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.

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!’

I’ve shared my opinion that traditional treatment methods for opioid dependence—i.e. residential, usually step-based treatments—are a waste of limited resources.  I’ve written that relatively few opioid addicts successfully complete such treatments.  And many of those who ‘clean up well’ after two or three months die from relapse and overdose, months or years down the line.

Those who disagree with me sometimes pointedly ask “if getting clean without Suboxone is impossible, how did YOU do it?!” My usual answer is that my situation was and is very unique, and it would be misleading to compare my experience to that of most people.  But in case someone uses my experience to justify a similar path as mine, i.e. through residential treatment, I’ll expand on my answer.

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!

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.