It has been a while, it seems, since I’ve checked in.  I’m at the point in the life cycle of a ‘blogger’ where I feel like I’ve said most of what I came here to say… so help me out by sending your questions, particularly those with broad implications, and I’ll chime in with an opinion.

In the meantime, check out the ‘best of’ page;  I have links there to some of the more popular post.   And for now, I’ll answer a question I received today on ‘TheFix.com’:

Do you believe in intervention of someone who does not ask or desire (to be clean)?

It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within. 

More common than you think!

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option. 

For example… let’s say that grandma has a problem with pain pills, taking more than what is prescribed, going to multiple doctors, going to the ER for pain pills, etc.  Her children don’t like her behavior, so they stage an intervention, to show her the problems her behavior is causing.  At the intervention, they tell her how hurt her grandchildren are by her absence at their functions, and they explain the risks of her behavior.  They set her up at a treatment center, and she is shipped off for 30 days.

She may go to all of the groups and meetings in treatment, agreeing politely in every setting that she has a serious problem, and that she really ‘gets it.’  And that would be great for the treatment center; they would collect their $30K, and everyone there would congratulate each other on how compassionate and bright they are. And later, when grandma is doing the exact thing she was doing before treatment, the counselors would put the blame on HER, acting as if SHE has a problem for not sticking to plan—even though almost all of their patients end up the same.

I used to be a bigger fan of residential treatment. But at some point I let go of the fantasy of residential treatment as the ‘gold standard’, and accepted the real numbers.  It is easy to clean a person up for a month in a closed environment.  But in regard to long-term sobriety… residential treatment rarely works.  Sorry to say something so horrible—but that emperor, sadly, has no clothes.

So back to grandma… I would expect her to go back to the same behavior after treatment. Why, after hearing from all the family, would she do that?

Because true change is very, very difficult. 

Besides, she has plenty of reasons to keep things the same.  She will likely think that the problem isn’t the use of pain pills, but rather that she didn’t hide things well enough.  Or she will assume that other people simply don’t understand what it is like to be 70 years old, trying to live with pain. She used to change the smelly diapers of these kids;  what could they possibly tell her that she doesn’t know?

And the major reason she won’t change?  For her to truly realize that her behavior is a problem, she would have to endure the shame for what was going on—and shame is a very strong motivator for denial.

In treatment, the team will try to try to break through that denial and have her admit, to herself, that she has a problem.  But that type of admission is rare, and only comes out when a person is desperate—and when there is no choice but to change.

But there are other ways to manage an intervention.  It would be best if grandma herself decides, at some point, that things must change.  How does that happen?  First, everyone has to stop enabling her.  If the grandchildren are angry that grandma didn’t show up at their birthdays, they should be allowed to express that anger—and when grandma protests, she is forced to hear why people are mad.  If grandma runs into problems with the doctor or pharmacist, nobody should help her sort things out;  she is left to juggle excuses on her own.  If she needs the ER for pain pills, she drives herself—or waits for a cab.

I chose ‘grandma,’ by the way, because I wanted to present the challenge of dealing with a person who deserves sympathy.  Nobody does her a favor by keeping her miserable.  Realize, though, that we are discussing addiction here;  I’m not suggesting that people abandon loved ones struggling with painful conditions!

The doctor should prescribe medications on a tight schedule, with strict refill dates that are maintained without exception.  Doctors are sometimes afraid to let people go into withdrawal, so they order ‘a few extra pills’ to get to the next refill;  medications should be long-lasting, so that withdrawal is uncomfortable, but not dangerous.  A short period of the medication- i.e. a one-week supply—will reduce the period of withdrawal.  If a person struggles to follow limits, the prescribing period is shortened until the person CAN follow it—even to the point of 3-day prescriptions with multiple refills.  If grandma complains about the multiple trips to the pharmacy, she is told that period will be lengthened if she sticks to the schedule— and shortened if she doesn’t.

The point of all of this is to make the person with the problem feel the consequences of their problem.  Too often, everyone else is aware of the need for an intervention, because everyone else feels the consequences—everyone but the addict.  The trick is to make the consequences hit the person who has the problem—and for everyone else to get on with life, until the person with the problem is sick and tired of those consequences.

Of course, every now and then an intervention turns out to be meaningful enough to get a person’s attention, and to spur change.  But in my experience those types of outcomes—the things we see on TV and in movies—are not the norm.

Below is an e-mail that I changed just enough to hide the person’s identity.  Every week, I receive messages that describe similar situations.

My husband has struggled GREATLY with substance abuse since in his 20′s; he is now in his mid-40′s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.

From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.

If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough. 

My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.

Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.

Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.
More and more physicians pay lip service to ‘addiction as a disease,’ but most do not yet treat addiction as a disease.  The comments about diabetes are ‘right on.’ One could substitute a number of diseases to demonstrate the same point.  We physicians have few illnesses that we cure; rather we manage illness over a person’s lifetime— and opioid dependence is clearly a life-long illness.

To address a couple points in the message:  the active ingredient in Suboxone, buprenorphine, has been in clinical use for over three decades, and has established a clean safety profile.  Buprenorphine has not been used at the high doses employed for treating opioid dependence for quite as long, but even that track record is significant, i.e. 8 years in this country, and longer in Europe.  Most physicians would not consider an 8-yr-old medication to be a ‘new drug!’

The situation described in the message is, in my opinion, the result of several factors.   First and foremost, the reluctance to prescribe buprenorphine is a consequence of stigma.  Doctors prescribe new antidepressants, pain relievers, blood pressure treatments, and cholesterol-lowering agents with much less concern over ‘safety.’     I wonder, frankly, if safety is the concern—or whether there is an unconscious sense that patients addicted to opioids, or to other substances, don’t deserve an ‘easy way out’ of their problem; that sitting through a miserable detox is  a more fitting ‘treatment’ than a pill that makes things better.

I come to this cynical conclusion only because the alternative—that buprenorphine is ‘dangerous’—doesn’t make sense.  The risk of any medication must be compared against the risk of not using that medication.  As the message states, we know the risk of ‘not treating’ the woman’s husband!  Similar comparisons are used to justify the use of chemotherapeutic agents that have severe toxic effects, including the risk of killing the patient.  As I’ve written in prior posts, the fatality rate from untreated opioid dependence is as high as for many cancers.  So does it make any sense to withhold buprenorphine out of safety concerns?!

There are other reasons for doctors’ reluctance to prescribe buprenorphine. Many fear they will do something wrong, and run afoul of the DEA during an audit—a process that all buprenorphine-certified prescribers are subject to.   Some doctors feel pressure from friends and family members of patients, who often blame the doctor for keeping the patient ‘stuck on Suboxone.’  Some doctors want to maintain high patient turnover in order to keep money  coming in, since practices are ‘capped’ at 100 patients per certified physician.

Finally, I think many doctors see ongoing treatment as less satisfying than a ‘cure.’  They consider residential treatment the gold standard, and buprenorphine as a less-intensive alternative.  They buy into the idea that the addict can be returned to ‘normal’—whatever that is—if he/she works at recovery hard enough.  I understand the thought, as that is the type of treatment experience that I went through.  But on the other hand, the relapse rate for opioid dependence, after residential treatment, is very high. I myself relapsed after seven years of recovery, losing my career, and almost my life.  During my years as medical director of a large residential treatment center, patients discharged as ‘successfully treated’ often became repeat customers, at least until they lost their job and health insurance.  Some of them– too many of them–died.

I won’t get into the specifics of treatment;  I’ll leave that to her husband’s doctor to work out.  But I do hope that the doctor will give some thought to whether stopping this life-saving treatment is truly in the patient’s best interest.

To the patient’s wife– I encourage you to continue as an advocate, and I hope your doctor will understand your perspective.

A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.

I drug-test patients who are treated with buprenorphine or Suboxone.  The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble.  It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example.  The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’

The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight.  Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important.  It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high.  On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.

In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me.  But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything.  As soon as I relapsed, nobody could be trusted. Nobody would understand me.  I was on my own.

Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations.  But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.

One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test.  In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience.  “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house.  With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’

After shooting the heroin, Paul immediately felt disappointed in himself.  Unlike in the old days, he felt nothing from the heroin.  While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.

His desire to talk is an amazing thing—and worth noting.  Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician.  In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.

There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients.  I don’t get the logic of those programs, and I become angry when I think about them.  As I’ve said before, if a person relapses, that person NEEDS help—not abandonment!  I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness.  And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!

Paul made an appointment to talk about his experience.  He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future.  He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues.  Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down.  Those are all big issues, I said as I agreed with him.  How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!

We talked about the challenge of being ‘someone’– of being proud of one’s self.  It feels good to do the right thing– but it may also feel bad.  Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.

Before buprenorphine, people struggled with opioid dependence largely on their own.  Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict.  Many people in AA or NA will say that “AA is a selfish program.”  It has to be.  When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.

On buprenorphine, relapse doesn’t necessarily cause instant loss of insight.  I don’t mean to minimize relapse, as bad things can always happen.  For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused.  But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.

This assumes, of course, that the person is not simply tossed from treatment for the relapse.  In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.

I received the following e-mail a couple days ago:

Hi

I had been on Suboxone for 9 years. I was put on it the week it was approved by FDA. I found your posts in a blog. I was looking for a class action suit against this terrible drug. That man who said he was enjoying a Suboxone was right. I was on it almost 9 years and did get high and stay high all day, just like methadone. It causes depression and brain damage. I have been off it for 2 months now and am very sick with depression, panic attacks, and have not been able to even take care of myself. Please, if people want to get off drugs help them and send to treatment and AA NA.

thanks

nancy

Those of you who have read this blog for a while may remember the posts ‘back in the old days’—a few years ago—when I would get these kinds of messages often. Thankfully, I rarely get them nowadays, although every now and then someone stops by SuboxForum.com intent on harassing people taking buprenorphine.

I get your complaint Nancy, I really do—but I don’t agree with your thought process, or your conclusions. First of all, buprenorphine has been around for over 30 years, and has never been associated with ‘brain damage.’ The high doses of buprenorphine used for opioid dependence have been in around for 15-20 years overall, 8 years in the US. Several million prescriptions for high-dose buprenorphine have been written—without evidence for any significant harmful effects from buprenorphine.

Your description of how you felt while taking the medication are not at all consistent with the descriptions I’ve heard from the several hundred people I’ve treated over the past 5 years; people almost always report feeling nothing from the medication after being on it for a week or two. Every now and then a person will say that he/she notices opioid effects after each dose, but the sensations are always subtle, and people have to focus to tell if they are really feeling them. Frankly, given that the feelings usually come well before the 45-minute absorption time of the medication, I think that they are often imagined, or created by the mind, as a ‘placebo effect.’

Preliminary studies suggest a role for buprenorphine for treating refractory depression. I would not recommend that use for the medication in people who are not already addicted to opioids- but the findings of mood elevation in some people runs counter to your suggestion that the drug causes depression.

Buprenorphine is different from methadone in a number of ways, the most critical being the mu receptor profile, where buprenorphine acts as a partial agonist, and methadone acts as an agonist. This difference is responsible for the unique actions of buprenorphine, compared to methadone and other agonists.

But my primary disagreement with you is because you completely disregard the conditions that you had before starting buprenorphine. I assume that you were dependent on opioids, as that is why the vast majority of people take buprenorphine. And opioid dependence is not a benign condition. In fact, opioid dependence is often fatal, particularly over a span of ten years. When you blame your depression and anxiety on buprenorphine and Suboxone, where do you get the image that you use as a comparison for your current condition?

For example, if you didn’t take buprenorphine, what are you assuming would have happened? The success rates for ‘treatment’ without buprenorphine are very low—well below 10%. And many young people who have taken opioids for more than a year or so can list several former confidants who have died from opioids. In other words– you seem to be assuming that you would have been fine without Suboxone, when the odds are more in favor of you having significant problems from your addiction—and maybe death.

You may have scraped up $5K – $50K to enter treatment and been in the lucky few percent who ‘got’ recovery; in that case, the odds would have been high that you would relapse in the next few years. As for depression and panic, those are common symptoms in anyone with longstanding opioid dependence—are you just assuming that you would have been fine?

You may have gotten arrested for doctor shopping, shoplifting, or theft from your best friend’s medicine cabinet. You may have gotten disgusted with yourself and committed suicide. You may have lost everyone close to you, and ended up living on the street. We don’t know what might have happened—but I remember the days before buprenorphine was available, and remember the revolving door of treatment centers and NA meetings. Heck, those revolving doors are still in use by the people who will buy into your comments!

This is where my anger used to really well up… every person who you convince with your story — fueled by your lack of recognition of the condition you were in and your lack of appreciation for the substance that saved your life—every one of those persons will have a higher risk of mortality, thanks to you.

And—sorry for my French—that still pisses me off!

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.

Some substance abuse treatment programs make use of other drugs to flush out the more addictive and dangerous substances in an addict’s body.

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.

I’ve shared my history many times, including mention of my ‘spiritual awakening’ in 1993 that kicked off about 5 years of active AA invovlement.  After struggling with an obsession to use opioids for months, a meeting with a psychoanalyst sparked the ‘awakening’ on my drive home.  I was suddenly very tired of what I was doing– the lying, hiding, desperately searching for something to stop the withdrawal, fighting with my wife… and running from psychiatrist to psychiatrist, trying to find one to agree with MY version of the world, who I would agree to see for treatment.  I now realize, by the way, that ‘change’ by definition appears foreign, wrong, and inappropriate;  a patient who sees a therapist who agrees with everything the patient says is guaranteeing the ABSENCE of change!  On the day of my ‘awakening’ I saw an analyst who told me I was full of BS, and I suddenly realized that he was totally correct.  I pulled off highway 41, crying, confused, and simply done with fighting the advice I had received from others.  I decided that I had to put myself into the hands of the experts and just listen, and do as I was told.  And I realized that I had no ‘will power’ over opioids (later learning that I had no will power over ANY psychoactive substances).  The amazing thing that felt like a miracle was that the desire to use suddenly disappeared.  I didn’t touch opioids again until my relapse, 7 years later.  And I didn’t need any ‘will power’ at all;  what I needed was to remember that I HAD NO will power.  Keeping that at the forefront of my mind was very easy– and very difficult– to do.  Other AA’ers will know what I mean by that comment.

Since then I have tried to look at the twelve steps ‘scientifically;’ to determine the essence of the program that leads to such incredible change in SOME cases.  With the introduction of buprenorphine maintenance, my opinion holds that the only way to live a clean life OFF buprenorphine is to adopt a life based in the steps.  The problem is that finding real ‘change’ through the steps (or through any other program) requires that the person abandon his/her former way of living, and that requires desperation.  And unfortunately, once on buprenorphine, addicts are no longer desperate.  I do not see any solution to this stale-mate situation.  Desperation is needed for change, and buprenorphine eliminates desperation.  So the addict must stay on buprenorphine to avoid using, and to avoid desperation.

The question that comes to mind is whether it is a good idea to stop the buprenorphine, thus bringing on the desperation required to change?  In some cases yes– when the person is using multiple substances and life is careening out of control, I think that buprenorphine might only prolong the agony, and the appropriate action is to stop it and allow the person to feel the consequences of his addiction.  But for pure opioid addicts I have a harder time recommending that they discontinue buprenorphine for the sake of bringing on desperation, because the risk of death during overdose is simply too high.

My philosophy for buprenorphine treatment is to try to add the elements of recovery that I found in the steps– to somehow pass them on to the patient without desperation.  I don’t know if that can be pulled off, but that is what I try to do.

I want to share this interesting story about the mechanism of AA from Wired magazine: http://www.wired.com/magazine/2010/06/ff_alcoholics_anonymous/5/

The old days

I worked for several years as the medical director of a residential treatment center in Wisconsin, leaving the position several weeks ago.   On my last evening in the place I took a moment to look around and think about how addiction treatment has changed in the past decade.  I looked at the pictures of the patients in their charts, who were mostly in their late teens or early 20’s.  The most common class of ‘drugs of choice’ were opioids, including oxycodone, heroin, methadone, morphine, and hydrocodone.  I thought about the different but similar program that I attended ten years ago, filled mostly with addicts and alcoholics in their 30’s and older.  I wonder if Bill W would have come up with the same twelve steps, had his target been not 50-year-old alcoholics, but teenage heroin addicts! 

On the walls around me were posted sheets of paper, and on them were lists of ideas from a brain-storming session about how to remain competitive in the modern era of addiction treatment.   I scanned the 20-some pages for mention of buprenorphine, and found the medication mentioned only once, under ‘challenges.’  On the other hand there a number of ideas related to marketing, endowment funding, and public image.  What I saw in that room essentially summarized the problems with traditional treatment in an era of buprenorphine.  It also validated my decision that it was time to move on.  

When I was an anesthesiologist I went through a period of frustration over the American Heart Association’s ACLS treatment guidelines, or more specifically over how they were implemented by the hospital where I worked.  The guidelines provide easy-to-remember steps to use when treating victims of cardiac arrest.  As an anesthesiologist, my education and training taught me to think ‘physiologically;’ if my patient on the OR table went into cardiac arrest, my training allowed me to quickly decide the likely cause, the appropriate medication for that problem, and the proper dose of medication based on body composition, patient age, other medications, medical history, fluid balance, etc.  ACLS guidelines were not initially devised for anesthesiologists, but for paramedics and other medical professionals who had less critical care training and experience.  To keep things simple enough to remember, the ACLS guidelines provide general medication and dose recommendations based on averages, not tailored to specific conditions or patients.  The dose of epinephrine listed in the protocol is 1 mg, whether the patient is a 20-y-o male athlete or a 95-y-o woman.  That dose may or may not be appropriate for either a 20-y-o or a 95-y-o–  but it is certainly not the correct dose for both!  But that’s OK, because we were just talking ‘guidelines,’ not hard and fast rules. 

The problem began when nursing educators started teaching ACLS classes not only to paramedics, but to physicians as well.  I attended those classes—I had to, just as most physicians who are part of networks are required to do every three years.  In most courses I attended, physicians who asked about optimizing doses based on patient characteristics were told to stick to the algorithm so that people didn’t get confused.  The result, of course, was to dumb down the classes, and to dumb down the people taking the classes.  The issue comes down to whether to trust that individual doctors will be able to think and get it RIGHT, or to assume that they will get it wrong and therefore give them easy-to-memorize instructions.  I could go off and extrapolate to modern society as a whole, but I’ll try to control myself!  The problem with telling docs to avoid thinking and to instead just follow the protocols is that the guidelines are SO generalized that they almost guarantee failure.  

Successful resuscitations are relatively uncommon, making it difficult to come up with treatment guidelines that are clearly good or clearly bad.  Over the years, ACLS guidelines have changed in drastic ways.  Some interventions recommended as beneficial were later found to make things worse.  It is hard enough to decide if standardized, dumbed-down guidelines are beneficial, so you can imagine how hard it would be to determine if a single doctor’s care was good or bad. 

What I took issue with was the push for consistency, and the effect of that push on patient care.  After a cardiac arrest and resuscitation in the hospital, the chart was reviewed by quality assurance and by a committee that included the people who taught the ACLS courses.  No problem so far.  But if a doctor deviated from the ACLS protocol, things got silly.  The doctor would be asked to provide reasons for deviating from protocol, including support from the literature for the deviation.  But the literature focuses on whether the ACLS protocols themselves are of any value, so there are few studies of non-ACLS approaches.  There are no studies of the effects of using 750 micrograms of epinephrine instead of 1 mg in a cardiac arrest in a 54-y-o man on beta-blockers, having hernia surgery, who is slightly dehydrated and has a history of mitral stenosis!  

Initially the ACLS protocols were designed to help people with less knowledge of physiology provide adequate treatment.   But over time, the protocols became the final authority on treatment.  So if a patient with an intelligent physician has a heart attack in the cath lab, the doc now has to make a decision.  Is the doctor going to give medications and doses of medication specifically geared toward this one patient—and then be hung out to dry by the hospital QA department (which is run by nurse educators who don’t understand this issue)?  Or should the doctor just turn his brain off and follow the ACLS protocols, guaranteeing that there won’t be any calls for explanations?  The irony is that a doctor who never successfully resuscitates a patient will never run into trouble, provided that the ACLS algorithms are followed—he/she may even get an award!  But the doc who saves an occasional patient by THINKING and figuring out the perfect treatment is likely to run into all kinds of trouble!  If you were the patient with that smart doctor, and you were facing low odds of survival, would you rather have the standardized, one-size-fits-all approach that rarely works?  Or would you want your doc to risk getting written up by using the new medication that he read about that he thinks would fit your condition, but that isn’t on the protocol sheet? 

How do we get back to addiction treatment?  About 100 years ago some people came up with the twelve steps.  I don’t know the history of early AA as well as many, but the steps were devised for the patients of the time, who were mainly middle-aged alcoholics, mostly Caucasian, and mostly male.  The steps have stood the test of time, and are now applied to many different substance addictions, and even to non-substance disorders such as eating disorders and pathological gambling.  Do they work for those conditions?  Sometimes.  Like cardiac arrests, the conditions treated by the twelve steps tend to have very low success rates for ALL treatment strategies, so the steps don’t have to work very well to be as good as anything else.  I have great respect for the twelve steps, but some have imparted them almost magical qualities that can be used to fix anything! 

Some addiction treatment centers are fixated on the steps not as a treatment tool but as a special entity, so that they seem to favor ‘purity of sobriety’ over saving lives.  As a fan of the steps myself, I too see ‘sobriety’ in a biased way, making it all the more difficult to describe this concept.  Bear with me—maybe my point will be clearer if I ask a few questions.  I encourage you to come up with your own answers, and to discuss this topic at the forum. 

What is the point of treatment?  When a patient enters a treatment program, how should them measure success?  If everyone is hugging each other and going to meetings at the end of 30, 60, or 90 days, is that enough?  If 85% of those ‘successful treatments’ are using after one year, should the treatment center feel good about the job they are doing? 

At the forum, we try to avoid discussions about ‘who is more clean’ because there really is no answer to the question.  Today I surfed past a silly TV program where the Real Housewives of New Jersey were divided into two groups, arguing with each other over who was meaner, who lied first, who said what to who… all shouting over each other.  Do they really think that one side will ‘win?’  That’s how I feel about ‘who is more recovered’ arguments.  And I am gratified that most of the discussions at the forum show far more class and intelligence than that particular topic!  My questions here are not intended to go down that path; these questions are to make the point that there are bigger issues than ‘whose recovery is better.’ 

Which of the following outcomes should a treatment center prefer?  Patient A leaves treatment totally free of all substances after 30 days of a 30-day program. He enters a halfway house and leaves after 90 days, still clean.  After six months he stops attending meetings.  Three months later his friend from his home town pays him a visit, and after drinking a few beers and taking a couple 80’s for old time’s sake he dies in his sleep.  Patient B leaves treatment after 21 of 30 days and against the counselors’ advice finds a doc who prescribes buprenorphine.  After a month on buprenorphine he takes a couple 80’s with an old friend, and doesn’t feel anything from taking them.  The next month he takes an extra buprenorphine tab every now and then, so that he runs out early.  He doesn’t call his doc, and instead gets sick for a day or two at the end of the month.  He even takes some methadone to ‘treat’ the withdrawal, but it doesn’t really do anything.  After four months he has talked to his doc about these things several times, and is starting to get used to—and enjoy–not feeling high.  At eight months an old friend visits and gives him a couple 80’s.  He knows that they won’t do anything, so he passes on them.  Or maybe he is having a rough day and he gives in one last time—but they don’t do anything. 

I am not implying that a patient necessarily does better with buprenorphine (although I do think that it is the case that patients do better with buprenorphine!).  My point is to show two types of ‘recovery,’ and to ask, which patient of the two is doing better?  MY answer is that the second person is better off, because he is ALIVE.  I would think that most people would agree—that it is better to be alive than dead.  But some of the attitudes I have witnessed among traditional counselors make me think that they are so intent on a twisted version of ‘perfection’ that they would feel better about the first patient!  I was speaking with the CEO of a hospital recently who said that if hospitals had a 15% success rate for other diseases, they would be viewed as dismal failures.  But in recovery, there seems to be an attitude that the failure rate is acceptable—as long as someone lives.  I hope that buprenorphine prompts movement toward a new paradigm where it is no longer acceptable, accepted, or ‘a given’ that many people die. 

The steps were designed, in my view, with the help of divine intervention.  They sometimes offer the gift of sobriety to a suffering alcoholic who has reached rock bottom.   There have been attempts to use them to achieve sobriety from other substances, including opioids, and they sometimes help a desperate opioid addict.  But it is much more difficult, and rare, for a teenage opioid addict to accept ‘powerlessness’ than for a jaundiced, middle-aged alcoholic to do the same.  Like the ACLS algorithms, the steps are a ‘one-size fits all’ approach to treatment.  Like the algorithms, they can be a valuable tool.  But for both the algorithms and the steps, the point should NOT be on the purity of the treatment approach; the point should be whether lives are being saved, and whether an imperfect approach that uses out-of-the-box thinking might save a few more. 

The REAL challenge facing traditional treatment centers will be to let go of their old ideas of ‘perfect sobriety’ and to use the treatment tools that have the best chance of keeping addicts alive.  Doing so should not be that difficult;  all they need  do is look at the faces of the young addicts entering their programs, and ask themselves, honestly, how many will be alive after a few years?  The honest counselors at traditional, non-buprenorphine programs should be humbled, and even ashamed, by what they know about those numbers.

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.

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.

Addiction to heroin and pain pills continues to grow

The article:

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.

I might as well keep this run of posts going with an e-mail exchange from earlier today.  As usual, minor aspects of the message were changed to protect anonymity.

The message:

I am interested in setting up a tele-psychiatry appointment with you.

My boyfriend is a heroin addict who has been on Suboxone for approximately four years.  He started at 12 mg and tapered down to 2 mg over a six month period.  He recently went through a detox program and has completely stopped Suboxone — except that he relapsed recently with a small amount of Suboxone.

I feel like I need to get smarter about supporting his fight to stop opiates.  I purchased one of your tapes where you say that willpower has nothing to do with quitting opiates.  I know that this is a recurring theme in combating drug abuse, but I have to admit that I don’t completely understand it.  I think that if I did, I could be more effective in helping him.

Is this a focused topic that a 30-minute session can effectively address?  What course of action do you recommend?

My Response:

Hi XXXX,

Without buprenorphine, an opiate addict needs immersion in Recovery

There might be some things that I could help you understand, but to be absolutely frank, I usually recommend that people separate from addicts until they are clean for a year.  The reason I recommend that is because people generally need to get to a point of utter desperation before ‘recovery’ takes hold… and any relationship tends to be ‘enabling’, even when the person tries not to enable the addict.  By enabling I’m referring to paying bills (making money and also just the physical act of paying them), making meals, washing the clothes, keeping the house in order…  all of those things eventually fall apart with active addiction, and the chaos that ensues is part of what gets the person better.  Of course, nobody wants to see a loved one go through such chaos… and the risk of death is great, as the addiction gets to the ‘chaos’ point.  The risk of death occurring before the development of a ‘rock bottom moment’ is what has made me a fan of long-term buprenorphine; the alternatives are just too dangerous.

My thoughts about will power come from my experiences with 12-step programs.  I had a ‘spiritual awakening’ in 1993 that instantly removed my desire to use, and ever since I have tried to look at the steps as a scientist.  I have tried to determine which elements are necessary for recovery, and why they have their effects– in some situations, and in some people.  The best way I can put it is that EVERYONE has multiple points of view on issues, shifting from one stance to another stance depending on external circumstance and internal emotional states.  Addicts always have some degree of ambivalence about using; even an addict in recovery for ten years has some part of himself who would like to use.  I refer to that part as the ‘addict inside.’  The addict inside has no interest in sobriety, and the addict inside grows in the presence of certain cues, memories, emotions, etc.  No matter how much self-control or will power your boyfriend has, the addict inside has NO will power– and has no interest at all in self control.  Addicts who focus on will power miss the point that the addict in them is not on board with the ‘will power thing.’  The 12 steps, on the other hand, acknowledge the absence of will power with the very first step, and in my own case that acknowledgement removed any desire to use (the problem though is KEEPING that belief in a lack of power.  In my own case, relapse came at a time when I was very confident in my ability to avoid relapse!)

Why does ‘powerlessness’ work?  I can’t say that this is the case in everyone, but in my case, powerlessness is something that translates well among ALL of my ‘addicts inside’ and other personality stances.  I believe that is the case because of FEAR, the emotion that is triggered by powerlessness (at least fear SHOULD be associated with powerlessness!).  Fear cuts through the cocky BS of the addict inside, and when the fear is recognized, it motivates behavior that protects the individual– including avoiding using.  I see relapses occur most often during times of self confidence, when the addict ignores the fear about using.  I think that is why some people in late stages of addiction will go through one short period of abstinence after another.  While the symptoms of withdrawal are present the addict remembers how horrible things are, and is motivated to remain clean.  But when withdrawal finally ends and the person starts feeling good again, the addict inside takes over, believing that things were not all THAT bad, and there is nothing to be afraid of in taking just a hit or two.  Then the misery and fear come back, motivating the addict to get clean for awhile.  I was stuck in this type of behavior for several months, and it was horrible– sick pretty much all of the time, and completely demoralizing from breaking promises to myself and others over and over.  Yuck.

If he is committed to making a go of it without buprenorphine, he will need a strong recovery program.  By ‘strong’ what I mean is that he cannot just be educated about recovery;  he must LIVE recovery, GET recovery, and actually CHANGE.  And that is very difficult to do, particularly if a person is not desperate.  There is a great like in one of the AA books that I have quoted many times– to paraphrase, recovery only works when a person clings to the recovery program like a drowning man seizes a life preserver.  My own words now:  if the addict is trying life jackets on– discarding the life jackets that are a little too loose or too snug or the wrong color or too cold or too warm or too frayed or too preppie– then the addict will not likely find meaningful recovery.

I have a patient who gives me too much credit for her own work toward recovery, but she tells me that when she was in treatment she kept thinking of my words over and over.  Unfortunately I can’t remember what they were right now!  But it was something like ‘Surrender.  Give up.  Let go.  You know nothing– ask for help.’ 

I hope this helps; you are welcome to call the office and set up more time if you have other questions.  The ‘anon’ programs all have much to offer, and I strongly recommend seeking them out if you continue with your boyfriend.  I would ask him the question, are you ready to commit to a recovery program?  If not, you may not be ready to stop buprenorphine.