Why the three "best things" about buprenorphine (Suboxone) and methadone maintenance can be detrimental to someone who is ready to leave addiction behind for good. Includes index of resources for finding a methadone clinic or a buprenorphine provider near you.
Ah, to reminisce...
Aunt Jemima Was a Friend of Mine
For those of you who don't know what buprenorphine (Suboxone) and methadone maintenance treatment are, I discuss the theory and practice of Medication-Assisted Treatment (MAT) for opioid addiction in my Metha-Don't screed (I also touch on the perennial Suboxone versus methadone debate, if you're interested in that).
Basically, these medications are opioids, meaning that they stimulate the same receptors in the brain and body as the opiates / opioids that people are addicted to, including morphine, heroin, oxycodone, hydrocodone, and fentanyl. However, these meds have longer half-lives and other chemical properties that allow stabilization of blood levels and subjective effects that is not possible with other opioids.
In a sense, prescribing buprenorphine or methadone to addicts is "substituting a drug for a drug," and in fact some people on maintenance do abuse their meds to get high. However, maintenance meds are also far and away the most effective way to stay alive as an opioid addict; the success rates with complete abstinence are so depressingly low that I don't even like to cite specific figures for fear of discouraging people from even trying.
Today, I want to talk about my experiences on opioid maintenance, not from the cliched pro-versus-con perspective, but from a trendier, très postmodern "the-same-thing-that-makes-you-live-kills-you-in-the-end" point-of-view.
But first, fam, to reminisce. Does anyone else remember those red boxes of Aunt Jemima pancake mix (pictured above)? I think they're still around, but I haven't bought one in many moons, thank God.
For 10 or 12 months of my first stint on Suboxone (buprenorphine), that b*tch Aunt Jemima was my best friend. I'd wake up, put an acrid-orange Suboxone strip under my tongue, and as it dissolved, I'd consult the box to refresh my memory on how to cook enough pancakes for six people (so that I could eat them all by myself*).
*I'm not being cute here. I perfected making a single skillet-sized pancake that was closer to a sheet cake than your average flapjack.
I was in between jobs at the time and living back at home with my mom. Other than my daily run, binge-watching TV (see photo / tangent below), and making an appearance at the obligatory family functions, I was pretty inert. I'm someone who finds it hard to sleep six hours a night when I'm not on drugs, and I was averaging 12 to 14 hours a day during this period.
The Netflix horror series Hemlock Grove was a vampire-werewolf tale so insipid and derivative that it practically demanded mind-altering substances to get through (although Bill Skarsgård and Landon Liboiron both got naked in due course, which helped). When I'm totally clean, I rarely watch more than an hour of TV / film per week; on Suboxone, I found myself watching eight or more hours on an average day.
Eventually, I mentioned these changes to the physician who was prescribing the Suboxone.
"Oh, that's just the anhedonia of early recovery... It's normal to find it hard to take pleasure in the things that you usually enjoy. It's your brain still healing."
Except that this hadn't been my experience during previous stints off of drugs. Quite the opposite, in fact. I'm someone who will be eight weeks off of benzos and opioids - riding an enthusiasm that borders on mania - and already have a sponsor / home group, a new career plan, a fresh creative project, and a race that I'm training for.
The longer that I was on Suboxone, the more that these side effects started to bother me. I began to feel more and more like someone having the stereotyped, zombied-out Prozac / Zoloft experience. I noticed that I wasn't writing or playing the piano nearly as much as I ordinarily would have, and aside from eating sugar-laden foods and running for 90 minutes to two hours a day (!), I had little drive to do anything.
In retrospect, this makes perfect sense from a biochemical perspective. My brain's preferred method of hacking dopamine - i.e., taking exogenous opioids - had just been cut off. I was now stable on a ceiling dose of buprenorphine, which meant that I couldn't take more to feel better, either. Instead, I was stuck at "blah," and the only things that seemed to break through were pretty powerfully dopamine-releasing activities like eating high-cal foods or exercising intensely (which, as we know, releases endorphins, which are the body's natural opioids; in fact, endorphin is a portmanteau of endogenous, meaning produced by the body, and morphine).
What my doctor didn't mention was that long-term use of opioids is associated with its own anhedonia.
"I feel less alive on Suboxone"; "I lost my soul on Suboxone"; and "I'm just not myself on Suboxone" are things that addicts commonly say to try to convey what this experience is like, but ultimately, it's one of those things that can be fully appreciated only through lived experience. Being on opioid maintenance is like applying a slightly smoky, dampening filter to all of reality. Moreover, these medications dim the very cognitive and emotional faculties that one would need to recognize these diffuse, subtle changes in oneself, which further complicates the introspective picture.
As I've said before, I have complex, entangled thoughts and feelings about maintenance. I believe that the trade-off of increased chances of staying alive versus decreased soulfulness or whatever you want to call it is something that must be weighed by each person; there is no one-size-fits-all conclusion.
Maintenance can be a very useful steppingstone, and it can also be a wonderful fallback for high-stress times when full-abstinence recovery is just too difficult or risky. In my experience, however, it can also be an insidious way for life to pass one by.
Having prefaced my points as best as I can, here are my reflections on the seven-plus years of my life that I've spent on these maintenance medications.
Mixed Blessing 1: They Stabilize Your Emotions
I had a counselor once tell me that recovery was about learning to live within the 4-to-7 out of 10 range of experience rather than constantly bouncing between 1 and 9 as active addicts do. There is great truth to this, and having a maintenance medication moderate emotion certainly reins in the high highs and low lows of early recovery, both of which can drive people to relapse.
However, there is also truth to the idea that the 8's and 9's are what make life worth living. I had a friend who was a young mother who tapered off of Suboxone, and she said that in the end, she was appalled to feel how much more "present" she was with her children. I've had similar experiences with "waking up" after tapering off of these drugs; in a way that is hard to pinpoint, I felt that my relationship with reality was less clear and less honest when I was on them.
The 8's and 9's might be what make life feel worthwhile, but the 1's and 2's are equally important (more important, even, for many addicts). Without those rock-bottom moments, sometimes it's hard to manifest and maintain the desire to stay clean off of all substances, forever.
"Remember your last detox" is one of my favorite back-to-reality slogans for when I'm slacking in my recovery. The visceral dread that I attach to the prospect of returning to that abject state is a great reinvigorator of my recovery program.
When headlining Commie Karl Marx called religion "the opiate of the masses" in 1843*, he chose opiates over alcohol and other chemical refuges for a reason.
*Luckily for us, we live in the 21st century, when opiates have become the opiates of the masses.
Opioids put a warm blanket between us and reality. In addition to releasing dopamine, they quiet our nociceptors, which are the receptors in our body that are responsible for alerting us to pain.
This shielding from discomfort often has the effect of decreasing the psychological impetus for change. On maintenance, I found it considerably more difficult to motivate myself to accomplish the simplest of unpleasant tasks. Something as basic as going to the dentist to get a cavity drilled / filled might be put off for weeks or months, for example.
Looking back, I have no doubt that this was due to my brain being enveloped in artificial feel-good. Pain and anxiety have psychological utility, and dampening them with comfort-inducing drugs is a dangerous game.
Character change and spiritual growth often hinge as much on processing our worst, most traumatic moments as they do on meditating on our golden ones, and to the extent that maintenance opioids shield us from the emotional impact of such events, they can delay or preclude our breakthrough moments.
Mixed Blessing 2: They Allow You to Bypass Withdrawal
Used properly, both methadone and buprenorphine effectively alleviate the vast majority of opioid withdrawal symptoms. To anyone who has been through this iconically awful experience, this seems like the ultimate gift.
It's not just about avoiding pain, either. When you've been taking powerful depressants regularly for too long, your body starts to ramp up its production of glutamate and other excitatory neurotransmitters to keep the balance. When you suddenly stop using your drug of choice, you end up with an excess of these "upper" neurotransmitters, which leads to a state called excitotoxicity that can cause neurologic damage and possibly damage to other organs, as well. There is no doubt that going on maintenance confers substantial protection against such damage.
However, you're trading the damage from withdrawal for the deleterious effects of long-term use of high quantities of opioids, which are by no means negligible. And make no mistake - the dosages used for buprenorphine and methadone maintenance are much higher than standard pain management dosages. Moreover, because these drugs have such long half-lives, your body is never getting a break from them.
Cue endless dry mouth leading to tooth decay (there is currently a multi-district litigation [MDL] case, which is similar to a class-action lawsuit, against the manufacturer of Suboxone for negligent conduct having to do with tooth decay caused by the drug; this case is making its way through the civil system at the moment [link is to a Lawsuit Legal News entry explaining who can file as part of this suit]). There is also severe, chronic constipation to contend with, not to mention dizziness, nausea, sleepiness, headache, depression, sexual dysfunction, and doubtless many other long-term and emergent side effects.
If you read Victorian literature, then you might know that a sort of opioid wasting syndrome has long been recognized in people dependent on opium, morphine, and similar drugs. In addition to physical deterioration from not being able to digest and absorb nutrients properly due to gastrointestinal changes caused by these drugs, mental decline of a specific type and generalized, bedbound apathy were widely observed.
When I was on a megalithic dose of methadone - roughly three to five times the amount that would kill an opioid-naive adult - my memory became so poor that I began to wonder whether I was developing dementia from my two decades of benzo abuse. Opioids dim your mental processes just as much as your physical ones, and for a STEM teacher who prided himself on his mental agility, this was a bitter pill to swallow (or put under my tongue).
One of my predictions is that we will see a significant increase in GI cancers as a result of our prescription and illicit opioid epidemic. Chronic constipation and diarrhea lead to oxidative damage that can cause mutations that in turn lead to cancer, and prescribing laxatives to counteract opioid-induced constipation is an imperfect fix at best. Again, this risk of GI cancers in habitual opium and morphine users was recognized well over 100 years ago, when these substances were legal and largely unregulated. Despite this fact, I have never heard it mentioned today.
Mixed Blessing 3: Sometimes They Put Your Addiction in Remission
With Suboxone in particular, Dr. Jeffrey Junig and other physician-advocates have advanced a model of addiction remission. According to this model, addicts can bypass recovery entirely; by restoring mental and physical functions to their pre-addiction baselines and preventing maintenance patients from getting high*, the argument goes, these meds allow people to move on with their lives almost as though they were never addicted at all.
*When used properly, both buprenorphine and methadone block other opioids from having an effect, although believe me - this doesn't keep people from trying.
I have known a few people who had this kind of experience with Suboxone or methadone. Almost invariably, however, it only lasted for six to 18 months, after which the blah syndrome that I described in the intro set in.
The other danger of this kind of thinking is that it ignores the fact that addiction has far-reaching tentacles. Addiction is never as simple as using one's drug of choice. Another way to say this is that drugs were my solution, not my problem; take them away, and I am still a woefully maladjusted human with severe anxiety, issues maintaining relationships, and other problems.
Best-case scenario, if you take their drugs of choice away, many addicts move to another source of dopamine - and, in fact, drastic weight gain, compulsive gambling, and promiscuity are not uncommon in people on maintenance. Many also switch to benzos, cocaine, or meth to get high, as well.
All addicts suffer from serious defects of character; another way to put this, as I have said before, is that well-balanced, resilient, self-actualized individuals rarely if ever fall into the trap of addiction. Selfishness, emotional volatility, and self-isolation are common problems.
Again, entering physiologic remission by taking maintenance meds does nothing to correct these underlying problems. Rather, it produces the opioid equivalent of a dry drunk, which is someone who is sober but not in recovery. To be a dry drunk is miserable - often as bad or worse than being a "wet" drunk - and to be around someone in this frame of mind is equally unpleasant.
Just to be clear, I'm not saying that people on maintenance can't make these necessary changes; some probably do. But the psychological impetus to do so is drastically reduced by the artificial well-being and stabilization that maintenance meds provide. The 12-Step Programs of AA and NA caution against looking for an "easier, softer way" out of addiction, and I can't help but think of opioid maintenance when I hear that phrase.
In Conclusion
Much of what I said above can be distilled down into two statements:
Buprenorphine and methadone maintenance induce an artificial well-being that belies the necessity of deep character change, trauma processing, and spiritual growth;
Opioids are by no means harmless drugs in the long term, particularly when used at high dosages; there are significant cognitive, emotional, and physical side effects, and there is the potential for organ damage, as well.
Ultimately, I decided that maintenance was a useful steppingstone between active addiction and complete abstinence. Past the honeymoon period, the efficacy of maintenance began to wane; plus, I wasn't okay with the trade-offs attached to indefinite usage.
When I remained on buprenorphine or methadone for longer than a few months, these drugs became a sort of Sword of Damocles hanging over my head, suspended by a horsehair - waiting for the slightest perturbation to come crashing down upon me.
If you're interested in buprenorphine maintenance, I highly recommend that you check out the injectable formulations, which last for several weeks. I've compiled a list of U.S. provider directories for various forms of maintenance below for those of you who are seeking a buprenorphine or methadone provider near you. As always, feel free to reach out with additional questions.
Stay safe! Thanks for reading. B.
Provider Directories
*Brixadi is another injectable formulation that you might want to look into
*In certain states, you might be able to obtain buprenorphine by e-consultation. I recommend avoiding this whenever possible because A) these doctors tend to be more expensive, and B) I have heard about too much sketchiness tied to these providers. Very few ethical clinicians are willing to dole out buprenorphine without seeing you face-to-face and drug testing you randomly.
*Includes methadone clinic listings
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