Opiate dependence treatment options

Below is one chapter of my long, long book– the one that I will probably never finish.  I wrote this chapter about two years ago, and have not published it anywhere else, at least not that I can remember.  It is LONG, but if you are addicted to opiates and considering your options, I hope you will check it out.  I invite other addicts and friends of addicts to read it as well, even though it is LONG (did I say that already?).  It essentially describes my ‘vision’ for addiction treatment going forward.  I am posting it now because I will be attending a summit in DC over the next few days, discussing the use of buprenorphine going forward with other experts in the field.  I will  bring back word of any new developments and share them here.

Addiction to heroin and pain pills continues to grow

The article:
The advent of HDP (high dose buprenorphine) for treating opiate dependence raises hopes that we are at the verge of an entirely new approach to opiate addiction, and perhaps to other addictions as well.  The traditional, step-based approach to drug addiction treats all substances as essentially the same.  The problem with addiction isn’t that the addict is ingesting a substance, but rather that the addict has become obsessed with the substance.  The effects of this obsession on the addict are in some ways similar to the effects of a toxic, codependent ‘love relationship.’  And while the addict develops this relationship with a specific drug of choice, the drug’s sister, brother, aunt, or uncle can step in and take the place of the drug of choice in a process called ‘cross addiction’.  This is one reason why traditional treatment demands sobriety from ALL substances.  Most opiate addict may have had no problem with alcohol when opiates are on the menu.  But alcohol may surprise the addict by becoming an important ally when the only alternative is ‘life on life’s terms.’
There is another, more complicated reason that traditional treatment of addiction requires sobriety from all substances, not just from the addict’s former drug of choice.  All addicts, opiate addicts in particular, over time become hyper-aware of their moods, comfort, and anxiety level.  Addicts constantly ‘check in’ somatically, thinking ‘am I OK? Or ‘am I coming down?’  Every bead of sweat portends the pain of withdrawal, and every ache is a reason to use.  Addicts become attuned to their schedule of use, as an internal 4-hour clock becomes all-important, and eventually the only thing that matters.  There is even something perversely comforting about reducing all of life’s problems to the need to use, as the other challenges of life become secondary.  But sobriety and recovery demand that the addict learn to face life on life’s terms, giving up the obsession for symptoms and medications.  Sobriety will extinguish the obsession with symptoms over time— sometimes only after a great deal of time.  As the obsession fades, the addict takes steps away from relapse.  But if the addict uses a new substance that changes that perception and re-directs the addict’s attention inward, even a substance like diphenhydramine that is not addictive, the pattern of somatic attention returns.  Many addicts are aware of an ‘addict frame of mind’ and a ‘sober frame of mind;’  any drug that causes the addict to look inward and again focus on somatic symptoms has the potential to trigger the return of the addictive mindset.  And once the addictive mindset is back in place, it can be very difficult to find the way back to a mindset of sobriety.
The reader may be asking, I see your point about total sobriety—but isn’t total sobriety required for buprenorphine treatment as well?  In my opinion from working with addicts taking and not taking buprenorphine, sobriety from other substances is beneficial during HDB for similar reasons, but there is less at stake.  During HDB the addictive mindset interferes with happiness, relationships, and the development of new, healthy interests.  But for the addict in traditional treatment a return to an additive mindset can disrupt the avoidance of opiates and result in relapse.
The need for total sobriety probably prevents some addicts from entering treatment. There are other addicts who enter treatment but who cannot maintain sobriety from all substances despite multiple attempts.  To widen the appeal and utility of addiction treatment, a variety of treatment models have appeared, including an approach called ‘harm reduction’.  Rather than total sobriety, the goal of harm reduction is to reduce the intensity of use, and reduce the harm that inevitably results from heavy or uncontrolled use.  By introducing ‘drink counting’ and other behavioral techniques, harm reduction has similarities to cognitive therapy.  There are people who do better in one vs. another approach, and there people who could benefit from either approach.  Specifically, some people use or drink in an almost nihilistic fashion—every episode of drinking characterized by drinking to total oblivion.  I would favor complete sobriety for such individuals, because the cognitive changes made in treatment will likely be obliterated by the first drink.  On the other hand, a person with 20 years of an unchanging pattern of drinking facing his first DUI may be a good candidate for a harm reduction approach.  In such a case, alcohol is a major part of the addict’s personality, and total sobriety after one offense would be a difficult sell.  But education—for example about changes in tolerance with aging, or an introduction to drink counting– may help the person do well for another 20 years.
There are several inherent problems with traditional treatment methods, beginning with the simple observation that relapse rates have always been high.  The high relapse rate has implications for addiction that go beyond treatment methods, as explained later in this article.  But relapse is a particular problem for programs that are based in ‘character modification’ because when the forces that encourage character change are removed, character tends to return to its prior state.  Addicts in traditional recovery tend to see themselves as ‘changed’ by the steps.  But at the same time every honest addict recognizes that if the meetings stop, relapse waits around the next corner.  Even worse, a ‘truism’ of step-based recovery holds that people who relapse generally return to a state of using that is even worse than where they were when they entered treatment! 
Another problem with traditional methods is that many addicts reject out-of-hand the ‘spiritual foundation for the program.  Admittedly such ‘rejecting addicts’ do not necessarily know much about this spiritual foundation and don’t likely know what is good for them!  But reasonable or not, having spirituality as one aspect of a recovery program is going to prevent the adoption of the program by a number of addicts.  Another problem is that traditional addiction treatment methods require significant motivation on the part of the addict–motivation that must be available to addicts over and over throughout their lives, including (and most importantly) at times when addicts are at their very lowest.  Finally, some degree of detoxification is often required before traditional treatment, requiring expensive medical services that may be far removed from the treatment center.  The cost of detox and the fear of withdrawal become major roadblocks to treatment.  Withdrawal uniquely miserable, and difficult to compare to other dysphoric experiences.  Physical symptoms include headache, fatigue, nausea and vomiting, abdominal cramping, diarrhea, and muscle spasms of the arms and legs that cause involuntary movements.  The withdrawing addict becomes profoundly depressed and anxious.  Even if there is no access to drugs, the addict feels a desperate need to use.  No description of symptoms can accurately capture the misery experienced by the withdrawing opiate addict.  I suspect a ‘kindling’ effect in opiate withdrawal where symptoms become more and more severe each time withdrawal is experienced, so that eventually there is no such thing as ‘mild withdrawal.’  Instead the addict experiences withdrawal as severe as the worst episode endured up to that point, regardless of the degree of tolerance going into the withdrawal episode.  Addicts who have suffered through severe, non-medicated withdrawal have a sense of camaraderie akin to that of disaster survivors.  But camaraderie is nowhere to be found in the midst of the withdrawal experience, and the addict feels utterly, horribly, alone.
For years there have been alternate addiction treatment models that are less dependent on character modification and more reliant on medication.  Opiate maintenance treatment using methadone, or opiate blockade using naltrexone are two approaches that may be used alone or in concert with traditional treatment.  Methadone and naltrexone treatments are diametrically opposed to each other in several ways, but have some things in common as well.  Methadone maintenance deliberately creates ‘hyper-tolerance’ to opiates by administering the addict increasing daily doses of methadone.  The high tolerance that results prevents recreational use of opiates, and the high dose of methadone satiates opiate cravings.  But patients in methadone programs often feel trapped because detoxification from high doses of methadone is very difficult, and violating the rules of the clinic (including not paying the bill) results in dose reduction and withdrawal.  Some addicts maintained on methadone claim that they always feel ‘high’, no matter their extent of tolerance.  And while high doses of methadone will satiate cravings for a time, eventually tolerance catches up and cravings return.  Moreover some addicts claim that methadone causes a lack of motivation for self-betterment through education or employment.  For decades methadone maintenance was associated with blighted urban areas, where addicts lined up each morning for their daily dose of methadone.  There have been more recent attempts to make methadone maintenance mainstream by improving the physical facilities or relocating to less-blighted neighborhoods.  But there have been few changes in the regulation of methadone, so methadone maintenance usually requires that addicts add morning dosing to their daily schedules, often acting as a barrier to occupational advancement.
Naltrexone is a molecule that blocks the binding site for opiates, preventing ingested or injected opiates from having psychotropic effects on the addict. The use of naltrexone for treatment of opiate addiction is limited by the requirement for two weeks of sobriety prior to treatment.  This period of sobriety is necessary for opiate receptors to normalize to a degree that avoids naltrexone-induced withdrawal.  Another problem is that the addict can ‘choose to use’ by simply skipping a day or two of naltrexone.  In fact, patients maintained on naltrexone develop a hypersensitivity to opiates, making them subject to dramatic highs during relapse and vulnerable to the associated risk of overdose by respiratory arrest.  Naltrexone is administered as daily tablets or as intramuscular, monthly injections, which help reduce the ‘choose to use’ problem.  The primary indication for this naltrexone is for alcohol dependence rather than opiate dependence, as naltrexone has been demonstrated to reduce cravings for alcohol.  A related form of naltrexone treatment is called ‘rapid opiate detox’, where the addict is anesthetized and given withdrawal-inducing doses of intravenous naloxone.  After 8 hours or so, the addict wakes with a slowly-dissolving chip of naltrexone implanted under the skin.  This technique has never been very popular because of reports of patient deaths during the procedure, high relapse rates, and several reports of suicide following rapid detox.
Suboxone is a hybrid of methadone and naltrexone treatments, and has a number of features that make it a unique and valuable tool for treatment of opiate addiction.  Suboxone consists of two drugs; buprenorphine and naloxone.  Regardless of what people on the internet say in message boards, the naloxone is totally irrelevant if the addict uses the medication properly.  If the addict dissolves the tablet in water and injects the compound, the naloxone will cause instant withdrawal.  When suboxone is used correctly, the naloxone is destroyed in the liver shortly after uptake from the intestines (‘first-pass metabolism’) and has no therapeutic effect.   Buprenorphine is the active substance.  It is absorbed under the tongue (and throughout the mouth) but inactive if swallowed by mechanisms similar to those for naloxone.  There is a formulation of buprenorphine without naloxone, called subutex;  I have used this formulation for times when the patient has apparent problems from naloxone, including headaches after dosing with suboxone.  I have also treated addicts who have had gastric bypasses, where the first part of the intestine is missed and the stomach contents empty into a more distal part of the small intestine.  In such cases the naloxone escapes ‘first pass metabolism’, where with normal anatomy the drug is taken up by the duodenum and transferred directly to the liver by the portal vein, where it is quickly and completely destroyed.  After gastric bypass the naloxone can be taken up by portions of the intestine that are not served by the portal system, causing blood levels of naloxone sufficient to cause brief, relatively mild withdrawal symptoms.
Buprenorphine belongs to a class of molecules called ‘partial agonists’ that have both stimulating and blocking effects at their receptor sites.  Buprenorphine has potent opiate effects that increase with increasing dose up to about four mg.  The opiate effects then reach a plateau, and higher amounts of buprenorphine do not increase narcosis.  This ‘ceiling effect’ is the basis for the use of buprenorphine for treatment of opiate dependence.  The average addict takes 8-16 mg of buprenorphine per day, and becomes tolerant to the effects of buprenorphine (buprenorphine has significant opiate potency but the opiate effects usually pale in comparison to the degree of tolerance found in active addicts).  The addict’s opiate receptors become completely bound with buprenorphine, and the effects of other opiate substances are blocked.  At the same time, the bound buprenorphine reduces cravings for other opiates.  Buprenorphine is marketed under brand names Suboxone and Subutex.  When used properly, buprenorphine is very effective in preventing relapse.  Getting an ‘opiate buzz’ requires the addict to first experience several days of withdrawal, in order to rid the receptors of buprenorphine so that other opiates will have an effect.  Taking into account addicts’ attitudes toward withdrawal, the appeal of this ‘choice’ is quite low. 
Treatment with buprenorphine may be somewhat limited in the case of addiction to multiple substances.  For example, an addict may be able to avoid opiates, but remain susceptible to alcoholism.  Or as described earlier in this report, addicts may change their attachment from one drug of choice to another. On the other hand, just as naltrexone reduces alcohol cravings, it is possible that buprenorphine, through similar mechanisms, reduces alcohol cravings as well.  Addicts treated with buprenorphine who move from one substance to another will likely require an approach that includes total sobriety.  But for pure opiate addicts, benefits of buprenorphine include the fact that that only mild withdrawal is required to start treatment, the drug is usually covered by insurers, prescribing restrictions are relatively minor, and there is less stigma associated with maintenance with buprenorphine than with methadone.  Insurers should appreciate the simplicity and efficacy of treatment, and would do well to encourage this treatment approach.
I expect that buprenorphine will eventually be the standard treatment for opiate dependence, and will change the treatment approach for other addictions as well.  My only reservation to this statement comes from observing the response of the recovering community to patients treated with buprenorphine, which runs from ambivalence to disdain.  Some recovering addicts reject recovering addicts taking buprenorphine for not being ‘completely clean.’  Addiction treatment counselors know less about buprenorphine than they should given the utility of the medication.  In some cases their focus appears to be more on job security than on the needs of the suffering addict.  There are also disagreements over the amount and type of counseling that should be prescribed for addicts taking buprenorphine.  From my own experience treating addicts, it is a mistake to assume that addicts taking buprenorphine are in a ‘dry drunk’ in need of a step program;  I have found that buprenorphine-maintained addicts make gains in occupational, social, and family domains at rates at least comparable to addicts in step-based recovery.  The present standard of care calls for addicts maintained on buprenorphine to be referred for counseling ‘as needed.’  But the message that should be delivered through such counseling is debatable.  By one perspective a patient maintained with buprenorphine becomes similar to a patient with hypertension treated for life with medication—the underlying problem persists, but the active disease is held in remission.  If the uncontrolled use of opiates is effectively treated, is that enough?  Should counseling focus on removing the shame of having the disease of addiction, and encourage addicts to get on with life?  Or should addiction be considered a consequence of deeper problems or faulty character structure, requiring group therapy and meetings if one hopes to become ‘normal?’  The use of buprenorphine runs counter to successful adoption of sobriety through step programs, which in the first step require acceptance that the addict is powerless over the substance—that there is no amount of will power that will allow the addict to control the deadly effects of the drug.  Buprenorphine may allow the addict to develop an impression that he/she has control, particularly if buprenorphine becomes popular on the street for self-medication of withdrawal.
Physicians and insurers should strive for greater consistency in the use of buprenorphine.  Some insurers demand that the drug be used only short-term, in some cases for only three weeks. This requirement discounts the nature of addiction, and ignores the known high relapse rate after short-term use of buprenorphine (why wouldn’t it be high?).  Some physicians use the medication short-term as well.  Hopefully the motivation for this ineffective treatment method is not related to the limit on the numbers of maintenance patients per physician, but the practice raises the question whether the cap on patients encourages good practice, or bad practice decisions.  Some physicians transfer their attitudes toward opiate agonists to the use of buprenorphine, and place constant downward pressure on the daily dose of buprenorphine.  Such an approach is not appropriate, as buprenorphine requires adequate dosing to achieve the long half-life and suppression of cravings that make addiction treatment possible.  At daily doses below two mg buprenorphine is essentially an agonist, so one might as well be give small doses of hydrocodone rather than buprenorphine!  There is no reason beyond cost considerations (which may be practical) to reduce the dose, as tolerance is limited by the ceiling effect of the medication. In other words, at some point higher doses of buprenorphine do not cause greater severity of withdrawal.  Another problem is that the medication is sometimes prescribed carelessly, without emphasizing the need to dose only once per day.  Addicts left to their own decisions will use the medication multiple times per day as a ‘PRN’ medication, staying in the same somatically-focused, actively-using state of mind that brought them to treatment.  Once per day dosing is necessary in order for addictive behavior and addictive thinking to be extinguished over time, and it often takes a great deal of work early in the treatment process to help addicts take buprenorphine properly.  Addicts starting buprenorphine may initially experience anxiety as they lose the distraction and placebo effect of frequent drug use.  But over time the anxiety will fade, and the void left by the removal of addictive obsession will allow the development of relationships and other positive character traits that were forced out by addiction.
While there are issues to be worked out, the advent of buprenorphine treatment has had a beneficial impact on many who have struggled with the disease of opiate dependence.  Treatment based on character change requires desperation before addicts will become willing to change, and for treatment to be effective.  And so before buprenorphine, addicts had to lose a great many things—family, employment, freedom, health—before getting better.  Only a fraction of addicts recovered, and those only after significant losses—and relapse rates were high.  Buprenorphine on the other hand allows treatment of addicts early in the course of their illness, and induces remission in most patients. 
Given the time pressures and payment structures of modern medicine, buprenorphine may eventually replace residential treatment as a more reliable, less costly alternative.  Is it time to replace the ‘recovery’ model with a new ‘remission’ model, which allows treatment of a much higher percentage of users at an earlier stage of disease?  With time, will we find analogous agents that provide a low level of intoxication in return for receptor blockade?  While not likely with alcohol, such an outcome is certainly within the bounds of imagination for cocaine, benzodiazepines, and barbiturates.  While it is true that daily use of a partial agonist would represent a reversal from our current approach where all intoxicating substances are to be avoided, it is also true that the current approach has no bragging rights based on outcome.  And perhaps the adoption of a remission model would lessen the time until opiate and other addictions carry as much moral stigma as hypertension or diabetes—two other diseases that are generally treatable, but that require long-term use of medications.

Buprenorphine and the Dynamic Nature of Character Defects

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

Buprenorphine and the Dynamic Nature of Character Defects

‘Suboxone’ and ‘Subutex’ are the trade names for medications that contain buprenorphine, a substance used to treat addiction to pain medications and/or heroin.  Buprenorphine treatment for opiate dependence has been an option in the US since 2003.  Other treatment approaches for opiate dependence have been used for decades but have had limited success.  With a little imagination, treatment approaches can be placed on a continuum depending on the degree to which the treatment demands changes in the personality and behavior of the addict.  Methadone maintenance is often described as a means of ‘harm reduction’ by preventing the behaviors related to the obsession for opiates or by reducing intravenous use of heroin or other substances.  At the other end of the treatment continuum there are the step-based and other Recovery programs.  One limitation of programs that demand personality change is that such change is difficult and rare, and usually only occurs after a significant amount of despair has been experienced by the addict.  Opiate dependence differs from other addictions in the lethality of overdose, and the fatality rate of even early abuse of that class of substances.  Opiate addicts are at significant risk of dying from their addiction before enough desperation has accumulated to motivate personality change.  A second limitation is the high rate of relapse that occurs even after sustained Recovery.  If a ‘changed’ addict stops actively participating in the program that induced the changes, the personality of the addict tends to revert back to the personality that was present during active drug use.
I initially had mixed feelings about buprenorphine treatment of opiate dependence, my opinion likely influenced by my own experiences as an addict in traditional recovery.  But my opinion has changed over the past four years from what I have seen and heard while treating over 400 patients with buprenorphine.  But while buprenorphine has opened a new frontier of treatment for opiate addiction, arguments over the use of buprenorphine often split the recovering and treatment communities along opposing battle lines.  The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that buprenorphine offers huge benefits for the health and lives of opiate addicts.
A unique medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.  The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.  First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.  Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.  Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.  Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.  Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use buprenorphine versus those who use a non-medicated 12-step-based approach.  People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking buprenorphine as having an ’inferior’ form of recovery, or no recovery at all.  This leaves buprenorphine patients to go to Narcotics Anonymous and hide their use of buprenorphine.  On one hand, good boundaries include the right to keeping one’s private medical information so one’s self.  But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of buprenorphine is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;  they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of buprenorphine.  The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable.  If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.  But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.  Success rates for long-term sobriety are lower for opiates than for other substances.  This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town.  The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.  The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:  Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Buprenorphine has given us a new paradigm for treatment which I refer to as the ‘remission model’.  This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed.  To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.  Opiate addicts have a number of such ‘defects.’  The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.  Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career.  The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.  The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.  The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using.  People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.  I had such an expectation when I first began treating opiate addicts with buprenorphine—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.  I realize now that I was making the assumption that character defects were relatively static—that they develop slowly over time, and so could only be removed through a great deal of time and hard work.  The most surprising part of my experience in treating people with buprenorphine has been that the defects in fact are not ‘static’, but rather they are quite dynamic.  I have come to believe that the difference between buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-treated patient has been freed from the obsession to use.  A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.   People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.  Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair.  With this in mind, I now view character defects as features that develop in response to the obsession to use a substance.  When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with buprenorphine.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice.   For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system.  The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean.  While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle.  The successful addict will view the substance with fear—a primitive emotion from the old brain.  When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.  Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade.  For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with buprenorphine have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic.  Buprenorphine removes the obsession to use almost immediately.  The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.  The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of buprenorphine patients, and more convincingly with the spouses, parents, and children of buprenorphine patients.  I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.  I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found buprenorphine treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted?  Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining buprenorphine treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between buprenorphine and traditional recovery becomes clear.  Should people taking buprenorphine attend NA or AA?  Yes, if they want to.  A 12-step program has much to offer an addict, or anyone for that matter.  But I see little use in forced or coerced attendance at meetings.  The recovery message requires a level of acceptance that comes about during desperate times, and people on buprenorphine do not feel desperate.  In fact, people on buprenorphine often report that ‘they feel normal for the first time in their lives’.  A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time:  In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s  powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character.  Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should buprenorphine patients be in a recovery group?
I have reservations about forced attendance, as I question the value of any therapy where the patient is not an eager and voluntary participant.  At the same time, there clearly is much to be gained from the sense of support that a good group can provide.  Groups also ‘show’ the addict that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts.  Some addicts will learn the patterns of addictive thinking and become better equipped to handle their own addictive thoughts.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power?  Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.  But for a person taking buprenorphine I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist that has a long half-life in brain tissue.  This long half-life promotes a relatively constant state of opiate stimulation, reducing opiate cravings between doses.  But while the ceiling effect of the partial agonist buprenorphine results in a stable, unchanging tolerance to the medication, methadone has no such ceiling, and tolerance will always increase with increasing dose of methadone.  This constant increase in tolerance erodes the ability of methadone to satiate cravings for opiates.  A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.  With cravings comes the obsession to use and the associated character defects.  This explains one difference in the subjective experiences of addicts maintained on buprenorphine versus methadone.  Methadone maintenance is also usually experienced as more sedating than the effects from buprenorphine.  There is a valuable role for methadone to play as we try to prevent deaths from opiate dependence, but I see the mechanisms of action of methadone and buprenorphine to be profoundly different.  Methadone is appropriately described as a ‘maintenance agent,’ but I see a more appropriate term for the actions of buprenorphine, as a ‘remission agent.’  This term accounts for the effects of buprenorphine on the obsession for opiates, and the ability of the medication to allow for dissolution of the character defects caused by active addiction.
The downside of buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine as at best a mixed blessing.  Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe buprenorphine.  Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety.  Buprenorphine itself can be abused for short periods of time, until tolerance develops to the drug.  Snorting buprenorphine reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.  Finally, the remission model of buprenorphine use implies long term use of the drug.  Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary.  Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not buprenorphine will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.  The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.  At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.  Some day we will likely look back on buprenorphine as the beginning of new age of addiction treatment.  But for now, the treatment community would be best served by recognizing each other’s strengths, rather than pointing out each other’s weaknesses.

STZ Now on Medpedia

Medpedia has been expanding on a number of fronts, with a ‘wiki’ approach to all things medical– including addiction.  This blog— Suboxone Talk Zone– will be included in the News and Analysis section of the site;  I also hope to submit content and contribute to our knowledge base about opiate dependence going forward.Capture
I invite readers to visit Medpedia and review my thoughts about the relationship between buprenorphine maintenance and traditional recovery.  The topic will be important as we sort out whether buprenorphine should be used as a bridge to step-based treatment, as a long-term treatment that stands on it’s own as a treatment for a chronic condition, or a combination of both paradigms.
When it comes to medical information there are many options on the internet, that vary greatly in the quality and independence of their information.  Medpedia follows the model of a similar site, where information is honed through the experiences and opinions of contributors.  I like what I see so far.  Please check them out sometime.
JJ

A Day With Reckitt-Benckiser

I just got back from Chicago, where I spent the day learning about ‘best practices with Suboxone’ with the people from Reckitt-Benckiser. I feel an obligation to share my experiences with those of you who are so strongly connected to the efforts of R-B —and I am not referring to owning stock in the company. I’m not in the mood to go on forever; meetings with pharmaceutical company people always tire me out and even bring me down a bit—I’m not sure exactly why. I would almost think it would be the opposite, because things look so easy from the perspective of a PowerPoint presentation. Although as I put my psychodynamic background to use, I realize that an opposite reaction makes sense. Tune into my radio show podcast sometime and listen as I talk about psychodynamics; dysphoric feelings often spring from unconscious conflict, and there was likely conflict between what I was watching and hearing during the presentations, and what I was thinking and remembering from my practice.
Those of you expecting a story about conspiracy theories will be disappointed. I had the impression that the company is sincerely motivated to help people with addictions for the right reasons. They made it clear through their actions and plans for the future that they are in addiction treatment for the long haul, even after the patent on Suboxone expires. There are some things about the company that have bothered me, and I was able to ask questions about those concerns. I will share their answers with you as best I can remember.
I spoke with someone Friday evening who has been with RB since 2003, about the lack of general support in the field for Suboxone compared to other new medications. She believed that RB did a good job of introducing Suboxone, and that their results in numbers of doctors trained and patients treated were good. I pointed out that many, perhaps most, ER docs have no idea what Suboxone IS, let alone know how to manage accidental ingestion or overdose. I compared Suboxone to Shire’s Vyvanse, a medication that has been out for just over a year but has 10 times as many sales reps in the state where I practice. If I want a coupon for Vyvanse, a rep drops off a box of them by the end of the day! But we have two reps covering the entire state for Suboxone! The difference in our perceptions was a classic ‘glass half full or half empty’ situation. She said that when she started in the RB pharmacy division, they had 20 US employees—a tiny fraction of the resources in place for product launches from the ‘big players’.
So I asked why they didn’t sell the drug to one of the big guys, so that it could be rolled out with the fanfare and support given to Cialis or Viagra? Another person from the company pointed out that had they done that, they would have had a bigger problem over the shortage of physicians certified to prescribe the medication. And that was a good point. The bottom line is that Suboxone was a truly unique situation; a small company that had no significant US presence, the unusual requirement for special certification for prescribers, a target illness that is complicated by stigma and the risk of diversion by patients… mistakes were probably made, but mistakes are always made. I left the conversation realizing that the company had some unique challenges to overcome, and so far has done pretty well.
A couple other areas of new perspective: on the issue of the high cost (although I often point out that for a fatal illness, the treatment isn’t all that expensive), it was pointed out that if Suboxone was super cheap, say a buck a pill, there would be a much greater profit motive for diversion of the drug. I think that is probably a fair assumption; there would be more Suboxone on the street if it retailed for a buck per pill than there is at five bucks per pill.
I was happy to see how strongly they connected with the disease model of addiction; in my opinion that is the genuine state of affairs, and the natural way to present Suboxone. Suboxone is a chronic medication for a chronic condition, period. I have always figured that it was a mistake that the company initially talked up using Suboxone for short-term detox, and I heard nothing to change my opinion. They mentioned that a few years ago 70% of patients were prescribed Suboxone for short-term use and 30% for maintenance, and now those numbers have reversed and 70% of prescriptions are for long-term maintenance treatment. Those numbers are consistent with my experience.
There will be other buprenorphine preparations in the future, including depot injectables made by RB or by someone else. Also watch for different types of oral products, including designs that reduce the likelihood of accidental exposure in children.
If I had to complain about something, I would say that the corporate presentation just does not seem to mesh well with the reality on the street. I talked to one of the leading developers briefly about the problem with twelve step groups—how there is a vocal anti-Suboxone crowd, who often talk people into stopping their medication or refer to doctors who prescribe the medication as ‘pushers’. He said that Betty Ford had given her blessing to the idea that people on maintenance medications are still ‘in Recovery’. My thought in response was ‘who the heck cares about Betty Ford?’ I would bet that 99% of the NA and 80% of the AA folks in my home town have never heard of her! I do think that the split among the recovering community over buprenorphine is a serious issue that should be dealt with in a formal manner, through communication between people who understand neurochemistry and buprenorphine, with people from the twelve step intergroup organizations.
I also believe that some in the company, and some prescribers, don’t understand what it is like to be an opiate addict. I realize that nobody who is not an addict will truly understand addiction, but I don’t think they get that we are just like they are outside of our addictions. To give an example, the issue came up about the degree of counseling and meetings that should be required of people on Suboxone. I have put forward my thoughts on this issue many times. Many of the docs at the meeting talked about their practice of requiring ALL people on Suboxone to go through intensive outpatient treatment, and/or requiring twelve step attendance as often as every day! They require AA or NA not because of some theoretical basis, but rather because they think that addiction and AA or NA just go together. I did point out my thoughts on the issue, namely that people only ‘get’ twelve step recovery when they have some degree of acute desperation, and people on Suboxone are NOT DESPERATE. I ‘got’ AA quickly the first time I went to treatment, but the second time it took several months before my mind opened sufficiently to truly accept the program. Only people who have had a spiritual awakening themselves will understand what I am talking about, but going to meetings and just sitting through them is not that beneficial. I have been to meetings with people mandated to attend, and those meetings are generally a waste of EVERYBODY’S time. ‘Getting it’ in twelve step recovery is a moving experience that sweeps the addict of his feet, and pulls him by the heartstrings into a new way of thinking and living. I like that saying that ‘insight maketh a bloody entrance’; the insight required to get clean through the steps is bloody indeed! But these docs just sit back and say ‘no meetings, no Suboxone’, and wear their inflexibility as a badge of honor. I have been in that horrible situation as an addict where my opinion didn’t ‘count’, since I was ‘too sick’ to think logically… that is a tough spot, as the harder you argue, the more belligerent you are accused of being.
As for the scientific topics, I was glad to see that I am pretty much on target with my thoughts about dose levels, tapering, receptor actions, etc. Many docs start patients on twice per day dosing and later convert to once per day; I like to start at once per day from the very start, to avoid setting up a pattern that might be hard to break.
All in all, it was an interesting and informative weekend. I will probably make a couple small changes in my practice in light of things that I heard. And as for RB, I left the conference thinking that I will buy a few shares of their stock. They want to be a premiere addiction-related pharmaceutical company, and given the epidemic of opiates and other narcotics in this country and in other countries, the sky’s the limit!
SuboxDoc
Suboxone Talk Zone

Is Suboxone At Odds With Traditional Recovery?

By now almost every opiate addict has heard of Suboxone, a medication for opiate dependence that has been around for about ten years. I admit to mixed feelings about Suboxone based on what I have seen and heard while treating well over 100 patients over the past two years. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery.While Suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines.Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.
An amazing medication
For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone.In this article I will use the name ‘Suboxone’ because of the common reference to the drug, but in all cases I am referring to the use and actions of buprenorphine in either form.The unique effects of buprenorphine can be attributed to the drug’s unique molecular properties.First, the partial agonist effect at the receptor level results in a ‘ceiling effect’ to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel ‘normal’ within a few days of starting treatment.Finally, the withdrawal from buprenorphine provides a disincentive to stop taking the drug, and so the drug is always there to assure the person that any attempt to get high would be futile, dispelling any lingering thoughts about using an opiate.
Different treatment approaches
At the present time there are significant differences between the treatment approaches of those who use Suboxone versus those who use a non-medicated 12-step-based approach. People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking Suboxone as having an ’inferior’ form of recovery, or no recovery at all. This leaves Suboxone patients to go to Narcotics Anonymous and hide their use of Suboxone. On one hand, good boundaries include the right to keeping one’s private medical information so one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of Suboxone is a bit at odds with the idea of ’rigorous honesty’. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on ‘drug addicts’;they are not in a good position to deal with even more shame coming from other addicts themselves!
An ideal program will combine the benefits of 12-step programs with the benefits of the use of Suboxone.The time for such an approach is at hand, as it is likely that more and more medications will be brought forward for treatment of addiction now that Suboxone has proved profitable. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other.But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.Success rates for long-term sobriety are lower for opiates than for other substances. This may be because the ‘high’ from opiate use is different from the effects of other substances—users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic—ready to go out and take on the town. The ‘high’ of opiate use feels content and ‘normal’— users feel at home, as if they are getting back a part of themselves that was always missing. The experience of using rapidly becomes a part of who the person IS, rather than something the patient DOES.The term ‘denial’ fits nobody better than the active opiate user, particularly when seen as the mnemonic:Don’t Even Notice I Am Lying.
The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active opiate addiction.
Drug obsession and character defects
Suboxone has given us a new paradigm for treatment which I refer to as the ‘remission model’. This model takes into account that addiction is a dynamic process— far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time. Opiate addicts have a number of such ‘defects.’The dishonesty that occurs during active opiate addiction, for example, far surpasses similar defects from other substances, in my opinion.Other defects are common to all substance users; the addict represses awareness of his/her trapped condition and creates an artificial ‘self’ that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely.  The obsession with using takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered, and the opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal.The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self.The active addict learns to blame others for his/her own misery, and eventually their irritability results in loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that simply remaining sober will cause a ‘dry drunk’—a nondrinker with all of the alcoholic character defects– when there is no active recovery program in place.I had such an expectation when I first began treating opiate addicts with Suboxone—that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user. I realize now that I was making the assumption that character defects were relatively static—that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with Suboxone has been that the defects in fact are not ‘static’, but rather they are quite dynamic. I have come to believe that the difference between Suboxone treatment and a patient in a ‘dry drunk’ is that the Suboxone-treated patient has been freed from the obsession to use.A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking. People in AA will often say that it isn’t the alcohol that is the problem; it is the ‘ism’ that causes the damage.Such is the case with opiates as well—the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with Suboxone.
In traditional step-based treatment the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession when they suddenly experience a ‘shift of thinking’ that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a ‘rock bottom’. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives—in the brain’s limbic system. The ineffectiveness of higher-order thinking has been proven by addicts many times over, as they make promises over pictures of their loved ones or try to summon the will power to stay clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear—a primitive emotion from the old brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted.Unfortunately it is man’s nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.
The dynamic nature of personality
My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a ‘dry drunk’, but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside. The elimination of negative character traits does not always require rigorous step work— in many cases the negative traits simply disappear as the obsession to use is relieved.  I base this opinion on my experiences with scores of Suboxone patients, and more importantly with the spouses, parents, and children of Suboxone patients.I have seen multiple instances of improved communication and new-found humility.  I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful—and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.
A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn’t it require a great deal of work?  The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.
Combining suboxone treatment and traditional recovery
Once the dynamic relationship between use obsession and character defects is understood, the proper relationship between Suboxone and traditional recovery becomes clear.  Should people taking Suboxone attend NA or AA?Yes, if they want to.A 12-step program has much to offer an addict, or anyone for that matter. But I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on Suboxone do not feel desperate.In fact, people on Suboxone often report that ‘they feel normal for the first time in their lives’. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.
The role of ‘desperation’ should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at ‘rock bottom’ to open the mind to see one’s powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943; there can be little interest in higher order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should Suboxone patients be in a recovery group?
I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level.But for a person taking Suboxone I see the steps as valuable, but not essential.
-Where does methadone fit in?
Methadone is an opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return.With cravings comes the obsession to use and the associated character defects.This explains the profound difference in the subjective experiences of addicts maintained on Suboxone versus methadone, and explains why in my practice I have many patients who have switched to Suboxone, but none in the other direction.
The downside of Suboxone
Practitioners in traditional AODA treatment programs will see Suboxone as at best a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe Suboxone. Suboxone is sometimes used ‘on the street’ by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug. Snorting Suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.Finally, the remission model of Suboxone use implies long term use of the drug.Chronic use of any opiate, including Suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of Suboxone is complicated when surgery is necessary. Short- or moderate-term use of Suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
The beginning of the future
Time will tell whether or not Suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable for at least one pharmaceutical company, and such success will surely invite a great deal of research into addiction treatment.At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today.Some day we will likely look back on Suboxone as the beginning of new age of addiction treatment.But for now, the treatment community would be best served by recognizing each others’ strengths, rather than pointing out weaknesses.
This article can be reproduced freely as long as the following attribution is included:
The author, Jeffrey T. Junig MD PhD is a psychiatrist in solo practice in Wisconsin, and is Asst Clinical Professor of Psychiatry at the Medical College of Wisconsin.  Read more about suboxone at SuboxForum.com, AddictionRemission, or at Suboxone Talk Zone. He can be contacted at Fond du Lac Psychiatry.