First off thanks for facilitating this great community, and offering your great perspectives and information. I was simply wondering if you still publish any videos anywhere online? I can't help but notice the majority of your YouTube video's are 5+ years old.
I really value the things you have to say, and as someone who has a very non-communicative doctor I think being able to hear from you on a regular basis would be cool. My last doctor was a lot like you, and very relatable, but he has moved. My current doctor is more worried about protecting his practice, writing my prescripiton, and getting me out the door as fast as he can.
I wouldn't want you to start cranking out generic video's just to fill the air like some other's do.. perhaps you've said all that can be said for now. I just thought I'd ask! If there are any other's out there similar to Dr. Junig that do experienced, knowledgeable vlogs I'd like to find them. I like DOC PARK okay, but he's not my favorite. He kinda goes more the way of cranking out the video's for YouTube success in my opinion.
Thanks for looking for me... I'm sort of back! I don't think I'll ever get as motivated as I was ten years ago but I'll try to increase my presence here, and maybe do a vlog or two.
I agree! I have so much respect for Dr. Junig and would love to see some updated videos! I always tell other recovering addicts about this forum and the website!
Dr. Junig, you are so appreciated! Anything you have time for would be awesome!
Jessica
"Though no one can go back and make a brand new start, Anyone can start from now and make a brand new ending." -Unknown
I used to think that I could treat anyone addicted to opioids using buprenorphine, and I took anyone who called my office. Part of that was because there weren't any other good options out there. I came from working in abstinence-based programs, and I was disgusted by what I saw there - people paying huge amounts of money after believing the promises that their addictions would be cured, only to relapse and sometimes die within a year of 'successful' treatment.
Back then, many people stuck on opioids were using pills, and still had some structure to their lives. They had been cut off pain meds by their doctors, often abruptly, and buprenorphine was a great substitute.
But now, opioid use disorder has become more aggressive - maybe because of increased IV use, maybe because of methamphetamine and fentanyl, or maybe just because more people have been sick longer. I find that people fresh into treatment don't do all that well with buprenorphine alone. When I get calls, I don't take anyone without 'vetting' them with questions about their use history. I don't take people who are regularly using meth, crack or powder cocaine, or alcohol. They just don't do well. Likewise I don't take people who are homeless, or who are unable to work (unless they are retired or on disability). People need structure in their lives in order to escape addiction, and working provides a lot of structure.
I refer most people to methadone-type programs. Many of those programs offer methadone, buprenorphine, or Vivitrol. The main thing they provide is structure, requiring patients to appear every day at about the same time, where they are seen by nurses and counselors. I will take people who have done well in that type of treatment and who want to stay on a long-term opioid, either for safety or to reduce pain.
I realize that patients often feel trapped by buprenorphine. I think doctors should do all that they can to make long-term treatment easier for those who don't need close monitoring. I find it ridiculous that many docs see people monthly forever, even when they've done perfectly for years. I see those people quarterly, but sometimes I think that is even more often than necessary in patients who have done well for years and years.
Some doctors also require urine testing with mass spectrometry and breakdown product measurements, month after month. Those tests cost thousands of dollars per year, and often become a source of income for the doctor (i.e. a scam). That testing can be valuable in select cases, but doctors often tell patients to 'don't worry about the bill from the lab company', and then patients are sent to collections and their credit ratings destroyed.
Those are the things that come to mind... I know that some patients really struggle to taper off buprenorphine, but at the same time I've seen literally hundreds of patients make it through the taper process, some without much trouble. There is ALWAYS a huge mental component to opioid use, and some people become more attached to opioids than others. Many times there is an initial hurdle to get over caused by fear, but once the person starts going down, they gain confidence in the process. The first half of the taper is very easy, and that helps reduce the fear of withdrawal. The second part of the taper, from 4 mg per day to zero, is the real challenge.... but people can now get the 2 mg generic film at a lower cost than the brand, and it is much easier to cut consistent doses out of the 2 mg film and reduce at a reasonable rate.
One thing I have seen at my clinic over and over is the patients who come in that have co-addiction to opiates and meth, they have the hardest time passing a drug screen. I’m talking barely if at all passing drug screens until they are eventually discharged because it’s been months and months and they haven’t stopped using meth. I have talked to patients that are literally breaking down crying wondering why they can’t get it out of their mind or stop, some tell me that buprenorphine helps with cravings for meth but most tell me it doesn’t help (I could definitely see how it may not help since it’s a medication for opiate addiction). I have seen so many wonderful people that just stop coming because they know they are going to fail yet another drug screen and they just give up the treatment.
One thing I have noticed in my area is the patients who were only abusing opiates, they do the best. They’re the patients who haven’t missed counseling or failed any screens or they aren’t trying to tamper with their urine to pass a screen....... there really is a difference and I hadn’t realized it before. I thought to myself last week that the people who come for that first initial visit, if they have methamphetamine in their system, they should be put on some type of waiting period or something to see if they can stop long enough to even just have a screen without meth. If that were somehow implemented I wonder what percentage would be able to do it? At the same time I’m conflicted because those people need help too...... I don’t think buprenorphine is necessarily the answer for most people addicted to meth.
Maybe I’m wrong, goodness knows I’m wrong a lot. I think in my clinic, it’s almost half and half with the patients that do well, just opiates vs opiates and meth and the meth patients don’t seem to benefit as much from this treatment. Some do, just not the majority that I’ve seen.
I probably should put a different title on this thread, but I don't know if that's possible without losing posts...
Jenn, we work in similar worlds. I agree completely on the meth issue, and similarly with cocaine. We can stop illicit opioid use very quickly with methadone, and heroin is usually the first thing to disappear from drug tests. But people really struggle with getting away from those other drugs.
We generally keep our focus on opioids during the first few months. We are always focused on benzos of course, given their risks... but we don't apply a lot of pressure on the use of stimulants until the opioids are under control. If a person keeps using cocaine or meth month after month, we eventually ratchet up the pressure to stop those substances. If a person won't stop using those substances, he/she will eventually be put on administrative detox and discharged. I would guess that about half of the people put on administrative detox stop using cocaine or meth during the taper process, and the other half leaves treatment.
I don't think it to be a good idea to keep those patients in the program forever, because their presence in the program takes away from the people who really want to change. The people doing it right shouldn't have drugs offered to them while they're in the waiting room, for example. Tough calls sometime.
Absolutely Dr. Jung!! 100% agree. I struggle seeing this so much because the people still using will do one of two things, they will either get it and start doing the right thing or eventually fail so many screens and not attend counseling.... they will eventually be discharged. One of my issues with all that is the taking away from the other patients and the disruption from them at times to other patients. Like seeing people high during counseling, and not everyone sees it but the patients do and me.... I recognize it a little more because I have more one on one time with them plus I am an addict and I see it like a bright flashing light when someone is high. When someone is on meth and high during IOP class or counseling, they want to talk the entire time or they cannot sit still and they are up and not only fixing coffee but they are washing every single cup and then they are sweeping and then dusting......... I mean I appreciate the cleaning lol but that is not usually normal.
There was a story I heard that happened previously to me starting, a lady who was continuously not passing her screens and testing positive for meth, she had been in IOP & went to the restroom, after she came out and someone else went in they found a bag of meth that had fallen out of her pocket. She had apparently been using in the bathroom. Patients there to do better do not need to be involved in that kind of stuff, it is supposed to be a safe place for them, not finding drugs and seeing someone next to them high. It can put some triggers around that should not have happened. Another thing is the meth crash..... where they have went without sleep for so long that they are now sleeping through their entire day, sleeping through counseling or IOP, heck even in the waiting room waiting for the doctor. I will hush about it because I know that I am just repeating myself but it is something that has been bothering me over the last couple of months.
Methamphetamine use among people with Opioid Use Disorder is rampant here in Colorado. In fact, some of my patients don't use one without the other. One of the most frequent excuses for meth use is that the methadone or buprenorphine is causing enough sedation that they have to use meth to be "normal". What methamphetamine users don't understand is that meth does not make your mind "normal" at all. It distorts your thinking to an alarming level. I have a patient who used meth daily and thought she was being gang stalked. It wasn't until she was in jail and stopped all methamphetamine that she realized that she wasn't being stalked.
Our clinic is completely dedicated to harm reduction. We do monthly random drug screens and track what each patient is on. If a new UA result, which we check daily, is positive for fentanyl or illicit benzodiazepines, we flag the patient to require them to see the doctor before dosing again. Alcohol positives require a two week period (at least) of daily breathalyzers, and two alcohol positives in a row require a doctor's visit the next time he's available. The doctor is guarding his medical license in this way.
We do NOT, however, discharge patients who are positive for methamphetamine. The harm reduction model dictates that we keep patients on their methadone or buprenorphine for their OUD, even if they're still using meth. We educate the patients that any stimulant, including meth, will increase the metabolism of their methadone dose. We inform patients that they will not earn take homes or exceptions (for vacation) if they are positive. Also, any patient who is still using in some form must attend a weekly group.
One of the difficulties of going on MAT is that once they are stable negative emotions will start to rise and often becoming overwhelming. Many of our patients started heavy drug use in their teens when their brains were still developing. They haven't learned to cope with the negative emotions, memories, or feelings that treatment gives rise to. Therefore they are still self-medicating, desperate not to feel their feelings. We have seen many patients start developing those skills, however, and learn to sit with the emotions that continue to hurt. We will never discharge patients based on methamphetamine use alone.
At the same time, Jenn is right that all of our patients deserve to feel safe in a non-using atmosphere. Our facility is small and everything is on camera. The dosing area and waiting room are within hearing distance of the counselors. I've known of one instance of dealing out in the parking lot. But one of our patients reported it and we took it very seriously. The offending party was put on a very strict behavior contract and one tow out of line will be punished by discharge.
In just the last 3 months at my clinic I have seen at least 4 patients come in extremely high on meth and openly admitted it during counseling. Yesterday I had a beautiful young lady sit in my office very high on meth and I couldn’t understand anything she said so I don’t think someone can be helped very much when they’re high..... that’s a whole other story though.
It has to trigger other patients, there’s no way it couldn’t trigger someone. I think bk to when I was a newer patient and if I had been around a fellow patient high on opiates (my doc) then I would have been so mad that the place didn’t protect me better than that. We’re talking IOP classes that are 3 hours long 3 days a week. These classes usually have anywhere from 12-18 ppl each in them, they see it if someone is high. I get so annoyed with the patients that do this and I tell ya.... by the time she had left my office I felt like I was coming down from meth lol. I was thinking to myself what in the world just happened! I didn’t understand the conversation, as you can imagine, she just mumbled for over an hour. That’s it, I couldn’t help her at all because I couldn’t understand anything she talked about.
My clinic doesn’t discharge ppl right away like they used to years ago. Now patients get a lot of chances to do better. We drug screen once a week before they see the doctor (for newer patients or patients that are weekly). If someone tests positive for something more than a couple times they get what is called a strike. They can get up to 3 strikes and after that they sign what we call a contract and what that is is them promising they won’t use anything at all for 30 days or they’re discharged. Imo it’s only fair to have to finally discharge someone because if you’ve had that many chances and can’t control it any better especially along with MAT, then maybe they aren’t trying to do better and someone is on a waiting list just praying a spot opens. See what I mean? Some people just are not ready to stop and in my experience here in my area it’s usually someone who struggles with meth.
I think certain areas are different in what is running rampant on the streets more than another. Here, heroin isn’t a big problem because it’s more in the bigger cities, meth is being made here left and right especially the shake and bake kind, it’ everywhere.
Having been a functioning meth user for over 30 years and then being treated successfully with suboxone I would strongly disagree with previous posts.
As ever generalizations are so often wide of the reality of the many who don't fit the brush they are being tarred with and in this case the descriptions although pointing out meth use has missed the problem which is obvious mental health breakdown with delusional psychotic behavior which is treatment resistant whether for mental health maintenance or opiate replacement therapy the reason nearly always non compliance.
Try and get someone who is psychotic on clozapine therapy and the issues are the same no meth involved in the equation at all
Discrimination doesn't cure addiction.
Opiate addicts who use meth are every bit as deserving of treatment as opiate addicts who don't.
Sorry therapists and care providers you need to work even harder.
I have two friends that battle stimulants. One is an opiate and meth addict. The other a cocaine addict. Both have struggled mightily to stay clean. They both go to an IOP that now RXs Strattera much like Suboxone, and for the first time ever these two have been racking up clean time.
This is the first I’ve heard of stimulant addicts being put on a medicine as a deterrent. Is this a one off thing by that one doctor or is that something that’s growing in popularity out there?
jeffg wrote: ↑Tue Dec 24, 2019 4:44 am
Having been a functioning meth user for over 30 years and then being treated successfully with suboxone I would strongly disagree with previous posts.
As ever generalizations are so often wide of the reality of the many who don't fit the brush they are being tarred with and in this case the descriptions although pointing out meth use has missed the problem which is obvious mental health breakdown with delusional psychotic behavior which is treatment resistant whether for mental health maintenance or opiate replacement therapy the reason nearly always non compliance.
Try and get someone who is psychotic on clozapine therapy and the issues are the same no meth involved in the equation at all
Discrimination doesn't cure addiction.
Opiate addicts who use meth are every bit as deserving of treatment as opiate addicts who don't.
Sorry therapists and care providers you need to work even harder.
i was also a functioning meth user and had one serious episode of addiction. in my opinion meth is extremely difficult to come off of after an extended period of use. i would rather come off opiates and just be mostly physically sick than go off of meth and suffer the most sever depression of my life ever again.
i don't really have a solution for those with multiple addictions, but i'd like to think that once the opiate part of the addiction is under control, the meth addiction will soon come into play too. It has to be different for every user though and there were definitely deep emotional reasons i was using meth.
Get your shit together and live your life." Black Snake Moan
BlueLight wrote: ↑Tue Dec 24, 2019 2:16 pm
I have two friends that battle stimulants. One is an opiate and meth addict. The other a cocaine addict. Both have struggled mightily to stay clean. They both go to an IOP that now RXs Strattera much like Suboxone, and for the first time ever these two have been racking up clean time.
This is the first I’ve heard of stimulant addicts being put on a medicine as a deterrent. Is this a one off thing by that one doctor or is that something that’s growing in popularity out there?
My prescribing Dr has been prescribing suboxone for a number of years now to clients with long term stimulant addictions, it's probably worth noting that the majority of people in this group also use other drugs opiates, rcs, alcohol, pot but doc is these days Meth.
I'm not sure if you could classify suboxone as a deterrent as it works the same way as it does with opiate addiction ie the desire to get high is controlled, the difference with it's use in stimulant addiction is you can still get high whilst being in maintenance therapy and that is going to be a problem particularly the way most clinics are run.
If prescribing is based on compliance and adherence to urine or blood testing then there will be very little chance of keeping people on a program and a pathway to health.
This unfortunately frustrates the best intentions of Doctors who care and Medical practitioners who are focused on and committed to a business model that can't accommodate the illness associated with stimulant abuse.
This is such a shame as the research shows that drug and urine testing does not keep people that need it most in treatment and is counter productive to the long term outcome of people with addiction of any narcotic.
My Dr frequently sais the tighter you apply control the further you push a client back into the world of illegality and away from treatment.
He is a solo treating Dr who has a clinic of 300 or so clients and has been practising in this field for 20 years, his mission statement is simply "Respect Empathy Dignity " and he claims 80% of his clients are still on maintenance or have completed therapy.
He is optimistic from his recent experience that suboxone can be used effectively for meth addiction.
Great discussion. If you guys don’t mind, I am going to move this a different thread because I don’t like seeing my name pop up over and over again. I’ll see what I can do with that later today, but again, interesting stuff. I’ll add a comment after Christmas morning has settled down…
Jeffg, your doctor's approach sounds similar to mine. I've changed a bit in recent years though. Ten years ago, there was nobody else in my area who would take anyone who I discharged. A hospital program operated then (and still now) such that any mistake warrants discharge. Patients must be in the IOP program to receive buprenorphine. One missed or cancelled appointment often triggers discharge. So I felt like I needed to stretch myself to keep patients, regardless of how well they avoided illicit substances. I couldn't see any moral value to adding heroin to their other problems.
But five years ago, I started working at a new methadone-assisted program in my town. I've been there since then. The value of those programs has nothing to do with methadone. The value is in the accountability, the daily appearance in front of good nurses, and the rapport that develops with patients over years in treatment. I cannot duplicate that in office-based buprenorphine treatment. Now, if a patient is still messing around on buprenorphine, I strongly consider discharging that person and referring to an MAT program.
There, we balance accountability with the realization that establishing accountability is very difficult at first. Patients will struggle, and often go back and forth between illicit drug use. But after five years, I'm convinced that we have a positive trend at our program. We have many patients who struggled for months or years, but then eventually the light turned on, and they did well.
Personally, I don't see value in trying to treat stimulant addictions with opioids like buprenorphine or methadone. But there are studies showing benefit to suppressing cocaine or meth use through prescribing amphetamine. One rationale for that approach is concluding that the patients often have severe ADD that causes distress and dysphoria, and stimulants remove the dysphoria that drives cocaine use. I understand the argument, but I also understand why the approach looks silly to some people.
Hi Doctor J and thank you for your input, even all the way back in 2016 when you clearly explained that doses up at 32mg were probably not doing any more than doses way lower, that post started me on the taper down.
I only know my experience with subs to come off a lifetime on primarily meth use, ok call it abuse, it took me a long time to call it that as I was pretty sure t was in control.
My Doc has chatted a lot about his other meth patients and how well subs holds them but as I said he is pretty relaxed about sometime casual use whilst being in maintenance and there is no doubt his model in his practise allows a very close hell it feels like a very personal relatioship with his clients and the trust that he allows seems to elicit some very un junkie like behaviour in return. You may want to take advantage of his method but very soon you realise you have a duty of care to ensure there is no blow back on the man that is allowing an amount of freedom and respect.
I had heard about add meds being used to help in the great meth debate and had tried to use them myself before subs and I just don't see how they can possibly be affective, if your brain has been exposed to the Niagara falls of dopamine, seratonin release that meth delivers the trickle that is Ritalin or similar is just going to be so very frustrating when your brain and muscle memory understands it's not going to happen.
I know it's probably counterintuitive to think subs might work for meth but the reality is most meth users are never going to describe themselves as opiate naive so I guess there is that similar effect from subs as on some alcoholics.
I guess it's never going to become a mainstream therapy for Meth addicts but I'm certainly thankfull as it saved my from certain death due to depression and pretty strong suicidal ideation, mind you it took 25 years plusof pretty well controlled use and then about 5 where if all headed south.
There has been a trade off though and I am still dependent on subs and whereas before although addicted to meth I only used it every 10 days or so.
I used to rail loudly about the downfall that subs could bring but i have become comfortable with a very low dose of 1mg and am tapering lower but although i occaisionally think i wish I'd never srarted subs i also realise i wouldn't be here to have that thought if i hadn't stumbled across my Doctor.
Look, I’m not at all trying to say anything negative about anyone with any kind of addiction? Why would I when I’m an addict myself and lost everything in my life including temporary custody of my children during my active addiction? Methamphetamine isn’t any worse than being addicted to opiates..... it is a bit of a different outcome sometimes though when someone is high on meth because they may experience hallucinations from being up for days straight without sleep.... those highs are different than someone who’s taken say an oxycodone or even heroin. When someone comes into counseling high on meth it can be more disruptive, that’s just how it is. Being like that in front of other patients isn’t fair imo. It isn’t fair to be high on opiates either in counseling but if they’re taking their suboxone then they won’t get high because of the opiate blocker. With meth there’s nothing there to keep them from using.
I’m not judging anyone and I’m sure as hell not saying someone shouldn’t get prescribed suboxone if they are on meth. What I am saying is that a lot of times the suboxone isn’t enough for a severe meth addict to stop using on a regular basis and if that’s the case then after a few months of that shouldn’t we consider discharging that patient. Most rehabs will discharge someone for using anything.... meth, opiates, whatever... so why should a clinic that primarily prescribes buprenorphine not discharge someone after a couple of months and someone is still using meth almost weekly? Given plenty of time within a couple or so months and still testing positive for meth weekly? That’s the scenario I’m talking about. I’m always on the addicts side but there’s limited space at most of these clinics with a big waiting list.
I'm interested in hearing what others do, but yes, Jenn, I hear your point. And the approach of jeffg's doc is unique - so unique that a medical board might call the approach into question. Buprenorphine is indicated for treating opioid addictions (opioid use disorder, to get the terms right!). Why would it treat meth addiction? I have no idea. But every now and then people get strange results that lead to knowledge.... for example antabuse has been found to treat cocaine addiction through a mechanism that I used to understand, but don't remember right now...
I have my buprenorphine practice where most patients are doing well. Then I'm also med director at a methadone-assisted program, where we have people doing well and people who are new to treatment. Meth and cocaine use are not uncommon, and we struggle over the best approach. The patient's counselor has the biggest impact on how things play out. If a counselor believes that a person is trying and moving in the right direction overall, the meth or cocaine use might be ignored for a long time. But if a counselor believes that the patient is 'checked out' from treatment and causing disruptions in the treatment program, the patient will be given an opportunity to make changes or face detox and discharge. Our program sounds similar to yours, Jenn, in that way.
I've seen a stark difference in the patients I've treated over the years. When I started back in 1999, I worried about heroin use, HIV, and HepC infections. I rarely saw concurrent stimulant use. Now, I struggle with treating patients who have co-occurring addictions to opioids and stimulants. It is too common. I mulled over not accepting those patients. However, I've had some amazing successes as well as spectacular failures. So now, I continue to give all patients a chance.
My approach to substance abuse treatment is to optimize function. A patient addicted to both opioids and methamphetamines may not be functional. However, that same patient on Suboxone and methamphetamine should be more functional. That's a small step but a step in the right direction along the path to full recovery. With the use of buproprion, aripiprazole and counseling, others have stopped using methamphetamine. I don't know if the medications worked or if the patients needed some extra attention to help them quit. Regardless, I am very apprehensive to discharge a patient who is sober on all substances except a stimulant. So, I focus on improving housing, employment, family and other aspects of their lives hoping that the stimulant abuse will subside or vanish.
I do have a patient who I treat with Suboxone and Vyvanse for his opioid and stimulant addictions. Despite long standing sobriety from opioids, daily group and individual counseling sessions, he continued to struggle with stimulant relapses. One of the counselors convinced me to prescribe Vyvanse and the patient flourished. No relapses, secured employment, married, treated his Hep C, and is now in college to become a drug counselor. He achieved one of those inspiring turnarounds that motivates me every time I see him. In my practice, he is not the only one who overcame his stimulant addiction. But the only one I actively treated with a legal stimulant.
Now, I do fear treating another patient with this method; I don't think the authorities would find it appropriate especially if a patient dies or sells the prescription. Nevertheless, when a patient walks into my office, I am optimistic that he or she will succeed regardless of the circumstances. If they continue to work hard at recovering, I will continue to treat them.
