North Carolina Pregnancy & Opioid Exposure Project

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Imagine being in a room filled with more than four hundred people: social workers, nurses, substance abuse counselors, and doctors specializing in obstetrics, pediatrics, and addiction medicine. Every one of them are there to learn how to care for pregnant women using opioids or addicted to opioids.

This actually happened earlier this month at the POEP conference in Greensboro, NC. (POEP stands for Pregnancy & Opioid Exposure Project. You can learn more about this organization at their website: http://www.ncpoep.org )

This organization, funded through a federal block grant through the NC Department of Mental Health, is run by the UNC School of Social Work. The organization has managed to bring together many of the people in our state who take care of pregnant women with opioid addiction. The goal of POEP is to disseminate information, resources, and technical assistance regarding all aspects of opioid exposure in pregnancy. The organization was formed in 2012 in response to concerns about the problem of pregnant women being exposed to opioids.

This organization is talking about all opioid use in pregnancy, not only about addiction in pregnancy. Some pregnancy women are prescribed opioids for the treatment of pain. These women may have physical dependence on opioids, though they may not have the mental obsession and compulsion to take opioids. However, the same problems can be seen in the newborn whatever the reason the woman takes opioids, so there is overlap in the problems faced.

This conference had renowned speakers; Marjorie Meyer, an expert in maternal-fetal medicine from Vermont, was the keynote speaker. This doctor participated in the MOTHER trials, and also set up an innovative treatment method in Vermont for mothers addicted to opioids. She has written about her data, and contributed greatly to our knowledge about buprenorphine in pregnancy (see my blog post of February 28, 2015).

Dr. Hendree Jones, lead author of the MOTHER study, did an excellent session on myths about medication-assisted treatment in pregnancy. She’s also a world-renowned leader in the field of addiction in women.

Dr. Stephen Kandall was there, and spoke about the challenges of advocating for women with addiction, with some historical perspective. He wrote an outstanding book, “Substance and Shadow: Women and Addiction in the United States,” which is one of my all-time favorites. It’s one of the best books about females and addiction. This conference was the first time I met Dr. Kandall, and I got all creepy-gush-y, and dithered about how much I loved his book. I can be such a nerd at times, but he was very polite and gracious.

There were many sessions going on at the same time, so it was impossible to go to all of the sessions that I wanted to attend. Other speakers talked about how best to coordinate care for pregnant women when they go to the hospital to deliver their babies, how to work with the court system if the pregnant woman has legal problems, and how to work with female patients on opioids about family planning.

I was honored to be one of the four-doctor panel that was organized to answer audience questions about medication-assisted treatment with buprenorphine and methadone during pregnancy. We got some great questions, like how to deal with co-occurring benzodiazepine use during pregnancy. Our session was only forty-five minutes long, and we probably could have spent a few hours answering all their questions. I was also impressed by the thoughtful opinions and recommendations from the other three doctors, all leaders in our state.

This conference was a great experience. I felt like many of the attendees got a better view of what opioid-dependent pregnant women need, and where and how to direct them for the best care. I’m pleased people in our state cared enough to start the difficult work of informing families and care providers about the problem of opioid use and addiction during pregnancy.

POEP has a great website that I’ll recommend to the pregnant women I treat, and I’ll also recommend it to their obstetricians. That site has clear information not only for families, but also for care providers. Here are the fourteen important points for infant care providers, taken directly from the POEP website:

“Key Messages for Infant Care Providers Working with Families of an Opioid-Exposed Newborn
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1. Parents should be counseled as early as possible (preferably well before delivery) about the need for close monitoring of an opioid-exposed infant.[2]
2. Parents should be encouraged to disclose any maternal opioid use that occurred during pregnancy and should be treated in a nonjudgmental manner.[3]
3. Hospital care of the newborn should be family-centered, meaning that the parents should be a driver in the care plan.
4. Parents should receive education about how opioid-exposed infants are monitored and how neonatal abstinence syndrome (NAS) is treated at their delivery hospital.
5. There are various approaches to monitoring for neonatal abstinence syndrome in opioid-exposed infants, such as the use of the Finnegan Scoring tool.[2],[3]
6. Monitoring for the onset of NAS may mean the infant will be monitored in the hospital for up to 5 days.
7. Infants at risk of NAS may be monitored in the mother’s room, in the newborn nursery, special care nursery or neonatal intensive care, depending on hospital protocols and resources.
8. There are various approaches to the management of NAS including non-pharmacologic interventions and pharmacologic therapy, depending on the needs of the infant. Approaches include:
• Non-pharmacologic management of NAS: environmental controls emphasizing quiet zones, low lighting, and gentle handling. Loose swaddling, as well as holding and slow rocking of infant may be helpful. The use of a pacifier for excessive sucking is also helpful.[2],[6],[7]
• Pharmacologic management of NAS: the use of a variety of medication to ease the withdrawal symptoms of the infant. Common medications include opioids (dilute tincture of opium, morphine, or methadone) and phenobarbital.[2],[6],[7]
9. Breastfeeding is encouraged for women in medication assisted treatment, unless there are medical reasons to avoid it. Reasons to avoid breastfeeding include an HIV infection or specific medication for which breastfeeding is not safe.[2],[3]
10. Infants experiencing NAS may have difficulty establishing breastfeeding or bottle-feeding. Women may need additional encouragement and lactation consultation to support breastfeeding.[2],[3]
11. Whenever possible, having the newborn room-in with the mother while in the hospital is encouraged. Benefits include opportunity to initiate breastfeeding, bonding and decreased need for treatment of NAS.[1]
12. Some infants will experience NAS as a result of maternal opiate use through a treatment program (such as a methadone maintenance program) or by prescription (such as buprenorphine for an opioid use disorder or prescription narcotics for pain management). The opioid exposure alone in situations where the mother was adherent to a prescribed treatment plan would not constitute an appropriate reason for referral to Child Protective Services. See structured intake 1407 http://info.dhhs.state.nc.us/olm/manuals/dss/csm-60/man/
13. Not all infants at risk of NAS are identified in the hospital, particularly in situations where maternal use of opioids has not been disclosed. This may be due to women not disclosing legal or illegal use of opioids.[2]
14. Withdrawal symptoms from opioids may appear in the infant after discharge to home. It is important for providers working with the infant and the family in the community (pediatricians, CC4C, Early Intervention) to be aware of signs and symptoms of NAS. If the infant displays any of these signs or symptoms, the family should be encouraged to seek pediatric care promptly.[2]”

North Carolina has a great start in addressing the problem of opioid-exposed newborns. The organizers of POEP can stand as an example of how other states can begin to address this challenging situation. Neighboring states (you know I’m talking about Tennessee!) have walked in the opposite direction, preferring to view opioid use during pregnancy as a crime rather than the medical problem that it is. That’s sad, because an aggressive attitude of judgment is correlated with poorer outcomes for both mother and infant.

Congratulations to the organizers of the POEP conference. Hopefully it was the first of many more to come.

Book Review: “Her Best Kept Secret: Why Women Drink-and How they can Regain Control,” by Gabrielle Glaser

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This book disappointed me. The title suggests a book of interesting research and conjecture about the reasons women drink. I was hoping for new insights that I could use in my practice with patients who drink alcohol. As it turned out, most of the book wasn’t about what the title implied. That topic was lightly touched on in the beginning, and there was a bit of summary at the end, but way too much of the book was about why AA sucks and why women don’t get the right treatment.

I liked the first third of the book, as it was basically history of alcohol and history of addiction treatment. She wrote about the shame women feel about having alcohol addiction, but that was brief. Overall, that portion of the book was mildly interesting, if a little tedious.

Then the next third of the book felt like an attack on AA. I admit I’m sensitive to AA bashing. I know AA works for many people, and I also know AA has never claimed to be the answer for every problem drinker. Given AA’s stance of “we will help you if you want help,” I don’t think it’s productive to berate the organization if you don’t want to go to their meetings.

My own opinion is that if you don’t like AA or don’t think it works for you, then fine. Take your ass on out of the meetings and go find another way that helps you. After all, AA members are under no obligation to help anyone; they help only because they want to, because it helps keep them sober. They don’t recruit new members, and they don’t ask for any money.

The author’s logic isn’t consistent. First she says AA isn’t helpful for women because it tells them they have to admit powerlessness and that interferes with women’s recovery process, rather than helping it. She says it’s insulting for women to be told that “your best thinking got you here,” and the slogans are too trite or hackneyed to help intelligent female problem drinkers who have problems with alcohol. She says women should be told they do have the power to make changes and stop drinking.

But then the next section, she says women are often victimized by men in meetings who have more time in sobriety, and thus more able to take sexual advantage of the fragile newcomer women. So which is it? Are the newcomer women tender blossoms with have no idea how to thwart a creepy man’s advances? Or are these women so powerful and capable that the simplicity of AA is insulting to their intelligence and capabilities?

Alcoholic Anonymous is made up of humans. Humans with drinking problems. It seems disingenuous to expect these humans to behave better than people in other human organizations (Catholic Church, for example). Also, I suspect some alcoholic women may have encountered creepy male advances in bars.

What kind of treatment does this author say works best? She correctly champions cognitive behavioral therapy and Motivational Enhancement therapy.

As an example, she describes an excellent treatment program that consists of treatment sessions from two therapists, with the addition of other services as needed (primary care consult, mental health provider). This treatment is done as an outpatient, where the person stays in a nice hotel close to the therapists’ office.

It costs ten grand. Ten thousand dollars.

This author gushes about how these therapists are so caring and dedicated that they even eat lunch with the patient. I would hope so. If I were paying ten thousand dollars for a few weeks of therapy, I’d expect my therapists not only to eat lunch with me, but also tuck me in at night and tell me a bedtime story!

So overall, I don’t think the ideas in this book extend to any new territory. Twelve step bashing has been done by many authors, so that’s dull. I found much of the book to be derivative, containing ideas from earlier books about women and addiction. Plus, I was surprised by how little time this author spent describing real barriers many women face when they are seeking help for alcohol addiction. For example, women are the primary caregivers for their children. Male partners may not want to take over childcare responsibilities while the woman gets treatment. Many times the woman’s partner is also in active addiction, and seeks to deter or undermine her efforts to get help and to stay in recovery. Transportation is a big problem, especially in rural areas with no public transportation. She may not have a car she can drive to treatment each day.

These issues were not addressed at any depth.

If you want to read a book about women and addiction, I highly recommend you read, “Substance and Shadow,” by Stephen Kandall, or “Women Under the Influence,” by the CASA program. Both are better written and with more information.

Avoid Burnout

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There’s a high turnover in the field of addiction treatment. That’s not good, because people with the most experience leave the field for more attractive work environments. I’d like to offer some ways of avoiding undue stress that leads to burnout.

Before we get to stress, it’s important to talk about why there’s burnout in this field. Many people think it’s all from patient behaviors, but that’s not the only reason.

True, it’s not always easy to work with patients in treatment for drug addiction. Addiction can cause all sorts of behaviors that can interfere with treatment, and trigger anger on the part of treatment providers. In patients with addiction, old behaviors don’t disappear overnight, and we have no right to expect them to do so. For humans, change takes time.

Program administrators can cause stress for program workers. Administrators who aren’t familiar with what happens on the front lines of addiction treatment may make unworkable changes to how treatment is to be provided. As an example, I once worked for an opioid treatment program who instructed a nurse to operate three dosing windows at the same time, by herself, to reduce wait time for patients to dose. I am not making this up. Obviously this was unworkable and unwise, yet the nurse was required to “prove” the unworkability before this lame idea was discarded.

Addiction treatment providers don’t make a great deal of money. Addiction treatment professionals earn an average income of $38,000 per year, with a range of $24,000 to $60,000 per year depending on experience, credentials and treatment setting.

Counselors at OTPs have tremendous workloads. State and federal regulations say OTPS can have no more than fifty patients assigned to each counselor. Even within that limit, there’s not enough time to attend to all patient needs. And besides time spent with the patients, the time spent on documentation and paperwork is overwhelming.

In the past, addiction counselors tended to be in recovery themselves, with their personal experience as their only credential. Now there’s a push for the substance abuse treatment field to become more professionalized. The pressure to prove competency causes ever-increasing paperwork to pop up like mushrooms after a rain. And the documentation forms change all of the time. Just as workers get used to one form, it’s changed again.

To paraphrase Terri Moyers, a world-renowned addiction treatment professional, the substance abuse field is addicted to documentation and they are in denial.

OK, so there are stresses working in the field. Maybe the field will improve someday. Until then, here are some ideas about dealing with burnout:

1. Take care of your physical health. We tell patients to do this, but are we setting good examples? Eat right, go to the doctor for routine medical health screens, get to the dentist periodically, and get enough sleep. We all know what to do.
2. Have a life outside of work. This is big. I have to remind myself of this one frequently. Don’t let work become your whole identity. When you are at home, is your mind also at home, or are you thinking about a work situation? Try to keep your mind and your feet in the same place.
3. Have a creative outlet. Right now, I make pillow covers out of recycled leather. I love it; I enjoy the process of creating, and it’s fun to give them as gifts, too. This last Christmas, everyone on my gift list got a pillow or two. My house is filling up again with pillows, so they can expect more pillows this year. I’ve even started selling them on ETSY, a website that sells arts & crafts https://www.etsy.com/shop/OoolaLeather?ref=search_shop_redirect
In times past, I’ve made quilts. I seem to be drawn to the textile arts.
What is your artistic outlet? It could be something you’ve never considered as art: cooking, decorating your house, or making home renovations, or something else.
4. Don’t take things personally. We all have bad days, and another person’s nasty response to you may have nothing to do with you. Make allowance and let it roll off.
5. Don’t stuff your feelings, either. If there’s a situation at work that you don’t like, don’t wait until you explode in anger to say something about it. Go to your supervisor or other appropriate person and state your feelings about what’s going on. You’re more likely to be heard if you’re calm and logical and not spew-y.
6. Don’t have unrealistic expectations. Drug addicts use drugs. Expect this to happen during the treatment of the disease. Relapse is never OK, but if the patient is lucky enough to live through it, help them figure out why it happened so they can avoid a similar situation in the future.
7. Do some kind of aerobic exercise if your physical condition permits. Besides health benefits, exercise can make a huge difference in my ability to handle stress. It doesn’t have to be heavy exercise; even going for a walk can reduce stress.
After I broke my leg last spring, I couldn’t exercise like I was used to, and I really missed it. I felt much better after my leg healed enough to do some of my normal activities.
8. Nurture your spiritual health. This doesn’t necessarily mean participation in an organized religion, although for some people it may. For me, anything that connects me to other people and to the God of my understanding is spiritual. I feel better and more centered when I regularly make time for prayer and meditation. Obviously people find different things that nurture them spiritually.

Despite the stresses, many of us prefer to work in the field of addiction treatment, for various reasons. For those people, working in the field of addiction treatment is an avocation, not just a vocation.

For me, I love to see the positive changes in patients’ lives, and to feel like I had some small part in that. In this field when addicts find recovery it isn’t just their lives that improve; families and then communities benefit, too. I didn’t see that when I worked in primary care.

I have the best job in the world.

Opioid Addiction in Pregnancy: More Information about the Use of Methadone Versus Buprenorphine

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The MOTHER (Maternal Opioid Treatment: Human Experimental Research) trial of 2012 (Jones et al) gave us much-needed information about how buprenorphine compares to methadone when used to treat opioid-addicted pregnant women. This landmark study showed us buprenorphine can be just as effective as methadone. Babies born to moms on buprenorphine had the same incidence of opioid withdrawal (called neonatal abstinence syndrome, or NAS) at 50%, but the withdrawal was significantly less severe, the babies required about half the medication as the babies born to moms on methadone. Also, buprenorphine-exposed babies spent significantly less time in the hospital – about half as long as methadone-exposed infants.

Some doctors point out that more women on buprenorphine dropped out of that study than women on methadone, and say that proves buprenorphine is less effective. However, the majority of those women didn’t leave treatment; they just left the buprenorphine arm of the study.

This week I read another study, by Meyer et al, soon to be published in the Journal of Addiction Medicine. This study also looked at pregnant patients being treated for opioid addiction.

The authors of this new study pointed out that the MOTHER trial was a placebo- controlled, double- blind study comparing buprenorphine with methadone, but in real life, the decision to start an opioid-addicted pregnant woman on buprenorphine versus methadone is more complex, and determined by other factors. So the study by Meyer et al did a retrospective analysis. They looked at cases where the choice of buprenorphine versus methadone was made by the patient and physician, as happens in real life, then studied the outcomes. The authors of the new study believed findings will be more pertinent to what happens in everyday clinical practice.

In this retrospective cohort study, 609 pregnant patients were started on either buprenorphine (361) or methadone (248). This study took place over the years from 2000 to 2012 at a single site, University of Vermont.

The study collected various data about the newborns: their sex, estimate gestational age at delivery, birth weight, head circumference, length of stay in the hospital, whether the baby received breast milk, and if the child was sent home with the mother. The study also looked at if the newborn has NAS and if the baby needed medication, and length NAS treatment.

In the results, first-time mothers were significantly more likely to start buprenorphine than methadone. Mothers positive for Hepatitis C were more likely to be started on methadone. In both groups, more than 80% of the moms were smokers. About 30% of both groups had to have a C-section at delivery.

Both groups had similar prenatal care; more than 65% of the mother in both groups initiated care within the first trimester. However, women in the buprenorphine group were significantly more likely to get what the authors defined as “adequate” prenatal care. Women on buprenorphine were also more likely to already be in treatment when they became pregnant, compared to the women in the methadone group.

Nineteen women switched from buprenorphine to methadone, out of the three-hundred and sixty-one women who started on buprenorphine. Only five of those patients switched because buprenorphine was not strong enough for them, or other medication side effects. Most were switched to methadone because they needed more intensive monitoring at an opioid treatment program due to continued positive urine drug screens. Only three women out of the three-hundred and sixty-one started on buprenorphine dropped out and were lost from treatment.

No women were switched from methadone to buprenorphine, as one would expect. That’s because in order to switch from a full opioid, methadone, to a partial opioid, buprenorphine, the pregnant opioid addict would have to go into at least mild withdrawal, thus putting her at risk for adverse events. That’s not a risk most doctors are willing to consider.

Babies born to moms on buprenorphine, as compared to methadone, were significantly more likely to have longer gestational age. This is a good thing, because it means there were significantly fewer preterm deliveries on buprenorphine compared to methadone. The babies born to moms on buprenorphine were significantly more likely to have higher birth weights and bigger head circumference.

Just like what we saw in the MOTHER trial, this study also showed that the infants born to moms on buprenorphine required significantly less medication to treat neonatal abstinence syndrome. The buprenorphine-exposed babies required medication for a significantly shorter time than methadone-exposed newborns.

More than 95% of the infants were sent home in the care of the mother or family, which makes me think this study was done on women with fairly good stability at the time of delivery.

The authors of the study concluded that this evidence suggests that buprenorphine gives outcomes that are at least as good as with methadone.

I’d take that conclusion one step farther and say we now have several studies that show less neonatal withdrawal in babies exposed prenatally to buprenorphine compared to methadone. I have to ask myself: knowing what I do from these studies, which medication would I want to take during pregnancy? I’d prefer buprenorphine, and if it didn’t work for any reason, I’d switch to methadone.

I explain all of this to pregnant patients with opioid addiction upon admission, though I’m careful to also point out that methadone is still officially the gold standard in many places.

I think that will change soon. We are getting more information that shows outcomes equal to methadone with less severe neonatal withdrawal.

Case Study of an Opioid-addicted Patient: New England Journal of Medicine

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A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).

The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.

But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”

Huzzah!

But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.

As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.

A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”

I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.

This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.

After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.

In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”

Can I get an “Amen!”?

The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.

This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.

At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.

This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.

I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.

During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.

Goblins of Addiction

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Time for some whimsy…

Misery and Deceit, two goblins who worked for the Emperor of Wretchedness, were talking in a dark alley. Hopeless, another goblin, had just left them and was shuffling down the street, trailing the stench of sulfur.

“Idiot,” said Misery, speaking about Hopeless. “He couldn’t stop his human from getting help for addiction. What an incompetent. Doesn’t he realize that addiction must continue so we can make these humans miserable? Addiction is a key method to keep people in our Kingdom of Wretchedness”

The other goblin, Deceit, fancied himself a guru to the younger and less experienced dark spirits like Misery, Despair, and Hopeless. He smiled as he thought about how much wiser he was than the others. After all, he had been the original dark spirit to help lead most humans to addiction. He promised these humans that drugs would allow them feel good all of the time. He promised freedom from the usual ups and downs of a normal human life. Many times, they believed him.

“Well, now, Misery, when you’ve been around as long as I have…” Deceit started.

“Yeah yeah. Whatever. But what advice can we give the poor fellow?” Misery really didn’t feel like listening to the bombastic Deceit blather on again, and cut him off with a question.

“There are things to be done. After all, his human, Joe, entered treatment at a methadone clinic. As you know, in his part of the country, many people have bad opinions about that kind of treatment. Especially if they know nothing about it.” Deceit began laughing, but the laugh ended with a phlegm-producing cough. Ironically, Deceit was strongly addicted to cigarettes, though he kept saying he could quit when he wanted.

“I’ll call on poor Hopeless, and give him some advice. That would be gracious of me.” Deceit said. In his mind, Deceit finished the sentence with, “And he would owe me a big favor.” The dark spirits kept careful tallies of who owed a favor to whom, and often fought bitterly about this.

“All right, great. I’ve gotta go.” Misery was sick of this conversation, and wanted to get away. Misery was never happy with where he was, and always wanted to be somewhere else, which made it difficult to have a conversation with him.

Later that week, Deceit knocked on Hopeless’s door. It was smudged with some dirty substance. Hopeless believed cleaning house was hopeless, as it only got dirty again. Deceit’s knuckles were black with the stuff. As he was wiping the filth off his hand, Hopeless answered the door. It looked as if he’d been crying, as his eyes were red and there was mucus sliding from his nose. “Hello Deceit. Come on it. I’ve been feeling down this week after my failure with my human, Joe. Sometimes I feel like I’ll never get anything right. And of course I’ll be blamed for it all.” Hopeless sighed dramatically as he said this last part, feeling very sorry for himself.

“I’ve come to help you. I have much sound advice to give you, so let’s sit and talk for a while.”

“OK. But I doubt it will work.”

Deceit ground his teeth at Hopeless’s predictable self-pity. Of all the dark spirits, Deceit thought Hopeless was the least pleasant to be around.

“It will work,” Deceit said more emphatically than he felt. “The key is to use the people around your human to discourage him in his recovery.”

“For example, Joe’s wife is happy that Joe is no longer spending $100 a day for pain pills off the street, and she’s happy he’s no longer snorting them. But she won’t be happy if you can convince her that methadone is a dangerous drug. Suggest she look on the internet. She’s sure to find negative and untrue information. But keep her off legitimate websites. You don’t want her to learn any of the benefits of methadone. Keep her on the more emotional sites, where people write about their beliefs, and not actual facts. And be careful she doesn’t understand the distinction between methadone bought on the street and methadone dosed each day as prescribed by a doctor. Try to get her to hysterically demand of Joe that he “get off that stuff.”

“Or you can use his friends. Have them call him a weakling for wanting to quit drugs, and
how foolish he is to go to the clinic. Tell him that the clinic only wants his money. Be careful not to remind Joe that all medical treatments cost money. Convince him his addiction treatment should be free. After all, he is giving up drugs. Maybe you can even get him to thinking people should pay him to give up his drugs.”

Hopeless began to mewl about the impossibility of such things, but Deceit cut him off again.

“You can get an addict to believe all kinds of outrageous nonsense. Oh, and keep him from remembering that some of these same so-called friends have sold him pain pills. We don’t want Joe to perceive that these people want to keep a good customer.”

“Get him to go to a family doctor who’s uneducated about methadone treatment. Even if he’s seen for an unrelated medical problem, these docs sometimes will give deadly advice to such patients. Some of these doctors tell their patients to get off methadone as soon as possible.”

“What, his doctor wants him dead? Surely not.”

“Oh no, but many of them aren’t well-educated about the treatment of addiction. So if you can get Joe in with one of these doctors, we have the delight of watching a medical professional, who should know better, give bad advice to one of our humans. If Joe follows that advice, it will be easier for us to steer him back into addiction again. And then if Joe relapses, and tells his doctor about it, the doc is likely to shame him for relapsing. You see how funny it gets to be? He wouldn’t have relapsed but for the doctor’s bad advice….” Deceit trailed off, smiling at fond memories of previously amusing times.

“I don’t know. Joe doesn’t seem to be listening to me, or his old friends. He used to be easy to lead with a suggestion or two. Now he wants to stand up for himself. He says he feels good and isn’t using drugs for the first time in years. It feels hopeless to try to convince him he’s doing a bad thing.” Hopeless shook his head and squinted at the floor.

Again, Deceit felt a great surge of annoyance at Hopeless’s attitude. “Then you must undermine his confidence. Have you had no training in that sort of interference? Tell lies, and plenty of them, before he gains even more confidence. His mind must be turned against him. I’ll get one of my friends to come and help you. His name is Denial, and he’s an expert at convincing such humans that their lives in addiction really weren’t that bad. How about I send him over here later today so you two can make a plan?”

“You can send your friend Denial, but I doubt there’s much that can be done…”

Shortly after this somewhat unsatisfying end of their conversation, Deceit waddled home. (He was very fat, having fed on the misery of humans for millennia). He knew this was not a hopeless situation, because he’d seen many recovering addicts, patients of methadone clinics, who had been shamed into stopping their treatment. It was entertaining to watch a person, leading a normal life but for dosing each day with methadone, slide back down into the darkness of active addiction once he left treatment. Quite often, goblins of the underworld used the twisted fears and inaccurate beliefs of the people who said they loved the addict to aid in the addict’s downfall.

Entertainment in the underworld didn’t get any better than this!

(…inspired by The Screwtape Letters by C.S. Lewis)

“We will not regret, nor wish to shut the door on it.”

aaaaaaaaaaamends

This was a tough blog to write. I want to thread the needle; I want to relate some solid help from 12-step recovery sources without angering some of my faithful readers who become angry with any mention of 12 step recovery, and don’t feel they help people with opioid addiction.

So you’ve been warned.

I know 12-step recovery isn’t for everyone. Some people tell of bad experiences with 12-step groups. And I know millions of people have been helped by these groups, too. So take what you like from this blog entry, leave the rest, and if you read something helpful, I’ll be happy. If not, try again next week because my topics fluctuate.

I talk to many recovering addicts who voice regrets about their past. The stories vary; the patients’ main theme is regret for behavior during active addiction. I understand those feelings, and feel tempted to tell patients how to deal with these feelings… but I don’t say anything, for fear that I’ll sound too “preachy.” Who am I to tell someone that they can examine past regrets, learn from previous mistakes, make amends when needed, and face the future with a clean slate? Isn’t that a conversation for a priest, imam, rabbi, or pastor?

Yes, it is. And yet, this person is in my office. Many times my patients tell me they feel unworthy to join or rejoin a religious community, and feel judged by such groups. Some of my patients’ perceptions could be colored by their own shame, but I fear many of them are accurate in their perceptions. Addiction is still regarded as a sin by some religious groups. Other groups do know addiction isn’t a sin but a disease, which can cause us to do and say things we regret, which are contrary to our values

Twelve step groups like Alcoholics Anonymous and Narcotics Anonymous have mechanisms for dealing with past regrets and ruptured relationships. These groups didn’t invent anything new. They use the same approach as other spiritual and religious groups, which are also sound psychological advice. However, the twelve steps provide a handy framework for handling regrets.

First, in Step 4, the recovering person assesses past behavior, called a “moral inventory” in recovery parlance. That inventory is shared with themselves (ending denial), another trusted person, and the god of their understanding. Patterns of behavior emerge, giving information to be used in steps 6 and 7, where the person becomes willing to give up old behavior and ask the god of their understanding for help with this.

In step 8, the recovering person lists the people he has harmed while in active addiction. With the aid of a sponsor or trusted spiritual advisor, in Step 9 the recovering person makes plans for how best to make up for past behavior.

Amends can be as simple as saying, “I’m sorry,” to someone for past bad behavior, or amends can be more extended, like resolving to be fully emotionally present for loved ones.

Sometimes direct amends aren’t possible, if the person has moved away, died, or unable to be located. A more general amends can be made instead. For example, if a person shoplifted to support their addiction, it may be impossible to remember where and what was stolen. Part of the amends process is not to repeat the old behavior, but a more general amends may involve volunteering in the same community to help society in some way, like donating to a food bank or giving time to help a child in need.

If the recovering person feels guilty about stealing money, amends may include apologizing for the past behavior, and making a plan of re-payment. For example, I know a person in recovery now for over 16 years who sends a check for $25 each month to a governmental agency to whom he owned money after a criminal conviction. He may never get the full amount paid off, but he’s taking action to fix what he broke.

Recovering people can move forward by planning amends for past actions, but also should consult a sponsor or spiritual guide for help. For example, if an addict stole money from a drug dealer, it should not be paid back, especially if it puts the recovering addict at risk. In some situations, the best amends may mean having no contact with the other person.

Some recovering addicts have long lists of bad behavior to make amends for, and other recovering addicts’ lists may contain only a few people. Many addicts harmed only their immediate family, by not being completely emotionally available to their spouses or children during their addiction. Some recovering people feel just as bad about that as others feel about committing armed robbery for drug money.

Addiction taught harsh lessons at an exorbitant price, so we should learn from past mistakes.

The point of amends isn’t how bad the behavior was, but how the recovering person feels, and how he can leave behind guilt and shame and move forward.

Addiction, like some other diseases, affects behavior. Rather than living with regrets, recovery means facing regrets, learning from them, fixing what we can, and then moving on. It doesn’t matter what you call it: making amends, cleaning your side of the street, getting right with the god of your understanding, or some other term.

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