Opiates and diving

[Mr P Pan]

I'm a relatively regular SC bod but have added a new id for obvious reasons.

I did my PADI OW whilst being addicted to heroin. Was slightly concerning but all was fine. Since getting clean, I've been on a substitute, for around 4 years now, buprenorphine, kinda like baby methadone. I've experienced zero ill effects from diving with this in my system, but I would nonetheless be interested in finding out more about the effects of opioids and diving. At sea level for example, the make your pupils constricted, likewise your bottom - hence constipation. Are there any known effects of opiates at depth? Also, when the chemical is wearing off, one gets the yawns, becomes un-constipated, pupils dilate, etc. - any potential risks with this too?

Anyhow, any info welcome...

 

[DocVikingo]

Buprenorphine (e.g., Suboxone) can have a wide variety of side effects. Of concern for SCUBA would be euphoria, headache, upset stomach, vomiting, pupillary constriction, difficulty breathing or swallowing, sleep disturbance, drowsiness and lack of energy. In the diver's favor, many of these adverse reactions tend to diminish/disappear early in the course of treatment.

While there have been no published studies on opioids and diving of which I am aware, theoretically these drugs could be problematic. The diver should aways be alert to the possible toxic and narcotic qualities of altered gases and how these may be affected by certain drugs. Obviously, buprenorphine impacts on brain chemistry at ambient atmospheric pressure and it is not unreasonable to suspect that its effects could be potentiated by increased partial pressures of gasses within the blood and additive with those of nitrogen narcosis.

As regards, "...when the chemical is wearing off, one gets the yawns, becomes un-constipated, pupils dilate...," dosing possibilities with buprenorphine (which is relatively long acting) are somewhat flexible and given a properly adjusted schedule such events usually can be minimized.

The diver on a maintenance partial opiate agonist who has "...experienced zero ill effects from diving with this in my system...," and who has been cleared for SCUBA by the treating physician, would seem to have little reason for concern.

Helpful?

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice.

 

[Mr P Pan]

Hi DocVikingo,

Thanks for the useful information. I had suspected as much, that the effects aren't significant. I didn't get it checked out by a physician. Well I did, I asked the doctor treating me but he had no idea. I didn't mention it to my GP as that could adversely impact my life assurance. And therefore I have never mentioned it or that I am taking medication when signing waivers etc. You may think I was being irresponsible but a person I always dive with knows I am takign this medication in the event of an emergency; being on an opiate is rarely well received with negative social stigma attached to it so I've kept it under wraps but wanted to find out whether there were any known effects I should be aware of.

FYI, the brand of buprenorphine presecribed here is called Subutex rather than Suboxone. Main different is that it doesn't contain Naloxone which blocks opiates. Not that that would have any bearing I can't imagine.

Thanks again for your response. Best regards, J

 

[fisherdvm]

Not being updated on addiction medicine for years, but as I understand, Subutex is intended for short term detox of opiate dependency. And not long term usage. There seems to be alot more complex issues concerning diving fitness and your complex medical conditions. Aside from adverse effect of the Suboxone, the more important issue is the addiction itself, whether it is a personality trait or diagnosis that lead to the addiction.

I think the question for your fitness to dive is going to involve the complex communication between your addiction specialist, and a dive medicine professional. The fact that you are not upfront and straight forward to your family doctor who cleared you to dive initially might be part of the cycle that might make it difficult for you to wean off your Suboxone. I am a firm believer in NA and AA - and I do not believe the twelve steps program encourages their members to be less than honest to health professionals who are looking out for your best interest. Just because you have a certificate, does not mean you were cleared to dive, or should be allowed a lower life insurance rate. Eventually, you'll have to be off Suboxone. I don't know how DocVikingo feels about it, but I would say NA and AA is a lifesaving option that is open, available, and a better substitute than methadone or Suboxone.

 

[Divingdoc112]

The medication you are referring to was released in the 1980's as Buprinex an agonist/antagonist of the opiate receptor used for pain control and not very effective. It lingered in the formulary and was relabled for use in heroin addiction. I am in agreement that a certificate does not constitute medical clearance. I am also a senior FAA aerospace medical examiner and you would not be allowed to fly. Problems at depth are similar to those in the cockpit. It has been my experience that the laws of physics are not subject to repeal or challenge in the court law or public opinion.

 

[DocVikingo]

Not being updated on addiction medicine for years, but as I understand, Subutex is intended for short term detox of opiate dependency. And not long term usage.

Hi fisherdvm,

In terms of getting up to date, you might find the following published material to be informative:

A. SAMSHA's latest recommendations:

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction
http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf

The "Treatment Protocols" section begins on page 49. On page 58, you will see: "Maintenance Phase -- The longest period that a patient is on buprenorphine is the period of maintenance. This period may be indefinite."

The following studies have found buprenorphine to be essentially as effective as methadone as a maintenance therapy:

1. West SL, O’Neal KK, Graham CW. A meta-analysis comparing the effectiveness of buprenorphine and methadone. J Subst Abuse 2000; 12:405–414.

2. Ling W, Wesson DR. Clinical efficacy of buprenorphine: comparisons to methadone and placebo. Drug Alcohol Depend 2003; 70(suppl):S49–S57.

I can go on if you like.

Regards,

DocVikingo

 

[DocVikingo]

Aside from adverse effect of the Suboxone, the more important issue is the addiction itself, whether it is a personality trait or diagnosis that lead to the addiction.

Hi fisherdvm,

I am having trouble interpreting what you are trying to communicate in the above sentence, particularly the segment in bold lettering. What in the world does, "...or diagnosis that lead to the addiction" mean?

BTW, I concur that NA can be a very valuable, and sometimes lifesaving.

Thanks,

DocVikingo

 

[fisherdvm]

Diagnosis of concerns from my understanding often do not reveal themselves until after one is sober. Such as anxiety or mood disorders. Being on maintenance medication for opiates makes me question whether one is yet sober.

The duration of length to maintain someone on methadone like medication or anxiolytics after "detox" is a debatable subject - probably best left in the psychiatry/psychology forum. In my personal opinion, it is like weaning from hard liquor to fine wine - and still say you're sober. I am glad you feel that NA is valuable. Unfortunately, many physicians don't - as they feel they lose control when NA/AA discourages the use of any medication (certainly not every sponsors feel the same, but the trend is strong in the 12 steps to discourage any medications).

On reading more about the subject, apparently 5 to 20% of individuals on methadone programs are maintained on long term, and some even for life. But the goals of most programs are for weaning off and being off methadone or methadone like drugs - from my understanding. Apparently, risky behaviors are decreased during methadone maintenance, therefore the reason why some individuals are maintained on the drugs long term.

This is the fine line we walk - when does detox ends, and when does rehab begin. But I have not been involved in addiction medicine since my residency. We ran a small 12 step for smoking cessation in our clinic, but it was nothing comparable to what goes on in the community. My understanding is you have a much better depth of knowledge than I do, so please tell me your personal experience with the controversies of methadone program and the like. I just wanted to put my 2 cents worth into the 12 steps program - they offer a large support, social, friend, and even employment network that can be wider than any other programs in the country. And likely available 24 hr/ 7 days in metro areas. I find that NA and AA are well accepted in the community, with bumper stickers, key chain, and necklace more seen today than ever before.

 

[DocVikingo]

The duration of length to maintain someone on methadone like medication or anxiolytics after "detox" is a debatable subject....

Hi fisherdvm,

I can appreciate your concerns regarding substituting one addiction for another, although the matter isn't quite as simple as you present it. For example, buprenorphine can be legally obtained while heroin cannot; with buprenorphine there is no risk of contracting life threatening infection from dirty needles; buprenorphine gives a lesser "high" and leaves the patient's level of consciousness and behavior less impaired; buprenorphine's withdrawal symptoms are less severe with discontinuation that are those from heroin; etc.

However, the fact remains that your original statement, "...Subutex is intended for short term detox of opiate dependency. And not long term usage," is incorrect. As per the material I cited (and there is much more out there), buprenorphine is intended for long term use where the treating source deems it appropriate.

Regards,

DocVikingo

 

[Mr P Pan]

The individual needs to find out what works for him/her. In my case I tried detox combined with Subutex, Methadone, Naltrexone, Hypnosis, Therapy & Counselling, all to no apparent avail for about 6 years. I then discussed stabilisation with my doctor in desperation, to which he agreed.

Stabilisation/maintenance was indeed the key, certainly for me. I have gone from a 20mg daily dose to (as of yesterday 400 mcg. In the next couple of months I will be off this too. And I am sure that at this point my story of addiction to heroin (and all opiates) will be over?

How do I know? You just know, just as you 'just know' when it's not over. Bar a major life event, I am 100% that I will not relapse and even in the event of a major life event I would be extremely surprised of the issue recurring.

One point I would like to mention is that short term detox without counselling or NA is virtually pointless. I would be surprised if anyone, and I mean anyone, ever went clean this way the first time. Total waste of money and time.

Stabilisation/maintenance I believe works out better because it gives one enough time to unravel the complex strands of the addiction. Frequently while being stabilised one will relapse, but over time the relapses become less frequent until they don't happen at all. So, as you may have guessed, I'm not a fan of 'Detox'. Detox is the easy bit and I've gone cold turkey more times that I've eaten it for dinner. Essentially the physical component to the problem of addiction is the minor partner. Psychological and socio-ecomonic factors are larger drivers.

In terms of absolute transparency, or lack thereof, with professionals with regard to the condition, this is tricky because it is difficult to find a doctor with competencies in both addiction/opiate stabilisation treatment and dive medicine. I realise that this doesn't absolve me of all responsibility in this area but it's a trickier issue to work around than you might imagine.

BTW, methadone is infinitely worse than Subutex as a maintenance product. It doesn't have as strong a blocking effect that Subutex does (subutex binds much more closely to the recpetors). But more importantly, the effects of being on Subutex are much less profound and I do think it is something of a wonderdrug. Finally, coming off Methadone is REALLY difficult. Withdrawal lasts for weeks. That's a very long time to ask someone to stay 100% strong for. Generally coming off Subutex gradually is barely perceptible (altho I do have minor withdrawal symptoms, apparently due to the length of time I have been maintained on this).

J