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 the recovering and treatment communities along opposing battle lines. The arguments are fueled by petty notions of ‘whose recovery is more authentic’, and miss the important point that Suboxone represents a novel, medical approach to treating addiction. For the first time, medications are available that allow for freedom from the potentially lethal disease of opioid dependence—a disease that was largely refractory to existing treatment methods.
The active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to deter diversion by the intravenous route. Another form of the medication, Subutex, consists of buprenorphine without naloxone. In this article I will use the generic name, buprenorphine, because of the existence of brands of buprenorphine other than Suboxone. For the purpose of this article, Suboxone and buprenorphine are interchangeable terms.
The unique molecular properties of buprenorphine create an ideal, long-term treatment for opioid dependence. Partial agonist actions at the mu opioid receptor cause a ‘ceiling effect’ to sublingual doses above about 4 mg, so that larger doses do not increase opiate effects beyond that level. The high binding affinity and partial agonist effect eliminate cravings for opioids, dispelling the destructive obsession that destroys the personalities of active addicts. High protein binding and the long half-life allow for once per day dosing, so the addict can break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward), which is the backbone of addictive behavior. And the ceiling effect and long half-life cause rapid tolerance to buprenorphine, allowing patients to feel ‘normal’ within a few days of starting treatment.
Even properties considered negative by pessimists are benefits to treatment. For example, the discontinuation effects from buprenorphine provide a disincentive to stopping the drug, improving medication compliance. Patients are assured that any attempt to abuse opioids would be futile, reducing thoughts about using.
There are significant differences between the treatment approaches of those who use buprenorphine versus non-medicated, 12-step-based treatments. People who stay sober through step work sometimes look down on patients taking buprenorphine as having an ’inferior’ form of recovery. The attitude causes buprenorphine patients attending Narcotics Anonymous to hide their use of buprenorphine. On one hand, good boundaries include the right to keep one’s private medical information to one’s self. But on the other hand, a general recovery principle is that ’secrets keep us sick’, and hiding the use of buprenorphine is at odds with the idea of ’rigorous honesty’. People new to recovery sometimes struggle to overcome the shame society places on ‘drug addicts,’ and are not in good position to deal with even more shame applied by other addicts.
The time has come for a unified treatment approach for opioid dependence. More medications will be brought forward for treatment of addiction, now that Suboxone has proved profitable. If traditional treatment was effective, we would want to combine compatible aspects of medication-based and traditional treatment programs. But opiate dependence has been refractory to treatment without medication. Success rates for long-term sobriety are lower for opiates than for other substances. One reason may be that the ‘high’ from opiate use is different from the effects of other substances. Users of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energetic. In comparison opioid users describe feeling content or even ‘normal’, as if gaining something that was always missing. The experience of using rapidly becomes a part of who the person is, rather than something the patient does.
The challenge for practitioners is to find ways to bring the recovering community together, and to use the most effective combination of tools in the struggle against active opiate addiction.
Traditional approach to character defects
Buprenorphine has given us a new paradigm for treatment which is best considered a ‘remission model’. This model assumes that addiction is a dynamic process. The traditional view from recovery circles is that addicts have a number of character defects that were either present before the addiction started, or grew out of addictive behavior over time. Such defects, such as the dishonesty that occurs during active opioid dependence, are common to all substance users. The addict represses awareness of his/her trapped condition and creates an artificial self that comes off as cocky and self-assured, when deep inside the addict is frightened and lonely. The obsession to use takes more and more energy and time, pushing aside interests in family, self-care, and career. The addict becomes more and more self-centered. The opiate addict often becomes very ‘somatic’, convinced that every uncomfortable feeling is an unbearable component of withdrawal. The opiate addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one’s self. The using addict learns to blame others for his/her own misery. Eventually, anger and self-centered behavior results in the loss of jobs and relationships.
The traditional view holds that these character defects do not simply go away when the addict stops using. People in AA know that in the absence of an active recovery program, simple sobriety will create a ‘dry drunk’—a nondrinker with the character defects of an active alcoholic. I expected the same, when I first began treating opiate addicts with buprenorphine. I assumed that without involvement in 12-step groups, patients would remain just as miserable and dishonest as active users. I now realize that I was making an assumption that character defects were relatively static; that they develop slowly over time, and could be removed only through intense step-work. The most surprising part of my experience treating people with buprenorphine was that character defects were not ‘static’, but instead dynamic, and responsive to treatment with buprenorphine.
The difference between buprenorphine treatment and a patient in a ‘dry drunk’ is that the buprenorphine-treated patient has been freed from the obsession to use. A patient in a ‘dry drunk’ is not drinking, but in the absence of a recovery program, continues to suffer the conscious and unconscious obsession to drink. People in AA often say that alcohol isn’t the problem; it is the ‘ism’ that causes the damage. The same consideration applies to opioid dependence. Opioid use is not as much the issue as the obsession with opioids, for causing misery and despair. Character defects are best considered as features that develop in response to the obsession to use a substance, sustained by the obsession to use. When obsession to use is removed, whether through working the 12 steps or with buprenorphine, the character defects caused by the obsession to use dissipate.
Fear as motivator
During traditional step-based treatment, the addict is in a constant battle with the obsession to use. Some addicts will have rapid relief from their obsession through a shift of thinking that allows them to see their powerlessness with their drug of choice. Other addicts require a great deal of addiction-induced misery to create the change in thinking. But whether fast or slow, the shift in thinking is only effective when it occurs in the neural circuits where addiction lives, i.e. the brain’s limbic system. The ineffectiveness of higher-order thinking is proven by addicts many times over, as they make promises over pictures of their loved ones and try to summon the will power to stay clean—promises that almost always fail. On the other hand, addicts find success in surrender and recognition of the futility of the struggle. The recovering addict views the substance with fear, an emotion encoded by the most primitive brain regions. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use resolves. Since human nature leans toward independence and freedom, the recognition of powerlessness will fade over time. So addicts benefit from meetings where newcomers arrive with stories of misery and pain, which reinforce powerlessness.
Buprenorphine and dynamic character defects
My experiences treating patients using buprenorphine have challenged my old perceptions, and led me to see character defects as more dynamic. Appropriate buprenorphine treatment removes the obsession to use almost immediately. But instead of creating a ‘dry drunk’, the removal of the obsession to use allows the return of positive character traits that had been pushed aside. This change in character does not always require rigorous step work. Rather, in many cases the negative traits simply disappear as the obsession to use is relieved. My opinion grew from experiences with scores of buprenorphine patients, and more importantly with the spouses, parents, and children of buprenorphine patients. I have seen many instances of improved communication and new-found humility. I have heard families talk about ‘having dad back’, and husbands talk about getting back the women they married.
A natural question is why character defects would simply disappear when the obsession to use is lifted? Shouldn’t such change require a great deal of work? The answer, I believe, is because the character defects are not the natural, hard-wired personality of the addict, but rather are traits produced by the obsession to use substances, and maintained by that obsession.
Buprenorphine treatment and traditional recovery
When the dynamic relationship between obsession and character defects is understood, the relationship between buprenorphine and traditional recovery becomes apparent. Should people taking buprenorphine attend NA or AA? Yes– if they want to. A 12-step program has much to offer an addict, or anyone for that matter. But there is little value in forced or coerced meeting attendance. The recovery message, including the recognition of powerlessness, requires a level of acceptance born from desperate times, and people on buprenorphine do not feel desperate. In fact, people on buprenorphine often report that ‘they feel normal for the first time in their lives’. A person with this state of mind is not going to do the difficult work of personal inventories and personality change unless otherwise motivated by his/her own desire to change.
Desperation plays an important role in personality change, and in traditional treatment is the most important prerequisite to making progress. Desperation opens the addict’s mind to the reality of his powerlessness. But when recovery from addiction is viewed through the remission model, desperation is less valuable, and may even be counterproductive by interfering with the reinstatement of the addict’s own positive character. Such a view is consistent with the ‘hierarchy of needs’ put forward by Abraham Maslow in 1943, as there can be little pursuit of higher-order traits when one is fighting for one’s life.
Other Questions (and answers):
-Should buprenorphine patients be in a recovery group?
One can question the value of any therapy where the patient is not an eager and voluntary participant. At the same time, there is much to be gained from the sense of support that a good group can provide. Groups help the addict realize that he/she is not as unique as he thought, and that his unhealthy way of visualizing his place in the world is a trait common to other addicts. Some addicts will learn the patterns of addictive thinking and become better equipped to handle addictive thoughts. New technologies provide additional options for patients on buprenorphine.
-What is the value of the 4th through 6th steps of a 12-step program, where the addict specifically addresses his/her character defects and asks for their removal by a higher power? Are these steps critical to the resolution of character defects?
These steps are necessary for addicts in ‘sober recovery’, as the obsession to use will come and go to varying degrees over time depending on the individual and his/her stress level. For patients on buprenorphine the steps are useful for personal growth, but not essential.
-How does methadone fit in?
Methadone is an opioid agonist. Increasing doses of methadone will prevent cravings, but as tolerance inevitably rises, cravings return. The return of cravings risks the return of associated character defects. But some patients are not able to maintain safe control of prescribed buprenorphine. The daily scheduling, frequent drug testing, and supportive therapy required by methadone maintenance programs provide structure for patients who are not able to manage buprenorphine prescriptions.
Downsides to buprenorphine
Practitioners in traditional AODA treatment programs will see buprenorphine as a mixed blessing. Desperation is often required to open the addict’s mind to change, and desperation is harder to achieve when an addict has the option to leave treatment and find a practitioner who will prescribe buprenorphine. Buprenorphine is sometimes used ‘on the street’ by addicts who want to take time from addiction without committing to long term sobriety. Buprenorphine can be abused for short periods of time, until tolerance develops to the drug. Nasal insufflation of buprenorphine results in a faster onset time, without allowing the absorption of the naloxone (that prevents intravenous use). Finally, the remission model of buprenorphine implies long term use of the drug. Chronic use of any opiate, including buprenorphine, has the potential for negative effects on testosterone levels and sexual function, and the use of buprenorphine is complicated when surgery is necessary. Short- or moderate-term use of buprenorphine raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.
Time will tell whether or not buprenorphine will replace traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other. The good news is that treatment of opiate addiction has proven to be profitable, and such success will invite research into addiction treatment. At one time we had two or three treatment options for hypertension, including a drug called reserpine that would never be used for similar indications today. Someday we will likely look back on buprenorphine as the beginning of new age of addiction treatment. But for now, the addiction treatment community would be best served by recognizing each approach’s strengths, rather than looking for weaknesses.
Silhouette image available from Shutterstock.