My Self-Care Guide to Helping Myself With Trauma

November 29, 2017 by

In 2007, I experienced school violence, a mass shooting, then school violence again. I am among the 15% predicted by research to develop post-traumatic stress disorder after community violence, and among the 5% of those anticipated to develop addiction.

Self-careWhile not all experiences of trauma result in post-traumatic stress disorder, those who experience trauma symptoms may find themselves:

  • alternating between feeling on guard, vigilant, wary, full of suspense, and distrustful, and then helpless, hopeless, and despairing
  • reacting quickly to words, actions or situations that may or may not be threatening
  • spiking quickly to intense feelings, including panic and rage
  • feeling flooded with feeling and unable to think
  • feeling intense feelings for longer than desired
  • having the sensation that one’s muscles and tissues are hardening to leather or stone
  • having trouble easing back to a steady state
  • having trouble choosing their behavior when they are full of feeling, finding themselves speaking and acting automatically, and possibly harming themselves or others
  • finding all the above happening more often than desired, in surprising settings, in surprising ways
  • having troubling thoughts out of nowhere, sometimes with extreme images suitable for a horror film
  • having troubled dreams or awakening from sleep in a startled state
  • having trouble getting over things, or getting through things, that might have seemed doable in the past
  • weighing the possibility of safety more heavily than the opportunity for growth or intimacy
  • distrusting everyone to avoid mistakenly trusting someone and risking re-injury, thus avoiding dangerous people but missing out on empowering, enriching people
  • withdrawing and isolating to limit exposure to the possibility of trauma-triggering situations and the anguish that results.

Working with a psychologist, and using my own training as a scholar and as a counselor, I engaged in personal study of the writing and research on trauma.  I learned these fundamentals about trauma:

As a result of trauma, my brain now functions differently than it did. That is a fact to acknowledge, a sadness to grieve, and a problem to solve, all at the same time.

I am either feeling alarm now, or am about to feel alarm. I may or may not be conscious of this sense of alarm, but that’s the major alteration that’s occurred in my brain as a result of trauma.

Upon discovering I am feeling alarmed, I may become alarmed. Alarm about alarm happens. Alarm triggers my brain’s survival instinct. Instinctual portions of my brain take over the pausing-to-think portions of my brain. I may not even be aware that I am fighting, fleeing, or freezing, even if it doesn’t help me or you, even if it hurts us both.

Sensory experience may be magnified. Tags in shirts may feel like bee stings. A bruise may feel like a fracture. Crackling from a package opening may sound like a nuclear explosion. Any and all non-threatening sights, sounds, and scents may alarm me.

I am not what happened to me. I have a new duality that I did not have before. I have an inner self, born with my personality and temperament, the pure essence of who I’ve always been. And I have a consciousness to which trauma happened, but which also contains my problem-solving and solution-executing skills and, therefore, my ability to make things happen for myself. I now have to have inner conversations with all these components, consulting all of them, appreciating all of them, and then deciding what to do based on what’s in the best interests of all of them – my whole self – trauma history and all.

My self-narrative can re-ignite and re-trigger trauma. What I tell myself about myself matters. At first, I am likely to not just hate what happened, but to hate myself. What I say to myself may further brutalize me. The essence of the blaming, punishing narrative that keeps destruction on-going is “How could you have let this happen to you?!”

Normal human hardships feel catastrophic. In every human life, conflict happens, illness happens, loss and death happen. After trauma, the brain can experience mild stress as alarming, and extreme stress as nearly unbearable.

Substances provide relief from all the above. And although it’s not logical, I can mentally pair abstaining from substances as causing all the above.

Trauma symptoms respond to care and kindness, not to willpower, confrontation, or reprimand.

In addition to professional care, self-care is the primary means of recovering from trauma.

Therefore, the essence of recovering from trauma is to help myself with alarm, all the while hanging on tight to myself, caring for myself, speaking kindly to myself, realistically protecting myself, and making decisions and taking actions that are helpful to my whole self and to my life, in the presence of a brain alteration that interferes intermittently and unpredictably with the whole process.

Oh, and if I have a co-occurring substance use disorder, I need to follow my treatment plan and abstain from problematic substances or engage in harm reduction.

“[T]he challenge in recovering from trauma is to learn to tolerate feeling what you feel and knowing what you know without becoming overwhelmed.”
– Bessel van der Kolk, 2014

A daunting challenge! It can be done.

My Self-Care Guide to Helping Myself with Trauma

First, I have to help myself with alarm.

That requires safety first.

Alarm is an exquisitely evolved, heightened, natural response to threat. I don’t want to eliminate alarm, therefore, because it helps protect me from danger. I just want to help myself with the over-presence of alarm given to me by trauma. To decrease the likelihood of alarm, I need to secure as much safety, of several types, for myself as I can.

External safety

  • I keep myself with safe people, in safe situations, and in safe places. If I’m not safe, I leave. If I can’t leave, I start figuring out how I’m going to leave.
  • I used to be able to tolerate, even enjoy, a bit of risk and danger, a little living on the edge, but that’s not helpful to easing alarm. If things get edgy, I exit as soon as I can.
  • I used to enjoy the thrill of drama – in the news, in books, shows, movies, and YouTube videos. Today, drama triggers alarm so I  limit my exposure to real and fictional drama.
  • I know, and am beginning to accept, that I, unfortunately, can’t create perfect safety for myself. I am learning to tolerate “safe enough.”
  • I am learning the difference between discomfort and threat. I practice skills to handle discomfort and I remove myself from threat as soon as I can.

Internal safety

  • I protect my inner self from the aggressive words of others. I might listen to the words, but I keep a hand up between them and my inner self.
  • I protect my inner self from my own harsh thoughts. I know that trauma can result in self-blame, self-hatred, and harsh self-judgment. I work to become aware of those thoughts and catch them before they strike my inner self. I then accept, without judgment, that these are normal thoughts after trauma. I release them by shifting my attention to helpful thoughts. (I shift my attention. I don’t shame myself by denying, repressing, or suppressing my thoughts. The brain’s wonder is that it thinks thoughts! I simply shift my attention to my pre-sorted pile of helpful thoughts. And I don’t try to find “good,” “right,” or “positive” thoughts. Those are judgments, too, simply the opposite of naming thoughts as “bad,” “wrong,” and “negative.” Deciding what’s “helpful” asks for neutral discernment, rather than self-critical judgment.)
  • I protect my inner self from the “volume” on my inner experience when it ramps up too high or dials down too low.

Creating safety by guarding against replay

As a result of trauma, my brain automatically – without my awareness or consent – replays what happened, or automatically generate feelings, thoughts, or sensations associated with what happened, even though it’s not happening now. This replaying of the past can happen during waking hours, or during sleep, sometimes startling me awake. If I’m awakened, sometimes with my mouth wide in terror, I may or may not even be able to remember the dream.

In addition, just as a human being, I wish what happened had not happened. I naturally replay what happened, trying to find ways to try to have made the outcome different, or to try figure out what I did “wrong” so I can protect myself in the future.

The problem with replaying what happened, either consciously or unconsciously, is that it alarms me. Alarm reignites the portions of my brain inflamed by trauma. My brain, plus my natural human tendencies to want to right wrongs from the past, can give me painful, re-damaging, mini re-traumatizations all day long.

When thoughts or memories of trauma occur, I can assist myself by saying statements to myself like these:

  • I am becoming aware of all my feelings, thoughts, and physical sensations.
  • When I become aware of feelings or sensations of distress or discomfort, I gently ask myself, “Is this alarm?”
  • My normal tendency is to become alarmed about feeling alarmed, to criticize myself for my feelings, and to try to control and contain alarm. Today, first and simply, I note when I am feeling alarmed.
  • If I become aware of dire or troubling thoughts, I gently ask myself, “Are these thoughts from trauma?”
  • When I become aware of feeling alarmed or thinking thoughts associated with trauma, I use skills* to help ease my alarm and to help shift my attention to helpful thoughts.
  • As I become increasingly practiced and skilled, I’m able to say, “Ah, yes, alarm, there you are,” then, “Right here, right now, am I safe?” I’ll be able to say, “Ah, trauma, so sorry you’re there, but it’s just trauma.” With practice, my skills to ease my inner state and shift my attention will begin to kick in nearly automatically.

If others ask me to recall traumatic events from the past, especially for therapeutic purposes, I ask if they’re aware of the latest brain research on trauma. While “getting used to” trauma by reliving it (termed “desensitization” through “exposure therapy”) might seem logical, and it may have support in the research, because of what we we now know about trauma works in the brain, reliving past trauma may do more harm than good.

“Exposure-based therapies help patients with post-traumatic stress disorder (PTSD) to extinguish conditioned fear of trauma reminders. However, controlled laboratory studies indicate that PTSD patients do not extinguish conditioned fear as well as healthy controls, and exposure therapy has high failure and dropout rates.”
– Noble et al., 2017

From my one, precious little life, I can’t risk “failure” and “dropout” from a PTSD therapy back into PTSD. I must protect myself from such costly anguish for myself.

I ask the person to, step-by-step, justify why he or she thinks it would be valuable for me to re-experience trauma. I become aware of the state of my inner sense of alarm as I listen. If I can’t use my personal skills* sufficiently to ease my alarm, I decline.

“‘The underlying dynamic of so much abuse is coercive control, so pushing people to disclose can replicate those patterns of coercion’ and backfire, Dr. Wathen said.”
– Benedict Carey, More Than 150 Women Described Sexual Abuse by Lawrence Nassar. Will Their Testimony Help Them Heal?

Part of the problem with trauma is that the brain said, “No!” but the situation made “yes” happen. The inability to escape overpowers the brain and is experienced as a helpless, powerless state of despair. If another person, even with the best of intentions, in any way tries to use the power of his or her position or status to persuade or force someone to recall or share trauma – or uses overt or covert force to try to make a traumatized person do much of anything – even a mild sense of feeling coerced or overpowered can trigger alarm, thus reigniting trauma.

This is why the presence of negotiation in relationships – whether intimate, casual, or work-related – is crucial to people who have experienced trauma. While talking things through and making mutual decisions is a sign of health in all relationships, for people who have experienced trauma, it’s a must-have in order to feel safe enough, to manage alarm enough, to function.

In relationships, I might find myself over-identifying with vulnerable beings for whom I feel empathy for their wounds that seem like mine, or over-identifying with seemingly invulnerable beings whom I imagine, if they had magically been there, might have prevented from happening what happened to me. If I’m about to adopt a rescue animal or get involved with someone with known “issues,” I can ask a safe, trusted person to ask me gently, “Might trauma be leading you to over-identify with this being?” My answer might still be to move forward, but that can help me make sure that I am making my decisions, and that trauma is not making them for me.

Troublingly, I may also under-identify with vulnerable beings, distancing myself from the ache I feel for them through contempt and scorn. If I find myself being aggressive with words or actions towards animals, children, and other vulnerable beings, I need to stop myself immediately and get professional help. It’s not a surprising development from trauma, but it’s one I need to take seriously, and right away.

Caution with re-experiencing trauma for people with substance use disorders is an imperative. Two-thirds of people with substance use disorders have experienced trauma. The magnitude of trauma symptoms may overwhelm the capacity for new skills to handle them. Substances may be perceived as needed to provide their reliable, predictable relief from trauma symptoms. (This is why 12-step programs’ Step 4 requirement to do an inventory of the past can be endangering, resulting in a recurrence of trauma symptoms, possibly a return to use.)

Summary

The effects of trauma are real and can be measured in the body and identified in the brain.

However, if I can:

  • maintain an inner dialogue with myself, no matter what I feel, think, or sense, no matter what happens,
  • become aware, with self-kindness, of my feelings, thoughts, and physical sensations, in the moment, all the while not judging them,
  • use that data, pair it with my inner wisdom, and assess the safety of the situation right here, right now,
  • decide whether to remove myself from what is unsafe, or to stay and tolerate discomfort if I determine things are currently safe,
  • monitor my internal sense of safety, and continue to assess the current situation with strategic calm rather than alarm,
  • dial up or down the volume on my feelings to a range that feels stable to me,
  • sort thoughts and memories, as they occur, into helpful and unhelpful piles, and keep shifting, with a light touch, my attention from the unhelpful pile to the helpful pile – not because the thoughts and memories are wrong, not to deny what happened, only because some thoughts are more helpful than others,

I can ease trauma symptoms in the moment, and, over time, decrease the frequency and intensity with which trauma symptoms occur.

. . . . .

The experience of trauma transformed me. I probably can’t restore myself to the way I was or “get my life back.” Although I can’t know for sure, my experience of my life may always be lessened by sorrow. It’s so deeply unfortunate, but it’s just the way it is. Regardless, the research on trauma reveals that, with up-to-date professional care, and specific, skillful self-care, I can create an inner, transformative experience for myself that refashions my strengths. Even after trauma, with these newly wrought strengths, deliberate, determined use of my skills, and stubborn self-care, I can create a safe-enough, contented-enough, beautiful-enough life for myself.

. . . . .

*The clinical term for what I’m referring to as “skills” and “personal skills” is “emotion regulation skills” which I’ll describe more fully in other posts.

Sources, listed in order by simplicity and immediate helpfulness:

Babette Rothschild, 8 Keys to Safe Trauma Recovery: Take-Charge Strategies to Empower Your Healing, 2012

Matthew McKay, Jeffrey Wood, and Jeffrey Brantley, The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance, 2007

The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder: Using DBT to Regain Control of Your Emotions and Your Life, Sheri Van Dijk, 2009, especially pages 199-203

Donald Meichenbaum, Roadmap to Resilience: A Guide for Military, Trauma Victims and Their Families, 2012

Judith Herman, Trauma and Recovery: The Aftermath of Violence – from Domestic Abuse to Political Terror, 1997

Marsha Linehan, DBT Skills Training Handouts and Worksheets, Second Edition, 2014

Marsha Linehan, DBT Skills Training Manual, Second Edition, 2014

“Experience is not what happens to a man; it is what a man does with what happens to him.”
– Aldous Huxley

“People may not have caused all their own problems, but they have to solve them anyway.”
– Marsha Linehan

This post is part of a series. The table of contents for the series is here.

Last updated 2/9/18

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Guide

Longing for Intimacy? Foster Interpersonal Safety First

November 13, 2017 by

A sense of interpersonal safety is a prerequisite for intimacy.

While popular notions of love and sex are goal-driven, i.e. commitment and penetration, a nuanced view offers so many more possibilities for enriching one’s own and one’s partner’s lives. If the “goal” is intimacy – and intimacy is where all possibilities begin – then the progression would look like this:

Safety > Attunement > Connection > Vulnerability > Intimacy

Attunement

For those seeking new romantic partners, or wishing to deepen their relationships with their current partners, intimacy, then, is a prerequisite for further emotional and sexual closeness. By looking at ways individuals contribute to creating a sense of interpersonal safety with others – and making safety-enhancing adjustments – they can increase the likelihood of fostering intimacy, that profoundly delightful, very human need.

“[E]ven though physical release may be involved, loving sex is a cherishing of each other’s minds, hearts and bodies – the whole person that is our partner.”
– John and Julie Gottman

So, safety first.

What helps create and maintain a sense of interpersonal safety? What harms a sense of safety?

Helps: Self-control as evidenced by courtesy and politeness in speaking and manner.

Hurts: Lack of self-control as evidenced by non sequiturs in speaking and manner that jar social norms or conversations. (“What an interesting conversationalist! But can I count on this person to be stable when the going gets tough?”)

Helps: Self-acceptance as evidenced by statements indicative of self-fairness.

Hurts: Self-judgment belied by self-shaming statements disguised as self-effacement. (“Uh-oh! When will it be my turn to be humiliated by that ‘humility’?”)

Helps: Humor that joins.

Hurts: Humor that separates by criticizing self, others, or institutions. (“Yikes! If they make fun of themselves/others/society, when will it be my turn to be the butt of the joke?!”)

Helps: Transparency, authenticity, clarity.

Hurts: Secretiveness, evasiveness, cleverness. (“Uh-oh! What problems are they hiding that might end up causing me pain?!”)

Helps: Present, mutual, lateral, reciprocal communication.

Hurts: Distractedness vs. attentiveness; “one-up” or “one-down” postures; leaning too far in or too far back; over-use or under-use of “air time.”

Helps: “I-statements.”

Hurts: “You-statements” that define the other person, and “we-statements” that include the other person, without permission.

Helps: Ability to read “closeness” cues and to adjust the dial on congeniality and assertiveness up or down.

Hurts: Insistence on making a point. Choosing “right” on the continuum of “Do you want to be right or do you want to be close?”

Helps: Physical self-care as evidenced by grooming and body morphology.

Hurts: Persistence in unhealthy behavior that endangers the self. (“Wow, they don’t seem to be taking very good care of themselves. I’m pretty independent, but I need help sometimes. Will they be able to care for me when I need a turn?”)

Interpersonal communication styles will vary, of course, but if intimacy is the goal, safety will always matter first.

Art by Caleb Flood

. . . .

This post is an excerpt from materials for Love and Sex After 50, a course I’ll be teaching for the Lifelong Learning Institute at Virginia Tech in Blacksburg, Virginia, in February, 2018. More about the course is here.

Last updated 11/18/17

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Love

My Guiding Principles as a Counselor for People with SUDs

October 29, 2017 by

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
– National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), 2014

Painting of a sunflower

Do no harm.

Use evidence-based treatment modalities.

I define evidence-based treatment as what research reports works for most people, most of the time, better than other treatments, and better than no treatment. Specifically, that means the treatment is supported by numerous, peer-reviewed scientific experiments with rigorous methods that include control groups, randomization of subjects to experimental conditions, and bias-free samples, with statistically significant results. Some treatments that are evidence-based to work for groups may not be helpful to a particular individual, however. It is an imperative that counselors and individuals continually monitor an individual’s condition and progress while engaged in treatment.

I contrast research data – the evidence resulting from research experiments – with “anecdotal data.” I define anecdotal data as an individual’s personal experience. Data from a sample size of one does not provide sufficient information from which a generalization can be made about a group or population. Principles believed to account for outcomes from inspirational individual stories, practitioner wisdom, or theories based on logic, cannot be safely applied to others without first subjecting those principles to rigorous research.

I have relentlessly studied what evidence-based substance use disorder treatment should be. An outline of my findings is here.

Provide the caliber of therapy and treatment you would want for your own child.

Champion the power and resilience of the individual.

Jettison all identity-compromising, stigma-perpetuating words and phrases from one’s vocabulary: addict, alcoholic, substance abuse, get clean, dirty urine, hit bottom, tough love, codependency, enabling.

Practice “love love,” not”tough love.”

Filed Under: Sundry

I Can’t Get You Treatment for Opioid Addiction in My Town

October 27, 2017 by

Let’s suppose that, against all the odds against it, and due to the likely trauma that preceded it, unfortunate mental illness that accompanied it, and financial and social misery that predisposed you to it, you develop an addiction to prescription pain pills.

I keep Narcan in my purse in case fellow citizens need help

I keep Narcan in my purse in case fellow citizens need help.

If you are addicted to pain pills, you’re likely to be among the 75% of  Americans who got the pills from a friend or family member, not from your doctor. Your brain has learned that they uniquely do what needs to be done for you, in ways that are unique to you, such that a turn happens  – still a black box of mystery in the brain, even to neuroscientists – and you realize you can’t stop taking the pills. And you’re experiencing negative consequences from continuing to take them. Let’s stretch the odds even further – perhaps you’ve even ended up injecting heroin.

My name is out there as someone to call. Let’s say you call me and say, “Anne, I have a problem with opioids. I’m ready to stop right now. Can you help me?”

If you stop now, I have just under 12 hours to get you help before you start going into withdrawal. Withdrawal is “uncomfortable,” not fatal? Try unremitting vomiting and diarrhea for 48 hours or more and see if you survive.

I’m a Virginia Tech Hokie, and a Good Samaritan, and an American. We don’t let our people suffer like that.

The top two treatments known to cut the death rate by half or more for opioid use disorder are methadone and  buprenorphine. Buprenorphine is commonly known by the brand name Suboxone.

Started on either one, ASAP, under medical supervision, with additional medications for symptoms and other conditions you might have, you can go through withdrawal and continue with this life-saving treatment.

In our town, I can’t get you methadone or buprenorphine, the top, evidence-based treatments for opioid use disorder.

Although research-backed to result in decreased social costs compared to abstinence-based treatments, methadone has been tied up in federal legislation for decades and can only be administered at a federally regulated clinic. A prescient local doctor tried to open a methadone clinic in 2006 in Blacksburg and was shut down. A need for evidence-based treatment for opioid use disorder has existed here a long, long time.

But buprenorphine can be dispensed at pharmacies, so you should be able to get a prescription from your primary care physician, right?

Federal law requires that physicians be certified to prescribe buprenorphine. They’re permitted to treat only 275 patients at a time. What that means is that you have to get in line behind every one else. Wait lists in our area are 6 months or more. In some rural areas, wait lists are a year.

If you can pay $500 cash for the first visit, and $180 per month after that – and, if insurance doesn’t cover it, an additional several hundred dollars per month for a prescription for buprenorphine – you may be able to be seen in one to two weeks at a local addictions medicine clinic that doesn’t take insurance.

So where does that leave us if you call me and ask me for help? I can’t get you methadone today or maybe ever, locally.

I can’t get you buprenorphine either. Even if I take you to the ER, they won’t administer it or prescribe it. I might be able to help you get into the private clinic in a few days, or on a 6-month or more wait list at a social services agency, although there are lots of hoops to jump through to get on a wait list, or to stay on it.

I can’t keep you stable or introduce you to treatment at a safe injection site because we don’t have any.

What if this scenario weren’t about you, but about your child? Let’s say he or she has an opioid use disorder. What can you and I do for that child right here, right now, in Montgomery County, Virginia?

We can call the two closest rehabs, one 45 minutes away, the other an hour and a half, and see if they have beds available in the next 12 hours. (Evidence is inconclusive on the efficacy of rehab.) However, administering buprenorphine at either facility is non-standard and occurs on a case-by-case basis. Patients administered buprenorphine are tapered before they leave. That puts them at an 80% chance of relapse. The barest minimum recommended time to be on buprenorphine is one year. Many people with opioid use disorder need to be on maintenance medications for life, just like many people with diabetes need to be on insulin for life.

Abstinence is not a treatment for substance use disorders.

Addiction is a medical problem requiring medical care. When your children with opioid use disorder leave rehab without medication, they’re not receiving treatment for it. Because their tolerances have dropped, they are at high risk of not only relapsing, but overdosing and dying.

Other than trying to find a rehab bed for your children, there’s nothing you or I can do to help your child stop using opioids right now.

Nothing legal, anyway. Can you imagine being a parent and saying to your child, “Keep using, honey. Keep swallowing pills into that precious body I held close to my own body when you were a baby. Keep breathing that substance in. Since you were tiny, I’ve watched to make sure you were still breathing while you slept. Keep injecting into your precious arm or hand or thigh. You might die if you don’t.” Or, “Honey, do you know someone on Suboxone that we could buy it from? Just until we can get you to a doctor?”

This is called the Heinz dilemma, used in ethics classes everywhere, to show the misery of two miserable choices. Should Heinz have broken into the pharmacy to steal the medication that would save his dying wife’s life?

Why did emergency department visits involving misuse or abuse of prescription opioids increase 153% between 2004 and 2011? Why did emergency room visits related to alcohol increase 50% in the past decade?

Why are people going to the emergency room for substance use disorder, a treatable, chronic illness for which medical care should begin with a visit to one’s primary care physician, according to the Surgeon General’s report, released in November of last year?

Emergency rooms are filled with people who have opioid use disorders, alcohol use disorders, and other substance use disorders because we limit access to readily-available, evidence-based treatment. They shouldn’t be in the ER at all. They should have received treatment long before things went that far wrong.

What’s a citizen to do in a town, in a state, in a country that declares a medical emergency but won’t let its people have the medicine to treat the medical condition?

I’ve been asked to answer the question, “What can we do about the “opioid epidemic”? I share with you my opinions.

  • Look around for elephants in every room. Even if you can’t see them, consider whether or not they might be there. If you see them, name them. Replace them with data.
  • Demand definitions of terms. If politicians or policymakers use the term “opioid epidemic” or “opioid crisis,” ask “How do you define ‘epidemic’?” and “How do you define ‘crisis’?” Ask, “To which opioids are you referring?”
  • Jettison these words from your vocabulary: addict, alcoholic, drug “abuse,” addictive personality, codependency, enabling, hit bottom, get clean, tough love. We are people who happen to have the medical condition of addiction. If you love us, help us. Period.
  • Say nothing about addiction that you can’t support with data. If you believe something to be true, but don’t know if it’s true or not, either identify it as an opinion, or don’t say it. Personal opinions about cancer, diabetes or addiction, – all dangerous conditions that result in premature death – can kill.
  • Demand data. Insist on sources. Don’t accept hype, opinion, belief, or personal experience as data.
  • Buy Narcan for yourself and your loved ones. It’s the opioid overdose reversal medication. I bought mine for $109 at CVS, University City Boulevard, in Blacksburg, Virginia. They currently keep one package on the shelf at all times and can have additional packages the next day, except on weekends. It’s sort of over-the-counter, but the pharmacist has to put a prescription label on it with your name? Anyway, I very much appreciate working with the CVS pharmacist at UCB and invite you to contact him.
  • Contact every elected official you know and ask them why access to the only treatments known to cut the death rate for opioid use disorder by half – the medications buprenorphine and methadone – are restricted by federal law, state law, insurance company policy, and medical board policy. If we really have an “opioid epidemic” and an “opioid crisis” – a state of emergency in the Commonwealth of Virginia and the nation – ask them why the medications to treat opioid use disorder are nearly impossible to get. Insist they declare a true state of emergency and suspend all laws and policies that restrict patients with opioid use disorder from getting buprenorphine and methadone.
  • Join with other stakeholders and put together an employment package – a work week limited to 40 hours, a position with a title, a house, a high salary, Virginia Tech football tickets, a brief contract, maybe 3 years – whatever it takes – and get some doctors in here who are willing to get certified to prescribe buprenorphine and treat people with opioid use disorder and other addictions full-time. Less than 10% of people with addiction get treatment and we have over 16,000 people with alcohol and drug problems in our area.
  • Boost our local economy. Invest in treatment. Treatment is up to 7 times cheaper than incarceration.
  • Whisper, then speak, into the silence. Maybe, maybe, 10 years later, it’s okay to ask people how they’re doing after the shootings. Ask yourself the same question. After community violence, 15% of people are expected to experience trauma symptoms. Of those, 5% are expected to develop substance use disorders.
  • Ask people how they’re doing, period. Ask if there’s anything you can help with. Do that.
  • Abstain for a month. You know that beverage or food or activity that gives you pleasure, that might be a tad problematic, but it’s optional? “Just say no.” Abstain without ceasing for 30 days. Note your observations and insights.
  • Engage in personal reflection about your own beliefs about acceptable pleasure and acceptable pain. Talk about this with friends and family members, at books clubs, at places of work and worship. Engage in “clearspeak,” not “doublespeak,” not “addictionspeak.” State what you truly feel, think, believe, and know.
  • Think less about what we can do to stop people from using alcohol and other drugs, more about how to help them, and a lot more about why in the world they would use them in the first place. Has America become a place where pleasure is hard to come by, pain is prevalent – especially when we are children – and substances work for both?
  • Call me. If I can answer any questions, or be of service in any way, please call me. I offer tough talk in public, but I have no tough love to offer in person. Only love love. I will do what I can to help you.

Ut Prosim.

Thank you again for inviting me to speak.

Who has questions?

. . .

This post is part two of an expanded version of a talk on the opioid epidemic for the Montgomery County, Virginia Democratic Party on 8/17/17. Part one is here.

Photo by Mike Wade

Last updated 12/8/17

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Addictions Policy

Elephants in the Room: Opioids and Epidemics

October 27, 2017 by

“Elephant in the room is an English-language metaphorical idiom for an obvious problem or risk no one wants to discuss, or a condition of groupthink no one wants to challenge.”
– Wikipedia

The first elephant in the room is pleasure. How much exactly are we allowed to have in America? By what means? Who’s allowed to have it? And how do we decide what’s enough and what’s too much and what’s a no-no altogether?

Let's talk about the elephants in the room

What’s a “nice high” and a “not nice high”? I get a nice high from exercise and fine food. I used to get a buzz from alcohol but I currently abstain. My dad’s in the room, so I won’t elaborate, but I get a nice high from sex with a fine partner. I get a buzz from caffeine.

If I were in Denver, it would be legal to get a nice buzz, a nice high from marijuana. Very same high, transported to Montgomery County, Virginia? Why, people get their children taken away from them for using marijuana in our neck of the woods. Is it because they’re having a “not nice high”?

Another elephant in the room is pain. How much exactly are we supposed to be able to bear on our own? Who deserves immediate pain relief, who needs to “tough it out,” and how do we decide? Does emotional pain count? Just physical pain? What’s okay to do to lessen pain? What’s not okay?

When I see a child crying in pain – and you know that sound that’s different from distress – there’s a helplessness to it that’s heartrending. I want to do anything I can, as fast as I can, to relieve that child’s pain. I remember when I was a child and fell, my mother would say, “Put ice on it!” We don’t think little kids should have to be in any pain.

What about adults, though? Men are told, “Big boys don’t cry”? Women are told, “Never let ’em see you cry.” Should a little old lady riddled with cancer at Warm Hearth be given pain meds? Should a roofer whose co-worker accidentally knocks him off a ladder be given pain meds after his back surgery? Should a teenaged girl who’s being sexually assaulted by her mother’s boyfriend be allowed to have a couple of beers and smoke a joint with her friends?

Our beliefs about pleasure and pain provide the context for understanding our beliefs about the use of substances to bring us pleasure and ease our pain.

I was asked to speak on the “opioid epidemic” and what we can do about it.  According to the Centers for Disease Control (CDC), an epidemic is “an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area.”

If you Google “opioid epidemic,” even among credible sources, you’ll find a confusing collection of terms: opioid crisis, opioid use, opioid abuse, opioid misuse, opioid dependence, opioid use disorder, opioid addiction, opioid overdose.

Which of these differently defined terms related to the “opioid epidemic,” exactly, are we upset about? And about which “opioid” are we talking? Prescription opioids for pain patients, heroin, street fentanyl, manufactured in clandestine labs?

According to the CDC, the number of people dying per day due to opioid overdose – with “opioid” defined all inclusively – is 91. That is a tragic number. From the effects of cigarette smoking, 1,300 people die each day. What orders of magnitude are we using to decide what’s upsetting us?

Are we upset about pleasure? Two-thirds of people with substance use disorders have experienced trauma. Half have a mental illness. They’re having fun, right?

Are we upset about pain? Do we think people should not have opioids for pain because they might become addicted to them?

Does the data support the term “opioid epidemic”?

Why are we cutting off opioid pain meds for chronic pain patients? Is it time for them to “tough it out”? Better they suffer before they die rather than allow for the extremely remote possibility they might be one of the 8 in 100 who develops an addiction to opioids from prescription pain meds?

I don’t know the answers to these questions.

But we’ve let the poor elephants free. Data is in the room now.

. . .

This post is the first half of an expanded version of a talk on the opioid epidemic for the Montgomery County, Virginia Democratic Party I gave on 8/17/17. The second half is here.

Last updated 11/18/17

The opinions expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Filed Under: Addictions Policy
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