Heroin, Coffee, And Suboxone®: On Not Replacing One Addiction With Another

Throughout my clinical career, I have had multiple conversations with patients, family members, and other clinicians about the role of Suboxone® (aka buprenorphine) in treating opioid addiction. The most common objection to the recommendation has to be, “Aren’t we just replacing one addiction with another?”

In the beginning, I used to give them a dry list of points as to why it wasn’t just replacing one addiction with another. But, over time, I sharpened my axe and learned to take a more conversational path. Below is my current approach, dramatized from multiple discussions and talks.

* * *

The Objection

Upon hearing my advice that he take Suboxone® for his heroin addiction, a patient says, “I heard a lot about it. I’ve heard that it is another narcotic, like heroin.”

“I don’t like the term narcotic. But, yes, Suboxone® is an opioid, which means it belongs in the same class of chemicals as heroin,” I reply.

“I’ve heard that it is also hard to get off from Suboxone®.”

“That is also true,” I agree, “Like all opioids, abruptly stopping Suboxone® can result in withdrawals.”

“Then why would you give it to me? Aren’t you just replacing one addiction with another?”

“I know we are not replacing one addiction with another. Would you like me to explain why I think that way?”

After he consents, I begin explaining. My goal is first to explain the difference between addiction and mere dependence.

* * *

Setting The Stage with Coffee

I ask, “Do you know anyone who is or was a big coffee drinker?”

“My dad,” he replies, “He used to drink 8-10 cups of coffee daily. He always had a cup in his hand. I think now he drinks 4-5 cups a day.”

“What happens when he can’t get his coffee for any reason?”

“He seems just a bit off. A bit annoyed. He also says he gets a headache if he can’t get his coffee.”

“So, he has withdrawals.”

“Yeah! He has withdrawals from coffee,” he chuckles.

“It almost seems as if his body needs coffee.”

He nods.

“Yes, anyone can get hooked to coffee,” I explain, “And when once we are hooked to coffee, we get withdrawals when we abruptly stop it.

“But let me ask you this,” I almost whisper for dramatic effect, “When was the last time you saw your dad steal money from anyone to fund his coffee habit? Or sold things he owns for coffee? Or said he couldn’t think of anything but coffee until his next cup?”

“Never,” he says, looking amused.

* * *

The Heart of The Matter: Addiction and Dependence

“See, a lot of people confuse addiction and dependence. Our bodies can become dependent on a host of things. People who stop their seizure medications abruptly increase their seizure risk. Same with certain blood pressure medications. People can also get certain symptoms if they stop their antidepressants abruptly. Of course, as your dad can tell us, stopping caffeine can cause withdrawal symptoms. Do you know the difference between dependence and addiction?”

He shakes his head, “No.”

“For something to be called an addiction, the 4 C’s have to be present,” I explain, holding up a finger for each C, ” “Craving, Control — as in losing control over how frequently or how much one uses, Compulsion to use, and use despite Consequences. Does that make sense?”

I wait for his nod before continuing, “Withdrawal symptoms are a sign of dependence. The 4 C’s are signs of addiction. Usually, both go hand in hand, but they don’t have to. For example, you may recall the earlier stages of your addiction when you had the 4 C’s but weren’t using them daily or as many times a day as you did before coming in for treatment. Or you may know some people who use cocaine but only use it a couple of times a week. They don’t have withdrawal but may still have the 4 Cs.”

He seems attentive, so I keep going, “And, of course, your dad with his coffee is the example of the opposite — dependence without the 4 Cs. You know how I asked you earlier — When was the last time you saw your dad steal money from anyone to fund his coffee habit? Or sold things he owns for coffee? Or said he couldn’t think of anything but coffee until his next cup? — I was looking for the 4 C’s.”

“I definitely have the 4C’s,” he interjects as I take a breather.

“An easy way to think about it is this. If abruptly stopping something causes withdrawals, then you have dependence. If substance use is accompanied by the 4 C’s, then it’s an addiction. Does this difference between addiction and dependence makes sense to you?”

“Yes.”

“By the time they come to treatment, many people with addiction, especially with addiction to heroin or other drugs in the same chemical class, are no longer experiencing any of the pleasure they felt from using when they first began. Instead, they are just using to avoid being sick from withdrawal. And the 4C’s have taken over their lives.”

“That’s me,” he affirms, “I am nothing but the 4 Cs. I can’t stop using even though I see what it has done to my life.”

* * *

Suboxone® MAT = Dependence Without Addiction

“What would you say if I told you I could give you a medicine you must take daily? It will stop your withdrawal. It will get rid of your cravings. While taking it, if you relapse on heroin, it will block the effects of heroin. Do you think that would get you free of the 4C’s?”

“Yes, but there must be a catch.”

“There is. That medicine is Suboxone®. Yes, it is an opioid. It is in the same class of chemicals as heroin. So, yes, you would be dependent on it. If you stop it abruptly, you will get withdrawals just like your dad does from coffee. But just like your dad with his coffee, you would no longer have the 4 C’s. Dependence without addiction. Wouldn’t that be better than what you have going on right now?”

“It would be loads better. But I still can’t get my head around the idea that I would be taking another drug.”

“Yes, you will be replacing one chemical with another, but here’s the most important part — the bigger picture. The whole thing is to replace your addiction with mere physical dependence. When you no longer deal with the 4 C’s day in and day out, it creates the emotional space necessary to engage in recovery. To work on the emotions that drive your addiction. Repair broken relationships. Re-engage with society.”

His eyes are listening. I continue, “And eventually when you have done enough of that difficult emotional work and armed yourself with the tools and tricks to prevent relapse, we could take you off Suboxone®. But, because of the dependence, we would have to do it slowly. And I must say, there are people whose addiction is so severe and their emotional challenges so great that they cannot get off Suboxone® without relapsing. They have to stay on it for the rest of their lives. Even if you end up being one of them, you will be like your father, who will probably keep drinking coffee without ever having the 4C’s. Only because Suboxone® is not coffee, you would do so under medical guidance and supervision.

“When you say it like that, it makes sense.”

“You don’t have to accept my recommendation right now. Or ever. But here’s the most important thing I want to repeat from our discussion just now and want you to remember. While treatment with Suboxone® involves using one chemical instead of another, it does not replace one addiction with another. We are replacing one addiction with mere physical dependence and creating the emotional room for recovery.”

He thanks me for explaining it this way but says that he wants to think about it. I respect that decision, and hoping he will call soon. His life is at stake.