Addiction Treatment Has it ALL WRONG

Today on SuboxForum members discussed how long they have been treated with buprenorphine medications.  Most agreed that buprenorphine turned their lives around, and most are afraid they will eventually be pushed off the medication.  Most buprenorphine patients described a reprieve from a horrible illness when they discovered buprenorphine.  But most have new fears that they never anticipated– that their physician will die or retire, that politicians will place arbitrary limits on buprenorphine treatment, or that insurers will limit coverage for the medication that saved there lives.

I joined the discussion with the following comment:

I give lectures now and then about ‘Addiction, the Medical Illness.’  Once a person thinks through the topic several times with an open mind, the right approach to treating addiction becomes obvious.    After all, doctors ‘manage’ all illnesses save for a few bacterial diseases, and even those will become at best ‘managed’, as greater resistance develops in most bacteria.  We doctors rarely cure illnesses.  We manage illness.

The public’s attitudes toward treating addiction differ from treatments for other diseases.  Avoiding effective medications isn’t  a goal for other illnesses.  In fact, in most cases doctors refer to skipping medication negatively, as ‘noncompliance.’  There are religious orders that don’t believe in medication including Christian Scientists… and there are religions with specific beliefs, e.g. Scientology, that don’t believe in psychiatry, or Jehovah’s Witnesses who don’t accept blood products. I assume that attitudes toward addiction developed over the years when no medical treatments effectively treated addiction.  Doctors and laypersons came to see addiction as untreatable, and the only survivors people who found their rock bottom and in rare cases, saved themselves.  And since nobody could fix addiction, and the only chance at life was to find ‘recovery’, a nebulous concept based on spirituality, adherence to a group identity, and correction of ‘personality defects.’

What an obnoxious attitude– that people with addictions have ‘personality defects’!  Even most of the docs and therapists who ‘get it’ about medication insist that no patient will heal until we ‘fix the underlying cause of his/her addiction’.  What a bunch of crap…  as if all of those people out there WITHOUT addictions have GOOD personalities, and all of those people who got stuck on opioids (mostly because of bad doctors by the way) have BAD personalities.  I call BULL!  Opioids are powerfully-addictive substances, and a percentage of people  exposed to them, regardless of character, become addicted.  My personality was apparently good enough to get a PhD, get married, save a drowning woman, have a family, go to medical school and graduate at the top of my class with multiple honors, become an anesthesiologist and get elected president of my anesthesia group an unprecedented 3 times.  But taking cough medicine that grew into an addiction to fentanyl means I have ‘personality defects’??!!

I’m sure everyone has his/her own story.  But we’ve all heard so often that we have some broken screw at the base of our brains that we’ve started believing it.  And the mistreatment by doctors and pharmacists (and reporters and media and society in general) perpetuates that shame among all of us.

The truth is that our ADDICTIONS caused us to do things that were wrong.  We developed an intense desire to find chemicals because of the activation of addictive centers in our brains.  And THAT caused our ‘character’ problems.

I’ve written before about the ‘dynamic nature of character defects’.  Search my name and that term, and you will find the comments- or just click here.  The character problems so obvious in using addicts are driven by the obsession to find and use opioids.  When you treat that obsession with buprenorphine, those ‘character defects’ disappear.  I’ve seen the process unfold over and over, in patient after patient.  Some doctors perpetuate character problems by treating patients like criminals, and ANY person will develop character problems if treated poorly long enough.  In that way, the defects can become a self-fulfilling prophecy.

The character defect argument is the whole reason for counseling.  But get this– there have been several studies that looked at abstinence after discontinuation of buprenorphine after one year, with or without counseling.   And the counseling group did WORSE in those studies!  Of course, everyone interprets those studies by saying that ‘the counseling must not have been done right’ or it was not intense enough, rather than accept the data with an open mind, as any good scientist would.

Vivitrol (i.e. depot injections of naltrexone) are the biggest example of treatment based on flawed ideology.  The treatment rests on the idea that if we block receptors and counsel the heck out of people, we can fix their character defects and their addictions so they won’t use when Vivitrol is removed.  The travesty is that nobody will look at the results of this vast experiment, mostly played out in drug courts.  When you think about it, we have a long history of experimenting on people caught in the criminal justice system.  Studies in Australia showed a 12-fold higher death rate in addicts maintained on naltrexone and ‘counseled’ compared to people maintained on methadone.   When the people forced onto Vivitrol by the legal system start to die, will anyone keep track?

Deaths after residential treatment are common, but nobody keeps track of them.  So I’m not holding my breath for outcome data from the failures of drug courts!

Every serious chronic illness warrants chronic medical treatment, save one.   All healthcare professionals will say, some reluctantly, that addiction is a disease.   It is time to start TREATING IT LIKE ONE.

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)

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.

How ‘Bout Them Packers?!!

How About Them Packers?
NFC Division Champions 2011

The last time the Packers were in the Super Bowl, in the mid-1990’s, I didn’t go;  I was in my30’s and I figured I’d go another time.  Now I’m in my 50’s.  The way things go, the Pack may never get there again in my lifetime.

On the other hand, I don’t have a couple grand laying around.  And we are talking about a 3-hour game.  I don’t drink or use drugs, so I won’t have any drug-fueled, strobe-lit parties to try to remember (or headaches to try to forget!).

I suppose I could start a fund– send Junig to the SuperBowl to fight addiction!  Think it would fly?

I don”t have any ideas for twisting this around to a lesson about addiction… except to encourage everyone to find something in life that you are passionate about.

Merry Christmas!

Best wishes to everyone for the holiday season!  Merry Christmas

I am not a big Christmas person.  I’m not sure when things changed;  I used to enjoy the season much more…  I remember past days when I would gaze at the tree and feel a warmth from memories of being a kid, sitting in church, feeling safe and loved.  Now it is so hard to let go of the worries over bills, fears about the health of older family members, concern about the economy….  it seems that there is so much to worry about!

But at the same time, there is nothing that I can do about most of those things.  So why worry?  Worrying makes me feel, I suppose, that I have some power over things that in reality I am powerless over.  It is all a big ruse– the worry is only there to fool me… and keep me miserable at the same time!

That is were ‘Faith’ comes in.  I am no expert on Faith by any means, but there was a time in my life where I at least understood what Faith was all about.  Funny enough, that time was when I was at my absolute lowest– when I had lost my career, when I feared losing my family, and when my finances were in shambles.  I remember being a a choice point, knowing that I had to decide whether to believe or whether to wallow in despair.  I don’t even know what it was that I had to believe in;  I suppose most people would expect that I’m talking about believing in God, and maybe that is what I’m talking about.  But it was also belief in life, and in optimism, and in choosing to let go of fear and despair.

So that is where I am on this Christmas Eve.  I have fears about the future– about many things involving myself, my family, and the world.  I have resentments from past arguments, and shameful feelings for mistakes that I have made over the years.  But I’m going to use this moment to remind myself of the Faith that I have had before– the Faith that I know can turn an average, busy day into a day of meaning and deep joy.

I hope that all of you can find that place as well, even if only for a moment.  If you find it, try to stay there for as long as you can.  I really can’t think of a downside.

Clean Enough, chapter 2.3 and 2.4, My story continued

My Story (cont.)

Local hero

Hero for a day in 1979

Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since.  During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks.  I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic!  To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy.  But then I realized that something was fast-approaching in the current.  I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight.  I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling.  I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her.  After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!).  To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”

I am grateful that I was given the opportunity to be a hero.  There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God, for the times when I had little else to feel proud of..

Getting serious

Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York.  After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program.  I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school.  My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.

Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways.  His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after.  After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country.  Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’.   But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.

Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home.  At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.

Why will power doesn’t work

For those of you who prefer watching to reading, here is a video with a few thoughts about why will power is NOT any kind of strategy for staying clean.  As I describe, believing in will power is not only unhelpful;  it even INCREASES one’s chance for relapse, and serves as a frequent justification for the using that leads to full-blown relapse.  Please share comments at Buprenorphorum.com.

Breaking Bad over RB

Remember back when I used to write those ANGRY posts, where I would take people to task for their silly comments about buprenorphine?  I remember them.  THOSE were the days!  I was always ready to go nuclear on anyone who tried to debate whether buprenorphine treatment was ‘good’ or ‘bad.’    C’mon punk– MAKE MY DAY. 

I’ve become more circumspect since then (OK, so I had to look the word up–  at least I had HEARD of the word before!)  I got tired of going to bed with heartburn every night.  I also realized that people will do what people want to do.  I have no power over them, and don’t WANT power over them.  Addicts must find their own truth, and all I can do is provide information when people are ready to ask for it.  Live and let live. 

I have a weekly radio show, by the way.  You can find it on i-tunes by searching for ‘junig’ or ‘shrinkzone.’   The show is on AM, but I recently got a small, monthly FM spot, which is a clear sign that I am moving up in the world.  I needed material for the spot, and I came across a book called ‘Positivity.’  The book is going to teach me to replace my negative energy with new, positive thoughts.  I’m expecting even less heartburn going forward!  Isn’t life GRAND!  Plus other good things have been happening.  I already mentioned the coverage that these pages received in Addiction Professional.  I also hope to be mentioned in the Carlat Report, a very cool source for independent information about the field of psychiatry.

Reckitt-Benckiser at Suboxone Talk Zone
Reckitt-Benckiser?

So imagine my surprise when I received a note from a doctor describing his interaction with some people from Reckitt-Benckiser.   He shared with me that his rep mentioned my name, saying I was a former RB treatment advocate who ‘went bad,’ referring to my earlier post about the company having ‘blood on their hands.’    The note went on to say some nice things about the blog and forum, but my head was already spinning with images from my favorite TV show, ‘Breaking Bad,’ with me as the antisocial chemist.  Like the guy on that show (and if you have not seen it, I strongly recommend that you rent the first two seasons and then try to find the episodes that you already missed this year), I don’ have the sense to back away from a fight!  Instead, I’ll invite new readers to click on the link to the article, and to leave your comments.

I would like to just close on that note, but I feel guilty now about not leaving any recovery ‘tidbits’ for the few people who read this far.  How about this:  be careful with resentments!  I have shared my thoughts about why buprenorphine is more than just a ‘replacement’ for the addict’s drug of choice– that the obsession for opiates that is the essence of addiction crowds out all other parts of a person’s life, creating character defects at the same time, and that buprenorphine removes that obsession, allowing character defects to be replaced by good relationships, healthy interests, and self respect.  I have shared what I see to be the reasons why addicts do not become ‘dry drunks’ when taking buprenorphine.  But at the same time, I recognize that addicts who take buprenorphine usually miss out on the intense, life-changing experiences that occur during residential treatment. 

My problem with residential treatment as the ‘treatment of choice’ is that relatively few people ‘get’ treatment, especially younger addicts, who rarely get to the level of despair necessary to truly ‘get’ step-based recovery.  And it isn’t as if we can just sit and wait for that despair to develop, because the fatality rate is just too great for opiate dependence.  In other words, too many addicts will die, BEFORE getting to the necessary level of desperation to ‘get’ recovery. 

So ideally, a person should go on buprenorphine and THEN do the step work, right?  WRONG.    It is true that many prescribers of buprenorphine force twelve step attendance, but I wonder how effective that is, beyond serving as a tool to weed out those who are not truly serious about staying clean.  ‘Getting’ the steps requires desperation… and once on buprenorphine, addicts are no longer ‘desperate!’  So intead, I try to use the principles of residential or step-based recovery in an individual manner, depending on the specific stumbling blocks of the addict under my care.  For a person like me, I might say ‘be careful with resentments.’  Resentments are a short step away from self pity.  And from self pity, we can justify all sorts of things that will lead us in the wrong direction.

There– I feel much better now.

JJ

Buprenorphine and the Dynamic Nature of Character Defects

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.

Another 'Dust-up' with the 'anti' crowd

A couple people have written to me saying that while I sound a bit ‘defensive’ and as if I am taking things personal, they like it when I let my true feelings out– including my anger.   If you are one of those people…. read on.  I will say, though, that I realize that there are times to maintain one’s composure.  I’m not the type of person who will excel in that environment.  When I worked in the prisons there were the inmates– people who had great difficulty holding back their anger– and the administrators– the shy, quiet people who would smile and shake your hand and then write you up for acting too ‘aggressively’ and hurting their feelings… or, if they read the manual would say that the work environment was ‘hostile’.   Funny–  I always felt safer around the inmates than around the administrators!
But that has nothing to do with anything…. accept maybe making a preemptive excuse for my behavior with the following posts.  The first post is from a reader/writer who defends the object of my last post.  I took his post and moved it from the comments to up here.
The comment: “I have put offers out on some of the Subox-hater sites asking for someone with 5 years clean to talk to me– and so far, I haven’t found a soul.”
Now doc that’s not quite true. Lots of people are clean and sober without your magic pills.
Your arrogance never fails to make me cringe.
“What makes 7 years think that all the withdrawal is just Suboxone’s fault?”
Ummm because it is Suboxone’s fault…clearly. The guy wasn’t withdrawing from narcotics of 7 years ago. Surely you learned that in your PhD training.
I still don’t understand why you think meetings are such a bad thing…as if they were a prison sentence. I happen to enjoy them- Being clean and sober is so much more than just avoiding cravings by popping a couple sublingual pills everyday. It’s just not that simple folks.
Eight years clean and sober…Sub-free.

My response:
Please don’t put words in my mouth.  There is nothing ‘magical’ about buprenorphine.  I do not call them magical, and I don’t call them a ‘miracle’.  I often point out that they do NOT CURE ADDICTION;  they induce REMISSION as long as they are taken, if used correctly.
As for your boastful claim, that’s great for you– the 8 years part.  It is no guarantee that you will make ten– I felt pretty sure of myself at 7 years, and realized later that even someone as ‘arrogant’ as myself can lose my way.  But even if you do remain sober the rest of your life, that puts you solidly in rare company.  I am med director of a 50-bed residential center that HATES Suboxone, and never uses it– not even for detox.  Suboxone gets in the way there– people think that they will be done with their withdrawal in a few days, and they aren’t.  We added two weeks on just for people coming off opiates, including Suboxone.  My beef is with those who place blame on Suboxone when they should be taking responsibility for their own addiction.  To be frank, if you could read what I write without looking for a reason to disagree with me you would see that everything that I say is geared toward sober recovery.  The person who blames 7 years of Suboxone for her misery, while acting like her 10 years of addiction were meaningless, is trying to completely pass the buck.  SHE (not he) is an opiate addict;  that is the cause of her misery.  She wants her misery to be due to Suboxone.  All Suboxone did was give her 7 years to avoid the inevitable.  For some people, that is a great thing;  it can allow the person to save money for definitive treatment, it can allow people to make amends to others and recover marriages.  There is nothing lost from taking Suboxone– she was faced with a choice– sober recovery or Suboxone’s easy way out.  Like most addicts, she chose the easier, softer way.  But it is disingenuous for her to now complain about the choice that SHE made.  It is so much easier to blame her past doctor, or Suboxone.  She continues to change usernames every day and post the same garbage, and not ONCE has she taken responsibility for her own behavior.  Just a question for you:  we have on the forum the rules posted that say ‘this is NOT the place to debate the pros and cons of Suboxone.  This is a place for people who have made that choice, or a different choice, to discuss Suboxone, methadone, or sober recovery WITHOUT being criticized for their choice.’  She ignores that rule, and interrupts discussions with her vitriol and bile.  Is that how you learned ‘good recovery’ works in NA?
I went to, I don’t know– a bunch of meetings during a five, and then another 5 year period.  One or two per week– sometimes more.  I quote the twelve and twelve all the time.  And from a step based recovery perspective, our ‘7 years’ friend is an embarrassment.  If you don’t agree with that, then I don’t know what meetings you are going to and enjoying.  The idea is to be an example.  What is she being an example of, exactly?
I don’t understand a couple of your comments;  you said about her withdrawal that  ‘it is Suboxone’s fault, clearly’… followed by some sarcastic comment about my PhD in neurochemistry.  I stand by my point. She is NOT just coming off Suboxone!  Yes, the last 7 years were buprenorphine (as I wrote, 7 is not possible–  I sent her a copy of the Federal Register dated May 22, 2003, announcing that Suboxone would soon be available in the US– so whatever you want to think of her, she is exaggerating by at least a year).  But she was on 10 years of other opiate agonists before the  (4-6) years of buprenorphine.  There IS a connection between the length of time on an opiate and the severity of withdrawal, and my point is that all things being equal, coming off ONLY 7 years of Suboxone is less miserable than coming off 10 years of agonists FOLLOWED BY 7 years of Suboxone.  The frontal lobes show decreased glucose metabolism during PAWS, which is probably related to the reduced insight and impulsivity that make early sobriety such a dangerous time for relapse.  This brain hypofunction is worse after longer opiate use than after shorter use.  The dysfunction is not from cell death, but probably from longstanding changes in firing patterns of neurons that become more and more entrained, the longer the aberrant signals are maintained.    So as I wrote initially, she is NOT just coming off the buprenorphine;  she is coming off the additive effects from 16 plus years of opiate use– the majority of the time using agonists.  No PhD needed to understand that–  simple addition is all you need to figure it out!
I do not say bad things about meetings.  If you read my blog much, you will come across the comment often that AA saved my life– twice.  I also have written in many columns that AA is great for those who want to go to meetings.  I disagree with forced attendance because in my opinion, AA can be taken two ways;  it can be taken in by the casual observer, and maybe some points will be taken in about how addiction progresses and how difficult sobriety can be.  But the other way it can be taken in is the ‘life saving way’– the way I took it in the first time quickly, and the way I took it in 7 years later after a great deal of very hard work.  To take it in the second way a person has to change his or her personality– and to do that, he must ‘cling to AA the way a drowning man clings to a life preserver’– to paraphrase AA.  That second type of experience, in my opinion, does not happen with people on Suboxone.  It requires the open mind that comes from DESPERATION– and people on Suboxone are not desperate!
If you read much of what I write, you would know all of this.  Like most of the flamers, you pick and choose certain posts or sentences and come to conclusions that completely miss the point of why I write, and what I write about.  What I find interesting is the role of ‘insight’;  it is impossible for a person on Suboxone to go to AA and have the same ‘insight’ that a person who is sick, in withdrawal, and desperate will have when reading the steps.  Similarly, it is impossible for someone like you, proud as a peacock over your sobriety without Suboxone, to have insight into the experience of those who choose medicated recovery.  You, and the others who write the same things that you just wrote, have your own blinders on–  they just point in a different direction.
I suppose I should point out that you made a comment about MY arrogance, and you close your note with a boast of ‘eight years clean and sober– sub free’.  Who is being arrogant?!
Everything that I do– putting up with people like you who call me ‘arrogant’, all while boasting about your OWN superior brand of recovery– is, believe it or not, because I have seen the people harmed by people like you.  I have talked to people who went to NA and got badgered off Suboxone– many people are ashamed and very suggestible early on in treatment, so it is easy to lead them astray.  That is one reason why twelve step programs caution against taking another’s inventory.  And yet, here you are, boasting about how YOU did it.  Look at what you wrote:  ‘Being clean and sober is so much more than just avoiding cravings by popping a couple sublingual pills everyday. It’s just not that simple folks.’  Sure sounds judgmental and arrogant to me!  I see those people after they stop the Suboxone and relapse, and spend 6 grand on drugs, almost die…. (thinking of the latest person this happened to)…  And then I get mad and keep writing what I write.   And when I get mad I feel free to write what I really think:  that stupid jerk ‘recovery-snobs’ like yourself make me HATE NA– not for the program itself, as the program was sound… until too many jerks like you came around.  And to you, it is more important to strut around with your 8 years than to truly listen to the pain of other people.  Only about 5% of opiate addicts get clean through step programs– a tiny fraction.  Many of the rest of them die, you dumb-ass.  Some of those people were friends of mine.    So either wipe the smug self-proud smile from your face, or take it somewhere else.  These people need help, and believe it or not, one size doesn’t fit all.  Heck, I imagine I’d have trouble finding anyone who wears YOUR hat size!
I used to wonder why there are people like you who can’t just mind your own business, but have to butt in where you aren’t welcome.  Then I realized that you have to come where you aren’t wanted, because you aren’t wanted anywhere!   I think of ‘7 years’– she has spent the last three or four days changing her IP address, registering and re-registering, spending hours to get her post on the forum…. and there are a bunch of us moderators who just delete it as soon as she puts it there.  What kind of great, solid recovery she must have- spending hours at the computer, making up phony names to get her post up for 30 seconds.   And here you are– supposedly living great recovery, and yet after 8 years you are still lurking around blogs intended for people with questions about Suboxone.  Sounds like some great recovery you got going there, dude!