Friday, February 22, 2008

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"
That's exactly why we're blogging and podcasting about this. Thank you.


Aqua said...

Hi Clinkshrink,
This is a really interesting and powerful post. I felt it was very empathetic towards those struggling with addictions. Thanks for taking the time to address this issue.

Anonymous said...

4mg klonopin a few mg lorazepam, ambien, some others. all doses crept up over time. i never asked for any of these meds but i did start taking them and i did take more when the initial doses stopped working and higher doses were prescribed because "you obviously need it".at this point i do not know whether my illness is an illness or whether i am in constant withdrawal since i have developed a tolerance to the doses i am on and i will not ask for anything more. yet, i am terrified of going off the stuff and the real withdrawal process. i do not crave the stuff but i do wish i had never started it.

ClinkShrink said...

Aqua: Thank you.

Anonymous: You are not alone and never give up. Recovery is possible, even for folks with severe problems. I've seen it happen.

April said...

Not that you can speak for all, but I'd be interested to hear what shrinks think about people who use drugs recreationally, assuming they still hold down jobs, take care of responsibilities, etc. There are plenty of people who are capable of using (certain) drugs for extended periods without causing major harm to themselves or others. Same categort as the addict b/c they are attempting to mask a problem instead of address it?

human carvery said...

thought provoking post, had been missing the in treatment updates but this has really swept my thoughts!

WritingMom said...

I'm a recovering alcoholic, almost 6 years sober. I always tell my doctors about it when they take a history, and inevitably, they congratulate me and promptly forget about it. The information that I'm an alcoholic seems to have no impact on their prescribing habits. No doctor has ever hesitated to write me a prescription for Vicodin, for example, usually for far more than I need. Fortunately, I've never been tempted to abuse that, so it's never been a problem, but I always find it a bit surprising that the issue never comes up.

Anonymous said...

I'm in the opposite position. I'm waiting for a ADHD diagnosis (one of hundreds of thousands of undiagnosed North American adults) and am looking ahead to finally getting a grip on my life. But also I imagine I will also become suspect as a possible "drug seeker" despite never having smoked, used illegal drugs, or had much of a taste for alcohol.

Because some people abuse stimulants, another large number of people have trouble getting the care they need. Infuriating.

Anonymous said...

I was just sitting here, on a Friday night, watching an ABC special called, "What Would You Do?" They convinced a woman that her best friend's S.O. was cheating on her to see whether or not she would tell the best friend the truth about the cheating. To her credit, the woman does decide to tell her friend about the cheating, but while she's doing it, she's handing her friend a Xanax pill from her purse. A futile effort, though, because her friend already has her very own prescription for Xanax! Can somebody tell me where the vending machine is? (Just kidding, of course. I'm a very, very strong proponent of trying cognitive behavioral therapies for anxiety before going to potentially addictive medications. Why aren't these therapies given more encouragement?)

I get pretty upset over this problem because I directly feel the effects of it, not as an addict or dependent, but as someone who can't get medical treatment because of the addicts. I have a very hard time getting proper pain management for a real chronic pain condition because doctors are so quick to suspect or be wary of drug abuse. They simply see: complains of migraine + bipolar = must be addict. I've been left with virtually no option other than to shut-up and suffer at times. It's horribly frustrating when some doctors create addicts, and in the process of "punishing" the addicts, they punish real patients as well.

Anonymous said...


You might want to visit the Paxil Progress Boards as that has been a great source of support for me regarding my tapering off of antidepressants. It is run by Laurie Yorke, an RN, who almost lost her son to a Paxil induced suicide/homicide.

There are posters there who are tapering off of klonipin and could be very helpful.

The key is to taper very slowly, which is 10% of the current dose every 3 to 6 weeks. Many of us, including me purchased a jewelry digital scale so we could weigh our doses accurately. It is a royal pain in the neck but definitely is worth the trouble.

You may even have to taper more slowly with these meds. I have never had that issue but I have read accounts of people who tapered who had to taper slowly.

I couldn't tell if you are ready to taper or not. But it is definitely doable in my opinion

The other anonymous

Sarebear said...

Thanks for the post. In December, when my psychiatrist prescribed Klonopin for my sleep-punching, and then when I came back in early January and reported back after a month that yep I was better rested (and so was hubby) but that I'd like the next dose down, please, he was happy to write out the lesser dose. As January went on and I continued to feel the gruadual benefits still build to a peak point of finally having enough rest, it was amazing the clarity and change in me. I was feeling like perhaps I was starting to get the sleep aspect of things, which is a HUGE HUGE Thing like my psychologist and psychiatrist have been telling me for years, into place, finally, and then the life-changing genetic time bomb of having the arthritis of a 67 year old, and having to think of things in terms of wheelchairs when my sister invites me on a summer trip (heck, for anything almost! . . . the shock of that had me curled up in bed for a month, trying to wrap my mind around how does THAT go from mild pain to horrific pain literally overnight that one summer day last year?)

Woops anyway off the subject I guess. That, and two deaths in the family have rather derailed things. Oh yeah, and my psychiatrist, in the middle of all this, taking me off the neurontin and onto a different med. It's not like we know life is going to do these things. It's not like my weight caused the arthritis (thought it doesn't help; the docs said it was completely genetic, that they just don't see anything this bad, they emphasized over and over, in 35 year olds)

woops, there I go again.

Sorry, it's been a bad couple of weeks, months, etc.

Just. Breathe. K.

Anyway, I did have something relevant to say, and I said it. I wandered, but I don't think any of you can blame me, right now. Dinah, Keep up my In treatment "fix" (ha ha, w/the "addiction" theme, but I'm joking because I won't be harmed if I don't get it but I enjoy your posts on that and other, cheers me up in the middle of all this schtuff).

Ok, since I'm making one big rambly comment anyway . . . . I'm kinda in spurts at the moment, given all the stuff going on. So you may see me address multiple posts in comments to one, I don't know, for awhile, I just don't know. One day at a time, holding together with spit and string if I have to. Because I can. So there you stupid fated from conception out to get me genetically fated flawed DNA crap.

Unknown said...

The interesting thing is all the talk about problems with prescription drugs. Not surprising but prescription drugs are replacing the street drugs as the biggest problems.

As the director of Novus Medical Detox, I daily see the ravages caused by prescription drug addiction created by doctors prescribing it to their patients and then the patients either continuing to obtain it or purchasing these drugs on the internet or the street. Probably the worst of these drugs is OxyContin--legal heroin.

Pain is real. I have had it much of my life first from polio and then from two surgeries. However, there are alternatives to painkillers and they must be tried first. Let's not treat the symptoms but the cause.

Prescription drug addiction is an epidemic and we must do everything we can to stop it before it overwhelms us. Education is a must.

Steve Hayes

Trébuchet said...

So many years late; do a follow-up entry!

I'm on both sides, and think if we'd legalize marijuana it probably wouldn't be such an issue. I don't smoke, but I think I might try it if it were legal.

I've got no mental disease, but (how did pdoc say it) 'real fear'-based anxiety (insofar as my fear is based in reality, not based on delusion). Loved lorazepam, but kept getting increased until five years later, I was on 4mg/day, and wondered if (1) I was still experiencing stress without the pills, and (2)if I was going to end up needing some extreme dose in the future (30mg/day or something when I'm 70yo). I got a bit scared being "attached" to a pill.

(My PCP told me to think of it as being diabetic, but don't diabetics go up and down with their insulin needs? It's not a steady trend up, like my benzo usage every year.)

I've now weaned down with a new pdoc and am trying some vitamins now for anxiety, and yes addiction sucks, and no I'll never know when or if I no longer needed them. Once you're on a benzo, the pill feeds the problem (you get anxious without it); I get that.

But even now, 6 years in, I'm fully aware that I needed that benzo. It helped me get through some extraordinarily stressful times without panic attacks and huge hospital bills. Withdrawal isn't easy, but I can't imagine how I would have functioned without them. Glad to be getting away from them, but would go back to them if needed one day. You can get off them.

One pdoc had me try a litany of antidepressants; I wasn't a candidate. I was already tachycardic; Zoloft increased my heart rate so that I had to go to the ER (where, guess what they shot me full of, LOL: Lorazepam.) Two tricyclics made me itchy and angry (tried both for over 4 weeks; the longer I stayed on them, the worse the anger got; terrible stuff). Wellbutrin made me hallucinate monkeys and feel 'high'. (Couldn't drive.) And the money spent trying to find a reasonable alternative to the benzo was outrageous.

In retrospect, I don't think benzos are bad, even though I'm addicted to them [physically]. Turns out my elderly dad has been on a small dose of Valium for decades (5mg/day). I think if you get on one and stick to a dose (no matter what!), respect it, it's a cheap, effective means of dealing with anxiety.

Opiates are a whole other story though. I'm just glad I can't take them (half a Percocet makes me throw up for two days), because I've seen the opiate addicts and they're just pitiful. Doctors who write these scripts so easily, over and over again for years, need to be, um, investigated.