Several years ago I worked with an intelligent, sophisticated couple who were addicted to heroin. Month after month they struggled to stop, but over and over they found themselves “chasing the high” by taking larger amounts of intravenous heroin or scoring smaller amounts to keep themselves functional. Finally, they moved abroad and lived in an isolated commune. Initially they went through a difficult and painful withdrawal but then lived a drug-free life for over a year. Having the sense that they had finally mastered the addiction, they returned to the United States. Upon arrival at JFK airport, they could think about little else than heroin. They broke into cold sweats, goose bumps erupted on their skin, and they both had to run to the bathroom with diarrhea. They hadn’t used drugs for over a year, and yet the mere access to their old lives stirred cravings so intense that they had the classic signs and symptoms of opiate withdrawal. Within hours they had returned to their lives of addiction.
I don’t know what happened to them after I moved to Martha’s Vineyard 18 years ago, but today they would have the relatively new option of taking buprenorphine (Suboxone and Subutex). Suboxone, like methadone, heroin, oxycontin and several other medications, is an opioid. But there are a few key differences. The most important is that it is legal for specially licensed physicians to prescribe to opiate addicts so that they don’t need street drugs. Suboxone binds so strongly to the opiate receptor that once an addict is on it, drugs like heroin or oxycontin have minimal, if any, effect. Suboxone lasts a long time, blocks craving, and doesn’t typically induce a high. And it often decreases craving for alcohol and other drugs.
Overdoses from opiates like heroin and oxycontin kill more people than firearms or car accidents. An American dies every 19 minutes from an O.D. In recent years, we have had several deaths from overdoses on Martha’s Vineyard. The relative risk of an addict overdosing from suboxone is miniscule. Had those individuals who died been on suboxone they would almost certainly be alive today.
Yet, there is considerable debate about whether replacement medications like suboxone are a crutch that allows drug users to substitute a legal drug for an illegal one. Most of my suboxone patients are living sober, healthy lives. But all too often they struggle with whether to keep their treatment secret from their doctors, families, and 12 Step sponsors out of fear that they will be judged and shamed by people who consider their sobriety a sham.
In studies of people who are maintained on adequate doses of long-acting opiates like methadone and suboxone, there is less use of other drugs, less criminal activity, and more engagement in work and family. Legal replacement medications allow addicts to live healthy and productive lives.
The down side? Suboxone can be as hard to get off of as heroin. Some people divert their medications — that is, sell their supply on the street. Replacement medications like suboxone decrease the motivation to get completely clean, and they require the prescribing physician to be vigilant about abuse, diversion, and other drug use. People taking these medications are dependent on the prescriber for as long as they are on them, and they must get urine screens.
Suboxone is not for every opiate addict. The people I see who are on suboxone are generally motivated, hardworking, and committed to sobriety. They tend to have occupations and families, and most have gone regularly to 12-Step meetings.
Despite the fact that individuals on Suboxone are by and large responsible, sober, moral members of society, many feel that they cannot tell their families, employers, fellow alcoholics or Narcotics Anonymous members about their use of suboxone. Many feel stigmatized by their pasts and ashamed of the need for suboxone. That sense of shame is reinforced by people who judge them because of a lack of understanding. Judgment about people who seek help for other neuropsychiatric problems such as depression seems to be fading. Hopefully, the time will come when the judgment toward individuals who need medication for their addictions will fade as well.
Dr. Charles H. Silberstein, a psychiatrist, practices at Martha’s Vineyard Hospital.
