Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here.  This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago.  I grew used doctors refusing to treat people addicted to heroin and other opioids.  I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise.  It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices.  I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine.  The comment surprised me, because from here I don’t see the influence.  My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years.  I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things.  I want to write about the little things.  The easiest way to have influence is to write about the things that nobody else writes about.  After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence:  If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way.  I want people to use .  I know I sound like some old guy frustrated by all of the new words and acronyms on social media.  YES, dammit, I AM frustrated by those things!  But communication has become so…. careless in the era of Twitter and texting.  Find an old book and notice the words and phrases used by educated people 100 years ago.  Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends.  Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?)   But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs.  Some large scams benefit from the informal attitudes toward health and medicine;  attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video.  As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.

Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term.  Is ‘treat’ the right word?  From my perspective I’d say yes in some cases, and no in others.  Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year.  They said (and I believe them) that they hadn’t used opioid agonists for at least that long.  I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances.  There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances.  Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv.  Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies.  I correct them and tell them that I have a hard time trusting patients who talk that way.  After all, those are street terms.  A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub.  Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing?  Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?

No, of course not.  I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression.  Getting that point across would be enough influence for one day!

Help for Heroin Addiction

A couple comments for regular readers…  first, watch for an upcoming change to a new name.  For years I’ve debated whether to adopt a name centered on ‘buprenorphine’, rather than the more-recognizable ‘Suboxone’.  I believe that time has come.   Second, I’m going to ‘reset’ with some introductory comments about the proper approach to treating heroin addiction, intended for those who are seeking help – starting with this post.

I’m addicted to heroin.  Which treatment should I use?

I’ve treated heroin addiction in a range of settings, including abstinence-based programs and medication-assisted treatment with buprenorphine, naltrexone, and methadone. My education prepared me for this type of work, and my personal background created empathy for people engaged in the struggle to leave opioids behind.

The first barrier to success is on you. Are you ready to leave opioids behind? How ready? Are you so ready that you will be able to end relationships with people who use? Are you ready to stop other substances, especially cocaine and benzodiazepines? You will find help during treatment and you don’t have to take these steps entirely on your own. But you must at least have the desire to get there.

If you’re ready, the next step is deciding the treatment that is likely to help you. Many people see abstinence-based treatment as a ‘gold standard’ – the ultimate way to escape opioids. Unfortunately, that belief has fueled many deaths over the past ten years, as desperate people paid large sums of money for themselves or loved ones expecting programs to alter personality over the course of three months. It doesn’t work that way for most people!

During several years working in abstinence-based programs, I helped fix people who were broken by addiction. After a couple months, people left treatment with healthier bodies, cleaner complexions, and better hair. But over 90% of those people returned to opioid use, some within a few days. Some of them died because of their new lack of tolerance to opioids. In each case, counselors said the same thing: ‘he/she didn’t really want it’. But I remembered that they DID ‘want it’ when they were in treatment. In fact, some were considered star patients! At some point we must hold treatments responsible if they fail over 90% of the time.

My perspective changed. Now I wonder, why does anyone expects those treatments to work? A person is removed from a life of scrambling and drug connections and poverty, placed in a box and shined up for a few months, then put right back in the same using world and expected to act differently?

I eventually learned about medications that treat opioid addiction. I realized that opioid addiction truly is a medical illness that should be treated like any medical illness. Think about it – we treat high blood pressure, asthma, and diabetes over time. We don’t cure any of them. In fact, the only illnesses that we can cure are infectious diseases, and even that accomplishment is fading as organisms develop resistance to current medications. Given that we can’t really cure anything, why do we expect anyone to cure addiction – in 12 weeks?!

Medication-based treatments for addiction represent a transition to normalcy. Doctors and nurses were removed from treating addictive disorders decades ago because of historical events that I’ll eventually write about. Clearly, it’s time for health professionals to take a role in treating addiction. In the next article I’ll discuss the medications currently available, and the reasons that one might work better than another for certain individuals.

In the meantime please check out my youtube videos under the name ‘Suboxdoc’, where I discuss the use of medications, primarily buprenorphine, for treating addiction to heroin and other opioids.

Clearbrook President Gets it Wrong

A blurb in the buprenorphine newsfeed (see the bupe news link in the header of this page), has the headline ‘Suboxone challenged by Clearbrook President’.  I followed the link, and after reading the ‘article’ I wanted to comment to that president but the person’s name wasn’t included, let alone an email address or comment section.  So I’ll have to comment here instead.

The article was one of those PR notices that anyone can purchase for about 100 bucks, in this case from ‘PR Newswire’.  It’s a quick and easy way to get a headline into Google News, which pulls headlines for certain keywords like ‘Suboxone’ or ‘addiction’.

The Clearbrook president makes the comment that this 180-degree swing to ‘medication assisted treatment’ is a big mistake.  He says that in his 19 years in the industry he has seen ‘thousands’ of people ‘experience sobriety’.   I’ll cut and paste his conclusion:

There is no coming into treatment and getting cured from the disease of Addiction. There is no pill or remedy that will magically make one better. Those looking for a quick fix to addiction and the treatment modality being used by the vast majority of treatment providers today, will be disappointed with the direction our field is taking when this newest solution doesn’t live up to its claims.

A word to the President of Clearbrook:   I’ve worked in the industry too.  But unlike you, I wasn’t satisfied to see a fraction of the patients who present, desperate for help, ‘experience sobriety’– especially when I read the obituaries of many of those patients months or years later.

The president says that ‘no pill or remedy will magically make one better.’  Addiction, for some reason, has always been considered immune to advances in modern medicine.  We all know that addiction is a disease, just like other psychiatric conditions including depression, bipolar, and schizophrenia.  Why is it that even as medicine makes extraordinary advances in all areas of illness, medications for addiction are considered to be ‘magic’?

Those of us who treat patients with medications, particularly buprenorphine, realize that addiction doesn’t respond to ‘magic’.  But I see a lot more hocus pocus in abstinence-based residential treatment programs than in the medications approved by the FDA for treating addiction.  Residential programs charge tens of thousands of dollars for a variety of treatments–  experiential therapy, art therapy, psychodrama, music therapy, etc.– that have no evidence of efficacy for treating opioid dependence.  Abstinence-based treatments have managed to deflect criticism from their failed treatment models by blaming patients for ‘not wanting recovery enough’.

Buprenorphine finally allows the disease of addiction to be treated like other diseases– by doctors and other health professionals, based on sound scientific and pharmacological principles.   Abstinence-based treatment programs have tried to tarnish medication-assisted treatments, but people are finally recognizing the obvious– that traditional, step-based treatments rarely work.

And that’s just not good enough when dealing with a potentially fatal illness like opioid dependence.

Obsessed with Suboxone Diversion? Raise the Cap!

Last week, HHS Secretary Sylvia Burwell announced that the cap on buprenorphine patients will be raised above the current limit of 100 patients per doctor.  This move, should it actually occur, will potentially save tens of thousands of young lives per year, given that over 30,000 people die from narcotic overdose each year.  But instead of cheering the good news, some doctors used the occasion to rant about diversion.  Those doctors get on my nerves, and I’ll explain why.

Buprenorphine, the active ingredient in Suboxone, prevents opioid withdrawal in heroin addicts while at the same time blocking the effects of heroin and narcotic pain medications.  Many heroin addicts keep a dose or two of buprenorphine handy for times when the heroin supply, or money to buy heroin, runs low.  Other opioid addicts use buprenorphine in attempts to detox off opioid agonists.  Their efforts almost always fail, as freeing one’s self from addiction is much more complicated than getting through withdrawal.  But the statistics don’t keep addicts from trying, over and over again.  After all, the belief in personal power over substances is part of the addictive mindset.

Buprenorphine is viewed as just one more drug of abuse when viewed through the superficial lens of news reporters. Even some buprenorphine prescribers fail to understand the important differences between buprenorphine and opioid agonists. But the differences are important.  While over 30,000 people die from overdose of opioid agonists each year, less than 40 people die each year with buprenorphine in their bloodstream.  Of those deaths, most were caused by opioid agonists, and would have been prevented by more buprenorphine in the bloodstream!

I admit to a great deal of irritation when I hear doctors who should know better spreading ignorance and stigma about buprenorphine—an ideal medication for the current epidemic of overdose deaths.  To you doctors:  Really? 40 deaths per year—deaths not even caused by the drug— are the horrible cost to society that you are complaining about?  The same number of people die from lightning strikes!  Maybe, while you are at it, you should complain about tall trees on golf courses!

Forty deaths.  FORTY!

I think of fields of medicine where doctors take the lead to guide society to do the right thing.  Getting insurers to treat AIDS was the right thing.  But when overdose is the biggest killer of young adults, my colleagues spread fear about buprenorphine?!

Buprenorphine diversion is a complicated issue. Contrary to the media-propagated image of addicts getting ‘high’, opioid addicts always, eventually, become desperate and miserable. Some miserable addicts learn about buprenorphine, a medication that almost instantly blocks the desire to use heroin or other opioids.  When buprenorphine was approved for treating addiction, a cap was placed on the number of patients treated by each physician.  Reasons for the cap range from a desire to prevent ‘treatment mills’ to political compromises.  But whatever the reason, treatment caps and other restrictions prevent doctors from prescribing buprenorphine.  In the absence of legitimate prescribers, addicts purchase buprenorphine at a street price determined by supply and demand.

Some patients sell their prescribed buprenorphine medications.  Such sales are against the law, just as selling Oxycontin or Vicodin is a crime.  But in a world where heroin can be purchased more cheaply than Suboxone, and where pain pills kill tens of thousands of people each year, I’m sorry if I don’t get hysterical about the ‘buprenorphine problem’.  If there was any evidence or suspicion that buprenorphine serves as a gateway into opioid dependence (there isn’t), I’d think differently. But use of buprenorphine, at this point anyway, is confined to miserable heroin addicts looking for a way out of active addiction, who can’t find legitimate prescribers of the medication.

So to the people who wrote on government websites over the last week that ‘it makes no sense to treat one addictive drug with another’: You don’t have a clue.  Buprenorphine has unique properties that treat the essence of addiction—the compulsion to use ‘more’. And addiction is a chronic illness that deserves treatment as much as any other chronic illness.

And to the doctors who prescribe buprenorphine products and get their undies in a bundle about greater access to buprenorphine:  With all due respect, you must be doing something wrong.  I have 100 patients right now who tell me, at each visit, that I saved their lives.  I credit the medication, since the unique properties of buprenorphine are far more important than anything I have to say!  But I know that something saved their lives, because their former friends are dead, and they are alive– working jobs, raising families, and occasionally reaching out to lucky friends who survived long enough to hear them talk about the wonders of buprenorphine.

To those same doctors:  How can you not be excited by a medication that has saved so many of your patients?  If you don’t have such patients, I suggest you give some thought to what you’re doing wrong!  In this field, with this medication, saving lives isn’t that difficult. After 20 years in medicine (including 10 years as an anesthesiologist), I’ve never had the opportunity to benefit human life as much as with these patients, with this medication.

I hate to mess up a passionate article with talk about neurochemistry, but a couple facts deserve clarification. Diverted buprenorphine is not a ‘pleasure’ drug.  I’ve heard stubbornly-ignorant doctors compare buprenorphine to heroin, as if their stubborn beliefs alone can turn an opioid partial-agonist into an opioid agonist.  Surely they know that if someone with a tolerance from regular use of heroin takes buprenorphine, the drug will precipitate severe withdrawal?!  And if the same person injects buprenorphine, the withdrawal will be even more severe!  On the other hand, if someone addicted to heroin goes without heroin for over 24 hours and then injects buprenorphine, the buprenorphine will reduce the withdrawal.  But since the maximum effect of buprenorphine is far below the maximum effect of heroin, there is no way for the person to get ‘high’ from buprenorphine.  This is all simple neurochemistry! When a person injects buprenorphine, opioid withdrawal will be relieved more quickly.  But that’s a far cry from thinking that buprenorphine causes a ‘high’ similar to the effects of heroin!

After treating hundreds of patients over the years and talking at length about every aspect of their drug use, including their use of buprenorphine products intravenously before they found prescribers of the medication, I have always heard the same thing: that buprenorphine relieved their opioid withdrawal.

When I ask why in the world they injected buprenorphine, I hear the same reason– because the drug is expensive, and lasts five times longer if they inject it.  That answer, by the way, is consistent with the 25% bioavailability of submucosal buprenorphine.

How depressing that patients with addictions are treated like idiots… when they have a better understanding of neurochemistry than some doctors!

Health Privacy at the Pharmacy

First Posted 12/20/2013

In the middle of an already-hectic schedule, my office received a call from a pharmacist at Roundy’s Pharmacy, Sheboygan WI saying that he couldn’t fill a script for oxycodone without the patient’s ICD-9 number.  The ICD-9 is soon to be replaced by ICD-10, a system that applies numbers to every medical illness under the sun.  The numbers are used for billing under Medicare, Medicaid and insurance networks.

The person at my office who answers such calls asked me about the number, and suggested that I leave it at that.  “Pick your battles” she said.  “No need to make enemies on purpose!”

She had a point… but I get frustrated as layer after layer of regulation squeezes the life out of the medical profession.  One more thing to attend to is not a huge deal; the extra 3 minutes that it takes to look up a number for each prescription will simply mean that patients have 3 fewer minutes to ask questions.  But this is just one little example of one script and one pharmacy.  Another pharmacy now requires patient diagnoses to be written on every controlled substance for Medicaid prescriptions.

The greatest frustration isn’t the rules themselves, but that individual pharmacies make up their own rules for their own reasons.  Each pharmacy cites good ideas that led to their new requirements.   But I can’t predict where each patient will fill each script, so someone is added to the office to handle these and similarly-needless calls.  In a clinic with many doctors, the extra employees really add up at some point.  And patients pay higher and higher costs, to support layer upon layer of ‘good ideas.’

I called the pharmacist and asked why he needed the code.  I’ll mention at this point that the patient, a man in his early-60’s, needs an opioid agonist for severe bilateral leg pain that forced him into early retirement.  Nobody—not myself, and not the many other docs who have consulted on his care—have been able to determine the reason for his pain, despite countless tests and imaging studies.  But I’ve known the gentleman for years, and his suffering is genuine.

The Roundy’s pharmacist said that ‘the DEA is all over us, and they require us to ask for it.’  Nice try, I thought to myself.  He was lying.  I asked him to refer me to the web site or register where the law is listed or described, explaining that I’ve never heard of such a rule.  He said that the rule isn’t ACTUALLY a DEA rule—but it probably WILL be.  He said that for now, Roundy’s has a policy that ICD-9 codes are written for any scripts for immediate-release oxycodone.

Is the rule just for oxycodone, I asked?  What about Opana, or fentanyl, or dilaudid?  ‘No—just for oxycodone’ he stated.   ‘Don’t you about the oxycodone problem out there?’

I asked, what about all of the other potent mu agonists on your shelves?  Isn’t it a bit arbitrary, requiring a code for oxycodone and not for even-stronger opioids?   He answered that he worked in Milwaukee, so he has special insight into the drug problem out there.  Oxycodone is abused ‘way out of proportion’, he explained. In fact, ‘you’re the only doctor who has ever had a problem with this.  Don’t you think we should be trying to reduce diversion?’

I asked how requiring an ICD-9 number reduces diversion.  He answered that with what is going on out there, it can’t hurt.  I asked how he knew that the number a doctor wrote on the script was accurate?  Did he have any way of checking to see if the diagnosis was correct, and not just made-up?  Did he know that people interested in obtaining opioids illicitly could use the same internet that I used to make up their own codes? He again pointed out that nobody else complains, and suggested that I have too lax an attitude toward narcotics. At this point I had to get back to my patients, so I gave him the all-important number:  338, Chronic pain. Don’t we all feel a bit safer now?

Beyond the hassle, I am surprised at how little people care about their privacy these days.  I gave the pharmacist the most general code I could, but most ICD codes are far more specific. When I asked the Roundy’s  Pharmacist if he thought it right that everyone who views the script would know a patient’s diagnosis, he acted insulted and said that HE was part of the patient’s health care too—so HE had as much ‘right’ to know the diagnosis as I did.   But it isn’t just the pharmacist; the script will be seen by other pharmacy staff that live in the same small town.  Should the person who collects the script at the Rx drop-off window know that Mr. Jones has cancer of the pancreas before he tells his family? Should the tech who transcribes prescriptions know that Mrs. Jackson has genital warts?

I read today about the lack of security of private data in the US Government’s foray into health insurance—cracks in data protection that would never be accepted from a private corporation.  But even if or when the software gets fixed, I’m amazed how few people are concerned that their diagnostic codes will be floating through the IRS, of all places.  I am amazed that the same country that elected people who passed HIPAA in 1996 would be so open with their health information with both the public and private sector.

I’m getting off-track; there are so many areas where things have changed, and I want to stick with the pharmacist, since he is the person who got me riled up earlier today.  What do readers think?  Do people know that pharmacists are demanding their diagnostic codes?  Do they care?  Are you comfortable standing in line to pay for your medication when the pharmacist says, loud enough for everyone in line to hear, ‘Oh– I see you are treated for opioid addiction!’  Do you think we will swing back to the era where healthcare data was considered intensely private?

And after viewing the attached chart—are you happy with the growing number of healthcare middle managers who add layers and layers of costs, without seeing a single patient?

I’ve had a couple comments— but for some reason the blog stuck them under the wrong post.  I’ll share them here:

Submitted on 2013/12/21 at 10:56 pm

Good Topic Dr. Junig, I personally and because I feel so strongly about my privacy, refuse to even use my company provided insurance. I pay out of pocket for my office visits and meds. I even have my Dr. write the script so the label on the bottle reads that it is taken for pain. I hate nosy people, much less government. I am neither ashamed or proud of my condition, but it is that….”MY” condition that’s most important to me. I will share it with who “I” want and that’s all. When the day comes when I am on medicare or medicaid, I guess my privacy will go out the window.

Submitted on 2013/12/25 at 7:26 pm

Had virtually the same conversation with a pharmacist at Costco, including the lie about it being required by the DEA, patient privacy, verification of the accuracy of the diagnosis and appropriate use of opioids for the condition, and how giving a pharmacist an ICD-9 code prevents misuse or diversion.  Then I realized how pointless the argument was.  Called the patient and advised that he use a different pharmacy, but the patient was without prescription coverage and desperate for the best price.  Called the pharmacist back and gave him the ICD code for lumbago.

Bangor to Maine: Too Much Suboxone Treatment!

First Posted 11/26/2013

As I read about the moratorium on buprenorphine treatment programs in Bangor, Maine, I thought about the scene from the movie Titanic where the people who found safety in lifeboats struggled to keep those in the water from climbing aboard. The Bangor city council recently voted to impose a moratorium on expanding buprenorphine treatment programs for 180 days, at least in part because of concern that Bangor had become ‘port in the storm’ for heroin addicts with nowhere else to turn.

I haven’t been to Bangor, but I live in Bangor-like conditions. Bangor clinics treat more than the city’s share of people addicted to opioids. The city has three methadone clinics, treating a total of 1500 people, many of whom travel from outside the city for treatment. Numbers on buprenorphine treatment were not provided in the articles I’ve read, and so I don’t know if buprenorphine/Suboxone prescribers in Bangor carry the same heavy load. Some editorials about the Bangor situation have suggested that buprenorphine treatment is unfairly targeted because of the large number of methadone patients. The two types of treatment are often confused, especially since methadone clinics now dispense buprenorphine to some patients and methadone to others. But buprenorphine-based products differ from methadone in that they can be prescribed for addiction treatment, whereas methadone can only be dispensed—initially on a daily basis. The medications are similar in that both are the most reliable methods to cut the number of overdose deaths from pain pills or heroin.

By ‘Bangor-like’, I’m referring to the lack of buprenorphine-certified physicians in northeast Wisconsin and the Michigan Upper Peninsula, and the need for residents of those regions to travel in my direction to see a buprenorphine-certified provider. There are also regions of the Upper Peninsula where pharmacies have stopped providing Suboxone. The exit of one pharmacy created greater pressure on remaining pharmacies, creating a death spiral that ended with no pharmacies dispensing Suboxone across a wide region.

To people without addictions, I suspect that large numbers of opioid addicts lining up for care look like the people who tried to climb into the Titanic lifeboats. People who have lost everything to addiction can seem a bit desperate with their dated clothes and late-model cars. Newcomers to treatment look rough after weeks of lousy sleep and the lack of toiletries that go with living in a car. A group of patients outside a methadone clinic are less picturesque than a Starbucks shop.

But there is nothing pretty about blocking treatment facilities that could save lives, out of concern that the good city of Bangor is doing too much good for the surrounding area. It is always revealing to apply attitudes toward addiction to other diseases. If Bangor was a Mecca for cancer treatment, with several hospitals to attract patients from miles around, would the city council be concerned?  Success rates with buprenorphine rival cancer treatment success rates;  is it more important, or more rewarding, to save the life of one patient over another?

I am frustrated that the regulations for treating opioid dependence keep more doctors from helping carry the load. I’m frustrated that the ‘systems’ that have taken over much of the healthcare landscape discourage buprenorphine-certification of their employed physicians. I find it ironic that almost all hospitals requires ACLS certification for their staff physicians, but none require buprenorphine certification—even though most doctors will rarely if ever have to run a ‘code’, while patients seeking help for addiction are plentiful—and ignored.

But a surplus of doctors willing to navigate the maze of regulations to offer methadone treatment or willing to sign on to random DEA inspections to prescribe buprenorphine medications is a good thing. An even better thing would be for a city council to take pride in not turning away people struggling with an epidemic that has become the number one killer of young adults in much of the country. We all agree that opioid dependence is a disease. Let’s hope that in 180 days, Bangor will decide to treat it like one. The solution, in 1912, wasn’t to have even FEWER lifeboats.

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.

An Addict’s Story

I received the following email last week.  I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients.  As usual, I will write a follow-up post in a week or so.

Dear Dr. J,

I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.

At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)

My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic.  In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.

The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication).  At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.

From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.

I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.

In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.

It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.

As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me half-a@@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).

I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.

Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.

Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).

Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.

Thank you to the writer;  I’ll be adding my thoughts soon!

 

Hydrocodone (Vicodin) Addiction and Buprenorphine

I recently accepted a young man as a patient who was addicted to hydrocodone (the opioid in Vicodin), prompting a discussion about treatment options for someone who hasn’t been using very long, and who hasn’t pushed his tolerance all that high. Perhaps it will be informative to share my thought process when recommending or planning treatment in such cases. In part one I’ll provide some background, and in a couple days I’ll follow up with a few more thoughts on the topic.

Most people who have struggled with opioids learn to pay attention to their tolerance level—i.e. the amount of opioid that must be taken each day to avoid withdrawal or to cause euphoria (the latter about 30% more than the former). For someone addicted to opioids, the goal is to have a tolerance of ‘zero’—meaning that there is no withdrawal, even if the person takes nothing. That zero tolerance level serves as a goal, making having a high tolerance a bad thing, and pushing tolerance lower a good thing.

Tolerance is sometimes used as part of the equation when determining the severity of one’s addiction. But looking at tolerance alone can be misleading. Tolerance is a consequence of heavy use of opioids, and also a cause of heavy use of opioids. Tolerance usually goes up over time, so having a high tolerance probably correlates with length of addiction in some—- but not all— cases. Tolerance is also strongly related to drug availability. A person with a severe addiction, who only has access to codeine, will likely have a lower tolerance than a person with a more mild addiction, who has free access to fentanyl, oxycodone, and heroin.

I think it is more appropriate to measure the ‘severity of addiction’ by the degree of mental obsession that the patient has for opioids. Tolerance is one piece of information in determining that obsession, but tolerance alone can be misleading.

To get a sense of the obsession for opioids, I look at many factors. Has the person committed crimes to obtain the substance? Violent crimes? What has the person given up for his addiction? Has he been through treatment? How many times? How long did he stay clean after treatment? Have his parents or spouse thrown him out of the house, and if so, does he still use? Did he choose opioids over his career? Over his kids?

Answers to these questions provide a broad understanding about the addicted person’s relationship with the substance—an understanding that is necessary when considering the likely success or failure of one treatment or another. It is also important to consider the person’s place in the addictive cycle—i.e. early, likely in denial, cocky, with limited insight– or late, after many losses, more desperate—and perhaps more accepting of treatment.

I am a fan of buprenorphine as a long-term treatment for opioid dependence, as readers of this column know. I consider opioid dependence to be a chronic, potentially-fatal illness that deserves chronic, life-sustaining treatment— and buprenorphine, in my experience, is a very effective treatment in motivated patients. But tolerance becomes a factor, when considering buprenorphine for THIS patient.

Buprenorphine has a ‘cap’ or ‘ceiling effect’ that allows the medication to trick the brain out of craving opioids. In short, as the blood or brain concentration of buprenorphine drops between doses, the opioid effect remains constant, as long as the concentration is above the ceiling level. In order to achieve the anti-craving effects of buprenorphine, the dose must be high enough to create ‘ceiling level’ effects. If buprenorphine is prescribed in lower amounts—say microgram doses— the effect is identical to the effects of an agonist, since the dose/response curve is linear at lower levels.

Buprenorphine is a very potent opioid, and the effects of the medication are quite strong at the ceiling level. Comparisons to other opioids will vary in different individuals, but in general, a person on an appropriate dosage of buprenorphine develops a tolerance equivalent to that of a person taking 40 mg of methadone per day, or approximately 60-100 mg of oxycodone per day.

A person taking even a dozen Vicodin per day has a much lower tolerance to opioids. Such a person who starts buprenorphine treatment will obtain a very significant opioid effect from the drug— unless the dose of buprenorphine is raised very slowly over a number of days. And in that case, the person’s tolerance level would be pushed much higher.

So if our current patient starts buprenorphine, he will have a much higher opioid tolerance if/when the buprenorphine is eventually discontinued. I receive emails now and then from patients who are angry at their doctor for starting buprenorphine, feeling trapped by the considerable threat of withdrawal from stopping the drug. But at the same time, taking hydrocodone and acetaminophen in high amounts creates the risk of liver damage from the acetaminophen, as well as the considerable risks from opioid dependence.

And so the dilemma. Should buprenorphine be considered in such a case?

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!