I’ve been writing teasers for a book about buprenorphine for a couple years now. I keep very busy trying to maintain a solo psychiatry practice, and for awhile there I was running constantly… keepiing the practice going by day and writing nonstop at night. I’m not sure what possessed me at the time; I know that I tend to focus more on what I have NOT done than the things I HAVE gotten done, and I really wanted to write a book. I still do. But after submitting the product to a number of publishers, I have learned that there is a wide range of publishing arrangements that people work out. A number of publishers, for example, require ‘new writers’ to make an investment in their own book before the publishers will invest money of their own; the starting ‘investment’ by the author comes to $3000 to $5000, money that I cannot afford to spend at this point.
I’m realizing, by the way, that I have become pretty open about a number of things on this blog. I have received a number of nice comments from people ‘out there’ over the years, and I feel like I know the people who are reading. If you are a newcomer and the situation is freaking you out, I’m sorry. It freaks me out sometimes too!
Since I have a book that needs a place to go, and a blog that needs material, I might as well share what I have written here– bit by bit. I invite you to read along, and if you like the story, consider purchasing it in one big hunk at some point in the future when I get my act together! I will be posting bite-size pieces; maybe one to three pages in length. The title of the book is ‘Dying to be clean.’ The first chapter is entitled, appropriately enough, ‘Introduction;’ subheadings will be numbered to help keep things in the proper order. Please ask for permission before copying whatever I put here… thanks!
1. Why write about buprenorphine?
Three years ago I applied for the DEA waiver to treat opioid dependence using Suboxone. I knew that the small town in Wisconsin where I live with my family had an ‘opiate problem,’ but I had no idea the extent of the problem, nor how Suboxone treatment would affect my approach to treating addiction in general. As the medical director of a residential treatment center I believed that residential treatment was necessary when dealing with opioid dependence, and that any maintenance agent would result in a condition akin to a ‘dry drunk’ where the person may not be using, but is miserable about being clean and sober. The AA joke about a ‘dry drunk’ is that he isn’t drinking—but everybody wishes he was!
But that is not what happened. Instead, when spouses came in with patients during follow-up visits the typical comments were ‘I got my husband back’ or ‘she is the woman I used to know’. From the addict him/herself I would hear, ‘I feel normal for the first time in my life’. Patients on Suboxone were nothing like the ‘dry drunks’ that I had come in contact with over the years of attending AA and NA. Instead of seeing addicts who were clean but miserable, I saw people who were excited to be free of active addiction and who were ready to get back to a happy and productive life. It seemed that as Suboxone made the obsession to use fade away, the addict’s pre-using habits and interests returned, filling the void that the addiction left behind.
I enjoyed treating opioid dependence with Suboxone. I was reminded of my anesthesia days and the gratefulness of the women after I placed their labor epidurals. Psychiatry is not a specialty that engenders that kind of gratitude! During my own active opiate addiction I desperately tried to stop using over and over again, only to fail every time. By the end of my using days I was depressed and demoralized. I had broken so many promises—to others and to myself. I stared at my kids’ pictures so many times, thinking surely my love for them would keep me straight, and when it didn’t I felt horrible for letting them down again. At the time I believed, like most opioid addicts, that there was no way out. Treatment would mean coming clean about what I was doing—which would destroy my career, and perhaps even take away my freedom. I now understand that since addiction is as fatal as any cancer, treatment simply must occur, regardless of the consequences—because otherwise there is no life at all. But to the actively using addict the shame alone appears insurmountable, let alone the career issues. In result, opioid addicts do not receive treatment unless they are forced to get it. And for most addicts that occurs only after they have lost almost everything, if it ever occurs at all.
Suboxone changes the dynamics of treatment in a dramatic way. With Suboxone (or more specifically with buprenorphine, the active ingredient in Suboxone) the typical opioid addict can force his disease into remission over the course of one afternoon! In a treatment called ‘rapid opioid detox’ the using addict is anesthetized for an entire day and naloxone is injected to precipitate withdrawal. 24 hours later the addict is still shaking as he stumbles toward his ride back home to complete the rest of his detox. That seriously-flawed detox strategy was the closest to a ‘free ride’ off opioids available ten years ago. Now Suboxone avoids detox almost entirely; the addict leaves the doctor’s office after Suboxone induction and can often return directly to work! Make no mistake—Suboxone treatment is a ‘remission’ or ‘maintenance’ agent—NOT a cure. But in many ways traditional, step-based recovery is ‘maintenance treatment’ as well. Any addict in recovery will tell you that if an addict quits attending meetings, relapse is not far away. Opioid dependence is a chronic condition that requires chronic treatment, whether that treatment is medication-based or program-based. And many addicts find medication easier to accept than the dramatic personality changes often required for step programs to induce and maintain sobriety.
And yet the more I worked with Suboxone, the more I became aware of another opinion about Suboxone—an opinion that is much less gracious. I discovered the ‘Suboxone-haters’; people who gather on internet discussion boards to bash Suboxone and to put down those who use buprenorphine to maintain sobriety. “It’s just swapping one drug for another!” they say, ignoring the dramatic and positive changes in mood, behavior, and relationships in people who use buprenorphine for treatment of their addiction. “You’re not really clean!” they say, ignoring their own relapses that occur on a monthly basis. “It is all a scam by those greedy doctors!” they say, ignoring the fact that few doctors want to prescribe the medication, and that many doctors stop prescribing it after finding that the reimbursement is not worth the work of dealing with such a difficult and frustrating illness.
There is a great deal of misinformation about Suboxone on the internet and in the community, and the misinformation is what fuels the negative attitudes toward buprenorphine. The shameful result is that young people are dying in my home town and others, at the same time that there is an under-used medication that could have saved them! Out of a desire to counter the misinformation about Suboxone, I set up an online blog called ‘Suboxone Talk Zone’ where more and more people write to me with comments and questions about Suboxone.
This book is a collection of those questions and comments from the past few years. These comments from addicts across America capture their desperation from years of active addiction, and show their excitement at the prospect of freedom from the obsession to use. They show the frustration of addicts struggling to find appropriate and effective treatment. The comments show the anger of addicts who face retribution in one form or another, first because of their addiction, and then again because of their choice of treatment. All together, the posts will give the reader an understanding of the process of addiction, the treatment options that are currently available for opioid dependence, and the factors that should—or shouldn’t– influence one’s decision whether or not to use Suboxone for treatment of opioid dependence.