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Suboxone for Opiate Painkiller Addiction: Are you Addicted

Are you addicted to Opiate painkillers? You certainly have company. The cycle of use, dependence, and use is playing out, over and over, in every community across the country. Note that I describe the cycle as use, dependence, use a description that is accurate, because in most cases the cycle of dependence, or pain pill addiction, starts when you appropriately use medication administered by a person who you trust - your physician.

Pain pills or painkillers are often called 'narcotics' a term that comes from the Greek word 'narcosis', or 'sleep' because of their sedative effects.

There are two types of painkillers narcotic and non-narcotic. Physicians use the word 'narcotic' to refer to different things in different situations. For example, when referring to controlled substances, 'narcotics' may be used to denote drugs regulated by the Drug Enforcement Administration. An anesthesiologist uses 'narcotic' to refer to the portion of the anesthetic that is comprised of drugs that bind to brain 'opiate receptors'. 'Opiate' is another word used by physicians in reference to painkillers. The word comes from 'opium', a substance derived from poppies and used to make heroin and morphine. The 'opiate' reference is also used for synthetic pain medications that have no connection to poppies or opium save their painkilling effects.

Most people have heard of 'endorphins'.

Endorphins are produced in the human body, and when released, block pain.

Endorphins are often referred to as 'endogenous opiates' because of their role in pain sensation, even though they have no relation to poppies or opium, and are structurally quite dissimilar.

These natural pain relievers have other functions in the body, roles not relevant to this discussion. Endorphins are one group out of dozens of 'neurotransmitters', substances involved in the communication between nerve cells. Endorphins and other neurotransmitters act at 'receptors', the receptor being a lock on a nerve cell, and the neurotransmitter being the key that fits in the lock.

Amazingly, poppies produce a substance that looks different from the natural key, but that acts like endorphins by fitting the exact same keyhole. That substance-one molecule from the sap of a red flower-has given the human species the ability to ease suffering in countless individuals, and has resulted in the deaths of millions of others.

Over the years scientists have developed synthetic 'opiates' with potencies far beyond anything produced by nature.

Anesthesiologists use 'sufentanil' reduce responses to pain during surgery. Sufentanil is extremely potent; an amount the size of one grain of salt, say one tenth of one milligram, placed on the tongue would cause respiratory arrest in a large man within seconds.

More commonly opiates are taken by patients in the form of codeine, hydrocodone (Vicodin), oxycodone (Oxycontin), or hydromorphone (Dilaudid). Prescriptions for these substances are handed out to millions of people each day in response to complaints of pain.

Opiates relieve pain, and work in different areas of the brain to elevate mood, ease tension, give a subjective sensation of warmth, and cause sedation. They can cause nausea and vomiting, particularly in patients who are naive to them.

Finally, they change the response of the brain to low oxygen and high carbon dioxide in the blood, and slow respiration. The most common cause of fatal overdose is respiratory arrest, where the brain stops sending impulses to the diaphragm, and the patient suffocates. This fatal response is most common during sleep, or when opiates are taken in combination with other sedative medications.

Opiates are addictive.

There is no way to take them without the body adapting and becoming dependent on them. 'Tolerance' to pain medication begins after the first dose, when the 'locks' on nerve cells adjust in response to all of the 'keys' floating around. With time it takes more and more keys to open enough locks to cause the reaction at the nerve cell.

Tolerance is one half of the process of addiction, and is the reason for 'withdrawal', the sickness that occurs when tolerance has developed and the drugs, or keys, are taken away.

The other half of painkiller addiction is so-called 'psychological', which I suppose is accurate to a point. For some reason, once something is assigned to the psychological category, it is treated differently by physicians, patients, and the rest of society.

'Psychological' does not imply that a person has more control than with a 'physical' condition-if anything, things occurring on a psychological level are far more difficult to recognize and treat than are physical conditions. The psychological addiction to opiates also develops very rapidly, and there is little if anything that can be done to prevent it. Psychological addiction is real, and is extremely powerful. The result is a desire to take opiates. The desire may take the form of physical symptoms, such as an increase in pain, and so psychological addiction and physical addictions are intimately connected.

To health systems, time is money.

Patient complaints are handled as quickly (and sometimes as superficially) as possible. When a person presents in pain, the first determination is whether the pain is a serious threat to health. The second determination is whether enough tests have been done to identify the cause of the pain. If the first answer is no and the second answer is yes, the goal is to clear out the room for the next patient.

There is a clock on the wall and a patient list in the hall, and the list has to be clear before the docs and nurses go home. And so there is the doctor-patients waiting in six rooms, more in the waiting area, and a person in the room complaining of something that isn't going to kill him/her. And in the doc's pocket lies a pad of paper. Amazingly, all that the doctor has to do to clear the room is write on the pad and wish the patient well.

That is how addiction starts.

Everyone intends well; everyone is honest; everyone is innocent. The patient is not told much about painkiller addiction.

The patient isn't told that within a few days, he will have some difficulty stopping the medicine.

He isn't told that after a week when he stops the medicine he will have some diarrhea, he won't be able to sleep, and he will feel depressed.

He isn't told that the pain that he has might not go away, and so he may get more potent medicine, and so on, and that it will get harder and harder to stop as the medicine gets stronger.

I don't know if the lack of information really matters; most patients would likely take the pain relief medicine now, and worry about the rest later. Besides, the doctor doesn't seem too concerned... and the patient is correct. The doctor isn't concerned, because this was a quick case that got him nearly caught up to schedule.

Unfortunately, there are pains that do not go away, even as we patients demand relief.

Doctors hate to feel impotent with patients it is difficult to take a person's money, and then tell him that there is nothing that can be done. And so prescriptions are written, even when the problem may be complicated, and the best advice to the patient would be 'learn to live with it'. This phrase angers patients with pain, but sounds intelligent to patients who have struggled to get off opiates. But usually, the person with pain walks out with a prescription. As tolerance develops, the pain comes back, and the patient goes to the doctor again, this time leaving with stronger medication. Tolerance continues, meds are changed, and tolerance develops again. The doctor gets nervous over the situation, realizing that at some point he will not have anything stronger. Suddenly calls to the doctor are not returned, or are returned by a curt nurse who sounds like the patient's mother. The patient realizes that he is stuck, and becomes depressed. Sound familiar?

It is not your fault.

I know about this stuff inside and out I earned my PhD in Neurochemistry at the Center for Brain Research in Rochester New York, studying drugs that cause addiction and tolerance.

I administered opiate medications every day as an anesthesiologist. I literally know everything that there is to know about opiates...expect how to stop taking them on my own. I thought I was smart enough to avoid addiction, but I was wrong-laughably wrong-and the outcome nearly killed me. It is not your fault. To get better, you will need to understand the meaning and truth of that statement. That is difficult for some, but possible for everyone.

Suboxone, a new treatment

Suboxone consists of two drugs; buprenorphine and naloxone. The naloxone is irrelevant if the addict uses the medication properly, but if the tablet is dissolved in water and injected the naloxone will cause instant withdrawal. When suboxone is used correctly, the naloxone is destroyed in the liver shortly after uptake from the intestines and has no therapeutic effect.

Buprenorphine is the active substance; it is absorbed under the tongue (and throughout the mouth) but destroyed by the liver if swallowed. There is a formulation of buprenorphine without naloxone called subutex; I have used this formulation when the patient has apparent problems from naloxone, including headaches after dosing with suboxone.

I have also treated addicts who have had gastric bypass, where the first part of the intestine is bypassed and the stomach contents empty into a more distal part of the small intestine. In such cases the naloxone escapes 'first pass metabolism', the process with normal anatomy where the drug is taken up by the duodenum and transferred directly to the liver by the portal vein, where it is quickly and completely destroyed.

After gastric bypass naloxone can be taken up by portions of the intestine that are not served by the portal system, causing blood levels of naloxone sufficient to cause brief, relatively mild withdrawal symptoms.

Buprenorphine has a 'ceiling effect'-the narcotic effect of the drug increases with increasing dose up to about one or two mg, but then the effect plateaus and higher amounts of buprenorphine do not increase narcosis.

The average patient usually takes 12-24 mg of suboxone per day, and quickly becomes tolerant to the effects of buprenorphine (buprenorphine does have significant narcotic potency, but the potency usually pales in comparison to the degree of tolerance found in active opiate addicts)..

The opiate receptors in the brain of the addict become completely bound up with buprenorphine, and the effects of any other opiate medication are blocked. Once the addict is tolerant to the correct dose of suboxone, the buprenorphine that is bound to their opiate receptors reduces cravings and prevents the effects-and so the use--of other opiates.

Suboxone is very effective in preventing relapse; the 'choose to use' issue is effectively removed by the fact that use would require the addict to go through several days of withdrawal in order to remove the receptor blockade and allow other opiates to have an effect. Given addicts' attitudes toward withdrawal, the appeal of this 'choice' is quite low. The only real problem with suboxone treatment relates to specificity. With suboxone, the addict stays off opiates, but there is nothing to prevent the substitution of alcohol.

On the other hand, naltrexone reduces alcohol cravings by blocking opiate receptors, and it is quite likely that suboxone, through its similar mechanism, will reduce alcohol cravings as well. Such an effect has been reported to me by a number of suboxone patients, but has not been reported in the literature at this point. The suboxone patients who move from one substance to another will likely require an approach that demands total sobriety. But for pure opiate lovers, other benefits of suboxone are that only mild (and possibly medicated) withdrawal is required to start treatment, the drug is usually covered by insurers, prescribing restrictions are minor, and there are fewer stigmas associated with maintenance than there are with methadone.

I predict that suboxone will eventually be the standard treatment for opiate addiction, and will change the treatment approach for other substance addictions as well. My only reservation with this statement is that it is unclear how the current recovering community will respond to patients treated with suboxone. If suboxone patients are rejected by the recovering community, what will be the long-term outcome of their addictions when the substance is removed but the personalities and issues remain untreated? Is it a given that all addicts have a disease that requires group therapy?

As things stand now, addicts maintained on suboxone are often referred for addiction counseling. But the exact message to deliver with counseling is debatable. In many ways, a patient maintained with suboxone becomes similar to a patient with hypertension treated for life with medication-the underlying problem persists, but the active disease is held in remission. If the uncontrolled use of opiates is effectively treated, is that enough? Should counseling be focused on removing the shame of having the disease of addiction, and on encouraging the treated addicts to get on with their normal lives? Or should we continue to see addiction as a consequence of a deeper problem or faulty character structure, which requires groups and meetings if one hopes to become 'normal'?

Unfortunately the use of suboxone runs counter to successful adoption of sobriety through 12-step programs, which in the first step require acceptance of the fact that the addict is powerless over the substance-that there is no amount of will power that will allow the addict to control the deadly effects of the drug. By using suboxone the addict may develop the impression that he/she has control, particularly if suboxone becomes popular on the street for self-medication of withdrawal.

Before suboxone, the only option for opiate addicts was to lose a sufficient number of things-family, employment, freedom, health-to cause them to accept treatment and recovery. Only a small fraction of addicts recovered, and only after significant losses-and relapse rates were high.

Suboxone is an amazing breakthrough; one that for the first time allows treatment of addicts early in the course of their illness, and that reliably induces remission in most patients. There are, however, some factors that have the potential to reduce the effectiveness of suboxone treatment. First, some insurers demand that the drug be used only short-term, in some cases for only three weeks! This requirement totally misses the nature of addiction, and ignores the known high relapse rate after short-term use of suboxone (and why wouldn't it be high?).

Some physicians use the medication in this short-term way; hopefully the motivations for this ineffective treatment method are not related to the limits placed on the numbers of maintenance patients per physician. Other physicians will transfer their attitudes toward opiate agonists to the use of suboxone, and place constant downward pressure on the daily dose of suboxone. This approach is not appropriate with suboxone; the value of the drug requires adequate dosing to achieve the long half-life and repression of cravings.

At doses of less than 8 mg, suboxone becomes more similar to a pure agonist; one might as well be giving small doses of hydrocodone to prevent withdrawal. There is no reason beyond drug cost to reduce the dose, as tolerance is limited by the ceiling effect that occurs with relatively low doses. In other words, higher doses of suboxone do not result in eventual higher degrees of withdrawal.

Another issue is that the medication is sometimes prescribed carelessly, without emphasizing the need to dose once per day. Patients left to their own devices will start using the medication multiple times per day as a 'prn' medication, and will remain in the same addiction behavior that brought them to treatment. Once per day dosing is important because it allows the addictive behavior to be extinguished over time. The frequent dosing does provide a distraction and placebo effect, and so initially patients will have an increase in anxiety when the dosing obsession is removed. But over time the anxiety will fade, and the huge void left by the removal of addictive obsession will allow the development of relationships and other positive character traits that were forced out by their addiction.

Given the time pressures and payment structures of modern medicine, suboxone may eventually replace residential treatment as a more reliable, less costly alternative. I believe that the time has come to replace the 'recovery' model with a new 'remission' model, which allows treatment of a much higher percentage of users at an earlier stage of disease. With time, will we find analogous agents that provide a low level of intoxication in return for receptor blockade? While not likely with alcohol, such an outcome is certainly within the bounds of imagination for cocaine, benzodiazepines, and barbiturates. While it is true that daily use of a partial agonist would represent a reversal from our current approach where all intoxicating substances are to be avoided, it is also true that the current approach has no bragging rights based on outcome. Finally, perhaps the adoption of a remission model will lessen the time until opiate and other addictions carry as much moral stigma as hypertension or diabetes-two other diseases that are generally treatable, but that require long-term use of medications.

Treatment Options for Pain Pill or Painkiller Addiction

Many people go to their doctors for treatment of an injury and are given a narcotic medication like vicodin or Percocet. These medications work initially, but over time two things happen; they tend to lose their effectiveness, and when a person stops taking them the person feels very sick. Both of these are signs of physical dependence, and are referred to as tolerance and withdrawal.

The medications that people take for pain relief have effects on how the person feels that go beyond their help with pain; people feel a sense of warmth and pleasure from the medication and often use the medication to temporarily relieve anxiety, tenseness, insomnia, or even fatigue. When the medications are stopped on the other hand the person has 'rebound' of these symptoms, and feels much worse than before starting the medication. Because of tolerance, patients often take more pills than prescribed, causing them to run out early; when they call the doctor they are suddenly treated as if they have done something wrong. Sometimes they are scolded; perhaps it is even worse when nobody says anything out loud, but instead the patients detects 'little looks' from the doctor's staff or rude treatment that suggests that people in the office are thinking of them in a negative way. Patients wonder if they are imagining things, or if people are really talking about them.

Trouble at Home

At home the patient on painkillers becomes more and more irritable. He is worried about running out early and having the return of pain, or even withdrawal symptoms. He feels sick more often. He has become more depressed. He starts to feel as if nobody understands him, and he takes more and more of the pain pills to try to keep his mood and energy level up so that he can go to work. The fights at home become more and more frequent, and he feels more and more alone inside.

Recreational Use of Painkillers

In other cases this same sequence will occur, but instead of starting win injury it starts with experimentation. A person is given the pills by a friend, or finds them in a parent's medicine cabinet. Or maybe the person has been feeling down, and notices that the codeine that they took for their wisdom tooth surgery made them feel better, and so makes up an injury so that the doctor will prescribe more. In all of these cases the people involved become more and more depressed and more and more sick and tired, eventually reaching a level of desperation. This is the good outcome; other people find medications that are more and more potent, and accidentally take too much - causing a fatal respiratory arrest.

Treatment Options

Until recently there was one primary treatment for this type of addiction - residential treatment for one to three months in a treatment center. Yes, another option is to attend AA or NA (Narcotics Anonymous) meetings, but meetings alone rarely make headway against opiate dependence. Another option that has been available is 'maintenance treatment' in a methadone program. This type of treatment carries a number of inconveniences, including the need to report to the treatment center each morning to receive the medication.

We now have a third treatment option - buprenorphine or Suboxone - that has saved countless lives. This treatment option is almost universally effective given one requirement: the person must be truly sick and tired of taking the pills and must be motivated to get better.

If you or a loved one suffers from addiction to these medications I strongly encourage you to seek out more information and to learn about your options. Life is too short to remain miserable.

Suboxone and traditional recovery

By now almost every painkiller addict has heard of suboxone, the amazing medication for opiate dependence that has taken the using world by storm. Despite an almost unanimous positive response among more then 100 suboxone-treated patients,I do have some mixed feelings about suboxone treatment. I also acknowledge that my opinions are likely influenced by my own experiences as an addict in traditional recovery. While suboxone has opened a new frontier of treatment for opiate addiction, it also threatens to split the recovering and treatment communities along opposing battle lines. Such and outcome would be a huge missed opportunity to improve the lives of opiate addicts.

For clarification, the active ingredient in Suboxone is buprenorphine, a partial agonist at the mu opiate receptor. Suboxone contains naloxone to prevent intravenous use; another form of the medication, Subutex, consists of buprenorphine without naloxone. Suboxone has become the popular term for buprenorphine treatment, and so this article uses the term to refer to any buprenorphine product. The unique effects of buprenorphine can be attributed to the drug's unique molecular properties.

First, the partial agonist effect at the receptor level results in a 'ceiling effect' to dosing after about 4 mg, so that increased dosing does not result in increased opiate effect beyond that dose.

Second, the high binding affinity and partial agonist effect cause the elimination of drug cravings, dispelling the destructive obsession with use that destroys the personality of the user.

Third, the high protein binding and long half-life of buprenorphine allows once per day dosing, allowing the addict to break the conditioned pattern of withdrawal (stimulus)-use (response)- relief (reward) which is the backbone of addictive behavior.

Fourth, the partial agonist effect and long half life cause rapid tolerance to the drug, allowing the patient to feel 'normal' within a few days of starting treatment.

Lastly, buprenorphine use does have a withdrawal syndrome that prevents the adddict from simply missing doses, consciously or unconsciously, and so the medication is always on board to prevent an impulsive relapse.

Different treatment approaches

At the present time there are significant differences between the treatment approaches of those who use suboxone versus those who use a non-medicated 12-step-based approach.

People who stay sober with the help of AA, NA, or CA, as well as those who treat by this approach tend to look down on patients taking suboxone as having an 'inferior' form of recovery, or no recovery at all. and so the addict attends Narcotics Anonymous prepared to lie about taking suboxone.

On one hand, good boundaries include the right to keeping one's private medical information so one's self. But on the other hand, a general recovery principle is that 'secrets keep us sick', and hiding the use of suboxone is a bit at odds with the idea of 'rigorous honesty'. People new to recovery also struggle with low self esteem before they learn to overcome the shame society places on 'drug addicts'; shame coming from addicts is expecially painful given what they are already struggling with!

An ideal program will combine the benefits of 12-step programs with the benefits of the use of suboxone. Now that subxone has proven to be profitable, it is likely that many more medications will developed to address addiction. If we already had excellent treatments for opiate addiction there would be less need for the two treatment approaches to learn to live with each other. But the sad fact is that opiate addiction remains stubbornly difficult to treat by traditional methods.

Success rates for long-term sobriety are lower for opiates than for other substances. This may be because 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 - ready to go out and take on the town. The 'high' of opiate use feels content and 'normal' - users feel at home, as if they are getting back a part of themselves that was always missing. Where users of other drugs are DOING drugs, opiate addicts internalize their use and BECOME opiate addicts. The term 'denial' fits nobody better than the active opiate user, particularly when seen as the mnemonic: Don't Even Notice I Am Lying.

The challenges for practitioners lie at the juncture between traditional recovery and the use of medication, in finding ways to bring the recovering community together to use all available tools in the struggle against active painkiller addiction.

Suboxone: A Problem For Traditional Recovery?

Suboxone has given us a new paradigm for treatment which I refer to as the 'remission model'. This model takes into account that addiction is a dynamic process - far more dynamic than previously assumed. To explain, the traditional view from recovery circles is that the addict has a number of character defects that were either present before the addiction started, or that grew out of addictive behavior over time.

Opiate addicts have a number of such 'defects. Opiate addiction is unique in the degree of dishonest that develops during active use. Other defects 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 with using takes more and more energy and time, pushing aside interests in family, self-care, and career. Addicts become extremely self-centered, and hyper-aware of every uncomfortable bodily sensation. The painkiller addict becomes obsessed with comfort, avoiding activities that cause one to perspire or exert one's self. The active addict learns to blame others for his/her own misery, and eventually their irritability results in 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 simply remaining sober will cause a 'dry drunk' - a nondrinker with all of the alcoholic character defects, when there is no active recovery program in place. I had such an expectation when I first began treating opiate painkiller addicts with suboxone that without involvement in a 12-step group the person would remain just as miserable and dishonest as the active user.

I realize now that I was making the assumption that character defects were relatively static - that they developed slowly over time, and so could only be removed through a great deal of time and hard work. The most surprising part of my experience in treating people with suboxone has been that the defects in fact are not 'static', but rather they are quite dynamic.

A suboxone patient differs from a 'dry drunk' by having been freed from the desire to use. A patient in a 'dry drunk' is not drinking, but in the absence of a recovery program they continue to suffer the conscious and unconscious obsession with drinking.

People in AA will often say that it isn't the alcohol that is the problem; it is the 'ism' that causes the damage. Such is the case with opiates as well-the opiate is not the issue, but rather it is the obsession with opiates that causes the misery and despair. With this in mind, I now view character defects as features that develop in response to the obsession to use a substance. When the obsession is removed the character defects will go way, whether slowly, through working the 12 steps, or rapidly, by the remission of addiction with suboxone.

In 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 when they suddenly experience a 'shift of thinking' that allows them to see their powerlessness with their drug of choice. For other addicts the new thought requires a great deal of addition-induced misery before their mind opens in response to a 'rock bottom'. But whether fast or slow, the shift of thinking is effective because the new thought approaches addiction where it lives-in the brain's limbic system.

The processes of the higher-order brain, including promises and will power, have proven to be of little value when it comes to staying clean. While these approaches almost always fail, the addict will find success in surrender and recognition of the futility of the struggle. The successful addict will view the substance with fear - a basic emotion from the lower-order brain. When the substance is viewed as a poison that will always lead to misery and death, the obsession to use will be lifted. Unfortunately it is man's nature to strive for power, and over time the recognition of powerlessness will fade. For that reason, addicts must continue to attend meetings where newcomers arrive with stories of misery and pain, which reinforce and remind addicts of their powerlessness.

The dynamic nature of personality.

My experiences with Suboxone have challenged my old perceptions, and led me to believe that the character defects of addiction are much more dynamic. Suboxone removes the obsession to use almost immediately. The addict does not then enter into a 'dry drunk', but instead the absence of the obsession to use allows the return of positive character traits that had been pushed aside.

The elimination of negative character traits does not always require rigorous step work - in many cases the negative traits simply disappear as the obsession to use is relieved. My opinion comes from my experiences with scores of patients, and also patients' spouses, parents, and children.

I have seen multiple 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. I sometimes miss my old days as an anesthesiologist placing labor epidurals, as the patients were so grateful - and so I am happy to have found Suboxone treatment, for it is one of the rare areas in psychiatry where patients quickly get better and express gratitude for their care.

A natural question is why character defects would simply disappear when the obsession to use is lifted? Why wouldn't it require a great deal of work? The answer, I believe, is because the character defects are not the natural personality state of the addict, but rather are traits that are produced by the obsession, and dynamically maintained by the obsession.

Can Suboxone and Traditional Recovery Get Along

The appropriate relationship between suboxone treatment and traditional recovery becomes clear once one understands the relationship between opiate obsession and character defects.

Should people taking suboxone 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 I see little use in forced or coerced attendance at meetings. The recovery message requires a level of acceptance that comes about during desperate times, and people on suboxone do not feel desperate. In fact, people on suboxone often report that 'they feel normal for the first time in their lives'. A person in this state of mind is not going to do the difficult personal inventories of AA unless otherwise motivated by his/her own internal desire to change.

The role of 'desperation' should be addressed at this time: In traditional treatment desperation is the most important prerequisite to making progress, as it takes the desperation of being at 'rock bottom' to open the mind to see one's powerlessness. But when recovery from addiction is viewed through the remission model, the lack of desperation is a good thing, as it allows 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; there can be little interest in higher order traits when one is fighting for one's life.

Other Questions (and answers):

Should suboxone patients be in a recovery group? I have similar reservations about forced attendance, but there is something to be gained from the sense of support that a good group can provide.

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. But for a person taking suboxone I see the steps as valuable, but not essential.

Where does methadone fit in? Methadone is just another opiate agonist. A newly-raised dosage will prevent cravings temporarily, but as tolerance inevitably rises, cravings will return. With cravings comes the obsession to use and the associated character defects. This explains the profound difference in the subjective experiences of addicts maintained on suboxone versus methadone, and explains why in my practice I have many patients who have switched to suboxone, but none in the other direction.

The downside of suboxone.

Practitioners in traditional AODA treatment programs will see suboxone as at best 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 suboxone.

Suboxone is sometimes used 'on the street' by addicts who want to take time off from addiction without committing to long term sobriety. Suboxone itself can be abused for short periods of time, until tolerance develops to the drug.

Snorting suboxone reportedly results in a faster time of onset, without allowing the absorption of the naloxone that prevents intravenous use.

Finally, the remission model of suboxone use implies long term use of the drug. Chronic use of any opiate painkiller, including suboxone, has the potential for negative effects on testosterone levels and sexual function, and the use of suboxone is complicated when surgery is necessary.

Short - or moderate - term use of suboxone raises a host of additional questions, including how to convert from drug-induced remission, without desperation, to sober recovery, which often requires desperation.

The beginning of the future.

Time will tell whether or not suboxone will work with traditional recovery, or whether there will continue to be two distinct options that are in some ways at odds with each other.

The treatment of painkiller addiction has certainly proven profitable, which will cause increased investment in addiction research. 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. Some day we will likely look back on suboxone as the beginning of new age of addiction treatment. But for now, the treatment community would be best served by recognizing each other's strengths, rather than pointing out their weaknesses.

About the Author

Jeffrey T Junig MD PhD has worked as a neuroscientist and as an anesthesiologist, and is a psychiatrist in solo, independent practice. Additional information about suboxone including the blog Suboxone Talk Zone can be found at Dr. Junig is available for patient care, consultations, or educational presentations through

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