I’ve shared my history many times, including mention of my ‘spiritual awakening’ in 1993 that kicked off about 5 years of active AA invovlement. After struggling with an obsession to use opioids for months, a meeting with a psychoanalyst sparked the ‘awakening’ on my drive home. I was suddenly very tired of what I was doing– the lying, hiding, desperately searching for something to stop the withdrawal, fighting with my wife… and running from psychiatrist to psychiatrist, trying to find one to agree with MY version of the world, who I would agree to see for treatment. I now realize, by the way, that ‘change’ by definition appears foreign, wrong, and inappropriate; a patient who sees a therapist who agrees with everything the patient says is guaranteeing the ABSENCE of change! On the day of my ‘awakening’ I saw an analyst who told me I was full of BS, and I suddenly realized that he was totally correct. I pulled off highway 41, crying, confused, and simply done with fighting the advice I had received from others. I decided that I had to put myself into the hands of the experts and just listen, and do as I was told. And I realized that I had no ‘will power’ over opioids (later learning that I had no will power over ANY psychoactive substances). The amazing thing that felt like a miracle was that the desire to use suddenly disappeared. I didn’t touch opioids again until my relapse, 7 years later. And I didn’t need any ‘will power’ at all; what I needed was to remember that I HAD NO will power. Keeping that at the forefront of my mind was very easy– and very difficult– to do. Other AA’ers will know what I mean by that comment.
Since then I have tried to look at the twelve steps ‘scientifically;’ to determine the essence of the program that leads to such incredible change in SOME cases. With the introduction of buprenorphine maintenance, my opinion holds that the only way to live a clean life OFF buprenorphine is to adopt a life based in the steps. The problem is that finding real ‘change’ through the steps (or through any other program) requires that the person abandon his/her former way of living, and that requires desperation. And unfortunately, once on buprenorphine, addicts are no longer desperate. I do not see any solution to this stale-mate situation. Desperation is needed for change, and buprenorphine eliminates desperation. So the addict must stay on buprenorphine to avoid using, and to avoid desperation.
The question that comes to mind is whether it is a good idea to stop the buprenorphine, thus bringing on the desperation required to change? In some cases yes– when the person is using multiple substances and life is careening out of control, I think that buprenorphine might only prolong the agony, and the appropriate action is to stop it and allow the person to feel the consequences of his addiction. But for pure opioid addicts I have a harder time recommending that they discontinue buprenorphine for the sake of bringing on desperation, because the risk of death during overdose is simply too high.
My philosophy for buprenorphine treatment is to try to add the elements of recovery that I found in the steps– to somehow pass them on to the patient without desperation. I don’t know if that can be pulled off, but that is what I try to do.
I want to share this interesting story about the mechanism of AA from Wired magazine: http://www.wired.com/magazine/2010/06/ff_alcoholics_anonymous/5/
Tag: will power
Why will power doesn’t work
For those of you who prefer watching to reading, here is a video with a few thoughts about why will power is NOT any kind of strategy for staying clean. As I describe, believing in will power is not only unhelpful; it even INCREASES one’s chance for relapse, and serves as a frequent justification for the using that leads to full-blown relapse. Please share comments at SuboxForum.com.
Addiction and Will Power
A person posted the following after one of my youtube videos about Suboxone:
While SuboxDoc knows what he’s talking about in his videos, not everything he says is always true. Not everyone needs permanent blocker therapy. Everyones willpower varies. The simple fact is, the worse withdrawal is, the more likely that person is to not want to go through it again, meaning abstinance. The easier withdrawals are, the more likely that persons mindset will be “one more can’t hurt”. Pain builds you, it builds character, personality, and maturity.
My thoughts:
I have had my share of bad withdrawals. So have most opiate addicts who have live with their illness for a few years. Unfortunately, there is much more to staying sober than remembering the pain of withdrawal. There is also much more to staying clean than ‘character, personality, and maturity.’
I’m not sure the best way to approach this discussion, but the first thing to do is to dismiss the comment about ‘will power’. The collective experiences of hundreds of thousands of addicts over the past 75 years have taught most of us that there is one thing we know about addiction: Will power does not work.
I learned this simple fact during a ‘spiritual conversion’ that removed my desire to use, back in 1993. Since then I have tried to approach the issue more scientifically. The first thing I come up with is the realization that if I had will power, I would have no reason NOT to use. I would just go ahead and use today, and stop tomorrow! But I can’t do that—I can’t use today– because I KNOW that I do not have will power over opiates. I KNOW that if I used today, I would never regain control again. I have mentioned my ‘7-year relapse’ before—after 7 or 8 years of sobriety, all the time working in the OR with potent opiates in my hands, I relapsed on some codeine tablets that I found for sale ‘over the counter’ in a little market in the Bahamas. I came back to the US terrified, but didn’t use after getting back to work. But six months later I had a cold, I was tired, and I was stressed…. and I had the sudden thought that I was able to stop when I came back from the Bahamas… so I must have Will Power!! And so I used that day, planning to stop the next day using that wonderful will power that I now had. But the next day I decided to wait, and use the will power the next day. And a month later, I started to wonder just how much will power I really had. Finally after about 5 months, I lost my job, my medical license, my friends, my vacation cottage, 30 pounds of my body weight, my self respect… and I went into treatment, planning on a quick ‘tune-up’, since I had done it all before, and thinking that I had that ‘will power’ to help me out. It ended up taking over three months to stamp out that thought of having ‘will power’. So as far as I am concerned, you are welcome to all the ‘will power’ you want. Take my share too, while you are at it!
From a psychological perspective, I wonder if ‘will power’ keeps us from experiencing the appropriate fear about addiction that is needed to stay clean. Addiction lives in the ‘limbic system’ of the brain—in the primitive part of the brain that controls basic drives. Too often we try to control our addictive behaviors with our higher-order brains, and with reason—but we end up just talking in circles and rationalizing further use! I think the way to take on addiction is to meet it where it lives—in the limbic system. That is a place where animals fight over territory, where mates are chosen, and where we fight to the death—or run like heck to get to safer ground. Will Power involves the higher order brain, and our ‘super-ego’ making the ‘right choices’; powerlessness and fear live in our id, in the lower structures of the brain, and they work to keep us safe—while the higher order parts ponder away. So from my way of thinking, BE AFRAID. Drop the will power. Addiction has killed friends of mine—wouldn’t I be a fool, not to fear it?
Then there is the question… does more severe withdrawal help keep one safer from relapse? The question reminds me of my anesthesia residency in Philadelphia, doing labor epidurals. The nurses wouldn’t let me put a labor epidural in a 14-y-o girl until she suffered for awhile— until she had a bit of what they called ‘punitive labor’. They assumed that the pain would help keep the girl’s legs together for the next few years. But I always wondered about that philosophy. Instead, what if the girl was hooking up too young because she had a rough life, and was always beaten down by one person or another… and getting pregnant was a consequence of a desperate desire to stop the emotional pain? If that was the case, maybe more ‘punitive labor’ would just make her burden a bit heavier, and make another pregnancy MORE likely!
That is where I am with the withdrawal experiences (note– since writing this post I have received a couple e-mails from people who don’t understand the analogy. Hopefully most people reading this understand what I am saying!) Beyond this apparently-confusing analogy, I don’t buy the argument that worse withdrawal provides protection from relapse for another reason as well. People don’t remember ‘pain’ very well. If you try to remember something painful, you will see my point. I don’t really remember the pain of my worst withdrawal episodes; I know that the last one, the final detox before treatment in 2001, was pretty horrible… but I don’t ‘feel’ it anymore. And even if I did, would it make me avoid using? Or would it make me think that I was safer, for example make me think that ‘the pain built me up.. . gave me character, personality , and maturity… so I probably am a stronger person now. In fact I am so strong and full of character that I don’t really need to go to meetings— I can handle it on my own. In fact, I am such a strong person… that I could probably take some codeine for this darn cough that has been keeping me up… I’m probably strong enough now to take it just once, and then stop… ‘
Tricky business, addiction. See the problem with thinking too much? That is why I choose to stick with fear– when it comes to addiction, fear will keep you safer than will character, in my opinion. Don’t get me wrong– build your character too! But don’t think that good character alone will keep you from using.
SD
Strong Enough?
I am moving a post from the comment section up to here, as it sets up a couple points worth making. As always, I suggest that the writer of the comment check out suboxone.com and naabt.com, two good sources of information about Suboxone. I also suggest my own ‘product’ for sale on the right, particularly for people who could use an introduction to the concepts involved in choosing between treatment options for opiate dependence.
The comments from the writer:
please email me at [email protected]. I have been using opiates on and off for 12 years with NO issues. July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit. I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break. 20 months later I thought I was strong enough and could handle anything. Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later. If the opiates were not so difficult to get, I probably would NOT quit. That being said, I am starting therapy with a therapist. Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs. But I am asking this entire community along with this doctor here to help me by sending me an email to my email address. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth. Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.
I hope that the writer doesn’t find this too obnoxious, but what I like to do is go through the message part-by-part. I do this for several reasons. First, as I frequently point out, opiate dependence is an amazingly-predictable disease. The progression is virtually identical from person to person, with variation only in the minor details. Opiate dependence affects the mind of the addict, causing denial among other things. At the same time, each opiate addict feels ‘terminally unique’ throughout the course of the illness, seeing faults in others, but blind to the same faults in him/herself. One of the benefits of attending a 12-step group is seeing the pattern unfold in person after person; this helps the recovering addict understand the progression of addiction and even learn to identify and predict his own ‘triggers’ and ‘addictive thinking’. I want to do the same with the comments; to point out examples of classic ‘addictive thinking’ that people can then learn to identify in themselves. I ask that writer try to avoid taking my comments ‘personally’– I am not trying to insult anyone, as we all are in, or have been in, the exact same place!
One more aside… for people looking for Suboxone treatment in the Midwest, I am now open to new patients and also participating in a study that pays up to $225 for patients who enroll and participate. My contact info is at Wisconsin Opiate Management Center. I require at least the first visit, the induction, in person–I can then do telepsychiatry for further visits if people live a distance from my office.
Going through some of the comments:
I have been using opiates on and off for 12 years with NO issue…
I don’t know what to make of this comment. I do not think that it is possible to take opiates for 12 months without issues, let alone 12 years. I guess it all depends upon what a person means by ‘issues’. The worst part of opiate dependence, in my opinion, is the most subtle, and the easiest to deny– the effects on personality. When a person uses any drug of abuse, the person almost always has some inner negative opinion about what they are doing. Most people have internalized parental messages about d oing drugs, so that even while they make fun of their parents’ being ‘up tight’, there is somewhere inside a small kernel of shame. Many people also have a ‘work ethic’ somewhere in the back of their minds, and doing drugs is at conflict with that as well. Some people have personal health standards that using violate. You get the idea… the conflicts result in shame, which is a horrible thing to feel– so we repress the feeling and awareness of our shame. We push the shame deep inside so that we don’t even feel it anymore; being around other people will sometimes trigger it though, so to keep it from bothering us we put on a fake, cocky exterior. As time goes on we get better and better at putting up that ‘fake self’, sometimes even losing track of who the ‘real me’ is! Again, when we are in that mode it is extremely uncomfortable to be around people who really know us; I remember being extremely uncomfortable just sitting at the dinner table with my family! During active use, close relationships with other people are simply impossible– instead we collect a bunch of shallow ‘buddies’ or relationships based solely on physical attraction.
Even if this were not the case, how does a person use opiates ‘on and off’? The physical dependence and withdrawal are unavoidable– and anyone who has been through several episodes of withdrawal recognizes that they are ‘issues’. Miserable issues. Moving on…
July 2006 I quite cold-turkey a 18 pill a day and was “clean” for 20 months. The opiates started out as a friend then became an enemy and that is why I quit.
So at some point during the 12 years, the drugs became the ‘enemy’. If this person is anything close to typical, the use was an enemy far earlier than the user recognized. I often speak to family members to verify the story, and close family members ALWAYS noted irritability, distant emotions, preoccupations, etc far earlier than the addict thinks. We think we cover things up so well! I should point out in AA and NA this would be considered a ‘dry drunk’– a person not using but who has not found recovery. This rarely lasts real long with opiates, although alcoholics can often remain ‘dry’ for years or even a lifetime. They are usually miserable people– more miserable even than when they were drinking.
I also quite all the people in my life that were part of the drug, in other words if they relationship was a drug relationship they had to go along with the drug because temptation never takes a break.
Always a good idea– drug friends have to either get clean themselves, or go, if a person is going to stay clean for any length of time.
20 months later I thought I was strong enough and could handle anything. D Met up with an old drug friend and within 20 minutes I was back on the opiates and here it is 8 months later and 10 pills a day later
Opiate dependence will wait. My relapse didn’t hit for about 8 years, long after I had forgotten about my ‘problem’. The main point I want to make, though, is about ‘power’. WILL POWER DOESN’T WORK! The main reason? If I can control my use, why should I quit? Heck, bring them on… I’ll quit tomorrow! The first step of a 12-step program is POWERLESSNESS– the realization deep inside that the person has no power over the substance. This realization is sometimes a wonderful event, and the reason for the ‘miracles’ that AA people talk about… an addict will sometimes suddenly ‘get it’– get the realization that they are powerless. When that happens, the urge to use will often just disappear, all of a sudden! It is a neat thing– and it makes sense when you think about it. I always think about my son, who liked strawberries, but when he found out that the miserable hives were from the strawberries it was quite easy for him to ‘just say no’ to them!
That being said, I am starting therapy with a therapist.
Unfortunately, therapists and psychiatrists have poor records at helping a person stay clean, unless the person is also in some type of group format. The 12-step group format is the only thing that has stood the test of time– going on 100 years! The problem with therapy is that it can make a person think that the personal insight will somehow make it OK for them to use. ‘Now that I know myself, I probably won’t go as crazy with them– and I can use just a tiny, controlled bit.’ It doesn’t work.
Will he help me with this dependence? Will he prescribe any of the drugs that you talk about on this blog? And finally, you mention several drugs here and I don’t know if they are the same drug and people just mispell them or if they are different drugs…. What drug do I take to get off of the Opiates? then for how long? Then what after that? And so on and so forth.
I think my spellings are usually correct. In most states, only MD’s or nurse practitioners can prescribe– not ‘therapists’ for the most part. And most docs cannot prescribe Suboxone– they need a special waiver from the DEA. Go to the web sites I mentioned at the top of this post, and they will help you find a prescriber. As for the basic info, I again point out my recording!! Or you can just read and read– everything is out there, and those web sites I listed have some good articles on them.
Thank you – all you strong humans. We humans have a strenght within us that our humanness does not know, but yet there is a part of us within that DOES know and it knows that it knows in a gnosis way. Please help. thx.
I don’t understand that last part. But I wish you well, my friend. There is a better life out there– that I promise.
SD