‘Open source sobriety: Getting past chauvinism in early recovery’ by Matt Robert

woman-in-cellHere’s the latest posting on Marc Lewis’s blog, a guest blog from Matt Robert.

‘Here’s another guest post, and it’s a winner. Sincere thanks to Matt Robert, a  SMART Recovery facilitator I met last June in Boston….

I’ve been spending a lot of time these days going in and out of locked detox units. And it’s interesting because, in most important ways, they haven’t changed very much at all. But I’ve changed, and the reason for my going into them has changed as well. Now I go into them because I want to, and I leave because I can.  I go into them now to talk about recovery.

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What works in treatment?: Michael’s Story

rsz_img_1525Treatment for addiction involves a number of different processes. What are the most important? Who better to tell us than the people who have used treatment to help them recover from addiction. 

During the next week, we’ll look at the views of some of those people who have so kindly given us insights into their lives through their Recovery Story.  We’ll start with my close friend Michael from Perth. Let’s look at some of his experiences from the moment he decided to stop drinking over 35 years ago and his views on treatment. 

‘I made the decision to stop drinking on April 10th, 1978, three years after my parents had died. My last drinking session took place at the Shenton Park Hotel. I finished my last drink and slammed the glass down, saying to myself that this was it! “No more drinking!” I have not had a drop of alcohol since then.

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Most visited content: Nos 10 – 6

rsz_img_5024And the drum rolls as we enter the top ten most viewed content on recovery Stories. 

10. Journeys into and out of heroin addiction, Part 2, is an article I wrote that focuses on living with addiction and covers such topics as relationships, changes in personality and lifestyle, hustling, crime and prison, impact on health, and treatment .

9. Opiate detox: methadone or suboxone by Peapod is the third part of Peapod’s Recovery Guide. Peapod was the most visited blogger on Wired In To Recovery.

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‘Opiate detox: methadone or suboxone’ by Peapod

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

This is the third part of Peapod’s Guide to Recovery, a series of articles written by Wired In To Recovery’s most visited blogger.

‘I don’t like stand alone detoxes, mostly because they almost always fail to deliver. Relapse is the norm if all you are offered is detoxification. I’ve written about this before in Detoxification: the nuts and the bolts so won’t go over old ground, but I will say again that success depends on the stuff that goes on around the detox and in the days, weeks and months afterwards.

This rough guide is written for those of you (or your clients) who might be thinking about detoxification.

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‘Opiate detox: methadone or suboxone’ by Peapod

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

“Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.”

I don’t like stand alone detoxes, mostly because they almost always fail to deliver. Relapse is the norm if all you are offered is detoxification. I’ve written about this before in Detoxification: the nuts and the bolts so won’t go over old ground, but I will say again that success depends on the stuff that goes on around the detox and in the days, weeks and months afterwards.

This rough guide is written for those of you (or your clients) who might be thinking about detoxification.

Getting ready
Preparation is key. Getting ready and knowing what it’s going to be like will make it easier. The goal of a good detox is to help reduce unpleasant withdrawal symptoms and to keep things safe. Make sure you understand from your prescriber what’s going to happen.

Let’s assume you have a package of treatment and support set up and detoxification is an early part in your journey. If you are coming off opiates then you may be offered some choices around the nature of your detoxification plan. On the agenda may be discussions around whether you should use methadone, Suboxone (or subutex) or even lofexidine to help you withdraw.

What should you choose?
NICE is an organisation which makes recommendations to the NHS based on research findings. There are many recommendations and considerations in their guidance. This blog is not an in-depth guide. It’s important that things are kept safe so speak with your prescriber.

In the NICE Opiate Detoxification Guidelines, they suggest that if you are prescribed methadone or subutex/suboxone on a maintenance basis, then you normally ought to detox on the same drug. Research indicates that neither drug is better than the other though withdrawals are over faster with Suboxone than methadone.

In practice, you’ll almost certainly get some choice around what drug to use for detox, but there’s more to think about than the drug alone. Here’s what NICE say:

“In order to obtain informed consent, staff should give detailed information to service users about detoxification and the associated risks, including:

  • the physical and psychological aspects of opioid withdrawal, including the duration and intensity of symptoms, and how these may be managed
  • the use of non-pharmacological approaches to manage or cope with opioid withdrawal symptoms
  • the loss of opioid tolerance following detoxification, and the ensuing increased risk of overdose and death from illicit drug use that may be potentiated by the use of alcohol or benzodiazepines
  • the importance of continued support, as well as psychosocial and appropriate pharmacological interventions, to maintain abstinence, treat comorbid mental health problems and reduce the risk of adverse outcomes (including death).”

How long will it take?
That depends on what sort of level of methadone or heroin or suboxone you are starting out from and also on the setting. In an in-patient unit, a detox will take less than a month generally (sometimes much faster).

In the community, it could be much longer though the guidance suggests that around three months would be reasonable. If you are doing it in the community you’ll probably have to pick your medication up daily from the pharmacy.

Methadone
Many folk have successfully completed detoxes on methadone. Withdrawals are generally not too uncomfortable with reductions at higher levels, but begin to bite a bit below thirty milligrammes. The NHS Orange Book Guidelines suggest reducing methadone at 5mg every one or two weeks. The last few mls can be problematic for many.

Methadone is generally more sedating than Suboxone but it has the advantage to many of familiarity and you don’t have to worry about moving onto a drug you’ve not tried before.

Suboxone/subutex (buprenorphine)
The main player here is buprenorphine. When naloxone, an opiate blocker is added in to reduce abuse, the combination is called Suboxone. Buprenorphine is a newer drug than methadone and it has some advantages and one or two tricky points.

The most important thing to remember is that you can’t start Suboxone when you still have significant amounts of methadone or heroin (or any other opiate) in your system because it can cause withdrawal to suddenly occur and when that happens it’s horrible. This is because opiate receptors in the body love buprenorphine and give up their methadone and heroin molecules at the drop of a hat to accommodate the buprenorphine. The sudden loss of the other opiates causes this withdrawal and there’s not much you can do about it, so it’s best to avoid the situation where it might occur.

The bottom line is that you need to have allowed at least 24 hours (often more) after the last methadone dose or eight hours after the last heroin dose before you can start subutex and the prescriber will want to see some evidence of early withdrawal just to make sure.

It’s also difficult to convert to Suboxone when you are on higher amounts of methadone. Generally prescribers like you to be under 30mls, so you will have to detox on methadone down to that kind of amount.

In some people, Suboxone causes a headache and for everyone it tastes a bit bitter (it’s absorbed from under the tongue). People commonly report a “clear head” on Suboxone compared to methadone.

The Orange Book Guidelines suggest reducing by 2mg every two weeks to start with and slowing down to reductions of 400 microgrammes towards the end. Withdrawals from Suboxone peak a few days after the last dose and get better rapidly afterwards.

Lofexidine (Britlofex)
Not an opiate, but works on a body system that turns the dial down on some opiate withdrawal symptoms. In some centres, you may be offered this alone to help with withdrawals, though it is most often added in to a methadone or Suboxone detox, usually towards the end.

It can drop your blood pressure, give you a dry mouth and make you feel a bit drowsy, but it’s quite good at taking the edge off withdrawals. Lofexidine is usually only prescribed for about a week, starting at a low dose, building up rapidly and then tailing off again. Not a good idea to stop it suddenly as your blood pressure can jump. Ask your prescriber about whether it might be helpful at some point. I don’t think it’s available in the USA.

Complicated detoxes
Where there are a few drugs in the mix, e.g. benzodiazepines and opiates or alcohol and opiates, then it’s often wise to be attending a specialist service and there’s more likely to be an in-patient admission involved.

The same might be true if you’ve had complications on detoxing before (e.g. seizures or mental health problems). If you have other medical problems or complex social issues, then a residential detox may well be best.

Down to you
Ultimately, the choice is yours. I would suggest when speaking with the prescriber or clinical staff that you ask them what they would choose in your position.

If you are asking me, it would generally be Suboxone though there would be some exceptions to this; I think people are more comfortable on it and the discomfort is over faster.

If you don’t fancy the (usually minor) discomfort of converting to Suboxone from methadone, that might be a reason to go down the methadone route.

I can’t stress enough that what goes with the detox will determine how successful you are at achieving your goals of a drug-free recovery. So many people think of the detox as being the important part. If recovery is the train journey from London to Aberdeen, then detox is the time taken to call the taxi. You need to think about the rest of the journey.

Being in an intensive treatment setting, attending mutual aid and being engaged with peer support services will increase the odds of success. The more support you have the better.

Don’t forget those harm reduction messages of loss of tolerance and risk of overdose on relapse. If you do go back to using: use less; don’t inject; don’t use alone and don’t mix drugs.

Being informed will empower you. Don’t be afraid to ask questions – remember it’s your detox. The prescriber is there to be your guide and supporter, not to dictate. Good luck!

PDF document >

‘Detoxification: the ‘nuts and the bolts’ by Peapod

“Expect the first few weeks to be rocky emotionally. Life can feel a bit ‘greyed out’ for a while and youʼll need to adopt a longer-term view. Getting to as many recovery meetings as you can manage during this period will help.”

“Expect the first few weeks to be rocky emotionally. Life can feel a bit ‘greyed out’ for a while and youʼll need to adopt a longer-term view. Getting to as many recovery meetings as you can manage during this period will help.”

Okay, youʼve got to the point where you are looking to detox but youʼre not sure what the nuts and bolts of it are. How do you go about it and how do you know you are ready? What can you do to boost success?

Here are my suggestions, which are based on guidance and my own experience of working with hundreds of people going through detox.

First things first: “detox plus”
The first thing to say is that any detox which is not connected to other things will almost certainly fail. You might get through the detox (or “stopped”) but remaining drug free (“staying stopped”) is very, very unlikely without other things added in. Not to mention that itʼs potentially dangerous too. Donʼt set yourself up to fail.

Itʼs best to see detox as a tiny part of the recovery process. Important, no doubt about it, but in the grand scheme of things not a giant cog in the machinery. Recovery is a longer-term process.

What is the “plus” part of “detox plus”: what needs to be added in?
1. Ask: am I ready? You will probably have a feel for this because youʼve been working towards this goal for a while and others have been supporting you. If youʼre using regularly on top of your script or have major stressful life events going on, you may want to wait a bit, or get referred for consideration of residential options where the support is highest.

2. Weigh up the pros and the cons. Everything involves some sort of risk. Talk to others whoʼve done it successfully. Make an informed choice.

3. My next suggestion is to get referred to an intensive community or residential rehabilitation programme. Some will offer detox as part of treatment. Your prescriber or support worker will be able to advise. Try to get onto a programme that is at least three months long and that prioritises connecting up their clients to peer-led recovery communities.

4. Get involved with local recovery community activities in any case. The most important of these is mutual aid. Groups like Narcotics Anonymous, Cocaine Anonymous (you donʼt need to have a problem with coke) and SMART recovery offer peer-based support.

The evidence suggests that engaging with these groups reduces relapse rates and adds much to quality of life too. You donʼt need to be drug-free to attend.

5. If youʼre not going to sign up to intensive treatment, then get started with meaningful activities daily. Find an educational course or volunteering opportunity and get stuck in. Structure your days and donʼt spend time in bed or stuck to the TV or computer screen.

6. Stay away from using friends and places you associate with scoring and using. These are powerful triggers to use when you are feeling vulnerable.

Detox basics

1. Donʼt do your own detox. Shutting yourself in a room with DFs and Valium might seem like a sensible idea, but it is not known for its success rates. Achieving your goals is much more likely if you have an expert in detoxification supporting you as you do it. Cold turkey is being unkind to yourself and has low success rates.

At the same time, this is your detox, so youʼll want to know you have some say in how it looks. It shouldnʼt be something that is done to you, but something you do with the support of the prescriber. Alcohol, GHB/GBL and Benzodiazepine detoxes are particularly dangerous if not medically supervised.

2. If you are coming off opiates, discuss whether you want to use methadone or Suboxone to detox. In some areas you might also have the option of lofexidine (Britlofex) too. Occasionally some doctors offer a dihydrocodeine (DF118) detox. Iʼm going to write a separate article on choosing between a methadone detox and a Suboxone detox.

3. Get as much support around you as you can. If you are in a structured day programme, residential treatment or a therapeutic community, the support ought to be built in.

If youʼve chosen to try this without that sort of intensive input, then tell your mutual aid group members what youʼre planning, get your prescriberʼs support and that of family members (non-drug using). Do some relapse prevention work and donʼt rely only on yourself. I canʼt stress this enough; most of us need help to do this.

4. If you are struggling, admit it. There are various medications that can be added in to help with any unpleasant symptoms like pain, insomnia, nausea, diarrhoea, cramps etc. Emotional support from positive people will boost your chances of success. If you know people whoʼve been through detox successfully, find out how they did it and get their help.

5. Expect the first few weeks to be rocky emotionally. Life can feel a bit “greyed out” for a while and youʼll need to adopt a longer-term view. Getting to as many recovery meetings as you can manage during this period will help.

6. Guard against relapse and if you do go back to using, remember loss of tolerance and the increased risk of overdose. Donʼt use as much, donʼt use alone, donʼt inject and donʼt mix heroin with other drugs (particularly alcohol or valium).

7. Remember a lapse is not the end of recovery. Itʼs common and not a cause for shame or giving up. Most of us need more than one go. Going back onto maintenance for a while is a viable option, as is getting referred to a more intensive treatment setting.

PDF document >

Detox and early abstinent recovery: make it easier

“If you are planning a detox, get ready for it. It’ll be much easier if you know what to expect. Don’t do your own detox, let someone else be in charge. Stand alone detoxes will almost all fail: you need detox plus. By that, I mean more has to be added in. Getting onto an intensive treatment programme (either residential or community) at least three months long is likely to help. Stay away from using or drinking friends and delete dealers’ numbers from your mobile. Always remember, you only need to do this once.”

“If you are planning a detox, get ready for it. It’ll be much easier if you know what to expect. Don’t do your own detox, let someone else be in charge. Stand alone detoxes will almost all fail: you need detox plus. By that, I mean more has to be added in. Getting onto an intensive treatment programme (either residential or community) at least three months long is likely to help. Stay away from using or drinking friends and delete dealers’ numbers from your mobile. Always remember, you only need to do this once.”

Peapod was one of the most prolific and respected bloggers on Wired In To Recovery before going into ‘retirement’. (S)he wrote a series of must-read blogs containing important hints to facilitate recovery which were very popular. Peapod’s empathy and understanding, as well as experience in the field, shone through in these blogs.

I’ve arranged these blogs into what I call ‘Peapod’s Guide to Recovery.’ This is the first of seven articles.

Detox and early recovery: what’s it feel like?
‘’Empty’; ‘cored out’; ‘flat as a pancake’; ‘anxious’; ‘aching’; ‘miserable’… all comments I’ve heard from clients after detox. It resonates with my own experience. I’ve been detoxed twice and I found it pretty hard going.

This week, I’ve spotted a few people on Wired In asking if it’s normal to feel so low after a detox. I’ve commented in each case I’ve spotted because I know what a vulnerable time it is. Have ever walked or driven across a salt pan? These are big flat expanses of endless monotony and sometimes used as a metaphor for the post-detox experience. So why is detox and the immediate time after so challenging?

A bit about the brain
Whether you sign up to the disease model of addiction or not, there’s overwhelming evidence to show that addiction causes changes in brain structure and function. As addiction takes hold, several things in the brain start to change.

Various drugs cause the pleasure chemical dopamine (a neurotransmitter or chemical messenger) to be released in large quantities. Cells near the ones that release dopamine pick it up on their surfaces through dopamine receptors stimulating the cell so we feel pleasure. Over time, the body thinks, ‘Wait a minute, with so much dopamine around, I’m feeling a bit over-stimulated; I don’t need all these receptors’ and shuts some of them down.

In addition, some drugs can suppress many of the brain’s activities. They turn the nervous system’s dial down a few notches, quietening nerves, worries and alertness. During detox, the dial gets turned back up suddenly. Lots of different neurotransmitters behave in odd ways. Pulse rises, blood pressure goes up, tremors, sweats and agitation are to the fore. It’s pretty unpleasant admittedly, but the good news is that all of this has a limited shelf life. It does get better.

Life is a bit greyed out
The first part of recovery is a bit of a pleasure desert. Scientists say that one effect of the limited number of pleasure receptors is that it is harder to feel pleasure from ordinary things early in recovery. Spending time with friends doesn’t do it. Having a meal out or going to the pictures hardly gets a blip on the pleasure radar. It’s no surprise that minds turn to the one thing that’s going to flood those limited receptors and create an oasis in the desert. Using or drinking again.

This does get better
As time goes by, the brain starts to readjust. Receptor production is switched on. The nervous system activity dial that’s been on max gradually gets turned back down again. We feel calmer, less empty and more hopeful, but only if we stick with it and get through the tough bit.

Clear and present dangers
There are three things to watch out for that might trip you up in those early weeks (or indeed at any time).

Stressful situations. Brain stress hormones can trigger the desire to use drugs or to drink. We need to find new ways of managing or avoiding stress. Sharing the journey with others is an effective way to deal with life’s stressful events.

Triggers and cues. Because drug memories and experiences end up engraved on the brain and because they encompass not just the pleasure, but the sensations, the context, where we were and who we were with, anything that reminds us of drinking and using can be a trigger to pick up again. Avoiding triggers and cues is a good idea.

The first drink or drug. It’s highly likely that this thought will pop into your mind at some point: “Maybe I’ll be all right now that my system has had a rest. Perhaps I’ll be able to drink and use normally.” Anything that floods those dopamine receptors can trigger off a powerful desire to have more. A glass of wine at the weekend, or a line of coke as a treat, are bad ideas for folk trying to recover. This kind of experiment easily leads to relapse.

What helps?
The brain’s function begins to recover in those early weeks and by two years is mostly back to normal. There are some things that you can do that are associated with making detox more comfortable, that make dealing with early recovery less grey and which reduce the risk of relapse.

In a nutshell it’s this: get connected! By that, I mean get connected to other recovering people. There’s research to show that increasing the number of sober people in your social network is associated with reduced relapse. Research from Connecticut has shown that simply by introducing one more sober person to your sober network you can reduce your risk of relapse by 27%. That sounds like a good deal to me.

If you are planning a detox, get ready for it. It’ll be much easier if you know what to expect. Don’t do your own detox, let someone else be in charge. Stand alone detoxes will almost all fail: you need detox plus. By that, I mean more has to be added in. Getting onto an intensive treatment programme (either residential or community) at least three months long is likely to help. Stay away from using or drinking friends and delete dealers’ numbers from your mobile. Always remember, you only need to do this once.

If you want success, then get involved with mutual aid groups. There are thousands of AA, NA, CA and SMART groups up and down the country. Almost everybody is nervous about going along, so phone the helpline first. If you know a member, ask them to take you along. Keep going back and check out lots of different meetings; don’t judge by your first meeting along. The more meetings you go to the better.

If relapse happens

Many people in long-term recovery will have had experience of lapse or relapse at some point. While you don’t need to use again, some people will and this can be a danger, particularly if you have been addicted to opiates. Loss of tolerance begins very quickly on getting drug-free and your system becomes more sensitive. Hundreds of people die every year in the UK from unintentional overdose.

You can minimise the risk. Do this by:

  • Smoking, not injecting
  • Using much less than before (as if you were starting for the first time)
  • Not using alone, have someone around
  • Don’t mix downers, like heroin, valium and alcohol (very important).

And if you do lapse it needn’t be the end of the world. Get help quickly. Get honest about it with your support network and put twice as much work into your recovery.

Important to know
Detox and even treatment are only small parts of recovery: for many of us, recovery is a long-term process. Most of the recovery journey will take place out of treatment environments – in social settings with other recovering people. Recovery is not about the absence of alcohol or other drugs. It’s about all the positives that come in, but you have to work for them and most of that work will be done more easily if you are shoulder to shoulder with other recovering people.

PDF document >

Peapod’s Guide to Recovery

Peapod, now ‘retired’, was one of the most prolific and respected bloggers on Wired In To Recovery. (S)he wrote a series of must-read blogs containing important hints to facilitate recovery.

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‘Detoxification: The nuts and bolts’ by Peapod

P1011113_2Why not check out the second of Peapod’s articles in his Recovery Guide, an article which focuses on detox and beyond?

‘Okay, youʼve got to the point where you are looking to detox but youʼre not sure what the nuts and bolts of it are. How do you go about it and how do you know you are ready? What can you do to boost success?

Here are my suggestions, which are based on guidance and my own experience of working with hundreds of people going through detox.’

‘Detox and early abstinent recovery: make it easier’ by Peapod

P4091276Peapod was one of the most prolific and respected bloggers on Wired In To Recovery before going into ‘retirement’.

(S)he wrote a series of must-read blogs containing important hints to facilitate recovery which were very popular. Peapod’s empathy and understanding, as well as experience in the field, shone through in these blogs.

I’ve arranged these blogs into what I call Peapod’s Guide to Recovery. This is the first of seven articles.

Read More ➔