I’ve written about the dangers of Xanax (alprazolam), Klonopin (clonazepam), and other drugs in a class of drugs called ‘benzodiazepines’. The drugs are grossly over-used by patients, and over-prescribed by psychiatrists, usually for patient complaints of anxiety.
My primary concern over use of benzodiazepines is that when used to treat anxiety, they are more likely to aggravate than improve a patient’s symptoms, especially if taken regularly. Patients develop physical and psychological dependence to benzodiazepines very quickly. Once physically tolerant, patients experience withdrawal symptoms if doses are missed, and generally interpret the withdrawal symptoms as manifestations of their own anxiety disorder. The progression from taking alprazolam or clonazepam ‘as needed’ to taking them regularly is as predictable as any other biological process. And after physical tolerance has developed, symptoms that were once considered manageable become part of an unmanageable ‘anxiety disorder.’
I have learned over the years that the term ‘anxiety’ means different things to different people. The complaint shouldn’t cause doctors to automatically reach for the prescription pad. When asked to describe his ‘anxiety’ in detail, a patient said ‘I will pace around the house, looking for something to do. I will turn on the TV and change channels, but there is nothing interesting. I feel…. restless and bored. I need to get out of the house, but there is nothing for me to get outside to do. I’m like a caged animal. You know— anxiety!’
I responded, ‘you mean you were bored?’
‘No’, he said. ‘Boredom is when there is something to do that isn’t interesting. This is just having nothing at all to do. It makes me uncomfortable.’
There are other types of anxiety, of course. But this particular patient, after leaving my office empty-handed, received valium, 10 mg, three times per day from his general practice doc. And I see the same thing happen over and over again.
Even the patients with ‘real’ anxiety, i.e. fear –based dysphoria, are no better off on benzodiazepines than the bored person in the example above. Benzodiazepines cause amnesia, a function that is useful in the operating room. But amnesia and other cognitive impairments from benzodiazepines prevent people from learning to …
Regular readers of my blog know that I believe buprenorphine is the most important development for treating addiction during my lifetime. At the same time, my own recovery from opioid dependence began over 20 years ago, long before the use of buprenorphine. I am grateful for the change in my perspective that occurred one desperate afternoon, when I first recognized the uselessness of ‘will power’ for stopping opioids. I was one of the lucky addicts who experienced a ‘spiritual awakening’— the realization that I could not recover through my own power, no matter my education or motivation.
I’ve searched, since then, for a scientific explanation of how acceptance of powerlessness and belief in a higher power removed, almost instantly, an obsession that I couldn’t control before that moment. I recognized the preciousness of my recovery as friends from treatment lost their sobriety. And I learned, at one point, that success in ‘traditional recovery’ requires lifelong attachment to meetings and step work.
Ten years later I was excited by the power of buprenorphine to induce remission of the same obsession. As patients on buprenorphine regained meaningful lives at a pace similar to those who practice traditional recovery, I realized that recovery from addiction and freedom from ‘character defects’ can stem from changes in thought, or from changes in neurochemistry. I realized that one approach isn’t more ‘natural’ than the other, and that both methods require lifelong efforts to prevent relapse to addictive behaviors. I wrote the following, several years ago, to explain what I was seeing.
Recovery in the era of buprenorphine
Most opioid addicts are familiar with Suboxone, a medication that erases cravings for opioids, and when used properly creates a state of remission from active addiction. My initial thoughts about Suboxone were influenced by my own experiences as an addict in traditional recovery. But that opinion has changed over the years, because of what I have seen and heard while treating over 700 patients with buprenorphine in my clinical practice.
Suboxone has opened a new frontier of treatment for opioid addiction, but arguments over the use of Suboxone split …
I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry. She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor. “Add a little of this, and if that doesn’t work, try adding some of that” she said. “Psych is all a gray area. You can be creative.”
Now THAT’S crazy. Her recommendations, sadly, will likely be followed in a number of actual patients. No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.
At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.
Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches. They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.
Evidence-based medicine encourages practitioners to ignore their own experience, and to instead anchor practice patterns to those supported by peer-reviewed research. Practitioners should know the difference in predictive value for comments by a mentor, the findings in a case report, and the results of a large, prospective clinical trial. Practitioners should appreciate the perils of using their knowledge of basic science to extrapolate findings from one set of conditions, to a case where some variables differ.
These distinctions are especially important in an era where insurance companies increasingly try to influence treatment patterns. For example, there is considerable evidence that Abilify effectively augments the …
Newborn abstinence syndrome from buprenorphine provokes strong emotions. Expectant patients rightly anticipate harsh attitudes from doctors and nurses. They read in forums and chat rooms about experiences of women who say that CPS was called after delivery, or about babies who were kept on opioid tapers, in the hospital, for weeks or even months after mom’s discharge. And in the absence of appropriate support from the medical profession, they worry that their use of buprenorphine will cause the baby to suffer from withdrawal.
A member of SuboxForum recently wrote that the hospital where her doctor had privileges required that she sign a formal policy about babies born to mothers on buprenorphine. She was told that her baby must go to the NICU for at least 10 days after delivery, regardless of condition, and she was not allowed to refuse that level of treatment.
Meanwhile, one of my buprenorphine patients came to her appointment last week, five days after the birth of her baby. Mom and baby left the hospital together less than 48 hours after deliver, and she brought the baby to her appointment. I realize that hospitals discharge patients more quickly these days but her discharge seemed a bit fast, but not because of anything related to buprenorphine. I just believe that new moms, who are frequently anemic and sleep-deprived, should have a bit more rest before taking on an infant’s schedule.
How can the ‘standard of care’ vary so greatly? What role does insurance coverage play in decisions about opioid tapers, NICU admissions, and discharge schedules? After having dozens of patients go through the process uneventfully, without intervention by a neonatologist, I have to wonder if newborns are always positively served by such efforts.
Realize that I respect neonatologists probably more than most people. As an anesthesiologist, there were times when a baby had to be delivered, whether or not a pediatrician had made it into the hospital. Doctors in our group (and in others across the country) argued whether an anesthesiologist had the duty to assist in the resuscitation of the newborn while simultaneously caring …
With all the recent attention over the epidemic of opioid dependence, why do some parts of the country report a shortage of physicians who are DATA-2000 certified, i.e. able to prescribe Suboxone and other buprenorphine products? The shortage of buprenorphine-certified doctors parallels shortages of mental health practitioners in general, including psychiatrists and addictionologists. Larger cities and areas near the east and west coasts are less likely to have shortages of doctors than are smaller and more-rural parts of the country, particularly across the Midwest.
The shortage is caused by a number of factors. All doctors train in medical schools, which are primarily located in larger cities. So by the end of training. most doctors have spent several years living in larger cities, establishing friends and business partners and sending their children to area school districts. As with members of any profession, doctors are more likely to choose positions in areas they know than to move to unknown areas, unless the area holds special attractions like morning sunrises over the ocean or mountain views. Even doctors who grew up in rural areas find it hard to move back, after living in more urban areas during the 12 years of college, medical school, and residency.
Beyond the regionalization pressures, doctors are discouraged from becoming certified to treat opioid dependence using buprenorphine. The coursework is limited by medical school standards, and the cost for buprenorphine training and registration is relatively minor. But to become buprenorphine-certified, doctors must sign an agreement that allows random inspections by the DEA without cause. Other doctors enjoy privacy rights similar to other businessmen, where search of the premises and review of records would require probable cause and issuance of a warrant by a judge. But in order to treat with Suboxone or buprenorphine, doctors must waive that right of privacy and allow inspections with no notice, even if such inspections require closing the clinic doors for the day. The requirement to allow random inspections has an effect on individual doctors, especially since the 100-patient limit (30 patients the first year) guarantees that buprenorphine-prescribing will not support a …
In ‘Addiction Treatment with a Dark Side’, Deborah Sontag of the New York Times shared her observations of the clinical use of buprenorphine for treating opioid dependence, warts and all. Readers of the Talk Zone know my bias—that buprenorphine/Suboxone is one of the only effective treatments for opioid dependence, and many patients are best-served by long-term, perhaps life-long treatment with buprenorphine. But I read the article the article with interest because I know that Ms. Sontag ‘did her homework’, including visiting a number of practices, speaking with a number of patients, and reviewing hundreds of studies about buprenorphine and Suboxone over the course of many months.
From my perspective, the article overstates the diversion problem. In my last post I asked if the fear of diversion should be a factor in whether buprenorphine-based medications become the leading edge of addiction treatment. I stated my opinion—that if overdose deaths don’t pull acetaminophen from pharmacy shelves and diversion doesn’t keep hydrocodone off the market, then diversion of buprenorphine deserves little discussion relative to the value of buprenorphine treatment for addiction.
With the wave of stories describing buprenorphine as ‘controversial’, every discussion of the medication seems to revolve around diversion. Do the numbers support the association? Deaths from Suboxone—deaths where buprenorphine was one of the drugs that caused death—amounted to several hundred over the past ten years, compared to 38,000 drug overdose deaths in 2010 alone. The magnitude of the difference is so staggering that it deserves repetition; 400 deaths in ten years, vs. 38,000 deaths in one year. The total number of deaths linked to buprenorphine over the past ten years is about equal to the number of people who die from acetaminophen– EACH year.
Diversion of buprenorphine is a complex issue. Words like ‘diversion’ and ‘overdose’ are loaded with so much emotion that one word seems to tell the whole story. A Google search of Suboxone brings up news reports such as ‘Suboxone found at overdose scene’, or ‘man arrested with cocaine, heroin, and three Suboxone tablets.’ The stories create an ugly image, with buprenorphine/naloxone as one more drug of abuse, found at ‘an increasing rate’, according to other headlines. But a superficial look …
The forces of nature appear intent on reversing mankind’s progress toward better health. An example is the ever-increasing resistance of bacteria to antibiotics. A timeline of the existence of humans and bacteria shows that bacteria have been around for a very long time— much longer than mammals, and much, much longer than humans. In fact by the dawn mankind, bacteria had been thriving, relatively uninhibited, for over 2 billion years.
Modern humans have been around for 40,000-200,000 years or so, depending on the definition of ‘modern.’ Bacteria have had the upper hand during all of mans’ existence, save for the past 100 years after penicillin and other antibiotics were discovered. Only the most self-centered of species would look at a timeline and conclude that humans have won the battle with bacterial diseases. There are always reasons for optimism, but a fair assessment of our current struggle with antibiotic resistance suggests that someday, people will look back on the current sliver of time, when humans can treat most bacterial infections, as a golden era of medicine that wasn’t appreciated as such at the time.
Viruses adapt to mankind’s health efforts too, with new variants arising from the sludge at the bottom of the food chain to infect birds, swine, or other creatures before moving on to human hosts. The CDC and other scientists work to predict the vulnerabilities of the next super-virus, hoping to reduce the severity of the next pandemic. As with bacteria, we are enjoying an era without smallpox, polio, or other dreaded viral diseases that used to kill otherwise-healthy people. We take the victor’s position for granted to the point that our children don’t know why chlorine was first added to swimming pools. Gone with the last generation are the fears associated with iron lungs, orange window-signs, and leg braces.
Even the Human Immunodeficiency Virus, an agent of certain death in the 1980’s was transformed into a chronic, treatable illness. I was new to medicine when ‘universal precautions’ were first instituted (can our children even imagine having their teeth examined by someone not wearing latex gloves?!) Researchers don’t celebrate, though, since medication-resistant strains of HIV were expected …
I generally write positive articles about the use of buprenorphine for treating opioid dependence, and my articles have been reflective of my attitude toward the medication. The field of psychiatry encompasses more conditions than it does effective treatments for those conditions, and my initial experiences treating people with buprenorphine were strikingly positive.
My first buprenorphine patients were extremely desperate after multiple treatment failures, and they responded to buprenorphine the way a person with strep throat responds to penicillin. Their lives improved so dramatically that I wondered if we needed a new understanding of ‘character defects’; whether the shortcomings should be seen not as semi-permanent flaws, but rather as dynamic, maladaptive personality traits, fueled and sustained by active obsession for opioids— and lessened when that obsession was reduced, using buprenorphine.
I still have a number of those patients in my practice, people who have done very well on buprenorphine and have little interest in discontinuing the medication. As much as I would like to take on a few new patients, I won’t force these people off buprenorphine in order to make room under the cap. They have worked hard, done well, and have earned the right to a medication that helps keep their illness in remission.
But I’ve noticed a change over the past couple years in the attitudes of patients coming for treatment. I’ve been slow to specifically identify the change, but when I do an honest assessment, a clear pattern emerges. To be blunt, young people don’t do as well on Suboxone or buprenorphine as their older counterparts. Maybe they have a harder time accepting the limits to their own mortality; maybe insight requires a longer time to accumulate life experiences. Maybe they haven’t suffered enough consequences. But after starting buprenorphine, instead of tearfully expressing disbelief over the lifting of cravings for opioids, younger patients are more likely to take the effects from buprenorphine in stride and continue to engage in addictive behaviors.
I always consider each new patient’s history of ‘consequences’. I believe that consequences are what eventually spur recovery, providing the patient lives long enough for that to happen—which is certainly not a given with …
A local District Attorney wrote to me last week to express his concern about the increased diversion of buprenorphine. I often sense an undercurrent of tension when I cross paths with attorneys, aware of the different attitudes that we hold that arise from our different roles in society.
The DA wrote about the dramatic increase in overdose deaths in the Midwest. Overdose scenes are often littered with a variety of substances, ranging from bags of heroin to the orange plastic vials used by pharmacies to dispense medications. If the overdose victim was on Suboxone or buprenorphine, the prescribing doctor is often contacted about the death and the ensuing investigation. Doctors notified about patient deaths have reactions beyond the grief over the loss of someone they cared about, including guilt that they couldn’t save the patient, and even fear of being blamed for doing something wrong. Every doctor has seen headlines featuring peers accused of reckless prescribing, and the addiction world is somewhat unique from other specialties in the way that patient deaths cause a sense of ‘guilt by association.’ Oncologists, for example, are not viewed with the same degree of suspicion when their patients succumb to cancer.
I felt a bit defensive about the DA’s letter. I know that buprenorphine saves lives, beyond a doubt. I also notice that the positive actions of medications are often taken for granted, while the risks are cited as scapegoats. I notice how quickly people complain about others ‘on buprenorphine’, without taking the time to ponder what would likely happen were buprenorphine not available.
Some physicians’ fears stem from dilemmas faced in treating addiction that are difficult or even impossible to resolve. For example, a DA may point out that the doctor’s patients are not behaving like ideal citizens, not realizing that the doctor is every bit as aware of the problem, yet unable to make things better. In some cases doctors do the very best they can (or that anybody could do, yet their patients struggle to maintain sobriety. Doctors may be tempted to abandon the problem patients altogether, to avoid being seen …
A late post tonight, since my new exercise program has pushed my blogging back by an hour or so each night. My suspicions about exercise were correct, by the way; it is much easier to suggest exercise to other people than it is to actually exercise. I’ve been at it since the beginning of the year, and I at least feel a bit less hypocritical.
While I’m on the topic… I’ve received many comments over the years from people complaining that they’ve been taking Suboxone or buprenorphine for X many years, and they have no energy, they feel stressed, they have gained weight, they don’t sleep well or they sleep TOO well… and concluding that all of the problems are from Suboxone.
The problems are the result of other things, including things that tend to occur naturally as our lives become less chaotic and more outwardly-secure. The problems I mentioned above, for example, come from inactivity. They come from thinking that we’ve ‘paid our dues’ at the age of 30, and it’s time to coast in life. They come from failing to seek out challenges, and from failing to do our best to tackle those challenges. They come from letting out minds be idle, smoking pot or watching American Idol instead of responding to the naggings sense of boredom that ideally pushes people to join basketball, tennis, or bowling leagues.
Our minds and bodies are capable of SO much. I (honestly) am not a network TV viewer, but I love the contrast of ‘before and after’ scenes on ‘Biggest Loser.’ People magazine (it sits in my waiting room) had a section a while back about people who lost half their body size, by exercise and dieting. The part I found most interesting was the deeply personal answer that each person had to the question, ‘what was your turning point?’ Each cited an episode of humiliation or shame that lifted the veil of denial, and helped them do what they knew, all along, needed to be done.
We are not all capable of ‘Biggest Loser’ comebacks. But it is important for people to understand that feeling good, physically or …