Do Suboxone and Methadone Prevent Us From Experiencing True Recovery?

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Do Suboxone and Methadone Prevent Us From Experiencing True Recovery?

By Joseph Desanto MD 08/18/16

An addiction medicine physician who is a recovering opiate addict questions whether MAT prevents the brain from learning new coping skills and experiencing natural euphoria.

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Does Medication Interfere with Recovery?

From a global health standpoint, there is no question that methadone and newer buprenorphine-based forms of medication-assisted treatment (MAT) save lives, prevent overdoses and lead to a host of other benefits. And recent legislation in response to the opioid overdose epidemic will make it easier for more people who are addicted to opioids to receive MAT. In this week’s Professional Voices, Dr. Joseph Desanto asks two important questions about this trend. First, does MAT blunt patients’ access to their inner selves and prevent them from confronting the underlying core issues that contribute to their addiction? Second, what will be the future public health impact of continuing to increase the number of people receiving MAT? Richard Juman, PsyD

Medication-Assisted Treatment (MAT), represented typically by Suboxone and methadone, is used to treat opiate addiction and appears to be useful in reducing overdoses and decreasing transmission rates of HIV and hepatitis C. Proponents of MAT claim it’s a great way to help addicts get away from the harmful activities surrounding their addiction and return to the trappings of a normal life. Those against it say we are plugging the holes in the proverbial dam, and eventually the damn will break if not fixed properly. In other words, opponents of MAT state that addicts will eventually have to face their addiction completely clean, and that coming off of long-term MAT will require assistance that the field of Addiction Treatment and Addiction Medicine are not ready to handle because of a lack of resources.

Addiction is not so much a disease, but more a process of improper learning based on the self-medication of underlying core issues.

The real question we should be asking ourselves is this: “Is it okay to trade off short-term (and possibly short-sighted) statistics of reduced overdoses and reduced expenses used to treat the newly emerging epidemic of hepatitis C, at the expense of having to treat huge numbers of patients trying to come off of MAT in the distant future?”

The new recommendations made by the American Society of Addiction Medicine are that patients who have a diagnosis of Opiate Use Disorder should be placed on MAT, in escalating doses, for long periods of time, so they don’t have cravings to use their drug of choice. Initial data show that MAT reduces overdoses and HIV and hepatitis C transmission. What it doesn’t show is the rates of addiction to Suboxone or methadone and and the rates of successful weaning of an individual off of Suboxone or methadone. The studies are failing to look at long-term (2 to 5 years) abstinence rates and how truly difficult it is to try to successfully wean oneself off of MAT. So why are we so quick to recommend these medications when the data are possibly short-sighted? I believe the push for MAT is a knee-jerk bureaucratic response (partly fueled by pharmaceutical companies that have a huge stake in MAT’s popularity) set by individuals who are not looking at the big picture, and by those who don’t have a true respect for the medications used in MAT. Suboxone and methadone are both extremely addictive by virtue of their half-lives and the way they bind to opiate receptors. My opinion, based on experience, is that many prescribers and policymakers don’t have a true respect for either Suboxone or methadone. Perhaps these individuals should try a month of either and then attempt a slow, gradual wean? I’d like to see the data on that observational study.

Who, then, should we trust to give us the best information, based on sound evidence, which is relevant to our day-to-day practices? We are in the business of saving lives, but I must implore you to look at an even bigger picture.

How DO we actually save lives?

First, we help our clients get reconnected to the people that they used to be. Second, we help them love themselves so that they won’t want to put themselves in a position where they need to use harmful coping mechanisms ever again. Third, we give them the tools to live empowering lives in which they’ll be able to overcome and process potential future traumas and stressors without using mind-altering substances.

THIS is how we save lives in the long run.

Opiates like Suboxone and methadone ultimately prevent these things from happening in the most optimal way. Behavioral and emotional changes happen only when an individual processes and “feels” the consequences of their actions, whether good or bad. Yes, Suboxone will prevent opiate cravings, but is it blocking the brain’s (and the heart’s) ability to perceive true pleasure, pain, connection, and healing? I believe it does. In reality, it perpetuates the addictive cycle both biologically and emotionally. The brain doesn’t have a chance to return to the normal numbers of opiate receptors and the addict continues to rely on a substance to get by. The emotional centers of the brain, like the amygdala, aren’t allowed to reset to lower thresholds, and the hippocampus continues to lay down memories in the presence of an opiate, which perpetuates the subconscious craving and obsession that fuels relapses.

Since I don’t want my opinions to come from a vacuum, a bit about me. I am a physician who is Board Certified in Addiction Medicine, and I am also an opiate addict in recovery with over four years clean and sober. I have utilized both SMART and 12-Step recovery on my journey through sobriety, and I utilize prayer, meditation and mindfulness as part of my daily routine in maintenance of that sobriety. I am the medical director of a substance use treatment center in Newport Beach, California, and I’ve been practicing Addiction Medicine for over 10 years. I have treated hundreds of patients, and have a large anecdotal sample of patients from which I can draw.

My story started with alcohol and stimulants recreationally in my younger years, but that all changed when I took my first Lortab.

When I discovered opiates, I felt better than great…I felt normal.

And for me, normal was better than great. I spent the next 17 years struggling with a drug that made me feel instantaneously “OK.” After a while, I learned that taking a pill was a lot easier than facing any new or old trauma or stressors. I had a fight with the boss, I took a pill, a spat with the wife, and I took a pill. I quickly learned that this was much easier and more predictable than developing and using other coping mechanisms. Craving and obsession were at the core of my disease. I eventually felt like I couldn’t live without them. If I didn’t have my drugs I was wrought with anxiety, and my trauma brought subconsciously into my adulthood from childhood was amplified. The shame and the guilt were intolerable. Eventually, a series of unfortunate (but lifesaving) events led me to treatment and I got clean and sober. I took Suboxone in my detox, but after the fourth dose, I began refusing it because it made me feel “loaded” and “protected” from the issues that I needed to face. I knew that if I were to stay sober, I would have to learn to live life with different coping mechanisms—more so I had to learn to know myself again and repair the damage I had done to the beautiful life I had made for myself but was too afraid to live.

I would have to learn new coping mechanisms.

What I have come to learn is that addiction is not so much a disease, but more a process of improper learning based on the self-medication of underlying core issues. These issues can range from mood disorders and developmental trauma, to early exposure to substances, traumatic brain injury and adverse childhood experiences. When the individual learns to cope with trauma and stress in the presence of mind-altering substances, and if it happens enough times, then addiction becomes a disorder of learning. Add to that a genetic predisposition, and the chances of becoming an addict are phenomenally high.

Statistically, most of us have tried drugs and alcohol at least once in our lives. Why do some of us stop and respond appropriately?

Like I said, I'm an opiate addict. Once I started using opiates, I couldn't stop. Yes, I felt good, but more that that—and as I stated before—I felt normal.

With what we know about the disease process of addiction, the plasticity of the brain and its ability to rewrite memories, how can we best treat each addict individually and how can we ensure that each person achieves the joy of sobriety and connection without the use of substances?

First and foremost, I believe that our work in the field of Addiction and Treatment demands that we all keep an open mind. Our therapies must be evidence-based, but that evidence should always be questioned and tested in the field. I have read the NIDA study that shows good data on a large number of patients in a limited period of time. But it does not speak to long-term sobriety. It is a short-term study. And it shows that study patients were “opiate-free” when they really weren’t! They were taking an opiate. I’m sure it would be just as easy to propose a study that would prove the hypothesis that Percocet therapy would reduce cravings for and usage of Vicodin.

So where do we need to look for answers before we wait for the long-term data?

A logical starting point is to understand that addiction, as stated before, is a disorder of improper learning, memory, and stress modulation. We must keep an open mind in thinking that abstinence makes sense when we approach addiction as such. If we truly believe that addiction is a disorder of learning, then we must teach the brain a new way of “learning” euphoria and “learning” to modulate stress. MAT is diametrically opposed to allowing this to happen. If we keep someone on buprenorphine or methadone, then are we doing them a disservice by keeping them on it and therefore preventing them from relearning positive coping skills and experiencing natural euphoria? Studies fail to show us the true breakthroughs of individuals who are abstinent that can handle anything that life throws their way. Studies also fail to show us the therapeutic benefits of trauma work in the truly abstinent individual.

Dr. Gabor Maté has stated that addiction is a trauma-based disease, and that we should help the individual process that trauma in hopes that they will heal. He also states that if stigma and shame are removed, individuals are less likely to use drugs. I believe the perpetuation of opiate use through MAT prolongs further stigma and shame, and it keeps us from truly connecting with trauma. EMDR is less likely to be effective if individuals are on buprenorphine and methadone, and most EMDR therapists won’t use it on an individual until they are off of all opiates and sedative hypnotics.

So, can effective trauma and mood disorder therapy occur if we keep someone on an opiate?

I believe it cannot.

This belief is supported by the hundreds of patients I've treated who have told me in hindsight that they couldn't really "feel" until they were off MAT, and that they weren't truly “sober,” even while on very low, constant doses of MAT. I know this evidence is anecdotal, but it’s very powerful. Is abstinence a more effective way to achieve true sobriety ? I believe it is for most, but not for all. There is a place for MAT in treating chronic relapsers and overdosers, or those who work in high-risk professions such as doctors, nurses, vets, and pharmacists. I believe buprenorphine should be used for a very short amount of time, and then naltrexone should be implemented as soon as it is safe to do so. During this “bridge” period, support medications can be used, optimally in a treatment center that is medically staffed. Naltrexone is a proven form of MAT that can be given in oral, injectable or implantable form and has been shown to reduce relapse rates without being mind-altering or addictive.

Furthermore, I believe we need more time and a better understanding of what long-term MAT will do to addicts' brains and what it will do to long-term sobriety rates. I think we need experts, who know and respect MAT under the mentorship of ASAM, to be the ones who dictate the recommendations to prescribing practitioners. I also believe that we should not be front-loading the field of Addiction Medicine with untrained prescribers (An 8-hour course to attain your Suboxone prescribing waiver is a ludicrously short amount of time) who, through no fault of their own, don’t respect or understand the medications they are prescribing. If this system we are being driven towards is left unchecked and unregulated in the very near future, we may be dealing with a huge population who are addicted to Suboxone or methadone, and who will need inpatient treatment to detox in a controlled environment off of these medications. We may not be ready to accommodate such large numbers, given the limited amount of Board Certified addiction practitioners and treatment centers in the United States today.

In conclusion, despite my concerns and pessimism, I still feel that this is a wonderful time to be in the field of Addiction Medicine. There are great strides being made in the field of epigenetics, interest in clinical trials are underway with new and proven medications, and the Comprehensive Addiction and Recovery Act was just passed by Congress and signed by President Obama. Because of this, I hope to see more effective treatments in the future so that discussions like this will be obsolete.

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