Below is one chapter of my long, long book– the one that I will probably never finish. I wrote this chapter about two years ago, and have not published it anywhere else, at least not that I can remember. It is LONG, but if you are addicted to opiates and considering your options, I hope you will check it out. I invite other addicts and friends of addicts to read it as well, even though it is LONG (did I say that already?). It essentially describes my ‘vision’ for addiction treatment going forward. I am posting it now because I will be attending a summit in DC over the next few days, discussing the use of buprenorphine going forward with other experts in the field. I will bring back word of any new developments and share them here.
The advent of HDP (high dose buprenorphine) for treating opiate dependence raises hopes that we are at the verge of an entirely new approach to opiate addiction, and perhaps to other addictions as well. The traditional, step-based approach to drug addiction treats all substances as essentially the same. The problem with addiction isn’t that the addict is ingesting a substance, but rather that the addict has become obsessed with the substance. The effects of this obsession on the addict are in some ways similar to the effects of a toxic, codependent ‘love relationship.’ And while the addict develops this relationship with a specific drug of choice, the drug’s sister, brother, aunt, or uncle can step in and take the place of the drug of choice in a process called ‘cross addiction’. This is one reason why traditional treatment demands sobriety from ALL substances. Most opiate addict may have had no problem with alcohol when opiates are on the menu. But alcohol may surprise the addict by becoming an important ally when the only alternative is ‘life on life’s terms.’
There is another, more complicated reason that traditional treatment of addiction requires sobriety from all substances, not just from the addict’s former drug of choice. All addicts, opiate addicts in particular, over time become hyper-aware of their moods, comfort, and anxiety level. Addicts constantly ‘check in’ somatically, thinking ‘am I OK? Or ‘am I coming down?’ Every bead of sweat portends the pain of withdrawal, and every ache is a reason to use. Addicts become attuned to their schedule of use, as an internal 4-hour clock becomes all-important, and eventually the only thing that matters. There is even something perversely comforting about reducing all of life’s problems to the need to use, as the other challenges of life become secondary. But sobriety and recovery demand that the addict learn to face life on life’s terms, giving up the obsession for symptoms and medications. Sobriety will extinguish the obsession with symptoms over time— sometimes only after a great deal of time. As the obsession fades, the addict takes steps away from relapse. But if the addict uses a new substance that changes that perception and re-directs the addict’s attention inward, even a substance like diphenhydramine that is not addictive, the pattern of somatic attention returns. Many addicts are aware of an ‘addict frame of mind’ and a ‘sober frame of mind;’ any drug that causes the addict to look inward and again focus on somatic symptoms has the potential to trigger the return of the addictive mindset. And once the addictive mindset is back in place, it can be very difficult to find the way back to a mindset of sobriety.
The reader may be asking, I see your point about total sobriety—but isn’t total sobriety required for buprenorphine treatment as well? In my opinion from working with addicts taking and not taking buprenorphine, sobriety from other substances is beneficial during HDB for similar reasons, but there is less at stake. During HDB the addictive mindset interferes with happiness, relationships, and the development of new, healthy interests. But for the addict in traditional treatment a return to an additive mindset can disrupt the avoidance of opiates and result in relapse.
The need for total sobriety probably prevents some addicts from entering treatment. There are other addicts who enter treatment but who cannot maintain sobriety from all substances despite multiple attempts. To widen the appeal and utility of addiction treatment, a variety of treatment models have appeared, including an approach called ‘harm reduction’. Rather than total sobriety, the goal of harm reduction is to reduce the intensity of use, and reduce the harm that inevitably results from heavy or uncontrolled use. By introducing ‘drink counting’ and other behavioral techniques, harm reduction has similarities to cognitive therapy. There are people who do better in one vs. another approach, and there people who could benefit from either approach. Specifically, some people use or drink in an almost nihilistic fashion—every episode of drinking characterized by drinking to total oblivion. I would favor complete sobriety for such individuals, because the cognitive changes made in treatment will likely be obliterated by the first drink. On the other hand, a person with 20 years of an unchanging pattern of drinking facing his first DUI may be a good candidate for a harm reduction approach. In such a case, alcohol is a major part of the addict’s personality, and total sobriety after one offense would be a difficult sell. But education—for example about changes in tolerance with aging, or an introduction to drink counting– may help the person do well for another 20 years.
There are several inherent problems with traditional treatment methods, beginning with the simple observation that relapse rates have always been high. The high relapse rate has implications for addiction that go beyond treatment methods, as explained later in this article. But relapse is a particular problem for programs that are based in ‘character modification’ because when the forces that encourage character change are removed, character tends to return to its prior state. Addicts in traditional recovery tend to see themselves as ‘changed’ by the steps. But at the same time every honest addict recognizes that if the meetings stop, relapse waits around the next corner. Even worse, a ‘truism’ of step-based recovery holds that people who relapse generally return to a state of using that is even worse than where they were when they entered treatment!
Another problem with traditional methods is that many addicts reject out-of-hand the ‘spiritual foundation for the program. Admittedly such ‘rejecting addicts’ do not necessarily know much about this spiritual foundation and don’t likely know what is good for them! But reasonable or not, having spirituality as one aspect of a recovery program is going to prevent the adoption of the program by a number of addicts. Another problem is that traditional addiction treatment methods require significant motivation on the part of the addict–motivation that must be available to addicts over and over throughout their lives, including (and most importantly) at times when addicts are at their very lowest. Finally, some degree of detoxification is often required before traditional treatment, requiring expensive medical services that may be far removed from the treatment center. The cost of detox and the fear of withdrawal become major roadblocks to treatment. Withdrawal uniquely miserable, and difficult to compare to other dysphoric experiences. Physical symptoms include headache, fatigue, nausea and vomiting, abdominal cramping, diarrhea, and muscle spasms of the arms and legs that cause involuntary movements. The withdrawing addict becomes profoundly depressed and anxious. Even if there is no access to drugs, the addict feels a desperate need to use. No description of symptoms can accurately capture the misery experienced by the withdrawing opiate addict. I suspect a ‘kindling’ effect in opiate withdrawal where symptoms become more and more severe each time withdrawal is experienced, so that eventually there is no such thing as ‘mild withdrawal.’ Instead the addict experiences withdrawal as severe as the worst episode endured up to that point, regardless of the degree of tolerance going into the withdrawal episode. Addicts who have suffered through severe, non-medicated withdrawal have a sense of camaraderie akin to that of disaster survivors. But camaraderie is nowhere to be found in the midst of the withdrawal experience, and the addict feels utterly, horribly, alone.
For years there have been alternate addiction treatment models that are less dependent on character modification and more reliant on medication. Opiate maintenance treatment using methadone, or opiate blockade using naltrexone are two approaches that may be used alone or in concert with traditional treatment. Methadone and naltrexone treatments are diametrically opposed to each other in several ways, but have some things in common as well. Methadone maintenance deliberately creates ‘hyper-tolerance’ to opiates by administering the addict increasing daily doses of methadone. The high tolerance that results prevents recreational use of opiates, and the high dose of methadone satiates opiate cravings. But patients in methadone programs often feel trapped because detoxification from high doses of methadone is very difficult, and violating the rules of the clinic (including not paying the bill) results in dose reduction and withdrawal. Some addicts maintained on methadone claim that they always feel ‘high’, no matter their extent of tolerance. And while high doses of methadone will satiate cravings for a time, eventually tolerance catches up and cravings return. Moreover some addicts claim that methadone causes a lack of motivation for self-betterment through education or employment. For decades methadone maintenance was associated with blighted urban areas, where addicts lined up each morning for their daily dose of methadone. There have been more recent attempts to make methadone maintenance mainstream by improving the physical facilities or relocating to less-blighted neighborhoods. But there have been few changes in the regulation of methadone, so methadone maintenance usually requires that addicts add morning dosing to their daily schedules, often acting as a barrier to occupational advancement.
Naltrexone is a molecule that blocks the binding site for opiates, preventing ingested or injected opiates from having psychotropic effects on the addict. The use of naltrexone for treatment of opiate addiction is limited by the requirement for two weeks of sobriety prior to treatment. This period of sobriety is necessary for opiate receptors to normalize to a degree that avoids naltrexone-induced withdrawal. Another problem is that the addict can ‘choose to use’ by simply skipping a day or two of naltrexone. In fact, patients maintained on naltrexone develop a hypersensitivity to opiates, making them subject to dramatic highs during relapse and vulnerable to the associated risk of overdose by respiratory arrest. Naltrexone is administered as daily tablets or as intramuscular, monthly injections, which help reduce the ‘choose to use’ problem. The primary indication for this naltrexone is for alcohol dependence rather than opiate dependence, as naltrexone has been demonstrated to reduce cravings for alcohol. A related form of naltrexone treatment is called ‘rapid opiate detox’, where the addict is anesthetized and given withdrawal-inducing doses of intravenous naloxone. After 8 hours or so, the addict wakes with a slowly-dissolving chip of naltrexone implanted under the skin. This technique has never been very popular because of reports of patient deaths during the procedure, high relapse rates, and several reports of suicide following rapid detox.
Suboxone is a hybrid of methadone and naltrexone treatments, and has a number of features that make it a unique and valuable tool for treatment of opiate addiction. Suboxone consists of two drugs; buprenorphine and naloxone. Regardless of what people on the internet say in message boards, the naloxone is totally irrelevant if the addict uses the medication properly. If the addict dissolves the tablet in water and injects the compound, the naloxone will cause instant withdrawal. When suboxone is used correctly, the naloxone is destroyed in the liver shortly after uptake from the intestines (‘first-pass metabolism’) and has no therapeutic effect. Buprenorphine is the active substance. It is absorbed under the tongue (and throughout the mouth) but inactive if swallowed by mechanisms similar to those for naloxone. There is a formulation of buprenorphine without naloxone, called subutex; I have used this formulation for times when the patient has apparent problems from naloxone, including headaches after dosing with suboxone. I have also treated addicts who have had gastric bypasses, where the first part of the intestine is missed and the stomach contents empty into a more distal part of the small intestine. In such cases the naloxone escapes ‘first pass metabolism’, where with normal anatomy the drug is taken up by the duodenum and transferred directly to the liver by the portal vein, where it is quickly and completely destroyed. After gastric bypass the naloxone can be taken up by portions of the intestine that are not served by the portal system, causing blood levels of naloxone sufficient to cause brief, relatively mild withdrawal symptoms.
Buprenorphine belongs to a class of molecules called ‘partial agonists’ that have both stimulating and blocking effects at their receptor sites. Buprenorphine has potent opiate effects that increase with increasing dose up to about four mg. The opiate effects then reach a plateau, and higher amounts of buprenorphine do not increase narcosis. This ‘ceiling effect’ is the basis for the use of buprenorphine for treatment of opiate dependence. The average addict takes 8-16 mg of buprenorphine per day, and becomes tolerant to the effects of buprenorphine (buprenorphine has significant opiate potency but the opiate effects usually pale in comparison to the degree of tolerance found in active addicts). The addict’s opiate receptors become completely bound with buprenorphine, and the effects of other opiate substances are blocked. At the same time, the bound buprenorphine reduces cravings for other opiates. Buprenorphine is marketed under brand names Suboxone and Subutex. When used properly, buprenorphine is very effective in preventing relapse. Getting an ‘opiate buzz’ requires the addict to first experience several days of withdrawal, in order to rid the receptors of buprenorphine so that other opiates will have an effect. Taking into account addicts’ attitudes toward withdrawal, the appeal of this ‘choice’ is quite low.
Treatment with buprenorphine may be somewhat limited in the case of addiction to multiple substances. For example, an addict may be able to avoid opiates, but remain susceptible to alcoholism. Or as described earlier in this report, addicts may change their attachment from one drug of choice to another. On the other hand, just as naltrexone reduces alcohol cravings, it is possible that buprenorphine, through similar mechanisms, reduces alcohol cravings as well. Addicts treated with buprenorphine who move from one substance to another will likely require an approach that includes total sobriety. But for pure opiate addicts, benefits of buprenorphine include the fact that that only mild withdrawal is required to start treatment, the drug is usually covered by insurers, prescribing restrictions are relatively minor, and there is less stigma associated with maintenance with buprenorphine than with methadone. Insurers should appreciate the simplicity and efficacy of treatment, and would do well to encourage this treatment approach.
I expect that buprenorphine will eventually be the standard treatment for opiate dependence, and will change the treatment approach for other addictions as well. My only reservation to this statement comes from observing the response of the recovering community to patients treated with buprenorphine, which runs from ambivalence to disdain. Some recovering addicts reject recovering addicts taking buprenorphine for not being ‘completely clean.’ Addiction treatment counselors know less about buprenorphine than they should given the utility of the medication. In some cases their focus appears to be more on job security than on the needs of the suffering addict. There are also disagreements over the amount and type of counseling that should be prescribed for addicts taking buprenorphine. From my own experience treating addicts, it is a mistake to assume that addicts taking buprenorphine are in a ‘dry drunk’ in need of a step program; I have found that buprenorphine-maintained addicts make gains in occupational, social, and family domains at rates at least comparable to addicts in step-based recovery. The present standard of care calls for addicts maintained on buprenorphine to be referred for counseling ‘as needed.’ But the message that should be delivered through such counseling is debatable. By one perspective a patient maintained with buprenorphine becomes similar to a patient with hypertension treated for life with medication—the underlying problem persists, but the active disease is held in remission. If the uncontrolled use of opiates is effectively treated, is that enough? Should counseling focus on removing the shame of having the disease of addiction, and encourage addicts to get on with life? Or should addiction be considered a consequence of deeper problems or faulty character structure, requiring group therapy and meetings if one hopes to become ‘normal?’ The use of buprenorphine runs counter to successful adoption of sobriety through step programs, which in the first step require acceptance that the addict is powerless over the substance—that there is no amount of will power that will allow the addict to control the deadly effects of the drug. Buprenorphine may allow the addict to develop an impression that he/she has control, particularly if buprenorphine becomes popular on the street for self-medication of withdrawal.
Physicians and insurers should strive for greater consistency in the use of buprenorphine. Some insurers demand that the drug be used only short-term, in some cases for only three weeks. This requirement discounts the nature of addiction, and ignores the known high relapse rate after short-term use of buprenorphine (why wouldn’t it be high?). Some physicians use the medication short-term as well. Hopefully the motivation for this ineffective treatment method is not related to the limit on the numbers of maintenance patients per physician, but the practice raises the question whether the cap on patients encourages good practice, or bad practice decisions. Some physicians transfer their attitudes toward opiate agonists to the use of buprenorphine, and place constant downward pressure on the daily dose of buprenorphine. Such an approach is not appropriate, as buprenorphine requires adequate dosing to achieve the long half-life and suppression of cravings that make addiction treatment possible. At daily doses below two mg buprenorphine is essentially an agonist, so one might as well be give small doses of hydrocodone rather than buprenorphine! There is no reason beyond cost considerations (which may be practical) to reduce the dose, as tolerance is limited by the ceiling effect of the medication. In other words, at some point higher doses of buprenorphine do not cause greater severity of withdrawal. Another problem is that the medication is sometimes prescribed carelessly, without emphasizing the need to dose only once per day. Addicts left to their own decisions will use the medication multiple times per day as a ‘PRN’ medication, staying in the same somatically-focused, actively-using state of mind that brought them to treatment. Once per day dosing is necessary in order for addictive behavior and addictive thinking to be extinguished over time, and it often takes a great deal of work early in the treatment process to help addicts take buprenorphine properly. Addicts starting buprenorphine may initially experience anxiety as they lose the distraction and placebo effect of frequent drug use. But over time the anxiety will fade, and the void left by the removal of addictive obsession will allow the development of relationships and other positive character traits that were forced out by addiction.
While there are issues to be worked out, the advent of buprenorphine treatment has had a beneficial impact on many who have struggled with the disease of opiate dependence. Treatment based on character change requires desperation before addicts will become willing to change, and for treatment to be effective. And so before buprenorphine, addicts had to lose a great many things—family, employment, freedom, health—before getting better. Only a fraction of addicts recovered, and those only after significant losses—and relapse rates were high. Buprenorphine on the other hand allows treatment of addicts early in the course of their illness, and induces remission in most patients.
Given the time pressures and payment structures of modern medicine, buprenorphine may eventually replace residential treatment as a more reliable, less costly alternative. Is it time to replace the ‘recovery’ model with a new ‘remission’ model, which allows treatment of a much higher percentage of users at an earlier stage of disease? With time, will we find analogous agents that provide a low level of intoxication in return for receptor blockade? While not likely with alcohol, such an outcome is certainly within the bounds of imagination for cocaine, benzodiazepines, and barbiturates. While it is true that daily use of a partial agonist would represent a reversal from our current approach where all intoxicating substances are to be avoided, it is also true that the current approach has no bragging rights based on outcome. And perhaps the adoption of a remission model would lessen the time until opiate and other addictions carry as much moral stigma as hypertension or diabetes—two other diseases that are generally treatable, but that require long-term use of medications.