Archives for December, 2010
Over the past several years I’ve written a book about my experiences with addiction, and about my take on traditional treatment methods, buprenorphine, and on the psychodynamic factors at play in those with addictions. I went through the standard process of sending requests to agents and publishers to take a look at a few of the 300-some pages, and received the standard series of rejections. I then discovered several companies that were very excited about what I had written, and found that by some odd coincidence all required a down payment on my part. So the book sits on my computer—or at least sat on my computer until now.
On my personal blog about opioid dependence I often respond to specific questions about buprenorphine or addiction. I would like to invite questions from readers here as well, using the ‘comments’ section. Specific questions or comments can generate an interesting give and take that in the end becomes quite informative—for all of us, myself included. Just remember to be careful with disclosure of personal information. When in doubt, don’t disclose, as information placed on the internet can never be completely removed! I’ll provide an example of the type of exchange I’m suggesting, using a question that I received a day or two ago.
I write about addiction being a disease in order to counter the negative stigma that society holds for those who, through little fault of their own, were captured by opioid dependence. One of the most potent examples of this stigma is the attitude toward addicted mothers on the labor and delivery ward from doctors, nurses, and family members of an addict who is a new mother. News stories, movies, and public service announcements have implanted images in our minds of babies in opioid withdrawal, suffering horribly because of their mothers’ bad habits. I was a part of the world of obstetric suites, newborns, and labor epidurals during my ten years as an anesthesiologist. During that time I met many new babies, and I became pretty familiar with the experiences they endured in their first few hours in the hospital. I like babies—my wife has had a few who I’ve become quite fond of—and so I don’t mean to sound unsympathetic toward them. But the images that most people have of babies craving a ‘fix’ are not accurate—not by a long shot.
I have a number of patients under treatment for opioid dependence taking buprenorphine who have become pregnant, deliberately or accidentally, forcing the decision whether to continue on buprenorphine, taper off the medication, or even whether to terminate the pregnancy. The decision is not made any easier by the large amount of misinformation people are subjected to, or by the shaming attitudes of some family members and even healthcare workers. I produce a website called SuboxForum in order to provide accurate information and to allow people to ask questions in a non-judgmental setting. A member of the forum recently wrote that her doctor informed her that a baby born to a woman on buprenorphine would likely be severely deformed, and that she shouldn’t even think of pregnancy until she was off buprenorphine for several months. And I wonder—who would say such a thing?!
Addiction fits any definition of ‘disease’ that a person might use. Addiction is progressive; there are familial and environmental influences; the course of a case of addiction bears certain similarities between individuals; the progression of illness is predictable; and recovery from illness is possible with appropriate treatment. There is a definite behavioral component to addiction in that people who become addicts often engage in behaviors that are ultimately harmful. But most illnesses have a similar behavioral component. For example, many diabetics would be cured by weight loss, and many cases of lung cancer or emphysema would be prevented by stopping smoking. From an unbiased perspective, addiction is a disease like any other disease.
Buprenorphine does not ‘cure’ opioid dependence. When buprenorphine is discontinued, the stimulation of opioid receptors ceases, the neurons with the receptors stop firing, and the craving for opioids returns. Moreover, since buprenorphine does have some agonist activity, discontinuation results in withdrawal—although the withdrawal is usually less-severe than the withdrawal after discontinuation of opioid agonists. At the same time, buprenorphine does much more than act as a ‘replacement medication;’ it treats the very essence of addiction, i.e. the desire to use.
I will take a moment to clarify the difference between the two major forms of buprenorphine on the market, namely Suboxone and Subutex. Suboxone is a medication that contains buprenorphine plus naloxone, an antagonist at the mu receptor used clinically to reverse opioid overdose. Subutex and the generic equivalent of Subutex contain only buprenorphine. The role of naloxone is difficult to understand without knowing a couple facts about the GI system.
Most people with a healthy curiosity about the mind and brain know that nerve cells transmit information in the form of electrical impulses. When an electrical impulse reaches the end of the axon of one neuron, packets of molecules (called neurotransmitters) are released from that neuron into the narrow space between that neuron and the next neuron. This space is called a ‘synapse.’ The neurotransmitters, after their release, have actions at molecules called ‘receptors’ that are imbedded in the lining of neurons. Neurotransmitters attach to receptors and change the shape of the receptors,, which triggers a range of actions depending on the part of the brain and the specific neurons involved. Endorphins and enkephalins are molecules that function as neurotransmitters in a number of brain regions, including regions that regulate pain, that affect mood, and that alter the body’s response to trauma. The receptors in these brain regions are activated not only by these neurotransmitters, but also by molecules that are found in the sap of certain poppy flowers. The sap is harvested and concentrated to make a substance called ‘opium.’ Receptors that are activated by this substance, and also by endorphins and enkephalins, are called ‘opioid receptors.’ There are a number of types and subtypes of opioid receptor; the mu type is the receptor activated by most opioid pain relievers, and also by most of the abused opioid substances, including morphine, heroin, oxycodone, and fentanyl.
Suboxone is the trade name for a medication that contains buprenorphine and naloxone. A similar medication, Subutex, contains buprenorphine without naloxone. Both are manufactured and sold by Reckitt-Benckiser, a company based in the UK with operations world-wide. Both medications are indicated for the treatment of opioid dependence. Both medications are also used 'off label,' or without FDA indication, to treat chronic pain and in rare cases, refractory depression. Because of longstanding regulations in the United States that prohibit treating opioid dependence with narcotics, a special waiver from the DEA is required in order for doctors to prescribe buprenorphine for that indication. Buprenorphine can be used to treat other conditions, including chronic pain, without special waiver or permission, provided the doctor has current DEA registration for Schedule III medications and a valid state medical license.