Several years ago I worked with a highly intelligent, sophisticated couple who were severely addicted to heroin. Month after month they struggled to stop, but over and over they found themselves “chasing the high” by taking larger amounts of intravenous heroin or scoring smaller amounts just to keep themselves functional. Finally, they left the States and moved to a kibbutz for a year. They went through a difficult and painful withdrawal syndrome but then lived a drug-free but isolated life for over a year. Having the sense that they had finally licked the addiction, they returned to the United States. Upon arrival at JFK airport, they could think about little else than getting heroin. They both broke into cold sweats, developed goose bumps on their skin and had to run to the bathroom with diarrhea. They hadn’t used drugs for over a year and yet the mere access to their old lives stirred craving so intense that they had the classic signs and symptoms of opiate withdrawal. Within hours they had returned to their lives of addiction.
I don’t know what happened to them after I moved to Martha’s Vineyard 18 years ago, but today they would have the relatively new option of taking buprenorphine (Suboxone and Subutex). Suboxone, like methadone, heroin, Oxycontin and several other medications, is an opioid. But there are a few key differences between Suboxone and the other opiates. The most important is that it is legal for specially licensed physicians to prescribe it to opiate addicts so that they don’t need street drugs. Suboxone binds so strongly to the opiate receptor that once an addict is on it, drugs like heroin have minimal, if any, effect. Suboxone lasts a long time, blocks craving and doesn’t typically induce a high. And it seems to also block craving for alcohol and other drugs.
There is considerable debate about whether these replacement medications are a crutch that allows drug users to substitute a legal drug for an illegal one. As a prescriber of these medications, I have found that most of my patients are living sober, healthy lives. But all too often they struggle with whether to keep their treatment secret from their doctors, families and sponsors out of fear that they will be judged and shamed by people who consider their sobriety a sham.
In studies of people who are maintained on adequate doses of long-acting opiates like Methadone and Suboxone, there is less use of other drugs, less criminal activity and more engagement in work, family and love. Safer, legal replacement medications allow addicts to live healthy and productive lives. The down side? They can be as hard to get off of as heroin. Some people divert their medications — that is, sell their supply on the street. Replacement medications decrease the motivation to get completely clean, and they require the prescribing physician to be vigilant about abuse, diversion and other drug use. People taking these medications are dependent on the prescriber for as long as they are on them, and they must submit themselves to regular urine screens.
Suboxone is not for every opiate addict. The people I see who are on Suboxone are generally motivated, hardworking and committed to sobriety. They tend to have occupations and families, and most have gone regularly to twelve-step programs.
Despite the fact that individuals on Suboxone are by and large responsible, sober, moral members of society, many feel that they cannot tell their families, employers, fellow Alcoholics or Narcotics Anonymous members about their use of Suboxone. Many feel stigmatized by their pasts and ashamed of the need for Suboxone. That sense of shame is reinforced by people who judge them because of a lack of understanding.
Judgment about people who seek other forms of help such as psychotherapy and antidepressants seems to be fading. Hopefully, the time will come when the judgment toward individuals who need medication for their addictions will fade as well.
Dr. Charles Silberstein is on the psychiatrist board in addiction and general psychiatry with offices at Martha’s Vineyard Hospital.