I’ve talked about some of the goals I have had for this site over the past couple years…  one of my ‘personal issues’ is that like most addicts, I like to take things on by myself and solve problems by myself.  I remember, in fact, my first time in treatment in 1993– an outpatient, 21-session group therapy program– when one of my assignments was to ask another person for help at least once per day.  That was a very difficult thing to do, and I must have gotten better at it because now I am asking for help all the time!  On the other hand, I have some areas of my life where I would never consider asking for help– so maybe I’m not as ‘better’ as I think I am.

Before moving on I should make a quick educational comment about addiction– one reason that addicts do not ask for help earlier is because we know that if we ask for help, there is a possibility that we will have to change for the better and lose our addiction.  And every addict has ambivalence about becoming sober– even at times when we recognize that we are powerless and that our lives have become unmanageable!  There is always some degree of ambivalence.  If you are being ’stubborn’ about getting help, consider whether you TRULY want to be done with using.   Sometimes a person who can’t find just the right treatment program is really concerned with something else– whether to really give up the secret life of an active addict.  If you are in such a situation, consider whether you are debating the REAL issues, or whether your concern for clean pillows and the ‘right treatment approach’ is just a distraction from a bigger question.

OK…  I am in need of some help.  I have written a pretty good book about addiction;  it is certainly different from what is ‘out there’, as it is personal and at the same time  educational, theoretical and at the same time practical, long and detailed but at the same time broken into bite-sized pieces.  I have patients on buprenorphine who are accountants, attorneys, nurses, businessmen, laborers, government employees… I find that opiate addicts are an incredibly talented bunch.  I figure that if they do OK in life despite having chains around their ankles, they will do wonderful when the chains are removed!  So out of the readers out there, I know there are people who work close to the publishing field– or people who know people in the publishing field.  If that person is YOU, please consider giving me a hand with the book.  I could just self-publish it, and that is what I may end up doing— but I would rather, of course, get the marketing that comes with ‘being published’ so that I can reach a wider audience.

As for the ‘non-profit’ thing– I am aware that of grants from government and private sources for educational projects related to drug addiction, but support is reserved for ‘non-profit groups’.  My efforts with the blog and forum are certainly not profitable– but I do not know how to go about setting up a non-profit agency.  I would like to make the site grow– to get a ‘real’ web designer instead of doing things myself (and I have no education in computer stuff, so in typical addict style I just try to figure it out myself).  When it comes to the IRS, I don’t want to figure it out on my own!  So if you can help–  either by pointing me in the right direction or something more– please let me know.   If you are unemployed, independently wealthy, and experienced in running a nonprofit company, come join me– be the ‘management wing’ and I’ll be the ‘medical wing’!

I realize these are long shots, but I always tell my kids to keep throwing baited hooks in the water.  If nothing else, we’re getting exercise!  If you even just know of someone who might or might not be interested, throw out another hook for me– I appreciate it!

Serious replies (or even funny ones) can write to me at ideas@fdlpsychiatry.com.

Thanks!

I invite readers to visit Medpedia and review my thoughts about the relationship between buprenorphine maintenance and traditional recovery.  The topic will be important as we sort out whether buprenorphine should be used as a bridge to step-based treatment, as a long-term treatment that stands on it’s own as a treatment for a chronic condition, or a combination of both paradigms.

When it comes to medical information there are many options on the internet, that vary greatly in the quality and independence of their information.  Medpedia follows the model of a similar site, where information is honed through the experiences and opinions of contributors.  I like what I see so far.  Please check them out sometime.

JJ

I went to Walgreens early this morning and they had the drug on hand. So, if there is anyone who still has doubts as to the drug being available at local pharmacies- this shows the 2nd largest drugstore chain has it available in its pharmacies.

Note: the writer is referring to a Walgreens in Wisconsin.

The tablets themselves are round and white with the imprint of 54 411 on one side and a blank opposite side. Really the best way to describe them, is that they are identical in every feature (minus the imprint code) as the “512 Generic Percocet” tablets. As for taste and texture I found them to be much easier to tolerate than the fake orange Pez flavor laced with formaldehyde that Suboxone leaves in your mouth for hours. To me it was as if chewing a large aspirin and holding it in my mouth. Yes, it was slightly bitter, but the flavor itself was mainly inert and inoffensive.

Now as for price… Walgreens lists the retail cash price for 60 tablets to be $152.99 which translates to $2.55 x tablet. Less than half of what the name brand cost!!!ee

Note: in Wisconsin, Walgreens has always been the costliest place to purchase Suboxone, with prices up to 50% higher than other pharmacies such as Wal-Mart, Pick N Save, ShopKo, and even the smaller mom and pop pharmacies.  I would expect for that reason that the generic could be found for even less money with a bit of calling around.

Hopefully some good news!

-jp

Thanks JP!

My feelings about counseling:

- A century of Recovery experience has taught us that psychiatrists and therapists have a horrible record of ‘talking’ people clean.  There is a common MISconception among lay persons that addiction comes from underlying psychopathology, and if you ‘fix’ the underlying problems, the addiction will ‘go away’.  This is the stuff of movies and fantasies– not a medical reality.  Addiction is a PRIMARY disorder– it is not SECONDARY to something else.  Yes, many addicts have emotional baggage– and so do non-addicts.  Many addicts have perfect upbringing, if there is such a thing.   It doesn’t matter.  Once a person has become an ‘opiate addict’, the addiction is the MAIN thing, and must be treated first.  You won’t fix depression or anxiety in an opiate addict by therapy or meds or anything else until the addiction is in remission.  It makes no sense to water the houseplants while the house is burning down.

- Add to often ‘counseling’ for bupe patients consists of going through the same classes and groups as the people NOT on buprenorphine.  This is an unexamined treatment strategy that maybe ‘makes sense’ in a superficial way, but that makes little sense if one looks at what happens during group therapy and step meetings.  Support groups  use the forces of peer pressure in a positive way;  the addict who relapses is letting down not only himself, but also a group of people who he will have to face and admit his error.  If a group consists entirely of people on Suboxone I could see some value, provided everyone had the same goal in mind.  But in practice, patients on bupe are often placed in groups that include addicts not on bupe, and that is a recipe for disaster.  In such cases you will have compliance problems with the patients on buprenorphine.  You will have envy, snobbery or anger by the people not on buprenorphine.  And you will have all kinds of bad behavior in the parking lot–  addicts ‘helping’ fellow addicts by sharing their medication, etc.

- Step programs work by changing personality– something that is rare and very difficult.  Most patients who try the steps never ‘get’ it.  Those who do are lucky indeed–  and they get there because they are so desperate that their minds open to a new perception of things.  Treatment is NOT education.  I love the saying ‘insight maketh a bloody entrance’ in regard to treatment.  If a person in treatment is happy and comfortable, he is not going to stay clean after leaving.  The ‘right’ person for AA or NA is a person who is sick, tired, humbled, and desperate– as it says in the AA readings, ‘only when a person clings to recovery as a drowning man seizes a life preserver’.  People on buprenorphine are NOT desperate– not in this way, and not to this degree.  They may have debt, may be alone and lonely, may be broke and unemployed… but they are no longer in the state of utter desperation that they were before buprenorphine.  Making a person who takes buprenorphine attend step meetings FEELS good, but is probably a waste of time and energy for everyone involved.  If a person WANTS to go, more power to him– but that is a completely different situation, as at least then you have a person who is interested in being there– not as good as being ‘desperate’, but better than being forced into going.

- Lest you interpret my comments to mean that a person is worse off by losing that desperation, that is NOT what I am saying–  because the success rate for staying clean using the steps or other components of residential treatment is very LOW when you look at opiate dependence.  I have been told I shouldn’t say this, as it takes away ‘hope’– but ‘hope’ ain’t all it is cracked up to be, at least when it comes to addiction.  Addicts USE hope to avoid getting clean.  Freedom from addiction comes when the person is hopeless.  If you are currently using, you are probably familiar with ‘hope’-  that is what allows you to take another hit!  You ‘hope’ that some day things will be different (sniff, sniff).  You hope that you will get your act together (sniff, sniff).   The success rate for ‘traditional’, non-buprenorphine treatment has always been very low– not a huge crisis when we are talking about a few heroin junkies, but now that we have an epidemic, we cannot settle for a 80-90% failure rate!

- The good news is that we now have something that will induce remission from active addiction WITHOUT requiring the near-impossible change of personality that used to be required to stay alive.  It is a mistake to think that we should mix both treatment strategies together.  For the reasons I have outlined, buprenorphine and the steps are more of an ‘either/or’ situation.  We used to treat depression by sending people to treatment centers (country spas for rich women;  horrible locked wards for the less fortunate).  Treatments consisted of ECT and even lobotomies.  Now that we have Prozac, we don’t make people take the Prozac and ALSO go to the ‘funny farm’, and then throw in some shock treatment for good measure!

- I’m ending soon, I promise…  Everybody has character defects.  When we only had the steps to treat addiction, we HAD to address the character defects and ‘change’ the addict’s personality.  The problem is that personality always changes back when the person stops attending meetings– so the addict in traditional recovery MUST keep going to meetings, or the old addict simply comes back.  With buprenorphine, the entire paradigm has changed.  Correction of character defects is a good thing… but I doubt it will happen with a person who is NOT DESPERATE.  Plus, I have been surprised at the extent to which character defects resolve from buprenorphine alone– leading me to see character as more fluid than I used to.  In other words, the constant obsession for opiates creates dishonesty and self-centeredness… and just removing the obsession has the effect of removing those defects!   This is a totally different way of thinking about addiction and character defects– and the time has come for this change in perspective.  With this new perspective, my question becomes… why do we force the addict to jump through all the hoops of trying to change his ‘character’ as a prerequisite to treatment with medication?!   If a person wants treatment for heart disease, do we FORCE character change before prescribing medication?  Do we FORCE a change in diet, or nutritional counseling?  Do we FORCE sobriety from nicotine before giving nitrates for an impending heart attack?

Of course not.

The requirement for ‘counseling’ is sometimes– not always– an example and a consequence of the stigma of addiction.  Addiction is a DISEASE, and we finally have a TREATMENT that works.  Yes, I encourage addicts to look at their character defects.  I also encourage doctors to look at THEIR character defects.  And I suggest that addicts who are staying clean using the steps stay focused on their OWN inventories.

Gosh, I talk too much.  The pitiful thing is that I’m just getting warmed up!

JJ

Suboxone Talk Zone

Need details about taking buprenorphine?  Get my e-book at BupeGuide.com–  proceeds help keep the info flowing!

I just got off the phone with Roxane Labs, the only approved manufacturer of generic Subutex and the product IS available in all 50 states. It is available to pharmacies and dr offices direct from the manufacturer as well as from all major distributors. There is an ample supply available and is not on back order.

Opiate addicts taking Suboxone are hoping for a drop in price with the announcement of new generic medication from Roxane Pharmaceuticals

I called around to the major pharmacy chains and all three can order the drug (CVS, Walgreens, and Wal-Mart). None, at least in the Milwaukee area, keep it in stock because of its “orphan drug” status; however most can have it within 24 hours. (Only one of the pharmacists I spoke with actually offered to “pre-order” the drug before the rx was presented- the rest said because of security they do not order scheduled rx’s until the script is presented.

Also, anyone who has rx insurance and pays co-pays based on a drug’s status as generic or brand name (or a tiered system), the Roxane formulation WILL process as a generic. I did ask the drug rep at Roxane if they were also seeking approval for the generic formulation of Suboxone, but they said that it was confidential information, but that if they do it will be announced by the FDA if and when it is approved = YES THEY ARE…

I wanted to email this to you in case you wanted to share it on the Subox blog. And, the doc I attached is the drug info from Roxane.

Anyway this might all be old news, but I wanted to share it with you in case you wanted to pass it on to anyone~

-jp

Thanks very much, JP, for the info.  the PDF file he refers to can be found by clicking here.

Blogging in general has been an educational experience.  I was initially surprised by the number of people who send out very angry messages to a person who simply tries to share knowledge and advice!  Just today I received a message accusing me of ‘getting my degree from a crackerjacks box’ for my opinion that ‘Suboxone withdrawal is NOT the worst withdrawal ever.’ I didn’t get it there, by the way.    I don’t know how to take the responses posted a few minutes ago that are tonight’s topic;  I am not sure if they are simple questions, respectful disagreements, or sarcastic comments.  You would think a psychiatrist would know one from the other!  Maybe the person will add more angry comments after my post, and then I’ll know for sure.  Or maybe there will be nice comments.  Whatever…

The comments, from someone going by ‘cbarrett34’ on youtube:

Dr. I’m curious, why do you say that there is no cure for opiate addiction? That doesn’t give people a lot of hope, if a Dr. is telling them there is no cure or hope for you. Basically leads to apathy and more using.

(That one was clearly very nice).

And the whole saying, once an addict, always an addict. That’s not a very positive viewpoint either.

(That one is harder to tell, don’t you think?  I might just be paranoid from that crackerjacks comment)

My answer, which as always is just one opiate addict/pain doc/psychiatrist’s opinion:

My first thought is that staying clean from opiates has nothing to do with ‘apathy’.  Maybe smoking pot has something to do with apathy, but people actively using opiates are some of the most non-apathetic people you will ever see!  There is no time for ‘apathy’ for an actively-using opiate addict;  there is that hit that is required every 4-8 hours to avoid being sick, there is that need to scam someone out of money to score the dope that is needed every 4-8 hours to avoid being sick, there is that need to come  up with a good lie to tell the parents/spouse/cops/PO/boss/kids to explain the lousy behavior over the past few months or years…  being an actively using opiate addict is a lot of work!  There is definitely a negative attitude that develops after months or years of using, but it is nothing like ‘apathy’.

My next thought is that I wonder what the writer would prefer—‘positive’ lies or ‘negative’ truth?  The idea that heroin or oxycontin addiction is ‘treatable’ is one of the big lies of society;  it makes for good movies and helps keep money rolling in to detox facilities and treatment centers, but if you think I’m wrong, seek out the numbers yourself!  Pick your own criteria for success– one year sobriety, five year sobriety, whatever.  If you look at people in their 20’s who go through residential treatment, the one year rate is way, way, way below 50%, even if you just use the numbers for people who go voluntarily and complete treatment!  Go out to 5 years and the numbers for opiate dependence are ridiculous- sobriety rates of less than 10%!  The writer sees danger in telling the truth about treatment I suppose because the truth will somehow take away ‘motivation’ and cause apathy.  But I see things exactly the opposite.  In my opinion based on how I thought as an actively using opiate addict, a sense of confidence is the ENEMY of sobriety.  As an addict goes from day to day using, and getting deeper into addiction, he/she comforts himself by saying ‘I’m going to get straightened out eventually’.  If the person knew that most people do NOT recover; that he is getting mired deeper in an incurable disease, maybe he will think about seeking help a bit sooner!  And if everyone knew that opiate dependence is a largely untreatable and surely incurable illness, maybe fewer high school kids would pick up in the first place.  I hear addicts say one thing over and over again:  ‘if I only knew that oc would have done this to me I never would have taken it.’  I don’t know if that is true for all of them, but I think that had the truth been known, at least some of them wouldn’t have started.

As far as the comment about ‘once an addict, always an addict,’ that is something that is not even controversial.  Yes–  at least with opiates, once an addict, always an addict.  About 7 years after getting clean ‘the first time’, I assumed that I was cured—after all I had only used opiates for 8 months or so, and it had been 7 years… I had been to hundreds of AA and NA meetings, I had worked the steps all the way through several times, and I never even thought about using!  I would get so annoyed when my old NA and AA buddies would come up to me if they saw me someplace and say ‘we miss you at the meetings, Jeff!’  I would want to tell them to bug off and leave me alone— I’m cured, after all!  I don’t need that crap.  Once an addict, always an addict…. NO WAY!

Had I listened to them I might have saved myself a great deal of trouble.  But probably not, since addicts pretty much need to find things out for themselves.    That is one of the personality traits of ‘us addicts’—we are independent thinkers who don’t think the rules of others should apply to us.  Those words on the Vicodin bottle about dosing and about the danger of dependence?  Those are just ‘suggestions’!

I wasn’t always a fan of the idea of taking a medication to treat opiate dependence.  Even after looking around me and realizing that all of the people who got clean with me had relapsed, I thought that it was better to have one out of ten people in ‘real’ recovery than have people taking medication!  Then I ended up in a position where I actually knew some of the people who were dying.  At NA or AA meetings people talk about the deaths with a ‘tsk tsk’ attitude, as if the person who died should have known better, or almost had it coming, since she stopped going to meetings.  But once I was a person who stopped going to meetings in spite of knowing better, it became harder to blame the dead person.

I have in my mind the images of four smiling people who desperately wanted to be free from opiates.  I knew all four of them pretty well at some point;  none took Suboxone, and all assumed they were going to be fine without it.  After all, they had all gone through at least part and in two cases entire treatment programs.  Three men and one woman, all less than 25 years old, two with children of their own.  Two died from suicides, presumably in part from the shame of failing to get better.  I wonder if they thought, before they died, that they were losers because treatment didn’t work for them?  The other two died from opiate overdoses, one the first time he used after being clean for several months.  I suspect he figured that he ‘beat the disease’;  that is what most of us think as we relapse.  One time won’t hurt, we tell ourselves;  we are different now.  We have been TREATED, after all!  The final person was a woman who had been resuscitated several times in her life, once after an overdose in a drug-treatment halfway house!   Maybe she had a death wish—some addicts seem to use as if they truly want to destroy themselves—or maybe she thought she was blessed by a guardian angel who eventually slept in one day and wasn’t there when she needed him.

To simply answer the writer’s questions without all the stories, I tell people that there is no cure for opiate addiction because my opinion is the same as that of everyone else who treats or studies opiate addiction—   there is no cure for opiate addiction.  As for ‘hopelessness’, sometimes ‘hope’ is just a campaign slogan.  Sometimes ‘hoping’ keeps a person from recognizing the cold hard facts of a situation and taking responsible action.  In medicine and in life, diseases do not always have cures.  Some diseases are simply not curable, and people die.  Want to have ‘hope’ about opiate dependence?  Then DON’T USE OPIATES.

The good news is that while there is no cure, there is a relatively new approach to addiction that is keeping many people alive who would have otherwise died from their addiction.  There are many diseases without ‘cures’—in fact there are probably many more ‘incurable’ diseases than ‘curable’ ones!  But every opiate addict should know the facts:  that he or she will always be vulnerable to relapse, no matter the amount of ‘treatment’.

I received a thoughtful e-mail the other day that deserves re-posting to a broader audience.  For those who are interested in the relationships between addiction and character defects, and the impact of buprenorphine or the twelve steps on these character defects, I suggest that you first read the original article, and then read the e-mail response printed below.  As always, your contributions to the discussion are appreciated, either at the bottom of this post or at Suboxone Forum.

The response:

Dear Dr. Junig,

I found your article ” Is Suboxone At Odds With Traditional Recovery?” to be an excellent piece, very informative and very helpful as we (my wife and I, both recovering alcoholics for 22 and 21 years, respectively) are working with a friend dealing with a pain pill addiction.

Just by way of background, though not a physician myself, I worked 18 years at ###### Medical School  and as a result have had considerable exposure to medical curricula, practitioners and research in medical education. That and my own personal experience, I am sure, are reasons I find the article compelling.

I would add just one note to your discussion: while addicts (of all types) do acquire “character defects” as a direct result of their addictions — a point you make and it is well taken — you do not allow very much for things that may have been wrong in their make-up PRIOR to addiction.

In other words, if I grew up in a “goodfellas” or any type of heavily dysfunctional family, I might have picked up some bad habits on the way to becoming an alkie or a junkie and just added more bad attitudes and behavior on top of the mound I had already built. Of course, all this is gradual and intertwined, but I believe you get my point.

So the person I brought into my addiction needed reparative attention long before the onset of the addiction, that so-called line we cross over.

I completely agree that a large set of people who might become pill pain addicted might likely be more “normal” than alkies-in-development, still they may have issues and we have found the step programs to be useful to anyone.

Certainly that set might be less aware or less motivated to do the work on themselves (might easily have greater denial, especially if they get into comparing) but they still likely have the need. Can’t hurt, as they say.

I hate to say this (only because 12-step programs are parsed into such small groups and subpieces) but I think a Pain Pills Anonymous that acknowledges the differentiation would be a great resource to the population you focus on.

Thanks for your attention to this.

-B

Time will tell whether a generic will be introduced and if it is, what the cost will be– but in general, generics do bring down the cost of medications.  When it comes to buprenorphine treatment of opiate dependence, the pricing relates to the number of people who receive treatment… so we can all hope that the price is lower than the current $5-7 per pill depending on the pharmacy and geographic area.

Thanks to the folks at Suboxone Forum for keeping me updated on the news about this exciting development!

I used all kinds of pain pills over the past ten years—Vicodin, then oxycodone, methadone, and even fentanyl patches. Then I got into heroin for a year and finally hit my rock bottom. I went to a Suboxone doctor and he put me on 16 mg per day. At first everything was great, but I don’t like the side effects. I get so tired every day. I’m not happy like I used to be. I wake up in the morning and don’t have any energy or excitement for life. I really don’t like what the Suboxone is doing to me and want to stop.

Sometimes it is a little different—the first part is the same, but then the person writes:

I really wanted to stop taking it so that my body is free of chemicals so I stopped. I was real sick for a month and now I don’t feel like myself—I am tired, I feel depressed and angry, and I’m wondering what the Suboxone did to my opiates—am I ruined forever?

I am a psychiatrist, and only about a third of my practice consists of addiction work. I get e-mails at times after people read the blog for my psychiatric practice at www.patienttimes.fdlpsychiatry.com. A typical message will be similar to this:

Dear Dr. Junig (they tend to be more polite to me there),
I used to be a very happy, energetic person. In high school I was outgoing and everybody liked me, and I had tons of friends. The problem? Now I am in my 30’s and I’m never happy anymore. I have worked at the same place for ten years (or maybe, I change jobs every 18 months) and every day I wake up and dread getting out of bed and going to work. I keep telling myself I should exercise, but I never get started actually doing it. I’m single and don’t have any interest in dating (or maybe, I’ve been married to the same person for ten years and sometimes I can’t stand the look of him). I’ve read about vitamin D deficiency and wonder if that is my problem—all I know is that I am getting more and more depressed and tired. My sleep is crappy too. What should I do?

I have an answer to the first two messages, and the third message is a hint. Does anyone know how I would reply to the first two messages? What would I say? If you get my point and describe it correctly in the comments section—either describe the -general point, or write the reply that I would write– by 6 PM Central time tomorrow, Sunday, September 27, I will send you a free copy of my e-book ‘user’s guide to Suboxone’. EVERY person who gets it correct will get a copy. The ONE person who explains my point the best will receive the user’s guide plus a copy of each of these three recordings—stopping Suboxone, how long will you take that stuff, and opiate dependence treatment options. That’s like almost a thousand—or a hundred dollars—something like that. You don’t have to put your real name or e-mail address, but your comment MUST be entered in the comment section after this post. I might have to approve it if you haven’t written a comment before, but that’s OK—it will still count, as long as it is written and submitted by 6 PM. C’mon folks—take a shot!

JJ