Tough truths garnered from relapse, including a series of recent slip-ups during my methadone taper.
I've been honest about having a history of relapse.
During the past 15 years, there have been periods when I've been clean and sober (and not on opioid maintenance) for several months to over a year and a half, during which I have allowed myself to hope that I had finally found my stride in long-term recovery. Unfortunately, however, that never really turned out to be the case.
I'm surprised by how difficult it is for me to admit to you all that I've been struggling lately. That's probably partly down to the fact that I know that friends and family read this, but it's also a result of the respect that I have for my readers and the growing sense of community that I feel around this blog.
I hate to disappoint, and I wish that I had the answers.
So, yeah. My methadone taper has been rough, and as my withdrawal symptoms accumulated and intensified, I used several times (fentanyl, probably contaminated with xylazine, which is everywhere in my area of Upstate New York right now; article on that worsening problem here).
For a three- to four-week period that ended about a month and a half ago, I was using fairly regularly - perhaps two or three times a week. It wasn't enough to justify going to detox or inpatient treatment, but it was enough that I noticed some mild to moderate withdrawal symptoms when I stopped.
I don't feel completely out of the woods yet, but I'm safe and feeling strangely stable; just taking stock and considering where to go from here.
***
Some experts on opioid addiction have moved away from the model of permanent sobriety as the goal / endpoint of recovery in favor of a cyclical model of addiction in which relapse is recurrent for most people.
For poorly understood reasons that probably have to do with the extent of physical dependence caused by these drugs, as well as the extended pain and grief reactions upon discontinuing them, this cyclical pattern seems more pronounced for opioid addiction compared to addiction to other substances.
I can tell you that in my own experience, I have been able to set aside cocaine, alcohol, and even benzos, all of which I have had substantial problems with at some point, with relative ease. Opioids, however, sunk their hooks into me so early on in my life and so deeply that quitting them has been another matter entirely.
It's not just me. As I've written about elsewhere, witnessing many of the leaders of my 12-Step recovery community - people who achieved months and years of recovery without buprenorphine or methadone maintenance, who became counselors and other types of treatment professionals - succumb to relapse was an absolute torpedo to my morale. It's hard to emphasize enough how much doubt and despair that left me with.
In general, one advantage of a fairly elite education is that it encourages trailblazing. I've always tried to maintain the mentality that I will be the one to forge a path where there is none and one is necessary.
However, with addiction, my struggles have been so profound that I really needed that person who reminded me of myself to light the next few steps of the path for me. Unfortunately, I haven't yet found that person; my sponsors have been alcoholics, not opioid addicts.
Don't get it twisted: People do leave opioids behind forever. I recently spoke with a doctor who lost a very successful OBGYN practice to morphine addiction; that was 21 years ago, and he's been clean and sober since! But the vast majority of opioid addicts, probably in excess of 97 or 98%, do not achieve long-term recovery.
Many of the people who successfully quit opioids are "dilettantes" who get heavily into pills or heroin for a few months, then switch to methadone or buprenorphine before tapering off; their whole experience with opioids is over in less than two to three years. I'm certainly not saying that what they accomplish is easy, or that it doesn't deserve to be celebrated, but I've never met someone who started using as early on in life as me, who continued using for as long as I did, who has gotten clean without buprenorphine or methadone.
Opioids shaped my neurodevelopment; they are in my marrow, if not my soul.
In terms of those few opioid addicts who do achieve long-term recovery, there is a telling statistic that used to bandied about in recovery circles. I can't find the source at the moment, so don't quote me on this, but it's a stat that I've heard Addiction Medicine docs cite, and it basically says that the average heroin addict attempts treatment and recovery five to seven times before it sticks. So, even for those opioid addicts who achieve long-term recovery, it seems that the process is iterative, which to me suggests that some essential learning is happening along the way.
My Aunt Sue said something beautiful to me once: That the sailors who survive the storms and shipwrecks aren't necessarily the brawny young bucks; rather, they're the old, service-hardened guys who have been through a dozen similar crises*. I think that recovery is like that for many people.
*This blog is nothing if not a pageant of tangents, and there's a related idea that my friend Will recently shared with me, which summarizes much of what is going on with Western democracy at the moment, in my opinion: Tough times create strong men, who create easy times, which create weak men, who create tough times, which create strong men.
I'm not here to dwell on the depressing statistics today.
Instead, I'd like to talk about what I've learned from my own experiences with relapse and how I hope to apply that knowledge to my present situation.
The stakes of relapse are life or death. As addicts, we can't ever forget the seriousness of the consequences of returning to use: Jails, institutions, and death.
There is a 12-Step precept that you "pick up where you left off" when you relapse, and I've found that by and large to be the case. Each return to active addiction tends to be worse than the last. The science of addiction tells us that physical and mental readdiction happen faster with each relapse, and the other consequences of use tend to compound with successive cycles of addiction, as well.
Using even once, particularly in the era of fentanyl and xylazine, can mean death. We can never afford to treat relapse lightly.
Relapse doesn't have to be a part of recovery. As much as relapse can be a valuable learning experience, every single thing that you need to know about recovery can be gleaned from your first (and only) time through it.
As notable nineteenth-century German Chad Otto von Bismarck* once put it, "A fool learns from his own mistakes, but a wise man learns from the mistakes of others." If you heed the successes and failures of other people in recovery, relapse is never necessary.
It is infinitely easier to maintain hope and momentum during your first and only shot at recovery, when optimism and energy are sky-high, than to try to recapture those positive feelings after having them dashed against the rocks by relapse. With few exceptions, believing in yourself gets harder each time that you fail.
*As an interesting historical tangent, Otto's great-great grandson, the debonair Count Gottfried von Bismarck, epically and tragically failed to heed his ancestor's wisdom. He was a flamboyant socialite who held infamously decadent parties at his London properties, where one young man died after falling out of a window or balcony. Although Count Gotty (as I call him) was cleared of wrongdoing, an outcome that many believed was due to British deference to his aristocratic background, he died of a speedball overdose in 2007, at the age of 44.
He had the highest cocaine level that the medical examiner had ever seen (in the coke capital of the world, mind you, where Thames eels' mating patterns have changed due to cocaine in the river water!). He tested positive for morphine, as well. He also had a veritable alphabet soup of life-threatening infectious diseases, including Hepatitis B, Hep C, and HIV. A man after my own heart.
Sometimes I'm glad that I wasn't born into money. As the stories of people like Count Gottfried and Princess Diana's friend Aileen Getty attest, money is a powerful amplifier of mental illness, and none more so than addiction; it provides isolation, freedom from responsibility and social censure, ease of access, legal protection, and the ability to use unlimited quantities 24/7, which amounts to a death sentence for most addicts.
For most people, though, relapse is a part of recovery. And beating yourself up about it, giving in to the shame and guilt, is really just providing fuel for your addiction.
The best way to approach relapse is to halt it immediately, restabilize, and then study it. Something, and likely several things, probably had to go seriously wrong for someone who was stable in recovery to relapse. Relapse can be due to (1) the breakdown of a recovery routine that worked, or (2) the failure of an incomplete or flawed recovery regimen.
For me, relapse is almost inevitably tied to three factors: insomnia; some injury or circumstance that suddenly prevented me from exercising; and uncontrolled or uncontrollable anxiety.
A return to a situation where I had readier access to my drugs of choice, such as coming back to my hometown, often provided the alley-oop that joined motive with means and opportunity.
Relapse can also result from a failure of motivation. Using is wonderful; we continued doing it for so long and in the face of so many negative repercussions because it is a powerfully effective coping mechanism, at least at first.
Unlike with benzos, cocaine, and other drugs, my drugs of choice (opioids) don't make me do embarrassing things when I am intoxicated. If anything, they make me chiller and more sociable, which the people around me often appreciate.
Unfortunately, I don't have the ability to restrict my use of these drugs to within reasonable bounds. The cons vastly outweigh the pros, and my only option is complete cessation.
As the weeks and months of recovery accumulate, it is easy to forget just how awful active addiction really was, to romanticize how amazing using felt and to begin to question whether this time, perhaps, things could be different (just this once).
There are several strategies for preventing such thoughts and feelings, which are only natural, from blossoming into relapse.
Cognitive-behavioral strategies such as "playing the tape through," writing lists of "not-yet's" that could happen with a return to use, vividly journaling about mortifying or dangerous experiences that resulted from active addiction, and other techniques help to keep reality fresh in our minds so that motivation doesn't falter.
Appreciating all of the meaningful relationships that we have built up in recovery, our treasured possessions, and our plans for the future can reinforce our forward momentum, too.
There's quite a bit of real estate between self-insight and change. A detailed plan for applying self-knowledge, as well as the diligence to follow through with it even when it's tough to do so, is necessary for long-term recovery.
Meetings and other recovery routines, I've found, are a lot like running: The days when you least want to do them are the days when you need them the most. It takes real grit and commitment to stick to a solid recovery routine on top of all of the other relationships and responsibilities of a full life.
Mindfulness meditation, spiritual practices centered upon gratitude, and proper diet, exercise, and adequate sleep all help to maintain a balanced, resilient state that is conducive to continued recovery.
A one-day-at-a-time attitude also helps to avoid overwhelm and burnout during recovery.
Heroin addiction in a single photo ft. the scrawny forearm of yours truly. Bonus points for the junkie clutter in the background, which gives that authentic traphouse feel. Because I took this during a relapse after a couple of years of not injecting, I don't have the raised, purplish track marks along my veins that indicate recent use; instead, my tracks have faded to white tracery along some of the major veins of my forearms and hands. As you can see, I'm having an allergic reaction to something in the dope that I shot (there's a parabolic red area spreading up my arm from the injection site); this type of reaction started to occur during the era of fentanyl, during which dope was cut much more ineptly than it had been in the past.
There's something poetic, almost metaphorical, about shooting up. You take all of the uncomfortable feelings and unpalatable realities and compress them down into a single, sharp point; you hurt yourself once, deeply, and are delivered. But in the end, you've taken all of that darkness and injected it into you, and it stays with you, becomes a part of you.
There are a couple of things that I've realized as I've processed my recent relapse.
One is that continuing to taper off of methadone while working at my current, high-stress teaching job in my home city is probably not possible without relapsing.
It entails being mentally and physically uncomfortable, often severely so, for months on end. I'm going to be sleepless, anxious, and in pain, and probably unable to exercise - at least, to do cardio - for much of that period. I'm also going to have to interact with dozens of perspicacious students and colleagues each day.
I've been delving into mindfulness meditation and practicing my radical acceptance skills, but the reality is that when that that one low moment of that one particularly rough day arrives, I will inevitably be able to score drugs within 30 to 45 minutes. There are one or two areas of projects in my hometown, which I pass by every day for work, where I can show up and score dope within minutes, 100% guaranteed, without communicating with a dealer beforehand.
It's untenable.
The conclusion that I've come to is that, for the worst, final part of my taper, I need to remove myself to a safer environment.
The average methadone detox lasts between one and two years when done at an outpatient clinic. However, I just had a consultation with a doctor who offers a two- to three-week methadone detox in a cabin in the mountains of Utah, which involves transferring the patient (me) over to a short-acting opioid (hydromorphone), then tapering down from there.
There are huge pharmacologic advantages to this approach, and the program in question also offers low-dose ketamine treatment for refractory anxiety and depression, a pharmacogenomic survey to explore how each patient's physiology interfaces with his / her psych needs, and other customized treatment tools.
I'm a rip-the-bandaid-off kind of guy, and if I had the money to commit to a program like this - which aren't covered by medical insurance in the U.S. and cost as much as a down payment on a nice house - I'd be on a plane tomorrow.
Instead, I'm currently exploring 30- and 60-day rehab programs that are covered by insurance. Going to inpatient treatment will allow me to devote all of my time and energy to getting into the rhythm of my recovery routine; it's a bootcamp to get me started off on the right foot.
Not having to work - just being able to look and feel as sick as I need to - will be an enormous, necessary relief. It causes me significant stress to feel that the people around me are noticing me being "off," which I've had some really humiliating experiences around in the past, so having that factor removed will greatly simplify the equation.
Even if the right opportunity doesn't arise in terms of inpatient treatment, I need to at least visit a friend or rent an Air B-n-B in a relatively isolated area for the roughest, final part of my taper.
As much as I don't want to cave in to defeatist thinking, the odds are just too stacked against me right now.
I'm also coming to grips with the fact that I need to consider taking medicine for my anxiety and insomnia.
I've always been an all-or-nothing guy, which has unquestionably played into my addiction. Because of this, when I get clean, I get really clean: I don't even like to take over-the-counter meds for sleep or congestion or aches and pains.
Unfortunately, because of my thyroid condition as well as the fact that I've used and abused benzodiazepines for 20 years, there has been some long-term ratcheting up of my anxiety, Lately, my anxiety has been so severe that friends and colleagues have commented upon it (which, of course, fuels the social component of that anxiety; thanks, guys).
If I can't get this under control, I don't think that I'll ever be able to do anything other than white-knuckle sobriety.
I've had negative experiences with SSRIs for anxiety in the past. Specifically, I had an activating reaction to Prozac and Lexapro, which induced a kind of hypomania that felt a bit like a low dose of E.
However, there are several other non-addictive antianxiety medication types that I need to consider. I loathe the thought of having to try out multiple medications and tolerate the side effects while my body is adjusting to them, but if it's necessary, it's necessary.
On a quick tangent, speaking of my reaction to SSRIs, there is a not-weak argument to be made on the basis of this response that I might have bipolar II.
I've often wondered whether having untreated bipolar or Borderline Personality Disorder would explain my difficulty maintaining long-term recovery. The possibility of BPD has been raised by at least one psychiatrist, but nothing ever really came of it because my life and relationships look so functional during periods of sobriety.
This is something that I'd like to look into, too. Again, it might be that I have such a rough time maintaining recovery because getting clean when you have a serious, untreated mental illness is more a matter of removing a powerful coping mechanism than it is returning to a reasonably healthy psychological baseline.
My insomnia is also a problem. Lately, it has reached Fight Club levels that often mean showing up to work after two or three hours of sleep and sometimes after none at all (literally not a wink). This isn't so bad to do once in a while in your 20s for a noble reason like finishing a novel or getting laid, but to deal with this chronically in my 30s while going through the sobriety struggle that I've taken on is another matter entirely.
Lack of sleep makes logical thinking difficult; it exacerbates emotional swings and drug cravings, as well.
I've taken trazodone, hydroxyzine, and other recovery-safe sleep meds in the past. Although I disliked the side effects, which can be significant, the pros outweigh the cons at this point.
And let's be real: The side effects of these meds are infinitely more bearable than the side effects of slipping back into active addiction.
So, yeah, meds. Again, I have always tried to stay away from psych meds in recovery because I relished the pure feeling of not needing any mind-altering substances and also didn't want to extend the "fix X problem with Y pill" mentality into sobriety. However, I'm realizing that not pursuing appropriate pharmacologic treatments for my anxiety and insomnia is really just a way to set myself up for failure as the weeks and months wear on and I become increasingly stressed and exhausted.
And I need to look into the possibility that an undiagnosed personality disorder or bipolar II condition is obstructing my path to recovery, too.
Fin
That's a wrap. Nothing mind-blowing, I know; just some honesty about how I'm faring, some thoughts on what I need to do differently to avoid falling back into active addiction, and some reflections on relapse that might hopefully help someone else walking down a similar path (or wanting to avoid doing so à la Otto von B.).
It's been a rough first Christmas without my stepdad, Lou, but we've kept it cozy, and I've enjoyed checking in with friends from all over the world.
Life can be so cruel, and my DMs here and on Insta (@concreteconfessional) are forever open to anyone who needs a nonjudgmental ear. For real.
I have some big news to discuss regarding Jay, and possibly me, relocating to London in the early spring of 2025, but I'll save that for a future post.
Love you all. If I don't post again in 2024, thank you for reading, and I wish you the very happiest of New Year's.
All the best,
Brian
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