Sick and Tired?

Suboxone, Buprenorphine, and Methadone

Over the years I have become an ‘accidental expert’ in addiction;  I experimented with uppers, downers, and hallucinogens (as we all did in the 1970’s!). I earned a PhD in Neurochemistry studying receptors for drugs of abuse at a leading Eastern University.  I earned my MD and trained in anesthesia at an Ivy League program.  I treated people with morphine, Demerol, fentanyl, sufentanil, and other narcotics for ten years as an anesthesiologist.  I became addicted to opiates, suffered many consequences, and went through 90 day residential treatment, and have been clean and in Recovery for 8 years.

I Know Addiction!

After treatment and some other sobering experiences I returned to residency, this time in psychiatry.  I now treat addiction and teach medical students and patients, drawing from my own experiences, the pharmacology and biologic effects of opiates, the strengths of 12-step-related programs, the most recent medications and other developments in neuroscience, and my favorite, the virtually unexplored relationships between psychodynamics and addiction, including the role of personality, defense mechanisms, evolutionary adaptation…  Trust me— fascinating stuff! 

The purpose of this site is to educate, from one addict— one over-trained, over-educated addict— to another.

Suboxone and buprenorphine have become extremely popular pathways out of the desolation of opiate addiction.  I have treated well over 100 patients with these amazing medications.  I have strong opinions on how they work best for different purposes— for detox, for long-term maintenance, or for pain treatment.  I have also seen them used in ways that are sure to worsen an already bad situation.  (See Below)

I would like to use this site to share my thoughts about suboxone, based on what I have seen and heard while treating well over 100 patients.  I also have opinions related to traditional recovery from my own experiences.  Unfortunately, at this point there are significant differences between the treatment approaches of those who use suboxone vs those who use a straight, 12-step recovery program.  People who stay sober with the help of AA, NA, or CA 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 NA 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’.

Ideally we will eventually find a way to combine the benefits of 12-step programs with the benefits of the use of suboxone, or other medications that aid sobriety.  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.  The character defects of active addiction can be addressed through 12-step programs, where the addict is in a constant battle with the obsession to use, and the obsession is relieved through recognition of powerlessness and a higher power.  But the remission model suggests that there is another way:  Suboxone removes the obsession to use almost immediately, and the absence of the obsession allows the return of positive character traits that were pushed aside by the obsession to use.  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.

Time will tell whether we can make this assimilation work or not.  But it is clear that the current paradigm needs adjustment.  For example, I see little benefit to forcing suboxone patients into 12-step programs, as such programs require desperation in order for the addict to be open minded to hearing the message at such meetings.  Suboxone patients, relieved of the obsession to use, no longer feel desperate.  In traditional treatment desperation is the most important prerequisite to undertaking treatment, and little success is expected without some sort of ‘rock bottom’. 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 Maslow and a ‘hierarchy of needs’— there can be little interest in higher order traits when one is fighting for one’s life.

Comments?

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