Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: prescription drug abuse (page 3 of 6)

Suboxone Debate At TheFix.com

Dorothy finds Oz via the opium poppies (credit: Turner Entertainment via Tumblr)

If you haven’t seen it yet, check out my first piece for TheFix.com, talking about two sides of the buprenorphine (Suboxone) treatment issue.

There is more complexity to this issue—more sides to it than just two, and I hope to follow up on that complexity in future stories.

I’m grateful to my two patient sources, folks who emailed me after having read this blog, who agreed to be interviewed for this piece—as well as to the physicians who gave their candid comments and their time…

Looking forward to hearing what y’all think.

G Gets Strong: What Do You Think Is Impossible For You?

Guinevere’s baby twin-pack

Day 71 of my 90-day fitness program.

During my workout last night I noticed I have two baby abs. (My son tried to make it into four but, poking just under my bra-line, he said, “No, you’re right, I think those are ribs.”  :))

This is not a vanity photo. This is evidence… This is an illustration for a story about a little girl who used to fall off the monkey bars in the playground and, in high school, couldn’t run even once around the football field without stopping to walk.

She came to believe she was “just not the kind of person” who was strong… and never would be that kind of person. In fact, she was taught she shouldn’t want to be that kind of person. It was just one of those choices in life—You’re either smart, or you’re strong. Pick one. You can’t have both.

This is the story of a girl who started, in tenth grade, having migraines that made her cry involuntarily, and still had to perform for her flute teacher with her right eye half-closed in pain—because her mom did not want the ten bucks spent on the lesson to go to “waste.”

And so she formed her priorities. And a lot of resentments and fears.

This girl grew up and the physical pain only got worse and worse… It wore her down and became entwined with the emotional pain, and though she knew she probably had “a problem” with medications she thought, Screw it, I’m defective, I’m broken, I’m physically weak and always will be.

Eventually she was told she had fibromyalgia and was, to her relief (and eventual delight), given opioid drugs to take every day, hydrocodone and morphine and OxyContin and fentanyl, one after the other, some times one with the other, and was told she might have to take them forever, because there is no cure for fibromyalgia or migraine—no one even knows what really causes them.

The drugs got stronger and stronger, more and more. They made her not-care about practically everything. That was what she wanted—not to care. She asked for the drugs, sometimes by name, and because she looked and sounded so professional and reliable, her wishes were granted.

This woman let stress and worry get to her so much that her muscles clenched, even in sleep, no matter how much medication she took. She came to believe “it would always be this way” and threw in the towel.

Then by the grace of God or HP or Whatever, she got sober. She asked for help.

This girl is now 46 and is two-and-a-half years off drugs and one year sober and is here to tell you: She can now do 50 pushups during a workout, can do three pull-ups without using her foot to help her up, and can do 13 dive-bombers (not the Hindu push-ups, the real thing) when on Day 1 she couldn’t do any.

Even her son trying to make the two abs into four feels strange for her… because she’s so used to the voice rooted inside that says, Those aren’t abs, who do you think you’re trying to fool, you can’t be that fit because YOU’RE G. You’re the one who fell off the monkey bars.

Well, not any-friggin-more she’s not.

HP told her last year to get going on the physical fitness… And she said OK, and went to any lengths just like she went to any lengths to get sober, and she’s finding that fitness in general is like a mathematical equation:

WILLINGNESS + EFFORT = RESULTS

And amazingly, she has LESS pain. The more physically fit she gets, the less pain she has. The more spiritually fit she gets, the less emotional pain she has—less often, and of shorter duration.

Because she is stronger. And because she has people around her, God/HP/Whatever bless them, who are willing to help her. Because she asked for help.

And now there are lots of possibilities going through her mind.

She is now thinking… What else do I think I can’t do, that I’ve always wanted to do??

This list is growing. She has found out that she’s hardly ever made lists like this before.

Wow.

Her fear still crops up

(what if i can’t do it what if i screw it up what if what if)

but she looks at the picture of her little baby abs and thinks, Wow. This gives her the guts to keep walking the walk. One foot in front of the other.

What do you think you can’t do? … I am here to tell you: You can do it.

Give it a shot.

Reader Questions: Addiction, Chronic Pain, and Drug Maintenance

A reader had some questions about my interview with Dr. Scanlan, a physician who conducts opiate detox in the Florida pill-mill hot-zone:

It would have been helpful if Dr. Scanlan had addressed those opiate addicts that became that way after dealing with chronic pain. If there is no long-term maintenance, how will they stay off of opiates? Maybe a different way to address that is how will they get pain relief? “Buprenorphine is now the 41st prescribed drug in the U.S.” Where is OxyContin, Fentanyl and morphine? Most opiate addicts became that way because of being prescribed pain medication for legitimate chronic painful conditions. Are they included the 5% of addicts that may need maintenance? Or are we just discussing the ‘recreational’ users?

These are good points. Many people do become addicted after seeking treatment for serious chronic pain conditions. For the last 15 years or so there has been a big push in the medical community to recognize pain as the Fifth Vital Sign, and to treat it aggressively with appropriate drugs. Along with treating more pain with more opioids comes the risk that more people will become addicted. Simple math.

I agree—those of us with chronic pain have to strategize about its treatment in order to avoid turning back to opioids. Speaking from my own experience, an important part of this strategy is recognizing that opioids are not the only solution for pain relief. They’re certainly not the best long-term solution for chronic nonmalignant pain.

If you have chronic pain and addiction, I’d like to ask, what have you done about your pain?

As for your other questions: Where are OxyContin, fentanyl and morphine in the list? Oxycodone in all its forms is quite high on the list, though not as high as hydrocodone, which is the top-prescribed drug in the U.S., bar none. Second on the 2009 list (the most recent) were cholesterol maintenance drugs, then amoxicillin (a trusty antibiotic). Codeine is also way up there, and lots of people get addicted via codeine cough syrup or Tylenol #3 for headache, for example. (I knew one professional person who always carried a bottle of codeine cough syrup in their bag—their way of dealing with stress.) See this Forbes piece for one explanation that includes good sources. …

Vicodin is being prescribed like a version of extra-strength Tylenol these days. People go in to have a tooth pulled or to have a wound stitched and are given 30 or 60 Vicodin. It used to be that they’d get 3-5 tablets, but physicians are so used to writing in counts of “30” or “60.” With that supply of a drug that strong on hand, the “addiction switch” (as I think of it) can get turned on within a matter of weeks. Then, when they beg but can no longer get any more refills from their doctor, they turn to other sources to keep the lights on.

A Florida corner-store pain clinic.

I’ve been told that, once you cross the Georgia-Florida border on I-95, the signs for places to score pills start appearing on the roadside, and they follow you all the way down the coast. It’s said that there are more “pain clinics” than McDonald’s restaurants in Broward County—and three times as many clinics as Starbucks outlets.

Dr. Scanlan’s patients, just like all addicts, have become addicted in all kinds of ways. In addition, he practices in this hotbed of pill-mills, some of which dispense painkillers without following good medical practice. These people may or may not be “recreational” users (from my experience, people who are taking 300-600mg of oxycodone each day are no longer engaged in “recreation”), but they’re still suffering from a problem they can’t control.

A Florida strip-mall pain clinic.

I don’t think Dr. Scanlan was talking about pain patients in particular as being in the five percent of addicted people who may need drug maintenance. Scanlan and others, such as Dr. Gabor Maté, some of whose patients live in extremely difficult circumstances—people from street conditions who continually relapse and can’t get sober-time not only because of the inherent power of the disease but also because of the corollary circumstances that go along with certain manifestations of it (homelessness; joblessness; criminality; needle-use; prostitution; etc.)—believe in drug-maintenance to help this set of people stop harming themselves first of all.

The way I understand Scanlan’s comment about drug-maintenance is, he thinks this option gets promoted (by greedy drug manufacturers and well-meaning but largely ignorant policy-makers who have little or no personal experience with addiction) as a “cure” for all addiction—when he many others know that there are non-drug solutions that are less costly to the individual’s physical health and also their wallet, and to society. He’s a living example, and he’s trying to bring that solution to the people who come to him asking for help.

 

How To Detox From OxyContin And Other Opiates

OxyContin

OxyContin tabs in a candy-colored rainbow.

Dunno why, but I seem to have paid short shrift to sharing detox experience on this blog. Which is weird, because I’ve got so many stories about opiate detox and recovery.

Received an inquiry recently about how to detox.

What do you know about getting off of OxyContin?—the length of time it takes, how safe it is, and what could the consequences be of going off too quickly. Do you have any idea?

Yes, I have some idea. Thanks so much for asking.

First I must say that none of this is medical advice or a substitute for it. If you want medical advice, please consult a doctor.

From one addict to another. About the length of time it takes to get off OxyContin—this depends on a few factors:

  • The level of Oxy you’re taking. (It could be any other drug. Not to put too fine a point on it: with the exception of methadone, Suboxone and tramadol, an opiate is an opiate. Heroin is Oxy is morphine is Vicodin is dilaudid. Even fentanyl is pretty similar, though it’s fat-soluble. They’re all short-acting full-agonists—though their dosage equivalencies differ.) If you’re taking maybe up to 120mg of oxycodone, chances are you could taper just using Oxy, following some rules for tapering that are few but non-negotiable. If you’re on a level that’s a lot higher than that, you might need some help. However, only you can tell, right? You know your own limits. I’ve known people who have detoxed cold-turkey off 600-800mg Oxy.
  • The reasons you started taking pharma-grade painkillers in the first place. If you have pain, you’ll need to work on figuring out other ways of managing it. Many non-opiate treatments exist that may help, depending on the circumstances. It may take time, consultation with professionals, patience, and a process of trial and error.
  • Whether you’re taking the drug “as prescribed” (i.e., swallowing it whole), or “not as prescribed” (i.e., chewing/snorting/shooting). OxyContin is also a bit difficult to taper from because you can’t split them. So another factor is the strength of dose you have available to you. One of the cardinal rules of a taper is: swallow whole, on schedule. If you can’t take your proper dose of Oxy on time and swallow it whole (I mean what addict can?), then you may need the help of a reliable detox doctor. (Operative word here: reliable. How I chose my doctor: I called the most reputable rehab in town and asked if I could please pay them to run my outpatient detox. When they said No, I asked for the name of someone else who might do it. Then I called my primary care physician and asked for her top referral. When they turned out to be one and the same person, I knew I had my guy.)

Let me also mention that the person who asked today’s question apparently got the idea from this blog that Suboxone treatment was Not Good. I’d like to correct this impression: Suboxone can be a very effective tool if it’s used properly. I myself got off an enormous level of opioids using Suboxone and Subutex. The danger comes when vulnerable, fearful detoxing addicts are encouraged to stay on enormous doses indefinitely rather than to use it as they often want to use it—as a tool to claim their right to lower their chemical load.

Using Suboxone or another drug as a detox tool doesn’t necessarily mean we’ll be “substituting one drug for another.” I mean, in a sense we are, but only for a short period, and under a doctor’s guidance. This can mean all the difference between addiction and recovery. … When I was detoxing with Suboxone, I did not write the taper schedule, my doctor did. I had to visit him every week, and later every other week; I paid him $80 a crack, aside from what I paid the pharmacy for the weekly prescriptions, and it was worth every penny to get free. I keep the receipts for my detox doctor’s visits in the drawer of my nightstand. The equivalent of my parents burning their mortgage (which they did, literally).

The reason I chose to taper off drugs using Suboxone is that I was on such an enormous level—more than 100mcg/hr of fentanyl. I was prescribed one patch every two days, and because I did not always take them as prescribed, I used a bit more than that. Fentanyl is a crazy-strong drug, it’s what they give you when you go in for surgery, and this level is roughly equivalent to 400-600mg morphine or oxycodone per day. Somehow my lizard-brain knew it was going to be impossible for me to taper off that level of fentanyl, or get enough of another drug to equal that level so that I could taper. And anyhow, I’d never been able to taper off a full-agonist—a drug that plugs into the receptors and stimulates them fully, like heroin, oxycodone or morphine.

Read Dr. Scanlan’s interview about Suboxone: it has a long half-life, which means it doesn’t create as much of a buzz as the short-acting drugs like oxycodone. As long as you keep tapering, and you have a doctor willing to help you keep the taper short, you can get free with Suboxone.

How safe is detox?—Opiate detox is not life-threatening. In contrast to alcohol withdrawal and detox from benzodiazepines (Valium, Xanax, etc.), both of which can cause life-threatening seizures if done too quickly, detox from short-acting opiates can be done safely at home. A “cold-turkey” detox happens in two phases:

  • Acute detox, which lasts 10-14 days or so (depending on level of use), in which the body excretes the drug and, in doing so, experiences signs of active withdrawal such as runny nose and eyes, sneezing, goosebumps, shivering, loose bowels, and restless legs and arms (kicking). All this means the body is healing.
  • Post-acute withdrawal syndrome (PAWS), which lasts an indefinite period (depending on level of use and how well we take care of ourselves), in which the body’s opiate receptors heal and the body learns to produce endorphins again. Most people find exercise and good nutrition help a great deal, as does some kind of support plan.

I can hear some folks out there thinking, “I think I’m endorphin-deficient.” I love hearing people register this claim. I used to believe this about myself before I got on drugs like fentanyl. Then, after I got on drugs like fentanyl (and morphine, and OxyContin, and whatnot), I used to believe that I’d MADE my body permanently endorphin deficient, so I should just stay on the drugs forever. Addiction lizard-brain. … Today I lift weights and cycle 30 miles and play tennis. I do all this having been diagnosed with two painful neurological disorders. I’m not bragging here, I’m just saying: I’m NOT endorphin deficient. If I can get off this stuff, I think anyone can.

The consequences of going off “too quickly”?—There is no “too quickly,” imo. If one is addicted, the only dangers are not quickly enough, or not at all. However, if your level of use is high, and you have kids and a job and still want to function during detox (as I did), it might be worth it to slow the detox down. I’ve always compared detox to learning how to land a plane. Not that I’ve ever landed a plane. But I imagined being in the pilot’s seat, and taking direction from the tower (higher power/physician/recovery community, etc.), and telling the tower I needed either to make a quick-and-dirty landing or a long slow smooth landing.

You can do either one safely. The first takes a lot less time, but it might be a rougher ride. The second is much smoother, but there’s more time to worry about whether you’re gonna crash. Which is why it’s helpful to get support, not only from a doctor but also from a community of people who have been through similar stuff.

Detoxing was one of the best decisions I ever made. It was the start of a new life.

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Suboxone: Amazing Detox Tool, Monster Maintenance Drug.

An Expert Talks About Suboxone: Dr. Steven Scanlan of Palm Beach Outpatient Detox

Steven Scanlan M.D.

Steven Scanlan M.D., medical director of Palm Beach Outpatient Detox

Steven Scanlan, M.D. is board-certified in psychiatry and addiction medicine. In his practice, Palm Beach Outpatient Detox (PBOD), on the Florida coast, he has detoxed more than a thousand patients off many drugs, including alcohol, benzodiazepines (Valium, Xanax, etc.), and sleep aids. But his specialty is opiate detox.

Scanlan has been practicing as medical director of PBOD for about two years. His practice, he said, is located in an area where more than two-thirds of all oxycodone prescriptions in the nation are issued—the south Florida coast that has become notorious for its “pill mills.”

Scanlan said 70 percent of his patients come to him addicted to oxycodone at levels of about 300 to 600mg per day. About 20 percent also come in with alcohol problems. “The rest use Vicodin and Ultram,” and a few come in addicted to Fentanyl, he said.

And then there are the increasing numbers who come to him desperate to get off Suboxonea drug that combines buprenorphine, a synthetic partial-agonist opioid, with another drug to prevent abuse. Suboxone (commonly known as “Sub” by people with addiction) is used in opiate detox and maintenance, it’s known and “prison-heroin,” and it’s now commonly sold on the street.

Scanlan says he has seen Suboxone work brilliantly as a detox tool and dangerously as a maintenance drug.

I first heard Scanlan speak on a podcast that’s now defunct. Two reasons I was eager to talk to him:

1. Scanlan chose addiction medicine as a result of his own recovery from opiate addiction. He understands addiction from personal and professional experience. While training to become an anesthesiologist Scanlan became addicted to Fentanyl, a strong opioid used in surgical procedures and for severe pain. After trying many times to quit on his own, he found a physician who helped him detox over two weeks using Subutex—plain buprenorphine—and other medications to ease the detox symptoms. He joined a recovery program, then decided he was well equipped to help others suffering from the same problem. Many of his physician colleagues didn’t like working with addicted patients, but he found he did. In his practice, he doesn’t just dole out drugs; he gives patients 24/7 followup until they’re physically comfortable and involved in some kind of support program.

2. I wanted to hear his clear-cut ideas about detoxing off opiates. He only does detox. He never does maintenance. Unlike so many other scientists, who believe people addicted to opioids can never stay off them, he believes we can get free.

“Believe me—it’s much more lucrative to do maintenance, to keep patients on Suboxone,” he said, adding that it’s even more profitable than, for example, doing Botox injections. Hundreds of practitioners—some of them with no experience with addiction—prescribe Suboxone as a maintenance drug, keeping patients on it for years at high levels and charging exorbitant cash fees. But for the vast majority of addicted people, Scanlan does not believe drug-maintenance is appropriate—or even safe. Buprenorphine is such a new drug, he says, and its long-term effects have not been adequately observed and researched.

He has said that Suboxone may curb cravings for other opiates and allow people to stop stealing and get their lives in order. But the problem is that, after three months or so, patients have terrible difficulties quitting Suboxone because of its sheer strength in binding to opiate receptors, its long half-life, and the fact that it’s a partial-agonist binding to receptors built for full agonists. And despite what the media tell us, there are many people who don’t want to spend a lifetime on high doses of Suboxone.

You know what? When I was detoxing off fentanyl in 2008, I felt so good on Suboxone that I thought about staying on it. Then something happened. I no longer felt so good. My feelings dulled. I no longer wanted food or sex. I realized my body was adapting to the drug—or trying to. Fortunately my outpatient detox doctor had no more slots for Suboxone maintenance patients, so I tapered off as quickly as I could. If my doctor had been operating under the new Comprehensive Addiction and Recovery Act, he may have had a slot for me, and I might have gotten trapped on Suboxone as so many others have.

Scanlan said most people, including physicians, do not comprehend the strength and effects of buprenorphine. “Everything changes in the body when you’re on opiates long-term—the way the body regulates pain, the way it regulates hormone production, sleep, emotions—everything,” he said. And buprenorphine, he repeats, is an opiate. Its effects are not just physical: as a psychiatrist, Scanlan has noticed in his practice that at long-term doses of just 2mg, Suboxone can block almost all of a person’s emotions.

In addition, buprenorphine’s half-life is 37 hours, which means it takes the body more than a day to excrete half the dose. When dosed once a day, the body doesn’t have time to catch up, so the drug builds up in the system—a phenomenon called “bioaccumulation” that Rachel Carson documented in the buildup of toxins among wildlife in her book Silent Spring. A patient dosing with buprenorphine at 8mg is not only getting 8mg—he’s getting the 8mg, plus the amount not yet metabolized from the day before (4mg). And 8mg is a low-end maintenance dose. In the U.S., patients are commonly dosed at 16mg or 24mg per day.

“There’s definitely a risk to going on Suboxone long-term—anything over three months,” he said. “It would be easier to detox patients if they were coming in at a year’s time at one milligram, or a half-milligram, which is where they should be. But they’re always coming in at 16 milligrams. Or 4 milligrams for four years but really they’ve been at 8 milligrams and they’ve lowered it just before they’ve come to see me. I have to get them to tell me what they’ve REALLY been taking.”

Scanlan is the only professional I’ve ever heard who can explain why the body reacts so differently to Suboxone than to full-agonist drugs like heroin, Vicodin and methadone. Read on…

Suboxone tablets

Suboxone 8mg tablets

G: Educate me about buprenorphine.

Scanlan: It’s the most amazing detox medication I’ve ever seen. But for maintenance—it’s harder to get off than methadone. Suboxone is 25-45 times as potent as morphine. It’s the king of the hill in terms of opiates—it displaces every other opiate off the receptors, except for Fentanyl. [Maintenance physicians] use way too much of it. When you build up to a serum level, it’s SO POTENT.

Americans should look at European countries’ use of buprenorphine. They’ve had it much longer than we have. They use lower doses; they have as much maintenance as we do. In Scandinavia, what do you think the number-one most-abused drug is?—buprenorphine. Simple facts: they’ve had it longer, and it’s the most abused drug. That’s what I’d like people to know about.

Buprenorphine is now the 41st most prescribed drug in the U.S. Five years ago, it was the 196th most prescribed. [Update, April 2016: Suboxone is now the 16th most prescribed drug in the U.S.] So you can see what a money machine it’s becoming. … The research to get Suboxone approved [by the FDA] was funded in conjunction with the NIH. Until the NIH is run by someone in recovery from addiction, this propaganda will continue. [National Institute on Drug Abuse Director] Nora Volkow is great, she’s smart, I’ve met her, but she doesn’t have a clue.

G: Why don’t you prescribe Suboxone as a maintenance drug?

S: I wasn’t against maintenance when I detoxed. But I’ve seen a lot since then. And I had a detox physician who told me, “Do NOT stay on this drug for more than three weeks, or else you’ll be dealing with a whole different problem.”

Buprenorphine is a partial-agonist opiate. It binds to the receptor and only activates it partway. Opiates are meant to bind to the receptors and activate them fully. But if you put something completely foreign in the body like a partial agonist, the body says, “What is this?” and it tries to reach homeostasis. It struggles to understand it as a full agonist, and it can’t. There is nothing in nature that is a partial agonist, and our opiate receptors are not designed to operate with partial-agonists. Buprenorphine definitely does something unnatural to the body.

I’m not against maintenance for a certain percentage of the population. I have a friend who runs a methadone clinic, and I think there’s a percentage of patients who need to be on maintenance for the rest of their lives. Perhaps five percent of the [addicted] population. If you want to do maintenance, though, you want to do methadone. Methadone at least has been used for a lot longer, and we understand it better.

G: How do you conduct detox?

S: To detox patients off long-term Suboxone, I use clonidine [a blood-pressure medication] and Librium [a benzodiazepine] because it’s more water-soluble. And I use Darvon, a weak opiate. Its half-life is short. … The Librium is the last to go. And they complain of disturbed sleep. I don’t use Seroquel because it can be abused. I use what acts on the antihistamine and melatonin receptors—the only two receptors they haven’t messed up yet. … It can take five months to get someone off long-term Suboxone.

For a Fentanyl detox, I give them Subutex. Fentanyl detox is the most brutal detox but it has the quickest recovery of the receptors because Fentanyl has such a short half-life.

I tell them to exercise. Studies show that 12 minutes of exercise per day with a heart rate of greater than 120 beats per minute restores the natural endorphin system in half the time. The people who do that, their sleep architecture returns to normal in half the time of people who don’t exercise. Twelve minutes. And of course you can do more.

G: And you urge them to join a recovery program?

S: They need some kind of support system. Let me tell you—everyone who’s stayed off Suboxone, they’ve been in AA or NA. Thirty-day inpatient programs have an average rate of 5 percent sober after one year. But from what I’ve seen in my practice, anyone who does an honest fifth step in AA or NA stays sober—the numbers are greater than 50 percent. And anyone who can do an honest ninth step and make amends, the number shoots up to over 90 percent.

Everyone who comes to me, I get them off opiates. One-quarter of the people I treat are sober at six months, and ninety percent of those are actively involved in some program. They’re not just going to meetings or involved in community service—they’re actively seeking some kind of spiritual growth. It all comes down to whether people want to do the work.

G: What about people who are afraid of becoming depressed after detoxing from long-term use?

I ask them, Was there ever a time you were sober? Did you have a bout of depression before then? If not, then it’s probably substance-induced. You have to take a thorough history. The statistics say: of all people who get clean, 15 percent have mental illness. Maybe a bit higher than the general population.

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Related posts:

How To Detox From OxyContin and Other Opiates

Reader Questions: Addiction, Chronic Pain, and Drug Maintenance

Have questions, or want to see someone interviewed here? Email me at guinevere (at) guineveregetssober (dot) com.

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