I guess I do get irritable sometimes…  but I’m getting better at controlling my anger as I get older.  One cool thing about a blog is that I can go back and see what I wrote years ago.  In this case, I was looking for a post about telling the difference  between opioid toxicity (from taking too much) versus opioid withdrawal. In that post I suggested looking at the size of the pupils.  The name of the post, in case anyone is interested, is called ‘abres los ojos’– the name of an old Penelope Cruz movie and spanish for ‘open your eyes.’ 

Penelope Cruz sounds very cool, by the way, when she whispers ‘abres los ojos…’ as you can hear at the beginning of the movie trailer.  The movie was remade and called ’Vanilla Sky’– again with Penelope Cruz, but this time with her speaking in English.

Am I the only one who cares about this stuff?!

The post BEFORE that one was from a time– 2009– when people often wrote to tell me how misguided I was for recommeding buprenoprhine.  Those comments, at a time when so many young people were dying from overdose, would really get to me.  I’ll share the exchange, for old time’s sake.  For people who enjoyed my older, feisty posts, they are still out there– you just need to keep hitting the ‘earlier posts’ button!

The post:

This guy doesn’t like Suboxone– or the horse it rode in on.  He has been trying to write angry posts under my youtube videos, but I have been blocking them– His feelings about Suboxone popped up on one of the health sites out there this morning, catching my attention through ‘Google alerts’ for Suboxone.  It must be the same guy, because the complaints are the same, the language is the same, and in both cases the screen names are related to frogs(!).  I will go ahead and post his comments, and then my response, so that he can relax– knowing that he has done his part in the epic struggle over Suboxone.

Ive looked all over the internet and still have not found more then 5 people who have quit suboxone like i have. I took it for 12 months tapered down to 2 mg and quit 5 days ago..Basicly i am writing this due to the fact that i am really pissed at the fraud i feel is being commited by the drug maker of suboxone. I was taking 15 10 mg a day of percocet and 10 mg a day of norco a day b4 i got on sub. Anyways the reason i am so pissed is that these last 5 days have been the worse 5 days ive ever had.My Dr says oh youll just feel little tired for a few days is all.. ya right… 5 days of not being able to move,anxiety,depression you name it.. and no i am not crazy i took pills for shoulder injury so i have an idea where these feelings come from and its the good ole subs that all these Drs are making a fortune off. You must remember that out of all My drs patients i am like the only one whos quit totaly and can actually sit here and tell you what its like.. Its terrible and after considerable thought i think people need to know this sub is just another opiate and what gets me is the withdrawls are even worse then reg opiates. I CLOSE WITH ONE LAST COMMENT: ITS ALL ABOUT THE MONEY WHEN IT COMES TO SUBS: Think twice before some slick talking Dr wants you on it.. its far from a magic pill. Just ask the few of us out of 1000000,0000 people who quit the phoney stuff.

There is no magic pill for addiction to pain pills and if you think sub is then think again..One last thing, try and ****** suboxone withdrawls and guess what youll find??? first 50 sites pop up are paid for by the drug maker of sub and you have to dig to find real facts from patients with experience.. Drug maker pays big bucks to keep all the info ” positive” on subs… They are no dam different then the crooks on wal-street !

My Response:

Before my answer, a quick comment–  I do like the ‘crooks on wal-street’ remark;  I haven’t seen that ‘play on trademark words’ before.  I am assuming that he was making a joke–  he had to be, right?

OK, here is my response.  As usual it is a bit ‘snotty’– but you have to remember that I get this garbage all the time, and it gets old:

I am sorry to be the one to break this to you, but you are an opiate addict. Moreover, you will always be an opiate addict; hopefully you will be an addict ‘in remission’. The brain pathways that make up ‘addiction’ are laid down in a manner that involves memory processes; becoming a ‘non-addict’ would be like forgetting how to ride a bike. It cannot happen. Again, you can be in remission, but with opiates, that is very difficult– and unfortunately very uncommon.

Many people write about how they used will power or vitamins or some other silly technique to quit opiates– once they have gone over 5 or 10 years, I am interested in listening to them. It is easy to quit using for a year– it is another thing entirely to quit using for 10 years. I got clean in 1993 and felt pretty proud of myself… I quit through AA and NA, not Suboxone. I worked with opiates the whole time, giving patients IV fentanyl, morphine, demerol, etc in the operating room… but in 2000, thanks to a little market in the Bahamas that sold codeine over the counter, I relapsed. I ended up losing almost everything, including my career, all my money, a vacation cottage, my medical license… ****** ‘mens health’ and ‘the junkie in the OR’ and you will read my story.

There is no ‘fraud’, no ‘slick doctors’. There are doctors trying to help, and some work harder than others to keep people on track. We now know that Suboxone is best thought of as a long-term treatment, just like most other illnesses; we treat diabetes, hypertension, asthma, etc with long-term agents; if you stop your blood pressure meds abruptly you will have ‘rebound hypertension’ that can be very dangerous… Suboxone is similar to any other treatment. The thing is, pharmacy companies never used to care about addiction; the money is in treating other illnesses– just watch the commercials on TV! The money has been in viagra-type drugs! Suboxone is the first generation of opiate-dependence medications; the next wave will have fewer side effects, and so on. That is what happens with every disease. I am glad addiction finally has the attention of pharmaceutical companies. As for ‘slick docs’, there are many easier ways to make a buck in medicine! I am at the ‘cap’ of patients; the money I make treating patients with Suboxone is a tiny fraction of what I made as an anesthesiologist; I could drop the Suboxone practice tomorrow and take one of the 30 jobs in my area frantically looking for psychiatrists and make as much or more money. Yes, there probably are some ‘bad docs’ out there– there are ‘bad everythings’. But a bad doc will make a lot more money treating ‘pain’ using oxycodone than treating addiction with Suboxone! For one thing, there is no cap on pain patients! And when a doc wants to prescribe Suboxone, he/she can have only 30– THIRTY– patients for the first year. Hard to get rich on 30 patients!

Suboxone has the opiate activity of about 30 mg of methadone. When tapering off Suboxone, the vast majority of withdrawal symptoms occurs during the final parts of the taper– the last 2 mg. That is because of the ‘ceiling effect’. But you are not just tapering off Suboxone…

Do you remember when you started Suboxone, how lousy you felt, and how Suboxone eliminated the withdrawal? YOU NEVER FINISHED GETTING OFF THE STUFF YOU WERE ADDICTED TO. There is no ‘free lunch’; Suboxone allowed you to avoid all that withdrawal; if you stop Suboxone, you have to finish the work you never finished before– going through the withdrawal that you ‘postponed’ with Suboxone! Welcome to the real world– you likely abused those pills for years, and if you don’t want treatment with Suboxone, you had better start a recovery program, or you will be right back to using again.

Human nature can be a disappointment at times… When I ‘got clean’ after my relapse 8 years ago, I was just grateful to be ‘free’– even for just a few days of freedom! To get to freedom, I was in a locked ward for a week, no shoelaces (so I wouldn’t hang myself!), surrounded by people who were either withdrawing or being held to keep them from self-harm (it was a psych ward/detox ward combined). After that, I was in treatment for over three months– away from my family all that time, and I couldn’t leave the grounds without an ‘escort’ (no, not that kind of ‘escort’!). Treatment started at 6:30 AM and ended at 10 PM. The rare ‘spare time’ was used to do assignments. After those three months I was in group treatment for 6 years, and also AA and NA meetings several times per week. I still practice and active program 8 years later– I know what happens to people who stop: they eventually relapse, and some of them die. I AM NOT EXAGGERATING ‘FOR EFFECT’ HERE.

I had better stop or I will spend all of 2009 with this post… My final comment: Most of what you are feeling is not ‘Suboxone withdrawal’. I have watched many people stop Suboxone; some have bad withdrawal, some have NONE. When you talk about ‘anxiety’ or other problems facing life on life’s terms, you are experiencing life as an untreated addict. ADDICTS WHO SIMPLY STOP TAKING THEIR DRUG OF CHOICE FEEL MISERABLE!!! That is not withdrawal, and it doesn’t go away! Suboxone held things ‘in remission’ and allowed you to pretend you were not an addict; it is NOT a cure. So now, off Suboxone, you will see what it is like to live life as an opiate addict without treatment– and if you don’t get treatment, you will likely relapse. You will relapse because untreated addicts find life intolerable.

My human nature comment– everyone wants good things, but nobody wants to do the work to get them… (I’m in a bit of a mood today I guess– sorry). Recovery from opiates has always taken work– very hard work. And even then, success was rare– most people had to go back to treatment over and over and over before finally getting it. If people stopped working, as I stopped working in 1997, they eventually got sick again. Enter Suboxone: now you can have instant remission from active addiction! So are people grateful for that fact? That now, instead of years and years of struggle, they can take one pill each morning and hold their addiction in check? NO. Now they complain that ‘I don’t feel good when I stop Suboxone!’. Sorry, but a part of me says ‘poor baby’. You have a fatal illness, and you think you are done with it… you will find going forward that you will either use, or you will take buprenorphine or a new medication along the same line, or you will be attending meetings for life. Those are your three choices– pick one.

If you find a 4th choice, tell me about it in 5 years. I would like to hear how you did it, and yes, I hope you do find it (rather than die using). But I looked for that other path myself for years and never found it, and so did millions of other addicts.

Back to the present…

Phew.  Makes me tired just remembering those days.  Since then the number of deaths have only gone up, but at least there is a better acceptance for treating opioid dependence using effective medications— at least for people ready to accept that help.

Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention.  This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’

I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness.  I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions.  In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do?  Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

This Jerk Counselor

We all know that certain professions attract certain types of people.  Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt.  When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people.  It’s the power trip, I suppose.

This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment.  He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way.  One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room.  But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.

Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position.  In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room.  We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.

The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power.  Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids.  Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.

This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety.  He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.

In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious:  when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts.  On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.

I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric.  I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach.  I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right.  But most of us leave that world behind when we commit to helping people suffering from illness.

What’s This Jerk’s excuse?  Is it that he just doesn’t get it?  Or are there other motives at play?  With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.

Or is it the power trip– that people with difficult addictions are an affront to therapists?  I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die.  I suppose This Jerk would say ‘not my problem!  I did MY job!’

Readers may suspect that this topic irritates me—and they’re right.  Maybe I’ve seen more death, up close, than the typical counselor.  I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery.  I have spent hours with the parents of young patients who died from overdose.  I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child.  Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.

I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior.  People like This Jerk hold power over an individual with an addiction history, but there is power in numbers.  It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle.  It is not appropriate to humiliate a patient in front of others.  If you see that behavior, collect witnesses, and bring it to someone’s attention.  Maybe that ‘someone’ will write a blog post about it!

Doctors in particular should treat patients with ALL diseases—including addiction—with respect.  It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite.  I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.

Would THAT make sense— even to This Jerk?

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.

Weeks ago I posted a few new ideas—things like a memorial wall for victims of opioid dependence, and a ‘wall of shame’ for doctors who are known for reckless prescribing of opioids.  I mentioned these ideas over at SuboxForum as well.

I received good feedback from readers here, and from members there.  Sometimes the best feedback is the hardest to hear;  I’ll get excited about a certain plan of action, and like anyone, I don’t like it when someone rains on my parade.

One of my addiction docs from years ago was big on ‘sober thinking.’  Back then, it seemed as if anything I came up with that pushed the boundaries was in need of more ‘sober thinking.’  I wondered if ‘sober thinking’ was simply code for ‘I don’t want to say yes to your idea, and maybe that was the case in SOME instances.  But I now recognize a part of myself that acts quickly, impulsively, with great optimism, and with little regard for risks.  ‘Sober thinking’ is simply letting an idea sit in one’s mind for a few days or even weeks, and keeping a truly open mind to the comments that one receives about the idea.

Beats Death--- Barely

I won’t spell out who wrote to me, but I’ll thank the people who did—who risked my ire by giving their honest opinions.  I mentioned a memorial page;  some people pointed out that a memorial on an addiction-related web page may add to the pain and shame felt by family members.  As for my ‘doctor wall of shame’, I was reminded that every story has two sides, and it may be more useful to simply provide referenced information that would allow readers to make up their minds without my own coloring of the facts.  I want to thank the people who wrote, and let them know that they made a difference—and the site will be better because of their efforts.

Instead of the earlier ideas, I added what I am calling the ‘consequences’ page.  The page will contain news stories identified to Google as having ‘drug overdose’ in their tags.  The information will be replaced every 24 hours or so.  I experimented with a couple different intervals and found that no day went by without a significant amount of news under that tag—a rather compelling statistic!

Click on ‘consequences’ to check it out, and let me know what you think!

When Suboxone first became an option for treating addiction to pain pills back in 2003, some people were excited about having a cure for opioid dependence. Those people were mistaken. It is true that Suboxone has been a huge benefit for treating opioid dependence, but the medication cannot cause the permanent changes in the brain that would be necessary to prevent relapse. Instead, in order for the medication to work, people must do what they do with other medications—keep taking it.

Not all scams are so obvious

I recently read an article on another web site that advocated a certain person’s ‘method’ for rapid opioid detox. I went to the primary web site for the developers of that method—pulled to the site in the same way that I am drawn to watch late-night commercials for get-rich-quick schemes or male enhancement products. On the web site I read that they have a new reason to take large sums of money from those addicts fortunate enough to have money, and unfortunate enough to believe their hype— a special, rapid way to change brain function.

We are spending tens of millions of dollars through NIH to understand neuronal ‘plasticity’—the term for the ability of the brain to adapt in response to the environment—and here some guy at a detox clinic has it all figured out!

As I read the web site, I thought about all of the addiction ‘cures’ that I’ve read about over the years, such as the secret blend of amino acids that one program offers (I wrote to the advocates of that treatment to ask how it works, and was told that they would give me the recipe for only $15,000). I thought about my opportunity a year or two ago to review the bill of a person treated at one of those $70,000 per month addiction treatment centers out west somewhere; the bill was padded with one type of therapy after another, with names like ‘mood therapy,’ or ‘PTSD resolution therapy,’ or ‘energy-field releasing therapy.’ The charge for a ‘treatment’? Prices ranged from $700 – $1200… per SESSION, day after day. On many individual days, the person was billed for multiple types of therapy, each costing $1000 or more. Now I know– THAT’S how you get to 70 grand per month!

With all this in mind, I have to wonder– is addiction treatment the last refuge for snake-oil salesmen? Where are the good folks at the FDA when people throw scientific mumbo-jumbo to extract money from desperate people? Maybe I should quit charging the peanuts of a typical private practice—where insurers think an hour is worth a hundred bucks, and the state considers an hour worth $37.50—and instead hang a sign, and make a web site, and offer ‘Selective Cranio- Axial Meningotherapy’ (SCAM) or Bitemporal Sensory (BS) Therapy or Rapid Intentional Pseudo – Olfactory Field Focusing!

I’ve criticized doctors who prescribe Suboxone as well; namely those who take the quick buck to get a person started on Suboxone, then leave the person to find a long-term prescriber on his/her own—knowing that such doctors are impossible to find in many areas.

It is relatively easy to get a person clean for a few weeks. In fact, if anyone desperately wants to get off opioids, bring me $20,000 and I will chain you to the steel post in the center of my basement—and I’ll even throw in meals. The hard part, of course, is keeping you clean AFTER you leave. So for an extra $50,000—the same price charged by many month-long treatment centers—I will provide a couple hours of therapy each day (weekends off of course), and put out an easel for you to draw pictures of traumatic events from your childhood.

Sounds silly, I know—but the truth is even sillier. I bet that the number of long-term cures from MY basement treatment would rival those from any of the methods or programs that I alluded to. From either program—mine or theirs– the long-term relapse rates would be very high.
Fortunately, there IS a long-term treatment for opioid dependence— buprenorphine– that has proven to be safe and effective. The way to make the treatment work is to follow the same principles that are used for a host of other medical conditions: 1. Get a good doctor. 2. Start the right medication. 3. Keep taking the medication. Psychotherapy might be helpful as well, but definitive studies on the value of psychotherapy for Suboxone patients have not yet been done. But we DO know the importance of staying on the medication.

Who knows– you might even save yourself a bundle.

By now, everyone who knows of Amy Winehouse is aware of her tragic death. I’ve always liked her music. So much music these days has been digitally processed and reprocessed, and assaults the senses– I’m thinking of Lady Gaga, for example, whose ‘Edge of Glory’ would be pretty boring in concert if you took away the flashing lights. But Amy Winehouse’s music had an earthy, sultry style that communicated her emotions in a way that words can’t… which is why we even listen to music, at least in my case.

Every now and then I’ll meet a person coming in for help who has an addiction that seems to be almost part of a death wish, as if the person is taking agent after agent with one goal: to eliminate any sense of consciousness or emotion. It is as if life is too painful for the person to tolerate, and the person won’t stop until the brain is finally quiet. I sometimes think that those people would club themselves in the head until they are unconsciousness, if psychotropic drugs were not available! I had that same thought when I read that Amy Winehouse had purchased a grab-bag of drugs including heroin, cocaine, and ketamine in the days before her death.

When I set out to right tonight’s blog I planned on including her picture. But when I went on Google images and searched under her name, I found a number of ‘before and after’ images that demonstrated the horrible toll that drug and alcohol dependence took on her health and physical appearance. The images were so bad that I felt very sad for her and for her family, and I couldn’t bring myself to post them here– as doing so would be ‘piling on’ a horrible tragedy.

I searched around for a suitable tribute, and I think I found one. Her personal, internal battle is apparent in the video, and I’m sorry that she wasn’t able to find a way to tolerate life.

Enjoy the music that she left behind:

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!

Ah yes…. another post about my book…

Over the past few years, I’ve taken posts from this blog, posts from other sources that I’ve written, some sections of a ‘memoir’ that I have not gotten around to writing… and combined them in a book about addiction. The book does not hold together as well as it should, and it is way too long– so instead of a ‘sit and read’ book it is more like a reference, similar to the blog itself. If you like this blog, you’ll like it; I’ve taken the more important posts and cleaned them up and organized them. I’ve added some new material as well, including a section about my own background. If you have a loved one on Suboxone, or have an interest in the medication yourself, you will know as much about the buprenorphine as anyone should you finish this book– particularly about the use of buprenorphine by addicts, the controversy over buprenorphine, the relationship between buprenorphine and methadone, etc.

There are some chapters that are dated– i.e. where my opinion has changed or softened over the years. I was much more ‘anti-methadone’ when I wrote most of the book; now I see methadone as something that some people simply need in order to survive. I am not a fan of how some clinics are run– but that is a topic that I don’t get into in this book.

Finally, you’ll notice how I have changed over the years; in early posts I would become angry and sarcastic with some writers. In part, that is because I was being attacked on a daily basis by the ‘anti-sub’ movement– which has largely disappeared. But I think I have also aged a bit, and I now tend to pick my battles more carefully.

The book (note- this is an e-book) goes for $14.99, and runs around 250 pages– long enough to occupy most of your summer! Proceeds continue to support this blog, and SuboxForum as well.

Thank you very much, to those of you who purchase it and check it out. I would be most grateful if you would leave comments about it– for me, and also for others– by writing them in response to this post. At some point I will get a page set up, and tranfer this promo and the comments to that page.

The book is called ‘Dying to be Clean’– and can be purchased using the links at the left of this page– or right below this post.

NOTE: Because I don’t want it simply passed around freely at this point, you need a code to open it– and it cannot be printed. The code will be included with the download link. Please understand why I take those actions.

Thanks again,

Jeff J