I Used to Be a Heroin Addict; Now I'm a Methadone Addict

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There's a solid piece at Wired News about Buprenorphine, a treatment for heroin that kills withdrawal symptoms quickly, but without the abuse potential of methadone. Unfortunately, it hasn't taken off as expected, in part because of some ill-conceived regulation:

After bupe had been on the market a year, the law was amended to permit methadone clinics to prescribe it, but only under the same rules used for methadone (one dose per visit), which erases one of bupe's major advantages—that you don't have to schlep to a clinic every day. Meanwhile, many methadone providers have remained openly skeptical of the new med, fearing that it will further stigmatize methadone, or siphon off their most stable patients. The government reimburses methadone programs for the number of patients they oversee, not for the specific services they provide, so the payment for a stable patient who takes a dose and goes to work subsidizes treatment for more fragile clients with multiple addictions, mental illness, housing and unemployment issues, and more.

The regulatory problems didn't stop there. Influenced by tales of unscrupulous methadone clinics taking on huge case-loads for the reimbursement cash, Congress barred doctors from maintaining more than 30 bupe patients at a time. And in a monumental blunder, the law classified giant HMOs like Kaiser Permanente, as well as hospitals, as single providers, with the same 30-patient cap that Kolodny has in the solo practice he maintains on evenings and weekends. Four years later, the law remains unchanged. One clear sign of the law's unintended consequences: The world-renowned Addiction Institute of New York (better recognized by its old name, Smithers) doesn't mention bupe in its advertising because with a 30-patient limit, it fears it would have to turn people away.

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  1. Smithers, bring me my methadone.

  2. How’s this for a Friday Fun link? Death, drugs, and prisoner abuse – oh, yeah! Giggidy Giggidy Giggidy

  3. I’m president of the Pinkus Plumbing Company.

  4. “Four years later, the law remains unchanged.”

    Of course it does. Congress has more important things to do, like regulating steroids in sports, calling midnight sessions to pass special laws, etc.

  5. “a treatment for heroin that kills withdrawal symptoms quickly”

    Perhaps this is a side issue, but as I’m sure Jake will tell you, withdrawal symptoms are not the major obstacle to overcoming addiction. Anyone serious about coming off smack can decrease their dosage over time and avoid them, or go cold turkey and be done with it in a couple of days. Methadone, is just another illustration of how ridiculous the WOD is. Methadone is really nothing more than another narcotic. The fact that it’s given once a day in small doses is what allows users to function. The same results could be achieve with small daily doses of heroin. But of course heroin is baaad mm’kay. Even if this bupe stuff works as advertised, it’s only relevant to the initial phase. I don’t see it affecting Methadone treatment as a whole.

  6. i gotta say i think the Friday Funnies picture being used on the main Reason page is a little tasteless today.

  7. Any opiate or opioid (like methadone or buperenorphine) in adequate doses can and will remove symptoms of opiate withdrawal. Buperenorphine is a schedule-III controlled substance and a horrible painkiller. There’s a lot of money in methadone, it’s so long-acting that it’s supposedly the hardest opiate to withdraw from (much harder than heroin is), and the government enjoys keeping people, especially drug users, in control.

    And don’t expect any progress anywhere where controlled substances are involved in the plan. Buperenorphine is such a substance.

  8. This is the second long story on a new method of heroin detox that Wired has run so far this year. Is someone on their staff having problems, or what?

  9. “Buprenorphine could end heroin addiction, curb disease, and cut crime. But bureaucrats, doctors, and much of the treatment industry are just saying no.”

    ::extreme eye roll::

    Wired goes a little far with the techno-utopianism sometimes, but this is really a laugh. Looking past the ridiculous suggestion of yet another “cure” for addiction in the form of a medication, the author doesn’t seem to know the first thing about addiction treatment, recovery or even the nature of withdrawal.

    some 34,000 people were on methadone maintenance throughout 2004, while only about 1,000 people filled a bupe prescription last year. “It’s depressingly few,” says Lloyd Sederer

    You really have to be a full blown bureaucrat to be mystified and saddened by buprenorphine’s unpopularity and wonder why it’s not yet replaced methadone.

    There’s a difference between addiction “treatment” vis-a-vis detox and “treatment” in the form of controlled addiction, aka “maintenance.”

    Bupe can help the later stages of non-acute detox treatment. (It contains an opioid antagonist, so it would actually precipitate withdrawal in someone not already well in the throes of the sickness). So yey(?) I guess on that breakthrough.

    The other niche bupe is competing for is in the maintenance opioid market. I dunno how many addicts the author asked in order to see what they rather be using. But I bet it rhymes with zero.

    Methadone is a nasty drug that’s harder to quit than heroin because of its long half-life designed to keep you good and dosed with a single daily ingestion. But that’s the *point* of maintenance therapy. To maintain you high, yes, HIGH on opiates so you don’t have to cheat and steal for your fix. *Many* on maintenance programs still use heroin. But they get by with less. Contrary to popular belief, opiate users don’t take infinitely increasing doses. When given a regular unbounded clean supply, most users level out and function in dialy life.

    You can’t level out with bupe. It levels out for you. Unlike almost all opioids (including methadone) and all natural opiates, bupe has an agonist ceiling of between 8-16mg. So if a maximum dose roughly equivalent to a tablet of vicodin doesn’t cut it for ya, too bad. Meanwhile, people on methadone maintenance get 40, 60, 80mg a day if needed.

    Don’t get me wrong. Methadone is shit. Heroin would be a better, cheaper and safer maintenance substance. But doing something like that requires calling a spade a spade. It would also require leaving people alone to get high and function, which might send the wrong message that you can get high and function. And we can’t have that.

  10. Guys, we’ll never make any progress as a political group until we try to understand others’ interest in making drug users suffer horribly…

  11. “I Used to Be a Heroin Addict; Now I’m a Methadone Addict”

    Great Woody Allen reference!

  12. Yeah–my second-favorite line from the movie.

    My first-favorite is the one with Allen’s parents arguing: “She’s a black woman from Harlem! Who’s she gonna steal from, if not us?”

  13. Nephalim.org is a drug-policy reform community run by a guy who was a heroin addict for 2 years and has been on bupe for 5. Seems like a smart guy, check out his articles on bupe.

    [Dis: No, I’m not him and have not been asked/paid to plug him.]

  14. “I sell talises.”

    “I’m into leather.”

  15. Pavel’s right. As a long-time heroin addict myself I first came in contact with buprenorphine in the early 90’s. It came in glass syrettes and you could inject it IM or IV or use it sublingually. Dr. Marks (sp? RIP) was the local Los Angeles MD who violated AMA protocols to prescribe syringes (for the bupe) to us dopefiends. Recently I’ve been prescribed both of the currently-fashionable flavors of sublingual buprenorphine tablets: Subutex (oval, white, bitter, straight bupe) and Suboxone (hexagonal, orange, orange-flavored, bupe with naltrexone). Interestingly, the more common version Suboxone’s added ingredient is also known by the name Narcan. Paramedics know that this is a short-acting opiate antagonist that can (and does daily) bring overdosed and very-near-death junkies right back to life. In higher doses it can literally strip all of an addict’s opiates right off their cells’ chemoreceptors and put that addict into major instant withdrawal. ER doctors consider this to be a valuable tool for educating the OD’s that clog their ER’s–taking valuable space away from those waiting who didn’t choose to be injured

    In the long and interesting history of opiate addiction the pharmaceutical companies have claimed several times to have solved the dependence problem. Morphine worked well but it was found to be addictive so some Germans came up with heroin. Heroin was believed to be more powerful as well as non-addicting when it was first marketed. It was proved to be more powerful than morphine but the other claim turned out to be specious. Some more Germans went back to the lab and came up with (Dolophine) Methadone. This was a synthetic version of the natural alkaloid’s active-ingredient molecule. Also billed as the non-addicting way to help those dependent on morphine or heroin, methadone has turned out to be more addicting than either of its precursors. Which brings us to bupe. The latest panacea.

    I just kicked a bupe habit that was nastier than the heroin habit I went on bupe to kick in the first place. I tapered the Suboxone down to where I was taking someting between a sixth and an eight of a *single 2mg pill* once every 24 hours. The pills are too small to fractionate much smaller than this; this is a microdose. When I stopped I was dopesick for almost two weeks. Of course the withdrawals felt like days 3-5 of heroin withdrawal but it *lasted two weeks.* I usually feel pretty good by day seven of a straight heroin detox.

    The bottom line is that this is more about the politics of the drug addiction problem than it is really about the drug addiction problem. One heavily-invested camp says, “The beaurocracy is keeping u$ from $aving addicts.” Another says, “What we have i$ working fine, don’t change anything.” But the only people addicts should listen to are the ones who promote being completely drug-free. And not as some long-term distant goal.

    Personal history: most of my 20’s on heroin, most of my 30’s clean and sober (no meetings), currently 41 years old with 40+ days off all drugs and alcohol. They call it a relapse because they call it a disease. I think of it more as a self-inflicted behavioral injury. But I’m a 12-step heretic.

  16. “But the only people addicts should listen to are the ones who promote being completely drug-free. And not as some long-term distant goal.”

    You don’t sound like too much of a 12-step heretic to me, Humann. The disease model always seemed like a DSM-4 thing more than a 12 step program thing to me. I attended AA for over a decade and abstinence was the only thing that was a constant in my view of the process of staying off the dope. After 20 years and long after my last AA meeting, I remain drug-free.

  17. A couple years ago I read about something called ibogaine that supposedly eliminates all cravings and withdrawl symptoms after a few days of hallucination….

    does anybody know anything about this?

  18. MK, what I should have said about being an AA heretic is that I have a great many difficulties with much of their dogma. On the other hand I’m very interested in sobriety. The disease concept, the externalization of our good choices (I turned my will and my life over to God?) and the circular logic that any argument against any AA precepts simply is more evidence of the arguer’s disease–these are my main issues. Also, the notion that 12-steps are the *only* way to recovery. MK, It sounds like you haven’t been to AA in a while (I hadn’t either until recently) or maybe you didn’t go in California. I’ve heard time and time again at recent AA meetings that addiction is a disease just like cancer. “So where’s the 12-Steps for cancer?” I ask. But of course I need to ‘take the cotton out of my ears and put it in my mouth’ in the face of such indisputable truths. I went to AA for 6 months in ’93 and ended up with 9 mostly wonderful and productive years of sobriety. After several ‘relapses’ with pain pills (two herniated discs in my spine) and ultimately heroin I feel I’m once again on the right path. My fellow AAers are quick to voice their opinion that I’ll be using again soon if I don’t do all of what they tell me to, but I’m happy with the portions of the program that suit my needs. “Don’t Drink or Use, No Matter What *plus* Everything I learned in Kindergarten.”

    Ben, ibogaine is available only outside the USA and it’s pretty expensive (@$4-10KUS) but they claim an over-two-thirds success rate. It sounds pretty interesting/scary to me–there have been times when I really wanted to try it but didn’t have the money. Here’s some more info:

    http://www.ibogaine.org/

  19. Opiates/opioids are easy to get off of. For me, anyway. We all have some various array of biochemical fuck-ups that make different things problematic for different people, but I always found heroin to be a bore or something I did to calm down. Well, morphine and or oxycodone as I never really found taking the time to acetylize heroin really worth it.

    Methamphetamine is a hard drug to get off of. The urge is all in your head, aka: “psychological” but the real problem is that with meth, if you can keep your schedule intact, you’re often better at whatever it is you do. Also, I resent sleep. I hate it with everything in me, and I find myself thinking “I’m not going to sleep. I’m surrendering to it.” This further makes things problematic. Add on the very engrossing habit of preparing and using the drug, and quitting is, to say the least more of a pain in the ass than just obtaining more and pressing forward. I enjoy rolling the pipe around, I enjoy the tedious sterilization of preping myself for IV use, although the latter is usually reserved for, erm, emergencies, or celebration!

    Back to the original topic, methadone is garbage. It would be better, should a person find despite years of failing treatment they’re unable to stop, to enroll themselves in a Euro-style heroin maintenance clinic and allow themselves to mature out of the habit, which most do. I suppose those who don’t are either functional and content in their current occupation, or have some other complicating problem, like intense, life halting chronic pain that needs to be addressed aside from their “drug problem.”

    That said, the biggest drug problem of all, for any drug or drug user to a great extent, seems to be lack of availability and insanity of extreme, artificially inflated prices. Any other peripherals of this problem, such as indepenent user related issues of functionality, are just that and seriously compounded by the former, more costly “asshole government problem.”

    Guess we already knew that, though. 😉

  20. Hi meth, I used to notice that too, about how I could simply stop doing heroin after several weeks and I wouldn’t get sick like my junkie friends did. I assumed I was made of sterner stuff than they were. Then I moved in with my band’s manager and shot dope every day for 2 months. I’d done heroin fairly frequently for about 5 years at this point without ever getting a habit.

    My main drug from ages 16-22 was meth (not the extracted-from-cold-medicine bathtub-made yellow-looking chicken crank–this 1970’s stuff looked like rock salt and a dime would dissolve in two drops of water, right in the bag). I too mostly used heroin to come down off the meth. You know, like day 3 or so. Until I did the manager’s special every day for two months. That’s when I got my first real habit. And it took me eight years to shake it. Now I can get a real physical habit in a few days just from taking Vicodin one very four hours as prescribed by the damn oral-surgeon.

    The hard part of quitting speed for me was the lethargy I’d feel for weeks on end. I don’t know if that’s just psychological but I always felt that there was a physiological component to it as well.

  21. I just realized that you could easily replace all the “heroin”s and “meth”s in these postings and you would basically be describing my attempts at doing the Atkins diet this past year.

    Lethargy, relapses, success,periods of control vs. periods of addictive overindulgence. Yep it’s all there. Damn those wicked donuts! There ought to be a law!

  22. that may be some of the root as to why the addiction model gets used from heroin to video games to fast food.

    well, that and its a rhetorical show stopper. there should be a godwin’s law of public policy about “addiction” somewhere.

  23. dhex,
    I agree but only with the stipulation that there be a Quirk’s exception

  24. Hey,gays all of you likes that shit.Do you whant realy to stop?

  25. don’t worry we all gonna die

  26. I learned how to enjoy methad. Here in italy h is so bad that people quit because of that, quality changes from time to time, usually social services tend to decrease doses

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