Europe Dumps Meprobamate

The European Medications Agency is banning meprobamate and meprobamate-containing medications from the sale in Europe, after concluding that the risks from the medication exceed the therapeutic benefit. The removal comes six months after a decision by the same agency to suspend authorization for all marketing for the medication.  I have not read of any similar […]

Xanax for Anxiety? Think Again!

Anxiety is one of the most common presenting complaints for people who come to my psychiatric practice. By the time people with anxiety visit a psychiatrist, they have usually discussed their symptoms with friends and family members, and some have been to their family care physician. And as a result of these initial ‘consultations’, they […]

Is My Withdrawal Permanent?!

A question from a reader: I am trying to decide what my best course of action might be in dealing with protracted withdrawals from a number of drugs, including benzodiazepines. My history is as follows:  I was snorting Oxycontin for about 6 months and went into treatment to stop.  Before entering the rehab hospital they […]

Clean Enough

In regard to my last post

There are many directions that we could take as we review that message.  My overall impression, as I read the letter, was of a person struggling to accept the reality of his condition.  Over and over, the person repeated the same behavior, starting Suboxone, stopping, and thinking this time will be different.

One thing I’ve learned as a psychiatrist, more than anything, is that change is difficult, and rare.  The writer ends with the thought that maybe this time will REALLY be different.  I have no idea if it will be, and for his sake, I hope it is… but unfortunately, the odds are that history will repeat itself.

Why, then, bother taking Suboxone—if everything just goes back to how it was?  The problem is not that Suboxone ‘doesn’t work’; the problem is in the expectations of some of those who take or prescribe the medication.  The active part of Suboxone—buprenorphine—is not a cure for addiction, but rather is a very useful tool.  Buprenorphine is a chemical that essentially tricks the mu opioid receptor.   Because of the ceiling effect—at higher drug levels, effects at the receptor remain constant as drug concentrations vary—the receptors function as if nothing is ‘coming on’ or ‘wearing off.’  That, in turn, eliminates cravings for the drug, and prevents the ‘reward’ for taking the drug.

Buprenorphine appears to work very well for the writer.  When on buprenorphine, he is able to avoid using opioid agonists.  The problem comes in the expectation that when buprenorphine is stopped, the condition of opioid dependence will somehow be gone, and will stay gone.   That is a completely different matter!

Opioid dependence is a complicated condition that can be viewed from different perspectives; behavioral, neurochemical, social, etc.  Some factors that contribute to ongoing addiction are addressed by buprenorphine, but most are not.  At one point the writer refers to being ‘stabilized on buprenorphine;’ the best way, I think, to view what happens with the medication.

During active addiction, a person finds that unpleasant emotions, thoughts, or feelings can be blunted by taking a substance.  In the long run, the consequences of using a substance become more and more negative, but the active addict cannot see beyond the pressing needs of the moment.  These pressing needs become worse, once addicted, because physical withdrawal – including depression, pain, and dread—are added to the other pressures of life.  Buprenorphine removes the neurochemical pressure to take opioids—i.e. the constant obsession to improve one’s subjective state.

Hopefully, relieving that obsession allows the patient to change the course of his life; to change social networks, to improve occupational standing, to improve self-discovery and personal insight.  If a person insists on stopping buprenorphine, the hope is that there will be enough changes in these other areas, so that the person will somehow be able to avoid responding to the urge to medicate the moment.

I think we are at a point where we need to consider the true nature of addiction.  Many treatment programs and physicians and treatment programs have an idealized image of how things should proceed after starting buprenorphine.  Patients ‘should’ be able to avoid all other substances, and patients ‘should’ be able to taper off buprenorphine at some point.  Through a process known as ‘counseling,’ patients are supposed to develop insight into their thoughts, emotions, and behaviors, so their lives follow a different course when the buprenorphine is eventually discontinued.

But what if patients CAN’T taper off buprenorphine?  What if patients eventually relapse, after stopping buprenorphine? What then?  Contradictions are apparent, when one looks for them.  We know that opioid dependence is a chronic, relapsing condition.  We know that relapse is more the rule than the exception.  We know that addiction is a process, not an event—and that ‘cure’ is not an accurate concept. Yet program after program requires people to eventually stop buprenorphine.  Talk about a set-up for failure!

To truly understand addiction and the role of buprenorphine, one must realize that addiction is a conditioned or learned phenomenon.  Parents of teens addicted to opioids will sometimes tell me ‘I just want my daughter back.’  I’ll ask the parent when he last rode a bicycle— and point out that even if the last ride was 20 years ago, he could still ride today.   And even if he hasn’t been to his childhood home for 20 years, he could likely drive straight to his front door.  THAT’S the challenge of ‘curing’ addiction!

Other thoughts…

About the ‘utilitarian’ approach… the way I suggest we view buprenorphine is the best way to consider other psychiatric medications as well, in my opinion.  We don’t think of SSRI’s as ‘curative’ for depression; rather they reduce obsession and worry, contributing to changes that allow recovery from depression.  Anticonvulsants do not ‘cure’ bipolar; rather they reduce the likelihood or severity of symptoms of mania.  Antipsychotics do not ‘cure’ schizophrenia; they prevent or reduce psychotic symptoms.

About anxiety… does the writer REALLY have it more difficult than others?  Maybe– or maybe not.  It really doesn’t matter.  Most patients who I see for opioid dependence believe they were dealt an unfair hand in life, from an emotional perspective.  Most feel that their subjective experiences are more difficult than the experiences of others.  Many say that they are ‘shy,’ or that they experience significant depression most of the time.  Most say that opioids relieved those uncomfortable emotions or sensations very effectively—at first, anyway—and that is why the addiction started.

Whether our load is truly heavier than someone else’s doesn’t matter, since we only experience our own load.  In other words, who would hurt more if his arm was severed, you or me?  It doesn’t matter—it hurts both of us ‘enough!’  At the same time, no amount of personal distress logically warrants taking something that only makes things worse.  If only addiction was logical!

About being able to choose the course of our lives… ‘Choice’ advocates–people who say that addicts choose to use drugs, and that they should simply choose NOT to use—say that addicts are weak in needing to medicate themselves through life.  In reality, there are few discreet ‘choices’ in life.  Our behavior flows seamlessly from one thing to the next.  ‘Choosing’ consists of a million tiny thoughts, sewn together and spread over a wide range of time.  The actual ‘choice’ to use occurs long before a person literally picks up the drug—- in a million subtle decisions and behaviors that the person may or may not have insight into.  Avoiding opioids, without the help of buprenorphine, requires constant awareness and engagement of insight.  Sober recovery is not effortless, and is not possible for everyone— just as some people cannot avoid depression without using SSRIs, and some diabetics cannot control their blood sugars without using exogenous insulin.  There is no shame in having one’s addiction treated!

Comments, as always, are welcome.  And to the writer, thank you for sharing your story, and provoking this discussion.  I can’t say whether it is time to stop Suboxone, or whether you will ever do well off the medication.  But in any case, I encourage you to appreciate life as best you can, and cultivate enough interests so that the buprenorphine issue falls into the background.  That, in my opinion, is the best way to use buprenorphine; to allow people to live life as if they had never become addicted, and to learn to tolerate life on life’s terms, as best they can.  For some people, maybe that’s ‘clean enough.’

The Problem with Benzodiazepines

Last night I came across a medical student web site that included a link to a post of mine from a couple years ago, that described my feelings about Xanax, Valium, Klonopin, and other benzodiazepines.   The people commenting at that site appreciated my comments, and my comments were ‘seconded’ by other physicians.  Here’s the post again, for those who missed it the first time:

Twelve Things I Hate About Benzodiazepines

Author: J Junig MD PhD


Because of several highly publicized deaths from combining Suboxone with benzodiazepines or “benzos”—a class of sedative medications that includes Xanax and Valium—I am frequently asked about the safety of combining Suboxone with those medications. The risk of life-threatening respiratory depression can be mitigated fairly easily, but that does not mean that benzos are safe or appropriate medications for people with or without addictions. They are commonly prescribed medications, and there are a number of misconceptions among laypeople about their proper use, so they deserve a thorough discussion. Most doctors with a bit of experience have learned to cringe every time a patient says the word “anxiety,” knowing that in all likelihood they are about to be placed in a difficult position. They will either do the right thing and disappoint their patient, or do the wrong thing and struggle with the consequences of their actions for months or years.

The problem is that the non-medical community sees SSRI’s as “antidepressants,” and believes that the proper treatments for anxiety disorders are sedatives like Valium or Xanax. Whereas the sedatives are appropriate for acute or short-term anxiety, chronic anxiety disorders are more appropriately treated using SSRI’s or SNRI’s.

Today, I saw a new patient who asked for treatment of her addiction to pain medications. When I asked about other psychiatric symptoms, she said that she takes alprazolam and clonazepam for anxiety and panic attacks. I explained that those medications are very dangerous for addicts and are intended for short-term use, and the primary treatments for anxiety disorders are SSRIs or SNRIs. I asked her dose and wasn’t surprised to hear that her tolerance was quite high. A milligram of alprazolam doesn’t do anything, she said—intending to mean that the meds are not potent enough to worry about. I of course took it the opposite way—she has taken benzos to the point that a very large dose has no effect due to her high tolerance. She then said she also has ADD and takes Adderall (ie, amphetamine). I explained that it makes no sense to take both amphetamines and benzos, particularly a long-acting benzo like clonazepam, which has a half-life of around 30 hours. Benzos CAUSE deficient attention; that is how they work! Worry consists of too much attention to a problem or a fear, and benzos prevent the brain from attending, attaching and remembering. In fact, anesthesiologists and dentists use the short-acting benzodiazepine midazolam during uncomfortable procedures to block the patient’s memory. Most adults have had the experience of watching the medication injected into the IV tubing, and next waking up to people saying “you’re OK—it’s all done.” Don’t take a benzodiazepine if you are nervous about an exam the next day! Beyond the amnesia, it is simply a bad idea to take two polar-opposite medications as this patient is doing. Stimulants cause wakefulness, attention, tight muscles, and anxiety. Benzos cause drowsiness, amnesia, relaxation, and the inability to remember what you were supposed to worry about. Instead of taking both, take neither.

A related question came to me by e-mail yesterday:

Hello, I found your website and see that you do phone consultations. I have been having anxiety problems and attacks for over a year. It has gotten worse and worse. I’ve been to the doctors in my area but no one wants to treat me for it…they just want to keep giving me Paxil, Zoloft, Prozac, Cymbalta and all these things I’ve tried and nothing seems to be helping me. I have anxiety attacks all the time where my heart beats out of my chest and I can’t breathe and go almost into this blackout stage. I have a lot of things that trigger it; one is my anxiousness all the time. I can’t focus, and any little dilemma sets me off. Everything is a crisis to me. And on top of that, I have the responsibility to take care of a 3 year old all by myself. I’m so scattered and anxious and upset all the time it is affecting me being a good mother. I cannot take it anymore and I am at the end of my rope. I don’t know what to do; no one will treat me with anything to calm me down along with the Paxil because of all the other people in this county that have abused it.. I DO NOT know what else to do. I have no one to talk to or turn to. It’s affecting my job, my personal life and my life in general. If you can’t help me maybe you know someone who will.

The person doesn’t come right out and say it, but her comments about needing to be calmed down and about abuse of the meds by others suggest that she is asking for a benzodiazepine.

Benzodiazepines include long-acting medications like clonazepam (Klonopin) and diazepam (Valium), intermediate-acting medications like lorazepam (Ativan) and alprazolam (Xanax), and the short-acting sleeping pills from my training years like triazolam (Halcion) and temazepam (Restoril). As an anesthesiologist, I gave patients midazolam (Versed) more than any other medication. All of these medications are appropriate in certain settings. Most have a street value. Some have active metabolites that accumulate in the body over time. All are sedating, all cause tolerance, and all have the potential to cause significant withdrawal symptoms. The longer-acting medications will self-taper to some extent, but the intermediate-acting agents in particular have the potential to cause withdrawal syndromes that are severe, and even fatal. The first patient I mentioned has been taking an anticonvulsant since presenting to the ER with a grand mal seizure while stopping Xanax “cold turkey.”

All of these medications have appropriate uses, almost always for short-term conditions. When given long-term, they cause problems. In fact, from the top of my head, I can think of 12 reasons to avoid prescribing benzos for “anxiety.”

1. Many anxious patients aren’t truly anxious. When a patient complains of anxiety, he or she is often complaining of something else. If I ask a patient to describe the symptoms without using the word anxiety, I often find that the patient is bored, restless, angry, depressed, overwhelmed, or appropriately frightened. Take a look at the second patient—the one who is “scattered,” “at the end of her rope,” and “caring for a 3-year-old boy all by herself.” Do you really think she will be a better mom if she is taking alprazolam or clonazepam? She is feeling overwhelmed, angry, tired, afraid, hopeless, depressed—feelings that when added together become anxiety. Do we really want to give a person in this condition a medication that will make her sleepier, more forgetful, more scattered, and more disinhibited?

2. Even if we get it right, her relief will be short-lived due to tolerance. Patients often escalate their dose at some point—no matter how many times they promise that they won’t. Dose escalation is not the patient’s fault—it is simply what these meds do. Once a pattern of dose escalation begins, it is difficult to control; patients will call after two weeks, reporting that they are out of alprazolam, and the doctor feels pressured to issue a refill to prevent withdrawal.

3. Benzos turn manageable anxiety into an anxiety disorder. Patients get a calming effect from the medication, but as the medication wears off, the anxiety returns, including extra anxiety from a rebound effect—a miniature form of withdrawal. Patients do not usually attribute that anxiety to rebound, but instead believe they have a horrible anxiety condition that appears as soon as the medication wears off. When I worked in a maximum security prison for women in Wisconsin, many inmates were taking benzos upon arrival; several months after the benzos were discontinued, the most amazing thing happened: the anxiety disorders went away!

4. A problem specific to addicts is that they don’t take sedative medications to achieve the absence of anxiety, but rather until they feel relaxed. They are not seeking normalcy; they are seeking relaxation. There is a difference between the two states: one is feeling normal without feeling excessive worry or panic; the other is feeling relaxed, something other than feeling normal. This doesn’t make addicts bad people; it is simply a consequence of the conditioning process during addiction. Addicts are not aware that they are seeking a fuzziness that non-addicts often find to be uncomfortable.

5. Again specific to addicts, benzos (like other medications that have an immediate psychotropic effect) direct the person’s attention inward. An addict becomes obsessed with how they feel; a goal in treatment is to get the addict out of his or her own head to experience life on life’s terms. Benzodiazepines encourage the opposite effect, encouraging the addict to focus on internal feelings and sensations.

6. Addicts with one favored class of drugs, for example opiates, will often move to a different substance when the first drug of choice is removed, for example using Suboxone. This phenomenon is called “cross addiction.”

7. A final concern for addicts is that benzos help preserve the mistaken thought that the person cannot function without taking something.

8. Benzos impair driving and have the potential to impair a person working with dangerous machinery. After all, patients get anxious at work too. They also make a person appear intoxicated by causing slurred speech, forgetfulness, and sometimes loopy behavior, risking the person’s job and having other unforeseen consequences. Some people have completely different personalities when disinhibited by benzos.

9. Benzos have been linked to fetal anomalies and early miscarriage.

10. They destroy sleep in the long run through tolerance and through rebound effects. If the patient takes the benzo during the day, he or she will be trying to sleep just as the sedation is wearing off. The alternative is to take the medication at bedtime, defeating the goal of finding relief for daytime anxiety. If the person takes benzos both day and night, tolerance increases even more quickly.

11. I have already mentioned the need to taper off benzodiazepines and the risk of seizures and worse during withdrawal.

12. Benzodiazepines may calm a truly anxious patient, but they do not generally increase the patient’s function. A person who can’t get out of bed becomes less likely to get out of bed. Bills that are unpaid become even less likely to be paid. Relationships do not generally improve when one partner is nodding off as the other talks about feelings.

I do prescribe benzodiazepines, usually for the short-term or while recommending they be taken no more than every other day. Some patients do fine with them, but for others, benzos are a Pandora’s Box that should never be opened. As a psychiatrist, I often resent the treatment that led to the mess that I try my best to clean up—such as the case with the first patient I mentioned. I think most doctors who read this will understand what I am saying, and many will have similar thoughts about benzodiazepines. Perhaps others will find the use of benzodiazepine much more beneficial than harmful. Comments anyone?

Would’a Could’a Should’a…

I received the following e-mail a couple days ago:

Hi

I had been on Suboxone for 9 years. I was put on it the week it was approved by FDA. I found your posts in a blog. I was looking for a class action suit against this terrible drug. That man who said he was enjoying a Suboxone was right. I was on it almost 9 years and did get high and stay high all day, just like methadone. It causes depression and brain damage. I have been off it for 2 months now and am very sick with depression, panic attacks, and have not been able to even take care of myself. Please, if people want to get off drugs help them and send to treatment and AA NA.

thanks

nancy

Those of you who have read this blog for a while may remember the posts ‘back in the old days’—a few years ago—when I would get these kinds of messages often. Thankfully, I rarely get them nowadays, although every now and then someone stops by SuboxForum.com intent on harassing people taking buprenorphine.

I get your complaint Nancy, I really do—but I don’t agree with your thought process, or your conclusions. First of all, buprenorphine has been around for over 30 years, and has never been associated with ‘brain damage.’ The high doses of buprenorphine used for opioid dependence have been in around for 15-20 years overall, 8 years in the US. Several million prescriptions for high-dose buprenorphine have been written—without evidence for any significant harmful effects from buprenorphine.

Your description of how you felt while taking the medication are not at all consistent with the descriptions I’ve heard from the several hundred people I’ve treated over the past 5 years; people almost always report feeling nothing from the medication after being on it for a week or two. Every now and then a person will say that he/she notices opioid effects after each dose, but the sensations are always subtle, and people have to focus to tell if they are really feeling them. Frankly, given that the feelings usually come well before the 45-minute absorption time of the medication, I think that they are often imagined, or created by the mind, as a ‘placebo effect.’

Preliminary studies suggest a role for buprenorphine for treating refractory depression. I would not recommend that use for the medication in people who are not already addicted to opioids- but the findings of mood elevation in some people runs counter to your suggestion that the drug causes depression.

Buprenorphine is different from methadone in a number of ways, the most critical being the mu receptor profile, where buprenorphine acts as a partial agonist, and methadone acts as an agonist. This difference is responsible for the unique actions of buprenorphine, compared to methadone and other agonists.

But my primary disagreement with you is because you completely disregard the conditions that you had before starting buprenorphine. I assume that you were dependent on opioids, as that is why the vast majority of people take buprenorphine. And opioid dependence is not a benign condition. In fact, opioid dependence is often fatal, particularly over a span of ten years. When you blame your depression and anxiety on buprenorphine and Suboxone, where do you get the image that you use as a comparison for your current condition?

For example, if you didn’t take buprenorphine, what are you assuming would have happened? The success rates for ‘treatment’ without buprenorphine are very low—well below 10%. And many young people who have taken opioids for more than a year or so can list several former confidants who have died from opioids. In other words– you seem to be assuming that you would have been fine without Suboxone, when the odds are more in favor of you having significant problems from your addiction—and maybe death.

You may have scraped up $5K – $50K to enter treatment and been in the lucky few percent who ‘got’ recovery; in that case, the odds would have been high that you would relapse in the next few years. As for depression and panic, those are common symptoms in anyone with longstanding opioid dependence—are you just assuming that you would have been fine?

You may have gotten arrested for doctor shopping, shoplifting, or theft from your best friend’s medicine cabinet. You may have gotten disgusted with yourself and committed suicide. You may have lost everyone close to you, and ended up living on the street. We don’t know what might have happened—but I remember the days before buprenorphine was available, and remember the revolving door of treatment centers and NA meetings. Heck, those revolving doors are still in use by the people who will buy into your comments!

This is where my anger used to really well up… every person who you convince with your story — fueled by your lack of recognition of the condition you were in and your lack of appreciation for the substance that saved your life—every one of those persons will have a higher risk of mortality, thanks to you.

And—sorry for my French—that still pisses me off!

Humana Sneak Attack– Lawsuit Anyone?

I have written about the sleazy actions of health insurer Humana.  Today I filed a formal complaint with the Wisconsin Commisioner of Insurance regarding their practices.  I’ll copy my letter below, rather than take the time to write everything over again.  If there is an attorney willing to work the case on contingency, please contact me.  Likewise, if other patients or physicians are having similar problems with Humana, send me an e-mail through my website at www.fdlpsych.com.

The complaint:

My patient, XXXXXX, has been treated for opioid dependence for two years, using maintenance treatment with Suboxone.  He has maintained sobriety from opioids.  He also suffers from panic attacks and takes Effexor daily.  He uses lorazepam, a sedative, several times per month, and takes a sleeping medication, Ambien, most nights.

The standard of care for treating opioid dependence with Suboxone includes long-term use of Suboxone, particularly in young people (Mr. XXXXXX is in his early 20′s).  Mr. XXXXXX was fully compliant with treatment, including attending weekly psychotherapy and avoiding illicit substances.

In December of 2010, Humana stopped covering Suboxone for XXXXXX.  When I wrote to the company and asked for an explanation, I was told that he was denied because he did not meet the criteria of the company’s ‘buprenorphine coverage policy’.  This new policy was introduced without warning, and stated that people would not be covered if they were prescribed ‘benzodiazepines’ like lorazepam.

I appealed the decision by Humana, stating that the lorazepam was important for treating Mr. XXXXXX’s panic disorder.  But I wrote that his life depended on buprenorphine (Suboxone)– so we would stop the lorazepam immediately so that he would fit their ‘buprenorphine coverage policy’. 

The company continued to deny coverage.  I wrote again, asking for an explanation, and they wrote that Mr. XXXXXX was not eligible because ‘he was taking the benzodiazepine Ambien.’  I noted that Ambien is NOT a benzodiazepine, and does not therefore violate their policy.  But again, I wrote that I would not debate whether Ambien was or was not a benzodiazepine, but instead we would stop the Ambien, given the importance of Suboxone to the patient’s life and health.

The company again denied coverage through the appeal process, writing that ‘maintenance treatment for addiction was not indicated.’  Humana did not explain WHY his addiction treatment was not indicated.  I note that many patients receive buprenorphine for years, and the death rate from untreated opioid dependence is significant and well established.  I appealed the decision, asking for the name of their medical director.  Humana refused to provide the name, even after I called their offices repeatedly.  They continue to deny coverage, and today Mr. XXXXXX received notice that his final appeal was denied.

In summary, Humana was covering maintenance treatment for Mr. XXXXXX’s opioid dependence using Suboxone.  They then abruptly stopped coverage.  Mr. XXXXXX was forced to go through withdrawal without any warning–to him or to his physician–placing him at great risk of relapse and death.  When I attempted to re-establish his coverage, Humana wrote that they had instituted a ‘buprenorphine coverage policy’ without any prior warning. The policy is arbitrary and discriminatory, essentially stating that patients who are treated for opioid dependence are not eligible for treatment of other mental disorders, including panic disorder.

Finally, Mr. XXXXXX was willing to give up treatment of panic disorder in order to receive Suboxone—a medication that is vital to his continued sobriety.  I have repeated notified Humana that Mr. XXXXXX now complies with their arbitrary coverage policy– yet they continue to deny his claim.

This is a very dangerous situation.  Patients who are taking buprenorphine can do very well when compliant with treatment using Suboxone.  Humana pulled the rug out from under Mr. XXXXXX without warning, suddenly denying the medication, and then refusing coverage even when the patient clearly met all criteria according to Humana’s own unfair, arbitrary coverage policy. 

At minimum, Mr. XXXXXX should have his coverage for buprenorphine resumed.  Humana should be punished to prevent this dangerous, discriminatory behavior from hurting other patients.

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night

Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?

This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.

Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’

The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.

The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.

All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.

My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night

Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?

This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.

Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’

The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.

The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.

All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.

My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.