Opioid Replacement Therapy: A Controversy In Medicine

Buprenorphine is a partial opiate agonist/antagonist that has been used as a pain medication for decades to treat mild to moderate pain under the brand name Buprenex. More recently, very much like methadone, buprenorphine has been used as a maintenance and detox medication for individuals dependent on opioid drugs. For this purpose, it is often combined with nalaxone, a pure opiate antagonist, to prevent misuse. This formulation is called Suboxone. In the absence of nalaxone, buprenorphine used for this purpose is marketed as Subutex. Subutex and Suboxone are designed to dissolve sublingually (a fancy term for "beneath the tongue").

There are three primary advantages of buprenorphine maintenance over methadone maintenance and are as follows:

1. Doctors are permitted to prescribe it directly from their office on a monthly basis (rather than requiring daily visits to a clinic)
2. It is supposedly easier to detox from than methadone
3. Buprenorphine has a ceiling effect which means that increasing effects are only felt up to a certain dosage level (often said to be around 32 mg). In effect, this makes it much more difficult to overdose from and less likely to be abused

Despite these facts, buprenorphine often proves less effective in maintaining long-term, hard-core opioid addicts. The medication is used more frequently to treat individuals who have a brief history of opioid dependence and who have not continuously used heavy amounts of opiates.

My addiction to opiate/opioid drugs began in much of the same way most addictions do. For as long as I can remember, I have been hyperactive, had difficulty concentrating, and suffered from bouts of insomnia. Self-medicating started for me almost as soon as I was able to reach the medicine cabinet. I recall mostly taking medicines that contained ingredients which produce drowsiness, such as Nyquil and Benadryl. Upon reflection, I now realize that this was my attempt to control my hyperactivity and sleeping troubles. My mother now believes, as do I, that I should have been diagnosed with Attention Deficit Hyperactive Disorder (ADHD) as a child.

As time progressed and I grew into my teenage years, I experimented with tobacco, alcohol, and marijuana, as is relatively common among adolescents. Although not too thrilled with the effects of alcohol, I did find that certain other pills helped with my anxiety which was just then beginning to surface and which was probably a more mature manifestation of my childhood hyperactivity. It wasn't until I reached the age of 16 that I discovered the "magical" effects of prescribed opiate pain-killers.

My first experience with opioid drugs was with oxycodone, an opiate derivative of thebaine, which I was legally prescribed as a post-operative pain-reliever. This experience was nothing short of miraculous, or so it seemed at the time. After orally ingesting the drug, I felt like I had more confidence, greater motivation, a higher level of energy, and yet at the same time I felt that I could fall asleep at will. As time progressed, I found myself searching for narcotic (opioid based) painkillers more and more frequently because I now fully realized the sense of calming peace and comfort they could provide. It was almost as if they gave me a sense of relief. But relief from what? Could it have been that the hyperactivity, lack of focus, and insomnia I had been experiencing for most of my life was the result of insufficient endorphin production - an endogenous chemical which opioid drugs mimic? This is a relatively newly recognized medical condition better known as Endorphin Deficiency Syndrome, or simply EDS, which I now firmly believe I have suffered from since childhood.

For the next few years, I remained extremely cautious with my opioid consumption as I knew about the imminent danger of dependence and addiction so commonly associated with incessant opioid intake. I remember I had this rule with my opiate use which I called the "Three Day Rule" and that I never broke... for at least a few years. Basically, its self-explanatory. The concept is to never get high on opiates or opioids more than once within a 72 hour period. This worked for me for quite some time until somewhere down the line, I ran into some personal troubles with school and life in general (that I won't go into) and started noticing that my rule was beginning to gradually slip away from me until it became just barely visible on the horizon of a huge ocean of addiction just waiting to swallow me whole. And that it did. Now I was approaching 20 years of age and I won't say that I hadn't experienced opiate withdrawal up to this point. I had somehow managed for a couple of years to keep my mild, yet fully apparent, dependence on opioid drugs at just that: 'dependence' and not 'addiction'. For instance, I would get high one morning, enjoy it and put it away for at least 72 hours no matter how bad the cravings got. By this time, I would be starting to feel slightly sick with just a few withdrawal symptoms. Enough, however, for me to fully realize that that is what it was - opioid withdrawal. Then I would get high again - usually on pain pills or poppy tea (I need not go into what that is) - the discomfort would evaporate and I would once again be flying high in my own little world of bliss.

Sadly, so much has changed for me since then. I eventually began taking drugs more and more often until I was getting high every other day in a continuous pattern. At this point I was beginning to see the consequences of addiction without even realizing it. I would have to make sure that wherever I was going or whatever I had planned, I had secured a supple amount of opiates to avoid feeling the overwhelming discomfort of withdrawal. I was now putting off important daily tasks such as class, homework, and even work in favor of getting a fix.

The situation never fully spiraled out of control until I discovered heroin, an opiate with a rapid onset and euphoria beyond what I had ever experience before. I had already experimented with just about every other drug and pill on the market, including morphine and cocaine, and I now knew it was time to finally extinguish the nagging curiosity I held about heroin. I must say that the only thing that really sets heroin apart from other opiates is its rapid onset and the fact that it requires such a small amount to feel high. Now I was having to use every day in order to avoid getting "sick" and I noticed that although heroin had a more rapid onset than other opioids I had been using, it didn't last as long by any means. This necessitated more frequent ingestion of the drug which in turn led to a faster rise in tolerance. It wasn't long before what began as a bag a day habit turned into two bags a day and eventually three, etc.

I had now given up my seemingly never-ending quest for prescribed painkillers in exchange for the seductive euphoria of what was now an easier-to-find and, initially, a cheaper drug. The inexpensive quality of heroin does not last long, however, since it requires its users to take an ever-increasing dosage in order to feel its pleasurable effects. Within about three months of daily consumption, I had gone from using the drug intranasally to intravenously injecting the drug to obtain yet an even quicker high. I had also gone from spending $10 a day to spending around $20 to $30 a day all within this relatively short period of time.

Heroin tends to have that effect on people. You try the high, you enjoy the high, and therefore, you wish to continue feeling the same high you experienced from the beginning. This particular opiate induces more rapid tolerance in the user than any other opiate drug - at least to my knowledge. At my peak, I was injecting about $70 to $80 worth of heroin per day, all dispersed between three or four shots.

I truly realized that I was officially an "all-out" junkie when I would unwillingly go without heroin for a day or two. Because of my well established physical dependence, this deprivation would initiate severe withdrawal symptoms in which I would become extremely restless, irritable, have stomach cramps, gagging sensations, chills and hot flashes, all in conjunction with profound insomnia. Due to the insomnia, no matter how much I desired to escape feeling the intense discomfort of "dope-sickness", I was doomed to ride it out while fully conscious. In addition to the symptoms mentioned above, opiate withdrawal causes heightened sensitivity with regard to all five senses. For instance, lighting is perceived to be extra bright - often to the point of physically hurting one's eyes - noises are much more irritating than usual, and unpleasant scents are magnified to the extend of nausea. Not to mention the fact that the craving for more heroin - which by now the addict knows is the only thing that will ease the pain and discomfort - is beyond anything I have ever experienced before. This is the main reason heroin addicts will often resort to extreme measures to obtain their drug of choice.

The first attempt I made at detoxing and getting clean was probably around 6 months into my addiction to heroin. Having dropped out of a top-notch school, I moved from New York back to Pennsylvania to live with my parents. Since I was unable to access heroin and other hard opiates at home, I had to make frequent trips back to New York City to stock up on my "supply". This, however, proved to be too much of a hassle and left my parents contemplating why I would consistently have to drive back to my old school dormitory to "pick up something I'd left behind". Eventually I had to tell them my dark secret as it became much too difficult to hide. Their first reaction was of horror and disbelief, but after the initial shock had passed, they knew it was time for me to get some help. I made a trip to the family doctor who prescribed me some sleeping medication and "Immodium-AD" to help ride out the debilitating effects of "cold-turkey" withdrawal. I became so sick that, after just a few days, I quickly went into drug seeking mode and called everyone I knew who I thought might be able to find me some narcotic painkillers. Sooner or later, I lucked-out and was able to get a hold of some hydrocodone, a chemical derivative of codeine. Since my tolerance had been lowered due to my abrupt detox, the pills made me feel a whole lot better. Mind you, I had to take a whole handful to "get straight".

By the end of the summer of 2003, I was able to convince my parents that I was well enough to go back to school in New York. Not even 24 hours after moving all my stuff into my new dorm room in the west village, I made my way to the east-side and asked the first junkie I saw where I could cop some "dope". I sniffed (rather than injected) the first couple of bags I bought, and tried my best not to get high two days in a row. Within about one week, I was fully immersed back into the dangerous cycle of drug addiction.

Classes quickly became secondary to securing a fix and ensuring that I was "well" enough to make it through each day. It was that semester at school that I experienced my first harrowing brush with the law and landed in jail overnight. Unfortunately, it wasn't the last time I would be arrested within those few months. I was arrested shortly thereafter for shoplifting to support my now thirty-dollar-a-day habit. This event led to one of the most regretful decisions I have made to date. I opted to drop out of school and move back home, leaving my education behind. I soon made the proper arrangements to officially withdraw from school and made my way back to Pennsylvania once again.

Now staying with my parents at the age of 21, I found out through some old high school friends where to cop heroin in Philadelphia, which was a mere 40 minutes away. From that point on, my addiction only grew worse until, again, I had to confide in my parents for help. I had recently heard of a doctor who helped opioid dependent people like myself by prescribing what was then a brand new medication. It was called Suboxone (buprenorphine), and was said to maintain addicts much like methadone. However, it could be dispensed directly by a pharmacy in monthly quantities. This, I thought, was a great advantage over having to attend a clinic on a daily basis; so I took the initiative and made the call.

I remained on Suboxone for about one month before relapsing and getting high. Soon enough, I discovered that taking Suboxone, which contains the opiate antagonist, nalaxone, completely blocks the euphoria of other fast acting opiates such as heroin. Consequently, I found myself neglecting my prescription in favor of getting high. As I remember, the only time I would reach for the Suboxone was when other street opiates were scarce, or when I could not obtain them due to lack of funds. Instead of stealing or committing other heinous crimes for street drugs, I would medicate the "dope-sickness" with my prescribed drug. Because of this fact, I must admit that Suboxone did help in some ways in that it kept me from going to extreme measures to obtain a fix. That said, I don't believe I was entirely ready at the time to commit to the self-discipline required for daily self-administration of such a drug. And so, I gradually began taking heroin more often and Suboxone less often. Before I knew it, I was completely back into the seemingly endless cycle of acquiring money, scoring heroin - this time in conjunction with coke and crack - and getting high.

The summer of 2005 could be referred to as the era of my heaviest drug addiction. During those three months, my habit soared to between eight and ten bags ($80 to $100 worth) of heroin a day. I also fell into the routine of either mixing my shots with coke, known as "speedballing", or alternating shots of heroin and coke. Furthermore, I embarked on a few crack-smoking binges that summer, but never without first securing a few bags of dope (heroin) to "soften the landing". Eventually, it got to the point where I knew I had to make a break and leave town, so that's exactly what I did. I rounded up the remainder of my Suboxone pills and caught a flight to Miami. I was able to clean up my act enough to hold down a restaurant table service position for a couple of months. Of course, I still had to be sure to take my daily dose of buprenorphine to avoid going through abrupt withdrawal. Before the pills ran dry, I made a wise decision and sought out a doctor in south Florida who was certified to prescribe buprenorphine - this time in the form of Subutex (Suboxone without the nalaxone) - for my opioid dependence. I did quite well with this medication for most of the six months I spent in Miami.

By April of 2006, I decided that I'd had enough of Miami Beach so I moved to the southern California desert with a couple of friends - lock, stock, and barrel. When I first arrived, I remember wandering around the town of Palm Springs in search of some black-tar heroin - a form of heroin only available on the west-coast and that I had never tried before. On the east-coast of the United States they sell a powdered form of the drug called "China White". Without much luck the first couple of days, I resumed medicating my withdrawal symptoms with the Subutex I had secured prior to leaving Miami. Before the end of my first week in California, I managed to find a little flower shop that sold dried poppy pods, from which one can concoct "opium tea". Opium tea is comprised of a variety of different opiate alkaloids; morphine and codeine being the most abundant, so you can imagine that it does more than its fair share in keeping the "dope-sickness" at bay.

I continued with the tea preparation on a daily basis for a couple of weeks straight before encountering the black-tar heroin I had been looking for. One day while trying to find a syringe to inject my prescribed Subutex, I came across a homeless man who pointed me in the direction of a methadone clinic which happened to be located right down the block from where I was staying. As you can imagine, I was thrilled to find out about this... but for all the wrong reasons. Instead of checking myself into the clinic as a patient, I waited just outside its premises for a patient who could help me find the two products I was in search of; namely, some heroin and a syringe. No more than 2 hours had passed before I became acquainted with a "methadonian" who, having just been medicated at a very low dose, was also looking to cop some "dope" to get high and make it through the day. So I shadowed him for the next few hours while he made the necessary phone calls and we both jumped on the next bus to Palm Desert to meet the guy. And so, thereafter, I made the proper connections and once again knew where to find heroin; now all the way out on the west-coast of the United States. Geography can change one's decisions and lifestyle, but its strictly up to the individual to make it happen.

For the next couple of months, I alternated taking shots of heroin and consuming opium tea. This got me through each day and kept the opioid withdrawal to a minimum, until one day, while working at my then current table waiting position at a local restaurant, I went to go "fix up" in the bathroom. I must have spent a bit too much time in there because when I resumed work, my boss had a few words with me prior to sending me home. The following day I was fired and, I must say, it was well deserved. Although I found a replacement job relatively quickly, I knew it was time to find a new treatment option for my addiction since I was now on my own, and couldn't risk losing another job - especially with the cost of my daily habit. I attempted to switch back over to what Subutex medication I had left, but quickly found that, with the severity of my drug dependence, it did little to help. So before the end of the first week at my new position, I made my way back over to the methadone clinic; this time with the intention joining the program as a new patient. Deep down inside, I knew that not only was this my last resort, but also my only hope.

From this point forward, I will start from the present and work my way back to where I left off (July of 2006). I am 28 years old and am just now beginning to really get my life on track. I have been on a methadone maintenance program for over 4 years, and I must admit that, although it can be a real hassle at times, it has been the only treatment to date that has helped me to stabilize and regroup my life. I medicate myself every morning around 8:00 am and carry on with the rest of my day, thinking very little of drugs. Since joining the program, I have been able to hold down a steady job and I now work part-time as a waiter at a local diner. Once I have enough money saved, I plan on going back to school to study neuroscience.

This past April I moved back to my home-town to reside with my parents so that I could get my life together for once and for all with minimal expenses. I currently have next to no living expenses, save for train fares and gas money to get to and from Manhattan where I attend my current methadone program twice a week. Due to good behavior and clean urine analyses, I have earned myself five take home doses of methadone per week where I am permitted to self-medicate at home without medical supervision. This privilege was not granted overnight, but rather took months upon months of strictly abiding by clinic regulations. I recently transferred from a clinic in downtown Manhattan to one located right around the corner from Penn Station where my train arrives every Wednesday and Thursday morning - usually around 8:00 am. The change was mostly for convenience purposes, but also partly for the type of methadone that is dispensed. At my last program, we were medicated with a cherry liquid formulation of methadone whereas at this new program, we are medicated with our choice of either orange or white wafers of methadone which are then dissolved in warm water. My preference for the wafers over the liquid has to do with the fact that they seem to "hold" me through an entire 24 hours more effectively.

I have recently begun attending a program to gain certification as an alcohol and substance abuse counselor, and my methadone treatment remains stable. My prospect is to begin gradually reducing my dosage over time from 80 mg, dropping 10 mg per month until I reach 40 mg. At that point, I will see how I feel and then determine whether or not I would like to continue with the taper.