It Might Not Be Me– Suboxone Talk Zone Impersonators

Just a quick note that I’ve been meaning to write for several weeks…  Over the past few months I’ve come across more and more web sites that have copied my web sites, copied my material, used my name, reposted my videos, resold my ‘user’s guide’… Someone once said that imitation is the sincerest form of […]

Withdrawal from Suboxone or Buprenorphine

I received a question from a reader about withdrawal symptoms from stopping buprenorphine. My answer has relevance to opioid withdrawal in general, and to a common misconception about the duration of withdrawal symptoms. The message: Basically I quit Suboxone about 18 days ago. When I decided to quit I was taking about 8 to 12mgs per day. I […]

A Save with Suboxone?

I’d like to share a recent email exchange with a reader. The post is long, but there are several interesting aspects to the discussion. I’ve removed the conversational parts, as well as the identifying information. The initial message: I was an intravenous heroin user for three years. After treatment I was able to stay clean […]

Kratom, Recovery, Elections

I received a question about Kratom, and searched for a earlier post about that plant/substance.  That post came shortly after Obama’s inauguration, after someone wrote to compare his experience at that event to his experience taking opioids.  Funny how every ‘high’ has its own ‘morning after!’

That Post:

On a message board called ‘opiophile’, a person wrote about being a long-term opiate addict, then taking methadone for a couple of years, then going on Suboxone for a couple of years.  He eventually stopped Suboxone, and had a miserable period of withdrawal… which never, by his recollection, ever totally went away.  He works for the Democratic Party (not secret info– it was in his post) and eventually used opiate agonists again (hydrocodone and oxycodone)… during his time in DC for the Obama inauguration.  He described how wonderful he felt, experiencing the opiate sensations while at the same time ‘being part of history’.

He returned to normal, boring, miserable life… until discovering a source for ‘Kratom’.  Kratom is a plant imported from Thailand that has opiate and other effects;  like many other ‘exotics’ it has not yet been scheduled as illegal by the DEA.  My understanding is that it is hard to find in pure form, and is expensive… there is also the risk of ingesting something (maybe toxic) that was substituted for what you think you are using.

In his post, the person asked if he is ‘clean’– whatever that means.  I don’t mean to be difficult here– I just mean that being ‘clean’ is different to different people.  Some people consider themselves ‘clean’ as long as they avoid their ‘drug of choice’…. the use of marijuana not a concern as long as they are depriving themselves of the Oxycontin that they REALLY want!  I don’t agree with that definition, but I can see the point of at least avoiding the things that are the most likely to cause problems.

He also asked if he was running the risk of returning to the same problems that have been a part of his life for many years.  I think the answer to that question is obvious to everyone reading this blog!  As for my other thoughts, I copied them below.

My Reply:

Kratom contains chemicals that includes mu receptor agonists– the chemicals do not show up (yet) in drug screens, but taking them is no different from activating mu receptors with anything else, legal or illegal. And the fact that Kratom is a plant should not make you think it is somehow ‘different’; if the chemicals in Kratom prove safe enough, they will eventually be extracted, identified, manufactured, and marketed in pill form– and will likely be DEA scheduled at that point.

Please read my article on the relationship between Suboxone and traditional recovery. I am aware of the anger some people have toward buprenorphine, but I think your case is the best argument for Suboxone that one can make.

You have had this endless malaise off opiates, and you seem to blame Suboxone (or if you don’t, I know that many people do– they use opiates for years, then go on Suboxone, then when they stop Suboxone they blame it for endless withdrawal symptoms). But the brain doesn’t work like that; tolerance occurs from agonist or partial agonist stimulation of a receptor, and the tolerance is reversible– at least on the ‘neuronal’ level. There is no reason that one drug, say buprenorphine, would cause a more ‘permanent’ state of tolerance than another drug.

I HAVE seen people with an almost permanent state of opiate withdrawal; I have not seen this so much in relation to specific drugs, as to their degree of ‘addiction’. Listening to your experience with opiates, one thing is clear– opiates are a huge part of your life. Even watching your dream candidate be inaugurated is not ‘enough’ of a kick in life; you wanted more. In fact, by your description, I don’t know which would have been a bigger bummer– seeing someone else getting into the Presidency or being deprived of that ‘buzz’! I’m not taking ‘pot shots’ here–I’m trying to add some insight, and I hope you take it as intended. The ‘person’ that you have become… PERHAPS that person just cannot exist without some level of mu receptor activation. Perhaps that whole ‘psyche’ requires the pleasant warm fogginess of an opiate– and without that, the psyche is miserable. If that is the case, of course you will be miserable off opiates— whether the missing opiates are heroin, methadone, Kratom, or Suboxone. The problem is that at least with the first three of these agents, there is no way to take them without ever-increasing tolerance, which eventually leads to cravings, compulsive use, and greater misery.

We know without a doubt that SOME addicts do recover, most often by using a 12 step program. How do THEY do it? I see the answer as consistent with the idea of a ‘psyche’ that needs opiates vs one that doesn’t need opiates. People who ‘get’ the 12 step programs can live without opiates because they have become completely different people. Treating addiction, we know that a person who simply sees the treatment as ‘education’ is not going to do well; people really need to change who they ARE– completely!

To put it into math form: Person ‘A’ plus opiates = an intact person; Person ‘A’ minus opiates = a miserable person; Person ‘A’ + NA = Person ‘B’ = an intact person. Maybe this last bit was a bit over the top… but hopefully you see my point.

I realize that some people will just never ‘get’ NA or AA; the question is, can those people ever be happy without exogenous opiates? I should add that there are other recovery programs out there that do, or intend to do, something like AA and NA, without the religious dimension– I am including them in the same way as AA and NA, although I don’t know as much about them. But knowing what I know about addiction and recovery, I doubt ANY program will make an addict ‘intact’ through education alone; in all cases I would expect the need for that person to change in a significant way.

In my opinion, the answer to the question is ‘no’– that a using addict, minus the object of use, without personality change, will always be miserable. Enter Suboxone… or more accurately, buprenorphine… and there now is a fourth option besides ‘sober recovery’, using (and misery), and ‘dry misery’. Buprenorphine provides a way to occupy mu receptors at a static level of tolerance, therefore preventing the misery that comes with chronic active addiction. And it allows a person to feel ‘intact’ without the need to change to a different person.

Buprenorphine fits well with the ‘disease model’ of addiction; the idea that an addict needs chronic medical treatment, and that if the treatment ceases, the addiction becomes uncontrolled, resulting in either active use or in your case, miserable ‘sobriety’. As for those who are ‘purists’– who think that every addict needs to get off everything and live by the 12 steps– I am glad that works for you, and others likely will envy you. But note that many, if not MOST, opiate addicts in recovery will relapse at some point in life– maybe multiple times. Recovery programs are not ‘permanent’; they need ongoing attention and activity, or they tend to wear off. There is no ‘cure’ for addiction; we ‘maintain’ addicts either through recovery programs, or now, through medication.

One last comment– I do know a person who was stable on Kratom for several years until suddenly going into status epilepticus with grand mal seizures over breakfast one day, in front of his wife and children. An extended work-up showed damage to multiple organ systems that seem to now be getting better after a couple of years. The studies never determined whether the organ damage came from the Kratom itself, or from some additive or pesticide used in Thailand. Use foreign substances at your own (substantial) risk!

JJ

Suboxone Talk Zone (dot com)

Clean Enough

In regard to my last post

There are many directions that we could take as we review that message.  My overall impression, as I read the letter, was of a person struggling to accept the reality of his condition.  Over and over, the person repeated the same behavior, starting Suboxone, stopping, and thinking this time will be different.

One thing I’ve learned as a psychiatrist, more than anything, is that change is difficult, and rare.  The writer ends with the thought that maybe this time will REALLY be different.  I have no idea if it will be, and for his sake, I hope it is… but unfortunately, the odds are that history will repeat itself.

Why, then, bother taking Suboxone—if everything just goes back to how it was?  The problem is not that Suboxone ‘doesn’t work’; the problem is in the expectations of some of those who take or prescribe the medication.  The active part of Suboxone—buprenorphine—is not a cure for addiction, but rather is a very useful tool.  Buprenorphine is a chemical that essentially tricks the mu opioid receptor.   Because of the ceiling effect—at higher drug levels, effects at the receptor remain constant as drug concentrations vary—the receptors function as if nothing is ‘coming on’ or ‘wearing off.’  That, in turn, eliminates cravings for the drug, and prevents the ‘reward’ for taking the drug.

Buprenorphine appears to work very well for the writer.  When on buprenorphine, he is able to avoid using opioid agonists.  The problem comes in the expectation that when buprenorphine is stopped, the condition of opioid dependence will somehow be gone, and will stay gone.   That is a completely different matter!

Opioid dependence is a complicated condition that can be viewed from different perspectives; behavioral, neurochemical, social, etc.  Some factors that contribute to ongoing addiction are addressed by buprenorphine, but most are not.  At one point the writer refers to being ‘stabilized on buprenorphine;’ the best way, I think, to view what happens with the medication.

During active addiction, a person finds that unpleasant emotions, thoughts, or feelings can be blunted by taking a substance.  In the long run, the consequences of using a substance become more and more negative, but the active addict cannot see beyond the pressing needs of the moment.  These pressing needs become worse, once addicted, because physical withdrawal – including depression, pain, and dread—are added to the other pressures of life.  Buprenorphine removes the neurochemical pressure to take opioids—i.e. the constant obsession to improve one’s subjective state.

Hopefully, relieving that obsession allows the patient to change the course of his life; to change social networks, to improve occupational standing, to improve self-discovery and personal insight.  If a person insists on stopping buprenorphine, the hope is that there will be enough changes in these other areas, so that the person will somehow be able to avoid responding to the urge to medicate the moment.

I think we are at a point where we need to consider the true nature of addiction.  Many treatment programs and physicians and treatment programs have an idealized image of how things should proceed after starting buprenorphine.  Patients ‘should’ be able to avoid all other substances, and patients ‘should’ be able to taper off buprenorphine at some point.  Through a process known as ‘counseling,’ patients are supposed to develop insight into their thoughts, emotions, and behaviors, so their lives follow a different course when the buprenorphine is eventually discontinued.

But what if patients CAN’T taper off buprenorphine?  What if patients eventually relapse, after stopping buprenorphine? What then?  Contradictions are apparent, when one looks for them.  We know that opioid dependence is a chronic, relapsing condition.  We know that relapse is more the rule than the exception.  We know that addiction is a process, not an event—and that ‘cure’ is not an accurate concept. Yet program after program requires people to eventually stop buprenorphine.  Talk about a set-up for failure!

To truly understand addiction and the role of buprenorphine, one must realize that addiction is a conditioned or learned phenomenon.  Parents of teens addicted to opioids will sometimes tell me ‘I just want my daughter back.’  I’ll ask the parent when he last rode a bicycle— and point out that even if the last ride was 20 years ago, he could still ride today.   And even if he hasn’t been to his childhood home for 20 years, he could likely drive straight to his front door.  THAT’S the challenge of ‘curing’ addiction!

Other thoughts…

About the ‘utilitarian’ approach… the way I suggest we view buprenorphine is the best way to consider other psychiatric medications as well, in my opinion.  We don’t think of SSRI’s as ‘curative’ for depression; rather they reduce obsession and worry, contributing to changes that allow recovery from depression.  Anticonvulsants do not ‘cure’ bipolar; rather they reduce the likelihood or severity of symptoms of mania.  Antipsychotics do not ‘cure’ schizophrenia; they prevent or reduce psychotic symptoms.

About anxiety… does the writer REALLY have it more difficult than others?  Maybe– or maybe not.  It really doesn’t matter.  Most patients who I see for opioid dependence believe they were dealt an unfair hand in life, from an emotional perspective.  Most feel that their subjective experiences are more difficult than the experiences of others.  Many say that they are ‘shy,’ or that they experience significant depression most of the time.  Most say that opioids relieved those uncomfortable emotions or sensations very effectively—at first, anyway—and that is why the addiction started.

Whether our load is truly heavier than someone else’s doesn’t matter, since we only experience our own load.  In other words, who would hurt more if his arm was severed, you or me?  It doesn’t matter—it hurts both of us ‘enough!’  At the same time, no amount of personal distress logically warrants taking something that only makes things worse.  If only addiction was logical!

About being able to choose the course of our lives… ‘Choice’ advocates–people who say that addicts choose to use drugs, and that they should simply choose NOT to use—say that addicts are weak in needing to medicate themselves through life.  In reality, there are few discreet ‘choices’ in life.  Our behavior flows seamlessly from one thing to the next.  ‘Choosing’ consists of a million tiny thoughts, sewn together and spread over a wide range of time.  The actual ‘choice’ to use occurs long before a person literally picks up the drug—- in a million subtle decisions and behaviors that the person may or may not have insight into.  Avoiding opioids, without the help of buprenorphine, requires constant awareness and engagement of insight.  Sober recovery is not effortless, and is not possible for everyone— just as some people cannot avoid depression without using SSRIs, and some diabetics cannot control their blood sugars without using exogenous insulin.  There is no shame in having one’s addiction treated!

Comments, as always, are welcome.  And to the writer, thank you for sharing your story, and provoking this discussion.  I can’t say whether it is time to stop Suboxone, or whether you will ever do well off the medication.  But in any case, I encourage you to appreciate life as best you can, and cultivate enough interests so that the buprenorphine issue falls into the background.  That, in my opinion, is the best way to use buprenorphine; to allow people to live life as if they had never become addicted, and to learn to tolerate life on life’s terms, as best they can.  For some people, maybe that’s ‘clean enough.’

Jerk Counselor

Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention.  This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’

I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness.  I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions.  In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do?  Or better yet—if I had diabetes, what would I want MY endocrinologist to do?

Some Jerks advocate punishing patients who struggle.

This Jerk Counselor

We all know that certain professions attract certain types of people.  Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt.  When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people.  It’s the power trip, I suppose.

This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment.  He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way.  One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room.  But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.

Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position.  In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room.  We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.

The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power.  Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids.  Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.

This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety.  He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.

In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious:  when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts.  On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.

I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric.  I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach.  I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right.  But most of us leave that world behind when we commit to helping people suffering from illness.

What’s This Jerk’s excuse?  Is it that he just doesn’t get it?  Or are there other motives at play?  With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.

Or is it the power trip– that people with difficult addictions are an affront to therapists?  I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die.  I suppose This Jerk would say ‘not my problem!  I did MY job!’

Readers may suspect that this topic irritates me—and they’re right.  Maybe I’ve seen more death, up close, than the typical counselor.  I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery.  I have spent hours with the parents of young patients who died from overdose.  I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child.  Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.

I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior.  People like This Jerk hold power over an individual with an addiction history, but there is power in numbers.  It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle.  It is not appropriate to humiliate a patient in front of others.  If you see that behavior, collect witnesses, and bring it to someone’s attention.  Maybe that ‘someone’ will write a blog post about it!

Doctors in particular should treat patients with ALL diseases—including addiction—with respect.  It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite.  I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.

Would THAT make sense— even to This Jerk?

My Book

Ah yes…. another post about my book…

Over the past few years, I’ve taken posts from this blog, posts from other sources that I’ve written, some sections of a ‘memoir’ that I have not gotten around to writing… and combined them in a book about addiction. The book does not hold together as well as it should, and it is way too long– so instead of a ‘sit and read’ book it is more like a reference, similar to the blog itself. If you like this blog, you’ll like it; I’ve taken the more important posts and cleaned them up and organized them. I’ve added some new material as well, including a section about my own background. If you have a loved one on Suboxone, or have an interest in the medication yourself, you will know as much about the buprenorphine as anyone should you finish this book– particularly about the use of buprenorphine by addicts, the controversy over buprenorphine, the relationship between buprenorphine and methadone, etc.

There are some chapters that are dated– i.e. where my opinion has changed or softened over the years. I was much more ‘anti-methadone’ when I wrote most of the book; now I see methadone as something that some people simply need in order to survive. I am not a fan of how some clinics are run– but that is a topic that I don’t get into in this book.

Finally, you’ll notice how I have changed over the years; in early posts I would become angry and sarcastic with some writers. In part, that is because I was being attacked on a daily basis by the ‘anti-sub’ movement– which has largely disappeared. But I think I have also aged a bit, and I now tend to pick my battles more carefully.

The book (note- this is an e-book) goes for $14.99, and runs around 250 pages– long enough to occupy most of your summer! Proceeds continue to support this blog, and SuboxForum as well.

Thank you very much, to those of you who purchase it and check it out. I would be most grateful if you would leave comments about it– for me, and also for others– by writing them in response to this post. At some point I will get a page set up, and tranfer this promo and the comments to that page.

The book is called ‘Dying to be Clean’– and can be purchased using the links at the left of this page– or right below this post.

NOTE: Because I don’t want it simply passed around freely at this point, you need a code to open it– and it cannot be printed. The code will be included with the download link. Please understand why I take those actions.

Thanks again,

Jeff J

Buy Now

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night

Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?

This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.

Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’

The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.

The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.

All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.

My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night

Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?

This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.

Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’

The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.

The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.

All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.

My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.