About the Rash…

Hi Cindy,

I haven’t been to the other site (suboxforum.com) yet, so I don’t know if anyone has answered.  I have treated over 100 patients and have not yet had a person develop a rash.  That doesn’t mean it can’t happen, but it does suggest to me that it is uncommon.  The rash does not sound typical of drug reactions, which usually start on the face and chest and then spread from there.  The spots– what are they like?  a drug rash usually would have red spots that are small but that can eventually join together to make the whole area look red.  They often itch.  A drug rash would not look like pimples, or bumps with ‘white heads’ (which are from pus)– those are more consistent with impetigo, which is an infection.

Try using google images and search for ‘drug rash’ or ‘allergy’– I haven’t done it yet but I bet you will find pictures of typical allergic drug rashes.  If you do have a rash from suboxone the first thing to do would be to change to subutex.  There is a good possibility that you are actually allergic to naloxone, not buprenorphine.  If you change, I would give it a good month before drawing conclusions, as it sometimes takes a long time for an allergic rash to go away after the stimulus is gone.

If subutex doesn’t help, hopefully you have an understanding doc who is willing to give you methadone for awhile to see if the rash is in fact due to buprenorphine.

A rash from Suboxone

I moved this post to a fresh discussion, so that it gets more attention.  Please post it at suboxforum.com also, if you haven’t already.

Cindy | mdyer78@yahoo.com | IP: 209.165.254.251

Ever since taking suboxone I have had a rash all over my pubic area which has now spread all over my body. Has anybody or know of anybody that has had this kind of reaction to suboxone? Please let me know if this is one of the side effects!

Very worried suboxone user,
Cindy

Mar 28, 12:01 AM

Why not just take narcotics for my chronic pain?

I received a letter today– a person discussing the use of opiates by a family member with chronic pain.  I was not sure if the letter was asking questions about my opinions, or was instead arguing that my ideas were off-base.  In either case it is worth publishing, as several topics are discussed.  As per usual, the names were blocked to keep things confidential.

Here it is, with my answers inserted at the paragraph breaks:

Why is it wrong to take pain medications for pain?  Especially if you have INTRACTABLE CHRONIC PAIN, what is there because detox.

Medications for pain are not ‘evil’—the only way I approach the issue is from a quality of life position.  There are many problems with pain meds as they are now.  At some point I expect we will find a way to avoid tolerance to opiates—that will truly revolutionize pain treatment.  But as things are now, tolerance is the basis for the problems with chronic use of narcotics for pain.  Any person taking narcotics, either for pain or for ‘fun’ (although there is nothing fun about opiate dependence after the first few weeks), will become tolerant to the effects.  The medication will become less and less effective, requiring increases in dose to get the same pain relief.  The dose cannot be increased forever—eventually the patient would be chewing on pills every minute of the day—and so the doc must limit the pills.  If I give enough medication to satisfy a person who is 40 yrs old, what will I do when the person is 42 years old?  Tolerance develops very quickly—this leads to tension between doctor and patient, and eventually the patient takes too many and asks for early refills.  This annoys, angers, or frightens the doc, who therefore eventually stops the narcotics or quits seeing the patient.  The patient, meanwhile, thinks he is being deprived, and gets mad at the doc, mad at all docs, and mad at the world.  Finally, pain meds get inside the head of everyone who takes them, whether they are being taken legitimately or not.  The patient becomes more and more focused on the meds, getting the meds, the pain, and the withdrawal.  Relationships suffer.  Depression develops.  The patient eventually becomes a one-dimensional shadow of who they once were, where the biggest relationship in the patient’s life is the relationship with the pain pills.  I have seen this all happen many, many times, with every patient who takes narcotics.  I do treat with opiates, but I do tell the patient all of this, so they understand what they are taking on.  This is why opiates are always the last resort.  Any good pain doc will tell you that they have seen patients who complain of terrible back pain, who ask for narcotics repeatedly and think they need them…  who get detoxed for some reason and after getting past the withdrawal are surprised to find that the pain is gone, or very small.   I have seen it many times, and I cannot explain it, other than the body trying to trick the person into thinking he needs pain pills as part of an addictive process.

For cancer pain, by the way, none of this is relevant—with a limited life span the doc should just give what is needed to control pain.  But for non-malignant chronic pain, I have never seen opiates improve a person’s quality of life in the long term.  And I have seen many lives destroyed.  The patient may not see it—he may insist things are great on the pain pills, even as his marriage falls apart and his kids disappear.

Why would you want to withdraw, if the pain was being controlled and it lowered your blood pressure?

We have plenty of ways to lower blood pressure—narcotics should never be used for that purpose, except in the case of acute myocardial infarction, when morphine has a number of helpful effects including lowering blood pressure.

What if the patient was limited, and could not do alot of physical therapy to get the benefits of endorphins to work for them.

Patients can do much more than they think with physical therapy.  They need to be taught patience, and they need to work at it every day at home—not only at the therapy center.  Physical therapy is so valuable—but patients generally look for short term solutions.  That is unfortunate.  As far as endorphins go, I caution people against getting wrapped up in thinking about what their brain chemicals are doing.  It is much more complicated than magazines suggest–  endorphins, for example, do many things besides pain control—including things that have nothing to do with pain.  Yes, they have been shown to be released by exercise, but… so what?  We don’t know if that release actually does anything helpful for people.

Like you said, there is a difference between dependency and addiction.  My family members suffer from chronic pain due to chronic pain conditions, that we were either born with or developed.

There is a difference early on, but over time the differences go away.  A person who I see for a congenital pain condition who takes loads of narcotics has very few differences with a person who started pain pills ‘for fun’ and who takes tons of narcotics.  If anything, the addiction is worse in the pain patient, because they are convinced they need the pills, and cannot see the destruction they are causing.  A person who starts ‘recreationally’ is more likely to truly hate the pills, and is often willing to go to greater lengths to get off of them.  That person hates the pills, where the pain patient thinks he loves them.

So, intervention should come, if I am just lying around getting HIGH in a chair, like the rubbish I have been reading.

I don’t know what you mean by this sentence.  If you are referring to addicts as ‘rubbish’, you are off base.  Yes, some addicts have bad characters, just as some non-addicts have bad characters.  It sounds like you see a difference between ‘good people’ on pain pills and ‘bad people’ on pain pills.  That difference does not exist.  Over time, any person on pain pills becomes a slave to them, and desperately wants to be free from them.  For some people, it takes longer to seek freedom; some people never seek it.   I can assure you, though, that opiate addicts are not sitting around enjoying themselves—not after they have been doing it for a few months.  They are scrambling for money to get something to avoid being sick—stealing, prostituting, whatever.

OR should it be, I take the pain meds, and I can walk around in the house, function a little better than suffering in pain.

That is your decision.  But it is more complicated than you would like to believe.

I wish you the best, and hope things work out.

Jeffrey T Junig MD PhD

Parole Officer demands stopping subox

This is irritating– a person is stable on suboxone, employed, turning their life around… and their PO from the case over a year ago wants them off ‘that drug suboxone’. Un-F-ing-believable. My letter to the PO:

I treat XXXXXXX for opiate dependence. He and I have arrived at a taper schedule as you requested. I do feel obligated, however, to let you know that tapering off suboxone is not appropriate care for his opiate dependence.

I have no shortage of patients on suboxone– I am always at the 100-patient limit, and there are always people waiting in line if a patient leaves my care (The most common reason for stopping suboxone is pregnancy). I have no financial incentive to keep XXXX on suboxone; if anything I will be paid more for a new patient taking his place. I have a great deal of experience with addiction; I treat some patients with suboxone, and others by different techniques, depending on their personality, addiction/treatment history, and circumstances. I have treated about 150 patients with suboxone over the past two years; other patients were treated by myself in outpatient therapy, or referred to residential treatment.

I remain current with the standard of care for addiction. I am the Medical Director of XXXXXXXX, a residential and outpatient AODA treatment center in Wisconsin. I am Assistant Clinical Professor of Psychiatry at the Medical College of Wisconsin, where I teach medical students and psychiatry residents. I do the teaching of the addiction section of the mental health/behavior block for medical students. In the case that you do not accept my opinion on the matter, you can easily find ample support for the use of buprenorphine for long-term maintenance of remission of opiate dependence. I suggest starting at ASAM, the American Society for Addiction Medicine: http://asam.org. The president of the organization, Dr. Michael Miller, practices in Madison Wisconsin and is a strong advocate for the use of buprenorphine and Suboxone.Despite efforts to educate physicians and the public, there are a number of misconceptions and prejudices about Suboxone. The active ingredient of Suboxone, buprenorphine, has a distinct mechanism of action at the opiate receptor that is unlike the effect of oxycodone or methadone. After two-three days of use a patient on Suboxone feels no effect from the medication– no ‘high’, and no sedation. A patient on Suboxone cannot get an effect from any other opiate. The action of Suboxone that sets it apart is the effective relief of craving for opiates, which in effect induces full remission from active addiction. Patients on Suboxone are relieved of the terrible obsession that keeps them from moving forward in life. My patients include attorneys, physicians, nurses, prison guards, and factory workers, all grateful to have opiate dependence out of their lives.

There are certainly cases where total sobriety is favored over Suboxone. It is important to realize, however, that even with thorough, residential treatment, the relapse rate for opiate dependence remains well over 50%, much higher than that of other substances. Patients who maintain sobriety through 12-step meetings can expect to have cravings for the rest of their lives. I have had a number of patients tell me that traditional recovery kept them clean and feeling like a ‘recovering addict’, whereas suboxone made them feel like a person who was never addicted in the first place. The role of meetings and therapy for patients on suboxone is debatable, as the relief from the obsession to use allows good character to return. Most of my patients are working and doing well in life– as is XXXXXXXX.

The best way to understone Suboxone treatment is to compare it to treatment of hypertension. Like opiate dependence, high blood pressure is in part genetic, and in part caused by behavior (diet, smoking, lack of exercise, e.g.). We cannot ‘fix’ the defect in hypertension– which is a brain abnormality that causes a faulty ’set-point’ for blood pressure. We instead artificially dilate blood vessels and weaken the pumping of the heart with medication, and the pressure drops. If we stop the medication, the high blood pressure is still there. The medication causes ‘remission’ of the high blood pressure– not a cure. Likewise, opiate dependence is in part familial and in part behavioral. We have no cure– no way to eliminate the obsession to use that characterizes addiction. But we now have a medication that will induce remission of that obsession. The comparison does not stop there– with both hypertension and addiction, we have non-medical ways to treat the diseases, using the power of the mind. For addiction, the person can work hard to drastically change their mind through hours and hours of treatment and life-long meetings. For hypertension, a person can use biofeedback and meditation to control their blood pressure– can you imagine how effective it would be if a patient put the same effort into it that an addict puts into meetings and treatment? Of course, we would never expect a person to go to that effort to control their blood pressure when medication is available… and yet we think of an addict very differently, and consider medication to be the easy way out. Yes, it is hard to get off suboxone…. Just as it is hard to get off some blood pressure medications, which cause ‘rebound hypertension’ when they are stopped.

As I said, XXXXX is prepared to taper off suboxone, as he has no choice. He will have life-long cravings that will at times occupy his mind and make him irritable. He will place himself at risk of relapse, which could land him in prison or even kill him. As his doctor, I have to wonder about the sense of that, particularly when he is being forced to deviate from the standard of care and face these risks because of someone else’s misconceptions and biases. I used to have similar misconceptions when I read the first studies about suboxone– after all, I treated my own opiate dependence by hours and hours of outpatient sessions and meetings, and then after ten years I treated my relapse by over three months away from my family, in residential treatment, followed by hours of groups and more meetings. The treatment was effective, but I lost my career as an anesthesiologist along the way, and almost lost my marriage and my life. And yet I was lucky– many people in the same position don’t survive. Thank goodness we have progressed to a point where almost everyone can be saved, treated to remission, and go on to live productive lives.

Sincerely,

Jeffrey T Junig MD PhD

Fond du Lac Psychiatry

Wisconsin Opiate Management Center

New Suboxone Forum

I invite anyone with an interest in Suboxone, either for one’s self or for someone else, to visit the Suboxone Talk Zone Forum at http://suboxforum.com . You can read posts without registering, but please register and take part in the discussion! You do NOT need to provide your real information to register– invent a good screen name and you will be all set before you know it. I hope to see you there!

Induction, Relapse, Benzo Questions

Some questions about the induction process and my answers:

If I try to just take the oxycodone for a period of time prior to meeting with you would that eliminate some of the problems and complications associated with the transition from methadone to suboxone? If I took only oxycodone for 4 days or 6 days might I be able to go directly to suboxone without that withdrawal period?

Yes, it is helpful to change from methadone to oxycodone for a stretch of time. Methadone is highly protein-bound, and takes forever to leave the body– I like people to be off methadone for at least 4 days, whereas 24 hours off oxycodone is usually sufficient to avoid precipitating withdrawal with suboxone. There is no way to avoid withdrawal completely, however, as a person must be in a bit of withdrawal at the time of suboxone induction. Otherwise the person will get very sick.

Would I be feeling well enough by (specific date) to be physically comfortable enough to be a joy to be around or will I still be suffering? I believe I will need some help just with the driving alone…

Some people start suboxone and go to work later the same day– it depends on the person’s individual ability to handle the withdrawal, and on their tolerance to opiates. A person who takes less than 40 mg of methadone per day (or the equivalent dose of oxycodone) will generally have no problem adjusting to suboxone. I have done inductions on people taking well over 100 mg of methadone per day, and they do OK as long as they have gone without methadone for a few days. If you can change completely to oxycodone and avoid methadone for a few weeks before suboxone, you will do better.

In addition to the methadone I have also been prescribed Clonazopam (a benzodiazepine) that I take with the methadone. I take 3 to 4 mg a day. Can Dr. Junig prescribe me that or a different one and get me tapered off the benzo’s? I really want to be clean and sober as I once was… I stopped going to meetings and I had gone to over a thousand during that time and was pretty darn healthy in all ways; but after I stopped I picked up a drink and eventually narcotics again.

Clonazepam is a dangerous med for anyone with a history of addiction. The tolerance that develops makes the drug helpful only for short-term use, for the most part. I will prescribe it sometimes for a person who is taking the proper medication for anxiety (like prozac or effexor) but who still has breakthrough anxiety, as long as the dose remains stable. 3-4 mg is a high dose, and I would want to try to taper that down a bit if possible.

The part about the meetings is typical. Opiate dependence is a long-term affliction—life-long for most people. People contemplating suboxone have two choices: life-long medication, or life-long meeting attendance. At this point there is no cure. Addicts who stop going to meetings eventually go back to opiates, for the most part. Likewise, it is important for people who stay sober through the 12-steps to avoid all intoxicants. Use of a different drug often results in ‘cross-addiction’ to the different substance, which then often leads back to using the drug of choice.

More Suboxone Information at subox.info.

 

 

Suboxone Use by a Health Professional

A reader writes:

I have been taking Suboxone for 2 months now and it has changed my life! I finally feel a freedom I haven’t felt in over 30 years! I am a nurse and am able to work around and administer narcotics with absolutely no thoughts, urges, or cravings…a miracle for me. BUT, the hospital I work for has just informed me I cannot be taking suboxone while employed there.

I am just in shock. Is there any recourse for me? Are there any laws protecting my disease/disability medical management?

I feel it’s like being told I can’t take my insulin if I were diabetic.

Any suggestions?!

Ouch!

I have been watching to see what position the various Licensing Boards take on suboxone. I did not expect to hear of such a silly demand by an employer– particularly an employer that supposedly has an interest in keeping people healthy.

If you read some of the forums out there you will come across this statement: “We need our doctors and nurses to be 100% on their toes– would you want your surgeon to be on suboxone?” My answer, of course, is YES– particularly if he/she has any history of opiate dependence. I want his/her mind 100% on my surgery… not on the last meeting they went to, not on the meeting that they need at the end of the day, and not on the narcotic prescription that they will write after the surgery If they are taking suboxone, then I know that they are essentially ‘normal’– they are not having cravings, they are not sedated, they are not ‘high’– they are the person that they would be, if they were able to dissect out their opiate addiction.

For our nice nurse, I wish that you could go and hire the best employee-rights attorney in the country, and sue the hospital for wrongful termination. In fact, as I think about it, I wonder if they can even make such demands. Can a hospital threaten to fire a patient for taking antidepressants? If not, how can they threaten to fire you for taking suboxone? They would have to claim that it somehow impairs you from your job– and how could they do that? As anyone taking suboxone knows, once you are used to the medication there is no significant effect from taking it.

I actually DO have a great attorney for this type of work. The problem is that lawsuits cost money. I will send him an e-mail and see if he has come across this issue before. In the meantime, don’t do anything drastic. You may want to consider drafting a letter that threatens to go the the EEOC over the issue. They cannot fire a person for having a protected disability, including addiction (they can fire a person for behavior, or even risk of behavior, related to the addiction– but if the addiction is only a ‘past’ issue they can’t hold it against you).

Stay tuned…

More Suboxone Information at subox.info.

Long-Term Effects of Suboxone

A note from a reader with a question about Suboxone:

Suboxone has really worked for me in getting off vicodin. But I have been unable to stop taking suboxone. It occurred to me recently that this may turn into a lifelong dependency. If so, what are the long-term side effects of suxone?

Thanks so much,

A

My Answer:

Hi ‘A’–

Suboxone really is best thought of as a long-term, perhaps life-long medication. Your attachment to pain pills will in all likelihood be life-long as well; most people who stop suboxone are surprised at the cravings for opiates that they have. I don’t think suboxone increases the cravings at all, but rather it is just so effective at eliminating them that people forget how attached to opiates they once were. I generally recommend that people stay on suboxone ‘forever’, or until something better comes around– they are much safer on suboxone, as it helps them avoid an impulsive relapse that can put them in jail, kill them, etc…

We do not know of many long term effects from suboxone. Long term opiate use in general can lower testosterone levels in men and cause things from that, like reduced sex drive and I suppose even infertility. I assume that buprenorphine will do the same. There are the other short-term side effects that over time become long-term side effects– dry mouth (which long-term can cause an increase in tooth decay), constipation (which could lead to hemorrhoids, diverticulitis, anal fissures or perirectal abscess), sweating (which could lead to… problems dating?). The opiate antagonist naltrexone can cause liver damage, and it is related to naloxone, which is a component of suboxone– in general the naloxone does not get absorbed, and so the chance of liver damage is likely minimal. It may be a good idea to check a set of labs once per year, though, to check the liver, kidneys, thyroid, and blood cell system, just for safety’s sake.

Probably the worst thing about long-term use is that some docs insist upon keeping everyone on suboxone in endless therapy. I do not think that therapy is generally required, and I do not think that ‘forced therapy’ is very helpful. But it is hard to find a doc who will treat with suboxone as they would treat with any other treatment for a chronic condition– that is, to prescribe the medication without placing a number of other requirements on the person.

I hope that answers your questions–

Take care,

J

More Suboxone Information at subox.info.

 

 

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I’m Not Like ‘Those People’

A recent letter and response that addresses the ‘terminal uniqueness’ issue:

Hi and thx for getting back to me. I have never tried anything to get off of these pills. I am not your stereotypical addict. Truth be told I have never been addicted in my life. I feel like such a loser for letting myself get out of control and if it was not for being sick I would have licked this a long time ago! I am not off them right now because I cant. I work hard all day to support my family and there is no time to be down and out. I have also suffered an incredible string of losses over the past two years. What a predicament huh? I lost my wife two years ago, and the story goes on. I have chronic back pain from degenerative discs, but I will deal with that. Will suboxone do anything for me?

My response:

I have a couple things to say that may come across as ‘brutally honest’—don’t take it personally, but rather understand that EVERY person who gets stuck on opiates has a unique story, and we all were reluctant to see ourselves as ‘stereotypical addicts’. There is a term in addiction—‘terminal uniqueness’—that refers to a state of mind that is common with addiction, and which keeps people sick. A frequent refrain by a person new to a treatment center is ‘I’m not like those people’. The fact of the matter is that one rarely sees a ‘stereotypical addict’ at treatment. What one sees are teachers, dentists, single and married moms, college students, high school students, people with back problems or fibromyalgia, people who have been through terrible tragedies… So try to avoid seeing the things that make you unique. Instead, try to see the things that make you like everyone else—the horrible feeling of being trapped by something, when you have always handled things well up until now. That is how most people who are stuck on opiates feel—trapped, embarrassed, ashamed, angry… and afraid. Others don’t feel anything because they repress all of their feelings and put up a fake, cocky exterior. That is what denial is all about.As an aside, I own the domain name ‘terminaluniqueness.com’– I will be advertising a book through there eventually… I hope…. But if you search under ‘terminal uniqueness’ you will find a number of things written by recovering people.

J

More Suboxone Information at subox.info.