Aftercare Made the Difference
I relapsed in 2000 after seven years of sobriety, and my attachment to opioids progressed much more rapidly than during my initial addiction. I wrote a post a number of months ago that described ‘living on two levels,’ and that was my experience at the time—as if one part of my personality was frantically taking ever-increasing doses of dangerous narcotics while the other part, horrified, looked on.
Eventually my behavior caught the attention of enough people that I was confronted about my addiction. I had been trying to stop using on my own for several months, but I argued over the need for residential treatment. I remember sitting with the hospital CEO, babbling that I would be able to straighten myself up on my own if I had a few weeks of sick-time, and his response: ‘Jeff, you have needle marks on your hands!’
I’ve written about the desperation required for abstinence-based treatment to yield lasting recovery. But while desperation is NECESSARY to initiate a recovery program, it is not SUFFICIENT to maintain sobriety indefinitely—at least not for addiction to opioids. Even after months of treatment, the relapse rate for opioid dependence is very high.
Every now and then, a member of the anti-buprenorphine crowd will ask me how, if traditional recovery is so ineffective, was I able to remain clean? I’ll answer that my own situation was quite different from the situation experienced by most opioid addicts, and so comparing my own sobriety to that of most addicts is comparing ‘apples to oranges.’ I can hear readers of my blog saying ‘But Dr. Junig, you said that EVERYONE believes his/her own experience to be unique!’ And yes, that is true… but allow me explain my point.
In some ways my situation was similar to that of others entering treatment. Everybody has a lot to lose from addiction, and I was no exception. But fear of losing everything—even losing one’s wife and children—does less to motivate sobriety than many people would think. The addict sees the world as a place where he himself must get his act together—not a place where experts in medicine, science, or spirituality can offer assistance. So even if the fear of loss becomes greater than the fear of withdrawal, the addict has nowhere to turn except for his own desperate efforts. To use other words, the addict IS motivated to save his family—but he thinks that the only way to do so is by managing his own taper schedule, because ‘the experts’ would never truly understand the situation.
I had become so sick by the time I entered treatment that I knew that my own efforts were futile. I believed that I had lost everything—and in many ways, I had. In one week I lost my job, my career, my hospital privileges, my medical license… and I thought that I had lost my family as well. I saw a mountain of debt looming ahead, along with bills for tens of thousands of dollars for treatment of my addiction. These fears probably helped me to realize the gravity of the situation, and to realize that beyond a doubt, I needed help from anyone who was nice enough to help me.
After a week in a locked detox unit I was transferred to residential treatment, where I would be for the next 3 months. Some people ‘coast’ through treatment, but my ability to return to medicine required a ‘thumbs up’ from the treatment team. I knew that I had to find ‘recovery’, because if I didn’t, the treatment team would know—and my life as a doctor would be over. So I worked as hard as I could, reading, doing assignments, participating in group, and pushing myself on the ropes course.
But the primary difference between my own situation and that of most opioid addicts was the nature of my aftercare. I believed, for good or for bad, that my medical license was so much a part of my identity that losing my license would be losing everything. So when the Licensing Board required an intensive monitoring program, I had no choice but to follow their instructions to the letter. For six years, I was required to be in group and individual counseling. Other addicts would come and go, but my group membership continued seemingly forever, helping recovery become part of my new identity.
For six years I was monitored by urine testing, at a frequency of twice per week for much of that time, and lesser frequency near the end of the monitoring period. One day near the end of the monitoring period I ate a Starbucks poppy seed muffin. I was familiar with the stories about positive drug tests from poppy seeds, but I assumed that the amount of opioids in one muffin would be negligible. But a few days later, my Board case worker called to ask why my urine contained 700 nanograms of morphine! In one muffin! I had to appear in person before the Board to explain what happened… and I changed my daily pastry to Classic Coffee Cake!
There were many other requirements from the Board; I was to attend a certain number of 12-step meetings each week; I was to provide letters from counselors and doctors at regular intervals; I was to avoid all medications, even over-the-counter medications, unless authorized by the Board or by my addictionologist. I had to appear before the Board each year and describe what and how I was doing.
My point is that I was watched very, very closely. The part of me that got into trouble—the part that I refer to as the ‘addict inside’—was clearly ‘persona non grata,’ if I was to ever practice medicine again. I don’t mean to reduce the importance of my family, and the importance of the rules and consequences that they established either openly or implicitly. It’s just that like all addicts, I knew on some level that my family would be there for me, even if I didn’t follow the rules perfectly. But that was not the case with the Board. I was smart enough to know that they had seen it all before—and were not going to be swayed by any excuses, should I fail to do what they required.
When someone says, then, that since I did it, everyone else should be able to stay clean without Suboxone, I answer that ‘anyone can stay clean, if placed in a sealed box!’ My own experience was different from that of other addicts in many ways- in the degree of fear, the value of what was at risk, the length of my treatment, and perhaps most importantly, the strictness and duration of my aftercare. If someone comes into my office and asks for help with finding sobriety from opioids, I most often recommend buprenorphine. But if the person says he is willing to be open with his family members and have them come in several times, to enter residential treatment for 3 months, and to commit to six years of weekly urine testing, group therapy, and individual therapy, all at his own expense—then I would consider that option as well.
Photo by N.Vitkus, available under a Creative Commons attribution license.
Junig, J. (2011). Aftercare Made the Difference. Psych Central. Retrieved on July 4, 2015, from http://blogs.psychcentral.com/epidemic-addiction/2011/05/aftercare-made-the-difference/