This is another section of my unpublished book, Clean Enough. I describe stages in the process of addiction that I’ve noticed in opioid addicts presenting for treatment. I must point out that these stages have not been validated by clinical research, but rather are drawn from simple observation. Read on:
J.T. Junig, MD, PhD is a Psychiatrist and PhD Neuroscientist in solo, private practice in NE Wisconsin. I treat adults, children and adolescents for all psychiatric conditions, with an emphasis on improving the strength of the doctor/patient relationship through longer appointments, greater access, and frequent e-mail communication. I teach psychiatry at the Medical College of Wisconsin, and provide psychiatric servicies for the U of WI Oshkosh Campus. Finally, I provided expert witness testimony for a wide range of cases related to psychiatry, neurology, addiction, and chronic pain. I am Board Certified by the American Board of Psychiatry and Neurology, and lifetime-Board Certified by the American Board of Anesthesiology.
Editor: Nadeem Noor
I am always impressed by how similar addiction progresses in one individual versus the next. The next reader’s comments and my comments afterward demonstrate a pattern that I have observed in one opioid addict after another. Throughout these posts, comments that I receive from others will be italicized.
I started on Suboxone in Feb 08 to get off opioids. It worked very well for me, I lost 20 pounds while on it, got very active, and above all was the happiest I had been in a long time. After 7 months of taking 32 mgs a day I had to wean off it because I had no more insurance and it was very expensive.
I tried to wean the best I could and the end of Oct was it for me. I was down to taking 2 mgs a day then completely stopped because I ran out of Suboxone. About 3 days after I stopped taking it I started withdrawing. I was getting the chills, I felt weak, I had this nervous feeling in my stomach which was very annoying and caused me to not be able to sleep. So what did I do? To get rid of the withdrawal feeling I was getting I started taking opioids again.
I am now on my 3rd day of Suboxone treatment again, I am only taking 1 pill a day and by the 10th day I am going to take 1/2 a day. I will stop at 14 days and stay completely away from opioids by keeping busy, working out, and most of all living a NORMAL life. I am also planning on attending NA classes for support. I will keep you posted and to everyone else doing the same… GOOD LUCK TO ALL OF YOU!!
Early in addiction, opioid addicts believe that if they could only get past the physical withdrawal, they would be done with opioids forever. During this first stage of opioid dependence, addicts are always fighting for that first piece of sobriety.
They hang out with each other on message boards on the internet comparing tapering plans using cocktails of amino acids or other worthless regimens, hoping to find the one that works– that gets them through withdrawal to become opioid-free. They are not interested in meetings or rehab; they don’t consider themselves to be the kind of addicts who need THAT kind of help. They insist that Suboxone be used only short-term, as a bridge to total sobriety. They have no interest in accepting a life-long illness, and argue that they expect to find a ‘cure’ even as they return to opioids again and again.
Denial is huge during this stage of addiction; addicts minimize the damage opioids cause in their relationships, work, and health. They can discount the damage in part because they consider their addiction temporary and easily corrected– once they just stop the darn opioids. They assume– often for a long time– that the right tapering method will come along and things will be fine. Hooked? Not them!
Addicts enter the second stage of addiction when they have successfully discontinued opioids and made it completely through withdrawal. From my vantage point of seeing many addicts over time, the point where sobriety is finally achieved is not associated with any particular taper method or amino acid formula, but rather occurs when addicts have had enough consequences to motivate them to tolerate the entire period of withdrawal.
More and more bad things pile up until they cannot be repressed and ignored; job(s) lost, friendships damaged or destroyed, finances in shambles, legal problems, and marital difficulties are some examples of these consequences.
During the first stage, addicts get to a certain level of withdrawal and say ‘enough of this!’ and resume using. But during the second stage the drug-related problems are remembered throughout the entire length of withdrawal, keeping addicts motivated to get free from opioids. Often addicts are so sick of using by this time that they don’t even use a taper, but rather just stop at a moment of self-disgust, without any plan or preparation. Or perhaps the consequences lead to a jail cell, resulting in sudden and absolute sobriety without the luxury of medication to reduce the severity of withdrawal.
That’s great, right? They are finally free of opioids! Unfortunately they are about to enter the third and worst stage of opioid addiction– the stage that can last for years and that totally demoralizes addicts. The stage begins with relapse — after a week or after a year, but the bottom line is that it almost always happens — even though NOBODY thinks it will happen to him.
I hear the comment over and over — ‘don’t worry, doc, I don’t plan to relapse!’ Or ‘I hear what you are saying — but you don’t understand how motivated I am!’ Many addicts consider themselves too smart for relapse, but I see the AA adage come true over and over: nobody is too dumb for Recovery but some are too smart for it! The meaning is that every now and then a person will avoid relapse — and it tends to be a person who has a simple take on life who didn’t really shine in other, more competitive areas.
The lucky person who finds recovery to be easy is someone who is well aware of his own limitations, and who never got in the habit of trusting his own opinions or his own abilities. That person can sometimes simply stop using because he accepts the idea that he has lost the fight — that opioids are much stronger than he is, and that he will never figure out how to take them without disaster.
But most people are far too smart to find easy sobriety. As soon as things start going well their minds take off again, and at some point they return to using. I’m not going to spend time on the triggers for relapse, as we will discuss them another time — but there are things common to all relapses, including rationalization, denial, grandiosity, and the feeling of ‘terminal uniqueness:’ a sense that all of the dangers of relapse apply, for one reason or another, to OTHER people.
During this third stage of opioid dependence, addicts will have repeated episodes of relapse and sobriety. There is little joy in using, because consequences occur much more rapidly now. More and more time is spent being sick from withdrawal. This is the stage that long-time addicts remember and fear the most.
In my case, I could stop using every weekend; I was away from the operating room and away from the drugs, and I would start the weekend determined that ‘this was the LAST TIME– come Monday I won’t touch ANYTHING!’ And so I was always sick; the kids would be playing outside and I would be in my bedroom curled up on the bed, hating myself for not being there for them. And of course, on Monday I would be right back at it again, telling myself that THIS weekend didn’t work because I needed just one more day… or because I had (insert incident here) to deal with.
As I mentioned earlier, during this stage addicts become truly ‘sick and tired.’ This is a dangerous period of time for addicts for several reasons; when addicts use they feel a great deal of shame, which fuels more using — making use more impulsive and reckless and more likely to cause a fatal overdose. Addicts in this stage become depressed — sometimes extremely depressed — and commit suicide, either actively or by not caring anymore about the risks of taking too much.
Addicts sometime feel such hopelessness or shame that they will do anything to change how they feel — swallowing any pill they come across, or shooting up unlabeled and unknown liquids — anything! Even a hammer to the head looks good at this point!
This is the time and level of desperation when traditional treatment has been effective; addicts are at ‘rock bottom,’ and no longer feel confident about any of their own abilities. They are ready to follow anyone or anything — after all, what do they have to lose? Life is over anyway — so why not listen?
If an addict can keep this attitude throughout one to three months of residential treatment and then keep it into an aftercare program, he has a shot at meaningful sobriety. But if he gets into treatment and quickly finds a girlfriend, or if he tells jokes and becomes the funniest, most popular guy in the facility, or if the counselors are in awe of his wealth, education, or power and tell him how cool he is… there is a strong chance that the treatment will prove worthless. To get better, an addict must hold on to the attitude that he knows nothing, for only that attitude will allow change to occur.
The ‘desperation’ issue relates to why, in my opinion, young people have lower success rates in treatment. Young people often feel too invincible for treatment to take hold. They also have short memories for painful events; consequences are quickly forgotten and dangerous self-reliance returns.
The true wonder of AA is that the program’s founders understood all of this; the program is about humility and powerlessness, and consists of a series of steps that if practiced completely, will take people to the right frame of mind and keep them there.
The reason treatment tends to work better for older people is because first, more are at the later stage of addiction and are truly ‘sick and tired,’ and second, self confidence tends to return a bit more slowly after a major blow in us older folks, so we hang onto our desperation a bit longer. We also tend to remember the bad things that happen because we know that people sometimes die, and that some friendships can be lost forever. Plus it is difficult to feel immortal when one’s body aches each morning!
In light of what you have read, go back and read the italicized comments from the reader again. See if you can tell the stage of addiction that the person is experiencing. I receive similar comments every day by e-mail. I have watched over the past 16 years as addicts (including myself) repeat these stages over and over again. Every person is convinced that he is different– only to eventually find that in regard to addiction he is the same as everyone else.
This is why I recommend seeing Suboxone as a long-term medication and seeing AA and NA as life-long programs. In either case, the natural tendency of the untreated addict will be to relapse and return to the horrible cycle of using and withdrawal.