Clean Enough, chapter 2.1 and 2.2: My Story

Chapter 2:  My Story
Nature vs. nurture
I grew up in a small town in Wisconsin, the son of a defense attorney and a teacher. I was the second of four children. I will not get into a drawn out psychodynamic exploration of my upbringing at this time except to note that I firmly believe that the way I ultimately turned out is a result of a combination of genetic, developmental, environmental, and personality factors. There were probably elements of my early life and also genetic factors that predisposed me to become an addict, but I believe that each person can point to similar predispositions. I am the one responsible for how I used the gifts and liabilities that shaped my life.
The nerd
I was a very cheerful young child, but at some point I began to struggle with social interactions. By the time I was in high school I was clueless about fitting in. The things that seemed impossible back then look easy now; why didn’t I simply look at what other kids were wearing and imitate them? That idea never entered my mind, and I cringe when I see pictures of myself at that age. Why did I think any boy should enter a school with embroidered blue jeans?!  I did well with the academic aspects of school, always scoring at or near the top of my class with little effort. There was little respect for academic achievement in my rural high school, and I blamed my academic performance for at least some of the harassment directed my way. By the time I was a sophomore I was literally afraid for my own safety on a daily basis. I had several incidents where I was facing bullies, my back against a wall. I was deeply ashamed when the bullying occurred in public, and I certainly didn’t want my parents to know that it was happening. I was physically beat up on two occasions, both times accepting the blows with no effort to fight back or defend myself. The clear message from my father was that real men do not run away from a fight, and so running was not an option. But I didn’t know how to fight back, and was afraid that if I tried I would only be hurt worse, so the outcome of my ‘don’t run’ strategy was not great!
I ‘tried on’ different personalities during my last two years of high school. I became a druggie, growing my hair long and replacing the smile on my face with a look of apathy or disgust. I sported an Afro and used a pick instead of a comb. I smoked pot and drank beer when not in school. The changes worked as intended, and the harassment from other students stopped. But I was still on the ‘outside looking in’.  Some people who lack social skills seem to come to terms with their unpopular position and quit trying.  That wasn’t me; I continued to try to be one of the popular kids, kissing up, tagging along, and laughing at the stupid comments of ‘jocks’… Yuck!  During my senior year I joined the cross-country and track teams, and in retrospect I was fitting in at the time without even realizing it.  But by my high school graduation in 1978, the year when marijuana use peaked in the United States, I was a daily pot smoker with a great GPA, little confidence, and no direction in life.
I attended the same liberal arts college that my older brother was attending mainly because that was easier than finding a college that I liked more.  I took the courses that were the most interesting and ended up majoring in biology.  College came very easy to me because I had a genuine interest in what I was learning.  Everything I learned seemed to answer a question that I always wondered about. That is, by the way, is a great way to attend college!
I was in a couple of relationships in college that in retrospect had addictive traits to them. After a difficult breakup during my sophomore year I became very depressed, and afterward spent several months engaged in the heaviest drug use of my life. My fraternity house provided ready access to pot, opium, cocaine, Quaaludes, marijuana, LSD, and hallucinogenic mushrooms.  I wonder if I carried so much anger under the surface that I had a ‘death wish’; I have hazy memories of walking on a ledge seven stories up, losing control of a motorcycle and ending up in someone’s front yard without wearing a helmet, and wandering around in tunnels under the streets of Milwaukee after climbing down a manhole.  I was lucky to survive those experiences, and I now try to understand similar behavior—extreme risk-taking and impulsivity—in addicts who are patients of my practice.

Clean Enough, Chapter 1.3: Bias of the book

Introduction
Bias of the book
You will notice the several times throughout the book I take issue with people over what they say about buprenorphine treatment of opiate dependence.  On my web sites I have been told by those who favor ‘total sobriety’ that I am biased in favor of Suboxone.  I don’t know how to best respond to those characterizations.  I have reviewed the studies related to buprenorphine and Suboxone and become sufficiently educated to understand and critically evaluate those studies.  I have experienced opiate dependence for 17 years and experienced treatment failures and treatment successes.  I have experienced relapse and watched friends relapse and in some cases die from addiction.  I have worked for years with addicts in solo practice, in the Veterans Administration setting, in prisons for men and for women, and in residential treatments that do not use Suboxone at all.  After all of these experiences, I have strong opinions over which treatment methods are more effective than others.  Does favoring the more effective method make me ‘biased’?
But my problem with the ‘bias’ accusation is more complicated than choosing winners and losers.  The people who speak of ‘bias’ usually present a choice between Suboxone and ‘being free of drugs’.  We know, and they should know, that being free of drugs is not a real choice. People who are addicted to opiates and who want to stop have always required intensive residential treatment for a period of 90 days or more.  Even with that intensity of treatment, one-year sobriety rates hover around 50%– much lower for 5 years of sobriety.  But opiate addicts who have not yet experienced treatment are living in a fantasyland where the second choice is to just go back to the person they were before their addiction.  If only!!  If the person considering ‘bias’ were to live in the real world, the choices faced by opiate addicts would be Suboxone, 90 days of residential treatment, jails, institutions, or death.  Forced to deal with the truth of the matter, many people would appear ‘biased’ in favor of Suboxone.
The reason addicts adopt a distorted set of choices is because of ‘denial’, the process where the mind refuses to see the horrible reality of a situation, perhaps to protect the mental state of the person carrying that particular mind around.  The result is a bit of insanity that compares active addicts to people drowning in the middle of the ocean.   Floating in the water around them are life jackets– the life jackets representing Suboxone.  The life jackets would hold the people afloat, but they smell bad and look funny.  Plus, there are several people treading water yelling ‘if you put on a life jacket, you aren’t really swimming on your own!!’   So while some people put on the smelly life jackets and live, another group insists on swimming for shore, 1000 miles away, confident that they will make it.  Some people are safely floating in a life jacket, but are made to feel weak and guilty by the swimmers… so they remove them and join the swimmers, setting off on the 1000-mile swim for shore.  In the end, one or two of the swimmers caught a good current and somehow made it to shore alive, but the vast majority of them drowning later that day, a couple miles from the empty life jackets that could have saved them.   I am strongly in favor of life, and of life jackets. 
I receive e-mails asserting that people are better off when they are completely free of narcotic substances.  On that point I completely agree—unless the people have a chronic illness that demands treatment.  When I am feeling sarcastic I will say that an addict living free of substances is a great thing… and so is ‘world peace’!  Heck, I would prefer if a person taking ten medications for heart disease was free of all heart medications and was ‘normal”!  But many people would not survive without their medications.  If one of my patients wants to go off Suboxone, I will share my honest opinion of the person’s odds, and then help him do what he wants to do.  I will point out the risk of relapse, and hold a spot open for some time in case active addiction returns.  One nice thing about Suboxone is that is does allow a ‘trial of sobriety.’  In the days before Suboxone, relapse meant months or years of misery.  But now a person can try sober recovery, and if active use returns he can high-tail it back to the safety of Suboxone.
I hope that you find the information in this book valuable to your understanding of addiction, and helpful in your search for answers for you and your loved ones.

Sharing My Story

Introduction:  2. Sharing my story
The book begins with a description of my own descent to active opioid addiction, my climb back to sobriety, and my efforts to remain sober.  It is important that I share my own story of addiction and recovery for several reasons. First, all addicts have some amount of internalized shame from addiction-related behavior. It is difficult for an addict to read a discussion about addiction without at some point feeling that the comments blame the addict for his bad behavior. This is especially the case if the discussion includes the type of dialogue that the addict must hear if he is to recover; i.e. comments that imply some degree of responsibility and accountability on the part of the addict.  By sharing my story I want addicts to know that I am one of them and that I have done what they have done, including many shameful behaviors wrought by desperation during my active addiction.
A distinction must be made in order for addicts to benefit from this text.  The distinction is between assigning accountability for the sake of making a person feel bad, versus attempting to instill the accountability and ownership of behavior vital to the addict’s recovery.  While there is no value in the former, the value of the latter is to deflate the grandiose ego of the actively using addict, and to help the recovering addict recognize and process repressed shame.  There is another important distinction that will help the reader understand the points made in this book:  the distinction between the cocky false ego of the using addict, vs. the true ego of the individual.  The true ego may be buried deeply within a person; so deeply that it seems to not exist. But except perhaps in sociopaths, a true ego lies inside each person, and it is that sense of ‘me’ and that ‘truthful reality’ that allows recovery to grow in treatment, and that I am trying to reach now. The true ego of the using addict, despite the false external cockiness, is fragile and insecure.  It is difficult for the insecure, using addict to lower his defenses and allow his true self to communicate with the outside world.  Hopefully the addict reading this text will have some recognition of what I am referring to.  If you are an addict, I hope you are tempted to lower your defenses and drop your cocky front, and open your mind to my comments.  I urge you to pay attention and to trust my comments on a deeper level.
All this talk about the ‘real person’ gets to the second reason I am sharing my story. Beyond the shameful behavior caused by our addictions, addicts have a number of common character defects related to addiction, including some present before our using and others that were caused by our using.  I want the addict reading this text to know, as I write about character defects, that I share the same character defects. If you understand my point about the two sides of personality or consciousness, the ‘real’ side vs. the ‘cocky front’, I urge you to let go of the fear that could prevent you from taking in what you need to hear from this book.  I have been there.  I know that confusion you sometimes feel over the nature of the ‘real me’. I understand feeling that ‘nobody understands me,’ and the thought that ‘therefore I can’t trust anyone to help me.’  I know the fear that ‘if I start to accept that I have a significant problem, there will be no end to the horrible reality and no end to all that I will have to own up to.’  If my comments cause anxiety, I urge you to drop your fear and allow the messages in this book into your conscious awareness, so that you can discover a way to move forward.
The third reason I am sharing my story is because in 12-step programs, sharing our stories is the tradition of first step meetings that welcome newcomers.  Since many readers of this book are newcomers to understanding addiction and Recovery, sharing my story is the most appropriate way to start.
After my story, I share the stories and comments of addicts who have written to me.  In all cases the information has been changed only enough to disguise the identity of the writer.  Sharing the stories is intended to keep the information true, and relevant to practical applications of buprenorphine.  The stories will help the reader learn to identify patterns of addictive thinking that are common to all opiate addicts, as the patterns are repeated in the stories of one addict after another.

The book

I’ve been writing teasers for a book about buprenorphine for a couple years now.  I keep very busy trying to maintain a solo psychiatry practice, and for awhile there I was running constantly… keepiing the practice going by day and writing nonstop at night.  I’m not sure what possessed me at the time;  I know that I tend to focus more on what I have NOT done than the things I HAVE gotten done, and I really wanted to write a book.  I still do.  But after submitting the product to a number of publishers, I have learned that there is a wide range of publishing arrangements that people work out.  A number of publishers, for example, require ‘new writers’ to make an investment in their own book before the publishers will invest money of their own;  the starting ‘investment’ by the author comes to $3000 to $5000, money that I cannot afford to spend at this point.
I’m realizing, by the way, that I have become pretty open about a number of things on this blog.  I have received a number of nice comments from people ‘out there’ over the years, and I feel like I know the people who are reading.  If you are a newcomer and the situation is freaking you out, I’m sorry.  It freaks me out sometimes too!
Since I have a book that needs a place to go, and a blog that needs material, I might as well share what I have written here– bit by bit.  I invite you to read along, and if you like the story, consider purchasing it in one big hunk at some point in the future when I get my act together!  I will be posting bite-size pieces; maybe one to three pages in length.  The title of the book is ‘Dying to be clean.’  The first chapter is entitled, appropriately enough, ‘Introduction;’ subheadings will be numbered to help keep things in the proper order. Please ask for permission before copying whatever I put here… thanks!
Introduction
1. Why write about buprenorphine?
Three years ago I applied for the DEA waiver to treat opioid dependence using Suboxone.  I knew that the small town in Wisconsin where I live with my family had an ‘opiate problem,’ but I had no idea the extent of the problem, nor how Suboxone treatment would affect my approach to treating addiction in general.  As the medical director of a residential treatment center I believed that residential treatment was necessary when dealing with opioid dependence, and that any maintenance agent would result in a condition akin to a ‘dry drunk’ where the person may not be using, but is miserable about being clean and sober.  The AA joke about a ‘dry drunk’ is that he isn’t drinking—but everybody wishes he was!
But that is not what happened. Instead, when spouses came in with patients during follow-up visits the typical comments were ‘I got my husband back’ or ‘she is the woman I used to know’.  From the addict him/herself I would hear, ‘I feel normal for the first time in my life’.   Patients on Suboxone were nothing like the ‘dry drunks’ that I had come in contact with over the years of attending AA and NA.  Instead of seeing addicts who were clean but miserable, I saw people who were excited to be free of active addiction and who were ready to get back to a happy and productive life.  It seemed that as Suboxone made the obsession to use fade away, the addict’s pre-using habits and interests returned, filling the void that the addiction left behind.
I enjoyed treating opioid dependence with Suboxone. I was reminded of my anesthesia days and the gratefulness of the women after I placed their labor epidurals.  Psychiatry is not a specialty that engenders that kind of gratitude! During my own active opiate addiction I desperately tried to stop using over and over again, only to fail every time.  By the end of my using days I was depressed and demoralized.  I had broken so many promises—to others and to myself.  I stared at my kids’ pictures so many times, thinking surely my love for them would keep me straight, and when it didn’t I felt horrible for letting them down again.  At the time I believed, like most opioid addicts, that there was no way out.  Treatment would mean coming clean about what I was doing—which would destroy my career, and perhaps even take away my freedom.  I now understand that since addiction is as fatal as any cancer, treatment simply must occur, regardless of the consequences—because otherwise there is no life at all.  But to the actively using addict the shame alone appears insurmountable, let alone the career issues.  In result, opioid addicts do not receive treatment unless they are forced to get it.  And for most addicts that occurs only after they have lost almost everything, if it ever occurs at all.
Suboxone changes the dynamics of treatment in a dramatic way.  With Suboxone (or more specifically with buprenorphine, the active ingredient in Suboxone) the typical opioid addict can force his disease into remission over the course of one afternoon!  In a treatment called ‘rapid opioid detox’ the using addict is anesthetized for an entire day and naloxone is injected to precipitate withdrawal.  24 hours later the addict is still shaking as he stumbles toward his ride back home to complete the rest of his detox.  That seriously-flawed detox strategy was the closest to a ‘free ride’ off opioids available ten years ago. Now Suboxone avoids detox almost entirely; the addict leaves the doctor’s office after Suboxone induction and can often return directly to work!  Make no mistake—Suboxone treatment is a ‘remission’ or ‘maintenance’ agent—NOT a cure.  But in many ways traditional, step-based recovery is ‘maintenance treatment’ as well.  Any addict in recovery will tell you that if an addict quits attending meetings, relapse is not far away.  Opioid dependence is a chronic condition that requires chronic treatment, whether that treatment is medication-based or program-based.  And many addicts find medication easier to accept than the dramatic personality changes often required for step programs to induce and maintain sobriety.
And yet the more I worked with Suboxone, the more I became aware of another opinion about Suboxone—an opinion that is much less gracious.  I discovered the ‘Suboxone-haters’; people who gather on internet discussion boards to bash Suboxone and to put down those who use buprenorphine to maintain sobriety.   “It’s just swapping one drug for another!” they say, ignoring the dramatic and positive changes in mood, behavior, and relationships in people who use buprenorphine for treatment of their addiction.  “You’re not really clean!” they say, ignoring their own relapses that occur on a monthly basis.  “It is all a scam by those greedy doctors!” they say, ignoring the fact that few doctors want to prescribe the medication, and that many doctors stop prescribing it after finding that the reimbursement is not worth the work of dealing with such a difficult and frustrating illness.
There is a great deal of misinformation about Suboxone on the internet and in the community, and the misinformation is what fuels the negative attitudes toward buprenorphine.  The shameful result is that young people are dying in my home town and others, at the same time that there is an under-used medication that could have saved them!  Out of a desire to counter the misinformation about Suboxone, I set up an online blog called ‘Suboxone Talk Zone’ where more and more people write to me with comments and questions about Suboxone.
This book is a collection of those questions and comments from the past few years.  These comments from addicts across America capture their desperation from years of active addiction, and show their excitement at the prospect of freedom from the obsession to use.  They show the frustration of addicts struggling to find appropriate and effective treatment.   The comments show the anger of addicts who face retribution in one form or another, first because of their addiction, and then again because of their choice of treatment.  All together, the posts will give the reader an understanding of the process of addiction, the treatment options that are currently available for opioid dependence, and the factors that should—or shouldn’t– influence one’s decision whether or not to use Suboxone for treatment of opioid dependence.