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Dear Dr. Junig,

our websites and commentary are inspiring. I have never before seen such a clear articulation of what addiction is like and what it is like for an addict as a member of society.  I too am an addict, but I have not admitted it before now. This will be my first step.

I have been using various opiates–ranging from hydromorphone to tramadol and hydrocodone for the past 2 years.  My current dose is moderate, around 40-60mg of hydrocodone per day.  I’m sure it has affected my life in numerous destructive ways, but at the same time I feel that it has given me hope.  As a lifelong sufferer of anxiety and depression I have always looked for solace, and found it in books, art, music etc. But as I got older I got into drugs, in my case a path leading straight to opiates. As soon as   found them they were solution to all of my problems; I felt secure, safe, confident, sociable, and adventurous.  I found myself taking the risks socially, academically, and spiritually that I always wanted to. The doubt, insecurity, contempt for myself and others were rendered inconsequential. I felt I had attained a balance in my mind that allowed me to be who I really was.

I now see that this was a perfect case of the splitting phenomena that you describe in addicts.  On one hand the opiates must correct something that is defective in my physiology—they are the solution to my problems. This is not to say that I attain some sort of elevated state of consciousness by ingesting them, but that the opiate boost to my system allows me to function in a way that is actually healthier than my “natural” state.  But on the other hand I am afraid that my addiction is about to come to a head. I can no longer go more than a day without a dose, and all I do is think about pills. To cover up my use I drive great distances and spend thousands of dollars. The lying is increasing, and so are my withdrawal symptoms. I have tried to stop my use, but I am absolutely dejected without them.  I want to do something before I have ruined my life. But unfortunately it seems that the system is not receptive to people who are on the brink of ruining their lives–just those that already have. I have seen shrinks for the past decade (I’m 23), been on every anti-depressant/anxiety medication known to man all with little to no success. Is there any other, less dramatic way to detox or begin some kind of maintenance therapy without checking into an in-patient rehab center? Would buprenorphine make sense for this situation? I’m sure  you get dozens (maybe hundreds) of emails like this and understand  completely if this question is too much or inappropriate for you to  deal with, but after days of reading your posts and learning your  philosophy on addiction medicine I could not help but to write to you.  Thanks so much.

This is an excellent letter, that captures the thoughts many addicts have as they get close to seeking treatment.  Instead of picking it apart, I will use the letter as a backdrop for a couple broad points.  To the message writer, I changed some of the content just enough to clarify your comments and to be certain that your identity remains hidden.  My intent, as always, is not to put you down or insult you, but rather to introduce a different perspective on some of the points you are making.

My first comment is to remember that addiction is a disease of insight.  Also remember that a person cannot ‘analyze himself.’  A person may see some patterns in his thought processes and make educated guesses about his unconscious motives, but he cannot ‘know’ his own unconscious—by definition, for one thing.  And if he does have something ‘huge’ in his unconscious that is affecting his behavior, his unconscious mind will easily keep if from conscious awareness.  That is why it is a waste of time for an addict in early Recovery to try to figure himself out; a much better use of his time would be to work on accepting his limitations in this regard!  The same point is made at a meeting when someone reminds an intellectual addict the ‘KISS’ principle:  for ‘Keep It Simple, Stupid.’   And I am making the point when I interrupt a patient in my office who is explaining all of the reasons he relapsed, telling him ‘it doesn’t matter.’   IT DOES NOT MATER.  Don’t let my psychobabble confuse you on this point!  When write about the unconscious pain that leads a person to become an addict.  I am going into those theories for fun, for filling this book, and for the sake of thinking about how the mind works— but that type of thinking will NOT keep a person clean.  A person might start to think ‘I know myself so well that I will be OK— I’m not like those other people who use.’  And that would be a big mistake.

The next thing I notice in the message is the common claim that opiates serve a purpose by medicating some troublesome, usually psychological symptom.  I told the first addictionologist that I saw back in 1993 that I had an ‘endenous opiate deficiency’—a deficiency of endorphins—and my use of opiates was actually ‘self-treatment’ of that deficiency.  That argument will never get you anywhere for a number of reasons;  it is laughed at by the addiction-treating community, for one.  Maybe someday science will prove you were right and they were wrong, but I doubt it.  Besides, even if you do have some type of deficiency, opiates cannot be taken to fix it.  See my next paragraph for more on this issue.

Every opiate addict has the fantasy on some level that they will find a way to keep using.  Early on, that fantasy fuels lots of use and lots of broken promises.  “I know… I will only use on Thursdays!” we say to ourselves.  But there is NO way to make it work.  I’m sorry to be the one to break it to you.  I am a smart guy, and I tried every way possible to make it work.  And thousands of people smarter than me have tried and failed as well.  You yourself have probably tried many times—and failed.  The only people who can take opiates without being destroyed are people who don’t like taking opiates.  How is THAT for messed up situation?  But it is true…  my wife had kidney stones in 1993 and was given a bottle of Percocet tablets;  she took one, hated feeling that way, and put the rest in the back of the cupboard for me to find a year later.  I decided, upon finding them, that I would take one each day to self-medicate my social anxiety.  Unlike my wife, I LIKED them.  And they were all gone, two days later.  Back to that fantasy,  I know where you come from when you say there MUST be a way to take those wonderful pills that provide safety, comfort, security, and adventure.  But smarter people than you and I have proved, many times over, that there is no way to have those wonderful things without having the other stuff–  lying, depression, and self-disgust.

My final point refers to the writer’s complaint that the care isn’t there at the time, or in the form, that he needs it.  This used to be a much more acute problem, and I would have answered the question ‘is there a less dramatic way to enter treatment?’ with a resounding ‘no!’  But this is the huge benefit that buprenorphine has brought to the treatment of opiate dependence.  Successful treatment used to require the near-total destruction of the addict before sufficient desperation set in to provide adequate motivation.  But buprenorphine allows treatment before the addict loses everything, provided the addict is truly sick and tired of using.  Suboxone is not a ‘miracle’, and the addict must truly want to be clean in order for Suboxone to work.  But it is a far cry from the situation ten years ago, when the addict had to be at deaths door in order to ‘get’ Recovery.

To the writer, thank you for your message and I hope my reply is helpful.

SD

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