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Wednesday, December 5, 2012

23

Rich People Quit Opiates Like This, Poor People Quit Opiates Like That

Kelly Bourdet on the affluence gap between addicts on maintenance regimens (as opposed to, right, that scene from Trainspotting) who can get Suboxone ("bupe") in the privacy of their doctor's office, and lower income or uninsured addicts who are stuck with methadone and the associated hoops:

The disease model of addiction is widely perceived as resulting in a decrease in stigma. (It could be argued that popular culture's obsession with celebrity—and their high rates of substance abuse—has done more.) Yet the stigma persists, especially for people who live on the margins because of the color of their skin or the size of their income—those who stand in line at the nation's methadone clinics. While no less an "addict," a person who is on Suboxone can, if desired, entirely skirt the stigma by keeping their disease private, even a secret, including no public acknowledgement at a clinic or a 12-step meeting. As Tom points out, bupe is white-collar maintenance; methadone is for everybody else.

As Bourdet points out, there ARE benefits to the clinic approach; addicts who receive bupe are substantially less likely to attend substance abuse counseling sessions than those who receive methadone, for whom it is generally mandatory.

23 Comments / Post A Comment

Tropical Iceland

Well this is timely. I was just wondering whether there was anyone here who might know about this stuff. I'm going nuts here.

It's insane that suboxone isn't more widely available. It's a miracle drug in the truest sense. I know so many hardcore addicts who have only ever been able to stay clean with its help. Opiate withdrawal is no joke, but beyond that, long term addicts need the maintainance treatment to manage cravings and deal with the months-long effects of withdrawal. A lot of people want to get clean without the supervision of clinics and pain of meetings, but suboxone can be really hard to get because of the stigma attached to the drug still. The few people who actually get the subscriptions will trade their strips around like currency.

On the other hand, a lot of people use suboxone and methadone so they can keep using heroin occasionally. My boyfriend is recovering from a 10 year addiction the only way he can, with suboxone. On the other hand, I saw him shoot up last night, so. Sorry for the possible over share.

ranran

@Tropical Iceland Whoa, hey, hi, I would like to talk to you privately about ... shared experiences, if you might feel comfortable with that.

Tropical Iceland

@ranran
I'd like that. Madickey@bellsouth.net.

jule_b_sorry

@Tropical Iceland As someone who has a very close family member struggling with opiate addiction, please have an e-hug. It's incredibly difficult to love someone and want to help them through the addiction, while still needing to be supportive through the inevitable backsliding. Sending you some mental strength vibes!

mc coolfriend

@Tropical Iceland My opinion is that Sub is best suited for people whose addiction is largely physical, more just a dependence really. Someone w/all the attendant addiction issues might need something to be addicted to while they do their recovery (methadone I mean), plus methadone junks up your enjoyment of other opiates once you are tolerant enough of it. I do not worry a lot about people finding out I have (had) substance abuse issues though, and shame and embarrassment--having to be seen at the clinic and all--is a serious hurdle blocking a lot of people from methadone treatment. Maybe your boyfriend is not totally ready to be on Subs yet....I think about them the way I do b/c they are firstly not supervised for diversion like w/a clinic and also the effect of them is like, say....Suboxone is like a cast and very effective painkiller for your broken leg but Methadone is like unbreaking it. If you are able to manage treatment independently then a cast and a painkiller is fine, you know? And it makes a big difference whether he has a doctor and a Rx, or if he is getting them off the street. Nothing is really changed if he is getting them off the street. There is no consistency to the dosing that way either, you never know when your guy will be out, and you are still putting all your money and energy to finding dope. I am not into meetings or the whole recovery literature/community stuff either, but sometimes you need something. A lot of former addicts are so religious b/c you do, you just need SOMETHING. It is okay to have a crutch, it has a negative connotation but there is no good reason for that. Maybe some of this is a new way to think about some of the things you have to go through w/him. I know, I have All The Feelings when it comes to dope addiction so I will go on if you want too.

katiemcgillicuddy

@mc coolfriend "My opinion is that Sub is best suited for people whose addiction is largely physical, more just a dependence really. Someone w/all the attendant addiction issues might need something to be addicted to..."

This, absolutely. I had a first row seat for someone for whom this was VERY true. She went on and off suboxone for a very long time, I eventually grew to resent the stuff because it didn't do much else other than enable her problem, despite the fact that I knew it did wonderful things for others.

beams!

@jule_b_sorry same here, it's basically the hardest thing ever esp. knowing something like suboxone could really improve their chances or recovery and quality of life if it weren't for the economic barrier.

ranran

Gonna read this later, and excited to do so, but I just wanted to note that you CAN buy subs on the street, though it's expensive and you have to know the right people (...like most drugs.)

Heat Signature

Sooooo many feelings about this...as a child protective worker, I am super-ambivalent about methadone clinics, since the "substance abuse treatment" provided is minimal at best and does nothing to address the underyling issues of addiction. Because of this, it is not uncommon (anecdotally, of course) for methadone patients to use other drugs like cocaine or Klonopin in conjunction with their methadone (drug testing does happen, but positive drug tests result in minimal increases in counseling or group work). There also seems to be little focus on weaning patients off of the drug, and it's VERY easy for patients to get an increased doseage by simply reporting vague feelings of anxiety, stress, and the like, resulting in parents getting so high that they nod off and place their kids in harms' way.

Suboxone is available to Medicaid patients in our state, but is not as widely utilized since doctors require additional certification and few are willing to undergo it, resulting in long wait lists for treatment.

Sella Turcica

@Heat Signature It's easy to jump the waiting list in my state- if you are a woman addict who gets pregnant. Women are getting pregnant to get methadone or suboxone. They have a 21 day stay in inpatient, then go to the clinic until they deliver. Then they are assessed for long-term or are tapered off until they get themselves pregnant again.

mc coolfriend

@Only does it to be popular I suppose these are the same women who were getting pregnant so that their welfare check would increase back in the 90s? They never did manage to catch one of those unicorns for us btw.

wharrgarbl

@mc coolfriend You do get sent straight to the head of the line if you're a pregnant addict seeking methadone treatment, but it's because withdrawal can cause miscarriage and the long-term outcomes of methadone on child development are pretty much nil. It's done for the fetus's protection. The problem tends to be less "women getting pregnant for the methadone"--which I mean, okay, if that's your jam? it's your uterus? have fun with that?--and more the comparative lack of negative consequences (physician-supervised dose decrease, eventual discharge from the clinic) for continued drug abuse by a pregnant patient until after they deliver. It's done for the sake of the pregnancy, but it means the patients themselves have poorer treatment outcomes and higher rates of involuntary discharge post-pregnancy.

I'm sure there are some women who've pursued pregnancy as a means of restoring their access to methadone (withdrawal from that in particular is a pretty brutal and lengthy process), but...it's addict logic. You're always going to have a non-zero number of addicts whose behavior defies rational assessment or predictable models because whatever cost-benefit analysis they're using is so heavily skewed by their addiction. The answer isn't going to be "Break the system for the other 98% of people using it."

Sella Turcica

@Heat Signature I know a least 8 of the women in a program that serves about 40 people in recovery in a town of around 50,000 in upstate NY. I am finishing up my training to become a chemical dependency counselor (CASAC in NY) and worked closely with the methadone program. 20% is a high proportion of unicorns.

mc coolfriend

All the barriers to treatment w/Suboxone are artificial. Buprenorphine is not new, or exotic, or hard to come by, but Suboxone is incredibly expensive. I think its something like 10.00 a pill (strip, whichever). Medicaid will actually pay for the Rx, but not w/out special paperwork. I notice the original article mentioned that. But most (all that I have encountered) doctors that can prescribe Suboxone do not accept Medicaid; it requires a few initial office visits back to back and they are expensive, the lowest price I heard was 1000.00 for induction (the first few days and your first month rx) so I do not know where the writer is located that she got her prices from. Even the methadone clinic will not accept Medicaid for Suboxone treatment. Maybe FL Medicaid will not pay for Suboxone treatment, is what it is. Locally, at least, pain management clinics and their narcotics are much more accessible and much more affordable. (Well, that is changing due to law enforcement trends and database monitoring, but you know what is taking its place in price and ease of access? Heroin! Way to track us all into compliance DEA). Suboxone, while it does carry w/it some withdrawal symptoms, is not nearly as physically addictive as methadone or oxycodone, and it is not a long term, recurring treatment. Of course it is only being made really available to those who can pay thousands of dollars to get to it, b/c there is just that one chance to get the cash for it. Methadone and oxy/dilaudid/patch/etc users can be billed to insurance every month for years and years, and even if it cannot--and plenty of times it cant b/c most pain managements do not accept insurance, but no matter--their users WILL figure out how to pay for it because there is such addiction, and it is a couple hundred bucks, not thousands.

I am of the belief that methadone works, and the addiction IS one of the reasons I think it works so well. The dependency, I should say b/c I only mean the physical aspect. You are sort of compelled to stick w/your methadone regimen, even if you are feeling demotivated, self destructive, or craving dope b/c you will be sick w/out it. And so you are forced to dose and stay clean and well enough to function for one more day. Conversely, you can skip your Suboxone for the day if you want to get high; once your methadone dose gets stable and you are acclimated to it you can really not get high at all no matter how many days you skip.

Ellie

Too bad for all this that the disease model is wrong.

Sella Turcica

@Ellie At the risk of feeding a troll, I'd love to hear you expound on that.

Ellie

@Only does it to be popular Haha, I'm not a troll!

It is way too much to go into here in more depth, but essentially, the disease model is not a correct account of drug addiction. Compulsive drug use is governed by the same factors that influence our decisions about a great many other actions. Stopping using drugs is a decision rather than recovery from a disease.

One of the reasons that the disease model is widely accepted and supported is because of reporting bias. We only hear about the most intransigent cases of drug addiction - people who haven't had success quitting drug use on their own despite repeated attempts. These people who don't have success quitting on their own access treatment facilities, enter the legal/correctional system, and/or develop health problems, which makes us aware of them as "drug addicts." The large majority of people who have at one point in their lives fit the criteria of a dependent drug user stop using drugs on their own without ever accessing treatment, and the general public is never aware of these people as "drug addicts." (Of course, this brings us to a semantic question about whether this should play into a re-definition of "addiction," but I think that's outside the scope of what I'm saying). The factors that inspire people to quit using drugs are the same factors that inspire people to "shape up" or change their habits in other ways. These factors are most typically when drug use begins to interfere with family life or employment, when social circumstances change so that it's more socially comfortable not to use drugs than to use, and when drug use becomes financially unsustainable or impractical. Also, many people simply "age out" of it.

When treatment plans based on the disease model genuinely help people permanently recover from addiction, there's nothing wrong with that, but I think that ultimately, a better scientific understanding of how people stop using drugs will be the most beneficial to helping people in the future.

Sella Turcica

It's not the disease model that's at fault, it's your understanding of it. You aren't grasping the idea of how chronic illnesses fit into the disease model.
A person with Type 1 diabetes does not "get better," they get treatment. The treatment is insulin. If they don't take insulin, they get sick, and possibly die.
A person with addiction needs treatment too to avoid the people, places and things that led them to use. They decide, yes, a million times a day, "don't use." "Don't go by the Chore Boy in the grocery store." "Stay away from that corner." "Call your sober friend instead of your oldest friend in the world who has the best stuff." However, not every person has the tools and support to make the best decision, over and over, every day of their lives. Treatment helps make people strong enough to make these decisions. Sometimes they can't. Sometimes people die from diabetes-related complications too.

It is not legal or health problems that make someone a drug addict, it is a combination of factors, the main two being withdrawal from a substance and tolerance of it. Do you need to take more to get the same high and do you crash or get a hangover when you don't get it? That is the only definition of drug dependence we have. Yes, people who have fit this criteria can stop on their own. People reading this have stopped smoking, given up coffee or stopped doing a shot of NyQuil at bedtime. Broken toes have healed on their own and the flu has gone away without a doctor's help. That didn't make the toe any less broken.

Ellie

@Only does it to be popular Sorry to be ad hominem, but I really think it's *your* interpretation of "disease" that is at fault. The account you describe above is not in any way discrepant with a view that addiction is not a "chronic, relapsing disease" but rather that drug use is governed by the same decision making processes as other actions in our lives.

We do see drug addiction as something that people can recover from without treatment and by using only "willpower" (for the sake of argument, let's say "that some people can recover from"). We would never see diabetes, or schizophrenia, or appendicitis, as something that anyone could recover from, or manage, simply by "willpower" (decision making), without treatment.

Anne_Hedonia

I'm a longtime Suboxone user/ex-heroin addict. Hi! I'm not "outing" myself here - I try to be open about it as much as possible; partly because honesty is good for sobriety, and partly to help decrease the stigma of addiction.

Buprenorphine/naloxone (the combo that makes up Suboxone) saved my life. I am still on about 2mg/day, down from 40 (a lot, I know) when I was induced. The drawbacks are that it is so expensive - I pay around $6.50 per pill - and that withdrawal from Subs can still be very unpleasant. The 2mg level seems to be the point where most people get stuck. However, I have gone through a few days of Suboxone withdrawal, and for me (and my husband), it was nowhere near the flat-out hell of a serous heroin/opiate kick.

Those of you who still think that addiction is a matter of choice: I highly recommend reading a book called "In the Realm of Hungry Ghosts", by Dr. Gabor Mate. He does a great job of explaining the many factors that create addiction, using scientific research, case histories, and his experiences running an addiction clinic/harm-reduction site in Vancouver's hardcore Downtown Eastside area.

I wish people would learn more about addiction before expounding on its being a matter of choice, because perpetuating the myth that addicts are simply "irresponsible" or "lack willpower" is not only just incorrect, it's also a demonstrably useless approach. Not just useless - hurtful, because shame and guilt can create powerful urges to use, in the mind of an addict - most of whom already carry around quite enough judgment and self-loathing.

Dr. Mate explains this much better than I can in "Hungry Ghosts" - addiction isn't something that just happens to people with normal, healthy brains. People whose brains produce sufficient stress-soothing chemicals such as serotonin, dopamine, and endorphins are unlikely to become addicts, even if they do take drugs at some point. These are the ones who say "Yeah, I tried cocaine in college but it did nothing for me." The addict brain lacks the ability to adequately produce and/or process the chemicals that relieve stress and give feelings of pleasure and happiness. As a result, if the addict takes a substance that artificially creates that ability, the intense relief they feel can become the single most powerful thing in the world.

Imagine living with a plastic bag over your head, taped around your neck. There's a tiny pinhole in the bag that allows just enough oxygen in to keep you alive, but you spend every minute of every day feeling some level of the desperate fear and panic that come with not being able to breathe. One day you find a substance that lets you take the bag off your head for twenty minutes or an hour; after that, the bag goes right back on. The drive to keep taking that pill will overpower your ability to make intelligent decisions, even if taking the pill is illegal and hurtful to you in the long term. You WILL take that pill, again and again.

Addicted brains are not genetic, as has been thought for years - rather, they're created by situations that most often reach back to infancy. The level of stress parents feel (especially mothers) has profound effects on the development of infants' brains. If a baby is not picked up and soothed, or is hurt instead, their brain will not develop the ability to create the soothing chemicals, nor as many receptors for those chemicals.

One very interesting point: Unpredictable soothing is worse even than no soothing at all. The stress levels in infants who never know if they're going to be taken care of or not are FAR higher than infants who never get picked up, interacted with, and soothed. Human babies are born extremely dependent (think of baby animals who are born precocious, with the ability to walk and hunt from birth!). When we're young, we depend entirely on our parents for our survival - not being "loved" by our mothers and fathers, or never knowing if we're going to be hugged or hurt or fed, is not just a matter of bruised feelings. In the brain of babies going through this kind of trauma, neural connections are being made - or NOT made - every second. If we do not get the soothing chemicals most babies get while bonding with their mothers or being soothed, we do not develop the ability in our brains to deal with stress, and have a far higher tendency to become addicts later in life.

Of course, this is not the only factor that creates addiction, but it's important to know that addiction is truly a disease. You can't "will" your brain to be physically and chemically different, though it continues to create new connections. It's partly why AA and NA programs work so well - they give the addict human interactions, structure, and measurable successes, all of which increase levels of serotonin, dopamine, endorphins, etc.

It's also why addicts can't "just stop". It's also why most addicts, when asked what their drug does for them, report things like "I felt like I could finally relax" or "I had such an incredible feeling of relief". That's how it was for me, and for my husband, and for every addict I've talked to in eight years of sobriety and four of active addiction.

I hope that, as a society, we change our thinking about addiction. Instead of judging and shaming addicts, we need to see them for what they are - people whose brains developed in ways that caused them to medicate themselves. We are not "bad people", nor are we stupid or weak. We're just sick. Speaking from experience, the only thing I ever got from the constant judgment and shaming was an intense need to use drugs. Being around addicts can be incredibly frustrating and awful, but belittling them for being too weak to "just stop" is worse than useless.

Lucifer Williams

On the other hand, a lot of people use suboxone and methadone so they can keep using heroin occasionally. My boyfriend is recovering from a 10 year addiction the only way he can, with suboxone. On the other hand, I saw him shoot up last night, so. Sorry for the possible over share.literature review writing services

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