While “trauma-informed care” and treatment that is gender responsive are becoming more popular, we have a long way to go. Many of the recommendations presented decades ago are still not fully realized in our treatment system. Breaking away from “one size fits all” and into an approach that supports the needs of individuals is the next great step in achieving parity for women in need of substance abuse intervention.
INJURY AND ILLNESS
Getting off heroin is scary. The last thing a person wants to worry about is an illness or injury sabotaging her hard work. One of the most common areas of concern I hear after a person has stopped using heroin for a period of time is the use of pain medication. What will happen to me if I need to get a tooth pulled? If I need surgery? If I am in an accident? Will this derail what I have built? It is a rational fear. Getting free of heroin may have been the hardest challenge the person ever faced. The detox, the depression, and the stigma are all brutal. Finally you feel as if you are on the right path. Once you feel confident enough to learn the needle won’t randomly slip into your arm or the straw accidentally go up your nose, it may be frightening to think that someday opioids may enter your body again. Medical issues are particularly scary because it feels as if you have limited choices.
Once you reach the other side, where you finally feel somewhat normal and perhaps even content without heroin, having a plan for potential traps is critical. You have to be your best advocate. If you are supporting a loved one, you may have to speak up for them. When I was a heroin user, I took the drugs orally, I snorted them, and I injected them without question. I put all my faith into the idea that whatever was in that plastic bag was going to make me feel better, even though that complete faith nearly killed me many times. The same blind faith can be applied to receiving medical treatment. Doctors seem like the ultimate authorities. But it is your body, your recovery. It is entirely okay to question whether a procedure or medication is necessary. That doesn’t make you a problem patient—it makes you an educated one. It makes you a person capable of making informed choices.
In a medical crisis, pain medicine may be necessary. The issue comes when we once again notice the shift in tolerance and our mood as related to the intake of these medications. Any doctor who prescribes these medications knows they can treat your pain. But he may not be fully aware of the fact that you have a history of using opioids. That distinction can be challenging to vocalize. Users fear that if they tell their health care provider of their history of addiction, they will experience discrimination and will be given less than what is necessary for pain management. On the other hand, in a case like mine where the doctor did not check my addiction history, the patient can be handed an excess of medication that creates the potential for refueling addictive tendencies.
I have been prescribed pain medication numerous times in my recovery. The first time was for my miscarriage. I received pain medicines with all three of my C-sections. The last time was for an abscessed tooth. While I experienced discomfort with the process of getting off these opioids, there was never a moment when I thought to myself: This makes me want to get heroin. I was well supported, well prepared, and honest with both my doctor and myself. There is also growing research that shows alternating ibuprofen and acetaminophen in the three days after surgery can be more effective than opioids in reducing the pain of many procedures. I found this to be true with my last surgery. I had assumed a person who had ingested two grams a day of heroin would get no help from over-the-counter medications. I was pleasantly surprised that this is not the case.
If you need medication, by all means take it. Be aware of how you can recognize any cravings, irritability, or withdrawal symptoms. Make a plan for managing your medication without abusing it. I asked myself every time I took the medicine: Do I need this? How am I feeling? How is my pain? If I feel uncomfortable, can I check in with someone to let her know I am taking this medicine? Know yourself, know your body, and ask questions. Be your own advocate. Only you know what you need. Communicate this to your providers.
THE PAST SHOULDN’T DICTATE MY FUTURE
I used to use heroin. I used to use heroin every day. I used to inject heroin. I used to inject it into my feet, my legs, my fingers. I lost everything—no, I gave up everything for heroin. These things are so easy for me to say now. I can type them. I can email you about them. I can show you pictures. I can even forget about them for a little while. I can go most of the day, part of a week, or a long string of moments without remembering I was once a hardcore heroin user.
Something always brings me back to that place. I am not just Tracey. I remember that I am Tracey, who used to use heroin. I might be reaching for the phone at work: I glance down. I notice the scar on my forearm. I might be on the train: I see someone nodding off in the corner. I might wake up in the morning with swollen hands, as when I used to inject drugs into my fingers. I walk past the police: I remember those times when I needed to avert my glance. I see sugar or dried creamer or even salt spilled on the counter: I slowly laugh at myself. I am different from others, I tell myself. Heroin use has subtly, irrevocably altered my worldview.
There comes a point when every former user must decide how much to disclose about herself. Should I tell people? Whom do I tell? What would happen if I did tell them? Will they reject me? Will they hold it against me for a lifetime? Will I always be that woman/man who used to do heroin? There are no easy answers. Some people feel that the first step in receiving help is admitting to others that they use heroin. This can be done anonymously in an Internet forum. It can be to a service provider. It can be to a close friend, relative, or even an acquaintance. Heroin, of all drugs, holds so much stigma. This admission can hold serious repercussions. I receive anonymous messages where people disclose, “I am worried about losing my family.” Or it could be a job, or housing, or their children. The admission holds so much power. It can be important to admit that you need help. But be aware that everyone you tell may not be forgiving.
After periods of abstinence, the question then arises: Should I tell people I am an addict? I just met this man/woman or I just applied for this job or I just decided to reconnect with my family. I can only suggest things that worked for me, like creating a checklist for yourself. What are my reasons for telling this person? Is there a medical reason I need to tell him, like having hepatitis C or HIV and planning to be intimate? Are you planning to rely on this person for support? How vulnerable are you? Would you be able to handle rejection?
We don’t need to lie or mislead. We also don’t need to immediately volunteer information. Imagine a job interview that started with “Hi, I am John. I used to be a heroin addict. Please trust me.” Or, on a date, when you discuss your history of abscesses over appetizers. Perhaps the family reunion can print up some T-shirts that announce, JOHN JUST GOT BACK FROM REHAB. In other words, a user needs to be in charge of his or her own history. Just as with any other medical information, use some discretion. Not because you should be ashamed. Quite the contrary. You should be wary of telling others because what you have accomplished is precious. It is something that may not be understood by everyone. Once that information is out there, you have no control over the outcome. Just be prepared for any outcome, both negative and positive.
After years of being off heroin, you may find you no longer identify with the term “addict,” “user,” or “junkie.” That is perfectly acceptable. The past should not dictate the future. Just be aware that some people find a power in connection. They enjoy using a common vernacular to explain their experience. Some days I use “recovering addict.” Other days I call myself a junkie. Most days I call myself a mother, a wife, and a friend. These things are not all mutually exclusive. They make me proud of who I am today.
THE BURDENS OF THE PAST
There was one night in the mid-90s when I was fumbling through my belongings in my shopping cart underneath the streetlight in the alley where I was essentially living at the time. As I folded one of my dirty sh
irts, I thought to myself, I am going to go back to school one day. This would seem completely incongruent with my circumstances at that time. Where would I even start? I didn’t know where my life would take me. I only knew where I wanted to go. My goals were a spark for my recovery. The loss of hope keeps people stuck doing the same things, getting the same results. Developing a goal was one of the things I did early on that took the needle out of my arm.
Unfortunately for me, I was a convicted felon. My felony conviction: “sales/transport of a controlled substance.” My whole future was sidelined by a $20 bag of drugs. Initially, as a convicted felon on probation I had no civil rights. I had no right to vote. The police had the right to search my home, my vehicle, or my person at any time without probable cause. I could be denied everything from federal financial aid for college to public assistance to the ability to live in any type of Section 8 low-income housing. These are all serious blows to a person coming out of jail with no money, no place to live, and the vast majority of employers unwilling to take a chance on employing her.
For the ex-offender, the road to recovery can be an uphill battle, but it is well worth the journey. The alternative is often a revolving door of incarceration and extended relapse.
Many ex-offenders may be unaware that once they complete some type of rehabilitation program, they may again become eligible to utilize public services. In my case, I was able to enter college through an ex-offender program called Project Rebound. They wrote a letter to the school to negotiate my admissions despite my low GPA. Many such programs exist around the country, some occupying spaces in student resource centers.
There are also job reentry services designed to help those in recovery find employment if they have criminal records. Finding a job is especially critical, because having meaningful activity in daily life is an integral part of recovery. Yet the National Institute of Justice found that a criminal record reduced the likelihood of a job offer or even a callback by nearly 50 percent. Job reentry programs can help with important things like securing identification, writing a resumé, obtaining clothes for an interview, and getting substance abuse counseling, housing referrals, and job leads. I applied for my first job in recovery by tapping into a program that actively solicited companies willing to hire ex-offenders for job openings. With the help of job coaching I received through the program, I was confident enough to explain my felony in the interview. I got that job, which led to an even better job as a counselor. Small steps on my part ended up leading to huge gains.
Ex-offenders with drug problems may find additional pressures when they return to the community. When I was released from treatment, I had to decide whether I was strong enough to move back to my old “stomping grounds.” In reality, that area was the only place I could afford. It was one block from where I used to buy my drugs. Drugs and violence were constant reminders outside my door. I wasn’t the only one. There was another halfway house for parolees located two blocks from me. To visit my probation officer, I had to walk through the open-air drug market; the only other option would have required traveling thirty minutes out of my way. These were tough situations to manage for someone with very little recovery under her belt. Similar triggers can occur if the person in recovery moves in with family. Using buddies and dealers can still be just around the corner. Experiencing the additional stress of feeling trapped is not uncommon when drug testing is a condition of probation or parole, even though the person is living on the outside.
WILL I EVER USE AGAIN?
There is no question that there is hope for those trying to stop heroin. Every day across the United States, users gather their courage, as well as their over-the-counter remedies. They call detox centers. They find out their prayers are answered: A bed has become available. They pack their bag for rehab facilities. They drive miles from their home in the dark to be the first one in line for their appointment at the methadone clinic. They walk slowly, scared and ashamed, next to their mother or father into a doctor’s office. Their hopes are high, their expectations are low. They have become desperate after months of sleepless nights wondering if this day would ever come. The time for action is now. Recovery, in whatever form it takes, begins with a step into the unknown. What comes next is chaotic at first. It is painful. It is beautiful. It is living, not existing. It is perfect in all its imperfections. Life falls into a rhythm, until one day heroin is no longer the first thing you crave. It will be the last thing you want to remember.
Through my personal life, in my work, and in my advocacy I have seen the most hopeless of users get off heroin. I have also seen them stay off. There isn’t a week that goes by when I don’t get a message saying, “Remember me?” followed by a few lines about their story. It’s been estimated that over four million people have tried heroin. Yet the vast majority of these people are not using today. Whether they “aged out,” used MAT, found religion, tried meetings, went to rehab, or simply stopped on their own, the numbers don’t lie. There is more than just hope that a person can quit: There is evidence. Like the users who never touched heroin after returning to the U.S. from Vietnam, even a change in environment can lead to a life free of heroin.
Will I ever use again? The research is certainly on my side. A study published in 2007 by M.L. Dennis, M.A. Foss, and C.K. Scott with eight years of data from more than 1,100 users found that for those who achieve a year of sobriety, fewer than half relapse. If you can make it to five years of sobriety, your chance of relapse is less than 15 percent. After many years of stable abstinence, there are those who will choose to return to social drinking. Others might choose to use cannabis. That isn’t my particular path. While I don’t believe that ingesting these substances automatically opens the door to a return to heroin or other drugs, it isn’t the path for me. When I think of drinking, I ask myself, Will this enhance my life in some way? The answer is always no.
To maintain a life free of heroin, I customized a familiar list of recommendations. The first thing I did was develop a strong system of social support. This included my family, my groups, and friends who were clean and sober. The second factor was obtaining stable affordable housing. The third factor was finding employment that was flexible enough to maintain my schedule of supportive activities. The fourth was finding productive activities I loved, including school and volunteer work. The final and critical element was gaining some insight into the reasons I started using drugs, so I could find new ways of coping. This came in the form of journaling, guided recovery worksheets, and individual sessions with a therapist. While replacement meds and antidepressants were not part of my individual story, they may also be a necessary tool. Although every person kicking the habit may not be able to do everything on this list, research shows that each of these things can increase your chances of success.
Will I ever use again? I say the answer is no. I work every day to make the distance a little farther between the needle and myself.
REFERENCES
Davidson, Peter J., Michael K. Gilbert, Stephen Jones and Eliza Wheeler. “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons—United States, 2014.” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly. June 2015. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm
Including:
a. Doyon, S., S.E. Aks, and S. Schaeffer. “Expanding Access to Naloxone in the United States.” Clin Toxicol (Phila) 52 (2014): 989–92.
b. Walley, A., Z. Xuan, H.H. Hackman, et al.
“Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: Interrupted Time Series Analysis.” BMJ 346 (2013): 1–12.
c. World Health Organization. “Community Management of Opioid Overdose.” Geneva, Switzerland: World Health Organization, 2014.
d. Coffin, P.O. and S.D. Sullivan. “Cost-effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Ann Intern Med 158 (2013): 1–9.
e. Substance Abuse and Mental Health Services Admini
stration. “Opioid Overdose Prevention Toolkit.” Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. Available at http://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit-Updated-2014/SMA14-4742.
Substance Abuse and Mental Health Services Administration. “Medication and Counseling Treatment,” September 2015. http://www.samhsa.gov/medication-assisted-treatment/treatment.
Brady, Kathleen T.; Randall, Carrie L., Psychiatric Clinics of North America, Volume 22, Issue 2. “Gender Differences in Substance Use Disorders,” June 1999.
Dennis, Michael L., Foss, Mark A., Grella, Christine E., Scott, Christy K. 2007 UCLA Integrated Substance Abuse Programs, “Gender Similarities and Differences in the Treatment, Relapse, and Recovery Cycle,” February 2008.
ACKNOWLEDGMENTS
There are many people I want to thank for helping to make this book possible. Thanks to my family for supporting me, especially my husband Christian and our three children. I want to thank: Debi Alley, Jason Norelli, Paul Dertien, Jen P. Bixler, the Sept 2007 moms, The She Wolves, Ron, my writing group including Teddie Honey and Justin Tyler Hughes, Ali Onder, Guilherme Borges da Costa, my workplace support system, my Reddit friends, Dr. Don Teater, Eliza Wheele, and the people, both alive and dead, who believed in me when I couldn’t believe in myself.
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