Opioids and BPD
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.
The writer describes twelve years of sobriety, but she still feels as if something is missing. Her situation is by no means rare; I would guess that most recovering people feel the same way, in the weeks or months before relapse. The standard diagnosis of her condition is a lack of ‘good recovery.’ People who work the steps would say that something is wrong with her program; that she is not truly ‘turning things over’ (to her higher power), that she is no longer buying into her own powerlessness, or that she isn’t using her sponsor often enough. And these things might be the case. The Twelve Steps include a spiritual dimension that is intended, I believe, to help fill the emptiness that many addicts were filling with alcohol or drugs.
At the same time, the spiritual glow from twelve step programs is strongest, for most people, early in recovery. It is difficult to hang onto the initial honeymoon that comes with step-based sobriety, even when working a good program. There is also a difference between the mood effects of alcohol vs. opioids, so that the remembrance of using opioids is a more potent factor in relapse. In other words, she may be doing everything right, and still feel lousy. Some people recovering from opioid dependence feel as if they discovered a door that leads to happiness, only to learn, in treatment, that happiness is forever unavailable to them.
I would suggest the writer be careful about ‘euphoric recall’—the selective recall of our using days, when we filter out the worst minutes and hours, and cling to the great moments. I wonder if that is what is going on, for example, when she recalls her relationship with her husband. My question for her, if she were she my patient, would be whether her husband remembers things the same way; that she was most ‘herself’ and most emotionally available during the days when she was using.
In treatment, we deal with euphoric recall by taking things ‘full circle’—i.e. remembering the relaxed feeling from pain pills, but then focusing hard to remember the rest of the story—the lying we did to protect our secrets, the paranoid feelings we had whenever our bosses called us to the office, the frantic digging through medicine drawers to avoid getting sick, and the guilt associated with spending the weekend in bed, when our son or daughter is playing soccer.
The writer wonders if she should consider taking opioids to treat her longstanding depression. Specifically, she wonders if buprenorphine—a medication with unique opioid properties—would allow her to treat her depression without becoming addicted to the medication. Buprenorphine has a ceiling effect at mu opioid receptors, such that the effects of the medication reach a peak and remain constant, no matter how high the dose is raised.
Her thoughts about treating depression with opioids deserve some consideration. Some people experience severe depression that fails to respond to any of the medications currently on the market. Alkermes is working on an antidepressant that contains buprenorphine and a second opioid ‘modulator’ designed to prevent physical dependence. In a year or two we’ll see if they’ve hit a home run.
Patients on buprenorphine often tell me that they feel ‘better’ on the medication; they are less moody, less depressed, or more outgoing. I don’t know if these effects come from receptor interactions or if they are a consequence of removing the obsession to take opioids—or if that even matters. Less moody is less moody!
Borderline PD is a very painful condition that stems from a combination of genetics and childhood experiences. There is some stigma to the diagnosis, as people with BPD tend to be difficult to treat (something that drives doctors crazy!). The condition is often misdiagnosed as bipolar, but the ‘mood swings’ in BPD tend to come over hours, rather than the weeks that characterize bipolar. There is high comorbidity between BPD and additive disorders, including opioid dependence.
There are problems, though, with recommending the writer start buprenorphine. 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. People taking buprenorphine develop a tolerance for the medication, and tolerance implies physical dependence and withdrawal.
If the writer were to start taking buprenorphine, she would experience potent opioid effects from the medication, including euphoria, nausea, vomiting, and respiratory depression. These effects could be avoided by starting the medication very slowly, of course, but there would be plenty of opioid effects that would stir up those old feelings from actively using.
The flip side of tolerance, of course, is physical dependence. If the writer decided to stop taking buprenorphine, she would experience considerable withdrawal. Many people on buprenorphine are profoundly grateful for being ‘saved’ by the medication, but eventually wish that they could ‘get off’ the medication—something that can be very difficult to do. I believe that starting buprenorphine makes complete sense for a person struggling to stop opioids. But I am very reluctant to ‘give’ physical dependence on opioids to a person who doesn’t already have it.
I’m realizing that this post may go on forever, so I think I’ll stop here for now. If I’ve stirred up further questions, please post them, and I’ll take another shot next week!
Man relaxing in bed photo available from Shutterstock.
Junig, J. (2012). Opioids and BPD. Psych Central. Retrieved on May 25, 2017, from https://blogs.psychcentral.com/epidemic-addiction/2012/02/opioids-and-bpd/