This Suboxone Doesn’t Work!

Today on SuboxForum people were writing about their experiences with different buprenorphine formulations.  Doctors occasionally have patients who prefer brand medications over generics, but buprenorphine patients push brand-loyalty to a different level.  The current thread includes references to povidone and crospovidone, compounds included in most medications to improve bioavailability.  Some forum members suggested that their buprenorphine product wasn’t working because of the presence of crospovidone or povidone.  Others shared their experiences with different formulations of buprenorphine and questioned whether buprenorphine products are interchangeable, and  whether buprenorphine was always just buprenorphine, or whether some people respond better to one product or another.

My comments, including my observations about patient tolerance of specific buprenorphine products, are posted below.

Just to get some things straight about povidone and crospovidone (which is just another synthetic formulation of povidone),  both compounds are NEVER absorbed, by anyone.   They are part of a group of compounds called ‘excipients’, and are included in many medications to help with their absorption.  They act as ‘disintegrants’– meaning they allow the medication to ‘unclump’ and dissolve in liquids, such as saliva or intestinal secretions.

Molecules tend to clump together, sometimes into crystals, sometimes into other shapes.  A pile of powdered molecules molded, packed, and dried into pill form wouldn’t dissolve in the GI tract if not for povidone or other disintegrants.  I remember reading somewhere about cheap vitamins that could be found in the stool, looking much the same as they did when they were swallowed.  Not sure who admitted to doing the research for that article..

Buprenorphine IS buprenorphine.  Period.  The absorption isn’t affected much by excipients, because nobody ever complains that their Suboxone or buprenorphine won’t dissolve.  Povidone or crospovidone are also added to increase the volume, because an 8 mg tab of buprenorphine would be the size of 100 or so grains of salt.  Excipients like povidone and crospovidone also help some drugs dissolve, especially drugs that are fatty and don’t usually dissolve well in water-based solutions.   This last purpose does NOT apply to buprenorphine, since buprenorphine is very water-soluble.  Zubsolv is supposedly absorbed more efficiently in part because it dissolves very quickly, and maybe that is due to excipients.

I realize that when I write ‘bupe is bupe’ it sounds like I don’t believe those who complain about their medication.  But honest, I work with people over this issue every day…  I have an equal mix of people who insist Suboxone doesn’t work for them and people who insist ONLY Suboxone works for them.    Today I was reading TIP 43–  a guide about medication-assisted treatment put out by SAMHSA and the Feds that is over 300 pages long, very well-cited– in a section that cited studies about the psychological triggers for withdrawal symptoms.  TIP 43 and other TIPs can be downloaded for free… just Google them.  TIP 43 is primarily about methadone, but some of the information applies to methadone and buprenorphine.  The pertinent section was around page 100, if I remember correctly.

The TIP information mirrored what I see in my practice.  For years, I’ve noticed that patients will complain about withdrawal symptoms even at times when their buprenorphine levels are at their highest.  Patients also report that their withdrawal symptoms go away ‘right away’ after dosing, when in fact buprenorphine levels won’t increase significantly for 45-60 minutes.  People who have been addicted to opioids may remember how even severe withdrawal mysteriously disappeared as soon as oxycodone tabs were sitting on the table in front of them.   The bottom lline– withdrawal experiences are remembered, and those memories are ‘replayed’ in response to triggers or other memories.

In my experience as a prescriber, I’ve come to believe that patients with an open mind will learn to tolerate any type of buprenorphine (the exception being the 1 patient I’ve met who developed hives from meds with naloxone– hives that appeared consistently on three distinct occasions).  But withdrawal symptoms seem to be triggered, in many people, by the expectation of withdrawal symptoms.  So someone convinced he will never tolerate Zubsolv, Bunavail, or Suboxone Film will probably never tolerate those medications.

As for buprenorphine, it IS just buprenorphine.  Molecules with a certain name and structure are always identical to each other.  They are not ‘crafted’ products like bookcases or tables;  some buprenorphine molecules aren’t made with a quality inferior to other buprenorphine molecules.  And once a molecule is in solution, I don’t see much role for excipients.  Of course a tablet or strip could contain too much or too little active drug, but that is an FDA issue, not an excipient issue.

Buprenorphine Regulations and Unintended Consequences

First Posted 8/28/2013

I realize that I am halfway through a post called ‘Suboxone Abuse Part I’.  This is poor form, but I am now going to get halfway through a second topic before finishing the first one.  Sorry.

I recently came across a problem relating to the new healthcare law.  I was thinking about writing ‘How the Affordable Care Act Is Killing a Few People’, but I figured that such an inflammatory title would chase away about half of my readership.   So I used the title I liked second-best.

I’ll first write about a couple background issues that are obvious to those of us who work in healthcare but less obvious to others.  These things are important to know, in order to understand the second post.  I won’t try to take one political stand or another, so hopefully the people who reflexively support or bash either side will take a chill pill, tune into the issue, and allow my perspective to filter into their knowledge base.

When I was in med school, I bought a brand new Hyundai for $3900. The car was a ‘loss leader’.  Businesses owners use loss leaders to increase buzz about the business or to get people through the door, hoping to make up the loss by selling more profitable merchandise.

You may have noticed the disappearance of private doctor practices over the past 20 years.  There are many reasons for the loss of private practices, but from the perspective of an owner of such a practice, a primary reason is because individual doctor visits, especially for primary care, have become loss leaders for healthcare systems.  Patients attached to systems through loss leaders– primary care physicians– become sources of profit when they are admitted, have MRI’s or surgeries, or see specialists.

Look at the cost for different types of ‘health care.’  Your insurer pays less than $200 for a doctor to sit with you, 1:1, for 15-30 minutes.  That same amount of time in an MRI costs your insurance ten times more, and an hour in the operating room costs $5,000-$20,000.

Health systems negotiate with insurers with an eye on the big picture.  An orthopedic injury—say a torn ACL—brings an ER visit, X-rays, MRI, surgery, and physical therapy, with revenues well over $20,000. A patient with heart disease brings in $50,000 or more for EKGs, stress tests, cardiac ultrasound, angiogram, angioplasty, and bypass surgery.  Cancer care can top $100,000 when surgeries, radiation therapy, and chemotherapy are included. Even a relatively common injury—lumbar disc herniation– requires MRI, PT, a variety of injections, and laminectomy or spinal fusion, with revenues up to and over $100,000.

While individual doctor visits are more common than heart surgery, the MRI suites and catheterization centers are the profit generators for health systems and the hot topics of insurance negotiations.  To the big systems, whether the family practice doc is reimbursed $120 vs. $160 per visit is a minor consideration—just as we are more careful buying a home than a soda.  But solo-practice docs must carefully consider the payments for office visits, since they are the ONLY revenue.   Independent docs are offered the discounted reimbursements that insurers pay the big healthcare systems, but unlike the systems, small practices have no high-revenue services to subsidize lower-revenue patient visits.  With no high-revenue services to subsidize lower-revenue patient visits, independent physicians must be very careful in providing discounts to be part of insurance panels.  Some types of payments—the $30 for a 20-30 minute office visit paid by Medicaid—won’t keep the lights on after malpractice, office staff, rent, and utilities are paid.

It is hard to run a business selling only loss leaders.  That’s why the Hyundai dealer tried so hard to get me to test drive other cars. It wasn’t until I threatened to make a fuss about ‘bait and switch advertising’ that I was allowed to buy the $3900 car pictured in the newspaper ad.  There was no profit in that sale, but the dealer knew that most people would turn away from the unwashed beater and consider other cars on the lot (he didn’t take into account how broke med students are!).  Without bigger sales, the business can’t survive.

The second issue I need to cover is the shortage of doctors who prescribe buprenorphine, and the reason that buprenorphine prescribers are more likely to be independent or small-practice physicians.

To prescribe buprenorphine, doctors must take a short course and fill out some paperwork—not a big deal.  A bigger deal is that buprenorphine-certified doctors must allow random inspections by the DEA without cause.  Doctors who work for health systems get a paycheck each week, often regardless of the number of patient visits.  For an employed doctor, does it make sense to take an extra course, file extra paperwork, and agree to random inspections, in order to see more people but for the same pay?

Patients in need of buprenorphine treatment have usually lost a great deal due to their addictions, and are not great ‘sources of revenue.’  I suspect that my own enjoyment treating addiction comes in part from my personal experiences ‘in the field’.    Beyond that type of interest, young doctors do not leave residency eager to take on patients who have been dishonest with other doctors, who early in treatment appear a bit ‘rougher’ than their other patients, and who have no disposable income!

The two issues must be understood and combined, in order to understanding the second half of the story (that I will get to eventually…).   In review, the first point is that individual medical practices are disappearing because of a flawed business model.  Fees charged for individual appointments are far lower than revenues from tests, procedures, and surgeries.  Large systems can subsidize doctor visits with revenue from MRIs and surgery centers.  Doctor visits are ‘loss leaders’ for more profitable services.  One cannot make a ‘business’ from loss leaders, without the second half of the equation.

And second, doctors who prescribe buprenorphine are more likely to be independent practitioners with their own businesses.  Another way to say it is that doctors who are employees of health care systems are less likely to obtain certification to prescribe buprenorphine.  The extra patients that comes with buprenorphine certification cause more paperwork and more regulation, without an increase in pay.  Beyond personal motivations, doctors have no incentive to treat addiction; in fact there are significant disincentives to becoming buprenorphine-certified.

Put the two together, and you have more and more communities where several large systems compete for patients, and nobody prescribes buprenorphine except for the one or two independent practices that haven’t closed yet.

Should Addiction Treatment Include ‘Shame’?

Originally Posted 3/23/2013

I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.

Is All Shame Bad?

My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin.  Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.

I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication.  As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap.  They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.

But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment.  I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges.  To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences.  Maybe they haven’t suffered enough consequences.   But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.

I always consider each new patient’s history of ‘consequences’.  I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with opioid dependence.  I note that consequences impact people similarly in some ways, and differently in other ways.  For example, most people have trouble imagining just how bad things are likely to become until they actually get to that degree of severity.  People who’ve never used a needle believe they will never do so, and people who haven’t been arrested can’t see themselves in that position.

But once consequences occur, people react to them in widely different ways.  Some people react to felony charges with horror, while others appear indifferent.    A near overdose might cause warning bells to go off in one person, yet cause little reaction in someone else. One person will be ashamed and humiliated the first time in jail, while another seems to simply adapt, as consequences move from bad to worse.

Are ‘consequences’ the missing piece of the puzzle for patients who don’t do well on buprenorphine?  If so, are the differing reactions that people have to consequences clues to helping poor responders? Should counseling efforts target for elimination those attitudes of ambivalence or indifference toward negative consequences?

In general, shame is viewed as a hindrance toward recovery.  The cycle of shame is well-known by everyone who treats addiction; the idea that ‘shame’ serves as a trigger of using, which in turn generates more shame, and so on.  But when I see a 20-y-o patient who is addicted to heroin shrug off another relapse, I wonder if in some people, a little shame would be a good thing.

Some comments from readers of the original post:

  1. Lg

Interesting article and noteworthy to me in the sense of shame being a big motivator. Mostly I think is the personal shame I feel for having let opioids kick my arse. In my case the amount of guilt/shame is unbelievable. I’ve been around the block many times and really don’t think I have another one in me. I hope and pray these younger guys get and stay with the program. The other choice just might be the last one they ever make. BTW C&S 5yrs

  1. devin91

Jeff, I think a little shame is probably a good thing. William Moyers (one of the guys running Hazelden and coincidentally Bill Moyers’ son) addresses the issue of shame head-on in his book “Broken” about his own battle with cocaine addiction (which, unfortunately, there is no medicinal treatment currently available for). His view, as I remember from reading the book, is that shame is an intensely emotional recognition of consequences, and one’s responsibility for those consequences. Obviously, too much of it can be bad – as you note. But a measured amount of shame is probably the appropriate response to a negative consequence or relapse.

On an another note, I think your observation about a positive correlation between age and response to buprenorphine is very interesting. However, it also highlights the fact that the opioid epidemic afflicts younger demographic groups with greater severity (by almost all measures) and in greater numbers than it does older age groups. Opioid addiction is growing faster among younger patients, and (according to SAMHSA data) female patients, and it is also killing them faster. Older patients therefore, *may* be statistical confounders, in the sense that they have already survived a lethal illness for longer. In other words, there may be some additional factors that make older patients “better responders” to buprenorphine, and to recovery in general. They are “better patients” overall, perhaps?

I agree that patients who don’t seem to acknowledge or care too much about “consequences” are extremely frustrating. But I think this phenomenon begs the question of WHY patients suffering from addiction seem to ignore consequences in general. In fact, the disease of addiction often seems to be the disease of IRRATIONALITY – taking actions against one’s own interest. It is my hope that medications like buprenorphine can give these younger patients a break from the cycle of relapse/shame/relapse, and give them time to develop a RATIONAL perspective about consequences. But I agree that a patient who blithely shrugs off a relapse IS FRUSTRATING, and perhaps IS a little bit “blameworthy”. But I hesitate to tread down that path of thinking, because then you come full circle to blaming the patient for their disease.

As the opioid epidemic continues to rage in the US and across the globe, I would rather see “shameless” patients ALIVE (to have a chance at developing an appropriate sense of consequences and shame) than see a trend towards the view that patients who don’t develop a rational perspective are somehow less deserving of treatment. In short, I’m hoping that your clinical frustration with these patients will not dim your passion for saving the lives of opioid-addicted patients, ESPECIALLY THE YOUNGER ONES. Yes, a little shame would be good, but I don’t find it terribly surprising that the younger cohorts have less shame, more “resilience”, more “arrogance”, and are harder to treat as patients. But that doesn’t change the fact that the opioid addiction epidemic is killing FAR MORE OF THEM than it is older patients.

This comment should not be taken in any way as a detraction from your commendable work, both at the clinical level and the policy level (e.g. lifting the caps, etc.). I’m just musing on these issues, and thinking out loud here.

Xanax Worsens Anxiety and Panic

First posted 12/13/2012

Anxiety is one of the most common presenting complaints for people who come to my psychiatric practice. By the time people with anxiety visit a psychiatrist, they have usually discussed their symptoms with friends and family members, and some have been to their family care physician. And as a result of these initial ‘consultations’, they often have been recommended or prescribed valium-type medications like Xanax or Klonopin— a class of chemicals known as ‘benzodiazepines.’

There have also been several highly publicized deaths from combining pain pills with benzodiazepines. The medications are commonly prescribed, and there are a number of misconceptions among laypeople about their proper use. I’ve written about this class of medications in the past, but given the frequency that they are prescribed and mis-prescribed, the topic deserves another visit.

Most experienced doctors have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are in a lose/lose position. Why lose/lose? Because the experienced doctor knows that the options are to do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.

A primary reason for the lose/lose proposition is that the non-medical community associates SSRI’s like Prozac or Zoloft with antidepressants, and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. But in reality, sedatives are useful in some situations, for example acute or short-term anxiety. But for chronic anxiety, the proper treatment consists of SSRIs or closely-related SNRIs.

Today a new patient requested treatment of her addiction to pain medications. When I asked about other symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are dangerous for opioid addicts, and are intended for short-term use. She assured me that the milligram of alprazolam she is taking doesn’t even do anything, intending to inform me that her medications are not potent enough to worry about. But I took her assurances the opposite way—that she has taken benzodiazepines to the point where even very large doses of the medications have little effect because of ‘tolerance.’

She then said she also has attention deficit disorder and takes amphetamine. I explained that she is doing herself a disservice by taking both amphetamines and benzodiazepines, since benzodiazepines CAUSE attention problems; in fact, that is how they work! Anxiety essentially consists of too much attention to a problem or a fear. Benzodiazepines treat anxiety by preventing the brain from attending, attaching and remembering.

Anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block memory. Most adults have had the experience of watching an anesthetic medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” For minor procedures they experience a loss of memory, not a loss of consciousness. They transfer to the OR table when asked, but have no recall of doing so because of the benzodiazepine’s effects. I repeatedly tell students in my university practice to avoid benzodiazepines, if nervous about an important exam. Amnesia and studying don’t mix!

The patient described above said that she takes stimulants for attention deficit disorder. Beyond amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.

A related question came to me by e-mail yesterday:

Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.

The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of meds by others suggest that she is asking for a benzodiazepine.

Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”

All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.” Let’s run through the list of 12 things, just in time for Christmas—and don’t forget to check it twice!

  1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become ‘anxiety.’ Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?
  2. Even if the medication is truly helpful, her relief will be short-lived due to tolerance. The human body quickly adjusts to benzodiazepines (and many other medications) so that a continued effect requires a higher and higher dose. Patients often escalate their dose at some point, no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault; it is simply what these meds do. Dose escalation is difficult to control, once it has begun; patients will call two weeks into a month prescription to report that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.
  3. Benzodiazepines turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzodiazepines upon arrival. Several months later, the most amazing thing happened: the anxiety disorders went away!
  4. A problem specific to patients with addictions is that rather than take sedative medications to achieve the absence of anxiety, they take the medication until they feel relaxed. In other words, instead of seeking normalcy; they seek relaxation. There is a difference between the two states! The mistaken goal is simply a consequence of the conditioning process during addiction. People with addictions don’t often realize that they are seeking ‘fuzziness’— a feeling that people without addictive histories often find uncomfortable.
  5. Again specific to people with addictions, benzodiazepines (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. People with addictions are overly aware of how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.
  6. People with addictions who favor one class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed. This phenomenon is called “cross addiction.”
  7. A final concern for people with addictions is that benzodiazepines help preserve the mistaken thought that the person cannot function without taking something.
  8. Benzodiazepines impair driving and working with dangerous machinery. And patients get anxious at work too—making the medications a poor choice. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzodiazepines.
  9. Benzodiazepines have been linked to fetal anomalies and early miscarriage.
  10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes a benzodiazepine during the day, he or she will go to bed just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzodiazepines both day and night, tolerance increases even more quickly.
  11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures (and worse) during withdrawal.
  12. Benzodiazepines may calm an anxious person, but they do not generally increase function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings!

I do prescribe benzodiazepines, usually for short-term or intermittent use. Some patients do fine with them, but for others, benzodiazepines are a Pandora’s Box that is best not opened. As a psychiatrist, I often see treatment plans that lead to a mess that I must try to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful; comments are welcome!

Addendum:  Since the original post, a large British study showed a higher death rate in patients who have been on chronic benzodiazepine therapy, and a more recent study showed a link between benzodiazepine treatment and the later development of Alzheimer’s disease.

Kratom, Recovery, Elections

I received a question about Kratom, and searched for a earlier post about that plant/substance.  That post came shortly after Obama’s inauguration, after someone wrote to compare his experience at that event to his experience taking opioids.  Funny how every ‘high’ has its own ‘morning after!’

That Post:

On a message board called ‘opiophile’, a person wrote about being a long-term opiate addict, then taking methadone for a couple of years, then going on Suboxone for a couple of years.  He eventually stopped Suboxone, and had a miserable period of withdrawal… which never, by his recollection, ever totally went away.  He works for the Democratic Party (not secret info– it was in his post) and eventually used opiate agonists again (hydrocodone and oxycodone)… during his time in DC for the Obama inauguration.  He described how wonderful he felt, experiencing the opiate sensations while at the same time ‘being part of history’.

He returned to normal, boring, miserable life… until discovering a source for ‘Kratom’.  Kratom is a plant imported from Thailand that has opiate and other effects;  like many other ‘exotics’ it has not yet been scheduled as illegal by the DEA.  My understanding is that it is hard to find in pure form, and is expensive… there is also the risk of ingesting something (maybe toxic) that was substituted for what you think you are using.

In his post, the person asked if he is ‘clean’– whatever that means.  I don’t mean to be difficult here– I just mean that being ‘clean’ is different to different people.  Some people consider themselves ‘clean’ as long as they avoid their ‘drug of choice’…. the use of marijuana not a concern as long as they are depriving themselves of the Oxycontin that they REALLY want!  I don’t agree with that definition, but I can see the point of at least avoiding the things that are the most likely to cause problems.

He also asked if he was running the risk of returning to the same problems that have been a part of his life for many years.  I think the answer to that question is obvious to everyone reading this blog!  As for my other thoughts, I copied them below.

My Reply:

Kratom contains chemicals that includes mu receptor agonists– the chemicals do not show up (yet) in drug screens, but taking them is no different from activating mu receptors with anything else, legal or illegal. And the fact that Kratom is a plant should not make you think it is somehow ‘different’; if the chemicals in Kratom prove safe enough, they will eventually be extracted, identified, manufactured, and marketed in pill form– and will likely be DEA scheduled at that point.

Please read my article on the relationship between Suboxone and traditional recovery. I am aware of the anger some people have toward buprenorphine, but I think your case is the best argument for Suboxone that one can make.

You have had this endless malaise off opiates, and you seem to blame Suboxone (or if you don’t, I know that many people do– they use opiates for years, then go on Suboxone, then when they stop Suboxone they blame it for endless withdrawal symptoms). But the brain doesn’t work like that; tolerance occurs from agonist or partial agonist stimulation of a receptor, and the tolerance is reversible– at least on the ‘neuronal’ level. There is no reason that one drug, say buprenorphine, would cause a more ‘permanent’ state of tolerance than another drug.

I HAVE seen people with an almost permanent state of opiate withdrawal; I have not seen this so much in relation to specific drugs, as to their degree of ‘addiction’. Listening to your experience with opiates, one thing is clear– opiates are a huge part of your life. Even watching your dream candidate be inaugurated is not ‘enough’ of a kick in life; you wanted more. In fact, by your description, I don’t know which would have been a bigger bummer– seeing someone else getting into the Presidency or being deprived of that ‘buzz’! I’m not taking ‘pot shots’ here–I’m trying to add some insight, and I hope you take it as intended. The ‘person’ that you have become… PERHAPS that person just cannot exist without some level of mu receptor activation. Perhaps that whole ‘psyche’ requires the pleasant warm fogginess of an opiate– and without that, the psyche is miserable. If that is the case, of course you will be miserable off opiates— whether the missing opiates are heroin, methadone, Kratom, or Suboxone. The problem is that at least with the first three of these agents, there is no way to take them without ever-increasing tolerance, which eventually leads to cravings, compulsive use, and greater misery.

We know without a doubt that SOME addicts do recover, most often by using a 12 step program. How do THEY do it? I see the answer as consistent with the idea of a ‘psyche’ that needs opiates vs one that doesn’t need opiates. People who ‘get’ the 12 step programs can live without opiates because they have become completely different people. Treating addiction, we know that a person who simply sees the treatment as ‘education’ is not going to do well; people really need to change who they ARE– completely!

To put it into math form: Person ‘A’ plus opiates = an intact person; Person ‘A’ minus opiates = a miserable person; Person ‘A’ + NA = Person ‘B’ = an intact person. Maybe this last bit was a bit over the top… but hopefully you see my point.

I realize that some people will just never ‘get’ NA or AA; the question is, can those people ever be happy without exogenous opiates? I should add that there are other recovery programs out there that do, or intend to do, something like AA and NA, without the religious dimension– I am including them in the same way as AA and NA, although I don’t know as much about them. But knowing what I know about addiction and recovery, I doubt ANY program will make an addict ‘intact’ through education alone; in all cases I would expect the need for that person to change in a significant way.

In my opinion, the answer to the question is ‘no’– that a using addict, minus the object of use, without personality change, will always be miserable. Enter Suboxone… or more accurately, buprenorphine… and there now is a fourth option besides ‘sober recovery’, using (and misery), and ‘dry misery’. Buprenorphine provides a way to occupy mu receptors at a static level of tolerance, therefore preventing the misery that comes with chronic active addiction. And it allows a person to feel ‘intact’ without the need to change to a different person.

Buprenorphine fits well with the ‘disease model’ of addiction; the idea that an addict needs chronic medical treatment, and that if the treatment ceases, the addiction becomes uncontrolled, resulting in either active use or in your case, miserable ‘sobriety’. As for those who are ‘purists’– who think that every addict needs to get off everything and live by the 12 steps– I am glad that works for you, and others likely will envy you. But note that many, if not MOST, opiate addicts in recovery will relapse at some point in life– maybe multiple times. Recovery programs are not ‘permanent’; they need ongoing attention and activity, or they tend to wear off. There is no ‘cure’ for addiction; we ‘maintain’ addicts either through recovery programs, or now, through medication.

One last comment– I do know a person who was stable on Kratom for several years until suddenly going into status epilepticus with grand mal seizures over breakfast one day, in front of his wife and children. An extended work-up showed damage to multiple organ systems that seem to now be getting better after a couple of years. The studies never determined whether the organ damage came from the Kratom itself, or from some additive or pesticide used in Thailand. Use foreign substances at your own (substantial) risk!

JJ

Suboxone Talk Zone (dot com)

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!

Wow (!) in Taipei, Taiwan

I often talk to my patients on buprenorphine (aka Suboxone) about the need to fill their minds with new ideas, plans, and experiences.  For years, those of us with addictions were focused on one thing– finding a way to avoid being sick for the next few hours.  That one issue became the center of our Universe, pushing out every other interest in our lives.  Treatment with buprenorphine removes that obsession, leaving room behind for interests to re-develop.  The challenge for patients on buprenorphine, particularly young patients, is to seize the initiative, and to fill their minds with healthy interests, relationships, and activities.The World's second-tallet building in Taipei

Many treatment professionals completely miss the point of buprenorphine treatment.  The unique action of buprenorphine at the mu receptor results in a constant level of opioid effect, even as the brain level of buprenorphine varies throughout the day.  This constant stimulation disappears through the phenomenon of tolerance; a process that allows the mind to ignore ANY input or stimulus that never varies.

The mind, then, has no evidence that the person is on a medication– so the person ‘feels’ normal, and IS normal– as normal as anyone can be, in a world with caffeinated beverages and wifi networks.  All of the mental activity that was spent fretting over opioids is removed during buprenorphine treatment– a process that really should be called ‘remission treatment,’ given what is occurring in the mind and brain.

I’m getting far afield here… my point is that the removal of all that ‘fretting’ allows for the interests of the person to return. The relationships pushed out and neglected by cravings can be restored, and hopefully repaired.  Hobbies can be taken up again.  Athletic interests can return.

But people who became attached to opioids at a very young age may have missed the normal opportunity to develop those relationships and interests.  Young people must develop interests in other things, once they are stabilized on buprenorphine. As an older person, I am not ‘hip’ to all of the things that younger people do these days (as evidenced by saying ‘hip’!), so I have to leave much of that to the creative energy of those patients!  But as an example of the things one can get interested in, this morning I had a few minutes of ‘do nothing’ time… and after watching one of the stars of ‘The Artist’, the silent movie that one all the Oscars, I Googled ‘silent movies’ and started reading.  Eventually I somehow ended up at a site for a college Asian Student Association (would LOVE to visit at least one Asian country some day…) where I viewed beautiful photos from Taiwan, including the countryside, the cities, the food…. and eventually the YouTube video below, of the Taiwan 2010 New Year firework display, at the world’s SECOND tallest building (for now) – Taipei 101.  (before clicking the link you just past, do you know the first?)

Watch in HD if possible–  turn  of the volume, listen to the people around you, and you’re almost there!

 

Do Interventions Work?

It has been a while, it seems, since I’ve checked in.  I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.

In the meantime, check out the ‘best of’ page;  I have links there to some of the more popular post.   And for now, I’ll answer a question I received today on ‘TheFix.com’:

Do you believe in intervention of someone who does not ask or desire (to be clean)?

It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within. 

Grandma needs an intervention
More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option. 

For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.

She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.

I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.

So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?

Because true change is very, very difficult. 

Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?

And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.

In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.

But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.

I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!

The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.

The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.

Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

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Relapse in an Era of Buprenorphine

A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.

I drug-test patients who are treated with buprenorphine or Suboxone.  The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble.  It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example.  The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’

The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight.  Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important.  It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high.  On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.

In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me.  But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.

Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations.  But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.

One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’

After shooting the heroin, Paul immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.

His desire to talk is an amazing thing—and worth noting.  Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician.  In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.

There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients.  I don’t get the logic of those programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!

Paul made an appointment to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues.  Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!

We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it may also feel bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.

Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.

On buprenorphine, relapse doesn’t necessarily cause instant loss of insight.  I don’t mean to minimize relapse, as bad things can always happen.  For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused.  But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.

This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

Buprenorphine and the Dynamic Nature of Character Defects

Sorry about the re-run—I wrote this several years ago, and I still agree with the concept of ‘dynamic character defects.’ As I read it now, I recognize how things have changed; buprenorphine (Suboxone) has been incorporated into many of the major treatment centers, and even the smallest programs have at least become familiar with the medication.

There still exist some programs where the staff remain ‘anti-Suboxone’, but those places are becoming the exception, and are essentially marginalizing themselves out of the treatment industry.

You may note that I had an attitude of cooperation when I wrote this post, years ago. I suggested that those who prescribe buprenorphine work WITH those treatment centers that were ‘anti-Suboxone;’ that they recognize each others’ strengths. Since then I’ve known several people who were taken in by the anti-sub treatment community, and who eventually died– all the time believing that they were failures at finding sobriety. The shame is not theirs; the shame belongs to those who tricked them, and kept them from the medication that would have saved their lives.

To those treatment centers that do not offer buprenorphine, and that employ counselors who fret about their own jobs to the point of keeping people away from buprenorphine, SHAME ON YOU. Your treatment centers WILL close. And given the high death rate of opioid dependence, I am glad to have such self-centered charlatans out of the industry. Each closing is one less place for people to waste money–while searching for real treatment.

Where was I? Oh yes—my old post about buprenorphine and character defects. This post gets to the issue of the ‘dry drunk’, and why I don’t see that happening with buprenorphine. The post also has implications for the discussion of whether counseling should be a part of EVERY buprenorphine prescription. As always, thanks for reading what I have to say…

I initially had mixed feelings about Suboxone, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the years, because of what I have seen and heard while treating well over 400 patients with buprenorphine in my clinical practice.  At the same time, I acknowledge that while Suboxone has opened a new frontier of treatment for opioid addiction, arguments over the use of Suboxone often split the recovering and treatment communities along opposing battle lines.  The arguments are often fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine and Suboxone can have huge beneficial effects on the lives of opioid addicts.

The active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opioid receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opioid effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response) – relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opioid.

At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach.  People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all.  This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone.  On one hand, good boundaries include the right to keeping one’s private medical information so one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;  they are not in a good position to deal with even more shame coming from other addicts themselves!

An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opioid addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opioid addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opioids than for other substances.  This may be because the ‘high’ from opioid use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opioid use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opioid user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.

The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opioid addiction.

Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opioid addicts have a number of such defects.  The dishonesty that occurs during active opioid addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opioid addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opioid addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually his irritability results in loss of jobs and relationships.

The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opioid addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.  I realize now that I was making the assumption that character defects were relatively static—that they develop slowly over time, and so could only be removed through a great deal of time and hard work.  The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic.  I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opioids as well—the opioid is not the issue, but rather it is the obsession with opioids that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.

In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.

My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Suboxone removes the obsession to use almost immediately.  The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.  The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.  I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.  I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.

A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.

Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?  Yes, if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But I see little use in forced or coerced attendance at meetings.  The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.  In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.

The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.

Here are a few common questions (and answers) about Suboxone and Recovery:

-Should Suboxone patients be in a recovery group?

I have reservations about forced attendance, as I question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there clearly is much to be gained from the sense of support that a good group can provide.  Groups also show the addict that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle their own addictive thoughts.

-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?

These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  But for a person taking Suboxone I see the steps as valuable, but not essential.

The use of Suboxone has caused some problems for traditional treatment of opioid dependence, and so many practitioners in traditional AODA treatment programs see Suboxone as at best a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone.  Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Suboxone itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of Suboxone use implies long term use of the drug.  Chronic use of any opioid, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary.  Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.

Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opioid addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.  But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out weaknesses.