I appreciate the feedback to my last post.  I had no doubt that the thoughts expressed in the original letter would ring such a chord, as I hear similar comments on a daily basis.  For people new to my blog this week, please review the letter in last week’s post, as that is where I’m starting today.

I had the same ‘love at first site’ reaction to opioids described by many people who become addicted.  My addiction began with a relatively weak opioid — codeine —but I still remember lying in bed as the effects of the substance drifted over me, easing the life-long depression that I had long accepted as ‘just how things are.’

I should make clear at this point that I do not mean to recommend that depressed people take opioids.  Unfortunately, every bit of relief that I found from opioids had to be paid back, in the form of sadness, loss, and despair.  There is some possibility that medicine will find a way to tap into the powerful mood effects of opioids at some point, but we are NOT there now.

For people who are thinking ‘I’m smart—I’ll find a way to tame the beast,’ I can only plead that you look beyond that feeling of uniqueness.  I was a pretty smart guy too. But a PhD in neurochemistry, honors in medicine, and board certification in anesthesiology offered no protection against addiction.  If anything, that advanced knowledge made me more difficult to treat.

I would like to discuss a comment from a reader:

I have been a recovering addict for 12 years. I was addicted primarily to Lortabs (active ingredient is hydrocodone) and Ultram. I was never an extreme user but I was consistently trying to modulate my feelings and feel better. I also have been battling BPD (Borderline Personality Disorder) for a very long time which appears to be my primary issue. I have been married for 17 years and let’s just say our relationship is difficult due to my inability to be present and emotionally and psychologically sound.

As with most other addicts, I distinctly remember the first opioid I took, even though I don’t remember my first sexual experience. The opioid made me feel unlike I had ever felt– like I was “normal” in a way, and happy, which was unusual for me.

Since I quit using 12 years ago I have only had a few days, yes, days, where I have truly felt good, and that was after intense work with someone for hours and hours at a time to help me get through an intense emotional roller coaster ride. I will feel “normal and happy” for a few hours or maybe a day and then I feel the despair creeping back in. I cut my thumb the other day and the first thought that I had was, I wonder if this injury will be sufficient enough to allow me a Lortab? I just never feel right without an opioid in my system.

I have been researching drugs available to help me. I have tried many different antidepressants which were never helpful. I am wondering about a small dose of Suboxone (maybe 2 mg/day) which I have read may decrease some of the problems associated with BPD. I have been reading that persons with BPD have shown to have an opioid deficit and that 40% of those with BPD are addicts.

A recent experience with a patient helped me realize the dramatic difference in the treatment of opioid dependence, in an era of buprenorphine.

I randomly drug-test for a wide range of substances.  I don’t test because of a lack of trust for patients;  I test because before the era of buprenorphine, insight—a more fundamental character trait than honesty– would rapidly change after relapse.  Almost immediately after the onset of an opioid high, the people using lost insight into the big picture and saw only what needed to be done right then—to cover up evidence of the relapse and avoid experiencing whatever shame-inducing consequences would likely come their way.

I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA, attending hundreds if not thousands of meetings over seven years.  I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’  I didn’t realize that at the instant one relapses, that door becomes nowhere to be found. 

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!’

In my last post I mentioned that one of my patients on buprenorphine had relapsed. Relapse on buprenorphine reminds me of the philosophical cliché, ‘if a tree falls in a forest and nobody hears it, did it make a sound?’ For those not familiar with the cliché, the question and the answers–from standpoints of science, art, and metaphysics—are discussed in great depth, I just discovered, on Wikipedia. I now know more about the question than I will ever need to know!

When a person on buprenorphine maintenance uses opioids, what happens? The answer, depending on perspective, ranges from ‘nothing’ to ‘everything.’ For example, we could focus solely on the effects experienced by the addict. Because of the blocking effects of buprenorphine, an addict may take significant doses of heroin without having any subjective response. One might argue that since the addict experienced no ‘high’ from the use of heroin, he/she didn’t really relapse. Someone else may focus on the intake of chemicals, and consider such use to be a ‘relapse’ whether or not the heroin had a noticeable effect.

Since I don’t have much on my mind tonight, I’ll respond to a cleaned up comment from a reader:

I have been on opiates for about 15 years now. I’m 43 and I have been through hell and back again. I’m doing the Suboxone thing now.  It’s a little better than the methadone clinic; that place just wanted your money and they still treated you like a junkie with no hope ….hope…… I’m starting to wonder if there is a way out with Suboxone.

You have the same withdrawal problems trying to wean from it just like anything else.  Your body has to adjust to being sober and being on Suboxone is not being sober.  I hope someday the people at the clinics quit turning their heads and look at opioid users as real people needing real help. I would love to just stop taking the Suboxone. I am done (with taking it) but I have children and a wife to take care of and a demanding job that I have to keep so when am i suppose to find the time to go through the withdrawals?

It’s a messed up way of life with the appointments, with drug counseling during the middle of the day, and getting the script from the doctor, taking a pee test every time you go… oh well, this is what you have to do if you want a halfway normal life as an addict.  It becomes a part of your life.  It will be over someday, just not today.

Wow—so much for the joy of recovery!  To the writer, I feel for you—you are clearly miserable.  I will try to throw out a few suggestions, and I hope they are useful.  I realize, of course, that some people are simply not as ‘happy’ as others;  I’m probably more on the unhappy side myself, and there is only so much ‘cheering up’ that can be done for me—and I imagine the same is the case for you.

I haven’t felt like writing for the past few days.  The wind was taken out of my sails a few days ago, when a patient’s mother called to tell me that her son died from a drug overdose.  She told me to use the information in any way that I could, in order to keep someone else from dying.

I have had several patients—all young men—who eventually died from their addictions.  Each time that I have heard the news, I wanted to stay away from work, the phone, the computer—everything seems so heavy, so useless, and so sad.

The grief of their parents is so great, and I have nothing to say to make them feel better.  In each case I think through everything that occurred, trying to find something that I could have done differently.  I know that in most of the cases, the parents have done the same, over and over again.

In case any of the parents are reading this column, I want to say very clearly that you did all that you could.  There have been times in my practice when I felt that parents were too harsh or too easy on their children. But in all of the cases I am thinking about now, the parents were about as perfect as they could have been—and yet in spite of their efforts, their children died.  That the parents cared so much, and handled everything so well, makes the outcomes particularly frightening.

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.