Archive for the ‘12-Step Recovery’ Category

Year in Review: 2018 and the Treatment of Opioid Use Disorders

This year has been difficult for many people, due to disasters both natural and unnatural. As in any year, good things also happened. Since my blog concentrates on opioid use disorder and its treatment with medication, this entry will focus on the positive events in my field. I’ll save the more negative events for another blog, when I’m feeling grumpy, for those days will surely come.

This last year, the problem of opioid use disorder is got essential attention from governmental agencies, the press, and the public in general. For too long, no one was talking or caring about this issue. Now, this widespread medical problem is getting the kind of attention that leads to change: financial attention.

Big money for treatment

The CURES grant money, approved by legislation in late 2016, made almost a billion dollars available to help treat opioid use disorder. That money was released starting in early 2017, and has helped many patients.

In mid-2018, legislation was passed to approve another near-billion dollars to treat opioid use disorder and its prevention. Called the State Opioid Response, or SOR, this money will be released through SAMHSA to each state’s single-state agency. This money must be used for prevention and treatment, and to increase availability to medication-assisted treatment with the three FDA-approved medications: methadone, buprenorphine, and naltrexone.

From my reading of SAHMSA’s description of the SOR grants (https://www.samhsa.gov/grants/grant-announcements/ti-18-015 ), most of the money will need to be used for treatment with MAT.

This is big money, and is intended for treatment that includes evidence-based treatment with medications. In other words, the abstinence-only, “we don’t believe in medications” type programs probably won’t qualify for these grant dollars.

I’d like to pause and say a big “Thank you!” to the legislators who wisely crafted this grant.

As an example of fiscal irresponsibility of the past, with CURES dollars, some areas of our state cycled patients through five-to-seven- day detox admissions that had very little chance of helping. We’ve known the abysmal data from such short stays for decades, yet many treatment dollars were flushed down that detox drain.

Now, to get grant money to pay for detox, patients will need to start on naltrexone (probably the month-long depot injection) prior to leaving the facility. This makes sense and should improve patient outcomes. They could also be started on methadone or buprenorphine, but presumable inpatient detoxification wouldn’t be needed to start these medications.

The end of a detox is a perfect time to use naltrexone. Once a patient has started on it, it’s much easier to continue, either at an opioid treatment program or even in a primary care office. Since it’s not a controlled substance, physicians and extenders don’t need a DEA number to prescribe this evidence-based medication.

We’ve seen the benefit of CURES grant money at our opioid treatment program, where patients are treated with either methadone or buprenorphine. (We also offer naltrexone, but don’t often get patients when they are suitable for this medication, since they are actively using opioids.)

Before CURES, self-pay patients had difficulty remaining in treatment, and often opted to taper out of treatment before they were ready. Now, we’ve seen those people stay in treatment and thrive. I don’t have data, but I’m sure it is being collected. Now with continued money from the SOR grants, we can continue to provide care to people who have no way to pay for care.

Sometimes people get angry about public funding for MAT. They feel that since they must pay for the treatment of their own chronic disease, patients with opioid use disorder should, too. I can’t comment on the fairness aspect, but I do know that each dollar tax payers spend on MAT saves between $4 – $11 in tax expenses, most of which is saved on incarceration costs, medical costs, and the like.

Personally, I’m happy my tax dollars go towards such a great investment.

Tolerance and inclusivity at some 12-step meetings

I see a trend of tolerance and inclusivity in the recovery communities…at least in my area.

In 2018, a new Narcotics Anonymous group started here with the express purpose of welcoming people on medication-assisted treatment for opioid use disorder. Since I work with patients on medication-assisted treatment, this delighted me. Some of them want to go to 12-step meetings, either Alcoholics Anonymous or Narcotics Anonymous, but don’t feel welcome at the existing groups. Now they have a meeting where they won’t be judged for being on medication, if they chose to share that fact.

This meeting was started by a handful of long-term members of Narcotics Anonymous with more than fifty years of recovery between them. They intended to honor the traditional primary purpose of all 12-step groups: to carry the message of recovery to those people still suffering. The founders of the meeting felt tearing down barriers for people on MAT was the best way to adhere to that primary purpose. At this new meeting, such NA members are full members, with the right to speak at meetings, do service work, sponsor and be sponsored.

The meeting started in February, and attendance ranged from two people to fourteen people per meeting. It’s still in a fragile state, with only a few people coming to nearly every meeting, but it’s a good start.

Some NA members have attended who didn’t share the group’s stated position on the topic. They too were welcomed warmly and asked to return frequently. Attendees don’t have to agree with the group’s position on MAT, as long as they respect the group and its members. Again, emphasis is on inclusivity. Also, the “still suffering addict” isn’t always a newcomer. Sometimes it’s the person with the most time in recovery, so everyone needs to be welcomed.

This is my opinion: if 12-step groups don’t embrace people seeking recovery who are on medications, they will become less relevant. If they fail to reach people on MAT, they will have failed their stated primary purpose, from a lack of open-mindedness and willingness, two of the essential spiritual principles of 12-step meetings.

Breaking Down Silos

I’ve seen and participated in more cross-specialty discussions about MAT in 2018.

In the past, medication-assisted treatment took place at opioid treatment programs (OTPs) and no medical providers outside the OTPs knew what happened there. Some providers and owners of the OTP companies preferred it this way; a low profile might mean no protesters outside, shouting NIMBY (not in my backyard) slogans. They tried to keep everything hush-hush, so the community wouldn’t try to expel them.

Now, providers at OTPs and owners of OTPs are asked to participate in the recovery efforts of people with opioid use disorders. Slowly, as communities desperate for answers have turned to the scientific literature for how best to treat opioid use disorder, they’ve re-discovered the literature that’s been the foundation of MAT at OTPs for decades.

Last year, I was asked to speak to a variety of groups about what we do at opioid treatment programs. In May, I spoke to a conference of U.S. probation and parole officers. In September, I was on a panel of people who spoke at a conference for pharmacists. Also in September, I was invited to talk to our state’s medical board, to explain more about medication-assisted treatment.

All these events were interesting. Some were enjoyable, and one, with the medical board, was transcendent.

I was a little worried about talking to this group, who make up the “doctor police.” When patients complain about a doctor, the medical board investigates. When physicians are suspected of medical incompetence, the medical board investigates. Each physician must have a license issued by the state medical board to work in our profession. By the nature of what they do, medical boards hold a great deal of power.

I was worried about my presentation, mostly because I had about fifteen minutes to explain a few decades’ worth of science, and to dispel the common myths held by most medical professionals about “methadone clinics.”

But it could not have gone better. Board members were welcoming and friendly. I did my presentation, finished just a little over time, and asked for questions. I got great questions that showed they grasped the complexities of treating people with opioid use disorder who have other challenges as well, and how best to treat them without abandoning them.

Another presentation was scheduled right after me, but the meeting halted while nearly all of the board members, who had been seated behind a raised dais, came to me to shake my hand and thank me for coming and tell me how important this work was. I was blown away by their kindness and support, and their eagerness to understand opioid use disorder and appropriate treatment.

I left there glowing. I felt like they understood, like they got what I was saying. The drive from Raleigh to Wilkesboro went by in a happy blur.

More opioid treatment providers

We have more treatment facilities available to treat opioid use disorders Since 2014, around 254 new opioid treatment programs, formerly called methadone clinics, have opened, according to a recent article in the Washington Post. [1]

Prior to that, the number of opioid treatment programs remained unchanged.

We’ve seen a push to get more primary care providers interested in prescribing buprenorphine for their patients with opioid use disorder, rather than referring all of them to specialty programs. Project ECHO at UNC started a few years ago, doing outreach to providers, and support to them in any way needed.

UNC ECHO now has three online interactive sessions per week for buprenorphine prescribers. In those sessions, cases are presented and feedback and suggestions are obtained from other providers. There’s also usually a short teaching session provided by one of the experts, on topics ranging from treatment during pregnancy to payment issues in an office-based practice. Besides providing essential guidance, providers get free continuing medical education credits.

More providers of medication-assisted treatment should mean fewer deaths from overdose. Multiple studies show reduced death risk when patients are on MAT, with an average reduction of death by three-fold.

I’m optimistic about treatment opportunities for people with opioid use disorders. I see a gradual lessening of stigma towards people who have this disorder, as well as towards the life-saving treatments for the disorder. I hope we continue to make progress in 2019.

  1. https://www.washingtonpost.com/national/health-science/some-states-add-more-methadone-clinics-to-fight-opioid-epidemic/2018/11/09/8cace992-e133-11e8-b759-3d88a5ce9e19_story.html?noredirect=on&utm_term=.59a7b585e0aa

 

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Harm Reduction and Abstinence-only Approaches to Treatment

 

 

First of all, I know the gif doesn’t have anything to do with this blog post, but I thought it was really cool, and I like langurs. It looks like he’s really enjoying his day.

 

 

 

I’m re-running a blog entry from the past, since I got some interesting comments the first time. Plus, I’m feeling lazy today, so here goes:

 

I’ve heard the harm reduction and abstinence-only debate about addiction treatment many times, not only at addiction medicine conferences, but also in my own head. In the past, I thought abstinence from all addictive drugs was the only true recovery from addiction. As I’ve aged, I’ve traveled far into the harm reduction camp, having seen people with addiction die from their disease when perhaps more could have been done to save them.

A wise mentor of mine once said try not to argue with people who aren’t actually in the room with you, so I’ve committed the debate to writing.

Following is an imaginary debate between two addiction treatment professionals. One professional believes harm reduction measures are worthwhile because they can keep people with substance use disorders alive and healthier, even if they never completely stop using drugs. The other professional feels harm reduction cheats them out of full and happy recovery, which she believes is seen with complete abstinence from all drugs.

First, they chat about needle exchange:

HR: I fully support needle exchange programs. They have been proven to reduce transmission of infectious diseases, including HIV and hepatitis. Why wouldn’t we want to help people avoid getting these potentially devastating diseases?

AO: Because giving out needles sends the wrong message. It says we are OK with people injecting drugs, and that we are willing to make it easier for them to do so. Appearing to condone drug use in any way sends the wrong message to young adults, who may be considering using drugs for the first time. Stigma towards drug users can be harmful, but perhaps stigma serves a good purpose if it discourages people from doing dangerous things like injection drug use.

HR: Studies do not show needle exchange increases the likelihood that people will start using drug intravenously. Easily available clean needles are not enough to convince a person to start injecting drugs. Besides, even if you have little compassion for the drug user, for every case of HIV we prevent with needle exchange, we save our society countless dollars in medical care. That’s just one disease. When you consider the health burden and medical costs of transmission of hepatitis C, it’s even more reasonable.

Even the ultra-conservative Mike Pence, our Vice President, changed his mind on needle exchange after an outbreak of HIV occurred in a rural community among people injecting opioids.

Besides being morally right, needle exchange makes financial sense.

AO: No, it doesn’t. It sends a message to people who inject drugs that we’ve given up on them. It says we don’t think they will ever be able to live without injecting drugs. In a way, it infantilizes them. By making drug use easier, we may cheat them out of a full and more satisfying recovery.

AO and HR move to the topic of medication-assisted treatment of opioid addiction with methadone and buprenorphine:

HR: First of all, medication-assisted treatment (MAT) is harm reduction only so far as all treatment should reduce harm. MAT is a good treatment in itself, and isn’t necessarily just a stop on the journey of recovery.

I fully support medication-assisted treatment. We have fifty years of studies that show people with opioid use disorder are less likely to die if they enroll in methadone maintenance or buprenorphine maintenance. It is one of the most heavily evidence-based treatments in all of medicine, and it is endorsed by many professional agencies, such as the Institute for Medicine, Substance Abuse and Mental Health Services Administration, the World Health Organization, and the American Society of Addiction Medicine.

We have study after study showing that people with opioid use disorder have a better quality of life when on medication-assisted treatment. We have more information about methadone because it has been use in the U.S. much longer than buprenorphine, which was approved by the Food and Drug Administration in 2002, after the Drug Addiction Treatment Act of 2000 was passed.

People with opioid use disorder who enter methadone treatment are more likely to become employed, much less likely to commit crime, and more likely to have improved mental and physical health. They receive addiction counseling as part of the process of treatment. We think buprenorphine has the same benefits, though there have been fewer studies than with methadone. We do know the risk of opioid overdose death is much lower when a person with opioid use disorder is treated with buprenorphine, too.

Because medication-assisted treatment is so effective, it should be considered a primary treatment of opioid use disorder, not only a harm reduction strategy.

AO: With MAT, people with opioid use disorder may be harmed more than if they continue in active addiction. It is no different from giving an alcoholic whiskey. Methadone is a heavy opioid that’s difficult to get off of. The opioid treatment programs that administer methadone don’t try to help these people to get off of methadone, because they make more money by keeping them in treatment. These patients are chained to methadone with liquid handcuffs forever. It’s also expensive over the long run, and patients have many restrictions put on them by state and federal governments.

HM: Methadone and buprenorphine treatments are not like giving an alcoholic whiskey, because the unique pharmacology of these medications. Both medications have a long half-life, and when patients are on a stable dose, they feel normal all day long without cravings for illicit opioids. This frees them from the unending search for drugs that occupies much of their days. Instead, they can concentrate on positive life goals. They can live normal lives while taking medication once per day that does not cause impairment or euphoria or sedation.

Also, many people with opioid use disorder still feel some withdrawal symptoms even after acute withdrawal is over. This syndrome, often called post-acute withdrawal syndrome, can cause fatigue, body aches, depression, anxiety, and insomnia. It’s unpleasant. Some people may crave opioids intensely. We think this occurs because that person’s body no longer makes the body’s own opioids, called endorphins.

Opioid use disorder is a metabolic disorder. Symptoms abate when the patient is started on appropriate replacement therapy, just like insulin with diabetes.

Methadone and buprenorphine are both very long-acting opioids. Instead of the cycle of euphoria and withdrawal seen with short-acting opioids, these medications occupy opioid receptors for more than twenty-four hours. It can be dosed once per day and at the proper dose, it eliminates craving for opioids, and eliminates the post-acute withdrawal, which is so difficult to tolerate.

And yes, methadone is difficult to taper off of, but most of the time it is in the patient’s best interests to stay on this medication, rather than risk a potentially fatal relapse to active opioid addiction. Some patients are able to taper off of it, if they can do it slowly.

Do you think of a diabetic who needs insulin as being “handcuffed” to it? What about a patient with very high cholesterol? Is she “handcuffed” to Lipitor? Do you think the doctor who continues to prescribe insulin is just trying to make money off that patient? Why is it OK for a doctor to make money from treating other chronic illnesses, but not from substance use disorders?

AO: What about the people with opioid use disorder who are doing well in abstinence-based 12-step recovery, who are healthy and happy off all opioids? Why are these people doing so well, even though their disorder was as bad as patients in opioid treatment programs? And 12-step meetings don’t cost anything.

HR: We don’t have all the answers to this question. One form of treatment, even medication-assisted treatment, won’t be right for every patient. Maybe the support that a 12-step group can provide got these people through the post-acute withdrawal. We don’t have much information about these recovering people, obviously due to the anonymous nature of that program.

If people with opioid use disorder feel OK off all opioids, that’s great. They don’t need medication. But they shouldn’t criticize the other people who clearly do benefit from medication-assisted treatment with methadone, and buprenorphine. Let’s support all options.

Besides, not all people with opioid use disorder want to go to 12-step meetings. Do treatment professionals have the right to insist everyone go to these meetings, even if patients don’t like them?

AO: Medications cheat patients out of full abstinent recovery. Methadone and buprenorphine blunt human emotions, and make it impossible to make the spiritual changes necessary for real recovery. Methadone and buprenorphine are intoxicants, and they prevent people from achieving the spiritual growth needed for full recovery. You keep these people from finding true recovery, and condemn them to a life of cloudy thinking from these medications.

HR: Various people assert patients on maintenance methadone and buprenorphine have blunted emotions and spirituality, but there’s no evidence to support that claim. How can you measure spirituality? If spirituality means becoming re-connected with friends and loved ones and being a working, productive member of society, then studies show that methadone and buprenorphine are more likely to assist patients to make those changes.

Physically, studies show patients on maintenance methadone and buprenorphine have normal reflexes, and normal judgment. They are able to think without problems, due to the tolerance that has built up to opioids. They can drive and operate machinery safely, without limits on their activities. Contrary to popular public opinion, patients on stable methadone doses are able to drive without impairment, assuming their dose is appropriate and no other substances are used that could be impairing.

People with opioid use disorder are far more likely to make significant and healthy life changes if they feel normal, as they do on medications like methadone and buprenorphine. If they chose abstinence, many times they feel a low-grade withdrawal for weeks or months, and this makes going to meetings and meeting life’s responsibilities more difficult.

Far too many people with opioid use disorder have had abstinence-only addiction treatments rammed down their throats. Most of these patients aren’t even told about the option of medication-assisted treatment, which is much more likely to keep an opioid drug user alive than other treatment modalities.

Too often, such patients cycle in and out of detoxification facilities over and over, even though we have forty years of evidence that shows relapse rates of over 90% after a several weeks’ admission to a detox facility. We’ve known this since the 1950’s, and yet we keep recommending this same treatment that has a low chance of working. And then we blame the addict if he relapses, when he was never given a treatment with a decent chance of working!

And a patient just released from a detox facility has a higher risk of dying from an opioid overdose. What other treatment in modern medicine is recommended that has such a poor response rate and an increased risk of death?

Medical professionals, the wealthy, and famous people are often treated with three to six months of inpatient residential treatment, and they have higher success rates. Physicians have about an 80% abstinence rate at five years into recovery, but besides prolonged treatment, they sign intense monitoring contracts (usually five years). They have mandated recovery meetings, random drug screens, and other supports available to them, along with loss of professional licensure if they relapse.

For most people with opioid use disorder, that kind of treatment and support isn’t available. It’s expensive, and many such patients have no insurance, or insurance that will only pay for a few weeks of treatment.

For most people, medication-assisted treatment can be a life-saving godsend. It isn’t right for every patient with opioid use disorder, but we know people are less likely to die when started in medication-assisted treatment. After patients make progress in counseling, there may come a time when it is reasonable to start a slow taper to get off either methadone or buprenorphine – or maybe not. But first we should focus on preventing deaths.

AO: Given the time, money, expense, and stigma against methadone and buprenorphine, it should be saved as a last resort treatment. If an person with opioid use disorder fails to do well after an inpatient residential treatment episode, then MAT could be considered as a second-line treatment. Let’s save such burdensome treatments for the relapse-prone patients.

HR: It seems disingenuous to claim stigma as a reason to avoid MAT when you are the one placing stigma on this treatment.

I could go on for many more pages, so let’s stop here. You get the idea.

In the past, harm reduction and abstinence were considered opposing views. I’ve heard some very smart people say this is a false dichotomy, and that in real life, these views are complementary.

I like this newer viewpoint.

Any form of treatment should reduce harm. If a patient achieves abstinence from drugs, then that’s the ultimate reduction of harm. Also, harm reduction principles can help keep drug users alive, giving them the opportunity to change drug use patterns later in life. Let’s give people more choice and more opportunities to transition out of drug use, if that’s what they desire.

Let’s do a better job of working together.

The Recovering: Intoxication and Its Aftermath, by Leslie Jamison

This book will stay on my bookshelf to read again; that’s the highest praise I can give any book. Any person interested in substance use disorders and recovery from substance use disorders will find the book interesting and informative.

This is a memoir of the author’s drinking days and her forays into recovery, but it’s more than that too. Intertwined with her story, she divagates down some interesting roads.

She talks about artists, and the relationship between intoxication and the artistic temperament. Since she is an author, most of the examples she gives are of other authors, like David Foster Wallace, who wrote Infinite Jest, or Charles Jackson, who wrote The Lost Weekend. She does talk about the singer Billie Holiday, and about the misery her heroin use brought into her life, and about many other artists.

By page 352 (out of a hefty 448 total pages), the author reveals that her PhD dissertation was about authors who got sober, and how their sobriety affected subsequent work. No wonder she had interesting details about these writers and their struggles. In some cases, she could point out their best works were in sobriety.

I appreciate this idea. I’m bored to death of the cliché of intoxication as artistic muse. Sure, some works of art, be they literature, paintings, music, or other forms, were inspired by intoxicants. Yet how many renowned artists’ lives have been cut short by substance use disorders? The main examples that spring to my mind are musicians, like Janis Joplin, Kurt Cobain, Michael Jackson, Prince…how much enjoyment has the world be cheated out of from the early demise of these artists?

Dead artists don’t create. I hate to hear people imply that great talents must have substance use problems, as proof of how much they suffer for their art. That’s a tired, inaccurate lie.

In her narrative segments, she gives a window into the mind of an alcoholic, or anyone with an obsession that causes harm. She describes the usual justifications and rationalizations she used while drinking, and the same thoughts that came to her while sober.

In other segments, she talks about how race, class, and sex impact how society regards people afflicted with substance use disorders. She points out the inequities of the legal system, and how the percentages of blacks in prison is higher than of whites. She uses the cocaine laws of the 1980’s to make her point. Then, crack cocaine, which was more often used by blacks, carried the same penalty as ten times that amount of powder cocaine, more often used by whites. This meant blacks received much stiffer sentences of incarceration than whites for the same amount of drug. That’s one example of many of how minorities face more consequences for drug and alcohol use disorders.

She gives some history of the Lexington, Kentucky, Narcotic Farm, where people with opioid use disorders went voluntarily or were sentenced for recovery.

She gives a little history of how Alcoholics Anonymous was formed, and how the 12 steps and recovery community work together. She describes what scientists found years later – that peer support and contingency management treatments work, and AA has offered a version of them since the 1930s.

She also writes about the negative aspects of AA. She writes about how simplistic it is, how it’s too reductionist for complex people, and how some people may feel too smart for AA. It’s obvious that she is highly intelligent, and she admits, throughout the book, to her struggles with AA’s basic concepts.

She didn’t have an easy recovery. During her first try at sobriety, she tells how her primary relationship suffered, how depressed she felt much of the time, and how she didn’t feel as creative. She planned her relapse ahead of time at her seventh month of sobriety, with predictable results. She initially enjoyed her return to drinking but it didn’t take long to become more miserable than ever.

Her second try at sobriety went better. She was more enthusiastic about AA, and she eventually sponsored other people. She stopped focusing on herself and saw the importance of being part of a bigger community. She saw the value of people’s stories, even when they were so similar. Indeed, she saw value in the similarity of the stories, because people in AA could relate to one another even though their life experiences were different.

The emotions behind the events of drug and alcohol use connected people seeking recovery. People from different lives and lifestyles bond over shared emotional experiences common to during substance use disorder and their recovery. That’s why it’s not unusual to see a tattooed biker dude hugging a nun at a 12-step meeting

Though much of the book is about her struggles with alcohol, she describes traveling to and working in some exotic places, all of which became dreary under the influence of alcohol. She describes similar drabness in her relationships while drinking, coloring her world gray.

I have few criticisms about the book. I got bored with her constant relationship problems before, during, and after sobriety, but then I tend to have little patience with that sort of thing. If the relationship isn’t working, then end the relationship instead of bemoaning the dysfunction. I understand that sometimes relationships, even the best ones, need work. But she described mostly the work and rarely the rewards of these relationships.

I thought she should have ended her relationship with her long-term boyfriend Dave when she suspected he was cheating on her. While I read about her painful moments when she was at home and he was out doing who knows what, I kept muttering, “Dump him! Dump him!” But who among us hasn’t held on to a relationship longer than we should? So, I do understand. I won’t spoil the book by telling you whether they stay together or not.

Best of all, I like how the author ultimately embraced Alcoholics Anonymous in all its imperfections, while acknowledging other recovery paths are valid. At the end of her book in the section “Author’s Note,” I was happy to read her clear statements that one treatment doesn’t work for everyone, and that medications should be made available to help people. She specifically mentions buprenorphine, which of course warmed my heart.

She also talks about the War on Drugs, and about countries who have found a better way to deal with substance use disorders, without the moral disapproval that is so common in the U.S.

In short, it’s an interesting book with information tucked into an entertaining narrative about one woman’s alcohol use disorder and recovery. It’s the best book I’ve read on this subject since Caroline Knapp’s “Drinking: A Love Story.”

I highly recommend this book.

 

Tiny Candle of Hope

 

 

Every Friday at 6 pm at the Crossfire Biker’s church in North Wilkesboro, NC, people gather to attend a tiny meeting of Narcotics Anonymous, called the Brushy Mountain Group.

It’s not a large meeting; only six to eight people are there on any given Friday. It’s not an old and established meeting; it only started three months ago. But this meeting’s impact could be massive because it has the potential to change the lives of the participants.

This meeting was started with the intention of giving all people seeking recovery a place to get well. Applying the spiritual principles of acceptance and unconditional love, this NA meeting welcomes every person who wishes to recover from the disease of addiction.

This meeting makes no distinction between members who are prescribed methadone, buprenorphine, anti-depressants, stimulants, or other medications. Everyone is welcome to attend and everyone is welcome to share their experience, strength and hope. The recovering people who happen to be prescribed methadone and buprenorphine are treated as full members.

For critics who say Narcotics Anonymous is meant to be a program of complete abstinence from all drugs, people at this meeting have no issue with this statement. They know there is a difference between using drugs and taking medication. Surely the founders of NA never meant for members to be completely abstinent from all medications!

These members know the Third Tradition of Narcotics Anonymous says, “The only requirement for membership is the desire to stop using.” The assumption is that this means using drugs, not medications. At this meeting, members make their own decisions about their “clean date.” For most, the clean date is the day after their last illicit drug use.

At this meeting, the Fifth Tradition of Narcotics Anonymous is felt to be of the upmost importance, and should be a main guiding principle of every meeting: “Each group has but one primary purpose: to carry the message to the addict who still suffers.” No clean time distinctions are made. This still-suffering addict may be a newcomer, or it may be a member with twenty years of recovery. Suffering is suffering, and the group is there to support suffering members.

If a participant shares about taking medication, no one clutches at their pearls and gasps. No one  tut-tuts and asks them to shut up and talk to someone after the meeting. These people are given the same esteem as all other members. The others listen in respectful silence, and sharing continues after that person is finished.

Participants don’t often share about medication, except in passing. Most share about how they are feeling and how their emotions affect their recovery. They talk about situations that could cause a relapse, and they share gratitude for achievements big and small. They talk about how to handle the guilt from their actions in active addiction, or about how they want to do a better job raising the children.

In other words, an observer couldn’t tell this meeting was any different from any other NA meeting where recovery is underway.

This meeting is a tiny candle, spreading just a flicker of light into a small corner of one community darkened by the opioid use disorder epidemic.

But what if this light spread…what if more 12-step meetings welcomed people on methadone or buprenorphine with open arms, with hugs and unconditional love instead of judgment and put-downs?

Then 12-step recovery could be ablaze with the light of changing lives.

That’s my prayer.

 

Comorbidity and a Sad Update


 

 

In 2011, I posted the following blog entry, and described an example of a patient from my office-based practice to illustrate:

Addicted patients are twice as likely as non-addicted patients to have mental illnesses such as mood disorders, anxiety disorders, schizophrenia, and attention-deficit hyperactivity disorder. The converse is also true: patients with mental illness diagnoses are twice as likely to have an addictive illness in addition to their mental illness.

Why is this? Is there a common factor underlying both types of disorders? Does one cause the other? For years, doctors and therapists have argued about this, and there are still no definite answers. However, why these diseases occur together isn’t as important to me as how to treat them most effectively.

We know patients get the best results when both diseases are treated at the same time, preferably under the same roof. That’s not always easy, but it’s the ideal.

To further complicate treatment, many times drug addiction causes the same symptoms as mental illness. For example, a person intoxicated on methamphetamine can look just like someone in the manic phase of bipolar disorder, or even schizophrenia. Another example can be seen in heavy drinkers, who are often depressed from the effects of alcohol, which is a depressant.

I rely on several methods to help me decide if drug use, abuse, or addiction is mimicking mental illness. First, I try to get information about what a patient was like during periods of abstinence from all drugs. If all of the mental illness symptoms went away during abstinence, it’s less likely that there’s an underlying mental illness. However, if the patient was still suffering with significant symptoms of mental illness even during a period of abstinence from drugs, the patient probably has a second diagnosis.

I ask about family history of mental illness, because if relatives have been diagnosed with these disorders, it’s more likely that the patient I’m treating will have mental illness in addition to addiction.

I ask my patient which started first, the symptoms of mental disorder or drug use? Often, symptoms of mental illness and drug use both started around the same time, at late adolescence/early adulthood, so that history often isn’t as helpful as I’d like.

Here’s an example of a case I saw recently: (identifying details have been changed):

A 24 year old female saw me in my office as a new patient. She wanted to be considered for my Suboxone program. She gave a history of illicit drug use for four years, and had used opioids daily for a year and a half, snorting up to 200mg of hydrocodone or oxycodone per day. She used marijuana three times a week, usually two cigarettes per day. She denied use of benzodiazepines or alcohol, and said her father was an alcoholic. She used cocaine heavily in the past, but stopped using it three years ago because of its expense. Besides, by that time, she preferred opioids. She acknowledged recent use of methamphetamine three or four days ago, and said she snorted methamphetamine when she couldn’t find any opioids, only to stave off withdrawal. Her answers about frequency and amount of methamphetamine used were vague and evasive, so I was unsure of her exact history.

When I asked about her mood, she said she was depressed because of all the bad things that were happening as a result of her addiction: she was broke, her boyfriend just broke up with her (he was her drug-using buddy) and her family wasn’t loaning her any money, so she was in withdrawal much of the time. She denied any period of abstinence from drugs since she started using drugs at age 15. Family history was significant for a maternal aunt with severe bipolar disorder, requiring psychiatric hospitalization on multiple occasions.

Her exam was worrisome for a very low body weight. At 5’6” she weighed 103lbs. (she denied any symptoms of eating disorders) She was tense, pleasant, intelligent, and well-spoken. She fidgeted in her chair to an extreme amount. She was in florid opioid withdrawal, with wide pupils that were briskly reactive, obvious runny nose, frequent yawning, sweating, and goose bumps visible on her upper arms.

Her mother, who paid for her treatment, came to the appointment with her. My patient gave me permission to talk with her mother, who had quite a bit to add to the story. Mom said her daughter often seemed paranoid, and last weekend she stayed awake all night on Saturday, peering out one window after another, and checking repeatedly to make sure they were locked. My patient’s weird behavior kept the family awake all night. My patient also claimed to be able to hear people talking just outside the windows, and was sure the government meant to take her from her family for a nefarious reason. The patient’s mother said this last weekend was the most severe paranoid behavior she had seen in her daughter, but she had seen similar conduct in the past.

At this point, I thought there was a good chance we were dealing with more than just addiction. I considered bipolar disorder with psychotic features to be the most likely diagnosis, or schizophrenia. I hoped her use of methamphetamine had caused these worrisome symptoms, since she shouldn’t have them once she stopped use of the drug and got out of opioid withdrawal.

With this new information, I changed my treatment recommendation, and thought an inpatient admission to a detoxification unit was most appropriate. Her psychiatric status could be closely observed, and she could be started on Suboxone. If the psychotic features resolved, great. If not, she could be started on appropriate medications, be stabilized and then come see me after she was discharged. I could maintain her on Suboxone after she was stabilized.

It was a great idea, but unworkable. The detoxification unit wanted a chunk of money up front, before admission, and she didn’t have that kind of money. It was also beyond her mother’s financial capability. This patient had no insurance and didn’t qualify for Medicaid.

The patient pleaded with me to start on Suboxone. She believed all would be well if only she could get out of opioid withdrawal. I had my doubts, but agreed to prescribe one week of medication with telephone contact. Her mother agreed to call me or take her daughter to the psychiatric emergency room if her mood or behavior deteriorated.

One week later, a calm, smiling young lady entered my office. She had gained seven pounds in one week, and was no longer restless. The change was remarkable. Her mom came with her and said she hadn’t seen any more paranoid behavior. Her mother started to cry, saying, “I have my daughter back.” I was thrilled at the improvement. I adjusted her Suboxone dose slightly, and made sure she had her first session with the addiction counselor in my office.

I’ve seen her every week for the past month. She goes to three Narcotics Anonymous meetings per week, which is fewer than I’d like, but at least she’s going. She’s met with the licensed addiction counselor in my office each week. She’s had negative urine drug screens for the past three weeks and continues to gain weight. She says her mood is good, and she just went back to work.

For now, I don’t see evidence on mental disorder, but I’ll keep watching for problems.

I have a sad update.

After about two years of doing extremely well in my office-based practice, this patient relapsed. She was taking Suboxone 8mg per day, and appeared to be enjoying a good recovery. She went to 12-step meetings, got a sponsor, worked the 12 steps of recovery, and did service work at her home group.

She also had some sessions with the therapist who works in my office, who is MINT certified and has LPC and LCAS certification. After the first six months, she didn’t see a need for this service, and I didn’t push the issue, since she appeared to be doing so well.

After nearly two years of recovery, she missed an office visit, without calling to re-schedule. When she came the next week, she was positive for opioids on her urine drug screen.

We talked about her relapse extensively. She said she was upset one day, and had taken a few pain pills her mom had around the house.

We talked about what this meant. She already talked to her sponsor and had picked up a white chip at her 12-step meeting. We talked about how relapse is often a part of a person’s recovery. Since she was fortunate enough to survive it, we needed to examine her relapse process in detail, to learn from it.

I was unsettled, since I thought she had been doing great. I could tell she was unsettled too, and I made her next visit in one week instead of our usual one month.

She missed that visit, and I was really worried.

When she did make it in to my office a few weeks later, she falsified her urine drug screen. I told her I was really worried, because that was so unlike her. She admitted to relapsing back to heavy pain pill use.

We discussed treatment options. I wanted her to go to an inpatient program, to become re-stabilized, and then come back into treatment with me. We also discussed transferring her temporarily to an opioid treatment program, where she can go each day to be dosed, and where there’s more accountability.

She refused both of these options, saying she couldn’t miss work, and both would interfere with her work schedule. She was sure she could pull herself out of this relapse, if only I would give her another chance.

She kept her appointment a week later, but she was still illicit opioids. She said she was filling my Suboxone prescription, but only used it if she couldn’t find anything else. She had stopped going to 12-step meetings. Her mom came with her to this visit, and I asked if we could include her mom in her session. My patient not only refused to allow her mom to be a part of the conversation about treatment options, she also revoked the release for me to disclose anything to her mom.

I told my patient it was no longer safe to treat her in an office-based setting. I gave her one more week’s prescription and told her she had one week to decide what option she preferred: inpatient medical detoxification followed by inpatient residential treatment, or transfer to an opioid treatment program. I gave her the number and address of the OTP, where I knew she could continue on buprenorphine while she regained her stability.

I never spoke to her again.

She didn’t keep her next appointment. Three weeks after this missed appointment, she went to an opioid treatment center (not the one I’d recommended), which only used methadone. After she took her first day’s dose, she took a handful of Xanax and died in her sleep that night.

I thought about those last sessions multiple times, and wished I’d handled them differently. I think I believed her when she said she could stop using heroin on her own, since she had done so well while in recovery. Surely, I thought, she doesn’t want to stay stuck in active addiction any longer. Surely she has the tools to get back on the right path.

But this is a deadly disease. Even two years of joyful recovery didn’t save this patient in the long run.

I’m sorry to end on such a somber thought. However, I need to remember the stakes are so very high for our patients, and all relapses are serious.

Those of Us Who Lie


 

 

 

I’ve written this blog article several times. I deleted one version because it sounded too mean, and another version because it was too shallow and unrealistic. It’s a difficult subject. Talking about people with substance use disorder who lie has potential to feel accusatory and judgmental, but lying is part of the behavior of people in active addiction.

Some medical professionals see lying as a character flaw and prefer not to treat patients with addiction because of this trait. They feel patients with substance use disorders lie more than patients with other disorders. I’m not sure that’s necessarily true, since I remember lies of patients I treated when I worked in Internal Medicine: “Yes, I always take my blood pressure medication,” stated by a patient whose pharmacist called me to say she hadn’t picked up her refills for several months. Then there’s me: “Oh yes, I floss every day,” said to my dentist, who can clearly see I don’t floss daily.

We all lie. If we say we don’t, then we are…lying, at least to ourselves. Most lies are based in fear. We’re afraid we’ll appear to be irresponsible, or careless. We don’t want others to think we are bad people. We lie because we’re afraid we won’t get what we want. We’re afraid of the consequences that may occur if we tell the truth. We lie because we don’t want to disappoint other people, or because we feel shame.

With addiction, fear is amplified. Patients with addiction are afraid of so many things: running out of drugs, running out of money to buy drugs, physical consequences of using drugs, what friends and family will think if their drug use becomes known. Many addicts fear they are becoming bad people because they act in ways that violate their own values. They find themselves doing things like neglecting family or stealing in order to satisfy the addiction. So they lie.

Addiction needs lies to survive. A person with an addiction can’t get money for pills from a loved one if he says it’s going to purchase drugs, but he may be successful if he says it’s for food. If he tells family and friends how many drugs he is using, it’s likely he will encounter some opposition, making it harder for him to keep using drugs.

Lies are part of substance use disorders.

Sometimes what appears to be a lie is really denial. Denial occurs when a person has convinced himself something is true when it isn’t. In addiction treatment, denial is common. Here’s one example:

I was seeing a patient in one of the opioid treatment centers about her urine drug screens. Six out of the seven since admission to the methadone program were positive for cocaine.

“I’d like to talk about your cocaine use. Can you tell me a bit about why you use, what triggers cravings to use?”

“I don’t use cocaine. I hate it. I hate the way it makes me feel, all tired and depressed when I wake up the next day. It’s awful stuff. It’s from the devil.”

“OK, you’re saying you don’t use cocaine?”

“I don’t. I don’t use it at all. I stopped using it.”

“Um…, but how long has it been since you stopped?”

“I quit years ago, but I did slip up and use just a little bit the other day.”

“I’m getting confused. You’re saying you quit years ago, but used cocaine the other day. Let’s look at your drug screens. Almost all of them have been positive over the last six months, and I see where you have talked to your counselor about it four or five times. In her notes it says you denied any use. We sent off one of the urine samples for a second, more exact test, and it still showed cocaine. How can you explain this? Is it possible you’re really using more than you think you do?”

“That one time I was helping my boyfriend package it. He’s a coke dealer. I don’t agree with all that. I’m going to break up with him.”

I don’t think this patient was lying. I think she was in denial, and a part of her couldn’t accept the extent of her cocaine use. Denial needs to be treated as part of substance use disorders.

Addiction isn’t the only disease with denial. When I worked in primary care, I’ve seen advanced cancers in patients who were in denial about the severity of their symptoms. Patients with serious chest pain ignored their symptoms until having a massive heart attack. With any problem, one of our defenses against facing a difficult situation may be to deny it exists.

A few decades ago, harsh confrontation was felt to be necessary when dealing with denial in drug addicts. Now we know we get better results with gentler, more positive counseling approaches. For example, I’ve read Motivational Interviewing: Helping People Change, by Miller and Rollnick, third edition. I loved the second edition, which gave me ideas about how to change my goal from confronting to collaborating. This edition is even better. It’s giving me tools to help move patients from denial at their own pace. This feels more humane than old methods of yelling at patients, who already are turning away from unpleasant truths.

This method can also be used with patients who are intentionally lying.

Just because a person with addiction enters treatment, lying doesn’t automatically stop. Habits are hard to break, and people in treatment may lie when it’s just as easy to tell the truth, merely out of habit. Then there are incentives to lie in treatment settings. For example, if treatment is court-ordered, a patient in treatment may face jail time if she admits to a relapse. If a patient’s children have been taken by social services, admitting to continued drug use or even to a relapse may delay getting his children back.

Particularly in opioid addiction treatment, patients have incentives to lie in part due to the extensive regulations put in place by the state and federal governments. Some of those regulations are in place to keep the patient safe, and some are to protect against diversion of methadone onto the local black market. Patients in treatment may lose take home doses if they are truthful about drug use.

Even if take homes aren’t at stake, many patients don’t like to talk about relapses, and lie about their drug use. Patients may fear their counselor will belittle or shame them for using drugs. Again, methods like Motivation Interviewing can help the counselor be more collaborative than confrontational. The counselor can have the approach of let’s look at this relapse and learn from it what we can, in order to help you in the future. When a patient admits to drug use, that’s a good thing. Now we’ve got something to work on. That means the patient is facing their disease, and we can now work on relapse triggers. We can track the events leading up to drug use, and the patient can decide if they would do anything differently the next time, if in the same circumstances.

Some patients cleverly say that if they always tell the truth about drug use, they should be rewarded for their honesty by not having any consequences for drug use. For example, a patient who had been in methadone treatment for about three weeks told me he was drinking his Sunday take home bottle on Saturday. I was alarmed, because I feared he could have an overdose death. I told him I was glad he told me, but that I couldn’t give him a take home dose for Sundays in view of that. He was angry and felt he was being punished for being truthful, while my main concern was a possible overdose death if he continued to get take homes.

I use a phrase from Ronald Reagan in my work with people in treatment for addiction: Trust, but verify. I can’t take everything that is told to me at face value. I’d prefer to believe all my patient all of the time, but they have this disease which leads them to lie. When patient safety is at issue, I have to confirm what the patient tells me with other facts, like clinical observation, patient history, and drug screens.

I’ve learned I can’t reliably tell when someone is lying. Years ago I foolishly thought I was really good at detecting lies, but I’ve been wrong so many times that I no longer make that assumption. Even lie detector machines are often wrong, which is why they aren’t admissible in court.

I’m learning not to take lies personally. Lying is part of addiction, and old habits don’t stop right away. How I react to a patient’s lie is more about me than about the patient. Lies sometimes still make me angry, and this happens more often when I’m not in a good place myself. I try to pay attention to my own physical, mental, and spiritual health. When I’m healthy I’m more likely to view people who lie (not only my patients) with more calm and acceptance.

I understand lies because I understand fear. If I come from a self-righteous place in my own heart where I believe I never lie, I am likely to judge another person who lies. So I’m no paragon of truthfulness myself, but I am a work in progress, as we all are.

 

 

Happy, Joyous, and Free…

aaaaaaaaaaaaaaahap

 

Avid readers of my blog will recognize the following as a re-run, but I’m feeling under the weather this week, from a virus that’s been circulating in the community:

 

JB: Please tell me about your experience with pain pill addiction and your experiences with buprenorphine (Suboxone).

XYZ: For me, my opiate addiction got so bad, I was taking two hundred and forty to three hundred and twenty milligrams of OxyContin per day, just to stay normal. It had gotten really, really bad. And it started out with a reason. I had kidney stones, and I was in all this pain, but then it got to the point where it solved some other problems in my life and it got out of hand. I tried a lot of different things. I went to detox, and they helped me, but it was…it was almost like I never came out of withdrawal.

JB: How long were you off pain pills?

XYZ: Even after being clean for thirty or sixty days, I would still feel bad. Bowels, stomach…really all the time.

JB: Did it feel like acute withdrawal or just low grade withdrawal?

XYZ: No…I’d try to fix it myself, sometimes, and I would just put myself back where I was. It got to the point where I was making myself sicker and sicker and sicker. And then I got off of it, and stayed off of it for a hundred and twenty days, I guess…but still just sick. Just miserable, and not feeling right. I was miserable. I wouldn’t eat, I was losing weight…

It [buprenorphine] gave me something that replaced whatever was going on in my head physically, with the receptors. It took that [prolonged withdrawal] away, to the point that I felt well. All that energy I would spend getting pills…and I was going to the doctors almost daily. Because taking that much medicine, nobody would write me for that much, so I had to doctor shop.

My only life was going to the doctors, figuring out what pharmacy I could use. I had a whole system of how many days it could be between prescriptions, what pharmacy to go to. It was sick. I was just trying to not get sick.

JB: And you were working during that time?

XYZ: Yeah! I was working, if you want to call it that. I wasn’t a very good employee, but I held a job. I was a regional vice president for “X” company. I traveled a lot, so I had new states where I could see new doctors. That was bad. When I came off the road, I owed $50,000 in credit card bills.

JB: And your wife didn’t know about it?

XYZ: No. It all came tumbling down. And I had gotten into trouble, because they were company credit cards, and they wanted the money back! So, all of the sudden my wife found out that not only do I have a pain pill problem, but we’re $50,000 short, and I wasn’t very ethical in the way I got the money, because it really wasn’t my credit, it was my company’s credit card.

JB: So addiction made you do things you wouldn’t do otherwise?

XYZ: Absolutely. I lied to people, I took money from people, I ran up credit cards tens of thousands of dollars, and really put my family in serious jeopardy at that time. But buprenorphine took away that whole obsessive-compulsive need for pills, made me feel better, and took away all the withdrawal symptoms at the same time. I didn’t worry about it. To be honest, I was such a hypochondriac before. I haven’t been sick in years now. I haven’t had a backache or headache that ibuprofen didn’t cure [since starting recovery]. I was fortunate it was all in my head. I would milk any little thing. I had two knee operations that probably could have been healed through physical therapy, but I was all for surgery, because I knew I’d get pain pills.

JB: That’s the power of addiction!

XYZ:  Yes. Finally I did some research about buprenorphine, online. Actually, I had some good family members, who did some research and brought it to me, because they were concerned for me, and they brought it to me and said, “Hey, there’s a medicine that can help. Call this number,” and I found places out there that would do it [meaning Suboxone], but my concern was the speed that a lot of them were doing it. A lot of them said, OK come in, and we can evaluate you, and after a week you’ll be down to this, and after a month you’ll be down to this.

This was in 2005. And when I asked them what their success rate is, it wasn’t very high. It was something like twenty percent of the people who were doing it [succeeded]. So when I’d finally gotten a hold of “X,” [receptionist for Dr. H], she saved my life over the phone. Because she said, you can come tomorrow, and she said that whatever it takes, they’ll work with you. And I felt good about going to a place where it wasn’t already determined how long it would take. Because I already knew how I was feeling after I would come off of opiates. I didn’t want to do that again.

I saw Dr. H. and felt better within twenty-four hours, although it took a little while to get the dosage right. I think we started off at a lower dose, then we went up on the dose and it kept me so level. I had no symptoms. It cured my worst withdrawal symptoms, my stomach and my bowels.

There’s always a kind of stigma in the rooms [12-step recovery meetings] because I’d been in NA for a little bit of time then [he’s speaking of stigma against medication-assisted treatment]. You realize who [among addicts in NA] is die-hard, one way to do recovery, and who is willing to be educated about some things and understand that there’s more than one way to skin a cat. And I was fortunate that I had a sponsor at that time, and still do, who was willing to learn about what exactly it was, and not make me feel guilty about it. It wasn’t necessarily the way he would do it, but he was a cocaine addict, so he didn’t understand that whole part of it.

He said, “Your family’s involved, you’ve got a doctor that’s involved, your doctor knows your history. If all these people, who are intelligent, think this is an OK thing, then who am I to say it’s not going to work?” He was open-minded. And there are not a lot of people I would trust right off the bat [in recovery], that I would tell them. [that he’s taking Suboxone]. I’ve shared it with some people who’ve had a similar problem, and told them, here’s something that might help you. I always preface it with, [don’t do] one thing or another, you’ve got to do them together. You have to have a recovery program and take this medicine, because together it will work. Look at me. I’m a pretty good success story.

One of my best friends in Florida called me, and I got him to go see a doctor down there, and he’s doing well now. He’s been on it almost eleven months now and no relapses.

To me, it takes away the whole mental part of it, because you don’t feel bad. For me, it was the feeling bad that drove me back to taking something [opioids] again. Obviously, when you’re physically feeling bad, you’re mentally feeling bad, too. It makes you depressed, and all of that, so you avoid doing fun things, because you don’t feel good.

Once I trained myself with NA, how to get that portion of my life together, to use those tools, not having any kind of physical problems made it that much easier to not obsess.

JB: So, how has your life improved, as a result of being on buprenorphine?

XYZ: Well, the most important thing for me is that I’ve regained the trust of my family. I was the best liar and manipulator there was. I’d like to think of myself as a pretty ethical and honest person, in every aspect of my life, other than when it came to taking pills.

JB: So, you regained the trust of your family, felt physically better…

XYZ: I gained my life back! Fortunately, I had enough of a brain left to know it had to stop. Once I started on buprenorphine, it gave me back sixteen hours a day that I was wasting. That’s when I decided I really don’t want to jeopardize my recovery, by going out and looking for a job again [he means a job in corporate America, like he had in the past], because I’ve got this thing, this stigma…they’re going to check a reference and I’m screwed. I’m not going to get a job doing what I was doing for the same amount of money.

My brother had enough faith in me that it was worth the risk of starting this business [that he has now] together. My wife and I started on EBay, making and selling [his product], and slowly grew it to the point that, three years later, I’m going to do over two million dollars in sales this year, I’ve got [large company] as a client, I’ve got [large company] as a client, I’m doing stuff locally, in the community now, and can actually give things back to the community.

JB: And you employ people in recovery?

XYZ: Oh, yeah. I employ other recovering addicts I know I can trust. I’ve helped some people out who have been very, very successful and have stayed clean, and I’ve helped some people out who came and went, but at the same time, I gave them a chance. You can only do so much for somebody. They have to kind of want to do it themselves too, right?

JB: Have you ever had any bad experiences in the rooms of Narcotics Anonymous, as far as being on Suboxone, or do you just not talk to anybody about it?

XYZ: To be honest, I don’t broadcast it, obviously, and the only other people I would talk to about it would be somebody else who was an opioid addict, who was struggling, who was in utter misery. The whole withdrawal process…not only does it take a little while, but all that depression, the body [feels bad]. So I’ve shared with those I’ve known fairly well. I share my experience with them. I won’t necessarily tell people I don’t know well that I’m taking buprenorphine, but I will let them know about the medication. Even though the information is on the internet, a lot of it is contradictory.

It’s been great [speaking of Suboxone] for someone like me, who’s been able to put a life back together in recovery. I’d tell anybody, who’s even considering taking Suboxone, if they’re a true opioid pill addict, (I don’t know about heroin, I haven’t been there), once you get to the right level [meaning dose], it took away all of that withdrawal. And if you combine it with going to meetings, you’ll fix your head at the same time. Really. I didn’t have a job, unemployable, my family was…for a white collar guy, I was about as low as I could go, without being on the street. Fortunately I came from a family that probably wouldn’t let that happen, at that point, but who knows, down the road… I had gotten to my low. And that’s about it, that’s about as much as I could have taken.

It [Suboxone] truly and honestly gave me my entire life back, because it took that away.

JB: What do you say to treatment centers that say, if you’re still taking methadone or Suboxone, you’re not in “real” recovery? What would you say to those people?

XYZ: To me, I look at taking Suboxone like I look at taking high blood pressure medicine, OK? It’s not mind altering, it’s not giving me a buzz, it’s not making…it’s simply fixing something I broke in my body, by abusing the hell out of it, by taking all those pain pills.

I know it’s hard for an average person, who thinks about addicts, “You did it to yourself, too bad, you shouldn’t have done that in the first place,” to be open minded. But you would think the treatment centers, by now, have seen enough damage that people have done to themselves to say, “Here’s something that we have proof that works…..”

I function normally. I get up early in the morning. I have a relationship with my wife now, after all of this, and she trusts me again. Financially, I’ve fixed all my problems, and have gotten better. I have a relationship with my kids. My wife and I were talking about it the other day. If I had to do it all over again, would I do it the way I did it? And the answer is, absolutely yes. As much as it sucked and as bad as it was, I would have still been a nine to five drone out there in corporate America, and never had the chance to do what I do. I go to work…this is dressy for me [indicating that he’s dressed in shorts and a tee shirt]

JB: So life is better now than it was before the addiction?

XYZ: It really is. Tenfold! I’m home for my kids. I wouldn’t have had the courage to have left a hundred thousand dollar a year job to start up my own business. I had to do something. Fortunately, I was feeling good enough because of it [Suboxone], to work really hard at it, like I would have if I started it as a kid. At forty years old, to go out and do something like that…

JB: Like a second career.

XYZ: It’s almost like two lives for me. And if you’re happy, nothing else matters. I would have been a miserable, full time manager, out there working for other people and reaping the benefits for them and getting my little paycheck every week and traveling, and not seeing my wife and kids, and not living as well as I do now.

I joke, and say that I work part time now, because when I don’t want to work, I don’t have to work. And when I want to work, I do work. And there are weeks that I do a lot. But then, on Saturday, we’re going to the beach. I rented a beach house Monday through Saturday, with just me and my wife and our two kids. I can spend all my time with them. I could never have taken a vacation with them like that before.

JB: Do you have anything you’d like to tell the people who make drug addiction treatment policy decisions in this nation? Anything you want them to know?

XYZ: I think it’s a really good thing they increased the amount of patients you [meaning doctors prescribing Suboxone] can take on. I’d tell the people who make the laws to find out from the doctors…how did you come up with the one hundred patient limit? What should that number be? And get it to that number, so it could help more people. And if there’s a way to get it cheaper, because the average person can’t afford it.

The main thing I’d tell them is I know it works. I’m pretty proud of what I’ve achieved. And I wouldn’t have been able to do that, had I not had the help of Suboxone. It took me a little while to get over thinking it was a crutch. But at this point, knowing that I’ve got everybody in my corner, they’re understanding what’s going on…it’s a non-issue. It’s like I said, it’s like getting up and taking a high blood pressure medicine.

I originally interviewed this patient in 2009, for a book that I wrote. Since that time, he and his family have moved to the west coast, but I’ve stayed in contact with him. He’s been in relapse-free recovery for over eight years, he’s still on Suboxone, and still happy. He has excellent relationships with his wife and children, and his business has thrived and continues to grow.

He’s an excellent example of how a recovering addict’s life can change with the right treatment. For this person, Suboxone plus 12-step recovery worked great.