Consequences Section

Weeks ago I posted a few new ideas—things like a memorial wall for victims of opioid dependence, and a ‘wall of shame’ for doctors who are known for reckless prescribing of opioids. I mentioned these ideas over at SuboxForum as well.
I received good feedback from readers here, and from members there. Sometimes the best feedback is the hardest to hear; I’ll get excited about a certain plan of action, and like anyone, I don’t like it when someone rains on my parade.
One of my addiction docs from years ago was big on ‘sober thinking.’ Back then, it seemed as if anything I came up with that pushed the boundaries was in need of more ‘sober thinking.’ I wondered if ‘sober thinking’ was simply code for ‘I don’t want to say yes to your idea, and maybe that was the case in SOME instances. But I now recognize a part of myself that acts quickly, impulsively, with great optimism, and with little regard for risks. ‘Sober thinking’ is simply letting an idea sit in one’s mind for a few days or even weeks, and keeping a truly open mind to the comments that one receives about the idea.

Prison is a better consequence to heroin addiction
Beats Death--- Barely

I won’t spell out who wrote to me, but I’ll thank the people who did—who risked my ire by giving their honest opinions. I mentioned a memorial page; some people pointed out that a memorial on an addiction-related web page may add to the pain and shame felt by family members. As for my ‘doctor wall of shame’, I was reminded that every story has two sides, and it may be more useful to simply provide referenced information that would allow readers to make up their minds without my own coloring of the facts. I want to thank the people who wrote, and let them know that they made a difference—and the site will be better because of their efforts.
Instead of the earlier ideas, I added what I am calling the ‘consequences’ page. The page will contain news stories identified to Google as having ‘drug overdose’ in their tags. The information will be replaced every 24 hours or so. I experimented with a couple different intervals and found that no day went by without a significant amount of news under that tag—a rather compelling statistic!
Click on ‘consequences’ to check it out, and let me know what you think!

Scam City

When Suboxone first became an option for treating addiction to pain pills back in 2003, some people were excited about having a cure for opioid dependence. Those people were mistaken. It is true that Suboxone has been a huge benefit for treating opioid dependence, but the medication cannot cause the permanent changes in the brain that would be necessary to prevent relapse. Instead, in order for the medication to work, people must do what they do with other medications—keep taking it.

Addiction treatment-- a scam?
Not all scams are so obvious

I recently read an article on another web site that advocated a certain person’s ‘method’ for rapid opioid detox. I went to the primary web site for the developers of that method—pulled to the site in the same way that I am drawn to watch late-night commercials for get-rich-quick schemes or male enhancement products. On the web site I read that they have a new reason to take large sums of money from those addicts fortunate enough to have money, and unfortunate enough to believe their hype— a special, rapid way to change brain function.
We are spending tens of millions of dollars through NIH to understand neuronal ‘plasticity’—the term for the ability of the brain to adapt in response to the environment—and here some guy at a detox clinic has it all figured out!
As I read the web site, I thought about all of the addiction ‘cures’ that I’ve read about over the years, such as the secret blend of amino acids that one program offers (I wrote to the advocates of that treatment to ask how it works, and was told that they would give me the recipe for only $15,000). I thought about my opportunity a year or two ago to review the bill of a person treated at one of those $70,000 per month addiction treatment centers out west somewhere; the bill was padded with one type of therapy after another, with names like ‘mood therapy,’ or ‘PTSD resolution therapy,’ or ‘energy-field releasing therapy.’ The charge for a ‘treatment’? Prices ranged from $700 – $1200… per SESSION, day after day. On many individual days, the person was billed for multiple types of therapy, each costing $1000 or more. Now I know– THAT’S how you get to 70 grand per month!
With all this in mind, I have to wonder– is addiction treatment the last refuge for snake-oil salesmen? Where are the good folks at the FDA when people throw scientific mumbo-jumbo to extract money from desperate people? Maybe I should quit charging the peanuts of a typical private practice—where insurers think an hour is worth a hundred bucks, and the state considers an hour worth $37.50—and instead hang a sign, and make a web site, and offer ‘Selective Cranio- Axial Meningotherapy’ (SCAM) or Bitemporal Sensory (BS) Therapy or Rapid Intentional Pseudo – Olfactory Field Focusing!
I’ve criticized doctors who prescribe Suboxone as well; namely those who take the quick buck to get a person started on Suboxone, then leave the person to find a long-term prescriber on his/her own—knowing that such doctors are impossible to find in many areas.
It is relatively easy to get a person clean for a few weeks. In fact, if anyone desperately wants to get off opioids, bring me $20,000 and I will chain you to the steel post in the center of my basement—and I’ll even throw in meals. The hard part, of course, is keeping you clean AFTER you leave. So for an extra $50,000—the same price charged by many month-long treatment centers—I will provide a couple hours of therapy each day (weekends off of course), and put out an easel for you to draw pictures of traumatic events from your childhood.
Sounds silly, I know—but the truth is even sillier. I bet that the number of long-term cures from MY basement treatment would rival those from any of the methods or programs that I alluded to. From either program—mine or theirs– the long-term relapse rates would be very high.
Fortunately, there IS a long-term treatment for opioid dependence— buprenorphine– that has proven to be safe and effective. The way to make the treatment work is to follow the same principles that are used for a host of other medical conditions: 1. Get a good doctor. 2. Start the right medication. 3. Keep taking the medication. Psychotherapy might be helpful as well, but definitive studies on the value of psychotherapy for Suboxone patients have not yet been done. But we DO know the importance of staying on the medication.
Who knows– you might even save yourself a bundle.

Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog. The picture has nothing to do with anything, except that the Packer win was pretty awesome. The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night
Lambeau

I have been using various opiates for the past 2 years. I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope. As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous. I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.
On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state. But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them. I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?
This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.
Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’ A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing. And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness. So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out. A much better use of time would be to work on accepting his limitations in this regard. In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’
The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle: for ‘Keep It Simple, Stupid.’ I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’ That’s right– IT DOES NOT MATTER. When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure. Reflective, self-analytic thinking will not generally keep a person clean.
The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom. Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community. Even if the writer does have some type of deficiency, opioids are not likely the solution. See my next paragraph for more on this issue.
All opioid addicts have the fantasy that they will find a way to keep using. Early on, that fantasy fuels a great deal of frustration and broken promises. “I know… I will only use on Thursdays!” we say to ourselves. But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work. And thousands of people smarter than me have tried and failed as well. The only people who can take opioids without being destroyed are… people who don’t like taking opioids. How is THAT for a messed up situation? For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets. She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later. I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety. Unlike my wife, I LIKED them. And they were all gone two days later. I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure. But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well– the lying, depression, and self-loathing.
My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it. Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’ But buprenorphine has increased the options for addicts seeking treatment. Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation. Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using. The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle. The addict must truly want to be clean in order for buprenorphine to be effective. But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

Clean Enough, 2.8 and 2.9

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.
I’m cured!
My admission of powerlessness was the start of my sobriety. I soon found a treatment program that let me enter outpatient treatment, and I also began attending 12-step meetings. AA and NA became guiding principles in my life, and over the next five years every area of my life improved. My marriage and family life improved, I became Board Certified, I was elected Chief of our Anesthesia Department, my wife and I had another healthy daughter, we bought a vacation home… what’s not to like?
After five years of avoiding all intoxicating substances and attending AA, there was no doubt in my mind that my problems with addiction and opioids were behind me. Avoiding alcohol was not difficult, because I was never much of a drinker. One afternoon I had some friends over to watch the Green Bay Packers, who had been having a great season. I was serving beer in my home, something that I had avoided for the first several years of my sobriety, but that I began doing after becoming convinced that relapse was not a concern. At some point during the game I asked my wife whether she thought it would be a good idea for me to have a beer. How sneaky– I have since learned that we addicts will do this type of thing on the road to relapse; we set up a situation where we know in advance what the outcome will be—that outcome being the answer that the addict inside our brains wants to hear. We are looking for permission to take a very small chip out of our sobriety. I manipulated my wife into saying what I needed to hear, and a few minutes later I was sipping a beer. From that day forward it was okay to have beer during Packer games. It was then a logical step to enjoy a glass of wine with dinner. I found a wine store run by two retired college Geology professors, and tasting wine from different parts of France became an academic exercise. In fact, I was so inspired by the idea of lifelong learning that I began to enjoy this academic exercise every evening at dinner time. At some point I was introduced to port, a fascinating beverage that has a noble history and just happens to have higher alcohol content. When eating Mexican food, margaritas were, of course, more appropriate. And then I found that there is a huge world out there of aged cognacs, which have a history all their own! Wow, I was learning a lot!

Clean Enough, Chapter 2.5, 2.6, and 2.7

My Story (continued)
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.
I’m cured!

Eleuthera beach
Eleuthera awaits...

My admission of powerlessness was the start of my sobriety. I soon found a treatment program that let me enter outpatient treatment, and I also began attending 12-step meetings. AA and NA became guiding principles in my life, and over the next five years every area of my life improved. My marriage and family life improved, I became Board Certified, I was elected Chief of our Anesthesia Department, my wife and I had another healthy daughter, we bought a vacation home… what’s not to like?
After five years of avoiding all intoxicating substances and attending AA, there was no doubt in my mind that my problems with addiction and opioids were behind me. Avoiding alcohol was not difficult, because I was never much of a drinker. One afternoon I had some friends over to watch the Green Bay Packers, who had been having a great season. I was serving beer in my home, something that I had avoided for the first several years of my sobriety, but that I began doing after becoming convinced that relapse was not a concern. At some point during the game I asked my wife whether she thought it would be a good idea for me to have a beer. How sneaky– I have since learned that we addicts will do this type of thing on the road to relapse; we set up a situation where we know in advance what the outcome will be—that outcome being the answer that the addict inside our brains wants to hear. We are looking for permission to take a very small chip out of our sobriety. I manipulated my wife into saying what I needed to hear, and a few minutes later I was sipping a beer. From that day forward it was okay to have beer during Packer games. It was then a logical step to enjoy a glass of wine with dinner. I found a wine store run by two retired college Geology professors, and tasting wine from different parts of France became an academic exercise. In fact, I was so inspired by the idea of lifelong learning that I began to enjoy this academic exercise every evening at dinner time. At some point I was introduced to port, a fascinating beverage that has a noble history and just happens to have higher alcohol content. When eating Mexican food, margaritas were, of course, more appropriate. And then I found that there is a huge world out there of aged cognacs, which have a history all their own! Wow, I was learning a lot!
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.