addiction relapseOne of my patients taking buprenorphine relapsed last week. He worked in a healthcare facility that stocked potent opioids, and he somehow came across an unlocked door. By the end of his shift he had consumed several hundred milligrams of oxycodone—enough to provide a mild buzz for a person taking buprenorphine. Several hours later the mood effects were gone—and so was the job. Relapse has always been a part of the disease of opioid dependence, and always causes a great deal of pain.

The relapse process– the complicated interactions between a person and his environment that lead to loss of control over drug use– are some of most fascinating, maddening, and tragic aspects of addiction. It is incredible that a person in one moment can be in complete control of his faculties, and a moment later is doing something at complete odds with his best interests.

The person I am referring to had been at the same job for a number of years, and he valued the salary, benefits, and security that the job provided. Like any of us, he had a great deal riding on his position. He has no other source of income, for example, and no family to bail him out of trouble. He knows that the economy is not that great, and that good jobs are hard to come by. If something had come along that threatened his job, I have no doubt that he would have expended considerable effort in order to keep the position.

Yet when he saw the open door, there was no debating over the path that he would take. I used to watch the TV show E.R. years ago, and in one of the early seasons, Dr. Carter became addicted to pain pills. There was a particular scene in the show that I remember noting, at the time, for its accuracy.

Dr. Carter returned to work after getting treatment, and a few days later came across a couple loose tablets of oxycodone (or some other narcotic) that had been left out for some reason. In a flash, he grabbed the tablets and swallowed them without thinking—then rushed to the bathroom, where he made himself throw them back up again. I was already an opioid addict when I saw that scene, and I could relate to the actions of the fictional Dr. Carter. I would guess that every opioid addict can relate to that scene, and to the ‘temporary insanity’ of the character at that moment.

addiction replaseI’ve learned over the years about the danger of surprises, and I try to impress those dangers on my patients. I try to help people with addictions realize that they have another identity—‘the addict inside’—who is ready to take action should the reins be placed in his hands. The addict inside does not negotiate or weigh consequences; the addict inside only acts.

We cannot predict what the addict inside will do; we can only do our best to keep that identity from emerging. For example, if we are working in an area that exposes us to dangers like unlocked doors to prescription narcotics, we cannot rely on our ability to ‘decide’ to take the proper path. As I frequently tell patients, if you are in the position of deciding whether or not to use, you are almost surely going to use.

The proper decision comes much earlier in the process—in deciding whether the environment is safe, and if it is not, finding a way to make it safe. For the person I have been describing, the best plan would have been to avoid working in an area that contained pharmaceuticals. If that was not a solution, next best would be to only work in such an area in the presence of other people. Even then, surprises occur; the best thing to do when seeing something related to our drug of choice—a tablet on the floor, a baggie behind a dresser, a vial in a medicine cabinet, or an unlocked door in a pharmacy—is to run the other way, and find someone who can help.

Next, I’ll write about the options after relapse for a person on buprenorphine.

Photo by Wildebeeste1, available under a Creative Commons attribution license.