One way?

A few weeks ago, The Fix posted one of its typical confessional pieces by a guy who had been in recovery and relapsed while writing a memoir/investigative report on opiate addiction in America.

He talks about his attempts to keep it real in his book led to relapse, he went to treatment, got kicked out of treatment for his insurance running out, relapsed, got on Suboxone, found Suboxone impaired him, found recovery on Suboxone unsatisfying, tried to get off Suboxone on his own and landed in an ER, and finally went back to treatment to stop “stumbling through life on material and chemical crutches”.

He goes out of his way to make clear he’s a newbie in recovery and doesn’t present himself as an expert in any way.

In the world of The Fix, par for the course.

However, it provoked an “enraged” response from a fellow writer at The Fix who also blogs for Time. Her Time blog posts are probably the most visible and influential blog about addiction and treatment.

one way by the rocketeer

Was the response enraged about the guy getting kicked out of treatment for his insurance lapsing? That his doctor putting him on a high enough dose that he felt high? That it sounds like his suboxone prescription was the only form of treatment and recovery support he was given during this period?

No. None of those things enraged her.

I was enraged by his characterization of buprenorphine (Subutex, Suboxone) as a “chemical crutch” and “the very drug that was keeping me from doing other drugs.”

She goes on to make the case for maintenance and then shout down critics by painting with a pretty vicious and broad brush.

This is the need of a certain type of person in recovery to demonize the drugs  to which they were previously addicted in service of their own abstinence. Because they rightly fear relapse, some who favor abstinence-based recovery feel compelled to proselytize about the dangers of the substances they once felt they could not live without—and often continue to crave. This “anti-drug” or “drug-free” rhetoric helps them avoid temptation. It also gives the added buzz of self-righteousness that comes from feeling superior to others.

I certainly understand this small-minded, mean-spirited attitude; I’ve been guilty of it myself. However, the self-aware—and adult—approach is to distinguish what works for you and your own recovery from what may work for others.

It’s not necessary for maintenance to be bad to make abstinence good. Such black-and-white thinking about methadone and buprenorphine is both divisive and dangerous. Recovery requires acceptance—and that includes acceptance of a diverse range of recovery methods and experiences.

And if acceptance is beyond your reach, then the least you can do is keep your opinions to yourself.

What if you’re a critic of the current push by pharmaceutical companies, doctors and even government for maintenance AND you accept there there is no single path to recovery and you accept any addict who has found a path to recovery?

I (and Dawn Farm) have no problem with any addict choosing Suboxone. If they find a full and satisfying life on Suboxone and call themselves in recovery, I have no quarrel with them and I am happy for them. What I do have a problem with is the failure of doctors and other experts to give opiate addicts enough information and treatment options to create meaningful informed consent.

  • Do these patients know that drug-free recovery is possible with treatment and recovery support of the appropriate duration and intensity?
  • Do they know that addicted doctors are not put on maintenance? That they get long term treatment, recovery support and monitoring and have outstanding recovery rates?
  • Do they know that years-long maintenance is the expectation when they begin Suboxone? (Most we see never had any discussion with the prescribing physician about this. After a month or three, they often ask, “When do I stop taking this?” Only to be told that they should take it indefinitely.
  • Do they know that tapering from Suboxone led to “nearly universal relapse in the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study“? (We don’t seem to understand this yet. Many people trying to come off of very low doses report that it is terrible in ways that other opiates are not. There is some speculation that its effects on kappa and delta opiate receptor sites are responsible for this. Whatever the reason, it reminds me of the early days of SSRIs when patients complained of a withdrawal syndrome while doctors dismissed it and attributed the symptoms to returning depression.)
  • Do they know that the kind of care doctors get doesn’t have to be insanely expensive?
  • Do they have access to drug free treatment of adequate intensity and duration?

If they know all of this and have decent treatment options, I have no problem with any addict choosing maintenance. It’s their right. If it works out, great! If not, they’ll end up moving toward drug-free treatment. [Update: And, yes, drug-free treatment recipients should know that Suboxone is an option for them too.]

Why the hostility to this story? (Especially from a newly sober guy who goes out of his way to position himself as a non-authority and wasn’t even making some universal statement about Suboxone.) Why the hostility to people who are worried about the push toward maintenance? How do people who share their feelings get to a place of such certainty and moral outrage?

To be sure there are plenty of one-way drug-free recovery advocates out there. Some of them can be troubling. But, aren’t there also plenty of counter-forces pushing opiate addicts in the direction of pharmacology and maintenance and interfering with the development of systems that provide drug-free recovery management?

If you want to know more about our opinion on Suboxone maintenance, you can read our position paper here.

5 thoughts on “One way?

  1. Hi Jason: I thought Maia’s reaction to the kid’s contentions about subuxone was quite understandable: Using drugs to treat drug addiction is the future, but it is highly controversial, and people are happy to throw roadblocks in the path. Of course doctors should fully inform patients about the drugs they take, including suboxone, and of course they fail routinely in that mandate. Your approach seems to be: “We allow it, but we don’t like it.” Do I have that right?

  2. I’m open to the idea that medication may play a very important role in addiction treatment in the future. But, you could also say that using drugs to treat addiction is the past, couldn’t you? (I was scorned as a Luddite in the 1990s for expressing skepticism about SSRIs for the treatment of alcoholism.)

    We still think buprenorphine is a great detox tool, but we’ve grown very concerned about using it for maintenance. We’re seeing the same kinds of concerns we’ve had with methadone. People sometimes stabilize and get by, but they are not thriving. They have something more like, what you might call, partial recovery. We’re also finding that Suboxone is strangely difficult to get off. We’re seeing people on very low doses (1mg) who are reporting vague but intense emotional misery when they try to reduce their dose. It’s not what you think of as opiate withdrawal, it’s something else. Steven Scanlan, MD has observed these kinds of problems and attributes them to buprenorphine’s effects on the kappa and delta receptors.

    At this point, some of this reminds me a lot of the 1990s when patients were reporting a withdrawal syndrome from SSRIs and medical professionals blew them off. It was only when internet message boards emerge that patients were able to learn that lots of people were experiencing the same problems. Another example was the insistence that Ultram was safe and non-mood-altering for addicts. I had patients reporting that they felt, “not high, but fucked up”. I bought the company line and told them things like, “Well, the act of taking a pill might be a little mood-altering.” I was wrong. It’s side-effects in the DSM were updated a few years later to include mood altering effects.

    We’re a small program and we’re getting calls every day from people looking to get off Suboxone. Not because of some moral objection, rather, because they don’t like its effects on their mood or motivation, it hasn’t interrupted their illicit opiate use and/or their doctor never told them they’d be on it indefinitely.

    I get it, but it’s difficult for me to be too concerned about roadblocks, this is a blockbuster drug with millions of prescriptions and massive professional, institutional and governmental support. (Suboxone has also turned into a big, shady industry–every article or post that mentions Suboxone, heroin, opiates, vicodin, etc. is flooded with spam from Suboxone clinics.)

    Medications may play an important role in the future of addiction treatment, but they have a long way to go and the cause is not helped by the people who oversell their benefits and shout down people who point out their shortcomings.

    I think, as out health care system focuses more on chronic disease management, we’ll be hearing more and more about the tension between procedures and medications that reduce symptoms versus behavioral strategies that reduce symptoms and foster global wellness. This isn’t to say that they can’t be complementary, but, in the real world, it often becomes either/or.

    1. Yeah, the either/or is unfortunate. And I take your larger point: I was part of the consumer movement that forced prescribing physicians to recognize the SSRI discontinuation syndrome. It went down just like you said. Internet pushback by patients on health boards culminated in official recognition by JAMA and other “official” medical news outlets. I have no personal experience with suboxone, however, so I’m just trying to learn from the debate. Yeah, in one sense, drugs for drug addiction is an old strategy (heroin for alcohol and vice versa) but I like to think we’ll get better at just picking off the craving component.

  3. Jason, I really appreciate your thorough and thoughtful discussion of the issue. Having done little specific study of the pharmocological approaches to addiction, your words come to me as clear confirmation of the anecdotal experiences I have had with some individuals struggling with addiction. This is not a structured research study, just some folks I have gotten to know. I have yet to encounter someone who is on maintenance and not also living a somewhat diminished life – then again, if a person on maintenance was living a full life, I might not hear about the maintenance.
    Take care,

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