This is a response to Melanie, who hopefully will be a good sport and not take the discussion personally. I will post the entire e-mail first– something I assume is OK, since she posted it herself in the comment section. Then I will post sections in order, associated with my comments. Melanie, If you want it edited please post a comment to that effect and I will do so.
The message is a perfect example of how opiate addiction works– how it changes one’s actual personality and thought process. During relapse prevention work I tell addicts that they must step outside of themselves and treat themselves like small children, rather than try to predict what they will do in a risky situation. The example I like to use is the bathroom at grandma’s house… if you need to use the ‘facilities it is tempting to tell yourself that you won’t look in the medicine cabinet, knowing there are pills inside. But as an addict, you cannot predict what will happen in the bathroom. You might very well change your mind, and decide to look– maybe just for some tylenol for the cramps you might suddenly think you are having. Then you might decide to ‘just look in a bottle for old time’s sake’. Who knows what you will do! So if you are a recovering addict, you learn to recognize your POWERLESSNESS in such situations, and you don’t use grandma’s bathroom… of if you do, you first bite the bullet and ask her to remove all her medications.
The Message:
Hi Doc, can you please please help me?
I am a recovering heroin/opiate addict who has been taking Suboxone for the last 2 years. I’ve been titrating down from a dose of 16mg with a 2mg reduction about every 3 months or so. I recently went from 6mg to 4mg. I was having a lot of trouble with this new lower dose… feeling jittery, high anxiety — scoring a (self-assessed) 9 on COWS. I made a mistake and I took a double dose on a few days, leaving me short on my prescription.
When I first decided to get help over 2 yrs ago, I hid about forty 10mg oxycontin pills, “just in case”… I put them away and I pretty much forgot about them. I guess I felt good knowing I had the drugs on-hand all the time, and that each & every minute I was consciously choosing not to use them. But I also thought I’d hang on to them, in case the final withdrawal from Suboxone was unbearable.
Well, guess what happened when I realized that I was about 5 days’ short on my prescription? I took out those Oxycontin pills and I used some of them. The thing is, by then, they were over 4 years old – according to the bottle they were in. Still, I snorted about 10 of the pills over about 60 hours, receiving very minimal effect, even after I’d been without Suboxone for over 2 days. My plan was to use the Oxycontin to help me make my prescription last as long as it should.
After about 2 1/2 days of doing this, I looked myself in the mirror and was like “What are you doing? You are JUST getting your life back, are you going to throw it away?” … I had a reality check because I REALLY didn’t like my behavior. So I flushed the rest of the pills — something I really thought I could never do. I had wanted to flush them for over 2 years, but I couldn’t bring myself to part with them. I wanted to tell SOMEONE that I had stashed these pills – to tell on myself – but I just couldn’t make myself do it.
I felt very empowered that I finally flushed them… because in the back of my mind I had planned to keep them “just in case” I couldn’t stand the final withdrawal from Suboxone, and now they are gone. It meant to me that I believed in myself enough to just live life on life’s terms and that I gave up control. I made my choice when I flushed those pills – I am done with opiates. I am done.
My problem is this… I took my last dose of oxycontin Monday, and about 6 hours after that I also took 4mg of Suboxone. The Suboxone felt effective, but not as strong as usual. The last two days have been the same: I wake up with a LOT of anxiety. I feel very jittery, but I can sit still for long periods. By the time its time to take my Suboxone, I’m yawning a lot & watery-eyed. The relief from Suboxone only lasts about 4 hours, and then it starts again.
I also don’t want to tell my treatment provider about this. I have had a very good track record with my treatment team, and I really really feel like this was an isolated mistake and that I have learned a very valuable lesson from it. I know more NOW than I ever have that I don’t want that life for myself anymore. I KNOW that my sobriety is not in danger, in fact, its safer than its ever been before.
I’m afraid if my treatment provider learns what I did, she will try to force me to go back to the beginning of intensive outpatient (which I completed 2.5 yrs ago!). I have a job and a life and I just can’t go back to the beginning of treatment. I also don’t have insurance, and I can’t afford to pay for treatment again (no sliding scale). But this is what I’ve seen happen to other people if they tried to use.
I’m at the end-part of my treatment, and I made a mistake. I very much have learned my lesson….
My question is, what’s happening? What do I need to do?
My Response:
There is a great deal of danger ahead, M. You are demonstrating the thought process of opiate addicts in several ways. I will point them out as we re-read sections of your post:
…I’ve been titrating down from a dose of 16mg with a 2mg reduction about every 3 months or so. I recently went from 6mg to 4mg… I was having a lot of trouble with this new lower dose… feeling jittery, high anxiety…
A clear example of how the ‘ceiling effect’ works in reverse when tapering Suboxone. Moves down from 16 to 10 to 8 to 6 are all on the ‘flat’ part of the dose/response chart, so there is little withdrawal. Below 4-6 mg you get to the steep part of the curve, and the work of experiencing withdrawal and lowering one’s tolerance begins. The physician should be aware of this, and warn the patient so it isn’t a surprise. Some clonidine is helpful here, especially at night.
I made a mistake and I took a double dose on a few days, leaving me short on my prescription.
Very common, and not the end of the world. Ideally, the patient would call the doc and re-assess the situation. Maybe we need a third person to control the medication at this point. If a number of addictive thoughts are reappearing, it may not be the right time to taper off Suboxone. The important thing is to avoid taking the use ‘underground’. If this is kept in the open it is a predictable and common problem during a taper. If kept secret, it is the start of a return to an active-addict’s lifestyle.
When I first decided to get help over 2 yrs ago, I hid about forty 10mg oxycontin pills, “just in case”… I put them away and I pretty much forgot about them. I guess I felt good knowing I had the drugs on-hand all the time, and that each & every minute I was consciously choosing not to use them. But I also thought I’d hang on to them, in case the final withdrawal from Suboxone was unbearable.
Oh-oh. Every addict knows this situation. This is a perfect example of ‘ambivalence’– how an addict will ‘want her cake (recovery) and eat it too (pills to fall back on… someday)’. This is in the days before Suboxone an addict needed a true ‘rock bottom’ in order to stay clean– because only total desperation will push the addict past ambivalence to a solid desire to get clean. Had Melanie been more ‘desperate’, she would have recognized that the addiction will KILL her– and so no matter her concerns of withdrawal, she would NOT KEEP OPIATES AT HAND! One of the basic principles of avoiding relapse is keeping as much distance as possible between the addict and the drug at ALL TIMES. It shouldn’t take one phone call to find something– it should take at least three, and hopefully the numbers are forgotten. If the addict sits on a stash, he/she will eventually use it. Look at the ‘addict inside’– how it set the whole thing up! The addict inside is a crafty ‘MF’!
The other noteworthy thing is the bizarre distortion of logic that rationalized keeping the stash– does it really seem like a good idea to plan to take oxycontin JUST AS THE ADDICT IS GOING OF PROTECTION AGAINST USING?! A horrible, senseless idea– and yet one that we all have had in one form or another, to rationalize during our using days.
…Well, guess what happened when I realized that I was about 5 days’ short on my prescription? I took out those Oxycontin pills and I used some of them…
No surprise. I would have too.
…I snorted about 10 of the pills over about 60 hours, receiving very minimal effect, even after I’d been without Suboxone for over 2 days…
Buprenorphine has a half-life of over 70 hours, and it is a very effective mu-receptor blocker.
…My plan was to use the Oxycontin to help me make my prescription last as long as it should…
We ALWAYS have a plan.
After about 2 1/2 days of doing this, I looked myself in the mirror and was like “What are you doing? You are JUST getting your life back, are you going to throw it away?” … I had a reality check because I REALLY didn’t like my behavior. So I flushed the rest of the pills — something I really thought I could never do. I had wanted to flush them for over 2 years, but I couldn’t bring myself to part with them. I wanted to tell SOMEONE that I had stashed these pills – to tell on myself – but I just couldn’t make myself do it…
But you HAVE to. Secrets keep us sick. Keep saying it… secrets keep us sick… secrets keep us sick.
…I felt very empowered that I finally flushed them…
It probably wasn’t ’empowerment’– it was more likely relief. You made a deal with yourself– ‘if I can dump them, I will let myself off the hook about telling my counselor.’ You are going down a dead-end path– essentially saying that ‘I have demonstrated enough control and power that I don’t need to rat on myself– I don’t need the counselor’s help– I can take care of myself on this one’. The small part of the problem is that you are taking another step into the secret world where the addict cares for herself, rather than gets help from others. The big problem is that your ‘power’ and ‘control’ will be the basis for your next big relapse– six months from now you will be having horrible cravings from a bad break-up, and the thought will occur to you that you aren’t TOTALLY powerless over opiates… after all, you were able to flush those pills down the toilet that one time! So taking a couple oxy, just to boost my mood, wouldn’t be the end of the world– in fact it will be a good thing! Yeah, that’s the ticket! It will actually help me stay CLEAN! One or two, and that’s all– that would make me feel better, so I don’t have to get real miserable and end up taking a BUNCH of them. Yep! Sounds like a good plan
My own relapse in 2000– the one that destroyed my anesthesia career– had its basis in my own ‘control’ six months earlier, when I demonstrated power over opiates after returning from the Bahamas. THE SECRET TO SOBRIETY IS POWERLESSNESS– COMPLETE AND UTTER POWERLESSNESS, WITHOUT A SINGLE EXCEPTION.
…because in the back of my mind I had planned to keep them “just in case” I couldn’t stand the final withdrawal from Suboxone, and now they are gone…
Fine– but there are always more out there!
…It meant to me that I believed in myself enough to just live life on life’s terms and that I gave up control. I made my choice when I flushed those pills – I am done with opiates. I am done…
This sounds like rationalization. You ‘gave up control’? What control? The fact that you KEPT the pills is evidence of a LACK of control. You have things backwards– to stay clean you want to recognize your lack of control. Control is not something you ‘gave up’– it is something you never had, and never will have… as far as opiates are concerned. That is a fact, and your sobriety requires you to realize that fact.
…My problem is this… I took my last dose of oxycontin Mondcoay, and about 6 hours after that I also took 4mg of Suboxone. The Suboxone felt effective, but not as strong as usual. The last two days have been the same: I wake up with a LOT of anxiety. I feel very jittery, but I can sit still for long periods. By the time its time to take my Suboxone, I’m yawning a lot & watery-eyed. The relief from Suboxone only lasts about 4 hours, and then it starts again…
It is hard to know what is happening here. I suspect that your symptoms and sensations are all ‘psychological’– essentially memories of prior withdrawal experiences that have been triggered by your mind returning to the unconscious scheming and planning that happens during addiction. I don’t see a ‘neurochemical’ reason for the symptoms, for example from an interaction between the Suboxone and the oxy that you used.
I also don’t want to tell my treatment provider about this. I have had a very good track record with my treatment team, and I really really feel like this was an isolated mistake and that I have learned a very valuable lesson from it. I know more NOW than I ever have that I don’t want that life for myself anymore. I KNOW that my sobriety is not in danger, in fact, its safer than its ever been before.
Secrets keep us sick. The last sentence is called ‘whistling past the graveyard’.
I’m afraid if my treatment provider learns what I did, she will try to force me to go back to the beginning of intensive outpatient (which I completed 2.5 yrs ago!). I have a job and a life and I just can’t go back to the beginning of treatment. I also don’t have insurance, and I can’t afford to pay for treatment again (no sliding scale). But this is what I’ve seen happen to other people if they tried to use. I’m at the end-part of my treatment, and I made a mistake. I very much have learned my lesson…
More rationalization, and more wishful thinking. It is NEVER a good time to need treatment. But you don’t know what a relapse might entail. People DIE during relapses. Consequences are always worse during relapses.
My question is, what’s happening? What do I need to do?
My best advice is to be open and honest with your counselor. After this long you hopefully trust the person to do the right thing by you. Addicts, myself included, cannot trust themselves to make the right decisions in these matters– we are all just too full of crap! DENIAL = Don’t Even Notice I Am Lying. Cute, huh?
If you truly need a ‘plan B’, I strongly recommend that you recognize the active forces of addiction within yourself and find some desperation. Write a paragraph or two or five about times when you thought you had it all worked out, all under control– only to let yourself down one more time. After finding the desperation, take you and your desperation to a bunch of NA and AA meetings. Go to a new meeting every day until you find one that fits. Then go to a few every week, and read the literature of AA and NA. Take what you need from meetings and leave the rest… principles, not personalities… meaning don’t get caught up in judging others and telling yourself you don’t belong. Don’t start trying to teach something to others. Work on HUMILITY… and listen.
These things you can do. If you do them they have the potential to keep you sober– they saved my life… twice. What’s more, working a program will often show a person the path to happiness, sometimes for the very first time in life!
Thanks for having the courage– and desperation– to write. We all wish you the best.
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