I am Addicted to Heroin. What Should I Do?

I’ve been spending more time answering questions on SuboxForum, and less time writing blog posts.   I’ll share a comment from today in the hopes that someone looking for help will stumble across this page.
A newcomer to SuboxForum posted this succinct question:
Will someone PLEASE help me take the first steps into the right direction? I have been on opiates and heroin for 10 years and it is starting to ruin my life. I don’t know what to do first?
My less-succinct reply, with minor editing:
Sometimes people get too focused on choosing the right approach and end up doing nothing—sometimes called ‘paralysis by analysis.’  Your options are largely determined by your circumstances– so your first mission is to find out what is available.  There are people who put down medication-assisted treatments like buprenorphine (aka Suboxone) and methadone, saying that they are ‘replacing one drug for another’.  But either of those approaches have much better success rates than residential treatment, and they are both easier to start.
Methadone or buprenorphine will each stabilize your situation fairly quickly, allowing you to step back and weigh your options without the daily search for opioids.  With either buprenorphine or methadone treatments you lose nothing by getting started.  If you start buprenorphine and decide it isn’t right for you, you can simply go back to heroin or oxycodone.  The same is true for methadone.    People rarely make that choice– and when they do, it usually wasn’t a deliberate change, but rather the addiction gained the upper hand and pulled them away.  But the point is worth making that you can always go back– because every now and then someone comes here and complains to be ‘stuck on buprenorphine’.  I try to point out that they are stuck on opioids– and they can always go back to where they were before they started buprenorphine.
The question is whether you have access to either medication in your area.  If you Google ‘find addiction treatment’ or a related search, you will get listings of many outdated web sites.  I’m disappointed to see that even the SAMHSA site is extremely outdated, listing programs that are no longer available and not showing newer treatment programs for either methadone or buprenorphine.
I have a web site that lists a number of buprenorphine doctor directories at SuboxDocs.com.  The site is a ‘directory of directories’, and some of the databases are more current than others.
I’m just now noticing how difficult it must be to find a treatment program.  The last time I really looked at the databases was maybe 5 years ago, and I remember seeing a number of sites that were fairly current.  I assumed that the information was only better now– but it appears to be worse.  If anyone reading this knows of good resources for FINDING treatment, leave a comment!
Another option for someone seeking treatment is to call your county health department.  I would think that most counties would have a list of programs in their area.  Finally, many people hear about a treatment program through word of mouth.  I don’t usually recommend increased contact with people who are actively using, but if you are in contact anyway, you might as well ask!
Buprenorphine treatment will have a higher ‘front end’ cost.  In my area, initial costs are $300-$500.  Ongoing costs include the medication (usually covered by Medicaid or private insurance) and the cost of monthly doctor visits.  Things to consider when choosing a long-term provider:  Are doctor visits covered by Medicaid or insurance?  If not, what will the visits cost?  Who pays for drug testing?  How much does that cost?  If you don’t have any insurance at all, will the doc prescribe plain buprenorphine (which is less costly than combination products)?  Are you required to be in counseling?  If so, how often, and where?  Some docs use buprenorphine to fill their counselors’ time slots, which pushes ethical borders a bit in my opinion.  Other considerations… Does the doctor provide other services such as mental health treatment?  Does the doc allow you to be treated with benzodiazepines?  What is the doc’s attitude toward marijuana?  Will you be kicked out if you test ‘dirty’?  Is the doctor ‘punitive’– i.e. will you be tossed from the program if you struggle a bit?  Or will the doctor work with you, if you don’t get it perfect right away?
Methadone programs in my area are covered by Medicaid, making them essentially free for people with that coverage.  But as people do better and find jobs, they often lose Medicaid and have to pay for methadone out of pocket, which can be costly… although never costlier than active addiction, especially when you factor in all of the related costs that come with actively using.
If you do not have access to medication-assisted treatments, you may need to consider abstinence-based treatment programs.  I’m not a big fan of abstinence programs for opioids because of the high relapse rates with those substances, and the high death rate during relapse.  And of course, an abstinence-based program requires detox and withdrawal.  People who lack an understanding of the usual course of opioid dependence see abstinence-based treatment as the best option.  But the only way to see things that way is by ignoring all of the data, or by assuming that in THIS case, things will go differently than usual.  That thought is very seductive to the parents of addicted young people, and I have known a number of people who died after falling victim to that seduction.
Most people who have been addicted to opioids for a year or more have already learned that detox alone provides little value.  If simple detox works for you, you were probably physically dependent, not addicted.  If you have detoxed and then relapsed several times, another detox is not likely to be helpful.  In fact, detox introduces danger into the equation, as many overdose deaths occur after a person has been through detox, either voluntary at a treatment program, or forcibly through incarceration.  Methadone and buprenorphine are both safer options because they keep tolerance high, reducing the risk of overdose.
My bias toward medication-assisted treatment comes across loud and clear, I know.   I don’t intend to assert that residential programs have NO value; I just think that too-often people enter them without understanding the long odds for finding success.  The people who do best with abstinence-based treatments are those who are monitored for a long time and have a lot to lose, such as people trying to regain professional or occupational licenses, or trying to avoid prison.  In all cases, the treatment is just the beginning of a lifetime of working to maintain sobriety.
An aside to the treatment community:  I often give talks about the need to treat addiction as an illness (and I generally accept requests to speak for a couple hours on the topic, in case anyone has need for a speaker!).  For decades, we all envisioned a paradigm where addiction responded to intensive, months-long abstinence-based treatments, followed by lesser-intense ‘aftercare’ and meetings.  Physicians had minor roles, or no role at all.   There is a growing awareness that things need to change.  I don’t claim that doctors understand addiction better than the current treatment community, and in fact I assume that the opposite is true.  But doctors can prescribe medications with the power to preserve life far more reliably than abstinence-based treatments.
There is a saying–  ‘perfect is the enemy of good’.  We are losing thousands of lives in the search for a ‘perfect’ treatment.  For almost all other illnesses, doctors provide medications and recommendations in order to ‘manage’ the illness.   Now more than ever, addiction warrants the same medical approach.

Short-Timers

Another question from a reader:
The current blog brings up the notion of long term use of Bupe or short term detox.  You say you are a fan of long term use, and that is clearly a good thing when the patient is one headed back to a drug culture of life of crime or is obsessed with the drug.  But-  what about patients like me and I think many others who have zero contact with the drug world, have never taken an illegal drug, and yet have taken Ocy C over the years for pain and find it all but impossible to stop the Ocy C.  
 The Suboxone helps with the W/D and just getting through with that is all we want.  NA meetings and the like are like being on Mars, it makes no sense.  There are no drug cravings at all and the goal is just normal.  Or rather, the goal is to make it through the W/D which is so harsh with Oxy C as to be dangerous for older people, whose only source of drugs indeed is the doctors Rx for them  And now that too is unavailable.  This group does not need Suboxone to become a new problem for them.  They just want the help.  It is not critically  important to determine “who” is being treated.  The certification training materials seem to brush over this so lightly that there is only one induction method allowed.  One that a drug company would love, but not always a patient —  pleading, do no harm.
My Thoughts:
I hear you, and watch for those patients.  Frankly I wish I had more of them, so that I could get some movement through my practice—- instead of being stuck with 100 chronic patients and a long wait list.   The financial motivation for the DOCTOR is to push people through, for that same reason.  Of course the drug company gets paid in either case.
The first question is whether buprenorphine even helps in the case you describe.   It is easier, in many ways, to taper with methadone than with buprenorphine, as you don’t have to divide such tiny pills.  It has been suggested that it is easier to taper off a partial agonist than an agonist—and I believe that to be true, simply because I have seen people do the former and not the latter.  But I don’t know HOW much easier it is—or if psychological aspects of the taper were more responsible than the person’s state of misery.
There were several studies a few years ago that showed relapse rates of 100% in people treated with Suboxone for less than a year;  those findings, it seems to me, put a damper on the idea that buprenorphine could be useful for short-term detox.  But I don’t know where those people would have fallen on the spectrum that you are presenting.  I do know that they were people with a primary diagnosis of ADDICTION— NOT chronic pain– so maybe they are not relevant here.
My caveat would be that I HAVE met many people over the years who are convinced that they fall in the pain camp you describe, but who turn out to be just as ‘addicted’ as anyone else.  They describe the process in different terms;  instead of admitting to ‘relapsing on opioids’, they describe ‘deciding the pain was worse than they expected, and that it was a mistake to go off opioids.’  They will claim to be different…. But an objective observer would see the same growing attachment to opioids, the same gradual dose escalation, the same excitement and activity when opioids are ‘on board’, and the same depression and misery if a day passes without using.
I agree with your thoughts, and get your point.  I just don’t know if very many people are as clearly-defined as you describe. One reason is because there are few conditions that cause pain severe enough to require high-dose opioid agonists for an extended period of time– say, a few months– that then go away.  Most pain conditions have residual symptoms—- from chronic inflammation, or even from the set-up of central pain circuits.  In a sense the pain is remembered, even after the original injury is repaired.  The severity of that residual pain is affected by the person’s emotional state, dependency, motivation, genetics…..  and the residual pain becomes a expressway back to using opioids— an expressway that is used often by many people.
Thanks for your comments!

The Downside of Methadone

An Article by Mike Berens and Ken Armstrong, Seattle Times, discusses some of the problems with using methadone as a first-line treatment for pain:
When it comes to battling pain, Washington health officials have encouraged doctors to reach for methadone, a powerful and inexpensive prescription drug. For the past decade, the state has declared methadone to be as safe and effective as any other narcotic painkiller.

Methadone

But in a striking reversal that has gained momentum this week, doctors are receiving stark warnings that methadone is riskier and more dangerous — a drug of last resort — because it’s unpredictable and poses a heightened risk of accidental death.
“It’s a dangerous drug because it accumulates in the body and people die in their sleep,” Dr. Jane Ballantyne, a pain specialist at the University of Washington, said Friday. “It’s very tricky and difficult to use safely.”
Ballantyne and the university are helping spearhead a series of state-sponsored training programs to educate physicians, pharmacists and advanced nurse practitioners about the risks of pain drugs.
Earlier this week, while delivering a continuing medical education course for dozens of physicians and other medical professionals at the university, Ballantyne presented a slideshow in which she cautioned that methadone “should be considered a last option opioid, never a first line opioid.”
The state’s effort is a response to a Seattle Times series, “Methadone and the Politics of Pain.” The investigation, published in December, detailed that at least 2,173 people in Washington have died from accidental overdoses of the drug since 2003.
The Times found that year after year, a committee of state-appointed medical experts sanctioned methadone, empowering the state to designate it a “preferred drug” and steer people with state-subsidized health care — most notably, Medicaid patients — to the drug in order to save money.
The state has included only two drugs, methadone and morphine, on its preferred list of long-acting pain drugs.
During the committee’s meetings, officials from state agencies that have a financial stake in methadone’s selection consistently deflected concerns about the drug.
Methadone’s death toll has hit the hardest among low-income patients. Medicaid recipients account for about 8 percent of Washington’s adult population but 48 percent of methadone fatalities.
After the series, the state sent out an emergency public-health advisory that singled out the unique risks of methadone.
Medicaid officials faxed a health advisory to more than 1,000 pharmacists and drugstores about methadone, as well as about oxycodone, fentanyl and morphine. The state Department of Health mailed advisories to about 17,000 licensed health-care professionals.
The health advisory confirmed that Washington ranks among states with the highest rates of opioid-related deaths, exceeding the number of deaths each year involving motor vehicles.
Most painkillers, such as oxycodone, dissipate from the body within hours. Methadone can linger for days, pool into a toxic reservoir and depress breathing. With little warning, patients fall asleep and don’t wake up. Doctors call it the silent death.
Ballantyne noted that methadone is an indispensable drug and plays an important role in the treatment of many patients. However, due to the heightened risks, methadone should be prescribed only by those with extensive training and experience — and only after every other option has been exhausted.
Dr. Jeff Thompson, chief medical officer of the state’s Medicaid program, now readily agrees that methadone use carries unique risks and that it should not be the first choice if other drugs are equally suitable.
He said physicians are stepping up efforts to unravel the long-term impact on the body from prolonged use of prescription drugs now that Washington’s new pain-management law has gone into full force beginning this month.
The groundbreaking law requires practitioners to follow new standards for treatment and record-keeping. It also requires prescribers to consult with state-certified pain experts when narcotic dosages reach higher thresholds.
While the law’s goal is to lower doses and, if possible, wean patients from narcotic pain drugs, doctors are finding the task more difficult than hoped, Thompson said.
For instance, methadone patients can suffer prolonged withdrawal symptoms, like nausea and depression. With most pain drugs, withdrawal subsides within a week. Methadone’s grip can last for months, even years, he said.
State officials will review methadone’s role on the state’s preferred drug list during a meeting next month.
“I think we’re going back and relearning how to treat pain,” Thompson said.

Consequences Section

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.

Prison is a better consequence to heroin addiction
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!

Would'a Could'a Should'a…

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!

Buprenorphine safer than methadone for neonates born to opioid addicts

A presentation at a recent meeting of ACOG, the American College of Obstetricians and Gynecologists, compared the use of buprenorphine or methadone for treating opioid addiction during pregnancy.  I hear from pregnant women often, who write out of frustration that their OBs have never heard of buprenorphine or Suboxone and asking what they should do to educate their physicians.  Let’s hope that studies like this one help get the word out.  If you search this blog you’ll find a number of my posts about pregnancy, opioid dependence and buprenorphine.  Some of the posts include articles about neonatal abstinence, breast feeding while taking buprenorphine, and comparisons between buprenorphine and methadone.  I also recommend, of course, the forum, where you will find many other women who have already wrestled with this issue.

Buprenorphine Favoured Over Methadone for Opiate Addiction in Pregnancy By Fred Gebhart   SAN FRANCISCO — May 19, 2010 — A recent study in Maine among women addicted to opiates has found that buprenorphine is safer for neonates than traditional treatment with methadone.

The research was presented in an oral paper on May 18 at the American College of Obstetricians and Gynecologists’ (ACOG) 58th Annual Clinical Meeting. The paper won ACOG’s Donald F. Richardson Memorial Prize.
“It has been shown that patients on methadone are more stable in terms of their physical and mental health and are more likely to receive standard prenatal care, but methadone has clear effects on the child,” noted lead author Michael Czerkes, MD, Maine Medical Center, Portland, Maine. “Buprenorphine is an attractive alternative, but there are few data on the effects on neonatal outcomes. Since our patient population uses both agents, we decided to find out.”

The key objection to methadone from the infant’s perspective is the appearance of neonatal abstinence syndrome (NAS), a combination of symptoms that include dysfunction of the autonomic nervous system, gastrointestinal tract, and respiratory system. NAS has a number of short-term consequences, including prolonged hospital stays, prolonged monitoring, and an increased need for intravenous medications. Methadone is also inconvenient for the mother, requiring daily clinic visits, and it is subject to diversion because it is a euphoric agent.

Limited data on buprenorphine suggest that it may carry less risk for perinatal morbidity, but trials have been small and somewhat contradictory. Buprenorphine can be dispensed in 30-day packaging, which eases the burden on the mother, and is less subject to diversion because it significantly less euphoric than methadone.

Researchers at the Maine Medical Center conducted a retrospective chart review of women addicted to opioids who were using either buprenorphine or methadone and who delivered their babies at the institution between 2004 and 2008. There were 101 methadone patients and 68 buprenorphine patients available for analysis. There were no significant maternal differences between the 2 groups.

The differences between offspring of mothers in the 2 groups were dramatic, said Dr. Czerkes. The mean NAS score for buprenorphine infants was 10.69 compared with 12.5 for methadone infants (P = .0012). While the difference was statistically significant, Dr. Czerkes cautioned that it might not be clinically significant.

Other outcomes were both statistically and clinically significant. Buprenorphine infants spent a mean of 8.4 days in the hospital compared with 15.7 days for methadone infants (P < .0001) and only 48.5% of buprenorphine infants required treatment compared with 73.3% of methadone infants (P < .001).

Among buprenorphine infants who needed treatment, withdrawal symptoms appeared by day 3 or did not appear at all. Withdrawal symptoms in methadone infants appeared anywhere between days 2 and 6. “That may be a clinically significant finding,” said Dr. Czerkes. “If you don’t see withdrawal in these babies by day 3, they may not have withdrawal at all.”
Overall, he concluded, buprenorphine appears to be safer for neonates than methadone. Researchers are recruiting patients for a larger randomized controlled trial.

[Presentation title: Buprenorphine Versus Methadone Treatment for Opiate Addiction in Pregnancy: An Evaluation of Neonatal Outcomes]

Pregnant and taking buprenorphine a.k.a. Subutex or Suboxone

As I’ve mentioned, I was at a ‘summit’ about buprenorphine in Washington DC earlier this week.  I didn’t hear anything earth-shaking at the meeting, but will share a couple things that I learned there over the next few posts. 
One night I was reviewing messages in my hotel room and I received an e-mail from a person saying that Social Services took her baby away from her at the hospital because she had delivered on buprenorphine.  The baby was essentially being held hostage by the hospital under Social Services orders, and was being treated, against her wishes, with opiates to avoid opiate withdrawal.  I had a patient a year or two ago who had a similar experience, where her baby was placed on a morphine drip against her wishes, after she delivered while on buprenorphine.  These stories really make me angry.  The literature contains case reports and even studies about buprenorphine in neonates, so why would a doctor do something so foolish, as treat withdrawal from a partial agonist using a full agonist?  The literature already suggests that neonatal abstinence syndrome is milder after buprenorphine than after methadone, and there are articles that have been out for several years describing the use of buprenorphine during pregnancy.  So how can a neonatologist act as if the mother is doing something abusive?
One of the more interesting speakers at the buprenophine summit had preliminary data from a study of NAS (neonatal abstinence syndrome) in babies born to mothers on methadone vs. those on buprenorphine.  The NAS scores that looked at infant behavior were not significantly different from one another, but the doses of PRN opiates used to treat NAS (morphine in this study) were ten-fold greater in the methadone group than in the buprenorphine group.  The lesson from the study is that much lower doses of morphine are needed to block withdrawal from buprenorphine than from methadone, in neonates from mothers on the substances. 
My own opinion takes things a bit further.  The studies found that the NAS scores were similar in both groups. The study was blinded, i.e. the nurses who scored the amount of withdrawal did not know which substance the mother was taking.  But the nurses DID know that the mothers were taking one or the other–  and from experience, it is clear that mothers known to be opiate addicts are viewed with scorn from the nursing staff in the average delivery suite.  I often receive messages from mothers describing varied forms of ‘tsk tsk’ every time their baby burps, even as the other babies in the nursery scream all night long.  So I take the NAS scores with a big helping of salt.  I suspect that once identified as an ‘addict’s baby’, the nuances of the baby’s NAS were masked by a general attitude of disdain toward the mother, and blurred by sympathy for the newborn for having been born into such a dire situation.
As this and other reports find their way to publication, one can only hope that OB teams and neonatologists will READ the publications, and realize that buprenorphine treatment does not require a report to child safety services, and does not automatically call for a week of intravenous morphine for the newborn!

Opiate dependence treatment options

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.

Buprenorphine and the Dynamic Nature of Character Defects

What follows is a lightly-edited version of one of my posts from a couple years ago.  I still think that this is a good model for understanding the actions of buprenorphine.

Buprenorphine and the Dynamic Nature of Character Defects

‘Suboxone’ and ‘Subutex’ are the trade names for medications that contain buprenorphine, a substance used to treat addiction to pain medications and/or heroin.  Buprenorphine treatment for opiate dependence has been an option in the US since 2003.  Other treatment approaches for opiate dependence have been used for decades but have had limited success.  With a little imagination, treatment approaches can be placed on a continuum depending on the degree to which the treatment demands changes in the personality and behavior of the addict.  Methadone maintenance is often described as a means of ‘harm reduction’ by preventing the behaviors related to the obsession for opiates or by reducing intravenous use of heroin or other substances.  At the other end of the treatment continuum there are the step-based and other Recovery programs.  One limitation of programs that demand personality change is that such change is difficult and rare, and usually only occurs after a significant amount of despair has been experienced by the addict.  Opiate dependence differs from other addictions in the lethality of overdose, and the fatality rate of even early abuse of that class of substances.  Opiate addicts are at significant risk of dying from their addiction before enough desperation has accumulated to motivate personality change.  A second limitation is the high rate of relapse that occurs even after sustained Recovery.  If a ‘changed’ addict stops actively participating in the program that induced the changes, the personality of the addict tends to revert back to the personality that was present during active drug use.
I initially had mixed feelings about buprenorphine treatment of opiate dependence, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the past four years from what I have seen and heard while treating over 400 patients with buprenorphine.  But while buprenorphine has opened a new frontier of treatment for opiate addiction, arguments over the use of buprenorphine often split the recovering and treatment communities along opposing battle lines.  The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine offers huge benefits for the health and lives of opiate addicts.
A unique medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  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 opiate 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 opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use buprenorphine 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 buprenorphine as having an ’inferior’ form of recovery, or no recovery at all.  This leaves buprenorphine patients to go to Narcotics Anonymous and hide their use of buprenorphine.  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 buprenorphine 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 buprenorphine.  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 opiate addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opiates than for other substances.  This may be because the ‘high’ from opiate 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 opiate 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 opiate 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 opiate addiction.
Drug obsession and character defects
Buprenorphine 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.  Opiate addicts have a number of such ‘defects.’  The dishonesty that occurs during active opiate 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 opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate 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 their 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 opiate addicts with buprenorphine—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 buprenorphine 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 buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-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 opiates as well—the opiate is not the issue, but rather it is the obsession with opiates 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 buprenorphine.
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.
The dynamic nature of personality
My experiences with buprenorphine have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Buprenorphine 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 buprenorphine patients, and more convincingly with the spouses, parents, and children of buprenorphine 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 buprenorphine 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.
Combining buprenorphine treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between buprenorphine and traditional recovery becomes clear.  Should people taking buprenorphine 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 buprenorphine do not feel desperate.  In fact, people on buprenorphine 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.
Other Questions (and answers):
-Should buprenorphine 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 buprenorphine I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist that has a long half-life in brain tissue.  This long half-life promotes a relatively constant state of opiate stimulation, reducing opiate cravings between doses.  But while the ceiling effect of the partial agonist buprenorphine results in a stable, unchanging tolerance to the medication, methadone has no such ceiling, and tolerance will always increase with increasing dose of methadone.  This constant increase in tolerance erodes the ability of methadone to satiate cravings for opiates.  A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.  With cravings comes the obsession to use and the associated character defects.  This explains one difference in the subjective experiences of addicts maintained on buprenorphine versus methadone.  Methadone maintenance is also usually experienced as more sedating than the effects from buprenorphine.  There is a valuable role for methadone to play as we try to prevent deaths from opiate dependence, but I see the mechanisms of action of methadone and buprenorphine to be profoundly different.  Methadone is appropriately described as a ‘maintenance agent,’ but I see a more appropriate term for the actions of buprenorphine, as a ‘remission agent.’  This term accounts for the effects of buprenorphine on the obsession for opiates, and the ability of the medication to allow for dissolution of the character defects caused by active addiction.
The downside of buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine 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 buprenorphine.  Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Buprenorphine itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting buprenorphine reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of buprenorphine use implies long term use of the drug.  Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary.  Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not buprenorphine 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 opiate 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 buprenorphine 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 each other’s weaknesses.

Withdrawal in newborns: Lay off the guilt trip!!

I will share some thoughts that I left at a discussion at a ‘linked in’ group about addiction.  I was responding to someone who was equating addiction and physical dependence in a baby born to an opiate-addicted mother.  My feeling is that such women are given way too much of an attitude by the nurses and others who care for them, and that was the motivation behind my response.  Read on:

There are many differences between physiological dependence and addiction to substances. For example, people who take effexor are dependent– and will have significant discontinuation-emergent side effects– but they are not ‘addicted’, which consists of a mental obsession for a substance. The same is true of beta-blockes, in that discontinuation results in rebound hypertension, but there is no craving for propranololol when it is stopped abruptly.

We have no idea of the ‘cravings’ experienced by a newborn, but I cannot imagine a newborn having the cortical connections required to experience anything akin to the ‘cravings’ experienced by opiate addicts, which consist of memories of using and positive reinforcement of behavior—things that are NOT part of the experience ‘in utero’.

It is also important to realize that the withdrawal experienced by addicts consists of little actual ‘pain’ (I’ve been there—I know). Addicts talk about this subject often, as in ‘why do we hate withdrawal so much?’ It is not physical pain, but rather the discomfort of involuntary movements of the limbs , depression, and very severe shame and guilt. The NORMAL newborn already HAS such involuntary movements as the result of incomplete myelination of spinal nerve tracts and immature basal ganglia and cerebellar function in the brain. And the worst part of withdrawal—the shame and guilt and hopelessness—are not experienced in the same degree in a baby who has no understanding of the stigma of addiction.

Finally, if we look at the ‘misery’ experienced by a newborn, we should compare it to the misery experienced by being a newborn in general. I doubt it feels good to have one’s head squeezed so hard that it changes shape—yet nobody gets real excited about that discomfort—at least not from the baby’s perspective.  I also doubt it feels good to have one’s head squeezed by a pair of forceps, and then be pulled by the head through the birth canal.  Many hospitals still do circumcisions without local, instead just tying down the limbs and cutting. Babies having surgery for pyloric stenosis are often intubated ‘awake’, as the standard of care– which anyone who understands intubation knows is not a pleasant experience. And up until a couple decades ago—i.e. the 1980s – babies had surgery on the heart, including splitting open the sternum or breaking ribs, with a paralytic agent only, as the belief was that a baby with a heart defect wouldn’t tolerate narcotics or anesthetic. I don’t like making a baby experience the heightened autonomic activity that can be associated with abstinence syndrome, but compared to other elements of the birth experience, I know which I would choose.

My points are twofold, and are not intended to encourage more births of physiologically-dependent babies. But everyone in the field should be aware of the very clear difference between physiological dependence and addiction, as the difference is a basic principle that is not a matter of opinion—but rather the need to get one’s definitions right.

Second, the cycle of addiction and shame has been well established, and there is already plenty of shame inside of most addicted mothers. If there are ten babies screaming loudly, only the whimper from the ‘addict baby’ elicits the ‘tsk tsk’ of the nurses and breast feeding consultants. My first child was born to a healthy mom years before my own opiate dependence, and he never took to breast feeding; he his mother been an addict, his trouble surely would have been blamed on ‘addiction’ or ‘withdrawal’. Unfortunately even medical people see what they want to see—and sometimes that view needs to be checked for bias due to undeserved stigma—for EVERYONE’S good, baby included.