I received the following email last week.  I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients.  As usual, I will write a follow-up post in a week or so.

Dear Dr. J,

I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy.

When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness.

I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.

A recent question from a reader:

Do you believe in intervention of someone who does not ask or desire (to be clean)?

It is hard to predict human behavior; sometimes people rise to the occasion when all appears to be lost, and other times people who have everything going their way make surprisingly poor decisions.  But in my experience, real sobriety requires the addict to feel a profound need to change that comes from within.

That doesn’t mean, necessarily, that interventions never work—but the intervention should be set up in such a way that the addict or alcoholic—him or herself– comes to the realization that getting clean is the only option.

Below are comments from a reader of my buprenorphine blog, followed by comments of my own:

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 I 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.

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 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.

Over the past several years I’ve written a book about my experiences with addiction, and about my take on traditional treatment methods, buprenorphine, and on the psychodynamic factors at play in those with addictions.

I went through the standard process of sending requests to agents and publishers to take a look at a few of the 300-some pages, and received the standard series of rejections.  I then discovered several companies that were very excited about what I had written, and found that by some odd coincidence all required a down payment on my part.  So the book sits on my computer—or at least sat on my computer until now.

I’ve shared a small amount of information about my own addiction to opioids. My addiction started in the early 1990s after I took codeine for a lingering cough from a respiratory infection. As an aside, codeine is converted to morphine by the liver, a metabolic process that varies in efficiency from one individual to another.

Some people obtain little pain relief from codeine because of the lack of conversion to morphine.  Unfortunately, some doctors interpret a patient saying ‘codeine doesn’t seem to work to me’ as evidence that the patient is an addict seeking strong narcotics.  I’m sure that in some cases, a request for non-codeine narcotics is a sign of drug-seeking.  But some people have a legitimate beef with taking codeine—a medication that in their cases has minimal pain-relieving activity.

I knew fairly soon during my use of cough medicine that I had become addicted, but I tried my best to push thoughts of addiction from my mind and instead get on with life. The realization of the depth of my problem became harder and harder to avoid as my tolerance increased. It is one thing to self-medicate a cough with a half-teaspoon of cough syrup; but something else to gulp down cough medicine from the bottle!

In earlier posts, I provided background for a problem that has captured headlines in recent years, namely the problem of addiction to opioid pain medication. My reason for providing background was to make clear that addiction to opioids is not a problem confined to high school kids or back-alley junkies, but rather cuts across all age groups and socio-economic divisions.

Moreover, the problem of prescription drug addiction blurs the dividing line between illicit use of substances and the appropriate use of medication; appropriate use that can become problematic over time. And while there are people, policies, or companies that can be blamed for some of the increase in opioid dependence, a number of cases arise from reasonable efforts by doctors or patients to relieve pain and suffering.

Thanks for the feedback so far– one of the comments included a question about depression and drinking:  I don’t drink at all – haven’t for 25 years – by choice, not because I had a problem… Could you explain to me why it is that when I am felling depressed… I feel like drinking?  It is a very strong urge and it takes a lot of work to not go to the liquor store.

The question fits nicely with the situation with our fictional pain patient.  Before commenting I need to point out that I am sharing my thoughts about addiction and psychiatry based on my personal, subjective experiences—not based on scientific research.  I don’t know, to be honest, whether anyone studies addiction from the perspective I’m trying to share, and I’m not even sure how such studies would be accomplished.  But from my way of thinking, the main goal of a person suffering from addiction is to reduce awareness of the pain of day-to-day life.

On the surface, this explanation appears obvious; people drink or use drugs to feel good—no kidding!    But I think that the mainstream perception of this explanation incorrectly implies a conscious or intentional process, and also grossly underestimates the ubiquitous nature of the desire to remain unaware.