Buprenorphine, Not Subbies

I’ve been writing longer and longer posts on SuboxForum so maybe I need to write more here.  This blog archives twelve years of frustration over the ignorance toward buprenorphine, at least until I ran out of steam a year ago.  I grew used doctors refusing to treat people addicted to heroin and other opioids.  I became used to the growth of abstinence-based treatment programs, even as relapse rates and deaths continued to rise.  It isn’t all bad news; I enjoyed the past couple meetings of AATOD, where people openly spoke about medication-assisted treatments without hushed voices.  I feel like I’m the conservative one at those meetings!

I don’t remember where I heard first – maybe in an interview with some reporter about addiction- that I was an ‘influencer’ with buprenorphine.  The comment surprised me, because from here I don’t see the influence.  My supposed influence is from this blog, although I may have changed a couple of minds in my part of my home state among my patients, who had to sit across from me and hear me talk. For an ‘influencer’ I’m not very happy about how many buprenorphine-related things have gone over the years.  I still see the same reckless spending of resources, for example. A couple million people in the US abuse opioids, and only a fraction receive treatment.

Those are big things, and anyone reading my blog knows all the big things.  I want to write about the little things.  The easiest way to have influence is to write about the things that nobody else writes about.  After all, that’s what made me an influencer in the first place, back when I had the only buprenorphine blog out there. Here’s what I want to influence:  If you’re trying to leave opioid addiction behind, do not call buprenorphine ‘subs’ or subbies.

On the forum I try to keep things real – not in a cool way, but in a medical or scientific way.  I want people to use .  I know I sound like some old guy frustrated by all of the new words and acronyms on social media.  YES, dammit, I AM frustrated by those things!  But communication has become so…. careless in the era of Twitter and texting.  Find an old book and notice the words and phrases used by educated people 100 years ago.  Or look in the drawer at your mom’s house where she kept letters from your dad, or from her friends.  Does anyone communicate in sentences anymore?

I’m not crazy (always pay attention when you catch yourself saying that!), so I realize this isn’t the start of a wave (what color would THAT one be?)   But I might show a couple people how loose language is used to take advantage of healthcare consumers. In the next post I’m going to show an example of ‘fad-science’ masquerading as alternative medicine, promoting substances that avoid FDA scrutiny by identifying as nutrients and not drugs.  Some large scams benefit from the informal attitudes toward health and medicine;  attitudes that might encourage more discussion about health, but also lead people to think that medical decisions are as easy as fixing a faulty indicator on the dashboard with the help of a YouTube video.  As in ‘I can treat it myself if I can find the medicines somewhere.’

The point is that common talk about medicines is helpful unless it isn’t.
Many people in my area addicted to opioids treat themselves with buprenorphine, either now and then or in some cases long-term.  Is ‘treat’ the right word?  From my perspective I’d say yes in some cases, and no in others.  Last year I took on 4 patients who were taking buprenorphine medications on their own, paying $30/dose, for more than a year.  They said (and I believe them) that they hadn’t used opioid agonists for at least that long.  I’ve also taken on patients who used buprenorphine but also used heroin, cocaine, and other illicit substances.  There is a big difference between the two groups in regard to level of function, employment, relationship status, emotional stability, dental and general health status, and finances.  Another difference between them is that people in the first group talk about taking buprenorphine or Suboxone or Zubsolv.  Those in the second group talk about finding subbies.

I also have patients in my practice to whom I prescribe buprenorphine, who sometimes talk about subbies, or subs, or ‘vives’, or addies.  I correct them and tell them that I have a hard time trusting patients who talk that way.  After all, those are street terms.  A pharmacist doesn’t say ‘here’s your subs!’

So here’s the rub.  Should I discharge these patients? Should I assume from their language that they are part of the street scene, and maybe selling medication I’m prescribing?  Or should I just watch them closer and be more suspicious, doubling the drug tests and pill counts? Should I tell the police?
No, of course not.  I took it that far to make a point about slippery slopes, and the struggle to find a foothold while sliding.

But I will continue to correct them, and let them know that their words create a certain impression.  Getting that point across would be enough influence for one day!

Addiction Treatment Has it ALL WRONG

Today on SuboxForum members discussed how long they have been treated with buprenorphine medications.  Most agreed that buprenorphine turned their lives around, and most are afraid they will eventually be pushed off the medication.  Most buprenorphine patients described a reprieve from a horrible illness when they discovered buprenorphine.  But most have new fears that they never anticipated– that their physician will die or retire, that politicians will place arbitrary limits on buprenorphine treatment, or that insurers will limit coverage for the medication that saved there lives.
I joined the discussion with the following comment:
I give lectures now and then about ‘Addiction, the Medical Illness.’  Once a person thinks through the topic several times with an open mind, the right approach to treating addiction becomes obvious.    After all, doctors ‘manage’ all illnesses save for a few bacterial diseases, and even those will become at best ‘managed’, as greater resistance develops in most bacteria.  We doctors rarely cure illnesses.  We manage illness.
The public’s attitudes toward treating addiction differ from treatments for other diseases.  Avoiding effective medications isn’t  a goal for other illnesses.  In fact, in most cases doctors refer to skipping medication negatively, as ‘noncompliance.’  There are religious orders that don’t believe in medication including Christian Scientists… and there are religions with specific beliefs, e.g. Scientology, that don’t believe in psychiatry, or Jehovah’s Witnesses who don’t accept blood products. I assume that attitudes toward addiction developed over the years when no medical treatments effectively treated addiction.  Doctors and laypersons came to see addiction as untreatable, and the only survivors people who found their rock bottom and in rare cases, saved themselves.  And since nobody could fix addiction, and the only chance at life was to find ‘recovery’, a nebulous concept based on spirituality, adherence to a group identity, and correction of ‘personality defects.’
What an obnoxious attitude– that people with addictions have ‘personality defects’!  Even most of the docs and therapists who ‘get it’ about medication insist that no patient will heal until we ‘fix the underlying cause of his/her addiction’.  What a bunch of crap…  as if all of those people out there WITHOUT addictions have GOOD personalities, and all of those people who got stuck on opioids (mostly because of bad doctors by the way) have BAD personalities.  I call BULL!  Opioids are powerfully-addictive substances, and a percentage of people  exposed to them, regardless of character, become addicted.  My personality was apparently good enough to get a PhD, get married, save a drowning woman, have a family, go to medical school and graduate at the top of my class with multiple honors, become an anesthesiologist and get elected president of my anesthesia group an unprecedented 3 times.  But taking cough medicine that grew into an addiction to fentanyl means I have ‘personality defects’??!!
I’m sure everyone has his/her own story.  But we’ve all heard so often that we have some broken screw at the base of our brains that we’ve started believing it.  And the mistreatment by doctors and pharmacists (and reporters and media and society in general) perpetuates that shame among all of us.
The truth is that our ADDICTIONS caused us to do things that were wrong.  We developed an intense desire to find chemicals because of the activation of addictive centers in our brains.  And THAT caused our ‘character’ problems.
I’ve written before about the ‘dynamic nature of character defects’.  Search my name and that term, and you will find the comments- or just click here.  The character problems so obvious in using addicts are driven by the obsession to find and use opioids.  When you treat that obsession with buprenorphine, those ‘character defects’ disappear.  I’ve seen the process unfold over and over, in patient after patient.  Some doctors perpetuate character problems by treating patients like criminals, and ANY person will develop character problems if treated poorly long enough.  In that way, the defects can become a self-fulfilling prophecy.
The character defect argument is the whole reason for counseling.  But get this– there have been several studies that looked at abstinence after discontinuation of buprenorphine after one year, with or without counseling.   And the counseling group did WORSE in those studies!  Of course, everyone interprets those studies by saying that ‘the counseling must not have been done right’ or it was not intense enough, rather than accept the data with an open mind, as any good scientist would.
Vivitrol (i.e. depot injections of naltrexone) are the biggest example of treatment based on flawed ideology.  The treatment rests on the idea that if we block receptors and counsel the heck out of people, we can fix their character defects and their addictions so they won’t use when Vivitrol is removed.  The travesty is that nobody will look at the results of this vast experiment, mostly played out in drug courts.  When you think about it, we have a long history of experimenting on people caught in the criminal justice system.  Studies in Australia showed a 12-fold higher death rate in addicts maintained on naltrexone and ‘counseled’ compared to people maintained on methadone.   When the people forced onto Vivitrol by the legal system start to die, will anyone keep track?
Deaths after residential treatment are common, but nobody keeps track of them.  So I’m not holding my breath for outcome data from the failures of drug courts!
Every serious chronic illness warrants chronic medical treatment, save one.   All healthcare professionals will say, some reluctantly, that addiction is a disease.   It is time to start TREATING IT LIKE ONE.

Clearbrook President Gets it Wrong

A blurb in the buprenorphine newsfeed (see the bupe news link in the header of this page), has the headline ‘Suboxone challenged by Clearbrook President’.  I followed the link, and after reading the ‘article’ I wanted to comment to that president but the person’s name wasn’t included, let alone an email address or comment section.  So I’ll have to comment here instead.
The article was one of those PR notices that anyone can purchase for about 100 bucks, in this case from ‘PR Newswire’.  It’s a quick and easy way to get a headline into Google News, which pulls headlines for certain keywords like ‘Suboxone’ or ‘addiction’.
The Clearbrook president makes the comment that this 180-degree swing to ‘medication assisted treatment’ is a big mistake.  He says that in his 19 years in the industry he has seen ‘thousands’ of people ‘experience sobriety’.   I’ll cut and paste his conclusion:
There is no coming into treatment and getting cured from the disease of Addiction. There is no pill or remedy that will magically make one better. Those looking for a quick fix to addiction and the treatment modality being used by the vast majority of treatment providers today, will be disappointed with the direction our field is taking when this newest solution doesn’t live up to its claims.
A word to the President of Clearbrook:   I’ve worked in the industry too.  But unlike you, I wasn’t satisfied to see a fraction of the patients who present, desperate for help, ‘experience sobriety’– especially when I read the obituaries of many of those patients months or years later.
The president says that ‘no pill or remedy will magically make one better.’  Addiction, for some reason, has always been considered immune to advances in modern medicine.  We all know that addiction is a disease, just like other psychiatric conditions including depression, bipolar, and schizophrenia.  Why is it that even as medicine makes extraordinary advances in all areas of illness, medications for addiction are considered to be ‘magic’?
Those of us who treat patients with medications, particularly buprenorphine, realize that addiction doesn’t respond to ‘magic’.  But I see a lot more hocus pocus in abstinence-based residential treatment programs than in the medications approved by the FDA for treating addiction.  Residential programs charge tens of thousands of dollars for a variety of treatments–  experiential therapy, art therapy, psychodrama, music therapy, etc.– that have no evidence of efficacy for treating opioid dependence.  Abstinence-based treatments have managed to deflect criticism from their failed treatment models by blaming patients for ‘not wanting recovery enough’.
Buprenorphine finally allows the disease of addiction to be treated like other diseases– by doctors and other health professionals, based on sound scientific and pharmacological principles.   Abstinence-based treatment programs have tried to tarnish medication-assisted treatments, but people are finally recognizing the obvious– that traditional, step-based treatments rarely work.
And that’s just not good enough when dealing with a potentially fatal illness like opioid dependence.

Menzies Gets it Wrong

In Opioid Addiction Treatment Should Not Last a Lifetime, Percy Menzies resurrects old theories  to tarnish buprenorphine-based addiction treatment.  Methadone maintenance withstood similar attacks over the decades, and remains the gold standard for the most important aspect of treating opioid dependence:  preventing death.
Menzies begins by claiming that a number of ideas that never had the support of modern medicine are somehow similar to buprenorphine treatment.  Replacing beer with benzodiazepines?  Replacing morphine with alcohol?  Replacing opioids with cocaine?  Where, exactly, did these programs exist, that Menzies claims were precursors for methadone maintenance?
Buprenorphine has unique properties as a partial agonist that allows for effects far beyond ‘replacement’.  The ceiling effect of the drug effectively eliminates the desire to use opioids.  Seeing buprenorphine only as ‘replacement therapy’ misses the point, and ignores the unique pharmacology of the medication.
Highly-regulated clinics dispense methadone for addiction treatment., and other physicians prescribe methadone for chronic pain.  Menzies claims ‘it is an axiom of medicine that drugs with an addiction potential are inappropriate for the treatment of chronic conditions.’  For that reason, he claims, methadone treatment is ‘out of the ambit of mainstream medicine.’ The 250,000-plus US patients who benefit from methadone treatment would be amused by his reasoning.    I suspect that the thousands of patients who experience a lifetime of chronic pain—including veterans with crushed spines and traumatic amputations—would likely NOT be amused by his suggestion that ‘opioids… were never intended to be prescribed forever.’   Those of us who treat chronic pain take our patients as they come—often with addictions and other psychiatric baggage.  Pain doesn’t stop from the presence of addiction, neither does the right for some measure of relief from that pain.
Menzies cites the old stories about Vietnam veterans who returned to the US and gave up heroin, as evidence that prolonged treatment for opioid dependence is unnecessary for current addicts.   But there is no similarity between the two samples in his comparison!  US Servicemen forced into a jungle to engage in lethal combat use heroin for different reasons than do teenagers attending high school.   Beyond the different reasons for using, after returning home, soldiers associated heroin with danger and death!  Of course they were able to stop using!  And that has to do with current addicts… how?
Teens in the US have no mainland to take them back.  Their addiction began in their parents’ basement, and without valid treatment, too often ends in the same place.
Menzies refers to buprenorphine treatment as ‘a conundrum’ that has not had any effect on deaths from opioid dependence—a claim impossible to support without an alternative universe and a time machine.  He claims that buprenorphine treatment is unsafe and plagued by diversion.  In reality, most ‘diversion’ consists of self-treatment by addicts who are unable to find a physician able to take new patients under the Federal cap.  In the worst cases, some addicts keep a tablet of buprenorphine in their pockets to prevent the worst of the withdrawal symptoms if heroin is not available.  But even in these cases, buprenorphine inadvertently treats addicts who take the medication, preventing euphoria from heroin for up to several days and more importantly, preventing death from overdose.
Just look at the numbers.  In the past ten years, about 35,000 people have died from overdose each year in the US with no buprenorphine in their bloodstream.  How many people died WITH buprenorphine in their bloodstream?  About 40.  Even in those cases, buprenorphine was almost never the cause of death.  In fact, in many of those 40 cases, the person’s life would have been saved if MORE buprenorphine had been in the bloodstream because buprenorphine blocks the respiratory depression caused by opioid agonists.
Naltrexone is a pure opioid blocker that some favor for addiction treatment because it has no abuse potential.  Naltrexone compliance is very low when the medication is not injected, and naltrexone injections cost well over $1000 per month.   Naltrexone may have some utility in the case of drug courts, where monthly injections are a required condition of probation.  But even in those circumstances, the success of naltrexone likely benefits the most from another fact about the drug, i.e. that the deaths from naltrexone treatment are hidden on the back end.  Fans of naltrexone focus, optimistically, on its ability to block heroin up to a certain dose, up to a certain length of time after taking the medication.  But Australian studies of naltrexone show death rates ten times higher than with methadone when the drug is discontinued, when patients have been discharged from treatment, and short-term treatment professionals have shifted their attention to the next group of desperate but misguided patients.
The physicians who treat addiction with buprenorphine, on the other hand, follow their patients long term because they see, first-hand, the long-term nature of addiction.  Menzies’ claim that ‘the longer you take it, the harder it is to stop’ has no basis in the science of buprenorphine, or in clinical practice.  Patients often get to a point—after several years—when they are ready to discontinue buprenorphine.  And while buprenorphine has discontinuation symptoms, the severity of those symptoms is less than stopping agonists—and unrelated to the duration of taking buprenorphine.   Until that point in time, buprenorphine effectively interrupts the natural progression of the addiction to misery and death.
The physicians who prescribe buprenorphine and the practitioners at methadone clinics are the only addiction professionals who witness the true, long-term nature of opioid dependence. In contrast, too many addiction practitioners see only the front end of addiction, discharging patients after weeks or months, considering them ‘cured’…  and somehow missing the familiar names in the obituary columns months or years later.

Media Bias Against Suboxone

First Posted 2.8.2014
After Philip Seymour Hoffman’s death, I anticipated a flood of articles describing the ineffectiveness of non-medication treatments for opioid dependence.  I assumed the media would finally report on the need for long-term treatment of a long-term illness.  Instead we read more articles describing Suboxone (i.e. buprenorphine) as a ‘bad drug’, since Hoffman may have used the drug to reduce withdrawal between heroin binges.
Taking buprenorphine within a few days of using heroin blocks most of heroin’s effects and makes overdose much less likely– a fact rarely reported.  Out of about 400,000 overdose deaths over the past ten years, only 400 deaths included buprenorphine as one drug in the fatal mix– a stunning statistic that calls out for more life-sustaining buprenorphine treatment, not less.  In most of those cases, death would not occurred had there been more buprenorphine in the victim’s bloodstream.
Vivitrol is the brand name for a monthly, injectable form of naltrexone that appeals to a superficial approach to opioid dependence.  Naltrexone advocates focus on the months of abstinence when patients are taking the medication, often during forced compliance mandated by drug courts. Rarely questioned is the long-term effectiveness (or lack thereof) of naltrexone for reducing the morbidity and mortality of opioid dependence.
The uncritical acceptance of naltrexone by some prescribers begs some important questions.  If short-term use of a treatment causes an increase in long-term mortality, is the treatment ethical?  If patients mandated to receive a course of treatment only relapse and reoffend a year later, is the treatment an efficient use of resources?
Naltrexone appeals to the same people who push abstinence programs that have long-term success rates well below 10%.  Current abstinence treatments often center around programs developed in the 1920′s, that ignore the advances in our understanding of neuroscience and addiction since that era.  Abstinence programs blame failures on patients rather than recognizing failed treatment approaches. The case of Philip Seymour Hoffman should call out for a new paradigm, where patients are treated with medication that works and continues to work over the years of a person’s life.
Naltrexone is a ‘blocker’—a great thing for the anti-drug attitudes in all of us.  But does it matter that people treated with naltrexone die from overdose at a rate 7-fold higher than people on methadone?   Proponents of naltrexone ignore the long-term nature of opioid dependence.  And whether naltrexone is administered by shot or by tablet, patients inevitably stop taking it.  The ‘naltrexone paradigm’ calls for only 6-12 months on the medication, and many patients drop out even sooner, when their probation ends.
Many patients learn from the internet or elsewhere that naltrexone increases their sensitivity to heroin, a ‘reverse tolerance’ effect that makes relapse impossible to resist. The same hypersensitivity causes greater risk of death, making ‘one last time’ a self-fulfilling prophecy.
On the other hand, headlines that decry ‘abuse of buprenorphine’ greatly exceed true harm from buprenorphine. Most buprenorphine abuse consists of self-treatment by addicts who have no access to the medication, because of limits on patient enrollment and regulations that discourage physicians from prescribing the medication.   ‘Abuse’ of buprenorphine is far more likely to prevent overdose than to cause harm.  Even one dose of 8 mg buprenorphine prevents death for several days by blocking opioid receptors.
Given the safety of buprenorphine, it is hard to justify the use of temporizing measures or ineffective step treatments.  Addiction deserves proper medical treatment—not superficial approaches that delay death for a year or so.

How and When to Stop Buprenorphine or Suboxone

First Posted 12/15/2013
People know my bias—that buprenorphine is best-considered a chronic, perhaps life-long treatment for a chronic, life-long disease.  That said, I am aware of how many people out there are convinced that they need to be ‘off everything,’ no matter the misery opioids have caused in their lives.  I don’t get it; my perspective over the years has been seeing obituaries of patients who were doing great on buprenorphine or Suboxone for years, until well-intentioned relatives convinced them that they weren’t really clean.
But I’ve written all of this before.  For those of you who are still intent on stopping buprenorphine, I’ll share my observations after watching hundreds of people stop the medication—some intentionally, and some before going back to H for some crazy reason.
First off—there is NO truth to the idea that ‘the longer you take it, the harder it is to stop.’  The idiots who peddle that line are the same people who are on and off buprenorphine, or perhaps who have run out of doctors willing to see them and now hoping that company will join their misery.   The opposite is true.  The patients who have done the best are the people who stayed on buprenorphine or Suboxone for at least 2-3 years, and came to a point where they just knew it was time to stop.  The ones that have done well—stayed clean—are the ones who made gains during their time on buprenorphine.  They got educated.  They got promoted.  They started families in a responsible manner (i.e fell in love first, and then had the family).
I’ve seen so many people stop Suboxone after 3 months, 8 months, or a year—and what I’ve seen mirrors the studies that show 90% relapse rates within one year of stopping buprenorphine.
I’ve developed a set of indicators that are associated with maintaining abstinence after buprenorphine.  In very-rough order of importance, they are:

  1. Taking buprenorphine once per day or at MOST twice per day, not in response to depression, fatigue, emptiness, insomnia, or urge, but completely ‘by the clock’—as they would take blood pressure medication.
  2. Having month after month with no extra calls reporting lost or stolen buprenorphine, having no ‘very bad weeks where everything went wrong that forced them to take a little extra’.
  3. No use of intoxicants, especially for treating mood or anxiety—i.e. the ability to live ‘life on life’s terms.’
  4. Age over 30.  Not sure why—but I have my theories.  Age brings wisdom, persistence of intent, insight into emotions, and the realization that life is temporary and precious.
  5. No history of depression or anxiety.  Not always controllable, unfortunately.
  6. Stable job, stable finances, and stable relationship, and preferably one or two hobbies.
  7. Complete loss of using contacts, and NO immediate access to opioids (no spouse on pain pills or Xanax;  no dealer calling every few days).
  8. Absence of a chronic pain condition- or acceptance that one will have to tolerate one’s pain.
  9. Being on a regular exercise schedule.
  10. The recognition that opioids kicked the snot out of them, multiple times—and a strong fear of relapse.

People who lack one or more of these items should strongly re-evaluate a decision to stop buprenorphine.  There are other factors—but it is late, so cut me some slack.
When someone wants to stop taking buprenorphine and I’ve educated that person about the numbers and risks, my next step is to ask the person to cut from 16 mg of buprenorphine (if on that much) to 8 mg.  That change done correctly will cause no physical withdrawal, but creates enough mental pressure to separate those who are ready from those who are not.
Remember at this point that all of these things are used in my own practice;  they are not intended to direct people who are not my patients, but rather to stimulate discussion with your OWN doctor(!)
 
The method I usually recommend is for the person to go to twice per day dosing—8 mg AM and 8 mg PM, and then change to 8 mg AM and 6 mg PM for two weeks, then to 6 mg/6 mg for two weeks, then 6 mg/4 mg for two weeks, then 4mg/4 mg.  If the person can do that without any problems, I am willing to help with the taper.
I usually have patients to make small reductions at their own pace every few weeks.  The goal is to move slowly; one common misstep is to make a reduction before arriving at a stable blood level from the last reduction.  A dose should be maintained for at least a couple weeks before dropping lower.
Most people benefit from more-frequent dosing during tapering, since the effective half-life of buprenorphine is shortened when blood levels drop below the ‘ceiling level.’  I’ve had some patients claim to do better dosing 3 times per day during tapers. My only concern about dosing that frequently is the risk of returning to conditioned addictive behavior. I suppose the other issue is that more-frequent dosing requires smaller doses, that are more difficult to keep consistent.  The 2 mg film is very helpful for tapering at lower levels, can with a razor or hobby-knife.
Patients on buprenorphine for pain treatment can avoid violating the Hamilton Act and progress down a series of Butrans patches—a process that is technically illegal for non-pain patients.    The biggest patch releases about 0.5 mg of buprenorphine per day, which seems like a big step from 2 mg of oral buprenorphine until you remember that only 30% of an oral dose is absorbed.  So 2 mg of oral buprenorphine yields about 0.7 mg of buprenorphine in the bloodstream—close to the amount delivered by the largest Butrans patch.
It is illegal to taper opioid addicts using Butrans, according to the Harrison Act.  I realize that the situation is not fair… but sometimes Presidents create laws, even put their names on them, thinking the law is a good idea… and then the future ends up showing what a bad, bad idea the law was. Just speaking of Harrison, of course…
When patients fail a taper by using opioid agonists or returning to a higher dose of buprenorphine, I suggest they go back to a comfortable dose, and try again in a year.  The hardest part of tapering is mental, but the physical symptoms are nothing to sneeze at.  When tapered slowly, the physical withdrawal from buprenorphine isn’t all that much worse than having a bad cold.  The goal is to stay in the game, hour after hour (after hour).
I recently met with a patient who stopped ‘cold turkey’ from 16 mg, who shared his experience in detail.  He worked every day in a factory job, and managed to stay at work throughout the entire process. He swore by the 5-hr energy drinks, and said that they kept him working on the worst of days.  His symptoms peaked at 11 days, and at 3 months he felt fully recovered.  He carried pictures of his kids, and looked at them every time he felt a hot flash or was stuck on the commode.
I believe that he will do well because he knows that addiction is truly cunning, baffling, and powerful, and understands that he must always be alert for some crazy, cocky idea to enter his thought process.   One interesting thing in this particular patient was that the entire time he went through withdrawal, he never experienced cravings.  He had been on buprenorphine for a number of years, and just felt ‘done.’
Finally… most of us were brought to addiction by our best ideas.  Sobriety requires CHANGE, and change is not comfortable or pleasant.  Nobody wants to attend his/her first meeting.  And everyone who loves meetings has many, many days when meetings are the last thing they want to do… but they go anyway.  THAT is what change is all about.

Treating Opioid Dependence Harder in Young People

Originally Posted 5/11/2013
The forces of nature appear intent on reversing mankind’s progress toward better health.   An example is the ever-increasing resistance of bacteria to antibiotics.  A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans.  In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.
Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’  Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases.  There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.
Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts.  The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic.  As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people.  We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools.  Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.
Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness.  I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!)  Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected to emerge– and have emerged.
As a medical student I learned about ‘non-A non-B hepatitis’, a small concern at the time that has since grown into the identity of ‘Hep C’ (Funny how long it took to come up with THAT name!)   Hepatitis C is a major public health threat, since routine vaccinations for hepatitis B and the surge in IV drug use.
Not all diseases are from non-human entities.   Cancers, for example, arise from errors in our own DNA, either inherited or acquired.  Cures have been found for a few cancers, but like bacteria, cancers have emerged that are resistant to current chemotherapeutic drugs, requiring a constant search for new agents.
Some illnesses are considered ‘lifestyle diseases’ because they are  related to obesity, smoking, pollution, substance use, inactivity, or poor diet— such as hypertension, heart disease, diabetes, cerebrovascular disease, asthma, and COPD.  The model of resistance show by bacteria doesn’t fit in the same way, but many of these illnesses draw public attention as ‘epidemics’ that demand resources, with apathy or cultural phenomena function acting as resistance to those efforts.
Bear with me;  I’m working up to something that I’ve alluded to before.  My point is that like with other illnesses, addiction doesn’t respond to medications– Suboxone and buprenorphine — quite the way it used to.
When Suboxone hit the US market in 2003, large numbers of opioid addicts were scattered across the country, sick and tired of their dependence on opioids.  Heroin was considered a ‘bad drug’ back then even by those with severe addictions, and was rarely encountered by teens and young adults.  Most opioid addicts used hydrocodone or oxycodone, prescribed by doctors or obtained from people with prescriptions.  Heroin was marginalized to those with the most-severe addictions, or used sporadically in combination with other drugs (e.g. speedballing).  Known doses of oxycodone were comparatively safer than heroin, which is stepped on to varying amounts and sometimes laced with deadly fentanyl.  Oxycodone was absorbed through mucous membranes more quickly than heroin, meaning lower motivation to use needles.  So in the early 2000’s, some people addicted to opioids found a way to get by, albeit in state of chronic misery and loneliness after spouses and friends moved away.
Enter Suboxone– a new medication to treat opioid dependence.  Suboxone carried some controversy, as some in the non-medication treatment lobby did their best to tarnish the medication (as in ‘you’re not as clean as I am!).   But despite the tarnish, Suboxone and buprenorphine were medications that were to be prescribed by doctors.  People who for years kept the same horrible secret were given an option that actually worked.  People returning to my office for follow-up had tears of happiness on their faces;  they thought they would never be free from their afflictions, and were grateful as Hell for a chance to return to the living.
Many of those patients have done well for years, in treatment in my practice and others.  Many are still on buprenorphine and grateful to be on buprenorphine, as happy and productive as they’ve ever been in life, with no desire to change.
But then, just as some of us were becoming optimistic about this great new medication, the disease of addiction changed in the direction that all diseases change– for the worse.  The substrate changed; oxycodone was largely removed from the market through well-intentioned anti-diversion efforts that made Oxycontin harder to abuse…  just as the US experienced a large influx of cheap heroin.  And as in the 1960′s, heroin brought out needles– something that many opioid addicts used to take pride in for not considering.
And Suboxone changed.   People on buprenorphine or Suboxone sometimes shared a bit of their medication with friends going through dry spells. Some people on Suboxone or buprenorphine sold portions of their prescriptions.   The image of Suboxone held by active heroin addicts changed from doctor’s medication to a self-directed treatment for withdrawal.  In fact, the perceived roles of patient vs. treatment provider became blurred by needle exchange programs and programs that provide addicts with syringes loaded with naloxone.   Against a confusing backdrop of publicly-provided needles, free syringes pre-loaded with naloxone, and expensive brand film vs. affordable generic buprenorphine, the image of Suboxone turned from orange to gray.
I don’t mean to criticize the well-intentioned efforts to save lives, such as the distribution of naloxone in areas where overdoses have become epidemic.   It’s hard to predict unintended consequences.  But now, new patients consist of 18-y-o heroin addicts who see Suboxone as a tool to provide cover for a few days, when the heroin supply runs dry.  Some see Suboxone as a tool to detox, although the detoxes never accomplish anything at all—the ultimate bridge to nowhere.  The bottom line is that after seeing a few Suboxone tablets ground up, dissolved, cooked, and injected, the medication loses a bit of luster.
And finally, patients themselves have changed.  Opioid addicts in 2013 are often acutely ill from unknown doses, toxic fillers, and dirty needles, presenting to ER’s with antecubital abscesses and hepatitis C.  And despite being very, very sick, many haven’t had enough time to get sick and TIRED.   Being started on Suboxone is less of a bit deal because they’ve BEEN on Suboxone— little chips of it, over and over and over, whenever the heroin ran out.
Gone are the easy buprenorphine patients.  Now we have young, fresh, sick addicts who won’t live long enough to hate their addictions.  Addiction as a disease has adapted to our treatment efforts, and become stronger– and deadlier.  Our side had better keep up the hard work.

Should Addiction Treatment Include 'Shame'?

Originally Posted 3/23/2013
I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.
Is All Shame Bad?
My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin.  Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.
I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication.  As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap.  They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.
But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment.  I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges.  To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences.  Maybe they haven’t suffered enough consequences.   But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.
I always consider each new patient’s history of ‘consequences’.  I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with opioid dependence.  I note that consequences impact people similarly in some ways, and differently in other ways.  For example, most people have trouble imagining just how bad things are likely to become until they actually get to that degree of severity.  People who’ve never used a needle believe they will never do so, and people who haven’t been arrested can’t see themselves in that position.
But once consequences occur, people react to them in widely different ways.  Some people react to felony charges with horror, while others appear indifferent.    A near overdose might cause warning bells to go off in one person, yet cause little reaction in someone else. One person will be ashamed and humiliated the first time in jail, while another seems to simply adapt, as consequences move from bad to worse.
Are ‘consequences’ the missing piece of the puzzle for patients who don’t do well on buprenorphine?  If so, are the differing reactions that people have to consequences clues to helping poor responders? Should counseling efforts target for elimination those attitudes of ambivalence or indifference toward negative consequences?
In general, shame is viewed as a hindrance toward recovery.  The cycle of shame is well-known by everyone who treats addiction; the idea that ‘shame’ serves as a trigger of using, which in turn generates more shame, and so on.  But when I see a 20-y-o patient who is addicted to heroin shrug off another relapse, I wonder if in some people, a little shame would be a good thing.
Some comments from readers of the original post:

  1. Lg

Interesting article and noteworthy to me in the sense of shame being a big motivator. Mostly I think is the personal shame I feel for having let opioids kick my arse. In my case the amount of guilt/shame is unbelievable. I’ve been around the block many times and really don’t think I have another one in me. I hope and pray these younger guys get and stay with the program. The other choice just might be the last one they ever make. BTW C&S 5yrs

  1. devin91

Jeff, I think a little shame is probably a good thing. William Moyers (one of the guys running Hazelden and coincidentally Bill Moyers’ son) addresses the issue of shame head-on in his book “Broken” about his own battle with cocaine addiction (which, unfortunately, there is no medicinal treatment currently available for). His view, as I remember from reading the book, is that shame is an intensely emotional recognition of consequences, and one’s responsibility for those consequences. Obviously, too much of it can be bad – as you note. But a measured amount of shame is probably the appropriate response to a negative consequence or relapse.
On an another note, I think your observation about a positive correlation between age and response to buprenorphine is very interesting. However, it also highlights the fact that the opioid epidemic afflicts younger demographic groups with greater severity (by almost all measures) and in greater numbers than it does older age groups. Opioid addiction is growing faster among younger patients, and (according to SAMHSA data) female patients, and it is also killing them faster. Older patients therefore, *may* be statistical confounders, in the sense that they have already survived a lethal illness for longer. In other words, there may be some additional factors that make older patients “better responders” to buprenorphine, and to recovery in general. They are “better patients” overall, perhaps?
I agree that patients who don’t seem to acknowledge or care too much about “consequences” are extremely frustrating. But I think this phenomenon begs the question of WHY patients suffering from addiction seem to ignore consequences in general. In fact, the disease of addiction often seems to be the disease of IRRATIONALITY – taking actions against one’s own interest. It is my hope that medications like buprenorphine can give these younger patients a break from the cycle of relapse/shame/relapse, and give them time to develop a RATIONAL perspective about consequences. But I agree that a patient who blithely shrugs off a relapse IS FRUSTRATING, and perhaps IS a little bit “blameworthy”. But I hesitate to tread down that path of thinking, because then you come full circle to blaming the patient for their disease.
As the opioid epidemic continues to rage in the US and across the globe, I would rather see “shameless” patients ALIVE (to have a chance at developing an appropriate sense of consequences and shame) than see a trend towards the view that patients who don’t develop a rational perspective are somehow less deserving of treatment. In short, I’m hoping that your clinical frustration with these patients will not dim your passion for saving the lives of opioid-addicted patients, ESPECIALLY THE YOUNGER ONES. Yes, a little shame would be good, but I don’t find it terribly surprising that the younger cohorts have less shame, more “resilience”, more “arrogance”, and are harder to treat as patients. But that doesn’t change the fact that the opioid addiction epidemic is killing FAR MORE OF THEM than it is older patients.
This comment should not be taken in any way as a detraction from your commendable work, both at the clinical level and the policy level (e.g. lifting the caps, etc.). I’m just musing on these issues, and thinking out loud here.

A Save with Suboxone?

I’d like to share a recent email exchange with a reader. The post is long, but there are several interesting aspects to the discussion. I’ve removed the conversational parts, as well as the identifying information.
The initial message:
I was an intravenous heroin user for three years. After treatment I was able to stay clean for 6 months… Well apparently to most people I was not clean because I was on Suboxone, but to me I was clean. People are so very discouraging when you tell them you’re clean and they find out you are on Suboxone. It hurts because of how much hard work you put in. I did well for six months, but then I relapsed and used for 5 days. After a short binge I again stopped, continued Suboxone and used once more for one day alone.
All of these relapses were with my girlfriend, and she used one extra time while I was working. She overdosed all three times she used. Her mother found her the second time in her room almost lifeless, and I was with her the other two times. I acted very quickly, giving her CPR immediately and calling 911 without the least bit of hesitation, as did her mother.
My girlfriend) is not on Suboxone, but I stayed on every day other than the times we used. I am pretty educated about opiates in general and I understand that she overdosed because of her lack of tolerance. I have read something you said before: A person on Suboxone maintenance has the tolerance of someone who takes 100mg of oxycodone a day. I need to know, for the sake of her life, my life or someone else’s life, if ever in a dire, life threatening situation and for some crazy reason 911 isn’t an option, could you melt down a Suboxone strip and inject the overdosed person and use it like Narcan if you absolutely had to? Or do you think I’m nuts for even asking?
One more topic… I obsess over heroin every day. It’s so bad that I sit with a calculator and tell myself, “alright, if I stay clean for these next two years and I finish my degree and start my career making this much salary then I can spend this much a day on heroin and it will total x amount of dollars a year and subtracted from my salary I will still have more than enough to survive.” How sick is that? It’s disgusting. It’s an absolute obsession of the mind. I seriously convince myself that with the right amount of steady income I could actually be a functioning addict.
Thank you so much for your time. I appreciate it so much.
My Reply:
Your email shows the incredible danger associated with use of intravenous opioids. I remember how impressed I was, when I was a resident in anesthesiology, over how the human body is SO strong and restorative, that we can survive and recover from horrible injuries… yet how fragile we are, that a lack of oxygen for only several minutes can cause death. Injecting opioids is a very effective, targeted way to kill a person. Doctors and nurses do not inject narcotics unless the patient is being monitored, usually using a ‘pulse oximeter’ to monitor the level of oxygen in the blood. Yet people with far less training are injecting the same drugs, not only without monitoring, but even in the absence of a non-impaired observer. It is no wonder that there are so many deaths from opioid dependence.
You probably know how I feel about being ‘clean’; people on buprenorphine are clean enough, in my opinion, to be considered sober. People on buprenorphine become fully tolerant to the effects at the mu receptor; there might be very minor effects at the kappa receptor, that may or may not have very minor cognitive effects…. but people take chronic medications for MANY illnesses, and some degree of sedation occurs with most of them, including medications for high blood pressure, migraine headaches, and seizure disorders. Should we consider all of THOSE people to be ‘not really clean’ too?
The question about using Suboxone to reverse overdose is very interesting– and shows that you have a good understanding of what is going on with medications like buprenorphine (in Suboxone).
One of my patients has described how he saved his girlfriend’s life by injecting Suboxone. He says that she was unresponsive and barely breathing, and out of desperation he put an 8 mg tablet of Suboxone in her mouth. When she didn’t respond after a minute or two, he quickly dissolved a tablet of Suboxone and injected it into her arm. He claims that she woke up 30 seconds later.
I’m glad his girlfriend survived, but I do NOT recommend that anyone rely on this approach to save a life. The most appropriate action, of course, is to do whatever one can to find appropriate treatment, and stop accepting the huge risks associated with IV injection of opioids. If a person has overdosed, call 911 immediately. The brain starts to die in about 3 minutes. Some parts of the country have instituted programs that provide naloxone injection kits for people addicted to opioids; injecting a pure antagonist like naloxone (Narcan) is much safer than injecting the partial agonist, buprenorphine.
The outcome after injecting Suboxone depends on a number of factors, including the person’s tolerance level and the presence or absence of other respiratory depressants. If a person has only used opioids– no benzodiazepines or barbiturates or alcohol— then in theory, injecting Suboxone would rescue the person from overdose. Both parts of the medication would contribute to reversing the effects of opioids; the naloxone (to a small extent) and the buprenorphine, which would have most of the effect. The ceiling effect of buprenorphine should prevent respiratory arrest in any person, as long as no other respiratory depressants are around.
But– one CANNOT expect the ceiling effect’s protection in the presence of other respiratory depressants. If other depressants are present, opioid tolerance becomes a big issue. I’ll describe two cases to demonstrate:
– Let’s take the low-tolerance scenario, with a person who has never used opioids or benzodiazepines, who ‘sniffs’ 40 mg of oxycodone and 10 mg of alprazolam. The risk of overdose would be high in that situation. And if, during overdose, someone injected Suboxone, the opioid effects of buprenorphine would be as great, or greater, than the opioid effects of oxycodone— so the person’s condition would likely worsen. (Note that I’m ignoring the effects of naloxone. Naloxone’s clinical effect last only about 20 minutes. That effect might help the person in this scenario, but it is hard to predict whether the naloxone would out-compete the buprenorphine that is also being injected. People who have injected Suboxone in the past tell me that they found are no difference between injecting Suboxone vs. injecting plain buprenorphine. That wouldn’t surprise me, given the high-affinity binding properties of buprenorphine.
– For the high-tolerance case, let’s take someone who is using 150 mg of oxycodone per day, but on this occasion took an amount of heroin equal to 300 mg of oxycodone. Let’s assume that there are no other depressants on board. In this case, injecting buprenorphine would be expected, theoretically, to block the effects of heroin, and not only wake the person, but precipitate withdrawal. Even if other respiratory depressants are on board, the buprenorphine would likely save the person from overdose, because the opioid effects of buprenorphine are significantly BELOW the person’s tolerance level, and below the effects of the heroin that is causing overdose.
Essentially, the high-affinity binding of buprenorphine displaces other opioids, causing an opioid effect equivalent to 60-100 mg of oxycodone. If the person’s tolerance is higher than that, the result will be precipitated withdrawal. If tolerance is lower, the result will be greater opioid intoxication.
I will stress, again, that the thing to do in case of overdose is to call 911. An even better thing to do would be to get help for anyone you know who is injecting heroin, and get help NOW—as the risks of IV drug use are very high, and nobody believes that he/she will be the next person to die. If you are in a situation where someone else is overdosing, and you inject that person with Suboxone or any other substance other than Narcan, you will likely be prosecuted, and convicted, for manslaughter.
The obsession described in your message is typical, and is the hallmark of opioid dependence. In my opinion, we (psychiatrists) should see ‘obsession’ as the primary defect in cases of addiction, as obsession is what destroys personality, undermines self-esteem, and crowds out other interests and interpersonal relationships. As I’ve written before, buprenorphine’s unique properties allow it to reduce or eliminate the obsession for opioids. Buprenorphine, I believe, is an effective, targeted way to treat opioid dependence.
His message back:
Being a psychiatrist, what are your thoughts on that obsessive thinking? I hate meetings and the 12-step programs. I lived in a half-way house for a month and a half that required 3 meetings per day. I agree with you that they create a fabricated sense of happiness and self-worth. Do you recommend staying on Suboxone for an extended period, especially during a time where i am still having these thoughts? And because of the way I feel toward meetings should I seek a psychiatrist and try to explain my thought process in order to try and change it? What would you recommend to someone in my situation who obsesses to that degree, and hypothetically plans his future around heroin?
Me Again:
I have seen SO many people who stopped Suboxone, then relapsed years later and lost a great deal. I’ve seen obituaries of former patients who used to be on Suboxone. If a person can take the medication without too much hassle— i.e. has a doctor who allows ‘remission treatment’ without making the person feel like a second-class citizen– then long-term Suboxone provides for the best chance of doing well in life, in my opinion.
Other than buprenorphine, the best ‘treatment’ for the obsession, in my opinion, is fear. Step programs tap into that fear, by emphasizing powerlessness— the realization that using even one time will definitely, without a doubt, lead to your destruction. Every thought about using should be confronted with that reality— that if you use, you will die. Relapse often starts with the idea that maybe the person can get away with it, maybe just once… so to stay sober, the person must KNOW that there is no way to try it, even once. That is a bummer, but not the end of the world! Humans love to feel powerful, but attendance at meetings helps reinforce the reality, and the value, of powerlessness. I’ve written about my own experiences back in 1993, when the realization of my powerlessness caused my desire to use to suddenly disappear. If only I could have remembered that powerlessness, even as my life got better!
I do not think that psychotherapy is all that helpful for obsessions. In fact, I think that psychotherapy can be dangerous, if it leads to the thought that you have everything figured out— a thought that the addicted personality loves to run with!
The challenge when treating with buprenorphine is to instill and reinforce the knowledge of powerlessness, even while treating the obsession for opioids with a highly-effective medication. The thought process becomes a little more complicated, but not impossible to grasp.