More on Understanding Opioids

In this blog post, I’ll use “opioid” to describe all opiates, organic and synthetic. There’s confusion with all the discussion surrounding opioids, opium, heroin, morphine, opiates, etc. Below is a good description to help clarify:

To understand the classification of heroin as a drug, we must first understand its origin. According to National Institute on Drug Abuse, heroin is “an opioid drug that is synthesized from morphine, a naturally occurring substance extracted from the seed pod of the Asian opium poppy plant.” Milky, sap-like opium is first removed from the pod of the poppy flower. This opium is refined to make morphine, then further refined into different forms of heroin (DrugFreeWorld.com).

There is a lot of back-and-forth discussion on the difference between opiates and opioids, but the general consensus is that opiates or opiate drugs “originate from naturally-occurring alkaloids found in the opium poppy plant” (Opium.com). Opiate drugs are best-known for their pain-relieving properties.

Opioids, on the other hand, while similar to opiates in that they are also partly derived from opium, are primarily different because their makeup is manufactured. Opioids are actually synthetic drugs that produce opiate-like effects.

Other definitions choose to lump opiates and opioids together under the broader category of “opioids.” This is the proper medical terminology. According to NAABT.org, an opioid is “any agent that binds to opioid receptors (protein molecules located on the membranes of some nerve cells) found principally in the central nervous system and gastrointestinal tract, and elicits a response.”

So, people start using opioids in all its forms for different reasons, pain relief, experimentation, the euphoric effect, to relieve boredom, but the reason a person eventually uses opioids addictively is because there are brain changes that cause what can be called “insane” compulsion. The opioid addict uses the drug in spite of negatively consequences, and craves the drug after it’s been removed from the body. This obsession with opioids is difficult for most people to understand. Most people aren’t susceptible to addiction, only about 10% of the people who use opioids. The average person is baffled when a friend or family member uses opioids in a way that appears self-destructive, extremely self-centered and irrational.

Because we all want to find reasons for things that appear to have no reasonable explanation, loved ones develop reasons — the person is irresponsible, or the person is using to deal with some traumatic incident from the past, or the person is influenced by others. Any of these reasons might be true in the beginning, but when the person’s brain changes the drug use is driven by other forces. Here’s a partial explanation from NCBI:

Brain abnormalities resulting from chronic use of heroin, oxycodone, and other morphine-derived drugs are underlying causes of opioid dependence (the need to keep taking drugs to avoid a withdrawal syndrome) and addiction (intense drug craving and compulsive use). The abnormalities that produce dependence, well understood by science, appear to resolve after detoxification, within days or weeks after opioid use stops. The abnormalities that produce addiction, however, are more wide-ranging, complex, and long-lasting. They may involve an interaction of environmental effects—for example, stress, the social context of initial opiate use, and psychological conditioning—and a genetic predisposition in the form of brain pathways that were abnormal even before the first dose of opioid was taken. Such abnormalities can produce craving that leads to relapse months or years after the individual is no longer opioid dependent.

Read the entire article for a better understanding. At NewDay Counseling, we offer free consultations to help find solutions to opioid addiction.

The Progressive Nature of Addiction

AddictionNo one is born a full-blown drug addict. Addiction is progressive, from early stage, to middle stage, to late stage. In early stage it’s difficult to tell addiction from misuse. Lot’s of people go through periods in which they misuse alcohol or other drugs, but they aren’t necessarily suffering from addiction. The progressive nature of addiction makes addiction easier to diagnose in middle and late stages. Here’s a definition of addiction from NIH:

Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences. It is considered a brain disease because drugs change the brain; they change its structure and how it works. These brain changes  can be long-lasting and can lead to many harmful, often self-destructive, behaviors. 

This doesn’t mean that a person can’t control drug use at all. In the beginning, the addict can periodically control the use of drugs, and alcohol is a drug, but loss of control becomes progressively worse. The early stage addict might go to the bar one night with the intention of drinking three beers and leaving, and does so. Maybe the person does this for two or three nights, but then the next time the person winds up drunk and in jail for DUI, not understanding how they lost control and made such a bad decision to drive. Later on, the person will find it difficult to control at all.

A person in early stage addiction has to consider why they need to exert control. Most people who don’t have a problem with drugs don’t have to worry about controlling the use. A social drinker might have a couple of drinks or not, it’s not a big deal — they don’t lose control. There are some drugs, like opioids, that can cause physical dependence if taken long enough for pain, but if the person is not susceptible to addiction, they won’t have the psychological obsession that drives usage in spite of negative consequences, so that would be different from drug addiction or misuse. This person who has become physically dependent on opioids from long usage for pain management will need detox, but they’ll be glad the medication is no longer needed and they won’t crave the opioids after detox.

The structure of the addict’s brain changes, and it takes a while in recovery for the changes to reverse. The addict will often crave the drug months after detox. This is why a recovery plan is needed. Addiction is progressive and it gets worse with continued use, and it gets harder to quit when it progresses to middle and late stages. The progressive nature of addiction can be arrested at any time, but it takes willingness and effort.

Understanding the Opioid Epidemic

OpioidFor someone who doesn’t understand opioid addiction, when media report an epidemic and talk about opioids leading to heroin use, without lots of context and historical, factual information, it causes fear and misinformation. Understanding addiction is important to understanding the opioid epidemic. My fear is that well-meaning public officials will attempt to “fix” the problem and actually make it worse. One such “fix” has been to place too much blame on doctors and prescription use of opioids, which might lead to restrictions on access to opioids, which might lead to more people seeking drugs on the street. Also, demonization of heroin complicates the matter.

Heroin and opioids are powerful drugs, and they can be dangerous. However, opioids, when prescribed for pain, are very effective and useful. The problem is that a certain percentage of opioid users will become addicted. Those who become addicted to opioids have a predisposition to addiction, and there’s treatment for this. The main problem with the opioid epidemic and the use of heroin is when people purposefully seek the drugs to feed an addiction. The addict isn’t treating pain, but rather using opiate-like drugs because they’re physically addicted and have a psychological compulsion to use the drugs even after they’re physically withdrawn from opioids. It’s the mental and emotional obsession that creates the insane use despite severe consequences.

So, until addiction in general is understood, it’s not likely that good solutions will arise to deal with the specific problem of an opioid epidemic. To put all this in perspective, though, let’s imagine a new drug is discovered. Let’s say this new drug is so popular that it’s legalized, yet it becomes the cause of approximately 90,000 deaths a year. Let’s say that around 80% of the population over 18 use this drug. Let’s say that 10 to 13% of the people who use this drug develop a problem of addiction or serious misuse that meet treatment criteria. Let’s say that 30% of all driving fatalities are related to the use of this drug. Let’s say that the consequences of the drug cost the US 250 million dollars a year. Let’s say the following are true:

  • Around 1,825 college students between the ages of 18 and 24 die from causes related to this drug.

  • 696,000 students between the ages of 18 and 24 are assaulted by another student who has been using this drug.

  • 97,000 students between the ages of 18 and 24 report experiencing sexual assault or date rape related to the use of this drug.

  • Roughly 20 percent of college students meet the criteria for treatment for addiction to this drug.

  • About 1 in 4 college students report academic consequences from using this drug, including missing class, falling behind in class, doing poorly on exams or papers, and receiving lower grades overall.

This drug, of course, exists. It’s alcohol. So, while opioid addiction is a serious problem, it’s best understood in the context of addiction in general. It’s strange to demonize a drug like heroin, or emphasize the addiction epidemic to opioids, and to focus most addiction-related resources toward a war to eradicate the demon heroin and restrict pain medication, when alcohol presents a larger problem than heroin, opioids, cocaine, pot and all drugs combined. I understand alcohol is a socially accepted and regulated drug, and I’m not a prohibitionist, but it helps to think about alcohol as just another potentially-addictive drug. The point is to focus attention on treatment. To understand addiction is the key to understanding the opioid epidemic. Opioid and heroin addiction are big problems — addiction, including alcoholism, is a huge problem, and it’s all treatable.

 

Motivation in Addiction Treatment

Motication in addiction treatmentOne of the hardest parts for counselors working in the addiction treatment field is helping clients sustain motivation to continue in treatment. Motivation in addiction treatment has to eventually come from within, but in the beginning, it’s very difficult for the client to resist the mental obsession with their drug of choice. Even if the client claims to desire recovery, the desire for the drug doesn’t leave very quickly.

Addiction treatment is a slow, arduous process, and many clients struggle with day to day commitments required to make treatment successful. The challenge for addiction treatment professionals is to constantly provide positive motivation in the face of resistance. Burn out in the addiction field is a risk, because professionals are working with a clientele that can seem hopeless and ungrateful– they resist, they relapse, they deny, they lie, they minimize, on and on. Yet, recovery is possible and does happen.

It takes someone dedicated to the addiction treatment field who understands the nature of physical addiction and the psychological aspects of addiction that make the first part of recovery so difficult. The addiction professional has to look past the personality to the person. The personality has been twisted by years of addictive behavior, addictive thinking and all the consequences that go along with addiction. The “person” is buried under the addiction twisted “personality”. The task is to reach the person, through all the barriers.

Some new therapists will take the resistance personally, but this is a mistake. The challenge for the therapist is to compassionately and objectively speak to the person and offer recovery. There are certain daily techniques the client in recovery can practice to get past dwindling motivation. Recovery is basically a daily commitment. One way to keep focused and motivated is to keep a daily record of negative thoughts, then look at these thoughts to see if they fit reality — turn the negative around and see how a positive perspective looks and feels. It helps to start the day with a positive reflection and there are many daily reflections books for all types of beliefs. Many clients find it helpful to start the day with quiet meditation, then stop periodically during the day to check their attitude and emotions. Calling someone who understands addiction and recovery and is supportive is very helpful.

Whatever works, a person who gets into a daily routine to keep motivation fresh usually recovers.

Addiction Recovery – Be Quiet and Listen

Addiction recoveryIn addiction recovery, clients are taught how to be quiet and listen. This doesn’t mean we tell clients to not talk. The “quiet” I’m talking about is all the brain-chatter that keeps a person distracted, confused or too busy thinking to really listen to themselves and others.

The art of being quiet and listening is usually something a person has to learn. Getting caught up in the commotion, hustle-bustle and noise of daily life, most people don’t learn how to slow down their brains so they can find their center that’s deeper than the usual semi-conscious level of every day life. It takes effort, planning and practice to stop and look inward. How many people are really practiced at true contemplation? How many think of it as wasteful navel-gazing? We’re supposed to get things done, right? What things? Get them done in what way? To what purpose? Yes, that’s the problem.

A life unexamined is usually a life that’s automatic and lacking in purpose. The person suffering from addiction will usually come to treatment not knowing why they do most of what they’re doing — they’re controlled by impulses and old, unexamined ideas that no longer fit in reality, if they ever did. The addicted person’s brain has been rewired to make their drug of choice a prominent part of life. In addiction recovery, the person has to learn to be quiet, to listen to their deeper core and to listen to others — it’s time to turn off the noise machine, the rationalizations, the minimalizing, the old excuses that keep the person from seeing the truth. It’s time to create the life they want to live.

Scheduled times for meditation is a good way to get in the practice of quieting the mind, but it doesn’t have to be just at those times. A person can learn to slow the mind in general. When a person’s reacting semi-consciously to daily stimulus rather than gaining some control and power over their reactions, they’re always at risk of doing things they don’t really want to do.

Victor Frankl wrote:

Between stimulus and response, there is a space. In that space is our power to choose our responses. In our response lies our growth and freedom.

Learning to be quiet and listen allows the time and insight to choose our responses. Addiction treatment is a time for self-examination, empowerment and freedom.

Starting Outpatient Addiction Treatment

Addiction treatmentIt’s difficult to make the decision to seek treatment, but the hardest part about starting addiction treatment is actually following through once the decision to seek treatment has been made. What will people think? How can I afford it? It will take too much time. I don’t know these people. On and on, the doubts flow and fear rises. If the person has never been through treatment, the fear of the unknown can become an obstacle. It’s easy to put addiction treatment off — when work slows down, after my birthday, when the kids are out of school, when I save a little more money, etc.

There’s never a good time, but there’s no time like the present. There’s a few things that a person should know that will help alleviate doubt and fear. First, just make the phone call. It won’t hurt to set up a free consultation. At NewDay, we don’t pressure anyone. The consultation should be without pressure. The consultation mainly gives a person knowledge of what level of care is indicated based on signs and symptoms and history of alcohol/drug use, how payment will be made, if there are other facilities that would be a better fit because of insurance or lack of insurance, and to answer any questions. If the person wants to go further, then an assessment is performed to confirm what was discussed during the free consultation.

Payment for treatment can become an obstacle if the person allows it to be — but we bend over backwards to make the financial part work painlessly. Most major insurance will pay the majority of the treatment cost, and the rest can be worked out in affordable payment plans. The payments will be far less than the cost of active addiction – comparatively, the cost of addiction treatment is minimal. A good exercise is to think back six months and add up all the costs of drinking alcohol, or smoking crack cocaine, or buying opioids — include expenses like legal costs, bars, lost time at work, and any other costs associated with addiction. Most people with an alcohol/drug problem are amazed at how much money is wasted on their addiction.

If it’s determined that outpatient treatment is sufficient and a payment method has been established, several things happen next. The new client will see our Medical Director to get lab work done and get medically cleared to attend groups. Sometimes withdrawal might be a concern, but there’s medicine to help with withdrawal that is administered on an outpatient basis. The person will receive an orientation, and during the first individual session a treatment plan is developed. All admission forms are signed and then treatment begins. It’s always easier than anyone first expects. We know that people have doubt and fear when they first consider starting outpatient addiction treatment, so we strive to make it comfortable, informative, friendly and accessible. It just takes a call.

Heroin in Gated Communities?

HeroinHeroin, in the US, has traditionally been associated with the poor, criminals, black communities, back alleys, hippies, AIDS, dirty needles and such. Actually, heroin use among middle class and affluent whites is nothing new. Here is an excerpt from a Washington Post article, Five Myths About Heroin:

In an article headlined “In Heroin Crisis, White Families Seek Gentler War on Drugs,” the New York Times recently claimed that “today’s heroin crisis is different,” because it is not “based in poor, predominantly black urban areas” and because use “has skyrocketed among whites.” NPR, the Atlantic and other major media outlets have run similar stories, often citing a study, published in JAMA Psychiatry, which found that 90 percent of new heroin users in the past decade were white.

 
It’s a shame that drug addiction is mostly ignored unless media decide to write sensational stories when drug use like presently with heroin spikes. Addiction’s a health problem that deserves constant, vigilant efforts from healthcare providers, insurance companies, self-help groups and all public and private helping organizations.
 
The myths about heroin persist, yet we know that heroin is not to be dismissed as a demon drug used by crazed criminals — heroin’s part of a larger drug addiction problem that includes alcohol. Alcohol does more physical damage and causes more pre-mature deaths than all other drugs combined. It’s time to learn the facts. Addiction affects just about all families in one way or another. If we remove the stigma, and stop treating drug addiction and drug addicts as the enemy in an ongoing “war”, maybe we’ll find innovative solutions and begin the process of learning, healing and recovery.

Opioids and Insurance

The argument over healthcare that’s raging in D.C. reveals different philosophies and values. There’s legitimate debate between government control of healthcare and free market forces, but if government decides to control healthcare, one of the worst things they can do is limit coverage of mental health and addiction. Typically, when money is trimmed from healthcare costs, addiction services are hit hard. This makes no sense, especially when large parts of the nation are presently beset by an opioid addiction epidemic. Opioids and insurance are important topics. The cost to society caused by untreated addiction is astounding.

The new GOP healthcare plan would negatively affect addiction treatment. Below is an excerpt from U.S. News regarding to lack of national concern for our addiction problem:

Addiction is America’s most neglected disease. According to a Columbia University study, “40 million Americans age 12 and over meet the clinical criteria for addiction involving nicotine, alcohol or other drugs.” That’s more Americans than those with heart disease, diabetes or cancer. An estimated additional 80 million people in this country are “risky substance users,” meaning that while not addicted, they “use tobacco, alcohol and other drugs in ways that threaten public health and safety.” The costs to government coffers alone (not including family, out of pocket and private insurance costs) exceed $468 billion annually.

Over 38,000 peopled died of drug overdoses in the U.S. in 2010, greater than the deaths attributed to motor vehicle accidents, homicides and suicides. Overdose deaths from opioids (narcotic pills like Oxycontin, Percodan and Methadone as well as heroin) have become the fastest growing drug problem throughout the U.S., and not just in large urban settings.

The opioid epidemic’s getting worse and insurance coverage will likely get worse, yet news outlets and politicians are obsessed with Tweets. It’s going to take a serious, national effort to curb the costly and deadly consequences of addiction, but I don’t see any real urgency among those who possess the most leverage to create change. So government policy makers deal with symptoms as the fundamental problem grows worse by the day.

Sober on St. Patrick’s Day

sober on st. patrick's dayBeing sober on St. Patrick’s Day is no doubt odd to many revelers who come to Savannah to party and drink hard. Does the recovered alcoholic have to hide from the festivities? No, not if they’re firmly grounded in recovery. This is what a lot of people don’t understand. It’s not uncommon to think of recovering alcoholics as always on the verge of drinking again, ready to pounce on a bottle of liquor if the opportunity is presented. The idea that a person prefers to be sober is a strange concept to the dedicated drinker.

I don’t know of any recovered alcoholics who would enjoy bumping shoulders with thousands of stumbling drinkers on River Street, but, if they wanted to view the spectacle, it wouldn’t be a problem. There are some alcoholics in the early stage of recovery who should avoid River Street because they aren’t grounded in recovery — to their minds, the drunkenness would most likely look appealing. That’s the difference between being grounded in long term recovery and still being at risk in early recovery.

The recovered alcoholic can do anything anyone else does except drink alcohol. The recovered alcoholic loses the desire for alcohol — they don’t want to drink. Being sober on St. Patrick’s Day is perfectly normal. It’s a sad statement that human beings have to have an artificial stimulus in their system to “party” and have a good time. It’s an untrue statement, actually. Sobriety is a valid choice. Sobriety allows one to fully experience life, to remember what happened, and to not pay dearly (and painfully) for drunkenness the next day with a hangover.

The brain learns in sobriety how to have fun without alcohol — there are natural feel-good brain chemicals that the sober mind learns to activate. It takes time though. It takes practice. The recovered alcoholic who practices Recovery Management will develop alternative ways to capture the good feeling alcohol once gave them but stopped providing. To the recovered alcoholic, being sober on St. Patrick’s Day is infinitely preferable, thank you.

Addiction and Reality

addiction and realitySometimes, reality sucks. I haven’t written a blog post lately because reality, as it has a way of doing, dealt me a set-back. I’ve been doing work on my kitchen lately. I usually hire out this type of work, but I enjoy doing it myself sometimes. I’ve never been injured doing remodeling or construction work, but 9 days ago I cut my hand with a chop saw, severing two tendons. They operated on the hand four days later, and now it’s healing, and I can at least type a little, now. I was angry for awhile — how could I make such a stupid mistake? — but like addiction and reality, first there’s acceptance of reality (you didn’t think I was going to write a whole blog post about hand, did you).

In addiction recovery, one of the first things a person has to do is accept reality. Addiction becomes a constant retreat from, or battle with, reality, and, thus, the active addict is always at odds with the way things are. The problem is that reality always wins. We can change some things, many things, and that’s where responsibility plays a big part in recovery — change the things we can. But there are certain immutable aspects of reality we can’t change — they’re accepted, if we’re going to make progress. We might change our perception of reality, but, contrary to the saying “perception is reality”, immutable reality isn’t changed through drug use, positive thinking, will-power, magic, stomping our feet, or fighting — if we don’t accept these unchangeable aspects of reality, then there’s constant turmoil, consequences, frustration, resentment and a general state of tension. Again, like the Serenity Prayer says, grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.

In addiction recovery, the tension that’s felt when a person is at odds with reality is dealt with positively or negatively. Goals are set in recovery, and hopefully expectations are realistic. It takes time to change ourselves, to repair the past the best we can, and to move forward creating a new life. There are set-backs, obstacles, and there are times it doesn’t seem possible or worth the effort. Impatience can cause us to try shortcuts, to skip the hard parts, to deny that certain things about ourselves are holding us back. This all creates tension, and we can either escape the tension by giving up and going back to drinking/drug use, or we can use the tension as creative energy.

Creative tension is when a person accepts where they are in life, accepts the gap between where they are and where they want to be, uses the tension to generate creative energy to achieve the set goals, making adjustments along the way. Tension can be painful and unwelcomed, or tension can generate creative energy and the desire to change and grow — it’s up to us. Addiction and reality can find peace in recovery.