By now almost every opiate 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. This result would be a tremendous loss-- a loss of the chance to ease the suffering of many actively using 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 substancesusers of cocaine, methamphetamine, and alcohol take the substances to feel up, loose, or energeticready to go out and take on the town. The 'high' of opiate use feels content and 'normal' users feel like they have gotten back a part of themselves that they didn't even know was 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 opiate addiction.

See Part Two: Drug obsession and character defects.