Hmmmm.. Those of you who know me, or those of you who have found or are finding insight into how addiction works do you know what I am thinking, and what I am about to say?  Think about the process of what is going on not the specific facts, but the general pattern.  Think about your own similar situations, as every opiate addict has had this type of a discussion at some time perhaps many times.  Think about it, then read my response:
XXXX,
I talked to YYYY about what is going on with you; I asked her to send you a copy of the policies for people on Suboxone, and she had already done that. Understand that the policies are in place just for my benefit; they are policies that are necessary when treating addictive disorders. One problem with addiction is that it changes one’s view of the world, leading the person to always find ways around the rules, ways to manipulate the rules, reasons why the rules shouldn’t apply in this specific case, etc. The policies are quite easy to deal with; they only cause problems when a person is in trouble and backsliding. Your current situation is a perfect example of how the policies are intended to work, and why they are in place. Even without reading them, you know how things are in any treatment arena; you certainly knew, or should have known, that I wouldn’t agree with just doubling up on your dose of Suboxone. First of all there is no reason to do so; I have described many times how the effect of buprenorphine peaks at about 2 mg, so a person taking even 8 mg is already taking 4 times what it takes to get the maximum effect. More importantly though, part of getting over addiction is following instructions on medication vials to the ‘T’. We are no longer playing doctor with ourselves; we are recognizing that we are like everyone else—we follow the directions of people treating us.
Suboxone is an amazing medication, but it is used in harmful ways on the street. In the wrong hands and when taken the wrong way, it is just another psychotropic drug! With its long half-life and unique properties, it should never be taken in response to symptoms—that defeats the purpose and turns it into something else. Instead it should be taken once per day, in the morning. Any thoughts of taking it at other times should be seen for what they are—addictive thinking that should be handled by firm resolve, by distraction and redirection, or through meditations on powerlessness if in a 12-step program.
More worrisome, though, is your follow-up letter where you say essentially ‘OK then—just so you know, I might now have to take narcotics!’ Adding the message between the lines, you are saying ‘if I use, it is YOUR fault!’ This is a classic pattern of relapse— and something that you have set in process, probably with the unconscious intent to use being decided weeks ago. The process, in case you don’t see it, is as follows: the addict comes across something that looks like an excuse to use (most addicts recognize that feeling every time they trip—the thought ‘cool—maybe I’ll break my leg and have to take narcotics!). The excuse if often a poor one, but as the addict thinks about it denial takes over and the excuse eventually seems reasonable through their distorted vision. The leads to what is initially a small rule violation; a ‘testing of the waters’. If the person controlling the use (a prescriber or monitoring agency) makes exceptions for the addict the next violation is a little bigger, and so on. If the prescriber holds fast to the rules (as I am doing), the addict uses that to his advantage, now citing the rules that are in place to enforce sobriety as justification for using!
I have seen this pattern many times before, and have likely engaged in it back in my own using days. It will not work that way with me; the policy clearly says that repeated violations are reason for termination—simple as that. When that happens, I really miss the person I have been working with, but there is nothing else I can do.

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