I’m sorry, those of you who have been reading this site for the past couple years, to go through this once more…   but I have another of THOSE messages, and it has been, what, a few weeks since I discussed the short-term/long-term issue?   Rest assured that I spare you, the reader, more times than not.  I suppose I could tell the writer of the message (the one I am about to share) that he could search the blog for ‘foolish pharmacist’ or any one of a dozen other posts about the topic and spare me from writing and all of you from reading… but he probably wouldn’t do that.   So in my typical fashion I’ll post his message interspersed with my comments.
The message:
I want to add my perspective on Suboxone. I think it is a great medication but ONLY if used in conjuntion with therapy. It is NOT an anti depressant. It is an OPIATE type medication you are putting into your body with an additional ingredient to block the “high” you get from regular narcotics. The mentality of staying on it “for the rest of your life” is NOT good.
Right off the bat, the writer makes a common mistake– which I’ll get to in a minute.  Of course it isn’t an antidepressant– I would hope that every regular reader of the blog knows that.  Yes, it IS an ‘opiate-type medication’– but so what?  I can assure you that the molecules that have little opiate labels hanging on them are no more evil than any other molecule!  Vivitrol and Revia are ‘opiate-type molecules’ as well– both are trade names for naltrexone, for injection or as a pill, respectively, and both indicated for treatment of alcohol dependence.  There is no logical connection between ‘it is an opiate’ and ‘the mentality of staying on it is NOT good’–  your body doesn’t know ‘opiate’ from ‘indole-amine’ or ‘butyrophenones’ from ‘thioxanthenes’–  they are just names of broad categories of molecules.  Don’t get hung up on labels– they don’t mean anything to the human body.  As for the mistake, the main ingredient in Suboxone is buprenorphine, a chemical that has been used for about 30 years as an analgesic with partial-agonist effects at the mu receptor– as you all know.  People who take Suboxone properly do not get ‘high’, and again, mentioning ‘high’ in the message only confuses the issue.  The added ingredient, by the way, is naloxone– a mu receptor antagonist.  ALL of the effects of Suboxone are due to buprenorphine;  naloxone is added to deter parenteral use of Suboxone.  Naloxone has no important effect for the regular use of Suboxone.
Don’t get me wrong, my partner was put on it last July and it pretty much saved his life as far as I’m concerned. HOWEVER, when the doctor put him on it he said it would help “heal his mind” if used in conjunction with therapy and after 3-4 months would begin to taper him off of it. Well, he went on a business trip and accidently left it behind at one of his stops. He had to be without it for about 5 days and it was hell but as soon as he got it back and resumed he was fine. He shared this with the prescribing doctor who IMMEDIATELY said “Well, you need to be on it longer then since you had such a bad experience being off of it.” There was then NO treatment plan made. Doctors seem to have a sense of vagueness about them when they prescribe this NARCOTIC medication as to what the treatment plan is.
That’s a pretty broad statement about us doctors!  I don’t think that doctors who work with addiction and Suboxone are any more ‘vague’ than other doctors;  I read complaints about doctors of all specialties at the forums I write for at medhelp.org and elsewhere.  I do think that medicine in general has gotten away from the interpersonal relationships that were once a significant part of the doctor-patient bond, but that is a general observation and not specific to addiction treatment.  As regular readers know, I am an opiate addict, and have been for the past 16 years;  I know enough about the mindset of other opiate addicts (I often point out examples of how alike we all are!) to wonder about the communication between your partner and his doctor.  We addicts have very selective hearing, particularly early in the treatment process– so I am reluctant to draw too many conclusions from the ‘he said this’ claims of another opiate addict (like me– did I mention that?).  In other words, I don’t know what the doc said, and to be frank if you weren’t there, you don’t know either.  I doubt that your partner does.  I don’t mean to be insulting;  I’m just telling it like it is, based on working with addicts every day for years, on or off Suboxone.
The reason I am writing this is because what I have observed with longer term use is that my partner was constipated DAILY, slept at least 10 hours per night AND took naps. He did not enjoy excercising as he once did and gained weight. He was mellow and sober but at the same time was not himself. He has been tapering off slowly and is down from 4 mg per day to 2 mg per day. He is not constipated daily any longer, now does fast walks with me every day and passes me up just like the old days. For a while I was out walking him and I hate excercise.
You are attributing all of those things to Suboxone?!  How about your hatred of exercise– what is that from?  Your partner was in the process of trying to stop one of the most addictive substances that there is;  opiate addicts LIVE for using opiates!  For an opiate addict there is but one concern in life– how will I avoid getting sick in four hours?  So here we have your partner– a person who is by all practical sense gravely mentally ill (I could easily argue that the loss of insight and near-delusional obsession to use causes ‘insanity’ as great as in any other psychiatric condition!), and in a span of a few weeks to months has had a dramatic change in his life–  suddenly the crutch that occupied his entire mind has been removed… and you are complaining that he doesn’t like exercising enough?
Today I had a patient who recently started Suboxone and now is having panic attacks.  I explained to him that months ago when he was burglarizing homes and stealing from relatives, he had no worries– because all his mind could think of was using.  Now his mind has been freed from the obsession to use– and all of a sudden he has to think about all of the people he harmed, the consequences that he is facing, etc– so of course he is having anxiety and panic!  Heck, he would be crazy not to!
The writer is blaming Suboxone for the partner’s issues– when the blame should be on his addiction!  It is VERY early, and there are so many things going on those first few months that ‘enjoying exercise’ is a bit silly.   He is trying to recover from a fatal illness, for Pete’s sake.  As for the constipation– I’ll give you that.  That is probably from the Suboxone… but I consider it to be a minor side effect for treatment for a fatal condition–  compared to chemotherapy it’s a great deal.
To sum this up there are no guarantees when it comes to sobriety but to preach horrible relapse statistics to anyone deciding to come off of this NARCOTIC medication is WRONG. Now, if this was something more like a Prozac type medication I would probably better support the “rest of your life” mentality of being on this medication.
I’m not sure how we got from the beginning to your conclusion– you basically say that your partner is addicted to opiates, a horrible condition that destroys and often kills those who suffer from it–  he took Suboxone and it ‘saved his life’… but it made him constipated and he slept too much and didn’t like to exercise– so preaching relapse statistics (correct ones, by the way) is WRONG!.  I don’t get the logic.
The writer is missing the point in a way that is all too common.  The writer blames the ‘rest of your life’ situation on SUBOXONE.  But the truth of the matter is that OPIATE ADDICTION is a life-long condition!    Suboxone isn’t the ‘rest of your life’ issue;  the partner’s opiate addiction is!!
Before Suboxone, opiate addicts like me had a life-long condition that had no good treatments.  Yes, there is NA and AA– they ‘work if you work them’, and I have worked them for a long time.  But twelve-step recovery has ALWAYS been for the very few people who are lucky enough to ‘get it’ before dying from the disease of addiction.  And  people in twelve-step recovery tend to relapse over time, and before Suboxone, relapse was often permanent– many addicts could never get back the sobriety that they once had.  Now we have another option.  But neither Suboxone nor step-work are cures.  And to be frank, there is no ‘therapy’ that cures opiate addiction either.  Yes, therapy is indicated for some patients, but some others do very well without significant therapy.  I do see all patients for at least 30 minutes for every appointment, as there are always things to discuss– but I disagree that EVERY patient on Suboxone needs therapy– just as every patient on meds for bipolar disorder doesn’t need therapy.
If anyone is interested in the issue of Suboxone versus ‘traditional recovery, please read my article on the topic.  Just Google ‘Suboxone’ and ‘traditional recovery’ and you will find it very easily.  To the writer– I’m sorry your partner is an opiate addict.  That is a tough life for anyone.  But Suboxone allows many of my patients the chance to live as if they DIDN’T have a fatal illness.  Many of them tell me that they don’t feel like addicts anymore– they feel like ‘regular people’ with just another illness.  And that is a major paradigm change from traditional treatment and therapy, where the point is to get the addict to identify very strongly with the addict label.   I think there is room for both types of treatment.  In fact, after 16 years of being an opiate addict– it’s about time!!


armme · May 11, 2009 at 10:06 am

I have been wanting to respond to this entry for days…but computer problems prevented it!
I agree with everything you wrote, Doc. I just had a couple of points to add that make me a little crazy when dealing with people like the writer of this email/letter. I can only hope that this person’s partner might realize that he already is achieving what he wanted out of treatment, and it just might be BECAUSE of the Suboxone, not IN SPITE OF IT! The person who wrote this letter is living in a fantasy world that many loved ones of addicts live in–the world where the problem is the DRUGS, not the addiction. Because it’s so much easier to believe the drugs are the problem–because drugs you can remove drugs from the equation …. a chronic life long disease, you can’t. The sad thing is, though, that by pushing to remove the Suboxone (the NARCOTIC, as she keeps calling it) in a vain attempt to “cure” him, she is most likely setting him up for a relapse. Even more sad is that when this is all said and done, she will most likely blame Suboxone for that relapse, instead of logically realizing it was the “going off” Suboxone that caused it, not going ON it to begin with! Afterall, there had to be a reason he went on it, right?
What bothers me the most about this letter (and there is much that bothers me!) was her comment about it being “OK” for him to be on antidepressants for “life”–but not Suboxone.
Why is it ok for a patient to be on anti-depressants long term but not, Suboxone? What RATIONAL reason can she give? She can’t, because there is no RATIONAL answer! For that matter, how can you possibly say FOR SOMEONE ELSE, what is “ok” to take and what is not? This isn’t about ethics or morality, this is about someone ELSE’s health! We aren’t talking about whether you should have sex before marriage here–we are talking about the medical treatment of a disease.
Usually, when I talk to someone who is of this opinion about long term maintenance medication for addiction vs. depression, I ask them why one “drug” is ok and not the other-I get an answer like “You know why! How can you say it’s the same? Ones and opiate and one isn’t!”–one is bad and one is good” sort of statement that has nothing to do with medical science.The truth is we aren’t even asking the right question of these people! What we should be asking them is “WHY IS IT OK TO TREAT ONE MENTAL ILLNESS AND NOT THE OTHER?” or “why is it ok to treat one person’s suffering, and not anothers?”
So lets contemplate the possible reasons someone might give for why it’s OK to take AD’s for life, but not Suboxone, shall we? ((smile))
“Suboxone is considered mood altering”
It can’t be because one is “mood altering” and the other is not…because AD’s, by their VERY NATURE, are mood altering! Why would anyone take them if it didn’t CHEMICALLY alter your mood?
Suboxone is “addictive”!
It can’t be because one causes dependency and the other doesn’t…..because most AD’s cause a withdrawal syndrome similar to Suboxones level of un-comfort level, when they are discontinued!
People can ABUSE Suboxone!
It can’t be because Suboxone is sometimes abused by naive drug users….because ALL drugs can be abused if used the wrong way and AD’s are COMMONLY diverted and abused by teenagers.
Suboxone is toxic to your body!
It can’t be because Suboxone is more toxic to the body than AD’s….because opiates are generally harmless to the bodies organs and most of their side effects are “quality of life” type of effects like constipation. Some AD’s, on the other hand, have a lengthy list of adverse effects….in children especially.
People DIE from Suboxone overdoses!
It can’t be because one can cause overdose on Suboxone and not on AD’s….because AD’s are VERY COMMON players in overdoses-suicidal and accident–and Suboxone is RARELY the listed cause of overdoses….you can overdose on ANY drug, chemical or substance (even WATER) if you take too much!
So the only reason left is “because I said so”–the morality of one drug vs. the other. The irrational “morality” score that many treatment providers,12 step groups and members of society put on certain drugs, that actually have nothing to do with the logistics of these medications, and have everything to do with stigma.
Whenever a patient comes to one of the message boards I frequent complaining about how much they want to get off medication and “live a normal life” again….how much they hate this or that and if they could JUST get off this dang medicine, their life would be perfect again….I know immediately that they aren’t even close to the place they need to be to be off medications and still live a good life. They haven’t even really accepted that they are addicts yet, and what that means as far as living with a chronic illness that not only could kill them, but could ruin the quality of their entire lives.
These folks are (just like this girlfriend writing above) still blaming all their problems on the DRUGS…whether it’s the drugs they are addicted to, or the medication they are taking to treat it, they are still focusing on the DRUG, and not the addiction. They still believe that if they could just remove certain drugs and medications from their bodies, their problems would be solved.
I try to always gently remind them that MOST people with chronic un-curable illness feel a sense of not having control over their own bodies and lives….that feeling resentment at having to take a medication to live well is normal and not exclusive to addiction, but sometimes, depending on the severity of the illness, its a fact of their lives they just have to come to terms with and accept.
Addicts and their families have to face that addiction is now a PART of their lives, but it doesn’t have to be your WHOLE life. And I think that is the absolutely wonderful part of moving addiction treatment into the medical arena-like Suboxone treatment….instead of always focusing on “how do we keep this guy clean, against all odds?” and “how can we keep addiction forefront in his mind at all times, so that he doesn’t relapse?” and “how can we teach him to cope with the symptoms of addiction?” Instead of teaching addicts that to save their lives they havr to become almost as obsessed with staying clean as they were with using drugs.
INSTEAD we can actually start to think of addiction treatment as “how can we lesson the symptoms of addiction so the patient doesn’t HAVE to cope with them?” and “how can we calm this obsession so this person can focus on other things besides their addiction?” and “how can we give this person as normal a life as possible, while having this illness?” In essence we can begin to treat addiction like the disease it is, instead of continuing to call it a disease but promoting treatments that we would NEVER recommend for other illnesses!
As addiction treatment moves more and more toward treatments that help eliminate the symptoms of addiction with medication or other therapies addicts can finally start to look forward to planning their future, instead of just getting through “one day”. A time where an addicts happiness and contentment with their treatment and quality of life is just as important as how long they’ve been clean! A time when there is no “bottom” that has to be reached and where a life can be saved, before there is no “life” to get back to!
ps- I apologize for any spelling errors, I am in a hurry but couldn’t wait to write a response!

samiam · March 27, 2011 at 7:50 am

First of all I would like to say that I wish with all my heart there was a magic pill that could help people with addictions but I don’t believe there is one yet. I am and addict and my partner is too. I have been able to stay clean for long periods of time but also don’t agree with all the 12 step program stuff. I have been working on recovery for 10 years now and stayed clean for 6 of those years and only have used a day hear or there through out the rest. I don’t keep track anymore though. Now for why I’m writing…my partner is a long term opiate addict with mental illness too. A couple of years ago she was put in the hospital due to a very bad overdose and mental break. She was put on suboxone to help with the detox but then was put on it long term. It has helped at first until she over came her fear of using other things with the suboxone. It seem to have just continued the using mentality now. It just doesn’t seem much different from actually using vicodine. She has the same look in her eyes and some of the same thinking as when she is using. No this can’t be blamed on the drug…that is addict thinking but the idea that a doctor gave her this and that it’s ok to take a drug give an addict justification. I’m on too so I understand it. This drug was first meant to help with detox not for long term treatment. The effects of it are not much different from the actual opiate. People sell it and if you talk to an addict that is being honest they will tell you it does get them high…not the same as an actual opiate but similar. It also isn’t much different from having to live life around when and how you will get the next one. The addict line up at the doctors office (at least in our area) and wait to get their next fix. They play around with the dose and then run out before they can get more…I just don’t see the difference. I know that not all addicts do this and I’m glad for anyone who is able to get help from this but I haven’t seen it work in one case. I used to work at and then run a recovery house so I have seen this in more than one or even a couple of cases. I think it’s almost criminal what doctors are doing with this drug. It’s make money for them…they have a sure thing…the addicts will come back every week and they get to charge an office visit every week to hand out more suboxone and tell the addict that they are helping them. Yep I’m angry and frustrated! I wish there was a magic pill but there isn’t. I don’t believe 12 step programs are the only way but I do believe that not having an opiate or opiate like drug is the only answer to getting clear minded enough to even have a chance at being and staying clean. I have notice that the people on this drug think they are not acting high…just like when they take a pill or drink and they think they perfectly fine. So if the people who are writing that it’s a good thing that suboxone is available are also taking this drug I don’t trust your judgement either. Your mind is under the influence of the drug too. You may be able to function better than at the peak of your addiction but you are still altered. It may be the lesser of two evils but it’s still an evil. There are no easy ways out of addiction just simple ones…put it down and don’t pick it up again. If that means meetings or therapy or yoga or what ever it takes but one drug in place of another just keeps the cycle going.

Please don't use your real name unless you want it to show. Thanks for commenting!!

This site uses Akismet to reduce spam. Learn how your comment data is processed.