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PLEASE NOTE* 
The names in this story have been changed to protect and respect the identities of the living and those no longer with us. 

IN DEFENCE OF SUBOXONE- PHARMACOTHERAPY SHAME

BY MAXIMILLION ALEXANDER

I had just started work for the morning at a Melbourne Central coffee stand when I heard that my best friend Liam had died. We had been close friends from the day I met him in a boot camp therapeutic community a year prior and we shared many similarities. But when we left rehab I had managed to stay 'clean', while he had teetered in and out of "recovery".


I will never forget that unbearable feeling of being torn three ways, between tending to his partner Diane’s anguish as she screamed hysterically into the phone, the frustrated glares of the customers lining up for their morning coffee fix, and between my own desire to run far away, anywhere but behind that coffee stand, out into the street and even into the arms of the same drug that stole my best friend in that moment. 


I couldn’t find the words for Diane, so I feebly told her I was "there for her, and I’d call her as soon as I had a chance to speak".

As I made coffee after coffee, my mind kept going back to the last time I saw Liam in the musty lounge of the inner-city halfway house he shared with 12 otherwise homeless men. He was a few days into his withdrawal, splayed across the tattered pleather recliner, detox sweat lining his brow, his legs jerking from time to time as we tried to make light of the situation. I reminded him that when he felt well

enough I would again drive him to 12-step meetings, and he’d proudly be able to identify as “clean” to those he felt didn’t accept him while he was on pharmacotherapy. This was my attempt to keep his eye on the prize. Little did I know that his desire to identify as “clean” may have been what killed him in the end.


I’d seen him a few days prior and had dragged him to the local NA meeting at a nearby church. During the intermission, the chairperson called out the obligatory "clean-time" countdown, as group members stood to acknowledge their respective times spent off all drugs and alcohol. The meeting was chaired by a gruff, portly middle-aged ex-bikie type who was a well-respected member of the local fellowship.

“Is anyone clean, three to six months?” he announced to the church meeting hall full to the brim with 'recovering drug addicts.'
A few members stood to the applause of their fellow NA members.

“One to three months?”, he continued.
Another group of members stood proudly to the cheers of the group.


“One to 30 days?”

The room cheered yet again.

The newcomer is the most important person in the room. "Is anyone clean one day?” The room fell silent as the gruff meeting chair scanned the room.

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One teenage guy stood, a kid in a white Adidas tracksuit and a gold chain. The room clapped and a group member behind him patted him on the back. He looked chuffed as he received his white 'Just For Today' key-tag.
“And has anyone used drugs today, or is anyone on drug-replacement?”


I looked over to Liam who is considered to be a part of this category, having been on Suboxone for months. I was unsure if he'd own up to being on “drug-replacement”-  a category of people who are generally looked down upon as they are seen as 'still on drugs' by those in many 12 step programs including NA. Sometimes he owns it, other times he’s known to shrink back into his chair.
He sighed and stood. He was the only one. 


The room clapped, he received his obligatory pat on the back. The chairperson chimed in “Welcome! Not many people own up to that.” I was proud of him, but as he sat back down all I saw on his face was a look of shame.


After the meeting we sat on a bench outside, shared a cigarette and debriefed.
“I gotta get off this bupe shit Max. I hate how it makes me feel about myself. I hate not being 'clean'.”
I reminded him again that there’s "no rush," that people "can have a good quality of life on pharmacotherapy."


“Besides, seeing the way you use 'smack', I reminded him, “it’s better to be on bupe than to be dead. Don't forget, you've been naloxone’d five times this year, man.”
And it was true. 
He had been resuscitated by the ambulance five times between leaving rehab and going on pharmacotherapy.
But my reminder wasn’t enough. 


Within a day of that meeting, Liam had been to 

see a doctor and received a script for diazepam and the staff at the halfway house cleared him to do a home detox while living on-premises. It was against their policy, but they made an exception given his pleadings, and the fact he had Diane and I as support, and I was taking him to regular 12-step meetings.


Six days later, on his pay day, Liam was found dead on the top story of an inner-city car-park. When a passerby saw his legs sticking out from between two cars, he rushed to find a doctor from the community health clinic nearby, but it was already much too late. He was already blue. They estimated he had stopped breathing at least 20 minutes prior.


In the coroner’s report, the doctor who was on site mentions that Liam "looked otherwise healthy, like someone who hadn’t used for a while.”  And he was right. Liam hadn’t used heroin for months while he was on buprenorphine. In fact the only time he wasn’t injecting heroin was when he was on pharmacotherapy. 


It’s obvious to me now that from the day Liam left rehab it was largely the bupe that was keeping him alive. It was Suboxone that allowed me to have those precious few good months with my friend. We had some really good times. He was funny, loveable, laid-back with a really quick, dry wit. And I cherish those last few months we had together.

I miss him dearly to this day.

Throughout that period of recovery with Liam I was seemingly incapable of expressing emotion. I found it difficult to grieve, to cry, and to express any form of hurt. But the day of Liam's funeral, as I helped carry his coffin and felt the weight of my best mate on my shoulder, and as I heard the sound of Diane’s impassioned cries as she pleaded to the Gods, “Please don’t take my boy! Please don’t take my baby boy!”
My tears flowed for the first time in years.


As tragic as the loss of Liam was to me, it wasn’t the first time I’d lost a best friend to overdose. My close friend Mike and I met in a short-term detox facility some years before I'd met Liam. Mike was a large man, both in stature and girth, and he carried an even larger personality. I was immediately drawn towards Mike’s manic, buoyant and infectious personality, and that cheeky smile. We were both diagnosed bi-polar type 1 which we laughingly referred to as “Think- Ya-Jesus” bi-polar, and our mutual diagnoses caused us to bounce off each other in a loud, manic cacophony nobody could contain.


We went on to use drugs together for a number of years, but there were many times we also helped and encouraged each other to stop using. The best years I had with Mike were when both of us were on pharmacotherapy. Sure we were far from 'paragons of clean-living', but our mutual decision to seek opioid substitution treatment turned our daily heroin habits into, at the very most, a fortnightly, pay-day dabble. 


There were even periods where we had both spent up to six months without using, and if one of us was using, we were careful not to bring the other into it. It was during these three years of relative stability that I'd found myself secure housing, entered professional employment for the first time in my life, fell in love and returned to university where I completed most of my units with a distinction average. Mike had also improved by leaps and bounds. He'd managed to stay out of the psychiatric units for up to a year at a time, and returned to higher education. This- from a pair of bipolar disordered, daily dope fiends- seemed almost a miracle.


Mike always had a much stronger desire to get off pharmacotherapy than I. He spoke a lot about his desire to go scuba diving in Thailand with his partner, and how much his dependence was a barrier to his newfound wanderlust. So when I called him on the phone one afternoon and discovered he’d already jumped off his 6mg dose of Suboxone and was nearly through the ensuing two week withdrawal, my words were only of encouragement.

“Good on you Mike!  
When you get to 3 months with no bupe and no heroin, I’ll jump off the bupe too. Then we’ll both go to Thailand!”

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The last time I saw Mike he called me over to rescue him from the latest big technological drama he was facing. He often called people over to soothe him through his technology induced panics. At one stage his family were called over to discover he’d relocated all his electrical kit, TV, Hi-Fi, computers to the front lawn while pacing frantically and lamenting that nothing was working anymore. Never mind.
However this trip to Mike's was over the rather benign and legitimate issue of an internet connection that was cut off owing to an unpaid bill. I explained to him what was going on, told him to quit being a three-toed South American sloth and get off his ass.
I also commended him on how well he was doing without Suboxone. Neither of us had used heroin for a number of months, but he was the first one to take the plunge and jump off his heroin-replacement. And I had a lot of respect and admiration for his 'chutzpah'. I never thought he’d get to one week, let alone five weeks without buprenorphine or heroin.
However there was one telling moment that gave away his underlying vulnerability, a moment that in hindsight I wish I paid more heed. As I sat on the computer he looked at me intently with devious grin, and without saying a word I knew what he was about to ask.
“Maxxy boy. Do you … ? “  He cut himself short, and gave me the look we’d given each other hundreds of times before, the cheeky wry look a heroin user gives one of his kin when he wanted us both to go and score together. 
I feigned ignorance.
“Do you what Mike?”
“Ahhh don’t worry.” He dropped it.
And that was the last of it. I left shortly after, but I left with a niggling worry in the back of my mind.
The next day I logged onto my Facebook after work, and was faced with the fateful news. Mike had been found dead in his flat earlier that day. He’d collapsed in the doorway between his lounge and his kitchen, having just sat at his kitchen table to inject a dose of heroin far too great for a person with no tolerance. I had little doubt about what he got up to that pivotal day. Many times we’d driven to that seedy Western suburbs bus-stop together to score, driven back to his place with excitement and frantically mixed up our bounty together on that same kitchen table.

Only that time he did it alone.

I couldn’t shake the feeling that had I accepted his offer to join him and kept an eye on him, I might still have my mate today. 

The survivor’s guilt was swift, merciless and suffocating.

When you’re a heroin user, you become quite familiar with death. 'Familiar' is the right word, because I can’t say you ever really get used to it. While you’re using and 'anaesthetised'- or I guess I should say 'while I was using' (because it's different for everyone), the gravity of the loss of a friend didn’t seem to register at all with me. All I cared about was using. But in Mike’s case, I wasn’t using. I was on bupe, and taking it as prescribed it doesn’t 'impair, detach or anaesthetise' me like other opioids seemed to. Like I said, the experience is different for everyone.


Every morning when I opened my eyes I had to face and work through the survivor’s guilt and blame I put on myself as a result of ignoring Mike’s urge to use. 
Could I have talked him out of it?  Or at least warned him of his low tolerance?  Those questions plagued me for many weeks until eventually I caved into my own cravings. The irony of dealing with a mate’s death by turning to the same drug that killed him isn’t lost on me at all.


But this isn’t a story about me. It’s about two friends who would likely be alive today if they didn’t feel compelled to stop taking a life-saving medication. 


There’s a lot of debate in 'recovery' circles of the merit of abstinence versus medication assisted treatment, OAT versus 12-step.

But the many lives lost to overdose, and Liam and Mike’s stories, should offer us the sobering reminder: that you can’t get "clean" once you’re six foot under.

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