Part Three: 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 just another
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 other's
strengths, rather than pointing out their weaknesses.
----------------------------------------------------
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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