Confessions of a life-long pillhead:
According to the US Government Department of Health & Human Services, less than half of adolescents with serious psychiatric disorders receive any kind of treatment. That in itself is a tragedy. One that will ensure a continual source of supply to the nation’s jails, prisons and homeless shelters.
DHHS fails, however, to address another potential source that feeds today’s salt mines: adolescents who are over treated.
My life as a pillhead started early. At age 7 or 8 I was being fed drugs in a nightly ritual. In later years I would later come to recognize the pale M&M-shaped pill with sweet coating as Mellaril; the round, sky-blue pill was Thorazine, and the triangular tab colored an interesting shade of aqua was Stelazine. All of these are powerful phenothiazine antipsychotics typically prescribed to schizophrenics and patients suffering from delusional or hallucinatory episodes. In later years, Ritalin and Elavil appeared in my personal pharmacopeia. Concurrent with this drug regimen were visits to psychiatrists — which I enjoyed because we’d assemble models of Tyrannosaurus Rex or an Iowa-class battleship — and clinical psychologists who would just grunt instructions for the tests they administered.
After my second EEG in five years, I asked my mother the reason behind it all. She replied: “Because you lie a lot.”
Students of developmental psychology agree that the ability to tell a lie, and get away with it, is crucial to the child’s growing sense of self, as an individual apart from his parents. There are many good reasons to be truthful with ones’ parents, it is said, but the inability to lie is not one of them.
When kids and teens are prescribed psychotropic drugs, every outburst, every expression of anger, sadness or frustration, every slammed door, every kicked chair, every book shut with undue vehemence — in short, those moments when life inevitably pushes back — elicits the anxious parental query: “Did you take your pill today?”
Like Warren Harding’s 1920 presidential campaign, the pill is a return to normalcy. In whatever form, be it phenothiazine tranquilizer, tricyclic anti-depressant or amphetamine analogue, the pill is expected to answer the vicissitudes of existence.
What do these drugs actually do?
“Little is known about the neurobiological effects of psychotropic medications on the developing brain,” a 2012 article, “The Neural Effects on Psychotropic Medications in Children & Adolescents”, published in Child & Adolescent Clinics of North America, concludes.
Frankly, I can’t say whether the phenos I took while in elementary school had much effect on me one way or the other. I had a pretty ordinary K — 6 career, with perhaps a touch more entrepreneurial enterprise than most. When I found an unused PE locker on the playground, I brought a lock from home and charged peers a nickel to store whatever they wanted there. Summoned to the Principal’s office to explain, he laughed: “Andy, I do like your style,” he said, handing me back the lock.
Unfortunately not every else did. Junior high supplanted elementary, and the home scene deteriorated as my elder sister ran away — not to be seen by me or anyone else in our family for at least two decades; my father’s employer, the Herald Examiner, locked him and the rest of the pressmen out, prompting a strike that would last … about twenty years, too. And my mother’s health began to fail precipitously, until she passed away during my sophomore year in high school.
Everyone pretty much agreed that these calamities were my fault.
I never doubted they were right.
By then the phenos had been replaced by tricyclic anti-depressants, primarily Elavil, which not only failed to elevate my mood, but caused me to nod off continuously in second period English class, to my utter and lasting humiliation. One morning sheer orneriness prompted me to refuse to take them. The result was instant and dramatic — I never slept in class again. Years later, after graduating nursing school and working in hospitals, imagine my surprise when I encountered Elavil once more — prescribed as a non-narcotic sleeping aid.
For a time I used no psychotropic drugs at all. When a patient died or was transferred from the hospital I worked in, I took part in the ritual flushing their schedule II or III meds down the toilet without the slightest pang of regret. But episodes of pretty severe depression led back to the couch — and the prescription pads: Trazadone — pay attention when the PDR warns of “priapism” as a side effect; Zoloft — another twenty-five pounds that I really didn’t need, and, with all of its retro charm, Nardil — a very old-school MAO inhibitor that works well the recipient’s psyche, but virtually nothing else.
Exercise, I was also told, was a golden bullet that would turn my frown upside down. After all, witness the “runners’ high”, or the “endorphin rush” people talk about as it pours its golden light into athlete’s body in reward for that maximum effort.
Sure, I read about them.
Even in high school, running through Angeles Crest with the rest of the football team with Coach chasing us like a junkyard Doberman, I never felt anything but exhausted afterward. Of course there’s pride in the accomplishment, in being an all around hard-body, but this “rush” people talk about? Not me.
And sure, there were trips to the dentist that resulted in a couple dozen Vicodin, and cough syrup made from pure hydrocodone (before it was spoiled by the addition of atropine) that resulted in nearly pure ecstasy. Too pure, in fact. I never felt spaced out and silly, the way medicinal opiate users are portrayed in films and TV. But they did relax me to the point where meeting the urgencies of life and career took a seat way back in the nosebleed section.
After our son was born, priorities changed. Even the occasional medicinal holiday ceased. Confronting, for the first time in my life, an actual blood relative, I thought: Suppose I had some idea of what issues might lurk behind his paternal heredity? Worth knowing?
I asked my dad: What gave with all of those tests, that brace of EEGs, the shrinks and heavy dope that filled the second half of my first decade on Earth?
He said, “I don’t know.”
Being the sort of guy who tells you he’s checking into the hospital next week for surgery because the doctor said to, but he has no idea why or what they’re planning to remove, I believed him.
With my mother having taken the answers with her to the grave (aside from that rather unsatisfactory one she gave me years before) I can only guess that I showed signs of ADD — not diagnosed with as much gusto in the 60s — which caused my folks to flip and put me through a kind of drug regimen animal rights activists protest when used on monkeys and beagles.
Maybe poultry provides the more precise analogy: was it the chicken, or the egg? Was I a screw up, prescribed heavy neuroleptics to get back on the straight and narrow? Or did all of these drugs and their side effects produce a fundamental chemical dependency in my brain, the absence of which left it feeling lopsided in some way?
Given that lobotomy was still occasionally used in those years to treat teen behavioral issues, I guess I got off easy.
My reintroduction to controlled substances came compliments of a severe injury to my left knee that forced me to change careers. After our family relocated to New York City, I decided not to sit for nursing boards to renew my license. I attended culinary school, instead. Chefing was great, until a bad fall completely wrecked my left knee, putting me on Workman’s Comp for the better part of a year, and making a return to the culinary world, with its endless hours of standing on a busted pin, less than desirable.
I’d dabbled in professional photography over the years, doing stock, headshots and even some spot news back home in LA. Maybe the time was right to jump in with both feet?
It’s a fact that our talents lead us whither they will. My forte was, and is, photojournalism. That meant chasing first Occupy Wall Street, then Black Lives Matter and ultimately anti-Trump activists up and down the streets of Gotham. I used my ‘scripts — Percocets, Vicodin, and ultimately a long running course of Tramadol — to keep in gear. For a time I obtained hydro ‘scripts via the Internet. It was never quite as easy as the media portrayed, but it was possible. Initially, I admit, I dosed myself with abandon. But it’s important to remember that schedule III hydro always came compounded, and the acetaminophen or ibuprofen they contain impose limits on how much one can safely consume in a twenty-four hour period. After the honeymoon period, I found it wasn’t terribly difficult to limit my daily usage to within quantities a physician would reasonably prescribe.
The Ryan Haight Act of 2008 essentially put a stop to online pharmacies prescribing controlled substances. After a brief, and foolishly expensive flirtation with dried poppies, I quit using altogether.
A short time later, their college careers temporarily on hold, my son and his fiancé arrived from Minneapolis, bringing with them their two adorable dachshund rescues and a sizeable heroin habit they had developed there. To fund their habit, they had taken to selling it as well. How serendipitous then that our Brooklyn neighborhood happened to be a key location for the distribution of China White, which many junkies preferred over the brown Mexican tar that fills so many East Coast shooting galleries.
“You know,” I told my wife when I finally broke the news to her, “They’re highly rated on Reddit. Very prompt and professional. You gotta be proud … in a way.”
No. She didn’t.
Offering whatever support we could, I agreed to take possession of and dole out the money they had earned … and the extra dope they had on hand.
Biggest. Mistake. Of my life.
Need I describe what happened then?
The time had come to consider Medication Assisted Therapy, or “MAT” to those which it provides daily sustenance and freedom from the screaming heebies. Here in the US, MAT comes in two principle forms: methadone and Suboxone.
Methadone, of course, is a synthetic opioid developed by German chemists shortly before World War 2 in anticipation of disrupted poppy supplies. Suboxone, a more recent development, combines its active ingredient, bupenorphine, with narcotic antagonist, Naloxone.
Between them, Methadone and Suboxone have saved thousands of lives, and improved the quality of thousands more.
But not everyone is a fan.
After kicking heroin with the use of Methadone, 28 year old Robert Lepolzki found himself in court facing a drug charge from the bad old days. Judge Robert Gulotta, Jr ordered Lepolzki to stop using Methadone or any other opioid substitute else face hard jail time. Wrote the judge: “Methadone treatment programs are crutches — they are substitutes for drugs and drug cravings without enabling the participant to actually rid him or herself of the addiction”.
Carrying Gulotta Jr.’s Weltaunschauung to its logical conclusion, a blind or paraplegic defendant appearing before him risked the seizure of his white cane or her wheelchair.
Are those not also “crutches”?
On the positive side, Lepolzki did manage to cast away his chemical crutch, permanently. Six months after appearing before Gulotta he died of an overdose of heroin.
Some inpatient rehab centers, especially for-profit ones, are also not on board. In an article written for St Josephs Institute in Minnesota, Michael Campbell, displaying a profound misunderstanding of the fundamentals of addiction, argues: “The addict’s actions are predictable: when you are stressed you use; when you are sad or angry you use; when you want to feel better and celebrate you use.”
Life’s stressors, positive and negative, might trigger relapse for the abstinent dope fiend, but within the full sway of addiction only the clock dictates the need to use.
Campbell argues further that MAT regimens are “substitutes” for the “work of recovery” without considering the possibility that they actually constitute recovery. For many recovering addicts, physicians and addiction counselors, who cut their teeth in the trenches of 12 Step programs, the use of any psychoactive substance creates a barrier to authentic recovery.
MAT also negatively impacts the bottom line of inpatient treatment centers by obviating the need for hospitalization save for periods of extreme detox.
Walter P. Ginter is the Founding Project Director of Medication Assisted Recovery Services, an organization dedicated to provide peer support to people in recovery who use Methadone and Suboxone to prevent relapse. In June of 2016 Ginter accompanied US Surgeon General Vivek Murthy and NYC First Lady Chirlane McCray on a tour of Montefiore Medical Center’s Addiction Treatment Center.
“My own history,” Ginter told the visitors, “is one of addiction, getting clean, and then, inevitably, relapsing. The problem for me wasn’t when I was high. It was when I was clean. Those periods rendered me vulnerable to relapse. It wasn’t until I started using Methadone that this cycle of using, kicking and falling back into the habit ended.”
I was there, covering the tour for wire services. Was I hearing this correctly? Was it possible that maintaining a supervised opioid substitution regimen could be seen as an end in and of itself, rather than a means to an end, i.e. total abstinence?
Many conditions of mind, and body, demand indefinite pharmacological intervention: schizophrenia, manic-depressive psychosis, diabetes, idiopathic hypertension, HIV, organ transplant, etc.. While ongoing counseling, advice from those with similar experiences and reliance on a higher power might help persons with these conditions cope, they are not the core elements of treatment.
Why is it so difficult to extrapolate this to opioid addiction?
My son and his fiancé found an MD who prescribed Suboxone for them. I followed. For my son, the transition was ghastly. He laid five days abed, sweating and vomiting, before he finally melted a couple of the Suboxone (which in one form is dispensed in gelled, sublingual strip) and shot them up. The whole thing was hairy as hell, but he made it through to the other end.
Because I hadn’t used nearly as long or in the same quantity, the transition was easier for me. I felt good. Bupenorphine, the opioid component of Suboxone, is only a partial agonist. Its euphoric potential is far less than that of traditional and synthetic full-agonist opioids. And because it attaches to the brain’s opioid receptors, blocking all competition like a fat man at an all-you-can-eat buffet, it’s the perfect bulwark against relapse . Even seventy-two hours after the mild euphoria wears off, bupenorphine molecules linger like a belligerently stubborn party guest who simply will not take a hint — demanding enormous, and very expensive, quantities of traditional opiates to dislodge.
I began my Suboxone regimen on three strips per day. Three years later, I still take three strips per day. And I’m content with that. After half-a-century of being a test monkey for the happy pill industry, I believe I have finally discovered the one that helps me to function on a consistent, even bearing. Suboxone relaxed me enough to be confident. In contrast to faster-acting opioids, it doesn’t produce a degree of euphoria that prevents the user from addressing the exigencies of life. People assume, because they see it portrayed on TV and movies thus, that a daily user of opioid medication is some drooling, glassy-eyed quasi-zombie, unable or unwilling to be a contributing member of society. My experience is different. While using Suboxone, I transformed a starting effort in stock photojournalism, earning pocket change, to a career in proper journalism, writing stories I also photographed, and earning a halfway decent living.
Prior to that, lacking the proper education and training of a journalist, I felt I had no right to call myself one. Instead, when the opportunity arose, I raised my hand, jumped in and did the work.
The successful MAT’s regimen’s downsides are almost entirely bureaucratic. The Methadone user winds up hooked on daily visits to a clinic where the slightest error in the medico-bureaucratic chain from triplicate prescription form to DEA control sheet equals twenty-four hours of growing nausea, cramps, sweats and the kind of existential panic a mouse must feel as the cat’s jaws close around it?
Bupenorphine, which remains, at least momentarily, on the DEA’s schedule III, is far more flexible. Would-be prescribers are required to obtain certification before prescribing it, but otherwise, a standard script will suffice, and can even be refilled without additional office visits.
Bupe, however, comes with its own set of issues. Because it’s not typically dispensed in clinics, patients are left to find their own prescriber. In any list of one-hundred bupenorphine-certified providers, it’s likely that one third will no longer be at the current location — today’s physician is nothing if not highly mobile; another third will have already reached the limit of how many patients they’re allowed to take on, and of the rest, some will say they prescribe only for inpatients, others limit their practice to long-term psychotherapy. The remainder don’t participate in your insurance.
Because bupe has a long half-life, withdrawal symptoms can persist for weeks. And purchasing it without insurance coverage is expensive. Out-of-pocket cost for the strips — which most users believe are more effective than the sublingual tablets — ranges as high as $730 per month.
Why choose to live with that monkey on your back, sweating out the end of each month, praying your prescriber didn’t pick this week for an extended vacation in the Antilles? It’s just substituting one addiction for another, right?
Not exactly. Bupeninorphine users who follow their scripts become dependent, not addicted. The key distinction between addiction and dependence is the addict’s need to chase an ever more elusive high by increasing dosages. Dependence, on the other hand, requires continued stable dosing. There are many other drug regimens that cannot be terminated abruptly without significant adverse reactions, such as oral corticosteroids, beta blockers, anti-epileptics and many anti-depressants. All require slow tapers, and so can be considered to foster a similar kind of dependence of a kind.
What dependence on bupenorphine means for me is after approaching the close of my sixth decade confronting creeping obesity, a rising blood pressure that matched my growing blood glucose levels, nights fractured by bouts of sleep apnea, and a recently diagnosed ascending aortic aneurysm, I managed to start my first formal diet, exercise regularly and stop smoking my beloved cigars until I lost 100 pounds, got my blood pressure, cholesterol and blood sugar back to normal sans beta blockers and diuretics.
Because diet and exercise are a journey and not a destination — you never just roll into town, drop your suitcase in the hall and yell, “Honey, I’m home! Let’s order pizza!” — it takes a tremendous amount of confidence to persevere. I have to believe I can continue this more disciplined path for the rest of my life, facing down constant temptation, not using episodes of stress or disappointment as a pretext to break training.
Now, perhaps you’re the sort who managed to initiate an effective diet and exercise regimen while forging a new career out of necessity and desire without recourse to a chemical backboard of any kind. You might say, “Why is this man making dope fiend excuses for his previous inability to live a more straightforward life?”
These are not excuses. They’re reasons. They might not be your reasons, but they are mine. When reporters asked Willie Sutton why he robbed banks, he said, “Because that’s where the money is.” They had given him the opportunity to make an excuse — he grew up poor; his parents neglected him — when instead he gave them a reason.
Had I been diagnosed as bipolar (which I came perilously close to a few years back) I might have been treated with a course of lithium carbonate, or something similar, the side effects of which can include vertigo, malaise, an inability to concentrate, or even read the printed word. Lithium compounds have been life-saving for many manic-depressives. Consider Kay Redfield Jamieson’s account of receiving lithium in her memoir, An Unquiet Mind. After starting the drug Jamieson, a well-published PhD., was unable to focus on the written word and took up needle point as a substitute until the dosage was titrated sufficiently, a process that took several years. But if you can stabilize your mood facing only a mild bout of constipation, why the hell not?
A 2014 study, reported in the Journal of Clinical Psychiatry, described an eight week course of low-dose bupenorphine to treat patients with treatment resistant depression (TRD). In spite of its small sample and lack of a placebo control, preliminary findings were encouraging: “The unique mechanism of action, potential for early effect, and acceptable safety profile make buprenorphine an intriguing molecule to test in older adults with TRD,” the authors concluded.
Two years later, in an NY Times op/ed, Dr Anna Fels wrote about the potential of opioids: “There is obviously a need for extreme caution, but research suggests that certain opioids may actually be useful in treating psychiatric diseases that have proved frustratingly unresponsive to current medications.”
Opiates, along with cannabis, are among humanity’s oldest psychoactive pharmaceuticals. Understanding of the link between opiates and elevated mood pre-dates Hippocrates, and until the middle of the previous century, opiates and opioids were the preferred treatment for many mood disorders. Of course a good strong blast of laudanum (opium in tincture) or heroin in suspension (often combined with cocaine) solved a lot of problems. They produced the sense that everything was right and copacetic — the whole world suddenly bathed in a gentle diaphanous glow.
But they didn’t stabilize mood. The effect was riding a roller coaster. Periods of euphoria gave way to utter despair when supplies ran low, and people frequently had no idea how habit-forming these medicines could be.
After World War II, new classes of drugs emerged — MAO inhibitors, tricyclics, SSRIs, SNRIs — all non-narcotic alternatives that essentially focus on monoamine receptors. Patients were cautioned that benefits could take weeks, or possibly even months of steady dosing before becoming manifest. Side-effects, on the other hand, typically appeared right away. Nevertheless they were a boon to many who suffered from depression, and, although available by prescription only, they were not controlled substances, subject to legislative fiat in times of perceived crisis.
Proposing bupenorphine as an anti-depressant and mood stabilizer draws on millennia of tradition, while bringing into play the stability of a state-of-the-art partial agonist that effectively transforms the roller coaster into a merry-go-round. Its inherent ceiling effect keeps the user grounded. Like Methadone, it produces a profound dependence, the downsides of which are nearly 100% bureaucratic rather than functional.
Also in common with the standard arsenal of accepted psychoactives, it isn’t for everyone. But as debate over the precise nature of what addiction is continues to rage — is it a disease? A learned behavior? Evidence of moral degeneration? — the application of proven, life-saving treatments should be one area upon which everyone can agree. That drug-fighting policy-makers appear to continue to support Methadone programs, while easing restrictions on bunenorphine providers offers a slender ray of hope that we might emerge from this period having made real progress.