I might as well keep this run of posts going with an e-mail exchange from earlier today. As usual, minor aspects of the message were changed to protect anonymity.
I am interested in setting up a tele-psychiatry appointment with you.
My boyfriend is a heroin addict who has been on Suboxone for approximately four years. He started at 12 mg and tapered down to 2 mg over a six month period. He recently went through a detox program and has completely stopped Suboxone — except that he relapsed recently with a small amount of Suboxone.
I feel like I need to get smarter about supporting his fight to stop opiates. I purchased one of your tapes where you say that willpower has nothing to do with quitting opiates. I know that this is a recurring theme in combating drug abuse, but I have to admit that I don’t completely understand it. I think that if I did, I could be more effective in helping him.
Is this a focused topic that a 30-minute session can effectively address? What course of action do you recommend?
There might be some things that I could help you understand, but to be absolutely frank, I usually recommend that people separate from addicts until they are clean for a year. The reason I recommend that is because people generally need to get to a point of utter desperation before ‘recovery’ takes hold… and any relationship tends to be ‘enabling’, even when the person tries not to enable the addict. By enabling I’m referring to paying bills (making money and also just the physical act of paying them), making meals, washing the clothes, keeping the house in order… all of those things eventually fall apart with active addiction, and the chaos that ensues is part of what gets the person better. Of course, nobody wants to see a loved one go through such chaos… and the risk of death is great, as the addiction gets to the ‘chaos’ point. The risk of death occurring before the development of a ‘rock bottom moment’ is what has made me a fan of long-term buprenorphine; the alternatives are just too dangerous.
My thoughts about will power come from my experiences with 12-step programs. I had a ‘spiritual awakening’ in 1993 that instantly removed my desire to use, and ever since I have tried to look at the steps as a scientist. I have tried to determine which elements are necessary for recovery, and why they have their effects– in some situations, and in some people. The best way I can put it is that EVERYONE has multiple points of view on issues, shifting from one stance to another stance depending on external circumstance and internal emotional states. Addicts always have some degree of ambivalence about using; even an addict in recovery for ten years has some part of himself who would like to use. I refer to that part as the ‘addict inside.’ The addict inside has no interest in sobriety, and the addict inside grows in the presence of certain cues, memories, emotions, etc. No matter how much self-control or will power your boyfriend has, the addict inside has NO will power– and has no interest at all in self control. Addicts who focus on will power miss the point that the addict in them is not on board with the ‘will power thing.’ The 12 steps, on the other hand, acknowledge the absence of will power with the very first step, and in my own case that acknowledgement removed any desire to use (the problem though is KEEPING that belief in a lack of power. In my own case, relapse came at a time when I was very confident in my ability to avoid relapse!)
Why does ‘powerlessness’ work? I can’t say that this is the case in everyone, but in my case, powerlessness is something that translates well among ALL of my ‘addicts inside’ and other personality stances. I believe that is the case because of FEAR, the emotion that is triggered by powerlessness (at least fear SHOULD be associated with powerlessness!). Fear cuts through the cocky BS of the addict inside, and when the fear is recognized, it motivates behavior that protects the individual– including avoiding using. I see relapses occur most often during times of self confidence, when the addict ignores the fear about using. I think that is why some people in late stages of addiction will go through one short period of abstinence after another. While the symptoms of withdrawal are present the addict remembers how horrible things are, and is motivated to remain clean. But when withdrawal finally ends and the person starts feeling good again, the addict inside takes over, believing that things were not all THAT bad, and there is nothing to be afraid of in taking just a hit or two. Then the misery and fear come back, motivating the addict to get clean for awhile. I was stuck in this type of behavior for several months, and it was horrible– sick pretty much all of the time, and completely demoralizing from breaking promises to myself and others over and over. Yuck.
If he is committed to making a go of it without buprenorphine, he will need a strong recovery program. By ‘strong’ what I mean is that he cannot just be educated about recovery; he must LIVE recovery, GET recovery, and actually CHANGE. And that is very difficult to do, particularly if a person is not desperate. There is a great like in one of the AA books that I have quoted many times– to paraphrase, recovery only works when a person clings to the recovery program like a drowning man seizes a life preserver. My own words now: if the addict is trying life jackets on– discarding the life jackets that are a little too loose or too snug or the wrong color or too cold or too warm or too frayed or too preppie– then the addict will not likely find meaningful recovery.
I have a patient who gives me too much credit for her own work toward recovery, but she tells me that when she was in treatment she kept thinking of my words over and over. Unfortunately I can’t remember what they were right now! But it was something like ‘Surrender. Give up. Let go. You know nothing– ask for help.’
I hope this helps; you are welcome to call the office and set up more time if you have other questions. The ‘anon’ programs all have much to offer, and I strongly recommend seeking them out if you continue with your boyfriend. I would ask him the question, are you ready to commit to a recovery program? If not, you may not be ready to stop buprenorphine.