Today I read interesting findings from a study in the Journal of General Internal Medicine, that examined the perceptions of doctors toward their patients.  The study, by Jeffrey Jackson of the Medical College of Wisconsin, classified ‘difficult patients’ according to what surveyed physicians considered as difficult, including patients who were hard to get along with, or those who did not get well as quickly as everyone would have liked.

When physicians were asked what percent of their patients were difficult, physicians overall placed the number at 18%– about one in five.  But the interesting part came when the survey responses were broken down according to the respondent’s age and experience.  Doctors with less than 10 years experience reported that 25% of their patients were difficult.  But doctors with more than 20 years of experience had an altogether different opinion, reporting that only 2% of their patients were ‘difficult.’

Wow.

I’ve been writing about will power for the past couple weeks in response to these comments from a reader:

Everyone’s will power varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinence. The easier withdrawals are, the more likely those persons’ mindset will be “one more can’t hurt”. Pain builds you; it builds character, personality, and maturity.

In part one I talked about the value of powerlessness and belief in a higher power.  In part two, I suggested that belief in will power may, from a logical analysis, contribute to relapse.

One remaining aspect from the reader’s comments deserves a closer look.  Does more severe withdrawal offer protection from relapse?  Can bad withdrawal serve as an aversion to using substances, just as an electronic shock collar keeps a dog from wandering into the more interesting yard next door?  Does pain truly build ‘character, personality, and maturity?’

In my last post I shared a comment from a reader that included the following:

Not everyone needs permanent blocker therapy. Everyone’s will power varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinence. The easier withdrawals are, the more likely those persons’ mindset will be “one more can’t hurt”. Pain builds you; it builds character, personality, and maturity.

I noted that I was relieved of the obsession to use opioids only by letting go of will power, and instead accepting my own powerlessness over substances, and trusting that a higher power could help restore my sanity.

When I left off, I was debating whether to leave well enough alone, or to seek a logical understanding of how the acceptance of powerlessness relieved my obsession to use.  Being the scorpion in the famous story of the scorpion and the frog, I chose the latter.  I’ll leave you to look up the famous scorpion story on your own.

This is part one of a three-part discussion about will power; look for the rest of the story next week, after the Packers beat the Bears in the NFC Conference Championship.

A person posted the following comments after one of my articles about Suboxone:

While Dr. Junig knows what he’s talking about, not everything he says is always true. Not everyone needs permanent blocker therapy. Everyone’s will power varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinence. The easier withdrawals are, the more likely those persons’ mindset will be “one more can’t hurt”. Pain builds you; it builds character, personality, and maturity.

I have had my share of bad withdrawals, as have most opioid addicts who have lived with their illness for a few years.  Unfortunately there is much more to staying sober than remembering the pain of withdrawal.  There is also much more to staying clean than ‘character, personality, and maturity.’

In response to my last post, a reader, Sunkissed, wrote about the many consequences of  active addiction, and noted that the consequences including spiritual impairment and the loss of self-esteem are as valid indicators of ‘addiction severity’ as are consequential effects on earning power—perhaps even more valid.

She wrote about the importance of replacing one’s relationship with a substance with a relationship with God, and asked ‘is there a case… for a positive ‘harm minimization’ approach in the addiction process with the following attitude as a goal:  I AM an addict… I AM ashamed (though i am at peace with God)….. I recognize that addiction DOES affect my finances and my parenting (but i have enlisted strategies and a care plan).  I AM seen as weak and selfish (but I have put in place actions that will minimize the effect of my using on my children)… in short, I am in acceptance of who I am, what I am, and what I do.’

Thank you, Sunkissed, for your comments and insight.  Hopefully I captured the essence of your remarks despite minor editing.

The essence of your question, if I understand correctly, is whether a person can remain in a low state of active addiction, or at least active using, yet reduce or even avoid the usual devastation caused by addiction by coming to terms with their condition on a deep personal level, and being at peace with him/herself and with God or higher power, depending on the person’s spiritual background.

I am going to promote a comment to this main section, as the material deserves a larger audience:

I’ve been taking Tramadol for 3 years now, 3 per day.  I’ve tried to taper down, I can’t even handle that.  I don’t know if I have a “problem” or if it’s all in my head?  My doctor doesn’t seem too concerned…. I feel powerless to them, yet I don’t even know where to begin.  I know that I’m very good about rationalizing my use of them.  Any advice for someone hooked on Tramadol, which is not technically an opioid, but equally as addictive.  It’s sometimes hard to see it as a problem, as my finances/marriage, etc. are not falling apart.

There are many interesting aspects to your question, and I thank you for sharing your concerns.

Most people addicted to substances spend great amounts of time and energy on tapering.  The natural thought, I suppose, is that ‘since I seem to need this substance, it will be easier to give up the substance gradually—maybe even so gradually that I won’t even miss it.’

But unfortunately, the mental forces that are causing you to take the substance are not rational, and not based on need.  The tiny decisions that lead to using are made in the dark, out of consciousness—or under the guise of what you insightfully recognize as ‘rationalization.’

This is another section of my unpublished book, Clean Enough.  I describe stages in the process of addiction that I’ve noticed in opioid addicts presenting for treatment.  I must point out that these stages have not been validated by clinical research, but rather are drawn from simple observation.  Read on:

I am always impressed by how similar addiction progresses in one individual versus the next.  The next reader’s comments and my comments afterward demonstrate a pattern that I have observed in one opioid addict after another.  Throughout these posts, comments that I receive from others will be italicized.

While I’m on the subject of rip-offs, I’ll mention an extreme form of ‘detox capitalism’; a process called rapid opioid withdrawal, rapid detox, or ‘the Waismann Method.’

The name of the process supposedly comes from a certain ‘Dr. Waismann’ who helped Israeli soldiers get off opioids after they were treated for various injuries.  It sounds like a pretty exciting history, but to be honest there is nothing in the technique that takes a rocket scientist to figure out.  The basic idea is to precipitate withdrawal using an opioid antagonist— something that is done many times over every day in emergency rooms across the U.S.—but to do it while the person is sedated with non-opioid medications.

Aarghh! (he said, moaning in frustration…)  I realize that it isn’t so much anger that shortens our lives as much as the repression of that anger—so pardon my venting!  I just finished an appointment with a patient who described something that is all too common, and that really makes my blood boil.

I’ve seen ‘Tom’ in my practice for about three years, since he presented with severe heroin addiction.  He once made good money working in the financial industry, but was reduced by addiction to a shadow of his former self.