Opioid substitutes: Take as needed

Last post I shared a conundrum with you. I’d written a chapter for a book for addiction doctors. But when I learned the title of the book I decided (after all that work!) to withdraw it. Was that the right thing to do? Your comments convinced me it wasn’t.

My chapter urged practitioners to view addiction as a learned habit, not a disease, and showed show how the brain changes corresponding with addiction fit our understanding of learning rather than pathology. And it seemed compatible with a book that was supposed to “create space for clinicians to go beyond narrow guidelines….to reflect more of the ‘art’ of working within addiction medicine.” I thought my chapter would fit right in.

Until I read the proposed title: A prescriber’s guide to methadone and buprenorphine for opioid use disorder. How could a “prescriber’s guide” advocate moving beyond conventional guidelines? At best I’d have to rewrite the thing. And even then, my whole argument for moving beyond the “disease label” starts to unravel when it comes to the prescription pad. (see last post for details) In sum, my chapter in this book would be a sellout! Not just a poor fit but a surrender to the opposition!

That’s where you guys came in. I asked commenters to give me the benefit of your perspectives, and that’s what you did. There were good arguments on both sides, but a majority of you articulated good reasons why I should have left the chapter in.

For example, Matt had this to say:  “I don’t quite understand why you would not offer your unique perspective to anyone, especially physicians, and especially since they asked for the chapter to begin with. There are so many physicians who would be exposed to your ideas who may have had no idea they existed.”

For “my ideas,” read “progressive conceptualizations of addiction that step around medicalization.”

Annette wrote that “your role is, undoubtedly, to EDUCATE. The world is shifting…Mental health advocates are talking openly about the impact of social, economic and political structures on our (fragile) mental health, so those of us who understand this need to keep educating.”

But Shaun came up with the coup de gras: “I imagine two scenarios,” he wrote. “ONE: a well-meaning doctor who has learned it all from the book of NIDA, Chapter Volkow, TIP63: Patient has life-long disease of brain that compromises free-will. They will manipulate and lie. I will insist that they pee in a cup [and] have medication discontinued if they test positive… Chance of getting on with life, zero.

“TWO: Having read Marc’s chapter, start by seeing a person who, for whatever reason, has learned to use heroin as a valid way dealing with life. Through collaboration and honest dialogue, with voluntary additional services that they may or may not request, I will prescribe their methadone without fuss and making them seem like I’m doing them the world’s biggest favour. I will…not wield [my] autonomy like a weapon…I would…’provide a scaffolding’ of methadone ‘to support a vision of future self,’ rather than use methadone as a straight jacket to constrict their right to breathe.”

(I suggest you to read these comments in their entirety.)

When I read Shaun’s comment I was still reeling from a psychotherapy session I’d had with Sally (fictitious name) a few hours earlier. I’d been meeting (online) with this fortiesh English woman for psychotherapy every week or two for about eight months, during which time I’ve tried to help her get on with her life, make peace with her demons and self-doubts, and keep her codeine habit within safe limits. This session she talked about her years of heroin addiction and hooking. It wasn’t the first time, but the level of detail, the pain she expressed so vividly, made me more aware than ever of the grinding inhumanity of the life she’d lived.

How did Sally get into heroin? When she was 14, a teacher at the children’s home began touching her genitals. She wasn’t angry at the time, she says, but her perception of adults changed entirely from that point on. A couple of months later, a math teacher–she remembers him as being very old, with bad teeth–started making advances. This time, she threw a chair at him. She got kicked out of school for her troubles, and that’s when she got to know Mike, who introduced her to heroin.

Sally had a pattern of running out of one children’s home and landing in another. She hated them all, she told me. Her parents came to visit her often enough, but they didn’t take her home with them. Maybe that was the problem. Her mom had told her she couldn’t handle her tom-boy ways. Sally liked looking for bugs under rocks rather than dressing nicely. That’s just Sally being Sally, the family concluded. And she became an outsider in her own home. By adolescence she’d often end up swearing at her mom, sniffing glue and hanging out with the wrong kids on the corner.

So it was the usual culprits: inadequate parenting, child abuse, growing up without any real protection…Sally’s credentials for drug use would include a pretty high ACE score. But Mike was the catalyst.

He started off as her friend, someone to love her and listen to her. Then he became her pimp, demanding that she go out and find money to score more dope. Her young body was all that stood between his well-being and withdrawal symptoms. He’d beat her up if she refused–broken ribs, a couple of teeth knocked out– except when he got worried about damaging the merchandise.

Sally’s life stabilized after all. She went out at night, looked for men, got the money up front, until she had enough to score. Then went back to Mike and shot up. This went on for years. Her mother saw her once, sitting at a street corner, head lolling back, almost unrecognizable because she was so thin. But she just kept driving. That’s just Sally being Sally. Skeletal and bruised, waiting for a man degraded enough to look past the bruises for 20 minutes of warmth. That’s who she became. Until she was rescued by a man who got her off dope, as long as she’d never look at another man again.

The real story of Sally’s addiction is so diametrically opposite anything resembling a disease. The web of social, economic, and familial factors, the absence of a social safety net, the play-it-safe inclination of child-welfare services that weren’t interested in the child’s version of events. That’s where the problem arose. So where was it to be solved? In a doctor’s office? In a methadone clinic?

At least once a year someone would demand sex without pay or else they’d hurt her, badly, they warned. And she’d have to “service” this man anyway, get it over with as soon as possible, because the night was wearing on. There weren’t many hours left to find a paying customer. And she needed to buy heroin. Her stomach was already knotting, her muscles cramping, the nausea rising. She couldn’t face it, not tonight. She couldn’t face Mike empty-handed and she had nowhere else to go.

Sally told me that she’d cry every day, even once her life had moved on. She just couldn’t process all she’d been through. Now, today, I couldn’t shake my own grief. That’s when I read Shaun’s comment. And that’s when I realized I should have submitted my chapter after all.

The horror of Sally’s circumstances could have been prevented if opiate substitutes had been available, without prohibitive costs, without further degradation. She would have left Mike, would have left the street, if she could have found a way out.

I’m not beating myself up about it, but I made a mistake. My reluctance wasn’t wrong. The “prescriber’s” shingle unfortunately strengthens the inclination to make OST (opioid substitution therapy) the goal of addiction treatment. It was my decision to withhold the chapter that was wrong.

I should have contributed the chapter to help doctors see OST as scaffolding, a means to an end, rather than an end in itself. That way, the social-developmental roots of (psychological) addiction and the doggedness of physiological dependency could have been specified as parallel aspects of an opioid habit, distinct but convergent, making it all the more insidious. Both are real. Both may need to be challenged head-on. And there’s no universal formula for which should come first.













40 thoughts on “Opioid substitutes: Take as needed

  1. Scott Knapp July 4, 2019 at 4:52 am #

    Vulnerability and transparency like this exemplify what a terapusr’s soul should be like….more powerful inspiration than a script pad! I’ve generally bolded the word “ASSISTED” when I’ve discussed “Medically Assisted Therapy” and for many years highlighted its role to work as a “helpful adjunct” to other forms of addictions treatment. I was once assigned to drive a committee where I worked to set up a MAT program, and noticed that I was beginning to become marginalized within the agency after I proposed that the program NOT be physician-centric, but that the prescriber be one voice amongst the chorus of a treatment team. Apparently that did not set well at all.

    • janet July 4, 2019 at 12:47 pm #

      Yes, Scott.

      Fear, and the iron will of the opioid need/want as the solution, drives this by all involved.

      We have to get the patient, and all those involved including family and friends, to accept the reality that the substitute opioid is an assistance to the entire program of therapies and treatments needed. Then the hard work begins.

  2. Marc July 4, 2019 at 7:09 am #

    Yes, that fits my experience. I was invited to submit this chapter by a bunch of doctors who knew my position on medicalization. So I thought we were on the same page, at least partially. But when I asked if they would consider changing the title of the book to something a little less “physician-centric” I was met with a stony silence.

    Change is slow, as a number of commenters have pointed out. But it was wrong of me to get in a huff about it. Better to keep pushing…

  3. Joanna "Nicci Tina" Free July 4, 2019 at 9:29 am #

    Hi Marc – I love the way you’ve grappled with this conundrum, and shared it with us. I have pondered it, too, since reading your earlier post and some of the comments in response.

    My issue, I realized, is with the timing of the publisher’s disclosure regarding the title of the book. It felt deceptive, or at least misleading. Why not tell you the working title before you wrote the chapter? Then you could have adapted your thoughts and delivery accordingly, in light of what the reader would be coming to the page to see.

    I would’ve been reactive, too, in the face of the circumstances you describe. And, although it is VERY important to me to share my ideas as widely as possible with others, it is also important to me to feel like I’m working with people who are rooted in their integrity regarding how they engage me, especially when I’m putting time and care into the way I express myself, mindful of the intended audience.

    So, I don’t think it’s about wanting something less “physician-centric” – I’m meeting more and more healthcare providers, especially in the filed of addiction, who are open to learning innovative perspectives and approaches (including my own;).

    This feels like more of a bait and switch on the part of the publisher. I expect I would have also recoiled from that, too.

    Thanks for sharing your process with us, and for the way you’re serving clients, too. Much love to “Sally” and to you.

    • Marc July 4, 2019 at 9:57 am #

      HI Joanna,
      That’s exactly what went through my mind. There were other murky details that I haven’t bothered to share. To sum it up, I felt like the ground was shifting under me, nobody was willing to acknowledge the weirdness in the communication process, and I just got cold feet. I’ve had plenty of chapters published in scientific or professional books, but this is the first time that the editors were a committee of doctors who functioned according to their own credo… It wasn’t a world that felt familiar to me or, for that matter, entirely honest.

  4. matt July 4, 2019 at 11:25 am #

    This is not a war. The war on drugs was a war, and we all know how that turned out. This is an opportunity to educate, elucidate, conversate…to insinuate a wedge wherever possible to clarify the problem…by any means necessary. And I mean that in the same spirit Sartre and MalcomX intended it (sans militant violence).

    Last night, I was talking with a group of women who had lost their children to homelessness and substance misuse. One very young woman began to express her fears about her daughter living in a society (in Massachusetts) that makes it easier and easier to obtain alcohol! Massachusetts used to have “blue laws” where alcohol could not be bought on Sunday, or bought in a grocery store. She thought that was the biggest challenge her daughter would face. Another had a similar story around crack and heroin. They eventually came to a consensus that it wasn’t the access that was the problem. It was lack of education and frank conversations about substance consumption. Why don’t we want to look at or talk about it? Why is it the elephant in the room under the throw rug?

    I just look at this chapter thing as a novel opportunity…something unusual and unexpected that might open someone’s eyes who never would have thought about this issue in this way. Information, inclusion, understanding is power, and it has to start somewhere.

    • Janet July 4, 2019 at 12:41 pm #

      So well said, Matt.

    • Marc July 8, 2019 at 8:52 am #

      Hi Matt. As you see, I came to align myself with the constellation of your thoughts. Maybe too late for this publication, but in future I’ll be more attentive to what I can provide in terms of perspective change, even in contexts where I may not feel at home or comfortable. Or to make things simple I could just tell myself: Do what Matt would tell you to do. Simon says Do This!

  5. Janet July 4, 2019 at 12:39 pm #

    Hello Marc,

    You have done no harm. Was pulling the chapter an opportunity missed? Possibly. Did you have the right to pull the chapter if you weren’t comfortable? Yes. I really like what Matt wrote, especially the last paragraph. Now be kind to yourself, Mark, as you are to others. You are saving lives. And you are on the font lines every day. That counts.

    The “trend” towards the opioid substitutes is strong, and seems to be getting more pervasive, and certainly confusing. I know of so many being treated this way. Mixed results all. My son is on Suboxone being prescribed by the Veteran’s Admin. He’s been on it and off it for a long time. Sometimes under a physician’s care, sometimes not. He says he would like to transition to Vivitrol but he can’t seem to get the two days Suboxone free to make the switch. The dependency is huge. He does know, that the Suboxone is harming him. He says he would like to get off it permanently. I don’t think he can imagine his life without it.. without opioids. He needs it and wants it. The providers really don’t know what to do… this is what they offer.
    And it does help. Sort of. ! But what’s the plan?? Again, we are caught in the ether and Marc, you are right, you are trying to stay on message.

    I’m attaching a really interesting interview from NPR with the now famous Dave Dahl :
    addict, felon, alcoholic, success story .. Dave’s Killer Bread. Dave mentions towards the end of the interview that he is now on Vivitrol. Along with a lot of recovery. ! And a lot of pain.


    Be well everyone. And thank you Marc for your fearless searching.
    And to “Sally”… compassionate recovery.

    • matt July 4, 2019 at 7:51 pm #

      Thanks, Janet for the link to this compelling interview! It really puts this interweaving of existential complexities in stark relief!

    • Marc July 8, 2019 at 9:01 am #

      Hi Janet. Always good to hear form you. I’ve clicked the link yo provided, now got a browser tab ready and waiting, just have to find a few minutes and I’ll read it. Meanwhile, thank you for understanding.

      Opioid substitutes are the epitomy of a compromise between restive opponents. It’s not the end game we want to settle on, but it’s a big improvement over the chaos that takes over when people are dependent on street drugs. I think the notion of scaffolding works pretty well here. OST is a structure that can support further construction, further building of the edifice of a strong and empowered self.

      Staying on message is important, but not at the expense of missing the obvious. People like your son need a leg-up, a place to rest, and I’d like to be seen as an advocate of that philosophy rather than a stickler for demedicalizing addiction.

      • Janet July 8, 2019 at 4:45 pm #

        Hi Marc, You should be able to listen to the NPR interview with Dave Dahl as well as read. I listened. His actual voice is part of the story!!

  6. Alison July 4, 2019 at 4:44 pm #

    Marc seems like this “missed”opportunity helped you gain insight
    into what your mission is….further define it….that’s a win for you in the end.

    But why do we give the power to create change to the doctors?
    Sure educating the “educated” helps.
    But I think real change comes in educating “the common people”.
    Breaking down FEAR that people in communities have about the “addicted”.
    And empowering the “addicted” that the cure lies within, not what some doctor says.

    In American Sickness, Rosenthal advocates for healthcare reform and she advocates reform needs to come from the consumers, the ones seeking treatment.

    The power to make change in NY is in the funding….the segregation of “mental health” and “addiction” treatment continues to grow as bureaucratic agencies create treatment they don’t understand. It’s coming from a lot of PHDs and MSWs that are no longer in touch with “the people”.

    Any real change in history comes from empowering the common people and society, no?

    And …”That’s sally being sally” … that’s joe being joe … that’s Julio being Julio
    that is the attitude that has to change in society.
    Cause the Sally’s and joes and the Julio’s make that their identity.
    “I’m bad I was born that way” ….most common thing I hear amongst
    the people I work with. So far from the truth.
    (I see poverty, trauma and learned helplessness.)

    I believe that access to 1 to 1 counseling is essential for people with addiction, that is what life taught me.
    But I just heard of 2 private practice counseling groups on Long Island
    that won’t counsel anyone until they have 6 months proven sober time.
    No doctors there. Just “mental health” Counselors.

    Yeah if you have money you have the freedom to pay for counseling but if
    if you don’t you go to medicaid hubs that promote outpatient groups
    that tell you that you will relapse if you don’t embrace AANA and offer 15 minute counseling sessions where you talk about the weather and the new movie you saw.
    And then blame “the addict” that they “sabatoge” treatment when they relapse.

    Sure I educate doctors when I can, sometimes I silence a room, but my focus is on educating the consumers, they are the ones who can make change.

    • matt July 5, 2019 at 6:57 am #

      Thanks, Alison
      I agree that the change has to come from within the community who are being marginalized. The sad fact is that without direct lived experience, one cannot understand the gravity and motivational disruption of “addiction.” That doesn’t necessarily mean you have to have been an “addict or alcoholic.” But you have to have had visceral, compassionate and extended immersion into the experience of persons with this affliction. It has to have changed you and your perspective on life the same way it changes a “recovered” person with the affliction.

      The real problem with over-medicalization is professional hypocrisy. If a person has cardiovascular disease because of their diet and life choices, they aren’t refused life-saving surgical interventions until they change their diet for some arbitrary period of time. If you have IV endocarditis you can be refused treatment until you can prove you can stay “clean.” It’s often the same with cirrhotic liver disease (in order to be on the transplant list.) Physicians aren’t supposed to refuse treatment to people suffering from a “disease.” “Physician do no harm,” remember? The biggest problem with the over-medicalization is the hypocrisy that emerges from the social stigma attached to this “disease,” and the lack of training physicians receive around it historically. Lepers used to be shunned, too. Either it’s a disease or it isn’t, but you can’t have it both ways.

      • Janet July 5, 2019 at 12:58 pm #

        Oh so true and so painful. If addiction made you rich and beautiful and content and healthy it would all be ok. But it makes you poor and dirty and desperate and sick.
        That poor, sick, dirty, desperate person is treatable….

        You start with housing, hygiene, nutrition, security, transportation, medical services, dental services, counseling services, legal services, social and educational services …

        A Rubik’s cube. And a timeline of years…

        And the great unknowing as well.

        Let’s admit that what we “need to know” , we don’t have yet, but we can build something with what we have. Like being on Mars with only a certain materials… We don’t know yet what it’s going to look like… but if we apply the basic principles of shelter and safety… who knows?

        We have to stop thinking of what it is and isn’t… and WE have to stop applying so much FEAR.

        Thank you fellow travelers…

        • Janet July 5, 2019 at 6:09 pm #

          And that “Rubik’s Cube” will never look the way you were told it would. Or the way any of us may have wished…
          It will look the way it ends up looking…
          The scars, the mismatched colors, the glued on pieces.
          That’s what it will look like.
          You’ve never see it before.
          Each time is it’s own.
          Everything in play…

          The not knowing
          is the single constant.
          But by applying the laws of nature…
          Shelter, food, safety.
          Accepting the laws of nature..
          disease, fear, death.
          Honoring the laws of nature…
          healing, rebirth…

        • Austin Wynn July 24, 2019 at 6:00 pm #

          I agreee! I feel like this is the most compassionate approach. Providing basic living skills and necessities – which are quite scarce among the addicted population.

          When I first got clean, I had no comprehension of the basic life requirements I needed, let alone the skills to build the foundation to attain that peace of mind. Referring even to Maslow’s hierarchy of needs, we could provide guidelines for treatment and educate, inform, and teach these essential components to building a life.

          I also get torn up thinking about the push for “brand name” suboxone, when generic buprenorphine is just as effective, if not MORE effective than brand name with the futile addition of naloxone.

          It may have an increased “abuse” potential, but to me the argument is a moot point as the intended effect (blocking receptors for full-agonist opioids and withdrawal minimization).
          See https://neveralonerecovery.com/2019/06/18/subutex-abuse-signs/ for a few resources on this point.

          Either way, I love that we’re here talking about compassion and treating everyone with the one thing they’ve always desired, LOVE (myself included in 8+ years of addiction).

      • Alison July 9, 2019 at 11:01 pm #

        Yes Matt good points …so much for do no harm …
        and for medicaid people most of suboxone doctors available will only prescribe if you jump through hoops… 3 hour intakes, told you must attend a certain number of groups usually 5 days a week, to get suboxone and if you miss a group you are grilled like a kid sent to the principal…
        Too bad if you have family or work commitments…
        Who came up with more is better in tx? We should be empowering people to figure out what they need….

    • Marc July 10, 2019 at 8:10 am #

      You make such good points Alison. Why do we give this policy-setting power to the doctors? Because we are afraid, as you say, and doctors are the professional stand-in for parental protection from everything from malignant viruses to ghosts that go bump in the night.

      It’s not really their fault. They take the power we give them and move forward in their ploddng way. Yes they are deeply misinformed about addiction and recovery. Yes, we have to educate them. Which means they have to listen! (they’re often not so good at that) But as much as I do respect doctors, they can be lazy and even cowardly, by not pushing back against policies that are so obviously wrong. The standard treatment model is such a travesty, as you point out. Access to buprenorphine is still highly restricted in many regions. Worse, many state-funded treatment centres and rehabs make treatment contingent on getting and remaining “clean” — was it you or someone else who reminded us of this idiocy? — but if you actually adhere to the disease model (as these agencies almost always do), then it must occur to you that it’s nonsensical to withhold treatment when your patient is sick or getting sicker. Some enlightened doctors will prescribe opiate painkillers even when they know that pain is not the main issue. But why is this so rare and so rife with risks for the doctor? If addiction is a disease, why on earth not prescribe a medicine to ease the suffering?

      These arguments are well known. But they do little to change the landscape, because there is little consensus on how to apply them and little energy to engage in that particular struggle. My brother, a GP in California, sometimes gets very pissed off at patients who “manipulate” for more opiates. He sees pressure and coercion, and I understand why he gets mad. But still I encourage him to step up to the plate and to fight back against regulations that severely limit pharmaceuticals for pain patients and people in addiction…or both. Sometimes he tries. But like everyone else in the professional world, he is overwhelmed by work, paperwork especially, tracking and checking and filling in forms, and so he reacts impulsively…and throws up his hands.

      Please make sure and read what I believe will be the next post. A guest post by a rehab/treatment marketer with a uniquely progressive approach and a whole lot of acquired wisdom. In the post (I’ve read a draft) he traces recent trends by which parents exert tremendous amounts of pressure on the public health system, yes, on doctors, simply because…their children are dying!!! So, yes, the “common people”…I agree: that’s where real change comes from. That’s the case with presidential politics and that’s the case with addiction treatment. But the common people need both the passion to fight (which can be buried and crushed under geological — viz. institutional — layers of learned helplessness) and the knowledge to fight with. Very hard for them (us?) to acquire both.

      One more word about Sally. She’s common people. And do you know how she exerts her power over addiction treatment policy? She asks her doctor for codeine, and she tells him straight out that she takes it only to stave off withdrawal symptoms, which trace back to her heroin days. Her pain is minimal. So her doctor prescribes a monthly amount, has for a few years I believe, and just recently she has started tapering…herself! She’s not sitting around and waiting for permission, or guidance, or instructions on how to handle her addiction. With a little encouragement (and zero coercion) from me as her psychotherapist, she finds herself changing — taking less than the prescribed amount some days. Why? I don’t know, she reflects, I just don’t feel like I really need it. Maybe I’ll save it up for a rainy day. When she recently asked me how I’d suggest she start getting off opiates, I had to inform her that she was already doing it herself! People’s intrinsic desire to move on, to expand their awareness beyond the phenomenology of getting high, is this motive force which we (and they) often don’t see at all. That’s a direct cause-effect sequence from the addict’s motives to the treatment system — no “higher power” needed, thank you, and that includes doctors. Of course she’s doing it within “the system”, and that’s terrific. But the system is adapting to her, readjusting itself to fit her needs and initiatives, not the other way around.

      Phew, I’ve just written another post without meaning to. Oh well, there’s lots to think about here. And again, everyone, “common people” breaks down to individuals with hearts and minds, with wishes and intentions. That’s where the fundamental power to change resides.

      • alison July 13, 2019 at 5:08 pm #

        thanks marc, tons of good thoughts you have.
        AND the paperwork process is insane in America…i see why your brother gets fed up. Something has to be reversed w that….it’s hindering treatment…

        Now intakes are 3 hours at substance abuse “clinics”, and not because people are talking about their individual struggles. No time for that. The intake consists of standard questions that people must answer, with a scripted response of either ” doesnt apply, a little, sometimes, often, always”.
        I went to an outpatient intake to support my client and I was ready to jump out of my chair! I have ADD as well…..
        And they had to return the following week for a 2nd “shorter” intake to “get assigned their treatment recommendation”.

  7. Terry John McGrath July 4, 2019 at 6:45 pm #

    Marc – there is apprehension for all who work in drug and alcohol who do not fit the old mold and want to change course by “coming out” about how much harm is being done to drug users by society and by even those charged with supporting them – i feel it working in the Australian rehab industry. As an advocate of drug law reform, even legalization, i am putting myself at risk in order to be honest about the failings of the sector but also because my clients do not have a voice. Even though other groups have been better accepted in today’s society the stigma and discrimination and ‘abuse’ heaped on drug users is too much for this nurse to sit by and bear without at least trying to stand up and say – give them a fair go. But if i feel i am too weak on a particular day and need to hold my powder dry that’s OK too because i can’t help if i just walk away or succumb to the ignorant who still at present hold the power. keep up your good work

    • Alison July 9, 2019 at 11:07 pm #

      Terry well said … I feel your fear for I face that daily….

      • Terry John McGrath July 9, 2019 at 11:13 pm #

        thanx Alison – feel the fear and do it anyway – there’s a part of me that realizes that ‘recovery (I prefer ‘change”); is all about turning anxiety into motivation and enthusiasm – manipulating the fear within for good rather than self destruction – as well as fear though for me is anger at systems that treat some humans so badly because of what they do to manage their fears which are too often borne from trauma or disconnection

        • alison July 13, 2019 at 4:19 pm #

          i wrote that quote down, feel the fear and do it anyway, thanks!

          • Terry John McGrath July 14, 2019 at 6:23 pm #

            i can’t claim it as my own – ‘;m sure i heard it somewhere else years ago – what it does mean for em though is that the energy that is fear can be used as excitement and motivation if one learns to channel it in the right direction – its a fine line though, cheers Alison

    • Marc July 10, 2019 at 11:30 am #

      Keep up your good work too, Terry! We can’t be strong every day. In fact, living by one’s own principles….it sounds so tawdry and old-fashioned, but it’s damn difficult. Your mention of the risk for addiction workers, extending themselves to their clients, twigged my memory of a recent article. Take a look: https://filtermag.org/2019/07/03/nurse-gave-medication-mat-deprived-patients-convicted/ Granted this is a different situation, and an extreme one at that. But the commonality is a deeply held empathy for one’s drug-using client. I am so heartened to hear that some of you addiction workers — I think many of you in fact — maintain this empathic connection despite steady erosion at the hands of a system that is mostly about making money.

      Many people ask me why addicts are so much more willing to talk openly, without restraint, to counsellors who have also been through addiction. In my mind, these accounts (yours and hers for example) hit that nail on the head.

      • Terry John McGrath July 10, 2019 at 6:37 pm #

        thank you Marc – your comments encourage me to keep going – as does the knowledge that many workers in this sector see right through the b … and hypocrisy of a society that is drugged legally anyway and is so full of addiction it ain’t funny to those that know the truth

  8. Daniel July 5, 2019 at 3:34 pm #

    To Marc and all of the dialogue contributors – thank you so much.
    Keeping the conversation flowing helps and encourages the little people,
    the addict, like myself to keep on track to a better future.

    • Janet July 5, 2019 at 5:06 pm #


      You are the hero.

      You are not invisible. You are not small.


    • Marc July 10, 2019 at 11:33 am #

      Good to hear, Daniel! That’s pretty much my main goal nowadays.

  9. Larissa Goruk July 7, 2019 at 8:32 pm #

    Thank you everyone for your comments. It’s important to realize that physicians don’t know everything, they’re only human despite all their education, they’re just as subject to bias as anyone else, and that clients have vital knowledge on what will really help them.

    A big thank you, Marc, for doing this work and hosting this site!

    • Marc July 10, 2019 at 11:20 am #

      You’re welcome, Larissa. And please see my long (!) comment above which specifically addresses the human-ness you speak of and the role of the patient in educating and guiding the physician.

      • Larissa Goruk July 11, 2019 at 1:48 pm #

        Yes your encounter with the “establishment” physicians must have been difficult to manage, because you are truth seeking in this situation, but they (unknowingly) have concerns about keeping in good standing within their profession and that kind of thing, which warps their judgment.

        It’s good to read everyone’s comments. Top down education or rehabilitation isn’t the best way for therapy. The clients have to be partners in the process.

  10. CM July 10, 2019 at 3:44 am #

    What I wonder is why is there such an obsession with finding a unified theory and model of addiction?

    If it’s not a


    Lack of morality

    Weak will

    Childhood trauma being self medicated

    Gratuitous pleasure seeking without boundary

    Class revolt

    Mental illness



    Just normal in context

    A problem

    Not a problem

    Incentive salience sensitisation

    Just the repertoire of normal human behaviour

    Neurological or Neurochemical makes alignment or conditioning and adaptation

    Existential and societal crisis

    A failed attempt at self repair

    Lack of connection, purpose and meaning

    Manufactured phenomenon

    Implicit cognitive biases and processes

    Anything else

    If not this then what is it and who can adequately and clearly explain this very complicated picture without using mystifying terminology and confabulated nonsense?


    • Larissa Goruk July 11, 2019 at 1:42 pm #

      Thanks for this poem

  11. Carlton July 12, 2019 at 7:10 am #

    It is Love. The impetus behind Love and Addiction are one and the same.

    But who can explain this very complicated picture remains to be be seen, but as a former addict, when the feelings changed, everything changed…as it does with Love.

    This list you made can apply to Love too.

  12. Dor July 15, 2019 at 3:12 pm #

    It’s very probable that “Sally” would have sold her suboxone for drugs. And methadone was probably very low cost already. Not sure you could have saved her from her horrible life.

  13. Selena Valentine November 15, 2019 at 2:16 am #

    Most people need drugs for one issue or another. I am for natural herbs as a treatment but drugs are often stronger.

    Addicted To painkillers: Opioid Use Disorder And Treatment

  14. David Owen January 18, 2020 at 12:44 pm #

    I have come around to your way of thinking of addiction and the disease model. I call myself a member of AA but only the desire to not drink variety. I have also had numerous back surgeries and deal with chronic pain daily. About 2 years ago I decided to try cannabis products to supplement or replace opiates. My daily use of opiates was manageable but as a result of long term use I found that whenever I took my bedtime dose, I developed insomnia which continued for many years. Upon using a controlled dose of thc/cbd I got immediate relief from the insomnia and was able to get enough pain relief (although not total relief) to justify my continued use. I have no plans of stopping anytime soon as it works so much better than just opiates. I have also reduced stress levels and lost 50 pounds. I’m not sure if this is at all related but I have not felt this well in quite some time. We are about the same age and cannabis was my first drug but I haven’t used it on a regular basis since my mid twenties. My question, am I on the right track?

    • Marc January 19, 2020 at 8:47 am #

      Hi David. You certainly are on the right track, by the sound of it. You’ve found a substance (or combination of substances?) that helps you with pain, with sleep, with being in charge of your own body. If you are wondering about whether this is “right” or not, perhaps you’re hearing old echoes from AA (which might, just might, connect with your insomnia — the “being good” litany that so easily slips into rumination). AA, at least in its traditional mode, assumes that all mood-enhancing substances/drugs are intrinsically bad. That strikes me as a sort of “anti-modern”…though it can be a handy ideological stance for people with serious addictions. It was inevitable that our societal and technological evolution would lead to aids, scaffolding, enhancements…in our approach to “inner states” as well as “outer” states (like staying warm in the cold, crossing the Atlantic). See our recent blogposts (and comments) on 12-step approaches vs. alternatives.

      The only problem I ever had with cannabis was cognitive blurriness and a bit of social anxiety. And yes, cannabis can be addictive. But for most people, these are not big problems, so once again, a simple cost-benefit analysis is all that’s needed, person by person by person.

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