Before You Taper…

This post will be the third in a series, describing factors that should be considered before a patient on maintenance medication (methadone or buprenorphine) begins a taper off that medication. I want to remind readers to look at my post on December 21st for data about the mortality rates for patients who taper compared to patients who remain on maintenance medications. Many specialists say, with good data to support their position, that patients doing well on maintenance medication shouldn’t risk tapering off of it.

But patients are different, and their situations vary widely. Many of the patients I see strongly prefer to taper off their maintenance medication, and most want to start before I think they are ready. I’m posting this series to help patients decide if they are ready to taper, or if they have more recovery work to do, and in which areas.

If you want to taper, let’s make sure your chances of success are optimal.

People in twelve step recovery tell members who are new to recovery to avoid people, places, and things that remind them of drug use. Now, we understand how this common sense wisdom has a basis in biology. During addiction, the brain undergoes conditioning, a type of learning where a stimulus (some sort of sensory event) is paired with an event. Usually, conditioning helps us to better respond to our environment.

To illustrate conditioning, let’s take the simplified example of Pavlov’s dog. In this famous experiment, Pavlov’s dog was fed after every time a bell was rung. After this happened for a number of times, the dog started salivating at the sound of the bell, because his doggy brain had been conditioned to expect food, a strongly positive reward.

Humans also learn by conditioning, though of course on a much more complex level. In the case of addiction, because the stimulus is associated with an extremely powerful reward (getting high) conditioned learning is very strong. This is why a heroin addict who has been clean a short time will react strongly to the sight of a syringe and needle. PET scans of the brains of these people actually show release of dopamine, our “pleasure chemical,” when they’re shown pictures of a syringe.

It’s so important for recovering addicts to avoid reminders of drug use, especially early in recovery. Recovering addicts can be triggered by sights, smells, and even music that have been associated with past drug use. Addicts can also be triggered by people with whom they used drugs, events where they used drugs, or locations where they used drugs.

I’ve tried to explain this to many people intending to taper off maintenance medications (methadone and Suboxone) and sometimes hear things from them like, “They’re my friends. I’m not going to abandon them just because I can’t use drugs.” Or “I can go to a concert where there’s drug use because I’m just going to hear the music.” Or, “I’m just going to the bar to see my friends. I’m not going to drink alcohol. I’ll have a soft drink.”

I know these patients are sincere. They don’t plan on drinking or using. But once in an environment where the stimulus overwhelmingly has been associated with getting high, relapse is much more likely to happen. They may not use the first time they’re around drugs, and maybe not even the second or third time. But chances are high that sooner or later, the recovering addict will be having a bad day, get around these drug-using friends, and say, “Screw it. Give me one of those pain pills.”

Patients who are tapering off maintenance medications should have already cut off ties with people, places and things associated with drug use. If you haven’t done this basic work, you are not ready to taper.

If you’ve done the hard work of stabilizing on a maintenance medication, tapered carefully, and are now living a comfortable, medication- and drug-free life, why take any risks that might jeopardize this? True, you can always go back to maintenance medications, and should do so at the first relapse, but wouldn’t it be better if you didn’t relapse at all?

Some patients have very hard decisions to make if they’re married to another addict, or if their whole family uses drugs. But if they are going to be successful, they have to set some careful boundaries around their recovery. Recovery has to become your most important possession.

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7 responses to this post.

  1. Thank you for something which is coincidentally relevant to my situation. But I am still crippled. I used Subs to get off of IV heroin use of years, using only 2 mg a day for 2 weeks. How should I approach the taper or am I deep in it enough yet for it to be hard to cold turkey? Also, I have found Xanax does more for my mood and appetite, let alone restlessness that I dont feel the need for the Subs mentally. The half-life countdown associated with suboxone d/t is the psychological killer for me, as every runny nose or ache can easily be a rationalized reason to use a sub. And often sickness is mistakenly blamed as sourced from the meds. Is it a cold or am I going to not sleep tonight? Stress….

    Reply

    • There are too many variables in your situation for me to give medical advice, which is why you need face-to-face contact with your doctor. You do have a doctor, right?? I hope you aren’t buying Suboxoone off the street.
      Regarding the Xanax…please read my December 21st blog entry.

      Reply

    • have you ever withdrawn from benzos? remember your worst heroin withdrawel and multiply that times 10.
      29 days.
      i didn’t sleep for 29 days.
      29 DAYS.
      since you were a heroin addict i won’t waste time convincing you that i don’t mean i didn’t sleep much, or well; i didn’t sleep at all. on the 30th day i slept for 2 hours, the next day not at all, then gradually more each night.
      it’s not just being awake. it’s being awake with your skin crawling, by far the worst anxiety attack you can imagine. at times i felt like i had my finger in an outlet, with a high’pitched’ vibration running through my body til i thought i’d lose my mind. the rest of the symptoms were similar to coming off heroin.
      since working with other addicts in 1993, i’ve been to 31 funerals. 28 were od’s resulting from opiate-benzo combinations. when i can’t feel the heroin any more, it’s mostly out of my system. not so with benzos. i can do xanax on monday and heroin on tuesday, and it’s like hamburger helper: the effects are multiplied.
      i went on and off methadone many times,and it saved my life. it’s interesting to note that everyone in my life was against meth maintenance before. now they are advocates.
      while meth maintenance isn’t a first choice, and maybe not even a third or fourth.
      it’s safe, effective, and legal. i tried sub. but it was too easy to stop taking it so i could get high the week after. still in all, these medications save lives.
      believe me i’ve heard all the arguments,but there’s something i don’t want on my tombstone: HERE SHE LIES WITH ALL HER POTENTIAL INTACT, BUT AT LEAST SHE DIDN’T SUBSTITUTE ONE ADDICTION FOR ANOTHER.
      one of the requirements for the addiction label is increased tolerance, requiring more to get the same effect.
      this doesn’t happen with suboxone or methadone maintenance.
      it does happen with xanax regardless what it’s used for.
      if you’re determined to take it, just be certain you will never run out or be cut off.
      ever. for the rest of your life. if you’re like me you can’t stockpile it [i never saved a ‘wake-up’ while on heroin, ever. well, one time almost. at 2am i decided “That’s enuff sleep, let’s go!”
      so xanax is an ok choice unless you live where there are snow storms, tornados, hurricanes,earthquakes, flooding, power failures, holidays, insurance mix-ups, human-therefore fallible- doctors,or pharmacists.
      it’s fine unless you’ve ever, in yr life, forgotten where you put something, lost anything, left it home, left it on the cruise,or left it where i might see it.
      there shouldn’t be a problem unless you’ve ever gotten to a store after it’s closed, ie ever had car trouble, ever been held-up in traffic, taken a wrong turn….
      you know, like when on heroin.
      i’ve never known, or known of, anyone who was ever a heroin addict being able to take xanax safely. but hey, maybe you’ll be the one!
      being a drug addict just sucks all the way around.
      i wish i wasn’t a drug addict.
      then i could do drugs….

      Reply

  2. after years of addiction and the typical desruction of my life, i finally managed to get and stay clean. some years ago my rheumatoid arthritis became severe enough to threaten my sobriety, but i was able to hang on with all the recovery assistance available, and one quiet promise to myself:
    when the pain was truly beyond what i could or should have to endure, when the ‘always’ pain and the ‘sometimes’ pain began to merge, and when i knew for certain and for real i wasn’t looking to get high but to get relief, then i would add narcotics to my pain management regumine…in about a year.

    it sounds crazy, but the reality of my addiction has taught me to be wary of my own ‘if…then’ scenarios.
    the first time i tried to get sober was back in the 1800s, when i came home from college with my beloved cat,”Cat.” One of the scenarios i projected i wouldn’t be able to handle sober was the unbearable possibility of something happening to Cat. i just knew id use drugs.
    what if she got sick, and died?
    what if she got lost, and died?
    what if she stopped liking me.
    until then she’d been an indoor/outdoor cat, but there were just too many dangers outside, like killer dogs, and fleas with the plague.
    then, as it got harder to stay clean, i experienced the first magical transformation of “would” to “could,; the first of a lifetime to come.
    that’s when i decided it was selfish and cruel to keep poor Cat a prisoner. she needed the freedom to go out and play in traffic with other cats.

    i never hoped the pain would become a license, but i knew it could. the pain is real, and severe. the fear of how much worse it will get, and the inevitability that it will, plus the physical debilitation it causes …well it surely sucks.
    its difficult for people who don’t have similar conditions to really understand what it’s like.
    …except for addicts, of course.

    the ingredients may vary, but the recipe’s the same.

    so i tapered from methadone so i could add narcotics to the pain management.
    unfortunately i ‘did the right thing’ and told the pain doctor i’ve been clean for years, and everything changed. if you saw mw you’d have no doubts that i am in pain. when i told him i’m a recovering addict, he changed the 1st med. he prescribed to something less effective, since unfortunately there’s a correlation between narcotics’ analgesic effectiveness and their high [and yes i know all the options for pain relief that don’t get you high, believe me i know. been there done that.]
    the new meds don’t help. oh i’m sure they ‘help’, like a tee shirt in a blizzard helps, but the reality is that what i feared all these years has come true. i’m not going to get the help i need.
    at least i can honestly say i tried.

    Reply

  3. Posted by markie mark on January 19, 2012 at 6:00 pm

    I think your style & your rap are great, Paula Suedi.

    Reply

  4. Posted by markie mark on January 22, 2012 at 3:58 pm

    @Paula Suedi: your war stories are great.

    Reply

  5. Posted by DK on March 1, 2014 at 1:22 am

    Thank you for taking the time to write about this . I’ve be on methadone for 10 years , I started on pills Oxy’s . The strange thing about me is , I only had a 1 year run , then tried quitting and found it to hard . I turned to methadone for a answer and 10 years later I’m still here , afraid to taper until recently . I’m going down 2 mg a month , why rush, I figure everything in my life is going great . I am employed , own my home , married with 2 kids , have not seen or heard from past drug using pals in 10 years . In fact I was ready to taper by your account 8 years ago. But reading horror story’s online have made me afraid of Withdrawals , I want off because of my fear of long term health issues from methadone , my testosterone levels dropped after year 2 and I’ve been on hormone replacement since , my energy levels fluctuate . My job is the other reason , I’m not sure what would happen if found out .I would be looked at like a junky by my co workers . Even though most of them drink and do drugs ! Lol , I just need to try . Even though deep inside I feel methadone made my life better . I stopped drinking and going out to bars and party’s where bad shit would always happen and I’ve been home for my family . The stigma is real , people are pathetic . I guess I really need to here that others have made it off after being stable for 10+ years . Sorry for the life story .

    Reply

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