My dad used to tell a joke about a bunch of soldiers sitting around the barracks.

One old guy yelled 31! – and the place broke out in laughter.  After a moment or two, another guy yelled 52! – and more laughter erupted.  Then a depressed-looking guy in the corner yelled 29! — followed by silence.  He yelled again, 68!—and again, the room was silent.

The new recruit asked the guy in the next bunk what was going on.  The guy answered, “we’ve been together so long that we know each others’ jokes too well—we decided to just number ‘em and save us the time.”

The new guy asked again, “but what about that guy in the corner?”

“Oh—that’s just Slim—he never could tell a joke.”

I recently exchanged emails with a patient about his complaints of back pain.  After reading about his symptoms and history by email, I told him– prior to his first visit– that I would consider treating his back pain and his use of opioids using buprenorphine, but I would not prescribe opioid agonists.

We met and started buprenorphine, but after the second or third visit, he began asking for opioid agonists.

Next month I will be presenting a paper at the annual meeting of ASAM, the American Society of Addiction Medicine.  The paper discusses a new method for treating chronic pain, using a combination of buprenorphine and opioid agonists.  In my experience, the combination works very well, providing excellent analgesia and at the same time reducing—even eliminating– the euphoria from opioids.

Ten years ago, I would have really been onto something. Back then there were calls from all corners to improve the pain control for patients.  The popular belief regarding pain control was that some unfortunate patients were being denied adequate doses of opioid medications. I remember our hospital administrators, in advance of the next JCAHO visit, worried about pain relief in patients who for one or another reason couldn’t describe or report their pain. Posters were put up in each patient room, showing simple drawings of facial expressions ranging from smiles to frowns, so that patients in pain could simply point at the face that exhibited their own level of misery.

What a difference a decade makes!  Purdue Pharma, the manufacturer of Oxycontin, was fined over $600 million for claims that their medication was less addictive than other, immediate-release pain-killers. Thousands of young Americans have died from overdoses of pain medications, many that came from their parents’ medicine cabinets.  Physician members of PROP, Physicians for Responsible Opioid Prescribing, have called out physicians at the University of Wisconsin School of Medicine and Public Health for having ties to Purdue while arguing against added regulations for potent narcotics.

A question was asked about the last post that warrants top billing:

“Buprenorphine acts similar to opioid agonists in lower doses, with the same addictive potential as oxycodone or heroin. In higher doses—doses above 8 mg or 8000 micrograms per day—the ‘ceiling effect’ eliminates interest and cravings for the drug.”

I’m not sure I followed this. Can you explain more? What would you think about someone who is taking 1-2mg of Suboxone twice a day without a prescription, and says they want to stay on that dose once they find a prescriber? Are they better off on 8mg or more per day, or would it be ok for a prescriber to keep them at the lower dose? Is the answer the same if they hope to taper off the medication completely within a year (they don’t feel able to do this on their own right now, but hope to be able to when some life circumstances change). Thanks!

This gets a bit complicated, but I’ll do my best.  A couple background issues;  buprenorphine has a ‘ceiling’ to its effect, meaning that beyond a certain dose, increases in dose do not cause greater opioid effect.  That is the mechanism for how buprenorphine blocks cravings. 

I appreciate the feedback to my last post.  I had no doubt that the thoughts expressed in the original letter would ring such a chord, as I hear similar comments on a daily basis.  For people new to my blog this week, please review the letter in last week’s post, as that is where I’m starting today.

I had the same ‘love at first site’ reaction to opioids described by many people who become addicted.  My addiction began with a relatively weak opioid — codeine —but I still remember lying in bed as the effects of the substance drifted over me, easing the life-long depression that I had long accepted as ‘just how things are.’

I should make clear at this point that I do not mean to recommend that depressed people take opioids.  Unfortunately, every bit of relief that I found from opioids had to be paid back, in the form of sadness, loss, and despair.  There is some possibility that medicine will find a way to tap into the powerful mood effects of opioids at some point, but we are NOT there now.

For people who are thinking ‘I’m smart—I’ll find a way to tame the beast,’ I can only plead that you look beyond that feeling of uniqueness.  I was a pretty smart guy too. But a PhD in neurochemistry, honors in medicine, and board certification in anesthesiology offered no protection against addiction.  If anything, that advanced knowledge made me more difficult to treat.

I would like to discuss a comment from a reader:

I have been a recovering addict for 12 years. I was addicted primarily to Lortabs (active ingredient is hydrocodone) and Ultram. I was never an extreme user but I was consistently trying to modulate my feelings and feel better. I also have been battling BPD (Borderline Personality Disorder) for a very long time which appears to be my primary issue. I have been married for 17 years and let’s just say our relationship is difficult due to my inability to be present and emotionally and psychologically sound.

As with most other addicts, I distinctly remember the first opioid I took, even though I don’t remember my first sexual experience. The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.

Since I quit using 12 years ago I have only had a few days, yes, days, where I have truly felt good, and that was after intense work with someone for hours and hours at a time to help me get through an intense emotional roller coaster ride. I will feel “normal and happy” for a few hours or maybe a day and then I feel the despair creeping back in. I cut my thumb the other day and the first thought that I had was, I wonder if this injury will be sufficient enough to allow me a Lortab? I just never feel right without an opioid in my system.

I have been researching drugs available to help me. I have tried many different antidepressants which were never helpful. I am wondering about a small dose of Suboxone (maybe 2 mg/day) which I have read may decrease some of the problems associated with BPD. I have been reading that persons with BPD have shown to have an opioid deficit and that 40% of those with BPD are addicts.

Below is an e-mail that I changed just enough to hide the person’s identity.  Every week, I receive messages that describe similar situations.

My husband has struggled GREATLY with substance abuse since in his 20′s; he is now in his mid-40′s. He is the kindest sweetest man and he is the BEST husband and father. When he is using he becomes someone he is not. We have run the gamut from jail to overdose.  Six years ago a friend introduced him to Suboxone and it LITERALLY gave him his life back. He bought it off the friend for years, where it was very expensive. Finally I brought him to a doctor a bit over a year ago. She is pretty adamant about weaning him off of Suboxone.

From experience, I know that 2-3 months after he stops Suboxone he will relapse. I strongly believe it IS a MIRACLE drug! I agree in the sense that if a diabetic needs insulin to save his life, you give it for a lifetime. My husband over the last 6 years has been the man of my dreams, the man I always knew he was. I have extreme anxiety because I know this doctor is just doing her job and trying to follow guidelines however my husband’s LIFE is at stake!  It’s not like if he stops this med he could ‘just’ have depression;  he could end up in jail, or worse. He has his life back. He is enjoying his family life as he should.

If this is what it takes for him to live a normal life then why not?  When we ask his doctor about staying on Suboxone, she says her concern is that we don’t know the long-term effects. She doesn’t want to keep anyone on any med without knowing what it could do. She says it hasn’t been on the market long enough. 

My husband had a SEVERE opioid addiction. He was taking 10-15 Oxycontin 80mgs a day and then ended up switching to 400mgs of methadone before he switched to Suboxone. He has found that he is comfortable with 4 of the 8mg pills per day. I believe it is because he was used to taking such high doses of opioids. He has tried really hard to decrease Suboxone for his doctor but I see the anxiety build in him. She says no one in her practice is on that dose. To be honest he was taking more when he was buying them from a friend but brought himself to a stable 4 pills per day when he started with the doctor. He and I both REALLY like her and would like to continue treatment with her. I wish I had a DVD of little clips of our life from before and after Suboxone. I am positive she would be floored. I am positive she would understand my concern. In my eyes my husband is back. He is such a beautiful soul and I hate to see that taken away from him yet again.

Doctor I read up at the top of this blog that you agree with a lifetime use. He currently has no noted side effects. Do you have any suggestions that I may present to his doctor? I dream of the day that she says it is alright for him to continue on this until maybe he chooses to wean if he so chooses to do so. That would alleviate SO MUCH stress on both of us. Please let me know what you think.

Anyone who reads this blog knows that I agree with most of the opinions expressed in the email.  I know how horrible things are for active opioid addicts—and for the families of active opioid addicts.

A recent experience with a patient helped me realize the dramatic difference in the treatment of opioid dependence, in an era of buprenorphine.

I randomly drug-test for a wide range of substances.  I don’t test because of a lack of trust for patients;  I test because before the era of buprenorphine, insight—a more fundamental character trait than honesty– would rapidly change after relapse.  Almost immediately after the onset of an opioid high, the people using lost insight into the big picture and saw only what needed to be done right then—to cover up evidence of the relapse and avoid experiencing whatever shame-inducing consequences would likely come their way.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA, attending hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found. 

Medications - image from Shutterstock

The point missed by the writers of the Bloomberg article, though, is the same point that is missed by many physicians– even by many addictionologists. The dirty secret that RB does not want anyone to realize is that the equivalent of generic Suboxone is already available, in the form of orally-dissolving tablets of buprenorphine.

I will get to my promised response to my last post– the one that called out the detractors from Suboxone.  But first I have to share the story I read in the Maine Sunday Herald today about the surge in overdose deaths over the past year or two.  The article mentions the 28,000 overdose deaths across the US in 2007– the last year for which we have such numbers;  numbers that have surely risen since then.  The article also describes, more personally, the current overdose death rate in Washington County, Maine, which has doubled in recent years.

My point in promoting this type of information is to emphasize the magnitude of the problem.  It is one thing to argue about marijuana laws, where the death rate is comparatively tiny.  But people using opioids die at an alarming rate. 

As many readers know, I maintain a forum for people who take buprenorphine for opioid dependence. The initial purpose of the forum  was to serve as a source of accurate information about the new medication. Now, several years later, the forum is also a gathering place for people who share certain interests.

Studies have established a connection between opioid dependence and certain personality traits, including a tendency toward depression. In my conversations with people addicted to opioids, many describe an emptiness experienced throughout their lives. Opioids, prescribed or illicit, initially eased that emptiness, relieving the depression and for some even giving a sense, for the first time, that life was worth living.

I suspect that the emptiness experienced by people with borderline personality disorder is akin to the emptiness that some people find responsive to opioids.  Over the years I’ve had many people write to me, independently, about a ‘hole’ they felt before taking pain pills. I suspect that the current studies of the antidepressant actions of buprenorphine are examining similar effects.