Search Results

Curated screenshots of a textbook example of stimulant-induced psychosis.

A run-down of the direct financial costs of my opioid addiction over the past 15 years of full-blown active addiction. I've also estimated some of the indirect costs in medical / legal fees and lost income to give a truer picture of total financial loss. God, this one's depressing. A high school graduation photo (I'm fourth from the left and in the back). Incidentally, not a single one of the fourteen guys pictured is looking at the camera. I was salutatorian (second in my class academically) and was accepted to my first-choice university, which is in the Ivy League, through its Early Decision program. I had a lot of "friends," but I bounced between social groups, and in those days, I was a lonely loner. I also had a desperately deep crush on a straight guy a year older than me. By this time, I had experimented with at least a dozen mind-altering chemicals. Although my high school was known for partying, injection drug use was not just unmentionable; it was unthinkable to 99.99% of my high school. No one knew that I had shot heroin for the first time during my sophomore year, when I was 15. American banking heir Matthew Mellon, who died while seeking treatment for his opioid addiction in Mexico, reportedly spent upwards of $100,000 per month on OxyContin pills. Southern gentleman-lawyer Alex Murdaugh, who murdered his wife and son and defrauded dozens of law partners and clients, claimed that financial stress from his oxycodone habit was the impetus for his white-collar crimes. He, too, spent tens of thousands at a time on oxycodone. People are shocked when I tell them that homeless addicts often scrounge up 50 to 100 dollars per day to fund their dope habits. The great truth of drug addiction is that no matter how much money you have coming in, it will never be enough. The Needle and the Damage Done I tried oxy for the first time when I was 14 and heroin for the first time when I was 15 (there's more information on my early drug use here). However, I didn't pick up a habit* until I found a reliable heroin connection in my college town midway through my sophomore year. *In junkie parlance, having a habit means that you are using regularly enough to experience withdrawal when you stop taking the drug. During that first year of collegiate use, I had what's called a chippy, which is sort of a baby habit: Something small and cuddly; a thing to be nurtured. During the second year, I descended into full-time, frenetic addiction. Even though I spent at least $3,000 to $4,000 on drugs during high school, most of which went to OxyContin and heroin, I'm chalking that up to youthful experimentation expenses because my addiction hadn't really gotten its hooks in me yet. To arrive at a reasonably accurate estimate of the direct financial costs of my opioid addiction over the 15 years during which my struggle with these drugs was the defining feature of my existence, I divided my addiction into several periods. (1) Collegiate use beginning halfway through my sophomore year and ending halfway through my senior year. This ended with the sh*t really hitting the fan when my drug dealer, a fellow student, was arrested with $50,000 worth of heroin while leaving my house. The arrest was covered in national media, which dubbed her the Ivy Queenpin. The incident led to the DA threatening me with a B felony conspiracy to distribute charge, which carries a prison term of 1 to 10 years, the mere specter of which was nearly enough to get me expelled from college.* *My dealer ended up going down for all of us; she served a year in prison. After her release, she became an award-winning journalist and documentarian who covers prison reform and addiction-related topics for national publications. She also wrote a bestselling memoir that earned praise from Piper Kerman, the author of Orange is the New Black. So many crazy stories to come. Subtotal for this two-year period: $20,100 A random soiree from my freshman year of college, which was one of the best years of my life. I had the highest GPA in our building (over a 4.0, which is very rare at my university), and I was one of the social leaders of our freshman group. Once again, however, I bounced around between cliques, keeping my distance without really meaning to. I avoided opioids almost entirely during this year, but I burned the candle at both ends by binge drinking on the weekends (which, in the grand collegiate tradition, occasionally stretched from Thursday night until Sunday afternoon). Another freshman year party night. This time, my friends and I traveled across town to party at the university that my cousin Megan attended (she's the brunette on the far right here; she's now a lawyer who works for a group that provides free legal counsel to incarcerated people). A photo that speaks for itself is a wondrous thing. Ah, the damp fall leaves / crackling Gothic fireplace nostalgia. The small city that my university is located in is the quintessential quaint East Coast college town. I basically chose my college because it was voted the most Hogwarts-y Ivy the year before I graduated high school. (2) My time in New York City, which I relocated to after graduating from college and securing my first job at one of the nation's cutting-edge hospitals. By chance, I ended up living in Williamsburg, a hipster haven that happened to be the dope capital of New York City, which conveniently happened to be one of the heroin capitals of our world. Predictably, this ended a year later when I was fired for being impaired and sketchy on the job. Subtotal for this period: $24,000 (3) An interlude for my first year of medical school in New Jersey, during which I mainly used prescription opioids and benzos / barbiturates. Right before Christmas, I overdosed and was treated at the teaching hospital affiliated with my school, which was mortifying. Somehow, I finished my first year at the top of my class academically. Nonetheless, my mental health was abysmal; the strain of my Jekyll-and-Hyde existence was really wearing on me, and I wanted nothing more than to return to being a full-time drug addict. I disclosed my addiction to my school and was granted a one-year leave of absence to get help. Subtotal for this period: Negligible (almost entirely prescription drugs covered by insurance) (3) Several years during my mid- to late-twenties after I left medical school, during which I moved around from Upstate New York (home) to Lebanon (Oregon), Delray Beach (Florida), and Maui (Hawaii). During this period, I was earnestly trying to get clean, but I just could not make it last. I alternated between Suboxone maintenance, which I detested, and being completely clean (my thoughts / feelings about opioid maintenance treatment are here and here [second link is specific to methadone]). There was a clear pattern: I would go to residential rehab for 30 days, graduate with flying colors, and hit early recovery full steam. Then, two to six months later, after securing a new job, apartment, personality, et cetera, I'd relapse. I'd use with increasing frequency / intensity until some crisis blew up my current incarnation*, after which I'd enter treatment again. *For example, a car accident that I caused in which I hit another car - whose driver was blessedly unharmed - and demolished my left elbow. Also, the time when I got a finish-line DWI in Oregon after veering off the road and taking out a goodly stretch of a white picket fence (court-assessed fence value: $950; symbolic value vis-à-vis the destruction of the American Dream: priceless). At the end of this period, fentanyl was contaminating the heroin supply all along the East Coast. My junkie friends began dropping like flies. I knew that I had to get out, so I took my friend up on her offer of a teaching job in Shenzhen, which began the next great adventure of my life. Subtotal for this period: $40,500 (4) My four and a half years in China. Despite the fact that I arrived in Shenzhen dopesick, I was clean for the first year and a half, which was one of the most tranquil, beautiful, challenging, and productive periods of my life. I met my fiancé, traveled extensively all throughout China, ate literally everything, and taught bio and chem to some of the country's best students (see "I Was Simon Song" if you're interested in these stories). After a year and a half, I discovered how to get prescription opioids and benzos from private hospitals catering to foreigners. This was epically bad news. I spent the next two and a half years heavily dependent on OxyContin and clonazepam / alprazolam, which I had a nearly limitless supply of. At the end of this period, I was forced to return to the U.S. because A) the pandemic had made it almost impossible for foreigners to live in China, and B) the police searched the apartment of a friend who I was staying with and questioned me regarding why I was taking 600 milligrams of oxycodone per day (although I wasn't technically committing a crime and obtaining gray-market meds is commonplace in China, they assumed that I was dealing because of the quantities involved). Again, insane stories to come. Subtotal for this period: $91,250* *That's right. Jay, my fiancé, is an accountant. Eiffel Tower with Chinese characteristics at Window of the World in Shenzhen (if you get that joke, then you're either Chinese or an expat who has spent quite a bit of time in Mainland China). Arriving in Shenzhen dopesick was a Tarantino-esque dream. We call Shenzhen the Silicon Valley of China, and it has a whimsical, futuristic vibe that sometimes made me wonder if I had died in an OD and been transported to some strange afterlife. My older brother saw this sign and summarized it as "no hovering hawks." He's brilliant like that. I've written elsewhere about how my relocation to China saved my life (geographical relocation had worked in my favor before, and this was an extreme case of new environment / new neurology). I lost six friends during my first two years in China, during which fentanyl was replacing heroin in the U.S. illicit opioid supply. Although I had been using heavily before I left for China, the adjustment to total sobriety wasn't nearly as agonizing as it should have been. It helped that I had to learn a new language (one with thousands of letters), acclimate to a new culture, get acquainted with a new way of doing business (cash was almost obsolete, so I quickly mastered making payment via WeChat Pay QR codes). In addition, I had to adjust to a radical change in diet and even used a squat toilet once or twice, which was intriguing. I was fully engaged in my teaching, and my students were incredible; that certainly helped, too. A late night at the aptly-named Fun Flower nightclub in Shenzhen, where rose petals flutter down from the ceiling of the three-story atrium at 4 a.m. One time, I woke up the next morning and found rose petals in my underwear when I went to use the bathroom. My thirtieth birthday party. Don't mind my hair; somehow, "auburn highlights" must've gotten auto-translated into "ruin my special day." Me at the end of the golden period that was my first year and a half in Shenzhen. I have pupils! And some meat on my face. Witness the deterioration of my appearance and affect in the next several photos as my relapse progressed. Me giving a talk to Chinese undergrad students about how PhD candidates in STEM subjects fund their research and living expenses in the United States. By outward appearance, I was a put-together young professional, but I had become physically dependent on OxyContin again. Me talking to a group of students and parents about the importance of personal narrative essay writing for undergraduate admissions in the United States. The disease is gaining momentum: I look wan and depleted at this event, during which representatives of American boarding schools gave talks for Chinese students and their parents. Frightening. I don't see myself gazing at the camera; I see the disease of addiction. All of a sudden, rather than getting 40 milligram OxyContin pills, which contain only oxycodone, I was forced to switch to a Chinese Percocet brand, which contained 5 milligrams of oxycodone and 325 milligrams of acetaminophen per pill. I was taking 70 to 90 of these pills on my worst days, which amounted to over 20 grams of acetaminophen. Anything over 12 grams of acetaminophen a day will cause liver damage, and 15 to 25 grams is considered a lethal dose. I was in acute liver failure and my kidneys were stressed to the point of serious dysfunction. I couldn't eat solid food for weeks. I was passing out randomly at work and home. I started searching for info about what happens when a foreigner dies in China because I didn't particularly want to end up a box of ashes on a shelf in some warehouse, which is what happens to most Chinese who don't have living family, but I certainly didn't want my family to bear the costs of bringing my body or ashes back home, either. Still, I couldn't stop taking the pills. I'm lucky that I survived this period. Grand total: $175,850 If any of you are interested in the prices that I paid for the legal and illegal opioids that I was using in the United States and in China, feel free to ask questions in the comments section. I've got a detailed spreadsheet that I used in arriving at this estimate, which I'd be happy to share; it provides a fascinating forensic accounting of a textbook opioid addiction progression. Hidden Costs The indirect costs were in the same ballpark. Over this fraught 15-year period, I accumulated medical bills for copays that totaled in excess of $20,000, over half of which I never paid. The legal fees from the incident during my senior year of college, my DWI in Oregon, and my car accident in New York easily totaled $10,000 to $15,000 (it would've been three times that if I hadn't had family help with these matters). I abused lines of credit by converting them into cash at casinos or through other tried-and-true junkie tricks, which led to further debt. I also had a year's worth of student loans from my (expensive) medical school, plus about $20,000 from undergrad. Needless to say, I wasn't paying these loans down during this period. Of course, the lost income from the months that I spent in treatment added up, too, but I'm not factoring that in right now. Overall, I ended up about $250,000 in the hole from these 15 years of soul-sapping opioid addiction. Sometimes when I relapsed, I would think about my financial picture and feel that there was no way out; I had already written myself off of the planet. Most of all, my opioid addiction screwed me by keeping me stuck. As a friend of mine once put it, I felt like I was playing the same level of a video game over and over. Until I moved to China, I had been working for seven years without making an iota of progress in my career. Because of this, my income wasn't increasing in the way that it should have been.* *It didn't help that my class graduated into the worst job market in my university's history, either. Economics has shown that recessions have a significant, lifelong effect on the earning potential of college grads who enter the job market during them. The worst aspect of this financial stress was constantly being down to my bottom dollar. For at least 10 of these 15 years of active addiction, my bank account was overdrawn. I paid thousands in overdraft fees. I was working hard, but I didn't have money for food or basic expenses, let alone a book that I really wanted to read or a drink with a friend. I had always enjoyed picking out gifts for friends and family, and I missed being able to give thoughtful presents more than I missed anything that I could have gotten for myself (I'm a monk at heart when it comes to possessions, including home decorations). When I had free time, I explored parks and libraries simply because they were free. The stress of always wondering if I was going to get the "insufficient funds" notification when I paid for something really took its toll. My Life Is an Anti-Drug Commercial The grand total of $175,850 was actually less than I expected, and it likely represents an underestimate. When I saw this figure, my first reaction was "It's bad, but it's not fatally bad." Some of my medical school classmates owed this much or more by the time that they graduated and began practicing. Starter homes in California cost twice or even four times this amount. On the other hand, it's a beautiful Victorian home for me, Jay, and Ti Qi the Wonder Poodle in my hometown. Bought, taxes paid - owned free and clear. It's a significant boost to my parents' retirement savings, which would change their quality of life. And imagine if I had put even half of that money into a small business, an investment property, or a riskier bet like Bitcoin. My future would be appreciably brighter, and I would have a nice nest egg by now. Instead, Jay is shouldering most of the financial burden of us hopefully relocating to the U.S. in the next couple of years. The cliches are painfully correct: What hurts most of all is the lost time. And time truly is a priceless commodity. During these 15 years, I lost my beloved grandmother. I am ineffably grateful that I was in my first year of medical school and by all appearances doing well when she passed. Nevertheless, my addiction tainted and overshadowed many beautiful moments with her. My parents grew old. I still don't feel that our dynamic has been reversed in the way that it should be for adult children. In some ways, I'm stuck at the same level of the video game, which makes it difficult for me to take care of them in the way that I should be. My friends from high school and college completed graduate school, got married, and had kids. I've only attended one wedding in my entire adult life. I've made the funerals / calling hours of several friends who died by overdose in their 20s and early 30s. I missed out on the rollercoaster romances of my 20s because I was in love with a chemical. There is no lover more jealous than heroin. I know that it's stupid, but when I was young, I used to daydream about the future relationships I'd have with handsome guys like the ones that I saw on TV. I imagined the deep talks we'd have, the trips we'd take, the dramatic fights we'd get into before reconciling into an even-closer love. I envisioned the secret worlds that we would weave together. I missed out on all of that. By the time that I met Jay, I was almost 30, and dating had become a more pragmatic, future-focused affair. I gave up the career in medicine that meant more to me than anything. It was my true passion, my raison d'être, and my God - there were moments when I was brilliant at it. At times, I prayed for an overdose just so that I didn't have to wake up and think about all of the hurt that I'd caused, all of my failures. The departed dreams and AWOL hopes. I spent much of my 20s and early 30s feeling like I had outlived my expiration date. I used recklessly because I was convinced that it was only a matter of time before I joined my dead friends. I didn't plan for the future in any meaningful way because it was inconceivable to me that I would have a future. To this day, I struggle to let go of the life I should have had. What I wouldn't give for a do-over. For those of you who are drug addicts, what has your habit cost you per day and over time? I'm very curious to know how this varies by area of the U.S. and how much legal and illegal drugs cost in other countries. As a heroin addict in the U.S., I was spending upward of $80 for a 10-bag bundle per day when I was in college. Then, when fentanyl replaced heroin in the dope supply, bundles became dramatically cheaper (down to $30 to $40 each), but because fentanyl doesn't last nearly as long, I needed to use three to four times as much per day. In China, two boxes of 40-mg OxyContin pills, each of which contained 10 pills, cost 700 RMB (about 100 USD). Benzos were much cheaper.

Gabapentin and xylazine provide a case study of why U.S.-style drug prohibition fails so miserably. I discuss how we can reform our system to prevent even more deaths from addiction. “Those who can make you believe absurdities can make you commit atrocities.” - Voltaire (18th-century French philosopher) Lesions caused by xylazine. This was the mildest picture I could find; don't Google "xylazine lesions" unless you're ready for medical journal pics showing exposed bone and limbs rotten to the point of amputation. For those of you who are still using "fentanyl," especially in the Northeast, know that these lesions can occur anywhere on your body - not just at the site of injection. The Nightmare Du Jour: Xylazine I was recently catching up with a friend of mine named Katie, who is a phlebotomist at a methadone clinic. She mentioned that the clinic has recently had to stock large quantities of Emergency Department supplies that it has never needed before. When I asked her why, she replied with a single word: Xylazine. This horse tranquilizer, which has long contaminated the supply of heroin and other drugs in places like Puerto Rico, is now infiltrating the drug supply in cities throughout the United States (with the Northeast feeling it worst so far). Katie recounted her interaction with a 26-year-old woman who came in for her intake appointment at the methadone clinic last week. This prospective patient showed up for the physical exam portion of the intake process and allowed Katie to draw blood, take her blood pressure, temperature, and heart rate, and so on. The young woman insisted again and again, however, that Katie not touch her right arm, which she held gingerly away from the rest of her body. Eventually, Katie became concerned enough about the arm that she asked the young woman to pull up her sleeve and show her what was going on. The young woman shook her head no, so Katie returned with the doctor, who explained that a thorough physical exam was necessary for safety reasons before methadone treatment could be started. Finally, the young woman pulled up her sleeve, revealing a four-by-two-inch hole in the flesh and muscle of her right forearm, which was eaten away to such an extent that both the radius and the ulna bones were visible. It was one of the worst lesions that Katie has seen in her two decades of medical experience and something that she never expected to see somewhere like the United States. It turns out that xylazine has hit our home city in Upstate New York, where much of the fentanyl being sold as heroin is now contaminated with this unscheduled anesthetic that is not approved for use in humans. Most of the people using it have no idea that there is something other than fentanyl in what they are putting into their bodies, but this so-called "tranq" or "tranq dope” has attracted a loyal following in some cities, including Philadelphia. It has been widely observed that users of xylazine develop necrotic ulcers - not just at injection sites, but all over their bodies, presumably because of changes in circulation caused by the drug. Because xylazine isn’t an opioid, overdose can’t be reversed with Narcan (naloxone), meaning that EMTs and other medical professionals now have an even more hellacious situation on their hands. More patients will need to be intubated and managed in the ICU, and undoubtedly, more sons and daughters and brothers and sisters will be lost. The public health authorities in my home city and across the United States are sounding the alarms. For those of you who are familiar with Russia’s putrid hallucination of a Krokodil problem, the parallels will be obvious (if you're interested, Vice had some okay coverage). If you're wondering what xylazine feels like, I've written a wild trip report about injecting pure, medical-grade xylazine. Okay, this is all good to know, but what does it have to do with gabapentin? Bear with me, please; I’ll loop back around to xylazine, I promise. What Is Gabapentin? I have been prescribed gabapentin so often during the past 10+ years that I turned it into a verb. “Are you gabapenting today?” I would ask my fellow detox patients over breakfast. I can close my eyes and picture the black imprints against the bright yellow capsules. Gabapentin (trade name Neurontin), which in 1993 was FDA approved for use in treating certain types of seizures, has been prescribed off-label for everything from opioid and benzo withdrawal to insomnia to anxiety. It helps with nerve pain, particularly the kind caused by diabetes, fibromyalgia, and other disorders, which doesn't respond well to opioids or NSAIDs. Gabapentin was the single safest and most effective anxiety medicine that I have ever taken. I found it much less addictive than the benzos (drugs like Valium, Klonopin, and Xanax). It was easy to regulate my intake of the medicine and much, much easier to come off of it. Gabapentin also gave me more relief from opioid withdrawal than any other medicine aside from opioids themselves. It got me through my buprenorphine (Suboxone) and methadone tapers, which involve months of severe anxiety, insomnia, bone pain, muscle cramps, diarrhea, and more. During my relapse, there were many times when I relied on gabapentin to get me through periods of 24 to 48 hours without my drugs of choice; this is an addiction hack that opioid addicts in the U.S. commonly use it for. To me, when taken sporadically, gabapentin feels similar to smoking a small amount of marijuana. It induces a light sedation with some relaxation, a mild body buzz, increased appetite, and a slight sensory shift toward more vibrant sounds, tastes, and colors. After three or four days of regular use, in my experience, gabapentin fades into the background; it becomes undetectable, though it still helps with pain, anxiety, and insomnia. When I was first prescribed Gabapentin around 2011, it was the “great new thing” that psychiatrists and other doctors were turning to in the fight against benzos and opioids. Many, many a pill-seeker from the aughts and ‘10’s will tell you about interactions with physicians that ended with a statement to the effect of “We can’t give you X (controlled substance requested), but gabapentin is no problem.” When I was first prescribed it, in fact, I was told that it was much safer than benzos but worked by a similar mechanism. No risk of dependence or addiction was mentioned, ever, period, by any of the several physicians who prescribed it to me through the years. As I mentioned above, gabapentin was being prescribed so widely in part because benzo prescriptions were being cracked down on as the long-term effects of seizures, memory loss, and cognitive decline became apparent. Unlike gabapentin's sister drug Lyrica, which is a controlled substance, gabapentin wasn’t regulated federally or at the state level, meaning that the stringent requirements attached to controlled substances weren’t something that physicians had to consider when doling it out. Now that we know more about gabapentin, we have realized that gabapentin has a more dangerous short- and long-term side effect profile than was initially appreciated. A benzo-like withdrawal syndrome sometimes involving seizures has been reported. Moreover, because gabapentin is often used to “boost” the action of prescription and black-market opioids alike, the respiratory depression that it causes has contributed to many polysubstance overdoses. Ostensibly for these reasons, some states began to classify gabapentin as a controlled substance even though it isn’t federally regulated in this way (yet). As of July 2022, eight states had implemented legislation making gabapentin a controlled substance, and several others had instituted more rigorous monitoring and reporting requirements for gabapentin compared to other noncontrolled substances. During New York State’s 2017-2018 legislative session, NYS Senate Bill S8145A was passed, classifying gabapentin as a controlled substance. Gabapentin Prescriptions Drying Up I am in somewhat regular contact with dozens of opioid addicts, probably half of whom live in New York State, and several have recently mentioned their doctors discontinuing long-term gabapentin prescriptions. Others have switched providers and found themselves unable to restart or continue the medication, as well. Although making a substance controlled technically shouldn’t stop doctors from prescribing it to patients who need it, practice is wildly different than theory in this regard, especially because of how litigious Americans are when it comes to malpractice cases and how vigorous the government has become in cracking down on doctors who overprescribe dangerous drugs (an otherwise positive development in response to the epidemic of Oxycontin overprescription that fueled the heroin epidemic). The available evidence strongly indicates that gabapentin is being prescribed less often and in smaller quantities in the areas where it is controlled at the state level. It is almost guaranteed that physicians in areas where it has not yet been regulated are paying attention to these developments and shifting away from gabapentin in anticipation of their own states regulating it and / or gabapentin being added to the federal controlled substance schedules. The bottom line: People who have used gabapentin for a long time, for whom it works well and hasn't caused deleterious side effects, can no longer obtain it. The notorious 80-milligram OxyContin formulation: Addiction in a pill. I remember walking through parties during high school in the aughts and seeing yellow (40 mg) and grayish-blue (80 mg) streaks on many a partier's t-shirt from removing the extended-release coating to get even more of a kick from these pills. Taking them was essentially like ingesting a high quantity of pure heroin. Most opioid addicts my age or older entered opioid addiction through these pills - they were sort of the Lemmon 714's (quaaludes) of our time. Back to Xylazine: The Big Picture A pattern that we’ve seen again and again during the failed War on Drugs is reoccurring: We take a legal substance with known risks and restrict its availability by controlling or banning it, and we ultimately push the people who have come to depend on that substance toward illegal behavior, such as buying prescription pills illegally or substituting street drugs for prescription ones. We trade limited, known or at least knowable risks for unlimited, unknown, and unknowable ones. We push people over the precipice into criminal behavior and full-blown addiction. Forced withdrawal from substances that cause physical and psychological dependence is a form of torture. Our government has made enemies of its own people and incarcerated millions of them for continuing to obtain something that their brains and bodies can no longer function without. In the case of gabapentin, street benzos like bromazolam – which have become ever more popular as Xanax and the other prescription benzos have gotten much more difficult to acquire through the medical system – are taking over. Because most of these chemicals are not approved for use in humans, we don’t really know their full risk profiles, but many of them are ultra-potent and long-lasting. (Many of them are much more dangerous in nearly every way than the prescription benzos; this much is clear). Moreover, users of these black-market benzos have no way to know for sure whether they’re taking the substance that they believe they are, how much they’re taking, and if they’re taking only that substance. (We know that pressed pills meant to look like Xanax “bars” have been seized that contain both fentanyl and bromazolam, which is a recipe for fatal overdose if ever there was one). So, just as we’re taking away gabapentin, an approved substance that opioid addicts use to manage their withdrawal symptoms and get off of these drugs, we’re seeing an increase in availability of xylazine, a cheap and highly dangerous drug that isn’t even approved for use in human beings. This is exactly the mistake that we made when regulators suddenly took away OxyContin by ordering its reformulation and clamping down on prescriptions after it had been massively overprescribed for years and years. We pushed people away from prescription opioids, and those people eventually ended up on heroin, then fentanyl – and now xylazine. One hundred and twenty years ago, an opioid addict could walk down to the corner pharmacy and buy tinctures containing opium, heroin, cocaine, and other drugs with medical and recreational functions. He or she could have visited the friendly neighborhood physician for a prescription for larger quantities of medical-grade drugs, who would have warned about the risk of addiction and helped manage tolerance and dependence in accordance with priorities set in collaboration with the patient. Addiction was still a serious issue, but it was no more onerous and awful than any other mental or physical illness. You could live a productive, prosocial life as an addict. I have experienced both sides of this coin as a prescription drug addict in the U.S., then an illegal drug addict in the U.S., then a prescription drug addict abroad. Even after relapsing, when I was able to go into a clinic and buy a known quantity of a known substance in another country, I was able to hold down a fairly demanding job, enter into a long-term relationship, adopt and care for a pet, and travel and enjoy life. Sucked down an extinction vortex by the criminalization of substance use in the United States, by contrast, all of my time and energy were spent getting money to cover the drastic over-pricing caused by prohibition; I bounced between ineffective treatment and active addiction for years, and avoiding incarceration became the top priority. I'm an educated person with a strong work ethic, but I have wasted much of the past 15 years because of the criminalization of a mental illness that I suffer from. My friend Kris K., a solid man who passed away in 2020 at the age of 43 from drug-related causes. He left behind two young, beautiful boys. Kris and I had a falling out shortly before he died, and I will carry the guilt of that until the day I join him. More than one million Americans have died of drug overdoses since 1999. This is more than all of the American soldiers who have died in battle during all of the wars we've fought since the end of the Revolutionary War. When you stop and think about it, can you really imagine? The Solution(s) 1. Right away, we can “grandfather” long-term users of gabapentin into lifetime prescriptions of the drug. We already have ways to flag patients for “bad” things - all of my medical readers will know about Epic and the PDMP. We can very easily make a note on any affected patient’s electronic medical records explaining that they need this substance for the conceivable future so that any prescriber who takes this patient under his or her care will be able to take this information into account. A grandfather clause for Oxycontin prescriptions could probably have prevented the heroin and fentanyl epidemics, saving millions upon millions of lives and billions upon billions of dollars. 2. We need to figure out the risks of drugs before we prescribe them, especially for off-label purposes, not after. The Food and Drug Administration (FDA), which approves substances for medical use in the United States, is a heinously corrupt organization whose leaders often walk back and forth through a revolving door with top positions in the big pharma sector. Let’s lose the advertisements for pharmaceuticals on TV, bring back protective, paternal medicine in the best sense, and hold our government properly responsible for keeping our children safe. As an interesting side note, the former head of the Chinese equivalent of the Food and Drug Administration, a man named Zheng Xiaoyu who was reportedly once in the good graces of President Xi, was convicted of accepting relatively modest bribes (by Chinese bribery standards) in exchange for approving pharmaceutical products. He was executed. The “big, bad” Communist Party of China has seen what FDA corruption has done to the United States, and it will never allow its own children to be poisoned, tortured, and corrupted in the way that ours have been. 3. We need systemic reform. We need a cultural change toward limiting our use of dangerous substances, controlled or otherwise, legal or not. We also need to reform our way of regulating people’s intake of recreational and medical substances, including the system for scheduling controlled substances at the federal and state level as well as the outrageous criminal penalties for the decision to exercise bodily autonomy by taking drugs. The War on Drugs has failed. We need a new approach. Portugal provides an instructive example, as I touch on in a previous post. Thank you for taking the time to read! As always, I’ll respond to all comments below. Let me know if you’d like to read more on these topics. B.

In the Program, people talk about alcoholics who haven't started drinking yet. They're referring not just to the genetic nature of alcoholism, but to a cluster of psychological and behavioral traits that addicts share, which manifest long before active addiction begins. These are my reflections on the early signs that I was destined for addiction. Me with a group of my cousins and their friends. I'm second from the left wearing that horrifying hat-without-the-headpiece thing (aka a vizor). I wasn't the kind of kid to have friends over or to go to other kids' houses to hang out - I think I only did that twice in all of middle school and junior high - but my brothers and cousins often tacked me on to whatever they were doing. *** I was never "normal." From my middle school memories onward, I recall an Edge™. My body didn't seem quite the right size. It felt like my arms and legs were too lanky, my hands too large on wrists too small, my head oversized and my neck elongated. These distortions imparted a jerky, imbalanced quality to my movements because my brain was always moving the body that it thought should have been there rather than the body that was actually there. I was terrible at sports. My voice, too, was tremulous and tentative. A cloud of minor dissociative symptoms followed me from the age of 10 or so onward. There was a voice inside my head that narrated nearly everything that I was doing, particularly when I was nervous or being observed by other people. "Okay, so you're going to walk in, go right up to the counter, and say 'Can I have a Big Mac, please?' Then, you're going to..." That same internal voice would correct me, encourage me, urge me, rebuke me. It's hard to describe, but there was quite a bit of meta activity going on in the mind of the young Brian, as well. A lot of examination of my own thought processes, wondering if they were normal, considering how my internal state compared to others'. Some of this is typical - a sign of intelligence, even. It's when it becomes distracting or obsessive that it's a problem (one of the great ironies of mental illness is that too much perseveration over whether you're mentally ill can make you mentally ill). In addition to being preoccupied, I was highly reactive: I had a nervous little nervous system. I remember my kindergarten teacher getting frustrated with me because every time she pulled out this big rain stick and flipped it upside down, which was the class' cue to run to our seats, I would scream. I couldn't help it. It was too much stimulation for me. When I look back now, I sometimes wonder if I'd fit the clinical picture of a low-key autism. In addition, I had some OCD tendencies when it came to hygiene, food, and other routines. I was more emotional than most boys are allowed to be. Partly because of that, I was the only boy who sat at the girls' table during 5th and 6th grade. I knew that I was very feminine relative to other boys, which was something that I was occasionally mocked for by my peers. I recognized that it made the adults around me uncomfortable / disdainful, as well. I became ashamed of my voice and mannerisms very early on in my life. One of my earliest memories is of a presexual experience with a handsome teenage boy named Dom, who was at one of the summer parties that my mom's law partner held at his cottage (read: mansion) on a lake Upstate. Dom "kidnapped" me and carried me out into deeper water, where he held me as the other kids tried to "rescue" me. I remember the feeling of Dom and I bobbing up and over the waves together, of him holding my body against his. I was happier than I had ever been on the ride home that day. I realized early on that I was gay, and by middle school I was praying fervently that God would change that. (God helps those who help themselves, so at one point in junior high, I forced myself to masturbate to a picture of Carmen Electra, which was sort of a do-it-yourself conversion therapy, I guess; I figured that, if Carmen Electra didn't do it for you, you were hopeless). Worst of all, I was fairly skilled at masking my discomfiture about all of the above, which meant that I appeared happier and more functional than I was. *** From an early age, fantasy and deception came easily to me. There was always something in my nature that was pulled toward the darker side of life. I remember being in second grade and telling my older brother about the hamsters that our parents were getting us. There was a nine-story cage that we were getting, I explained, in which the warrior hamsters were holding things down on the bottom rung, the sleeping barracks were on levels two and three, the food was stored on level four, and so on. My brother knew that it wasn't true, but it was so interesting to hear me spin the yarn that he listened for an hour. I lied a lot. Sometimes as a game, often to benefit myself when dealing with my parents or peers, and sometimes just to invent a better, more interesting reality that I could invite someone else into. "I'm sure that's objectively true, but would you like me to create a convincing-sounding alternate reality for the two of us to exist in?" Reading was my first drug. From elementary school onward, I devoured upwards of 10 novels a week. When I was immersed in these tales, I was literally transported. I wouldn't eat or go to the bathroom until I finished my book. If you pulled me away from it mid-tale, I would seem displaced, distracted; all of my thoughts and emotions would be tied up in that world and those characters. I'd imagine myself interacting with literary or cinematic characters as though they were real, and I'd make up fake friends (usually handsome guys my age) and daydream emotionally intense relationships with them, as well. Every candid photo of me from middle school shows me carrying a book. I once brought a novel with me to Yankee Stadium to read "before the game." I was literally "the kid who reads all the time" to my extended family. Me at junior prom. I was always a loner, but by the time that I reached this age, I had mastered hiding that fact by bouncing between social cliques. I was considered "popular" and was runner-up for the Best Personality senior superlative (I won "Most Likely to Succeed"... still waiting on it). "Oh, the hell that awaits you," I think as I look at this picture now. Not to be too dark, but if I had known then what the next 20 years of my life would be like, I would've killed myself. I think that's true for more people than would care to admit it, though. *** Reality was an ill-tailored suit, and from my very first experiences with psychoactive drugs, I knew that I had found the hack for correcting my physiology. At some point in treatment, I read about a study in which psychologists gathered volunteers, some of whom were addicts and alcoholics and some of whom were “normies." Using basic, general terms in the prompt, they asked them to write about their first experiences with mind-altering substances. As the researchers reviewed the responses, it quickly became clear that the addicts / alcoholics gave much longer, more detailed, and more emotionally-oriented answers. They were struck by the extent of the differences between the two sets of responses. This isn’t surprising, but it rings profoundly true. Mind-altering substances had a different, much stronger impact on me than on those of my peers who used them recreationally. Some of my earliest and most vivid memories involve the first times that I used various substances. I drank for the first time when I was 11. My cousin had a couple of shots of the gin that we swiped from a family function. I drank a third of the bottle and was sick for two days. That didn't stop me, though. From that first time that I drank, my internal clocked shifted; I began measuring time according to how much longer it was until I could get f*cked up again. By seventh grade, I was coming home from cross-country practice and sneaking three or four ounces of wine from whatever bottle my mom had open before showering and starting my homework. There was never a time when I used substances non-addictively. Those blessed one- or two-hour vacations from my natural brain chemistry were the only times when I felt comfortable in my own skin. I never had a best friend during middle school or high school. Substances were my safe place. I sought out opportunities to get messed up obsessively during these years. What substances were on offer at a particular social event was much more important to me than who would be there or what we would be doing. Even when I wasn't actually getting f*cked up, I spent hours upon hours reading trip reports on Erowid; psychonaut fiction and nonfiction by Hunter S. Thompson, Aldous Huxley, Terence McKenna, Timothy Leary, and the other greats; and technical materials from biological and chemical journals. When I bought three five-milligram, instant-release oxycodone pills for the first time during 10th grade, they cost me a total of $15. By then, I had tried weed, mushrooms, acid, cocaine, Ecstasy (MDMA), MDA, phenobarbital, alprazolam (Xanax), and clonazepam (Klonopin), so I wasn't exactly chemically naive. But my God: From the start, I knew that opioids were different. If there were a soundtrack to the sh*tshow that is my life, then the track for that first opioid experience would be Berlin's "Take My Breath Away." I fell in love. I really did. The nod: I'd drift downward into velvety unconsciousness, which felt like the plushest, most soul-fitting duvet imaginable; then, as my forehead approached my knees, angels would arrive, gently take my hands, and pull me back toward the light, all the while whispering to me about the Pulitzers I'd win, what it would feel like to hear ten thousand people clap for me at once. My eyes would flutter open. I'd smile goofily, and then it would begin again... Opioids ushered me through the gates of paradise. I was home. I was free. I was fine. For those of you who became addicted, does the above ring true? What were some of the early signs that were going to become an addict / alcoholic (both before you tried substances and in your early experiences with them)? For more about the science / nature of addiction, check out my piece on Johann Hari's "Everything You Think You Know About Addiction Is Wrong."

"The opposite of addiction is not sobriety. The opposite of addiction is connection." A hundred years into drug prohibition, British-Swiss journalist Johann Hari, who grew up in a family of addicts, trots the globe in search of answers. Do mongeese enjoy hallucinogens? Yes, Hari asserts, but only under certain circumstances. Trippy photo from Boing Boing. YouTube link to the talk here. Hari's talk is short and powerful; anyone who loves an addict should listen to it. I thought I'd share some of my takeaways. Addicts are born, not made. Addicts and alcoholics are addicts and alcoholics before we ever take a drug or drink a sip of alcohol. This wisdom, often repeated in the rooms, is frequently misconstrued. What we mean is that - in addition to running in families due to a strong genetic component - there are personality traits and tendencies that all addicts share that manifest before our drugs of choice enter the picture and persist long after abstinence from substances is achieved. Emotional dysregulation; tendencies toward compartmentalization, perfectionism, and obsession; and selfishness / self-absorption, loneliness / isolation, and difficulty connecting with others on the deepest levels (bonding) are a few. The way that I explain this is by saying that for me, taking opioids didn't feel like adding something to my neurochemistry; it felt like correcting something, like completion. Like I was finally the person I was meant to be. It was that sensation of someone rubbing your back and relieving a deep knot in your muscles, which you didn't even realize was there carrying all of your tension. Addiction isn't a "choice," even in the beginning, in that A) most of us are exposed to alcohol and other drugs of abuse so early on in life, long before our executive decision-making has matured enough to appreciate the risks that we are taking, and B) addiction commandeers the reward circuitry of the brain and erodes the very neural networks that would allow us to step back, recognize a behavioral pattern that isn't working for us, and change it. Almost all of us are exposed to a drug of abuse in a social or medical setting at least once in our lives, whether it is after wisdom tooth removal or in a club for our 21st birthdays. The vast majority of people return to sobriety afterward with something like gratitude. For addicts and alcoholics, by contrast, a seed has been germinated, and a deadly weed begins to grow. The Rat Park experiments demonstrate the relationship between isolation and addiction. Hari reviews Canadian psychologist Bruce Alexander's Rat Park experiments, which provided evidence that properly socialized and stimulated rats failed to become addicted to heroin and cocaine even following extended exposure under conditions of unlimited use. On the other hand, rats kept in isolated and stressful conditions almost invariably began compulsive use, which often led to overdose. Addiction is an expedient solution to psychological and social/familial imbalances whose deadly cost doesn't register until it is too late. It has less to do with substances and more to do with psychosocial circumstances. The experience of Vietnam War vets shows that, without an addictive predisposition, even "hard drug" use doesn't lead to addiction. Hari references the Vietnam War example that I mention at the beginning of my post on geographical change as an aid to recovery. In the U.S., the Archives of General Psychiatry's robust dataset revealed that of the 20% of U.S. soldiers who used heroin regularly doing their tours of duty in Vietnam, 95% of them came home and left the drug behind - many without experiencing the hellish withdrawal syndrome of Trainspotting fame. Why? They became dependent on heroin in nightmarish circumstances; when they left those circumstances behind, the great majority of them lacked the addictive predisposition necessary to continue using in a healthier, balanced environment. Prohibition doesn't work because it increases stress and isolation through criminalization and stigmatization. In fact, it exacerbates nearly every facet of addiction. Addicts need especially strong social networks to stay healthy, and prohibition precludes addicts' participation in society on many levels. This worsens people's natural aversion to dealing with active addicts: Everyone loves to have a recovered addict as a shining example of a friend, but few people want to be bothered by rambling phone calls and other erratic behavior from relapsed addicts - who are exactly the people most in need of support. Portugal's 21st-century policy shift demonstrates that decriminalization of drug use works. In 2000, a shocking one percent of people in Portugal were addicted to heroin. Faced with the failure of the punitive War on Drugs model, Portuguese leaders conducted a review of evidence that led to decriminalization of all drugs. Then, they used the money that would've been put toward prosecution and incarceration to fund programs that reconnected addicts with society, such as microloans for small businesses (in addition to offering residential treatment and other standard medical interventions). Everyone needs something to get out of bed for in the morning ("ikigai" in Japanese). Fifteen years later, Portugal's program has been a success by every metric - decreased addiction rates, relapse rates, HIV / Hep B and C infection levels, overdoses, and so on. The common thread of all addictions - from food to sex to gambling - is engaging in compulsive behavior in place of connecting / bonding with others in healthier ways.* A huge component of bonding, in turn, is developing a network of responsibilities to others. In this light, 12-Step programs' insistence on immediately being of service to others as a newcomer, even if it's just by committing to making the coffee for the meeting once per week, checks out. *Technology and modern life in general have made true human connection IRL an increasingly rare commodity, which partly explains the drastic increases in rates of advanced addiction during the 21st century. As Hari puts it, "We are one of the loneliest societies there has ever been." When 12-Step programs work, it's because they promote bonding. To expand on (7), I have long believed that most of the efficacy of 12-Step programs comes from their social component; in other words, if you removed the 12 Steps and simply rebranded these programs as intensive peer support with mentorship, most of the (not particularly statistically impressive, from what we can tell) benefits would remain. Hari's view on addiction substantiates this, as do the datasets that he developed it using. Punishment and shame drive addiction. Most people can appreciate that a bipolar person in the grip of a manic episode might behave oddly because he is not fully in possession of his faculties; despite all of the neuroscientific evidence, however, they will not extend the same kindness to an addict in the midst of a cocaine binge, who goes for days without sleeping and drains his / her bank account to the last cent. I suppose this is partly because of the perception that the addict / alcoholic is getting something "pleasurable" out of his or her faulty wiring, although anyone acquainted with the hell of regular substance abuse will understand that the initial pleasures dissipate very quickly as addiction sets in. Sit with us. Hari affirms the pain and frustration of connecting with struggling addicts. His solution is as beautiful as it is simple and powerful: "...to say to the addicts in my life, I want to deepen my connection with you. I love you whether you're using or not, no matter what state you're in, and if you need me, I'll come sit with you." Thank you to everyone who has ever sat with me. I am still alive because of you. I've changed the settings so that you should be able to comment below without registering. I'm eager to hear what everyone thinks of this talk. If you're interested in an in-depth elucidation of Hari's views on addiction, he wrote a book called Chasing the Scream.

A Shakespearean sonnet for all of the drug dealers through all of the years. William Shakespeare with a needle and spoon on the table in front of him. Gencraft's free AI image generator delivers again! Drug Dealer’s Sonnet: People Helping People To the man whose number is branded on what’s left of my soul Sorry for always blowing you up Shall I cook a rinse while I wait for you? Yesterday’s cottons fuse fever today I’ll smoke a cig; nothing better to do I’m five short, and I don’t know what to say You text: On the highway back from homeboy’s - as the city throbs; an expectant vein - I thank my dread gods and set up my toys: Rig, spoon, cotton; some leftover cocaine Symbolic selves; invented protections To ward off more lucid observations You deliver death in small confections Eighty-milligram raven vacations This is all there is, and - frankly - it’s bliss Got to focus now so that I don’t miss Druggie Glossary (1) Blowing you up: Messaging a dealer’s phone repeatedly while you’re waiting for him to call back or show up. Hey man, I’m sick. You around? You back yet? You on your way? Just think of it as the addict version of "Are we there yet?" I used to be the worst at this when I was in withdrawal. Legit dealers will hit ignore just to punish you if you blow them up too often. I had one dealer named D in Williamsburg (Brooklyn, NYC) who would always tell me that he was “two traffic lights away” even when he hadn’t left his apartment yet. Used to drive me insane. I became much chiller with time, though. Part of being a junkie is learning to cope with the agony of withdrawal, which becomes quotidian. (2) Rinse: Cooking up a shot using old cotton or used bits of cigarette filter from previous shots, which still have some dope absorbed into them. This is dangerous because most street drugs are cut with sugars, which means that bacteria love to grow on them, especially after they’re wet. This can lead to cotton fever, a very high-temp, hard-hitting bacterial infection that will make you as sick as you’ve ever been for 12 hours. It can lead to sepsis, organ damage (especially endocarditis), and death. Don’t shoot drugs. But if you do, use clean needles and fresh cottons. Always. (3) Short: Same meaning as common usage. Not having quite enough money. There is huge cultural and personal variation in how American drug dealers react to this. Some will refuse to sell to you; others will hurt you; a few will take a more Christian tact. It’s always a gamble. So is showing up with part of the money in quarters. Like strippers, serious drug dealers are likely to chuck them back at you. (4) Homeboy: Generic slang for friend, in this case meaning drug dealer. Sometimes “dopeboy” is used for heroin / fentanyl dealers specifically, but obviously no one is going to put that in a text message about getting drugs. Experienced drug dealers will often not text at all. You’ll call them, they’ll ask how much, and you’ll say either boy / girl for heroin / cocaine or m / p for heroin / cocaine (m and p are from the Spanish slang for these drugs used when you’re dealing with a papi). So, “50 boy 30 girl” is 50 bucks’ worth of heroin and 30 of cocaine. It gets more complicated than that because heroin is often sold in bundles of 10 bags and coke in eightballs of 3.5 grams because drug dealers like to give bulk discounts just as much as Costco - but hopefully you won’t ever need to know any of that. The dealer will call you when they’re at the meetup point, and that’s it. Depending on where you are in the US, you might need to go to a trap house to pick up. My hometown is like that; the West Side is notorious. Back in the day, if you were a white guy walking or driving to / from the West Side, that alone was cause for a cop to pull over and make your day. The opioid epidemic hit us so hard that the cops around here don’t even bother anymore. (5) Rig: Needle, usually the orange-capped, 28-30 gauge variety used to inject insulin. And heroin / fentanyl / cocaine. In the US, you used to need a prescription for these. It can be illegal to possess them without a valid medical reason (you can be charged with possessing drug paraphernalia even if you haven't used the needles yet). The explosion of HIV and Hep B / C during the '80s and '90s led to needle exchanges opening so that addicts could get clean rigs for free, which is a very controversial social program here. The decrease in HIV and Hepatitis B / C infection rates in areas that have needle exchanges is incontestable. (6) Miss: Not hitting the vein when you inject. Missing when you have just put your only 20 or 40 bucks into a needle is a junkie’s worst nightmare; a wail of “I just missed!” is part of the standard infernal trap house soundtrack. As your veins get damaged by years of abuse, it becomes harder and harder to hit. Plus, the further you are into withdrawal, the more your blood pressure rises, which tends to constrict them, as well. For this reason, even if I only had three or four bags, I’d always snort half a bag, wait for it to calm my body down, then shoot. Missing creates abscesses, which are walled-off infected areas that can lead to sepsis or amputated arms / legs. I’ve seen abscesses being popped - lanced in medical terms - where the pus shot across the room because of how pressurized it was. Form I wanted to do something creative today because the Jessica Kent stuff was getting me down. I firmly believe that someone needed to write those articles, but it didn’t feel good to have that someone be me. Although I’m a high school science teacher, I’ve had to teach lit, including poetry, for Chinese college-prep programs in the past. I wrote a Shakespearean sonnet, a type of love poem that uses the rhyme scheme ABAB CDCD EFEF GG. Fun fact: When you say “GG” at the end of the rhyme scheme in the way that a native speaker tends to, it sounds almost exactly like the Chinese jiji (鸡鸡), which means penis. So, I had to adjust my pronunciation to avoid saying “ABAB CDCD EFEF penis!” to my Chinese highschoolers. Shakespeare adapted the sonnet conventions from Italian; the original, Petrarchan sonnet in Italian had a different form. The meter should be iambic pentameter, which means ten syllables per line with alternating stress. Iamb is Greek for foot, so each iamb is a stressed-unstressed syllable pair. There. You learned your useless fact for today. I didn’t confine myself to this meter too strictly because I’m nobody’s poet. If you ever want to read some legit poetry, Shakespeare’s 154 sonnets are immortal. There is a fascinating body of lore around the Dark Lady who appears in them, and they contain as much ribald humor as they do ethereal beauty. Meaning The “people helping people” thing is something that my first drug dealer used to say. As in: “There’s no drug dealing going on here, folks; just friends helping friends, people helping people.” That guy, who was a total chad, was really just a kid from my suburb who sold Ecstasy, weed, and different prescription pills to our high school. Over the years, I ended up dealing with progressively scarier / sketchier people. The, umm, higher message of the poem was fumbling toward a theory of depressant drugs as small-scale inoculation against the existential terror of death and nonexistence. Early psychologists theorized that all of society was an attempt to create symbolic selves that would outlast our mortal coils. Getting f*cked up helps with that angst, too. Just something fun and facetious for this epitome of a Saturday in June. Have text messages between Anne Boleyn and her ladies-in-waiting on the eve of her execution coming up, too. Plus, a breakdown of the direct and indirect costs of my drug addictions over the past 15 years, which is, ugh… a doozy. Thanks for reading! Be good, Brian

A consideration of some of the most significant drawbacks of Methadone Maintenance Treatment (MMT), informed as always by extensive, unfortunate personal experience. Several take-home doses of methadone - the infamous liquid handcuffs. For the young Jedis among you: In the context of this discussion, Medication Assisted Treatment (MAT) for opioid addiction involves switching a patient from whatever opioid agent they are addicted to (oxycodone, hydrocodone, heroin, fentanyl, et al) to another opioid, typically buprenorphine or methadone, that is taken once or twice daily. Although these latter medications activate the same receptors as other opioids and produce many of the same effects in the brain and body, buprenorphine and methadone have properties, including long half-lives and - in the case of buprenorphine - a lesser stimulation of the opioid receptors, which allow physical and psychological stabilization that is not possible for addicted patients who are taking other opioids. One of the concrete - pun pun pun; get it, it’s a pun - advancements in addiction treatment that has been realized in New York State and other areas with progressive policies during my lifetime has been a dramatic reduction in the wait time for doctors who prescribe buprenorphine and methadone. When I was first searching for a buprenorphine / Suboxone prescriber in my early twenties, even with Cadillac insurance coverage in a state with a relatively high number of clinicians with the special certification necessary to provide these drugs, you were looking at a minimum of a month for a slot to open up. Wait times for methadone programs could be nine months to a year or more. Thankfully, the overly restrictive requirements for such programs and providers have been eased somewhat, and the overall number of trained providers has increased with demand. When I enrolled in a methadone program two years ago after a years-long relapse into prescription opioid and benzo addiction, I was set up with state insurance (Medicaid) and enrolled in the program in a shockingly efficient three days. This reduction in wait times is a huge achievement; needless to say, people who were ready and willing to engage in treatment died, lost limbs, damaged heart valves and livers, and were arrested and incarcerated during those weeks and months of waiting. Let’s take a moment to remember that, in the face of a seemingly ineluctable epidemic that has caused such despair, we are making progress, and we do recover (with or without MAT). Unfortunately, not a single staff member at the clinic questioned whether methadone was a suitable option for me; the presumption from the time that I made my first appointment at the clinic, which was by self-referral, was that I was a suitable candidate. To be succinct for a change, I ended up strongly wishing that I had instead pursued a monthly buprenorphine injection, an option which wasn't on my radar because it hadn’t been available during my last stint in treatment years earlier. Without further ado, these are a few of the key downsides of Methadone Maintenance Treatment (MMT), which is one form of MAT for opioid addiction. 1. In the beginning, you are required to show up at the clinic six or seven days a week to dose each morning, typically between 5:30 a.m. and 10 or 11 a.m. You will also be required to submit to random drug testing, which can increase the hour or so (with transportation time) that you’re committing to this treatment every single day. Although the staff at the clinic that I go to are mostly kind, competent people, there is a certain spiritual degradation inherent in being observed at a dosing window every morning as the very first element of my day. To be succinct (again!), the regulations that require this for MMT are draconian and constitute blatant discrimination against drug addicts compared to other patient populations; they were formulated during a different epoch, when drug addiction was frightfully stigmatized, and they should have been reformed or repealed years ago. In other countries, including the UK, methadone can be picked up at a pharmacy weekly, bimonthly, or monthly; this improves access, retention, and patient outcomes. In the United States, methadone clinics have powerful lobbies that actively oppose changes to the current system. On an optimistic note, however, I am aware of several companies that have designed new systems, including tamper-resistant labels and “portable clinics” that patients can take home as well as apps that video-record patients taking each day’s dose, which reduce the required in-person appointments to once or twice a month. Addiction is the most heavily regulated area of medicine that I am aware of, and this kind of pseudo-penal monitoring still constitutes discriminatory treatment of addicted people as a patient population, but progress is progress, and we’ve got to get to where we’re going from where we’re starting, not from where the UK or the Netherlands is. So, point number one is to think long and hard about how dosing will fit within your daily schedule, especially given constraints around transportation, weather, work, family responsibilities, and other medical conditions and treatments. In my experience, patients tend to underestimate the onerousness of in-person daily dosing. The frank truth is that take-home doses are earned slowly and that the vast majority of patients never achieve the 30 days of take-home doses that are technically possible under the most “generous” programs. (The program that I am enrolled in, for example, will limit take-home doses to two per week unless you are working 20 or more hours; for elderly and disabled patients, some of whom are receiving what is effectively end-of-life care, this is cruel, illogical, and decreases patient retention and motivation). 2. Methadone is a full-agonist opioid with a highly variable half-life, and if your body eliminates it faster than is compatible with once daily dosing, you are going to end up spending a significant portion of each day in withdrawal. The first part of this - that methadone is a full-agonist - simply means that its effects on the brain and body increase in proportion to dose / blood concentration. This is a good thing in some cases, because partial agonist opioids like buprenorphine have a ceiling effect, meaning that patients dependent on high doses of full agonists and / or especially potent drugs like fentanyl may not have their withdrawal symptoms adequately ameliorated by buprenorphine (in fact, this situation can lead to a nightmare known as precipitated withdrawal when buprenorphine is given to someone dependent on a full-agonist whose opioid tolerance is too high, but that is beyond the scope of this discussion). The important point is that this isn’t such a big deal if your body eliminates methadone on the half-life of 12 to 24 hours that is suggested as average by some sources; you’re still going to have somewhere between 30% and 50% of the previous day's dose when you dose 24 hours later, and that should be enough to ward off severe withdrawal reactions. Methadone has a long average half-life, true, but it also has one of the most variable half-lives of any opioid (I have seen half-lives as short as five hours cited in the literature). What this means is that you are going to have effectively none of the drug left in your blood by the time that you dose 24 hours later, and depending on when during the day it wears off, you are going to spend most of the evening and night in significant discomfort. Methadone clinics are aware of this problem to some extent - though many clinicians at my program had no idea that it existed and cited the 24-hour half-life as though it were Biblical truth. For this reason, some programs offer twice-daily dosing to a very small number of patients, but this requires peak-trough blood testing and often additional paperwork filed with regulatory authorities. I went through this because I take a full-replacement dosage of synthetic thyroid hormone (levothyroxine) for a non-addiction-related, autoimmune thyroid condition. I was burning off the methadone so quickly that I was spending every night fully awake, sweaty, with dilated pupils, bone and muscle aches, and urges to use. I could come to terms with these negative side effects, since the net effect of methadone in my life was still a positive. What I couldn’t contend with in the long term, however, was the massive feeling of physical and mental relief that I experienced each morning after dosing. (Anyone who has been addicted to opioids knows that the obsession with one’s withdrawal symptoms, and the feeling of relief after dosing, is a powerful driver of the addiction). The point of MAT is that it is supposed to smooth or stop the wild ups and downs of blood levels of medications in active addiction, and if it doesn’t do this, you will essentially just experience addiction to methadone. The staff at my clinic upped my dosage to a massive 190 mg of methadone per day before even considering peak / trough testing (and this was for a patient on a metabolism-altering drug known to interfere with methadone maintenance). For this reason, as long as there is no reason that your body cannot tolerate buprenorphine, if your tolerance is low enough to be maintained on buprenorphine rather than methadone, that option should always be taken (in my opinion). The ceiling effect of buprenorphine means that it is much easier to maintain a stable level of opioid receptor stimulation, which makes MAT effective. *How do you know if your tolerance is above or below the ceiling stimulation provided by buprenorphine (which I have seen cited as equivalent to 25 to 40 mg of methadone per day)? Clinicians have charts, which you can also find online, allowing them to make rough equivalencies between prescription opioids; good clinicians also have an idea of how people using various amounts of illicit opioids in their area react to buprenorphine and methadone at different dosages. Sometimes, unfortunately, the only way to know for sure is to experiment on yourself (under clinical supervision!). 3. To add to what I have said in point (2), the biggest argument for not going on MMT is that buprenorphine is so far superior by so many metrics. You are more likely to be effectively stabilized; you will quickly be allowed at-home dosing for weeks or months at a time, or you can take an injection that will last for several weeks; you will end up on a lower effective dose of opioids than on methadone, which must be increased over time because full agonists cause tolerance buildup for all patients to some degree. 4. Even if methadone works for you, it can take forever to reach an effective maintenance dose. I went up as fast as my clinic allowed in the beginning, starting at 20 mg per day and increasing from there first every day, then every three to five days. It took me a good six months before I was feeling significant relief for 12 hours after dosing. During this same time, if I had been on buprenorphine, yes, I would have been experiencing withdrawal symptoms equivalent to the difference in opioid receptor stimulation between the opioid that I was dependent on before starting treatment and the ceiling effect of buprenorphine. However, at the end of this discomfort, I would have actually become less dependent on opioids and stabilized with respect to blood levels if I had gone on buprenorphine, two things that were not true for me on methadone. The Infamous Opioid Constipation Visage. You all know that your boy is too classy to make this one a separate point, but – perhaps because it is taken orally – methadone caused opioid constipation far beyond anything that I had experienced even on high doses of oxy and heroin and fentanyl. Suffice it to say that taking a methadone s*it was the only time in a wildly painful life that I have actually lost consciousness due to pain; it felt like someone was jabbing a knife into my rectum. Like the little foxhole theist that I am, it also made me pray – like, I am not kidding, really pray, offer to dedicate my life to God – for the first time in several years. There are meds that help with this significantly, I can happily say. The constipation part, at least. 5. Participation in MMT will greatly restrict your ability to take other medications for any reason. At my clinic, it is difficult to get prescriptions for things like gabapentin, and it is nigh on impossible to get benzos (even if, as in my case, you have taken them for most of your adult life). The clinicians are worried about increased respiratory depression from using these downers in combination with methadone; this is a valid clinical concern, but if someone is still using outside of the clinic because they aren’t getting adequate relief from methadone alone, the risk of them dying is exponentially higher from that than it is from any combination of prescribed, managed meds. For this reason, countries with more progressive MMT protocols have achieved much higher retention and success metrics by prescribing patients break-through opioids, benzos, and other drugs. Things like ADHD medications are also an issue, as the stimulant meds can increase the rate at which methadone is cleared from your body. Forget about alcohol, which most clinics will not allow you to drink at all even if you have never had a problem with it, and in many cases non-medical THC, as well (at my clinic, several patients with medical weed cards were reputedly refused take-homes because they had been given cannabis use disorder diagnoses at some point in their addiction treatment [this can just mean that an intaking clinician noted that you used weed without a prescription at some point in the distant past]). *Please be aware that being treated surgically or under hospitalization for other issues on methadone can be a harrowing experience. Clinicians’ level of knowledge has increased in the past 10 to 15 years, but many still subscribe to frighteningly ill-informed beliefs (for example, that patients stable on MMT get pain relief from their daily dose; not true). 6. You must always be available for a recall, during which you bring in your take-homes so that the clinic staff can verify that you’re taking them as directed. If you miss the call to notify you of this for some reason or are forced to travel suddenly without having time to make appropriate arrangements with your clinic, the best possible outcome is that you will lose your take-home doses. It is possible to travel while on MMT, and clinics may give you special take-homes for a trip if they deem it important enough and you stable enough (however, this involves a significant discretionary component). *One of the most ridiculous things that I heard of a patient at my clinic losing take-homes for was having a “damaged” label on one of her bottles, which must be returned, which had a small scratch on it; this is the kind of ridiculousness that comes about from clinic politics and power plays, discussed below. She was someone who had been stable in the program for a long time and who I think was very likely telling the truth about not having tampered with the label intentionally. **Another thing that I experienced personally was a false-positive drug test. I looked into things further and learned that my clinic was using Quest’s initial, presumptive, antibody-based drug test as a final (confirmed) result because my insurance would not cover the confirmatory GCMS testing that even Quest’s paperwork stated was required; because of this, when I brought the issue to their attention, they had to switch drug test providers. Had I not successfully challenged this, I would have lost my take-homes due to a false positive. I intend to write a second post at some point on methadone clinic policies that I have successfully challenged at the hospital level, as well as what methadone patients can do to achieve change at the state and federal levels. Needless to say, it makes it very difficult to “trust in the process” when you see the low level of education of many counselors at these clinics and then learn that they are revoking take-homes based on an easily corrected misconstruction of drug testing results. 7. Clinic politics and a punitive mentality: Methadone clinics have a distinctly correctional vibe. Many of the clinicians at my clinic, which I consider to be quite good in terms of the grand scope of services currently offered in the U.S., have more of the mentality of correctional officers than addiction counselors. Their presumption often seems to be that their patients are lying, and a few of them seem to enjoy the power they wield to a grotesque extent and / or nurse unhealthy beef with select patients. Anyone who has been in an MMT clinic knows about the importance of staying on the staff’s good side and the drama that occurs when someone falls from grace. There is so much more that I want to say on this topic, but I am conscious that I’m pushing against the upper limits of readable length for most of my audience. Perhaps I’ll hold a podcast with other patients and / or MAT clinicians at some point, and then come up with organized notes to use in individual and group advocacy. For the time being, let me end by saying that methadone saves lives, and that it is vastly preferable to be alive and dealing with all of the above downsides of MMT then dead of an overdose or other complications of addiction. However, the availability of buprenorphine, as well as the fact that many patients are not able to successfully stabilize on methadone, mean that all available options should be carefully considered. For those of you who don’t know, my undergraduate degree is in physiology, and I completed two semesters at a U.S. medical school. I tried to keep the jargon in this piece moderate, if not minimal, and you’re always welcome to comment with a request for clarification.

Part 2 of my series on the downfall of Jessica Kent, a prison reform and addiction / recovery YouTuber with over one million followers. Part 1 here. Jessica Kent during the halcyon days of prison nacho recipes and advice on how to make creative use of bodily cavities to conceal contraband. I'm not about shaming people for trying to look their best, but in the beginning, Jessica swore that she wouldn't fix her crooked teeth because "they're a part of who I am." It was in some ways a red flag, then, when she pursued Invisalign, a boob job, and other cosmetic enhancements as her fame grew and her persona became more "gangster." In Part 1, I mentioned the tale of the Gordian knot. I should've explained it then, but frankly, I didn't have the time or the wordcount. I'll give you the Walmart version now. In ancient Turkey, there was a knot tied to an oxcart. This knot was so complex that it was puzzled over by mystics and philosophers, stoners and engineers. The snarl was so formidable, in fact, that it was rumored that whoever could untangle it was destined to rule all of Asia. Along came Alexander the Great, the son of a Macedonian king who would create one of history's greatest empires, which stretched from Greece to northern India. Alexander the Great was challenged with the Gordian knot. He took one look at it, withdrew his sword from its scabbard, and sliced through the knot with one fell blow. In doing so, of course, he demonstrated the kind of boundary-defying brilliance that ignores expectations, that embraces iconoclasm, that makes its own rules.* *Though he knew well the power of brute force, Alexander the Great wasn't a barbarian. He was undefeated in battle, true, but he paid homage to the gods of the peoples that he conquered; he fused Greek and Asian culture to create a stable foundation for his empire. Of course, I don't have a sword. I'm no Alexander the Great, anyway. I originally intended to publish a single piece on Jesica Kent. However, when I arrived at the maximum practical wordcount and I still hadn't come close to wrapping up my thoughts, I took the easy way out and promised a Part 2. I've been putting off Part 2 as I wait for my Alexander the Great moment - only to decide that it was never to arrive. There's just so much to learn from this fiasco that I've got to pick a random loose end and start untangling from there. Appearance vs. Reality We all know that what we see on social media doesn't represent reality. Our digital culture is rich with truisms like "Don't compare your day-to-day to someone else's highlight reel." But in the case of Jessica Kent, it was so much more than that. It was more like "Don't compare the face that you see in the mirror first thing in the morning to someone else's expertly crafted mask." Almost every single part of the life that she depicted was a lie. I remember the early, Wild West days of the Internet. During computer lab in seventh grade, I stumbled across a blog about how to have a romantic relationship with a dolphin. The Internet was a strange, unfettered place in those days, when true anonymity seemed to exist. At the time, the only motivations for creating content were self-expression and connecting with / entertaining others. People let their freak flags fly. Social media, likewise, was used primarily as a means for connecting with others and expanding one's worldview. MySpace and the other early social networks were the ultimate pen pal hack. I can vividly remember the tingle-thrill of finding my first e-friends from exotic countries like Trinidad and Tobago. Today, the online world has become so boundlessly, nauseatingly commercialized that polish supersedes presence and substance. Algorithms have acquired godlike omnipotence in shaping our digital behavior. In one fashion or another, almost everything that we see on social media these days is a lie. Who Succeeds on Social Media? Succeeding on social media involves the marriage of luck and skill. Physical beauty, particularly of the feminine sort, can also play a significant role. There is technical knowledge about digital systems involved; there is certainly business acumen that comes into play in monetizing social media success, as well. But the more that I reflect on Jessica Kent's story, the more that I realize that social media success tends to elevate a certain personality profile: People who are unhealthily dependent on external praise; people who don't play by the typical social rules, who aren't afraid to disclose thoughts and experiences that go shockingly far into what an "average" person would consider TMI territory; people who well understand how to manipulate others' sympathies and exploit their vulnerabilities. Very often, the people who venture online in search of connection and validation are the people who lack these elements in real life, which creates a dangerous disconnect that incentivizes dishonesty. In the real world, building the life of our dreams is an arduous, long-term affair. Online, we can achieve it - or at least simulate it - overnight. From a psychological standpoint, many of the people who succeed on social media are Cluster B personalities. And even if people don't start off as borderline or antisocial or histrionic, they might very well have their personalities warped by social media fame until they begin manifesting these behaviors. It's a Black Mirror episode about an algorithm that poisons personality, except that it's our reality. At one point while I was living in China and watching YouTube was my main way to connect with a recovery community, I realized that almost all of my favorite addiction and recovery creators maxed out at around 10K to 40K followers. This was no coincidence. These were people with full, balanced offline lives who used honest strategies to grow small, stable followings over the course of several years. They didn't make it beyond that point because they weren't willing to engage in the sensationalism, ever-intensifying histrionics, and other dishonest tactics necessary to. Another way to express this is that in many ways, Jessica Kent is not the exception. She is the rule. YouTube maven Trisha Paytas benzo'd out, binge eating, and blubbering hysterically on her kitchen floor. I believe that this was when she originated her enigmatic yet eternal post-breakup line: "I feel like a chicken nugget." In China there is a not-so-ancient saying: "Five thousand years of culture reduced to this." Social Media Shouldn't Be Anyone's Primary Job I will die on this hill. Unless you're an Only Fans creator making 1.5 million USD a year and banking 90% of your take-home for 3+ years, social media is not going to provide for you for the rest of your life. At the height of her social media clout - depending on which online tool for estimating creators' earnings you use - Jessica Kent was making somewhere around a quarter million USD per year (pretax). All the usual caveats apply. We know that giving a substantial amount of money to someone who isn't used to that rarely results in long-term net gain of wealth. People who win millions in the lottery end up broke in short order. My mom once represented a man who was released from New York State prison after serving years on a wrongful murder conviction that was overturned based on DNA testing. After release, he won a slam-dunk lawsuit worth several million dollars against the state. Just a couple of years later, he was calling his trial attorney's office to ask if he wanted to buy a Bentley for a few hundred dollars. The very first thing that Jessica should have done when she received that $10,000 check for a million views from YouTube was retain a financial planner. Instead, we know from the receipts from this mess that she gave generously and spent lavishly as her life imploded until she was cash-strapped once again. She was used by the people around her; she had no comprehensive financial strategy; and she made the deadly mistake of assuming that things would continue to get better forever. $250,000 per year for two years - a half million total - isn't that much in current dollars when divided by the 40 years or more that you're likely to live post-social media fame. And it is the nature of the beast that almost no one stays on the top for very long. But forget about the financial side of things. We need outside careers to keep us tethered to reality, to avoid succumbing to our own hype. The praise of hundreds of thousands of people is a drug as powerful as a speedball. It takes an extraordinarily grounded, humble, and wise person to avoid letting it go to their head. As I've suggested above, such individuals rarely swallow the social media lure in the first place, let alone do so hook, line, and sinker. So, we end up with figures like Jessica Kent and Trisha Paytas at the top of the YouTube hierarchy. They're driven to ever more extreme behavior to keep the clicks coming in, but from day one, it's a losing battle. At one time, Jessica Kent's diagnosed Antisocial Personality Disorder (ASPD) was at least quiescent. Contrary to popular belief about borderlines and sociopaths, even severe personality disorders can go into a kind of remission. It seemed that prison time had beat Jessica into submission. There's no shame in that; plenty of us learn the important lessons the hard way. Furthermore, to her credit, it seemed that something really did change in her with the birth of her first daughter. Jessica wanted to give her daughter better than what she had growing up, and she was willing to say goodbye to an entire identity and way of life to do so. Jessica and Reece were engaged and moving into their dream home in the Chicago burbs before YouTube money came into the picture. Everything wasn't perfect - it never is - but her daughters had a stable, two-parent home with a mom who was around to care for them all day. That is so much more than many people have. In fact, it's everything. Jessica Kent threw it away for an illusion. Social Blade stats for Jessica Kent as of May 28, 2024. Pay attention to the estimated yearly earnings - down to about 50K from around 400K at the height of her clout. Because most of these numbers incorporate prior success, they paint a much rosier picture than reality; the truth, which Jessica Kent has acknowledged, is that the "drama" has hurt her reputation and earnings significantly. The Value of YouTube Content The psychology of productivity teaches us that the people who are most deliberate about how they spend their time are the ones who succeed. When I think back on the many hours that I spent watching Jessica Kent videos, I have a weird "what remains?" response. What did I really get from all of those videos? My first response is that Jessica gave me a backstage pass to a prison subculture that I wasn't particularly familiar with and that I found intriguing. Except that isn't really true. I've spent quite a bit of time in treatment with men and women who have done serious time. I've heard their stories in a more in-depth way and within a more personal setting. What's more, I worked for a prison reform nonprofit for a year before I left for China. In my own small way, I helped contribute to bail reform measures, problem-solving courts for addiction and human trafficking, and the effort to close Rikers Island. I guess that the more accurate answer is that I got entertainment from Jessica's videos. In many ways, the quality of Jessica's content was low. She wasn't a particularly eloquent speaker; she didn't draw on data to connect her anecdotes to the wider picture. Moreover, the vast majority of her prison reform and addiction / recovery content had been pioneered by Christina Randall and other creators before her. However, Jessica had charisma, and she knew how to tell a story. In particular, I appreciated the colorful cast of supporting characters who populated her prison tales - like the "hot shot" meth addict who perpetually waved her arms above her head to beat off birds that no one else could see or the seasoned convict granny who taught the newcomer girls how to make a special dessert out of French vanilla coffee creamer. I suppose that there is value in this type of prison reform and addiction / recovery content because it can appeal to the masses in a way that the more rigorous, nuanced, data-driven, and specialized material won't - at least not in the beginning. In other words, it can awaken an interest in people who wouldn't otherwise have these topics on their radar. But the supreme irony of Jessica Kent's story is that she went from being an exemplar of rehabilitation to a case study on why people find it hard to believe that addicts and criminals can ever really change. That undermining of people's belief in redemption, in my opinion, is the worst consequence of Jessica Kent's actions. Before her YouTube career took off, Jessica was poised to enter some sort of prisoner support services career. She had an outstanding warrant in Texas to clear up first, but I am certain that she would've eventually been cleared to speak to prisoners. Imagine the impact that she could have had - not on a general audience made up largely of Zoomers, many of whom watched her videos out of lurid fascination - but on the women who were a few steps behind her on the path to getting their lives back on track. Jessica could've convinced them of the endless small pleasures of having an ordinary, functional life; the beauty of healing intergenerational trauma through responsible parenting; the sustainable pleasures that come from delayed gratification and the peace that comes from atoning for selfish acts. Again, even from the standpoint of pure entertainment, when I think back on her content now, I'm underwhelmed. To put things into further perspective, I'm currently reading a novel called Red Rabbit by Alex Grecian. It's a magical realist tale that takes place in a Wild West filled with witches, demons, and ghosts. The characters are electric and the language - you could get drunk on it. And this is, in some ways, an unremarkable contemporary novel; it's not like I'm reading great history or timeless fiction at the moment. From this standpoint, the time that I frittered away watching Jessica Kent videos on YouTube feels wasted - like the entertainment equivalent of McDonald's. I'm getting old. I have books to publish and more to write. Do I really want to follow any creators on these new media platforms anymore? A Warning for Content Creators Even though I am a "content creator" in the most modest sense, the Jessica Kent Affair - which I am styling after the Dreyfus Affair - has been a wake-up call for me. When I began blogging two months ago, I had a list of fairly ambiguous goals centered around "sharing my story." But starting to create content with the goal of sharing one's story is like entering medical school "to help people." With a few notable exceptions, the best, most fulfilled doctors are the ones who know exactly what specialty they want to end up in from the beginning. This knowledge helps to guide them, ground them, motivate them; to manage stress and to create reasonable component goals. A task as Herculean as American medical school shouldn't be undertaken without a highly specific vision of where it's going to lead. Social media content creation as a non-hobby undertaking is the same. Without clearly defined, finite goals, we put the algorithmic monster in charge. We end up worshipping at the altar of clicks rather than building a small to midsized, stable community made up of people who are interested in what we have to say for the right reasons. In my case, I've winnowed my lengthy list of initial aims down to three: (1) To provide information that helps people to understand the science of addiction / recovery and to navigate the inpatient / outpatient treatment systems, the 12-Step Programs, the world of psychiatry, and other aspects of recovery; (2) To use this blog as a sort of proof of concept for the two books that I am in the process of querying (to demonstrate that I have interested readers who appreciate my style and content, that is); (3) To organize a group of addicted people and other stakeholders to petition to change the outdated, draconian U.S. methadone regulations (see Metha-Don't for some of my thoughts on this subject). After those three goals are attained, if they ever are, I'll re-evaluate. One Last Point: Recovery Is IRL I saved the most important point for last. I follow quite a few addiction / recovery creators on various platforms, and I love to view their inspirational content. In particular, I really enjoy viewing before / after and sobriety birthday pictures where you can see the miracle at work, as they say in the Program. If I have five minutes of free time at the end of my lunch break, it beats scrolling through advertisements for things that I don't need, I suppose. And there is real value in this content in terms of its ability to reach people who are in untreated active addiction and who might be considering quitting drugs and alcohol. But I've noticed a dangerous trend lately. A couple of influencers on my radar are selling an app with the tagline "I couldn't stop drinking until I downloaded this app..." Perhaps for a non-alcoholic whose drinking has gotten a bit out of hand during a time of stress, an app such as this will be helpful. But no app - whether for peer coaching, Suboxone maintenance, group therapy, or whatever - is going to keep a true addict or alcoholic clean and sober for the long run. All addicts are consummate liars. This is true even when we don't mean to be deceitful because so much of the disease involves lying to ourselves. As anyone who has ever deceived themself for an extended period knows, this kind of lying gets away from you. The brain starts bypassing the middleman - that executive function that allows you to decide whether you will lie or not. It learns the "hack" of stating reality as we wish it would be rather than reality as it is. I have no doubt that Jessica entered into this state of pathological deception at some point during her relapse. She displayed all of the inconsistencies and cognitive dissonance of someone who is desperately trying to believe their own lies, to "make it all make sense" in a way that doesn't sacrifice ego. This is why it's imperative to have some regular recovery supports in real life. Words are wind, but eye contact, appearance, emotional affect, and a hundred other subtle indicators add up to tell the story that we might be trying to hide. Once you've been an addict, you'll never miss the signs in others ("you spot it, you got it" is one of my favorite NA / AA sayings). I have rarely been surprised when someone who I've gotten to know in recovery tells me that they've relapsed; the warning signs are unmistakable (this is why the Program works, after all). No one can tell how we're doing from behind a computer screen. If Jessica had had people in her real life who questioned her, who urged her to reach out to in-person recovery supports, things might have gone very differently. She had changed herself for the better in major ways in the past; logic says that she could've done this again. Instead, Jessica was hired to represent treatment and recovery services when she was the last person on Earth who should've been guiding anyone else in recovery. Most of the true recovery leaders who I know, who are some of the most interesting and resplendent souls on this planet, have no time for social media because they are out there doing the work every single day in real life. Sure, it can be great to share our recovery struggles and victories online, but we can never depend on e-recovery to keep us clean. Recovery from addiction simply doesn't work that way. Final Thoughts (Don't You Have Somewhere You Should Be?) I admire those bloggers who can open with an engaging anecdote, meander at a comfortable pace along their stream of thought, and then bring the reader to a conclusion that wraps things up so artfully and decisively that it seems self-evident, like the only possible final chord for the symphony. Unfortunately, I'm not one of them. I almost always gain great insight into my thoughts and feelings while writing a piece such as this one, but very often this does not translate into the sort of clarion conclusions that lend both reader and writer a sense of closure. I have picked and picked at this Gordian knot. It feels endless; there is just so much here to untangle. About social media. About falling back into addiction and other harmful behaviors. About character and change and how way leads on to way, as Robert Frost once put it. It doesn't help that I'm a Millennial; I've been steeped in postmodernism almost from the womb. If I had to boil this whole dispiriting saga down into a single life lesson, it would be to stay humble. Kindness can make us vulnerable and shield others from unpleasant truths that they may need to hear; goodness is a philosophical question, ever up for debate; even honesty and transparency have their caveats attached. But you can never go wrong with humility. And it's not just a virtue; it's a practice. I go to 12-Step meetings partly because I need to remind myself of how badly I've hurt other people through my awful, selfish decisions - those caused or fueled by my addiction and those independent of it. As uncomfortable as it is to remind myself of this fact, I mustn't forget that I once caused a car accident while driving under the influence of opioids and benzos. I hit another car, and I could have killed the person in it (she was uninjured, which is both fortunate and surprising considering the extent of my injuries). I can't ever let myself forget that. I don't want to, and I don't deserve to. Humility could've prevented Jessica's descent into megalomania and saved her and her daughters incalculable grief. I stand by what I said at the conclusion of Part 1, namely, that Jessica Kent has a tremendously human, broadly applicable, and very powerful story to tell about what social media success does to a certain type of personality with a certain sort of past. I don't think that we'll ever hear it from her, but I hope that I am wrong. Grass. Go touch it. If you enjoyed this series, you might want to check out my review of Cat Marnell's autobiography How to Murder Your Life and my piece on the Soft White Underbelly YouTube channel.

Part 1 of my two-part series on the downfall of Jessica Kent, an addiction recovery and prison reform YouTuber with over one million followers. This is a wild ride. Jessica recounting one of her most popular stories. Some observers have suggested that her facial expressions tend toward the theatrical and that there are strange gaps in her cadence that indicate emotional dishonesty. (Okay, it's me. I'm "some observers.") Part I: The Rise At the height of her fame as a YouTuber, Jessica Kent was riding a wave of peripatetic praise the likes of which few human beings will ever know. After a troubled childhood and years of opioid and methamphetamine addiction that resulted in several stints in jail and prison, Jessica had finally turned things around. She had given birth to her first daughter in shackles, which was the story that made her famous. But Jessica had served her time, been released, and then jumped through hoop after hoop to regain custody of her daughter. As she rebuilt her life with two pairs of shoes, no refrigerator, and a mattress on the ground, she met a fellow recovering addict named Judd (aka Reece), an Iraqi War veteran. The two of them dated, became engaged, and added another daughter to their family. Jessica devoted herself to being a mother and enrolled in online college to study prisoner support services and psychology. The image of this heavily tattooed, waifish ex-con with the crooked teeth attending PTA meetings beside blonde, buxom, pearl-clutching Midwestern Marys was YouTube dynamite. Jessica spoke with refreshing candor. She often concluded stories about her past mistakes with a statement along the lines of "I just wasn't a very good person in those days, guys." Her girlish giggling as she shared tales of prison purses and prison suitcases* was punctuated by downcast glances; she discussed her institutional PTSD and periodic depression. *Men have only a prison suitcase, whereas women have both a prison purse and a prison suitcase. I hope that you can figure it out from there. When things got too dark, Reece's Midwestern Everyman mellowness balanced Jessica's depressive streak. Jessica was interviewed on daytime talk shows. She gained hundreds of thousands of followers on YouTube and other platforms. She became a spokeswoman for Groups Recover Together and was featured in Inked Magazine. Jessica appeared to be a paragon of addiction recovery, and it seemed like she had it all. Part II: The Reality Except that Jessica wasn't in recovery. At least, not fully. Although most of her video intros included a statement affirming that she was "a person in long-term recovery," it eventually came out that she had long been drinking a glass or two of wine along with dinner. No big deal, right? Jessica had been stable for several years. Clearly, she had her stuff together. Later on, Jessica shared that her after-dinner glass of wine sometimes devolved into day drinking and binge drinking. Still, she didn't intend to stop because "alcohol wasn't her problem" and because it was her stress over Reece's relapse that was driving her to drink. She also mentioned using THC for her anxiety and depression. We subsequently found out that she was also taking gabapentin and prescription amphetamine salts (Adderall).* *One of Jessica's drugs of choice was methamphetamine, so her taking Adderall was like a heroin addict taking morphine. Anyone in recovery knows where this story goes. At some point, Jessica progressed into full-blown relapse. Part III: Jessica's League of Extraordinary Gentleman One of a score of videos in which Jessica denounced Reece (Judd), an Iraqi War veteran who she diagnosed as a covert narcissist and an abuser. At least Jessica had Reece to support her, right? Well, yes and no. It turned out that Jessica had been carrying on a yearslong affair with a federal inmate named Jason, a member of the Spanish Cobras gang who she had met during her incarceration in Arkansas. Wondering how we found out? Well, from Jason himself. We'll get there. "Uncle Jason" moved in with Jessica and her girls after his release on federal parole. This was shortly after Jessica and Reece had separated, following which Jessica decried Reece as a covert narcissist and abuser. Jessica released a video in which Reece screamed at her as she cried and cowered. When viewers questioned why her phone happened to be recording at such a convenient angle at exactly this moment, Jessica wondered how anyone could ever question a victim of domestic abuse. When it later came to light that Jessica had punched Jason in the face because he had left rehab (where he was because he had relapsed on meth while at Jessica's house), Jessica described this as "reactive abuse from a single mother victim of intergenerational trauma and institutional PTSD against my covert narcissist abuser ex who manipulated me into loving him with all my heart and intending to marry him six months ago".* *I'm altering her words slightly here to make a point, but trust me - you wouldn't believe just how close they are to verbatim. She developed a habit of using a weird word salad of sympathetic psychological terms to justify her actions. Jessica released a recording of a phone call from a time when she had an acquaintance who Reece didn't know "go to check on him" in his new apartment. Reece threatened this man with a gun and allegedly fired this gun into the air outside his apartment building, which resulted in criminal charges. Again, astute observers questioned whether the suspiciously edited phone call was really evidence of Jessica trying to provoke a PTSD episode in Reece, thereby instigating him to doing something regrettable. This, in turn, would sway the court and public opinion in her favor, of course. Before the end of this 12- to 18-month saga, there would be visits from at least two more men, including Jessica's former drug runner, Robbie, who she also slept with. How do we know this? From Robbie and his ex-girlfriend, who Jessica mocked for living in low-income housing. Jessica is currently with Berner 420, a Tik Tok creator and alleged hobosexual who arrived on her porch in Chicago to make content right after Jason returned to prison, then never left. Jessica and Berner 420 have relocated* to Utah, where she is now celebrating the state's permissive attitude toward firearms. *Some would say fled rather than relocated, although their current location is unconfirmed. CPS had been called on Jessica by well-intentioned and likely not-so-well-intentioned viewers. During CPS' first visit to her home in Chicago, which was at the beginning of the Mindy Scorpio saga discussed below, there is evidence to suggest that Jessica intentionally diluted her urine to foil the drug test that she was required to submit to; Jessica herself admitted that the test had to be redone. Boy, that's a lot of new uncles for two young girls, isn't it? It also came to light that Jessica was spending time with another prison reform content creator who had been charged with domestic violence; she released a video of her daughters doing the hair and makeup of this pretty hard-looking dude, which under other circumstances might have been sweet. Part IV: The Hangers-On At least Jessica had her friends to support her, right? Well, not exactly. The crap really hit the fan when Mindy Scorpio, another addiction and prison reform content creator, came to visit Jessica outside Chicago. This was shortly after Jessica's separation from Reece, when Jason was frequently staying with Jessica as well. Mindy was honest with Jessica about having relapsed and needing to get away from her life in Kansas City while she cleaned herself up. During her visit, Mindy got to know the people who Jessica surrounded herself with. This colorful cast included a gay man named Vern, who Mindy described as a sort of Platonic ideal of a tweaker. Vern frequently brought his disabled son* with him to Jessica's house, where he helped watch her daughters and ran errands for her. *Used in the street kid sense. So, not really a son. During her visit, Mindy smoked meth with Jason in Jessica's basement, then helpfully texted him to let him know that his glass d*ck was back in his shoe. She took Jessica up on her offer to ask Jason to get Mindy Xanax, which is another one of Mindy's drugs of choice. On another occasion, Mindy asked for an Ambien from Jason, though it turned out that he couldn't find the pills. By now, Jessica was apparently drinking to the point of blackout and next-morning debilitation. She confessed to Mindy that she had taken a hit of meth "while riding Jason" because she thought it was "hot".* *Jason got a tattoo of a sexy Jessica smoking a meth pipe during this period. Jessica still hasn't admitted to meth use, so this was pure fantasy, I'm sure. Mindy later alleged that Jessica had been taking amphetamine salts (Adderall) without a prescription, which Mindy herself might have helped to procure. How do we know all of this? Well, it turned out that Mindy was a bit of a burn-the-house-down-with-yourself-in-it kind of gal.* *As people who strongly identify with the Scorpio sign are wont to be, I have realized. I am one of them, after all. Mindy and Jessica argued toward the end of her visit because Mindy was continuing to use despite having come to visit on the pretense of wanting to get herself back together. At some point, Jessica refused to continue to enable Mindy. The problem was that Jessica knew that Mindy was pissed and that she had seen some shady goings-on during her visit. Jessica told Mindy that she would only help to pay her way back home if Mindy showed her that she had deleted all of their text messages and signed a Non-Disclosure Agreement (NDA)*. *Favored legal instrument of lascivious American Presidents, assistant-abusing celebrities, and assorted scumbags. Safe in the knowledge that Mindy didn't have receipts and that she couldn't legally speak about what had happened at Jessica's house anyway, Jessica preemptively attacked. She warned her hundreds of thousands of followers not to buy from Mindy Scorpio's online store because it would only fuel her relapse. Except that it turned out that there was a new iPhone update that meant that Mindy's messages could be recovered. It also turned out that Mindy didn't give a rat's behind about an NDA. So, the messages between Jessica and Mindy were released. Jessica's house started to seem a lot more like a sordid trap-house than a quaint little home in the Chicago suburbs.* *Oh yeah; I remembered the blow, but I forgot the hookers. It turned out that a prostitute who Reece had slept with was hanging out in Jessica's basement on at least one occasion; to her credit, Jessica didn't hold this against her. I think that she might even have offered her some pizza, judging from the text messages. Part V: The Hubris Watch this video. Seriously. With no extraneous commentary and minimal overlaid content, using purely her own unedited words, it does a better job than I ever could to show just how extensive and brazen Jessica's lies and manipulations became. It contains screenshots of the text messages and other receipts for many of the assertions in this article. It is in its own way one of the most shocking videos that I have ever seen on social media, a stunning indictment of how easy it can be to deceive an audience of hundreds of thousands. Jessica could have saved herself a world of grief and likely a small fortune by simply taking a break from social media as soon as she and Reece had separated. She needn't have confessed to relapse. A simple "The girls and I are dealing with a lot now, and I'm not myself; I'll come back when I've got my feet back under me" would have sufficed. Instead, she launched into her series of videos about Reece's abusive behavior, which prompted many viewers to question her decision to put all of this information online, where it was readily discoverable by her daughters' friends, classmates, teachers. Jessica just could not stop herself from trying to prove that she was in the right. At one point, viewers brought up a past video in which Jessica had admitted to being diagnosed with Antisocial Personality Disorder (ASPD) by a prison psychologist. Instead of ignoring the comments and questions about this, she doubled down and insisted that this was a misdiagnosis because the psychologist in question had misinterpreted a statement that she had made about remorselessness for her crimes.* *I highly doubt that expressed remorse was the scales-tipping diagnostic factor, but that's beside the point. Remember that I'm not being a hypocrite in using Cluster B terminology to describe Jessica because she was officially diagnosed under creditable circumstances (see my article on the misuse of these terms here). As the controversy grew and commentary channels began to cover it, viewers revisited Jessica's old videos. They discovered that some aspects of her story, including the amount of time that she served, changed significantly from one telling to another. One prison reform content creator filed Freedom of Information Act requests to get to the bottom of things. She uncovered paperwork that allegedly contained evidence of Jessica turning state's witness ("becoming a rat"). Jessica threatened some of the people questioning her story with legal action. Intellectual property infringement strikes were endlessly initiated against the creators who were bringing these inconsistencies to light. In her lying, Machiavellian maneuvering, end-justifies-the-means attitude, and arrogant refusal to believe that her viewers had brains, of course, Jessica was acting remarkably like someone with Antisocial Personality Disorder. Overall, my reaction to all of this was a mortified "Earth, swallow me whole!" But there were some lighter moments, too. On YouTube, Jessica had presented herself as responsible, reformed, and chastened. However, as her fame ballooned and her YouTube audience grew suspicious of her, Jessica built a following on Tik Tok, where she cultivated a bad kid / cool mom vibe. In one video, for instance, she reenacted a conversation with a high school teacher who was praising her for focusing on her work for once. Jessica shared with her audience of young people that she had actually been completing another person's college coursework for money. Imagine the schadenfreude, then, when Jason released the Corrlinks / Trulincs* copies of their amorous correspondence, which included phrases like "choak me in heels." *Electronic communication system used by federal inmates. Jessica termed her detractors "vial" and called a mutual acquaintance of her and Jason a f*g - proving that, like so many other parts of her story and personality, her LGBT allyship was performative. In a megalomaniacal message to Reece at one point when they seemed to be reconciling, Jessica gloated that "I'd forgotten how much my name means on the streets." "Do you need me to get some guys there?" She offered. "I'm the queen of them all..." She also shared that calming down violent men on meth was her superpower. I can relate, as this is what I told my second-grade teacher when she asked me what superpower I'd choose if I could have any. It sure beats flying or mind-reading. Part VI: The Denouement Things have finally calmed down. As I mentioned above, Jessica and Berner 420 have supposedly relocated to the Southwest. Jessica made a series of videos called "The Truth Never Dies," which she promised would vindicate her. They did no such thing. They were mostly focused on supporting her narrative that she was a victim of narcissistic domestic abuse, although she did provide some documentation about the specifics of the time that she served and clarify that she was never an informant. At one point in the final video in this series, Jessica did acknowledge that she had lost sight of her larger responsibilities in the midst of the fracas. There seemed to be some sincerity to this, but for many viewers, this acknowledgment was the proverbial band aid for a bullet hole. Jessica has acknowledged that her reputation has been damaged and that she has lost substantial views over this "drama." She also mentioned having had mental health crises during this period; I am not surprised, and I do feel for her for this. The YouTube commentator Radiant Britt used a brilliant analogy to describe Jessica's way of "getting honest": That of the magician with the endless series of scarves up her sleeve; every time you think that you're about to see the last of it, another scarf emerges. Even now, I am tempted to forgive most of Jessica's behavior because the lying, the messiness, even the self-delusion and ridiculous arrogance, can all be part of relapse into active addiction. However, the thing that doesn't fit is the meta-narrative that Jessica was so committed to and clever about crafting in the midst of her chaos. She dedicated great energy to deceiving her audience, silencing her detractors by abusing intellectual property regulations and other aspects of the legal system, and obtaining evidence of the abuse directed at her by Reece and Jason. In my experience, someone in the throes of relapse will not have the premeditation, lucidity, or even the energy to do all of the above. There is no "meta" during relapse; addiction is a desperate and animalian affair. The overall picture is, however, consistent with a Cluster B personality using abuse and addiction as shields against responsibility for her actions. I don't doubt that Jessica is the victim of abuse, and I condemn Reece if he did in fact get physical*; I am, however, highly suspicious that Jessica is an abuser of others. *Jason admitted to getting physical on one occasion, though he said it was after Jessica had punched him in the face for leaving rehab (not that this changes the morality of hitting a woman). I think that Jessica could have a spectacularly interesting story to tell if she could get honest. At one point, her personality disorder was at least quiescent. Although she says that she was secretly suicidal during many of her years as a stay-at-home mom of two daughters who was engaged to Reece, she was also stable and responsible. Social media brings out the worst in all of us sometimes. It would be refreshing and powerful to have someone admit how it went to their head, how they got caught up in their own myth, how this made superpowers of their character faults and ultimately destroyed them. That's if she can get honest. And that's a big if. In Part 2 of this series, I discuss what Jessica Kent's debacle meant to me as a longtime fan / follower. I reflect on what it says about the e-recovery community and what those of us who make recovery-related content can learn from it. If you enjoyed this content, then you might want to check out my review of Cat Marnell's autobiography How to Murder Your Life and my piece on the Soft White Underbelly YouTube channel. A footnote: There was a dedicated team of Redditors active on the original Jessica Kent sub-Reddit who investigated much of this Gordian knot of drama, undertook the tremendously difficult task of unknotting it, and then provided receipts for all of the above. This sub-Reddit was eventually shut down, and it has fragmented into at least two descendent sub-Reddits, which still contain many of the original text messages, e-mails, and so on. I discovered the original Reddit community by Googling "Jessica Kent lies" after becoming suspicious of her. These folks did a tremendous service by investigating Jessica's claims, organizing and presenting the evidence against her, and making more of Jessica's viewers aware of her lies. Though some members' snarking eventually got too intense and hateful, in my opinion, most of them were well-intentioned former fans, many of whom are in recovery. I owe them a great debt. I also owe Jessica, Reece, Mindy, and some of the others involved a thank-you. Had they not turned on each other and then reconciled unstably and repeatedly, it would never have been possible to triangulate the truth. Thanks to their ill-advised disclosures, we have primary receipts for all of the above claims.

This is the first installment of the China Chronicles (aka the Last of the Laowai or any other twee alliterative pair that you'd care to substitute). In Part I, I introduce elite higher educational consulting in China, a dizzyingly disproportionate world in which teams of Ivy League grads sit around conference tables in sleek skyscrapers in Shenzhen, Shanghai, and Beijing, earning doctors' salaries for reviewing the homework and planning the futures of "clients" who have only recently sprouted body hair. In Parts II and III (forthcoming), I discuss what it was like to live in China during the pandemic, as well as the ominous shift in mood after President Xi bypassed the two-term limit in place since Chairman Mao's disastrous latter days, deciding instead to star in an IRL adaptation of 1984. In addition, I recount some wild stories stemming from my relapse into prescription opioid and benzo addiction during my time in China. Skyline of Shenzhen, my Chinese hometown. It has a population of almost 13 million and is located just across the border from Hong Kong in Southern China. Shenzhen was a fishing village until the 1970's, at which point the Mainland Chinese government began building it up as a rival to HK. Due to the preponderance of finance and tech companies headquartered in the city, as well as its balmy weather, it is often referred to as China's Silicon Valley. I. The cursor blinked uncertainly over the Student Name field. Are you sure that’s your name? It seemed to ask. Positive that you want to go through with this? “Student Name: Simon Song,” I began typing; “Date of Birth: 11/14/2006.” At the top of the page was a banner for Northfield Mount Hermon, an elite boarding school in Massachusetts whose campus and endowment could be mistaken for those of a liberal arts college. NMH was a place of chapels and uniforms, French Crops and brahmin noses. It was the kind of preppy institution that my public high school classmates and I would have snubbed our decidedly un-brahmin noses at. (We would still have sold them weed, of course). “Hey, Simon. We’re in the Yale Room today,” I called from the corner of the lowlighted, luxe waiting area five minutes later. We walked down the hall, a gauntlet of American luminary portraits – Oprah and Michelle Obama, Tom Brady and Steve Jobs. We passed rooms named after each of the Ivies. I had been trying to get Cici, my boss and the CEO of Pinnacle Education, to add someone cool to the portrait collection, maybe a Joan Jett or a Jonathan Franzen or even someone so badass that she only had one name, like Gia or Madonna. So far, no dice; no dice. The fact that these portraits and these rooms were on the twenty-second floor of a skyscraper in Shenzhen, a city of 12.6 million people on the southern coast of Mainland China that some called its Silicon Valley, never failed to drag me out to sea on a riptide of jamais vu. Then again, despite the jarring juxtaposition, there was an underlying logic. Many of these famed figures had risen from obscurity to immortality, just as Shenzhen – an undeveloped fishing port into the 1970s – had grown up to not just rival, but surpass Hong Kong, the city across the border. It was now home to Tencent, Huawei, China Merchants Bank, Ping An Insurance, and more top-flight tech and finance companies than I could list on two hands. This afternoon, Simon was aflutter with talk about a trip that he had taken with his science club. They had traveled to Guilin in nearby Guangxi Province, a place of twisting mists and oddly shaped mountains that reminded me of those unfortunate penises that look like tree roots. There, they had taken geological core samples from a set of caves bearing inscriptions from as long ago as the Tang Dynasty (619 AD - 906 AD). It was reassuring to see Simon restored to his usual animated self. Last week, he had fallen asleep during a bathroom break in the middle of our two-hour lesson. (As he had offered his mortified apology, all I had been able to think about was how you fall asleep while using a squat toilet). Simon had several interviews coming up, first with a company called Vericant that recorded a generic preview interview to send to multiple schools. Later on in the application season, he would meet with admissions staff and alumni interviewers at the high schools themselves or when they were visiting China. I remembered what Cici had told me when we signed Simon: “He’s a great kid. Second place in a national mathematics competition and first place in an international robotics competition. Ninety-two TOEFL, Exeter hopeful. But he’s a little shy. Some of these students, Brian, they need some time to catch up with the American kids in terms of personality…” “What do they do, order that shit from a factory?” I had responded; I was the poster child for Western personality. Cici had a big head atop a yoga body. Her eyes were large and somehow self-illuminating, and she had the lush lashes and oval features that the Chinese coveted. She also had several million followers on WeChat, the Chinese social media, payment, and transportation app. Cici never wore the same outfit twice. On the day that we had discussed Simon, she had been wearing a black velvet villainess pantsuit. Cici claimed that she had studied at Harvard, always in those exact words: “I studied at Harvard.” Occasionally, I struggled to understand her English. Basically, I thought of her as the Gatsby of Shenzhen. Back to Simon and his interview prep. Adolescent acne was digesting a third of his face, hopefully to pave the way for something better to come. Simon was a self-contained kid with the soul of a scholar. He noticed small alterations, like when I switched colognes or changed my sock color. As we took our seats in the Yale Room, Simon pulled a rock from his pocket, a gray-black, postmodern glob about the size of a life-threatening tumor. This one was ugly, marred by tiny pocks and larger, cream-colored splotches. Simon had regurgitated rocks and their histories before; I thought of him as a geologic Napoleon Dynamite. “See this?” Simon asked. “Yup. It’s a rock,” I affirmed. “It’s a kind of shale. See these tiny holes? They’re from cyanobacteria, maybe from 3.5 billion years ago. Only 300 million years after the Earth cooled down! And there’s another kind of rock in the caves, which has calcite in it. If you hit it with UV light, it glows red. During the Tang Dynasty, they thought these caves were holy, maybe because they saw them glowing at night…” Simon, too, was aglow. He sounded confident, enthusiastic, knowledgeable; I knew that we had it. I asked Simon to tell me about his visit to the caves, this time in a more organized and succinct way. Then, we ran through how he could adjust the story to accommodate multiple angles of approach. (What’s your favorite subject? Science → science club → rocks. Tell me about an extracurricular activity? Science club → rocks. Tell me about a trip you took? Science club → Guangxi → rocks). I had discovered that successful interview preparation didn’t require anticipating every possible question; it had more to do with developing a few strong, versatile responses to form the core of the conversation. I liked interview prep, and I was pretty good at it (just ask any of my bosses from the jobs that I never should have gotten). “Simon? One more thing, okay?” I asked him as the end of the session drew near. “Sure, Brian.” I employed my best it’s our little secret tone. “Cici is going to tell your mom that we practiced this answer, and your mom is going to tell you to run through it 157 more times,” I warned him. “Promise me that you won’t do that, okay? The schools will know that it’s rehearsed, they’ll assume that it’s inauthentic because of that, and boom, we’re done. The way that you said it today was perfect. Understand?” “Got it, Brian,” Simon said. He really was a solid kid. Pictures of my second apartment in Shenzhen, which was located in the city's Grand Theatre district. It was a two-level, two-bedroom affair with a spiral staircase (!) and interior windows in the bedrooms (!!), which allowed me to torment my fiancé and poodle with my laser collection. Note the absence of sheets underneath the comforter, a classic junkie chic design element. II. For his thirtieth birthday, I gave John Friedman a T-shirt that said “All my dreams are dead.” He was my coworker at Pinnacle, a Tisch School stoner with brooding good looks who had moved to LA after graduation. Friedman had gotten one big break, a Taco Bell commercial that ran during the Super Bowl, in which he played himself as a stoned, aimless boyfriend. Then, he blew the thirty grand on coke and came to China to advise our students on how to walk the path of success. Tonight, we were dining al fresco at a restaurant called Azurro, run by a Florentine couple, where tortelloni, osso buco, and Malbec would quell Friedman’s malaise for a time. It was a Friday evening in late October, and the stifling humidity of the long, searing summer had finally lifted. A playful breeze tousled Friedman’s unwashed hair, and Shenzhen was verdant with bushes bearing pink and white flowers that were all the more beautiful because I would never know their names. As our appetizers arrived, Isabel joined us. Izzy was a poem and an incantation: Pink and black, a brazen Brazilian beauty who looked like a sophisticated Shakira. We had met during undergrad at Cornell, after which Izzy had finished an M. Ed. at Harvard while I dropped out of medical school. If it weren’t for Izzy, I would still be sleeping on a mattress on the floor of my Williamsburg sublet, which was stained with the acrid sweat of opioid withdrawal. During the five months before I left for China, the stain had become increasingly defined, differentiating into a head and torso, then sprouting stumpy arms and legs. The three of us were the elite of the American educational consultants in China, a group smaller and more inbred than my high school class in the Ewok Upstate New York town that I grew up in. Together with Dora, another Harvard Grad School of Ed aluma; Josh, a chemical engineering doctoral student at Cambridge; and Izzy’s sister Sofia, who had graduated from U Mich - Ann Arbor, we had founded a loose confederation of higher education consultants known as College Nation. We were wanderers and misfits, and we were now in the profitable but unenviable position of selling a dream that, in one way or another, hadn’t panned out for us. We had colleagues from Penn and Yale, MIT and Amherst. Then there were the Oxbridge alumni and the other UK grads, plus a handful of consultants from continental Europe, Canada, and Australia. These were all significant study abroad destinations for Chinese students, but in terms of prestige, American schools had always been number one. Between Friedman, Izzy, and I, we pulled in an easy half a million USD a year, and that number was growing. In a city where I could eat three takeout meals for 80 RMB (10.99 USD) a day and rent on my swanky apartment near the CBD was only 7000 RMB (961.58 USD) a month, it went a long way. “Hey, guys,” Francesca, the owner’s wife, greeted us. Tanned and taut, in a short, golden dress plated like body armor, she was as sleek and shiny as Shenzhen itself. “Chi è l’uomo triste?” (“Who is the sad man?”) She asked me sotto voce. “This is my friend John,” I responded in English. We were living well, and we had two whole months free after the March 15 transfer application deadline each year, during which we strolled along boner-optional beaches in Thailand and took in continental Europe at horse-and-buggy paces. All of this was true, and yet what we were pulling in wasn’t even a drop in the bucket of the Chinese private education market, an industry valued at 500 billion RMB (78 billion USD) a year when I arrived in 2017. It had started in the ’80s and ’90s, when a burgeoning Chinese middle class sought to provide its children with supplemental tutoring as well as alternatives to the brutally effective state educational system, in which high school culminates in a comprehensive exam, the Gaokao, which constitutes a single-variable admissions system. In pursuit of competitive advantages, the Chinese middle and upper classes began to send their sons and daughters abroad for college. The Chinese often compare themselves to water – ancient, ubiquitous, changeable, and, properly harnessed, unstoppable. What began as a trickle in the ’80s and ’90s had become a deluge by the time I entered the industry, with over 350,000 Chinese students matriculating at US colleges and universities per year by 2018. As competition intensified and it became increasingly difficult for Chinese students to attain top-tier acceptances at American universities, an entire sub-industry of summer programs in China and the US, led by American faculty specializing in every conceivable subject, popped up. Throughout the ’90s and ’00s, an increasing share of the most competitive students further improved their chances by attending high school in the US. Of course, as the Chinese secured US and Canadian residency or citizenship for their children, many additional students who had been raised in China and were morally, culturally, and intellectually Chinese matriculated at US institutions as citizens or residents of the US and other Western countries. New Oriental is the flagship Chinese educational consulting group, a listed company with a market capitalization of 14 billion USD in 2017. It has been plagued by cheating scandals virtually from its inception in 1993. The company’s consultants have been accused of writing personal statements for their clients; duplicating certificates from huge national contests so that multiple students applying to different schools could bolster their applications with the same achievements, a problem compounded by the long and often generic titles of these competitions in Chinese; and forging transcripts with the attention to detail of currency counterfeiters. In one instance, a female educational consultant allegedly put her head in the lap of a young man who was being interviewed via Skype, whispering answers to him as each question was presented; the interviewer initially mistook the black hair visible at the bottom of the frame as cat hair until a round hairline and smoky eyes entered the picture. I had to give it to Cici: Pinnacle prospered on the strengths of its students and programs. Cici required each contract student to take lessons on prose and poetry, science and history, and speaking and writing, all led by native-speaker consultants like me. A yearly contract with Pinnacle cost a minimum of 250,000 RMB (34,112.00 USD), with substantial bonuses contingent upon acceptances. Many students engaged with the company for two-year terms to afford themselves more preparation time. The hourly lessons, of course, were extra – at a rate of 1500 RMB (206.11 USD) per hour. Cici sidestepped the worst of the industry’s problems by creating an elite, boutique consulting firm that accepted only those students who were so competitive that it was virtually impossible for them to fail in the admissions process. How could a motivated middle school or high school student who had access to an entire team of Top 20 college grads for support and enrichment for years prior to the admissions process, who would spend a dedicated summer preparing for the SAT, and who had essentially unlimited funds for extra programs, projects, and preparation, not end up competitive at the highest level? By the time that they were accepted into America’s best colleges and universities, my students were walking refutations of the stereotypes about Chinese students. They were bold, innovative thinkers who transcended geographic and disciplinary boundaries. They were refined and worldly, having lived in multiple countries with dramatically discrepant social and political systems. And they were humble. I was invited into their homes for thank-you dinners, where I would often find a pair of clown-sized indoor slippers awaiting my big laowai boats. It was my most fervent hope that, returning from their studies after having absorbed the best that Western democracy has to offer, my students would act as a critical mass of intellectuals who would transform Chinese society according to the freedom, equality, and justice that they had seen we Westerners fumbling toward. Of course, there were bound to be a few exceptions. The day after my dinner with Friedman and Izzy, I was meeting with another new student named Jack Lian. Unlike most of my students, who came from families based in first-tier cities like Shenzhen and Shanghai, Jack was a provincial princeling whose father had made a fortune as the owner of one of China’s few wine labels. I remembered Jack’s sharp features and anchorman hair; he had distinguished himself by his lack of participation in my personal narrative writing workshop. When I had tasked his group of students with writing a short story about values in action, he had rolled his eyes and said meiguo (“American”), as though only an ingenuous American could be dumb enough to believe that people really had morals. Jack’s father, a portly man wearing alligator loafers that weighed in at at least a grand, was with him today. I asked my Chinese colleague to translate for me as we consulted Mr. Lian about his family’s preferences regarding his son’s high school. Elaine and I asked about size and location, educational philosophy and extracurricular offerings. We were met with the same response each time: “Rank,” Mr. Lian directed, “we will go by the school’s rank.” I changed tactics and asked Jack to introduce himself in English. “I like racquetball,” he offered. “Do you practice at school or in a gym?” I followed up. “My dad built me a court in our basement,” Jack answered. I was so alarmed by Jack’s strained, garbled responses that I considered walking across the hall and telling Cici that I refused to work with him. Cici did this with a couple of students per year, usually offering some explanation calculated to produce sympathy for the student. “Please write the first couple paragraphs of Jenna’s personal statement for her, Brian. She’s having a hard time with mental health, and I’m really worried about her.” Sometimes she’d say something more direct, like “Brian, his dad is head of this company or that government division.” Still, I stuck to my guns. All of my students had to take my weeklong personal narrative composition class. The ideas and language for their personal statements had to be their own. I would not ghostwrite. That didn’t mean that Cici wasn’t up to other shady shit, of course. She regularly advertised deceptively, such as when she marketed Friedman’s summer drama camp as “NYU Drama Camp.” Her WeChat was full of innuendo about backdoor connections with American admissions officers, and she had once shown Izzy an email from an admissions director at one of the top two U.S. prep schools asking which two of her students they should accept that year. (Cici being Cici, she had chosen two of her VIP students, both capable but not nearly at the top of that year’s cohort, because they had paid extra for their contracts). I knew that Cici was courting former admissions officers from Duke and Harvard to develop “a more systematic program,” which set RICO bells ringing in my head. I had begged for two years now for her to allow me to take on a couple of pro bono students per year, perhaps a talented kid from a rural province or an Uyghur, a member of the much-persecuted Muslim minority in Xinjiang, many of whom were allegedly being detained in forced labor and cultural indoctrination camps. “There are too many good students whose families have money to work for free,” Cici had chided me. At times, I was able to assuage my conscience by telling myself that I wasn’t providing much more help than I had gotten with my own application from my mother, a criminal lawyer whose wordsmithing was legendary. And my students were already at such a disadvantage in so many ways. After all, they came from a culture in which academic writing of this sort wasn’t valued, which considered the type of introspection necessary for narrative writing to be uncomfortable and vaguely narcissistic. My kids had had to master two languages as different from each other as languages can be, one of which (Mandarin, of course), was reputedly the most complex of them all. Still, every time that a student, parent, or colleague asked for a favor and I let a boundary slide a little, I felt a tug that was all too familiar from my past: The feeling of losing something as insignificant as a single feather, which, ignored often enough and over a long period of time, would eventually result in losing my ability to fly. By teaching my students that money and connections were essential to advancement, reinforcing external metrics of success, and participating in a system that hopelessly favored the rich, was I really helping to seed China with students who would have the faith and idealism necessary to transform our world? Pics from the drone shows commemorating the 70th anniversary of the People's Republic of China (October 1, 2019). I highly recommend viewing this one-minute video of the joint show put on by Shenzhen and Hong Kong, which I attended. I don't have adequate words for how privileged and proud I felt in those moments. III. If you had told me in 2018 that in two short years, my concerns about undue influence and unfair advantage would seem minor, almost trivial, within the bigger picture, I would’ve called you crazy. I had arrived in China at the tail end of a golden period, during which Chairman Deng Xiaoping and his successors presided over unprecedented economic and social opening up, which resulted in the greatest economic expansion in history. The 70th Anniversary of the People’s Republic of China, celebrated in October of 2019, was one of the most powerful moments of my life. I sat with a group of friends from the U.S., U.K., Poland, Iran, and Egypt as the Ping An Tower, the world’s fourth tallest building, flashed through a rainbow of colors; the rest of the buildings of Shenzhen’s CBD lit up in unison. In the next moments, 800 drones rose into the night sky, executing complex whirls and pirouettes as they, too, blinked brilliantly as stars. I watched awestruck as the squads of drones formed images of Chairman Mao and the buildings of Beijing’s Forbidden City. In potent crimson, they spelled out the revolutionary slogans that had motivated the Chinese people as they built a new country after the collapse of Imperial China in the early twentieth century, which had been followed by a brutal Japanese invasion and a civil war that rent brother and sister apart. These slogans had been the sustenance of those who had survived the Great Famine of 1959 to 1961, during which as many as 36 million Chinese died due to inclement weather, ineffective agricultural policy, and Chairman Mao’s desperation to establish China as a grain exporting power. No doubt there had been countless times when these words rang hollow, conjuring vivid dreams destined to dissipate into the gray fog of reality. But here I was, 70 years later, witnessing what I intuitively recognized as one of history’s great inflection points as these promises came true. With little more than peerless tenacity and cunningly leveraged late-player advantage, the Descendants of the Dragon had once again established their country at the forefront of history. Lying in the soft grass of the People’s Park as a kaleidoscopic firework show capped the evening, I felt ineffably proud of my own modest contribution to this great effort. Let’s face it: Chinese society had a leanness, a cohesion, and a focus that contemporary America lacked. They’ve got us beat, part of me wanted to begrudgingly admit. Still, there had been ominous signs from the time of my arrival. President Xi advocated a return to austere, restrictive Maoism, reversing the tide that had carried China forward throughout the 1980’s and 1990’s, when China’s rulers had envisioned China modernizing and liberalizing until it achieved some optimal hybrid of Eastern and Western social and political characteristics. In November 2018, mere months after I had arrived in China, President Xi effectively abolished the two-term limit that had been in place since Chairman Mao had made disastrous mistakes during his latter years in office. It began with the arrest and imprisonment of artists and lawyers who spoke out against the government, deemed to be spreading corruptive Western influences. Next, there were crackdowns on “sissy boys” and the VPNs necessary to bypass the Great Firewall, without which Chinese citizens can only access state-approved websites, effectively preventing them from viewing the vast majority of Clearnet content. Then, as the pandemic raged, I was confined to my apartment for months at a time under the “two points, one line” system that forbade me from going anywhere other than my place of employment and my apartment. Even a quick detour to the grocery store was forbidden. I went a little mad in my solitary confinement; I perfected the skill of isolating a single grain of rice with my chopsticks. In October of 2022, I texted my friend Jing an offhand comment about the Bridge Man of Beijing, a lone protester who had ignited a wave of dissent when he hung a banner bearing anti-government slogans off a bridge in Beijing. Jing, who had been educated at China’s prestigious Wuhan University and Heidelberg University in Germany, was a corporate lawyer whose lively, openly critical political commentary had formed the basis of much of our dialogue during my early days in Shenzhen. “What are you thinking, Brian,” Jing hissed down the telephone line. “They will be monitoring for keywords. You are jeopardizing us both.” Through this and similar incidents, I became acquainted with autocracy not just as a textbook term, but also as a novel element in the air, a highly reactive species that stifled conversation and suffocated hope. Unexpectedly, it opened doors rather than closing them: In hotels and apartment complexes alike, I noticed more and more doors left open throughout the day and early evening, a throwback to Cultural Revolution times when the Chinese did this to demonstrate that they had nothing to hide. My Chinese friends assured me that their people had endured imperial rule for centuries. We know how to survive under dictatorship, they assured me. Besides, our country is too big to be democratic. Their poorly cloaked despair frightened me more than I can articulate; dread became my constant companion. Inevitably, the educational sector was targeted. Beginning in July of 2021, when President Xi decried the private education industry as a “stubborn malady,” there was a sweeping crackdown on companies like New Oriental, English teaching centers, and boutique consulting firms like Pinnacle. Although Pinnacle avoided problems by rebranding as an “educational technology and innovation company,” a change in title that had no effect on operations, hundreds of similar companies shut down as the government sought to ensure that the only voice that its young students heard was the monotone sanctioned by the Chinese Communist Party. Elsewhere on the chessboard, Beijing began to encourage a series of mutual recognition agreements between Chinese universities and their western counterparts. Supposedly designed to facilitate transfer of credit between equivalent educational tracks, these programs are often entirely financed by Beijing, and they allow it to exert the same influence on Western curricula that it already has on Hollywood cinema. Given the enormous importance of Chinese students’ tuition dollars to the colleges and universities that enroll them each year, it is unlikely that these schools would risk disrupting such accords by teaching content deemed verboten by the CCP, which would jeopardize the competitiveness of their programs. And, as China seeks to attract leading Chinese-American businesspeople, intellectuals, and athletes, these agreements provide one more means for reabsorbing talent that might otherwise remain in the West. Foreigners like me, who had intended to stay in China long term, began reevaluating our plans with our Chinese spouses. Expat friends departed in droves as the government continued its campaign against foreign influences, which inspired rabidly xenophobic TikToks about “Why I’m Proud Not to Be an American'' and “How to Avoid Diseased Foreigners.” Against this ominous backdrop, I no longer had the luxury of worrying about the ethical nuances of my strange profession. More students than ever were seeking to study in the US, and I simply wanted to get as many out as possible. I was terrified to consider a new China in which entire generations would never be able to browse the internet to make contact with conflicting viewpoints, much less to participate in open dialogue about governmental policies and failures. In my blackest thoughts, though, there lurked an even deeper fear. Western democracies were unprecedentedly besieged by corruption, doubt, low participation, and efficacy challenges. I was shamefully aware that I was part of the problem. When my Chinese friends charged that there was “too much freedom” in the United States, I couldn’t help but feel that they were referring to people like me: I had taken liberties with my liberty, setting my compass to whatever ephemeral desire entered my mind, leaving chaos in my wake. I had forgotten one of the first principles of democracy, namely, that freedom is commensurate with responsibility, and that to have one without the other spells personal and societal disaster. Most of all, I feared that President Xi might actually be making the correct decision in closing the country off to destabilizing influences. In a world where technology allowed both information and disinformation to travel at lightspeed, in which our thoughts and actions are increasingly subject to manipulation by parties with technological advantages and nefarious intentions, perhaps a top-down, rigorously controlled system was necessary. Maybe they’ll beat us after all, I considered during my darkest moments. Maybe it’s better this way. As I glanced through my Facebook contacts one day, scrolling through the Jays and Peters and Tonys who I had taught, I came upon Jack Lian, the wine heir. After a year of intensive English lessons, he had improved enough to attend a boarding school in Virginia. Now, three years later, I was surprised to see a rainbow filter applied to Jack’s profile picture. It showed him beside a bright-faced, blonde young man in black tie finery, their hands around each other’s waists. Had Jack remained in Mainland China, I knew, he would likely have been disowned for this photo. He would certainly have found it difficult to secure housing and impossible to gain employment with this as his WeChat avatar. Instead, like many of my queer Chinese friends, Jack would have been pressured into a marriage of convenience, probably with a lesbian, and they would have turned to adoption or surrogacy to provide the grandson demanded by the Confucian family pyramid. In the U.S., by contrast, Jack had been given a little grace, some extra space in which to discover himself. In Jack’s sure smile and steady gaze, I saw that, for one student, at least, it had made all the difference.

Why the three "best things" about buprenorphine (Suboxone) and methadone maintenance can be detrimental to someone who is ready to leave addiction behind for good. Includes index of resources for finding a methadone clinic or a buprenorphine provider near you. Ah, to reminisce... Aunt Jemima Was a Friend of Mine For those of you who don't know what buprenorphine (Suboxone) and methadone maintenance treatment are, I discuss the theory and practice of Medication-Assisted Treatment (MAT) for opioid addiction in my Metha-Don't screed (I also touch on the perennial Suboxone versus methadone debate, if you're interested in that). Basically, these medications are opioids, meaning that they stimulate the same receptors in the brain and body as the opiates / opioids that people are addicted to, including morphine, heroin, oxycodone, hydrocodone, and fentanyl. However, these meds have longer half-lives and other chemical properties that allow stabilization of blood levels and subjective effects that is not possible with other opioids. In a sense, prescribing buprenorphine or methadone to addicts is "substituting a drug for a drug," and in fact some people on maintenance do abuse their meds to get high. However, maintenance meds are also far and away the most effective way to stay alive as an opioid addict; the success rates with complete abstinence are so depressingly low that I don't even like to cite specific figures for fear of discouraging people from even trying. Today, I want to talk about my experiences on opioid maintenance, not from the cliched pro-versus-con perspective, but from a trendier, très postmodern "the-same-thing-that-makes-you-live-kills-you-in-the-end" point-of-view. But first, fam, to reminisce. Does anyone else remember those red boxes of Aunt Jemima pancake mix (pictured above)? I think they're still around, but I haven't bought one in many moons, thank God. For 10 or 12 months of my first stint on Suboxone (buprenorphine), that b*tch Aunt Jemima was my best friend. I'd wake up, put an acrid-orange Suboxone strip under my tongue, and as it dissolved, I'd consult the box to refresh my memory on how to cook enough pancakes for six people (so that I could eat them all by myself*). *I'm not being cute here. I perfected making a single skillet-sized pancake that was closer to a sheet cake than your average flapjack. I was in between jobs at the time and living back at home with my mom. Other than my daily run, binge-watching TV (see photo / tangent below), and making an appearance at the obligatory family functions, I was pretty inert. I'm someone who finds it hard to sleep six hours a night when I'm not on drugs, and I was averaging 12 to 14 hours a day during this period. The Netflix horror series Hemlock Grove was a vampire-werewolf tale so insipid and derivative that it practically demanded mind-altering substances to get through (although Bill Skarsgård and Landon Liboiron both got naked in due course, which helped). When I'm totally clean, I rarely watch more than an hour of TV / film per week; on Suboxone, I found myself watching eight or more hours on an average day. Eventually, I mentioned these changes to the physician who was prescribing the Suboxone. "Oh, that's just the anhedonia of early recovery... It's normal to find it hard to take pleasure in the things that you usually enjoy. It's your brain still healing." Except that this hadn't been my experience during previous stints off of drugs. Quite the opposite, in fact. I'm someone who will be eight weeks off of benzos and opioids - riding an enthusiasm that borders on mania - and already have a sponsor / home group, a new career plan, a fresh creative project, and a race that I'm training for. The longer that I was on Suboxone, the more that these side effects started to bother me. I began to feel more and more like someone having the stereotyped, zombied-out Prozac / Zoloft experience. I noticed that I wasn't writing or playing the piano nearly as much as I ordinarily would have, and aside from eating sugar-laden foods and running for 90 minutes to two hours a day (!), I had little drive to do anything. In retrospect, this makes perfect sense from a biochemical perspective. My brain's preferred method of hacking dopamine - i.e., taking exogenous opioids - had just been cut off. I was now stable on a ceiling dose of buprenorphine, which meant that I couldn't take more to feel better, either. Instead, I was stuck at "blah," and the only things that seemed to break through were pretty powerfully dopamine-releasing activities like eating high-cal foods or exercising intensely (which, as we know, releases endorphins, which are the body's natural opioids; in fact, endorphin is a portmanteau of endogenous, meaning produced by the body, and morphine). What my doctor didn't mention was that long-term use of opioids is associated with its own anhedonia. "I feel less alive on Suboxone"; "I lost my soul on Suboxone"; and "I'm just not myself on Suboxone" are things that addicts commonly say to try to convey what this experience is like, but ultimately, it's one of those things that can be fully appreciated only through lived experience. Being on opioid maintenance is like applying a slightly smoky, dampening filter to all of reality. Moreover, these medications dim the very cognitive and emotional faculties that one would need to recognize these diffuse, subtle changes in oneself, which further complicates the introspective picture. As I've said before, I have complex, entangled thoughts and feelings about maintenance. I believe that the trade-off of increased chances of staying alive versus decreased soulfulness or whatever you want to call it is something that must be weighed by each person; there is no one-size-fits-all conclusion. Maintenance can be a very useful steppingstone, and it can also be a wonderful fallback for high-stress times when full-abstinence recovery is just too difficult or risky. In my experience, however, it can also be an insidious way for life to pass one by. Having prefaced my points as best as I can, here are my reflections on the seven-plus years of my life that I've spent on these maintenance medications. Mixed Blessing 1: They Stabilize Your Emotions I had a counselor once tell me that recovery was about learning to live within the 4-to-7 out of 10 range of experience rather than constantly bouncing between 1 and 9 as active addicts do. There is great truth to this, and having a maintenance medication moderate emotion certainly reins in the high highs and low lows of early recovery, both of which can drive people to relapse. However, there is also truth to the idea that the 8's and 9's are what make life worth living. I had a friend who was a young mother who tapered off of Suboxone, and she said that in the end, she was appalled to feel how much more "present" she was with her children. I've had similar experiences with "waking up" after tapering off of these drugs; in a way that is hard to pinpoint, I felt that my relationship with reality was less clear and less honest when I was on them. The 8's and 9's might be what make life feel worthwhile, but the 1's and 2's are equally important (more important, even, for many addicts). Without those rock-bottom moments, sometimes it's hard to manifest and maintain the desire to stay clean off of all substances, forever. "Remember your last detox" is one of my favorite back-to-reality slogans for when I'm slacking in my recovery. The visceral dread that I attach to the prospect of returning to that abject state is a great reinvigorator of my recovery program. When headlining Commie Karl Marx called religion "the opiate of the masses" in 1843*, he chose opiates over alcohol and other chemical refuges for a reason. *Luckily for us, we live in the 21st century, when opiates have become the opiates of the masses. Opioids put a warm blanket between us and reality. In addition to releasing dopamine, they quiet our nociceptors, which are the receptors in our body that are responsible for alerting us to pain. This shielding from discomfort often has the effect of decreasing the psychological impetus for change. On maintenance, I found it considerably more difficult to motivate myself to accomplish the simplest of unpleasant tasks. Something as basic as going to the dentist to get a cavity drilled / filled might be put off for weeks or months, for example. Looking back, I have no doubt that this was due to my brain being enveloped in artificial feel-good. Pain and anxiety have psychological utility, and dampening them with comfort-inducing drugs is a dangerous game. Character change and spiritual growth often hinge as much on processing our worst, most traumatic moments as they do on meditating on our golden ones, and to the extent that maintenance opioids shield us from the emotional impact of such events, they can delay or preclude our breakthrough moments. Mixed Blessing 2: They Allow You to Bypass Withdrawal Used properly, both methadone and buprenorphine effectively alleviate the vast majority of opioid withdrawal symptoms. To anyone who has been through this iconically awful experience, this seems like the ultimate gift. It's not just about avoiding pain, either. When you've been taking powerful depressants regularly for too long, your body starts to ramp up its production of glutamate and other excitatory neurotransmitters to keep the balance. When you suddenly stop using your drug of choice, you end up with an excess of these "upper" neurotransmitters, which leads to a state called excitotoxicity that can cause neurologic damage and possibly damage to other organs, as well. There is no doubt that going on maintenance confers substantial protection against such damage. However, you're trading the damage from withdrawal for the deleterious effects of long-term use of high quantities of opioids, which are by no means negligible. And make no mistake - the dosages used for buprenorphine and methadone maintenance are much higher than standard pain management dosages. Moreover, because these drugs have such long half-lives, your body is never getting a break from them. Cue endless dry mouth leading to tooth decay (there is currently a multi-district litigation [MDL] case, which is similar to a class-action lawsuit, against the manufacturer of Suboxone for negligent conduct having to do with tooth decay caused by the drug; this case is making its way through the civil system at the moment [link is to a Lawsuit Legal News entry explaining who can file as part of this suit]). There is also severe, chronic constipation to contend with, not to mention dizziness, nausea, sleepiness, headache, depression, sexual dysfunction, and doubtless many other long-term and emergent side effects. If you read Victorian literature, then you might know that a sort of opioid wasting syndrome has long been recognized in people dependent on opium, morphine, and similar drugs. In addition to physical deterioration from not being able to digest and absorb nutrients properly due to gastrointestinal changes caused by these drugs, mental decline of a specific type and generalized, bedbound apathy were widely observed. When I was on a megalithic dose of methadone - roughly three to five times the amount that would kill an opioid-naive adult - my memory became so poor that I began to wonder whether I was developing dementia from my two decades of benzo abuse. Opioids dim your mental processes just as much as your physical ones, and for a STEM teacher who prided himself on his mental agility, this was a bitter pill to swallow (or put under my tongue). One of my predictions is that we will see a significant increase in GI cancers as a result of our prescription and illicit opioid epidemic. Chronic constipation and diarrhea lead to oxidative damage that can cause mutations that in turn lead to cancer, and prescribing laxatives to counteract opioid-induced constipation is an imperfect fix at best. Again, this risk of GI cancers in habitual opium and morphine users was recognized well over 100 years ago, when these substances were legal and largely unregulated. Despite this fact, I have never heard it mentioned today. Mixed Blessing 3: Sometimes They Put Your Addiction in Remission With Suboxone in particular, Dr. Jeffrey Junig and other physician-advocates have advanced a model of addiction remission. According to this model, addicts can bypass recovery entirely; by restoring mental and physical functions to their pre-addiction baselines and preventing maintenance patients from getting high*, the argument goes, these meds allow people to move on with their lives almost as though they were never addicted at all. *When used properly, both buprenorphine and methadone block other opioids from having an effect, although believe me - this doesn't keep people from trying. I have known a few people who had this kind of experience with Suboxone or methadone. Almost invariably, however, it only lasted for six to 18 months, after which the blah syndrome that I described in the intro set in. The other danger of this kind of thinking is that it ignores the fact that addiction has far-reaching tentacles. Addiction is never as simple as using one's drug of choice. Another way to say this is that drugs were my solution, not my problem; take them away, and I am still a woefully maladjusted human with severe anxiety, issues maintaining relationships, and other problems. Best-case scenario, if you take their drugs of choice away, many addicts move to another source of dopamine - and, in fact, drastic weight gain, compulsive gambling, and promiscuity are not uncommon in people on maintenance. Many also switch to benzos, cocaine, or meth to get high, as well. All addicts suffer from serious defects of character; another way to put this, as I have said before, is that well-balanced, resilient, self-actualized individuals rarely if ever fall into the trap of addiction. Selfishness, emotional volatility, and self-isolation are common problems. Again, entering physiologic remission by taking maintenance meds does nothing to correct these underlying problems. Rather, it produces the opioid equivalent of a dry drunk, which is someone who is sober but not in recovery. To be a dry drunk is miserable - often as bad or worse than being a "wet" drunk - and to be around someone in this frame of mind is equally unpleasant. Just to be clear, I'm not saying that people on maintenance can't make these necessary changes; some probably do. But the psychological impetus to do so is drastically reduced by the artificial well-being and stabilization that maintenance meds provide. The 12-Step Programs of AA and NA caution against looking for an "easier, softer way" out of addiction, and I can't help but think of opioid maintenance when I hear that phrase. In Conclusion Much of what I said above can be distilled down into two statements: Buprenorphine and methadone maintenance induce an artificial well-being that belies the necessity of deep character change, trauma processing, and spiritual growth; Opioids are by no means harmless drugs in the long term, particularly when used at high dosages; there are significant cognitive, emotional, and physical side effects, and there is the potential for organ damage, as well. Ultimately, I decided that maintenance was a useful steppingstone between active addiction and complete abstinence. Past the honeymoon period, the efficacy of maintenance began to wane; plus, I wasn't okay with the trade-offs attached to indefinite usage. When I remained on buprenorphine or methadone for longer than a few months, these drugs became a sort of Sword of Damocles hanging over my head, suspended by a horsehair - waiting for the slightest perturbation to come crashing down upon me. If you're interested in buprenorphine maintenance, I highly recommend that you check out the injectable formulations, which last for several weeks. I've compiled a list of U.S. provider directories for various forms of maintenance below for those of you who are seeking a buprenorphine or methadone provider near you. As always, feel free to reach out with additional questions. Stay safe! Thanks for reading. B. Provider Directories Find a Sublocade treatment provider (injectable buprenorphine) *Brixadi is another injectable formulation that you might want to look into SAMSHA's Buprenorphine Treatment Practitioner Locator *In certain states, you might be able to obtain buprenorphine by e-consultation. I recommend avoiding this whenever possible because A) these doctors tend to be more expensive, and B) I have heard about too much sketchiness tied to these providers. Very few ethical clinicians are willing to dole out buprenorphine without seeing you face-to-face and drug testing you randomly. Zubsolv find a doctor (sublingual buprenorphine) SAMHSA Opioid Treatment Program Directory *Includes methadone clinic listings

To the woman who taught me about the Golden Rule and the Rules of Evidence; how to walk the narrow path of righteousness and how to avoid sentencing enhancements if I didn’t. My mom and I hiking Letchworth State Park in Upstate New York. She hates pictures; I hate pictures. For my fifth-grade global history project, I had to create a diagram of the Egyptian social hierarchy. You know, with the pharaoh at the top, then the nobles and priests followed by the scribes and soldiers all the way down to the slaves*. *I had to Google this to help me remember. I’d waited until the night before the project was due, then I’d grabbed any posterboard-like item lying around our basement to draw it on. It wasn’t until I finished my presentation and brought the poster back home that I noticed what was written on the back of it: Exhibit 12A. Timeline for ethylene glycol poisoning. “What’s that, Mom?” “Oh, it’s from a trial. To show that what the prosecution was saying about when my client supposedly poisoned her husband with antifreeze didn’t make sense.” My mom had just gotten home from work. She answered me in between throwing clothes in the dryer, dinner in the oven, and changing into something more comfortable. During my entire adolescence, now that I think back on it, I don’t think I ever saw my mom doing just one thing at a given time. “Do you think she really poisoned him?” “Eh, not in the way the prosecution said she did,” my mom replied. “He was an alcoholic, and he physically abused her, so it’s possible that she snapped…” My mom didn’t just teach me about the Golden Rule of not hurting others. She also taught me about diminished capacity - that sometimes, for example, when we are hurt badly enough and for long enough, we lose our ability to evaluate right and wrong in the clearheaded way that the law requires for full responsibility. She gave me an appreciation for how early life circumstances can affect people’s later behavior and for how some people just seem predisposed toward certain problems. My mom’s perspective wasn’t the intellectualized, pity-laden point-of-view that many educated, liberally leaning individuals seem to develop. She told me a story about one of her clients, a career junkie, being charged with stealing two benches from a store. This man was indignant - not that he was facing his umpteenth larceny - but that he had been charged with grand larceny rather than petit larceny. My mom went to the store and verified that what her client was telling her had been true. The benches had been on sale, and - whatever the cutoff was between grand and petit larceny at the time - her client had made sure that he didn’t steal enough to be charged with a felony. She laughed as she told me this story and many others like it; she had real appreciation for the resilience, wit, and sometimes even the audacity of the criminals that she defended during the first part of her career. *** I’ve been in rehab enough to have heard about some true horror-story upbringings. In addition to feeling for whoever was sharing their story, my first response was always: Why am I here with you? The first 10 or 12 years of my life were halcyon. I lived in a safe, small town where everyone seemed to have their place. We went to my mother’s parents’ and my father’s parents’ houses at least once a week to spend time with aunts and uncles and cousins. We took camping trips to the Adirondacks and vacations to South Carolina, Florida - anywhere with a beach. My Dad spent every Guy's Night Wednesday sleeping in a small bed with my two brothers and me. We had to lay the “wrong” way on the rectangular bed so that we could all fit, which meant that my dad’s legs hung off the edge cartoonishly. We went to Yankee Stadium for baseball games. When it became clear that I wasn’t a baseball game kind of guy, my parents tacked on a Broadway show to those trips like it was nothing. I realize now how much work and stress this all must’ve entailed, but in those days, my parents made it look easy. *** Things changed for our family as my brothers and I entered middle school. There is never a good time for divorce, but middle school has got to be the worst of all. You’re old enough to fully understand what’s at stake after enjoying family togetherness for long enough to take it for granted, but young enough that your personality is still developing and the awkward turbulence of adolescence is still ahead. My parents did the right things. They talked to us about the changes in our family. My mom bought a house within walking distance of the one that we grew up in, where my dad still lived. We spent even more time with our extended families, which gave us a needed sense of continuity. Still, as I look back now, I can appreciate how for my parents, who were both Good at Life™, this probably felt like the first full-stop failure of their lives. Shortly after my parents separated, my dad’s business shut down, and the fallout from this and his later cancer diagnosis would take him the better part of a decade to recover from. Because of this, during those crucial years, my mom bore the burdens of a single parent in many ways. She seldom let the stress show. Her own mother (my beloved grandma, of course), was many wonderful things, but one of these was not an able cook. My mom made sure to put a healthy, delicious dinner in front of her three ravenous boys every single night. Somewhere in between making it through college on athletic scholarships, finishing law school while waiting tables, and then diving headfirst into motherhood, she had taught herself to make crab-and-orzo on asparagus and pasta dishes to rival anything that the Italian side of my family could concoct. One hard boundary for this blog is that I won’t talk about family members’ mental health struggles, but let me clarify that, while neither of my parents is an addict, there is an extensive family history of addiction on both sides of the family, particularly my mom’s. So, during the crucial adolescent years, when both my parents were a bit overwhelmed / distracted and OxyContin was so prevalent at parties that kids were walking around with gold and turquoise smudges on their shirts from removing the extended-release coatings from these “hillbilly heroin” pills, some faults had appeared in our family foundation. Especially when the addictive predisposition is strong, that’s all that addiction needs; it’s like a weed that creeps up through the hairline cracks in your driveway. *** In many ways, the next 10 to 15 years of my life were a blur, and I hope that they’ll always stay that way. There were countless family plans interrupted by overdoses, car crashes, or legal incidents. There were three straight years when I was in rehab from my birthday in November through New Year's. There was a time when I had to kick down the upstairs bathroom door so that my mom and I could give Narcan to another family member who was so blue-gray that I truly thought he was dead already. On that afternoon, my mom handed me the Narcan vial and talked me through the injection process. I hadn’t known that we had Narcan in the house, and if she hadn’t come home from work at just that minute, this family member would’ve been dead. End of story. That probably sounds crazy to most of you, right? Like something from a movie? Something so traumatic that you’d never forget it? For a few years, that became our family’s normal; there were so many similar incidents that it’s hard to keep track of them all. There was pawned jewelry and missing cash; late-night errands and suspicious phone calls. My mom always knew what was going on, but she had to wait in dread for the inevitable phone call that started with "Your son..." I have a memory from I-don’t-know-what year of my mom sitting my brothers and I down a week before Christmas. “Please, you guys, if we can just make it through Christmas without any major incidents this year…” My mom isn’t someone who begs. That was as close as she ever got, I think. Unfortunately, there were times when my mom’s legal background came in handy for her own family, and I can’t imagine how awful that must've been for her. She didn’t have the separation from the justice system that most “normal people” benefit from: She had visited her clients when they were locked up, so she knew full well the dangers, the indignities, the difficulties of getting back on track. My mom rarely complained. She never faltered. While other parents were watching their kids graduate from college and launch into successful lives of their own, she accepted her lot with a head-down stoicism that speaks to a strength and a love much greater than I can wrap my head around even now. *** If you met my mom in the grocery store or ran into her at the courthouse today, you wouldn’t guess any of this about her. She looks like any other late-middle-aged mom of three from our small town. She never misses more than a day or two of work each year, and she doesn’t talk about her kids’ problems with her colleagues or even many of her friends. I decided to write this post after seeing this headline on CNN: Mother of two CEOs and a doctor shares what you should know about raising children. I rolled my eyes a little bit when I read it; it was a for all the rest of us, there’s Mastercard moment. American society in particular has such a sore winner mentality. If you didn’t rise up to the top in every area of your life, then it’s because you did something wrong. This is extended to people's children in an especially cruel way. And I’m not saying that the mother of the three wunderkinds wasn’t a beautiful person. I’m sure she is. Although maybe at least one of the two CEOs will turn out to have paid hush money to a series of transgender prostitutes (just an example). I’m just saying that our parents can no more protect us from mental illness than they can from physical ones. And that parenting teaches us how to walk through the fires of our lives; it doesn’t guarantee that we’ll avoid them altogether. In our case, our little family of five ran headlong into the black maw of addiction. In that battle, winning often looks a lot like simply staying alive. *** I don’t hold out hope of heaven anymore, and I’m sure that our family’s troubles have done a number on my mom’s faith, too. But if there is a heaven, then my mom deserves the TSA PreCheck treatment when she gets there. In closing, some lines by Frank Bernard Camp: And when he goes to Heaven, To St. Peter he will tell: Another soldier reporting, Sir; I’ve served my time in hell. Happy Mother’s Day. Love you, Mom. To everyone who has lost a son or daughter to addiction, my heart is with you today.