The 'Hole'

A question from a suboxone user:
I feel this big empty hole that I tried to fill with Opiates. Since on the Suboxone I’m not pulled towards the Opiates but I still have this hole that there is still a need to fill with something. It’s not there because I’m off the Opiates. It was there before the Opiates. They just happened to fill that hole to some degree. Does anyone know what I’m talking about or have the same experience?
Thanks
R.
My Response:
I understand what you are saying– at least I think I do. It is always hard to compare subjective experiences– for example, is my experience of ‘green’ the same as yours? But I do know that feeling of emptiness, darkness, loneliness, sadness, abandonment, despair… and like you, in my case it was present long before opiate addiction. I have heard many opiate addicts speak of the same thing as well– I wouldn’t say it is universal, but it certainly seems to be present in most people with opiate addiction who I have met over the years. I can tell you that most people found opiates to be the ‘perfect medication’ for that type of pain… at least until tolerance and the craziness of needing more and more took over and ruined everything.
I also often hear that the pain of that ‘hole’ is treated, at least partially, by suboxone. Again, I think that the main problem is tolerance– which is measured with suboxone (or more accurately with buprenorphine, the active drug), but which still occurs to some extent.
I think that the hole is often a manifestation of what we psychiatrists call ‘Borderline Personality Disorder’. Everybody has their own way of seeing the world– of seeing relationships, of seeing one’s own role in the grand scheme of things, of seeing their own traits as compared to others…. all of these views total up to form the ‘personality’ of the individual. The collection of views, perspectives, opinions, etc are a result of genetic influences, developmental influences, cultural and societal experiences, and life experiences, and for the most part the entire assembly is relatively ‘fixed’ at an early age– at least by our late teens. Ideally a person has a certain amount of flexibility built into their personality– the ability to change views and reactions to a wide range of situations. If a person has an inflexible way of seeing things they often run into recurrent problems in life– and in such a case may be considered to have a ‘personality disorder’.
Borderline PD likely forms in reaction to genetic factors to some extent, but a common environmental factor is the failure to form the intense bond with a parent (usually mom) at an early age– before age 2 for the most part. Many people will have the opinion that mom was perfect and so they didn’t have anything like I am describing– at least until I get to them and start talking about specifics. The point, of course, isn’t to blame our mothers, but rather to understand all of the factors that made us who we are, with the understanding that our mothers and fathers are products of their own upbringing just as we are. Anyway, mom may look ‘perfect’ when viewed through our adult eyes, but when we were babies she may have been unable to bond with us– perhaps she had her own addictions, or was depressed, or had an anxiety disorder… or perhaps she worked 80 hours per week and was just too tired to spend much time gazing into our eyes. Maybe she had 8 other kids to take care of. Or maybe we were born premature and we were so fragile that she was nervous every time she held us. Maybe we cried to much that she was often too angry to appreciate the quiet times. Who knows… but it is clear that the failure to bond is connected to BPD, and that BPD is not something restricted to single parents or to lower socioeconomic groups– it occurs in people who are CEO’s, doctors, electricians, teachers… and homeless people as well.
People with BPD have an ache that never goes away, and a ‘hole’ that can never be filled. I won’t go through all of the characteristics, as you can easily find them by googling ‘borderline personality symptoms’ or something similar. People with that basic personality often try to fill the emptiness with drugs, or more often with relationships– which are usually dysfunctional because the person tends to seek out traits that don’t make for healthy relationships. For example, people with BPD are attracted to very intense emotional connections, and for that reason they tend to attach to other people with BPD. People with such a personality tend to see people and the world in ‘black and white’– so people are either idealized and placed on a pedestal or hated and seen as completely without value. A partner may initially be seen as perfect, but over time the relationship is bound to disappoint, and then the partner is seen as horrible. Other problems include that fact that in healthy relationships, a person enters the relationship already ‘whole’ and complete, and brings assets to the relationship, but in BPD people enter the relationship looking for a person to MAKE them feel complete– and again, no person or relationship can be relied on to do that for very long.
Patients with BPD are often cutters; they often have intense mood swings that are misdiagnosed as bipolar (the mood swings in BPD are of much shorter duration and are ‘reactive’ to the environment); they often have periods of intense emotional pain– they ‘become’ depression rather than ‘have’ depression. They often feel entirely alone in the world. They often have a history of multiple suicide attempts, and are often treated with dozens of medications over their lifetime– none of which ever work very well.
There are many books about BPD that patients may find helpful– one such example is a book called ‘I hate you– don’t leave me’, reflecting the intense fear of abandonment that is classic in BPD. There is a type of therapy called ‘DBT’ or ‘dialectic behavioral therapy’ that reportedly has shown some success in reducing the behaviors that cause problems for patients, such as cutting or suicide attempts. My usual approach is to first do no harm– to try to avoid hurting the patient by either prescribing medication that is ultimately harmful (like benzodiazepines) or by forming professional relationships that are too intense and that make a patient dependent on their therapist.