If there is a speck of silver lining to be found in the abrupt passing of Prince, it’s the attention being paid to buprenorphine (brand name Suboxone), a drug used to treat opioid addiction that, according to local press reports, Prince’s representatives sought from a Bay Area doctor the day before his death.
“Overwhelmingly, studies show that Suboxone saves lives by decreasing lethal overdoses, reduces the transmission of HIV and Hepatitis by decreasing the use of dirty needles, and decreases the legal consequences associated with illicit opioid use,” said Luis Giuffra, MD/PhD, a professor of clinical psychiatry at Washington University in St. Louis.
Dr. Guiffra is also the medical director at Clayton Behavioral, a clinic in St. Louis that utilizes buprenorphine to treat opioid addiction. Despite the facts Dr. Guiffra cites, and the success he sees with patients every day, there is a strangely ideological stigma attached to buprenorphine’s use.
“There were some people in [my] 12-step groups that would say, if I was on Suboxone that wouldn’t classify me as being sober,” said Claudia, 28, a foreign languages teacher at a middle school outside of St. Louis, who has been on Suboxone for the last 15 months.
Claudia first used alcohol in excess when she was a teenager, one of the early warning signs that she might struggle with substance use later on as an adult. Shortly after her father died five years ago, she had a surgery and was given prescription painkillers. “The combination of surgery and the grief of my dad’s death, I just found myself hooked on the painkillers. It kept getting worse and worse,” she said.
After taking a leave of absence from teaching, and numerous attempts to kick her painkiller habit without medication, Claudia’s doctor suggested she would be an ideal candidate for Suboxone maintenance, because her relapses were both frequent and dangerous. “At first, I was not very happy about the idea of being on [Suboxone],” she said. “Treating an opiate addiction with an opiate was kind of scary to me,” a notion she said she picked up at 12-step support groups.
“After I learned about it more, I decided to give it a shot, and it turned out to be one of the best decisions I ever made.” Claudia is now teaching again, and says her quality of life is the best it’s been in years. She still attends 12-step meetings but prefers not to bring up her recovery sustained through medication.
Claudia’s initial apprehension of treating an “opiate addiction with an opiate” is not uncommon. There are objections to the drug being used by those in professional circles, which tend to promote and market complete abstinence as the marker of recovery from drug addiction. Amidst a crisis of unprecedented opiate overdoses, opinions rooted in tradition are now colliding with 21st century empirical evidence about the best way to solve an epidemic killing 129 people every day.
“My personal view [of Suboxone] is that I’m not a huge fan,” said David Cohen, LCSW, CADC, formerly the clinical director for the Hazelden Betty Ford Foundation in Chicago, the originator of the 28-day inpatient, abstinence-based model. Cohen now works at Ocean Recovery in Newport Beach, California. “I think to achieve true recovery one has to be free and clear of any type of mood altering chemicals, that includes Suboxone.”
Though Cohen does say the drug is a useful tool for harm reduction and an important feature of addiction care, he does not think it is “true recovery.”
Cohen’s personal stance, sharpened through over a decade of clinical experience, is unsupported by the Hazelden Betty Ford Foundation. In 2007, a definition of recovery was put forth by a Betty Ford Institute Consensus Panel, which included formerly opioid-dependent individuals who use buprenorphine as prescribed, and are abstinent from alcohol and all other non-prescribed drugs (PDF).
His stance is also not supported by science. An empirical investigation of mortality found that people addicted to opioids who only received psychological support were twice as likely to die from a fatal overdose post-treatment, compared to individuals given buprenorphine and methadone.
“Treatment facilities that do not offer Suboxone to opioid addicts are ignoring the data, and are not serving patients well,” said Dr. Giuffra. “These facilities have opinions, but not data to support their opinions other than a priori arguments and strings of anecdotes.” Addiction treatment is the only area of medicine where people are not given scientific solutions to their ailments, said Dr. Guiffra.
Due to the drug’s complex chemical makeup, overly simplistic explanations about how it works distorts its true physiological function, leading to misconceptions about how the drug affects those who take it.
“I have never gotten high on Suboxone,” said Mike Schoder, 26, a Chicagoan who has been on maintenance since he stopped using heroin five months ago. He was barely getting high on heroin itself, as the addiction eventually became a circuitous loop from being sick to being well. “I take Suboxone now just like any other medication. I’m just trying to feel normal.”
“Those who argue that using Suboxone is ‘replacing one drug for another’ are not being scientific,” said Dr. Giuffra. “Buprenorphine is an opioid. As such, it does have the ability to produce euphoria, respiratory depression, and analgesia. However, it has unique pharmacologic properties that make these effects milder than those caused by heroin or methadone.”
One of those properties is that it only partially activates certain receptor sites. “You can think of a full agonist [heroin] like it’s a large basketball filling a basketball net,” said Dr. Adam Rubinstein, Double Boarded in Internal Medicine and Addiction Medicine, who is also a National Physician Expert at Indivior Pharmaceuticals. “You can then think of Suboxone [a partial agonist] as a bunch of ping pong balls filling up that net a little bit, but not fully.”
The word endorphin means “morphine from within” in Latin. The human brain has what’s called an endogenous opioid system, which naturally produces chemicals that kill pain. After this system is flooded with large doses of a drug like heroin, over time it stops producing its own natural chemicals, leaving the system starving for more.
Knowing how the brain’s opioid system works explains the physiological reasons why taking Suboxone does not produce the euphoria both Claudia and Mike were chasing while using painkillers and heroin. It gives the system just enough opioid to keep it from starving for more, because it has stopped producing these chemicals on its own. Suboxone is like the lubricant for a cranky machine, making it run like it did before it dried up.
“It’s night and day between taking painkillers for the high and being on Suboxone,” Claudia explained. “I don’t feel high at all, I just feel more like myself.”
Claudia’s experience demonstrates how Suboxone calms the starving receptors. She describes wanting to feel like her old self again—the way she felt before her painkiller addiction wrecked her relationships and career. “Being on Suboxone has allowed me to get that feeling back.” Her system is now running as it should, thanks to help from Suboxone.
Why “replacing one opiate for another” is overly simplistic also has to do with dosing schedules and tolerance. In her new book Unbroken Brain: A Revolutionary New Way of Understanding Addiction, Maia Szalavitz elegantly explains why people like Mike and Claudia don’t experience a high while on maintenance. “The more steady and regular the dosing is, the more tolerance will build. Very rapidly, an opioid user on maintenance will no longer experience a high because he or she will be on a stable plateau of tolerance,” she writes.
This point is critical to the foundation of maintenance. A person in addiction will use erratically, typically as much as he or she can afford in that moment. This creates a cycle of moving from euphoria to sickness, often several times throughout the day, which is a master recipe for addiction.
Compare such chaotic dosing to the stable dosing one receives on methadone and buprenorphine. The quantity of the drug is always the same, taken at the same time everyday, leaving one able to live his or her life without craving and without hurting themselves or others.
“In lower doses, Suboxone prevents withdrawal, physical symptoms, and cravings. Really you can stay on Suboxone for years and years,” said Dr. Rubinstein. “I have patients who have been on Suboxone for five years or more, on the same stable dose, and they’ve never needed more, and their brain doesn’t tell them they need more.”
This is not the case with drugs like heroin and oxycodone, where the user needs more and more of the drug to achieve the same effect, creating the need to do whatever one can to stay well that day.
Quitting opiates with the aid of medication is sometimes described as the easier, softer way. “If someone really wants to do the hardcore, trauma work, to get at what’s underneath the addiction, it’s difficult to do that when you’re on a mood altering chemical,” said Cohen. “In terms of really offering the gift of recovery, Suboxone doesn’t do that.”
People undergoing maintenance disagree with such a statement. “People can say it’s a crutch, they can say whatever they want, but the way I see it, if the person using Suboxone feels content and happy with the way things are going, that’s all that matters,” said Schoder. “Any stigma people are going to throw at me, I can handle because it is right for me at this point in my sobriety.”
Claudia echoed Mike’s sentiment, that one must define recovery for his or herself. “Just look at my life 16 months ago and look at my life now,” she said. “My quality of life is so much better on Suboxone.”
Abstinence narratives have dominated the recovery movement in America. But people like Claudia and Mike are living proof that life after addiction is possible. They are demonstrating that abstinence is becoming an increasingly arbitrary metric to define recovery. They are forging their own paths.