Suboxone Talk Zone: A Suboxone Blog http://suboxonetalkzone.com Questions and Answers about Opioid Dependence and Buprenorphine Thu, 26 Feb 2015 20:15:57 +0000 en-US hourly 1 Another Suboxone Argument http://suboxonetalkzone.com/another-suboxone-argument/ http://suboxonetalkzone.com/another-suboxone-argument/#comments Sat, 14 Feb 2015 17:11:02 +0000 http://suboxonetalkzone.com/?p=20821 Continue reading Another Suboxone Argument]]>

It has been awhile since I posted a give and take with a misguided reader. I’ve taken that interval as good news that education is winning over misinformation.

But then I read this comment.  I didn’t fix her typos, as I think they provide insight into her opinion:

My daughter was on Suboxone, because she was a heroin addict, when she could not afford this med, the withdrawal lasted for mnths, and was far worse than I have ever seen her go through Heroin withdrawal. These are a Psyhiatrist facts, I absolutely hate Suboxone, YES peple do get high on Suboxone, Yes they absolutely can and do inject this garbage. This medication may have helped people who were not addicts for pain, or addicts who truly took this drug to remain clean, and that’s o.k BUT NO THE DRUG COMPANIES are not going to put the facts out about this dug, and about the deaths caused from overdosing on this drug using it in combination with other drugs. They will not report the abuse of this drug, and the effects of this drug on the bodies organs or how it causes Bone Marrow depression. THE TRUTH WILL COME OUT NO MATTER HOW THE DRUG COMPANIES AND GOOD OLD DOCS, TRY COVER IT UP. Half these Suboxone Dr’s are addicts themselves, I took my daughter to one who’s pupils were so pinned, he was slurring and could hardly stay awake, HMMM Could it be he was abusing the same drug he was supplying. They had a great plan for getting people on it but none what so ever for getting people off of it. The Truth about Suboxone will come out. It should be used only for detox only taken no more than for 10 days. I am a Drug and ETOH detox Nurse, so I have seen not just with my own child, but with clients who, by the way do abuse the drug sell it on the street, so they can buy heroin. IT’S A MONEY MAKER FOR BIG PHARMA, AND THE MAKER OF THIS DRUG PAID DOCTORS THOUSANDS TO BECOME CERTIFIED TO PUSH THIS POISON. I will get the true facts of this drug, but Do NOT JUST PUSH THE PRETTY SIDE TELL THE TRUTH ABUT THE UGLY AND YES SOMETIMES DEADLY SIDE. DR. My daughter committed suicide January 4th 2015 overdose of heroin, among other substances. She went to heroin again because she started going through post SUBOXONE withdrawal. The withdrawal last weeks to months with post withdrawal. So please do make this sound like a miracle drug that saves lives, it also kills and that truth will come out. I am sick of these companies, hiding the facts! Facts to me because I have lived it and have seen personally the effect of this drug.

I responded as follows:

I wish you were at least partially correct, given that you work in the field, and have the potential to spread such inaccurate information.

Deaths…  in the past ten years there were about 35,000 overdose deaths in the US.  None of those people had buprenorphine in their system when they died.  What number of people had measurable amounts of buprenorphine in their bloodstream when they died from overdose?  40 per year.  Most of those 40 people would be alive if there had been more buprenorphine in their bloodstream– the only exception being the few cases each year where a young child ingested the drug.

Note that 400 people die from Tylenol each year in the US– compared to 40 deaths of people who had buprenorphine in the bloodstream.  It is very hard to die from buprenorphine;  those who die must have little or no opioid tolerance, and must also take a second respiratory depressant that they have little tolerance to.

Bone marrow depression?  Really?  Buprenorphine has been in use for almost 40 years.  It has a better safety profile than most meds out there.

‘Plans for getting people off’?  The whole point of buprenorphine is to provide chronic treatment for a chronic illness.   You apparently want something that instantly changes the brain and erases addiction, but that product is not invented yet– and I wouldn’t hold my breath for it.  Your daughter developed a condition that will last the rest of her life.  She will treat it for the rest of her life.  She can take a medication each day, or she can attend meetings several times per week. The latter approach works, mind you, only in the relatively few people who are moved by the 12-step message.  Both approaches must last for years and years, if not a lifetime.  Many people do well on buprenorphine, but some survive without it.  But if she isn’t attending meetings or doing something with similar intensiy, her prognosis off buprenorphine is not good.

The withdrawal from the partial agonist buprenorphine is less severe than from agonists.  ALL opioid withdrawal lasts for 2-3 months, and is followed by post-acute withdrawal.  On buprenorphine, a person’s tolerance is equal to 40 mg methadone per day.  Realize that heroin addicts typically have tolerance that is several times higher.  Your daughter developed a high tolerance to agonists, and then continued to have a high tolerance on buprenorphine.  Any addict, including your daughter, is facing months of detox.  Buprenorphine delayed the detox, giving her the chance to get her act together first.  Many people are successful with that approach, but some blow the chance and keep up the negative behavior.  Buprenorphine relieves cravings;  it doesn’t fix personalities all by itself.

I suspect that the reason you never saw such bad withdrawal in your daughter coming off heroin is because she could never stop heroin long enough to demonstrate 2 months of withdrawal.  Nobody just stops heroin; they stop for a couple weeks and then use again.  On the other hand, many people taper off buprenorphine, and have the chance to experience the full course of opioid withdrawal.

The cost…  The drug companies make much more money from chemotherapy, anti-hypertensives, pain pills, and other meds.  Reckitt Benckiser, the biggest maker of Suboxone products, recently spun off the drug because of the anticipated losses.  Even if buprenorphine was a blockbuster, though, I have nothing against drug companies being rewarded for the risks they take to develop new meds.  There is no doubt that the efforts to market buprenorphine have saved thousands of lives.

If your daughter sold her buprenorphine to buy heroin, that’s her bad.  Most people do not do that, but some probably do.  Understand that heroin is very addictive, and drives all sorts of bad behaviors– theft, prostitution, robberies, etc.  I guarantee you that selling her prescription of buprenorphine alone did not make enough money to pay for a heroin habit.

There are so many things you have wrong…. ‘the drug companies paid doctors to push this drug’… I’m sorry, but you are clearly a zealot, and I can’t even take you seriously with that argument.  If you know of a single doctor paid to prescribe a drug, call the Feds, as that would be a crime.  There are some doctors paid to WORK for pharma— to give lectures about new drugs, for example.  I have done that in the past for drugs I believed in.  Some people seem to hate it when doctors take any money from pharma, but when they do, it is for work–  for travelling to some cheap motel in the middle of nowhere and giving a talk to a group of doctors.  The work is highly regulated, and just like TV commercials, docs are required to stick to a very narrow script that educates, rather than promotes.

‘Detox’ has been marginalized (thankfully) because of recognition that it does nothing to treat addiction.  Likewise, non-medication treatment has very low success rates, especially if you count everyone who enters the door, instead of blaming those who fail for ‘not wanting it bad enough’.

I’m sorry about your daughter.  But one thing many parents eventually realize is that even when a kid is acting irresponsibly, buprenorphine at least keeps them alive.  Buprenorphine allows people to stay alive, even if their recovery is imperfect.  And relieved of most of the cravings to use, many of those patients eventually get it right.

Back to the present…  I’d like to think that I cleared up some misconceptions.  But two days after my comments, I received a very similar set of comments from the same person—except that most of the words were capitalized.  That is the reason I’ve tired of these types of posts….

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Must-Read Article About Buprenorphine http://suboxonetalkzone.com/must-read-article-about-buprenorphine/ http://suboxonetalkzone.com/must-read-article-about-buprenorphine/#comments Tue, 10 Feb 2015 14:18:19 +0000 http://suboxonetalkzone.com/?p=19926 Continue reading Must-Read Article About Buprenorphine]]> For about 600 reasons I generally avoid the Huffington Post.  But one of their writers did an absolutely perfect job of describing the need for buprenorphine, and the failure of ‘traditional’ treatments.  The article is entitled Dying to be Free.

The challenge, though, is getting the article into the hands of policy-makers.  It is too late for some areas, where the damage has already been done (I find myself humming the old Pretenders tune about Ohio).  When it comes to buprenorphine, too many DA’s, judges, and politicians seem to develop opinions from inaccurate data, and then cling to those opinions no matter what they learn after the fact.  To put it another way… the idiots will always be idiots.  So if anyone reading this post has a relationship with an open-minded politician, now is the time to share the Huff Po story.

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Newborn Buprenorphine Abstinence: Get Real! http://suboxonetalkzone.com/newborn-buprenorphine-abstinence-get-real/ http://suboxonetalkzone.com/newborn-buprenorphine-abstinence-get-real/#comments Sun, 08 Feb 2015 16:08:02 +0000 http://suboxonetalkzone.com/?p=19526 Continue reading Newborn Buprenorphine Abstinence: Get Real!]]> First Posted 2/6/2014

A few weeks ago I wrote about the differing standards of care for women who deliver babies while treated with buprenorphine for opioid dependence.  Some hospitals require newborns exposed to buprenorphine to stay in the neonatal ICU for arbitrary length of time.  Intravenous infusions of opioid agonists are given to infants whose first yawns or cries are interpreted as neonatal abstinence syndrome.  Other hospitals allow women on buprenorphine to take babies home at the regular schedule, allowing a natural taper from buprenorphine by breast-feeding.

Regardless of hospital policy, many women on buprenorphine enter into the delivery process with a sense of dread, knowing they are harshly judged by doctors and nurses.  Doctors warn women that their babies will suffer from withdrawal if they don’t taper off their medication before delivery.  And members of the media decry the selfishness of women treated for addiction who become pregnant, suggesting the more responsible expectant mothers would use ‘will power’ to avoid all substances.

Even while experts recommend that women treated for addiction stay on medication treatment regimens during pregnancy, society looks negatively on women who do the right thing.   A new mom on SuboxForum recently wrote about how horrible she felt, for putting her baby through such a difficult time.  But should women compliant with recommended treatment for opioid dependence feel so guilty?

Until 30 years ago or so, newborns having major surgery often received paralytic agents with little or no anesthesia or pain medication.  Surgeons and anesthesiologists did not think babies with heart anomalies would survive anesthetics, and saw no reason to anesthetize a brain that lacked a ‘record’ function.   Now, most babies having major surgery receive anesthesia.   But in many situations, non-medicated babies are simply restrained during procedures that would be painful in adults, ranging from awake intubation to circumcision to multiple attempts at IV access (the latter is required when doctors insist on treating neonatal abstinence with morphine infusions).

I did not enjoy working on newborns in those settings back in my anesthesia days, especially after having three children.  But there will always be times when anesthesia is too dangerous or impractical, leaving no choice but to tune out the baby’s cries and focus on safety.  In these cases, do babies experience pain?  We know that babies react to stimuli that adults would find painful, and generate stress responses to those stimuli.  But the answer to the question about pain is far more complicated than a simple ‘yes’ or ‘no.’

People having conscious sedation for colonoscopy, gastroscopy, or some emergency procedures (like reduction of a displaced fracture, emergency D and C, or insertion of a chest tube) often appear awake while appropriately sedated.  Patients who will later think that they were blissfully sleeping, in reality, carry on conversations and move about as directed on the OR table.  Depending on the anesthetic used, patients may react strongly to pain.  Patients who can’t be fully anesthetized because of the risk of aspiration or airway obstruction may yell out in response to the injection of local anesthetic, even when administered enough Versed and Ketamine to guarantee full amnesia.   They moan in pain throughout the procedure, and then thank their anesthesiologist for keeping them completely ‘asleep’.  Similar experiences are the norm in every GI suite across the country.

In this common scenario, do patients experience pain?  When someone sedated beyond the point of recall complains of discomfort, did the discomfort really happen?   Did the patient feel pain and then forget it?  How do we know?  Before my endoscopy, I knew that I would experience pain going forward in time.   But afterward, when I thought back about the procedure, it was a piece of cake.  Did I suffer?  Not at all.

Similar experiences occur in newborns.  Babies are not capable of remembering those first weeks or months.  One could argue that repeated discomfort creates brain pathways that lead to a heightened stress response in later years… but if that is true, how does the brain differentiate ‘normal’ pain experiences of the newborn from ‘abnormal’ pain?  The baby’s head is squeezed hard enough during delivery to change the shape of the skull.  That has to hurt… not to mention the discomfort of being squeezed inside a uterus during the last 4 weeks before delivery.  During delivery, the baby is transferred from a 37 degree uterus, where oxygen is delivered through the umbilical cord, to a bright, cold, environment where getting oxygen requires gasping for air, with every bit of strength.  Sounds traumatic to me!  During deliveries, babies sometimes experience dislocated shoulders and major nerve damage (shoulder dystocia).  Forceps or suction cups may be used to pull the baby, by the head, from the birth canal.

Newborns have immature nerve supply to the gut, so early peristalsis– the coordinated contracting that propels digestible material downstream in the fully developed intestine– creates cramping and ‘pain’ in infants (sometimes called ‘colic’).  Limb muscles are spastic, and the spasticity would likely be painful in an adult.  Choking or coughing on breast milk is a normal part of the newborn experience.

How does ‘withdrawal’ compare?  What is the worst part of withdrawal— diarrhea?  Cramping?  Body aches?  Anxiety?  Depression?  Compared to the normal experience of a newborn, how do these symptoms rate?  Babies do not feel embarrassed or ashamed of their condition.  They don’t feel guilty or remorseful.   And after raising children through, I don’t think a baby coming off buprenorphine could be more ‘depressed’ than other babies.  Can a baby who turns purple crying his lungs out, feel any worse?  Normal infants get pretty miserable at baseline!

Like most parents I have always been willing to put my life or discomfort before that of my kids, if that were possible.  I don’t lack empathy for babies experiencing pain.  But ‘to keep it real’, writing about those ‘poor babies going through withdrawal’ is an emotional response, not an accurate understanding of the newborn experience.

Most new moms torture themselves enough with fears about their mothering skills, without the medical profession piling on.

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Buprenorphine Plus Hydrocodone http://suboxonetalkzone.com/buprenorphine-plus-hydrocodone/ http://suboxonetalkzone.com/buprenorphine-plus-hydrocodone/#comments Tue, 13 Jan 2015 04:00:52 +0000 http://suboxonetalkzone.com/?p=14870 Continue reading Buprenorphine Plus Hydrocodone]]> I often receive emails with requests for my opinion about various aspects of buprenorphine treatment.  A recent exchange, for what its worth:

Hi Dr. Junig,

I hope you are well.  I know you have written a lot about this, and I have read most of it.  But I still needed to ask your advice on my particular situation.  I will give you all the pertinent details and you can feel free to keep the answer succinct.   I know you do not have a lot of time on your hands. 

I have been successfully using Suboxone for over a year. My current dosage is three 8mg strips of Suboxone a day.  

After a recent traumatic injury I was given an Rx for  20 x 10/325 norcos.  I knew it was tricky to implement this into my Suboxone routine, but I also knew that it WAS possible to do so successfully, and that I really needed to try for purposes of comfort.   

Anyhow, my last doses of Suboxone were yesterday: 1 strip @ 7am, 1 strip @ 1130am.  

I then waited 4 hours and took 2 of the norco, followed by 2,   later, and another 2, 4 hours after that.   I took 2 at 9am this am today, followed by 3 at 1pm today.  And now I am having some serious concerns and reservations about this.  I just feel like shit now. 

And I don’t know if it’s because I am in withdrawal from the Suboxone, or because the Suboxone is still bound and the norco isn’t working?  

My current symptoms are headache, dilated pupils, restlessness, anxiety.  I just don’t feel *right*, and I suspect it’s the opiate situation that is doing this.  I don’t feel comfortable taking more norco at this point, for obvious reasons, but I am also apprehensive about taking any Suboxone right now.  

I appreciate your time and your opinion immensely.  Any guidance (opinion, gut feelings) you can provide me with would be valuable to me.  

Regards,   XXXX

My Response:

Hi XXXX,

My best guess is that you are experiencing early withdrawal from reducing the buprenorphine/Suboxone, and that hydrocodone is not strong enough to replace the buprenorphine you’ve discontinued.  I say that because in the multiple times my patients have had surgeries, I always do the same thing—  continue the buprenorphine at a reduced dose of about 8 mg, once per day, and  add oxycodone, 15 mg every 4 hours, for pain control.  I’ve never seen precipitated withdrawal when starting an agonist when buprenorphine is already established.  Precipitated withdrawal comes when a person is on an agonist, and then takes buprenorphine—not the other way around.

With that in mind, if you were my patient I would cross my fingers, and have you restart Suboxone at a dose of about 12 mg per day— for example 8 mg in the morning, and 4 mg in the evening.  For pain I would give you 15 mg of oxycodone.  If you are like most people, you would get pain relief, without any of the euphoria that you used to get with opioids.

My advice to you would be the same.  I have some concern that you are feeling ‘lousy’ now, when you should still have plenty of buprenorphine in your system after only one day away from it.   But maybe the misery is psychological, or from some other random viral illness.

I have some patients with severe chronic pain, including a firm diagnosis and a solid pain history – i.e. not people with moderate pain, but people who are suffering greatly who other doctors had abandoned.  I start them on 8 mg of buprenorphine per day, and when they are tolerant to buprenorphine I add oxycodone, 10 or 15 mg every 4 hours.  The several people I’ve treated with that approach think I’m a miracle worker because they get pain relief from far lower doses of narcotic than they used before, and never (at least for a year or two that I’ve been doing this) develop tolerance.  Based on those experiences, I would think you would be fine resuming a half dose of buprenorphine, and taking an agonist on top of it.   I don’t know if you can get to an effective dose of hydrocodone and stay safe with the acetaminophen though; hydrocodone may not be potent enough to displace buprenorphine.

Good luck!

Jeff J

 

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Newborn Buprenorphine Abstinence: Standard of Care http://suboxonetalkzone.com/newborn-buprenorphine-abstinence-standard-of-care/ http://suboxonetalkzone.com/newborn-buprenorphine-abstinence-standard-of-care/#comments Tue, 30 Dec 2014 04:54:15 +0000 http://suboxonetalkzone.com/?p=11077 Continue reading Newborn Buprenorphine Abstinence: Standard of Care]]> First Posted 2/1/2014

The topic of newborn abstinence syndrome from buprenorphine provokes strong emotions.  Expectant mothers anticipate harsh attitudes from doctors and nurses.  They worry that their use of buprenorphine will cause their babies to suffer from withdrawal.  They hear about the experiences of women reported to CPS after delivery, or whose babies were kept on inpatient opioid tapers for weeks.

A member of SuboxForum recently wrote that the hospital she planned to use, in downstate NY, required mothers on buprenorphine to sign a formal policy regarding the care of their newborn infants.  The policy stated that all babies of mothers on buprenorphine must go to the NICU for at least 10 days after delivery, regardless of condition. Mothers were not allowed to refuse that level of treatment for any reason.

Last week, one of my buprenorphine patients came to her appointment with her 5-day-old baby, after both she and her baby left the hospital less than 48 hours after delivery.   Her discharge struck me as premature, not because of anything to do with buprenorphine, but because new moms are frequently anemic and sleep-deprived and can use a bit of rest before taking on an infant’s schedule.

How can the ‘standard of care’ vary so greatly?  What role does insurance coverage play in decisions about opioid tapers, NICU admissions, and discharge schedules?  After having dozens of patients go through the process uneventfully without intervention by neonatologists, I wonder if newborns are always positively served by their interventions. I also question the wisdom of using opioid agonists to taper from a long-half-life, partial agonist, i.e. buprenorphine.

In blinded studies, only half of babies born to women on buprenorphine show objective signs of ‘withdrawal’, which is a misleading word for describing the experience of an infant.  I have no doubt that in the typical non-blinded nursery, neonatal abstinence symptoms are grossly over-diagnosed.  Mothers on buprenorphine describe a biased diagnostic approach to their newborns, where babies who cry are ‘too agitated’, and babies who sleep are ‘too sedated’.

In the case of babies who truly show symptoms of NAS, do the symptoms always warrant ten days in the NICU?  Is a baby distressed by mild neonatal abstinence better off in mom’s lap nursing with breast milk containing small amounts of buprenorphine, or lying alone in a plastic incubator under fluorescent lights, with multiple IV lines? Some docs and nurses in my area allow moms on buprenorphine to nurse, a policy that makes sense from an anatomical and developmental perspective.   As the baby’s liver matures, ingested buprenorphine is eventually completely destroyed through first-pass metabolism.  The process allows for a gradual, natural taper, without the misery and cost of IV infusions and monitoring systems.

Decisions about monitoring and discharge should, of course, revolve around safety.  I question whether the various approaches to buprenorphine abstinence in the newborn are based on informed, intellectual consideration, or are instead liability-motivated rules supported by ‘best guesses’ by people who don’t understand buprenorphine.  Given the 180-degree difference between the approaches of different hospital systems, somebody is clearly doing it wrong.

I’ve griped about how research studies about drug addiction are so-often focused on demographics, where the data does more to describe the past than to improve care going forward.  The best approach to babies born to mothers on buprenorphine should be near the top of the list for research funds.  The hard part of such studies will be identifying (and following) the conclusions that are derived from science, vs. those that come from concerns about litigation, where the costliest and most-intense treatments always win out.

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Rapid Opioid Detox from Suboxone http://suboxonetalkzone.com/rapid-opioid-detox-from-suboxone/ http://suboxonetalkzone.com/rapid-opioid-detox-from-suboxone/#comments Sun, 28 Dec 2014 05:48:11 +0000 http://suboxonetalkzone.com/?p=10603 Continue reading Rapid Opioid Detox from Suboxone]]> First Posted 1/26/2014

I recently answered a post at SuboxForum by a member who asked what to expect from rapid detox from opioids, and specifically from buprenorphine.

My reply:

Several of my current buprenorphine patients have been through rapid detox at some point in their past.  Their stories are so similar that it becomes difficult to distinguish one from the next.   A typical history would go something like this:

“I started pot and alcohol by 16, but discovered pain pills when I was about 17 when I had surgery. My doctor gave me pain pills when I hurt my back, and when he stopped, I started getting them from my aunt’s house. She had cancer so she had tons of them. Then she died, and I was getting them from friends at work until they got more expensive. I switched to heroin a couple years ago.”

I’ll ask, “have you been through treatments?”

“Yep– detoxed 3 times, twice to rehab, once for 30 days and once for 3 months…. I did NA on and off, and was on methadone for a couple years. Oh, and I did rapid detox in Florida 5 years ago.”

I’ll ask, “what is the longest you stayed clean?”

“I was clean most of the time when I was in rehab…  so maybe 2 months?  other than that it would be a few days here or there– usually not more than 3 days.  After rapid detox I stayed clean for 2 months because I didn’t have any money left to buy anything.

I’ll ask, “Have you been on Suboxone before? Any time totally off opioids?”

They’ll say “I was on it for 1 year but I stopped. Not sure if I was ever totally clean… there was always something around.”

I don’t mean to be flippant about relapse, especially given the high rate of death associated with relapse to opioids. But I want to give an idea of how my attitudes about buprenorphine were formed over the years. Patient after patient have provided stories about repeated relapses despite a variety of treatment efforts, including rapid opioid detox.

During my own period of active using in the early 1990′s, desperation drove me to my own ‘rapid detox’, without the anesthesia.  I kicked off my ‘clean time’ with IV naloxone, followed by a couple 50 mg tabs of naltrexone.  I had stopped opioids for several days, so I didn’t expect severe withdrawal…. but was I wrong!  I could walk by the end of day one, just barely, but I remained very sick for a week or two.  I’m sure I would have stayed sick at least a few weeks longer, had I stayed clean….  but as soon as I realized that I had made it through such a nightmare alive, I decided that I must have some awesome will power, and I could always just do that again, if I had to…. so I ‘rewarded’ myself with a bit more controlled using.

Crazy.

As I see it, the problem is that the person who walks out of the door of rapid detox is not all that different from the person who walked in.  Yes, the person had his mu opioid receptors antagonized for a day. But that’s not long enough to get one’s receptors back to normal, not by a long shot. After a day or two of naltrexone, patients still have weeks of withdrawal awaiting them.

What if a person stays on naltrexone for the entire several months that it takes for tolerant opioid receptors to be replaced by new, normally-sensitive opioid receptors? That would be a better option than rapid detox alone, reducing the odds for relapse by blocking receptors during the most intense physical cravings.

But in reality, addiction is much more complicated than physical cravings.    Despite the promises of a new life in ads for detox programs, naltrexone is not fairy dust that changes how a person deals with good and bad news. Most people who seek detox have been conditioned, for years, to use opioid in response to resentments.   So the person who picked up at age 18, 20, 25, and 28 tends to pick up again, unless something makes a real difference in how the person responds to life’s challenges.  For most people, I do not believe that rapid detox makes enough of a difference.

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