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 activates opiate receptors like any other 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.

Traditional AODA treatment specialists are not as excited about suboxone treatment. 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, 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 opiate 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.