What follows is a lightly-edited version of one of my posts from a couple years ago. I still think that this is a good model for understanding the actions of buprenorphine.
Buprenorphine and the Dynamic Nature of Character Defects
‘Suboxone’ and ‘Subutex’ are the trade names for medications that contain buprenorphine, a substance used to treat addiction to pain medications and/or heroin. Buprenorphine treatment for opiate dependence has been an option in the US since 2003. Other treatment approaches for opiate dependence have been used for decades but have had limited success. With a little imagination, treatment approaches can be placed on a continuum depending on the degree to which the treatment demands changes in the personality and behavior of the addict. Methadone maintenance is often described as a means of ‘harm reduction’ by preventing the behaviors related to the obsession for opiates or by reducing intravenous use of heroin or other substances. At the other end of the treatment continuum there are the step-based and other Recovery programs. One limitation of programs that demand personality change is that such change is difficult and rare, and usually only occurs after a significant amount of despair has been experienced by the addict. Opiate dependence differs from other addictions in the lethality of overdose, and the fatality rate of even early abuse of that class of substances. Opiate addicts are at significant risk of dying from their addiction before enough desperation has accumulated to motivate personality change. A second limitation is the high rate of relapse that occurs even after sustained Recovery. If a ‘changed’ addict stops actively participating in the program that induced the changes, the personality of the addict tends to revert back to the personality that was present during active drug use.
I initially had mixed feelings about buprenorphine treatment of opiate dependence, my opinion likely influenced by my own experiences as an addict in traditional recovery. But my opinion has changed over the past four years from what I have seen and heard while treating over 400 patients with buprenorphine. But while buprenorphine has opened a new frontier of treatment for opiate addiction, arguments over the use of buprenorphine often split the recovering and treatment communities along opposing battle lines. The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine offers huge benefits for the health and lives of opiate addicts.
A unique medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone. 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 opiate 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 opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use buprenorphine 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 buprenorphine as having an ’inferior’ form of recovery, or no recovery at all. This leaves buprenorphine patients to go to Narcotics Anonymous and hide their use of buprenorphine. 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 buprenorphine 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 buprenorphine. 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 opiate addiction there would be less need for the two treatment approaches to learn to live with each other. But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods. Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate 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 opiate 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 opiate 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 opiate addiction.
Drug obsession and character defects
Buprenorphine 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. Opiate addicts have a number of such ‘defects.’ The dishonesty that occurs during active opiate 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 opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal. The opiate 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 their 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 opiate addicts with buprenorphine—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 buprenorphine 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 buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-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 opiates as well—the opiate is not the issue, but rather it is the obsession with opiates 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 buprenorphine.
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.
The dynamic nature of personality
My experiences with buprenorphine have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Buprenorphine 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 buprenorphine patients, and more convincingly with the spouses, parents, and children of buprenorphine 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 buprenorphine 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.
Combining buprenorphine treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between buprenorphine and traditional recovery becomes clear. Should people taking buprenorphine 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 buprenorphine do not feel desperate. In fact, people on buprenorphine 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.
Other Questions (and answers):
-Should buprenorphine 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 buprenorphine I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist that has a long half-life in brain tissue. This long half-life promotes a relatively constant state of opiate stimulation, reducing opiate cravings between doses. But while the ceiling effect of the partial agonist buprenorphine results in a stable, unchanging tolerance to the medication, methadone has no such ceiling, and tolerance will always increase with increasing dose of methadone. This constant increase in tolerance erodes the ability of methadone to satiate cravings for opiates. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return. With cravings comes the obsession to use and the associated character defects. This explains one difference in the subjective experiences of addicts maintained on buprenorphine versus methadone. Methadone maintenance is also usually experienced as more sedating than the effects from buprenorphine. There is a valuable role for methadone to play as we try to prevent deaths from opiate dependence, but I see the mechanisms of action of methadone and buprenorphine to be profoundly different. Methadone is appropriately described as a ‘maintenance agent,’ but I see a more appropriate term for the actions of buprenorphine, as a ‘remission agent.’ This term accounts for the effects of buprenorphine on the obsession for opiates, and the ability of the medication to allow for dissolution of the character defects caused by active addiction.
The downside of buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine 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 buprenorphine. Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Buprenorphine itself can be abused for short periods of time, until tolerance develops to the drug. Snorting buprenorphine reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use. Finally, the remission model of buprenorphine use implies long term use of the drug. Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary. Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not buprenorphine 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 opiate 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 buprenorphine 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 each other’s weaknesses.