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.

Tough Choice

I have been struggling with part II, primarily because there are no easy answers to the situation. I realize that I could easily criticize whichever path a doctor suggests for our imaginary patient.
As an aside, I believe that a major reason for the lack of sufficient prescribers of buprenorphine in some parts of the country is the ‘damned if I do, or damned if I don’t’ scenario. All docs are aware of the current epidemic of opioid overdose deaths, and I think most doctors assume that tighter regulations on opioids are appropriate, and are just around the corner. Some addiction physicians and some pain physicians, particularly those who prescribe opioids, fear being grouped by the media, DEA, or a licensing board as part of the problem, rather than as part of the solution. I recently read of a doctor charged with manslaughter for being one of several prescribers for a person who died from opioid overdose. He prescribed meperidine—and outdated and toxic medication—which likely contributed to the charges… but the story creates a chilling atmosphere, regardless. Suboxone and buprenorphine are much safer medications, but when the target population consists of people with addictions to opioids, there will always be some people who use the medication inappropriately— some with disastrous results.
For those late to the party, we are discussing the best treatment approach for someone who cannot control using opioids, but who for now, at least, has a low opioid tolerance. Starting buprenorphine in such a patient will cause opioid side effects, as described in an email that I received from a woman who was addicted to hydrocodone for four years, who stopped taking hydrocodone for 7 days before induction with buprenorphine.
She wrote:
This Suboxone is making me feel like crap. He has me on 8mg/2mg sublingual 2/day. It’s awful…
She had been taking 20-30 mg of hydrocodone up to 5 times per day, stopping them a week before induction. She continued:
Have had a headache in the base of my skull since starting Sub 4 days ago, nausea, vomiting, sweating a lot, face feels like it’s on fire, can’t taste anything, throat hurts, can’t sleep because my face & eyes itch so bad that I’ve rubbed them raw.
These are classic side-effects of over-narcotization from buprenorphine. A person in this position typically feels better holding the buprenorphine, and when the nausea is eventually gone, taking a greatly reduced dose of the medication. The problem is that if the dose is too low, there is no advantage to buprenorphine over other opioids. The whole point of taking Suboxone is to stay on a blood level HIGHER than the ceiling effect, as that essentially tricks the brain, since the opioid effect stays constant even as the blood level falls.
In a few days, the writer’s tolerance will increase to a level where she can take an entire dose of Suboxone without nausea. And by that time, the medication will greatly reduce the desire to take opioids.
Will she be better off on buprenorphine or Suboxone than she was on hydrocodone? Her tolerance will be higher—meaning greater physical withdrawal if she stops the buprenorphine, than she would have had stopping the hydrocodone.
But on the other hand, she tried to stop taking hydrocodone for several years, and couldn’t. She was taking over 4 grams of acetaminophen per day— the other medication present in Norco besides hydrocodone— which is enough to cause death through liver toxicity. And the ups and downs of hydrocodone addiction create a living Hell that eventually demoralizes the person.
I hear from writers who are angry at their physician for getting them ‘stuck on Suboxone’, saying they should have simply tapered off the hydrocodone instead. My answer is that it is easier to SAY ‘I would have tapered of hydrocodone’ than it is to actually taper and stay off hydrocodone!
A doctor seeing the patient I wrote about in part one, or the person above, would face two options:
1. Cause an incidental ‘high’ by administering buprenorphine, and titrating the dose up to a level that eliminates cravings, or:
2. Use an alternate treatment strategy.
Some doctors would opt for the latter, saying they are not comfortable with deliberately intoxicating patients with opioids—something that is unavoidable when starting a low-tolerance patient on buprenorphine (or Suboxone; note that the naloxone component of the medication is irrelevant to this discussion, as it has no action unless injected).
In such cases people are often referred to step-based or other residential treatment centers. I’ve written some pessimistic opinions about those places, but I’m just trying to be accurate. I realize that there are many people dedicating their lives to treating people with addictions in such places—ranging from free, community-supported programs to $80,000 per month luxury rehabs. As dedicated as those people are, the success rate of such programs remains low, and the risk of fatal overdose is present upon discharge. Most people who have gone through residential treatment relapse. And many people have been through rehab multiple times, yet continue to struggle.
Vivitrol, a monthly, injectable form of naltrexone, has been marketed to fill in this space, as a protection against relapse after residential treatment or after several weeks of detox. But for whatever reason, most people opt to forgo that medication, instead placing misguided faith in their own ability to stay clean. So what usually happens is that people with a lower tolerance to opioids repeatedly go through detox, or repeatedly pay for residential treatment, only to return to using opioids. Tolerance increases over time and eventually they present with a tolerance level where Suboxone seems more appropriate.
Assuming, of course, they live that long.

Weezer Ex-Bassist Dies, Suspected Overdose

Written by Daniel Gordon at ThirdAge.com:
Former Weezer bassist Mikey Welsh was found dead in a Chicago hotel room Saturday afternoon, the Chicago Tribune reports.
Raffaello Hotel staff reportedly found the 40-year-old ex-musician on the floor of his room around 1 p.m. Saturday. The Chicago Tribune reported that narcotics are the suspected cause of death.
Chicago Police News Affairs Officer Laura Kubiak told reporters that police are currently conducting a death investigation. An autopsy was scheduled for Sunday, according to the Tribune.

Weezer Former Bassist Mikey Welsh
Weezer Former Bassist Mikey Welsh

Welsh performed with Weezer from 1998-2001. According to Weezer’s Website, he left the band after having a nervous breakdown and reinvented himself as a painter.
In 2002, shortly after leaving Weezer, he told the MetroWest Daily News that he felt the need to move on from music, adding that he was much happier as a painter.
“Music is still an important part of my life, but I really have no desire to actually play it,” he told the Daily News.
A tribute to Welsh on the band’s Website says, “It saddens me and the guys in Weezer so much to say that our beautiful, creative, hilarious and sweet friend Mikey Welsh has passed away at the very young age of 40. A unique talent, a deeply loving friend and father, and a great artist is gone, but we will never forget him. His chapter in the Weezer story (’98 – ’01)
was vital, essential, wild, and amazing.”
Current Weezer bassist Scott Shriner posted a note on his Twitter account saying, “Really bummed about Mikey. My heart goes out to his family and friends. Such a talent… he made a special mark on the world with his art.”
Weezer is playing at the Chicago Riot Fest Sunday, a show Welsh was expected to attend.
The post on Weezer’s site ends by saying, “Mikey was planning on attending this show and we were looking forward to seeing him again. As sad as it is to think about, we know Mikey would never want the rock stopped on his account – quite the contrary in fact. While we wont see him, we know he will be there rocking out with us!”

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!

Narcissism, Celebrity Rehab, and Another Overdose Death

On May 27th, 2011, actor Jeff Conaway died from complications of opioid dependence. His death has been attributed to several causes—sepsis, pneumonia, and aspiration among them— but there is little debate over the ultimate cause of his death at the age of 60 years, that being addiction to opioid pain medications.
Mr. Conaway reportedly struggled with chronic pain and addiction to pain medications for a number of years. His situation was particularly tragic—living with severe pain that was relieved by nothing save for a substance with the power to destroy him. Such situations are, unfortunately, not uncommon.
It is easy to take the position that Mr. Conaway should have avoided pain pills; that his addiction essentially disqualified him from even considering them. I will take that attitude myself from time to time, after a series of appointments with patients who are clearly worsening their situation by using opioids for pain that appears ‘tolerable.’ But about the time I start to become confident in my position, I always seem to develop a painful condition of my own—minor sciatica, plantar fasciitis, or lumbar strain, far less severe than the condition of the patients who I have decided should ‘tolerate’ their pain. Whenever that happens I realize, very quickly, something that I had forgotten– pain hurts! Funny how easy it is to ‘tolerate’ pain that is being experienced by someone else!
Most studies that follow patients with chronic pain over periods of years show that people are more ‘functional’ if they never use opioids for chronic pain. But there is considerable debate among the medical community over this issue, with each side finding little to appreciate in the other side’s position. Through my 25 years as a physician I’ve seen the pendulum swing back, and forth, and back again over the issue of opioid treatment for nonmalignant chronic pain. At present, science suggests that opioids are grossly overprescribed. But patients who are taking pain medications for severe pain have a hard time accepting the results of those studies.
There is also considerable confusion among people with addictive disorders about the proper treatment of addiction. I read that Mr. Conaway tried to recover from addiction using methods based in Scientology, as well as ‘traditional’ treatment methods. When he appeared on ‘Celebrity Rehab’, he had every reason to trust his treatment team, and to believe that the advice that he received was sound. But was he told that the success rate for the type of treatment offered in that silly, exploitative TV show is perhaps 5%—and that the presence of TV cameras probably made the success rate even lower?
And am I the only person who finds it bizarre that the doctor behind that TV show has a new book coming out about the harmful effects of narcissism on society– a book that he wrote after building his career off putting movie cameras in the treatment sessions of people who were dying from the end-stages of fatal disease?
I watched the same guy—the doctor writing about all those darn narcissists— do family ‘sex therapy’ on another TV show, offering 15 minutes of fame for teens who would talk about the most intimate details of their young lives, again providing one more step up the career ladder for the guy who is supposedly critical of narcissism.
Wow.
That same doc who is fuzzy on narcissism has made statements about buprenorphine that have done little to clarify the science of treating addiction. He was often on record on his celebrity show stating that buprenorphine should only be used short term, because otherwise people would become ‘dependent’ on it. Those comments surprised me, as I used to think that anyone with a TV show was at least up on the literature in his supposed field of expertise—and the literature has shown quite clearly, for several years now, that opioid addicts LIVE when they are on buprenorphine, and often DIE when they are not.
I can state without reservation that every patient I have treated with buprenorphine has remained alive while taking the medication—the vast majority of them feeling entirely normal, with no side effects save for constipation—which was a problem when they were using opioid agonists as well. I tell patients on buprenorphine that I’m sorry that they need medication, but they have a fatal illness after all—and that yes, they are dependent on buprenorphine—just as diabetics are ‘dependent’ on insulin.
We will never know for certain, but I strongly suspect that had Mr. Conaway received THAT recommendation—that he had a chronic illness, and that he deserved chronic treatment with a chronic medication—then I would have had to find a different topic for this blog post.
And that would have been fine with me.
Rest in Peace, Jeff Conaway.

A true epidemic, with no easy scapegoats

Today an article on the web site Medscape describes the epidemic of opioid dependence in this country.  The article describes what people who work with addiction already know– that use of opioid medications has increased in a way never seen before for any medication.  The article does a good job of presenting the statistics, and puts forward the more obvious conclusions that can be made about the cause of the problem and some possible ways to reduce the magnitude of the problem.  As the article suggests, the databases that have been established in many states to monitor narcotic prescriptions will reduce doctor shopping.  Some experts are calling for special training and certification for doctors who prescribe opioids.  I am surprised that at a time when so many states are recognizing the problem, there are still numerous pain clinics throughout Florida that each pump out thousands of scripts for opioids, seemingly without any effort to stop them.  What’s with Florida, anyway?!

Death rates due to accidental overdose

The largest newspaper in Milwaukee Wisconsin has featured several articles about the local prescription drug problem.  I spoke with the author of the latest front page story about the subject, and tried to explain the complex nature of the problem.  I hoped that he would do the topic justice by writing something deeper than the typical ‘find someone to blame’ article that most papers resort to these days.  I even offered to set him up with a patient of mine who used those Florida-based pain clinics in the past, who ended up on ridiculously-high amounts of pain medication, and still struggles years later to lower his tolerance level.  The patient would have explained that it isn’t just ‘bad doctors.’  He would have explained that sometimes the problem is that a person will have severe pain, and will not be able to say ‘no’ to relief of that pain.  He would have explained that more and more doctors are simply ‘opting out’ of prescribing pain medications;  that if he had the gall to say to his primary care doc that his back hurt, his doc would have cut off the discussion and looked at him suspiciously from that point forward.  Because so many docs won’t deal with the difficulties associated with treating chronic pain, patients are left searching for pain pills in all the wrong places– and left taking them with little or no guidance or supervision.
Unfortunately the Milwaukee Journal-Sentinel writer took the easy way out, and instead of trying to capture the true essence of the problem he wrote a hack piece about ‘pill pushing doctors.’  I don’t personally know any of the docs he pointed out by name in the story– the story he wrote from the safety of behind his desk, where like most reporters he never has to make the tough decisions himself.  I wonder, though, if all of the docs he smeared were ‘bad docs,’ or rather if some of them were struggling with the tough questions that many docs now choose to avoid.  The article featured a photo of a tearful couple who lost a family member to overdose;  their daughter was being treated by one of the pain docs presented in the article as the lowest-of-the-low, a pill-pusher who destroyed the girl’s life.  And my heart goes out to those parents.  I see many people just like them in my practice; parents who have lost a child or who are struggling with the decision whether to put their addict-son or addict-daughter out on the street, or to instead let them live in the basement where they are using every night, where the parents dread looking each morning, into the dark silence, afraid of seeing their worst fear come to pass.
Drug deaths become number one

I don’t know the pain doc smeared in that article, but I do know what it is like to sit in the office with a person crying out in pain, begging for medication to provide relief from that pain. I was an anesthesiologist for ten years, after all, working in a pain clinic of my own.  And when treating someone’s pain, there is no way to get inside that person and determine exactly what the person is experiencing.  Yes, there were many times when I wondered if the pain was REALLY that severe.  There were some things I could try to use to determine whether the patient was ‘faking;’  I could check the respiratory rate, the blood pressure, and try to determine if the tears were real, or came from the drinking water down the hall.  My answer about faking, most of the time, was that the patient was NOT faking.  The patient was experiencing severe pain.  I knew that many people with the same injury would NOT have such severe pain, but for some reason this person DID have severe pain.  Who was I to say differently?  How can any doc listen to a patient describe severe pain, and then look at the patient and say ‘no– you are not in pain.’  Would YOU go to that doctor? 
Are you ready for the complicated article that Tom Kertscher of the Milwaukee Journal Sentinel SHOULD have written?  Those grief-stricken parents in the picture in his article about pill-pushing doctors, who are mourning the loss of their daughter and struggling to assign blame, are blaming the guy who might be the ONE doctor who truly cared, and who tried to help their daughter.  The daughter came to him, looking for help for her pain.  Other doctors turned her away, and told her ‘you DON’T have pain,’ when in reality they didn’t know whether she did or not.  They just knew it was easier to tell her to take a hike, or to say ‘I’m sorry, but I don’t prescribe pain pills,’ or to say ‘my healthcare system won’t let me prescribe them.’  Those doctors who ignored her pain didn’t know if her pain was real or not.  But there was one thing that they DID know– they knew that if they DID empathize with this patient, someone’s daughter, and if she ended up taking too many of the pills one night, they knew that some reporter hack would come ’round and blame them in some one-sided, simpleton-pleasing, ‘gotcha’ article in the Milwaukee Journal Sentinel.  So those docs closed their hearts to the pleadings for pain relief from a patient and kept their licenses for another day.  And the doc who couldn’t say no to her requests for help– who gave in and prescribed pain-relieving medication for the couple’s daughter– ends up being the bad guy.  Go figure.
Deaths rise as prescriptions rise

I have to point out that for non-malignant pain that has no finite endpoint, narcotics are rarely a good answer.  I have had patients say to me ‘I would rather live without pain for today and die next year, than have pain for the next twenty years,’ and to that I have said ‘that is why you need a doctor.  I cannot let you make that choice.’  I recognize that there ARE docs who prescribe pain pills MUCH too easily and loosely, causing a great deal of trouble for the patient in the end.  But they don’t prescribe because they are ‘evil;’  they prescribe because they have a hard time ignoring someone’s pain.  Maybe they need help dealing with confrontation.  Maybe they need to toughen up a little bit.  But they are not ‘evil.’ 
This is a little of the story that SHOULD have been written about the pain pill epidemic.  Then it could go into how people these days want everything to be ‘fixed,’ and that is why everyone takes pain pills.  Or it could say that the bad economy puts so much pressure on people to avoid missing work that they cannot rest an injury, and that is why everyone takes pain pills.  Or it could say that the violence of the inner city or the divorce rates in the suburbs leave people with emotional pain, and THAT is why everyone takes pain pills.   If only every problem had something to blame. 
I’m struggling with closing this post, and it is getting way too late.  I’ll just say one last thing– for those with young kids, keep talking about how horrible this problem is.  Don’t glamorize it, because it is not pretty– just let them know that unlike many things that young people do, taking pain pills incorrectly causes something that lasts a lifetime.  I invite people to check out some of the links in my ‘blogspot’ to see some of the faces of the epidemic, and to share those with your kids as well.
JJ

Is She Still Using?

I have been involved in Q and A with a person in another part of the country, and will share some of our exchange after removing the identifying info. BTW, I receive many e-mails from people and I just don’t have time to answer most of them; I DO provide ‘educational consultation’ (not a ‘medical’ relationship) at a rate of $100 per 30 minutes, and anyone is welcome to set that up by writing to appointments@fdlpsychiatry.com.
The person below consulted me over her daughter, who is addicted to opiates and on buprenorphine but not doing well. The grown daughter receives some level of support from her parents, who are in that horrible position of trying to pull back to avoid enabling while at the same time fearing that pulling back will cause relapse or worse. The mother has had the impression that her daughter is sedated from buprenorphine, and that the buprenorphine may be making things worse. Mom considered helping daughter pay for ‘rapid opiate detox’ to ‘get off Suboxone’ at one point; I was not a big fan of that idea, as I have seen people do poorly after that approach (in my opinion, GETTING clean is much easier than STAYING clean).
Our exchange:
She is still on suboxone but we are paying for it. her weekly appt last week was on wednesday and she did not bring us her prescription to have it filled until saturday which means she did not have any meds for 3-4 days.
She was like a wild animal when we saw her and told us she has filled it herself. Then finally Saturday she gave us the prescription and told us to fill it for her.
Number one: why would she have waited so long, would this be a sign of a relapse? Number two: can you stop for 4 days and then start up again? Wouldn’t this make you high from it? She is on 16 mg.
She is NOT doing well with Suboxone, could she be using it to subsidize the in-between times or something?
Just can’t figure out why a medicine that is supposed to make her better is making her worse?
Hi XXXX,
I find myself in the position of defending Suboxone– and wish I had something else to suggest. People taking buprenorphine comprise about 20% of my psychiatry practice, and I have not taken a new patient for buprenoprhine treatment for over a year, so I want to make it clear that I am not a ‘Suboxone zealot’. I’m just trying to be frank about what I see with addiction.
I often end up saying things like ‘it isn’t fair to Suboxone.’ When I say that, I am not concerned about ‘fairness’ toward a business plan or marketing strategy; I am speaking of ‘fairness’ in an intellectual sense. Maybe instead of ‘fair’ I should say ‘proper’—I will try that below and see if it helps clarify my point.
Your last comment is an example of why I have the forum and blog, as I hear similar comments frequently— i.e ‘why a drug that is supposed to help making her worse?’ That is NOT an intellectually honest question. SOMETHING ELSE is making your daughter worse, and buprenorphine is keeping her alive. I lived as an addict for 10 years BEFORE Suboxone, and I saw what things were like with only methadone as an option. While there has always been residential treatment, the results of treating opiate dependence with residential treatment have always been poor.
In the past six years, 1200 people died in Milwaukee from overdose. There is nothing special about Milwaukee; recent stories in Time, Newsweek, and elsewhere have highlighted the dramatic increase in overdose deaths from ‘prescription medications,’ largely opiates and benzodiazepines. We do not know what would have happened in your daughter’s case, had she not gone on buprenorphine. She very well might have died by now. She might be in prison. We don’t know—but at any rate it is not PROPER to ‘blame’ buprenorphine, when in fact the medication may have saved her life. The fact that she is still sick is most likely because addiction has many factors and consequences that are impossible to define, let alone treat. I have seen the outcome of untreated opiate dependence too many times. That outcome consists of either death or incarceration. The deaths have been mostly ignored until recently, and I imagine that after this ‘news cycle’ we will return to ignoring them. But the deaths are still there, every day. One result of being a physician who treats opiate dependence is that I now read the obituary section of the newspaper; I sometimes get ‘follow-up’ there on people who had at one time sought help, but for whatever reason had stopped coming to appointments.
To answer the other questions, it is very unusual for a person who is doing things right to forget to fill a prescription for buprenorphine. At first, people in treatment may wait until the last minute, then call in a panic saying they will run out the next day. One of my jobs is to get them living like ‘normal’ people, i.e. planning ahead of time and respecting boundaries, including not expecting me to drop everything because THEY forgot to schedule an appointment. Your daughter should learn to take care of the basics herself, and suffer some degree of consequences should she ‘forget’ to plan ahead. Every addict, of course, has many excuses for not being able to make appointments, call in requests for refills ahead of time, etc… even if the addict is doing nothing all day, and the caretaker is working three jobs! That dynamic must change so that the addict is responsible for herself.
Yes, stopping buprenorphine for 4 days and then restarting it will result in the person ‘feeling’ opiate effects. It is difficult to sort out whether the person is feeling ‘high,’ or just feeling the loss of withdrawal—but there would definitely be relief associated with taking the buprenorphine after 4 days. The goal with buprenorphine is to avoid that cycle of ‘sickness’ and ‘relief’ and to instead feel normal all the time. And ‘normal’ is what the vast majority of my buprenorphine patients describe; they say that they feel nothing with each dose, and that they don’t feel ‘high’ at all. Feeling ‘normal’ is consistent with the chemistry of taking buprenorphine; the person becomes completely tolerant to the effects of the medication and as long as the blood level remains above a certain threshold, there is no sense of something wearing off.
In the case of your daughter, I agree with you—something is not right. She is either using opiate agonists intermittently or she is still very much wrapped up in wanting to ‘feel’ something—or both. There are deficiencies to all testing methods, but she should have a ‘state of the art’ urinalysis at some point when things are irregular. By ‘state of the art,’ I mean a test that is witnessed (most labs can provide this service), that has a chain of custody, and that is analyzed at a certified medical laboratory.
In a case like that of your daughter, it is important now and then to return to basics– does she WANT to live a clean life? What is motivating her to do well, and what is motivating her to do poorly? Are there sufficient consequences for bad behavior? Is SHE the one working the HARDEST on her sobriety? She SHOULD be, by the way… when I see a situation where everyone else is working to help a person stay clean, I know that bad things are coming.
I realize that it is simply horrible, what is happening to you and to your daughter. You are being forced to distance yourself from her so that she will take on more responsibility for herself, and so that you are protected to a small degree from the horror of the current situation and the fear of what could come at any time. That distance is just like any other significant loss. Understand that it isn’t your fault, and you are not alone. I often compare opiate dependence to cancer; both illnesses have consequences far beyond the risk of death. The loss that you are experiencing is similar in some ways to what cancer patients go through, when they see close friends back away out of fear of death and dying.
The one consolation is that for most people, age brings insight. I have many people on buprenorphine who do very well—they take a daily medication as they would for any other chronic illness, and lead happy and productive lives. But I also have a few younger patients who do not do as well—particularly those under age 20. In those cases, the course of illness includes a constant battle to prevent the addiction from going ‘underground,’ i.e. where the addict keeps secrets from the physician, and there are periods of stability and relapse. In such cases I hope that buprenorphine at least allows me to keep the person alive and out of prison (and hopefully employed or in school as well). The addict’s life may still be chaotic, but each day the person is a little closer to age 30—an approximate age when insight seems to have a better chance of taking hold. Hopefully your daughter will gain insight as well as time passes. If she only loses a decade of her life, she still has much to live for.
As always, I’m sorry for what you are going through. Protect yourself first; make sure you are doing all that you can to keep your own sanity intact.
JJ

Overdose Memorials during an Epidemic

I sometimes get the sense that there is a parallel universe besides this one, and I am not sure which one is real.  In one, the kids grow up safely, and every premature death is cause for alarm that generates immediate effective action by the community.  In the other universe, kids in their teens are dying in ever-increasing numbers, and only their family members and a few close friends react with alarm.  After a few weeks each death is forgotten and life goes on–  for some.  The parents and siblings of the children who lose their lives somehow stumble forward, living the rest of their with the horrible realization of this second universe–  the one that they didn’t know about until it was forced upon them.
My heart goes out to any parent who has found the way to this blog.  If it is not too late, take the situation– the addiction of a child to pain pills- in the most serious way possible.  If you have the resources to move to the middle of nowhere– a place where there is not a significant problem with opiate addiction, if such a place even exists– just go.  Take severe and drastic measures. 
I wanted to share two things that I heard about today.  The first is that there are several ‘sober schools’ in Wisconsin-   Charter high schools for students who have been through addiction treatment.  I figure that it is tough to get a kid to go to such a high school… but in the case of opiate dependence the teen should not be given a choice in the matter.  The risks of death are simply too high for a teenager to comprehend.
The second thing is a web site devoted to preventing prescription pain pill use by teens, with a focus on Florida.  The memorial page— or more accurately pages– are quite moving.

Deaths on Suboxone

I wish I had more time to devote to this topic right now, but I am on my way to a short vacation… so I will not be available by e-mail for at least a few days.  Everyone is pacing around the house right now, waiting for me to finish with ‘that stupid computer’.
I had to to write, though, because of a horrible incident in Milwaukee a couple days ago that took the life of a 15-year-old girl named Maddie Kiefer.  According to news stories, she snuck out from her house in Whitefish Bay, one of Milwaukee’s’nicer’ suburbs– by nicer meaning a place where the houses are kept up, many children grow up with two parents, and the public schools send a high proportion of students to colleges.  The suburb lies just north of Milwaukee, and along with other northern suburbs has seen a significant increase in heroin use by young people over the past 5-10 years.  I live another hour or so to the north, and we are seeing more and more heroin ‘up here’ as well;  the opiate addicts that I treat used to report taking oxycodone mostly, followed by methadone, then fentanyl;  now I am hearing histories of heroin use almost as often as oxycodone.
Most people know about some vague danger of combining Suboxone with ‘benzos’ like Xanax (alprazolam);  the risk is respiratory depression, which can kill a person– and is usually the cause of death in overdose of opiates.  Opiates desensitize the brain’s response to carbon dioxide, causing the person to breathe at a slower rate and allow carbon dioxide to build up.  The high level of carbon dioxide isn’t fatal, but if a person breathes slow enough, or stops breathing altogether, the oxygen level eventually falls… and the low oxygen level either makes the brain stop working– including ceasing the urge to breathe entirely– or the low oxygen level triggers a cardiac arrhythmia that halts the flow of blood, which then affects the brain, causing unconsciousness, apnea (no breathing), and death.
A couple quick points:  Suboxone and benzos are a dangerous combination particularly if a person is naive to both.  If a person is opiate-tolerant, for example is addicted to opiates, then the risk of death from such a combination is very low.  In any case, the risk of Suboxone plus benzos is MUCH LOWER than the risk of combining a benzo with a full opiate agonist, like oxycodone or methadone!  There is nothing especially dangerous about Suboxone in this regard;  in fact, it is much safer than a full agonist.
I suspect that the teen killed in Milwaukee was not used to opiates;  in such a alcase Suboxone alone would almost never be fatal… unless combined with other respiratory depressants, such as alcohol or benzodiazepines.  The story of her death is horrible– it displays the utter lack of concern for others that takes over the soul of a person addicted to opiates.  I will not make any excuse for a person who dumps someone in a driveway who needs life-saving assistance– but I understand how people get that way.  Many opiate addicts do things that are similarly devoid of conscience– and that is behind the ‘split’ that occurs with addiction, where the addict represses the horror of who they have become, and carries a fake outside personna that is cocky, glib, annoying, and easily recognizable to those who understand addiction.
When I talk about tapering, I assume people are working with a physician;  I do not condone the practice of buying Suboxone on the street or sharing it with friends or ‘loved ones’– even out of concern for them.  When people treat themselves, they are fooling themselves;  the addict is firmly in control and there is minimal chance that the person will recover.  People who share or sell Suboxone with others deserve to be incarcerated.  Period.