Archive for the ‘Recovery’ Category

Is Your Recovery Portable?

Today I listened to a friend talk about the difficulties of keeping her recovery program going after she moved to a new area.

 From what my patients tell me, this is a common problem. Last week I had yet another patient say that her relapse started when she moved to this area from another state. She had more than eight years of good recovery, but when she moved to North Carolina, she stopped doing all the things that previously made up her recovery program: 12-step meetings, calling a sponsor, and helping other addicts. Gradually, staying clean off alcohol and other drugs lost its priority, and addiction was a distant memory. She listened to the old lie of addiction: she could use drugs now, and it would be different. Her disease told her she’d been clean so long, she knew how to keep from going back to active addiction.

 This was, of course, not true. I saw this patient shortly after she lost her job because of intravenous opioid addiction.

 Why does moving to a new area seem to begin a downward slide toward relapse for some people?

 My friend in recovery who just moved was able to describe it to me. She says it’s a starting over process, and she feels like she’s on the outside. She feels like she did when she was a newcomer to meetings. She misses the feeling of being at home in meetings, surrounded by people she knows who love her. She says getting involved in meetings in a new area is the hardest thing she’s ever done, more difficult than coming to meetings for the first time.

 She says, “I’ve done this before, and I think to myself this should be easy. It took me by surprise. The loneliness is super-dangerous. I have these dangerous feelings, like I don’t belong. It’s just like my first few months of recovery, except now I keep thinking that it should be easier, and I shouldn’t be having these feelings. In early recovery, I had that gift of desperation. I was acutely aware that the drugs brought me to that point and I had to come to meetings to stay clean. I had willingness to do whatever it took. Now I don’t feel that desperate, and have a hard time making myself go to meetings. It’s hard as hell.”

 “Plus, I don’t know who in these new meetings is working a program of recovery, and whose life is just full of drama. I don’t know who the winners are. And the formats are different, though I like them. They have topic meetings and everyone who shares stays on the topic!”

 My friend seems to be doing better than she’s feeling. The last I saw her, she was surrounding by laughter and hugs. She says she’s getting through this difficult time by sharing about her feelings, and listening to the experience of other recovering people who have moved to a new area and new meetings. She stays in touch with her old friends from previous meetings, and travels the four hours to visit these friends once or twice per month during her transition.

 I think my friend will be fine, so long as she continues to do what she needs to. Going to new meetings is difficult and staying at home would be easier, but not in the long run. Given the havoc addiction has caused in her life, she’s not willing to risk a relapse with all the heartache it brings.

Interview with a Suboxone Doctor

The following is an interview with one of the first prescribers of Suboxone in Charlotte, North Carolina. Dr. George Hall is an experienced physician, board certified in both Family Practice and Addiction Medicine, who has worked in both fields for many years and helped countless addicts and their families:

JB: What have your experiences been, treating opioid addiction with buprenorphine, or Suboxone?

GH:   It’s been pretty incredible from day one…….watching people, and the difference it’s made in their lives, when they come on buprenorphine.

JB: Of the patients you’ve started on buprenorphine, what percentage would you say improved on it?

GH: Ninety-plus percent, I would think. You’ll have the occasional patient who doesn’t come back, and an occasional patient who can’t afford it, but there’s not many that stand out in my mind through the years [who have done poorly with buprenorphine].

JB: Can you describe how you decide to do a detoxification with a patient on buprenorphine, versus keeping the patients on it for longer, and what your experiences have been?

GH: The people I detox on buprenorphine are the ones who have to come off of it in a short period of time. They say, “I want off by one month or two months or three,” and generally those people actually change their mind over a period of time, as they see their life getting better.

So, most of the time, it’s patient-driven. As you know, the data for opiate dependency shows that this population just doesn’t seem to do very well. Perhaps that’s the reason I have such a positive feeling about buprenorphine. We’ve used it for maintenance, since day one, in a lot of patients, and those are the people whose lives you see continue to change over a long period of time.

JB: Are there any problems that you’ve seen with buprenorphine?

GH: I think the problem with buprenorphine is similar to the problem with methadone …we see these people getting extremely well. They don’t get euphoric, but they’re not ill any longer. They’re able to function, they’re able to sleep. It’s a long-acting medication that allows them to have a normal day. When they’re out on the street or they’re buying from the internet or they’re going to multiple doctors, they just don’t have normal days.

So is that a problem? Only if you define any sort of recovery as abstinence-based. But, if you’re defining recovery as improvement in quality of life, not using other substances, able to hold jobs, able to have families and interact with families, treat their depression, then these people do extremely well.

But…I think the problem for me is…..once they begin to do so well, it’s just like with anything else, whether it’s an alcoholic or a cocaine addict or a marijuana addict that’s been in recovery for a period of time. The acuity of the disease drops in the patient’s mind, and it seems like they think, “I’m cured,” and “I’m just normal now so I don’t need to do other things. I don’t need to go to NA meetings. I don’t need counseling. Why do you keep pushing me to do this, because I haven’t used in two years? I’m doing great.”  Whether this is the disease talking to them or it’s just part of life…

And that’s what I see with any addiction…the disease itself says you don’t have a disease, whether it’s alcohol dependency or opiate dependency, and perhaps we see that even more with opiate dependency. We see that on maintenance therapy.

JB: If you had an opiate addicted patient who had unlimited money, time, willingness, and resources, what treatment would you recommend first? If they were addicted only to opiates?

GH: When I think about that question, I think about gold standards of treatment. The people who have the highest recovery rates are professionals. Physicians in North Carolina have over a ninety percent recovery rate at five years. It’s not because they’re physicians, it’s not because they’re brilliant, it’s because they’re made to do a lot of stuff to help convince them they have an illness, and to treat it as an illness on an ongoing basis. They are made to do at least twenty-eight days, to three months, to six months of inpatient treatment, most of them from the beginning. If we had an IV opiate-addicted anesthesiologist, [he would get] probably at least twelve weeks of inpatient treatment, monitoring, and perhaps even a job change. So [addicted doctors] do extremely well. Not that they have unlimited funds, but if they want to remain a physician, they have to do certain things.

So that kind of brings me around to what you’re asking. If money were no object, I would think fairly long term – two to four months of inpatient treatment, with a slow detox with something such as buprenorphine, which is a very soft detox compared to some of the ones we’ve used in the past – followed up by intensive group therapy,  and then getting them involved in 12-step recovery programs. And after we bring them out of inpatient treatment, [they would get] some sort of follow up over a period of one to two years if we are looking at unlimited funds, and the willingness to do that. Which isn’t practical in the general population.

JB: Because of the expense and time?

GH: Because of the expense and the time we have.

Bibliotherapy: Women and Addiction

If you’ve looked at my blog before, you know I like to recommend books. I prescribe books as medicine. Looking over my sagging bookshelves, I saw a number of my favorite titles  are specific for women and addiction. While some are a bit dated, all contain information that’s helped me better understand how women, especially pregnant women, have unique needs in their recovery from addiction.

 For example, in the past, when I talked to a pregnant patient who was still using drugs, I would tell her every awful thing her drug use could possibly be doing to the fetus. I thought I could scare her into sobriety.

  It turns out that studies show this approach is associated with a worse outcome for baby and mother than an approach that emphasizes compassion and hope. Pregnant addicts carry a tremendous burden of shame and guilt, as arguably the most stigmatized people in our society. Even other addicts look down on pregnant addicts. So when physicians add to their shame, they tend to run. They leave treatment (physically or mentally), and everyone suffers. With a gentler approach, these women tend to participate in their own treatment and mother and baby have better outcomes.

 Duh. Don’t we all do better with gentler approaches?

 Anyway, here’s a list of books about women and addiction. Some I have mentioned before, like Women Under the Influence, by the National Center on Addiction and Substance Abuse at Columbia. This is maybe the most comprehensive book, full of references, about addiction in women. Happy Hours by Devon Jersild is more conversational, with excerpt from interviews with women addicted to alcohol, but it also contains solid information. One of the most entertaining, because it is a well-written story told by a female alcoholic is Drinking: A Love Story, by the late Caroline Knapp. And Lit: A Memoir, by Mary Karr, is a current best-selling book about the experience of a female alcoholic.

 Parched, by Heather Kind, is similar to Ms. Knapp’s writing, and also worth a read. This book is a well-written, entertaining documentation of an intelligent woman’s descent into alcohol addiction. Thankfully, she also describes her recovery. This is a better-than-average addiction memoir, and hasn’t gotten the recognition it deserves.

 Using Women: Gender, Drug Policy, and Social Justice, by Nancy Campbell, written in 2000, is an unusual and fascinating book. It describes how society has viewed female addicts throughout history and how they are frequently judged more harshly than male addicts. Throughout the decades, addicted women don’t do what’s expected of them by their society, and society’s expectations often shaped U.S. drug policies. The author contends that female addicts cause more outrage than male addicts because they stray so far from assumed female roles. The book is filled with cool black and white photos of sensationalized news stories from the girl addicts of the 1950’s to the crack moms of the 1990’s. This book has not gotten the accolades it deserves.

 Women, Sex, and Addiction: A Search for Love and Power, by Charlotte Davis Kasl, PhD, 1989, focuses more on the way the inequities of power in relationships shape female behavior with sex and drug use and addiction. The author discusses all sorts of addiction, not just sex or drug addictions.  For many female addicts, codependency and sex are strongly intertwined. The book also has sections of lesbian and bisexual lifestyle and addiction, and male codependency and addiction. Some sections were interesting and helpful, and others…not so much. The author uses older terminology, from the time when codependency was more in vogue.

 Women on Heroin, by Marsha Rosenbaum, 1981. This book follows the careers of 100 female addicts in a street study. The author talked with a hundred women of many ages and various races to hear what their lives are like while addicted to heroin. One theme of the book is that initially, drug use gives the illusion of empowering the women, but eventually the need to support their habit steals their power. Women resort to criminal means to support their habits, and this is more difficult for women caring for small children. Treatment programs often don’t consider how children can be a strong motivating factor for a woman to get clean, but not if she’ll lose her kids while she goes off to treatment. Lots of quotes from the women she interviews are scattered through the book.

All counselors working with female patients need to read this book to more fully understand how effectively to engage women into treatment. Besides containing useful information, it’s just a really interesting book.

 Crack Mothers: Pregnancy, Drugs, and the Media, by Drew Humphries, 1999. Here’s a book bound to stir controversy. The book describes how the “crack baby” was a media invention, not a medical reality. While some children born to women addicted to cocaine had medical issues, we now know these kids didn’t grow up to be the permanently and hopelessly damaged human beings as conjured by the media. This book talks about the racist prosecution of pregnant minority addicts, and how they tended to be the ones to be jailed, while middle and upper class pregnant addicts were able to use their resources to avoid prosecution. In some cases, pregnant women had asked for treatment but were turned away because it wasn’t financially accessible, and they were jailed instead. I thought this book was very interesting and I read it in just a few days. But then, I am a book nerd.

 Substance and Shadow: Women and Addiction in the United States, by Stephen Kandall, The author is a renowned neonatologist, and this book is scholarly, filled with references. I’m reviewing the book from memory, since I loaned it to a friend and I can’t remember who has it. The author talks about the paternalistic methods of physicians in previous centuries, and how their attitudes increased the risk for female addiction to opioids. Then he traces the history of drug policy in the U.S., paying special attention to how women were treated – or not treated – differently. This book is a bit more intense, and not as light or quick reading as most of the others listed.

 A Woman’s Way Through the Twelve Steps, and A Woman’s Way Through the Twelve Steps Workbook, by Stephanie Covington, 2000. Compared to the method of working the twelve steps outlined in either AA’s Big Book, or NA’s Step Working Guide, this workbook felt a little “fluffy.” It’s a softer way of looking at the steps, and may be quite beneficial for women who have been traumatized by abuse in the past. For some women, harsh rhetoric occasionally heard in 12-step meetings can triggers memories of abuse, verbal or physical. For women who are turned off by more traditional steps guides, this book and workbook offer an alternative. I liked the book better than the workbook. For some people, this could be a great resource. For others, it will feel too mild.

 Women and Addiction: A Comprehensive Handbook, by Kathleen Brady, Sudie Black, and Shelley Greenfield, 2009.  I’ll let you know. I’m just starting it.

 Do you have favorite books about women and alcohol or drug addiction? Please tell me what they are.

 

 

Addiction Treatment Centers Behaving Badly

A dear friend of mine, who happens to be the best addictions counselor I know, was turned down for a job at a nearby inpatient drug addiction treatment center. They said it was because of his criminal background. He has non-violent felony offenses directly related to his active addiction.

 OK. You’re thinking, “I could see that. He might steal or something.”

 But the felony occurred more than a decade ago. He has had over a decade of stable recovery from the disease of addiction. It astounds me that a drug addiction treatment center – theoretically in business because they believe change is possible for addicts – refuses to hire such a person, who has been able to change his whole life since entering recovery. Is he not more likely to be able to teach addicts how to change and recover than someone who is educated about counseling but has no personal experience?

 I am in favor of having educational standards for addictions counseling. Treatment centers shouldn’t be able to hire people off the street to be counselors if they’ve had no training, even if they are recovering addicts. But my friend isn’t only in recovery; he has a B.S. in Psychology and a Master’s degree in both Community Counseling and Addictions Counseling. I suspect he’s one of the more qualified applicants they’ll have for the job.

 My friend, though disappointed, isn’t bitter. He knows there are other treatment centers, and he will find the job he’s meant to have. It’s not his loss. It’s the treatment center’s loss. They lose out on his amazing ability to help people with addiction.

 I’ve referred patients to this inpatient program. Should I continue to send patients to that center? I don’t want them to be tainted by the attitude that they won’t be able to overcome what’s happened in the past.

  I know decisions about hiring ex-cons and recovering addicts are made high up in this organization, and not by the people actually working in the trenches. Still, I’d rather patients get help at treatment centers who practice what they are supposedly teaching.

Interview with a Recovering Addict, Part 2

…continued…

I had regular correspondence with friends, who sent me recovery literature. There was a “black market” step working guide. I used it and that’s the first time I did a “fearless and searching moral inventory” of myself. I didn’t have anyone to do my fifth step with [this is the step where the addict admits to God, himself, and another human being the exact nature of his wrongs].

At this point, I was in the county jail, about to go to state prison. This guy from Minnesota was in jail for thirty days for old warrants. It turns out he had a few years of recovery. He heard my fifth step and guided me through step seven. He mentioned his dad got [was sentenced to] forty years for murder. In the late 1970’s, when I was bringing cocaine out of Miami, the guy who set me up with the Columbians was named “Z”. I would meet him in a field [to exchange drugs] and he had a young boy with him. The guy who heard my fifth step was his son!

I’d been going in the front door of this state prison for six years, as an NA member, bringing meetings to the prisoners. Now I was in that prison. I progressed on through the steps, and experienced a change in my being…a real deep change that I can’t put into words. I recognized it was the beginning of a change that would continue to occur over a lifetime.

I relapsed once more, after nearly ten years clean. I got away from people in recovery, quit doing all the things I’d done on a regular basis, like prayer and meditation, meetings, contact with people in recovery. That relapse lasted a year. I was rescued by the Macon County Sheriff’s Office. I knew I was going to die. I was waiting for the overdose, the gunshot, whatever. I had no hope.

An addict always has the potential for relapse. I don’t care who they are, where they are, how long they’ve been clean or whatever. But once I experienced change on a deep level, mentally, emotionally, spiritually, and then used drugs again…you’re not the same addict. You don’t have the hustle. You can’t be as thoughtless, selfish, and solely self-focused as you were, before you experienced that change. I knew I couldn’t use drugs successfully, and I knew it was going to kill me. But when I lost that support, when I pushed away that foundation, that God of my understanding…That allows self-deception. It might be only momentarily, but you forget. You forget who you are, and if you’re where substances are available, you’re deceived.

JB: How’s your recovery now?

ML: Awesome. If you’d asked me in 1999 how I’d be doing now, I wouldn’t have gotten close. My life today is better than it’s ever been. I’m extremely blessed and grateful to be where I’m at today. I’m blessed to have the work, the people, a wonderful fiancée … I’m blessed to be able to share my life with the people I have in my life.

JB: What kind of work do you do?

ML: I work as a counselor. I work in a jail’s substance abuse treatment program. Looking at what they have available in jails now…fully staffed treatment programs, right in the county jail! From having to pay a candy bar to hold a meeting to where they have whole dorms in the county jail to treat addiction…the change has been awesome to see.

            This addict, ML, now has over ten years of continuous abstinence from drugs, but has been in and out of recovery for twenty-seven years. He described how his recovery progressed over time, and how he had setbacks and relapses. Obviously, given the morbidity and mortality of active addiction, treatment professionals and addicts prefer relapse-free recovery, but for many, relapse is part of the recovery process. Many fortunate addicts are able to get back into recovery, before catastrophe occurs.

ML is also a good example of how 12-step recovery meetings can help. Addiction treatment professionals should always inform addicts seeking recovery about these meetings, and encourage addicts to go to at least a half-dozen meetings, before deciding if 12-step recovery is right for them or not.

There are many recovering opioid addicts who used 12-step resources or other counseling to become completely opioid free and were able to get through both the acute physical opioid withdrawal and the more prolonged post-acute opioid withdrawal. Therefore, it does appear that drug-free recovery may be a reasonable goal for some opioid addicts who are motivated to do the work of recovery. For addicts who find the spiritual theme of 12-step recovery unacceptable, secular recovery groups are available.

            12-step recovery is free, widely available, and proven to work. It’s still the best deal in town.

Interview with a Recovering Addict, Part 1

Following is an interview with a recovering addict. His history demonstrates how NA can help an addict, and illustrates some of the main tenants of 12-step recovery.

JB: What kinds of drugs did you use?

ML: Everything. I shot cocaine, Dilaudids, heroin, quarter-grain morphine tablets, and always alcohol. Alcohol and marijuana were just a given. They were daily.

JB: Can opioid addicts get clean just using NA?

ML: Yeah. My sponsor did, and other people [have].

JB: What percentage of people in NA used opioids?

ML: Back in1982, when I entered recovery, it seemed like seventy-five percent of people in NA used opiates. Then in the 1980s, more people addicted to crack came into NA, so now I’d estimate about fifty percent or less. But there’s no numbers [statistics kept by NA].

JB: How else has NA changed?

ML: Back in the early days of NA, most addicts hit a low bottom, before coming to NA, but now, with the growth of treatment centers, drug courts, information on the internet…when my father told me I had to leave the house unless I got help, I looked in the phone book and there were only two numbers to call for help. I called the Council on Alcoholism and got directed to AA. There’s been such a growth in [addiction treatment resources]. Every family has had experience with some kind of addiction. There’s more acceptance and knowledge now. People get to NA before they hit the kind of bottom that I did. That’s a good thing.

JB: How effective is NA? Some people say that only two percent of people who go to a twelve step meeting stay clean. What do you say to that?

ML: (laughs) I’d like to know where they got their numbers.

A lot of people get their start in NA and find other means to recover…other fellowships, churchs,…it’s an individual thing. It depends on what kind of living situation the individual is in, how willing the individual is [to get clean], and what kind of recovery the people at those [NA] meetings have. It depends on how deeply they get involved in that fellowship [NA].

In my case, I went to meetings for more than a year, but I didn’t work any steps. But I stayed clean, by going to meetings and getting support from the people at the meetings. Then I moved away and didn’t have that support. It didn’t take long for me to relapse. I was around old friends I used with, old sights and sounds…It takes more than just going to meetings to be successful. There are always exceptions, though. Some people have stayed clean for years that way.

In my case, the seed was planted. I wasn’t at a point where I could honestly look at my situation. So after I skinned my ass up [experienced consequences from using drugs], I went to inpatient treatment and then a halfway house. Plus meetings [Narcotics Anonymous and Alcoholics Anonymous]. I had a little more honesty, a little more willingness. But that second time, I didn’t work all the steps. I had three and a half years clean, got to the fourth step, and I relapsed. That relapse happened when my priorities shifted from going to meetings five or six times per week to relationships, working twelve hour days, hunting and fishing. Looking back, being surrounded by people in recovery was carrying me along.

It wasn’t long. I hadn’t experienced the change that comes from working all of the steps. It was only a matter of time before the self-deception set in. How in the hell could I talk myself into thinking I could sell dope, without using it? I was dissatisfied with my job, went traveling, and met “X.” He knew I’d hauled dope out of Florida in the past, for my brother in law. He asked about my connections and asked if I could help him move some kilos. I told him I still knew a few people, but I can’t be handling the stuff. I talked myself into believing I could sell that stuff and not use it. Insane.

That led to two and a half years in state prison. This put me in a controlled environment. I knew enough about recovery and the twelve steps and the change that can happen. I’d heard enough about it that I reached out and asked people I knew in NA to get me some [recovery reading] material. That was in 1988. They didn’t have as many 12-step meetings or substance abuse programs [in jail] then like they have now. I had to reach out and ask for help. I paid “Y” [an inmate] a candy bar so he would allow me to have an NA meeting in his cell, because it was the biggest. I paid a candy bar to him each meeting. He’d never been to a meeting in his life. This was in the county jail.

When we both got to state prison, they had NA meetings there. He got real involved. He got clean and is still clean today! He has twenty-one years in recovery, works in construction, and travels the world. I went to an AA meeting a few years ago, when I was visiting a town in Alabama, and it turned out he was speaking that night. He pointed to me and said, “That man is one of the reasons I’m here.” (At this point, ML tears up and takes a pause).

…continued tomorrow…