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Is She Still Using?

Posted Apr 11 2010 10:09am

I have been involved in Q and A with a person in another part of the country, and will share some of our exchange after removing the identifying info. BTW, I receive many e-mails from people and I just don’t have time to answer most of them; I DO provide ‘educational consultation’ (not a ‘medical’ relationship) at a rate of $100 per 30 minutes, and anyone is welcome to set that up by writing to appointments@fdlpsychiatry.com.

The person below consulted me over her daughter, who is addicted to opiates and on buprenorphine but not doing well. The grown daughter receives some level of support from her parents, who are in that horrible position of trying to pull back to avoid enabling while at the same time fearing that pulling back will cause relapse or worse. The mother has had the impression that her daughter is sedated from buprenorphine, and that the buprenorphine may be making things worse. Mom considered helping daughter pay for ‘rapid opiate detox’ to ‘get off Suboxone’ at one point; I was not a big fan of that idea, as I have seen people do poorly after that approach (in my opinion, GETTING clean is much easier than STAYING clean).

Our exchange:

She is still on suboxone but we are paying for it. her weekly appt last week was on wednesday and she did not bring us her prescription to have it filled until saturday which means she did not have any meds for 3-4 days.

She was like a wild animal when we saw her and told us she has filled it herself. Then finally Saturday she gave us the prescription and told us to fill it for her.

Number one: why would she have waited so long, would this be a sign of a relapse? Number two: can you stop for 4 days and then start up again? Wouldn’t this make you high from it? She is on 16 mg.

She is NOT doing well with Suboxone, could she be using it to subsidize the in-between times or something?

Just can’t figure out why a medicine that is supposed to make her better is making her worse?

Hi XXXX,

I find myself in the position of defending Suboxone– and wish I had something else to suggest. People taking buprenorphine comprise about 20% of my psychiatry practice, and I have not taken a new patient for buprenoprhine treatment for over a year, so I want to make it clear that I am not a ‘Suboxone zealot’. I’m just trying to be frank about what I see with addiction.

I often end up saying things like ‘it isn’t fair to Suboxone.’ When I say that, I am not concerned about ‘fairness’ toward a business plan or marketing strategy; I am speaking of ‘fairness’ in an intellectual sense. Maybe instead of ‘fair’ I should say ‘proper’—I will try that below and see if it helps clarify my point.

Your last comment is an example of why I have the forum and blog, as I hear similar comments frequently— i.e ‘why a drug that is supposed to help making her worse?’ That is NOT an intellectually honest question. SOMETHING ELSE is making your daughter worse, and buprenorphine is keeping her alive. I lived as an addict for 10 years BEFORE Suboxone, and I saw what things were like with only methadone as an option. While there has always been residential treatment, the results of treating opiate dependence with residential treatment have always been poor.

In the past six years, 1200 people died in Milwaukee from overdose. There is nothing special about Milwaukee; recent stories in Time, Newsweek, and elsewhere have highlighted the dramatic increase in overdose deaths from ‘prescription medications,’ largely opiates and benzodiazepines. We do not know what would have happened in your daughter’s case, had she not gone on buprenorphine. She very well might have died by now. She might be in prison. We don’t know—but at any rate it is not PROPER to ‘blame’ buprenorphine, when in fact the medication may have saved her life. The fact that she is still sick is most likely because addiction has many factors and consequences that are impossible to define, let alone treat. I have seen the outcome of untreated opiate dependence too many times. That outcome consists of either death or incarceration. The deaths have been mostly ignored until recently, and I imagine that after this ‘news cycle’ we will return to ignoring them. But the deaths are still there, every day. One result of being a physician who treats opiate dependence is that I now read the obituary section of the newspaper; I sometimes get ‘follow-up’ there on people who had at one time sought help, but for whatever reason had stopped coming to appointments.

To answer the other questions, it is very unusual for a person who is doing things right to forget to fill a prescription for buprenorphine. At first, people in treatment may wait until the last minute, then call in a panic saying they will run out the next day. One of my jobs is to get them living like ‘normal’ people, i.e. planning ahead of time and respecting boundaries, including not expecting me to drop everything because THEY forgot to schedule an appointment. Your daughter should learn to take care of the basics herself, and suffer some degree of consequences should she ‘forget’ to plan ahead. Every addict, of course, has many excuses for not being able to make appointments, call in requests for refills ahead of time, etc… even if the addict is doing nothing all day, and the caretaker is working three jobs! That dynamic must change so that the addict is responsible for herself.

Yes, stopping buprenorphine for 4 days and then restarting it will result in the person ‘feeling’ opiate effects. It is difficult to sort out whether the person is feeling ‘high,’ or just feeling the loss of withdrawal—but there would definitely be relief associated with taking the buprenorphine after 4 days. The goal with buprenorphine is to avoid that cycle of ‘sickness’ and ‘relief’ and to instead feel normal all the time. And ‘normal’ is what the vast majority of my buprenorphine patients describe; they say that they feel nothing with each dose, and that they don’t feel ‘high’ at all. Feeling ‘normal’ is consistent with the chemistry of taking buprenorphine; the person becomes completely tolerant to the effects of the medication and as long as the blood level remains above a certain threshold, there is no sense of something wearing off.

In the case of your daughter, I agree with you—something is not right. She is either using opiate agonists intermittently or she is still very much wrapped up in wanting to ‘feel’ something—or both. There are deficiencies to all testing methods, but she should have a ‘state of the art’ urinalysis at some point when things are irregular. By ‘state of the art,’ I mean a test that is witnessed (most labs can provide this service), that has a chain of custody, and that is analyzed at a certified medical laboratory.

In a case like that of your daughter, it is important now and then to return to basics– does she WANT to live a clean life? What is motivating her to do well, and what is motivating her to do poorly? Are there sufficient consequences for bad behavior? Is SHE the one working the HARDEST on her sobriety? She SHOULD be, by the way… when I see a situation where everyone else is working to help a person stay clean, I know that bad things are coming.

I realize that it is simply horrible, what is happening to you and to your daughter. You are being forced to distance yourself from her so that she will take on more responsibility for herself, and so that you are protected to a small degree from the horror of the current situation and the fear of what could come at any time. That distance is just like any other significant loss. Understand that it isn’t your fault, and you are not alone. I often compare opiate dependence to cancer; both illnesses have consequences far beyond the risk of death. The loss that you are experiencing is similar in some ways to what cancer patients go through, when they see close friends back away out of fear of death and dying.

The one consolation is that for most people, age brings insight. I have many people on buprenorphine who do very well—they take a daily medication as they would for any other chronic illness, and lead happy and productive lives. But I also have a few younger patients who do not do as well—particularly those under age 20. In those cases, the course of illness includes a constant battle to prevent the addiction from going ‘underground,’ i.e. where the addict keeps secrets from the physician, and there are periods of stability and relapse. In such cases I hope that buprenorphine at least allows me to keep the person alive and out of prison (and hopefully employed or in school as well). The addict’s life may still be chaotic, but each day the person is a little closer to age 30—an approximate age when insight seems to have a better chance of taking hold. Hopefully your daughter will gain insight as well as time passes. If she only loses a decade of her life, she still has much to live for.

As always, I’m sorry for what you are going through. Protect yourself first; make sure you are doing all that you can to keep your own sanity intact.

JJ

     www.sajithmr.com


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