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Regular readers of this blog know that I am a big fan of buprenorphine treatment of opiate dependence. I used to spend hours arguing with people over whether or not buprenorphine represents “a drug for a drug”, before eventually deciding that those who must be talked into buprenorphine treatment are poor candidates for buprenorphine treatment. I am now less motivated to engage in such discussions, but for those who are interested, my arguments are scattered throughout the archives of the medhelp.org addiction board, the commentary section of my YouTube videos, and in earlier posts to this blog.
The motivation for this current post stems from two recent incidents. The first was the reaction of a group of physicians at a dinner several nights ago, when I was speaking about a different medication. When I mentioned “Suboxone” I heard hissing and other negative reactions from the assembled group of doctors and nurse prescribers. I am the medical director of a residential AODA treatment center that does not use buprenorphine, so I am familiar with the attitudes of non-prescribing counselors– which tend to run against the use of buprenorphine. But the people at this particular dinner were not addiction counselors, but instead were general practitioners from central Wisconsin. After hearing the negative reaction to mention of Suboxone, I deviated from the topic of my lecture to address their reaction. But I soon realized that their opinions were as fixed as those that I ran up against during the arguments described in the first paragraph above. Despite my certainty that buprenorphine has saved thousands of lives, these practitioners see the medication as ‘villain’ rather than ‘hero.’ The assembled physicians see Suboxone as just one more drug of choice for opiate addicts. More disturbing, they see docs who prescribe Suboxone on a par with physicians who overprescribe opiate agonists.
Deaths by drug overdose in Milwaukee County over 7 years
The second incident that motivated this post was the publication of an excellent group of articles in the Milwaukee Journal Sentinel about the epidemic of opiate dependence in Milwaukee County. The article included statistics on the number of deaths by overdose, the vast majority consisting of respiratory arrest caused by opiates. The numbers included deaths from Suboxone taken in combination with other respiratory depressants by people who lacked significant tolerance to opiates. One of the most striking images from the series was a graphic with the deaths color-coded by year, by age of the deceased, and by type of drug. I am well aware of the epidemic of heroin and oxycodone addiction in my part of the country, but I was shocked at the sheer number and ubiquitous nature of deaths by overdose over the past six years.
I am grateful for the availability of buprenorphine in the form of Suboxone, but I wonder how different the current situation might be had a different pharmaceutical company been involved in the U.S. introduction of buprenorphine for the treatment of opiate dependence. Reckitt-Benckiser is a consumer-goods company based in the UK. When Suboxone received FDA approval in 2003, the pharmaceutical wing of the company did not exist in any meaningful form. From the vantage of a Reckitt-Benckiser stockholder, the company did well. They grew their international pharmaceutical division at an amazing pace thanks to the growth of their one product. But when I take a broad look at the current state of affairs, I wonder where we would be if Reckitt-Benckiser had made the decision to team up with one of the bigger players in the pharmaceutical industry. Doing so would have cost them a portion of their profit from Suboxone. But had a company the size of Pfizer, for example, set their sales force on a mission to market Suboxone, I doubt we would have the now-recognized problems with diversion and low physician acceptance. I am also confident that there would have been far fewer deaths by overdose of opiates over the past six years.
I am old enough to have experienced a number of launches of innovative medications, and I have always been one to quickly adopt the newest approaches and medications. But my early use of Suboxone for treating opiate addiction was a unique experience in many ways. I cannot think of any other medication that was (and still is!) as poorly understood by other physicians. I blame some of the lack of knowledge about Suboxone on the stigma of mental health and addiction, but many psychiatric medications with far more complex mechanisms of action—e.g. atypical antipsychotics—have been introduced without the ignorance that is associated with Suboxone. Even in 2007, four years after the release of Suboxone, the vast majority of physicians had not heard of the medication. Doctors have the bad habit of blaming unknown medications for unusual symptoms, so patients often called me after visiting ER’s or after doctor’s appointments where they were told that their symptoms were ‘from the Suboxone.’ One patient returned to the ER after I called the staff and persuaded them to take a second look, explaining that Suboxone does not generally cause fever or chest pain. On his second visit they did a chest x-ray that showed his pneumonia and pleural effusion. I continue to see examples of the same phenomenon today. The ignorance is not confined to emergency care– I frequently receive e-mails from new mothers with horror stories describing bizarre statements by neonatologists, OB nurses, and obstetricians.
A more common problem is described in the following e-mail:
I need help to figure out what’s wrong with me and what to ask my doctor to do about it. I’ve just been through knee surgery to replace my ACL. It was pretty painful but the pain is a bit better now. I’ve been on 16mg Sub for at least five years, although I recently tapered it to 8mgs. This past month I was down to maybe 4mgs/day when I found out my surgery was scheduled. Since I wanted my pain meds to work I immediately cut down even more and called my doc to see if he would give me some pain meds, because the surgeon refused to help me on the grounds that I was on Suboxone and he doesn’t understand it. Unfortunately my doc was out of town. Nobody would help me, everyone said *my* doc was the only one who could, and sorry he’s gone but oh well. This meant i had to get horribly sick the week of my surgery.
I got to see my doc the day before surgery, and he gave me some Norco which helped the w/d symptoms. Then after surgery I had Norco every four hours. Unfortunately after my release the surgeon AGAIN didn’t want anything to do with me. He wrote a script for Norco and told me I’d have to see my own doctor for anything else. The Norco was barely keeping me out of w/d’s, never mind helping my pain. I was waking up every morning with my nose running, sneezing, and my legs dancing. I got hold of my doc and he prescribed me Percocet, on the theory that those last longer. I’m permitted 1 or 2 of them every six hours, to a maximum of 6 per day. This seems to be utterly inadequate but I don’t know why my doctor would prescribe me something utterly inadequate unless he doesn’t think it’s inadequate.
Please, I need some solid experienced information so I can talk to my doctor. I am NOT trying to get a buzz here. All I asked of everyone prior to my surgery was “please treat me fairly given my tolerance level”. I wonder if my doc thinks that he is treating me fairly. But I’m clearly not getting sufficient dosage of opiate, and I don’t know how to present my case, especially over the telephone and via an intermediary nurse. (As yet, he won’t talk to me in person.) If I have to re-induct on the Suboxone and just deal with the pain then I’ll need some medicine to keep me asleep and not dancing until I’m sick enough, but I’m running scared asking for anything at all because everyone is treating me like a junkie.
Because of my blog, I receive messages like this one almost every day. Most doctors have no idea what Suboxone is used for, and how the medication affects the use of other pain medications. Patients are paying for that lack of knowledge with unnecessary pain and hardship. Of course, they are just addicts, right? (Readers should know my sarcasm by now!).
What should have happened?
To describe what could have happened I will use the example of another medication, Vyvanse, which is owned by a different British company called Shire pharmaceuticals. Vyvanse is a clear advance in ADD treatment. Amphetamine was bound to lysine to create an inactive molecule, and the amphetamine is released at a measured pace after Vyvanse is absorbed into the circulation. Shire is a relatively small company, so they paired with the much larger company, GSK, to get the word out about Vyvanse. The result is that thousands of GSK representatives have provided information about Vyvanse to physicians, pharmacies, and hospitals. Had Reckitt-Benckiser done something similar, doctors everywhere would at minimum know the basics about buprenorphine. And more, the treatment of addiction may have been brought into the mainstream where it belongs.
Reckitt-Benckiser eventually came out with a program called ‘Here to Help’ in order to provide education and by their description to improve compliance in addicts taking Suboxone. I was disappointed that the program began a number of years after Suboxone was released, not until the eve of the launch of a generic form of the medication. The timing left the impression that the program was more about maintaining brand loyalty than concern for addicts. The program pales in comparison to the education and outreach provided by major US pharmaceutical companies when they release a new medication. There are comments about the ‘Here to Help’ program associated with an earlier post on this blog, and I have received a number of similarly negative e-mails, including one just today that included these comments:
This “Here to Help” thing is really not very good. I actually signed up as a patient, and the girl was clueless. Every single issue I wanted to talk about, she told me to “Talk to your physician”.
“I feel scared that when I reduce my dose I’ll go nuts”
Talk to your physician
“I feel like I’ll never, ever feel ok again”
Talk to your physician
“I feel shaky before my morning dose”
Talk to you….
You get the point.
When I asked how her course of treatment had gone, she told me that they don’t ever talk about their own personal recovery. Oh, well THAT’S helpful, huh?
There are other complaints about the manufacturer of Suboxone even by addicts who appreciate the medication. They resent the fact that so few non-addiction doctors have any knowledge about the medication. Many have fallen victim to what is described in the first e-mail above, and have suffered painful postoperative recoveries. There are complaints about the cost of the medication, once a pricey four dollars per pill and now up to twice that amount. The patient assistance program offered by Reckitt-Benckiser limits support to only 2-4 patients per practice, a limit that is not present for any other medication that I prescribe for psychiatric patients. Many addict-patients have experienced poor treatment practices as a result of insufficient education for physician prescribers. Buprenorphine should be taken once per day in a dose range of 8-16 mg, but I have had new patients whose prior doctors prescribed much larger doses at much more frequent intervals. In my experience frequent dosing of buprenorphine is much less effective at extinguishing the psychological component of addiction. Instead of eliminating the relationship between ‘feelings’ and ‘using, such patients remain fixated on how they feel and take small doses of buprenorphine multiple times per day in response to imaginary withdrawal symptoms. Their physicians should have been taught about the value of less-frequent dosing by people who understand addiction. I was, by the way, a Reckitt-Benckiser/Suboxone ‘Treatment Advocate’ for several years. My experiences as an opiate addict for 16 years, my PhD in neurochemistry, my 3+ months of residential treatment and 6 years of formal aftercare, the hundreds of AA and NA meetings I have attended, the eight years I spent working in pain clinics as an anesthesiologist, my psychiatric training, my experience treating over 450 patients using buprenorphine, and four years as medical director of a large residential treatment center have all contributed to some level of insight into addiction and addiction treatment. I called and wrote to R-B multiple times asking that they use me to educate other physicians. I was called upon to do so three times in four years. As a comparison, I have been asked to educate groups of prescribers about Vyvanse over ten times in the last month or two alone. Can you imagine the knowledge-state about buprenorphine had similar efforts been made by Reckitt-Benckiser over the past 6 years?!
I have blogged about my frustration trying to find an application for an educational grant from Reckitt-Benckiser that would allow me to apply for funding to expand my educational efforts on the internet. To compare, a visit to the Mallinckrodt Pharmaceuticals website quickly leads to the application for funding educational programs. There are, in fact, several significant web-based educational programs related to the prevention and treatment of addiction supported by unrestricted educational grants from Mallinckrodt, who manufactures methadone among its products. There is a similar online application for grant support on at least every pharmaceutical company that I visited this evening as I prepared to write this post. I have not found such an application for Reckitt-Benckiser. I even spent four years calling, writing, and e-mailing different branches of the company in search of an application for such support. My hopes were raised on two occasions when I was visited by regional sales directors and promised that information about grants would be provided. But after the visits nothing happened, and when I called in an attempt to follow up, I was back to square one, talking to people who claimed to have never heard about my prior contact with the company.
Does this all sound like ‘sour grapes’ over a snub by Reckitt-Benckiser? Perhaps it is, to some extent. I am, after all, only human. But I am not only resentful. I spend a great deal of time reading and responding to e-mails from addicts, parents of addicts, spouses of addicts, and friends of addicts, and I am acutely aware of the suffering caused by opiate dependence. I’ve spoken to many people who were close to addicts who lost their lives to opiate dependence, and I have at least some sense of the suffering that they go through. And I have no doubt much of this suffering could—and should– have been avoided.
I fear that the actions of Reckitt-Benckiser, specifically their close-fisted release of a life-saving medication, have permanently endangered the successful use of buprenorphine for the treatment of opiate dependence. Once doctors start hissing, it becomes extremely difficult to create positive impressions of a medication or of a practice technique. I will, for what it is worth, continue with my own small efforts. And I hope that Reckitt-Benckiser will observe one of the principles that we teach addicts in recovery: Ask for help when help is needed.
How ironic if the success of a medication with the potential for a profoundly positive impact on addiction fell victim to addictive thinking by its own manufacturer!?!
Comments? Write below, or join us at Subox Forum– Soon to be called ‘Buprenorforum’.
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I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction. I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother. My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response. Read on:
There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.
We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.
It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction!
Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about THAT discomfort—at least not from the baby’s perspective! I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal! Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s (!), babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose!
My points are twofold, and are not intended to encourage more births of physiogically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right. Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.
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A member at the buprenorphine forum wrote about his own health issues including hormonal imbalances, prompting me to do a literature search on buprenorphine and testosterone. I found a couple interesting studies and invite people to visit the forum and read about them, and comment if you wish. To find the comment thread, just go to the bottom of the first page and the ‘index’ will list the new topics.
Oh– and please consider signing up while you are there. Feel free to use an alias to maintain confidentiality. Our numbers are growing, and the forum is open for anyone– including friends and family members of opiate addicts, or even people who only have an interest in the topic of opiate dependence. We ask only one thing– that those who are looking to debate whether or not buprenorphine maintenance is ‘good’ or ‘bad’ take it outside. Addicts have enough shame to digest already, and this is one place where the need for chronic treatment is a given.
JJ
A quick addendum– a reader had trouble finding the articles– they are at this link.
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I will introduce this topic by typing my response to a reader who asked whether buprenorphine, the active ingredient in Suboxone, shows up in urine drug tests. More specifically he asked whether companies have the ability to test for buprenorphine. I will end the post with a question… so please stick around to the end!
Typical 10-panel urine dipstick test
There are tests out there—multi-panel dipstick tests– that react ‘positive’ to Suboxone in the opiate panel. Or at least there used to be; I used to see that reaction with a brand of tests I no longer remember, that I used several years ago. For the past couple years, every dipstick brand that I have purchased has responded ‘negative’ to buprenorphine (or naloxone for that matter) as an ‘opiate,’ and positive in the ‘buprenorphine’ column (i.e. so I know that the urine truly contained buprenorphine). I pay more for dipstick tests that have a separate panel for buprenorphine, but yes, that test is available if a company wants it. From what I have heard from owners of companies or from people privy to the inner workings of companies, some businesses will do a dipstick first, and then send only positive samples to a lab for more formal testing in case a firing is challenged in court. They do the dipstick first because it is MUCH cheaper- $5 for a dipstick test, and several hundred for a laboratory test for several substances. It costs more for each test at the lab, so companies will only have the lab test for the substance of concern.
I assume that it comes down to the attitude of the company, but there may be issues that I am not aware of. I assume that some HR folks know what bupe is, and deliberately choose not to test for it, believing that it is a medication in most cases and not a drug of abuse. I’m sure there is a company somewhere that tests for bupe to catch any sign of even ‘prior’ addiction, but that has not been the experience of the people who have written to me. I have not heard from anyone who tested positive for buprenorphine in a random test—but I will put the question on my blog and see what comes up!
So there is my question: has anyone tested positive for buprenorphine in the workplace? Has anyone tested negative who takes buprenorphine? Please share your responses in the comment section below, so that I will have more than guesses for people who write. My attitude, for what it is worth, is that your medication list is your own business, providing that the medication does not influence your ability to perform your job. But I realize that the answer to the question can be complicated. For example, I was first treated for opiate dependence in 1993, and was completely ‘clean and sober’ for many years, active in 12-step Recovery and regularly attending meetings. Every two years I received a re-appointment packet at the hospital where I worked, and one question was ‘Do you have a chronic illness that affects your ability to care for patients?’ I knew what the question was getting at— but to my way of thinking, as a person who had been clean for several years and who was never planning on using again, the correct answer was clearly ‘no, I had no illness that affected my care of patients.’ But when I relapsed in the year 2000 the hospital made much of my answers to that question, reporting to the Board that among my other (much more significant) transgressions, I lied on my re-appointment packets. I was going to defend myself by saying ‘it depends on what the meaning of ‘is’ is…’ but someone else used that excuse before I could use it!!
The problem people face with workplace drug testing– at least something that would be considered a problem for those sympathetic to people on buprenorphine– is that people are often asked to provide a list of the medications they are taking BEFORE the test. If not for that question, they could go take the test and explain themselves in the event of a positive result. But if asked about medications beforehand, the worker must decide whether to disclose a history of addiction to an employer who may be overly judgmental, or keep the medication use private and risk being accused of lying.
To those who are going to write that ‘taking buprenorphine is impairing a person and therefore the person must put the info out there,’ I will say in advance that my patients on buprenorphine, who take the medication properly, are NOT impaired by any definition of the word. They are completely tolerant to the mu receptor effects and are getting no ‘opiate effect’ from the medication. I will also point out the double standard applied to addiction. A person with a history of epilepsy is at risk for losing consciousness while operating a crane from a seizure. A person with diabetes is at risk for the same from a hypoglycemic reaction. Someone with heart diseast could drop dead of a lethal arrhythmia while driving a school bus filled with children. Should opiate addicts who are doing the ‘right thing’ and keeping their addiction in remission be forever identified as ‘addicts’ to employers?
As always, thanks for your comments; please also be sure to join the forum if you have not already. You will note that when leaving a comment, it will take a day or so to get read and approved; I do that because there are people who have nothing better to do, apparently, than respond that I am ‘a little bitch’ or call me some other name– for reasons that are not always entirely clear! When I read such comments I always get a mental image of Mr T. saying ‘I pity the fool!’ (then I think of the scene in Pee Wee Herman’s Big Adventure where Mr. T. says ‘I pity the fool… who doesn’t eat my cereal!) I guess you really have to be there.
SD
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I’ve been posting more lately, but I’m hoping to slow down by the end of the holidays to let everyone catch up. I’ve also mentioned ‘my book’ several times in the past year, promising to myself and to others deadline that comes and go. I wish I could take a month and work on it full-time, but I don’t see much chance of that happening… so I’ll have to just keep chipping away at it. I can be a perfectionist and everything can be worded just a little better… I’m the same way some mornings with my electric razor, until my wife gets sick of watching me ‘make it perfect’ and takes the razor from me. I came across an article the other day that described a form of OCD that involves exactly that behavior– so at least I know the nature of my problem!
I want to thank those of you who responded to the ‘here to help’ post, and please, if anyone else has had positive or negative experiences with the Here to Help program run by Reckitt-Benckiser, let me know. You don’t have to report anything ‘profound’– just a general comment or two whether it was helpful, whether you stuck with it, etc.
I have written about benzos a number of times and I still have more to say. I would hope that everyone is familiar with the danger of respiratory depression when combining benzos and opiates. Most of the deaths involving buprenorphine that I have reviewed or read about had two things in common. First, the person took buprenorphine along with a second respiratory depressant– often a benzodiazepine, but alcohol acts at the same receptor sites as benzos and so alcohol has similar dangers. The other commonality is that the person who died was not ‘tolerant’ to high doses of opiates, benzos, or both. I do not want to say anything that puts addicts at risk, and I am NOT condoning benzo use, particularly the use of medications that are not prescribed by your addiction doc. Doing so will eventually destroy you– but for the opiate/benzo combination to kill someone quickly generally requires that the person is not tolerant to one or the other chemical. THIS IS NOT SOMETHING TO RELY ON TO AVOID DEATH! Did I make myself clear? Understand that the danger of combining opiates and benzos is not greater than the risk of combining benzos with opiate agonists. There is nothing ‘more dangerous’ about buprenorphine EXCEPT the false sense of safety that users may have about buprenorphine. But other than that false sense of safety, combining a pure opiate agonist with a benzo is MORE dangerous than combining similar potencies of buprenorphine with the same benzo.
I wanted to get that issue out of the way so that I could get to the main danger for addicts on buprenorphine when taking benzos, i.e the long-term effects on sobriety. Opiate addicts will become actively addicted to other drugs when opiate addiction is prevented if no efforts are made to change. I have written about my opinion that ’standard AODA counseling’ is not the best fit for many people. But that does NOT mean that change is not required. At the very least the addict must find a way to fill the time spent using, and find a way to tolerate the harsh glare of reality when the mind is not constantly occupied with using, coming down, craving, or regretting the use of opiates. I have had many patiens go through an initial ‘happy honemoon’ stage, and several months later struggle with all of the feelings that were being held at bay by preoccupation with opiates. That preoccupation burns off a great deal of emotional energy, and suddenly our minds have plenty of time to worry about OTHER things! There is also the fact that many of us used to dull our feelings and our reactions to life’s challenges. So opiate addicts often compain of ‘anxiety’ early in buprenorphine maintenance, as they experience unpleasant feelings that should really be considered plain old cravings rather than an anxiety disorder. I’ve written about what people say when I ask them to describe their ‘anxiety– they feel edgy, there is nothing to do, they are pacing, restless– they sound more bored than ‘anxious!’ But right now, for the sake of the argument I will accept that some addicts are having real ‘anxiety.’ This is a big thing to accept, since anxiety is fear, and the people with anxiety are generally not the ones taking on new challenges, but rather tend to be the people who are doing nothing but playing video games all day… so I’m not sure where the ‘fear’ is coming from. But even so– if that person was in residential treatment (before the days of buprenorphine) and complained of anxiety, every counselor would say ‘poor baby…. how HORRIBLE that you feel so ANXIOUS! And so UNIQUE– why, nobody has EVER felt like THAT before!!’
Do you get my point? Sorry to be such an ass about it, but we are dealing with a fatal illness here. Before buprenorphine, addicts would avoid narcotics after surgery in efforts to avoid risking relapse– now with buprenorphine, some people want to take the easiest way that they can find. I will tell you straight up– if you are on the verge of finding stability on buprenorphine, you are extremely blessed. Many people have died before you from opiate dependence, without the opportunity to improve their odds with buprenorphine. You must do SOME tough things— and one is to learn to deal with life on life’s terms. If you cannot do that, your chances for avoiding using–even with buprenorphine– are low. Yes, for a time you are going to be ‘anxious’, or dysphoric, or whatever you want to call it. You haven’t dealt with life lately, so of course it will be a tough adjustment! But what do you expect– that you can just be numb and relaxed the whole time, and everything will just fall into place?
People with cancer deal with extreme pain, nausea, surgeries, deformity of body parts… YOU must deal with your ‘anxiety.’ Why? It is hard to explain to people who have not been through residential treatment, where a person at least learns some things about what addiction is all about. Addiction is complicated, and occurs for many reasons– there is not ‘one reason’ for being and staying an actively using addict. One reason relevant to the benzo issue, though, is that addicts become very aware of their own physical discomfort– we become ‘big babies’, basically. Benzos only make this worse; the addict in early recovery feels uncomfortable about many things, and having a pill to take when things get bad enough only makes the addict look inward even more often to decide whether things are bad enough to deserve a Klonopin. Another reason people stay addicted is because of distortions of insight, specifically losing the ability to predict what they will do in the future. The addict says ‘I will take it only for severe anxiety’, but after a few days the addict finds that there is ALWAYS a reason to take another dose of a benzos. Addicts didn’t know life was so tough until benzos became available, when suddenly EVERYTHING seems like a severe situation– snowed in, new coworker, lost job, getting a new job, a first date, a break-up, an NA meeting… ALL of these things are great reasons for Klonopin!!
Another problem for addicts taking benzos is that when addicts take a benzo for ‘anxiety’, they don’t focus on the disappearance of their anxiety– they focus on the appearance of the ‘buzz’ from the benzo. ‘Normal’ people hate that feeling, and so they find benzos to be too sedating or too impairing. But addicts LOVE that feeling– any feeling– and so they dose until they feel it– not until the anxiety is gone. And that extra ‘dosing for feeling,’ combined with the fast tolerance characteristic of benzos, leads to rapid escalation of dose. And what a surprise– that dose escalation even occurs in people who say ’don’t worry doc– I don’t plan to raise the dose.’
I realize I’m expressing anger with this post, but hey, I have to express it somewhere! Part of my anger comes from the repeated behavior of addicts– behaviors that I resent that will always remain within myself as well. I realize my anger is for the addiction, not for the person suffering from the addiction… but sometimes I am frustrated by the unwillingness of addicts who are at the edge of relapse to ’step up’ and face the challenges, and to fight for their lives. I was also angry at what happened on a TV show this AM as I was getting dressed. I shouldn’t admit this… but I was watching MTV, the show about the teens who became pregnant and had babies, which is now a show about teen moms… and one of the teen moms went to the doctor and complained of her ‘anxiety’. She is young, bored, stuck at home with a crying baby… and she has ‘anxiety.’ Some mornings she ‘just lays in bed and doesn’t want to get up.’ What a surprise that she isn’t just thrilled to get up every morning! She sees a doc (who could pass for a beetle if he had the right markings on his back) and the doc prescribes… Klonopin. The next morning the baby is fussing and the teen mom holds the baby at arms’ length, passes him to her BF, and says ‘I have to take my Klonopins.’ A close shot of the bottle shows instructions to take ‘one tab twice per day’ (clonazepam has a half-life of about 24 hours, so the level in her body will increase over several days to a high steady-state level). The next camera shot the next day shows her laying on the couch, yawning, saying that the medication seems to be working. Her one-yr-old, meanwhile, is… somewhere…. not sure where I left him…
But at least she isn’t ‘anxious’!
I went off on something that I was only going to mention in passing… so I guess I’ll finish the story I intended to write in a few days. I want to write about a couple studies that looked at the cognitive effects of buprenorphine, methadone, and benzos. Thanks for letting me vent… good luck returning to work tomorrow for those of us lucky enough to be working, and I hope those who are looking find somethng soon.
JJ
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I frequently point out the lack of outrage over the epidemic of opiate dependence and the consequence of that epidemic. I live in ‘middle America,’ and sometimes it seems that everyone I know has some connection to opiate dependence– a relative who is an addict, a friend who died, a parent who is in prison. My perceptions are admittedly distorted by the work that I do, but I don’t know who has the more accurate perceptions; me or the people who seem surprised to hear that most high school kids know where they could get heroin. Addicts who I treat who come down from the U.P. of Michigan tell me that heroin is very easy to get up there now, even cheaper than oxycodone. I guess that’s to be expected, given the horrible economic situation up there. One thing is certain though– SOME people are making money! In my part of Wisconsin, oxycodone generally sells for 60-80 cents per milligram; the average user that I see tries to find one or two ’80’s’ per day, ending up with a habit that costs over $100 per day. Given the number of people actively using, there is a LOT of money going into someone’s pockets! Of course much of the oxycodone on the street is bought by insurance coverage and then stolen from grandma’s medicine cabinet by her granddaughter, who replaces them with plain tylenol tablets… but the herion money is probably leaving town, eventually finding its way back to Chicago. Sorry, Chicago. We have to blame SOMEBODY.
Many diseases have prominent celebrities who put on pink ribbons and fight for funding. Not so for opiate dependence, even though the deaths from opiate dependence must rival those from breast cancer. I’ll have to look at the numbers. But celebrity opiate addicts tend to end up like Kurt Cobain or Michael Jackson– or slink off to rehab and later proclaim themselves cured. Anyone who watches knows that there is no cure for opiate dependence, and the celebrity addicts only go back to rehab again as society goes ‘tsk tsk’. Society doesn’t say ‘tsk tsk’ when someone’s breast cancer comes back.
I found an interesting web site called ‘informationisbeautiful.net’ where information about a variety of topics is presented in visual form. Below I have a couple images from the site using data from the UK on deaths from overdose of a number of substances. The images are relevant to the current discussion, as he compares the death rates to the reports about deaths due to the substances in the National media. At the web site he discusses data collection; I won’t make conclusions on the data but rather simply let is provide ‘food for thought.’ After viewing the first image be sure to contine to the next image down.
In the next image he manipulates the data slightly to add a denominator to the information– he provides the number of deaths per user of the substance. Again, I will let people truly interested in his findings visit his web site to look into whatever assumptions were made and which data sources were used. I would like to again leave the data without much comment, in part because I don’t really know how to explain the high rate of fatalities among methadone users. I will point out that use of methadone in the UK may be quite different than in the US, because in the US the medication is prescribed in two ways– as a cheap opiate for chronic pain management, and as a maintenance agent for opiate dependence. In the latter case, prescriptions for the medication are regulated very closely (actually ‘prescription’ is not even the right word, as addicts must personally pick up their dose of methadone each morning for at least the early part of their management by a particular clinic). I should also point out that Heroin is a pain medication in the UK that is prescribed by physicians (as well as a ‘black market’ substance), whereas in the US all Heroin is illegal and cannot be prescribed for ANY indication. Finally, paracetamol is the Brit’s term for acetominophen, or Tylenol. The graphic:
I do have a couple final comments. On other blogs or in response to my videos I sometimes come across remarks by people who are ‘anti-suboxone’ that ‘the problem with treating addicts with buprenorphine is that you then can’t get them off buprenorphine, and you have another problem to deal with’– that the addicts are ‘addicted to buprenorphine.’ I find that argument to be faulty for a couple reasons. First, ’addiction’ is not so much about the taking of the substance as it is about the obsession with the substance. An addict who is properly treated with buprenorphine loses the obsession for opiates– something that is amazing to witness at the first follow-up appointment, when the addict sometimes cries over how wonderful it is to be freed from the obsession to use. So I don’t see buprenorphine as a ‘replacement’, and I don’t see the physical dependence on buprenorphine as ‘addiction’ any more than people taking effexor or propranolol are ‘addicted’ to those medications (which also have withdrawal symtoms of stopped abruptly). But even beyond that consideration, given the high mortality rate for opiate dependence, when people complain about taking buprenorphine I am always tempted to say ‘compared to what?’ People are DYING from this disease– frankly I don’t CARE if they get dependent on buprenorphine. I am on the record here over and over with my opinion– that buprenorphine should be a long-term medication. Use it to keep a person alive during his or her 20’s, and then worry about tapering off– and if the person cannot taper off, so be it! It beats death. And any parent of an addict in his or her 20’s knows that a string of ’sober’ treatment centers and repeated relapses is NOT a great life… assuming the person even manages to stay alive. We are left with comparing the two options of taking buprenorphine and living or avoiding it– and likely dying. A pretty easy choice to make in my opinion. I have to wonder what the people making arguments about ‘the problem with buprenorphine’ think about all of the problems with chemotherapy… if a person’s child develops leukemia, if you treat him with chemotherapy he may end up sterile, and with an increased risk of a different cancer years later. Would you recommend avoiding using chemotherapy to save his life now? What’s the difference?
As always I am interested in your comments here and over on the forum. We’ll talk again in 2010!
JJ
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