Clean Enough

In regard to my last post
There are many directions that we could take as we review that message.  My overall impression, as I read the letter, was of a person struggling to accept the reality of his condition.  Over and over, the person repeated the same behavior, starting Suboxone, stopping, and thinking this time will be different.
One thing I’ve learned as a psychiatrist, more than anything, is that change is difficult, and rare.  The writer ends with the thought that maybe this time will REALLY be different.  I have no idea if it will be, and for his sake, I hope it is… but unfortunately, the odds are that history will repeat itself.
Why, then, bother taking Suboxone—if everything just goes back to how it was?  The problem is not that Suboxone ‘doesn’t work’; the problem is in the expectations of some of those who take or prescribe the medication.  The active part of Suboxone—buprenorphine—is not a cure for addiction, but rather is a very useful tool.  Buprenorphine is a chemical that essentially tricks the mu opioid receptor.   Because of the ceiling effect—at higher drug levels, effects at the receptor remain constant as drug concentrations vary—the receptors function as if nothing is ‘coming on’ or ‘wearing off.’  That, in turn, eliminates cravings for the drug, and prevents the ‘reward’ for taking the drug.
Buprenorphine appears to work very well for the writer.  When on buprenorphine, he is able to avoid using opioid agonists.  The problem comes in the expectation that when buprenorphine is stopped, the condition of opioid dependence will somehow be gone, and will stay gone.   That is a completely different matter!
Opioid dependence is a complicated condition that can be viewed from different perspectives; behavioral, neurochemical, social, etc.  Some factors that contribute to ongoing addiction are addressed by buprenorphine, but most are not.  At one point the writer refers to being ‘stabilized on buprenorphine;’ the best way, I think, to view what happens with the medication.
During active addiction, a person finds that unpleasant emotions, thoughts, or feelings can be blunted by taking a substance.  In the long run, the consequences of using a substance become more and more negative, but the active addict cannot see beyond the pressing needs of the moment.  These pressing needs become worse, once addicted, because physical withdrawal – including depression, pain, and dread—are added to the other pressures of life.  Buprenorphine removes the neurochemical pressure to take opioids—i.e. the constant obsession to improve one’s subjective state.
Hopefully, relieving that obsession allows the patient to change the course of his life; to change social networks, to improve occupational standing, to improve self-discovery and personal insight.  If a person insists on stopping buprenorphine, the hope is that there will be enough changes in these other areas, so that the person will somehow be able to avoid responding to the urge to medicate the moment.
I think we are at a point where we need to consider the true nature of addiction.  Many treatment programs and physicians and treatment programs have an idealized image of how things should proceed after starting buprenorphine.  Patients ‘should’ be able to avoid all other substances, and patients ‘should’ be able to taper off buprenorphine at some point.  Through a process known as ‘counseling,’ patients are supposed to develop insight into their thoughts, emotions, and behaviors, so their lives follow a different course when the buprenorphine is eventually discontinued.
But what if patients CAN’T taper off buprenorphine?  What if patients eventually relapse, after stopping buprenorphine? What then?  Contradictions are apparent, when one looks for them.  We know that opioid dependence is a chronic, relapsing condition.  We know that relapse is more the rule than the exception.  We know that addiction is a process, not an event—and that ‘cure’ is not an accurate concept. Yet program after program requires people to eventually stop buprenorphine.  Talk about a set-up for failure!
To truly understand addiction and the role of buprenorphine, one must realize that addiction is a conditioned or learned phenomenon.  Parents of teens addicted to opioids will sometimes tell me ‘I just want my daughter back.’  I’ll ask the parent when he last rode a bicycle— and point out that even if the last ride was 20 years ago, he could still ride today.   And even if he hasn’t been to his childhood home for 20 years, he could likely drive straight to his front door.  THAT’S the challenge of ‘curing’ addiction!
Other thoughts…
About the ‘utilitarian’ approach… the way I suggest we view buprenorphine is the best way to consider other psychiatric medications as well, in my opinion.  We don’t think of SSRI’s as ‘curative’ for depression; rather they reduce obsession and worry, contributing to changes that allow recovery from depression.  Anticonvulsants do not ‘cure’ bipolar; rather they reduce the likelihood or severity of symptoms of mania.  Antipsychotics do not ‘cure’ schizophrenia; they prevent or reduce psychotic symptoms.
About anxiety… does the writer REALLY have it more difficult than others?  Maybe– or maybe not.  It really doesn’t matter.  Most patients who I see for opioid dependence believe they were dealt an unfair hand in life, from an emotional perspective.  Most feel that their subjective experiences are more difficult than the experiences of others.  Many say that they are ‘shy,’ or that they experience significant depression most of the time.  Most say that opioids relieved those uncomfortable emotions or sensations very effectively—at first, anyway—and that is why the addiction started.
Whether our load is truly heavier than someone else’s doesn’t matter, since we only experience our own load.  In other words, who would hurt more if his arm was severed, you or me?  It doesn’t matter—it hurts both of us ‘enough!’  At the same time, no amount of personal distress logically warrants taking something that only makes things worse.  If only addiction was logical!
About being able to choose the course of our lives… ‘Choice’ advocates–people who say that addicts choose to use drugs, and that they should simply choose NOT to use—say that addicts are weak in needing to medicate themselves through life.  In reality, there are few discreet ‘choices’ in life.  Our behavior flows seamlessly from one thing to the next.  ‘Choosing’ consists of a million tiny thoughts, sewn together and spread over a wide range of time.  The actual ‘choice’ to use occurs long before a person literally picks up the drug—- in a million subtle decisions and behaviors that the person may or may not have insight into.  Avoiding opioids, without the help of buprenorphine, requires constant awareness and engagement of insight.  Sober recovery is not effortless, and is not possible for everyone— just as some people cannot avoid depression without using SSRIs, and some diabetics cannot control their blood sugars without using exogenous insulin.  There is no shame in having one’s addiction treated!
Comments, as always, are welcome.  And to the writer, thank you for sharing your story, and provoking this discussion.  I can’t say whether it is time to stop Suboxone, or whether you will ever do well off the medication.  But in any case, I encourage you to appreciate life as best you can, and cultivate enough interests so that the buprenorphine issue falls into the background.  That, in my opinion, is the best way to use buprenorphine; to allow people to live life as if they had never become addicted, and to learn to tolerate life on life’s terms, as best they can.  For some people, maybe that’s ‘clean enough.’

Clean Enough, Chapt. 3: A Primer on Suboxone

What is Suboxone?
Suboxone is the trade name for a medication that contains buprenorphine and naloxone. A similar medication, Subutex, contains buprenorphine without naloxone.  Both are manufactured and sold by Reckitt-Benckiser, a company based in the UK with operations world-wide. Suboxone is FDA indicated for the treatment of opioid dependence.  Both medications are also used ‘off label’ (**see footnote ), or without FDA indication, to treat chronic pain and more controversially,  refractory depression.  Because of longstanding regulations in the United States that prohibit treating opioid dependence with narcotics, a waiver from the DEA is required in order for doctors to prescribe buprenorphine for that indication.  Buprenorphine can be used to treat other conditions, including chronic pain, without special waiver or permission, provided the doctor has current DEA registration for Schedule III medications and a valid state medical license.
The use of buprenorphine to treat opioid dependence in the US was made possible by the Drug Abuse Treatment Act of 2000 (DATA 2000).  In order to become certified to use buprenorphine, a physician must have his/her credentials approved by the DEA and must take an 8-hour course that describes proper uses and regulations related to buprenorphine.  Even after the passage of DATA 2000, the use of buprenorphine for treating opioid dependence was not possible until 2003, when the FDA approved Suboxone for that indication.  Buprenorphine, which had been a Schedule V drug for many years, was moved up to Schedule III by the DEA.  To differentiate the use of microgram doses of buprenorphine for treating pain from the use of milligram doses of buprenorphine for treating opiate dependence, some authors who have written about studies of buprenorphine have used the term ‘high dose buprenorphine’ or HDB for the latter.  I will try to use HDB to refer to the use of buprenorphine in milligram doses, except when the specific brand medication is discussed.
Naloxone is not necessary
The naloxone in Suboxone has no significant action when the medication is used properly, and is not responsible for the ‘ceiling effect’ of Suboxone. Suboxone is taken by dissolving the tablet in the mouth; buprenorphine enters the bloodstream via capillaries that flow just beneath the lining of the oral cavity. To get into the capillaries the dissolved buprenorphine must stick to the surfaces inside the mouth and then diffuse through those surfaces. Naloxone is a large molecule that is less soluble in fatty tissues, and so is less likely to stick to the oral surfaces (cell membranes consist of fatty molecules, so molecules that dissolve in fats pass through the membranes more easily). Since naloxone doesn’t stick to, or pass through, the cell membranes lining the mouth, little or no naloxone enters the bloodstream.  Eventually the non-absorbed molecules are swallowed, and the naloxone and the remaining buprenorphine are absorbed into the bloodstream from the intestine.  The anatomy of the circulatory system has important effects on Suboxone at this point; the blood that drains the small intestine flows into the portal vein, which takes newly-absorbed substances directly to the liver. Some substances—including buprenorphine and naloxone—are destroyed so efficiently by the liver that few molecules survive to enter the general circulation. This phenomenon, the efficient breakdown of an absorbed medication by the liver, is called the ‘first pass effect.’  The first pass effect for buprenorphine makes the medication ineffective if the tablets are swallowed, and the first pass effect for naloxone prevents oral naloxone from reaching the systemic circulation and causing withdrawal.
The reason naloxone was added to Suboxone is probably more theoretical than medical.  Buprenorphine has been used for thirty years as an intravenous pain medication, and so there are concerns over diversion and abuse of the substance.  If Suboxone is injected, the naloxone would be active (injected naloxone bypasses the first pass effect).  Naloxone blocks opioid receptors and is used clinically to reverse opioid effects during overdose, so an addict who dissolves and injects Suboxone will experience withdrawal rather than euphoria. 
I should point out that the withdrawal from naloxone that occurs when Suboxone is injected is completely different from the withdrawal that can occur when Suboxone is taken too soon after opioid use.  In the latter case, called ‘precipitated withdrawal,’ the buprenorphine is responsible for the withdrawal symptoms, NOT.  The mechanism behind precipitated withdrawal will be discussed later in this text.  I should also point out that naloxone is sometimes confused with naltrexone, which is an opioid blocker that is active when taken orally.  Naltrexone is indicated, curiously enough, to reduce cravings for alcohol in alcoholics.  It is sometimes used ‘off label’[1]  in opioid addicts in early sobriety to prevent the possibility of a ‘high’ from opioids; it has this effect by blocking receptors for opioids in the brain.  Naltrexone causes withdrawal in people who have a high tolerance to opioids, even if opioids haven’t been used for weeks.  The brain and nerve cells take up to 8 weeks to return to normal tolerance after stopping opioid agonists, and so naltrexone is generally started only after a prolonged period of sobriety.  The exception is a form of opiate detox called ‘medicated withdrawal’ or ‘rapid opiate detox.’  In this procedure the addict is given an almost-general anesthetic, and then a large dose of intravenous naloxone.  Sometimes a slow-dissolving piece of naloxone is also implanted under the skin to prevent the addict from getting high for weeks following the procedure.  The procedure sounds good in theory, but in reality the procedure costs up to $10,000 and the benefit questionable, both in terms of avoiding misery and maintaining sobriety.
Opiate receptors and opioid effects
The use of HDB for opioid dependence stems from the actions of the drug at opiate receptors.  There are many opiate receptor types and subtypes; mu, kappa, sigma, delta, and others.  The actions of most pain medications, including buprenorphine, occur at mu opiate receptors.  To provide some background, neurons communicate with each other when one neuron releases chemicals called ‘neurotransmitters’, which cross a space or ‘synapse’ and attach to ‘receptors’ on the cell membrane of another neuron.  Endorphins are naturally-occurring chemicals in our brains that act as neurotransmitters.  Endorphins (and smaller molecules called enkephalins) are released during severe trauma, activate mu receptors on neurons, and cause those neurons to block signals from pain receptors.  The teleologic reason for such a system is because during severe injury, pain serves no adaptive advantage, but rather gets in the way of survival of the injured animal.  Pain-fighting chemicals like oxycodone and hydrocodone mimic endorphins, attaching to mu receptors and causing neurons with those receptors to fire at a rate even greater than the firing caused by endorphins.  The extra activity of these neurons causes analgesia, euphoria, relaxation, energy… good feelings for the most part.  When the chemicals leave the receptors the neurons stop firing, and the good feelings go away, and so the person wants to take the pain pills again– and again.
Most parts of our bodies, including neurons, have some ability to repair themselves. The neurons stimulated by endorphins and pain pills recognize that they are firing at an abnormal rate, and make changes to bring the firing rate back down to normal.  They do this by changing the receptors, essentially making the receptors less sensitive to the chemicals that activate them.  It then takes larger levels of chemicals to get the same effect– something called ‘tolerance’.  Over time, the receptors become less and less sensitive in response to increasing doses of pain pills.  That is why patients with chronic pain can end up taking huge doses of pain pills yet get little benefit from them.  A person in this situation must take large doses of pain pills just to get the neurons to fire normally! The person is now ‘physically dependent’ on opioids.  The receptors have become so insensitive that the person’s own endorphins no longer activate them.  And without activation of the receptors, the neurons become quiet, allowing pain input from everywhere to flood the brain.  This situation is experienced as ‘withdrawal’—a miserable state of affairs that opioid addicts learn to avoid at any cost.  As before, the neurons can ‘fix themselves’; they recognize that they are firing at an abnormally slow rate and adjust the receptors, this time making them more sensitive to stimulation.  The sensation of withdrawal will go away when the neurons have made the receptors normal again, so that native endorphins will activate them– a process that takes days, weeks, or even months, depending on a number of factors.
**
The term ‘off label’ refers to the prescribing of medications for purposes other than those approved by the FDA.  A pharmaceutical company will submit evidence to the FDA that a given drug, say ‘drug X’, is effective for treating depression.  If the FDA gives approval, the drug is then ‘indicated’ for that use.  The company can run ads and market the medication for that use, provided they also list the risks of the medication in the commercials—those fast words at the end about how the medication might kill you.  If a few years later drug X is found to cure something else, say baldness, doctors can prescribe the drug to treat baldness without needing any special FDA permission.  This is called ‘off label prescribing’, and is actually very common.

Clean Enough: Some Distorted Thinking

Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup.  Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.

A horrible relapse in Eleuthera
Eleuthera: not a soul in sight

In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket!  I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days!  So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera.  I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well.  Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way.  I eventually learned that both were true—but that and other realizations required further ‘education.’  I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.

Clean Enough, Chapter 2.5, 2.6, and 2.7

My Story (continued)
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.
I’m cured!

Eleuthera beach
Eleuthera awaits...

My admission of powerlessness was the start of my sobriety.  I soon found a treatment program that let me enter outpatient treatment, and I also began attending 12-step meetings.  AA and NA became guiding principles in my life, and over the next five years every area of my life improved.  My marriage and family life improved, I became Board Certified, I was elected Chief of our Anesthesia Department, my wife and I had another healthy daughter, we bought a vacation home… what’s not to like?
After five years of avoiding all intoxicating substances and attending AA, there was no doubt in my mind that my problems with addiction and opioids were behind me. Avoiding alcohol was not difficult, because I was never much of a drinker. One afternoon I had some friends over to watch the Green Bay Packers, who had been having a great season. I was serving beer in my home, something that I had avoided for the first several years of my sobriety, but that I began doing after becoming convinced that relapse was not a concern. At some point during the game I asked my wife whether she thought it would be a good idea for me to have a beer. How sneaky– I have since learned that we addicts will do this type of thing on the road to relapse; we set up a situation where we know in advance what the outcome will be—that outcome being the answer that the addict inside our brains wants to hear. We are looking for permission to take a very small chip out of our sobriety. I manipulated my wife into saying what I needed to hear, and a few minutes later I was sipping a beer. From that day forward it was okay to have beer during Packer games. It was then a logical step to enjoy a glass of wine with dinner. I found a wine store run by two retired college Geology professors, and tasting wine from different parts of France became an academic exercise. In fact, I was so inspired by the idea of lifelong learning that I began to enjoy this academic exercise every evening at dinner time. At some point I was introduced to port, a fascinating beverage that has a noble history and just happens to have higher alcohol content. When eating Mexican food, margaritas were, of course, more appropriate. And then I found that there is a huge world out there of aged cognacs, which have a history all their own!  Wow, I was learning a lot!
Some distorted thinking
You see where this is going. My behavior was an example of cross addiction, where an addict stops one substance but continues to use another, only to find that the previously safe substance becomes the drug of choice. My use of alcohol increased, and soon I was drinking as soon as I got home from work, to ‘unwind.’ When my wife protested I started sneaking small bottles of whiskey and hiding them in places once reserved for bottles of cough syrup.  Once again I knew that I had a problem, and I also knew that I was in denial. The funny thing is that simply knowing that I was in denial did nothing to stop the denial. I would pause for a moment and think to myself that there were problems ahead, but I would quickly sweep the thought aside to be dealt with on another day.
In June of the year 2000 our family rented a house for a week in Eleuthera, Bahamas. My son sprained his neck snorkeling, and the spasms caused him to grimace with pain whenever he tried to move. Desperate for a solution, I drove from market to market on the small island looking for something that would work as a muscle relaxant in addition to the several bananas full of potassium that I had already given him. I eventually came across a market that sold, over the counter, a dissolvable tablet that contained aspirin along with my old friend, codeine. I felt a rush of excitement as I purchased a packet of tablets for my son… and another packet of tablets for myself, to treat the headache that I suddenly realized I would probably get later that evening.
I have since learned that this is another common behavior of addicts: setting up an eventual relapse. Rather than relapse directly I carried the tablets in my pocket for about 24 hours, before eventually realizing that I had a headache. In fact, I had a severe headache—so it was lucky I had the codeine in my pocket!  I took the codeine with nervous excitement and an hour later was disappointed that the effect was not as great as I had anticipated, so I took a couple more tablets. An hour or two later, I still was not satisfied, and I took several more. By the end of the evening I had used up all of the tablets that I had assumed would last the next four days!  So there I was, late at night on a small dark Island, driving on the left hand side of the road back to the market to buy more codeine, ‘just in case my son needed them.’
I learned a great deal about addiction because of that trip to Eleuthera.  I was amazed at how quickly, after seven years, I resumed the behavior that I thought I had left far behind. I also noted that I was returning to substances not out of desperation, but rather at a time in my life when things were going very well.  Either there was a self-destructive aspect of my personality that needed to bring me down a notch (a big notch!), or I wasn’t as happy as I thought I was—that despite the money and success I was still ‘desperate’ in some way.  I eventually learned that both were true—but that and other realizations required further ‘education.’  I continued using codeine during the remainder of my vacation, and I returned to the United States scared to death about what the future would hold.

Clean Enough, chapter 2.3 and 2.4, My story continued

My Story (cont.)
Local hero

Hero for a day in 1979

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, for the times when I had little else to feel proud of..
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.

Clean Enough, chapter 2.1 and 2.2: My Story

Chapter 2:  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.

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.