Buprenorphine and emotional reactivity

The following article was shared with me by a reader. Not surprisingly, the emphasized portion below caught my eye. [emphasis mine]


Addictions to illicit drugs are among the nation’s most critical public health and societal problems. The current opioid prescription epidemic and the need for buprenorphine/naloxone (Suboxone®; SUBX) as an opioid maintenance substance, and its growing street diversion provided impetus to determine affective states (“true ground emotionality”) in long-term SUBX patients. Toward the goal of effective monitoring, we utilized emotion-detection in speech as a measure of “true” emotionality in 36 SUBX patients compared to 44 individuals from the general population (GP) and 33 members of Alcoholics Anonymous (AA). Other less objective studies have investigated emotional reactivity of heroin, methadone and opioid abstinent patients. These studies indicate that current opioid users have abnormal emotional experience, characterized by heightened response to unpleasant stimuli and blunted response to pleasant stimuli. However, this is the first study to our knowledge to evaluate “true ground” emotionality in long-term buprenorphine/naloxone combination (Suboxone™). We found in long-term SUBX patients a significantly flat affect (p<0.01), and they had less self-awareness of being happy, sad, and anxious compared to both the GP and AA groups. We caution definitive interpretation of these seemingly important results until we compare the emotional reactivity of an opioid abstinent control using automatic detection in speech. These findings encourage continued research strategies in SUBX patients to target the specific brain regions responsible for relapse prevention of opioid addiction.

I started out skeptical of the methods and researchers, but, from what I can tell, the methods don’t seem to be fringe pseudoscience.

I don’t know what to make of the associations of Blum, it looks like he was involved in very important research on the genetics of alcoholism in 1990. Since then, it looks like he’s been involved in a lot of entrepreneurial ventures. Bios say that he’s on faculty at Department of Psychiatry and McKnight Brain Institute, but I could find no reference to him on  their website.

Berman appears to have a robust academic career and is affiliated with NIAAA, VA, Boston University and ATTC.

The article was also peer reviewed.

What do you think?


14 thoughts on “Buprenorphine and emotional reactivity

  1. Does the article define what “long term use” is? Is it a year, two, more? My son is on it and its helped him get to a year clean from heroin but I worry about the effects on him.

    1. This is the first study I’ve seen of its kind, so I’m cautious about reading too much into it. That said, it mirrors a lot of anecdotal reports I hear. So…we’ll wait and see.

      If your son is doing well and enjoying a good quality of life, I’d be reluctant to make a change without a lot of support. Relapse rates for people trying to get off suboxone are so high that we’re really only seeing success with people who put themselves in something like residential treatment to get off it.

  2. I think as the authors suggest in their summing up we need to be cautious interpreting these results – the flattened affect could be caused by years of street opiod use , not the SUBX, neither control groups have necessarily any experience of opiod addiction they dont explain why they recruited from AA not NA. Like they say if they used a control group of recovered opiod addicts ie from NA you could make a stronger case but even then the difference in affect etc might be not that they dont have opiates in there system but that the NA controls have learnt through the process of recovery to get in touch with their emotions

    1. Agreed, though it fits with anecdotal reports and I have vague recollection of a study looking at abstinent opiate addicts and MMT patients. As I’m writing this, I think that focused on cognitive rather than emotional functioning.

      I hope we see more research in this area.

      1. One more thought.

        While I agree this has to be a “wait and see”, when this is put into the context of studies finding cognitive impairment, driving risks and failure to benefit from concurrent treatments, it feels like some pieces of a puzzle are starting to converge to form a picture of adverse effects from bupe.

        If this ends up being the case, it doesn’t mean that it should be dismissed, but it does set up real a conversation about potential pros and cons based on empirical evidence.

      1. Hey Jason,

        I finally got around to this study – this is a fascinating reading though I found quite complex to get my head around. I wanted to make I understood it all before I commented because these papers are a game changer for me re the downside of maintenance therapies.

        As the authors claim, these are major findings with significant clinical implications.

        There are two articles from this study, the one you found which deals with emotional and social factors plus another one dealing with cognitive factors. http://www.ncbi.nlm.nih.gov/pubmed/22726911

        It is no surprise that compared to people who had never used heroin (the control group) the maintenance group had poorer cognitive, emotional and social functioning – that is fairly well established by previous research. But it has not been certain (up until these studies?!?) whether the differences were due to the maintenance itself or the prior heroin use or associated brain injuries or the life conditions that led to the addiction in the first place.

        The most straight forward finding is that there is no difference between maintenance drug i.e. methadone or buprenorphine despite the latter being far less sedating. It appears reduced functioning may be unrelated to sedation.

        What is so striking about this study is that they found NO difference in cognitive, emotional and social skills between the control group that had never used heroin and recently detoxed ex-users in a residential therapeutic community (who on average had been there around six weeks).

        It seems on the face of it that removing opioids from their systems rapidly restored the ex-users cognitive, emotional and social functioning to near normal, as if they had never used!!

        The authors seem quite taken aback by this result calling it ‘puzzling’ because while generally research shows that there are few differences between never-users and long term ex-users, in this study there was no differences between the never-users (controls) and the recently detoxed abstinent group even though they had histories of opioid dependence as long as the maintained group.

        The first paper about emotions and social factors is interesting in that, instead of photos, they used videos of method actors (who try to summon up real emotions and body language rather than just pretending). These actors in a series of vignettes display the six basic emotions common to all cultures which the participants have to guess correctly. The other videos show vignettes of the actors being sarcastic vs. being sincere with each other, testing participants social skills.

        These videos were developed to test similar deficits in people with acquired brain injury and this the first study to use such sophisticated stimuli (i.e. not just photos) in opioid users.

        They found that those on maintenance were “much poorer than abstinent or controls when being asked to recognise emotions and interpret conversational inferences” which may “impede communication significantly including important therapeutic information”. The main predictor of low social functioning was poor cognitive functioning consistent with other research which shows that cognitive functioning is essential to understand ambiguous complex social information (like sarcasm). The authors suggest that “cognitive function mediates between group membership and social cognition” via emotional regulation ie you need your wits about you to navigate busy social situations without getting upset.

        They suggest that because maintenance clients have significant difficulties in reading the emotional states of theirs and understanding conversations “where what was said is not what was meant” (e.g. sarcasm) this leads to “significant interpersonal problems characterised by misunderstanding everyday interactions including humour and misreading the moods and intentions of others.

        For treatment staff, it is important to … avoid hyperbole, humour, sarcasm and hints when communicating important information.” Also that “impairments in recognising emotional reactions may also deprive maintenance clients of important social feedback by which they can regulate their behaviour.” They go so far as to suggest that clinicians communicate with maintenance patients in the way that should with clients with acquired brain injury!

        This raises the possibility that brain damage due to overdoses is causing the differences but the same level of risk factors were found in the abstinent group who were no different from normal.

        It seems all arrows are pointing to the actual maintenance drug (either methadone or buprenorphine). Interestingly the authors are quite skittish about coming the most “parsimonious conclusion”. They argue because there was no relationship between functioning and length of abstinence in one group and or maintenance dose or between maintenance drug in the other group, “it is unlikely that maintenance medication were responsible.”

        I don’t buy this.

        Regarding time in abstinence, the assumption seems to be that there should be a slow return of functioning which would relate to time since detox, i.e. a slow wash out. But it is quite likely the reduced functioning is due to the acute effect of the opioids on the brain and functioning returns as soon as the drug leaves the system.

        After all, reduced functioning is the effect that users are often seeking, reduced cognition, i.e. disturbing thoughts, reduced emotional awareness, i.e. unpleasant feelings and maybe even reduced social functioning i.e. less need for social interaction and less social anxiety – all of which may be far more important than any euphoria from the drug (which face it by the time you get to treatment has long gone). This would explain why maintenance drugs are successful at reducing cravings, – because like heroin they successfully suppress normal, unpleasant cognitive, emotional and social functioning.

        The lack of relationship between maintenance dose and functioning is more intriguing. You would expect the more drug on board the less able they were to function, perhaps there is a certain dose below typical maintenance levels which is enough to impede functioning but additional drug has less additional impact.

        Anyway the authors then go looking for other possible reasons and suggest that maybe maintenance patients are less cognitively skilled and self-select (choose) maintenance over the more demanding requirements of residential rehabilitation, (which seems a bit unfair).

        They also suggest that the reduced cognitive function is not the only causal factor of poor social functioning. Other factors such as poor parenting or childhood abuse or in-utero alcohol could be to blame. But if this were the case it should also apply to the abstinent users as well, who had similar histories and risk factors.

        In the end they say despite all this evidence, that due to the lack of dose-response described above, it is unlikely that the maintenance drugs were responsible for the observed reduced functioning and it must be something else.

        The question arises as to why the authors are so reluctant to accept that the maintenance drugs are responsible for these outcomes. One reason is that the institution the researchers work for, NDARC, is a bastion of harm reduction and politically disinclined to give any ammo to the significant anti-maintenance lobby in Australia. While I have some sympathy with this concern, plus also the possibility that these kind of results could generate further stigma against an already stigmatised group, downplaying or even disregarding important side effects of treatment is not the way to go about it.

        And I love how this study comes from my home town Sydney. If there ever was a city that loves its drugs it’s the open air gulag that gave birth to Australia!

      2. Wow. That’s quite a comment.

        Check out this paper exploring the question of whether buprenorphine maintenance should be used with health professionals. They came down against it. Cognitive impairment was one of the concerns.

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