The Truth About Suboxone
Studies show that maintenance therapy is the most effective treatment for opiate addiction. So why are abstinence fundamentalists so bitterly against it?
While reading Joshua Lyon’s recent account in "Jagged Little Pill Head" of recovering from opioid addiction, I was enraged by his characterization of buprenorphine (Subutex, Suboxone) as a “chemical crutch” and “the very drug that was keeping me from doing other drugs.” This outdated and stigmatizing attitude towards maintenance treatment can—and frequently does—kill hundreds of struggling addicts who depend on these meds to stay off the streets. Lyon is typical of a large contingent of so-called recovery experts—from Dr. Drew to many 12-step participants—who continue to publicly push this perspective, despite decades of evidence to the contrary.
That's why it was pleasantly surprising that the issue got a public airing on, of all places, late-night TV. Kristen Johnston, star of the '90s TV hit 3rd Rock From the Sun, was a guest on The David Letterman Show on Monday, discussing her new addiction and recovery memoir Guts, including a pull-no-punches account of how her daily Vicodin–cum–wine consumption ate a hole in her stomach and caused her guts to explode—a life-threatening moment that led her to get clean. Letterman asked her if she used any "pharmacological medications" to help her recover from her opiate addiction, and Johnston said that she sure as hell did and the drug was called Suboxone and it was very effective and anyone who had a problem with that could shove it. Well, that was her tone if not her exact words. Johnston's admission is undoubtedly a first for a celebrity on the recovery circuit.
Even the Betty Ford Center agrees that people taking daily methadone or buprenorphine should be considered every bit as "in recovery" as those who just “don’t drink and go to meetings.” A 2007 consensus panel to define recovery convened by that august facility put it plainly: "To be explicit, formerly opioid-dependent individuals who take naltrexone, buprenorphine or methadone as prescribed and are abstinent from alcohol and all other non-prescribed drugs would meet this consensus definition of sobriety."
So why do even people like Lyon—who benefited from bupe himself—continue to see maintenance as “cheating” and as some kind of limbo between the hell of active drug addiction and the heaven of abstinence-based recovery?
There are several reasons, but they all mostly boil down to the mistaken notion that people on maintenance are somehow “always high” or not “emotionally” sober. This misunderstanding rests on an ignorance of basic pharmacology. With most psychoactive drugs, the pattern of use has an enormous impact on the drug experience. This is abundantly clear with opioids. Take them irregularly in varying doses and you will relatively reliably experience a robust high. But take the same exact drug on a regular schedule at the same exact dose and you will develop a tolerance that makes getting high virtually impossible.
Some in abstinence-based recovery feel compelled to proselytize about the dangers of the substances they once could not live without. This “drug-free” rhetoric helps them avoid temptation. It also gives the added buzz of self-righteousness that comes from feeling superior to others.
Lyon’s claims about getting high on Suboxone are almost certainly related to taking it irregularly or in varying doses. Like any opioids, Suboxone and methadone can cause highs when taken this way.
Tolerance is why addicted people escalate the amount of drugs they take and often feel that they are always chasing—but rarely achieving—that elusive ecstasy they experienced early on. It is also why people on opioid maintenance, including heroin itself, can function without being cognitively, emotionally or physically impaired. Even car-driving performance has been found to be safe in reviews of the data on opioid-tolerant patients. Nonetheless abstinence proponents like Dr. Drew and addict authors like Lyons not only portray these medications as inferior, but implicitly or explicitly push addicts to stop taking them, even when the meds are working.
That can be deadly—as it apparently was for two of the patients Dr. Drew detoxed from maintenance, Mike Starr, the former bassist in Alice in Chains, and film and TV actor Jeff Conaway. Both victims of Celebrity Rehab With Dr. Drew died of overdose or related issues, the risk of which is very far reduced by maintenance treatment. Research repeatedly finds that when access to maintenance is reduced or eliminated, deaths from drug overdose rise, as do rates of infection with HIV, hepatitis C and other blood-borne diseases. In fact, patients on maintenance treatment have a death rate three to four times lower than those who leave it.
It is clear that maintenance saves lives.
Another misconception that fuels the stigma of maintenance in the recovery community is that the use of opioids is inherently “numbing” and therefore people on these drugs are emotionally deadened or at least diminished. There are two problems with this argument. First, tolerance to opioid effects often includes tolerance to this emotional distancing as well. Second, different people respond to opiate effects in different ways. Those who are highly emotionally sensitive may actually benefit from taking a chill pill; methadone or buprenorphine can allow them to react normally instead of overreacting to everyday experience. Paradoxically, being less oversensitive to their own emotions may make their behavior toward others more sensitive.
Because individual responses to opioids are extremely variable—opioid-receptor genes are among the brain's most heterogeneous—maintenance can be numbing for some people and not for others. You may find methadone uncomfortably distancing but buprenorphine effective, while I may find the opposite. The bottom line is that a drug that makes one person miserable can be magnificently beneficial for another.
Beyond the issues of pharmacology and individual variance, one final factor also comes into play in the widespread disdain of maintenance. This is the need of a certain type of person in recovery to demonize the drugs to which they were previously addicted in service of their own abstinence. Because they rightly fear relapse, some who favor abstinence-based recovery feel compelled to proselytize about the dangers of the substances they once felt they could not live without—and often continue to crave. This “anti-drug” or “drug-free” rhetoric helps them avoid temptation. It also gives the added buzz of self-righteousness that comes from feeling superior to others.
I certainly understand this small-minded, mean-spirited attitude; I’ve been guilty of it myself. However, the self-aware—and adult—approach is to distinguish what works for you and your own recovery from what may work for others.
It’s not necessary for maintenance to be bad to make abstinence good. Such black-and-white thinking about methadone and buprenorphine is both divisive and dangerous. Recovery requires acceptance—and that includes acceptance of a diverse range of recovery methods and experiences.
And if acceptance is beyond your reach, then the least you can do is keep your opinions to yourself.
Maia Szalavitz is a columnist at The Fix. She is also a health reporter at Time magazine online, and co-author, with Bruce Perry, of Born for Love: Why Empathy Is Essential—and Endangered (Morrow, 2010), and author of Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (Riverhead, 2006).