Surgery, Pain Killers & Recovery

So, you have planned surgery coming up, are in recovery, and feel conflicted about whether or not you should take pain medications post-operative.

On one hand, several of your friends in recovery are adamantly advising you too definitely “not” take the pain medications; on the other hand, from your own research (on pain and healing time) you have learned that when one is in pain, they heal more slowly.

Your friends are concerned that being on the pain medications you will end up with a “habit” and return to your former using ways; regardless of whether or not pills were your primary addiction in the first place.

You are concerned since your readings on pain and healing time indicate that without the pain medications you will be in pain longer and heal more slowly; the longer I remain in pain, the higher the possibility of my wanting to self-medicate the pain away.

What should I do?

Take the pain medications.

However, I suggest this with several stipulations in mind.

The first is to have someone else hold the medication for you; even if pain killers were not the issue when you were an active addict.

Secondly, make sure the prescribing doctor titrates the medication down over the course of the prescription to end at zero.

It should never be here are 90 Percocet’s, take three a day for thirty days, and then stop. Then just stop? What are you kidding me? Even people without an “addiction” would feel withdrawal after that.

Having been a preceptor in the past for first year residents at a local area medical school on addiction & co-occurring disorders, I was always amazed at how little overall training time our future doctors were getting on addiction & other mental health issues.

Then again, I must admit I am biased due to working in the field of addiction. I view my position with doctors as that of a colleague in this arena; we learn from each other. We can and do work together on addiction issues.

A suggestion that I make to all my patients and clients is to find a PCP (primary care physician) that belongs to A.S.A.M. - American Society of Addiction Medicine. Doctors that join this organization are attending workshops throughout the year to stay current in the field of addiction and addiction treatment.

Is this a guarantee that the doctor will always prescribe appropriately for those that have addictions? No, not necessarily. However, by belonging to A.S.A.M they are obtaining more information on addiction & addiction treatment then they initially received in medical school. This can increase the quality of care for their patients that have addiction issues (active or inactive).

You Look Familiar...

It was a Sunday morning and there was a knock on the front door of the detox. When I opened it two women in their late twenties stood there smiling at me. For a couple of long seconds they just stood there.

Something about them looked familiar, I felt like I knew them from somewhere. When I introduced myself they laughed.

One of them spoke up, “Willy don’t you remember us, you called us the “Toxic Twins” when we were here.

I took a harder look, “For the love of God, Mary, Beth, I can’t believe it!” You guys look great, what have you been up to?

They had gone to the same halfway house and when they graduated; had found an apartment, gone back to work, and were taking a couple of college courses.

They said they just wanted to drop by and say “thanks” for the help they had received from the staff during their stay some eight months previous.

“You did the work, we just made the suggestions,” I said as I stood there beaming at these two walking miracles.

I asked them to come in and visit with the rest of the staff. While they were chatting with us we learned that the AA commitment that was scheduled for that morning had cancelled out. Without skipping a beat, they asked if they could put on the commitment.

“Absolutely” all of us almost simultaneously quipped. The two of them said they would be thrilled to be able to speak about their recovery at the spot where it all began for them.

Afterwards the patients commented on what a terrific impact these speakers’ stories had made on them, particularly because they had been at this detox and they were doing so well.

They are a reminder as to why I do the work I do…

"Willyisms" (Thoughts from working in the field)

Meet the Patient where they are at, NOT where you are at, or, want them to be at

Often times the angriest patients are the ones in the most psychic pain

If you work in the addiction field and are in recovery yourself, keep your recovery program separate from your work

No one ever broke out because they stopped going to meetings, you need to help them look at what was going on, or, not going on

You show me a person with ten plus detoxes, and I will show you a person that has other issues going on aside from substance abuse/chemical dependency

I’m glad you made it back to the detox…not everyone does’…

Always have family meetings at the detox if the patient is willing…the apple does not fall very far from the tree

You really do not see a lot of addicts/alcoholics sent to long-term inpatient psych facilities. That is where you find their friends and families (without substance abuse issues) that have been trying to make sense out of their loved ones’ use (without supports)

Said to a fellow counselor (in recovery) after hearing his interaction with a patient at the detox: ‘just because a course of action worked for you, that does not in and of itself mean it will work for the patient you are working with (are you hearing them or just waiting for them to stop talking so you can take on the Expert Role)’

‘Hey, are you a professional counselor, or, looking to be a sponsor for all the patients?’

‘Hey, nice boundaries, you better see them at the meeting on Saturday after they discharge?’

‘I’m concerned, (to a fellow counselor), from how you describe your life everything centers around work and meetings…nothing else’

‘There is no place for sympathy on the part of a therapist toward the client; empathy and compassion yes, sympathy, no’

‘I believe every person that works as a therapist/counselor needs not only supervision, but ongoing therapy in order to stay healthy’

People working in Psych, People working in Addiction - Never have two groups had so much in common, yet, been so separated by language (sort of churchillian, no?)

Layman’s definition of Bipolar I & Bipolar II: Bipolar I, “I am God,” Bipolar II, “I act like I am God”

No one grows up wanting to become an addict or alcoholic…I have yet to see it on a resume

Show me a person that espouses the view that addicts and alcoholics ‘want,’ to be the way they are and I will show you a person that more than likely, has rampant addiction issues in their family

Spirituality should not be confused with emotionality

The patient has to want recovery for themselves as much as, or greater than I want it for them

Hope without a plan of action is pretty much dead in the water

So long as my patient/client is breathing, change is possible

I wonder how many drug overdose deaths are suicides without a note

Substance Abuse & Co-occurring Disorders are the Expectation not the Exception

Chapter 3. "Already Dead"

This patient still haunts me to this day. Pat was one of our old time alcoholics. He was forty-six, and the last twenty five of these years were a series of unending trips to the detox. He had well over a hundred documented detoxes, but this last one was especially disturbing. Mary, the director, had asked me to sit in with her on a family intervention we were hosting. Pat’s mother (who was in her seventies) and his sister (whom I recognized from a town organization to which we both belonged) were among the attending.

We were trying to convince him to include a half-way house his discharge plan. He had never tried one before and was less than eager to try now. But his liver function tests and biopsy showed late stage cirrhosis - If he drank again, the ball game was almost definitely over.

As I was talking to him an eerie feelings came over me. I had only experienced this feeling once before when talking to a patient, and that patient died less than twenty-four hours later. It is difficult to describe but it felt like I was talking to a person that was already dead, a shell of a person. He stared straight ahead as I talked. His eyes were like black, lifeless coals. When he spoke there was no emotion, just a vacancy, almost as if his soul had already left his body.

He was adamant in a quiet, monotone voice. He would only go to a half-way house if he broke out again. We all tried to point out to him that he had tried on his own over a hundred times without success. Maybe it was time to let others do his thinking for him; at least until he reached some comfortable level of sobriety. His sister’s eyes were welling up with tears, but even this did not alter his blank stare. His mother, as the matriarchal glue that had held this family together after Pat’s father had died of cirrhosis, tried her best – but alas, to no avail. Pat wasn’t taking in what we said to him. His plan was to return home again to his mother’s house where he had a basement apartment, and go back to AA.

About a week after his discharge, Mary called me into her office one morning. “I know you have tomorrow off, but can you come in Thursday morning? We have a funeral to go to.”

I looked at her and said, “Pat?”

“Yes,” she said. "The family would really like us to be there for all the time we had spent trying to get him to change his mind." When he got back home he had locked himself up in the basement apartment and proceeded to drink himself to death.”

“Yea, but Mary I feel like we failed him and his family.”

“No Willy, his addiction was too powerful,” Mary said to me. “We did all we could. Sometimes we have to let go when a person is listening but unable to hear what we are suggesting. We may work on behalf of a Higher Power, but we are not the Higher Power, right?”

“Yea, I guess so,” I muttered.

The next day we attended the funeral. At the grave site an unseen bagpiper began to play Amazing Grace. I took one look at Mary and we both began streaming tears. God, that song hits me the same way every time I hear it. Pat’s mother was one of the few that were not crying. She thanked us for coming and said, “Well, at least Pat is out of his misery now. He suffered for so long.” What a strong woman I thought to myself.

Death by alcohol – First her husband, then her son.

What Is Normal???

I am always amused when someone poses this question to me; whether it is a student, a colleague, or a patient.

What an all-encompassing, general, biased question to ask.

The German philosopher Arthur Schopenhauer stated, “Every man takes the limits of his own field of vision for the limits of the world.”

In other words, if you grow up in a house of chaos with yelling, screaming, fighting, kicking, drinking and drugging going on; that is ‘normal’ for you.

The answer one gives to such a question is based on their experiential history.

One of my favorite examples is a woman I will call Mary. At the time Mary had five years ‘clean’ from heroin and was telling me about a recent event in her life.

Say Willy, how are ya!

Good Mary, how’s by you?

Oh Wicked Excellent! Things couldn’t be bettah! (Boston accent).

That’s great to hear.

I can’t believe my luck!

How so Mary?

I recently got engaged to a guy with seven years clean…and he’s never been to prison! Can you believe my f-in luck!

Hmm, you don’t say.

As I was driving home that night and what she had said started to reverberate through my head. Thinking of her background it started to make sense to me.

Let’s see, she had grown up in the “projects” in Boston. Weren’t her father and uncle doing ‘federal time’ for bank robbery? All the men in her life to that point were either up for a ‘bid,’ doing a ‘bid,’ or were just released from completing a ‘bid.’ (Bid is jail time).

The term ‘normal’ does not in and of itself state anything regarding healthy versus unhealthy however.

Entering into my 21st year in the mental health arena this fact became readily apparent early on.

People become accustomed to behavioral patterns that are not necessarily healthy for them; it is what they know.

This may explain in part why people avoid or fear change even it means they will have the possibility of being in a healthier state.

Some will work a job for twenty years and ‘bitch’ about it every day. Sort of like a tea kettle that lets off steam so it does not explode. Start to mention possible options such as going back to school or looking for a new job and the excuses start flying, I’m too old, I wouldn’t know where to look, etc.

In essence, “I know how much misery to expect on a daily basis and if something nice happens, great.

Instead of the possibility, most days my life is fairly happy and once and awhile something miserable happens.

What is normal? I do not know what is normal for you; I only know what is normal for me
I guess more importantly what it comes down to is, ‘Is your state of being ‘normal’ healthy, or unhealthy for you.

I wrote a blog similar to this one several years ago and one of the comments I got back was, “The concept of Healthy or Unhealthy can be challenged as a personal perception of preconceived concepts arising from present day values and inherent biases. What is "Healthy"?

The example I had written about was drinking a quart of scotch a day. My response in part was, “Would not drinking a quart of scotch daily at the least, compromise one's health? You tell me, and if so, would this not be deemed biologically unhealthy? (I had no response back from “Anonymous,” big surprise, lol)

One can hide behind an “intellectual guise” by referencing, “personal perception of preconceived concepts arising from present day values and inherent biases” if they want to.

Bottom line, cirrhosis is never healthy, is it?

Death of a Detox (June 25th, 2009)

The rumor had been circulating for more than a year that the detox might be closing. Ever since the state had been reforming the public healthcare system we understood that major changes were going to be implemented.

Our organization and primarily one other in the state had been divvying up the free care pool, of which detoxification beds had been a part.

Prior to the state healthcare reform, our detox had been receiving over two thousand dollars a day per bed. Since the reforms were enacted we had seen that amount dwindle to just over two hundred dollars a day. Something had to give; in this case it was our unit of twenty-six beds.

So on the morning of January 28th, 2009, the head of nursing for the organization, the nurse manager for our unit, a representative from HR, the medical director for our unit, and several mid-management people made their way onto our unit.

They gathered us into the back staff room like a herd of cattle and asked us to sit down they had an announcement to make (I chose instead to sit on a computer desk, staring at the floor). In my ‘gut’ I knew what was coming.

“Due to the financial crisis within our organization, we will be closing the detox on June 30th” (later revamped to June 25th). Most of the people in the room initially sat in stunned silence. My feelings went from rage to sadness. After all this time of “wondering” what was going to happen, we finally knew.

Not that we had ever been allowed to be a part of the process, or decision. This was probably the reason I had initially felt such rage when they made the announcement; we were just the peons that ran the unit, nothing more, and nothing less.

This was strictly a business decision on their part; at least this is how they presented it. For years the organization had essentially ‘raped’ the free-care pool, now that those monies were gone they were walking away from providing this inpatient service. No, “we have been developing a plan so that when the closure comes, patients in need of detoxification services will still be served.”

To some, it seemed amazing that DPH (substance abuse services for the state) would allow this. A few counselors felt that DPH would not consent to the final sign-off on the closing of the unit. “It’s not over yet!” was their credo. I knew better. They never would have made this announcement without already having discussed it with DPH

Wake up people. Do you really think that DPH would slash its’ own programs to fund a unit that had been outside of DPH looking in at them for years? Don’t be foolish, absurd.

Besides, the organization had more to gain financially if these patients were channeled into their DMH regulated beds; a higher rate of reimbursement and they would not have the DPH constraint of only 3-5 days for detox.

How could these patients in need of detoxification make their way onto the locked psych/addiction units? Quite simple my friends, it begins in the Emergency Department where the street smart addict/alcoholic will say they are suicidal. Next the assessor will ask them if they have a plan, they will answer “yes.” Next the assessor will ask them what the plan is and the addict/alcoholic will refuse to tell them. Viola! Now you can not let them go, they could pose a danger to themselves and/or others and they have a detox bed.

Psych is the bastard child of medicine, and addiction is the bastard child of psych.

Treatment: What To Look For (Part II)

What type of a treatment program should I be looking for? A thirty day, a sixty day, maybe even a three or six month program. Should it be day, evening, or a residential program?

It is all just so confusing!

Why yes it is. To begin, I would find out as much information as you possibly can about any potential programs.

Information such as: the ratio of staff to patients; the credentials and years in the field of all staff; what specific modalities of treatment they employ (12 Step based, CBT or DBT based, Expressive Therapy based, or a mix of these and/or other modalities) and why they utilize those specific methods.

The concern I always have for families or individuals trying to chart their way through the maze of choices is the fact that there are programs out there in it for one reason, and one reason only, the Greenback (in much the same way that an unscrupulous funeral director can take advantage of a grieving family).

Place a call to the Better Business Bureau about any program that you might be interested in to see if there have been past negative reports regarding their practices.

If they boast a success rate of say, ninety percent do not be afraid to ask them how they arrived at that number. If the number was not calculated on “evidence based” information, move on to the next program on your list.

Think about enlisting an experienced addiction therapist or counselor to make the initial inquiring calls to the programs. This often will have the effect on the program of “cutting to the chase” in their information since the perspective client is being represented by a professional.

One of the suggestions I make to patients in the day treatment where I work is to think in terms of what was working in the past (to a certain extent – otherwise they would not be hearing me say this to them, right?), now, what can I add on to that to increase the probability of staying sober.

For some that might mean joining a men’s or women’s trauma/grief group, acquiring the services of an individual therapist, a support group for people with affective disorders, such as depression and bipolar disorder, etc.

I emphasis to them that if they do not do anything different, they will probably be coming back; not that everyone makes it back, many don’t. Over the past twenty plus years in the field I have attended too many wakes and funerals.

“What can you do differently this time” is my credo to them.

Spending $100,000.00 for a treatment facility in "Boca" is definitely not a guarantee of sobriety post-program.

If you have specific questions please feel free to ask in the comment section at the end of this blog and I will get back to you within twenty-four hours.

Treatment: What To Look For (Part I)

Almost every time I discuss this topic with colleagues in the field of psych/addiction, we end up in heated arguments.

I am a believer that a person does not have to be in recovery to be a good therapist or counselor (please read a previous blog entitled, “Are You in Recovery?”). This is not where most of the arguments begin however.

An area that can start arguments is when I state I believe a person should basically, ‘interview’ a therapist that they are going to see for the first time.

Their usual response back to that statement is, ‘well, if the therapist is properly trained they should be able to see any type of client.’

I disagree.

It would be difficult to convince me (or practically impossible) that a person with addiction issues and a history of trauma would be a good fit with a therapist that has worked in the substance abuse field, but has never had a client that also had trauma issues. Or, vice versa for that matter.

What if they had courses on trauma? That is a start. The client would benefit more I believe if the therapist has actual clinical experience working with those that have trauma in addition to their addiction issues. In all likelihood a therapist working in this area would know the resources available and how their client can access them.

Book smart alone doesn’t cut-it for me. Academia is great and necessary, and definitely enhances ‘clinical’ experience. In and of itself though, ah no.

Personally, the first time I meet with a perspective new client I will tell them beforehand that I would like to meet with them for twenty minutes or so (no charge) to have a discussion on specifically what they looking for from therapy and/or counseling, what is their understandng of therapeutic relationships, and then the two of us can decide if it is a good fit or not.

I know the areas where my expertise lies within the field of addiction and co-occurring disorders. If during that initial conversation they mention trauma issues, I would offer to refer them to several therapists that specialize in that arena as well as the addictions. I feel that I do not have enough academic nor clinical experience to assist them in a truly beneficial therapeutic relationship. Therefore referral.

For those with Bipolar and Depressive Disorders I always sugest that that they find a local chapter of DBSA (Depression Bipolar Support Alliance) and attend one of the meetings. Usually the largest sub-group within the meeting is 'Double Trouble' for those with the aforementioned disorders and addiction issues as well.

Additionally, and also of great import is one can learn from discussion with the members whom they would recommend as a therapist and psychopharmocologist.

Part II will be looking at treatment programs.

Success Rates????

I love when I read the Sunday magazine supplements from the Globe and the NY Times and in the back they often have advertisements for "luxury" addiction treatment centers that boast say, 90% success rates.

Being a curious fellow I felt it my obligation to call one posing as a perspective client to inquire about their facility and the purported "success rate."

After some initial questions such as is it true 12 Step meetings are held poolside before the afternoon tennis matches, and, can one schedule a massage after dinner hours; I hit them with the main question I had in mind for the phone call in the first place.

I read that you have a 90% success rate, that is fantastic I must say! I am curious though, how did you arrive at that number?

Well, we call past clients periodically that have attended our program;

Oh, how soon after they leave your program do you call them;

that varies, sometimes a week or two, maybe several months.

I see. You must get people that do not respond to your phone calls, how do they fiqure into your numbers;

we don't include them.

Interesting...

The person on the other end of the phone is beginning to suspect the reason for my call so it abruptly ends.

I am a bit perplexed by those that would send their loved ones to such a facility.

So let me get this straight, your 'loved one' that when they were using stole everything from you such as money, jewelry, your sanity (if you were not getting help for yourself) and you are going to secure a second mortgage on your home to finance having them go to a luxury treatment center that boasts a "90% success rate?"

Jesus, what would you do if they burned your house down and kidnapped your dog for ransom, send them on a three month European vacation?

I mean come on, really?

There are other options that are more cost effective. My next blog will talk about those options in depth.

There is a program in our area that charges $52,500.00 for a month.

Be my guest...

Don't Want To Get Them In Trouble?????

You know, I have heard this story before. Fortunately not that often. A student in a class that I currently teach came up to me during a break obviously feeling bothered by something.

The student stated they did not know what to do after hearing a couple of counselors where they are interning discussing two of their clients that had tested positive on their random urine tox screens.

Seems these two counselors were not going to notify the probation officers involved because they did not want to get the two of them in trouble.

The counselors would get them in trouble? Here is a reality check: ah, they got Themselves Into Trouble!

I question whether these 'two' counselors are getting adequate supervision. They need to be taught about external versus internal thinking.

These clients are now being enabled by their counselors to continue using without consequences for their actions.

Will the clients benefit from the counselors actions (or inactions in this case) no, definitely not.

While reporting them may seem punitive, the reality is the true punitive action is the drug(s)continuing to run their lives for them.

Reminds me of several instances where I have had patients screaming at me, "why are you throwing me out of the program!"

I'm throwing you out of the program? Hey, take ownership of the fact that you "threw youself out." You knew what the rules were. I'm not here to pay your consequences.