He’s Chipping on Heroin While Taking Suboxone

Ivy2015 is riding the spiral of addiction and recovery with her son. Just when it feels like things are improving, there's a backslide. How can she get more treatment for her son, who takes Suboxone but also continues to occasionally use heroin?

"Hi again. I always want to start out by saying how grateful I am for this site and all the information contained here. It is one of the most useful tools that I have found in this journey.

I am writing again about my 23 year old son who is in recovery for heroin addiction. He is currently on Suboxone which he has been on for about 6 months now. Also, he lives with us. Last, he is a regular marijuana smoker, and he is currently still attending outpatient treatment one day a week. The treatment center is aware of his marijuana use and is working to help him reduce it, and he intermittently sees a therapist.

He has relapsed several different times to heroin even since he has been on the Suboxone. Two of the times it was due to some very traumatic events that happened in the summer. After that, I took over dispensing the Suboxone to him, and that seemed to work very well. However, recently he started becoming more resistant to letting me give him his Suboxone. So, I let him take over. Then, yesterday, I suspected that he had taken heroin just by how wide his eyes looked (for some reason, he always holds his eyes open wide when he takes this drug). Also, if he tries taking his Suboxone and he has used heroin within the last day, it causes him to throw up. This evening, I went out to his car, and I noticed it didn't smell good. I asked him if he had thrown up, and he said yes.

At this point, I know he has used again…..but, I am unsure what caused this relapse. He does not want to go back to inpatient treatment, and he has agreed to let me start giving him his medicine again. I really feel that we aren't getting to the root of his problem, and maybe we haven't found the right therapist to help him, either. He has bounced around quite a bit from therapist to therapist. Mostly that was my fault because I suggested he see therapists that didn't take our insurance, and at some point it becomes a huge financial burden.

I really feel he needs more intense therapy than he is getting. But, how should I force the issue (I know the answer to that….no). This is a very dangerous drug, and it scares me, a lot. Just when I think things are getting better, they revert back. It is so hard to watch him struggle so much. I just want him to find happiness and live without these cravings.

As always, your input is much appreciated."
 

Your son has been on suboxone for heroin misuse for 6 months. He is still occasionally relapsing to heroin. You know this because you are aware of how wide he holds his eyes open and that he vomits when he takes the suboxone on top of having taken heroin.

The most recent time he used heroin, you were able to get him to agree to have you dispense the suboxone on a daily basis as you had before.

Good for you, catching the signs of his use. You are maintaining a bridge with your son and are able to negotiate tightening things up when he uses. This is so important going forward. If you can—as calmly as possible—talk through what is happening, you are much more likely to get to solutions. You have taken back control for dispensing Suboxone and are asking how to get him into additional more intensive treatment. 

Suboxone is a combination drug that includes an active opiate and an opiate blocker that saturate the opiate receptors and prevent the person from feeling high when they take another opiate on top of the Suboxone. A person can override this by taking more of the illicit opiate. It doesn’t work well (the high can be weak and therefore frustrating and all that opiate in your system can be dangerous) so the better strategy is to stop the Suboxone for a day or two when planning a relapse.

The Suboxone clinic should be aware of all this, since their urine testing looks for Suboxone in the toxicology as well as the illicit opiates. Medication Assisted Treatment (MAT) clinics are very busy and, while they monitor what’s going on, they have differing red lines as to when a client is in real trouble. In other words, your son’s clinic may be expecting and tolerating a certain amount of use, waiting for your son to level out on the Suboxone. (6 months though seems like a long time to me…..I would expect they are talking to him). Clinics don’t have a lot more to offer, other than checking a box to note that the client is getting therapy or not.

Suboxone providers are well aware that clients do these things to get around the Suboxone. The cravings for heroin are somewhat dampened by the Suboxone, but not completely. The rituals, the desire for everything that pushes one to use (like the triggers, the low moods, the trauma of the past, etc.) are still in the picture and still need to be addressed.

Will your son sign a release that allows you to talk to the clinic? In particular, I would want to know at what point the clinic will tighten the circle around your son and move to get him into more intensive treatment? What treatment would they refer him to if they did see more treatment as an avenue to pursue?

In your opinion, your son has not been working on “the root” causes of his addiction. There are differing opinions about the type of therapy that should be provided in early recovery. My own preference is for addressing the day-to-day of early recovery: the skills that need to be used to stay aware from drugs, how to cope through difficult times. Reaching back into the past will be important but I say it can wait until a good amount of stability has been achieved and your son can handle entering into painful life events. The most critical piece in early recovery is learning how to stay drug-free in the day, and how to find substitute activities and behaviors that start to compete with being high and give one’s life a little joy and meaning.

It’s a tall order. Your son is dabbling with getting high and dabbling with therapy. The team around him includes you. The Suboxone clinic should be talking with you. Together you could suggest a new round of intensive outpatient treatment (3-4 days a week, 3-4 hours a day, for 3-4 weeks). That seems like the easiest thing to encourage. It’s also the treatment most likely to be covered by insurance.

I am glad you are using this site. Learning Module 8 breaks down the tactics for suggesting treatment. If and when your son uses heroin again, after he is clearly no longer high, it may be the right time to calmly and lovingly talk to him about more treatment. Provide him with the IOP option; is there an early recovery group he can attend? What about peer supports? I suggest you put it all in a list that you give him. Call his insurance and ask them what they suggest in terms of what is covered. The list of covered therapists is typically bewildering and lacks sufficient detail to make an informed choice. Push back on this, talk to someone at the insurance company. The MAT clinic, the current therapy providers, the insurance company, should all be helping you identify additional treatments to suggest to your son.

The road to recovery is dotted with lapses. The pot use is its own project but for now I suggest you link your behavior and message solely to the heroin.

Your son is trying. The huge hurdle was getting him to Suboxone. This provides him protection from overdose, painful withdrawals, and offers a little space to negotiate the internal world of trigger that cause him to use.

I like the idea of having a family member dispense the Suboxone. Suboxone provision wasn’t designed to be observed like this on a daily basis, but in so many cases it should be.

I hope this helps. I hope your world also gets a little space to negotiate the difficult thoughts and fears that accompany having a child that uses opiates. Learning Module 7 is a good primer in this regard. Our best wishes to you and for your son. Let us know what you learn.