Almost Ready to Get Help?

Another chapter from my untitled book, ‘Clean Enough,’ begins with comments from a reader of my blog.  The picture has nothing to do with anything, except that the Packer win was pretty awesome.  The view is from my seat at Lambeau during a game this season.

Lambeau Field club seats at night
Lambeau

I have been using various opiates for the past 2 years.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.
On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade, been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation?
This letter that captures the thoughts many addicts have as they get close to seeking treatment, and I will use the letter as a backdrop for a couple broad points. My intent, as always, is not to ridicule the writer, but rather to challenge some of the writer’s perspectives.
Remember that addiction is a disease of insight, and realize that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if a person’s unconscious contains a conflict that affects behavior, the same unconscious mind will easily keep the conflict from conscious awareness.  So I consider it to be a waste of time for an addict seeking early recovery to try too hard to figure himself out.  A much better use of time would be to work on accepting his limitations in this regard.  In fact, one of my favorite sayings is ‘a good man knows his limitations;’ recovering addicts should have version of that idea at the ready at all times, in order to quickly end those dangerous moments when we think that we ‘understand ourselves.’
The same point is made at a meeting when someone reminds a particularly-intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   I am making the point when I interrupt a patient in my office from explaining all of the reasons he relapsed, to tell him ‘it doesn’t matter.’   That’s right– IT DOES NOT MATTER.   When I write about unconscious factors that contributed so someone becoming an addict, I am writing for the sake of thinking about how the mind works—not to suggest a path to a cure.  Reflective, self-analytic thinking will not generally keep a person clean.
The writer also makes a common claim that opioids serve a purpose by medicating some troublesome psychological symptom.  Maybe someday science will support the idea that some people have ‘endogenous opioid deficiency syndrome,’ but for now the idea is not taken seriously by the addiction-treating community.   Even if the writer does have some type of deficiency, opioids are not likely the solution.  See my next paragraph for more on this issue.
All opioid addicts have the fantasy that they will find a way to keep using.  Early on, that fantasy fuels a great deal of frustration and broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work. End of story, period. I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  The only people who can take opioids without being destroyed are… people who don’t like taking opioids.  How is THAT for a messed up situation?  For example, my wife had kidney stones in 1993 and was given a bottle of Percocet tablets.  She took one, hated how it made her feel, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my depression and my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone two days later.  I know where the writer comes from when he says there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than he or I have proven, many times over, that there is no way to have those good things without having the other stuff as well–   the lying, depression, and self-loathing.
My final point refers to the writer’s complaint that care isn’t present at the time, or in the form, that he needs it.  Such complaints used to be more common, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But buprenorphine has increased the options for addicts seeking treatment.  Successful treatment used to require the near-total destruction of the addict, which in turn caused sufficient desperation to fuel adequate motivation.  Buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  The availability of buprenorphine for treatment is an amazing step forward, but it is not a miracle.  The addict must truly want to be clean in order for buprenorphine to be effective.  But it is a far cry from the situation ten years ago, when an addict had to be at death’s door in order to ‘get’ recovery.

Chapter 4, Pt 2: Stages of Addiction

I am always impressed by how similar addiction progresses in one individual versus the next.  The next reader’s comments and my comments afterward demonstrate a pattern that I have observed in one opioid addict after another.  Throughout the book, comments that I receive from others will be italicized.
I started on Suboxone in Feb 08 to get off opioids. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it because I had no more insurance and it was very expensive.
I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped because I ran out of Suboxone. About 3 days after I stopped taking it I started withdrawing. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. So what did I do? To get rid of the withdrawal feeling I was getting I started taking opioids again.
I am now on my 3rd day of Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from opioids by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you posted and to everyone else doing the same… GOOD LUCK TO ALL OF YOU!!
Early in addiction, opioid addicts believe that if they could only get past the physical withdrawal, they would be done with opioids forever.  During this first stage of opioid dependence, addicts are always fighting for that first piece of sobriety.
They hang out with each other on message boards on the internet comparing tapering plans using cocktails of amino acids or other worthless regimens, hoping to find the one that works– that gets them through withdrawal to become opioid-free.  They are not interested in meetings or rehab; they don’t consider themselves to be the kind of addicts who need THAT kind of help.  They insist that Suboxone be used only short-term, as a bridge to total sobriety.  They have no interest in accepting a life-long illness, and argue that they expect to find a ‘cure’ even as they return to opioids again and again.
Denial is huge during this stage of addiction; addicts minimize the damage opioids cause in their relationships, work, and health.  They can discount the damage in part because they consider their addiction temporary and easily corrected– once they just stop the darn opioids.  They assume– often for a long time– that the right tapering method will come along and things will be fine.  Hooked?  Not them!
Addicts enter the second stage of addiction when they have successfully discontinued opioids and made it completely through withdrawal.  From my vantage point of seeing many addicts over time, the point where sobriety is finally achieved is not associated with any particular taper method or amino acid formula, but rather occurs when addicts have had enough consequences to motivate them to tolerate the entire period of withdrawal.
More and more bad things pile up until they cannot be repressed and ignored; job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.
During the first stage, addicts get to a certain level of withdrawal and say ‘enough of this!’ and resume using.  But during the second stage the drug-related problems are remembered throughout the entire length of withdrawal, keeping addicts motivated to get free from opioids.  Often addicts are so sick of using by this time that they don’t even use a taper, but rather just stop at a moment of self-disgust, without any plan or preparation.  Or perhaps the consequences lead to a jail cell, resulting in sudden and absolute sobriety without the luxury of medication to reduce the severity of withdrawal.
That’s great, right?  They are finally free of opioids!  Unfortunately they are about to enter the third and worst stage of opioid addiction– the stage that can last for years and that totally demoralizes addicts.  The stage begins with relapse — after a week or after a year, but the bottom line is that it almost always happens — even though NOBODY thinks it will happen to him.
I hear the comment over and over — ‘don’t worry, doc, I don’t plan to relapse!’ Or ‘I hear what you are saying — but you don’t understand how motivated I am!’ Many addicts consider themselves too smart for relapse, but I see the AA adage come true over and over: nobody is too dumb for Recovery but some are too smart for it!  The meaning is that every now and then a person will avoid relapse — and it tends to be a person who has a simple take on life who didn’t really shine in other, more competitive areas.
The lucky person who finds recovery to be easy is someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities.  That person can sometimes simply stop using because he accepts the idea that he has lost the fight — that opioids are much stronger than he is, and that he will never figure out how to take them without disaster.
But most people are far too smart to find easy sobriety.  As soon as things start going well their minds take off again, and at some point they return to using.  I’m not going to spend time on the triggers for relapse, as we will discuss them another time — but there are things common to all relapses, including  rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness:’ a sense that all of the dangers of relapse apply, for one reason or another, to OTHER people.
During this third stage of opioid dependence, addicts will have repeated episodes of relapse and sobriety.  There is little joy in using, because consequences occur much more rapidly now.  More and more time is spent being sick from withdrawal.  This is the stage that long-time addicts remember and fear the most.
In my case, I could stop using every weekend;  I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME–  come Monday I won’t touch ANYTHING!’  And so I was always sick; the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them.  And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.
As I mentioned earlier, during this stage addicts become truly ‘sick and tired.’  This is a dangerous period of time for addicts for several reasons; when addicts use they feel a great deal of shame, which fuels more using — making use more impulsive and reckless and more likely to cause a fatal overdose.  Addicts in this stage become depressed — sometimes extremely depressed — and commit suicide, either actively or by not caring anymore about the risks of taking too much.
Addicts sometime feel such hopelessness or shame that they will do anything to change how they feel — swallowing any pill they come across, or shooting up unlabeled and unknown liquids — anything!  Even a hammer to the head looks good at this point!
This is the time and level of desperation when traditional treatment has been effective; addicts are at ‘rock bottom,’ and no longer feel confident about any of their own abilities.  They are ready to follow anyone or anything — after all, what do they have to lose?  Life is over anyway — so why not listen?
If an addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a shot at meaningful sobriety. But if he gets into treatment and quickly finds a girlfriend, or if he tells jokes and becomes the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is…  there is a strong chance that the treatment will prove worthless.  To get better, an addict must hold on to the attitude that he knows nothing, for only that attitude will allow change to occur.
The ‘desperation’ issue relates to why, in my opinion, young people have lower success rates in treatment.  Young people often feel too invincible for treatment to take hold.  They also have short memories for painful events; consequences are quickly forgotten and dangerous self-reliance returns.
The true wonder of AA is that the program’s founders understood all of this; the program is about humility and powerlessness, and consists of a series of steps that if practiced completely, will take people to the right frame of mind and keep them there.
The reason treatment tends to work better for older people is because first, more are at the later stage of addiction and are truly ‘sick and tired,’  and second, self-confidence tends to return a bit more slowly after a major blow in us older folks, so we hang onto our desperation a bit longer.  We also tend to remember the bad things that happen because we know that people sometimes die, and that some friendships can be lost forever.  Plus it is difficult to feel immortal when one’s body aches each morning!
In light of what you have read, go back and read the italicized comments from the reader again.  See if you can tell the stage of addiction that the person is experiencing.  I receive similar comments every day by e-mail.  I have watched over the past 16 years as addicts (including myself) repeat these stages over and over again.  Every person is convinced that he is different– only to eventually find that in regard to addiction he is the same as everyone else.
This is why I recommend seeing Suboxone as a long-term medication and seeing AA and NA as life-long programs.  In either case, the natural tendency of the untreated addict will be to relapse and return to the horrible cycle of using and withdrawal.

Chapter 4: The Disease of Addiction, pt. 1

The universal nature of addictive experience
What I enjoy the most about having a presence on the internet is receiving comments from people from around the world.  The writers describe the same progression of symptoms that characterize opioid dependence, a disease that affects people from all cultures and socioeconomic groups.
I often think about how surprised most ‘normal’ people would be to learn the true extent of what can only be described as an epidemic of opioid use.  Writers, stockbrokers, artists, businessmen, doctors, lawyers, factory workers, photographers, teachers, students, IT professionals, waitresses, realtors, landlords, welders, professors, home-makers, mothers and dads… I have patients with opioid dependence from all of these occupations in my practice alone.  And in each patient, the story is the same…  the initial use, the loss of control, the assumption that the control will come back, the feeling of being ‘different’ from those ‘other people’ who get addicted, the assumption that what happens to other people won’t happen to ME, the repeated failures to control use, the repeated episodes of withdrawal, and the fear deep in the gut that maybe I really AM in trouble after all.  Each addict knows the deep shame that ‘I should have known better.’  Each addict makes a weak effort to blame someone or something else—a lie that even the addict doesn’t fully believe but that he still uses since the alternative– accepting all the blame himself– is intolerable. Each and every addict has done things that he never thought he would do—spending the family Christmas fund on pills, picking the kids up late from school because of a dope deal or from ‘nodding off’ at work, lying to friends, spouse, or children, stealing pain pills or money from family members, and eventually criminal activity and serious consequences that leave the addict thinking, ‘how did I become one of THOSE people?!’ At that point the addict often rationalizes that his constant guilt keeps him from getting clean, but that is just another excuse; he could just as easily say that being sick of hating himself is the reason he MUST get clean.
The first choice is the one that is taken, because for an addict, there is ALWAYS an excuse to use. The family is too distant… or is‘suffocatingly close.’  The weather is too horrible, or too nice.  The house is too empty or too full; my wife is too attractive and flirty, or too unattractive and boring.  There is always an excuse– which really means that there is never an excuse.  I run short on patience when addicts telling their stories get to the excuses; I have heard them all and none of them mean anything.  And yes, I have used many of the same excuses back in my own using days.
For the typical opiate addict, those first few weeks of using felt great.  He/she was stressed over a busy job and the opioids provided extra energy at home.  The spouse and kids were happy about the changes in attitude.  But after a short time the addict began to feel miserable inside (note:  even after years of sobriety I will hear addicts wonder if they can pull it off;  find a way to capture that initial euphoria without the misery that follows.  I can save them much trouble—the answer is ‘no’).  The addict retreats further and further into a world of secret thoughts.  His personality and interests grow smaller and smaller and he puts up a cocky façade, thinking he is fooling everyone. His kids might be the first to notice that something isn’t right, only because they lack the ability to ignore and repress thoughts that are too painful or frightening to acknowledge.
A parent living behind a façade is a set-up for causing borderline personality in the kids;  later when the kids talk to their own therapists they will say that everything seemed OK– there were no beatings, and dad was always happy…  but normal child development doesn’t do well with ‘fake’ personalities.  The kids internalize the growing distance from the addict (dad or mom) as somehow related to them.  To kids, everything relates to themselves… so the distance becomes part of low self esteem, mood swings, cutting, and impulsive behavior that is really borderline personality but that some shrink with 7-minute appointments will misdiagnose as ‘bipolar.’   The kid will be put on Depakote or Seroquel or Zyprexa and will gain 100 pounds, assuring a lifetime of self-consciousness.  It is hard to acknowledge, but our addictions are horrible for our children.
The good news is that sometimes the addict will get miserable enough to take action.  The bad news is that the damage will last a lifetime– not just the addict’s lifetime, but the kids’ lifetimes as well.

Sharing My Story

Introduction:  2. Sharing my story
The book begins with a description of my own descent to active opioid addiction, my climb back to sobriety, and my efforts to remain sober.  It is important that I share my own story of addiction and recovery for several reasons. First, all addicts have some amount of internalized shame from addiction-related behavior. It is difficult for an addict to read a discussion about addiction without at some point feeling that the comments blame the addict for his bad behavior. This is especially the case if the discussion includes the type of dialogue that the addict must hear if he is to recover; i.e. comments that imply some degree of responsibility and accountability on the part of the addict.  By sharing my story I want addicts to know that I am one of them and that I have done what they have done, including many shameful behaviors wrought by desperation during my active addiction.
A distinction must be made in order for addicts to benefit from this text.  The distinction is between assigning accountability for the sake of making a person feel bad, versus attempting to instill the accountability and ownership of behavior vital to the addict’s recovery.  While there is no value in the former, the value of the latter is to deflate the grandiose ego of the actively using addict, and to help the recovering addict recognize and process repressed shame.  There is another important distinction that will help the reader understand the points made in this book:  the distinction between the cocky false ego of the using addict, vs. the true ego of the individual.  The true ego may be buried deeply within a person; so deeply that it seems to not exist. But except perhaps in sociopaths, a true ego lies inside each person, and it is that sense of ‘me’ and that ‘truthful reality’ that allows recovery to grow in treatment, and that I am trying to reach now. The true ego of the using addict, despite the false external cockiness, is fragile and insecure.  It is difficult for the insecure, using addict to lower his defenses and allow his true self to communicate with the outside world.  Hopefully the addict reading this text will have some recognition of what I am referring to.  If you are an addict, I hope you are tempted to lower your defenses and drop your cocky front, and open your mind to my comments.  I urge you to pay attention and to trust my comments on a deeper level.
All this talk about the ‘real person’ gets to the second reason I am sharing my story. Beyond the shameful behavior caused by our addictions, addicts have a number of common character defects related to addiction, including some present before our using and others that were caused by our using.  I want the addict reading this text to know, as I write about character defects, that I share the same character defects. If you understand my point about the two sides of personality or consciousness, the ‘real’ side vs. the ‘cocky front’, I urge you to let go of the fear that could prevent you from taking in what you need to hear from this book.  I have been there.  I know that confusion you sometimes feel over the nature of the ‘real me’. I understand feeling that ‘nobody understands me,’ and the thought that ‘therefore I can’t trust anyone to help me.’  I know the fear that ‘if I start to accept that I have a significant problem, there will be no end to the horrible reality and no end to all that I will have to own up to.’  If my comments cause anxiety, I urge you to drop your fear and allow the messages in this book into your conscious awareness, so that you can discover a way to move forward.
The third reason I am sharing my story is because in 12-step programs, sharing our stories is the tradition of first step meetings that welcome newcomers.  Since many readers of this book are newcomers to understanding addiction and Recovery, sharing my story is the most appropriate way to start.
After my story, I share the stories and comments of addicts who have written to me.  In all cases the information has been changed only enough to disguise the identity of the writer.  Sharing the stories is intended to keep the information true, and relevant to practical applications of buprenorphine.  The stories will help the reader learn to identify patterns of addictive thinking that are common to all opiate addicts, as the patterns are repeated in the stories of one addict after another.

The book

I’ve been writing teasers for a book about buprenorphine for a couple years now.  I keep very busy trying to maintain a solo psychiatry practice, and for awhile there I was running constantly… keepiing the practice going by day and writing nonstop at night.  I’m not sure what possessed me at the time;  I know that I tend to focus more on what I have NOT done than the things I HAVE gotten done, and I really wanted to write a book.  I still do.  But after submitting the product to a number of publishers, I have learned that there is a wide range of publishing arrangements that people work out.  A number of publishers, for example, require ‘new writers’ to make an investment in their own book before the publishers will invest money of their own;  the starting ‘investment’ by the author comes to $3000 to $5000, money that I cannot afford to spend at this point.
I’m realizing, by the way, that I have become pretty open about a number of things on this blog.  I have received a number of nice comments from people ‘out there’ over the years, and I feel like I know the people who are reading.  If you are a newcomer and the situation is freaking you out, I’m sorry.  It freaks me out sometimes too!
Since I have a book that needs a place to go, and a blog that needs material, I might as well share what I have written here– bit by bit.  I invite you to read along, and if you like the story, consider purchasing it in one big hunk at some point in the future when I get my act together!  I will be posting bite-size pieces; maybe one to three pages in length.  The title of the book is ‘Dying to be clean.’  The first chapter is entitled, appropriately enough, ‘Introduction;’ subheadings will be numbered to help keep things in the proper order. Please ask for permission before copying whatever I put here… thanks!
Introduction
1. Why write about buprenorphine?
Three years ago I applied for the DEA waiver to treat opioid dependence using Suboxone.  I knew that the small town in Wisconsin where I live with my family had an ‘opiate problem,’ but I had no idea the extent of the problem, nor how Suboxone treatment would affect my approach to treating addiction in general.  As the medical director of a residential treatment center I believed that residential treatment was necessary when dealing with opioid dependence, and that any maintenance agent would result in a condition akin to a ‘dry drunk’ where the person may not be using, but is miserable about being clean and sober.  The AA joke about a ‘dry drunk’ is that he isn’t drinking—but everybody wishes he was!
But that is not what happened. Instead, when spouses came in with patients during follow-up visits the typical comments were ‘I got my husband back’ or ‘she is the woman I used to know’.  From the addict him/herself I would hear, ‘I feel normal for the first time in my life’.   Patients on Suboxone were nothing like the ‘dry drunks’ that I had come in contact with over the years of attending AA and NA.  Instead of seeing addicts who were clean but miserable, I saw people who were excited to be free of active addiction and who were ready to get back to a happy and productive life.  It seemed that as Suboxone made the obsession to use fade away, the addict’s pre-using habits and interests returned, filling the void that the addiction left behind.
I enjoyed treating opioid dependence with Suboxone. I was reminded of my anesthesia days and the gratefulness of the women after I placed their labor epidurals.  Psychiatry is not a specialty that engenders that kind of gratitude! During my own active opiate addiction I desperately tried to stop using over and over again, only to fail every time.  By the end of my using days I was depressed and demoralized.  I had broken so many promises—to others and to myself.  I stared at my kids’ pictures so many times, thinking surely my love for them would keep me straight, and when it didn’t I felt horrible for letting them down again.  At the time I believed, like most opioid addicts, that there was no way out.  Treatment would mean coming clean about what I was doing—which would destroy my career, and perhaps even take away my freedom.  I now understand that since addiction is as fatal as any cancer, treatment simply must occur, regardless of the consequences—because otherwise there is no life at all.  But to the actively using addict the shame alone appears insurmountable, let alone the career issues.  In result, opioid addicts do not receive treatment unless they are forced to get it.  And for most addicts that occurs only after they have lost almost everything, if it ever occurs at all.
Suboxone changes the dynamics of treatment in a dramatic way.  With Suboxone (or more specifically with buprenorphine, the active ingredient in Suboxone) the typical opioid addict can force his disease into remission over the course of one afternoon!  In a treatment called ‘rapid opioid detox’ the using addict is anesthetized for an entire day and naloxone is injected to precipitate withdrawal.  24 hours later the addict is still shaking as he stumbles toward his ride back home to complete the rest of his detox.  That seriously-flawed detox strategy was the closest to a ‘free ride’ off opioids available ten years ago. Now Suboxone avoids detox almost entirely; the addict leaves the doctor’s office after Suboxone induction and can often return directly to work!  Make no mistake—Suboxone treatment is a ‘remission’ or ‘maintenance’ agent—NOT a cure.  But in many ways traditional, step-based recovery is ‘maintenance treatment’ as well.  Any addict in recovery will tell you that if an addict quits attending meetings, relapse is not far away.  Opioid dependence is a chronic condition that requires chronic treatment, whether that treatment is medication-based or program-based.  And many addicts find medication easier to accept than the dramatic personality changes often required for step programs to induce and maintain sobriety.
And yet the more I worked with Suboxone, the more I became aware of another opinion about Suboxone—an opinion that is much less gracious.  I discovered the ‘Suboxone-haters’; people who gather on internet discussion boards to bash Suboxone and to put down those who use buprenorphine to maintain sobriety.   “It’s just swapping one drug for another!” they say, ignoring the dramatic and positive changes in mood, behavior, and relationships in people who use buprenorphine for treatment of their addiction.  “You’re not really clean!” they say, ignoring their own relapses that occur on a monthly basis.  “It is all a scam by those greedy doctors!” they say, ignoring the fact that few doctors want to prescribe the medication, and that many doctors stop prescribing it after finding that the reimbursement is not worth the work of dealing with such a difficult and frustrating illness.
There is a great deal of misinformation about Suboxone on the internet and in the community, and the misinformation is what fuels the negative attitudes toward buprenorphine.  The shameful result is that young people are dying in my home town and others, at the same time that there is an under-used medication that could have saved them!  Out of a desire to counter the misinformation about Suboxone, I set up an online blog called ‘Suboxone Talk Zone’ where more and more people write to me with comments and questions about Suboxone.
This book is a collection of those questions and comments from the past few years.  These comments from addicts across America capture their desperation from years of active addiction, and show their excitement at the prospect of freedom from the obsession to use.  They show the frustration of addicts struggling to find appropriate and effective treatment.   The comments show the anger of addicts who face retribution in one form or another, first because of their addiction, and then again because of their choice of treatment.  All together, the posts will give the reader an understanding of the process of addiction, the treatment options that are currently available for opioid dependence, and the factors that should—or shouldn’t– influence one’s decision whether or not to use Suboxone for treatment of opioid dependence.

Part of my story; part of my book

I’m often asked “hey, what is YOUR story?”  That opens the door to a long, drawn out presentation… or I’ll just say “I have a book about the subject ready to go– do you know any publishers?”  I DO have a book ready to go, by the way…  and I welcome any e-mails from people with ‘industry connections.’  The book is about my story, of course, but is also an attempt to examine ‘addiction’ in a way that provides greater understanding of the condition.  A family member of an opiate addict will understand addiction better after reading the book, for example.  I also talk about Suboxone quite a bit.  In fact, readers of this blog will know how the book goes, as the book is a reflection of this blog.  In some chapters I share comments from other addicts, and use my responses to their letters to make a point or two.  My goal while writing was to discuss opiate addiction and buprenorphine using what I learned about the mind and brain while getting my PhD in Neuroscience, using insights from my experiences as an opiate addict, and using what I have learned as a doctor and psychiatrist.  My perceptions were also influenced by my experiences in residential treatment, aftercare, recovery, working as med director of a treatment center, and my own psychodynamic psychotherapy.
This post is a ‘teaser;’  I will share the first part of chapter one here, and you can finish the chapter at SuboxForum, at this link.   I hope you like it– and  if you know a publisher or book agent, please send me an e-mail–  you can go to my private practice site and just send it from there.

My Story

Nature vs. nurture
I grew up in a small town in Wisconsin, the son of a defense attorney and a teacher. I was the second of four children. I will not get into a drawn out psychodynamic exploration of my upbringing at this time except to note that I firmly believe that the way I ultimately turned out is a result of a combination of genetic, developmental, environmental, and personality factors. There were probably elements of my early life and also genetic factors that predisposed me to become an addict, but I believe that each person can point to similar predispositions. I am the one responsible for how I used the gifts and liabilities that shaped my life.
The nerd
I was a very cheerful young child, but at some point I began to struggle with social interactions. By the time I was in high school I was clueless about fitting in. The things that seemed impossible back then look easy now; why didn’t I simply look at what other kids were wearing and imitate them? That idea never entered my mind, and I cringe when I see pictures of myself at that age. Why did I think any boy should enter a school with embroidered blue jeans?! I did well with the academic aspects of school, always scoring at or near the top of my class with little effort. There was little respect for academic achievement in my rural high school, and I blamed my academic performance for at least some of the harassment directed my way. By the time I was a sophomore I was literally afraid for my own safety on a daily basis. I had several incidents where I was facing bullies, my back against a wall. I was deeply ashamed when the bullying occurred in public, and I certainly didn’t want my parents to know that it was happening. I was physically beat up on two occasions, both times accepting the blows with no effort to fight back or defend myself. The clear message from my father was that real men do not run away from a fight, and so running was not an option. But I didn’t know how to fight back, and was afraid that if I tried I would only be hurt worse, so the outcome of my ‘don’t run’ strategy was not great!
I ‘tried on’ different personalities during my last two years of high school. I became a druggie, growing my hair long and replacing the smile on my face with a look of apathy or disgust. I sported an Afro and used a pick instead of a comb. I smoked pot and drank beer when not in school. The changes worked as intended, and the harassment from other students stopped. But I was still on the ‘outside looking in’. Some people who lack social skills seem to come to terms with their unpopular position and quit trying. That wasn’t me; I continued to try to be one of the popular kids, kissing up, tagging along, and laughing at the stupid comments of ‘jocks’… Yuck! During my senior year I joined the cross-country and track teams, and in retrospect I was fitting in at the time without even realizing it. But by my high school graduation in 1978, the year when marijuana use peaked in the United States, I was a daily pot smoker with a great GPA, little confidence, and no direction in life.
I attended the same liberal arts college that my older brother was attending mainly because that was easier than finding a college that I liked more. I took the courses that were the most interesting and ended up majoring in biology. College came very easy to me because I had a genuine interest in what I was learning. Everything I learned seemed to answer a question that I always wondered about. That is, by the way, is a great way to attend college!
I was in a couple of relationships in college that in retrospect had addictive traits to them. After a difficult breakup during my sophomore year I became very depressed, and afterward spent several months engaged in the heaviest drug use of my life. My fraternity house provided ready access to pot, opium, cocaine, Quaaludes, marijuana, LSD, and hallucinogenic mushrooms. I wonder if I carried so much anger under the surface that I had a ‘death wish’; I have hazy memories of walking on a ledge seven stories up, losing control of a motorcycle and ending up in someone’s front yard without wearing a helmet, and wandering around in tunnels under the streets of Milwaukee after climbing down a manhole. I was lucky to survive those experiences, and I now try to understand similar behavior—extreme risk-taking and impulsivity—in addicts who are patients of my practice.
Local hero
Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since. During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks. I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic! To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy. But then I realized that something was fast-approaching in the current. I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight. I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling. I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her. After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!). To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”
I am grateful that I was given the opportunity to be a hero. There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God.
Getting serious
Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York. After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program. I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school. My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.
Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways. His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after. After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country. Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’. But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.
Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home. At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.

Junig as anesthesiologist at Suboxone Talk Zone
A stage of my life

Treating myself
In the spring of 1993 I took codeine cough medicine for a cold. A few weeks later I was still taking the codeine each evening. It worked so well; finally I could relax and get some quality sleep! I started feeling more irritable in the morning as the codeine wore off, so I began taking cough medicine in the morning too. By this time I was prescribing myself larger and larger amounts of the medicine. My wife found empty cough medicine bottles in my car and we argued over the secret I had been keeping. I promised that I would stop, honestly meaning every word. I knew I had a problem and wanted to fix that problem. I tried my best to stay busy and keep my mind occupied, but as time went by and my use continued I became more and more frustrated. I had ALWAYS accomplished what I set out to do! By now I was making more money than I had ever imagined, and by all measures I appeared to be a successful young physician. But as my use of codeine grew I became more and more irritable at work, and eventually more and more depressed. The ultimate trigger for seeking treatment came when I was taking a walk and heard birds singing– and in response I cursed them. I had always loved nature and wildlife, and the contrast between those old interests and my state of mind helped me see that I had lost my bearings.
I scheduled appointments with several addictionologists and treatment programs, knowing the type of treatment that I wanted but finding no programs that would go along with the treatment that I considered appropriate. I believed that I was a ‘special case’, after all! Yet all of these doctors wanted to treat me as if I was just another addict—they didn’t see how ‘special’ I was! I had an appointment with Dr. Bedi, a Freudian psychoanalyst in Milwaukee. After I explained what I knew about addiction and how ‘special’ a patient I was, Dr. Bedi began speaking. “I know you very well,” he said. “You sit with your family every night and feel like you don’t belong there, like you are miles away. You feel no connection with any of them; you feel depressed and afraid. There is no connection with your wife. You are only going through the motions.” I felt a chill down my spine as I realized that he was absolutely correct. How did he know me so well?
As I drove home I began to cry, and I pulled off the highway. I suddenly had a wave of insight into something that should have been obvious: I was powerless over my use of codeine. After trying to find will power and failing over and over, I finally ‘got it’; I had no control! As this realization of powerlessness grew stronger, instead of feeling more fearful I felt more reassured. That moment was a profound turning point in my life that continues to play out in unexpected and important ways to this day.
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