Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: buprenorphine (page 1 of 3)

Middle-Aged White Women: Why Are We Dying?

Selfie of G. I'm 51, and I'm in the demographic that's dying fastest from painkiller addiction.

Selfie of G. I’m 51, and I’m in the demographic that’s dying fastest. I have six years in abstinence-based recovery from painkiller addiction.

The New York Times is all over the “narcotic epidemic” this week.

Probuphine

First we had a story about the recommendation for FDA approval of Probuphine, the implantable plastic matchsticks saturated with buprenorphine. The story was mostly about how sticking this drug inside our bodies would reduce overdose deaths from heroin, prevent us from selling buprenorphine (Suboxone) on the streets, and keep us compliant with taking our doses.

The trajectory of the story (“Let’s cure all addicts with this drug!!”) was saved by a CDC physician and a West Virginia University doctor, both of whom said we can’t just implant these sticks into people and send them on their merry way.

But you know what?—that’s exactly what will happen. Because that’s exactly what has been happening for two decades with SSRIs, which were approved for major depression, were never intended for lifetime use, and were recommended for use concurrent with psychiatric therapy. But the NYT has run stories about, gosh, therapy is so expensive! And to get SSRIs you no longer have to see a psychiatrist. You can go to your PCP, who most likely isn’t qualified to treat depression.

But you’re probably diagnosing yourself, so hey.

And you know what else?—the FDA will approve Probuphine for opioid addiction, but dollars to donuts it will be prescribed off-label for other stuff. Also, doctors will up the doses—off-label. Because that’s what happens with drugs. Doctors aren’t bound to prescribe only for approved uses. And they don’t. And doctors usually don’t know much about the drugs they prescribe. Most doctors who prescribe buprenorphine have no idea how strong it is.

I bet you a dollar that many people with opioid addiction who try Probuphine will wind up with permanent bupe implants.

Because doctors know how to get us on this stuff, but they never know how to get us off.

BIG News: Whites Are Dying Of Overdoses.

omg, AND!!: whites are now dying of overdoses faster than blacks. Which is HUGE news.

Because guess which race makes up the majority of the NYT’s audience—and that of the other major media outlets (except AlJazeera).

For the past five or six decades, black heroin addicts have been dying from overdoses (and ancillary illness and crime), and their communities have been bombed out by the war on drugs, but their deaths and mass incarcerations have not spurred the kind of critical, apparently sympathetic spotlight that the media is now turning on white overdose deaths.

The headline (“Drug Overdoses Propel Rise in Mortality Rates of Young Whites”) says young people are dying fastest, but when you get to the graphs, you can see that among women, the age group that’s dying fastest is 45-54—my age group.

Deaths from drug overdose. Source: NYT.

Deaths from drug overdose. Source: NYT.

Eileen Crimmins, a professor of gerontology at the University of Southern California, said:

For too many, and especially for too many women, they are not in stable relationships, they don’t have jobs, they have children they can’t feed and clothe, and they have no support network.

It seems weird that they spoke to a gerontologist for this story, but in fact among white women it’s the older ones of us who are dying fastest.

We have no support network. She says.

Recovery is all about building a support network. It’s also all about finding out how we can contribute to society, which is how we earn a living.

It’s strange that the Times didn’t put these two stories together. After all, the thinking in one (“painkillers are killing whites”) leads directly into the other (“Probuphine will save painkiller addicts’ lives—because everyone knows dopefiends can’t stay off drugs any other way”).

That is the way treatment is headed, by and large.

There is no reliable science to show that people addicted to opioids have a tougher time staying off their drugs than anyone else addicted to any other drug, as long as we have access to a support network. But the popular idea is that we painkiller addicts have wrecked our neurology for good.

And this is the line scientists will take because their research is funded by pharma. This is the line pharma will take because it will sell more drugs. This is the line physicians will take because prescribing drugs takes less time in the consultation room and helps them avoid the time-consuming work of actually getting to know patients. And this is the line journalists will take because they don’t bother to challenge their “expert” sources’ thinking.

So why are we dying?

Painkillers kill pain—physical and emotional. They numb the human being.

In a larger sense, to get at the real cause of why we’re dying, we could ask what we’re numbing out. What is the pain that we’re bombing out with drugs?

That’s a discussion I’d love to participate in, and that would not only keep people alive in a minimal, technical way but rather help them thrive and also cultivate people’s overall long-term quality of life.

Update, August 2016

You know how I talk above about Probuphine being used off-label? Well guess what—this blog is now getting hits from people searching for “Probuphine off-label.” In the words of Pete Seeger, When will they ever learn?

This site has always been add-free and fee-free. If this post helped you, please like and share.

I’m Not A Unicorn.

It’s been a long time, dudes!! The New York Post is running a story today about middle-aged women and addiction to prescription painkillers. The reporter was looking for a middle-aged middle-class white chick to talk about this, and guess who she found.

The online headline says I was a “perfect mom and wife,” but I was not a perfect mom and wife inside my addiction. I was a lot less than that.

And as always with newspaper stories, some things didn’t make it in:

  • That my son (who is now 18) knows about my addiction, is my biggest supporter in recovery, and has always had my back (read here, and here, and here, where I told him about my addiction)
  • That both my parents were addicted to legal substances and died because of their abuses of those substances.
  • That I do not hold my doctor responsible for my addiction, but I do hold her responsible for failing to screen me for risk of addiction before giving me drugs like pure hydrocodone and morphine and fentanyl, and for failing to recognize my addiction and respond with compassion and treatment, not judgment and punishment.

The biggest thing that didn’t make it in is my main reason for talking to the Post. (I mean, the Post is famous for Page Six, right? but if it had been the New York Times or Pro Publica or the Kalamazoo Gazette, my motive would have been the same.)

I talked to this reporter because there are other reporters out there (here is one example; there are many others) saying that once you’re addicted to opioids, you may as well resign yourself to taking drugs for the rest of your life.

black-unicorn-tattoo-design

(It’s hard to find an edgy unicorn image. They’re usually pink and lavender and sparkly. This black tattoo-design is cool. I’ve been thinking about getting a tattoo—maybe I’ll ask Cara to put this somewhere on my skin)

I am, however, not a unicorn. I know so many people, including many many women, who no longer cop heroin or snort Oxy. And they don’t take methadone or Suboxone, either.

But in some public health circles, it is said that there is no “proof” that we can actually do this. Nobody (except the tens of thousands of people who live opiate-free today) has “proven” that abstinence from opioids is possible—that human beings can choose to live drug-free and actually for-real carry out that choice.

There does exist, however, some evidence that people who are addicted to painkillers or heroin stay off street drugs and stop injecting if they take other opioids. (A lot of the research is driven by the desire to find a way to control the spread of HIV infection through needles.) So indefinite maintenance with these drugs—possibly for a lifetime—is now touted as the “evidence-based standard of treatment” for illnesses like the one I have, no matter what your circumstances.

I’m very cool with anyone who chooses to take drugs for life. If you WANT to drink methadone or suck on bupe films forever to keep from shooting or copping, it doesn’t matter to me. I considered it myself at one point. I have no problem with it, and I will not bristle at you in comments sections.

It’s unfortunate that a lot of people who choose maintenance say the way I do recovery—and the way so many other people I know who have long-term abstinence from opiates do recovery—is not “evidence-based” and therefore is sentimental, stupid, unscientific, or dangerous.

I will bristle at that. (I will still not judge you, but I will bristle, because you are judging me.)

It’s the people who DON’T WANT to drink methadone or eat bupe that I hear from.

I write and speak to places like the New York Post because I have heard from so many people who want to quit their maintenance meds and can’t find anyone to help them. Including, probably, many people who stand in grocery store lines reading the New York Post.

Let me restate in words of one syllable: they want help and can’t find help. Think about that. They are paying, per month, maybe $400 cash to the “Sub doc” plus whatever it costs them to buy bupe, or they are buying bupe on the street, and they want to quit, and they can’t find help.

I want to demonstrate that help is available. In order to demonstrate this, I’m willing to do hard stuff.

It’s kind of a little bit hard to talk to a total stranger from a newspaper with a circulation of half a million and admit that you took oxy just so you could, like, make breakfast for your family. And that you changed dates on scripts, and that you let people down, including the people you loved and who loved you most, and made super-problematic moral decisions inside your addiction.

But anyone who has been inside addiction and who hopes to get out will know what I’m talking about when they hear these stories. And hopefully they’ll see a light at the end of the long dark tunnel.

This site is free. If this post helps you, please use the buttons to “like” and pass it on!

Suboxone Detox Redux.

Four years after posting this interview with Dr. Steven Scanlan of Palm Beach Outpatient Detox, I’m still getting mail about how to tolerate Suboxone withdrawal. This piece and a couple others I’ve written rank in the top 10 in Google searches, and over the years I’ve been so deluged with comments and private emails about people’s struggles to get free of this drug that I keep a huge separate file for them all. I’ve talked or exchanged emails with some of these folks, and eventually I plan to put out a booklet that collects people’s experiences with this drug that is—depending on where you live—variously doled out like candy by doctors who don’t understand its strength, or available only if you drive two hours or three hours through the wilderness and pay cash to doctors who run their Suboxone clinics like whorehouses.

A reader named Bob wrote this morning:

I was using 16mg a day for 2 1/2 years, I was in excellent physical shape, ran 4 times a week, multiple half marathons, but felt enslaved to this drug. I went to an out-patient 6 week detox program, just in one week I went from 16 to 8 a day, next week went down to 4 a day, then the following week I went down to 2mg a day for a week before I “jumped”, I stayed off of it for 2 days, had ungodly withdrawals, so they gave me 2mg for one more day, I then went 9 straight days with nothing before I did 4mg on a relapse, now I am at day 6 with nothing. I am a business owner and cannot afford to be ” on my game”…any ideas as to when it gets to be ” manageable?”

I think Bob meant he couldn’t afford to be OFF his game. It seems like, in his detox center, they wouldn’t let him taper down to the minuscule doses that are most helpful in Suboxone detox. Many, many practitioners prescribing this drug do not understand its pharmacokinetics—how it behaves in the body, and how the body processes and neutralizes it. They think 2mg is a small amount.

 

A Suboxone film, cut for tapering.

A Suboxone film, cut for tapering.

Look at this picture. This is how some people taper off Suboxone. They cut the dissolvable films into little bitty pieces. The company that makes Suboxone does not advise doing this, because they say they can’t guarantee the drug is evenly distributed throughout the film, but guess what?—I think it’s because they don’t want people to taper off it. I’ve talked to Tim Baxter, M.D., global medical director of Reckitt Benckiser, manufacturer of Suboxone. In two separate interviews he told me, “We don’t promote detox.” They want you to stay on this drug. But you don’t have to.

Disclaimer: I’m not a physician, I’m just sharing experience and making space for many others to share theirs. If you want medical advice, you need to see a doctor. ... That said, Bob, 2mg is a significant amount of bupe to jump from. Like jumping from about 60 or 70mg of morphine (the gold standard drug to which all other opioids are compared in their analgesic and receptor-binding strength). I was tapering off the equivalent of 400-500mg morphine per day, and I used Suboxone for two months. I jumped off about 1/8 of a milligram—the tiniest bit in the photo above. Dr. Scanlan and other doctors who understand buprenorphine, the opioid drug in Suboxone, taper people down to fractions of a milligram before they jump.

So you’ve been six days clean after taking 4mg, and you continue to be physically active? Awesome job. Keep it up.

Some tips—take what you need and leave the rest:

  • Get good food. Eat no sugar, no caffeine, and as much organic protein (meat, fish) and vegetables and fruits as you can. Fuel your body well.
  • Get good sleep. Don’t take sleep aids, except for maybe benadryl or melatonin, which Dr. Scanlan prescribes during Suboxone detox (see above). A low dose of gabapentin helped settle my legs and get sleep. Hot baths also did the same thing—fill your tub with scalding water and enjoy feeling your muscles relax. Scanlan also prescribes Librium (chlorodiazepoxide)—if you can get a provider to help you for a month or so by prescribing a low dose of this, it may help you sleep.
  • Keep exercising. This will ease your restless legs and arms, reset your opioid receptors, and increase your energy levels and your appetite for good food. Yoga is also effective to stretch and relax the muscles that feel cramped and jumpy.
  • Meditate. Research shows that for recovering addicts, meditation restores the connection between the limbic brain (the part where cravings live) and the prefrontal cortex (the part that lets us make good decisions). In detox and post-acute withdrawal, meditation calmed my mind and helped me understand that every goddam moment of detox passes and that I could make good choices to foster my health.
  • Read Dr. Scanlan’s paper about Suboxone detox. Pay special attention to the section called “The Jump,” in which he says he tapers people down to very low amounts and advises his patients to stop the drug when they have a week or two to take it easy on themselves.
  • Find a supportive community. Anyone who has been taking Suboxone is struggling with an addiction. And nobody gets sober alone. We all have to learn to ask for help. When I was detoxing, I needed to be in touch with people every day. I did this partly on the public forum Opiate Detox Recovery (which has a special Suboxone forum), and partly in a 12-step program, where I got a sponsor who I called almost every day, and where I went to meetings where I met people who had done what I was trying to do and were holding down jobs, raising kids, and most of all being happy.

Even more information about how to take care of yourself while detoxing and dealing with post-acute withdrawal is included in my book, The Recovering Body, which you can get on Amazon and in your local independent bookstore. 

Edit: Here is an email from a guy called Larry that came in several days after Bob’s:

I’m a 60 yr old male engaged in hiking, climbing and biking.  I’ve had a 15 year long opiate addiction.  I’ve used suboxone for 2 years.  I started at 4mg.  I requested the low dose as I felt 8mg/16mg was more than I needed.  I reduced my dosage from 4mg to 1 mg over 4 months,  from 1mg to .25mg over another 4 months.  I jumped off from .25mg  ( 1/8 of a 2mg strip).  I had moderate WDs for a week, 3 weeks of significant lethargy and continuing mild lethargy.  I’ve been clean for 2 months.   I can feel it getting better and I’m staying the course.  I really don’t have any choice.  The alternatives are all non starters for me.

If you don’t make it this time, taper to a lower dose, no more than .25 mg.  It’s worth doing.

(Emphasis mine. 🙂 ) Fifteen years on opioids, and he’s now free. Congratulations, Larry.

Good luck to Bob, Larry, and the countless people out there who are trying to get free. Let us know how it goes.

Recovering Body_small

The Treatment that Might Have Saved Phil Hoffman.

Cross-posted with AfterParty Chat.

Philip-Seymour-Hoffman

Late last week it was suggested that a cultural stigma against maintenance medications such as methadone and Suboxone helped kill Philip Seymour Hoffman.

This doesn’t make much sense to me given the fact that, shortly after he died, it was reported that buprenorphine was found in Hoffman’s Bethune Street apartment. Buprenorphine is a long-acting opioid the FDA approved in 2002 for opioid detox and maintenance. It’s used mostly for maintenance: it’s the New Methadone, but it’s much easier to get, because while methadone is approved for addiction-treatment only in a clinic setting, buprenorphine can be dispensed in a doctor’s office. Refills can be called in or faxed to pharmacies.

So how did Hoffman get his bupe? Either he was being prescribed buprenorphine for his opioid habit, i.e. he was “on maintenance”—as so many opioid addicts are: buprenorphine maintenance is a booming business in this country. Or else, as many heroin users do, he obtained his buprenorphine on the street.

Poor heroin users often cop street “bupe” to tide them over between fixes. But Hoffman was far from poor. So it’s speculation, of course, but I think it’s more likely he got his buprenorphine from a doctor. That’s what doctors do these days with opioid addicts: When we get honest about our addictions inside the exam room (and because Hoffman had spent 23 years sober and abstinent via 12-step fellowships, it may be fair to say he had practice in being rigorously honest) the doctors’ fear kicks in and they boot us into Suboxone clinics, where we’re prescribed upwards of 16mg of this very strongly-binding, fat-soluble drug that stays in our bodies for days before it’s excreted. In painkilling power it’s weaker than morphine or oxycodone, but in binding power—in its ability to stick to the body’s opiate receptors—it’s the second-strongest out there.

The strongest is fentanyl, the drug that’s been cut into heroin and has killed nearly two dozen in my region alone.

//

812

Some publications are wont to report that opioid addicts—like Hoffman, like me—wreck our brains’ opioid receptors forever through drug-use. (This proves they don’t understand how the body’s painkilling system works: a great portion of the body’s opioid receptors actually reside in the gut. Which is why we get that lovely warm feeling throughout our bellies when we use painkillers or shoot heroin.) But there’s at least as much scientific and anecdotal support for the idea of neuroplasticity in recovery—the fact (it’s not just an idea anymore, it’s a fact) that the central nervous system is far more adaptable than we ever before believed and is evolved to use this resilience to recover from major traumas and illnesses, including addiction—especially if we help it by taking care of our bodies in basic ways, with exercise, good nutrition, and relaxation.

So the “old-school” idea is not 12-step programs, as these pieces suggest. “Old-school” is what I was taught as a kid: that once you lose brain cells, you never get them back, that our nervous systems cannot heal.

Still, these publications are putting the idea out there—and it is not a fact, it is just an idea—that if “most opioid addicts” don’t take maintenance medications forever to “correct” the “permanent damage” we’ve done through drug-use, we’re doomed to relapse.

//

Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

Philip Seymour Hoffman just four or five years before he got sober, in his 1985 high-school senior-year portrait.

The clearest example that this isn’t the solution exists in our states’ physician health programs (PHPs)—systems of recovery designed to help addicted and alcoholic physicians keep their licenses to practice. These programs vary from state to state but generally provide five years of continuous care and oversight. Success rates for PHPs are extraordinarily high—upwards of 80 percent of physicians finish five years of treatment and are able to keep practicing.

These programs ought to be considered models for our citizenry. But they remain off the radar because they’re rigorous, expensive and intensive—five years, as opposed to a 28-day rehab, or even a ten-day or three-day detox.

Also, studies of PHPs show that linking recovery to one’s work is one of the strongest incentives you can give an addict to take responsibility for healing. Addiction thrives in situations of un- and under-employment not because the poor are somehow more susceptible to addiction, but because the people affected don’t have enough, or any, productive work.

It’s sometimes said that PHPs are effective for “highly motivated” addicts. Which leads me to my last point. I find it astonishingly patronizing that some are suggesting that public prejudice against maintenance killed Hoffman. Hoffman was an extraordinarily intelligent, articulate, “highly motivated” man and consummate professional whose work, he said, required him to be extremely introspective and emotionally present. I find it hard to believe he would be so easily swayed by public opinion about his choices.

I can more easily see him protecting his ability to work.

To act with the depth of feeling and nuance that he managed required full use of his entire internal emotional range. And opioid medications—including buprenorphine—necessarily dull one’s range of feeling.

I think it’s more reasonable to suggest that Hoffman tried bupe and found that, while taking it, he couldn’t access his feelings to the degree to which he’d become accustomed.

To be sure, he likely felt a great deal of shame during his relapse. One of the more damaging aspects of some 12-step groups, in my opinion, is their focus on “sober-time”: to “come back” from a relapse after a sober period of 23 years—half one’s life—would have been not only extremely embarrassing for anyone but also physically difficult, given that the heroin available these days is wicked strong.

But no way could Hoffman have wrecked his neurology permanently by using heroin for less than a year. I think it’s likely he did what so many who use heroin do: he chipped heroin, then switched to bupe, thinking it might remove his cravings. In fact, buprenorphine reliably does this for many opioid addicts who take it.

But craving is a feeling, and you can’t numb feelings selectively. My bet is that, feeling not-high but not-normal—after all, he’d been sober for 23 years: he knew what His Normal felt like; he knew what it took for him to do his job with the precision and quality with which he was used to doing it—he said what so many of us say when we’re caught between a rock and a hard place.

Fuck it.

What he needed was not more drugs. What he needed was a better form of treatment, perhaps the best evidence-based addiction treatment system we have going: the time-consuming, attentive one we give to doctors, the people we trust to protect other people’s lives.

But because Hoffman was “just” an artist, he followed the cheap, easy, brief trajectory that ordinary people in this country follow.

Pills. Then heroin. Then Suboxone. Then heroin again. Then death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

Hoffman in perhaps the last photo ever taken of him, a tintype made by Victoria Will two weeks before his death.

Trapped on Suboxone: A Woman Who Can’t Say No.

My comrade-in-arms Jason Schwartz, who blogs at Addiction & Recovery News, has a good post today on harm reduction. I filed a comment on his post and was compelled to cross-post it here, in greater detail, just because I have to start sharing this information I’ve been collecting or I’m gonna burst.

A Suboxone film.

A Suboxone film.

I’ve been interviewing people who are part of the new state of American harm reduction: Oxy and Vike addicts who are “stabilized” on enormous doses of Suboxone. (If you’re part of this trend and want to share your story, please email me.)

Over the weekend I spoke to a woman who, for a 50-75mg/day Percocet habit, was prescribed 16mg Suboxone per day. She had emailed me in desperation for advice about how to quit. She’s been at this level for 7 years. She has gained 75 lbs. and has gone into menopause. She feels emotionally dead.

I can’t tell you how crazy it makes me when I hear 1) that doctors are “treating” a 75mg Percocet habit with 16mg buprenorphine (you don’t need to atom-bomb a small Oxy habit; this is how to quit); and 2) that harm reduction advocates think these prescribing practices improve people’s lives.

An ad for a Florida Suboxone doctor. Suboxone ads promising to "free" people from addiction crowd the back pages of city alternative weekly newspapers and are posted on signs across the hillsides of poor urban neighborhoods.

An ad for a Florida Suboxone doctor. Suboxone ads promising to “free” people from addiction crowd the back pages of city alternative weekly newspapers and are posted on signs across the hillsides of poor urban neighborhoods.

Here are her Suboxone doctor’s prescribing practices: she has a five-minute visit with him every two months—via Skype. (This is one of the “good” doctors—one of the ones who doesn’t charge exorbitant cash fees for twice-monthly visits.) And when she told her doctor she wanted to quit taking Suboxone, this physician told her that, if she wanted to quit , she would one day just “forget” to take it and then she would be done.

“I think he just doesn’t get it,” she said.

He’s never taken it, so he’s in this la-la land that people can come in with an addiction and take Suboxone, and boom—they’re cured.

She’s desperate to get off Suboxone, but she knows she can’t do it by herself. She looks back at her previous Percocet habit with longing and regret—withdrawal from that level would have been comparatively easy.

She recently had surgery, and the anesthesiologist and nurse told her that they’re seeing more and more OR patients on bup—it’s the new wave. … After her surgery she took 2 Percocet every 4-6 hours as directed, and within five days a devastating withdrawal descended upon her. She described it as a band of fire belted around her abdomen, along with all the other symptoms of withdrawal, magnified. She managed to abstain from Suboxone for almost two weeks, hoping she could stick it out—and it only got worse, despite taking 3-4 Percocet every 3 hours.

In the end she couldn’t hack it. Within half an hour of taking one strip, the belt of fire disappeared.

I told this woman that there are public health experts and media mouths who think she’s better off because she’s no longer doctor-shopping or significantly threatened with overdose. I asked, How would you respond to them?

“I’ve lost my freedom to choose,” she said.

I’ve lost my personality. I’m more quiet and withdrawn. I feel like part of me is dead. And I’m a slave to it. I have to have it. I’ve lost the ability to say no.

A woman caught in a system that doesn’t let her say no. Don’t we call that “rape,” or “coercion”?

Suboxone revenues, 2005-2011. A curve generally thought of as "exponential."

Suboxone revenues, 2005-2011. A curve generally thought of as “exponential.”

And, please, Jason, let’s talk about the money. Reckitt Benckiser pulled in $1.4 billion from Suboxone products in 2012. A Harvard researcher who is looking at American Suboxone prescribing and reimbursement tells me much of it is paid by Medicaid.

So, though my middle-class, employed, insured source gets her Suboxone through Cigna, and though her doctor does not accept Medicaid or other public assistance, taxpayers—you—are indeed underwriting a great deal of this system.

It’s mostly poor people who are trapped on this drug.

Reckitt and Titan (who is developing the implants—the ones recently rejected by the FDA for not delivering enough drug to to the patient) see Oxy and Vike junkies, along with heroin addicts, as a deep mine of insurance and taxpayer revenue, just as Purdue saw pain patients—potential OxyContin buyers—10 years ago.

And, finally, let’s talk about how “people can’t abuse Suboxone.”

melted_suboxone

A melted Suboxone film, ready for injection.

 

People can and do abuse Suboxone.

Older posts
Visit Us On FacebookVisit Us On Twitter