Methadone, Buprenorphine, and Mood a.k.a. ‘the hole’ Part 1

A person replied to the ‘hole’ discussion with comments about methadone.  I will post the other person’s comments in Part 1, and then my response in Part 2 later today.  My response consists of my opinion– an opinion based on 1. My own experiences with opiates (not currently active, thank God); 2. My experiences treating over 150 people with Suboxone over a two-year period; 3. My PhD work in neurochemistry as a ‘grind and bind’ man, studying receptor mechanics at the molecular level; 4.  My ten years as an anesthesiologist in the OR and labor floor (where I gave patients opiates including buprenorphine)  and in the pain clinic (where I prescribe methadone and other opiates); and 5. My residency and practice in psychiatry and my own psychodynamic therapy, where I learned to respect the power of the unconscious side of personality. 

In other words, my opinion is my opinion, but it is based on a great deal of education and experience.  I do my best to keep an open mind. 

The post:

I have heard often from Suboxone patients this same thing–that this “hole” seemed to be helped by subs at first, but then it slowly doesn’t work. This could be attributed to tolerance-however dose increase don’t appear to help.

\I have also heard the opposite-from a very dear friend who is thankful still, a year later, that her “hole” seems to have closed up because of her time on Suboxone.

I think R may find better luck with Methadone. See I don’t nessecarily believe as the “Experts” do that Suboxone is better for less tolerant and methadone better for “heavier” users of short acting opiates. I I I I believe that if you were a person who, while in active addiction, could take just enough to get high and be happy and content to save the rest you may do very well on Subs. However, if you were the type that was reaching for more before you even let the first pill, line or shot take effect–essentially you were the type of addict who loved to OVERFILL the “hole” then methadone might be for you.


If you look at this “hole”-lol- theory you could consider that suboxone has a ceiling effect and can only fill that hole to a certain point–which for the first group of people is just enough to be content, but for the second group is inadequate. Methadone seems to take up more “room” in the hole, therefore it fills past the point of Suboxone’s celing and there comes a point in treatment where you stop craving to OVER FILL the “hole”. That is a magical place to be when you’ve craved “filling the hole to the brim” most of your life.

Of course, this all might not make a whole lot of sense to anyone that hasn’t walked around feeling half whole their whole life.

Part 2 coming…

By the way, for those of you who enjoy reading my comments, please visit my practice, Fond du Lac Psychiatry, at http://fdlpsychiatry.com .  You will find links to my weekly radio show (send an e-mail to discuss on the air!) as well as things I have written about psychodynamic psychotherapy.

JJ

Bitter taste, euphoria, dosing…

From a person new to suboxone:

This is my, well, second day off opiates seeing it is 12:05am where I am. I had a 11 year on and off love affair with opiates. It got worse in the last 6-12 months or so. That feeling of euphoria really gets you and when you don’t have your pills you feel like you are going to die, literally!! I woke up this morning with no more pills. OH BOY was I sick… I found a list of docs who detoxed using subutex and/or suboxone… He did a patient and family history on me… He wrote me a script for six 2mg/0.5 suboxone. His instructions were take two under my tongue immediately… The taste was disguisting. I just took my second 2 and am cringing because of the taste… After 30-60 minutes, I felt wonderful… I was surprised he started me off at 2 and not 8mgs. The 2mgs do just fine. What is funny is that the euphoria you get from opiates, I am getting from this drug. I read up everything possible on the internet about this drug and it is supposed to be the best drug for opiate users. I have been posting a lot and hope you do not mind. I understand addiction and how hard it is so I want to help people. I am just starting my recovery and have a long road ahead, I know this but if more people know about SUB, there would be less addicts. I am making it clear to everyone that you absolutely cannot take any op’s while on Sub. Apparently you will get the worse side effects imaginable…

I deleted the parts that are identifiable or more specific to the individual than necessary here.

Some comments: As for the taste, there are some little tricks that will make suboxone more palatable; try chewing an altoid or another strong mint right before taking the suboxone, you can also try holding an ice cube in your mouth for 5 minutes first, spitting that out, and then taking the suboxone. Just be sure to start the suboxone dose without saliva or water in your mouth– you will produce saliva while you are dosing, and you want a high concentration of buprenorphine in the saliva, which means you want a low volume of liquid. Other people have used listerine strips. Finally, subutex has a different taste– it is bitter, but not ‘fruity’, and some people like it better. It is, though, significantly more expensive. Contrary to misconception out there, you do NOT need the naloxone to get the ‘blockade’ effect at opiate receptors. Subutex has an identical action in almost all patients– the exception being perhaps people who have had a gastric bypass or who have a (very unusual) allergy to naloxone.

For best results start with a ‘dry’ mouth, bite the suboxone with your front teeth to crush it and dissolve it immediately upon putting it in your mouth, then use your tongue to spread the the concentrated, dissolved medication over all surface areas inside your mouth. A couple points: the intact tablet is not doing anything, so holding it under the tongue takes needless time– get it dissolved right away. Second, there is nothing special about the area under your tongue; the medication will get absorbed from all surfaces inside the mouth, so use as much surface area as possible to increase absorption and speed the process. Third, after dosing for 5-10 minutes you can either swallow the saliva or spit it out– if the bitter taste really bothers you, perhaps spitting it out is the better option (also a better option for the rare individual who seems to get headaches from the naloxone in suboxone). Finally, do not drink anything or rinse your mouth with liquid for at least 15 minutes after dosing, as that will remove some of the buprenorphine that you are trying to absorb.

Euphoria… the initial effect of taking buprenorphine will depend to an extent on the individual’s degree of tolerance. A person taking over 80-100 mg of oxycodone per day who waits 24 hours to have moderate withdrawal, and then takes suboxone, will probably feel relief from the withdrawal, but will not feel much of an ‘opiate’ effect. On the other hand a person taking 5 vicodin per day (which contains hydrocodone, a weaker opiate) who waits 24 hours and then takes suboxone will likely have euphoria and other opiate effects– because the ‘opiate agonist’ activity of buprenorphine is stronger than what the person is used to or ‘tolerant’ to. In either case, the person’s opiate receptors will adjust fairly quickly to the potency of buprenorphine, and after a few days both patients will feel ‘normal’ after taking buprenorphine– no withdrawal, no euphoria. That is what makes it such a popular treatment– patients who take it regularly feel ‘normal’. In fact, many people experience life without the constant craving for opiates for the first time in years, and for the first time in years feel like a person who is not an opiate addict.

This leads to a much broader issue that I have talked about before– an issue that is more controversial: what other things should be required of patients taking suboxone? I have heard ‘second hand’ that Dr Miller, the President of ASAM, the American Society for Addiction Medicine, takes the approach that patients on Suboxone should be sober from all other intoxicants and attending group treatment and 12 step programs. I am in agreement on the ‘total sobriety’ issue but not with the second part, for a couple of reasons. Elsewhere in this blog I theorize a bit on the issue of Suboxone and 12-step attendance (I also discuss the issue here: http://fdlpsychiatry.com/subox.info/suboxandrecovery.pdf) but I have some practical concerns as well. First, ‘recovery’ is all about ‘rigorous honesty’, and yet if a person is honest about taking suboxone at an NA meeting he/she will end up being confronted and harassed– so patients are told to be honest about everything except suboxone use– and that is a problem because we are then reinforcing one of the things the addict has been doing for years– hiding the use of an opiate. Second, people on suboxone are different from people who are not on suboxone– they don’t have the constant awareness of the desire for opiates (or the unconscious drive for opiates manifest as irritability), and have an entirely different subjective experience. They don’t ‘feel’ like opiate addicts. Yes, they are still opiate addicts– don’t get me wrong on that. But they don’t feel the same way. And so I don’t know if a 12 step meeting will do anything for them. I know that to buy into recovery a person has to be desperate; not because there is anything wrong with the 12 step message as I think it is a great, universal approach to life that benefits everyone lucky enough to ‘get it’. But to adopt the 12-step way of living, of seeing the world, a person has to change. And change is very, very hard, and very rare. I remember my own first experience with the twelve steps: sick with withdrawal I wandered into a mall bookstore, found a book about AA, and read through the 12 steps. I concentrated for a few minutes, and considered what they said. Later that day, after using, I thought… ‘that didn’t work’. I’m trying to be a bit funny, but my point is that many people think that ‘recovery’ consists of intense education. Those people are eventually frustrated in treatment, as they think they are ‘getting it’ and yet their counselors and peers keep telling them that they are not getting it. In reality, treatment through a 12 step approach requires a deep change of attitude that is very difficult to come by. I like the saying ‘insight maketh a bloody entrance’. True change usually requires a significant period of distress– a rock bottom, a depression, a great deal of personal turmoil… another comment frequently heard in treatment is ‘crisis equals opportunity’, or ‘the Chinese symbol for crisis is the same as for opportunity’– something that I suspect is not actually true, but I could be wrong.

Wow. I talk too much. OK… practical problems to requiring 12 step attendance… My point (in case you zoned out) was that sitting through 12 step meetings, while not in the middle of a personal crisis at least at the start of 12 step exposure, may be a total waste of time. Ditto for attending ‘recovery group therapy’. Those things work for one type of treatment, and I see little reason why they would be helpful for people on Suboxone. An analogy… (wish me luck)… people with hyperthyroidism sometimes have the thyroid gland surgically removed; other times the thyroid is destroyed by taking radioactive iodine. If a person has had the entire thyroid removed, it makes little sense to then make them take radioactive iodine. Wow… that isn’t bad…

On the other hand… people with thyroid cancer have their thyroid surgically removed and then take radioactive iodine just in case some thyroid tumor cells were left behind. Given that opiate addiction is a fatal illness– at least as fatal as any cancer– maybe the more done, the better. I will say that anyone who is on Suboxone who is attending NA or AA or who wants to attend, and who can deal with the privacy issue of taking Suboxone, GREAT! If you can ‘get it’– if you can truly understand your powerlessness over substances and turn your life over to your ‘Higher Power’– you will be better off for doing so. You will also be in the position to get off of suboxone at some point.

I had better close, but will add one last thing. I will save the ‘dosing’ issue for another post, but please stay tuned because it comes up very often and there are some important concerns. But my last point today is that Suboxone does NOT cure opiate addiction, just as atenolol does NOT cure high blood pressure. To be honest, ‘cures’ are rare in medicine– we usually help the body heal itself or provide medication that ‘maintains’ a reduction in symptoms. We don’t fix the faulty blood pressure set point that is the core problem with hypertension– we give meds that artificially force the heart to pump with less force or at a lower rate, or that make the blood vessels open up wider, and that drops the blood pressure. Stop the medication and there often is a situation like ‘withdrawal’ where the blood pressure rebounds higher. Suboxone is an incredible medication– I know what it is like to be trapped by addiction before the days of Suboxone, and I understand why suicide is such a common outcome with addiction– if taken properly Suboxone will put addiction into complete remission, and that is a wonderful advance of science that saves many lives. BUT…. a person who becomes addicted to opiates has only three options: Buprenorphine maintenance for life, 12-step meetings for life, or prison and death.

DO NOT THINK THAT YOU CAN TAKE SUBOXONE FOR AWHILE, DO NO OTHER TYPE OF TREATMENT OR INSIGHT WORK, AND THEN STOP SUBOXONE.

In my next post I will try to talk about what a person on Suboxone CAN do to eventually stop taking the medication. I will also discuss the ever-important dosing question. The ‘sneak preview’ nutshell version is to follow the instructions of your prescribing doctor. Addicts take what they think they need to take– patients take what they are prescribed. You are not an addict anymore– are you?

The ‘Hole’

A question from a suboxone user:

I feel this big empty hole that I tried to fill with Opiates. Since on the Suboxone I’m not pulled towards the Opiates but I still have this hole that there is still a need to fill with something. It’s not there because I’m off the Opiates. It was there before the Opiates. They just happened to fill that hole to some degree. Does anyone know what I’m talking about or have the same experience?
Thanks
R.

My Response:

I understand what you are saying– at least I think I do. It is always hard to compare subjective experiences– for example, is my experience of ‘green’ the same as yours? But I do know that feeling of emptiness, darkness, loneliness, sadness, abandonment, despair… and like you, in my case it was present long before opiate addiction. I have heard many opiate addicts speak of the same thing as well– I wouldn’t say it is universal, but it certainly seems to be present in most people with opiate addiction who I have met over the years. I can tell you that most people found opiates to be the ‘perfect medication’ for that type of pain… at least until tolerance and the craziness of needing more and more took over and ruined everything.

I also often hear that the pain of that ‘hole’ is treated, at least partially, by suboxone. Again, I think that the main problem is tolerance– which is measured with suboxone (or more accurately with buprenorphine, the active drug), but which still occurs to some extent.

I think that the hole is often a manifestation of what we psychiatrists call ‘Borderline Personality Disorder’. Everybody has their own way of seeing the world– of seeing relationships, of seeing one’s own role in the grand scheme of things, of seeing their own traits as compared to others…. all of these views total up to form the ‘personality’ of the individual. The collection of views, perspectives, opinions, etc are a result of genetic influences, developmental influences, cultural and societal experiences, and life experiences, and for the most part the entire assembly is relatively ‘fixed’ at an early age– at least by our late teens. Ideally a person has a certain amount of flexibility built into their personality– the ability to change views and reactions to a wide range of situations. If a person has an inflexible way of seeing things they often run into recurrent problems in life– and in such a case may be considered to have a ‘personality disorder’.

Borderline PD likely forms in reaction to genetic factors to some extent, but a common environmental factor is the failure to form the intense bond with a parent (usually mom) at an early age– before age 2 for the most part. Many people will have the opinion that mom was perfect and so they didn’t have anything like I am describing– at least until I get to them and start talking about specifics. The point, of course, isn’t to blame our mothers, but rather to understand all of the factors that made us who we are, with the understanding that our mothers and fathers are products of their own upbringing just as we are. Anyway, mom may look ‘perfect’ when viewed through our adult eyes, but when we were babies she may have been unable to bond with us– perhaps she had her own addictions, or was depressed, or had an anxiety disorder… or perhaps she worked 80 hours per week and was just too tired to spend much time gazing into our eyes. Maybe she had 8 other kids to take care of. Or maybe we were born premature and we were so fragile that she was nervous every time she held us. Maybe we cried to much that she was often too angry to appreciate the quiet times. Who knows… but it is clear that the failure to bond is connected to BPD, and that BPD is not something restricted to single parents or to lower socioeconomic groups– it occurs in people who are CEO’s, doctors, electricians, teachers… and homeless people as well.

People with BPD have an ache that never goes away, and a ‘hole’ that can never be filled. I won’t go through all of the characteristics, as you can easily find them by googling ‘borderline personality symptoms’ or something similar. People with that basic personality often try to fill the emptiness with drugs, or more often with relationships– which are usually dysfunctional because the person tends to seek out traits that don’t make for healthy relationships. For example, people with BPD are attracted to very intense emotional connections, and for that reason they tend to attach to other people with BPD. People with such a personality tend to see people and the world in ‘black and white’– so people are either idealized and placed on a pedestal or hated and seen as completely without value. A partner may initially be seen as perfect, but over time the relationship is bound to disappoint, and then the partner is seen as horrible. Other problems include that fact that in healthy relationships, a person enters the relationship already ‘whole’ and complete, and brings assets to the relationship, but in BPD people enter the relationship looking for a person to MAKE them feel complete– and again, no person or relationship can be relied on to do that for very long.

Patients with BPD are often cutters; they often have intense mood swings that are misdiagnosed as bipolar (the mood swings in BPD are of much shorter duration and are ‘reactive’ to the environment); they often have periods of intense emotional pain– they ‘become’ depression rather than ‘have’ depression. They often feel entirely alone in the world. They often have a history of multiple suicide attempts, and are often treated with dozens of medications over their lifetime– none of which ever work very well.

There are many books about BPD that patients may find helpful– one such example is a book called ‘I hate you– don’t leave me’, reflecting the intense fear of abandonment that is classic in BPD. There is a type of therapy called ‘DBT’ or ‘dialectic behavioral therapy’ that reportedly has shown some success in reducing the behaviors that cause problems for patients, such as cutting or suicide attempts. My usual approach is to first do no harm– to try to avoid hurting the patient by either prescribing medication that is ultimately harmful (like benzodiazepines) or by forming professional relationships that are too intense and that make a patient dependent on their therapist.

A Reply to Chronic Pain:

I feel that I have a good understanding of suboxone…. With the exception of the pain issue. The reason for my lack of confidence in that area is because first, I have seen less-consistent results in pain patients, and second, some of the claims made by patients just don’t make sense!

Suboxone has several characteristics that make it different from opiate agonists (like oxycodone); the ‘ceiling effect’ combined with the long half-life results in a very stable subjective experience—there is no up and down, but rather there is a constant level of opiate effect over time. Tolerance occurs very rapidly—that is a good thing for addiction treatment, as the person taking suboxone feels ‘normal’ within a few days. But just as the person becomes tolerant to the sedation, respiratory depression, and other side effects of buprenorphine, I would expect tolerance also to the analgesic effects. So theoretically it should not be a good pain drug because the rapid tolerance would eliminate the analgesic effect after a few days.

In reality, though, patients will claim relief from suboxone for an indefinite period of time in many cases. I have no explanation for such an effect; perhaps it is all a placebo response, or perhaps (more likely probably) the pain control system is much more complex than we imagine. The other odd thing is that pain patients will often claim that the analgesic effect of buprenorphine increases linearly with dose, without reaching a ceiling and leveling off. That makes no sense to me either—the analgesic effect of opiates occurs at the mu receptor, which is the site where buprenorphine binds as a partial agonist, and so the ceiling effect should apply to the analgesic actions of buprenorphine. I suspect that in this case the placebo response is the reason for the patients’ perceptions.

Suboxone certainly has advantages over other opiates, if it is found to be effective. The tolerance with buprenorphine is limited, whereas the tolerance to a pure agonist has not limit—so there is a lower amount of withdrawal if/when the drug is eventually discontinued. The stable blood level prevents the temporary ‘highs’, the miserable lows, and the cravings that can accompany the use of agonists. The patient feels much more clear headed on suboxone compared to opiate agonists. And suboxone can be dosed once per day, which has a couple effects—first, it just is less trouble to take, but more importantly the absence of ‘as needed’ dosing all day long will help prevent the patient from focusing as much on the pain.

As far as the personality effects… many people have told me that suboxone seems to work as a ‘mood stabilizer’—they feel less labile, more regular, and generally a bit happier on the drug. There are case reports of opiates treating depression or precipitating mania, but buprenorphine doesn’t seem to push people to euphoria, but instead seems to ‘level’ their mood. Maybe that is what you have seen in your friends. I think that part of the effect relates to cravings; cravings can manifest as mood symptoms, and as suboxone eliminates cravings, it also eliminates some of the mood symptoms. This raises the issue of whether buprenorphine should be used to treat mood disorders… and for that I will leave the readers to do their own research. A couple years ago there was an article in Elle magazine by a woman describing her treatment of depression using suboxone. I do not know of any large clinical studies that support such use at this point.

Chronic pain is a very difficult issue, and I wish you the best. I encourage you to avoid opiates as much as possible—there is generally little future in opiate treatment of pain, since tolerance always chips away at the effects of the opiate over time. I am sure that at some point we will have ways to prevent tolerance, which would be quite a thing for people with chronic pain. On the other hand I can imagine many dangers associated with such a discovery. Thank you very much for your question; I am going to go ahead and post on my blog, http://suboxonetalkzone.com , and on the forum at http://suboxforum.com (without your real name).

J

About the Rash…

Hi Cindy,

I haven’t been to the other site (suboxforum.com) yet, so I don’t know if anyone has answered.  I have treated over 100 patients and have not yet had a person develop a rash.  That doesn’t mean it can’t happen, but it does suggest to me that it is uncommon.  The rash does not sound typical of drug reactions, which usually start on the face and chest and then spread from there.  The spots– what are they like?  a drug rash usually would have red spots that are small but that can eventually join together to make the whole area look red.  They often itch.  A drug rash would not look like pimples, or bumps with ‘white heads’ (which are from pus)– those are more consistent with impetigo, which is an infection.

Try using google images and search for ‘drug rash’ or ‘allergy’– I haven’t done it yet but I bet you will find pictures of typical allergic drug rashes.  If you do have a rash from suboxone the first thing to do would be to change to subutex.  There is a good possibility that you are actually allergic to naloxone, not buprenorphine.  If you change, I would give it a good month before drawing conclusions, as it sometimes takes a long time for an allergic rash to go away after the stimulus is gone.

If subutex doesn’t help, hopefully you have an understanding doc who is willing to give you methadone for awhile to see if the rash is in fact due to buprenorphine.

Why Not Just Take Narcotics for my Chronic Pain?

I received a letter today– a person discussing the use of opiates by a family member with chronic pain.  I was not sure if the letter was asking questions about my opinions, or was instead arguing that my ideas were off-base.  In either case it is worth publishing, as several topics are discussed.  As per usual, the names were blocked to keep things confidential.

Here it is, with my answers:

Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN.

Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.

If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.

I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.

For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.

Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?

We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.

What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.

Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.

Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.

There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.

So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading

I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.

OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.

That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

J

Parole Officer demands stopping subox

This is irritating– a person is stable on suboxone, employed, turning their life around… and their PO from the case over a year ago wants them off ‘that drug suboxone’. Un-F-ing-believable. My letter to the PO:

I treat XXXXXXX for opiate dependence. He and I have arrived at a taper schedule as you requested. I do feel obligated, however, to let you know that tapering off suboxone is not appropriate care for his opiate dependence.

I have no shortage of patients on suboxone– I am always at the 100-patient limit, and there are always people waiting in line if a patient leaves my care (The most common reason for stopping suboxone is pregnancy). I have no financial incentive to keep XXXX on suboxone; if anything I will be paid more for a new patient taking his place. I have a great deal of experience with addiction; I treat some patients with suboxone, and others by different techniques, depending on their personality, addiction/treatment history, and circumstances. I have treated about 150 patients with suboxone over the past two years; other patients were treated by myself in outpatient therapy, or referred to residential treatment.

I remain current with the standard of care for addiction. I am the Medical Director of XXXXXXXX, a residential and outpatient AODA treatment center in Wisconsin. I am Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, where I teach medical students and psychiatry residents. I do the teaching of the addiction section of the mental health/behavior block for medical students. In the case that you do not accept my opinion on the matter, you can easily find ample support for the use of buprenorphine for long-term maintenance of remission of opiate dependence. I suggest starting at ASAM, the American Society for Addiction Medicine: http://asam.org. The president of the organization, Dr. Michael Miller, practices in Madison Wisconsin and is a strong advocate for the use of buprenorphine and Suboxone.Despite efforts to educate physicians and the public, there are a number of misconceptions and prejudices about Suboxone. The active ingredient of Suboxone, buprenorphine, has a distinct mechanism of action at the opiate receptor that is unlike the effect of oxycodone or methadone. After two-three days of use a patient on Suboxone feels no effect from the medication– no ‘high’, and no sedation. A patient on Suboxone cannot get an effect from any other opiate. The action of Suboxone that sets it apart is the effective relief of craving for opiates, which in effect induces full remission from active addiction. Patients on Suboxone are relieved of the terrible obsession that keeps them from moving forward in life. My patients include attorneys, physicians, nurses, prison guards, and factory workers, all grateful to have opiate dependence out of their lives.

There are certainly cases where total sobriety is favored over Suboxone. It is important to realize, however, that even with thorough, residential treatment, the relapse rate for opiate dependence remains well over 50%, much higher than that of other substances. Patients who maintain sobriety through 12-step meetings can expect to have cravings for the rest of their lives. I have had a number of patients tell me that traditional recovery kept them clean and feeling like a ‘recovering addict’, whereas suboxone made them feel like a person who was never addicted in the first place. The role of meetings and therapy for patients on suboxone is debatable, as the relief from the obsession to use allows good character to return. Most of my patients are working and doing well in life– as is XXXXXXXX.

The best way to understone Suboxone treatment is to compare it to treatment of hypertension. Like opiate dependence, high blood pressure is in part genetic, and in part caused by behavior (diet, smoking, lack of exercise, e.g.). We cannot ‘fix’ the defect in hypertension– which is a brain abnormality that causes a faulty ‘set-point’ for blood pressure. We instead artificially dilate blood vessels and weaken the pumping of the heart with medication, and the pressure drops. If we stop the medication, the high blood pressure is still there. The medication causes ‘remission’ of the high blood pressure– not a cure. Likewise, opiate dependence is in part familial and in part behavioral. We have no cure– no way to eliminate the obsession to use that characterizes addiction. But we now have a medication that will induce remission of that obsession. The comparison does not stop there– with both hypertension and addiction, we have non-medical ways to treat the diseases, using the power of the mind. For addiction, the person can work hard to drastically change their mind through hours and hours of treatment and life-long meetings. For hypertension, a person can use biofeedback and meditation to control their blood pressure– can you imagine how effective it would be if a patient put the same effort into it that an addict puts into meetings and treatment? Of course, we would never expect a person to go to that effort to control their blood pressure when medication is available… and yet we think of an addict very differently, and consider medication to be the easy way out. Yes, it is hard to get off suboxone…. Just as it is hard to get off some blood pressure medications, which cause ‘rebound hypertension’ when they are stopped.

As I said, XXXXX is prepared to taper off suboxone, as he has no choice. He will have life-long cravings that will at times occupy his mind and make him irritable. He will place himself at risk of relapse, which could land him in prison or even kill him. As his doctor, I have to wonder about the sense of that, particularly when he is being forced to deviate from the standard of care and face these risks because of someone else’s misconceptions and biases. I used to have similar misconceptions when I read the first studies about suboxone– after all, I treated my own opiate dependence by hours and hours of outpatient sessions and meetings, and then after ten years I treated my relapse by over three months away from my family, in residential treatment, followed by hours of groups and more meetings. The treatment was effective, but I lost my career as an anesthesiologist along the way, and almost lost my marriage and my life. And yet I was lucky– many people in the same position don’t survive. Thank goodness we have progressed to a point where almost everyone can be saved, treated to remission, and go on to live productive lives.

Sincerely,

Jeffrey T Junig MD PhD

Fond du Lac Psychiatry

Wisconsin Opiate Management Center

New Suboxone Forum

I invite anyone with an interest in Suboxone, either for one’s self or for someone else, to visit the Suboxone Talk Zone Forum at http://suboxforum.com . You can read posts without registering, but please register and take part in the discussion! You do NOT need to provide your real information to register– invent a good screen name and you will be all set before you know it. I hope to see you there!

Induction, Relapse, Benzo Questions

Some questions about the induction process and my answers:

If I try to just take the oxycodone for a period of time prior to meeting with you would that eliminate some of the problems and complications associated with the transition from methadone to suboxone? If I took only oxycodone for 4 days or 6 days might I be able to go directly to suboxone without that withdrawal period?

Yes, it is helpful to change from methadone to oxycodone for a stretch of time. Methadone is highly protein-bound, and takes forever to leave the body– I like people to be off methadone for at least 4 days, whereas 24 hours off oxycodone is usually sufficient to avoid precipitating withdrawal with suboxone. There is no way to avoid withdrawal completely, however, as a person must be in a bit of withdrawal at the time of suboxone induction. Otherwise the person will get very sick.

Would I be feeling well enough by (specific date) to be physically comfortable enough to be a joy to be around or will I still be suffering? I believe I will need some help just with the driving alone…

Some people start suboxone and go to work later the same day– it depends on the person’s individual ability to handle the withdrawal, and on their tolerance to opiates. A person who takes less than 40 mg of methadone per day (or the equivalent dose of oxycodone) will generally have no problem adjusting to suboxone. I have done inductions on people taking well over 100 mg of methadone per day, and they do OK as long as they have gone without methadone for a few days. If you can change completely to oxycodone and avoid methadone for a few weeks before suboxone, you will do better.

In addition to the methadone I have also been prescribed Clonazopam (a benzodiazepine) that I take with the methadone. I take 3 to 4 mg a day. Can Dr. Junig prescribe me that or a different one and get me tapered off the benzo’s? I really want to be clean and sober as I once was… I stopped going to meetings and I had gone to over a thousand during that time and was pretty darn healthy in all ways; but after I stopped I picked up a drink and eventually narcotics again.

Clonazepam is a dangerous med for anyone with a history of addiction. The tolerance that develops makes the drug helpful only for short-term use, for the most part. I will prescribe it sometimes for a person who is taking the proper medication for anxiety (like prozac or effexor) but who still has breakthrough anxiety, as long as the dose remains stable. 3-4 mg is a high dose, and I would want to try to taper that down a bit if possible.

The part about the meetings is typical. Opiate dependence is a long-term affliction—life-long for most people. People contemplating suboxone have two choices: life-long medication, or life-long meeting attendance. At this point there is no cure. Addicts who stop going to meetings eventually go back to opiates, for the most part. Likewise, it is important for people who stay sober through the 12-steps to avoid all intoxicants. Use of a different drug often results in ‘cross-addiction’ to the different substance, which then often leads back to using the drug of choice.

More Suboxone Information at subox.info.

 

 

Suboxone Use by a Health Professional

A reader writes:

I have been taking Suboxone for 2 months now and it has changed my life! I finally feel a freedom I haven’t felt in over 30 years! I am a nurse and am able to work around and administer narcotics with absolutely no thoughts, urges, or cravings…a miracle for me. BUT, the hospital I work for has just informed me I cannot be taking suboxone while employed there.

I am just in shock. Is there any recourse for me? Are there any laws protecting my disease/disability medical management?

I feel it’s like being told I can’t take my insulin if I were diabetic.

Any suggestions?!

Ouch!

I have been watching to see what position the various Licensing Boards take on suboxone. I did not expect to hear of such a silly demand by an employer– particularly an employer that supposedly has an interest in keeping people healthy.

If you read some of the forums out there you will come across this statement: “We need our doctors and nurses to be 100% on their toes– would you want your surgeon to be on suboxone?” My answer, of course, is YES– particularly if he/she has any history of opiate dependence. I want his/her mind 100% on my surgery… not on the last meeting they went to, not on the meeting that they need at the end of the day, and not on the narcotic prescription that they will write after the surgery If they are taking suboxone, then I know that they are essentially ‘normal’– they are not having cravings, they are not sedated, they are not ‘high’– they are the person that they would be, if they were able to dissect out their opiate addiction.

For our nice nurse, I wish that you could go and hire the best employee-rights attorney in the country, and sue the hospital for wrongful termination. In fact, as I think about it, I wonder if they can even make such demands. Can a hospital threaten to fire a patient for taking antidepressants? If not, how can they threaten to fire you for taking suboxone? They would have to claim that it somehow impairs you from your job– and how could they do that? As anyone taking suboxone knows, once you are used to the medication there is no significant effect from taking it.

I actually DO have a great attorney for this type of work. The problem is that lawsuits cost money. I will send him an e-mail and see if he has come across this issue before. In the meantime, don’t do anything drastic. You may want to consider drafting a letter that threatens to go the the EEOC over the issue. They cannot fire a person for having a protected disability, including addiction (they can fire a person for behavior, or even risk of behavior, related to the addiction– but if the addiction is only a ‘past’ issue they can’t hold it against you).

Stay tuned…