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The Opiate Epidemic

When Getting High Becomes Just Getting  Straight.

There is great concern about the misuse of opiates these days and it’s hard not to fall into one of two categories.

Either you look upon opiate use as something super severe and extreme and totally apart from the world you know and your everyday world, or you have gut wrenching life-changing experiences on the front lines.

Heroin is one of the most commonly used opiates and until the recent past, most people who had “opiate problems” were heroin users. Because of the stigma of heroin, folks who were addicted tended to live in an alternate world-amongst the junkies. It was obvious that these people were once kids, once someone’s sibling or spouse, once “normal,” but at some point in their lives they began to remove themselves from society and only exist in the alternative junkie world.

The mass production and use of over the counter pain medications has changed the face of opiate addiction and our communities.  While the eventual end result may be a needle in the arm, today’s opiate users typically start with a pill that is prescribed by a doctor. And the fact that there are so many pills available and so many users of these pills, means that this epidemic has made its way into a multitude of lives. In addition, people are able to maintain an “opiate lifestyle” while still looking and functioning “normally” in the world for extended periods of time. The good looking clean cut college student and the sweet older lady could both be hooked, and you’d never know it…unless of course you were a person who was close to them.

I will generalize a bit, but usually the college student type and the older lady type have different trajectories of use. The college student typically uses pills (often prescribed legitimately for someone else) to party and feel good and get “high.” The older lady typically uses medications prescribed to her by well-meaning doctors to deal with myriad aches and pains associated with aging. The college student may take the pills or snort the pills or inject the pills or snort or inject heroine; the older lady most likely will take them in pill form only.

Many people use the term “addiction” to describe something they have a hard time stopping. The term “dependence” can be  more apt, though, because it encompasses both psychological and physiological symptoms of withdrawal. Some drugs have one or the other and some have both. Though both are terrible to experience, physiological dependence is quite dangerous and could result in death. 

Opiates can lead to both psychological and physiological symptoms of withdrawal.. Opiate use (over time) leads to tolerance, and stopping leads to withdrawal. Tolerance essentially means that a person’s body (and mind) will become used to the opiates, requiring more to achieve the same effect (whether it be pain relief or feeling high). Withdrawal is a process which begins when the body begins craving the presence of a particular substance.

The psychological symptoms include irritability, difficulty concentrating, impatience, restlessness, mild depression and anxiety, feelings of hopelessness and despair, lethargy, sleep problems,  headaches or mild stomach problems (the latter two admittedly physical in nature but in this case, associated with psychological distress). 

Have you ever stopped drinking coffee, smoking cigarettes, indulging in ice cream in the evening, or eating doughnuts in the morning? Do some of these symptoms sound familiar to you? You do not need to be a drug addict to have these kind of psychological withdrawal symptoms, but many folks who are, have them in a stronger form, often called PAWS (Post Acute Withdrawal Syndrome).  As the name suggests, they are at their most severe immediately after and tend to dissipate over time.

As previously alluded to, opiates have both psychological and physiological symptoms of withdrawal (after a period of sustained use). Therefore, a person cannot simply stop using opiates because if they do they might, within a few hours, begin to have withdrawal symptoms. Added to the psychological symptoms (stated above) there is a tendency for fever, aches, pains, stomach problems including severe nausea and diarrhea, blurry vision, rapid heartbeat, high blood pressure and inability to sleep. These symptoms, particularly after the first 12 hours, have been described as “the flu on steroids.”

People in opiate withdrawal are unable to function in any meaningful way and often times are in need of constant supervision and sometimes immediate medical attention. It is not uncommon for the severe symptoms to last up to 72 hours. Opiate withdrawal can be traumatic not just for the addict for those who witness it—it is excruciating to see hear and often smell.

There are only two solutions. The first is to ride it out (with or without medical help) which for physical symptoms takes 3-4 days and for the psychological weeks. The second is to use opiates, which has an almost immediate effect in stopping the withdrawal symptoms in their tracks. People who choose this solution are not morally defective, weak willed, selfish or mentally ill. They are desperate, and it is difficult to turn down the quick easy solution. Looking for a quick easy solution is very human; we all do it.  The problem is, using opiates is only a short term solution; the symptoms return.  An additional risk is overdose, which happens when the amount of opiates in the body overwhelm the opiate receptors in the brain causing heart rate and breathing to slow and eventually stop. Overdose, unattended and untreated, leads to death.

A person enters a hellish cycle once they become addicted to opiates.  Each day is focused on getting a “fix” (whether it be swallowed snorted or injected) because the symptoms of withdrawal will begin about 8 hours after the last use. As you can imagine, the fear of the onset of withdrawal can make otherwise normal, loving, pleasant people act in very destructive, selfish, and sometimes illegal ways, taking great risks to both themselves and the community as a whole.

Staying “straight” (not feeling withdrawal symptoms) becomes the life’s work of every opiate addict. It is not usually about enjoyment, pleasure or getting high; it is about warding off the horrible symptoms of withdrawal.  People addicted to opiates are often referred to as “living dead” because of the state in which they live.



The Voice in My Head Is an Asshole

This is such a great line. I read it in this wonderful book by Dan Harris, 10% Happier which speaks about incorporating mindfulness meditation into your life.

This is not a book review. However, I can relate too much of what the author describes, particularly his tendency to have an incessant ongoing dialogue in his head that tends to do more harm than good. I guess we all have this experience in one form or another.

We may call it our “inner dialogue,” “self-talk,” “conscience,” or, for those in recovery, “The Addict” (more to come on this concept).  Many of us have always felt its presence and have come to accept it as our internal critic or narrator. In fact many credit this “voice” with pushing them forward towards success.  Unfortunately for many of us this voice is no friend; it is a tormentor.

Pay attention to what you say to yourself even over the course of one day. Listen carefully to yourself from the moment you open your eyes and become conscious in the morning. I am willing to bet that at least some of what you say is self-critical or negative.

Maybe your voice comments on how you look how you behave and what you say. Maybe your voice observes your environment and comments upon others, or takes a global view and has something to say about religion, politics or whatever the news story of the day is. Listen to your voice and chances are, I’m sorry to say, it is an asshole.

I suspect that your voice has little good to say about you, your environment or the world.  Worse, it pits you against others by way of comparison. Think of walking down the street. Isn’t your voice commenting on how other people look or act, and comparing you to them? You look so much better than that one; you’ll never look as good as that other.  This one looks happier, sexier, more successful or more fashionable than you. On and on it goes.

I am here to tell you that you don’t need to live this way, allowing this inner asshole to make you feel bad.  Here is my handy 3 step process:

1-Start by becoming more aware of your internal dialogue. This takes time and practice because we are so used to it that often we tune it out, even though its messages continue to be picked up.  You may have to start with small chunks of time. Listen to what you say when you open your eyes in the morning or get ready or drive your car or prepare supper. Focus on specific times and eventually you will become more aware in a general sense.

2-Develop some reasonable expression of self-talk that you may begin to insert into your daily life as a means to counter-act the asshole voice. If “I Love Myself” sounds too corny, something like “I am a good person’ “I accept myself”  “I am capable” can be a start. There are oodles of suggested sayings/mantras online.

3-Practice meditation. I talk to people about meditation and teach people basic principles every day. I will not attempt to do that here, but I will explain why meditation is the remedy to your asshole voice. Meditation helps slow down the body and breathing and as a result helps clear the mind.  If you meditate regularly and consistently I promise you, you will feel increased levels of serenity, and be visited by your asshole voice much less often. Not only will the frequency and force of your inner dialogue (asshole) decrease, but you will become much more detached from, and more of an observer of, your thoughts than a victim of them.


“The Addict”

For those who struggle with addictive behaviors or substance misuse, this inner voice can be even more detrimental and possibly life threatening. A common framework in recovery is to conceptualize “The Addict’ (sometimes called “My Addict”) as a separate and distinct entity that resides within oneself. This is very useful because it speaks to the many parts of us. It is a way for a person to identify as an “addict” but also be much more.  Let’s face it, most addicts have a part of themselves that wants to use and a part that does not. Work in treatment often focuses on fostering a conflict between these two sides with an eventual positive change in behavior as a result.

So for people with addictions, their asshole voice becomes “The Addict.”  The Addict does not want a person to stop the addictive behaviors, does not want them to have happy, productive, healthy, fulfilling lives with quality relationships. The Addict always wants to pull them back into the hole of addiction and the longer a person has experience with the former and not the latter, the less of a pull the Addict has. However, people in recovery conceptualize the Addict as always there lurking and waiting to strike, thus the importance of diligence and vigilance. Recovery is an active process of daily growth.  In recovery group meetings there is an expression; “While you were at meetings your addict was doing push-ups.” This serves as a reminder not to let your guard down.

It is no coincidence that one of the 12-steps, step 11, suggests incorporating prayer and meditation into your daily routine. Way back in 1939 when the steps were written, the founders knew about the asshole voice and how to deal with it. We in everyday society are now just catching on.

So I hope that you will take some time to pay attention to your incessant internal dialogue. If you do, you may find that it is not your friend but in fact your foe. If so, I suggest that you do something about it, because you deserve better. And if you have addiction issues, that asshole has become your Addict.  Living daily in the solution of recovery as opposed to the problem of addiction, can keep it at bay.


12-Steps Is Not Treatment

Thank goodness for innovation. Where would we be if not for those who think outside of the box; people coming to situations with a new set of eyes and a passion for understanding and people who question the status quo. Particularly at this time in history, information and knowledge is exchanged, research is performed and ideas are expressed in a more instantaneous and widespread manner than any previous time.

It is against this back drop that idea of “Non-12-step” treatment has grown in the recovery community, which unfortunately, has spread into “Anti-12-step” offshoots. I’d like to clarify two points:

1-      That 12-step recovery is not treatment.

2-      That in order to be non-12-step you don’t necessarily have to be anti-12-step.

First, a very brief overview and history lesson:

At the time of AA’s founding and beginning growth (mid to late 1930’s) there was no such thing as substance abuse treatment, nor psychiatric treatment, as we know it today. Psychiatry was (and often still is) considered the step child of medicine and substance abuse treatment a step child to it. Though psychoanalysis was in its heyday, those who could not afford daily time on the analyst’s couch or had severe mental health or substance abuse issues were typically put in a hospital or “sanitarium” for long periods of time, sometimes for life. Therefore, the “first generation” AA’rs who became sober were often the first group of people that had severe addiction issues and were able to maintain sobriety without being locked away in a sanitarium. As medical science developed, mental health (and to a lesser degree) substance abuse treatment became less stigmatized and more widely available. The individuals who developed and facilitated treatment programs early on came to sobriety though 12-step recovery and so their treatment models were built upon the same principles.

Since AA was developed by and for severe alcoholics who literally were on the brink of death or lifetime hospitalization, understandably, it is abstinence based. There is an AA slogan “Jails, Institutions or Death” that comes directly from this. Substance abuse treatment was built upon this idea and for much of the 1960’s through1990’s this was the only option. Thankfully science, research and treatment have grown and there have been great leaps forward which have led to different options for people seeking treatment. Not everyone who uses drugs or alcohol, even to excess, is an “addict” and not everyone needs to go to “rehab” for treatment. And 12-step meetings are not the same as treatment.

The reason for this confusion, I think, is because for almost 30 years almost all treatment centers used some form of the 12-step model (often called the Minnesota Model) for assisting people. During this time most of the counselors who worked at these programs were themselves in recovery and almost always they gained their sobriety though the 12-steps. It is easy to understand how the erroneous belief of “If I got sober through AA, then the only way you can get sober is through AA” permeated treatment during this time.

Today there is a difference between 12-steps and treatment. The basic idea of any 12-step meeting is for people in similar circumstances to share their experience, strength and hope with each other to support each other in living healthy sober lives. Treatment should be science and protocol based and professionally run.   The people providing the treatment should have advanced degrees and professional experience as the basis for their “authority” to provide a service for a fee. The only qualification to attend an AA meeting is a desire to stop drinking.

Quite often people are told to “go to a meeting” because of finances and geography. Treatment may be expensive, far away or not covered by insurance. 12-step meetings are everywhere and don’t cost a dime to attend, however this should not be construed as treatment. It is disheartening to read statistics that compare 12-steps to treatment because they are misleading and they compare two different things. I recently read a statistic comparing a specific form of family treatment called CRAFT (Community Reinforcement and Family Training) to Al-anon. CRAFT is a wonderful and effective form of treatment but it is completely different than al-anon. CRAFT is a treatment model designed to support family members in encouraging loved ones to enter treatment or discontinue unhealthy behaviors, Al-anon is a mutual support group of loved ones effected by alcoholism which focuses on sharing experience strength and hope in maintaining  health in the face of alcoholism. The focus in each is completely different, and yet their outcomes were compared.

This leads to my second point: anti-12-step approaches can be quite dangerous, particularly to the uninformed. From my experience I have seen anti-12-step folks fall into two categories; ones that erroneously compare 12-steps to treatment and then take issue with the 12-steps because of their “unfavorable” outcome, and ones that have had difficulty in maintaining abstinence (if that is the goal) and may find it easier to blame the process rather than look at themselves. In my opinion the former are ill informed and the latter have an axe to grind.

What to do?

Here is my thought. Become an informed consumer, learn what you can and experience what you can. Then do what works for you.

It is human nature (and by extension absolutely acceptable) to desire the least amount of intervention to obtain the maximum amount of change. Define what your problem is-in essence, do you want to cut back, or stop and if you are capable of making this change on your own, more power to you. Time will tell and numbers don’t lie. If you continue to struggle and negative consequences stack up, ratchet up your plan. This may include redefining your goal, or seeking some professional help, it may also include mutual support or all three.

Luckily we live in a time in which there are lots of different options; it is not the 1960’s anymore. I would caution against exclusive and in favor of inclusive thinking. No one way is better than another, bad or good, old school or new. You don’t have to be against something in order to be for something else. What works for me might not work for you. What is often most effective, as studies have shown, is buffet style, a little of this and a little of that, more of this and less of that.

Bon Appetit!



Detaching With Love

I find myself leaning upon this well-worn expression lately and feel as though, for my sake and yours, I should examine and expound upon it.

As I know it, this expression comes from Al-anon (mutual support groups for loved ones affected by alcoholism). Anyone who has attended an Al-anon meeting (or other related support group such as Nar-anon or Families Anonymous) can sense the devastation of addictive behaviors. There is often a feeling of tension, rigidity anxiety and fear in the air. To be fair these sensations tend to dissipate as the power of the group and the process slowly takes over.

Have you ever watched bull riders, how they hang on for dear life as the bucking bronco jostles them around? Even when they fall down the bronco drags them, limp and helpless along the floor until someone can intervene. This is the best way to describe being very close to a person with an addiction. Imagine living that way, emotionally, for years or decade.  Believe me it takes its toll.

Detachment was suggested in Al-anon as a way to keep people off of the bucking bronco, or to get them off as quickly and safely as possible when they did get on. One of the concepts that loved ones most struggle with is the idea of powerlessness. I can’t tell you how many times I have been contacted by a loved one who truly feels that if he/she just (fill in the blank here), they would get their life back on track.

Examples to fill in the blank:

-found the right therapist

-dealt with their depression

-got on the right medications

-found the right 12-step meeting

-had a spouse who was more/less…

-got a better job

-had more structure in their lives

-could find a passion.

This belief is founded on two faulty assumptions:

1-human behavior is simple, one dimensional and predictable

2-one human being can control another human being

Please note that all of the above issues are quite important and valid for a healthy life, however, we often fall into the habit of putting the cart before the horse. We believe that if we fix the external issue (see the list above) the person will have a better chance at staying sober, or the person wouldn’t have the need to use the substances in question.

Healthy coping skills and strong sobriety transcend external stresses. Life is full of bumps, missteps disappointments and sometimes tragedies. Knowing how to cope and stay sober is the foundation for dealing with life, if that does not happen first, then all else is lost. You can fix the job problem, for example, and this may buy some time, but if the addict is not actively working on recovery and healthy coping skills, he/she will turn to their coping skill of choice (their preferred substance) when the next difficulty arises.

It is easy to get sucked into the vortex of addiction and easier to look for solutions. My solution is to try not to get too sucked in. Often we, the loved ones, look for solutions for ourselves. If your drunken husbands behaviors makes you crazy, then getting him help or trying to get him to stop both “helps” him, but by extension, helps you.

Detaching with love, is avoiding the vortex, and staying off of the bulls back.

Erroneously, people believe detaching with love is not caring, it’s not helping, it’s disconnecting or abandoning. It is not. It is setting up healthy boundaries, it is developing patterns of self-care, it is developing an identify outside your role in relation to the addict. It is getting out of the way of your loved ones journey, however harrowing it might seem and it is being thoughtful and measured in expending your time, energy and money when it comes to the addict, and doing so as it relates to the solution, not the problem.

Addicts have extremely limited capacity to cope with life, (by virtue of their addiction), trying to get involved with saving or fixing them only adds to this as it disallows them to cope with their own problems.

How do you know when you need to detach?

Well here are some guidelines:

If you’re feeling overwhelmed with feelings, frantic, fearful guilty or rueful, you need to detach.

If you believe you can control outcomes (if he only does this, he can get himself together), you need to detach.

If you find yourself suggesting, commenting, questioning or in any other way ‘playing God,” you need to detach.

If your motives are shaky (fear, anxiety, dread, anger, frustration, deceit) you need to detach.

If you can take 2 minutes to stand back from a situation and aren’t certain if your intended intervention is for the solution or the problem, you need to detach.

Detaching with love is for you, the loved one. It is not intended as a tool for someone to get sober. Anyone who has lived long enough with an addict knows that the there is nothing you can do to get someone sober, that all of the work has to come from the addict.

Often times people will ask me very specific do and don’t questions;

“Should I pay for this?”

“Can I take his call?”

“What should I say if…”

Life isn’t usually black or white and therefore it’s difficult to give definite answers in these kinds of situations, and it’s absolutely 100% impossible to determine outcomes. The truth of the matter is, if you mess up, you’ll have another opportunity to try again, very soon, maybe in the next breath.

This topic is fraught with opinions, so I’m very interested in yours.




Philip Seymour Hoffman and the Russian Roulette of Relapse

I had the great fortune once again of working with a near and dear friend of mine, sadly, again  the occasion was sad. William Irwin, PhD is professor of Philosophy at Kings College in Pennsylvania and, among other distinctions, is the series editor of Philosophy and Pop Culture. Bill and I have been friends since we were teenagers and are both fans of Philip Seymour Hoffman and so we thought it fitting to write a piece about this untimely passing. We chose the venue of his blog on I have included it here in its completed form below:

Recognizing that he had a problem, Mr. Hoffman quit using drugs and alcohol after college, but he resumed his habit several months ago. Heroine, Hoffman’s preferred drug, produces “an exaggerated sense of wellbeing,” and this is the lure. As heroine use persists, though, it becomes less about the high and more about staving off withdrawal symptoms, which start within 6-8 hours of the last use. Heroine withdrawal has been described as “the flu on steroids” and can result in death if not medically monitored. Heroine addicts call using “getting straight” because it has the immediate effect of minimizing or stopping withdrawal symptoms.

Unlike other Hollywood celebrities who make the news with their on-and-off battles with addiction, Hoffman had been clean and sober for 23 years before resuming drug use several months ago. One might think all that time free from addiction would mean that he would stand a better chance of beating it when he resumed his drug use. Not so. There is an expression in the world of recovery that addiction is “chronic, progressive, and fatal.”

When an addict like Hoffman stops using drugs his body can often heal from much of the damage. Unfortunately, though, no amount of time away from the substance is enough to erase the addiction. This is why people in 12-step programs refer to themselves as “recovering” alcoholics or “recovering” addicts. They recognize that, even though they are sober and abstinent, their addiction is alive and well. It is “doing push ups outside the meeting room,” as they say. The bottom line is that addiction can be treated but it cannot be cured. Hoffman likely knew that, but the subtle insanity of addiction led him back where he came from.

In the world of recovery there are “slips” and there are “relapses.” A slip is a one-time or small-scale occurrence with immediate return to sobriety, whereas a relapse is a full-scale return to the former way of life. There is no way of predicting whether using the drug again after a period of sobriety will amount to a small slip or result in a major relapse. So, several months ago, when Mr. Hoffman took heroine for the first time in 23 years he was, in effect, playing Russian roulette. And he lost. The slip was actually a relapse, and the relapse cost him his life.

What could he have done differently? It’s easy to play Monday morning quarterback. We do not know the details of Hoffman’s recovery, but we do know that he would have been welcomed back in the rooms of 12-step programs. It’s not okay to have a relapse, but if you have a relapse it’s okay to come back. There is no hierarchy in 12-step meetings. The person with 20 years of sobriety is no better than the person with 6 months. Movie star or maintenance man, any individual is treated equally. Although an individual might feel like a failure if they have a relapse after a long period of sobriety, they are always treated with dignity and often a round of applause and effusive hugs when they return. Coming back under those circumstances is literally like getting a second chance at life. The Russian roulette of relapse doesn’t have to end badly.