urine of suboxone pt I just took over.....

I'm learning stuff here.
Thank you, to all.

whopper said:

About maintenance, it is a step forward, and there are patients where you have to be wary of them being on it for too long. Like I said above, how to handle this becomes grey because there is no exact science on how long they should be on it. I have seen patients be on maintenance for over a year and appear to be sincere and have nothing I find wrong in terms of drug screens, maintaining interviews, etc. I see a group that doesn't want to take any steps forward in terms of getting off of it even afer being on it for months. That group makes me wonder. Like I said, I understand if one's scared to take the next step, but on the other hand someone is supplying the drug dealers.

Click to expand...

Sometimes people around the patient can inadvertently create an atmosphere of fear whereby there's almost an expectation that coming off of the Suboxone (or Methadone as was the case for me) will automatically equal failure and ultimately total relapse. I did a very slow Methadone taper over 2 years, and even 18 months after I'd started the program, with zero illicit drug use, extensive hours of therapy to learn how to deal with triggers, happily married, and doing contract work for the Red Cross Blood Bank in my city I still heard the same thing from my pharmacist, from my therapist, from other Doctors - "Wait until your off the Methadone". Almost every time I expressed excitement at how well I was doing, and how different my life was now, I got the same response - "Don't get too far ahead of yourself, wait until you're off the Methadone'. It almost set coming off of Methadone completely up to be this huge scary deal, and in reality, for me at least, it wasn't like that at all. I think I might have even tried to come off the program earlier if it hadn't been for the fact that I was so scared of relapsing and losing everything I'd gained, and the people I came into contact with did nothing to alleviate that fear.


10 years clean this year btw.

Ceke2002 said:

10 years clean this year btw.

Click to expand...

SomeDoc said:

...What defines recovery? Satisfactory social and occupational functioning in the presence of continued maintenance? Sustained and full remission? I think the answer is not as simple as it seems.

Click to expand...

Informal polling of counseling staff at my MI/CD treatment program:

"Recovery is process, a process of putting the disease of addiction in a remission state".

"I like the Big Book definition of 'a daily reprieve based on our spiritual fitness.' "

I'll share more as they come in.

vistaril said:

maintenance on suboxone is not recovery.

Click to expand...

So someone who is able to return to work, feel fulfilled there, reunite with family, manage their finances, avoid legal issues, and feel a return to their spiritual side as opposed to seeking the next hit isn't "in recovery" when they're taking suboxone, even when they had not been able to do any of the above with any consistency due to their addiction prior to such?

Because I've seen many do just that on suboxone.

I'm currently of the camp that says if ain't broke, don't fix it. And if it's running better than it ever has before, it ain't broke. I see no reason why long-term suboxone maintenance shouldn't be considered recovery when someone is taking a medication to treat disease that no longer runs their life and that instead they are leading the life they'd want to live.

Call it what you want, but if I were a patient, I know what I'd call it.

vistaril said:

no, that patient is not in recovery. They may be doing well for them and it may be the best they can hope for....but it's not recovery. Suboxone is a harm reduction strategy. Not recovery.

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Your definition of addiction recovery adopts a very absolute and narrow view of what addiction really is. I recommend you take care of healthy patients that physically injure themselves after they slip on banana peels. In most cases, regardless of your interventions, you'll get close to 100% recovery and maybe a few good laughs while you're at it. You'll also get to use the word "real recovery" as much as you like around your colleagues and not have as many of them look at you with a jaundiced eye.

10 years clean this year btw.

Click to expand...

Congratulations. That's great.

I'm currently of the camp that says if ain't broke, don't fix it.

Click to expand...

And there's the holding the wolf by the ears problem. I've noticed that adopting that attitude allows some to slip through, wean themselves off and sell it. That's also an attitude developed by people on benzos. They're fine on their Xanx 8 mg a day, so why am I trying to get them off of it?

Yeah, I know it's not the same exact thing as Xanax, IMHO it's far worse to be on Xanax than it is Suboxone but there are parallels.

Even if one were in the position where they have a patient who is not selling it, I wouldn't encourage a patient to stay on it indefinitely because there's no guarantee it'll be paid for indefinitely by the insurance company. The insurance company can stop paying for it. I've seen that happen even with patients with clean urine drug screens and faithfully showing up to their meetings.

I've seen some insurance companies pay for it for years with no problems, others will only pay for it for months.

While Suboxone can help a patient tremendously, to simply give it out and think that's the best their going to get IMHO is wrong. If I felt that way about psychiatry in general, I'd be giving a heck of a lot more benzos out and telling patients that are stabilized that they might as well forget about psychotherapy because if it ain't broke don't fix it. The manufacturer doesn't encourage that, they do encourage psychotherapy, and therapy can help the patient get over things such as having triggers to use, resorting to drug use as a coping mechanism, and prevention of relapse.

So someone who is able to return to work, feel fulfilled there, reunite with family, manage their finances, avoid legal issues, and feel a return to their spiritual side as opposed to seeking the next hit isn't "in recovery" when they're taking suboxone

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I'd say no (hey I'm agreeing with Vistaril). Per the manufacturer and the prescribing guidelines set up b the government, they're in Suboxone maintenance, still undergoing treatment and that's not the end point. Recovery implies they're at the end of the road in getting better.

whopper said:

If I felt that way about psychiatry in general, I'd be giving a heck of a lot more benzos out and telling patients that are stabilized that they might as well forget about psychotherapy because if it ain't broke don't fix it.

Click to expand...

I think what was implied by the previous statement of "if it ain't broke don't fix it" was really a risk/benefit assessment to do "what is best for the patient". Although it does have a very complacent tone. Psychotherapy is key. It is hard work, and the opposite of complacency if done correctly.

whopper said:

Recovery implies they're at the end of the road in getting better.

Click to expand...

Recovery isn't a clinical term. It's something much more humanistic, and I would say it's not even in the realm of a psychiatrist's or a physician's duty to define it (we are in the fortunate position of being able to support our patients who participate in 12 steps, but we certainly aren't the ones who came up with it, and we're not the ones calling the shots). I think OPD's staff member's definition of the "process of putting the disease of addiction in a state of remission" is a lovely definition. There is no "end of the road" in getting better from addiction.

Some of this is a matter of politics, but addiction treatment has a set of politics that goes with it. Words matter because they affect thoughts, attitudes, and behaviors.

The generic statement "you're not in recovery if you're on opioid maintenance" is misguided. It may be true in some instances, but it may not be true in others.

Irony. I'm agreeing with a guy who mentioned in another thread he didn't find a problem with giving out benzos. Vistaril-I agree with your Suboxone stance--well I think I do, but it contradicts the benzo one you had weeks ago.

If one views recovery as getting rid of the ailment, then no, I'd say Suboxone use is not recovery. The person still has opioid dependence. Yes they're in a better situation, but they still have opioid dependence. If one sees improvement as recovery, then yes, but I don't see doctors using it in that manner.

E.g. if a patient has HIV and is on an med for it, docs don't say they're "recovered."]

But in any case, I think to argue this point is splitting hairs and agree with Billy on this. I just know I wouldn't use the word recovery around patients because then many of them get the idea that this is it, there's no getting better.

More recovery definitions from the experts:

"a sustained change in lifestyle"

"In recovery, the goal is a contented life always achieved through progress, never perfection (which is unattainable)."

"Embracing wellness through taking the required steps toward regaining health in the area in which one is recovering."

Again, despite vistaril's protestations, not inconsistent with Suboxone, in my practical experience.

Sneezing. didn't respond to your post.

All your points are ones I'm aware of, and I actually agree with you.

The question is not keeping patients on long term vs never ever doing so. IT will depend on each patient. I do think there are some merits for some patients with longer treatment.

But, as I said before, if someone wants to be on it, is doing well on it, and they just want to leave their treatment there, I don't like it, and from personal experience some of those people want to be on Suboxone for the wrong reasons.

One thing I like about this thread is there's no hard science or even from what I've seen debate on just how long someone should be on Suboxone.

whopper said:

Sneezing. didn't respond to your post.

All your points are ones I'm aware of, and I actually agree with you.

The question is not keeping patients on long term vs never ever doing so. IT will depend on each patient. I do think there are some merits for some patients with longer treatment.

But, as I said before, if someone wants to be on it, is doing well on it, and they just want to leave their treatment there, I don't like it, and from personal experience some of those people want to be on Suboxone for the wrong reasons.

One thing I like about this thread is there's no hard science or even from what I've seen debate on just how long someone should be on Suboxone.

Click to expand...

I don't know much about it, but atleast for people abusing Rx opiates, apparently 12 weeks +counseling doesn't help much once suboxone is tapered.

"Overall success rates 8 weeks after completing
the buprenorphine-naloxone taper in phase 2
(week 24) dropped to 8.6% (31 of 360 patients), again
with no difference between counseling conditions."

Conclusions: Prescription opioid–dependent patients are
most likely to reduce opioid use during buprenorphinenaloxone
treatment; if tapered off buprenorphinenaloxone,
even after 12 weeks of treatment, the likelihood
of an unsuccessful outcome is high, even in patients
receiving counseling in addition to SMM.



From: Adjunctive Counseling During Brief and Extended
Buprenorphine-Naloxone Treatment for Prescription
Opioid Dependence : A 2-Phase Randomized Controlled Trial

whopper said:

And there's the holding the wolf by the ears problem. I've noticed that adopting that attitude allows some to slip through, wean themselves off and sell it. While Suboxone can help a patient tremendously, to simply give it out and think that's the best their going to get IMHO is wrong.

Click to expand...

I don't think you got my gist, but I also agree I made my last post more carelessly and with a degree of disdain at the blanket statement that a patient who is on suboxone isn't in recovery--to a degree that I woudn't agree with my own post.

I was referring more to a patient who had begun to take control of his or her life again. That's not a broken individual, and it's most certainly someone on their way to recovery. Telling someone like that they're not in recovery until they're off of suboxone (somewhat pejorative and stigmatizing, no?) is counterproductive, in my opinion. I've seen that attitude at NA and AA meetings and seen patients try to come off of suboxone too quickly, as a result, only to relapse, send their life in a downward spiral, and undo all the progress they'd made.

Recovery implies they're at the end of the road in getting better.

Click to expand...

I'd argue that recovery is an ongoing process that's never fully achieved. You've got a lifelong disease in addiction and likely years of chaos in one's life as a result. It's all semantics, but someone who is in "suboxone maintenance" and rebuilding his or her life is in recovery in putting together those broken pieces that lead to and resulted from their addiction. I see recovery as rebuilding the individual in all respects, not just opiate dependence.

I think it's somewhat debateable whether weaning patients off of suboxone is in their best interest, especially as a rule. When it comes to first doing no harm, I question and don't know if there really can be an answer whether taking an addict off of suboxone is less harmful than leaving them on it long-term. The relapse rates are pretty high... That's kind of the patient's call. I recall a retrospective case study that followed 150 or so buprenrophine patients over 18 months, and those that remained on bup were more likely to be employed, to have not relasped, and to be attending groups as compared to those who had stopped buprenorphine.

vistaril said:

yes words do mean things in the addiction community, and maintenance on a controlled substance is NOT recovery. It is harm reduction.

Click to expand...

Why are you clinging to this narrow, binary, and restrictive view of what recovery "should" be?

I agree with freaker, your view is pejorative, stigmatizing, and counter-productive. The staff I quoted are all people in recovery, working a program, and they would never judge my suboxone patients who are sincerely working a program (some of whom they treat with me) to not be in recovery as well.

surftheiop, nice post.

OldPsychDoc said:

M
"In recovery, the goal is a contented life always achieved through progress, never perfection (which is unattainable)."

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I think you hit the nail on the head with this one. Although "recovery" is not technically considered clinical terminology, I still think this is an important point of discussion. Several reasons. With the high rates of relapse, it's important for us to understand the nature of addiction and have a better handle on empathizing with the strife of our addict patients. It also highlights that relapse is not complete failure. These patients have often been neglected, abused, overly-controlled, their emotional experiences have been dismissed or met with hostility. Imagine how failure as a child resulted in a slap across the face. Rather, relapse is a part of the process. Making room for this experience may help addicts stay engaged in treatment. As we know, addicts are terrible at keeping their appointments. It also helps shatter the illusory omniscience of absolute resolution that often addicts have and we hear them make these types of statements ie. "I can quit whenever I want to", "all I have to do is put my mind to it and I'll never pick up again". Addressing the wish and eternal struggle for ultimate mastery is a hot avenue for the therapist to then engage the patient in a tactful and delicate way by empathizing and making room for the patient to experience and hopefully move on to more reality based thinking.

It also highlights that relapse is not complete failure.

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Agree. So many people relapse, but it can be so heart-breaking that it could cause someone to not restart the road to recovery. (Aw nuts used that word again!)

billypilgrim37 said:

Recovery isn't a clinical term. It's something much more humanistic, and I would say it's not even in the realm of a psychiatrist's or a physician's duty to define it (we are in the fortunate position of being able to support our patients who participate in 12 steps, but we certainly aren't the ones who came up with it, and we're not the ones calling the shots). I think OPD's staff member's definition of the "process of putting the disease of addiction in a state of remission" is a lovely definition. There is no "end of the road" in getting better from addiction.

Some of this is a matter of politics, but addiction treatment has a set of politics that goes with it. Words matter because they affect thoughts, attitudes, and behaviors.

The generic statement "you're not in recovery if you're on opioid maintenance" is misguided. It may be true in some instances, but it may not be true in others.

Click to expand...

Recovery has different definitions from region to region, group to group, individual to individual.

Here's an interesting article:

What is recovery? A working definition from the Betty Ford Institute

specifically sections 5.1.2: Sobriety sustained by medications.

"Finally, it appears that only few of those presently
in recovery within the United States consider individuals
whose illicit opioid use is blocked by buprenorphine or
methadone to be in recovery (Murphy & Irwin, 1992; White
& Coon, 2003)"

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This seems to agree with the experiences I've had with people in the addiction community. But the paper argues that these people should be considered in "recovery".

Another interesting paper:
"Narcotics Anonymous and the Pharmacotherapeutic Treatment of Opioid Addiction in the United States"

Page 12:
"In NA this powerlessness is ascribed to addiction, rather than to a particular drug. In this
view, either the use of any mood-altering drug or the use of any medication to treat
addiction would be considered the antithesis of the first step: a continued effort at control
rather than surrender (“We dreamed of finding a magic formula that would solve our
ultimate problem—ourselves.”)
49 Through this lens any form of drug substitution and any
medication used to treat addiction is seen as one more effort at using a material
solution—a technological fix—to solve what is at its core a spiritual problem (“Our
experience indicates that medicine cannot cure our illness.”
50)."

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It seems the members of AA and NA would generally agree more with the point of view that Suboxone is not recovery. As far as I know I think both groups don't have a centralized view on this subject. But I think this is a philosophical issue which shouldn't concern psychiatrists too much because our main task is to restore health and function to our patients and help them meet their goals, not to have them meet these philosophical guidelines.

Why can't the endpoint of addiction be full remission, sayanara to all triggers, cravings, etc? I mean they weren't like this before using so why can't you go back to the way you were prior to starting?

I don't think it necessarily has to be dragged on and on and on. I am sure a few achieve this or come very close. In fact, I have a dear friend who was IV heroin user for many years and he is 8 years clean and has achieved this level of "sobriety." Its just not an issue anymore. Period.

I believe you can keep what you earn and never look back. I've seen it firsthand.

toothless rufus said:

Why can't the endpoint of addiction be full remission, sayanara to all triggers, cravings, etc? I mean they weren't like this before using so why can't you go back to the way you were prior to starting?

I don't think it necessarily has to be dragged on and on and on. I am sure a few achieve this or come very close. In fact, I have a dear friend who was IV heroin user for many years and he is 8 years clean and has achieved this level of "sobriety." Its just not an issue anymore. Period.

I believe you can keep what you earn and never look back. I've seen it firsthand.

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The people that get to that point are in full remission and there are plenty that do. That doesn't mean that the process ends there. There are many instances of people being in full remission that return to use after 10,15,20 years of sobriety. That's what makes this a lifetime process for a lot of people, the maintenance treatment of meetings, spirituality, therapy, or whatever else never ends even if they don't experience the triggers, cravings, etc., because they would come back otherwise. Others just kick it and they're done. But for most it's a relapsing-remitting type process that requires life-long treatment of some sort. The question is when do we let people be on permanent maintenance therapy. Do we keep pushing AA/NA meetings on them over and over? People's rates of recovery with AA/NA are probably as good as with DM and diet and exercise - very poor. But we don't deny the diabetics their pharmacotherapy and keep telling them to diet and exercise. I'm sure their quality of life would be a lot better with diet and exercise, kind of like a person that doesn't need suboxone therapy and goes to meetings, but we shouldn't be denying them this option because we have an idea of what recovery/remission really is.

billypilgrim37 said:

Click to expand...

whopper said:

Congratulations. That's great.

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Cheers, thanks

My treating Doctor worked on a system of three strikes you're out, so long as you were honest with him. If you lied about drug use, & got caught out by a random drug test, it was instant dismissal. If you admitted straight up if you'd had a slip, and were prepared to spend time exploring ways that could be prevented in future, you were given another chance. Once you'd used up your 3 chances, if you messed up again, that was it. I personally never had to be given any chances on the program, but I did think it was a fair system.

BS81 said:

It seems the members of AA and NA would generally agree more with the point of view that Suboxone is not recovery. As far as I know I think both groups don't have a centralized view on this subject. But I think this is a philosophical issue which shouldn't concern psychiatrists too much because our main task is to restore health and function to our patients and help them meet their goals, not to have them meet these philosophical guidelines.

Click to expand...

Nice post. I would add that I'm not so worried about the at-large community (it wasn't so long ago that 12 step programs vehemently opposed people even taking prozac), but rather the community of folks who are pursuing opioid maintenance, many of who do so within context of 12 step programs and local chapters that are less rigid with their definitions. Within that community, some are "working a program," and some aren't. If you're "working a recovery program," I'm not sure anybody else gets to tell you you're not in recovery if you're actually working pretty hard.

Pulled some data from the NSDUH (https://nsduhweb.rti.org/) sponsored by SAMHSA and DHHS, illustrating some of the challenges we face in the field of addiction.

Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older: 2002-2010

Source: 2010 National Survey on Drug Use and Health (NSDUH).



Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2010

Source: 2010 National Survey on Drug Use and Health (NSDUH).



Reasons for Not Receiving Substance Use Treatment among Persons Aged 12 or Older Who Needed and Made an Effort to Get Treatment But Did Not Receive Treatment and Felt They Needed Treatment: 2007-2010 Combined

Source: 2010 National Survey on Drug Use and Health (NSDUH).

My treating Doctor worked on a system of three strikes you're out, so long as you were honest with him. If you lied about drug use, & got caught out by a random drug test, it was instant dismissal

Click to expand...

I use a soft system like that with some offenses (such as being arrested and found guilty) as immediate dismissal. A dirty drug screen, I'm willing to consider one of the three strikes if the patient tells me upfront, tell me why it happened and appears sincere in not allowing it to happen again.

As for long-term use, I do want patients to get to 12 mg a day, the minimum the manufacturer says can still offer protection against relapse in terms of the opioid receptors blocking other opioids out. If they achieve this, I am willing to keep them on it longer...

billypilgrim37 said:

Recovery isn't a clinical term. It's something much more humanistic, and I would say it's not even in the realm of a psychiatrist's or a physician's duty to define it (we are in the fortunate position of being able to support our patients who participate in 12 steps, but we certainly aren't the ones who came up with it, and we're not the ones calling the shots). I think OPD's staff member's definition of the "process of putting the disease of addiction in a state of remission" is a lovely definition. There is no "end of the road" in getting better from addiction.

Some of this is a matter of politics, but addiction treatment has a set of politics that goes with it. Words matter because they affect thoughts, attitudes, and behaviors.

The generic statement "you're not in recovery if you're on opioid maintenance" is misguided. It may be true in some instances, but it may not be true in others.

Click to expand...

Also very much agreed (wish i wasnt on my phone and could write more)

OldPsychDoc said:

More recovery definitions from the experts:

"a sustained change in lifestyle"

"In recovery, the goal is a contented life always achieved through progress, never perfection (which is unattainable)."

"Embracing wellness through taking the required steps toward regaining health in the area in which one is recovering."

Again, despite vistaril's protestations, not inconsistent with Suboxone, in my practical experience.

Click to expand...

Love these quotes, thanks. Question, are you asking about the substance using definition of recovery or the more general mental health use of the term that applies to living with illnesses such as schizophrenia etc (because the statements can very much apply to either)?

Recovery is something defined by an indivual in terms of his or her own goals. Other than that, i hear a lot of normatization and execution of moral superiority by institutions of power. I dont think AA, manufacturers guidelines, the law, or even medicine can define it for a person (though they can define the terms of participating or being excluded from that institution).

aphenomenon said:

Love these quotes, thanks. Question, are you asking about the substance using definition of recovery or the more general mental health use of the term that applies to living with illnesses such as schizophrenia etc (because the statements can very much apply to either)?

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I just asked the staff at our MI/CD IOP to give me their definition of "recovery". No other prompting.

vistaril said:

ummmm....that's pretty damn important. I mean what about the person whose "sustained change in lifestyle" was switching from shooting dilaudud to snorting oxy.......I suppose he can claim "recovery" as well.

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Just personally I considered it recovery when I went from being on the streets, prostituting myself to pay for my Heroin habit to being in a stable, happy marriage, re-earning the respect of my friends and family, and looking at a return to gainful employment, Methadone or not.

Ceke2002 said:

Just personally I considered it recovery when I went from being on the streets, prostituting myself to pay for my Heroin habit to being in a stable, happy marriage, re-earning the respect of my friends and family, and looking at a return to gainful employment, Methadone or not.

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Cheers

I've heard one addiction specialist say that a little bit of Suboxone diversion might not be entirely bad, as he/she had experienced a number of patients who tried Suboxone for the first time on the streets and then decided to seek out a doctor to do maintenance. Kind of a, "This isn't so bad. I could quit using and take this," kind of a thing.

I'm curious; have others had this experience? Have others out there treating outpatients with opiate dependence had these situations occur?

The director of our treatment program offered the following link in response to the "What is recovery?" question:
http://www.samhsa.gov/newsroom/advisories/1112223420.aspx

I'm curious; have others had this experience?

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Yes. Several have compared Suboxone to a miracle. While it certainly may seem so for the first few months of treatment, unfortunately from my experience, several patients don't follow the guidelines. They're the minority but a sizable one, forcing me to stop their treatment or tell them I will not be able to tolerate further behavior on that order (e.g. a dirty drug screen, telling me they gave some of their Suboxone away to help a friend, etc).

The overwhelming majority from what I've seen are stabilized to the point where they can stop using illicit opioids and get back to feeling "normal" again. That is not having to freak out every day in search of their next hit. From there most people can start working again or not lose their jobs in addition to other things like their marriage, custody of children, etc. That is for the first few months.

The problem is that many people with drug abuse had problems that got them into abusing opioids in the first place such as untreated ADHD, being with the wrong crowd, impulsiveness, recklessness, what have you, and those things are not effectively treated by Suboxone. Several patients see you as their miracle-giver at first, not the guy who's going to lay the law down and tell them they're going to be SOL if they continue to have dirty drug screens, miss payments, or have a fit in the waiting area.

During my treatment sessions, the first session (the induction) where the patient literally goes from drug-seeker living in fear of where they'll find their next hit to being able to live without fear, I tell them these things but, IMHO understandably, it doesn't register in most. When someone is going from withdrawal to feeling normal they usually are too sick and then euphoric and too relieved to fully take in that data.

But in the next few weeks, I do try to reinforce in them that I don't want to stop their treatment because they might not follow the rules, reiterate them, and enforce that they have to have the responsibility to maintain their treatment and strive towards a mental model of being independent from illicit substances. That includes asking them if they have a possible untreated mental issue such as ADHD or anxiety, doing CBT, identification of triggers, and laying down with them structured goals based on directives that I try to leave up to them e.g., How long do you want to be on Suboxone? Why?"

Several of my patients have told me that Suboxone has saved their life literally, or saved their marriage, profession, or family, but despite this, treating patients with it can be cumbersome in dealing with the UDSs, dealing with patients with a (+) drug screen, and plenty of Suboxone patients doing chronically reckless things such as missing meetings and then screaming at the receptionist for not getting them in at a moment's notice.

It's funny how many patients claim to lose their Suboxone script (maybe about 1-2 a month out of 60 Suboxone patients) despite me warning them I will never refill a lost script, when out of thousands of my non-Suboxone patients on a prescription medication that is not abusable, I've gotten maybe 5 my entire career where this happened. IMHO, I think some of it wasn't that the Suboxone patient was lying but that they're just too used to being too impulsive. One of my patients scoured the parking lot for about two hours and then found it, and security had her on camera on her hands and knees looking for it.

Not taking this as direct medical advice, but Im an MS3 interested in psych. Plenty of my own time on the opposite side of the desk. But pertaining to this, what current strategies can anyone tell me about for fentanyl addiction. My mom, dad too i think still. And that obvious compounding factor of both them married

Need to formulate more of a concrete plan. Just saying to them or bringing up a shrink or detox isnt helpful

What kind of dosing schedules are recommended?

16 weeks max?

Im not even sure it would be wise as I dont want them to have future insurance problems as they both do have legit chronic pain issues.

Whats the out of pocket cost for the drug if I didnt want to involve insurance? Cant be more than fentanyl so theyd probably be happy

I do know one psychiatrist who they might see and i trust but he doesnt RX this. Hes done an addiction fellowship and plenty qualified otherwise

Just need to hear some viewpoints and personal experiences treating. All the psychotherapy in the world wont crack my mom and my dad just piggybacked with her and has a natural compulsive personality.

Is it best for couples to enter detox for the same 90 days?

Post that besides probably an SSRI and trazadone one has

Appreciate it, not many opportunities to ask about this openly and hear several professionals viewpoints

Fentanyl is really the ****ing devils drug

I have seen no hard science other than one of the links above over just how long the person should be on Suboxone, and I believe the more studies are done, the more it will suggest it will likely be more person specific.

The manufacturer has a suggested an algorithm of lowering the dosage if the patient has no triggers. The maintenance dosage is between 12-16 mg a day with 12 being the minimum dosage needed to offer protection should the person relapse. Once the person is confident they will not relapse, lower the dosage below 12 mg and eventually get them off of it.

So then just how long should the maintenance phase be? That's up for debate. Some doctors IMHO may suggest patients stay in that phase longer than need be because it frankly makes good money for them. Being on that phase too long IMHO may put the patient in a comfort zone where they will not want to get to the next level for the wrong reasons, others may wean themselves to a lower dosage and sell the rest (and yes I've seen that happen), others may truly need to be on it for extended durations and IMHO anectdotal opinion, people with extremely long durations of abuse (e.g. years, even decades) and poor coping skills are more likely to fall into this category.

If there's one thing I learnt in recovery it was that there's no such thing as a right way, or a wrong way to recover from addiction, there's just what works best for you. Dealing in absolutes (the 'one true way' approach to recovery) is just setting yourself up for potential failure, imho.

vistaril said:

(sigh)


the fact of the matter is that medicine and psychiatry have very little to offer opiate addicts and alcoholics......we can detox them. then after that we can educate them and tell them they need to go to AA/NA.....but thats about the only way we can help

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So on one hand you want us to believe your this super intellectual physician who went to a great medschool and great residency program, then on the other hand you believe detox and educating people to get them to NA/AA is the only viable role an addiction psychiatrist has to offer?

vistaril said:

the fact of the matter is that medicine and psychiatry have very little to offer opiate addicts and alcoholics......we can detox them. then after that we can educate them and tell them they need to go to AA/NA.....but thats about the only way we can help

Click to expand...

If you really believe that 12 step and detox is the only treatment for addiction and psychiatrists have no reason to understand neurologic diseases like epilepsy, I'm really starting to doubt you're a psychiatry resident at all.

This combined with all your other posts is enough for me to start to suspect a troll. Psych drop-out or never-ran? Medicine intern dumped by a psychiatrist SO? Scientologist? Many possibilities here...

surftheiop said:

So on one hand you want us to believe your this super intellectual physician who went to a great medschool and great residency program, then on the other hand you believe detox and educating people to get them to NA/AA is the only viable role an addiction psychiatrist has to offer?

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Absurd statements like this from our contentious boardmate make it clear that there is simply nothing to be gained by engaging him. Add him to your ignore list!

notdeadyet said:

If you really believe that 12 step and detox is the only treatment for addiction and psychiatrists have no reason to understand neurologic diseases like epilepsy, I'm really starting to doubt you're a psychiatry resident at all.

This combined with all your other posts is enough for me to start to suspect a troll. Psych drop-out or never-ran? Medicine intern dumped by a psychiatrist SO? Scientologist? Many possibilities here...

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I'm guessing burned-out IM resident who couldn't get into the fellowship he wanted...or worse, got into GI and hates himself for having to do rectals all day.

notdeadyet said:

If you really believe that 12 step and detox is the only treatment for addiction and psychiatrists have no reason to understand neurologic diseases like epilepsy, I'm really starting to doubt you're a psychiatry resident at all.

This combined with all your other posts is enough for me to start to suspect a troll.

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Yes the inconsistencies do seem to be piling up, just personally my BS meter was pinged when Vistaril skated a little too close to the edge of giving medical advice in the thread I started. I've never seen any of the actual Doctors on this forum just come straight out and say 'your diagnosis doesn't sound right, give me a history of your symptoms'.



Hey, if I'm wrong, I apologise, but I would assume anyone in the medical profession would know you cannot risk giving medical advice online. Think of all the ways that could have gone wrong , not being medically trained myself I take Vistaril at his word, decide my treating Psychiatrist has it all wrong, go off my meds. -- yeah, that's gonna end well.

notdeadyet said:

Psych drop-out or never-ran? Medicine intern dumped by a psychiatrist SO? Scientologist? Many possibilities here...

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Patient who knows just enough to pass themselves off as a Doctor...