substance abuse

Some Thoughts On Addiction

Note: Before you continue, no matter your personal or professional backgrounds and experiences, I ask that you surrender those for a moment.  Read this objectively, do your own research, and get the conversation going. Don't make the mistake of following the masses on social media or falling for false promises claimed by others.  This affects more people than you may understand.

The topic of addiction, in particular to opiates like heroin, has been in the news and our social media feeds frequently in the past few months.  A lot of what I see is uneducated opinions, personal biases, and information from people who frankly have no particular background or experience with addiction.  Addiction and substance abuse/misuse is not a simple problem; therefore there is no simple solution.  As long as humans have been roaming the earth, someone somewhere has had an addiction.  This can even be seen as far back as some of the early Chinese dynasties.  Opium had become such a problem with the population that it was punishable by death.  Even with the extreme consequences associated with even being in possession (or sometimes just associated with) we still see a world-wide problem with substance abuse - and it isn’t likely to ever stop.  It will always be an issue in our societies no matter how hard we may work on it, the laws that are passed, or the alternatives offered to those afflicted, and particularly in how we personally view it.  How we respond to this problem is what will make the biggest impact.  This is not just for ourselves, the ones we love or care for, but also for society as a whole and the world we are leaving for the next generations.

Since the beginning of my recovery, I have never kept a secret what happened to me and the circumstances that lead me down the road I took.  I am open about this because at the time, no one else would be.  The public service realm is particularly bad with this because we tend to be private people and always want to put on the best show of who we are whenever we can.  We often hold the issue of addiction as a personal problem when it is so much more than that.  It affects not only our health, social lives, personal lives, professional being but also our families, those we work with, and the world we survive in.  I discuss what happened to me for a few reasons: I don’t want people to take the path I did, I want you to understand that there is help, this can be managed if you are willing to do what it takes, and most importantly that you are not alone.  Since I went public with my story and began my outreach work I have met and helped many people with similar issues and a range of addiction coupled with other issues.  I was initially a little taken back by just how many people experience issues in the public service sector, but after talking with them it makes more sense.  You would be very surprised to know just how many people secretly deal with these problems.  Addiction has been referred to as one of the “great equalizers” - your social status doesn’t matter, your professional abilities or experiences don’t matter, your living situation doesn’t matter, and what you have accomplished in life doesn’t matter either.  Addiction does not discriminate either.  It doesn’t matter what your ethnic background is, religious affiliation (or lack of), status in society may or may not be.  The simple truth is that we are all human and therefore inherently flawed and prone to the same issues as anyone else.  Stories and circumstances may vary, but there is always a majority commonality in everyone that is often overlooked - sometimes purposefully.

When we talk about addiction as a “disease” people are often confused or resentful of that for a variety of reasons.  People tend to think of a disease more like cancer or tuberculosis because they can be contagious and produce physical and noticeable effects.  Others may see substance use or abuse as a pure, purposeful, well-educated decision and could just “stop at anytime” unlike my Aunt Sally who died from cancer. While that may ring true to an extent for some people and with some of the “lighter” substances out there it isn’t particularly true.  It’s not quite that simple; because if it were we wouldn’t be having this discussion.  You are getting hung up on the word and not the process.  Addiction is a disease of the mind and body.  Though not contagious it features physical and emotional manifestations as part of any disease process.  Continuing to do something, in this case the use of a substance, despite the often deadly or otherwise undesirable consequences implies that a process is not working correctly - in this case the brain and how things are processed and the individual reacts.  Even if you chose to stop using, there are very real physical effects to doing such (like withdrawal) coupled by many mental aspects.  Like most diseases, addiction ends in one of two ways: you get better or you die. That is the hard reality of the situation.  Ever try to quit smoking?  Multiply that by around 100 and see how likely or successful you are to quit.  Opiates, in particular heroin, are especially difficult because of how quickly and vastly it changes your brain chemistry.  There is far more to the process than we may realize.

An often overlooked or marginalized issue with addiction is that these people very frequently have underlying issues, particularly with mental health or general wellness.  These individuals are referred to as having a “dual diagnosis”.  The most frequent misstep I see is when someone elects to get help they are treated for the substance use only - not for the underlying issues.  This happens a lot because addiction is very often a visual thing.  It’s typically easy to tell when someone is strung out or acting inappropriately and otherwise frequently making poor decisions.  That tends to mask any causative factors that cannot be easily identified.  I mean issues with trauma, abuse or sexual assault, depression, mood disorders like bi-polar disorder, chronic pain, brain injury, anxiety or panic disorder, and many more.  When elected to treatment, the most frequent misnomer is that by eliminating the substance abuse everything else will “fall into order” and they will “get better”.  It reminds me of some of these terrible TV shows where celebrities go in for treatment and after a few days are “back to normal” with no residual effects.  If you follow them, you’ll understand that is rarely the case.  While that may be true for some, as a general rule that is incorrect.  The two issues often feed off each other and if both are not addressed the risk of relapse and falling back into the prior habits and behavior are typically very high.  Being clean and sober is one thing, but not feeling well once that is achieved results in a significantly increased risk of future events.  In my experience it has also contributed to accidental death during relapse and suicide.  An individual who has elected to be well and sober for a period of time will occasionally decide to “tempt fate” in a momentary relapse.  After being without the substance for a period of time, your body no longer has the tolerance it once did.  In their mind, they often pick up where they left off resulting in undesirable situations and death.  This is particularly true with opiates and alcohol.  The body no longer has the tolerance it once did, but the mindset tells them they do.  People often take failure very hard and personally, so when they feel like they fail (or are a failure) they can get into the mindset that they are hopeless and abandon their wellness.  Relapse is very often part of recovery, so if someone does relapse it is important to have a prevention and management plan in place to deal with it - and a realistic one at that.  A relapse should not be an automatic death sentence or be explicitly labeled as a failure.  Doing so is not only false and provides negative emotions for the individual but only perpetuates the wrong mindset of going through recovery with “absolutes”.  An absolute would be “well, they completed treatment so they will never use again” or referring to a “cure” with no possibility of future problems.  The bottom line is that all issues need to be addressed and by competent clinicians who will help plan for the future and proper care after treatment.

Another important thing to remember is about the mindset of addiction.  If the individual is not ready or willing to commit to being well, there is very little that can be done to help them.  That does not mean that you should enable them however.  No money, no rides, no assistance or active role in enabling the behavior.  We can pass every law imaginable, stand them in front of a judge, have family and friends plead with them, send them to jail, remand them to a treatment center, or any other forceful mitigation but a simple truth remains: if they aren’t ready to make the commitment, it usually results in failure.  Though putting them in prison may technically force them to become sober there is rarely a long-term benefit.  Just look at anyone with frequent or recurring arrests and convictions and that becomes clear.  In a time where budgets and funding are being unceremoniously slashed or eliminated, many prison systems either have a lack of or severe inability to properly address their issues.  There is rarely any justice to be had in these situations either.  Putting someone in prison for 60 days just to have them be released and continue the same behavior is incredibly useless to everyone.  I’m not suggesting that a “free pass” is granted to them.  Consequences are often a deciding factor for the individual to seek help and setting limits is important; but you have you stick by your word and the boundaries you set.  Part of the mindset of addiction is manipulation or exploitation, so that cycle needs to be broken.

Personal accountability on the part of the person is also important during the recovery process.  As mentioned above, there should be no passes on past behavior barring of course an extenuating circumstance.  Answering for and doing your best to mend the issues created in a time where you were in a bad position is important to do.  This is particularly important in people who take the “12-step” process.  It creates a better understanding of their situation and assists in the healing process for everyone - not just the addict.  This should be done in a way where they are educated about the effects of what happened in order to maintain a working understanding of their actions, behavior, and habits.  Doing things like revoking their yearly invite to Christmas dinner is not positive feedback and only serves to alienate and (in their mind) justify prior activities.  Space can be good, but cutting someone off without the possibility of reunion or reconciliation serves little or no purpose.  Life is only so long; holding a grudge or hostility over someone else’s circumstance just isn’t worth it.  As the line goes: “hate is baggage in the end”.  And to be clear, I am not talking about instances where abuse was involved.  With that, you need to seek your own guidance and do what is best for you.

For those of us in public service, there is no question that opiate use (particularly heroin) is more frequent and wide-spread than most of us can remember.  Communities all over have expressed their concerns and rightfully so.  An interesting event has taken place over the past few years where the antidote for opiates (Narcan or Nalaxone) has been placed almost everywhere.  Fire and EMS have had access to this for years but recently many Police departments, schools, and public buildings are equipped with it.  You can also get a prescription for an auto-injector if you or a family has an opiate problem and most pharmacies can hand it out when asked.  Narcan is only a temporary solution for a long-term problem. Our elected officials tout this program as a way to save lives from the opiate epidemic.  While this is partially true, it is not the “fix all” solution that it is very often sold as.  While it’s great that you now have the ability to save another by just spraying something up their nose, it creates several other issues.  Narcan is not as inert of a medication as it is often billed as.  Serious complication are relatively rare but can happen.  There is also a trend where every time someone sees another unconscious person Narcan gets blasted up their nose.  Though unlikely to cause harm, it’s not always the best option.  Issues can arise with acute withdrawal and seizures, heart failure, and a host of other issues.  Occasionally the opiate overdose can mask a serious problem with mixed drug use or other medical problem such as a head injury.  Anyone who has ever administered Narcan to someone only to have them regain consciousness and start fighting because they also snorted an eight-ball of cocaine knows what I’m talking about.  If you’ve never administered any drug to someone there needs to be a certain amount of caution exercised in doing so, and if you aren’t trained in it also be cautious and do your best to seek professional guidance.  I would have rather seen a program where people were taught the basics of CPR and airway management first.  That would benefit a far greater demographic of people.  Basic logic dictates that outcomes are better when a procedure or medication is given by people who have experience with it and know what to expect.  Since the introduction of this program, the amount of people getting Narcan has drastically increased and the death rate from opiates has increased as well.  This program had more to do with making it seem like they were trying to curb an epidemic than effectively manage or mitigate it.  It’s not all bad, but it shouldn’t be looked at as a primary deterrence either.

Speaking of Narcan, another interesting series of events is starting to unfold.  Since the demand for the medication has increased, so has the price.  As the potency and mixing of opiates has increased, more doses are required for resuscitation.  Agencies and municipalities who pay for the supply are now feeling the financial burn, some over the six digit per year mark.  This has prompted some officials to advocate for a “three strike” policy and try to impose that on our first responders.  Basically after someones third time of being resuscitated with Narcan they would limit the provider in giving any more.  While this logic makes sense in a punitive fashion to the typical old angry grandpa, it is incredibly unethical from a medial and legal standpoint.  It’s a lot closer to manslaughter than trying to prove a ill-conceived theory.  The reigning principle in medicine is “do no harm” not “well because I think this person is a scumbag they deserve to die”.  This is a good example on the lack of education or working knowledge exercised by our officials.  It simply isn’t going to go anywhere and I highly doubt that even through some odd stroke of bad luck becomes an acceptable practice will have any effect on the use or distribution of opiates.  It’s another fool-hearted effort of making it seem like they are trying to address the problem while taking a stand against all that medicine stands for and basic human decency.

Addicts need to be in recovery or at very least have the proper access to those resources and dealers and suppliers need to be in prison.  Any variation of this will likely result in failure.  Rarely is it ever the case where someone picks up a substance on a whim and starts using.  As discussed earlier there are normally reasons why people decide to use substances; weather trying to manage a problem themselves (self-medicating) or out of circumstance.  The people who supply these drugs are not dumb either.  They know who to pick potential “clients” and how to run a business model that works to their benefit.  They are predators.  It is rarely coincidence that people go back to the same life they may have just gotten out of without some help.  Harassment or threats from former dealers, opportunistic preying, and a readily available supply are all factors.  The “customer” needs to be redirected (recovery) and the business (dealing and supplying) needs to be shut down whenever possible.  The cycle needs to be broken somewhere in order to effectively manage this problem.  Issues with our current justice system are a conversation for another day.  We seem to have a well-established system of predators and victims that shows no sign of slowing in the near future.  I hear often about how the hands of law enforcement can be tied in dealing with this.  It’s time to find a new way to handle it - and aggressively.

Recovery resources can also be very difficult to get ahold of.  This is particularly true of people on government funded insurance plans or are underinsured with little financial means.  I worked with someone a while back who was looking to get into a detox program to start their journey.  All of the ones in Connecticut had a wait list of at least a week and out of state programs that had space didn’t participate in their program.  Government run health plans also rarely come with out of state benefits as well making it financially impossible.  It was a real mess, and more often than not acts as a deterrent for those seeking help.  It has been my experience that when someone reaches out, you typically have less than 24 hours to get things going before they change their mind or die waiting. It needs to be addressed that for situations where initial recovery need to be started that they can reasonably access it.  Despite calls and pleading with the HUSKY office, they were able to offer nothing of help.  This individual ended up having several interactions with various public services, visits to the ED, an admission to the hospital, and several other things that could have most likely been avoided if they had the proper access to care.  They are now doing well, but the road to being well again was far more difficult to access than it should have been.  It is a disservice to everyone in these situations and contributes to expenses that likely could have even avoided in the first place.  And they aren’t the only one I’ve encountered this issue with either.  If you don’t believe me, go to a local AA or NA meeting and gently ask around if anyone would be willing to share their experiences.  This is a multi-layered problem.

We need effective, driven, and evidence-based methods for dealing with this.  A few new and creative ideas couldn’t hurt either.  Until those who create policy actively listen to those who have been down this road, change will likely be slow or nonexistent.  Empty policies and political rhetoric are going to get us nowhere.  This will always continue to plague us, but there are things we can do to make ourselves and our communities better - we just have to push for it.

Keep this in mind the next time you deal with someone with an addiction problem.  Their life is very likely not full of rainbows and unicorns pooping candy - there is likely a sad and unfortunate set of circumstances behind it.

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