Thursday, July 22, 2010

Suboxone – Miracle or Menace?

I have recently been following a lively discussion on Linked-in with this title. Suboxone has now been available for a few years and we are all starting to now see many patients who are having serious problems with it.

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Suboxone is a powerful opiate (narcotic) that can be prescribed by physicians for patients who have opiate dependence problems. It can be used either for detoxification or for maintenance. The problem is we are now seeing that it can also be abused. Suboxone was approved in the US in 2000 and is now prescribed by many physicians thought the country. Last time I checked there were over 25 physicians just in Richmond Va. who are licensed to prescribe it. In 2009, Suboxone generated profits for the company of about $440 million.

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So it is a popular drug and it has become a very popular treatment option for patients. There are a number of reasons for this. Firstly, opiate addiction is a common problem. If you combine Heroin addiction with all of the people using opiate painkillers in a non- medical way, there are over 30 million people in the US affected by this disease. Secondly, standard treatments are not very effective. Opiates are extremely powerful. It is very difficult for patients to detoxify off them. And if patients are able to get off opiates, it is even more difficult to stay off them. Opiates go straight to the pleasure center and people feel so good being on them and they feel so awful when they don’t have them. So without help most patients relapse back to opiate use pretty quickly.

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Suboxone is very powerful and can be useful because of its two unique properties. Firstly it binds very tightly to the opiate receptors, and secondly it only turns the receptor on partially. Because it binds so tightly to the receptors it lasts a very long time, and it has a kind of blocking effect. That is, if someone is on Suboxone and they try to use Heroin or OxyContin, they only get a small effect because most of the receptors are already occupied. This is good because the whole idea is to stop patients from using street drugs. Because it only turns the switch on partially Suboxone doesn’t produce a dramatic high. This is good because we don’t want the drug we are switching patients to, to be even more pleasurable than the one they were on.

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But there are two major problems with Suboxone. Firstly, it does turn the receptor on (so it is highly addictive), and secondly it lasts a very very long time (which means the withdrawal off it takes a very long time). This means it is highly addictive and the withdrawal off Suboxone is very unpleasant and lasts much longer than the withdrawal off Heroin or OxyContin. Patients usually only find out about this when they want to come off their Suboxone.

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Other problems with Suboxone are starting to rapidly mount up. Many people are abusing the Suboxone itself. There are reports from all over the world of patients abusing Buprenorphine (the active ingredient in Suboxone). Many are reports of people abusing Buprenorphine intravenously or snorting it. Often it is combined with Benzodiazepines. According to DAWN data from 2006 there were over 4,400 ER visits associated with Buprenorphine.

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The most common problem we and other clinicians are hearing about is that a lot of opiate addicts are using Suboxone illegally when they can’t get their Heroin or other opiates. They continue to use street drugs to get high, and then use Suboxone to avoid withdrawal. Suboxone is a lot cheaper than street drugs so patients will use it to avoid withdrawal when they can’t afford their regular drug. Many patients are getting a prescription for Suboxone and their only intention is to sell or swap the Suboxone for more “pleasurable” drugs. Patients tell me that it’s been very easy to see their physician every month and keep getting their Suboxone prescription. They just have to make sure they don’t use street drugs before their appointment in case the physician gets a drug screen.

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Other people who are hooked on street drugs are using Suboxone before they have to provide a drug screen – if they are going for a job interview for example. Suboxone will only be picked up with specialized drug screen, although this is starting to change.

So, it seems pretty clear that Suboxone is not any kind of magic bullet – for most people it is not an “easier, softer way”.

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We believe that for most people the combination of our Accelerated Opiate Detox and Naltrexone Implants is the best solution. The detox helps patients quickly get off their drugs in a safe and comfortable way. The Naltrexone implants give them the support they need to deal with cravings and allow them to get into real recovery. It is not an easier softer way, but it brings the happiness and peace that people really crave.

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For patients who are hooked on Suboxone, our Accelerated detox program is able to get hem fully detoxed in about 8 days.

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Dr Peter Coleman

“Nobodies Perfect?!?”

Step 7: “Humbly asked God to remove all our shortcomings”

“No-No… nobody’s perfect but maybe I come awfully close”, muses Gene Simmons on the new KISS album entitled Sonic Boom. It seems that Mr. Simmons could learn a thing or two from the 12 Steps of addiction recovery. According to the 12 Steps, no one is perfect. And that is a good thing. Allow me to explain.

Shortcoming, faults, defects, mistakes, and failures contribute in a huge way to why people use alcohol and drugs. Naturally, most people tend to try and escape when things are going poorly. However the way they try to escape is not always healthy. For example, people exercise, go to the movies, read a book, or take a nap when things are overwhelming. Others find comfort in the arms of a love one or through the words of a close friend. These are not bad coping skills. However, a large section of the population is unable to make wise decisions in dealing with problems and they choose alcohol and/or drugs to try and solve them.

This is where shortcomings come into the picture. Pride, selfishness, impatience, ego, judgment of others, resentment, greed, and immaturity cause so many problems for the addict. Paradoxically, it is these very shortcomings that help the addict operate in the world. And when presented with the work of Step 7, many of them balk!

If we look at the step, it is no light matter. It commands a specific course of action. It involves surrender. It involves giving over control to a higher power to change them from the inside out. Step 7 is the ultimate step toward “dying to self” and living for God and others.

The first part of this step involves the quality of humility. Humility is the ability to understand our right place in the world. For example, I have been playing bass guitar for 22 years and feel pretty confident at my skill level. However, it is quite clear to me that I am not or will I ever be Gene Simmons of KISS and play stadiums with 100,000 people. Through humility, I understand and know my right place in the world, namely, a good bass player who is not a rock star.

But how does one become humble? I share with our patients at TCI that there are 5 attitudes that are essential to staying clean. They are:

1). I cannot stay clean alone (i.e. accountability and community are essential),

2). I am not the center of the universe (duh! You’d be surprised how many people think that is their title and geographic location),

3). I do not have all the knowledge in the world (lack of knowledge means you still have to learn and be a student),

4). I do not have all the power in the world (lack of power means I still need help),

5.) I am broken and I need help (lack of wholeness causes fissures in my person and I need others to patch me back up)

If an addict will adopt these attitudes, then I believe they will have come a long way in paving the road to humility. Once someone becomes humble, they then become teachable. Once they are teachable, they can learn to stay clean.

The second part of this step is a verb: ask. You cannot receive what you do not ask for. It is that simple. The beauty or curse, as the case may be, of Step 7 is it requires the addict to change attitudinally by adopting an attitude of humility and by taking a purposeful course of action in asking their higher power to remove all their shortcomings.

Step 7 is not for the faint of heart. It requires a lot but it gives a lot in return. To the addict who is willing, much will be received by taking this step to include a new way of speaking, thinking, and acting in the world they formerly navigated using the broken compass of shortcomings.

As for Mr. Simmons, while I respect his contribution to American popular music, things are not always what they seem, for even the mighty Demon hides his shortcomings…namely lack of hair!



Chris Newcomb - Aftercare Coordinator

Monday, July 19, 2010

Ready to be Happy

I just finished reading an article that John Bowe wrote for the on-line version of the New York Times, Formerly Unsober (4/12/10). He describes his experiences with alcohol. He never had a DUI and hadn’t yet “impregnated a Hooters waitress”, but he’d had his usual four glasses of wine the night before. He had long been using alcohol to help him sleep—the uninsured man’s anxiety medication-- and hoping not to run into his neighbor as he carried his bottle-laden bin out to recycle.

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In a moment of clarity, he was blessed with the liberating thought, “I’m ready to be happier now.” It was the last time he drank (except for a small glass of port, which he states he quite regretted drinking).

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The line I love best in this article: “I am going to pursue every single aspect of this existence as fully as I possibly can.” Hence, no more booze.

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A common theme among our patients who come to The Coleman Institute for an alcohol detox is the question “How is this serving you?” Whatever thoughts are leading to the actions, they need to be examined so the behavior can change.

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At The Coleman Institute, not only can we safely guide you through an alcohol detox, we can steer you toward some good therapy. Call us if you are ready to ‘pursue every aspect of your existence as fully as you possibly can.’

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Joan Shepherd - FNP

Saturday, July 17, 2010

How the Hell Did I Get Hooked on Suboxone??

That’s what many of my patients are asking themselves. Most started out having a problem with opiates. Some started out recreationally and some started out for medical situations that involved being prescribed addictive narcotic medications.

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When I worked as a nurse practitioner in my previous position, I remember when the drug representatives who sold Suboxone were coming through and educating us about this wonder cure. It seemed too good to be true…but sure enough, the doctor I worked with got his DEA designation to prescribe, and we were able to get patients off heroin and Oxycontin, Percocet and dilaudid and the rest. It was amazing!

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What no one seemed to know—or say—was how difficult it can be to get off Suboxone. Woops. No one prepared us for this small detail.

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When I accepted the position to work with Dr. Coleman here at The Coleman Institute, my former colleagues laughed when I told them we help people get off Suboxone! Why, they asked, would you do that? Suboxone is specifically used to detox people off those drugs.

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Suffice it to say, we are now experiencing the fallout from the ‘miracle cure’. Every month hundreds of people call us wondering how the hell they got hooked on Suboxone and is there anyone anywhere who can help them get off.

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We now have six offices around the country, and getting people off Suboxone is a growing specialty. Please call me if you have any questions.

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Joan R. Shepherd, NP

Wednesday, July 14, 2010

How do we treat Doctors with Addiction problems?

A recent article from The Journal of Substance abuse treatment, written by Robert DuPont MD and others, reviewed how we treat physicians with addiction. They reviewed the records of 904 physicians and remarkably 78% had no drug screens positive for alcohol or drugs over a 5 year period.

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They looked at the features of the treatment programs that lead to this remarkable success rate. What they found was that the physicians were treated over an extended period of time in excellent residential or outpatient programs. Usually the physicians were treated in an inpatient program for about 3 months and then they were given less intense follow up treatment in outpatient programs that could last for 3 to 12 months. They were subject to random drug tests. There were usually programs to help the family members learn about addiction and how they could help. The physicians were typically closely linked with 12 step programs.

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My own recovery began back in 1984, and I was treated in this same kind of intensive and extended program. I have now been clean and sober for over 25 years and the other physicians that I know who received this kind of treatment are also doing well.

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This is why we try as hard as we can to get our patients to commit to intensive, comprehensive and long lasting treatment. If they will agree to this and then participate in it they have the best chance of lifelong recovery. We can all learn from these doctors.

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Dr Peter Coleman

Sunday, July 11, 2010

“ACTION NOT REACTION!”



“A life of reaction is a life of slavery, intellectually and spiritually. One must fight for a life of action not reaction.” Rita Mae Brown


As the old saying goes, “for every action, there is a reaction.” How true this is! Just pay attention the next time you approach an intersection; if the light turn’s red, my guess is you react by placing your foot on the brake to slow down and avoid an accident. Or, for example, if the water that is boiling on the stove starts to boil over, you react by cutting the stove off and moving the pan. A life without action or reaction is the life of a statue. This is not what we are meant to be!


However, there is wisdom in differentiating between action and reaction. Dictionary.com defines action as, “an act that one consciously wills and that may be characterized by physical or mental activity.” To act is to be alive. Action is using our intellect and our will to move about in space and time. It is a gift and a responsibility.


In a seemingly similar, but different, fashion we often experience reaction. The same site defines the word reaction as, “action in response to some influence, event, etc.” What a subtle but important distinction. When we react, it is always in response to some external source (e.g. a co-workers attitude) or internal source (e.g. attacking a co-worker with a stapler due to your anger at the co-workers aforementioned attitude). Our reactions often get us into trouble especially in the area of substance abuse and recovery.


In recovery, addicts are literally recovering from a life of reaction. Out-of-control emotions such as anger, fear, boredom, apathy, rage, and jealousy caused them to medicate through substance abuse. The tyranny of other people’s opinions often ravaged their self-worth leaving them no seemingly better action than to react with substances. It is a vicious cycle. That is why it is important to learn the skill of action instead of relying on the knee-jerk, life-destroying incompetence of reaction.


So, how does one move from reaction to action? Very slowly! Breaking a habit takes time. People don’t become addicted overnight; neither do they learn to take right actions in the same timeframe. Therefore, it is wise to learn how to work the Steps and apply the wisdom of your sponsor. In addition, it is helpful to learn how to live and act right in a community of like-minded individuals such as those in A.A. and N.A. It is in community that we break isolation and experience personal accountability, two key components to right action.


The good news is that this can be done! The 9th Step promises state, “Fear of people and of economic insecurity will leave us. We will intuitively know how to handle situations that used to baffle us” (Alcoholics Anonymous, p.84). What an awesome set of promises…to be able to be free to do the next right thing and forget about doing the next wrong thing! You’ll know you are starting to get somewhere when you start thinking, “action not reaction!”


Chris Newcomb – Aftercare Coordinator

Wednesday, July 7, 2010

Why people don’t get treatment

According to the 2008 National Survey on Drug Use and Health there were about 24 million people who needed drug or alcohol treatment who didn’t get it. When they were asked why they didn’t get treatment the biggest reason given was that they didn’t have the health care coverage or they couldn’t afford it.

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This is a modern day tragedy. The evidence is very strong that money spent on treatment is money very well spent. I think the last study on this issue found that for every dollar spent on treatment, there were seven dollars saved, either in future medical costs or other costs such as incarceration, child neglect, marital strife, etc.

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It is hard enough for people who have addiction problems to reach the point of being willing to accept help. The last thing they need are barriers preventing them from getting it. Hopefully the new Obama health care bill will correct this problem so that at least all the people who want treatment can actually get it.

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Dr Peter Coleman

Saturday, July 3, 2010

The Graduate

Have you ever been to an orthodontist’s office and seen the Before and After Braces photos? Well, unfortunately it’s not entirely appropriate for The Coleman Institute to display the Before and After pics of our patients who have successfully made it through a year of naltrexone pellets…

We had one of those winners ‘graduate’ today.

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There were a few times during the year I didn’t think he would make it. Once after a four hour drive to get here, he stomped out of the room and left without a pellet because he didn’t appreciate some of my observations about the choices he was making. He was frequently cavalier about whatever recent charges he’d incurred. He really didn’t seem to be getting it.

Things gradually changed.

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Jack (not his real name) started hanging out with other people who take their Recovery as the single most important thing in their lives. He found daily meetings and became accountable to a sponsor. He began working out regularly at the gym (we all ooohed at his 6-pack), and he’s enrolled in classes again at the local community college. His ambition? Nothing less than a pilot’s license.

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He’s also got a set of amazing parents who have really figured out—with the help of Narc-Anon—where to help and where, what looks like helping, is actually a hindrance to their son’s sobriety.

So, Jack, thank you for giving us one more success story to share with people who really need some inspiration. Maybe someday we’ll do a Coleman Institute Calendar and invite you to be Mr. April.

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Joan Shepherd, NP