I have several blogs and forums, all part of the mission to educate people about opioid dependence and buprenorphine.  Because of my online presence I am frequently contacted by reporters or journalists, and asked to provide my opinion about some aspect of opioid dependence.  The requests have become more frequent over the past year, suggesting that either my name recognition has increased, or that there is greater awareness—finally—that an epidemic of opioid dependence is killing people in large numbers.

Among those who contact me are people who are ‘anti-Suboxone.’  Some people are very heated in their arguments against the medication.  I run the addiction forum for another large health-related web site, and a couple years ago my presence on that site provoked ‘hate e-mail’ from readers, who accused me of being ‘just another drug pusher’ for my advocacy for buprenorphine!

Yesterday I received the following e-mail:

Hi Dr. Junig,

Please let me first say – Suboxone SAVED MY LIFE. I was down and out until 2 years ago, when I began using Suboxone. Now, having completed all the pre-req’s for medical school with nothing less than straight A’s, I find myself on track to apply to medical school.

But here’s the problem. I’m still taking Suboxone and have no desire to stop. I will quit if absolutely necessary, but I’m wondering if you’ve heard anything new regarding the legalities of health care providers taking buprenorphine.

I would love to enter a field like psychiatry or family medicine, as these are the doc’s I’ve grown fond of over the past two years. I haven’t told my doctors of my med school plans, as I fear that they will block my attempts to apply/matriculate. Do you have any insight on the subject? Do you know of any patients who have gone on to medical school?

Thank you,

MD to be

I have received a number of similar messages over the past few years.  Just today I received an e-mail from a person who wants to become a CNA.  I have been asked the same question by people wanting to work as truck drivers, nurses, and police officers, among other professions.

In my last post I mentioned that one of my patients on buprenorphine had relapsed. Relapse on buprenorphine reminds me of the philosophical cliché, ‘if a tree falls in a forest and nobody hears it, did it make a sound?’ For those not familiar with the cliché, the question and the answers–from standpoints of science, art, and metaphysics—are discussed in great depth, I just discovered, on Wikipedia. I now know more about the question than I will ever need to know!

When a person on buprenorphine maintenance uses opioids, what happens? The answer, depending on perspective, ranges from ‘nothing’ to ‘everything.’ For example, we could focus solely on the effects experienced by the addict. Because of the blocking effects of buprenorphine, an addict may take significant doses of heroin without having any subjective response. One might argue that since the addict experienced no ‘high’ from the use of heroin, he/she didn’t really relapse. Someone else may focus on the intake of chemicals, and consider such use to be a ‘relapse’ whether or not the heroin had a noticeable effect.

One of my patients taking buprenorphine relapsed last week. He worked in a healthcare facility that stocked potent opioids, and he somehow came across an unlocked door. By the end of his shift he had consumed several hundred milligrams of oxycodone—enough to provide a mild buzz for a person taking buprenorphine. Several hours later the mood effects were gone—and so was the job. Relapse has always been a part of the disease of opioid dependence, and always causes a great deal of pain.

The relapse process– the complicated interactions between a person and his environment that lead to loss of control over drug use– are some of most fascinating, maddening, and tragic aspects of addiction. It is incredible that a person in one moment can be in complete control of his faculties, and a moment later is doing something at complete odds with his best interests.