I received the following email last week. I considered trimming it down, but the story is well-written and describes a history that is similar to that of many of my patients. As usual, I will write a follow-up post in a week or so.
Dear Dr. J,
I have read many of your posts over the past few years. Like many, I started out disagreeing with your comments and insight, while blaming my inability to manage my addiction on the Suboxone treatment. My active addiction to opiate pain medications was brief, about 4 months of hydrocodone/oxycodone use in the end of 2007. In early, 2008), I reached out to my primary care physician who directed me to an inpatient stabilization followed by Suboxone maintenance/addiction therapy. When I entered treatment I maintained the belief that I was not an addict, and my doctor initially supported this attitude. He described my situation as physical dependence stemming from treatment of pain. I was a recent college graduate, I had a wonderful upbringing, a bright future…I believed that “people like me don’t become drug addicts.” So of course I wanted to minimize the seriousness of my illness. I convinced myself that this physical dependence “happened to me,” and I was doing what needed to be done to resolve the issue. So I saw my doctor monthly and went to weekly addiction therapy sessions. I did not use “street drugs,” or any other RX meds, so my UAs were always clear, and eventually I was seeing the doctor for a refill every few months.
At the same time, I was dealing with the onset of some anxiety and panic issues, which I also used to rationalize my initial abuse of the opiates. As college came to an end I began to get very anxious about the future and panic in certain situations. When I was prescribed the Vicodin and Percocet for a knee injury, it was like finding the key that turned off all these negative feelings/physical sensations. My beliefs regarding success and failure fueled my anxiety, and allowed me to rationalize abusing the opiates as self-medication. When I began taking the pain medications I had no understanding of addiction or opioid dependence, and I honestly thought “this is an RX medication, I am prescribed it for pain, it also helps with this anxiety issue, so taking a few extra is fine.” So, as I said, it was very easy to go along with this idea that I was somehow different than all the other addicts.(“terminal uniqueness,” one of my NA friends taught me that term, I have always loved it.)
My starting dose of Suboxone was 16mgs/daily. Between January and August 2008, I tapered down to about 1 mg/daily. However, in July I experienced a major panic attack and was prescribed clonazepam for my anxiety/panic. In August, I discontinued my Suboxone and was prescribed Bentyl, Tigan, and Clonidine for acute WD symptoms. The withdrawal was really not bad. It lasted about a week; the worst of it was my anxiety, stomach, and exhaustion, which continued beyond the week. I tried to push on through it, however, it was as though I had traveled back in time to the day I had gone into treatment.
The reality was that I had done nothing during those 8 months to understand or manage my addiction or anxiety (beyond medication). At the time, of course, I didn’t understand this– and was immediately looking to place blame with the Suboxone. “Why the hell did I take the drug if I was going to end out feeling the way I did right when I started…I wasted 8 months delaying this inevitable hell”…the usual retorts from an addict in denial. I tried a number of different SSRIs/SNRIs, as well as amphetamines, to help with my exhaustion and focus. Nothing helped; I lost 35 lbs. by late November 2008.
From the very first follow up after stopping the Suboxone, my doctor suggested starting again. I had never relapsed during my treatment with Suboxone, and I had not used since stopping, so starting Suboxone did not make sense to me at the time. However, I knew that it would make my discomfort go away, and decided to start the Suboxone again in early December 2008. We determined that my decrease from 8 mg to 1 mg over two weeks prior to discontinuing was too fast. I still wasn’t willing to deal with the reality of my anxiety and addiction, and continued to minimize.
I went back on the Suboxone. Over the next year, I stayed on the Suboxone consistently, and just focused on living life. I did not do any NA/AA, addiction therapy, etc. In early 2010, I began relapsing. I would run out of my prescription early and substitute with other pain medication. Still rationalizing that the Suboxone was a pain, and I was just doing what was needed to make it work. It was during this period that my addiction became fully active, and the use became less about self-medicating and more about the feeling/escape.
In late 2010, I checked into a treatment center to detox from all opioid medications. Again, the immediate WD symptoms were very mild and the isolation of the center helped with my anxiety. I was able to isolate and almost hide from the anxiety by being in the center and cut off from the world. I left the center 4 days later, prescribed Gabapentin and clonazepam for anxiety. The day I left, I relapsed on the ride home from the center.
It is amazing, but it still had not clicked for me. The anxiety was in the forefront, and I still thought that the addiction was a symptom or result of those issues. Needless to say, I ended up sleeping all day, exhausted, depressed, with the same stomach issues. I was finishing up business school, and trudging through. I would rationalize taking the pain medications again on days when I had school. And I walked down the same road again. The entire time I cursed Suboxone as the cause of all my issues. “If only I would have gone cold turkey from the pain killers back in 2008….I wasn’t an addict until I was prescribed Suboxone”…again the usual BS.
As you can probably guess I hit the wall again, and ended out back in treatment. However, this time something clicked in me, and I was fortunate to have a team of caretakers who could see through my BS. I realized that I had crossed so many lines that I thought I never would, and could not control myself. Instead of just doing a short-term stabilization, I spent 3 weeks in intensive out-patient treatment following my inpatient stay. I was stabilized back on Suboxone, and then for 3 weeks, 8 hours a day, I was focused on my addiction, and the team at the center was not letting me [email protected]@ anything. I started that program in mid June 2011. I learned about my addiction, and got honest with myself, my family, and my friends (I had hidden my addiction and treatment from everyone in my life except for my mother and father up until last summer).
I was humbled in a major way, and finally got real with myself. I had always thought that saying “I have an addiction” was a cop out. Coming to terms with my lack of control was and continues to be very hard. I feel a great deal of guilt and disappointment towards myself. And there is part of me that still wants to believe that I can control all of this and with enough will-power fix all my issues. Ironically, in a way, I am striving to maintain control and fix these issues every day, as I stay clean and focused on my sobriety. I was always afraid of being defined by my addiction. However, when I got honest, I realized that the more I tried to ignore reality, the more my addiction consumed my life.
Ultimately, I wanted to write this email as a thank you to you and share my story with those who visit your site. It took me 5 years, 3 times off and back on Suboxone, and 2 stays in treatment to realize that I am an addict. In hindsight, I think much of my downfall was classic addict behavior; placing blame, terminal uniqueness, etc. I expected Suboxone to resolve all my issues, without doing any actual work.
Looking back on all of my experiences, I thought this is where I would end out. However, working through my addiction has helped my anxiety immensely. And I am beginning to feel it is time to appropriately taper and discontinue my Suboxone. With all the support I have now, and the skills I have gained I feel very optimistic (cautiously).
Dr. Junig – I would be interested in your advice regarding tapering or insight on my story in general.
Thank you to the writer; I’ll be adding my thoughts soon!
Tag: relapse
Jerk Counselor
Every now and then I hear about a therapist or addiction doc who is doing such a disservice to the practice of addiction medicine as to deserve special mention. This week’s award goes to a certain counselor at a treatment program in Oshkosh, WI, who I’ll refer to as ‘This Jerk.’
I’ve made no secret, over the years, about my hope for addiction to eventually be treated with the same respect for patients and attention to medical principles as for any other illness. I certainly try my best to work according to those ideas, and find that doing so really helps when it comes to making treatment-based decisions. In other words, I’ll ask myself—if this person had diabetes, what would an endocrinologist do? Or better yet—if I had diabetes, what would I want MY endocrinologist to do?
We all know that certain professions attract certain types of people. Some of us have been pulled over by the cop who was the kid subject to playground taunts, now all grown up, determined to make life a living Hell for anyone with a loose seat-belt. When I worked in the state prison system, I worked with guards who belonged in the same category; men and women who loved to carry keys to cages that held real people. It’s the power trip, I suppose.
This Jerk apparently loves the power trip of ‘treating’ people who are sent back to jail for ‘failing’ his treatment. He doesn’t have to worry about being a lousy therapist; he has a captive audience, and likes it that way. One difficult aspect of being a therapist is treating patients who don’t like us for one reason or another, or who don’t kneel every time we enter the room. But when This Jerk feels disrespected, he picks up the telephone and calls the patient’s PO to report ‘noncompliance with treatment’– then gloats about sending the patient to jail.
Treatment professionals who are in a position of unusual power over a patient must be particularly careful to empathize with their patient’s position. In medical school, we were placed on gurneys and wheeled around by fellow students, to emphasize the vantage of patients coming to the emergency room. We were taught to sit at the same or lower eye-level of our patients, as speaking down to people creates an unsettling power differential.
The power to prescribe or withhold buprenorphine (let alone the power to send to prison!) comes with an obligation not to abuse that power. Withholding buprenorphine causes patients to go into withdrawal—something dreadful to people addicted to opioids. Worse, withholding buprenorphine places patients at very high risk of relapse—which in turn places them directly in harm’s way from overdose and legal repercussions.
This Jerk, I’ve been told, takes issue with psychiatrists who continue to treat patients on buprenorphine who struggle with sobriety. He considers it ‘good care’ to withhold buprenorphine from an addict who uses, supposedly to punish the patient into sobriety.
In case This Jerk (or a similar ethically-challenged counselor) is reading, I’ll point out the obvious: when a doctor pulls the rug from under a patient by withholding medication, that patient might easily join the ranks of other dead addicts. On the other hand, when I work with a patient who is struggling with sobriety, keeping the person on buprenorphine and working to identify triggers for using, that person almost always ‘gets it,’ eventually.
I’ve been working with people addicted to opioids, using this approach, for so long that the other approach—the punitive, ‘cut ‘em loose for struggling’ approach—seems barbaric. I don’t understand how people identified as healthcare workers (nothing professional in his behavior!) rationalize the dismissive approach. I suppose, if This Jerk views addicts as the scum of the Earth, or as people with weak characters, or people who lack ‘will power,’ punishing relapse by withholding treatment feels about right. But most of us leave that world behind when we commit to helping people suffering from illness.
What’s This Jerk’s excuse? Is it that he just doesn’t get it? Or are there other motives at play? With the current cap on patients on buprenorphine, the most lucrative way to practice is to keep turnover high, rewarding practices that hire therapist-idiots like This Jerk.
Or is it the power trip– that people with difficult addictions are an affront to therapists? I’ve met therapists with this attitude before, who seem to have a form of codependency with their patients. They take credit for any success by their patients, but think the patients who fail are not worth their time, and should be dumped, expunged, or kicked-out to relapse and die. I suppose This Jerk would say ‘not my problem! I did MY job!’
Readers may suspect that this topic irritates me—and they’re right. Maybe I’ve seen more death, up close, than the typical counselor. I’ve attended autopsies; I’ve reviewed post-mortem photos from overdose scenes; I’ve pushed IV fluids into people with fatal injuries who presented for emergency surgery. I have spent hours with the parents of young patients who died from overdose. I’ve seen the parents’ faces as they struggled with the thought that they could, or should, have done something else—just one more thing to save their child. Death, to me, is not ‘theoretical.’ It is not something to toy with, and certainly not something to invite into the life of a person who made me angry, for not recovering at MY pace.
I suspect that the Jerks of the world will continue to justify their sadistic approach to ‘treatment.’ But patients—at least SOME patients—don’t have to put up with that behavior. People like This Jerk hold power over an individual with an addiction history, but there is power in numbers. It is not appropriate to use one’s power vindictively, or to gloat over a patient’s struggle. It is not appropriate to humiliate a patient in front of others. If you see that behavior, collect witnesses, and bring it to someone’s attention. Maybe that ‘someone’ will write a blog post about it!
Doctors in particular should treat patients with ALL diseases—including addiction—with respect. It is not respectful, or ethical, to deprive a patient of life-sustaining medication—especially out of spite. I look forward to the day when the thought of ‘kicking someone off Suboxone’ is viewed as similar to kicking a poorly-compliant teenage diabetic off insulin.
Would THAT make sense— even to This Jerk?
Relapse in an Era of Buprenorphine
A recent experience with a patient helped me realize some of the dramatic differences in the treatment of opioid dependence, in an era of buprenorphine.
I drug-test patients who are treated with buprenorphine or Suboxone. The point of testing is not to catch someone messing up, but rather to determine when a person is in trouble. It would be great if we could simply rely on the word of our patients, but once a person is using opioids, his/her own ability to know what is true falls apart. All of us who treat addiction have heard patients rationalize relapse as something they ‘had to do’ for one reason or another, for example. The effects of active using on insight are why I like the use of ‘DENIAL’ as a mnemonic for ‘Don’t Even Notice I Am Lying.’
The effects of relapse on telling the truth are part of the profound impact of using on a person’s insight. Insight disappears very quickly during active using, as the mind abandons the broad view and becomes focused on one goal. Before buprenorphine, drug testing was in some ways more, and other ways less important. It was more important because after relapse, the person was immediately thrown back into the world of desperate scrambling, where risks for consequences are high. On the other hand, testing was less important—or maybe necessary– because experienced addictionologists (and spouses) could see the effects of using, including the loss of insight, in the active addict’s eyes.
I was one of those people who experienced that rapid loss of insight after my relapse, back in 2000. For years I had attended AA and NA; hundreds if not thousands of meetings over seven years. I remember comforting myself that ‘if I ever get off track, at least I now know where the door is to get back.’ I didn’t realize that at the instant one relapses, that door becomes nowhere to be found.
In retrospect, I don’t know if the door actually disappeared. I suspect that with the right attitude, that same door would have opened for me. But the honesty and humility that I needed, in order to ask for help in finding and passing through the door, were suddenly replaced by the need for secrets—secrets about everything. As soon as I relapsed, nobody could be trusted. Nobody would understand me. I was on my own.
Contrast that with the experiences of patients on buprenorphine who relapse with opioid agonists. As I compare their experiences to mine, I realize that I am using the experiences of a couple people to make broad generalizations. But I have seen a number of examples that support these generalizations, that have consistently followed the paths that I’m about to describe.
One patient—call him ‘Paul’—told me about his relapse before I even mentioned that I would be asking for a urine test. In fact, he was eager to tell me about his experience, as if he looked forward to getting it off his conscience. “I have to tell you that I really screwed up last week,” he said. When I asked him what happened, he said that a friend who he hadn’t seen for several months came through town and stopped by his house. With little warning, his friend pulled out a bag of heroin and a couple clean needles, tossed them on the table, and said ‘let’s fire up.’
After shooting the heroin, Paul immediately felt disappointed in himself. Unlike in the old days, he felt nothing from the heroin. While his old friend nodded off next to him, Paul wondered what the heck happened—and immediately wanted to talk to me about the situation.
His desire to talk is an amazing thing—and worth noting. Without buprenorphine, a person who relapses is not generally eager to speak to his/her sponsor, let alone counselor or physician. In those cases, the mind reels from an avalanche of shame, and the need to keep secrets—even from one’s own awareness—becomes paramount.
There are many buprenorphine programs that would discharge a person for one relapse—and in such cases, I would not expect the same type of honesty from patients. I don’t get the logic of those programs, and I become angry when I think about them. As I’ve said before, if a person relapses, that person NEEDS help—not abandonment! I believe that the proper approach to treating addiction can be found in almost all cases simply by considering opioid dependence to be another chronic illness. And if someone with heart disease overexerts himself and comes in with chest pain, we don’t boot him from treatment!
Paul made an appointment to talk about his experience. He explained how he felt when his old buddy contacted him, and we discussed ways to avoid meeting up with ‘old friends’ in the future. He discussed the urge to escape when he saw the paraphernalia—to escape from life’s responsibilities—and we talked about how difficult it can be to simply tolerate life sometimes, and the powerful effects of triggers and cues. Most interesting to me, as a psychodynamic psychiatrist, he talked about a complicated set of thoughts and feelings that came up when he saw the drugs—questions about who he was, about shame, about the heavy load that comes with doing the right thing, and about the pressure of not letting people down. Those are all big issues, I said as I agreed with him. How much easier, at least for a few moments, to just be ‘nothing’—to have no expectations about one’s self!
We talked about the challenge of being ‘someone’– of being proud of one’s self. It feels good to do the right thing– but it may also feel bad. Am I letting my old friends down, if I do better? I suggested that he might watch the old movie, Ordinary People, where a younger brother struggles after surviving an accident that claimed the life of his brother.
Before buprenorphine, people struggled with opioid dependence largely on their own. Yes, we had twelve step groups—and still do—but twelve step groups place the responsibility to get one’s act together squarely on the back of the using addict. Many people in AA or NA will say that “AA is a selfish program.” It has to be. When one relapses, one is left with his own distorted insight, accumulating consequences until, hopefully, he finds his way back to the pathway established by the simple program of the steps.
On buprenorphine, relapse doesn’t necessarily cause instant loss of insight. I don’t mean to minimize relapse, as bad things can always happen. For example, I have had patients stuck in a pattern of chronic relapse that was difficult to straighten out, even though there was little or no psychic effect from the drug being abused. But from an optimistic standpoint, relapse on buprenorphine stimulates a deeper investigation into what is missing from the person’s life, and a renewed effort to gain what is missing.
This assumes, of course, that the person is not simply tossed from treatment for the relapse. In that case, other people are left trying to figure out what happened—when the obituary appears a few months later.
Clean Enough: An Educational Process
Clean Enough continues:
An Educational Process
I was able to stop using codeine after returning home and to my job in the operating room. I dodged a bullet– or so it seemed. I continued to drink wine, beer, and the occasional margarita, but I had convinced myself that drinking was an isolated vice that was necessary given the stress of my job. Yes, the AA and NA people said that alcohol would take me back to my ‘drug of choice’, but they didn’t understand my special situation, and didn’t know how smart I was. The scary incident in the Bahamas faded from my memory. Looking back, it wasn’t that big of a deal.
About ten months later I was having a tough week. I had a bad cold, I was feeling depressed (my mood always takes a hit when I am sick), and my wife and I were in one of those low stretches that visit most marriages. Seemingly out of the blue, I thought about how I had stopped the codeine after my vacation months earlier. Hey– I must have learned to control my use of codeine! And since I have control, I can take a small amount of codeine for my cold… and perhaps get a tiny bit of euphoria… but then I will stop just like I did before! That thought—that I now had ‘control’—would be the end of my career as an anesthesiologist. Similar to the experiences of many other addicts, my relapse was horrible; much worse than my original addiction. I was like a rat pushing a lever to get food in a lab experiment, using medications from work, shooting up intravenously, and taking doses that I knew could be fatal. I even injected contents from unlabeled syringes, hoping they contained something to make the sickness go away, and not the paralyzing agents that would have killed me. Every Friday I brought home enough fentanyl to cover the weekend, but no matter the amount, it was gone by Friday night, leaving me sick from withdrawal every Saturday and Sunday. At some point I didn’t even care about getting busted. There is a great line in the movie ’28 Days’: “this is no way to live…. this is a way to die!”
I was met by a security officer one Saturday morning as I entered the hospital to scrounge the operating rooms for drugs, and he apologized for having to escort me out of the hospital. The next morning I met with the my wife, a member of my anesthesia group, and the hospital CEO, telling them that I only needed a minor, outpatient ‘tune-up’, since I knew all this recovery stuff already. But the CEO pointed out the needle marks on my hands and arms, and said that any possibility of working again required residential treatment. I left the meeting wondering whether to just put all of us out of our misery or to instead go into treatment. As an aside, I remember that feeling now when I am trying to get a person to enter residential treatment– my aversion to treatment was so strong that suicide seemed a reasonable alternative! I did choose treatment over death, but not by a long-shot.
The night before going to treatment I watched my 12-year old daughter play a piano duet, her teacher playing the part that I was supposed to play. Laura and I had practiced the piece together for weeks, but with my hands shaking and dripping sweat I was in no condition to play. I have many shameful memories from my ‘using days’, but memories of that night will always be among the worst of them.
I was in severe withdrawal the next morning, too sick to enter the treatment facility, so I spent some time in acute detox in a locked psych ward. My shoelaces were taken from me so that I couldn’t hang myself. I was given a room at the end of the hall where I waited for the pain to stop, minutes becoming hours. Clonidine was ordered, but was to be held for blood pressure below 90. Every time I heard the nurse I tensed my muscles, trying to push my pressure higher, but I was so dehydrated that I couldn’t get my blood pressure high enough for even one dose! I will point out that people write on the web that ‘Suboxone withdrawal is the worst;’ in detox I could barely walk for the first few days, and for a month or two I was so weak that I became short of breath after walking 100 feet. Sleep and appetite took a couple months to return. After experiencing withdrawal many times, and watching many people go through withdrawal from substances including buprenorphine, I can say with complete confidence that buprenorphine withdrawal can be significant, but is NOT as severe as withdrawing from opioid agonists. Those who say otherwise are being influenced by the fact that current misery always feels worse than ‘remembered misery.’ People withdrawing from buprenorphine go to work every day and complain about how bad they feel; those withdrawing from oxycodone, methadone, heroin, or fentanyl lie in bed and DON’T complain, as they are too sick to write on the internet!
I eventually transferred to the treatment center where I would spend the next three-plus months of my life. The program consisted of work from sun-up to bedtime, and included individual therapy, group therapy, art therapy, music therapy, experiential therapy, relaxation training and guided imagery, ropes and challenge course, physical training, and twelve step groups. One irony of treatment is that a person is ready to leave at about the time when he no longer wants to go. I now see the experience as a wonderful gift to myself.
I had a number of ‘consequences’; I lost my job and my hospital privileges, and I was disciplined by the licensing board. I was ordered to attend treatment and twelve step meetings for the next five years, and I was subject to random urine testing at a frequency of at least twice per week. I did as I was told and time went by. At one point I decided to repaint the interior of our house, and beige walls were replaced by forest green, golden tan, and light burgundy. I took up running and got in better shape. I became active in community theater, something I had always wanted to do but now had time for. I became more involved in the day-to-day lives of my children.
I had been released from residential treatment the day after September 11, 2001, and I found out a few days after the horrible attacks that my best friend from college, Commander Dan Shanower, had been killed at the Pentagon on that day. My attention to his tragic death led to finding a job with the Transportation Security Administration providing medical clearance for new airport screeners. That brought in some money, and we sold our vacation cottage to help pay the bills, but I knew that I needed a new career. I loved being an anesthesiologist, but I knew that most relapses in anesthesiologists came to light when the addict was found dead in a call room. After significant sober reflection I decided to return to residency—this time in psychiatry, to get back to my early interests in the mind and brain.
Starting over
It was difficult being a lowly resident again, but things could have been worse. I know doctors with addictions who never made it back to practicing at all. I have known addicts who died from their addictions. Those AA bumper sticker slogans often contain true wisdom; my most appropriate bumper sticker reads ‘Gratitude is the Attitude.’ A common recovery phrase is ‘the Chinese symbol for crisis means opportunity.’ I don’t know whether the statement is true, but the sentiment is accurate. I have seen recovering people do some amazing things, and I hope to be one of them.
My relapse, horrible as it was, resulted in a wealth of opportunity. I mentioned my participation in Community Theater; circumstances also led to a position as a columnist for the trade journal Psychiatric Times. I for years had dreamed of teaching but only now do I participate in that dream, teaching addiction and other topics to medical students and residents. I appear in a weekly radio show about psychiatry and addiction, and I am, of course, writing this book! None of these things would have happened if not for that fateful day in Eleuthera seven years ago. I am not saying that my relapse was a good thing—don’t get me wrong about that! But addiction– and relapse– do not have to be the end of one’s life. For me, in many ways they were only the beginning.
Clean Enough: Some Distorted Thinking
Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup. Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.
In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket! I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days! So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera. I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well. Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way. I eventually learned that both were true—but that and other realizations required further ‘education.’ I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.