Anxiety, step-work, and gratitude

One of the primary insights that I want addicts to gain from reading this blog is the similarity between their own thoughts, feelings, and pattern of use and the thoughts and patterns of use of other opiate addicts.  We are all dealing with the same beast, we have all felt the same desperation, and we have all experienced the same distorted thinking.  I hope that reading the desperate stories of others will help the reader understand that he or she is not alone, and will help readers identify their own distorted thinking.  But tonight I finished the final performance of a Holiday play with Community Theater (I played the psychiatrist who interviews Santa in a take-off on Miracle on 34th Street) and so I want to tell a happy story related to something that I heard from a patient last week.
The treatment of opiate dependence is in a state of flux;  regular readers know all of this very well, but some of the new readers from my last post (!) may not know my ‘philosophy’ on treatment.  I have an article out there somewhere called ‘Suboxone’s complicated relationship with traditional recovery’ that sums things up pretty well for those who want to see how one person (i.e. me) has come to terms with buprenorphine and the twelve steps.  I find the two approaches to be difficult to combine, since ‘getting’ recovery through the steps requires personality change, which requires desperation.  And once on buprenorphine, addicts quickly lose that desperation.  One could say, then, that buprenorphine is ‘bad’ because it gets in the way of ‘stone cold sober’ recovery.  But I would NOT say that myself, because I know that the success rate for treating opiate dependence using the steps is lousy.  The steps have remained as the mainstream treatment for opiate dependence for one reason:  They were all that we had!  The steps saved my life not once, but twice– but they fail for most others.  I got lucky–  maybe having my medical license hanging over my head made the difference.  It is impossible to predict who the lucky ones will be.  All I know is that I am grateful to be one of them.
At the same time I am haunted by the faces of the people I knew who died from opiate dependence.  And I find the current attitude toward opiate dependence to be heartless– the attitude that leads to discharge of patients from treatment for one ‘dirty’ urine.  I personally know of several people who died after forced discharge from treatment centers.  Who benefits from that approach to ‘treatment’?  Sometimes I am tempted to write to the treatment centers that discharged the dead teenager after his or her ‘dirty urine’, to ask if they are satisfied with the ‘care’ they provided!  Before buprenorphine, we had to accept the fact that 80-90% of young opiate addicts would fail treatment over and over, losing everything– losing dreams of attending college, losing family relationships, and sometimes losing their lives.
New readers are now asking, ‘this is a ‘happy story’?’
Sorry.  I tend to wander a bit.  The point I am leading up to is that I became a fan of buprenorphine treatment because the idea that we can simply ‘treat’ opiate addiction has been mostly myth.  Opiate dependence has been treated successfully in a small fraction of addicts.  Yes, the steps CAN work in those who ‘keep coming back’.  But the truth is that people in their 20’s do NOT ‘keep coming back’.  Instead they relapse over and over until everything is gone, and they have become shadows of their former selves.  But then buprenorphine came along.  Buprenorphine is NOT a panacea;  many people fail treatment with buprenorphine as well.  But in a fatal disease with no real effective treatments, buprenorphine is an exciting step in the right direction.
If you are new to buprenorphine, you will likely have a few months of excitement at the feeling that you have been delivered from opiate dependence.  But then reality will set in, and the work will begin– or at least SHOULD begin if you expect to remain free from active using.   After a few years of treating patients with buprenorphine I have learned that THIS is the point where traditional step work can be helpful to understand what is happening in the mind of the addict, and to guide further treatment.  For example, many (MANY) opiate addicts complain of ‘anxiety’.  I used to worry that the ‘anxiety’ would increase the risk that the patient would use, and I would go to great steps to treat the anxiety- including the judicious use of benzos (the respiratory depressant effect of benzos can be dealt with if they are used properly, but people must NOT combine benzos and buprenorphine without guidance by their doctor).  I found that universally, patients who took benzos did WORSE.  They thought they needed them, and even thought they benefited from them.   But the patients who did the best were the ones who accepted the fact that the ‘anxiety’ was nothing but a craving to be ‘numb’, who then worked on reducing the cravings in HEALTHY ways, without taking benzos.  The patients who eventually wore me down and got me to prescribe a small dose of a benzo only ended up wanting more, and then needing more… until they eventually became people who couldn’t do anything without a benzo on board.  I now realize that the ‘anxiety’ that addicts feel is nothing but the cravings that they taught me about when I was in residential treatment.  When I was in treatment, I felt physically horrible much of the time– nervous, tense, trouble sleeping, etc.  But if I went to a counselor and complained of ‘anxiety’, they would have had a great laugh!   People taking buprenorphine are no different than I was;  they are trying to make HUGE changes in how they deal with their feelings.   Of COURSE they will feel all messed up inside!  But the answer is NOT to find another subsstance to reduce those uncomfortable feelings.  The answer can be found instead in many of the principles that make up the twelve steps.  If a person in ‘sober recovery’ has anxiety, the universal recommendation is to go to a meeting.  I think the same is the case for those taking buprenorphine– not so much for the personality change that is needed to ward off the most severe cravings, but rather to help deal with the more minor cravings that are disguised as anxiety.  Other remedies that are used by twelve steppers include meditation, prayer, reflection, readings, step work, and acting ‘as if’.  All of these techniques will work– if the addict works them.
Gratitude is another major part of twelve step programs.  And again, I find that the people on buprenorphine who find gratitude are the ones who tend to stay clean.   The patient from last week that I referred to a moment ago is a patient who has done well on buprenorphine who NOT coincidentally, I believe, uses lessons from the steps in her day to day life.  During our appointment she talked about how grateful she was for where she is today in comparison to where she was a few years ago.  She talked about looking around her home at the material things she can now afford, like a TV set (two 80’s of oxycontin), nice furniture (four 80’s), the microwave (one 80), etc.  She was grateful for the positive changes in her relationships as well.  No, things were not perfect– they never are.  But they sure tend to be better when OC and ‘junk’ are taken from the equation.
She may or may not realize how everything ties together.  Not being broke and sick all the time allows a person to start to feel like a contributing member of society.   Being able to go all day without telling her friends or partner a lie has improved her relationships.  Realizing that she is not ‘anxious’, but instead is having normal consequences of positive change, allows her to feel a sense of personal empowerment and self esteem for dealing with the feelings without taking pills.  And feeling grateful is a great antidote to resentments, and resentments are common triggers for relapse.  As I mentioned earlier, those recovering addicts who are grateful tend to do well.
The experience of speaking with her during her appointment helped me understand one more ‘piece of the puzzle’ for how buprenorphine and the steps are best combined.  No, I do not FORCE patients get into the steps, because I see buprenorphine as something that is more effective at blocking the intense desire to use.  But addicts who are past the honeymoon stage of buprenorphine and who are starting to drag a bit would do themselves a favor by checking out a program that has been around for almost 100 years.  As always, your personal health history is YOUR business;  if people at a meeting are asking which meds you are taking I recommend finding a healthier meeting– after telling the person that it is none of his/her business!  If you are experiencing ‘anxiety’, realize that we ALL struggle with those feelings, particularly early in recovery.  You will feel better in every way if you see that anxiety as a form of craving, and learn to deal with it in a non-benzo way.  If you have anxiety or panic that does warrant medication, the proper medication is an SSRI– NOT Xanax.
And as the Holidays approach, take time every day to notice what you are grateful for.  If you cannot find anything, be grateful for being alive, as many opiate addicts have lost even that gift.  With all of the Holiday activities I may be absent for awhile.  My kids– the ones who saw me in a locked psych ward 9 years ago, sick from withdrawal– are coming home from college for a couple weeks.  Back then I thought my life was over– no job, license suspended, anesthesia career effectively over.  I couldn’t imagine going back to do a whole new residency in a new field– but it turned out to be an entirely new calling, and has included experiences that I wouldn’t trade for anything.
One last thing.  I was incredibly self-conscious throughout life up to that point in 2001, even needing to enter from the back of the med school auditorium to avoid feeling like everyone was staring at me– what everyone in AA calls ‘being an egomaniac with an inferiority complex’.  I learned through meetings that EVERYONE with addictions felt that exact same way.  After years of watching Community Theater productions from the seats and wishing I had the guts to get up on stage, I used the two years that I was out of work to act in four productions– including two with major solo singing parts (and I had never even been in choir).    Until the play that ended today, I’ve been too busy to participate.  But today I was on the exact same stage where I stood 9 years ago.  Today I reflected on all that has happened since feeling so hopeless back then.  I am grateful that back then I KNEW that I didn’t know anything about how to stay clean.  I am grateful that I somehow stopped listening to myself, and started listening to those who had the clean time that I wanted so desperately for myself.  Had I continued to insist that I knew what I needed, I would not be here today.
I wish you all a very special Holiday season.
JJ