Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: suboxone detox

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.

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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.

Suboxone Detox and Post-Acute Withdrawal Syndrome

We seem to have opened a little tin of worms here with the posts about Suboxone, starting with my interview with Dr. Steven Scanlan, a Florida detox doc who uses Suboxone and Subutex to detox patients off opioids.

People are writing in about Suboxone. It’s great that folks are asking questions! I need to emphasize (this also appears in my “About” page) that I’m not an expert or practitioner. I don’t dispense professional advice; I share personal experience. I’m a person with addiction who has been through the mill. I write from the place of “beginner’s mind.” The experience of detox—choosing a method; committing to it; literally waking up and smelling the roses—is still fresh for me, and the feeling persists in my daily life of being lucky to be alive. I write this blog because I used to take so many different drugs, and had lost control, and am now able to stay sober. I know there are solutions out there, some of which don’t involve being on drugs for the rest of one’s life.

And I seriously used to think I’d just have to be on drugs for the rest of my life. I’m only 46.

So a reader wrote in with a question about feeling really crappy post-detox. This person had been taking OxyContin for a little over a year, at between 90 and 400mg per day, but usually around 90-120mg. They ran out of cash and got their doctor to prescribe Suboxone. They were able to taper from, as far as I can tell, 16mg per day to one-quarter of a tablet or a film (they used both)—which, depending on whether they were taking the 2mg or the 8mg formulations available in the U.S., means they were dosing at either .5mg or 2mg per day at the end. It’s unclear from the way the email is written exactly what dose they jumped from at the end.

This is important, though: the jumping-off dose. Get to that in a minute.

They write:

In the last two days I have altogether stopped taking it. The problem is I have been experiencing extreme tiredness; major digestive issues, especially gastric reflux and an on and off “lump in my throat”; and muscle weakness. I am a middle-aged cardio athlete and I now have extreme sensitivity to air conditioning or temperature change between rooms at the gym. Overall I feel like I gotta be dying of cancer or something is really wrong with me! I am not sure how long this is going to last and have yet to come across an article describing Suboxone withdrawal and how long it may take for me to feel “normal” again or if that is even going to be possible? I am kind of determined to stay off the Suboxone as I believe is causing me lots of physical problems I don’t read about in the “side effects” articles. Is what I am experiencing “normal” and if so how long do you think it may be until these awful sensations and other problems go away?

The experience this person is writing about is called “post-acute withdrawal syndrome” (PAWS). What this means: after we’re done with the “acute” detox—the period of time in which the body is getting rid of the remnants of drugs still in our systems—there can be another phase of detox that is “post-acute,” when the body is still working to heal from the effects of our addiction.

Suboxone, like methadone (or any drug with a long half-life), takes a long time to be excreted by the body. It’s not like the day you stop taking it, your body is free of the drug. One nurse I know who detoxed from Suboxone put herself through urine tests, and could detect Suboxone in her blood up to three weeks after jumping.

One critical thing to remember about the healing process after detox: Opioid drugs hijack our body’s ability to make its own opiates, called endorphins. When we’ve hijacked our body’s ability to produce endorphins, and we detox, it takes a while to heal.

So ALL withdrawal symptoms mean the body is healing. Withdrawal is a healing process. (It sux, but it’s healing. :))

The symptoms of opiate PAWS include some of the ones mentioned in this email:

  • Persistent fatigue: endorphins help regulate the body’s energy; when we take extra opioids, it can affect our endocrine systems, which regulate our metabolism and sex hormones (many opiate addicts have experienced lack of sex-drive, women sometimes go into menopause, and men sometimes demonstrate low testosterone levels). When we detox, these systems don’t just switch back to “normal” immediately.
  • Digestive problems: this person has gastric reflux and a feeling of a lump in the throat; other people have persistent loose bowels and lack of appetite. Did you know that the brain isn’t the only place that has opiate receptors?—the entire GI tract is lined with them, especially the “gut” or intestines. Which is why opiate addicts usually experience constipation: opiates slow down the body’s “autonomic” functions, including digestion (and breathing, which is why ODs can be lethal, and why morphine is standard treatment for people at the end of life experiencing “dyspnea,” or breathing problems). When we detox, suddenly the GI system is shocked back into action, because there’s nothing numbing it anymore. It takes a while to settle down.
  • Temperature sensitivity: endorphins help regulate the body’s thermostat. When we take extra opioids, the body’s ability to perform this function on its own is compromised; when we detox, it takes time for the body to regain this function.
  • Sadness, anxiety, and pessimistic feelings: This person says they feel like they might have cancer, or that “something is really wrong.” Just as opioids numb certain physiological systems, they also numb our feelings. (Candace Pert, the neuroscientist who discovered the opiate receptor, calls opiates the “molecules of emotion.”) One of the main reasons opiate addicts choose opioids over other drugs is because these drugs are so efficient at numbing emotional life. But when we detox, all the feelings numbed out by the drugs come back, and because our native endorphin production is out of whack, it takes a while for our body-mind to begin to “feel” in normal ways again.

Who gets PAWS: There’s a ton of stories from people who have detoxed or tried to detox from Suboxone demonstrating that many of us experience PAWS. On the other hand, some people don’t experience much PAWS at all. A great deal depends on the differences between each of our bodies and minds, as well as how long we were taking drugs, what level we detoxed from, how low a dose we tapered to, how well we’re taking care of ourselves, and how much support we’re getting.

 

Tae Kwon Do

Tae Kwon Do: “Lies My Mother Never Told Me,” a memoir by Kaylie Jones, describes how the author recovered from her alcoholism in part through this discipline.

Some common-sense tips for managing PAWS:

  • Shorten your detox: If you want to use Suboxone to detox, try to stay on it a minimal amount of time. The many personal accounts I’ve heard, as well as some professional opinion, suggests that people using Suboxone to detox should try to use it no more than three to four weeks. Beyond that, the body begins to get used to Suboxone (just as it becomes used to any opioid after such a time), which can become a problem in and of itself. Again, this doesn’t seem to be the case for everybody.
  • Taper as low as you can before jumping, especially from long-acting drugs such as Suboxone. In Europe, buprenorphine is made in doses of .2mg, which is helpful for tapering to minute doses. In the U.S., tapering this low has to be done by splitting 2mg tablets into slivers of a quarter or an eighth-milligram, or securing the films, which can be cut to facilitate very low tapering. As an example, I tapered to .125mg (one-eighth) before jumping. Those who jump from even 1mg usually have a rougher ride. It’s estimated that 1mg Suboxone equals about 33-40mg morphine (in binding power). I wouldn’t want to jump from 35mg morphine.
  • Begin serious daily aerobic exercise, as soon as you know you want to detox. Exercise is one of the best ways to help the body restore its own endorphin production. … I detoxed in the fall. I was exhausted, but I loaded upbeat songs on the iPod and dragged myself for a 20-minute walk every day, going as fast as I needed to go to sweat. I also rode a stationary bike. My sleep and temperature regulation wasn’t great when I finally jumped off Suboxone, but today I sleep normally. Even better, I can cycle 30 miles, play 2 hours of tennis, clean the house; and two days ago I scored my first pull-up. (Yaaaah!) We do heal.
  • Ask for some kind of 3-D support. Work some kind of program of recovery. The way I look at it: when I broke my elbow, I had to do PT, right? I can’t numb out my body and feelings without doing some kind of repair work. I started going to 12-step meetings, and sharing my experience with and learning from others who had been through the same thing helped ease the anxiety and let me know I could get better. It doesn’t have to be meetings; it could be therapy, or a spiritual community, or a physical discipline such as Tae-Kwon Do—anything that helps us enlarge our perspective and grow.

A great resource and support for those detoxing from Suboxone is the Suboxone Forum at Opiate Detox Recovery.

Please share your experiences here, too. And if there are any physicians or researchers who can point to studies about PAWS and Suboxone, please give us a heads-up. I checked Ovid this morning and couldn’t find any. … Not that studies tell the whole truth, but this reader was looking for “articles.”

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