Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: buprenorphine (page 2 of 4)

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.

Among Addicts, It’s A Small World After All.

The other day I get an email from an English guy who says he has a story about Subutex, if I’m still collecting stories about buprenorphine (I am still collecting them and will be talking to folks starting in May—if Suboxone saved your life and/or kicked your ass, please email me).

This guy spent 10 years on buprenorphine after a devastating heroin habit. He took methadone to get off heroin, and he thought that in Subutex he’d found a painless stepping-stone off methadone. But bupe has given him all kinds of problems with his intellect, emotions, creativity, ambition, passion. He writes,

I cannot feel joy.

He jumped off Subutex two weeks ago and writes that he has already had a couple slips because he’s so impaired that he can’t stand it.

I have a loving wife, two beautiful sons, supportive friends, an ok job and yet I have been wanting to die for a few years now—not actively suicidal (you can’t be actively anything on long-term sub maintenance) but quietly hoping that fate would off me.

I know what he’s talking about. So does my jump-buddy, Bonita, who kicked Suboxone days ahead of me in 2008. So do thousands of other people who have had trouble either being on or kicking buprenorphine, or both.

//

So, but here’s where it turns “most uncanny,” as Nigel said: In writing back, I mention I’ve spent tons of time in the UK, mostly in London and Yorkshire.

Nigel replies: he was raised near Kensington High Street (London), and he was educated at the Catholic boarding school, Ampleforth (York).

I know where Ampleforth is, I say, because I’ve been practically everywhere in the North from the Lakes to Robin Hood’s Bay, and all the dales and moors in between.

And I’ve lived in London. I tell him about a very unhappy, lonely winter I spent in London 15 years ago. “To combat a serious case of depression,” I tell him, “I used to push my son up Marloes Road toward Ken High Street and into Holland Park every day I could. I retain a great affection for Holland Park, and for a little tiny key-garden called Edwardes Square.”

Edwardes Square, West London. Photo courtesy of Londonholic.

Edwardes Square, West London. Photo by Londonholic.

Most Americans visit St. James’s Park, Regent’s Park, Hyde Park. Holland Park is an underrated treasure, appreciated mostly by Londoners, who, on warm summer nights, enjoy outdoor concerts and pick-up footie matches on the lawn. And friggin nobody knows Edwardes Square. I get blank stares when I mention it to anyone. It’s just a little tiny square in West London. When people get that far they make the cab fare worth their while by visiting Kensington Palace, the V&A Museum, the boutiques on the Kings Road. You can’t even get into Edwardes Square unless you live in one of the houses facing it. I myself couldn’t get in. But it was my little psychic refuge that long-ago early spring.

Nigel, however, says: his parents live off Pembroke Gardens Close, adjacent to Edwardes Square:

I know the area intimately.

Then:

He says he himself used to live on Marloes Road across from the Devonshire Arms.

Devonshire Arms pub.

Devonshire Arms pub.

(Nigel has lived in some fancy places. Not Belgravia, but still.)

I picture the Devonshire Arms: big corner pub; patio paved for pleasant outdoor boozing. (I never drank at the Devonshire Arms; I had my baby with me, always, and my codeine back at the flat.)

Nigel tells me,

My bedroom window overlooked Marloes Road, and I spent some of the darkest days of my heroin addiction in that ivory tower. I would have been there in 1998.

So. While I was struggling with killer postpartum depression the winter of 1998, walking several miles per day with my boy in a stroller, up Marloes Road and then Campden Hill Road to Notting Hill Gate, then west to the northern entrance to Holland Park—I was passing Nigel in his house every day.

G was rationing out her American codeine.

Nigel was banging his British smack.

And now here we are, on opposite sides of the sea, talking about how to live sober.

Most uncanny, 

Nigel writes.

Definitely a very small and funny old world.

Thank you, Nigel.

Suboxone: Addiction, Recovery, And Self-Confidence.

Hi folks, good to be with you again.

I miss writing on this blog. I used to file two or three blogs per week. That was before I got a job—several jobs, actually. I need to earn my daily bread, and I need to take care of my kid, who the other day flipped over head-first, fell on his head and shoulders, and was back-boarded off the soccer field (he’s OK but yes—shocking to watch the trainer test him for paralysis and hear her say, “We have to call an ambulance”). So sometimes the blogging goes by the boards. I’ve been filing a lot on my Facebook page, but you have to be my friend to see it. So, won’t you be my neighbor?

Been teaching writing to university students. An interesting experience: the last time I taught was four months before I got sober. The other day I was sitting in a meeting next to an acquaintance in recovery, a woman sober about two years who just got tenure at one of the universities in town, and I told her I was teaching again. “Teaching sober is AWESOME!” she said. This is someone who does not usually include the word “awesome” in her lexicon.

“I know!!!” I said. I am someone who usually does not speak with multiple exclamation points.

Teaching sober is, in fact, awesome. The best thing about it is that, having practiced Step 10 on a regular basis for four years, I now have a much better sense of what’s my responsibility and what’s not. Which enables me to relate to the kids (they’re kids: they’re just three or four years older than my kid) on a much clearer basis than when my head was wrapped up in films of fentanyl.

In other words, I have more confidence.

The root of the word “confidence” is the Latin fidere: fidelity, trust.

Sober, I can trust myself. At any rate, much more than I could when I was taking drugs.

It is 3 a.m. and I’m writing this because I got up to pee, checked my phone, and this email came in overnight. She is taking drugs to feel self-confident. She wants help.

The drug she is taking is Suboxone. She was using heroin for five months—“five long, brutal months,” she writes, “and even though that’s a short period of time compared to most people, I was really addicted”—and her doctor put her on Suboxone. Her doctor told her taking it for three months would lead to a lower “success rate” than taking it for at least eight. (I’d like to see the data behind the claim, and I’d like to know who financed the studies.) So she took it for a year—along with two antidepressants and a long-acting benzodiazepine.

No idea what kind of doctor she went to, but in fact family doctors and internists, who are generally ignorant about addiction and recovery, can prescribe Suboxone, a long-acting fat-soluble opioid that’s more powerful, milligram for milligram, than heroin. Just as family doctors and internists, who are generally ignorant about mental illness, can prescribe antidepressants—drugs that also change the brain, usually not for the better, according to Robert Whitaker, who wrote a comprehensive and almost universally acclaimed book on the subject of psych meds and mental illness. Any time-frame over six weeks is considered “long-term” treatment by most physicians and researchers, and lots of folks wind up on these drugs indefinitely.

My reader writes,

I have been living with the knowledge for about 18 months that Suboxone is this wonder drug. It turns out I didn’t know too much about it. I kept a couple of the film strips in case I felt like I was going to relapse. One day I took the Suboxone after about three months of being off of it and I felt so high that it scared me… so I tried it again after.

Of course she tried it again. She’s an addict, and she has drugs in her stash.

This person has a job, too. She’s a college student, like my students. She’s studying to be a doctor, “so I could go help people with the problems I had,” she writes. And since starting school in August, she’s been on “a Suboxone binge,” she says.

Not to get high, but because it gives me my confidence back.

She needs confidence. She has to make friends, she writes. “I became socially awkward after my addiction”—as though her addiction is “over”—“and I felt like I needed it to talk to people.” So now she’s back to taking it every day.

Just little, tiny pieces, probably like 1/9th of a pill a day, but I don’t want to take it anymore, and I want my confidence and ability to talk to people back… can you please help me?

I have news for whoever is reading this who thinks that one-ninth of a Suboxone pill isn’t a lot. If it’s one-ninth of an 8mg pill, then that’s almost 1mg of buprenorphine, and that’s roughly equivalent to 30mg morphine. Which ain’t nothin to sneeze at.

This 18-year-old girl (she is 18: she told me) is taking drugs simply because she wants to trust herself. She has a drug that gives her that fleeting feeling of self-trust. She knows it won’t last.

These emails I get from readers feel like silk threads that bind me to folks around the world who are desperate for help with their drug problems. It’s like each of these people is Spider-Man, firing out webs that reach around the world and go straight inside me and attach themselves there. And they pull.

To my reader: your addiction is not “over.” If indeed you were “addicted” to heroin, then you are an addict. Being an addict doesn’t mean you’re a low-life. It means you have an illness, and like anyone who is ill you need to learn to take care of yourself. To do this you must ask for help In Real Life. However scary it might seem.

On the other side of that reality of needing to ask for help is this problem my reader will most likely run into: she may go to her doctor and tell him that she stashed her films and she’s been using again. You know what may happen? He’ll decide she’s a “chronic relapser” and put her back on Suboxone, perhaps at a higher dose, perhaps for a longer time. She is 18. Her brain and central nervous system aren’t really even out of childhood.

She writes, in a voice that is perhaps not self-confident but certainly reaching toward self-awareness,

I don’t want to take it anymore.

“I don’t want to take it anymore.”

The famous scene with Peter Finch from the film, “Network.”

I’m mad as hell and I’m not gonna take it anymore.

Reader, there are two ways I might be able to help you. One is to suggest you call Alcoholics Anonymous or Narcotics Anonymous and get help from real people who have been through this (and worse). Don’t Take It Anymore.

The second is something I think I need to do for all the folks who write in, to me and to forums for drug addicts, saying they can’t quit Suboxone. And that is to write about Suboxone.

If you have a story you want to tell about how Suboxone either helped you or kicked your ass, please email me at guinevere (at) guineveregetssober (dot) com.

Alive: Third Anniversary of Detox

Foxgloves in G’s garden.

Always feel particularly alive August 29-31. Those were the days I spent in precipitated withdrawal, as fentanyl and Suboxone duked it out in my body.

I’m sitting right now in the same spot where I spent most of those two days: my side of the bed. The weather is the same—80 degrees, cloudless sky arching over the trees—but it looks entirely different today from the way it did for me three years ago.

Back then I was a writhing mess. My son, almost 11 at the time, didn’t know what what happening to me. He kept coming upstairs, asking, “Are you all right, Mama?” I told him I was having a bad reaction to a new medicine. Which was entirely true. And which left out all the rest of the truth.

How to Find a Good Detox Doctor

I’d wanted to go to rehab, but I knew I’d already been too absent from my son to justify being gone an entire month. So I got a detox doctor in the best way I knew, and in my opinion it’s still the best way: by word-of-mouth. I called the offices of a reliable rehab in the region, and when they refused to manage my medical detox on an outpatient basis, I asked who they recommended. They gave me a name; then I called my PCP and asked her, and she named the same guy.

I scheduled an initial consultation with this guy in July 2008. I told him I was a pain patient who was getting tired of the red tape involved in managing Schedule II medications, that I wanted to “reduce my tolerance” (this is how I put it to myself: I’d just reduce my tolerance and get back onto something like Vicodin, pull a feat that would impress my physician and enable me to continue receiving meds—just ones that weren’t so strong or so tightly controlled). I was afraid of how much pain I’d have once I started detoxing.

He said I’d be a perfect candidate for detox, that we could try it and see how it went.

While I sat in the waiting room I watched his patients come and go. The guys were huge, linebacker-types, or scrawny; almost everyone had tattoos; and of course I saw myself as Better Than All Of Them. What was a nice girl like me doing in a place like this? But everyone was quiet and respectful and when the detox doctor came out of his office, a little room in the back of a house on a main street in one of the poshest neighborhoods of the city, he reminded me of no one so much as Mr. Rogers. Actually, I’d met Mr. Rogers years before, and Mr. Rogers was shorter and thinner than this guy, but they both had the same humble, interested attitude: when you sat before either of them, they paid full attention only to you. And these huge biker-guys practically knelt before him like he was one of the prophets.

“He’s really working in the trenches,” the medical director of a big rehab nearby told me recently. “He’s always been on the forefront of treatment in the city. We need more guys like him.”

This medical director told me he estimates about 30 percent of all physicians prescribing buprenorphine for detox or treatment are “entrepreneurs”—physicians who are in Suboxone/Subutex treatment just for the money. They require twice-monthly followups, and they charge upwards of $300-$400 or even more per office visit. They make you pay in cash. And they prescribe large doses that are impossible for patients to quit by themselves. It constitutes exploitation.

You have to be careful to get a good detox doc.

My detox doc didn’t take insurance, but he’d accept a check or a credit card, and his fees were by no means outrageous: $110 for the first visit, and $80 for followups. He usually conducted 3-week detoxes for which he saw patients once per week, but because my drug-use had reached such a high level, he agreed to allow me to go more slowly. My entire two-month detox came to less than $700. By contrast, rehab stays cost tens of thousands of dollars.

The day I was scheduled to start my detox was the Friday before Labor Day. He prescribed something like 10 or 15 Suboxone tabs, gave me detailed directions about how to take them, and gave me his cell phone number in case I had problems.

Precipitated Withdrawal

Because fentanyl hangs around so long in the body’s tissues, and because it’s the only drug that can fight with buprenorphine in the body, I should have waited longer to take the Suboxone. But I took it too soon and wound up in precipitated withdrawal, which means the fentanyl and Suboxone were competing for space on my opiate receptors. Eventually the Suboxone won and kicked the rest of the fentanyl off. But it put me more deeply into withdrawal than I’d ever experienced. I couldn’t sleep but I couldn’t raise my body; I couldn’t stand long enough to take a shower. Of course I could not eat. I couldn’t even tolerate the smell of food without retching. (Severe opioid withdrawal makes the world smell like rot—people often forget to mention this; they mention the goosebumps and the gut-cramps and the sweats, the yawning and sneezing, but this is moderate opiate withdrawal. Severe opiate withdrawal makes the world smell like it’s covered with invisible black mildew. And it absolutely prostrates the body. Nothing works anymore.)

I spent two days like that. And on the third day, a Sunday, yeah. I rose again.

Today

Today I had a massage early and then spent the rest of the day with my son, cleaning his room (school starts tomorrow; his desk was piled with crap from a summer spent drinking San Pellegrino—those little foil tops from the cans—plus gum wrappers, various art supplies and drawings, tangles of earbuds, Nerf darts, tools, and scraps of paper and metal and wood and wire from his handmade projects. I put the drawings to one side and put everything from desk, dresser, and floor into three paper bags, then told him he’d have to sort it out by the time I take him to Milwaukee, otherwise it would go into the trash. “Are you serious?” he said. We ran errands, I took him to his guitar lesson, we picked out some yarn for me to make him some felted socks. We went to Trader Joe’s, where I saw a little boy about 4 come out holding his mom’s hand, five or six stickers plastered across his forehead. I laughed out loud, and he smiled proudly.

The air was hot and smelled of bus exhaust and late-summer grass.

I didn’t care about this stuff when I was using. None of it: not the crap on the desk or cleaning it off, not teaching my son how to take care of his space. Well—I cared about spending time with him, but even that was compromised by my addiction, and there was nothing I could do about it, short of the hard work of getting clean and sober.

My son is a funny guy, and we have a lot of inside jokes; we use silly voices to tell stories, and both of us are very observant. We’re always noticing something: a funny bumper sticker, somebody’s hippie outfit, the numbered purple protractors that people are pasting on bridges and light poles around our city. “I saw another one,” my son said as we pulled out of Trader Joe’s.

“Where?” I asked.

“Back there,” he said.

“Where?” I said again.

“Back there,” he said.

“Yeah, BUT WHERE?” I said, then I realized he was having me on. I ruffled his long hair.

Most of all I feel free today. I am more myself than I ever have been.

If there’s anyone reading this who is wondering if it’s possible to get off a shitload of drugs or quit a destructive habit, I’m here to tell you, it’s not only possible, it’s the best thing you can do for yourself and your world. Make the investment.

This is the song I played “over and over / and over again” while I was detoxing… it came up on random play today, so here it is for you.

There’s no telling where I’ve been,
How I returned here, how much I have seen

 

New York Times Addiction Story—Is Addiction Really Like Diabetes?

Yesterday the New York Times ran a story called “Rethinking Addiction’s Roots, and Its Treatment,” about how medical schools are starting to establish accredited residencies in addiction medicine. This would allow med students who have completed such residencies to enter the field of addiction medicine right out of med school, rather than go through additional training.

So glad to see the NYT covering addiction issues. Something that needs to continue, in order to bring addiction into the national public health discourse. But:

Lots of complaints in the comments section about how problematic this story is.

Here are a few I found.

Problem 1: The Diabetes Analogy

Man, what a tired analogy. Let’s either get rid of it, or take it all the way. Right now, people only take it up to the point where diabetics inject insulin—implying “real” addiction treatment should be about drugs. Then they miss a critical part: most cases of diabetes these days are Type 2, which indeed has a genetic component but is largely influenced by poor “lifestyle” factors: smoking, drinking, and obesity. These problems are all related to addiction, and they all have underlying psychological drivers about alleviating stress.

Another critical part missed: in the vast majority of cases of diabetes, the pancreas never recovers its function, whereas in the vast majority of cases of opioid addiction, the opioid receptors do recover their normal functioning—if, at some point, when the recovering person is ready, they’re allowed to remain abstinent for a while.

Both addiction and Type 2 diabetes can be considered the result of unfortunate genetics and poor lifestyle choices. As for treatment: insulin doesn’t “cure” diabetes. While no drug or treatment could restore the function of the pancreas to normal, treating the cause of diabetes would address the underlying compulsions—the addictions—so people wouldn’t continue to smoke, drink, and eat compulsively.

The diabetes/insulin analogy drives the ending of the NYT story, where Suboxone comes in to save the day for a 53-year-old patient on bupe maintenance. This sets up Suboxone (and, implicitly, other future Miracle Drugs), as the magic bullet that can “cure” addiction simply by “blocking cravings.”

Hmmm.

Problem 2: Unexamined Conflicts of Interest

Is it really news that “the medical establishment is putting its weight behind the physical diagnosis”? The medical establishment, in the U.S. at least, is largely funded by Big Pharma—through government institutions such as NIDA. The most recent study on extended-release buprenorphine, the opioid drug in Suboxone and other preparations, was funded by NIDA to the tune of $7.6 million. The government did not hire the researchers of this study independently; the grant went to Titan Pharmaceuticals, the maker of the proprietary buprenorphine formulation being studied, who then turned around and picked the UCLA researchers—who were already being paid speakers’ fees and research funds from both Titan and Reckitt Benckiser, the makers of Suboxone.

Hmmm.

Problem 3: The Split Between Medicine and Psychology in Recovery

It’s important that med schools are starting addiction-medicine residencies—this helps to educate more doctors about addiction. Nora Volkow makes a good point when she says it’s a “very serious problem” that general practitioners lack knowledge about addiction—this is true, and leads to the corollary thought that it might actually be best to spend the money training primary-care physicians in addiction, rather than create more specialists. PCPs are on the front lines; they’re the ones prescribing, for example, the most Oxycontin and Vicodin. They could do with more education about addiction.

And it’s important to think of recovery from addiction as the management of a chronic problem, the way high blood pressure and diabetes are managed. (Addicts have been thinking of the problem this way for a long time. 🙂 )

But why should we automatically think about addiction as EITHER a medical OR a psychological problem? Why can’t its treatment involve both disciplines, as well as others? Most active and recovering addicts and alcoholics are able to articulate the experience that addiction involves not only their physical response to the substance or behavior, but also a psychological component—we use/drink/eat/gamble/have compulsive sex to alleviate “stress.”

“Bringing Respectability to Addiction Medicine”?

In the third graf the writer mentions a guy named David Withers from a rehab called Marworth (a physician? addiction specialist? the writer does not tell us… aha! quick Google search reveals he’s an M.D. and associate medical director at Marworth). Withers says that the establishment of residencies in addiction medicine is “the first step toward bringing . . . respectability and rigor to addiction medicine.” What a slap in the face for the many doctors in America already dedicating their practices to addiction medicine. Be interesting to hear what, for example, Dr. Drew thinks of this (as of this morning he hasn’t yet tweeted on it). I intend to call my local, renowned rehab and speak to the well-known medical director about this statement.

 

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