Part one: An amazing medication
By now almost every opiate addict has heard of suboxone,
the amazing medication for opiate dependence that has taken
the using world by storm. I will 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.
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.
See Part Two: Drug obsession and character defects.
----------------------------------------------------
Jeffrey T Junig MD PhD has worked as a neuroscientist and
as an anesthesiologist, and is a psychiatrist in solo,
independent practice. Additional information about suboxone
including the blog Suboxone Talk Zone can be found at
http://subox.info . Dr. Junig is available for patient
care, consultations, or educational presentations through
http://fdlpsychiatry.com .
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