The Well-Known Effects of Opioids

I was re-reading a book by George MacDonald, entitled The Curates Awakening. I had forgotten an aspect of one of the main characters plight: opioid addiction. What struck me as I read this paragraph was the age-old, well-known addictive qualities of opioids:

“From a tragic accident of his childhood, he had become acquainted with the influences of a certain baneful drug (opium), to which one of his Indian servants was addicted. Now…to escape from gnawing thoughts, he began to experiment with it. Experimentation called for repetition, and repetition first led to a longing after its effects, and next, to a mad appetite for the thing itself…on the verge of absolute slavery to its use.”

This was written in 1870. Laudanum – an opium tincture that contains almost all of the opium alkaloids, including morphine and codeine – was developed in the 16th century. By the 18th century, the medicinal properties of opium and laudanum were well known.

By the 19th century, laudanum was used in many patent medicines to relieve pain, to produce sleep, to allay irritation.The Romantic and Victorian eras were marked by the widespread use of laudanum in Europe and the United States. The early 20th century brought increased regulation of all narcotics as the addictive properties of opium became more widely understood. By mid 20th century, the use of opiates was generally limited to the treatment of pain, and were no longer medically accepted “cure-alls”. (Wikipedia)

How is it that the manufacturers of OxyContin (Purdue Pharma) and other prescription opioids claimed and advertised that they were not addictive? Their scheme was so persuasive that I have friends today that believe that if you are truly in pain, opioids are not addictive. This is absolutely false. And how did the FDA let this go on?

Yes, we can be thankful that new ways to deliver pain relief were developed for patients with extreme pain from cancer and terminal illnesses. I have seen the need for it when I cared for my sister who was dying of brain cancer and had a morphine drip. But the wholesale promoting – pushing – of these drugs for every ache and pain while knowing how absolutely addictive they were is unconscionable. Had we really understood the power of opioids when we first learned our son was addicted, we would have taken a much more pro-active approach to his initial recovery program.

On October 30, 2017, The New Yorker published a must-read multi-page exposé on Mortimer Sackler, Purdue Pharma, and the Sackler family, by Patrick Radden Keefe:
https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain

“The Sacker dynasty’s ruthless marketing of painkillers

has generated billions of dollars – and millions of addicts.”

The article links Raymond and Arthur Sackler’s business acumen with direct pharmaceutical marketing and the rise of addiction to OxyContin. The article implies that the Sackler’s bear moral responsibility for the Opioid epidemic. During the sixties, Arthur got rich marketing the tranquilizers Librium and Valium using techniques were sometimes blatantly deceptive. In 1974 Mortimer renounced his US Citizenship and lived a flamboyant life in his many residences in Europe.

OxyContin was introduced in 1996 and just since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids.Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers. Our son is one of those statistics – and fatalities.

PAIN – Part 2

Not only did we, and many of our generation of parents, try to shield our children from as much physical pain as possible, we tried to spare them emotional pain too. But there is one source of pain that we will all experience and that parents and loved ones of an active addict experience on a daily basis: pain of loss. Lost hopes, lost dreams, lost potential, lost futures. When we  birth our children, we experience the joy of a new life and all the expectations of journeying through life together. We embark on a path with goals and plans and dreams fueled by hope and joy. But life rarely delivers what our dreams foresee.

“Awakening to joy awakens us to pain….Eventually, I am guaranteed to lose every earthly thing I have ever possessed. I will lose every single person I have ever loved. Either abruptly or eventually. All human relationships end in loss (death).” (Ann Voskamp, One Thousand Gifts)

The losses that people who are addicted (to anything) experience on a daily basis brings pain for them too. Sadly, addicts will lose most of their relationships while they are still alive. We watched this happen to our son as his addiction progressed. Initially, friends who were not involved in drugs slowly distanced themselves. Eventually, JL was spending more time on his relationship with heroin and had no energy left for friends. When he was sober, this was a source of pain – and shame – for him.

The sense of shame that hangs like low black clouds gathering over our lives any time we as humans engage in something we know is not good for us – or others – is the ultimate loss of self-worth. It erodes the very core of our being and I believe it is the hardest obstacle (aside from the physical addiction) for opiate addicts to surmount in seeking recovery. Shame paralyzes us.

“Shame is an overwhelming negative sense that who we are isn’t okay. It is a no-win situation. Authentic, legitimate guilt is the feeling or thought that what we did is not okay…Compulsive and addictive behaviors are shame-based. If we participate in them, we will feel ashamed. It is inevitable…When guilt is legitimate, it acts as a warning light, signaling that we are off course, and need to make a change…Learn to change shame into guilt, correct the behavior, and move forward.” (Melody Beattie, The Language of Letting Go)

Yet, it seems that for the rare few who have escaped their addiction and are in recovery, that very shame and sense of worthlessness somehow became the impetus for seeking change. Herb Stepherson is a young man who is in active recovery and helping others. His website/blog is: https://junkboxdiaries.com/.  It seems he had a similar story to our son, with one exception: he was not propped up by well-meaning parents and was allowed to experience the full degradation of his heroin addiction. While in prison and planning on suicide, he had an epiphany and God entered the story.

As we look back at the path of our son’s addiction, we feel that by our being overly involved probably prevented him from hitting whatever ‘bottom’ would have been the stimulus he needed to desperately seek help. Although we know he felt a lot of shame, our continual encouragement to him as a person of value and worth to us and God was constant. The conflict was how to communicate that to him without enabling his addiction? Did we short-circuit the role of shame fueling legitimate guilt and the desire to change? We were never sure. We always tried our best. May others learn from our story and do better.

PAIN

One time when our son was camping with friends and their families in the wilderness, a friend of ours asked him why he used heroin. JL said: “Because it takes away all the pain.” Our friend shared this with us and several hundred other friends at our son’s memorial – and said he always wondered if JL was referring to physical pain, emotional pain, or both.

From my earliest memories, my knees and legs ached at random times and varying intensity. Sometimes I thought it was from running or playing too hard. At other times, it seemed like it happened when it rained. But, being in a large family growing up in the late 1950’s and 60’s, there were not many options for relieving that pain. My parents would sometimes rub my legs with witch hazel, which made my legs feel good at the time. Sometimes they would wrap my knees in an Ace bandage to help while I was at school. Yet there was one thing that never happened: I was never given any medicine to relieve my pain.

I didn’t realize when I was young that most likely even if my parents had known of a drug that would have relieved my pain, they would not have given it to me because they were not worried about me having to suffer a little pain. They knew that pain was an inevitable and bearable part of life, and an important part of forging resilience. Sadly, John and I — and many of our contemporaries — did everything we could to help our kids avoid pain. Now we are  experiencing the result of those mistaken values. We found the same thoughts expressed by Sam Quinones, as he discusses this at length in Dreamland: The True Tale of America’s Opiate Epidemic. (www.samquinones.com/books/dreamland/) He believes this dynamic is in large part responsible for the opiate epidemic because it is intertwined with our American culture of comfort and prosperity.

Yes, the pharmaceutical companies and their executives who shamelessly promoted drugs that they knew were highly addictive are responsible for much of what we are living with — and dying from — in America today. But we are responsible for facilitating a culture of pursuing a pain-free existence. It can be obtained, but at what price? Is it one more way we humans think we can overcome the perils of nature and living in an imperfect world?

We are not sure when our son first started using opiates, but we think that it started with prescription pills that were not his or ours. And we know that after a serious accident, when the doctor would no longer give him prescriptions, he bought Oxy on the street, then switched to BT Heroin. He just couldn’t deal with the pain and he was not motivated to do physical therapy — it was too much work.

I feel certain that JL was referring to both physical and emotional pain. What may have started as looking for relief from some physical pain when he was a young teenager, turned into a monster that was causing him shame and ruining his life — and that is painful.

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.