HOW TO GET HELP: THE FIRST STEPS OF RECOVERY
Recovery starts with a decision—one worth validating. To help people understand with addiction problems and how to motivate them, researchers Carlo C. DiClemente and J. O. Prochaska introduced a six-stage model of change: precontemplation, contemplation, determination, action, maintenance, and termination or potential relapse. When a person gets to the point where he finally realizes it is time to stop—the determination stage—he has made huge progress, even if he falls back into an earlier stage. Heroin recovery is frequently a messy process that rarely results in the user getting clean forever the first time he is motivated to stop. However, with some support and encouragement it is possible to make the trajectory to long-lasting recovery a smoother one.
Breaking free from heroin is complicated at first, beginning with the painful three- to five-day withdrawal process. Many times I have heard loved ones ask, “Why don’t they just stop?” This is easier said than done. Imagine figuring out how to schedule yourself for the flu. How can you take the time off work? Who will take care of your children? Who will help you when/if you are unable to care for yourself? Where is a safe place for this to happen, with twenty-four-hour access to both a bathroom and a shower? What are the things you need to alleviate your suffering? Can you afford these things having spent all your money or at least all of your disposable income on heroin? The tasks that need to be completed just to begin a journey to recovery can seem overwhelming.
Formulating a plan is the best way to be successful. Gather your tools and your support. There are some over-the-counter remedies such as loperamide and diphenhydramine that may help if a person has no insurance or plans to “kick” at home. For a person with access to medical care, a doctor may prescribe anything from gabapentin to a limited script of a benzodiazepine for sleep. You may also be referred to a substance abuse specialist since your practitioner may not have the legal ability to prescribe any kind of opioid replacement medication.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has created tools that anyone seeking a program can access. The first one is a general treatment locator on SAMHSA’s website at https://findtreatment.samhsa.gov, where you can find program information as well as phone numbers and addresses. SAMHSA also provides a comprehensive list of those providers who offer medication-assisted treatment (MAT) for substance abuse disorders at http://dpt2.samhsa.gov/treatment/directory.aspx.
If you or your loved one has some form of private insurance, call your plan administrator to see what your plan covers. Some people are completely unaware that their insurance covers MAT interventions such as buprenorphine until they call. Most plans have a preferred or required set of providers. This may require waiting for an opening, which can be extremely frustrating when a heroin user is motivated to receive treatment now.
With public insurance like Medicare or Medicaid, a person seeking treatment may need to contact individual sites to see what forms of insurance are accepted. With the passing of the Affordable Care Act, otherwise known as Obamacare, access to services was expanded. Unfortunately, many individual states took a pass on expanding Medicaid, leaving hundreds of thousands of Americans with limited resources still without coverage.
If a user is without any kind of insurance, there are some low-cost and no-cost options scattered across communities. Some residential treatment programs have scholarship programs. Most opioid replacement therapy clinics have private pay options for as low as $15 a day. This may seem high, but it’s low in comparison to the $50 or $100 a day that’s required to support a heroin habit. There are free support groups such as SMART Recovery (http://SMARTRecovery.org), LifeRing Secular Recovery (http://lifering.org), and 12step.org. Users may also find support through their local churches.
The news is not all dire. In fact, there is some very good news. Gene Heyman (http://geneheyman.com/books.htm), a research psychologist at McLean Hospital in Massachusetts, found that between 60 and 80 percent of people who were addicted to illicit drugs in their younger years were free by their thirties. In fact, most people who quit drugs do it on their own. I like to use the expression “five days to freedom.” If you can dedicate five days to kicking, that is the first step to rebuilding your life. I kicked heroin cold turkey—completely unmedicated—in jail. I survived the worst-case scenario for detox. Then I stayed clean. The most important thing is finding someone to talk with, creating a plan, and believing you can stop using heroin. The research proves it.
THE MOST DANGEROUS TIME
When I started my process of recovery, I couldn’t imagine that I would never use drugs again. If this had been suggested to me out loud, I might have laughed at the idea. Not because I didn’t want this for myself. I simply did not feel I was capable of such a task. After getting out of jail many times before, I had started using again within a few hours. Fortunately, that last time I was transported directly to rehab, with no chance of finding my old friends in between. As I completed my rehab stay, I was surprised by just how many people I knew who had left rehab only to overdose and die. It wasn’t just those who “split” or left the program before their time was completed. Over and over, it was a sad refrain. I constantly wondered, Why is this happening? When I got involved in harm reduction in 1999, I started to get answers.
Statistically, the most dangerous time for heroin users is after periods of abstinence. This includes incarceration, trips to rehab, extended hospital stays, and voluntary attempts to curb use. After periods of not using drugs, the body experiences a drop in tolerance. The same amount that a user was ingesting a few days, weeks, or months earlier is now potentially fatal. Compounding the risk is the fact that users may be too ashamed to admit to cravings when there is an expectation of sobriety. They may be using alone or in a location where they are less likely to receive any assistance if they overdose. While saying “Just don’t use” is good in theory, falling short can be fatal. Instead, users need to be educated on their risk of overdose, as well as provided with naloxone.
What is naloxone (also known as Narcan)? The Harm Reduction Coalition describes it as an “opioid antagonist;” that is, it’s used to counter the effects of an opioid. Specifically, during an opioid overdose naloxone can be used to counteract life-threatening depression of the central nervous system and respiratory system, allowing the victim to breathe normally. Naloxone is a non-scheduled (or non-addictive) prescription medication. It only works if a person has opioids in her system.
Naloxone is an important tool in preventing overdose deaths, but it is not just for medical providers. It’s being used every day by so-called laypersons or non-medical individuals trained to administer the drug to friends, loved ones, or even strangers in the event of an opioid overdose. In a report titled “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons—United States, 2014” (Davidson, et al.), published in June 2015 by the Centers for Disease Control and Prevention (CDC), the authors reported:
Providing naloxone kits to laypersons reduces overdose deaths, is safe, and is cost-effective. U.S. and international health organizations recommend providing naloxone kits to laypersons who might witness an opioid overdose, to patients in substance use treatment programs, to persons leaving prison and jail, and as a component of responsible opioid prescribing.
The report also shows that since the first harm reduction program began distributing naloxone to drug users and their friends and families in 1996, more than 150,000 people have been trained and provided with naloxone, which has resulted in over 26,000 overdose reversals nationally. Most of the people who use their naloxone to revive someone are drug users themselves—the people most likely to witness another person’s overdose.
This may seem confusing. Why should I have naloxone when I plan on staying clean? Why should I get naloxone for my loved one when he is doing so well? Isn’t naloxone simply encouraging him to return to heroin use by providing him with a safety net? Naloxone is critical—again, a person canno
t get clean if he is dead. If we fully understand that there’s the slightest possibility that relapse will be part of an individual’s journey, then we should certainly be prepared for the very worst. In 2013, over 8,000 people died of heroin overdoses in the U.S. One of the biggest contributing factors is release from incarceration or treatment. Parents who have lost a loved one to overdose are slowly becoming the most vocal advocates in changing the laws that limit the distribution of naloxone.
RECOVERY ESSENTIAL: WHAT IS MAT?
While twelve-step lingo has become a staple of the lexicon in the United States, MAT, or medication-assisted treatment, is much less familiar. Yet MAT is an important part of any discussion about the treatment of heroin users. According to SAMHSA, MAT “is the use of medications in combination with counseling and behavioral therapies to provide a ‘whole-patient’ approach to the treatment of substance use disorders.” MAT starts with the principle that medication can be a great tool to assist patients in reaching their recovery goals. In the case of heroin, continued use can come with considerable risks, including conditions like soft tissue infections known as abscesses; infection of the lining of the heart, known as endocarditis; hepatitis C; HIV; and overdose. Starting MAT can provide a bridge back to a healthy life.
Two of the most common forms of MAT are methadone and buprenorphine. These long-lasting opioid replacement medications are taken orally on a daily basis to ease withdrawal symptoms, reduce or eliminate cravings, block the impact of shorter-acting opioids like heroin, and create a routine of normalcy without procuring and ingesting illicit substances on a daily basis. By filling up the opiate receptors of the brain, the patient no longer experiences the ups and downs of addiction. Some opiate replacement patients report that these medications have the additional benefit of acting as mild antidepressants. On a therapeutic dose, the patient feels “normal.” At a higher dose, opioid replacement medications also make it hard to “feel” shorter-acting opioids—again, like heroin.
After stabilizing on their dose of methadone or buprenorphine, the vast majority of users discontinue use of other opioids. Some users even find that MAT relieves their physical cravings from day one. I have heard patients describe this feeling as being like a miracle. This is not to say that these drugs are not without unpleasant side effects. With opioid replacement medications, there can be an elongated withdrawal process if the person is not tapered off the medication. There can be sedation, constipation, and excessive sweating. However, at a therapeutic dose and with close monitoring, an MAT patient can resume the activities of daily living.
Another form of MAT is oral or injected naltrexone. Unlike buprenorphine and methadone, which partially or fully fill the opiate receptor site, naltrexone blocks the effects of drugs such as opioids and alcohol. In other words, it takes the rewards out of using these drugs. Vivitrol is a time-release, injectable form of naltrexone that can last up to twenty-eight days. “The shot,” as it is called, has become popular with criminal justice programs and parents who are concerned about what will happen when a heroin user reenters the community after jail and rehab. Of course, “the shot” is not without its own set of drawbacks. The main one is a high risk of overdose death after the shot reaches the end of the cycle. Others include issues with depression, being unable to taste food, and infections at the injection site.
I had positive experiences with MAT in my early attempts to quit heroin. While I did not stay off, it was no fault of the methadone. It was more an indication of my lack of support and the negative experiences I had that were related to the clinic environment. Because opiate use holds so much stigma, MAT sites are frequently located in undesirable areas or on the outskirts of the city. In addition, my MAT did not include the intensive counseling I would later receive in residential treatment. The rules around receiving MAT vary from location to location. Some programs that provide MAT for receiving the medication, while others may only require drug testing. Anyone considering MAT should first look into the specific requirements of the program.
Despite being evidenced based, MAT is not without its controversy. Some recovery communities consider MAT a “crutch.” There is special value placed on those who can do it on their own. Twelve-step, in particular, is built around the concept of “abstinence from all drugs.” What if these drugs are lifesaving medications? For those who use MAT, they are often told they are still in active addiction. Twelve-step literature clearly states, “The only requirement for membership is a desire to stop using,” yet those on MAT may feel like outsiders. They may even be encouraged to lower or stop their doses, discontinue their treatment, or even be forbidden to share or speak at meetings.
Recovery can be a long process with or without MAT. Anyone who is seeking treatment for heroin addiction should consider all the options. I made up my mind that I would try rehab. If that didn’t work, I was going to go back on methadone. I had thought that even if I spent my life on methadone, it would certainly be better than sticking syringes in the soles of my feet. MAT, while not for everyone, should certainly be a consideration for those struggling to stay off heroin.
GENDER DIFFERENCES
When I am asked what the biggest barriers were early in my sobriety, I say being female is near the top of my list. In early recovery, it seemed as if everything was designed without any thought of the particulars of a woman’s specific issues. I had questions, many questions, about everything from the return of my period to how a person comes to terms with having engaged in “survival sex”—trading sex for drugs. In addition, many women I knew in treatment were dealing with the loss of their children to “the system.” Gender differences between men and women with substance abuse issues have been well researched in the past twenty years. Unfortunately, the treatment system has been slow to respond.
In a report prepared for clinical psychiatrists in 1999, Kathleen Brady and Carrie L. Randall outlined many of the factors that impact women and girls who use substances. They found that women typically begin using substances later in life than men, and are strongly influenced by spouses or boyfriends to use. This was true in my case: I was encouraged to use heroin for the first time by a male friend who was a seasoned user. The research found women and girls report different reasons for maintaining substance use. Many women, as I did, use drugs as a form of self-medication for conditions such as depression and anxiety. Dr. Brady and Dr. Randall also discovered that women tend to enter treatment sooner than men do. I was happy to be part of that statistic. At twenty-eight years old, I was one of the youngest clients out of nearly one hundred people in residential treatment. This made it challenging to find a peer group I could bond with until I was able to expand my support system outside of the treatment environment.
There is also significant stigma attached to being a woman with a drug problem. Women are seen as mothers and caregivers, capable of carrying a greater burden in society. When a woman acknowledges that she needs assistance, she is not measuring up to the impossible standards of femininity frequently portrayed in the media. It’s seen as some kind of failure on her part. One can wonder whether, in response to these stressors in recent years, women have developed an increasing share of the epidemic of prescription opiate use. Since they are given in a medical setting, these highly abusable medications are often seen as an acceptable alternative to street drugs. As a direct result, overdose death rates among females are quickly rising.
For women who do decide they’re ready to seek help, there may be barriers to finding care that is responsive to their unique needs. With nearly twice as many men using substances, there is frequently disparity in resources. In the treatment facility I attended, there were four male beds for every one female bed. In my experience, the program was based almost entirely on the medical model, a cookie-cutter approach that is still prevalent and manifests as a top-down approach in which addiction is discussed in terms of a “disease.” This can be problematic for women whose substance abuse is a response to domestic violence, sexual abuse, or ch
ildhood trauma. Not only do the women feel diseased or broken, they may also find it impossible to trust staff members who hold positions of authority over them, without understanding their history of trauma.
In a 2009 report, “Substance Abuse Treatment: Addressing the Specific Needs of Women” (http://www.ncbi.nlm.nih.gov/books/NBK83252/), the Center for Substance Abuse Treatment (CSAT) recommends that “programs should ensure that all counseling activities are conducted in a respectful and caring manner and should not use counseling approaches that are contraindicated for trauma survivors.” This type of treatment may be difficult to find in a sea of twenty-eight-day “spin dry” rehabs. I have seen women come to me in tears after being confronted in counseling sessions. I have been told of group activities that led to women being publicly shamed by their peers. In my treatment center, we were told the center was a “house,” yet the “brothers” were frequently sexually aggressive. Trauma survivors may have a tough time building their self-esteem when they are being consistently triggered by predatory behavior from their fellow male residents.
For those who are lucky enough to find responsive care, the next barrier for women comes when they are attempting to get on their feet financially. Women need jobs as part of their rehabilitation process in order to achieve lasting recovery. The CSAT found evidence that “gainful employment can be a protective influence for preventing relapse,” especially because they often have dependent children or other family members to support. In my rehab experience, men quickly found higher-paying jobs in the construction trades or information technology, whereas women were mostly only able to find jobs in the lower-paying retail or food service industries. Women need more job training, and they also need treatment that allows them to care for their children.
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