Suboxone, a New Treatment Paradigm

By: Jeffrey T Junig

Suboxone is a relatively new medication for opiate dependence that will result in a sea change in addiction treatment. Physicians currently prescribing suboxone are aware of the usefulness of this medication, and news of the medication has reached 'the street' to such an extent that opiate addicts often call addictionologists and ask for the drug by name. Word of mouth is spreading the news about suboxone without the benefit (or need) of television commercials. My experiences with suboxone make me wonder if we are at the verge of an entirely new approach to opiate addiction, and in turn to other addictions as well.



The traditional approach to drug addiction treats all substances as essentially the same. Yes, the addict does develop a 'love relationship' with his/her substance, but the substance's sister, brother, aunt, or uncle can easily step in and take the place of the drug of choice in a process called 'cross addiction'. This is one reason why traditional treatment demands sobriety from ALL substances, but there is a more complicated reason as well. The addict, over time, becomes hyper-aware of his/her mood, comfort level, and anxiety. The addict constantly 'checks in' somatically, asking 'am I going up? Or 'am I (oh no!) coming down? Every bead of sweat may portend the pain of withdrawal. Every ache is a new excuse to use. The addict takes comfort in the '4-hour schedule' of use; an internal clock becomes all-important, and eventually the only thing that really matters. Sobriety and recovery demand that the addict learn to take life on life's terms, and give up the obsession with symptoms and medications. Sobriety will 'extinguish' the learned obsession with symptoms over time-sometimes a great deal of time. As the obsession fades, the addict takes steps away from relapse. But if the addict uses a new substance that changes perception, even a substance like diphenhydramine that is not addictive, the old attention to feelings and symptoms returns. Many addicts are aware of an 'addict' frame of mind and a 'sober' frame of mind; a drug that causes the addict to look inward and focus again on symptoms can trigger the addict mindset to re-appear. And once the addict is back, it can be very difficult to return to the mindset of sobriety.

The need for total sobriety no doubt keeps some addicts from asking for help, and there are other addicts who ask for help but simply cannot maintain sobriety from all substances despite multiple trials of treatment. To widen the appeal and utility of addiction treatment, other treatment models have appeared, including an approach that has been called 'harm reduction'. The harm reduction approach helps the addict find ways to reduce his/her intake and so reduce the harm that inevitably results from heavy or uncontrolled use. By introducing 'drink counting' and other behavioral techniques, harm reduction has similarities to cognitive therapy. Regarding the various traditional treatment approaches, there are patients who would clearly do better in one vs. another approach, and there also patients who would benefit from either approach. Specifically, some people use or drink in an almost nihilistic fashion-every episode of drinking characterized by drinking to total oblivion. I would favor complete sobriety for these individuals, because the cognitive changes made in treatment will likely be obliterated by the first drink. On the other hand, a patient with a 20-year long smoldering addiction facing his first DUI may be a good candidate for a harm reduction approach. In such a case, alcohol is a major part of the addict's personality, and the idea of total sobriety after one offense would be a difficult sell. But with education about changes in tolerance with aging, and an introduction to drink counting, the patient may do well for another 20 years.

There are problems with traditional treatments, beginning with the simple observation that relapse rates have always been high. The high relapse rate has implications for addiction that go beyond treatment methods, as I will explain later. Another problem with traditional methods is that they require significant motivation from patients--motivation that must be accessible over and over throughout patients' entire lives. Finally, some degree of detoxification is usually required before tradition treatments, requiring expensive medical services that may be far removed from the treatment center. The specter of detox and withdrawal are major roadblocks to treatment. Withdrawal is a unique experience, difficult to compare to other dysphoric experiences. Physical symptoms include headache, fatigue, nausea and vomiting, abdominal cramping, diarrhea, and muscle spasms of the legs that result in involuntary movement. The withdrawing person usually feels profoundly depressed and anxious. Even in situations where there is no chance of access to drugs, the addict feels the desperate need to use. The description of these symptoms does not do justice to the misery experienced by the withdrawing opiate addict. I also suspect that memory has a 'kindling' effect on withdrawal such that symptoms become more and more severe each time withdrawal is experienced, so that eventually there is no such thing as 'mild withdrawal'-the addict experiences withdrawal as severe as any experienced to that point, regardless of the degree of tolerance going into the withdrawal episode. Addicts who have suffered through severe, unmedicated withdrawal have a sense of camaraderie akin to disaster survivors. Camaraderie is nowhere to be found during the withdrawal experience, however, and the addict feels completely alone.

There have been alternate treatment models for years that are less dependent on character modification and more reliant on medication. Opiate maintenance with methadone and opiate blockade with naltrexone are two treatment approaches that are not dependent on the 12-steps or cognitive therapy that may be used alone or in concert with traditional treatment. Methadone and naltrexone treatments are diametrically opposed to each other in several ways, but have some things in common as well. Methadone maintenance creates deliberate 'hypertolerance' to opiates in the addict by providing very high daily doses of opiates (usually methadone). The high tolerance prevents recreational use of opiates, and the high daily dose of methadone serves to treat opiate cravings. Patients in methadone programs often feel trapped, in that withdrawal from such high doses of methadone is extremely difficult, and any violation of the rules of the clinic (or problems paying the high cost of treatment) result in dose reductions. People maintained on methadone often claim that they always feel 'high', no matter the tolerance that develops. And while high doses of methadone will satisfy cravings for a time, eventually the tolerance will catch up and cravings will return. There are other problems with methadone; some users claim that methadone results in a lack of motivation to better themselves through education or employment. For decades, methadone maintenance was associated with blighted urban areas, where addicts could line up each morning for their daily 'fix'. There have been recent attempts to make methadone maintenance 'mainstream' by improving the physical facilities, and in some cases relocating to less-blighted neighborhoods. There have been few changes, however, in the regulatory control of methadone. Methadone maintenance for the most part requires addicts to add morning dosing into their daily schedules, which in some cases becomes a barrier to occupational growth.

Naltrexone has already been partially discussed. The Use of naltrexone is limited by the difficulty of achieving two weeks of sobriety prior to treatment, because it takes that long for the sensitivity of opiate receptors to normalize to a degree that avoids naltrexone-induced withdrawal. Another problem is that the addict can 'choose to use' by simply missing a couple days of naltrexone dosing.. In fact, patients maintained on naltrexone develop a hypersensitivity to opiates, making them subject to dramatic highs during relapse, and vulnerable to the associated risk of overdose by respiratory arrest. In addition to pills, naltrexone is marketed as an intramuscular, monthly medication, which helps reduce the 'choose to use' problem. The primary indication for this medication, interestingly, is alcohol dependence rather than opiate dependence. Naltrexone has been demonstrated to reduce cravings for alcohol. A related form of naltrexone treatment is called 'rapid opiate detox', where the addict is anesthetized and given withdrawal-inducing doses of intravenous naloxone. After 8 hours or so, the addict awakes with an implanted, slowly-dissolving chip of naltrexone under the skin. This technique has popularity since reports of patient deaths during the anesthesia, or by suicide some time afterward.

In Part Two, I will explain how Suboxone represents a dramatic improvement in the treatment of opiate addiction.

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