Ah yes…. another post about my book… Over the past few years, I’ve taken posts from this blog, posts from other sources that I’ve written, some sections of a ‘memoir’ that I have not gotten around to writing… and combined them in a book about addiction. The book does not hold together as well as it should, and it is way too long– so instead of a ‘sit and read’ book it is more like a reference, similar to the blog itself. If you like this blog, you’ll like it; I’ve taken the more important posts and cleaned them up and organized them. I’ve added some new material as well, including a section about my own background. If you have a loved one on Suboxone, or have an interest in the medication yourself, you will know as much about the buprenorphine as anyone should you finish this book– particularly about the use of buprenorphine by addicts, the controversy over buprenorphine, the relationship between buprenorphine and methadone, etc. There are some chapters that are dated– i.e. where my opinion has changed or softened over the years. I was much more ‘anti-methadone’ when I wrote most of the book; now I see methadone as something that some people simply need in order to survive. I am not a fan of how some clinics are run– but that is a topic that I don’t get into in this book. Finally, you’ll notice how I have changed over the years; in early posts I would become angry and sarcastic with some writers. In part, that is because I was being attacked on a daily basis by the ‘anti-sub’ movement– which has largely disappeared. But I think I have also aged a bit, and I now tend to pick my battles more carefully. The book (note- this is an e-book) goes for $14.99, and runs around 250 pages– long enough to occupy most of your summer! Proceeds continue to support this blog, and SuboxForum as well. Thank you very much, to those of you who purchase it and check it out. I would be most grateful if you would leave comments about it– for me, and also for others– by writing them in response to this post. At some point I will get a page set up, and tranfer this promo and the comments to that page. The book is called ‘Dying to be Clean’– and can be purchased using the links at the left of this page– or right below this post. NOTE: Because I don’t want it simply passed around freely at this point, you need a code to open it– and it cannot be printed. The code will be included with the download link. Please understand why I take those actions. Thanks again, Jeff J
I’m often asked “hey, what is YOUR story?” That opens the door to a long, drawn out presentation… or I’ll just say “I have a book about the subject ready to go– do you know any publishers?” I DO have a book ready to go, by the way… and I welcome any e-mails from people with ‘industry connections.’ The book is about my story, of course, but is also an attempt to examine ‘addiction’ in a way that provides greater understanding of the condition. A family member of an opiate addict will understand addiction better after reading the book, for example. I also talk about Suboxone quite a bit. In fact, readers of this blog will know how the book goes, as the book is a reflection of this blog. In some chapters I share comments from other addicts, and use my responses to their letters to make a point or two. My goal while writing was to discuss opiate addiction and buprenorphine using what I learned about the mind and brain while getting my PhD in Neuroscience, using insights from my experiences as an opiate addict, and using what I have learned as a doctor and psychiatrist. My perceptions were also influenced by my experiences in residential treatment, aftercare, recovery, working as med director of a treatment center, and my own psychodynamic psychotherapy. This post is a ‘teaser;’ I will share the first part of chapter one here, and you can finish the chapter at SuboxForum, at this link. I hope you like it– and if you know a publisher or book agent, please send me an e-mail– you can go to my private practice site and just send it from there.
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. Local hero Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since. During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks. I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic! To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy. But then I realized that something was fast-approaching in the current. I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight. I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling. I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her. After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!). To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!” I am grateful that I was given the opportunity to be a hero. There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God. Getting serious Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York. After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program. I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school. My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today. Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways. His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after. After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country. Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’. But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family. Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home. At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.
Treating myself In the spring of 1993 I took codeine cough medicine for a cold. A few weeks later I was still taking the codeine each evening. It worked so well; finally I could relax and get some quality sleep! I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word. I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated. I had ALWAYS accomplished what I set out to do! By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed. The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings. I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all! Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said. “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.” I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well? As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine. After trying to find will power and failing over and over, I finally ‘got it’; I had no control! As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day. Continue…
Had to mention that I heard that Steve Tyler went in for rehab for ‘pain pill addiction’ related to falling off a stage or some other injury… Wish I had that ‘falling off the stage’ line when Men’s Health did their story about me!
I keep thinking that wil all the young people dying from overdoses of opiates (Heroin or oxycodone) and all of the ‘fancy people’ who have died or been destroyed by opiate dependence, why hasn’t the issue become a national crisis? I bet that 10 times more young people died of opiate dependence in the past year than died from H1N1 virus, but which one gets all the press? Is it the shame of the victims that keeps it so quiet? I meet often with parents of children who have died from opiate overdose or suicide related to opiate addiction, and their suffering is every bit as great as the suffering faced by parents who lose children in other ways. In fact, they probably suffer more, since they have such mixed feelings about sharing the story with others. They even feel guilty for what happened– no matter how hard they tried to do everything right. My hope is that the use of buprenorphine will allow opiate dependence to become just another chronic, potentially fatal illness. I hope that people realize the obvious– that it is not ‘cured’. That shouldn’t be a big deal, because most other medical illnesses are not cured either. We MANAGE illness. This is not Steve Tyler’s first go-round with opiates– and if he is like most addicts it won’t be his last– unless he goes on Suboxone and finds a way to just keep taking it, and to deal with all of the idiots telling him he isn’t ‘clean’ if he keeps taking it! Mr. Tyler– good luck, dude. I love your music– all the way back to ‘Toys in the Attic’ when I was about 16 years old. I don’t know how you lived so long, but I’m glad you found a way– otherwise we would have missed out on Jamie’s Got a Gun and some other fine tunes. If you are in the decision process over how to go forward, consider taking a chronic medication– buprenorphine– for the chronic illness of opiate dependence. Oh– I also don’t know how such a strange looking dude like you put out such a good-looking daughter… but thanks for that as well! The world can always use another good looking person. Just don’t let her mess up her lips with that nasty collagen nonsense! JJ
Reckitt-Benckiser, the first (but surely not last) manufacturer of orally dissolvable buprenorphine sold under the brand names Suboxone and Subutex, has been aggressively pushing doctors to refer addicts taking buprenorphine into a program called ‘Here to Help’ that they promote as something that will keep patients compliant with buprenorphine maintenance. Regular readers of STZ know that I have not been impressed by Reckitt-Benckiser over the years, and so I’m not going to just jump on the ‘here to help’ bandwagon unless I see value in the program for my patients. I have referred SOME patients to the program, but the feedback I have received has not been positive. Patients have told me that they receive confusing or conflicting information, or that the person on the phone seemed ‘scripted’ and not responsive to the person’s specific needs, or that the information they were given assumed a knowledge level below what the patients already had. Why am I unhappy with R-B, you ask? If you go on the web site of any pharmaceutical company– from the smallest, like Dey Pharmaceuticals, distributor of the MAOI patch called Emsam, to the large companies such as Pfizer– you will find a section with procedures and applications for grant support for unrestricted educational programs, investigator-initiated trials, or other purposes. Little Dey Pharma has released tens of millions of dollars for community educational projects. Pfizer provides hundreds of millions of dollars for similar purposes. But try to find a similar web site for Reckitt-Benckiser (the Suboxone division) — let alone any contact info for grant applications! I have tried for several years to simply get the name of a person to speak to about financial support to expand my efforts, and the result is always the same? I will receive a phone number of a low-level sales manager who tells me ‘he (she) will look into it and get back to me.’ I’m still waiting. I would like to apply for assistance for what I do best– educate addicts about opiate dependence, and educate physicians about how addicts feel about treatment and about what their doctors are missing. I would also like to create a program to address the internalized shame that most addicts on buprenorphine continue to struggle with, no matter how long they are away from active using. I won’t go into specifics here, but there are so many things that could be done—that SHOULD be done. I know some of the things the company spends money on; I resent that they do not see the value in my efforts. And I am annoyed that they don’t even have an application process that would allow them to at least pretend that they are interested! There are so many ways to become involved with buprenorphine; there are organizations like SAMHSA and CSAT and others that provide education and research into the use of buprenorphine. I was a ‘mentor’ for physicians with new buprenorphine practices for a short time and I have considered becoming active in SAMHSA or the other agencies. But if find those types of organizations to be inefficient compared to what I can do speaking to addicts directly, through the blog or forum. I also know where my strengths lie, and where they don’t. I do not do well as a ‘consensus builder’, for example—such people must be careful about what they say, whereas I tend to say what I am thinking. If a meeting is running long because someone is repeating how much he/she wants to do the right thing for all of these poor addicts, I am the person who will stand up and say ‘y’know, that is a given—and this is all a massive waste of time.’ And then for some reason I won’t get invited back again! Those meetings are not for me. My favorite recovery ‘saying’ is ‘a good man knows his limitations’—and that is one of my limitations. My strength comes from the fact that I understand how opiate addicts feel, and how they think. I always seem to know what an opiate addict is going to say next. On the other hand, I never have any idea what a government bureaucrat is going to say, or what I should say when speaking to one! I suspect that R-B would like me to get on board the Here to Help message. But I have reservations about the program. I suspect, for example, that it is primarily being supported by R-B in the hopes of somehow using it to maintain their ‘brand’ over buprenorphine. If that is their intention, good luck to them– it is going to need some awesome content to keep people buying Suboxone for $8 when generic Subutex is selling for $2.55 at Walgreens! Today I received a brochure describing the results of a ‘study’ that claims that patients in the ‘Here to Help’ program had improved compliance as measured by maintaining appropriate use of prescribed buprenorphine. As some of you may know I got my PhD in Neurochemistry doing basic science research and I have served as a Peer Reviewer for Academic Psychiatry for a number of years, so I know how to evaluate whether a study is ‘sound’ or is instead misleading. Even in the material that I received today, R-B refers to the findings as coming from a ‘quasi-study design’—so they at least apparently recognize that the findings are biased. I participated in the data collection for the study, actually; those of us who participated would invite new patients to participate, and the patients who accepted the invitations would then be randomized so that one group would get the ‘here to help’ info and the other group would not. R-B found that the here to help group had better compliance and fewer drop-outs than the other group. One problem I have is that I don’t know what they did for the ‘non-study’ group. For example if they told the non-here to help group ‘Suboxone will kill you if you keep taking it’, then the difference in compliance would be meaningless! I’m sure they didn’t say that, but what DID they say? Second, there was no way to ‘blind’ the study on either side—both the addict and the phone person knew which group the study person was in. We like studies to be ‘double-blind’, and this one was not even single-blind. Finally, participation in the study was voluntary, and we don’t know anything about the factors that caused some people to enroll and others to avoid enrolling. Let me explain how that bias could have affected the results. Patients were paid to participate in the study, so I would guess that the addicts who were unemployed were more likely to participate. Likewise, the addicts who were, say, executives from a high-profile company or physicians or attorneys would be less likely to participate, as they would be more concerned about disclosure of their status as addicts. So at best, the ‘here to help’ study looked at a specific subset of addicts—those who were interested in making $100 by talking on the phone for a half hour. Would the here to help program be of any value for a person who is still working, making good money, who has not suffered many consequences yet? We don’t know. So… I am interested in your feedback. Have any of you used the ‘Here to Help’ program? If so, what do you think about it? If you have NOT used it, why not? Did your doc tell you about it? Leave your answers in the comments section—you do NOT have to leave a real name, and I will not use your e-mail for anything (it does not get displayed in your comment either). Your comment won’t show up immediately; for spam purposes I will approve the messages as I receive them. But here is your chance to let RB how you feel about that program—or about anything else, for that matter. Will you use the generic, or stick with the brand? Why or why not? Leave your comments and I will be sure to send them at least as far up the chain as I can reach! Finally, I continue to ask for your support. I note that our forum is over 1500 registered members strong and growing; the older forum supported by R-B has about 200 registered members. You must know that your presence just warms my heart! If you have some money to spare and want to join me in my efforts (a pipe-dream of mine!), let me know and we will truly do some good things out there. Lest anyone thinks I’m getting rich from this, I have received 3 donations of $50 over the past few years, and a few of $5-$10. That’s it. And that’s fine—I just don’t want y’all to think I’m cleaning up with this blog. Maybe I should start posting each donation—leave a comment if you have an opinion on that as well! If I help you out or if you care to support my typing away on the blog, or help with the self-publishing of my eventual ‘big book,’ a small financial donation is always greatly appreciated. The main thing you can do to support me is to spread the word. Send my links to anyone you know who takes buprenorphine– links for the blog, and for the forum too. Better yet, print out the link and give it to your doctor and tell him that you like it (if you do!). Got all that? I suppose I could have just typed ‘what do you all think about the here to help program’ and gone to bed an hour ago! As always, thanks for reading. And I wish you all the best at keeping the scourge at bay. JJ
There are so many people who feel like the person who wrote to me today. I remember that feeling so clearly– that there was no solution– but now I see that there is another life, and that some people will find it. And tragically, some won’t. There are many different levels of ‘insight’– it isn’t the case that I now ‘have it’ and before I didn’t have it. I will always have blind spots– some large, some small; some short-term, and others that will last a lifetime and that I hope won’t trip me up again. I will do my best to share the insight that I have gained with the person who wrote to me– today, and going forward. I don’t know if I will be able to help or not. Dr Junig; It is XX am on Sunday, November 29th, 2009. I am supposed to be at a XXXXX party for XXXX. I am frozen with fear, I have nothing to say, and I have been drinking my wine to numb the fear. I so wanted to be the one to break this alcoholism….but find myself as I am aging, becoming my Mother! Please, if you can, tell me how to get control of my fears and the drinking to numb the fears. Thank you, in advance, for any help you may have for me. Sincerely; XXXX My reply: XXXXX, The first step is to realize that the drinking is not ‘medicine’ for anxiety or help for your fears, but rather that alcoholism is a progressive, predictable disease that makes everyone feel the same way. The standard pattern is for the alcoholic, or addict, to shift from one state of personality to another, back and forth– one believing that the problem is not that significant and that it can be ‘fixed’ on one’s own with a little bit more will power, and the second feeling horribly shameful, alone, and hopeless. The problem that I face as a psychiatrist is that a person will call when at that low state of mind, finally realizing that he/she needs help and will do anything to be free from the misery. But the next morning, the other personality wakes up and convinces herself that everything is fine—decides to throw all the pills or booze down the drain and do the ‘right thing’ next time. The truth is that both personalities are wrong. The trick comes in recognizing that your insight will only keep changing back and forth, back and forth, until you do something to change the pattern. The progression of addiction causes the person to feel worse and worse until finally getting to a ‘rock bottom’ where there is NO way to kid yourself anymore. We need to get you to that ‘rock bottom’ sooner if we can, so that you can stop the torture. The challenge for you is to remember how you are feeling now, or when you wrote this message—and keep THAT memory alive for days, weeks, a lifetime. I can help you with that, but only if you can manage your part- which is to drop the insistence on seeing it how you have always seen it. I need you to see the alcohol as the PRIMARY problem—not a consequence of something else, like fear. You also will need to understand that some medications, especially the Valium/Xanax/Klonopin medications, do the same thing as alcohol. When we first met I suspected this was going on; I am, after all, in recovery, and I have had the exact same feelings that you are having now. I still remember when and where the ‘realization’ came to me that I was seeing things wrong, and that I needed to open my mind to the thought that everything I was thinking needed to be dropped and replaced by a new way of thinking. The change after that moment was remarkable; I realized that I needed to do drastic things in order to live, and so when I was told I needed to go to an AA meeting, I simply went—there was nothing to argue about and nothing else to say. If you can get yourself to THAT point, Deborah, we can do wonders to improve your life. But even if you are not completely there, consider coming in to discuss the situation. There IS a better life out there—I promise. But you can’t find it by doing the same things just a little differently; if that were the case, you would have found it by now! Consider dropping EVERYTHING and letting go. Come in soon if you can. Take care XXXX, Jeff J