Fishhook Effect

Fishhook Effect

What is the difference between a fishhook and a paperclip? It’s the barb. The sharp, triangular part at the beginning of the hook. It’s the point of entry, the first part that enters a fish’s flesh. And, it is what keeps the fish from escaping and swimming away.

Many medications must be tapered carefully.

There is an unpleasant withdrawal syndrome that comes with sudden discontinuation. This is true for a wide variety of medications. Blood pressure, anti-depressants, anti-anxiety meds and more. The same is true for pain meds. It is also true for some street drugs, such as heroin.

Buprenorphine, the main active ingredient in medications such as Suboxone, Subutex and ZubSolv, also requires tapering. If you quit too fast or too soon, you get sick. The sickness can last for days or even weeks. However, there is something different about what happens when you gradually reduce the dose over time in an attempt to quit. I call it the fishhook effect.  It can be a problem, but there is a solution.

When you have reduced to a fairly low dose of buprenorphine, it seems like you should be able to just stop taking it and be fine. Common sense would lead you to believe that it should be around 1 or 2 mg or even less. If you started at 16 mg, 1 mg seems to be fairly low. So, why doesn’t it work for many people? Why is it that so many patients end up stuck at that low, low daily dosage.

It has been described by some professionals as a security blanket effect.

The patient does not want to make that final jump to complete abstinence. Suboxone is what made it possible to get your life back and quit drugs. What happens when it’s gone? What do you have to hold on to to prevent relapse?

Others theorize that there is something else going on. Possibly, the difficulty in quitting Suboxone is due to the fact that at low doses, it acts more like an opioid agonist and less like an antagonist. That is to say, that it works more like a traditional opioid, the thing you were trying to get away from in the first place. So, maybe there is a physical explanation in addition to the psychological one.

It almost seems like buprenorphine, or Suboxone, has a fishhook effect. As if there was an imaginary barb at the end of tapering down the dose. Something that makes quitting it hard to do. Does this mean that buprenorphine is as addicting as any other drug?

No, it is not addicting in the same sense as your drug of choice was addicting. Taking an effective, single small dose of medication daily is not the same as 24 hours of constant obsession over a drug that consistently causes significant harm in your life. Drugs lead you to loss of freedom, institutions, degradation and death. Buprenorphine leads you to see your doctor once a month.

So, how do you finally quit buprenorphine?

If you want to be completely abstinent by the standards of recovery groups, such as Narcotics Anonymous, you may be motivated to take this step of ending your therapy. The way to do it is to taper gradually using a plan agreed upon with your doctor. It should be documented in your medical record and you should keep a written log for yourself as you go.

When you get to the end of tapering and it is time to no longer take buprenorphine, it is time to face the barb at the end of the fishhook. It is not going to be easy. You may be physically sick for a while. It could be as long as days or even weeks. You may have thoughts about resuming therapy or even thoughts of drug use again.

These are just thoughts and feelings. You don’t have to act on them.

This is why it is so important to go to therapy and also to develop a psychosocial support system. You need friends in recovery to talk to who understand what you are going through. Regular 12-step meeting attendance can is important.

This is why medication assisted treatment with Buprenorphine, Suboxone, Subutex and ZubSolv involves much more than just taking medication. The program is a three part program. Medication is only one part. Private therapy and group therapy involving an ongoing support system are just as important if not more important. The psychosocial support is how the fishhook barb is broken off, allowing the medication to finally be tapered and discontinued.

If you do not build your network of solid support by going to regular private therapy sessions with a psychologist or other licensed therapist. If you do not go to group meetings, find a sponsor, talk to recovering friends daily and work the 12-steps, you may find your self stuck. Stuck on medication maintenance for a very long time.

Buprenorphine maintenance long term is not the worst thing in the world. Overdose death on street opioids, such as heroin, is the worst thing. Buprenorphine is protective in this sense. However, it is important to have realistic expectations regarding the end point of medication therapy. So, start off on the right foot in the very beginning. See your therapist regularly. Go to meetings. Meet other people in recovery who know how to stay clean and what it was like to get clean. Call them daily. Find a sponsor. Work the 12 steps.

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