Question for Jackstem..Suboxone

  1. Jackstem,

    I have been reading this message board off and on over the years and have always been impressed by your knowledge, writing style, and the great support you give people on this forum.

    I was wondering what your stance is on Suboxone use for opiate dependence/addiction. (Maybe you have already discussed this here somewhere but I have not seen it)

    I believe Suboxone is a unique medication that is largely misunderstood by the general public and many health care professionals as well. For example, Suboxone has a "celing effect" that methadone and other full opiate agonists do not. I think all nurses, addicted or not, would benefit from a little lesson on how this medication works. I think Suboxone is just the begining of a new way of treating addiction...I would love to see the day when addiction is treated like the brain disease it actually is.

    I am concerned that some health care professionals, AA/NA groups, treatment centers, and the general public think that people using this medication are not "clean" or are not in "real recovery." If HTN can be controlled with a medication and lifestyle changes, why not the disease of addiction too?

    If a heroin addict(or a fentanyl addict) can use Suboxone to give him some freedom from the obsession and craving so he can focus on recovery and get his life back, why is this not "real recovery?"

    Jack, you always give such thoughtful and educated responses so I thought I would ask what your thoughts are..

    Thank you, zofran
  2. Visit zofran profile page

    About zofran

    Joined: May '09; Posts: 105; Likes: 369
    RN hospital
    Specialty: 5 year(s) of experience


  3. by   Magsulfate
    I am not Jack, but I do remember that he discussed suboxone some time ago on this forum. So, I found it by searching suboxone and jackstem. I don't want to quote him, and I know that he will give you a good answer once he reads this.

    You're not asking my opinion, but I am going to type it anyways. I think that it is a wonderful drug, however some people think that you're still using drugs if you're on this. Those people are NOT the ones taking the suboxone. I have read about the withdrawl side effects and most people say that they are horrible. Worse than withdrawing and staying clean from opiods? Who knows? Anyone?

    I will say, if suboxone keeps a person from taking 20-30 vicodin each day, then HELL yeah go for it. It could save lives. But if you want to get technical, then yeah, it's still a drug. But so what? You're alive and sober.
  4. by   zofran
    LOL Mag,

    I have been active on this board for a while and I have never thought to search that way! So thanks for the tip! I actually tried it and the last post I saw relating to jackstem and suboxone was from 2009..So maybe he has new info or something. And I don't mind you chiming in at all....the more the merrier.

    I guess it just sucks that some people in recovery judge the people on Suboxone so harshly. The traditional recovery model idoes not have a very good sucess rate. In fact, it has a very low sucess rate. I think we need to make some changes in how addicts get treated. I can't stand it when I read or hear people who say that addiction/alcoholism isn't a disease. There should be no debate on it. It would be like saying diabeties isn't a disease.

    Anyway, thanks again Mag, take care.
    Last edit by zofran on Aug 6, '10 : Reason: typo
  5. by   jackstem

    Thank you for the kind words (and we ALL need those, especially with some of the rather nasty remarks many of us face when discussing this disease).

    Before I can provide any sort of answer to the question: Does suboxone maintenance qualify as "recovery"?

    So far, the best definition I've come across is provided by the Betty Ford Institute. They gathered a consensus panel to develop the definition. They are encouraging additional input in order to refine their work. So here's the current definition discussed and explained in depth in the article, "Special Section: Defining and Measuring "Recovery" - What is recovery? A working definition from the Betty Ford Institute" [Journal of Substance Abuse Treatment 33 (2007) 221- 228] (PDF format).

    Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.

    2.1. Sobriety
    Sobriety refers to abstinence from alcohol and all other nonprescribed drugs. This criterion is considered to be primary and necessary for a recovery lifestyle. Evidence indicates that for formerly dependent individuals, sobriety is most reliably achieved through the practice of abstinence from alcohol and all other drugs of abuse.

    Early sobriety = 1-11 months;
    Sustained sobriety = 1-5 years;
    Stable sobriety = 5 years or more.

    2.2. Personal health
    Personal health refers to improved quality of personal life as defined and measured by validated instruments such as the physical health, psychological health, independence, and spirituality scales of the World Health Organization QOL instrument (WHO-QOL Group, 1998a,b).

    2.3. Citizenship
    Citizenship refers to living with regard and respect for those around you as defined and measured by validated instruments such as the social function and environment scales of the WHO-QOL instrument (WHO-QOL Group, 1998a,b).

    Criteria 2 and 3 extend sobriety into the broader concept of recovery. Personal health and citizenship are
    often achieved and sustained through peer support groups such as AA and practices consistent with the 12
    steps and 12 traditions.
    Combining that definition with my own experience of recovery over the 20 years since I first entered treatment (the first 5 years I really struggled - relapsing a couple of times and surviving an interrupted suicide attempt and an accidental OD), as well as over 5 years as a peer advisor for Ohio's CRNA/SRNA population, and a year and a half as a "Recovery Specialist" for a nurse attorney who specializes in license defense in 3 states, I have to say it's a pretty decent definition.

    However, I think we need to adapt that definition to the real world. It is my current opinion that those individuals involved in "high risk" occupations, (health care professionals, fire fighters/paramedics, police, pilots, truck drivers, etc.) should be held to a different standard than the "average Joe/Josephine". Until there are more studies that show that those on suboxone are not "impaired" (based on testing, not someone's opinion of how they "feel"), the recommendation a majority of licensing agencies are following is to not allow the above groups to practice while taking suboxone. I am aware of a couple of states that have allowed a nurse on suboxone to practice, but that appears to be rare. I attended the NCSBN forum this past April in Chicago. They are developing updated recommendations for Alternative to Discipline programs (trying to get them all on the same page). Their recommendation is going to be no practicing while on suboxone.

    While suboxone (buprenorphine + naloxone) has a lower abuse potential than pure agonist opioids (heroin, morphine, oxycodone, etc.), it does have mild opioid agonist effects. It's why it is so effective in diminishing cravings. Buprenorphine is a partial agonist with a much greater affinity for the mu receptor. And yes, it does have a "ceiling effect". But if it's combined with other CNS depressants, the neurological depression can be profound AND it can be difficult to reverse. Buprenorphine is very difficult to dislodge from the mu receptor with naloxone or naltrexone, especially if high doses have been taken. So, as long as the drug is taken as prescribed, and no other CNS depressants are taken, it is a safe and effective maintenance medication. I remember when buprenorphine was first introduced in the mid to late 80's as an alternative analgesic. It was hailed as the next great drug due to it's high affinity, ceiling effects for respiratory depression (and analgesia), and it's supposed low abuse potential (the same selling points for Stadol and Nubain...which are abused. Read Patricia Holleran's book, originally titled "Walks Like a Duck", telling her story of addiction to Stadol).

    Here are a few articles that look at the use of suboxone, discussing abuse potential and neuropsychological functioning with replacement therapies.

    Lambros M., et al. "Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochlorideTherapy"' human psychopharmacology Hum. Psychopharmacol Clin Exp 2009; 24: 524-531. Published online 3 August 2009 in Wiley InterScience (Wiley InterScience :: Session Cookies) DOI: 10.1002/hup.1050

    Stimmel, B., MD, "Buprenorphine Misuse, Abuse, and Diversion: When Will We Ever Learn?" Journal of Addictive Diseases, Vol. 26(3) 2007. Available online at 2007 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J069v26n03_01

    Impaired decision-making in opiate-dependent subjects: effect of pharmacological therapies
    . Pirastu R, Fais R, Messina M, Bini V, Spiga S, Falconieri D, Diana M. Drug Alcohol Depend. 2006 Jun 28;83(2):163-8. Epub 2005 Dec 15.PMID: 16343811 [PubMed - indexed for MEDLINE] (Impaired decision-making in opiate-dependent subje... [Drug Alcohol Depend. 2006] - PubMed result)
    Bringing Buprenorphine-Naloxone Detoxification to Community Treatment Providers: The NIDA Clinical Trials Network Field Experience

    I think it's a huge improvement in assisting with detox and maintenance for difficult cases, but it's not the Holy Grail for drug treatment.

    I conduct an introductory 12 Step group at an outpatient treatment center. Many of the folks attending are on suboxone. I know that they are all early in their treatment, but I do see altered neurological effects. I'm not saying that will be seen in everyone, or to the extent that I see it in this population. As tolerance develops there is a decrease in the effects. One thing I will say is suboxone appears to provide a much more "humane" detox experience which is a great thing. We have a chronic, progressive, potentially fatal disease...we don't deserve to be "punished" as part of the treatment protocol. I can honestly say, once the relapse process began, remembering how bad detox was had no effect in stopping my eventual return to using.

    I think we should attempt to help all addicts obtain abstinent recovery whenever possible. Abstinence is the "gold standard". But to try to achieve that in every person is unrealistic. Just as their are "brittle" diabetics (do they still use that term, or am I showing my age?), I have no doubt there are "brittle addicts". These folks need a different level of treatment and recovery program. The bottom line for me is, does the treatment protocol allow the person to live as full a life as possible, enable them to give back to their community, and be involved in the lives of their families?

    Sometimes we have to accept changes in our lives as a result of a chronic illness. There are numerous people who have had to change parts of their lives in order to achieve the highest level of health possible while also not endangering those around them. I happen to be one of those folks. At the time, leaving anesthesia just didn't seem "fair" and I was definitely angry. But in all honesty, I love what I'm doing now, despite the fact that I'm making about 80% less than I did as a CRNA. Titles, money, and fancy things don't define my success...the relationships I've developed as a result of my recovery, especially with my 2 daughters, is far more rewarding and satisfying than anything I've ever experienced before all of this "stuff" started 20 years ago.

    As we make the transition from waiting until the "defecation hits the ventilation" (otherwise known as "bottom") before intervening, to early intervention and long term treatment and maintenance, we'll see success rates rise. The most important task we have right now is to educate our colleagues about this disease. By aiming our educational efforts at the nursing profession, we'll get the trickle down effect, changing society's stigma based paradigm to the chronic, treatable disease paradigm.

    We have to take things one day at a time!

  6. by   jackstem
    Quote from zofran
    I guess it just sucks that some people in recovery judge the people on Suboxone so harshly. The traditional recovery model idoes not have a very good sucess rate. In fact, it has a very low sucess rate. I think we need to make some changes in how addicts get treated. I can't stand it when I read or hear people who say that addiction/alcoholism isn't a disease. There should be no debate on it. It would be like saying diabeties isn't a disease.

    Anyway, thanks again Mag, take care.
    I agree with you, we definitely have to change the treatment paradigm. It's a tough job because there is so much ignorance when it comes to most mental health diseases and disorders. W

    We have a difficult time collecting accurate data on rates of addiction and recovery because of the stigma associated with this disease. There has been an increasing discussion in the recovering community about anonymity being one of the reasons people believe treatment doesn't work. I know of many health care providers in recovery who never discuss it outside of their support groups. As a result, we see the addict who relapses in far greater numbers than those in recovery willing to speak out about their addiction, treatment, and recovery. Who can blame them!? ESPECIALLY recovering health care providers!

    I've mentioned this DVD in some other posts. If you want an excellent explanation about the disease of addiction, get your hands on "Pleasure Unwoven" by recovering physician Kevin McCauley of The Institute for Addiction Study. He was a navy flight surgeon who ended up in a military prison as a result of his addiction. Until this time he didn't believe addiction was a disease. So he used his time in prison to research the info regarding the disease. He wanted to prove his belief addiction isn't a disease. Instead, he ended up realizing it IS a disease of the central nervous system's areas involved in survival, motivation, and pleasure.

    You can watch several clips on YouTube.


  7. by   LilRedRN1973
    Here is one of the main problems I have with suboxone: new folks who may not have tried any other way to get sober or find recovery FIRST. I had a discussion with a client recently (some may call it an argument) about the fact that suboxone was indeed an opiate. She continued to tell me that it was not an opiate and I had to pull up some research online to show her that it was. She was dumbfounded and wanted to know why the detox center that had given it to her and then the doctor who was continuing to prescribe it to her didn't make that clear to her. She was a recovering heroin addict who started out her addiction with vicodin, then moved to oxycontin, and finally heroin. This was her first time out, trying to get sober and I guess the way I see it, if we don't give these kind of folks a chance to see that a 12-step program CAN work to maintain absolute sobriety (I'm one of THOSE who don't believe in using ANY mood-altering substances, even something like ambien that could lead to, I feel we are doing them a disservice if we stick them on suboxone right away.

    Now, if you have a chronic relapser who has tried through the years to stay sober and cannot seem to do it for whatever reason, then fine....put them on suboxone. I was given the option of suboxone when detoxing and I said "hell, no". I had done my research on it and I didn't want to trade one dependency for another. I was given clonidine, trazodone, and robaxin for the withdrawal instead and within about 3-5 days, I was okay. Not great, but okay. I don't regret my decision for a minute. That's a personal decision and for me, I would not consider myself truly sober if I was taking suboxone long term. But that's me. I would have cheated myself out of working the program of AA to its fullest to help with the cravings and obsession. Again, that's me. Everyone is different. Do I think it has its use? Definitely. But I am seeing TOO many of my clients coming into my work on long term suboxone and they are not addicts who have been chronic relapsers. For some, it was their first experience with the disease and their first time around, trying to get sober. For those, I feel we are doing them a disservice. That's my humble opinion. I don't have nearly the knowledge that Jack does and it's just an opinion. It's not to meant to offend in the least and I hope that it wasn't taken that way.

    P.S. I make not be making much sense as I've been up since 4:30am, it's now almost 11pm, and I've been training for a 5k and am BEAT! Please excuse any grammatical or spelling errors and there may even be some missing words. LOL
    Last edit by LilRedRN1973 on Aug 7, '10
  8. by   zofran
    Jackstem and others,

    Thank you for the thoughtful replies.

    I did check out the You-Tube are right, he is great.

    I liked how he demonstrated with the hoses and the bubble gum....made it easy to understand.

    Have you read any articles by Dr Jeffery Junig? He has some really interesting things to say about opiate addiction and suboxone. You can also see some of his videos on YouTube by searching "suboxone."

    I have seen alot of close family and at work (RN hosptial). I have seen how these people are treated by the very people who are supposed to be knowledgeable about the disease of addiction. Doctors cutting off pain meds after major surgery "because they are seeking" or witholding IV pain medication because the person came in positive for marijuana. Nurses who will not give pain meds one minute early because the pt has a known history of addiction. I could go on and on. It is begining to make me sick.

    As for Suboxone...I don't think it is the magic pill everyone is looking for either....I just think it is a huge step in the right direction.

    All I can do, as a human being and a nurse, is make sure I have the correct and current knowledge regarding the disease of addiction.

    So thanks again you guys. You all gave me something to think about. Zofran
  9. by   matt2401
    Hi all, recovering RN here. 4+ yrs clean. I personally did not use suboxone for my detox (I detoxed myself) but I see no reason why it can not be employed as tool in detox/recovery. I have seen many people successfully use suboxone for an extended period of time and have no indication of any sort of impairment, although admittedly I am not qualified to say that for sure. I have also seen suboxone used in a rapid detox.

    My feeling on suboxone is that it is a reasonable treatment when prescribed by an addictionologist. My own personal "rule" towards my dealings with doctors on potentially controlled substances are:
    • If I am in pain to where an OTC NSAID is not effective I will always seek the opinion of a medical doctor. No self medicating ever!
    • I never "ask" for any specific medication. I explain to the doctor that I am in recovery and the pain that I am having. I leave it to his/her decision what the best treatment is for me. Sometimes I specifically ask for no narcotics for various reasons.
    • I never exceed the amount to take or increase the frequency on my own of any medication. If the medication is not working, I call the doctor and explain the situation and leave it to his or her judgement on how to proceed.
    I have gotten through three surgeries in recovery (yea, crappy luck for four years!) with this. Two of them I threw out my narcs when I no longer needed them. (One was intensely painful!). Why am I sharing this? I think this same model would work well for detox. If symptoms are too painful, explain the situation and allow the judgment of the doctor managing the detox to decide the best course of action.

    To me, this is my part of "letting go and letting God" take care of it. It takes some faith that the person managing your care will do so effectively. I know my higher power has been with me for a few 24 hours, I don't think he is going to leave me anytime soon.

  10. by   june2009
    I don't mean to butt in on the conversation but I have some personal experience with suboxone that may be helpful to those who are interested. My father is an addict. started with alcohol and when he decided to quit drinking he switched his chemical to opiates, mostly vicoden, lortab, etc. then he moved on to methadone and yes, suboxone. he was buying them illegally off the street, spending hundreds of dollars a week on pills.

    Finally when he started missing some work here and there (which he never did before) he decided to go to an addictionologist to "face his addiction". I'm not really sure what his intentions were/are; if he really wants to stay "clean" or if he just doesn't want to withdrawl or what. My dad never went to a single NA/AA meeting, he never got a sponsor, he never worked a single step, none of that. He's been on suboxone for 2.5 years now.

    Nothing in his life is better. He still has addict behaviors, he's not working on his character defects, his resentments; he's not working the program. Although he takes that pill every day he is still very much sick.
    I have always been told that suboxone/methadone are meant to be worked with a 12 step program.

    Well, some could argue "It's all about harm reduction". Let me tell you what I think about harm reduction. My dad is also on xanax. He does not take that as prescribed. The psychiatrist he gets the xanax from dispenses it like it's candy, and doesn't know my dad is on suboxone. The addictionologist KNOWS my dad is on xanax and prescribes him subs anyway.

    After rehab, I stayed in this little receovery town for two months in a three-quarter house to get a foundation in receovery. people came from all over to this town because of all the recovery houses and meetings so you get a mix of different types of rehab programs. Suboxone was everywhere on the street. People would go and get their subs filled, sell them, and then go buy heroine/drug of choice with the money they got. people get a lot of money for suboxone on the street let me tell you.

    I remember stealing some of my dads suboxone (which I could tell he wasn't taking as prescribed either since there were a bunch of halves in the bottle and he was supposed to be taking a whole one daily). Don't ever let anyone tell you they don't get you high. And that's all I'm going to say about that.

    Plain and simple, my experience with suboxone is you're replacing one chemical with another. But then again, the same could be said for people getting clean and being put on psych meds....People can abuse anything.
    I've seen some success stories with suboxone but those are people who really want to be clean, use subs as a short term crutch, and start working a 12 step program.
    Last edit by june2009 on Aug 9, '10 : Reason: misspelled words
  11. by   RROUSE
    I do not agree with the last post.I am a recovering addict also. I am on suboxone and it has NEVER made me "high". It simply keeps me from craving all those other pain pills. Trust me, I probably wouldnt be alive if it wasnt for suboxone and my doctor.I have heard of people saying it made them sick when they first started taking it, however this was not the case for me. It changed my life. I am now an LPN and will probably go back for my RN in the near future. Thank you for letting me vent, that statement about suboxone makes people high.... simply IS NOT TRUE.
  12. by   LilRedRN1973
    I remember stealing some of my dads suboxone (which I could tell he wasn't taking as prescribed either since there were a bunch of halves in the bottle and he was supposed to be taking a whole one daily). Don't ever let anyone tell you they don't get you high. And that's all I'm going to say about that.
    There is a book I read recently about an addict who said pretty much this same thing. He was given suboxone in rehab and once he was discharged on it, figured out a way to abuse it and get "high", although not the same way his viciodin/oxycontin did. I do think addict will figure out a way to abuse just about anything out there. Not too long ago, I was having horrible cramps, took one of my prescription 800mg ibuprofens my OB/GYN had given me and when they cramps were still killing me about 2 hours later, my addict brain starting thinking "hmm...wonder if I take another, the cramps would go away?". I had to remind myself it wasn't time to take another IBU and that it would not be taking it as prescribed. But my addict head thinks if "one is good, 5 is better".

    I do think suboxone has a place in recovery but that place needs to be defined better than what it is currently be used least where I live. Because right now, it's being used without much education and without much discretion.
  13. by   zofran
    I think this thread took a wrong turn.....

    I am aware Suboxone is an opiate that can be abused. I am aware that some people will find a way to abuse it.

    I am also aware that if the correct dose is taken properly, Suboxone will take away the powerful craving that almost always leads to relapse. This gives the addict the ability to focus on recovery.

    If used properly, this medication can be a tool in ones recovery, not the only answer.

    It is attitudes like "Suboxone gets you high" and " Suboxone is an opiate" and "You are trading one drug for another" that scares people away from a very good treatment option. Addiction is a disease that people DIE from. Would you rather have a person alive on suboxone or "clean" but dead from a relapse OD.

    Congrats to the LPN who posted for getting your life back. Good luck with getting your RN, I wish you the best.
  14. by   genaa75
    Well what if the IPN Dr , you had to go see agrees you have a serious painfull , longterm injury and stated i had to get off Methodone i was using for pain of couse prscribed , and switch to suboxone as a long term medication for pain management.......????