"I'm so ready to stay sober."
February 1, 2015 11:41 AM   Subscribe

"Dying to be free : there’s a treatment for heroin addiction that actually works. Why aren’t we using it?" -- A long-form article, focusing on heroin addiction and its "treatment" in Kentucky, by Jason Cherkis. (Huffington Post Projects)

In letters home from an abstinence-based facility in Prestonsburg, Kentucky, Kayla Haubner gushed about how she was taking to the program, but worried it wouldn’t be enough. “I’m so ready to stay sober,” she wrote in early 2013. “Believe me, I know how hard it’s gonna be when I leave here + go back into the real world. I’m safe here.” It was a sentiment that she would repeat often to family and friends during her time in treatment. In a subsequent letter, she confessed, “I’m so scared for when I leave here + go back home.” Two weeks after graduating from the program, she fatally overdosed in a gas station bathroom.
posted by spitbull (50 comments total) 32 users marked this as a favorite
 
I read this the other day; it's a harrowing article.

The main problem with rehab facilities, as I see it--and in many ways this seems to hold true for any short-term inpatient mental healthcare--is that one day you're there and supported and safe and kept away from triggers and access to whatever your substance is.

And the next day, poof, back into the real world and all of that support is gone. Prison's no different, in that respect. We really need to start understanding that recovery from anything is a process, and reintegration takes time.
posted by feckless fecal fear mongering at 11:48 AM on February 1, 2015 [20 favorites]


There should be a corollary to Betteridge's law, one that states, "If a headline promotes a simple solution to a problem, it is neither simple nor a solution."
posted by Cool Papa Bell at 11:50 AM on February 1, 2015 [3 favorites]


AA (and, one assumes, its various 12-step peers) has a success rate of between five and ten percent, which is basically a disaster and a horrible black mark on medicine and addiction treatment as a field. So I'm going to take a crazy guess before clicking that link and say "because people are treating mental illnesses like moral failings and character flaws again, right?"

... and there it is, one page in.

Yet of the dozens of publicly funded treatment facilities throughout Kentucky, only a couple offer Suboxone, with most others driven instead by a philosophy of abstinence that condemns medical assistance as not true recovery.

This is regressive, horrible puritan bullshit and it has to stop. If we treated medical conditions like anaphylaxis the way we treat mental illnesses we'd be scolding people about not trying hard enough to breathe instead of jabbing them with a goddamned Epipen like everybody in the world who isn't a sanctimonious sadist knows to do immediately.
posted by mhoye at 11:56 AM on February 1, 2015 [97 favorites]


I thought the best treatment for heroin addiction was giving heroin addicts free clean heroin to take. Though this goes in and out of fashion.
posted by alasdair at 12:26 PM on February 1, 2015 [6 favorites]


I thought the best treatment for heroin addiction was giving heroin addicts free clean heroin to take....

and food and a place to live with social support. But then what does that say to everyone else who is forced to work for those things?

it's yet another example of how "social welfare" has to apply to everyone.
posted by ennui.bz at 12:34 PM on February 1, 2015 [3 favorites]


But then what does that say to everyone else who is forced to work for those things?

"Aren't you glad you're not addicted to heroin?"
posted by Horace Rumpole at 12:52 PM on February 1, 2015 [54 favorites]


The son had been through five residential treatment stays, costing the family more than $150,000. When McLellan mentioned buprenorphine, the father said he had never heard of it.

In the US, we seem to believe strongly that the profit motive is a good one. So why aren't the manufacturers of this drug out there pushing it harder? Is it because they think that most of the target audience is too poor to afford it?
posted by Slothrup at 12:56 PM on February 1, 2015 [1 favorite]


A lot of words, but seems like so little dedicated to the thesis. Maybe legalized heroin and more access to buprenorphine could be the solution, but I didn't get that from the article.

Here is the Times story that is referenced about halfway through as the reason why this drug has been restricted. I'm not sure the Huffpo article really addressed all of the issues surrounding the drug like how there is more potential for abuse.

And the Huffpo writer seems to be making some grand accusations about the journalistic integrity of that story, but his reasoning is relatively weak. Something about how the doctor she interviewed was an expert on methadone, not buprenorphine. Other statements just sound like subjective complaints about rehab. The subject would have been better served by an epidemiological study of the number of people who have used various techniques and what the outcomes were.
posted by destro at 12:57 PM on February 1, 2015 [2 favorites]


The subject would have been better served by an epidemiological study of the number of people who have used various techniques and what the outcomes were.

One of the (unsubstantiated?) points of the article seems to be that the treatment industry is largely dissociated from any kind of real science.
posted by Slothrup at 12:59 PM on February 1, 2015 [3 favorites]


Maybe legalized heroin and more access to buprenorphine could be the solution

Ain't no maybe about the first part, see Portugal.
posted by feckless fecal fear mongering at 1:03 PM on February 1, 2015 [1 favorite]


Like methadone, Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication.

Suboxone is no panacea. I'm glad it exists for addicts willing to take it -- unlike methadone the idea is that you can taper off the suboxone instead of using it as a maintenance drug long-term, but here's what I know from the streets -- you can still get high off of it, there IS a withdrawal period between heroin & suboxone, and also a withdrawal period from suboxone, though not as bad as quitting heroin cold-turkey. It has a street value, and heroin addicts with no intention of actually quitting heroin long-term will take it to get them through until they can get more smack, so a lot of what gets out there is being misused. I have a close family member currently addicted to heroin & they've tried suboxone at least 3 times now, & because you still experience some sort of withdrawals, and the craving doesn't really go away, they've fallen back into illegal drug use each time. Sometimes they just sell it to go buy more smack with the proceeds the same day they pick up the prescription.

It's pretty awful watching this go on and on and on and on and on. Treatment + 12 steps + suboxone (plus a stab at methadone) have really not yielded any results. I fucking hate the fact of it, but all the medicine & all the doctors in the world don't have a 100% solution for everyone at this point. Blaming this kid's relapse solely on his refusal of suboxone in favor of abstinence might make for a great outrage-inducing, eye-ball-drawing article, but it's a whitewash.
posted by Devils Rancher at 1:06 PM on February 1, 2015 [25 favorites]


As one who spent 35+ years working with people who have addictions and/or mental illness Devils Rancher is on target--and I knew as soon as this was posted there would be the let's jump on AA and list its failings because it is .......... Many, if not most, current AA groups fully support members being on concurrent medication plans--if you are in one (or know someone ) who is in an AA group where members insist on total abstinence--find a new group. it is usually just a few outspoken long timers And please do talk about addiction as a disease or condition that responds well to an articulated treatment (bacterial infection/anaphylaxis, etc)--try cancer, chronic rheumatoid arthritis, lupus or other life threatening chronic illnesses. If there was a simple solution or well documented treatment paradigm it would be used.
posted by rmhsinc at 1:32 PM on February 1, 2015 [7 favorites]


Jesus huffpo is unreadable in a mobile browser. I gave up.
posted by clvrmnky at 1:42 PM on February 1, 2015 [1 favorite]


In a novel I have coming out this summer*, I have an ethical drug dealer who sells premixed syringes of fentanyl and LAAM. Fentanyl is short acting and gives the high of heroin while LAAM prevents the rapid drop-off of affect and craving (it is a long-acting opioid like methadone). LAAM has a half-life of 2.6 days plus an active metabolite.

The difference is that this strategy rewards the user with the high and attempts to deal with the drug problem by reducing the frequency of needing the drug. I'd like to think that this strategy could work. Giving out free heroin? That will be a lot of veins collapsing over time.

(*Never Kill A Friend, Ransom Note Press)
posted by dances_with_sneetches at 1:47 PM on February 1, 2015 [1 favorite]


Whatever happened to ibogaine treatment? Has anything come out of that?
posted by crapmatic at 1:52 PM on February 1, 2015 [3 favorites]


“I understand they are talking about harm reduction,” Thomas said. “Those things don’t work in the criminal justice system.” In a subsequent interview, the judge added, “It sounds terrible, but I don’t give them a choice. This is the structure that I’m comfortable with.”

For too many people, the most important thing about addiction is that it is another opportunity to moralize.
posted by thelonius at 2:00 PM on February 1, 2015 [12 favorites]


One of the (unsubstantiated?) points of the article seems to be that the treatment industry is largely dissociated from any kind of real science.

The 2012 CASA Columbia Report referenced in the article.

All 586 pages of painstaking detail of just how dissociated the treatment industry is from evidenced based practice are downloadable for free.
posted by space_cookie at 2:02 PM on February 1, 2015 [9 favorites]


My dad ran an in-patient methadone clinic in the seventies. While he agreed that methadone was cutting edge for the time, he scoffed at the idea that it was a panacea. "Sure, they say you can't get high from it, so then, why do addicts save doses?" Why indeed.

His approach was both medication and 12-Step and the program worked better than most for more than most. Mostly because my dad is a brilliant therapist.

He later worked for a bit at Hazelden. It made his skin crawl. He worked with adolescents and determined that most of them were there because their parents had tried nothing and were all out of ideas. He hated how the facility warehoused the kids, and blamed them for what were clearly family problems, not kid problems.

What's so frustrating is that the whole abstinence movement, for EVERY societal ill doesn't work. It doesn't prevent most teen pregnancy, it doesn't keep most addicts sober. I submit that while a few benefit, it's VERY few. It fails more than it serves.

I believe that 12-step programs are important parts of the process of sobriety, but hand in hand with cutting edge medical support, including drugs like Suboxone.

It's also frustrating that the whole puritanical politics of morality are keeping pharmaceutical research from being profitable, because why would a company devote money to this problem, when our own government will refuse to fund the cure, should there be one, unless the poor addict struggles, and meets his higher power and all the other entitled bullshit we hear from people in power. Bootstrap it!

But again, why let science screw with your ability to apply the law to a medical problem?
posted by Ruthless Bunny at 2:03 PM on February 1, 2015 [11 favorites]


Well, actually, suboxone and methadone are both intended and work best as maintenance... not detox drugs. The idea that Suboxone was intended as detox or short term treatment is a myth spread by 12 steppers, mainly.

And what that article unfortunately left out is the most important statistic in the debate:

Methadone and suboxone *maintenance* reduce mortality by 2/3 to 3/4 compared to any abstinence based treatment including anything 12 step.

That is why Hazelden finally broke down and introduced Suboxone maintenance recently.

Dead addicts don't recover— and there's no difference between living the rest of your life on Prozac and living the rest of your life on methadone or suboxone. Like Prozac, these drugs have side effects— but unlike Prozac, they *are* linked reliably with reduced mortality. (Not to say that Prozac isn't lifesaving for many: just that it doesn't show up well in the data because it also makes some people worse).

If there were any other condition where a drug that can cut mortality by that rate was available and it wasn't prescribed, people would be winning massive malpractice cases.

But no, this is addiction. We don't think it's a disease: the main treatment is meeting and prayer and confession in 12 step groups. People believe you are always high if you are on maintenance (not true: tolerance prevents this so much that can you safely drive once stabilized), people believe you are "emotionally numb" if you are on maintenance (not true, same reason as it doesn't get you high) and most importantly, people believe that maintenance is too nice to addicts who we really should be punishing.

12 step programs are useful as a self help adjunct to treatment for a small percent of people— they should *never* have become the core ideology of treatment and insurance companies are insane to pay for 12 step based treatment give that AA's own traditions say it should be given away for free!!!
posted by Maias at 3:05 PM on February 1, 2015 [41 favorites]


Btw, the drug company that sold this had to be pushed into it by the FDA via "orphan" drug status and lots of other prodding by NIDA— and now makes decent money from it.

That fact is being used by abstinence folks to say that it's all a plot by evil pharma— not the best treatment, just a profit center. This is made worse by the fact that sleazy doctors often are the ones who prescribe it— because no one else fucking will!

It's hugely annoying, especially the people making the big pharma claims.

The New York Times piece on suboxone was journalistic malpractice: it was as if they'd covered chemotherapy by focusing on the people who die from it while ignoring the fact that many times more are saved by it than die from it.
posted by Maias at 3:13 PM on February 1, 2015 [5 favorites]


I thought the best treatment for heroin addiction was giving heroin addicts free clean heroin to take....
and food and a place to live with social support.

There's something a lot of people don't realize and that is for many people, after a certain point heroin stops getting you high. They literally can not ingest enough without ODing.

Most long-time addicts need heroin to simply stave off the horrific symptoms of withdrawal. Giving addicts heroin (or methadone) does not mean letting heroin addicts get high and party for free, it means letting them get to Not Sick, Just Normal again so they can work and lead ordinary, productive lives. That's why it's called maintaining. (Many of those people will eventually be motivated to quit entirely because heroin maintenance is no picnic either. I'm not a huge fan of 12-step programs but nothing ranger truer for me personally than the saying "sick and tired of being sick and tired.")

it's yet another example of how "social welfare" has to apply to everyone.


And jesus christ, this is unrealistic, penny-wise, pound-foolish thinking. When has denying social services ever paid off for society? You think it's unfair? Do people get tax breaks that other people don't get? What did they really do to deserve them? Be able to afford a 2nd bedroom to work in exclusively? What about people who do the same work but can't afford that separate room? Is the first group a bunch of freeloaders? Are they working harder?

On preview, Maias is much more articulate and nicer than I am on the subject.
posted by Room 641-A at 3:28 PM on February 1, 2015 [6 favorites]


I was speaking strictly from personal experience as a layperson. I would much sooner have [family member] take suboxone every day for the rest of their life than ever take heroin again, but it's been presented to us and them as a thing they will eventually withdraw from as well. I wonder why that is? Cost, I suppose. We've never gotten to the point where they've even stabilized enough to re-enter society anyway, so the question is academic. Seems like the first doctor to prescribe it was talking about at least 6 months to a year. Suboxone has never gotten us more that 2 weeks, while methadone at least bought us almost 6 months one time.

I think we have an edge case, though. This is a person who checked into a treatment center at 2 PM and walked out the door at 10 pm on their last visit. Insurance is done with them -- insured from the neck down only for the rest of their life. Sigh.
posted by Devils Rancher at 3:34 PM on February 1, 2015 [1 favorite]


Suboxone is no panacea. I'm glad it exists for addicts willing to take it -- unlike methadone the idea is that you can taper off the suboxone instead of using it as a maintenance drug long-term, but here's what I know from the streets -- you can still get high off of it, there IS a withdrawal period between heroin & suboxone, and also a withdrawal period from suboxone, though not as bad as quitting heroin cold-turkey. It has a street value, and heroin addicts with no intention of actually quitting heroin long-term will take it to get them through until they can get more smack, so a lot of what gets out there is being misused. I have a close family member currently addicted to heroin & they've tried suboxone at least 3 times now, & because you still experience some sort of withdrawals, and the craving doesn't really go away, they've fallen back into illegal drug use each time. Sometimes they just sell it to go buy more smack with the proceeds the same day they pick up the prescription.

So:

- Instructions for starting suboxone/buprenorphine are usually to wait 24 hours after your last dose of H (if you are a regular user) - longer for certain synthetic opioids. That's no fun, but it's much better than cold turkey, especially accounting for post-acute depression etc.

- Buprenorphine is a really interesting mixed agonist-antagonist for opioid receptors. What this seems to mean in practice is that there's something of a ceiling for effect. If you have a high tolerance, as you do if you take it every day, you don't really get high - maybe a little if you space out doses or double them - and it's nearly impossible to overdose. If you don't have an opioid tolerance it's extremely potent, so I'm sure it does get diverted for recreational use. As a very strong drug in a compact package I don't find it hard to believe it could be dangerous to a opiate-naive person.

- If you take it as directed it's pretty effective at blocking other opioids. This is due to the high binding affinity of buprenorphine, not naloxone. It binds so well in fact that contrary to the marketing that it will outcompete the naloxone - you can totally shoot up suboxone. If you have a tolerance it still won't get you that high though, people just have needle fixations and/or want to conserve their doses. I would humbly suggest the best thing to do here is make sure bupe is formulated so that injecting it won't kill you!

- It definitely gets used by "heroin addicts [who]... will take it to get them through until they can get more" but you're going to have a really hard time convincing me that they are worse off not having this option. Worrying about this "misuse" seems to come from those same old moralistic ideas about addiction.

- Cravings do go away or are reduced for most people but I'm sure not everyone. Opinions seem to vary about withdrawal/tapering off. Probably not as bad as methadone - one of the very worst opioids to quit really - but it's still a long process.

Absolutely there's nothing that works for everybody. But for a lot of people - especially if they are employed, functional, etc. - it is so much better to just get off dope without taking your whole life apart. Ask me how I know! And if you want to stay off it usually helps a lot. If you don't want to, there's not a lot anyone can to to make you.
posted by atoxyl at 4:09 PM on February 1, 2015 [5 favorites]


I thought the best treatment for heroin addiction was giving heroin addicts free clean heroin to take.

Not exactly.

There are two models for this. First was the old-school British system, which started when the majority of heroin addicts in the UK were doctors, nurses and people who'd gotten dependent on a therapeutic dose.

The problem with this was that when the younger, later generation of recreational heroin users came along, they died at about exactly the same rate as people who use street heroin users do. I don't know why this would be a surprise to anybody -- in the UK at least, they were using exactly the same drug. We didn't have a market in imported heroin then. Why would we?

So it fell into disfavour. Young idealistic doctors came into the field and found huge numbers of their patients dying. It kind of put them off. So they started to copy the USA. Nobody ever got sued copying American medicine, right?

But a handful of doctors in some backwater places carried on doing what they'd always done, because some people didn't do at all well on methadone, but continued to do fine on heroin.

And then the Swiss came over and took a look, and thought it was interesting, but they decided there was no way that they'd do it like the British do. They'd see the same outcomes. So rather than giving people a weeks supply to take home, they forced people to use it under supervised conditions. And they researched it. And found they had good outcomes.

Then the Dutch copied it, and they had good outcomes as well. And because David Blunkett had heard the old saw about how prescribing heroin was better and safer, he made an election promise to do more of it -- and was talked down into making it a British multi-centre study. And that has pretty good outcomes as well. But using that same Swiss model of supervised consumption.

So it isn't a first line treatment. It's hugely expensive (methadone treatment on the NHS costs about £1000 a year, Suboxone/Subutex, a little more but not outlandishly so. Outpatient treatment under the old system cost about £30k a year -- without the supervised facility. Add to that the cost of having a medical team on site, 24/7 and you can imagine how much it costs.) So while it does have it's advocates (and I include myself among them) it's rarely advocated as anything but a last resort for people who aren't responding to the other, less expensive interventions.

And you'd be surprised how many people get on the programme and find that it's just too much hassle to have to be at the clinic, twice a day, seven days a week, 365 days a year. Most people eventually find that it's not worth the effort and so eventually reach an accommodation with one of the longer acting opiates.
posted by PeterMcDermott at 4:41 PM on February 1, 2015 [9 favorites]


According to the Times story, there have been a number of attributable deaths.
posted by destro at 4:42 PM on February 1, 2015


Suboxone is no panacea. I'm glad it exists for addicts willing to take it -- unlike methadone the idea is that you can taper off the suboxone instead of using it as a maintenance drug long-term,

This is such a tight little ball of myth and misinfo that I feel I should address it directly. As noted above, both suboxone and methadone are intended primarily as maintenance. The reason you can get Suboxone from doctors— not just clinics in the ghetto— is that the FDA realized it had *overregulated* and literally ghettoized methadone by isolating it in clinics. Methadone should be available from doctors too.

but here's what I know from the streets -- you can still get high off of it, there IS a withdrawal period between heroin & suboxone, and also a withdrawal period from suboxone, though not as bad as quitting heroin cold-turkey.


Yep, it's an opioid with mixed agonist /antagonist effects, which means that it will cause withdrawal if given to someone dependent on other opioids without a withdrawal period first and at high doses will cause withdrawal (thereby reducing overdose risk). This also means you can get high on it on moderate doses— but tolerance means that this doesn't happen for people on a stable dose.

It has a street value, and heroin addicts with no intention of actually quitting heroin long-term will take it to get them through until they can get more smack, so a lot of what gets out there is being misused.

The only people it has a real street value to are heroin addicts: if there weren't such tight limits on treatment (docs can only have 100 patients at a time, and if this is for maintenance, this is an insane limit because someone has to die or leave town before a slot can open), it would have little street value. It only has a street value where other better drugs aren't around or for addicts who can't find them. So, the tight controls against diversion actually *create* diversion.

I have a close family member currently addicted to heroin & they've tried suboxone at least 3 times now, & because you still experience some sort of withdrawals, and the craving doesn't really go away, they've fallen back into illegal drug use each time. Sometimes they just sell it to go buy more smack with the proceeds the same day they pick up the prescription.

Why are they not staying on maintenance? Could it be in part because people around them have the attitude that you display in this post that they aren't "really" in recovery when they are on it, so they may as well still be using smack?

Educate yourself. Every time your relative comes off the drug, they are at intensely high risk of OD. Be sure you have naloxone around: this can save their live if they do. And try to get them to stay on and get a complete psychiatric evaluation, because at least 50% of opioid addicts have a preexisting psych condition and if you don't treat that, simply treating the addiction won't work.
posted by Maias at 4:53 PM on February 1, 2015 [13 favorites]


in the UK at least, they were using exactly the same drug. We didn't have a market in imported heroin then. Why would we?

Wait, are you saying they were being given street heroin for maintenance? I thought the idea was to give standardized doses of pharmaceutical diamorphine, which I thought was available in the UK. In which case the poor results - which I did know about - are absolutely surprising. Of course people do manage to kill themselves with known doses of pharmaceutical opioids all the time, and supervised use is obviously going to work better but I would have expected some improvement in safety.
posted by atoxyl at 4:54 PM on February 1, 2015


heroin addicts with no intention of actually quitting heroin long-term will take it to get them through until they can get more smack

Only if you've got a habit the size of a mouse (or more likely, no habit at all.)

The agonist/antagonist properties of subutex means than anyone with an opioid tolerance of any significant size will be plunged into immediate withdrawal. You won't do it twice.

The protocol among British treatment providers is that you have to reduce to less than 20mg of methadone a day, and then wait two days until you're in withdrawal proper before they start you on Suboxone.

And they invariably use Suboxone now -- which contains a full antagonist to further reduce the misuse potential.

Here, it was used primarily in Scotland, which at the time had poor access to good quality imported drugs -- and even then, they'd mix it with a benzo sleeper -- Temazepam, because the shit is too damn weak on it's own.

And they use it in prisons. Other than that -- it's mostly just people using them to try and do home detoxes without signing up for treatment proper.
posted by PeterMcDermott at 4:57 PM on February 1, 2015 [2 favorites]


So why aren't the manufacturers of this drug out there pushing it harder? Is it because they think that most of the target audience is too poor to afford it?

I couldn't get it for love OR money when it was the only thing keeping my elderly cat comfortable. My vet would always set some aside for me whenever she could get any, because she never knew when it would be available again.
posted by The Underpants Monster at 4:57 PM on February 1, 2015


Wait, are you saying they were being given street heroin for maintenance?

The opposite. All the street heroin in the UK until the late 70's was pretty much diamorphine. Either from pharmacy break ins or diverted from people on heroin prescriptions.
posted by PeterMcDermott at 4:59 PM on February 1, 2015 [1 favorite]


According to the Times story, there have been a number of attributable deaths.

Yes, but

1) deaths reported to that system simply mean the person had the drug in their system, not that it caused the death. I could have aspirin in my system and die randomly (not of stomach bleeding) and that's suddenly an aspirin related death if reported.

2) studies show that when you introduce suboxone into a population of heroin users, OD deaths decline dramatically. France had a 50% drop in new HIV infections and a 79% drop in OD deaths. They also had a small rise in deaths associated with suboxone— again, note my chemo analogy.

Chemo certainly kills some cancer patients— the reason we give it is that it saves many, many more.
posted by Maias at 4:59 PM on February 1, 2015 [4 favorites]


But the whole impurities thing is something of a red herring. (Less so lately, as we've had a bunch of dope contaminated with anthrax that keeps coming out of stash every few years, and they sell a bit more and a few more people lose their arms or whatever) but the more common risks are overdose and BBV's.
posted by PeterMcDermott at 5:01 PM on February 1, 2015


The only people it has a real street value to are heroin addicts

I dunno, a person without a tolerance can get pretty damn high on suboxone. And it's very conveniently formulated and extremely long-lasting - though that might be a downside for some people. I agree that it isn't something you see much - I guess you can't keep it going very long.

The opposite. All the street heroin in the UK until the late 70's was pretty much diamorphine. Either from pharmacy break ins or diverted from people on heroin prescriptions.

Ohh ok, I didn't get that, sorry.

But the whole impurities thing is something of a red herring.

I wasn't thinking about the toxicity of impurities, I was talking about the difference in potency between batches as an overdose risk.

Only if you've got a habit the size of a mouse (or more likely, no habit at all.)

Going directly and immediately from long-term, regular use of a full agonist to suboxone will cause precipitated WDs. But many/most people can get away with a quicker transition after a shorter binge, and it's pretty much always going to be easier to come down with than without. I've known people personally who do this. Some can even e.g. wait 36 hours after taking bupe, shoot enough dope to actually get (sorta) high, then go right back to maintenance when they need it. There's probably a fair amount of variation in personal physiology here.
posted by atoxyl at 5:20 PM on February 1, 2015 [1 favorite]



2) studies show that when you introduce suboxone into a population of heroin users, OD deaths decline dramatically


Yeah, that's what the article should have been about.
posted by destro at 5:24 PM on February 1, 2015


I've known people personally who do this.

"This" meaning they'll use H for a couple weeks, use suboxone to soften the landing, repeat. Or that they'll just keep it around in case they can't get real dope. I don't particularly think this is a terrible thing though.

The protocol among British treatment providers is that you have to reduce to less than 20mg of methadone a day, and then wait two days until you're in withdrawal proper before they start you on Suboxone.

Methadone->sub is kind of an outlier because the half-life is so long. For H they usually just say 24 hours or sometimes a score on the opioid withdrawal symptom scale.
posted by atoxyl at 5:36 PM on February 1, 2015


That was a very well-written and important article and I hope many people will read it, and I hope the abstinence-only crowd will finally open their eyes to the benefits of dealing with heroin addiction as a largely treatable public health problem, not criminal offence or moral failing.

I've been a heroin addict, off and on, since 2007. I lost a best friend from childhood to a heroin overdose. Ironically, right about the time my friend was ODing, I was trying my first bump of smack. I never had a chance to speak to her about it. I knew about her use and had encouraged her to get help. I thought it would be easier to find--until I tried to find help myself. Because we had lost touch for about 2 years I don't know if Suboxone was ever an option for her. When we were talking, her plan was to amass as much street-purchased xanax as possible, and hole-up in a cabin somewhere with her boyfriend, who was also an addict, and try to sleep through most of the physical horrors of detox. I don't know if she was ever able to attempt that method. If she was, it clearly didn't work. I will also never know if her overdose was intentional or not. Could have been. It is a question that will haunt me for the rest of my life.

Myself, I have only been successful getting "clean" with the use of Suboxone or Subutex (I also tried cold turkey). The first time, I was able to use a month's worth of someone else's prescription. Most people need far less buprenorphine than they think. My boyfriend at the time and I both kicked our 2-year habits by using what was supposed to be ONE MONTH's worth of pills. IIRC about 60 8mg tablets. Suboxone has it's own withdrawal, and it lasts a good long time. It is not as severe as heroin withdrawal by any measure--it doesn't feeling like your bones are breaking, you don't sweat and dry heave and shit your pants and fantasize about death the way you do when trying to go cold turkey--but you will experience a general feeling of malaise and depression for at least a month. You wake up not feeling so great, but you also wake up knowing that each day is getting incrementally better, and the experience of even a month of "normal" living, where every facet of your existence is not dedicated to the procurement of a drug just to stave of sickness and misery prior to that is a tremendous gift. It gave me the will to see it through. It showed me there was a light at the end of the tunnel.

I cannot speak to methadone treatment. I've never tried it. I have used methadone recreationally. It lasts a good deal longer than heroin or any other opiate I've ever personally tried. I understand the withdrawal is quite excruciating, but I can still see how methadone maintenance is preferable to the desperate life of a heroin addict.

I think the key to Buprenorphine withdrawal is to decrease and step down incredibly gradually. This is an extremely potent drug and thinking you can step from a half, quarter or even and eighth of a mg to nothing is a big mistake. At the end of my last detox I marvelled at how a sliver of orange dust, smaller than a pinkie-nail trimming, was the difference between me having a functional day and feeling too achy and stomach-cramped to do much.

My relapse was a humiliating defeat. If I'd had a doctor who had been a little less of a hard ass about weaning me off my benzos, it might not have happened, but I cannot blame her. She never knew I had been a heroin addict previously. It was nothing I wanted in my medical record in the entire university medical system files for all time. In any case, I chose to deal with the problem the way I did, so I accept responsibility, but I was going through benzo withdrawal, which in many ways is worse than opiate withdrawal. It makes you want to crawl out of your own skin. Light is too bright, sounds too loud, smells too strong and mostly revolting. I trembled uncontrollably. I'd jump at every sound and flinch at the slightest touch.

**Side note: PLEASE, people, for the love of God, NEVER take benzos (xanax, valium, klonopin, etc.) daily for longer than a week EVER. Originally my prescriptions were all legit and I had NO idea what I was getting myself into.**

Anyway, I contacted a drug dealer who had previously sold heroin, benzos and other drugs to me and asked for benzos. She had been able to get them before but she was out. Out of desperation, I decided to try a bit of dope to beat down the extreme anxiety and oversensitivity I was feeling. A year and half clean and there I went. Just a dime at first. Then it spiralled out of control, like it does. I was underemployed. I knew of treatment programs but they were far out of my reach financially. I had a friend who was able to sell me a small amount of suboxone each week, as was my heroin dealer, but never enough to get by for any length of time. Because my current employer doesn't test for buprenorphine, I secured a job and started working towards un-fucking my life again.
For about the first 6 months of employment I ping-ponged back and forth between heroin use and suboxone when I could get it. I felt trapped.

I've contacted the county health department where I live twice in the last few years, hoping to be put on a Suboxone program, desperate to be free from the miserable cycle of addiction. The last time I called, I told them I was pregnant and on the needle (this was a lie, but I knew pregnant women and needle users were higher priority) and was still told I would be put on a waiting list for an inpatient treatment program but that they had already exhausted their funding for the year--in March. I never heard from them again. Mind you, this county has seemingly endless resources to prosecute and incarcerate users and sellers, but nope, no money for you addicts who want to get clean.
The best they could offer me was a room where I could kick cold turkey in some facility that preached abstinence only. I thanked them but declined. I can kick in my own apartment with my own creature comforts, thanks.

Finally, I found an amazing doctor in my area who is up on the latest science, runs her own, well-respected private practice, who was very sympathetic and compassionate and continues to help me stay on the road to where I want to be. I am lucky, because I was was using and working at the same time but didn't get caught, and I was able to save up enough money for her initial fees and I have been able to pay out of pocket for the treatment and the meds for about a year. I am not ready to go off the Bupe yet, but when I do, she will be there to guide me.

Many people will snidely insist that if you have the money to buy dope then you should have the money to afford treatment. Unfortunately, it doesn't work that way. Most dope addicts live hand to mouth as a matter of course. The money you spend on dope COULD be spent on treatment but many people can buy enough dope to get them through the day for $20, $40, $60. Sure if they saved that up for a week or two they might have enough for treatment but what are they supposed to do during that week or two?

Suboxone is a gift. It can be misused, but not as much as you would think. It gives you the gift of normalcy. Of feeling not high, not sick or withdrawing but just...OK. Which is really worth more than I can say. One of the features of buprenorphine is its "partial opiate agonist" nature, meaning it blocks other opiates from making contact. You can try to relapse, but you have to go to the trouble of stopping suboxone for a while first, because otherwise you won't feel much pleasure from the dope you try to do. It's a unique and helpful safety feature in my opinion.

It isn't perfect, but it's close enough to a miracle drug for me. I don't know if I would be here without it. It is unconscionable that it is not more readily available to those in need. It is an expensive drug, although generic Subutex (without the Naloxone) is cheaper. Where I live, a Suboxone strip costs as much on the street as it does in the pharmacy. $10. Not cheap, but cheaper than dope. People just need a reliable source. They need competent health care workers to prescribe the medication and monitor its use. This has become an enormous public health care problem where I live and from what I can tell, public policy makers and law enforcement refuse to acknowledge it for what it is and continue to treat it as a moral failing, which is worse than useless, it's incredibly destructive.

Thank you for posting this and thank you to anyone who takes the time to read my rambling confessional, personal tale, but I feel that speaking of these things in terms of theory and hypothetical situations lacks the impact of hearing about it from someone who has experienced them first hand.

I've known 3 friends to die from heroin overdoses. A close friend is in prison for 14-30 years for a very bad decision made from his desperate need to get money for more heroin. Would all of these people have been better off if Suboxone had been a readily available, easily affordable option for them? Guess we'll never know for sure, but my own experience tells me that YES, they would. As for my friend in prison, a Suboxone treatment program would have cost a hell of a lot less than feeding and housing him for 14-30 years (at which point he will emerge--if he is lucky) an essentially unemployable black man in his 50s who will have few options for material survival and may return to the drug trade or other criminal activities....ARGHHHH! But, uh, I digress...

Incidentally, I am white (not that it matters, really), female, college educated, and didn't try heroin until I was in my early 30s. I had never been addicted to anything. Never smoked cigarettes. Drank only socially. No one expected me to become a junkie, least of all me, but when you're there it doesn't matter. The only thing that matters (if you want it) is how to get out of it. Medical science has provided a truly effective way of giving people who have become non-functioning slaves to heroin a path to freedom. It is completely insane that every effort is not being made to see that this breakthrough is made available to anyone who wants it.
posted by apis mellifera at 6:28 PM on February 1, 2015 [72 favorites]


I think meta is done here, no?
posted by clvrmnky at 6:59 PM on February 1, 2015


I understand the withdrawal is quite excruciating.

That's another of those junkie myths. It's no more or no less excruciating than any other opiate withdrawal. It lasts a little longer, but not significantly so. But people attribute all manner of things to it because they usually encounter methadone much later in their opiate using career, so they're comparing their withdrawals from methadone to those really easy ones that just last a few days and have a few sniffles.

My personal rule of thumb about opiate withdrawal is you can do it fast or you can do it slow. You can use medication or not. But the total amount of discomfort you're going to suffer is a constant, so you pays your money and you takes your choice.

I don't know why we spend so much time obsessing about withdrawal. That's the easy bit.

Methadone->sub is kind of an outlier because the half-life is so long


Sure. It's kind of unusual in the UK though, to come across a heroin user who isn't dependent on methadone. We've got an aging population, most of whom got into it in the 80's, and during the aughties, we had a huge expansion of treatment -- which mostly meant MMT. Which actually led to drug treatment becoming politicized for the first time ever, with our current government looking to the retarded US treatment providers (as opposed to science) for how they should be doing it.

When our treatment providers see 'new' opiate dependent people, they'll tend to push them straight to suboxone, but those tend to be rarer than hens teeth. Heroin and crack use is associated with old, poor people here now.
posted by PeterMcDermott at 8:01 PM on February 1, 2015 [2 favorites]


This is such a tight little ball of myth and misinfo that I feel I should address it directly.

OK, frankly, this is news to me. It has always been presented to us primarily as a means of getting off of heroin to begin with, followed by an eventual tapering-off of the suboxone. Presented to us mostly second hand, according to our addict, who tells us what the professionals tell her at her appointments, supposedly. I believe my wife has spoken to one of these doctors on one or two occasions, and that it was never suggested to her as a long-term treatment plan either, beyond the 6-month to one year point, anyway. Like I said, maybe it's money. They're un-insured. The shit doesn't grow on trees. Any business we've had with doctors or treatment centers has been pretty short-term focused on just getting this person safely off the streets TODAY.

Could it be in part because people around them have the attitude that you display in this post that they aren't "really" in recovery when they are on it, so they may as well still be using smack?

Jesus Christ, no. Where did I display that attitude? I said literally in this thread that I'd much prefer suboxone worked for this person, if it meant being on it the rest of their life. Please don't put words in my mouth. you know, I really respect you & the work you do, but please.

The DOCTORS have laid out a timeline for withdrawal -- this person has never even come close to approaching that because they are unable or unwilling to stick to the short-term regimen of taking it in the first place, as prescribed. We don't understand the doctor's rationales, because we are not in good contact with them. Our contact is at this point pretty limited, except for crazy phone calls & the occasional unannounced drop-in to use our bathroom & raid the refrigerator. We don't have a lot of input as to the options presented to this person, who is of the age of majority, and not living in our house. We don't know when we're being lied to about what the doctors said, or what happened at the treatment center, or where this person is living on any day of the week. Don't make assumptions about how I'm incorrectly dealing with my family & suggest that I'm contributing to the addiction by being misguided or ignorant. It seems condescending of you, even obliquely.

We'd do anything, but when someone is in the throes of this thing and they're unwilling or unable to make good decisions, we can really do nothing but hope. We can't will them to take their prescription drugs as prescribed, from across town, any more than you can will the sky to be green.

at least 50% of opioid addicts have a preexisting psych condition and if you don't treat that, simply treating the addiction won't work.

No fucking shit. You don't know my story, and I really don't want to talk any more about it publicly, but I may mellow out enough to continue this conversation privately, if you'd like.

Sorry to everyone else in the thread for making this about my particular situation - I'm stopping here.
posted by Devils Rancher at 8:03 PM on February 1, 2015 [1 favorite]


Blaming this kid's relapse solely on his refusal of suboxone in favor of abstinence might make for a great outrage-inducing, eye-ball-drawing article, but it's a whitewash.

I have to say, someone pointed this article out to me a few days ago, and that was my response to it as well. Anyone who's been around drug users or drug treatment for any length of time knows that there's no magic bullet -- different people have different goals, different aspirations and different abilities to tolerate things. Suboxone and subutex have been pretty widely available for almost twenty years now. They work fine for some people, they don't work for everyone.

No fucking shit. You don't know my story, and I really don't want to talk any more about it publicly, but I may mellow out enough to continue this conversation privately, if you'd like.

I don't want to speak for maias, but so often, here in the UK you come across parents don't know anything about addiction or drug treatment that all they're really worried about is to get my kids off this shit, NOW. I bet, given how much more moralistic about this stuff the US is when compared to the UK, it's easy to make the assumption.

I also don't know anyone who spends more of their free time talking to worried parents about this stuff than maias does, so I'm pretty sure she'll be mortified when she realizes that she misspoke.
posted by PeterMcDermott at 8:20 PM on February 1, 2015 [1 favorite]


Sure. It's kind of unusual in the UK though, to come across a heroin user who isn't dependent on methadone. We've got an aging population, most of whom got into it in the 80's, and during the aughties, we had a huge expansion of treatment -- which mostly meant MMT. Which actually led to drug treatment becoming politicized for the first time ever, with our current government looking to the retarded US treatment providers (as opposed to science) for how they should be doing it.

Coming from the US this is all pretty fascinating to me.
posted by atoxyl at 9:36 PM on February 1, 2015


A large part of addiction to any hard drug is addiction to the routine of using. Substitutes like suboxone allow an addict to live or return to a normal lifestyle without their drug addiction routine. It allows the addict to avoid their network of addicted acquaintances and re-start broken relationships with those that can support them in a new routine, even if they're unaware of the addiction. Abstinence often isn't an option for all of the functioning addicts that can't take time off work or explain time away to the judgmental.

It is perfectly acceptable to slowly reduce suboxone dosage over several years, so that the addict can return to normal life. It is most definitely a useful tool in the arsenal against drug addiction. It is a significantly more useful tool than any the drug war has perpetuated.
posted by bigZLiLk at 12:23 AM on February 2, 2015 [2 favorites]


FWIW, I thought this was an excellent thread--thanks for all the input--the diversity, knowledge and sensitivity to the issues of addiction and treatment--thanks
posted by rmhsinc at 12:25 AM on February 2, 2015 [1 favorite]


I have a friend who has been in a methadone program. She initially had difficulty getting them to take her, because they found out she had a job and a house, and they were inclined to see her as not being a "real" addict, I think. Her savings were gone and her job wasn't going to be far behind, but this cruel and stupid idea that "addicts must hit rock bottom" had no regard, it seems, for the possibility that someone could say hey, I better do something now, before it's too late to save anything.
posted by thelonius at 7:15 AM on February 2, 2015 [1 favorite]


This is a very good article (amazingly so for HuffPo), and dovetails neatly with my theory that most of the people who really hate the 12 Steps were forced into them either by rehab or as part of a plea agreement. AA really should be the last resort for people in recovery, not the first; even Bill W. (founder of AA) only listened to his friend from the Oxford Movement after he'd been in rehab four times and the best medical treatment for alcoholism that 1930s America had failed him each time. (It involved something called the "belladonna treatment", which may or may not have been exactly what it sounds like.) Doing a searching and fearless moral inventory of yourself is hard, making amends to the people that you harmed in your addiction is hard, and I'm not saying that as some sort of humblebrag, because I'm working my way through the steps very slowly. If there had been some sort of drug to treat my addiction, hell yeah I'd have wanted to try that, and fuck anyone who wouldn't allow anyone under a prescription for their disease in their meeting. Even Bill W. experimented with LSD as a means of getting in touch with your Higher Power. (There have been a number of promising studies in the use of naltrexone in the treatment of alcohol addiction, although it seems to be most effective in treating alcoholics with a particular gene marker. I wouldn't consider it now, simply because I know my self well enough now to realize that any drug that requires you to take it to block the addictive effects of alcohol would not work for me, because I'd "forget" to take it and drink anyway.)

Sadly, the part where many of the people in authority won't try bupe to treat heroin addicts because of their moral stance is all too plausible. (I don't know that I'd put too much weight behind the suggestion that some rehab places won't do it because it cuts into their repeat business, though, because of the long waiting lists at almost every rehab place.) I'm also disturbed by some of the cult-like aspects of some of the more hardcore rehab facilities--as if Synanon wasn't a complete clusterfuck--and wonder if this is why people think that AA itself is a cult.
posted by Halloween Jack at 8:58 AM on February 2, 2015 [1 favorite]


If we treated medical conditions like anaphylaxis the way we treat mental illnesses we'd be scolding people about not trying hard enough to breathe

Not anaphylaxis, but did you read the Eric Garner thread? People on this very site suggested Garner's ability to say "I can't breathe" was proof that he could have breathed if he'd really tried.
posted by DirtyOldTown at 9:56 AM on February 2, 2015 [1 favorite]


The reason why methadone/suboxone treatment falls by the wayside to abstinence treatment is simple: Americans do not care what works. They care which solutions sound morally superior, and there are bonus points if the solution puts the person through a terrible crucible as comeuppance for all their many failings.
posted by DirtyOldTown at 10:00 AM on February 2, 2015 [2 favorites]


my theory that most of the people who really hate the 12 Steps were forced into them either by rehab or as part of a plea agreement.

My experience is around 25 years old so I realize many things have changed, but I think there's a third group of people who have unsuccessfully used it as their only means of support. I guess this is where I see myself, anyway. Many friends and I drifted in and out of NA this way. On a bad day I knew I could probably find someone to go out [and use] with me, and on a good day I was caught up in the the unhealthy dynamics of being addicted to the program. (I don't mean that AA is a cult.)

I do think there's a particular danger for new members going it alone. If you're feeling vulnerable, spending an hour listening to people talking about getting high is precarious, and when you throw in stuff like being 13th-stepped it can be very confusing in what is supposed to be a safe space.
posted by Room 641-A at 10:10 AM on February 2, 2015 [1 favorite]


There should be a corollary to Betteridge's law, one that states, "If a headline promotes a simple solution to a problem, it is neither simple nor a solution."

You could call it the Mencken principle.
posted by fivebells at 10:35 AM on February 2, 2015


I've linked MIT professor Carl Hart's statement that "drug effects .. have less to do with pharmacology and more to do with context : the history of the user, the dose of the drug, etc.", but this experiment is worth noting :

"In Rat Park, all the rats obviously tried both water bottles, because they didn’t know what was in them. But what happened next was startling."

"The rats with good lives didn’t like the drugged water. They mostly shunned it, consuming less than a quarter of the drugs the isolated rats used. None of them died. While all the rats who were alone and unhappy became heavy users, none of the rats who had a happy environment did."

posted by jeffburdges at 4:37 AM on February 12, 2015 [1 favorite]


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