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Case Studies
Case Studies:
Experience has shown us that often the best way to serve the suffering dependent patient is by education and example. For this reason Recovery Advocates felt certain that illustrations of common addiction models in the form of actual case studies would be helpful to individuals uncertain about their predicament or the struggle of loved ones.
The case studies presented here are composites and reflect no one patient in particular. Any similarity to any of our patients is purely coincidental.
Case Study I: The Cheerleader
The first patient that we would like to discuss is a 29-year-old cheerleader. She was a cheerleader in high school and in college, and cheered later for a professional team. Her cheerleading regime had become very acrobatic and she was doing multiple jumps, had falls from twenty feet in the air on her back, and multiple injuries doing flips on the ground, which is common with athletes. She had damaged vertebra, had hurt the lumbar region of her back which created a chronic pain situation. So beginning in her early twenties she started taking opiates.
It started with Percocet but because of the high amount of Tylenol in Percocet she went to Vicodin, and then eventually wound up on OxyContin. She came to Recovery Advocates because she was planning on getting married; she was teaching now, and coached cheerleading. She wanted to get married and wanted to have kids but she didn’t want to start her marriage addicted to opiates.
She had been taking about 200 to 240 mg of OxyContin a day. We asked her, “what brought you here today?” She said, “‘I’ve got to get off these pills. The pills are ruining my life. My husband is a high profile professional and doesn’t like me taking these pills. I get drowsy. I tend to isolate more and I’ve put on weight.” Her weight was one of her biggest issues with the use of the OxyContin pills. She was taking 3/80 mg a day. Our doctor asked her, “Where is the pain?” She replied, sheepishly, “The pain, Doctor, is in my lower back. I have ruptured discs. I think it is L4-L5, L5-S1.” This kind of injury is common and we hear it a lot.
“There are other ways to treat that pain. We can work around this and we can use a non-opiate solution to treat your pain, but what you have to remember is in the chronic pain patient, which you have become, if you pull the opiates away you have been numbed for so long by these opiates that any experience of pain is interpreted by the brain in an exaggerated way.” If you have someone on opiates for a long period of time and you stop the opiates every sensation is exaggerated. Their entire sense of pain is blown out of proportion.
“You have to expect this,” our doctor continued, trying to soften the blow, “don’t make judgments that the pain you are experiencing as we take you off the opiates is the pain you are going to experience for a lifetime. It will last one month, maybe two.” So what we must do is put you into withdrawal from the opiates. You will completely stop using them. Sixteen to eighteen hours later you will start to take Buprenorphine, which is known by the brand name Subutex, and we will begin to taper you down.”
Our doctor examined her a week later and she said that it was rough at first but that she felt more active, more awake, more energized, however her lower back was still hurting her. It was, as predicted; the patient was experiencing greater pain because of the brain’s response to the sudden lack of opiates and its natural response to any stimuli.
The patient returned the second week. Our doctor had titrated her Subutex dose down to 4 mg twice a day and suggested she start on Topamax. It suppresses neuropathic pain responses. He also gave her Ambien for sleep and continued the Buprenorphine taper. She returned a week later. We cautioned her to be careful of Topamax because it may interfere with her birth control pill; but her pain was definitely diminishing. She was tolerating the Topamax well, although she was experiencing some of the drug’s major side effects: forgetfulness and mental slowing. She liked the Ambien for sleep; she was becoming more comfortable.
We brought the Subutex down from 4 mg twice a day to 2 mg twice a day, and then, after a week, 1 mg twice a day for a week, and then 1 mg a week and I stopped her completely. Her taper from the original dose of Subutex had taken forty-two days (six weeks). She had started at 240 mg of OxyContin to taking no OxyContin and no Buprenorphine.
The patient reported that her pain was less, her mood was brighter, she had much more energy, and the pain in her back was not near what she thought it would be. She had felt that her OxyContin use had medicated away her desire to exercise. Now she was back exercising on the elliptical trainer and the bicycle and getting back into shape. She was getting ready for her wedding.
The Cheerleader’s case was a classic chronic management problem. The outcome was successful. We agreed that opiate use to medicate any pain was no longer a viable solution for her. “You saw where that got you.” She nodded, now fully understanding. Her opiate use had isolated her, it caused her to gain weight, caused her to withdraw, it caused emotional blunting, it caused her to have problems with her fiancé, it caused her to not be social, friendly, happy, or animated in her expressions, and to just “sort of” go to work and use her OxyContin. Now the Cheerleader was much more bubbly, more active, more energized, happier, staying on her Topamax, using Ambien as needed for sleep, entirely off the Buprenorphine, using occasional Motrin or Tylenol for pain.
We continued to track her progress. She had mood symptoms within 4-6 months, which is common after coming off of opiates; depression often ensues. We used Cymbalta, another medicine which would help neuropathic pain and improve her mood. It is an antidepressant that she was given at night, 60 mg a day. She is now stabilized. She is no longer dependent on opiates. Although she is on three medicines now (Topamax, Cymbalta, and Ambien), her life is better. She is grateful. She is happy. The newly married couple are planning getting pregnant and having a child within the next year or two at which point we will stop the Topamax, Ambien, and Cymbalta. I will manage the patient by using, if necessary, either Prozac, Zoloft, Fluoxetine or sertraline during the pregnancy to get her through.
Case Study II: The Ex-Rodeo Clown
Dan was a fifty-five year old ex-rodeo clown from Corpus Cristi, Texas. For those unfamiliar with Dan’s vocation, for those who have never attended a rodeo, or for those unlikely and unfortunate few who have never seen a Western, the rodeo clown is a kind of daredevil. Not unlike his Spanish counterparts who help in a bullfight by distracting the bull when his adversary, the Matador, falters or stumbles and in so doing spares his life, the rodeo clown uses his body as a human shield. When a cowboy is riding a bull or astride a wild stallion and falls he is, for a few terrifying moments, vulnerable to attack and may easily to be tread upon and stomped to death. The rodeo clown, quietly, heroically, while playing the fool distracts, the bucking or charging beast with acrobatic adroitness, tumbling and dashing about in the ring. He gives the Cowboy time to gather himself and escape from becoming a form of sawdust road pizza. However, in the process, the clown will often be kicked, run over or trampled on by the bull or the bucking bronco. It is, as it sounds, a most dangerous gig.
These individuals, when they are young, break all kinds of bones. Often they get hurt, and incur injuries that they don’t perceive as serious when they are young. When you hurt your back, or hurt your hip, when clobbered or kicked by a bull, the dire consequence of this interaction does not manifest itself until later in life.
Dan’s back was broken. He had fractured maybe twenty or thirty bones in his body; he had injured his neck, and had multiple head injuries. He was now working as a roofer, a very physical job, which frequently requires a great deal of lifting.
Dan came into our office and muttered, with a stylish cowboy drawl that seemed to jump right out of a classic John Wayne flick, “Doc, I’ve been using opiates since I retired from bein’ a rodeo clown.” He had, in fact, hung up his spurs and baggy pants at the ripe old age thirty. It has been twenty plus years since he had. He continued to explain, fighting back tears, that he had first become dependent on opiates to ease his many pains. He fidgeted with the Stetson on his lap and pressed on, uneasy with his breach in pioneer stoicism, “There just ain’t no way. I wake up and I hurt. I hurt all over.”
This case reinforced what we had seen over the years, of the thousands of patients treated, the striking reality of what happens when old age finally catches up to youth. The old body is built on the foundation of the young body. If the youthful body is strong and healthy, although not always the case, the old body endures, is heartier. When the boy is broken, his distant counterpart will inevitably suffer from his casualties of excess. As a rule, at approximately fifty years of age, if you have lived a physical life, your body will often experience chronic pain.
The clown, a countrified Paliacci, was profoundly depressed at this point. He had gone through a divorce, his wife had left him; he admitted that his opiate use had gotten out of control. Using Vicodin 10 mg, he was taking twenty to thirty a day. Dan could barely function. He was missing work. He was tired all the time; he was drowsy. Dan assured us that the Vicodin would wake him up. We educated him on the terrible facts of this kind of addiction. This amount of acetaminophen (Tylenol), the acetaminophen used in the Vicodin, was going to destroy his liver and Dan was already complaining of right flank pain, a clear indication that this was coming to pass. Other symptoms of this kind of abuse include rotting teeth, weight gain, a general slowing down, and a slowing of the thinking process; it causes mood swings, depression, and the sufferer often isolates.
“I would just work and use the Vicodin and now I just use the Vicodin and I’m barely showing up for work.” The ex-clown called us at Recovery Advocates: “I reckon I need to come in because I don’t have a wife and I don’t think I’m going to have a job much longer and I don’t see having much of a future. I am very low.” He had been severely depressed for over a year.
He complained of a growing sadness and despair, low self esteem, complained the he couldn’t do anything that he was isolating from friends, and enjoyed absolutely no activities for fun (ahedonism). He was living alone. His wife had left him a year ago. He had stopped having sex three years ago, a condition common when strung out on opiates.
“Your body is going to be in pain,” we informed him, frankly, “your situation is different because we know you are going to be in pain and in your situation, yes -- your body will interpret pain and exaggerate it after stopping your opiate use. The body is not used to experiencing any sensation,” but we emphasized, “your history of trauma is so severe that multiple spine fractures, head fractures, femur fractures, arm fractures, shoulder fractures, sternum fractures -- when the major bones of the body are fractured repeatedly arthritis will set in, and along with it comes chronic pain.”
The Cowboy shifted uncomfortably in his chair. Who wouldn’t. He was going to be in pain and it was explained, “You are going to have to make a decision. Your pain is going to be there. It’s not going away. You are going to have to decide how you want to live your life. The opiate life has led you to destruction. Let’s try to manage you off the opiates.” His opioid use had grown. By the time he had come to us he was ingesting approximately 300 mg a day of Hydrocodone a day.
He was started on the Subutex (Buprenorphine) and was brought down over a six week period. We knew this individual would be in pain and used Lyrica to help minimize it. We also used Ambien to help Dan sleep. The doctor also added Cymbalta and Topamax to this regimen. His level of pain was severe. We used Motrin around the clock for the first few months. The doctor had to start Wellbutrin, an antidepressant, because he grew more depressed. Our physician also prescribed Provigil. His situation was very complex and to bring him out of his stupor, his lethargy, his fatigue the Provigil was used to energize him. The Wellbutrin is an antidepressant, but also used to energize him. Provigil is a nonaddicting stimulant. The Ambien use, because this individual was getting absolutely no sleep, we felt was justified.
We continued with these medicines and we got him off the Vicodin. His energy improved. He was working again but not doing any heavy lifting. His mental state became clear enough; he started dating again. He was out in the world doing things again. He visited every six months for two years. He still complains of pain. He limps when he walks, every movement hurts but his choice was a life imprisoned by opiates or a life freed from it. He came to the same crossroad visited by so many who suffer legitimate underlying pain and turn to opioids for relief. His decision was to manage the pain, to live with some discomfort, but the operative word is “live.” The rodeo clown was smiling again. He has come back to life.
Case Study III: The Non-addict Addict
Alex W. was a fifty year old man who suffered from a lifetime of kidney stones. Alex had surgeries, lithotripsy, but his condition was chronic and he was constantly getting kidney stones. Kidney stones are extremely painful when they pass and every time they did pass he would wind up on some opiate: Percocet, OxyContin, Hydrocodone, etc. Eventually, after repeatedly treating his condition this way, he found he was unable to get off them. Two years passed and he was entirely dependent on these drugs.
Alex was running a large company in the Phoenix area and he was getting the medicine shipped to him in his office. One day he crossed the line. He went from getting them “legitimately” from doctors for his kidney stone ailment to just ordering them off the internet. The trouble is -- Alex had no kidney stones anymore.
Here is an example of a recurrent, painful, medical condition which has led someone down the road to addiction. Alex is an example of an individual who, like millions of others who are repeatedly exposed to opiates over a period of time, found himself developing an unshakable dependency on opiates and all the goodies that come along with it: drug seeking, mental ruminations about the drug, the inability to stop the drug, using more drugs than you want to, hiding the drugs from people, getting the drugs in an illicit way, spending time hiding how much money you are spending on the drugs. And this was poor Alex in a nutshell.
He was running a big company and didn’t want to live this way anymore. That’s when he contacted Recovery Advocates. By the time he came in from the cold, he was on 400 mg a day of Hydrocodone. Our doctor said to Alex, “you are going to have to decide how you are going to deal with these kidney stones in the future.” He agreed, “I’ve had enough. I can’t continue treating them with opiates. What should I do?” The critical thing is, the businessman had enough with this monkey-on-my-back business and was brave enough to acknowledge his problem to someone other than the guy in the mirror. Acknowledgement is always the first step on the road to recovery.
We detoxed Alex W. He had no family history of opiate addiction. He had no history of previous addiction. It all began with repeated exposure to opiates and eventual dependency. Alex was put on Subutex (sublingual Buprenorphine tabs) for 42 days, weaning gradually down until the six week was taking only 1mg of the opioid “substitute.” Alex has been clean ever since.
Alex chose not to follow his detoxification with a 12-step program (like Alcoholics Anonymous or Narcotics Anonymous). Here is an example of someone who I don’t think was an addict by nature. He was able to overcome his dependence to opioid narcotics with the help of a program that blocked detox and blocked cravings and set him down the path to health and freedom from his drugs. He seized the opportunity and never looked back. That is a good example of a medical condition that predisposes someone to opiate addiction and how a well designed, properly administered program of Buprenorphine detoxification and strict supervision can get an individual out of this kind of dilemma in a few short weeks. Alex W. was a non-addict addict.
Case Study IV: The Motocross Racer
The case of Terrell T., the motocross racer, was complex. He came in, twenty-seven years old, a professional racer. As a child he grew up with attention deficit hyperactivity disorder (ADHD). He was very impulsive, he was a risk taker, and he was very aggressive. He liked energy, he liked thrills. He was also attracted to any activity as long as it was dangerous, and especially if it was fast.
TT was a successful motocross racer. He raced motorcycles on dirt roads and, as a natural consequence of this hair-raising business, would frequently fall and get severe injuries: back injuries, hip fractures, spinal fractures, leg fractures, arm fractures, collar bone, multiple concussions, skull fractures, etc. TT was very impulsive and instead of going to a doctor he surfed the net until he found his endless wave of OxyContin online. He used them to treat his pain. But his body was so wracked with injuries, finally, at the tender age of twenty-six, he could no longer do the thing he loved the most -- ride motocross.
As a child TT was given Ritalin and Concerta, which are stimulants and amphetamines, and dextra-amphetamine for his attention deficit disorder. He had a long history of marijuana smoking. He was abusing alcohol. He was also abusing Xanax. He was popping Xanax up to 3 mg a day. He had a history of ecstasy abuse, LSD abuse, and his excessive lifestyle finally caught up with him.
When TT presented himself he was wearing shorts and a t-shirt. He had tattoos all over his body, scars everywhere, and was the apparent recipient of multiple surgeries. He presented with one other thing; TT had the wherewithal to realize and admit he was an addict: “I know I’m an addict.” Indeed, his father was an addict and clearly he exhibited risk-taking behavior as a by-product of his attention deficit disorder manifested in impulsivity and aggressiveness. “I have been in a lot of fights, a lot of motorcycle accidents and it’s time for me to change my ways.”
We put him on the Subutex program. He stayed on it about a week and something happened – he missed the high. When you switch from an opiate like Hydrocodone or OxyContin or Lortab or Percocet, you lose the “buzz.” TT was looking to be altered and wasn’t finding it in the detoxification process. So he started to use again.
He was honest when he came back to us, admitting frankly, “You know what? I’ve used 400 mg of OxyContin for the past 2 days.
“Okay,” said our doctor, “you are honest and I respect you. We are going to start with more frequent visits but I think we are going to have to look at this a little bit differently. This is going to have to be a multiple detox with multiple meds.” It’s very difficult to treat someone who is going to use other medicines to alter their mental state. I would say alcohol and marijuana being the most common and Xanax a strong second.
“So we have to stop the marijuana, Terrell, and your alcohol use and your Xanax dependency. And you are going to have to check into our Sober Living Program where you can be supervisied.” He was unsettled, but agreed to try. We started by tapering him off the Xanax (a benzodiazepine) using Librium over a three week period. We tapered him off the opioids using Subutex over a 6-week period. His underlying pain was severe. We used our common cocktail: Lyrica, Topamax, Ambien for sleep, and Cymbalta. Lo and Behold, TT came around. He was treated for his physical dependence, but was supported by continued recovery treatment in a sober, drug free environment. He received extensive therapy as well along with serious 12-step work. He went to meetings, twice a day. He got a sponsor in the 12-Step program. He required counseling twice a week and worked a good IOP (Intensive Outpatient Program). There were no shortcuts, medical or otherwise, for TT’s continued recovery. It’s an ongoing process to bring this kind of individual help. During the first six months he had he had multiple relapses. But relapse doesn’t mean failure; it is just part of the process. Each time we restarted the detox. The young man is trying, making every effort to stay clean. We cannot judge TT. He is neither weak nor bad. He is suffering from a chemical imbalance that came with addiction and which has effected his mid-brain and its relationship to his executive functioning cortex. TT is giving it a go. He was given a Neuro-imaging evaluation which confirmed his diagnosis of ADHD. He began their Neuro-development program and after nine months is entirely off stimulants which triggered his relapses.
TT is a drug addict and detox simply wasn’t enough. He continued with his weekly therapy and continued with 12-step program. He would work towards living a life. The theory is behavior modification--you live it and then it happens.
After a year he had the structure of a life without drugs in place and was clean of all drugs the Subutex. Here is an example of someone who is trying to get clean, has had multiple relapses in the program, and required extraordinary measures because the cravings are unbearable in him. His brain needed time to heal, to rejuvenate, to let his brain rebalance and rebuild by exercising it a day at a time. The brain development work (Neuro-cognitive development) had a huge impact on his impulsive behavior and along with 12 Step support did the trick. Sometimes, with cases like TT – it’s a heartbeat at a time. But where there’s breath, there’s hope.
Case Study V: The Navy Seal
We’ve discussed the cheerleader and ex-rodeo clown who had trauma, the motocross man who liked being high. In the case of the rodeo clown his pain was chronic; the cheerleader’s pain was probably less than she made it out to be and could really just stop. The rodeo clown’s pain was severe and had to be managed in other ways to successfully get him off opiates, while the motocross racer was a classic addict who was just looking for a high. We’ve seen how their predicaments were handled with different approaches. Here’s yet another example of an individual grown dependent. It may resonate with the times, as our country is still at war.
We see a lot of patients who are in the military. Roger was in a branch of the Special Forces – The Navy Seals. Military personnel are, to say the least, very active and sadly, but often enough, find themselves participants in events that can be described in no other way than horrific.
Roger had no physical injury, he had taken some hard falls, scaling from helicopter ropes and he had seen serious combat in both in the Persian Gulf and the invasion of Iraq. He was sent in by Special Forces prior to our main military coming in, prior to the war starting. Roger has shrapnel in his body, but the piece of metal is not his big problem. True, he was injured, but this his injuries were not those of the clown or the cheerleader; this warrior’s injuries were psychological. Roger had killed up to ten men with his bare hands. He watched his friends-in-arms mutilated, disfigured, blown to smithereens by hand-held rockets and IED’s (Improvised Explosive Devices) while in armored vehicles. This individual has such a shocking psychological history of trauma, of near-death experiences and watching people die and killing people that his physical discomfort paled in comparison to his emotional pain. Of course, Roger didn’t want to admit it. He didn’t want to admit he was suffering from posttraumatic stress disorder. He came in saying “My back is hurting,” and our doctor would say “Well, do you have x-rays? Let’s take a look at your back?” He hesitated, clearly uncomfortable, “No, I just fell out of my chopper and my back hurts. He was prepared to leave it at that. The back injury claim wasn’t impressive. We studied him for a while. He was crawling out of his skin.
“What do you do on the weekends?”
“I ride horses, I hunt, I fish, I like running and jogging.”
“How bad could your back be?” Then he got into it, the whole story of his horrendous military history.
“Doctor, I have not mentioned this or talked about this to anyone.” At this point, he went into the deep detail of the ten men he had killed and the five or six men who had lain dead in his hands. He spoke deliberately, presenting with a stony countenance, of his buddies who had lost limbs and how he had picked up hands and legs and put them all in his pack or his pocket and took them back to base with him.
This combat Vet was having constant nightmares of these events, along with flashbacks. In Roger’s case, flashbacks meant he would go back to the Iraq, literally thinking he was there and not realizing he wasn’t. It’s not just a memory, but an emotional return to the traumatic even that you physically feel. It’s as if you can touch it and he really thought he was there. This is a very bizarre experience. Anything that reminded him of what happened --people, places, things that reminded him of these awful trials would set him off.
He said he was having temper tantrums and the only thing that would calm him down was OxyContin at 400 mg a day. He had been doing this a long time. He was out of the military and running a business when he sought our help. Our psychiatrist educated him generally on posttraumatic stress disorder, explaining to him the hows and whys of re-experiencing his trauma. His drug taking was avoidance of all things that reminded him of it. He was becoming hyper vigilant and easily angered. He had a sense that he had no future. He had multiple depressive symptoms and a depressive disorder. “You have had no treatment for this posttraumatic stress disorder and this depressive illness. Unless those illnesses get treated how are you going to come off OxyContin? I’m going to take you off OxyContin. OxyContin has been the solution to your psychological problems. If we removed that solution, your psychological problems are going to manifest.”
Sure enough, when we withdrew him from the OxyContin, as predicted, things started happening. He began having exaggerated responses to his emotional pain—the horror of watching people being mutilated and blown up and the images of him describing how he had taken people out. In one instance he describe an incident that was at one and the same time gripping and appalling. He had executed a man, “I let the guy finish his sandwich and then I shot him. I decided when he would die.” That “tape” kept going over and over in his head.
He was on antidepressants for the posttraumatic stress. There was no way this individual was going to manage coming down off the OxyContin without being treated simultaneously for depression and PTSD. He was given Remeron to help him sleep, to decrease anxiety, and to hopefully stimulate his appetite which was a problem. He was given Zoloft in the morning to decrease his depressive symptoms and posttraumatic stress and his anxiety symptoms. Sleep was his major issues, so we also added Ambien. We insisted that he do psychotherapeutic work with a therapist. He entered our Sober Living Program at the Lake House where he went to two 12 Step meetings a day. We also insisted that he try a “group” with others suffering from PTSD.
Roger was ready. Here was an individual who could never face psychological treatment. It was not in his military culture and now he was saying “Enough is enough. I’m no longer going to medicate away my psychological pain. I’ve been kidding myself to think it was my back. It was never my back. The doctors at the VA just believed me and heard about my horrible life and did anything I said. They gave him the OxyContin, but he knew “that wasn’t doing it for me. I am going to get off of this stuff.”
And he did and so began his trip into recovery. It was possible only when given the chance to block the cravings and obsession for the OxyContin with Subutex and utilizing the support system he found at Recovery Advocates. Detox was followed by psychiatric treatment. This is another reason why Recovery Advocates emphasizes the bio-psycho-social aspects of addiction and leans heavily on a Neuro-Science model at the center of its program. Addiction is a disease, a brain illness, and it is all encompassing in the psychiatric spectrum of illness, which includes chronic pain, psychological traumas as well as addiction.
Case Study VI: Migraines
Suzanne K. had migraines. She was a forty-five-year-old housewife from the suburbs of Los Angeles. Her husband was a successful real estate developer. Suzanne had been suffering migraines her entire life. Her husband had fallen in love with a younger woman. He sued for divorce. During this agonizingly stressful period her migraines worsened dramatically and she started using Fioricet, which is a combination of an opiate and a barbiturate and Tylenol—the triple drug combination. She started using more and more, first five to ten of these and then fifteen to twenty pills a day. She complained to her physician of chronic headaches which her personal physician diagnosed as migraines; he prescribed more Fioricet.
Suzanne was unraveling. It got to the point, as a result of her heavy use of these pills, that she couldn’t think straight anymore. Her divorce lawyer told her that she wasn’t making sense. She slurred her words, especially at night when she grew tired, dropped her things during the course of normal chores, and regularly lost her train of thought. It was time. She found Recovery Advocates on the internet. When this women presented herself we knew she was in trouble. Thankfully, so did she.
“I’m really in screwed up and I don’t know what to do.”
“It’s quite common, “ explained our doctor, “for people who have chronic conditions like yours over long periods of time, especially during times of stress, for the condition to deteriorate progressively.” Neurological conditions (i.e., neuropathic pain in general, multiple sclerosis, Parkinson’s as well as migraines) commonly worsen with stress. Divorce, death, loss in particular are classic stressors.
“Fioricet is a very dangerous drug, Suzanne. She was quick to defend herself.
“I’m not an addict,”
“Well, not sure what you are, but we know that you are dependent on a barbiturate and an opiate and we have to detox you off both drugs at the same time.”
“Am I going to be an addict for life?” She was frightened.
“Right now your body needs these drugs. Without them you’re going to become physically sick and, once we stop them, you are going crave them as well.”
She agreed to try our approach utilizing buprenorphine to detox her off the opiates. “In addition, we are going to use Librium to get you off the barbiturates.”
Suzanne began the detox and was tapered her off both drugs over a six-week period. It turns out the migraines had gotten much better and her migraines responded to both a combination of Inderol, Depakote, and Topamax. Her migraines resolved. She had never looked into other options for her migraines because she was so intent on getting her Fioricet. Once we took her off that she engaged in therapy locally in one of our Intensive Outpatient Programs. We blocked her cravings for a long enough period of time that this individual was able to wake up and start dealing with her divorce in a more appropriate way. Suzanne came to understand although she started her pill taking because of her migraines; eventually she crossed that line into addiction. At that point, the tail wags the dog; behavior is always dictated by drug.
Case Study VII: The Pharmacist
Max B. was a pharmacist from Northern California. This intelligent, erudite man whose father was a renowned local restaurateur began using at the age of twelve. He started with alcohol, then marijuana, then ecstasy, then cocaine, then Xanax, then Percocet, and finally OxyContin. Of all the drugs he’d pumped through his system over the years the most addicting of all, the drug with the most dominating effect was OxyContin. Max would sit in his room, high on Oxy’s and watch old movies. That’s all he did. He managed two shifts a week at a local pharmacy to make enough money to keep his apartment going and to get enough money for OxyContin. He wasn’t into girlfriends; he wasn’t into anything except getting loaded and zoning out on Turner Classic Movies. It was a very sad story. There was nothing this individual did that wasn’t geared around getting high or creating time to get high or making money to get high. Max was a gifted individual, very bright, but his life was only about achieving an altered mental state. That is all he knew. It’s all he would ever know.
When this individual came to Recovery Advocates and we got an exacting portrait of his life, strung out continually from twelve to twenty-seven, we couldn’t recommend outpatient detox. Instead, we suggested he go into our residency program. In the beginning he would take 2mg of Subutex twice a day.
“You have to learn what it is to live clean. While taking the daily doses of Buprenorphine for a short period of time, you will not crave opiates, you will have energy, you will not be impaired or altered, you can go about your life, develop support systems utilizing 12 Step work, and ultimately continue working, having relationships. Your goal is to find balance.” We insisted that he involve himself in life and although the new medication was critical, he needed the additional support found in an extended sober living program.
“Max, you’ve been off the life cycle so long you need training wheels.” Concurrent to short-term Buprenorphine therapy, he was immersed in 12-Step work, bonding with people in recovery, as he was introduced to individual therapy, CD counseling, Intensive Outpatient Programs which, as part of the Recovery Advocates program, provided support day and night. He needed structure; he needed to learn how to live again. His universe had shrunk down to the size of a little orange pill.
He was ahedonistic. The drug imbalance in his brain rendered him incapable of enjoying anything in his life except those things that were poisoning and destroying him.
Max wound up taking time off from work and entered our sober living program, continuing with two meetings a day, and he found an individual sponsor in AA. Max is fighting the battle to stay clean. He is walking a tightrope but now he has support from people who have “been there” before. He may fall off. He may not. This is a cautionary tale. The young pharmacist’s only chance, despite all the help he is getting, is to surrender to sobriety. He must say, he must believe, “I just don’t want to be high or mentally altered today. No matter what.”
Case Study VIII: The Sexual Abuse Victim
Margot was a sexual abuse victim, age forty-five. It is very common to have a woman this age open up about her sexual history because that is the point in the development for many of these individuals where they feel comfortable enough in their own skin to actually deal with sexual abuse. This was Margot’s case.
Margot came from the home of an alcoholic father and a very passive co-dependent mother. Her father would get drunk and come into her room, starting at age six, and penetrate her, have oral sex with her, and make her perform oral sex on him. It happened until she was eighteen. The mother knew, but the father continued to have active intercourse with the daughter until that time. This kind of behavior is not an exception; it is usually the rule. Margot went through a period of bulimia, which is also very common.
This woman never told anyone about the abuse, she just left home. Very common. When Margot left home she never went back.
She educated herself and became a teacher. By the time we met her she had been teaching for over twenty years. One day, a little girl in her class confided in her that she was getting abused at home.
“Who is abusing you,” the Teacher asked?
“My father.”
From that moment on Margot was never the same. She could no longer sleep. She would re-experience the trauma. She started getting graphic flashbacks of the molestations. Until this watershed event Margot had blocked it out of her mind. She had been living alone, she had never formed relationships with men, but through the experience of this girl’s suffering and pain (which the teacher dealt with through the appropriate channels and had the schoolgirl removed from her home), a virtual emotional volcano had erupted from within her. Margot had constant nightmares of being a little girl terrified by an enormous man, smelling of alcohol, who entered her room, engulfing her body. Each night he came and penetrated her, forcing the child to perform oral sex on him. She relived how he would simply walk in when she was in the shower, or walk in when she was pretending to sleep -- but wasn’t. The pain was unbearable.
She started having crying spells along with the nightmares and flashbacks. She had outbursts of anger, breaking into cold sweats for no reason, having bizarre smells and tastes, seeing images or hearing voices reminding her of the trauma over the years. She had not spoken to any member of her family in twenty years.
She felt compelled to call her father and confront him. She did. She promised him she would never speak to him again. It was like the dam erupting. And if that eruption was a small roar it then became a cataclysmic tsunami of emotions, accompanied by deterioration in her functioning. She still managed to teach but it was going poorly. She was getting written up, she was getting letters of warnings, she was having crying spells, showing up late.
At first she began to drink. She was neglecting herself, gaining weight, had poor oral hygiene. She wasn’t taking care of her teeth and at one point she went to a dentist, needing extensive work. He put her on Vicodin. And that was it. From that day on it was all downhill.
Margot told us that when she took the drug – the very first time, from the ingestion of the very first pill, it felt to her as if God told her to sit down and relax.
“He was like he put a warm blanket around her, massaged her temples, and said to her ‘Margot, everything will be okay now.’” From that one pill!
The pain was blocked; it’s that simple. After that experience, and for the next three years, she sought out and did everything in her power to use and abuse as much Vicodin as she could get her hands on. Margot wound up taking 20-30 a day. She lost her job as a teacher; she just lost interest. She was fighting to get disability and she had come into the office saying that she couldn’t work, she couldn’t function anymore and after I heard her history I said “First, you need to stop using Vicodin and then we need to get into what is really going on.”
Margo began therapeutic work with one of Recovery Advocates’ licensed psychotherapists and confided in her for the first time what had happened, the sexual abuse, the duration of it, as well as the shame and disgrace that accompanied it until the age of eighteen.
“This is common,” the therapist appointed out. “It’s common that it went on that long and it’s common in an alcoholic family for a mother not to intervene, to be co-dependent. It’s very common for it to take until middle age before being able to deal with it. That little girl in your class was a trigger and it set off the process of healing that should’ve taken place many years ago. It couldn’t have started earlier because if it had you would have decompensated and lost all functionality.”
She needed detoxification from the Vicodin. That was clearly the first step. We began a 6-week process of taking her off the opiates. She continued with the psychotherapist who also specialized in grief and loss. She was started on antidepressants. She was given Lexapro, minimizing the side effects and it appeared to help. The therapy appeared to help, getting clean appeared to help. We put her in a sexual abuse group and for the first time she was able to talk to other women in a safe location about what had happened to her. She was directed to a survivor’s group and in this group she was able to get out her feelings and she wasn’t turning to drugs of abuse anymore. This allowed her to move forward and create a new life for herself -- for the process of healing to begin.
Case Study VIIII: The Nurse
Helen W. was a 35-year-old nurse who had worked in an Intensive Care Unit. Instead of giving her patient the full dose, she was injecting herself with Demerol, a very strong opiate. She also used Fentanyl, another potent opioid, a hundred times stronger than heroin. She had access to all sorts of opiates, including OxyContin, but she couldn’t live with herself anymore. This nurse’s story is quite common with Health Care Professionals. Access, temptation, it’s always there. Helen is used to watching the warm fuzziness take hold of patients as she pushes the intoxicating drugs through the I.V. It’s like being in a room with popcorn popping and someone putts the bowl in front of you, but you aren’t allowed to have any. You can smell its aroma of melted butter and feel the warmth of it; you can hear people eating it, fluffed kernels crunching. And you can’t have any! It’s very difficult. To see the drugs, their immediate effect, to see how they relieve emotional as well as physical pain. To see how they offer comfort and eliminate distress.
Helen had been in a difficult relationship. Her boyfriend was in a motor vehicle accident. She was supporting him. As a result she was working double shifts. She had no life. She was a nurse at work and she would have to come home and nurse her ailing husband. Her life was one of dedication, discipline, helping others in pain—but there was nothing left for her.
One day the count comes up short in the medicine cabinet and those in charge at the hospital want to know where the opiates went. They drug tested her in front of her supervisor and she came up positive. They asked her if she had a script? Well, you have someone who has an opiate in their urine, who has no prescription for it, the medication is missing and she is in charge. Helen got busted. They put her on temporary leave. It is a common story, not only with nurses, but with many doctors, too. Those who can get the meds are most likely to use the meds. It is the universal law of accessibility.
Helen came to Recovery Advocates and we helped her detox and block her cravings. She had chipping away at these medicines for nearly ten years, but the last six months got out of hand. It is also very common for professionals in these desperate situations to subconsciously want to get caught.
“You know, I was tired of lying,” she said, finally confiding in us. “I was tired of covering it up and I was tired of giving the patient’s less and less medication.”
Sometimes the addiction simply gets so bad they cannot cover their tracks. The addiction grabs hold and they stop making sense or can’t do the job. Helen was a highly moral person, a dedicated nurse and the idea that she might hurt someone, even kill them was finally too much. She was relieved when she came into the office. She wanted it. She wanted off the merry-go-round. We detoxed her over a six week period, eliminating her cravings and that was it. After a slow taper, ending with 1mg of Subutex in the last week, Helen just walked away. She was clean and determined to stay that way. She stayed in one of our sober living programs and when she returned home got involved with the Impaired Nurses Program in her state. She has never looked back.