Archive for the ‘Am I an Addict?’ Category

Recovery Means….

Image result for recovery month

September is National Recovery Month, so it’s a great time to review what recovery means to me. I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….understanding it’s more important what I think of me than what other people think of me.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

 

This Should Never Happen

 

I had a frustrating admission to the opioid treatment program last week. The patient wasn’t frustrating; she was delightful. Her experience with the healthcare system was frustrating and disappointing.

This nice lady (details have been changed to protect her privacy) has been going to a local pain management group for several years, with some success. About five months ago, she expressed a desire to taper off her prescribed opioids because she didn’t like worrying about running out of medication. She thought if she worried about withdrawal, it was a sign of opioid use disorder (which she called addiction).

The pain clinic provider listened to her concerns, then switched her to Suboxone in divided doses. It’s not clear if the provider thought the patient had evidence of opioid use disorder, or if he thought switching the patient to suboxone would help manage symptoms of pain, or if he was trying to keep the patient happy.

At any rate, the patient felt well on a relatively low, divided dose of Suboxone. She was able to go about her daily business with relatively less pain for some months.

Then she unexpectedly became pregnant.

That’s when the problems began. The patient says her prescriber got excited about her treatment, and what should be done during her pregnancy. This doctor told her the suboxone could damage her pregnancy and he couldn’t prescribe for her any more. She was also told it was very dangerous to come off Suboxone while pregnant.

As an aside, I need to inform readers that in the past, only the monoproduct buprenorphine was approved for pregnancy. Researchers and physicians worried the combination product, with both buprenorphine and naloxone, could cause withdrawal and side effects. Now, I have information from experts that the combo product is just as safe as the monoproduct. Professionals at the University of North Carolina’s Horizons Program, which treats pregnant women with opioid use disorder, say that the combination product, buprenorphine with naloxone added, can be safely used. This program, which was part of the landmark MOTHER trial back in 2010, has done renowned work for years.

Anyway, after hearing conflicting information from her pain management physician, the patient didn’t know what to do. She was terminated as a patient at this pain medicine practice because she became pregnant, but also told that if she stopped taking Suboxone, it could kill her unborn child. The pain clinic referred her to office-based prescribers of buprenorphine products in a nearby city.

When she called these practices, she was asked questions over the phone about her opioid use disorder. The patient answered honestly, but she was turned down for treatment since she didn’t meet criteria for opioid use disorder.

Not one of her providers or potential providers mentioned going for evaluation at an opioid treatment program. Her obstetrician didn’t give specific instructions for her, instead telling her to taper off her Suboxone if she could.

Thankfully the patient had a friend who knew about our opioid treatment program. This friend thought we could either help this patient or tell her where to go for help.

A day or two after the patient called our opioid treatment program, I did an admission history and physical exam for her. This means I listened to her complete history of opioid use, asked questions for clarification, and did a limited physical exam. When we finished, I told her I didn’t think she met criteria to be diagnosed with opioid use disorder,

How did I come to this conclusion? I asked a series of questions to determine if she met the criteria for opioid use disorder. She had tolerance to and withdrawal from prescribed opioids, but that’s not enough to meet diagnostic criteria. She hadn’t misused her medication by snorting or injecting and hadn’t taken more than prescribed. She didn’t use extra opioids from friends or family and didn’t ever run out early on her medications. She didn’t overuse her medication to the point of intoxication and didn’t use her medications to treat emotional states. She didn’t use alcohol to intensify effects. In short, she wasn’t my average patient.

But what was she supposed to do? Abandoned by her pain management physician, she was in a pickle. Clearly, continued treatment with buprenorphine, either mono or combo product, was the best thing for this patient and her fetus. Since she didn’t seem to have any alternatives, I admitted her to our opioid treatment program. It was the right thing to do.

I took her dose back to the 8mg per day that she’d been on, and I saw her again this past week. She felt fine, with no withdrawal, and we talked more about what to expect while on buprenorphine during pregnancy. I think she will do very well.

After she delivers, she can seek treatment at a pain clinic if that’s what she desires. Right now, she plans to taper off buprenorphine after delivery. That may work well, though tapering with a new baby at home sounds daunting to me. We will help her with whatever she desires.

We aren’t a pain clinic, and the once daily observed dosing isn’t necessary for this patient who has not developed opioid use disorder. It’s a much more intense level of care than she really needs. But we were willing to help her until she can find a better solution, for her well-being and the well-being of her baby.

She was thankful to have a solution and some answers but puzzled as to why other providers didn’t want to help her.

Pregnant ladies taking opioids, with or without opioid use disorder, are hot potatoes, at least in my region. No one wants to take care of them, so they get tossed to one provider after another. This patient’s experience is common.

You would think, now a few decades into this opioid use disorder epidemic, that we would have evidence-based guides to the treatment of these patients. We do, but providers are still reluctant.

Doctors get nervous about pregnant women taking drugs, licit or illicit. They fear extra liability comes with the extra person, the fetus. For many physicians, pregnant ladies are someone else’s problem, preferably their obstetricians’.

But obstetricians in this area, with rare exceptions, don’t want to take care of the substance use disorders. Some providers still think people who develop substance use disorders are bad people, or have bad morals, or are weak-willed. They prefer their patients take their drug use somewhere else for treatment.

How could this have been handled better?

I think the pain clinic should have continued to treat this lady with no interruptions in her care. They should have communicated with her obstetrician and coordinated care with the obstetrician. They should have been given the information that it’s now acceptable to continue the patient on Suboxone, and that pregnant patients don’t necessarily need to switch to the buprenorphine monoproduct, although that would have worked fine, too.

If the pain clinic physicians couldn’t manage this patient, they should not have dropped her until/unless they found her a new provider, instead of giving the patients a few phone numbers to call to seek help on her own. It felt to the patient like they were punishing her for becoming pregnant.

This opioid use disorder epidemic started about two decades ago. How long is it going to take for medical providers to learn how to manage or refer patients with opioid use disorder for proper care?

It’s kind of like flying a plane…if you don’t know how to land, maybe you shouldn’t take off in the first place.

Holiday Guide for Families

 

 

 

The holidays are upon us. For many people in recovery and their families, this means family celebrations and interactions. Many of us feel stress about this. No matter how much we love our relatives, there can be misunderstandings and hurt feelings. To help families identify what could lead to problems, I composed this guide last year, and I decided to re-run it this year:

What to do:

Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.

Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.

Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.

Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.

Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.

Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.

If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally.

For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.

If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication (meaning methadone or buprenorphine)?Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business..

Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.

Remember your loved one is more than the disease from which they are recovering. Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

Holiday Guide for Families

 

 

 

 

 

 

This post is written for the friends and relatives of people in recovery from substance use disorders.

What to do:

  1. Do invite your loved one in recovery to family functions, and treat her with the same respect you treat the rest of the family. If you have resentments from her past behavior, you can address this privately, not at the holiday dinner table. Perhaps given how holidays can magnify feelings, it’s best to keep things superficial and cheery. Chose another time if you have a grievance to air.
  2. Allow your relative some privacy. If the person in recovery wishes to discuss her recovery with the entire family, she will. Let her be the one to bring it up, though. Asking things like, “Are you still on the wagon or have you gone back to shooting drugs?” probably will embarrass her and serve no useful function.
  3. Accept her limitations graciously and without comment. Holidays can be trigger for drug use in some people, and your relative may want to go to a 12-step meeting during her visit. Other people in recovery may need some time by themselves, to pray, meditate, or call a recovering friend. Allow them to do this without making it a big deal.
  4. Remember there are no black sheep. We are all gray sheep, since we all have our faults. In some families, one person, often the person with substance use disorder, gets unfairly designated as the black sheep. She gets blamed for every misfortune the family has experienced. Don’t slip into this pattern at holiday functions.

What not to do:

  1. Don’t ask the recovering person if she’s relapsed. If you can’t tell, assume all is well with her recovery. If she looks intoxicated, you can express your concern privately, without involving everyone.
  2. Don’t use drugs, including alcohol, around a recovering person unless you check with them first. Ask if drug or alcohol use may be a trigger, and if it is, abstain from use yourself. If you must use alcohol or other drugs, go to a separate part of the house or to another location.  Being around drugs including alcohol can be a bigger trigger during the first few years of recovery, but any recovering person can have times when they feel vulnerable, so check with them privately before you break open a bottle of wine.
  3. If your family’s usual way of celebrating holidays is to get “ all liquored up,” then understand why a recovering relative may not wish to come to be with family at this time, and don’t take it personally. For some of us, remaining in recovery is a life and death issue, so please accept we will do what we must to remain in recovery, even if that means making a holiday phone call rather than making a holiday visit.
  4. If your recovering loved one is in medication-assisted treatment with methadone or buprenorphine, don’t feel like you have the right to make dosage recommendations. Don’t ask “When are you going to off of that medication? (meaning methadone or buprenorphine) Your loved one may taper off medication completely at some point, or he may not. Either way, that’s a medical decision best made by the patient and his doctor. Asking when a taper is planned is not your business.
  5. Refrain from giving hilarious descriptions of your loved one’s past addictive behavior, saying, “But I’m only joking!” This can hurt her feelings, and keep her feeling stuck with an identity as a drug user. She can begin to believe that with her family, being an addict is a life sentence.
  6. Remember your loved one is more than the disease from which they are recovering. Some people have diabetes and some people have substance use disorders. These diseases are only a small part of who they are.

I hope this helps.

May all my readers have a Merry Christmas and Happy Holidays!

Fentanyl is the New Heroin

aaaaoverdose-deaths

 

 

 

Big drug labs in China and Mexico have found it’s cheaper to manufacture the potent synthetic opioid fentanyl than it is to harvest and process opium into heroin. Therefore, much of what is sold as heroin is now mixed with fentanyl and its more potent analogues, sufentanil and carfentanil.

This is causing heroin overdose deaths in the U.S.  The National Institute on Drug Abuse issued a recent report saying that heroin overdose deaths increased over six-fold from 2002 to 2015. This is shown in the graphic at the beginning of this blog.

This problem is worse in some regions of our country than others; the Northeast has traditionally been plagued with heroin deaths at a high rates, but other areas of the country have higher rates of increase in heroin deaths.

There’s no way to know the potency of drugs sold as heroin, making it much easier to overdose and die.

There are some basic precautions that drug users can take to prevent overdose deaths. This is data all comes from the Harm Reduction Coalition:

  • Don’t use alone. Use with a friend, and stagger your injection times so that one person is alert enough to summon help if needed.
  • Have a naloxone kit available and know how to use it. You can get a free kit from many places, including harm reduction organizations. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/od-kit-materials/
  • Do a test dose. This means instead of injecting your usual amount, try a tiny bit of the drug first, to help assess how strong it is.
  • Use new equipment, if possible. Some pharmacies are willing to sell new needles and syringes with no questions asked. Other drug users in your community may be able to tell you which pharmacies are willing to do this.
  • Remember that if you’ve had a period of time where you’ve been unable to use any drugs, your tolerance may be much lower. Highest overdose risk is seen in patients who have just been released from jail, from detox units, or from the hospital. Do NOT go back to the same amount you were using in the past.
  • Don’t mix drugs. Opioid overdose risk increases when other drugs are used too.
  • Consider getting into addiction treatment. https://findtreatment.samhsa.gov/

 

aaaaodpills

 

My Favorite Patients Have Opioid Use Disorder

dogs-asleep-and-falling-off-couch

 

 

I’m lazy and bloated from too much tryptophan from turkey, so I’m going to post an article today that’s a re-run. I wrote it for a physicians’ magazine, and I’m pleased to say it was published (around six or so years ago). The original title was “My Favorite Patients are Drug Addicts,” but in keeping with newer language, I updated the title:

When I was a fresh faced, newly unleashed graduate from my Internal Medicine residency twenty-three years ago, I never dreamed my favorite patients would be drug addicts.

In medical school, I learned little about drug and alcohol addiction and its treatment, and in residency, even less. I was well trained in the management of acute alcohol withdrawal, acute GI bleeding from alcoholic gastritis, and antibiotic coverage of endocarditis in an injection heroin user, but I couldn’t tell any of these patients how to find recovery from the actual underlying cause of their problems. I could only treat the sequellae, and I didn’t always do that with much grace.

The addicted person caused their own miseries, I thought, and since these were the Reagan years, they should “just say no” when offered drugs. My attitudes mirrored those of the attending physicians in my residency program. When an addict was admitted twice for endocarditis, needing an artificial valve the first admission, and its replacement on the second admission for re-infection, I was just as irritated as the attending and the rest of the house staff. I remember we discussed whether we could ethically refuse him treatment if he came in a third time! We were so self-righteous, though we had offered him little in the way of treatment for his disease of addiction. We might have had a social worker ask him if he wanted to go away for inpatient treatment, he said no, and that’s where our efforts ended.

I knew nothing about medication-assisted therapies for opioid addiction. Now I know better.

I was working part time in primary care when a colleague, the medical director at a local drug addiction treatment center, asked me if I could work for him at this center for a few days while he was out of town. He was a good friend so I agreed. I thought it would be easy money, and fun, doing admission histories and physicals on addicts entering the inpatient residential program, and I was right…but I also saw patients entering the clinic’s methadone program.

This appalled me. It seemed seedy, shady, and maybe a “fringe” area of medicine. It just seemed like a bad idea to give opioid addicts methadone. However, I had made a commitment to my friend, so I told myself I would work those few days, tell my friend politely when he returned that I didn’t “believe” in methadone (as if it were a unicorn or some other mythical beast) and could not work there again.

But when I talked to these patients they surprised and intrigued me. Some patients were intravenous heroin addicts, but most were addicted to pain pills, like OxyContin, various forms of hydrocodone, and morphine. Most of them had jobs and families, and expressed an overwhelming desire to be free from their addiction. I was most intrigued by how the patients talked about methadone treatment. They said such things as “It gave me my life back” and “Now I don’t think about using drugs all the time” and “Methadone saved my marriage and my life”.

Huh? With methadone, weren’t they still using drugs?

My curiosity piqued, I started reading everything I could find about methadone – and to my surprise discovered that the treatment of opioid addiction with methadone is one of the most evidence-based treatments used in medicine today, with forty years worth of solid data proving its efficacy. So why had I never heard of it? I could have referred many intravenous heroin addicts that I saw during my residency, which happened to be during the height of the spread of HIV, for effective treatment of their addiction. Because of methadone’s unique pharmacology, it blocks physical opioid withdrawal symptoms for greater than 24 hours in most patients, and also blocks the euphoria of illicit opioids. At the proper dose, patients should not be sedated or in withdrawal, and are able to function normally, working and driving without difficulty. Therefore, methadone maintenance is not “like giving whiskey to the alcoholic” as some ill informed people – like me – have accused.

For the next eight years I happily worked part time with my friend at this drug treatment center, and saw most methadone patients improve dramatically. Certainly methadone did not work for everyone, but it was a good treatment for many addicts. I did see some tough characters, but I was struck by how normal most of the patients seemed; most were not scary thugs as I had imagined, but housewives and construction workers.

Then I began hearing about a second medication to treat opioid addiction, called buprenorphine, better known by its brand name, Suboxone. The principle of this drug is the same as for methadone: it is a long-acting opioid, can be dosed once per day, and at the proper dose removes the physical withdrawal symptoms, and does not impair patients or give them a high. As an added bonus, it can be prescribed through a doctor’s office. In 2000, the Drug Addiction Treatment Act allowed doctors, for the first time in about 80 years, to prescribe specifically approved schedule III, IV, or V controlled opioid for the purpose of treating people with opioid addiction. Shortly after this, the FDA approved buprenorphine for the treatment of opioid addiction, and the drug became available in 2003. In order to prescribe buprenorphine, a doctor must take an eight hour training course, petition the DEA for a special “X” number, and give notice to CSAT, the Center for Substance Abuse Treatment, of her intent to prescribe. Doctors prescribing buprenorphine also must have the ability to refer patients for the counseling that is so necessary for recovery from addiction.

Buprenorphine, a partial opioid agonist, is a milder opioid and there’s a ceiling on its opioid effects, making it a safer and better choice for many patients than methadone. It is particularly good for addicts with relatively short periods of addiction, and fairly stable lives. Since it is a milder opioid, it is relatively easier to taper, if appropriate.

I started prescribing buprenorphine from a private office and loved it from the first. Initially, Suboxone was expensive, but now generic forms have been approved, and prices have come down a little. Opioid treatment programs, formerly known as “methadone clinics” have started offering buprenorphine in addition to methadone.

The opioid addicts I met both in the opioid treatment program and in my private office have not been what I expected. The vast majority are ordinary, likeable people with jobs and families. They are your hairdresser, your grocery clerk, the guy that works on your furnace. They sit beside you at the movies and behind you at church. Because they have built a tolerance to the sedating effects of opioids, they do not look impaired or high; they are able to function normally in society…as long as they have a supply of opioids.

If they are in withdrawal, without a source for opioids, they will be sick. Some people compare opioid withdrawal to having the flu, but it is not. It is like having the flu…and then being hit by a truck. Most addicts in opioid withdrawal are unable to work because of the severe muscle aches, nausea, vomiting, and diarrhea. Many of these patients are blue collar workers with physically demanding jobs who initially used pain pills to mask their physical pain so that they can work harder, better, faster…never guessing that what seemed to be helping was actually causing them more harm than they could imagine.

Some patients seen in the office setting were professionals. Most professionals can afford the more expensive inpatient thirty- to ninety- day rehabs, a luxury for many of the working middle class. But I saw some lawyers, nurses, even policemen with opioid addiction who refused to consider inpatient treatment even if they could afford it. These professionals were concerned about their livelihood if it became public that they had a problem with addiction, or because they were unwilling to take time off work. They were willing to come to a doctor’s office where no one would know why they were being seen, and they did very well on buprenorphine.

I am thrilled when seeing a patient respond positively to treatment with buprenorphine. Many return on the second visit looking like younger and happier versions of themselves. On the second visit, a common phrase is “It’s a miracle!” Many patients say they just feel normal, even though they had forgotten what normal felt like. When an addict begins to recover, the changes are usually dramatic; they begin to smile, to restore relationships, to rejoin their families and their communities. When an addict recovers, the ripple effect extends throughout the community.

We know now that addiction is indeed a chronic disease much like asthma and diabetes. Just like these diseases, there are behavior components that can make the disease worse, and there are genetic and personal factors that put some people at higher risk. Sadly, many addicts are still treated with distain and disgust by their doctors, an attitude we would not tolerate towards any other disease. This causes patients to hide addiction from their doctors, and the disease worsens.

Many people, even doctors, still object to the use of medication assisted therapies for addicts, saying “it’s trading one drug for another,”  when in reality it is trading active addiction for medication, when prescribed responsibly and appropriately. Drug-free recovery is ideal, but with opioid addiction, it does patients a disservice to dismiss the mountains of evidence proving the effectiveness of medication-assisted therapies with buprenorphine and methadone.

Detoxification alone (usually five to seven days) does not work, and shows relapse rates of up to 96%. If detoxification alone worked, the policy of imprisonment for addicts promulgated in the 1950’s would have solved the opioid addiction problem. It didn’t.

For most patients, their big question is: “How soon can I get off of this drug?” Most express a desire to be completely drug free at some point, but I think it’s important to get each patient involved in a recovery program before tapering their medication. This can be an intensive outpatient program at a treatment center, an individual therapist, or through 12-step recovery.

Some patients, particularly those with both opioid addiction and chronic pain, prefer to remain on buprenorphine or methadone indefinitely as the safest treatment for both problems, and these patients also seem to do very well.

As for me, I plan to continue treating addicts of all types. These patients have been among the most grateful that I have encountered in primary care, and show the most improvement. When I treat addicts and see peace return to a face that had been filled with shame, I get a unique feeling of accomplishment. These are events I am honored to witness.

 

September is National Recovery Month!

recovery

September is National Recovery Month, so it’s a good time to come back from my blogging break. Following are some things that recovery means to me, and I hope my readers will write in with their own definition of recovery.

Recovery means…

….taking the worst and most embarrassing thing in my life and turning it into my greatest asset.

….becoming less judgmental of other people.

….remaining teachable.

….having more free time, after the burden of looking for the “next one” has been lifted.

…looking in the mirror, and feeling content at what I see.

….being satisfied with the small pleasures in life.

….developing a thicker skin for judgmental people. They aren’t going to ruin my day.

….re-connecting with the human race.

….re-connecting with the God of my understanding.

…reconnecting with myself.

….doing what I need to do for my well-being, even if other people don’t approve.

….being happy when I make progress, no longer expecting perfection.

….understanding it’s more important what I think of me than what other people think of me.

….talking frequently with other people who share my passion for recovery.

Recovery goes beyond 12-step programs or medication-assisted treatment. Recovery can apply to issues other than drug addiction. It can apply to eating disorders, co-dependency, gambling problems, sex addiction, or any other compulsive activity that is bad for our health. We can be in good recovery in one area of our life and be in active addiction in other areas. We have good and bad days. We relapse, and we try again, and we stop listening to the voice of addiction that tells us we should give up because we will always fail. We learn from our failures and come to look at them as opportunities for growth. We turn stumbling blocks into stepping stones. We lift up our fellow travelers when they weaken and they do the same for us.

We do recover.

 

Recovery Rocks