Short-Timers

Another question from a reader:
The current blog brings up the notion of long term use of Bupe or short term detox. You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug. But- what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.
The Suboxone helps with the W/D and just getting through with that is all we want. NA meetings and the like are like being on Mars, it makes no sense. There are no drug cravings at all and the goal is just normal. Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them And now that too is unavailable. This group does not need Suboxone to become a new problem for them. They just want the help. It is not critically important to determine “who” is being treated. The certification training materials seem to brush over this so lightly that there is only one induction method allowed. One that a drug company would love, but not always a patient — pleading, do no harm.
My Thoughts:
I hear you, and watch for those patients. Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list. The financial motivation for the DOCTOR is to push people through, for that same reason. Of course the drug company gets paid in either case.
The first question is whether buprenorphine even helps in the case you describe. It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills. It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter. But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.
There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year; those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox. But I don’t know where those people would have fallen on the spectrum that you are presenting. I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.
My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else. They describe the process in different terms; instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’ They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.
I agree with your thoughts, and get your point. I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away. Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits. In a sense the pain is remembered, even after the original injury is repaired. The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics….. and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.
Thanks for your comments!

Mean Streak

I guess I do get irritable sometimes… but I’m getting better at controlling my anger as I get older. One cool thing about a blog is that I can go back and see what I wrote years ago. In this case, I was looking for a post about telling the difference between opioid toxicity (from taking too much) versus opioid withdrawal. In that post I suggested looking at the size of the pupils. The name of the post, in case anyone is interested, is called ‘abres los ojos’— the name of an old Penelope Cruz movie and spanish for ‘open your eyes.’

Penelope Cruz sounds very cool, by the way, when she whispers ‘abres los ojos…’ as you can hear at the beginning of the movie trailer. The movie was remade and called ‘Vanilla Sky’– again with Penelope Cruz, but this time with her speaking in English.
Am I the only one who cares about this stuff?!
The post BEFORE that one was from a time– 2009– when people often wrote to tell me how misguided I was for recommeding buprenoprhine. Those comments, at a time when so many young people were dying from overdose, would really get to me. I’ll share the exchange, for old time’s sake. For people who enjoyed my older, feisty posts, they are still out there– you just need to keep hitting the ‘earlier posts’ button!
The post:
This guy doesn’t like Suboxone– or the horse it rode in on. He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone. It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!). I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.
Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to 2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the good ole subs that all these Drs are making a fortune off. You must remember that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.
There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !
My Response:
Before my answer, a quick comment– I do like the ‘crooks on wal-street’ remark; I haven’t seen that ‘play on trademark words’ before. I am assuming that he was making a joke– he had to be, right?
OK, here is my response. As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:
I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.
Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.
There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!
Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…
Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.
Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.
I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.
My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.
If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.
Back to the present…
Phew. Makes me tired just remembering those days. Since then the number of deaths have only gone up, but at least there is a better acceptance for treating opioid dependence using effective medications— at least for people ready to accept that help.

Size Matters?

I’ve received several complaints from patients and readers about one of the current buprenorphine formulations. The primary complaint is that the tablet is ‘not ‘working as well as the other formulations;’ that it seems to wear off earlier, or that people feel compelled to take more than what is prescribed.

buprenorphine formulations
Buprenorphine 8 mg tabs

My understanding, admittedly based only on what people have told me, is that there are three current formulations of buprenorphine. The brand form, Subutex, comes as a relatively-large, flat-oval tablet, white or off-white in color. The Roxanne version is a round white tablet, with a diameter of about 0.5 inch. The tablet people have complained about is from Teva, and is smaller; about the size of a tic-tac.
In general, I think that generics are as good as brand name medications. I have never come across a reliable instance, in my practice, of generics being less potent or less active. I recognize that particularly for psychiatric medications, the placebo effect accounts for significant portions of the actions of medications—so if a person BELIEVES that generic fluoxetine is less likely to work, it IS less likely to work. But take away the placebo issue, and a molecule of fluoxetine is a molecule of fluoxetine—regardless of where it comes from.
That said, I realize that the delivery of molecules can be affected by the design of capsules and tablets. I remember a study, years ago, that showed that many of the vitamins sold in the US passed through the intestinal system without even dissolving, let alone getting into the bloodstream. If the active substance is encased inside insoluble resin, there is little to be gained from taking it.
The delivery issue is less of a concern with a medication that is delivered through the oral mucosa, as with buprenorphine. There are several factors that affect absorption of buprenorphine; the concentration of buprenorphine in saliva, the amount of surface area that buprenorphine is allowed to pass through, and the time allowed for that passage to occur. If the smaller tablet dissolves more slowly, molecules of buprenorphine may have less actual contact-time with oral mucosa, thereby reducing absorption.
On the other hand, I am well aware of the psychological reward that people describe from taking buprenorphine or buprenorphine-naloxone, even in the absence of any subjective sensation. The fear of withdrawal is relieved by taking buprenorphine—making the dosing experience ‘rewarding.’ It may be that the smaller tablet provides less reward, as the small size engenders less confidence in those unfelt ‘effects.’
In any case, I invite readers to share their experiences, just in case those who have already written are truly onto something. Please leave comments below—and thanks for sharing!

Jerk Counselor

Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention. This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’
I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness. I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions. In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do? Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

Some Jerks advocate punishing patients who struggle.
This Jerk Counselor

We all know that certain professions attract certain types of people. Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt. When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people. It’s the power trip, I suppose.
This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment. He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way. One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room. But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.
Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position. In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room. We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.
The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power. Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids. Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.
This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety. He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.
In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious: when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts. On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.
I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric. I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach. I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right. But most of us leave that world behind when we commit to helping people suffering from illness.
What’s This Jerk’s excuse? Is it that he just doesn’t get it? Or are there other motives at play? With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.
Or is it the power trip– that people with difficult addictions are an affront to therapists? I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die. I suppose This Jerk would say ‘not my problem! I did MY job!’
Readers may suspect that this topic irritates me—and they’re right. Maybe I’ve seen more death, up close, than the typical counselor. I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery. I have spent hours with the parents of young patients who died from overdose. I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child. Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.
I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior. People like This Jerk hold power over an individual with an addiction history, but there is power in numbers. It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle. It is not appropriate to humiliate a patient in front of others. If you see that behavior, collect witnesses, and bring it to someone’s attention. Maybe that ‘someone’ will write a blog post about it!
Doctors in particular should treat patients with ALL diseases—including addiction—with respect. It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite. I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.
Would THAT make sense— even to This Jerk?

Cinderella and Snow White Smuggle Suboxone

I’ll often joke with others who have histories of addiction over the ingenuity of addicts when it comes to finding or using drugs. If that amount of creativity and work ethic were ever harnessed for legitimate reasons, the opportunities would be limitless!
Cinderella at Suboxone Talk Zone
I have similar thoughts when I read the story about several county inmates at a New Jersey jail, who smuggled Suboxone into jail disguised as watercolor paint on cartoon images!The story has a humorous side, of course– but after we stop laughing, we are all sobered by the memories of the living hell created by opioids, detox, and withdrawal. I’ve met many, many people who went through detox in jail or prison, and I realize that being in such a state is no laughing matter. I assume that the experience of withdrawal in prison is about as bad as things get; an experience that will never be part of someone’s bucket list!
The story also reminds us that buprenorphine is a very potent opioid. One tablet of Suboxone contains 8000 micrograms of buprenorphine– enough to provide about 100 ‘hits’ of 80 micrograms each, which would have significant effects in people not tolerant to opioids. The illicit use of tiny doses of Suboxone–yet significant doses of buprenorphine– has become the most troublesome avenue for diversion of buprenorphine. This diversion is one reason for keeping prescribed doses to only the amount necessary to block receptors– which in the vast majority of people is 16 mg or less.I just had a thought on a different topic… do you think we will ever get to the point of seeing addiction as a disease, where people who are sick, depressed, and dehydrated from withdrawal, in prison, would be treated in a way that reduces their misery?Now THAT’S funny! Sort of…