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. 

As a solo-practice psychiatrist, I am more connected to the cost/value equation of my services than the typical system-employed physician.  I’ve also written in prior posts about my concerns with modern psychiatry.  I have worked in a variety of settings over the course of my career, and I realize that coming to an understanding of something as complicated as another person’s subjective life experience is a very difficult endeavor.

At the very least, such an understanding takes time.  It also takes a willingness to maintain the constant recognition that my perception may be wrong, and may be the result of my own bias.  Finally, it takes a certain amount of intelligence.  Over time, certain patterns of thought become apparent and easier to recognize– but these patterns are extremely complex, and trying to provide insight into such patterns, without causing a person to take offense, requires intelligence, patience, and tact.

I have come to the realization (a somewhat surprising realization, frankly) that psychiatry works, when practiced properly.  I’ve come to realize that the ten-minute med check is worse than worthless, as a ten-minute glimpse of a person’s day is more likely to lead to the prescribing of a harmful medication than a helpful one.

I think that it is because of my own experiences as a study participant back in medical school that I get such a kick out of volunteer studies today.  Years ago, my classmates and I were paid to undergo bronchial lavage (a procedure where a tube is passed into the lung and the alveoli rinsed with fluid—all while wide awake), to be infected with the cold virus and then receive various treatments (administered by squirting substances up the nose), and to take antidepressants or other medications to allow researchers to screen for side effects.  The greater the inconvenience, risk of injury, or physical discomfort, the bigger the payoff for test subjects.

We were often faced with the question, ‘how bad do I need the money, and how much pain can I tolerate to get it?’  Oh, the things med students will do for $100!

A new study out of Great Britain reminds me of those desperate days as a research subject, and also bears relevance to prior discussions here.  The study, published in the Journal of Science Translational Medicine, subjected volunteers to a beam of heat applied to the leg, to induce pain that was 70% of what the volunteers thought they could tolerate.  The subjects were then given an intravenous infusion of a potent, ultra-short-acting narcotic called remifentanil, all while having their brains imaged by fMRI, an imaging technique that determines electrical activity in certain brain areas by measuring regional blood flow.

Researchers in Pisa, Italy recently published findings from a study of heroin addicts treated with either buprenorphine or methadone.  The study was a follow-up to earlier studies by the same group;  one that examined the personality characteristics of heroin addicts, and a second that measured the impact of agonist treatment on psychiatric symptomatology and the quality of life of heroin addicts.

The recent third study, published in the Annals of General Psychiatry, divided heroin addicts according to personality traits, and then examined whether these personality traits predicted success with one agonist treatment over another (i.e. methadone vs. buprenorphine).

‘Agonist treatment’ is used in the Italian studies to refer to maintenance with methadone or with buprenorphine—even though buprenorphine is technically a ‘partial agonist’ rather than an ‘agonist.’  Personality characteristics were defined using an instrument called the SCL-90 (Symptom CheckList-90).

In the first study, researchers found that the 1000 or so addicts could be divided into five subgroups, according to clusters of symptoms.  One subgroup was characterized by depressive symptoms.  The second was characterized by somatic symptoms, i.e. focus on physical symptoms and complaints.  The third group was characterized by ‘interpersonal sensitivity’ and symptoms of psychosis—such as delusions.  The fourth group had significant panic or anxiety symptoms, and the final group had symptoms related to violence toward self or others, including suicidality and self-mutilation.

I relapsed in 2000 after seven years of sobriety, and my attachment to opioids progressed much more rapidly than during my initial addiction.  I wrote a post a number of months ago that described ‘living on two levels,’ and that was my experience at the time—as if one part of my personality was frantically taking ever-increasing doses of dangerous narcotics while the other part, horrified, looked on.

Eventually my behavior caught the attention of enough people that I was confronted about my addiction.  I had been trying to stop using on my own for several months, but I argued over the need for residential treatment.  I remember sitting with the hospital CEO, babbling that I would be able to straighten myself up on my own if I had a few weeks of sick-time, and his response:  ‘Jeff, you have needle marks on your hands!’

In my last post I shared a comment from a reader that included the following:

Not everyone needs permanent blocker therapy. Everyone’s will power varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinence. The easier withdrawals are, the more likely those persons’ mindset will be “one more can’t hurt”. Pain builds you; it builds character, personality, and maturity.

I noted that I was relieved of the obsession to use opioids only by letting go of will power, and instead accepting my own powerlessness over substances, and trusting that a higher power could help restore my sanity.

When I left off, I was debating whether to leave well enough alone, or to seek a logical understanding of how the acceptance of powerlessness relieved my obsession to use.  Being the scorpion in the famous story of the scorpion and the frog, I chose the latter.  I’ll leave you to look up the famous scorpion story on your own.

This is part one of a three-part discussion about will power; look for the rest of the story next week, after the Packers beat the Bears in the NFC Conference Championship.

A person posted the following comments after one of my articles about Suboxone:

While Dr. Junig knows what he’s talking about, not everything he says is always true. Not everyone needs permanent blocker therapy. Everyone’s will power varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinence. The easier withdrawals are, the more likely those persons’ mindset will be “one more can’t hurt”. Pain builds you; it builds character, personality, and maturity.

I have had my share of bad withdrawals, as have most opioid addicts who have lived with their illness for a few years.  Unfortunately there is much more to staying sober than remembering the pain of withdrawal.  There is also much more to staying clean than ‘character, personality, and maturity.’

In response to my last post, a reader, Sunkissed, wrote about the many consequences of  active addiction, and noted that the consequences including spiritual impairment and the loss of self-esteem are as valid indicators of ‘addiction severity’ as are consequential effects on earning power—perhaps even more valid.

She wrote about the importance of replacing one’s relationship with a substance with a relationship with God, and asked ‘is there a case… for a positive ‘harm minimization’ approach in the addiction process with the following attitude as a goal:  I AM an addict… I AM ashamed (though i am at peace with God)….. I recognize that addiction DOES affect my finances and my parenting (but i have enlisted strategies and a care plan).  I AM seen as weak and selfish (but I have put in place actions that will minimize the effect of my using on my children)… in short, I am in acceptance of who I am, what I am, and what I do.’

Thank you, Sunkissed, for your comments and insight.  Hopefully I captured the essence of your remarks despite minor editing.

The essence of your question, if I understand correctly, is whether a person can remain in a low state of active addiction, or at least active using, yet reduce or even avoid the usual devastation caused by addiction by coming to terms with their condition on a deep personal level, and being at peace with him/herself and with God or higher power, depending on the person’s spiritual background.

This is another section of my unpublished book, Clean Enough.  I describe stages in the process of addiction that I’ve noticed in opioid addicts presenting for treatment.  I must point out that these stages have not been validated by clinical research, but rather are drawn from simple observation.  Read on:

I am always impressed by how similar addiction progresses in one individual versus the next.  The next reader’s comments and my comments afterward demonstrate a pattern that I have observed in one opioid addict after another.  Throughout these posts, comments that I receive from others will be italicized.

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.