Suboxone, a new treatment paradigm: Part One

Suboxone is a relatively new medication for opiate
dependence that will result in a sea change in addiction
treatment. Physicians currently prescribing suboxone are
aware of the usefulness of this medication, and news of the
medication has reached 'the street' to such an extent that
opiate addicts often call addictionologists and ask for the
drug by name. Word of mouth has spread the news about
suboxone without the benefit (or need) of television
commercials. My experiences with suboxone make me wonder
if we are at the verge of an entirely new approach to
opiate addiction, and in turn to other addictions as well.
The traditional approach to drug addiction treats all
substances as essentially the same. Yes, the addict does
develop a 'love relationship' with his/her substance, but
the substance's sister, brother, aunt, or uncle can easily
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,
but there is a more complicated reason as well. The
addict, over time, becomes hyper-aware of his/her mood,
comfort level, and anxiety. The addict constantly 'checks
in' somatically, asking 'am I going up? Or 'am I (oh no!)
coming down? Every bead of sweat may portend the pain of
withdrawal. Every ache is a new excuse to use. The addict
takes comfort in the '4-hour schedule' of use; an internal
clock becomes all-important, and eventually the only thing
that really matters. Sobriety and recovery demand that the
addict learn to take life on life's terms, and give up the
obsession with symptoms and medications. Sobriety will
extinguish the learned obsession with symptoms over
time-sometimes 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 perception,
even a substance like diphenhydramine that is not
addictive, the old attention to feelings and symptoms
returns. Many addicts are aware of an 'addict' frame of
mind and a 'sober' frame of mind; a drug that causes the
addict to look inward and focus again on symptoms can
trigger the addict mindset to re-appear. And once the
addict is back, it can be very difficult to return to the
mindset of sobriety.

The need for total sobriety no doubt keeps some addicts
from asking for help, and there are other addicts who ask
for help but simply cannot maintain sobriety from all
substances despite multiple trials of treatment. To widen
the appeal and utility of addiction treatment, other
treatment models have appeared, including an approach that
has been called 'harm reduction'. The harm reduction
approach helps the addict find ways to reduce his/her
intake and so 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. Regarding the various
traditional treatment approaches, there are patients who
would clearly do better in one vs. another approach, and
there also patients who would 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 these individuals, because the cognitive
changes made in treatment will likely be obliterated by the
first drink. On the other hand, a patient with a 20-year
long smoldering addiction 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 the idea of total sobriety after one offense would be a
difficult sell. But with education about changes in
tolerance with aging, and an introduction to drink
counting, the patient may do well for another 20 years.

There are problems with traditional treatments, 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 I will
explain later. Another problem with traditional methods is
that they require significant motivation from
patients--motivation that must be accessible over and over
throughout patients' entire lives. Finally, some degree of
detoxification is usually required before tradition
treatments, requiring expensive medical services that may
be far removed from the treatment center. The specter of
detox and withdrawal are major roadblocks to treatment.
Withdrawal is a unique experience, difficult to compare to
other dysphoric experiences. Physical symptoms include
headache, fatigue, nausea and vomiting, abdominal cramping,
diarrhea, and muscle spasms of the legs that result in
involuntary movement. The withdrawing person usually feels
profoundly depressed and anxious. Even in situations where
there is no chance of access to drugs, the addict feels the
desperate need to use. The description of these symptoms
does not do justice to the misery experienced by the
withdrawing opiate addict. I also suspect that memory has
a 'kindling' effect on withdrawal such that symptoms become
more and more severe each time withdrawal is experienced,
so that eventually there is no such thing as 'mild
withdrawal'-the addict experiences withdrawal as severe as
any experienced to that point, regardless of the degree of
tolerance going into the withdrawal episode. Addicts who
have suffered through severe, unmedicated withdrawal have a
sense of camaraderie akin to disaster survivors.
Camaraderie is nowhere to be found during the withdrawal
experience, however, and the addict feels completely alone.

There have been alternate treatment models for years that
are less dependent on character modification and more
reliant on medication. Opiate maintenance with methadone
and opiate blockade with naltrexone are two treatment
approaches that are not dependent on the 12-steps or
cognitive therapy 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 creates deliberate 'hypertolerance' to opiates
in the addict by providing very high daily doses of opiates
(usually methadone). The high tolerance prevents
recreational use of opiates, and the high daily dose of
methadone serves to treat opiate cravings. Patients in
methadone programs often feel trapped, in that withdrawal
from such high doses of methadone is extremely difficult,
and any violation of the rules of the clinic (or problems
paying the high cost of treatment) result in dose
reductions. People maintained on methadone often claim
that they always feel 'high', no matter the tolerance that
develops. And while high doses of methadone will satisfy
cravings for a time, eventually the tolerance will catch up
and cravings will return. There are other problems with
methadone; some users claim that methadone results in a
lack of motivation to better themselves through education
or employment. For decades, methadone maintenance was
associated with blighted urban areas, where addicts could
line up each morning for their daily 'fix'. There have
been recent attempts to make methadone maintenance
'mainstream' by improving the physical facilities, and in
some cases relocating to less-blighted neighborhoods.
There have been few changes, however, in the regulatory
control of methadone. Methadone maintenance for the most
part requires addicts to add morning dosing into their
daily schedules, which in some cases becomes a barrier to
occupational growth.

Naltrexone has already been partially discussed. The use of
naltrexone is limited by the difficulty of achieving two
weeks of sobriety prior to treatment; it takes that long
for the sensitivity of opiate receptors to normalize to a
degree that avoids naltrexone-induced withdrawal. Another
problem is that the addict can 'choose to use' by simply
missing a couple days of naltrexone dosing. 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. In
addition to pills, naltrexone is marketed as an
intramuscular, monthly medication, which helps reduce the
'choose to use' problem. The primary indication for this
medication, interestingly, is alcohol dependence rather
than opiate dependence. 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 awakes with an implanted, slowly-dissolving chip of
naltrexone under the skin. This technique has popularity
since reports of patient deaths during the anesthesia, or
by suicide some time afterward.

In Part Two, I will explain how Suboxone represents a
dramatic improvement in the treatment of opiate addiction.

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Jeffrey Junig lives in Fond du Lac, Wisconsin. He has
worked as a neuroscientist and as an anesthesiologist, and
is a psychiatrist and pain physician in solo, independent
practice. Additional information can be found at
http://wisconsinopiates.com or http://fdlpsychiatry.com .
He is available for patient care, consultations, or
educational presentations.