-aged alcoholics, mostly Caucasian, and mostly male.  The steps have stood the test of time, and are now applied to many different substance addictions, and even to non-substance disorders such as eating disorders and pathological gambling.  Do they work for those conditions?  Sometimes.  Like cardiac arrests, the conditions treated by the twelve steps tend to have very low success rates for ALL treatment strategies, so the steps don’t have to work very well to be as good as anything else.  I have great respect for the twelve steps, but some have imparted them almost magical qualities that can be used to fix anything!

Some addiction treatment centers are fixated on the steps not as a treatment tool but as a special entity, so that they seem to favor ‘purity of sobriety’ over saving lives.  As a fan of the steps myself, I too see ‘sobriety’ in a biased way, making it all the more difficult to describe this concept.  Bear with me—maybe my point will be clearer if I ask a few questions.  I encourage you to come up with your own answers, and to discuss this topic at the forum.

What is the point of treatment?  When a patient enters a treatment program, how should them measure success?  If everyone is hugging each other and going to meetings at the end of 30, 60, or 90 days, is that enough?  If 85% of those ‘successful treatments’ are using after one year, should the treatment center feel good about the job they are doing?

At the forum, we try to avoid discussions about ‘who is more clean’ because there really is no answer to the question.  Today I surfed past a silly TV program where the Real Housewives of New Jersey were divided into two groups, arguing with each other over who was meaner, who lied first, who said what to who… all shouting over each other.  Do they really think that one side will ‘win?’  That’s how I feel about ‘who is more recovered’ arguments.  And I am gratified that most of the discussions at the forum show far more class and intelligence than that particular topic!  My questions here are not intended to go down that path; these questions are to make the point that there are bigger issues than ‘whose recovery is better.’
Which of the following outcomes should a treatment center prefer?  Patient A leaves treatment totally free of all substances after 30 days of a 30-day program. He enters a halfway house and leaves after 90 days, still clean.  After six months he stops attending meetings.  Three months later his friend from his home town pays him a visit, and after drinking a few beers and taking a couple 80’s for old time’s sake he dies in his sleep.  Patient B leaves treatment after 21 of 30 days and against the counselors’ advice finds a doc who prescribes buprenorphine.  After a month on buprenorphine he takes a couple 80’s with an old friend, and doesn’t feel anything from taking them.  The next month he takes an extra buprenorphine tab every now and then, so that he runs out early.  He doesn’t call his doc, and instead gets sick for a day or two at the end of the month.  He even takes some methadone to ‘treat’ the withdrawal, but it doesn’t really do anything.  After four months he has talked to his doc about these things several times, and is starting to get used to—and enjoy–not feeling high.  At eight months an old friend visits and gives him a couple 80’s.  He knows that they won’t do anything, so he passes on them.  Or maybe he is having a rough day and he gives in one last time—but they don’t do anything.

I am not implying that a patient necessarily does better with buprenorphine (although I do think that it is the case that patients do better with buprenorphine!).  My point is to show two types of ‘recovery,’ and to ask, which patient of the two is doing better?  MY answer is that the second person is better off, because he is ALIVE.  I would think that most people would agree—that it is better to be alive than dead.  But some of the attitudes I have witnessed among traditional counselors make me think that they are so intent on a twisted version of ‘perfection’ that they would feel better about the first patient!  I was speaking with the CEO of a hospital recently who said that if hospitals had a 15% success rate for other diseases, they would be viewed as dismal failures.  But in recovery, there seems to be an attitude that the failure rate is acceptable—as long as someone lives.  I hope that buprenorphine prompts movement toward a new paradigm where it is no longer acceptable, accepted, or ‘a given’ that many people die.

The steps were designed, in my view, with the help of divine intervention.  They sometimes offer the gift of sobriety to a suffering alcoholic who has reached rock bottom.   There have been attempts to use them to achieve sobriety from other substances, including opioids, and they sometimes help a desperate opioid addict.  But it is much more difficult, and rare, for a teenage opioid addict to accept ‘powerlessness’ than for a jaundiced, middle-aged alcoholic to do the same.  Like the ACLS algorithms, the steps are a ‘one-size fits all’ approach to treatment.  Like the algorithms, they can be a valuable tool.  But for both the algorithms and the steps, the point should NOT be on the purity of the treatment approach; the point should be whether lives are being saved, and whether an imperfect approach that uses out-of-the-box thinking might save a few more.

The REAL challenge facing traditional treatment centers will be to let go of their old ideas of ‘perfect sobriety’ and to use the treatment tools that have the best chance of keeping addicts alive.  Doing so should not be that difficult;  all they need  do is look at the faces of the young addicts entering their programs, and ask themselves, honestly, how many will be alive after a few years?  The honest counselors at traditional, non-buprenorphine programs should be humbled, and even ashamed, by what they know about those numbers.

Why will power doesn’t work

For those of you who prefer watching to reading, here is a video with a few thoughts about why will power is NOT any kind of strategy for staying clean.  As I describe, believing in will power is not only unhelpful;  it even INCREASES one’s chance for relapse, and serves as a frequent justification for the using that leads to full-blown relapse.  Please share comments at SuboxForum.com.

Buprenorphine and the Dynamic Nature of Character Defects

What follows is a lightly-edited version of one of my posts from a couple years ago.  I still think that this is a good model for understanding the actions of buprenorphine.

Buprenorphine and the Dynamic Nature of Character Defects

‘Suboxone’ and ‘Subutex’ are the trade names for medications that contain buprenorphine, a substance used to treat addiction to pain medications and/or heroin.  Buprenorphine treatment for opiate dependence has been an option in the US since 2003.  Other treatment approaches for opiate dependence have been used for decades but have had limited success.  With a little imagination, treatment approaches can be placed on a continuum depending on the degree to which the treatment demands changes in the personality and behavior of the addict.  Methadone maintenance is often described as a means of ‘harm reduction’ by preventing the behaviors related to the obsession for opiates or by reducing intravenous use of heroin or other substances.  At the other end of the treatment continuum there are the step-based and other Recovery programs.  One limitation of programs that demand personality change is that such change is difficult and rare, and usually only occurs after a significant amount of despair has been experienced by the addict.  Opiate dependence differs from other addictions in the lethality of overdose, and the fatality rate of even early abuse of that class of substances.  Opiate addicts are at significant risk of dying from their addiction before enough desperation has accumulated to motivate personality change.  A second limitation is the high rate of relapse that occurs even after sustained Recovery.  If a ‘changed’ addict stops actively participating in the program that induced the changes, the personality of the addict tends to revert back to the personality that was present during active drug use.
I initially had mixed feelings about buprenorphine treatment of opiate dependence, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the past four years from what I have seen and heard while treating over 400 patients with buprenorphine.  But while buprenorphine has opened a new frontier of treatment for opiate addiction, arguments over the use of buprenorphine often split the recovering and treatment communities along opposing battle lines.  The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine offers huge benefits for the health and lives of opiate addicts.
A unique medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use buprenorphine versus those who use a non-medicated 12-step-based approach.  People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking buprenorphine as having an ’inferior’ form of recovery, or no recovery at all.  This leaves buprenorphine patients to go to Narcotics Anonymous and hide their use of buprenorphine.  On one hand, good boundaries include the right to keeping one’s private medical information so one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of buprenorphine is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;  they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of buprenorphine.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opiates than for other substances.  This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Buprenorphine has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opiate addicts have a number of such ‘defects.’  The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opiate addicts with buprenorphine—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.  I realize now that I was making the assumption that character defects were relatively static—that they develop slowly over time, and so could only be removed through a great deal of time and hard work.  The most surprising part of my experience in treating people with buprenorphine has been that the defects in fact are not ‘static’, but rather they are quite dynamic.  I have come to believe that the difference between buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with buprenorphine.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with buprenorphine have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Buprenorphine removes the obsession to use almost immediately.  The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.  The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of buprenorphine patients, and more convincingly with the spouses, parents, and children of buprenorphine patients.  I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.  I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found buprenorphine treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining buprenorphine treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between buprenorphine and traditional recovery becomes clear.  Should people taking buprenorphine attend NA or AA?  Yes, if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But I see little use in forced or coerced attendance at meetings.  The recovery message requires a level of acceptance that comes about during desperate times, and people on buprenorphine do not feel desperate.  In fact, people on buprenorphine often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should buprenorphine patients be in a recovery group?
I have reservations about forced attendance, as I question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there clearly is much to be gained from the sense of support that a good group can provide.  Groups also ‘show’ the addict that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle their own addictive thoughts.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  But for a person taking buprenorphine I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist that has a long half-life in brain tissue.  This long half-life promotes a relatively constant state of opiate stimulation, reducing opiate cravings between doses.  But while the ceiling effect of the partial agonist buprenorphine results in a stable, unchanging tolerance to the medication, methadone has no such ceiling, and tolerance will always increase with increasing dose of methadone.  This constant increase in tolerance erodes the ability of methadone to satiate cravings for opiates.  A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.  With cravings comes the obsession to use and the associated character defects.  This explains one difference in the subjective experiences of addicts maintained on buprenorphine versus methadone.  Methadone maintenance is also usually experienced as more sedating than the effects from buprenorphine.  There is a valuable role for methadone to play as we try to prevent deaths from opiate dependence, but I see the mechanisms of action of methadone and buprenorphine to be profoundly different.  Methadone is appropriately described as a ‘maintenance agent,’ but I see a more appropriate term for the actions of buprenorphine, as a ‘remission agent.’  This term accounts for the effects of buprenorphine on the obsession for opiates, and the ability of the medication to allow for dissolution of the character defects caused by active addiction.
The downside of buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine as at best a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe buprenorphine.  Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Buprenorphine itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting buprenorphine reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of buprenorphine use implies long term use of the drug.  Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary.  Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not buprenorphine will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on buprenorphine as the beginning of new age of addiction treatment.  But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out each other’s weaknesses.

SuboxDoc Goes Negative!

I received a couple responses to my youtube videos tonight that are worth responding to.  For people who haven’t stumbled across the videos, you will find them if you go to youtube and search under ‘suboxone’ or ‘suboxdoc’.  They are pretty much the same thing as what you read here—a combination of my experiences in treating opiate dependence using Suboxone, education on the actions of buprenorphine, some of my personal ‘theories’ (maybe ‘opinions’ is a better word) on the relationship between sober recovery and buprenorphine maintenance (what I like to call ‘remission treatment’, to distinguish it from methadone maintenance, which works through a different mechanism), and my thoughts on the different treatment options for opiate dependence.

Blogging in general has been an educational experience.  I was initially surprised by the number of people who send out very angry messages to a person who simply tries to share knowledge and advice!  Just today I received a message accusing me of ‘getting my degree from a crackerjacks box’ for my opinion that ‘Suboxone withdrawal is NOT the worst withdrawal ever.’ I didn’t get it there, by the way.    I don’t know how to take the responses posted a few minutes ago that are tonight’s topic;  I am not sure if they are simple questions, respectful disagreements, or sarcastic comments.  You would think a psychiatrist would know one from the other!  Maybe the person will add more angry comments after my post, and then I’ll know for sure.  Or maybe there will be nice comments.  Whatever…

The comments, from someone going by ‘cbarrett34’ on youtube:

Dr. I’m curious, why do you say that there is no cure for opiate addiction? That doesn’t give people a lot of hope, if a Dr. is telling them there is no cure or hope for you. Basically leads to apathy and more using.

(That one was clearly very nice).

And the whole saying, once an addict, always an addict. That’s not a very positive viewpoint either.

(That one is harder to tell, don’t you think?  I might just be paranoid from that crackerjacks comment)

My answer, which as always is just one opiate addict/pain doc/psychiatrist’s opinion:

My first thought is that staying clean from opiates has nothing to do with ‘apathy’.  Maybe smoking pot has something to do with apathy, but people actively using opiates are some of the most non-apathetic people you will ever see!  There is no time for ‘apathy’ for an actively-using opiate addict;  there is that hit that is required every 4-8 hours to avoid being sick, there is that need to scam someone out of money to score the dope that is needed every 4-8 hours to avoid being sick, there is that need to come  up with a good lie to tell the parents/spouse/cops/PO/boss/kids to explain the lousy behavior over the past few months or years…  being an actively using opiate addict is a lot of work!  There is definitely a negative attitude that develops after months or years of using, but it is nothing like ‘apathy’.

Too Negative?
Too Negative?

My next thought is that I wonder what the writer would prefer—‘positive’ lies or ‘negative’ truth?  The idea that heroin or oxycontin addiction is ‘treatable’ is one of the big lies of society;  it makes for good movies and helps keep money rolling in to detox facilities and treatment centers, but if you think I’m wrong, seek out the numbers yourself!  Pick your own criteria for success– one year sobriety, five year sobriety, whatever.  If you look at people in their 20’s who go through residential treatment, the one year rate is way, way, way below 50%, even if you just use the numbers for people who go voluntarily and complete treatment!  Go out to 5 years and the numbers for opiate dependence are ridiculous- sobriety rates of less than 10%!  The writer sees danger in telling the truth about treatment I suppose because the truth will somehow take away ‘motivation’ and cause apathy.  But I see things exactly the opposite.  In my opinion based on how I thought as an actively using opiate addict, a sense of confidence is the ENEMY of sobriety.  As an addict goes from day to day using, and getting deeper into addiction, he/she comforts himself by saying ‘I’m going to get straightened out eventually’.  If the person knew that most people do NOT recover; that he is getting mired deeper in an incurable disease, maybe he will think about seeking help a bit sooner!  And if everyone knew that opiate dependence is a largely untreatable and surely incurable illness, maybe fewer high school kids would pick up in the first place.  I hear addicts say one thing over and over again:  ‘if I only knew that oc would have done this to me I never would have taken it.’  I don’t know if that is true for all of them, but I think that had the truth been known, at least some of them wouldn’t have started.

As far as the comment about ‘once an addict, always an addict,’ that is something that is not even controversial.  Yes–  at least with opiates, once an addict, always an addict.  About 7 years after getting clean ‘the first time’, I assumed that I was cured—after all I had only used opiates for 8 months or so, and it had been 7 years… I had been to hundreds of AA and NA meetings, I had worked the steps all the way through several times, and I never even thought about using!  I would get so annoyed when my old NA and AA buddies would come up to me if they saw me someplace and say ‘we miss you at the meetings, Jeff!’  I would want to tell them to bug off and leave me alone— I’m cured, after all!  I don’t need that crap.  Once an addict, always an addict…. NO WAY!

Had I listened to them I might have saved myself a great deal of trouble.  But probably not, since addicts pretty much need to find things out for themselves.    That is one of the personality traits of ‘us addicts’—we are independent thinkers who don’t think the rules of others should apply to us.  Those words on the Vicodin bottle about dosing and about the danger of dependence?  Those are just ‘suggestions’!

I wasn’t always a fan of the idea of taking a medication to treat opiate dependence.  Even after looking around me and realizing that all of the people who got clean with me had relapsed, I thought that it was better to have one out of ten people in ‘real’ recovery than have people taking medication!  Then I ended up in a position where I actually knew some of the people who were dying.  At NA or AA meetings people talk about the deaths with a ‘tsk tsk’ attitude, as if the person who died should have known better, or almost had it coming, since she stopped going to meetings.  But once I was a person who stopped going to meetings in spite of knowing better, it became harder to blame the dead person.

I have in my mind the images of four smiling people who desperately wanted to be free from opiates.  I knew all four of them pretty well at some point;  none took Suboxone, and all assumed they were going to be fine without it.  After all, they had all gone through at least part and in two cases entire treatment programs.  Three men and one woman, all less than 25 years old, two with children of their own.  Two died from suicides, presumably in part from the shame of failing to get better.  I wonder if they thought, before they died, that they were losers because treatment didn’t work for them?  The other two died from opiate overdoses, one the first time he used after being clean for several months.  I suspect he figured that he ‘beat the disease’;  that is what most of us think as we relapse.  One time won’t hurt, we tell ourselves;  we are different now.  We have been TREATED, after all!  The final person was a woman who had been resuscitated several times in her life, once after an overdose in a drug-treatment halfway house!   Maybe she had a death wish—some addicts seem to use as if they truly want to destroy themselves—or maybe she thought she was blessed by a guardian angel who eventually slept in one day and wasn’t there when she needed him.

To simply answer the writer’s questions without all the stories, I tell people that there is no cure for opiate addiction because my opinion is the same as that of everyone else who treats or studies opiate addiction—   there is no cure for opiate addiction.  As for ‘hopelessness’, sometimes ‘hope’ is just a campaign slogan.  Sometimes ‘hoping’ keeps a person from recognizing the cold hard facts of a situation and taking responsible action.  In medicine and in life, diseases do not always have cures.  Some diseases are simply not curable, and people die.  Want to have ‘hope’ about opiate dependence?  Then DON’T USE OPIATES.

The good news is that while there is no cure, there is a relatively new approach to addiction that is keeping many people alive who would have otherwise died from their addiction.  There are many diseases without ‘cures’—in fact there are probably many more ‘incurable’ diseases than ‘curable’ ones!  But every opiate addict should know the facts:  that he or she will always be vulnerable to relapse, no matter the amount of ‘treatment’.

A Day With Reckitt-Benckiser

I just got back from Chicago, where I spent the day learning about ‘best practices with Suboxone’ with the people from Reckitt-Benckiser. I feel an obligation to share my experiences with those of you who are so strongly connected to the efforts of R-B —and I am not referring to owning stock in the company. I’m not in the mood to go on forever; meetings with pharmaceutical company people always tire me out and even bring me down a bit—I’m not sure exactly why. I would almost think it would be the opposite, because things look so easy from the perspective of a PowerPoint presentation. Although as I put my psychodynamic background to use, I realize that an opposite reaction makes sense. Tune into my radio show podcast sometime and listen as I talk about psychodynamics; dysphoric feelings often spring from unconscious conflict, and there was likely conflict between what I was watching and hearing during the presentations, and what I was thinking and remembering from my practice.
Those of you expecting a story about conspiracy theories will be disappointed. I had the impression that the company is sincerely motivated to help people with addictions for the right reasons. They made it clear through their actions and plans for the future that they are in addiction treatment for the long haul, even after the patent on Suboxone expires. There are some things about the company that have bothered me, and I was able to ask questions about those concerns. I will share their answers with you as best I can remember.
I spoke with someone Friday evening who has been with RB since 2003, about the lack of general support in the field for Suboxone compared to other new medications. She believed that RB did a good job of introducing Suboxone, and that their results in numbers of doctors trained and patients treated were good. I pointed out that many, perhaps most, ER docs have no idea what Suboxone IS, let alone know how to manage accidental ingestion or overdose. I compared Suboxone to Shire’s Vyvanse, a medication that has been out for just over a year but has 10 times as many sales reps in the state where I practice. If I want a coupon for Vyvanse, a rep drops off a box of them by the end of the day! But we have two reps covering the entire state for Suboxone! The difference in our perceptions was a classic ‘glass half full or half empty’ situation. She said that when she started in the RB pharmacy division, they had 20 US employees—a tiny fraction of the resources in place for product launches from the ‘big players’.
So I asked why they didn’t sell the drug to one of the big guys, so that it could be rolled out with the fanfare and support given to Cialis or Viagra? Another person from the company pointed out that had they done that, they would have had a bigger problem over the shortage of physicians certified to prescribe the medication. And that was a good point. The bottom line is that Suboxone was a truly unique situation; a small company that had no significant US presence, the unusual requirement for special certification for prescribers, a target illness that is complicated by stigma and the risk of diversion by patients… mistakes were probably made, but mistakes are always made. I left the conversation realizing that the company had some unique challenges to overcome, and so far has done pretty well.
A couple other areas of new perspective: on the issue of the high cost (although I often point out that for a fatal illness, the treatment isn’t all that expensive), it was pointed out that if Suboxone was super cheap, say a buck a pill, there would be a much greater profit motive for diversion of the drug. I think that is probably a fair assumption; there would be more Suboxone on the street if it retailed for a buck per pill than there is at five bucks per pill.
I was happy to see how strongly they connected with the disease model of addiction; in my opinion that is the genuine state of affairs, and the natural way to present Suboxone. Suboxone is a chronic medication for a chronic condition, period. I have always figured that it was a mistake that the company initially talked up using Suboxone for short-term detox, and I heard nothing to change my opinion. They mentioned that a few years ago 70% of patients were prescribed Suboxone for short-term use and 30% for maintenance, and now those numbers have reversed and 70% of prescriptions are for long-term maintenance treatment. Those numbers are consistent with my experience.
There will be other buprenorphine preparations in the future, including depot injectables made by RB or by someone else. Also watch for different types of oral products, including designs that reduce the likelihood of accidental exposure in children.
If I had to complain about something, I would say that the corporate presentation just does not seem to mesh well with the reality on the street. I talked to one of the leading developers briefly about the problem with twelve step groups—how there is a vocal anti-Suboxone crowd, who often talk people into stopping their medication or refer to doctors who prescribe the medication as ‘pushers’. He said that Betty Ford had given her blessing to the idea that people on maintenance medications are still ‘in Recovery’. My thought in response was ‘who the heck cares about Betty Ford?’ I would bet that 99% of the NA and 80% of the AA folks in my home town have never heard of her! I do think that the split among the recovering community over buprenorphine is a serious issue that should be dealt with in a formal manner, through communication between people who understand neurochemistry and buprenorphine, with people from the twelve step intergroup organizations.
I also believe that some in the company, and some prescribers, don’t understand what it is like to be an opiate addict. I realize that nobody who is not an addict will truly understand addiction, but I don’t think they get that we are just like they are outside of our addictions. To give an example, the issue came up about the degree of counseling and meetings that should be required of people on Suboxone. I have put forward my thoughts on this issue many times. Many of the docs at the meeting talked about their practice of requiring ALL people on Suboxone to go through intensive outpatient treatment, and/or requiring twelve step attendance as often as every day! They require AA or NA not because of some theoretical basis, but rather because they think that addiction and AA or NA just go together. I did point out my thoughts on the issue, namely that people only ‘get’ twelve step recovery when they have some degree of acute desperation, and people on Suboxone are NOT DESPERATE. I ‘got’ AA quickly the first time I went to treatment, but the second time it took several months before my mind opened sufficiently to truly accept the program. Only people who have had a spiritual awakening themselves will understand what I am talking about, but going to meetings and just sitting through them is not that beneficial. I have been to meetings with people mandated to attend, and those meetings are generally a waste of EVERYBODY’S time. ‘Getting it’ in twelve step recovery is a moving experience that sweeps the addict of his feet, and pulls him by the heartstrings into a new way of thinking and living. I like that saying that ‘insight maketh a bloody entrance’; the insight required to get clean through the steps is bloody indeed! But these docs just sit back and say ‘no meetings, no Suboxone’, and wear their inflexibility as a badge of honor. I have been in that horrible situation as an addict where my opinion didn’t ‘count’, since I was ‘too sick’ to think logically… that is a tough spot, as the harder you argue, the more belligerent you are accused of being.
As for the scientific topics, I was glad to see that I am pretty much on target with my thoughts about dose levels, tapering, receptor actions, etc. Many docs start patients on twice per day dosing and later convert to once per day; I like to start at once per day from the very start, to avoid setting up a pattern that might be hard to break.
All in all, it was an interesting and informative weekend. I will probably make a couple small changes in my practice in light of things that I heard. And as for RB, I left the conference thinking that I will buy a few shares of their stock. They want to be a premiere addiction-related pharmaceutical company, and given the epidemic of opiates and other narcotics in this country and in other countries, the sky’s the limit!
SuboxDoc
Suboxone Talk Zone