Triggers

A young friend visited our blog this week and had a very disturbing experience. She is a recovering IV drug user and someone I rely upon for  honest input and opinions on drug addiction and recovery. She is one of the few opioid addicts we know who has survived to have a second chance at life.

When she saw the image of a needle in a spoon she said: “I absolutely can’t handle that kind of trigger. For the families of users and people in recovery, that image is especially traumatic. It would make my parents panic, and it made me panic also.”

I felt so unwise – and sorry. I thought back to why I had used that photo. It was one we found on our son’s phone months after he died – I was stunned when I saw it and found that he had taken it two weeks before he died. The fact that he took that photo, documenting his using, was so distressing to us – I felt he did it to urge himself to get help but just couldn’t. 

I wanted the photo to convey the reality of what we, as families of addicts, face in our daily lives. But, as another young recovering addict friend said: “It’s like having a graphic image of someone on their death bed being injected with chemo – and trying to use that for an article about cancer. It adds shock value, but not too much else.”

So what are triggers? Are they the same for everyone? Our son said it was not hard for him to be around us when we were drinking alcohol – it was his decision to drink or not. But that was not what actually happened when he was around friends and alcohol – he ended up drinking – and then relapsed on drugs. We don’t know what the other triggers were for him with opioids, but when an addict sees things that they associate with drugs and their own using, it causes intense cravings, memory flashbacks, PTSD symptoms, racing heart, panic – and ultimately a step towards finding and using their drug of choice.

There are many good articles on internal and external triggers for addicts and alcoholics. I will summarize a few important points from this article, well worth reading: Understanding Triggers

by Sonia Tagliareni  https://www.drugrehab.com/recovery/triggers/

Long-term drug use creates an association in the brain between daily routines and drug experiences. Individuals may suffer from uncontrollable drug or alcohol cravings when exposed to certain cues. The cravings act as a reflex to external or internal triggers, and this response can even affect individuals who have abstained from drugs or alcohol for a long time.

External triggers: are people, places, activities and objects that elicit thoughts or cravings associated with substance use…A NIDA study maintains that exposure to drug-related objects may influence a former addict’s behavior. The brain registers these stimuli and processes them in the same areas involved in drug-seeking behavior.

Internal triggers: are more challenging to manage than external triggers. They involve feelings, thoughts or emotions formerly associated with substance abuse. 

Stress: stress rendered people in recovery more vulnerable to other relapse triggers.

Another good article:

https://www.thefix.com/content/triggers-addiction-dawn-roberts0318

I am grateful for the feedback from our young friends. Reviewing the role of triggers has been an important reminder that there are many friends and strangers who need me to be more thoughtful about what they are struggling with on a daily basis and to take the time to find out what I can do – or should not do – to support their recovery efforts.

The Ghosts of Grief

My husband and I just returned from a long trip – away from our home, away from all the reminders of our son’s life and death. One would think that being ‘away’ from those physical cues would minimize, or even alleviate, the consistent thoughts and feelings of our now-absent loved one. But it doesn’t.

I don’t know whether that is something to lament or cherish. I find both emotions surface at alternate times. What did strike me while we were away – away with our daughter, son-in-law, and granddaughters having lots of fun and constantly occupied – was that as soon as I had a moment alone and still, my son returned to center stage.

And it reminded me of a friendly ghost – those ones I grew up seeing in old cartoons and movies – the ones that continued to visit their loved ones and prompt them to do something, or help relieve them of guilt, or reassure them of their love.

What made me especially think of this connection was that I found myself saying inside “Not now – I don’t want to think about you now – it’s too emotionally draining, and I need to stay in the present with those I can actually love and be with now.” And, surprisingly, I find that I am able to push the memories and sense of his presence aside. The ‘ghost’ vanishes, at least temporarily. This is definitely a progression in grief. For the first year or two after JL’s death, I was not emotionally able to make this choice. Many times I was physically present with those around me but emotionally re-living some moment from the past.

It causes me to wonder if the real reason I am now taking this step is to avoid pain and if so, does that pain mean I have unfinished business with my son’s death? I’ve thought much about this and believe that is not the reason. It is more just avoiding the pain that surfaces with reminders of my son and a life cut short. And I think that pain will always be present because death, although it is our common fate, is not how things should be. I believe we are beings who were created for unending life and everything in me longs for the actual reunion I will someday have with my son, whatever that may look like.

I never want to lose the sense of my son’s presence, and the reminders of his life. So, I’m OK with the occasional ‘ghost’ appearing in my mind, even at inconvenient times, and accept it as part of the cost of life, love, and death.

Access to Medications for Addiction?

In a conversation with a friend, she felt that drug addiction was basically related to poor choices and that recovery was also just a matter of choosing to stop. I guess at the core of it, she is right. An addict needs to decide they want to stop – but then what? Do they just exert will power, go through withdrawals and possibly a 12-step program, then all is well?

Sadly, this simplistic approach will not work for most opiate addicts. The physical changes that have taken place in the brain that cause the addiction need time – and lots of it – to even partially regenerate. The Ohio Society of Addiction Medicine recently posted this (https://ohsam.org/2018/01/12):

“Studies…have found that opioid addiction medications in general cut all-cause mortality among opioid addiction patients by half or more. The CDC, National Institute on Drug Abuse, and World Health Organization acknowledge their medical value.”

The blog continues to discuss the lack of access that the majority of addicts in America have to the three medicines that specifically treat opioid addiction and some of the reasons for it:

“A major reason for that is stigma. These medications are often characterized as ‘replacing one drug with another’…This fundamentally misunderstands how (opioid) addiction works. The problem is not drug use per se; most Americans, after all, use caffeine, alcohol, and medications without major problems. The problem is when drug use becomes a personal or social burden — risk of overdose or leading someone to commit crimes to obtain drugs.  Medications for opioid addiction, by staving opioid withdrawal and cravings without leading to a significant risk of overdose, mitigate or outright eliminate those problems — treating the core concerns with addiction.”

Then there is the issue of large segments of the country without doctors who can prescribe buprenorphine/naloxone due to licensing limits – and the costs for patients.

“In a 2016 report by the surgeon general, just 10 percent of Americans with a drug use disorder obtain specialty treatment…attributing the low rate to severe shortages in the supply of care, with some areas of the country lacking affordable options for any treatment — which can lead to waiting periods of weeks or even months.” By then, it is too late for many addicts seeking help.

“Another reason for the treatment gap is a lack of federal attention…the Cures Act committed $1 billion over two years…woefully short of the tens of billions annually that experts argue is necessary to deal with the opioid epidemic…the total economic burden of prescription opioid overdose, misuse, and addiction of $78.5 billion in 2013, about a third of which was due to higher health care and addiction treatment costs.”

I can say that our son desperately wanted to be free of his addiction that started when he was too young to realize the ball and chain that would drag him down and keep him from his hopes and dreams – and eventually take his life. Thankfully, he did have access to some medical help. Incredibly, even after so many relapses, his father and I felt he could beat his addiction without medication – if he just worked harder. We were sadly mistaken.

Grieving The Living

For many, 2017 was a year of loss: a job, a home, a relationship, an opportunity. For between 120,000 parents to well over a million friends and relatives of the 60,000 persons who died from opiate overdoses in 2017, the new year will be a continuation of the grief process. Once we are forced to enter this unexpected, unwanted, and uncharted new territory, we have no choice but to travel through it. With support from our communities of friends and God’s love, we will somehow come out on the other side. If we have grieved honestly and fully, we will be better people who see others through different eyes.

But what about those who are living with a loved one in active addiction, or in a recovery program for the umpteenth time, or whose whereabouts are unknown? What is their 2018 going to be like? I can tell you, because my husband and I were there a few years ago. We were in constant flux between hoping against hope as we prayed and waited for a miraculous change, and discouragement and depression as we watched our young adult son struggle against an unrelenting foe. We were grieving the loss of the son we loved and raised and had hoped to see move successfully into adulthood. We were grieving the living.

Dr. Susan D. Writer wrote an excellent article on “Grieving the Living” posted on the Coalition For Healthy Minds website: http://cahmsd.org/grieving-the-living. The short article is well worth the read, but here are a few highlights:

“For those of us who have a loved one who struggles with mental illness or addiction, we are all too aware of how we can ‘lose the living’.  When that individual is in the throes of…any unmanaged mental illness or addiction, their behaviors are altered. They are not themselves – or at least not the version of the people that we have grown to know and love. In some instances…we can only watch as they spiral down a dark or dangerous path.  No matter what the outcome, our relationship with this loved one changes as a result of what we are experiencing, separately and together, and we often feel a deep sense of loss.  But we must grieve the relationship of the past if we are to create a new one in its place for the future…though there may be remnants of the person we knew ‘before’ the illness or addiction, the change has occurred and all of us must learn to adapt… But we all must honor these changes in our loved ones and recognize that if we are to have any relationship with them we need to learn to adjust and adapt on our end… Grieving is a process and a necessary part of life…In order for us to realize the potential for a new relationship, with new opportunities for connection and intimacy, we must grieve the old relationship, and essentially ‘grieve the living’ to allow for life to move on… On the other side of grief is growth.  And on the other side of grief is also acceptance and peace.  But most importantly, on the other side of grief is love.”

I don’t know if while grieving our living son we ever got to consistent acceptance and peace, but the love between us all remained, even up to his last phone call to us the night before his death. And for that, I am eternally thankful.

Holidays

Holidays – a time for family reunions, shared meals, communal celebrations, watching favorite movies together, reminiscing over photographs and discussing hopes and dreams for the next year.

For many families of opiate addicts, there will be an empty place on the sofa or seat at the table. If 60,000 individuals have died this year alone, the number of people affected by those deaths is multiplied by two parents, siblings, relatives, and friends: the circle of people who knew and loved our addicted ones could be in the hundreds.  If even only 10 people were impacted by the death of one addict each year, there are over half a million new surviving and grieving individuals this holiday season alone. How many more from the last decade?

For my husband and I, this is our third Christmas without our son. We can say that it is not as painful as it was three years ago, but there is still the sense that things are not as they should be. This excerpt from Roger Edwards’ article “Don’t Grieve Like the Rest of Men” from The Barnabas Letter, July 2001, p 4-5 continues to help us:

“What is hard in microwave, quick fix, America is that grief takes time. By necessity, the implications must seep and settle into all the parts of our lives. The process is inherently long, occurring slowly and over real time. Twelve months is a wise time span to remember as you grieve. Give yourself at least a full cycle of holidays, birthdays, and seasons to suffer the loss. But a year doesn’t cover it either. There are longer cycles in our lives. Loss slowly infiltrates all the corners of our lives. It wakes us late at night with memories, reintroduces itself to us when we run across pictures or possessions, and recurs during cycles of holidays and anniversaries.

We wonder, isn’t there any other way to make it through loss? But there isn’t. There is just one honest way to respond to loss. That way is to grieve. Christian grief peers into the hideous face with brutal honesty and tells the truth by deeply experiencing the loss…it mourns, it sometimes even wails. Grief is there to walk with us through despair. Everyone else fights death and loss by pretending. The grieving fight death by the truth. Death is real and is as hideous as it is real. Grief knows that death is the enemy. And it tells the truth with sorrow.”

I wish I had a magic potion for all who are grieving a loss for the first time this holiday season. I don’t. What I can offer is what I have experienced: openly telling the truth not only helps us grieve, it helps others in ways we may never know. As we honestly (and selectively) shared our feelings, we availed ourselves of empathy and comfort from those who love and care for us. And they gained understanding about grief and joy from knowing they were helping us walk through our dark times.

And in the broader scope of a nations’ corporate suffering, it is only by openness and honesty that the tide will begin to turn as solutions are found that will prevent the scourge of addiction from robbing our families of their loved ones and the joy of  holidays together.

Suboxone, Buprenorhpine, and limits on treatments

With approximately 150 people dying every day currently in the USA from an opioid overdose (CDC stats) – 60,000 a year – I want to share some basic information about Harm Reduction treatment options that my husband and I regret not choosing 6 months before our son died of a heroin overdose.

Buprenorphine (Subutex) is a narcotic that is an opiate agonist. Like heroin and other drugs derived from morphine, buprenorphine contains chemicals that link with opioid receptors in the brain to reduce pain and produce feelings of well-being. Buprenorphine was prescribed for many years as a pain reliever before it was approved for opioid addiction in 2000. It replicates the actions of opioid drugs — only to a much lower degree due to long-acting effects that can relieve cravings for opiates without giving the high and has a more mild withdrawal. But it can still be abused and overdoses do happen, especially when used with other drugs or alcohol.

Suboxone is a combination 4:1 of buprenorphine and naloxone, an opioid antagonist. Naloxone (Narcan) is used to quickly bring someone out of an opioid overdose. Suboxone was developed in response to a need to discourage users from abusing buprenorphine by injecting or snorting the drug to get high. Naloxone was added to the buprenorphine to keep the user from feeling the effects of the opioid. It was first released for use in 2003.

Our son’s addiction doctor prescribes Suboxone due to its proven ability to help addicts gradually and safely detox while they also participate in 12-step programs and counseling. It can take years of gradually decreasing doses to help and addict fully recover. Sadly, there is a federally imposed limit on how many patients a certified addiction doctor can treat each year with these drugs. Until 2017, the limit was 100 patients. It has now been raised to 275. This is woefully insufficient given the number of people addicted to opiates in our country.

In 2000, Congress passed the DATA-2000 Law limiting the number of patients a physician can treat annually for addiction. National Alliance of Advocates for Buprenorphine Treatment (https://www.naabt.org/reasons.cfm) has an excellent article on why we need to end the limit on care with these life-saving drugs. They give 20 reasons the law needs to be changed immediately. #20: “No other medications have such restrictions, including the prescription drugs people get addicted to and die from. Like many well-intentioned laws, the unintended consequences are significant.”

Suboxone is not a magic bullet, and we knew that when we rejected it for our son in 2014. He had been on Suboxone 5 years before and he was prescribed 32 mg a day – the starting dose now is 8 mg a day. Because of that high dose, the withdrawals were so much worse than those from heroin – and he was hesitant to go through that again at some future date. We thought he needed to ‘just try harder’ and be more committed to a recovery program. And it was expensive and not covered by our insurance. Sadly, we failed to realize that he needed both medication and a program. He went through withdrawals once again, entered a sober living home and did great for almost 6 months. But he needed oral surgery and was given Percocet and within 3 weeks he had relapsed and died of a heroin overdose. As it has been said, Harm Reduction methods may not be perfect, but you can’t recover if you are dead.

 

The Hijacked Brain

I watched an interview on the PBS Newshour the other night with a physician whose young son recently died of a heroin overdose. He has started a foundation to help raise awareness and to bring an end to this deadly epidemic. My husband and I connected with him on so many levels: having a wonderful and brilliant son – who desperately wanted to be free of his addiction – die a needless death; the remorse over not knowing what we could have done differently to help our son; the desire to do something to help others before they are forced to share our pain and grief. In the interview he reiterated the truth that few people understand about opioid addiction: once a person is addicted to opioids, they are truly not normal or themselves any more. The drug has hijacked their brain and they are not capable of thinking normally. They must have the drug at any cost.

This is the reason that there are so few opioid addicts who live long enough to enjoy recovery, as opposed to addicts who use uppers like cocaine or meth. As Tracey Helton Mitchell said in her memoir, The Big Fix: “Heroin kept me chasing my tail, but crack (cocaine) finally sent me into recovery.” Our son’s addiction doctor put it this way: “Most people will build up tolerance to opioids and that tolerance is what leads to addiction. Once addicted, it is only over a long period of time with medication and group therapy (like the 12-Steps) that a person has hope of being free. This is why I call it the cancer of brain diseases’.”

In her article in The Washington Post, December 1st, Dr. Sandra Block (a neurologist) gives further evidence as seen on EEG’s on the changes to the brain that opioids cause:

“Neurologically speaking, opioids are crafty. They turn the brain’s own electricity against it, rewiring connections in an endless feedback loop for more drugs. They trick the brain into a death trap, as users chase the chemical bliss from the drugs with more drugs. Acute opioid usage (that is, the high itself) translates into slowing on the EEG. Usually, such an effect is transient, carefully monitored by an anesthesiologist during surgery, for instance. But when the patient becomes the anesthesiologist, the cycle can become lethal…the opioids overwhelm the brain’s respiratory center, causing cardiac arrest… I’m seeing brain death in people who haven’t lived their lives yet, whose brains haven’t even fully developed, brains that are literally killing themselves for drugs.”

My goal in sharing this information is that it will bring awareness to families and friends – and addicts – about why opioids are so pernicious and that we will begin to see those trapped in the addictive spell as individuals who really do want help. Learning what actual help is, as opposed to enabling the addiction, is a topic for another time.