I almost couldn’t contain how happy I was,” remembers Michael. He is referring to the road trip he took with his parents to treatment, one state and 160 miles from his home. “I knew recovery was going to be a long, hard journey. But I really wanted it. I really wanted recovery. Getting clean is easier to deal with if you really want it, and I couldn’t wait.”
During the drive to the rehab center, Michael’s parents felt mostly relief. Treatment will work, they told themselves. For JoAnn, Michael’s mom, failure was not an option. Treatment had to work. She knew she could not go through the experience again. Michael’s parents had already lost all trust in Michael, who confers that “trust is lost in buckets but gained in drops.” During the drive, he knew he would have to work hard to earn their trust again. And he wanted this just as much as he wanted to put his opioid use behind him.
Michael did all he could to make it in recovery. After a month in residential treatment, he went to a sober house for four months. He was drug tested daily, returned to his room a half hour before curfew without fail, and never broke a single rule. He attended an intensive outpatient program and asked to do the next level. His parents, encouraged yet apprehensive, told him “by all means.”
At age twenty-three, Michael moved into a sober-living apartment in Manhattan with a recovering buddy. He knew the big city offered a lot in the way of temptation, but there was also a lot of recovery. Michael attended outpatient treatment five days a week, talked about his addiction at Twelve Step meetings, and saw a psychiatrist. Again, Michael’s parents agreed to foot the bill but on one condition: Michael, who has an aversion to needles, had to get his monthly naltrexone injections. If he didn’t show up, the doctor would let his parents know.
A year later, as Michael prepares to return to his hometown, he is overcome with anxiety. At home, triggers to use are everywhere. But Michael has an idea: There is a drug-testing lab three miles from his parents’ home where he can get tested three times a week. His parents agree to pay for the testing.
After a year and a half on naltrexone, Michael feels solid enough in his recovery to stop taking the medication. He regularly attends Twelve Step meetings and sees a psychiatrist once a month. He doesn’t have cravings, nor does he notice much of a difference, except on the twenty-eighth of each month, when he feels a phantom soreness, as if he had just gotten his monthly injection.
Michael is now taking classes to become an alcohol and drug counselor. Schools regularly invite him to speak to high school students about drug use, where he and his parents are told how impactful his speeches are.
Now that Michael has been sober four years, JoAnn has stopped picking apart the past to figure out what she did wrong as a parent. “It was like beating a dead horse,” she says. “I was a stay-at-home mom, I knew where my kids were, I went to hockey games, volunteered in the school. I did the best that I could. I don’t feel responsible for his drug use anymore.”
While Michael’s treatment cost a small fortune, JoAnn says it was worth every penny. And she is ever grateful the family had the resources. “When one door closes, another door opens. This horrible, horrible tragedy has opened up a whole new world to him where he can help people. For me, it was worth it. If he can get through to one kid, it will have been worth it.”
Michael smiles when he talks about the dark days of using. He gets emotional, on the verge of tears, when he speaks of recovery. “There was a time when my parents didn’t like talking about me,” he says. “Now everyone is proud of me. Six months into my recovery, I was best man at my brother’s wedding. When I was using, my brother wouldn’t trust me to walk his dog. Now he lets me babysit his daughter. That might not sound like a big deal to some people, but to me, it’s everything.”
A New Beginning
Treatment does not signal the end of addiction. Addiction has no On and Off button. In time the brain heals, rerouting neuronal pathways as the recovering person practices new behaviors and creates new memories. But the genetic makeup and deeply learned behaviors connected to drug use still exist and will remain forever. Using can set off some of these pathways in an instant or after a matter of days or weeks. So, treatment is the beginning of recovery. It’s a means to a new start—a chance to reinvent oneself or at least function without the constant longing for the powerful positive effects of opioids.
Michael’s recovery sounds picture-perfect. At every juncture, his family backs him up, financially and emotionally. He stays in treatment as long as possible, takes his medication as prescribed, makes new friends, goes to self-help meetings, and goes back to school. With the support of his family, Michael creates a new, incredibly satisfying life for himself in recovery.
But even with everything going for Michael, he will tell you he didn’t win the lottery. Recovery comes with trials and tribulations. It takes effort. Even when taking medicine, people can struggle in recovery, some more than others, especially during the first few months. The threat of relapse lingers, and triggers (of which there are many) can quickly turn into excuses to use again. Motivation level, quality of life, support system, and sense of personal responsibility are large factors in recovery. Preparation is also key—has the physician or addiction specialist informed their patients of what to expect and what to do if they feel that using is imminent? Is a prevention plan in place? Is there an emergency plan? Are family members involved?
Family members benefit from being prepared for what lies ahead. Thinking that everything will return to the way it used to be, before drug use, is self-deception. No one is the same, and life will be different. But different can also mean better.
Nicole’s Recovery
Every month, Nicole goes to her appointment to get her naltrexone injection as if she were going to get her nails done. There is no drama, anxiety, mistrust, or arguments with family about keeping her appointments. Her medication works, and she is more than happy to take it. For Nicole, naltrexone blocks all thoughts of using.
Still, being opioid-free means emotions can hit Nicole when she least expects it. When her mom makes a casual comment about the dirty dishes in the sink, Nicole reacts. Her mom accuses her of being moody and jumps to the conclusion that Nicole is using again. But Nicole does not recall ever being defensive when using. She was checked out, just “there.” In this argument, Nicole gets the last line: “I just feel more now, Mom. When I don’t react—that’s when you need to worry.”
After seven months, Nicole reminds herself that she needs patience. She has every intention to stay in recovery and raise her son. But she knows that trust can take years to rebuild. She has lied, stolen, and been in and out of rehab for the past ten years. Her family is recovering, too.
Nicole is lucky. Although Jake, Robbie’s father, is gone, and Nicole is a single parent, she has the unconditional love and support of her very large and close-knit family—and has had them all along. Even when Nicole was using, lying, and stealing, she felt loved and supported.
Robbie is doing exceptionally well. At age two, he has met all of his developmental milestones. He is healthy and happy, with a voracious appetite. Every day, he revels being in the company of more than one doting relative. And he adores his mom.
Nicole has just recently returned to work at her dad’s contracting business. Working and raising a son leave her little time for much else. She does not attend Narcotics Anonymous or counseling. “The idea of sitting around talking about drugs made me want to use drugs. In my mind, it wasn’t for me,” she says. “I just want to live a normal life. Go to work, be with my family. Do normal things.” For now at least, her family is support enough.
It doesn’t occur to Nicole to stop getting her monthly naltrexone injections. It’s not controlling her life or hurting her. As long as her insurance covers it, she can think of no reason to stop. Physically, mentally, and emotionally she feels better than ever.
For Nicole, recovery comes with pacifiers, sippy cups, and joyous giggles. “It’s not just about me anymore. I have to keep reminding myself of that. Also, my son already has only one parent because of drug addiction. I want to live. I never did drugs because I wanted to die. I can’t even tell you why I did drugs. I want to live and have a nice family.
“As hard as life can be sometimes, being in recovery is so much easier than using. Using makes everything so much harder.”
Be an Asset in Recovery
You are likely well aware that you can’t control addiction or the person in recovery, but you can be an asset. This is not to say that your loved one’s recovery is your responsibility, but you and other family members play a large role. You influence whether recovery is easier or harder, a plus or a negative.
In early recovery, people need a lot of support, more than you might think necessary. Thinking and concentration can be foggy for a while, as the brain adjusts. Energy is low because a good night’s sleep is hard to come by, at least initially. A car, job, or money might be issues. Basic skills, from hygiene to job interviewing, might be lacking. All of this is because of a serious chronic illness. If your loved one suffered from a serious disorder other than addiction, how would you treat them? Would you help them learn to do new things? Drive them to appointments? Support them financially? Make sure they take their medication? Help them apply for a job? Be forgiving?
Addiction gets a bad rap because addicted individuals hurt those they love. But if you think of addiction as a chronic disorder of the brain that impairs normal thought processes, it becomes easier to separate the disorder from the person. Although there is no cure for addiction, people can begin to heal the parts of the brain affected by ongoing drug use. Those who have support fare better than those who do not.
Everyone’s experience is unique, yet we can predict events that can lead a person with opioid use disorder back to using. The number one deal breaker is not taking the medication—or taking too much.
Monitor Medications
Even the most motivated of patients can have a change of heart when it comes to taking their medication. Sometimes it is because the medication is working too well. About 50 percent of people stop taking buprenorphine after a while, and some do so because they feel they are back to “normal.” Stopping medication because everything got much better happens even more often with XR-naltrexone, as there is no withdrawal or any other change right after naltrexone is stopped. Many people question whether they need to keep taking it, especially when they feel so good. Yet they still have a chronic disorder and are exposed to stress and cravings, which leave them vulnerable to relapse. Getting off medication can make maintaining abstinence much more challenging.
In one study, despite high levels of treatment satisfaction, more than 60 percent of patients maintained on buprenorphine or methadone expressed interest in discontinuing medication in the near future, and more than 70 percent had previously tried to stop—sometimes because of pressure from family or even the addiction professional being paid to help them. So, a major challenge is how to retain patients in treatment with medications and recovery over the long term. You can help by overseeing the medication and making sure your loved one takes it on schedule. Michael’s parents, for instance, set this condition: If Michael didn’t show up for his naltrexone injection appointments, they would stop paying for his treatment and his apartment.
How you can help:
Accept Ambivalence as Part of Recovery
Ambivalence about being in recovery is one reason people don’t take their medication or go to counseling. On days when your loved one feels stressed or low, the numbing or uplifting effect of opioids might sound attractive. When bored, your loved one might recall some of the good times they had with their using friends. These kinds of thoughts can put a recovering person in a using frame of mind. They might act and sound as if recovery is not for them and a waste of time. On other days, they are happy and grateful to wake up without wondering how to get their next fix. They are elated to know that they have a job to go to or a child to cuddle.
Ambivalence is normal. People in the grip of addiction look for reasons to use. Sometimes your loved one will be motivated for abstinence; other days they will feel conflicted. Once you expect and accept this, you will find the seesaw characteristics of ambivalence much easier to deal with.
We do not berate soon-to-be brides or grooms for questioning the decision to marry. We listen, comfort, and try to understand what they are thinking or feeling. We accept it as a normal part of the process, because marriage is a big commitment with lots of unknowns. The same is true with recovery. Giving up the freedom to use is a commitment. Your loved one grieves their loss at the same time that they are learning to participate in life again. When participating in life gets hard or dull, ambivalence grows.
It’s also important to validate that there are downsides to abstinence, at least initially. Be open to seeing recovery challenges from your loved one’s perspective.
How you can help:
The Importance of a Contingency Management Plan
When a Family Member Is Opposed to Medication
A detrimental yet all-too-common mistake is when family members try to convince their spouse or child or parent to stop taking OUD medication. The notion that a person in recovery should not take medication is frustratingly common among family members. This mind-set usually stems from stigma or misunderstanding about the nature of OUD. People do not fully comprehend what it takes to recover from the disorder. Family members who would not question why their spouse needs to take medication many years after a cancer goes into remission should not question the need to take medication to prevent addiction from recurring. The focus on taking medication, rather than on recovery itself, creates turmoil and gets some patients and families into trouble. For Eric, it created a reason to think about using again.
Although Eric feels good on buprenorphine and Samantha is more than happy that her son is no longer shooting up heroin, Tom, Eric’s dad, is sullen. He distances himself from Eric and his “recovery.” If he thinks about it too much, Tom gets angry. His son has caused enough grief and wasted enough family resources already. He wants to put Eric’s addiction behind him. He wants his son to buck up and face life without any drugs—including his buprenorphine, which Tom thinks is a crutch or just another way to get high. Although Samantha tries to stay matter-of-fact when Tom brings up Eric’s medication, Tom and Samantha argue. Hearing the fights, and knowing he is the cause, brings Eric to the verge of tears. His guilt over not being able to stay abstinent in college and his remorse over failing his family, mixed with the good feelings he has taking buprenorphine, leave him feeling confused.
Eric considers that maybe his dad is right. Maybe it is better to recover without meds. It has been two months, he has not used once, and maybe he is ready.
Samantha has been keeping a close eye on Eric, making sure he takes his medicine in front of her every day. This is one of the family rules, and Eric is fine with it. He feels a little like a kid, yet he is grateful. But this evening, he tells his mom he is going out for an early morning run and not to bother getting up early. He promises to take his medication.
Eric goes for a run. He takes a tablet from the bottle but flushes it down the toilet. He feels pretty good for the rest of the day, and his mom believes Eric has followed through with his promise. That evening, Eric goes to work. A co-worker comes in high, and Eric starts having thoughts about using for the first time in two months. He snorts a small bit of heroin and feels great. He is not high enough to feel intoxicated but remembers how much he enjoyed the blissful effect. The next morning, Eric wakes up and Samantha dispenses his medication.
In one short evening, Eric has learned that he can play the game of skipping his medication so he can get high every now and then. His early-morning runs are a great cover-up. On those days, Eric goes to work and snorts a little, but the third time he does this he starts thinking of what it feels like to inject heroin. He stays out all night, without calling or letting his parents know that he has plans.
Eric has broken a major house rule. Samantha is convinced Eric has lapsed. Before confronting Eric, Samantha shares her suspicion with Tom and the psychiatrist. Tom is no longer angry but concerned. He thinks Eric has lapsed, too. Eric was doing well, and Tom didn’t see this coming. The psychiatrist makes it clear that Tom and Samantha need to be allies in this battle. Tom agrees. That morning, they confront Eric in unison, and he caves in.
Ambivalence feeds on discord, and the person who is still hostage to addictive thinking may eventually fall prey to it. Family members who are pitted against one another need to talk and agree on a plan. Base your plan on the best evidence-based treatment and seek input from a professional. The family member who is skeptical about medication should speak with the doctor directly. Families must present a unified front toward the affected family member. There is no way around it. Families who do not agree about how to handle recovery can be torn apart by this type of thing.
Do your best to focus on what matters. What is your loved one’s life becoming? If they are happier and involved in activities, it should not matter whether they take an antipsychotic, antihypertension, or antiaddiction medication. The objective is to improve and stabilize their life. Coming off medication should never be on top of the list. It can be low on the list, if it is on the list at all. Stigma around taking medicine and false expectations about recovery are leading causes of relapse.
How you can help family members who struggle with accepting medications for their loved one:
When the Person in Recovery Wants to Discontinue Medication
George used to see his psychiatrist once a month, then every two months. Now, after three years on buprenorphine, he goes four to five times a year, mostly to talk about major events in his life and what might be stressing him out. He knows that uncomfortable and unaddressed feelings, or getting on a wrong train of thought, can lead him back to pills. George has considered getting off buprenorphine but cannot find a good enough reason to. It works for him, and he has already tapered down to 2 milligrams a day. His wife, who at first questioned the need for staying on medication that long, has fully accepted the idea. She sees that it works, and she has her husband back.
When patients tell me they want to stop using their medication, I keep an open mind. Some patients do indeed seem ready. They are on a low dose, have a solid support system, have a stable job they love, and
seem to enjoy the benefits of therapy. They are motivated and have found ways to better fill the time they once spent finding and using drugs. They have a lot of what we call “recovery capital,” enough positives in their lives to help carry them through the more difficult days. Others have little in the way of recovery capital but begin to feel like their old selves again, which makes medication seem no longer necessary.
Accumulating “Recovery Capital”
How you can help:
All patients need to understand the risks of tapering off medication. After discussing the pros and cons with patients who are ready (that is, who have plenty of recovery capital), the doctor can taper, or slowly wean, them off the medication, and monitor how they are doing. Some patients reach a stage during the taper where cravings, discomfort, and agitation get to be too much, which is what happened with George. Not being able to taper off completely is not failure by any means, although patients sometimes feel this way. Most decide they are fine staying on the medication at a low dose.
Life does not stand still for someone because they are in recovery, and so I recommend ongoing counseling whenever possible. If a stressful situation presents itself, people may need to return to medication or increase their dosage, at least temporarily. Sometimes, a conversation with a therapist is medicine enough.
How you can help:
Support Attendance at Appointments and Meetings
Psychological and behavioral treatments as part of ongoing counseling or outpatient treatment give professionals an opportunity to assess the progress of people in recovery. They can talk through stressful situations or identify disruptive thoughts and behaviors that can lead to drug use.
Such groups as Narcotics Anonymous (NA) help people understand they are not alone. Others like them have gone through some of the same experiences and come out stronger. NA welcomes people who are on medication to attend meetings, but not all members will see attendees who are taking medicine as being abstinent, or in recovery. Do not force your loved one to go to meetings, but if they are interested in doing so, support them.
How you can help:
Encourage Abstinence
Abstinence is a troublesome word when discussing medication-assisted treatment. Because buprenorphine and methadone are opioids, they are considered mood altering, yet they are not the same as other opioids. Taking painkillers and heroin is considered “using.” Taking methadone or buprenorphine as prescribed should not produce any immediate effect on the mood, is not intoxicating, and therefore does not contradict the idea of recovery. The same applies to other psychiatric medications, such antidepressants, antipsychotics, or mood stabilizers, which can of course “alter mood.” Some psychiatric medications that are controlled substances, such as antianxiety or sleep medications or medications to treat ADHD, are also occasionally considered to be “off-limits” for a recovering person.
This notion is based on the same assumption that considers buprenorphine, another controlled substance, inconsistent with recovery. If used properly, any of the medications used to treat underlying psychiatric symptoms can only help rather than impair recovery. An untreated psychiatric symptom is one of the top reasons for relapse. Occasionally, psychiatric medications are misused or have more side effects than benefits, but for the most part they are effective if given under close monitoring by an experienced addiction specialist. If people take medications, including controlled substances, but do not use any other mood-altering drugs, they are still sober. This is the new definition of recovery, despite what some people believe.
For the brain to fully heal, a long period of abstinence is necessary. Staying away from all mood-altering drugs, even alcohol, promotes recovery. On medication, staying away from opioids becomes easier. But if your loved one starts feeling “normal,” pouring a drink or grabbing a beer might seem like a good idea to them. People with addiction can easily justify that some drugs are not a problem for them. And the intoxicating effects of any drug can weaken resolve. Under the influence, your loved one could decide that using opioids is not such a bad idea after all. And while it may be true that some will be able to use another drug recreationally and not get addicted, there is no way to predict who will be able to do so. In my opinion, the risk of “getting it wrong” is too high and not justified, definitely not in the first one to two years of recovery.
Everyone in the family has to review their relationship with drugs and put their use on hold. Drinking or smoking weed in front of the person in early recovery is a trigger. Having painkillers around is detrimental. In time, your loved one may not see alcohol as a trigger.
How you can help:
The solution for how to manage life with OUD is recovery. So do what you can to make recovery attractive. Being nagged about not exercising is an excuse to use, whereas being offered a membership to or ride to the gym or a yoga class is affirming, supportive, and positive. When being in recovery is more attractive than using, staying in recovery is easier and more likely.
Relapse is about what is happening inside as well as outside of the person in recovery—their feelings, thoughts, and environment. If they are bored or hanging out with using friends, identify the problem and help them think of the solution. Help them find new activities to stay busy and engaged; invite them to new places where they might have a good time and meet new friends. Do what you can to eliminate barriers and avoid the temptation to point fingers. Do what you can to encourage your loved one to want to be on the recovery side of the fence.
Being involved and positive enables recovery, which is a good thing. This high level of involvement is not lifelong. In time, your loved one will be more self-motivated and will eventually reciprocate. Positive behavior is contagious.
How you can help:
When Relapse Happens
Some people really struggle in recovery and may relapse one or more times before they find it. Others decide to give up before they even give recovery a chance because it is too hard. Environment, mental health, physical health, financial stability, friends and family, and the level of motivation and denial are only a few of the many factors that merge to either lift people up or drag them down during recovery. When the barriers people must surmount seem too great, and the urge to use is more powerful than the desire to get better, people may relapse.
Relapse is heartbreaking, yet it is a normal part of the process for many opioid users, some of whom relapse multiple times, especially if they do not have a chance to try medication. Opioids are powerful drugs, and the craving for them can be even more powerful. Medication can minimize or eliminate relapse and improve quality of life in most patients, but it is not failure proof. Doctors may need to adjust your loved one’s medication dosage or change medications. Patients may need to take medications for depression or PTSD and add therapy to their treatment regimen.
The suggestions outlined in this chapter give you some tools to encourage your loved one to stick with recovery and recognize when something is awry. If relapse does occur, make sure your loved one returns to treatment as soon as possible. You can repeat what you did in the first place to get them to treatment.
OUD is a serious disorder. Relapse does not mean that the treatment was not impactful; it only means that it was not sufficient at that time and that it needs to be repeated. Intensity of treatment should match the severity of the disorder. When symptoms recur, the treatment needs to be repeated and possibly upgraded. This is the same standard used to treat most chronic medical disorders. Some patients may need to stay in treatment and on medications for the rest of their lives to get the disorder fully under control. We are fortunate to have medications to treat OUD. To this day, we do not have effective treatment for a number of serious and debilitating disorders.
Everyone Is in Recovery
Recovery is a time to exhale, but not fully. As your loved one adjusts to new feelings and the new way in which they must now operate in the world, you and other family members need to shift gears and recalculate where you stand. You will have a new role in the new family dynamic, which changes how you interact with your loved one. You will also need to rediscover the parts of your life that you have disconnected from—the friends, hobbies, and interests you dropped to focus on the addiction. In other words, you will be recovering, too.
Recovery is not intuitive. It is hard to see how another’s addiction changes and reshapes us. I always recommend involving the family in the recovery. Recovery is not guaranteed. Relapse is forever a possibility. Therapy teaches people how to live with the uncertainty inherent in recovery. Therapy helps people see what has happened to their sense of self, as well as how their behaviors affect their loved one’s recovery.
When efforts at recovery fail repeatedly, you need to protect your sanity. Counseling helped Lacey draw some desperately needed boundaries for herself when Jason’s third attempt at treatment did not go well.
Lacey’s New Boundaries
Shortly before Jason’s third treatment, and against his wishes, Lacey started therapy for herself. Jason berated her with such lines as, “It’s too expensive” or, “You don’t have time for this” or, “I need you here to help me.” But because of therapy, Lacey feels stronger. She stands her ground and keeps going.
When Jason enters residential treatment, Lacey attends the family program. Livid at Jason, she does not absorb all of what she is offered in the way of tools and supports. Still, she is grateful. She learns a lot about the dynamics of addiction and identifies with other spouses who are in the same boat. A woman in treatment for alcoholism for the tenth time attends Lacey’s small-group session. She shares that in the past she went to treatment for her husband. This time, she is going for herself, and she is hopeful. This rings true with Lacey, who cringes at the thought of Jason’s claiming to be in treatment for her and their daughters.
Lacey also goes to Al-Anon, the Twelve Step support group for spouses of people struggling with addiction and alcoholism. She at first searches for out-of-town meetings, where she will not run into anyone she knows, but the travel time is a constraint. Finally, she breaks down and goes to the meeting nearest her home. Glancing around the room, she sees four people she knows, but she does not care. Hiding the addiction and the family “shame” is suddenly no longer a priority. She has reached her limit, the place where enough is enough. She is done pretending and feeling crazy.
In Al-Anon, Lacey learns that she is not crazy. The people around her tell stories that are both disturbingly and refreshingly similar to hers—if not in the details, in the emotions. She begins to realize what has been happening to her. She is awash in relief and regret as she remembers who she used to be and considers the empty, angry shell of a person she has become.
Before Jason comes home from treatment, Lacey “is done.” She can’t seem to find any other words. She is done with the lies, the manipulation, the self-pity, and the excuses. When Jason comes home after twenty-eight days and against his treatment team’s recommendations, he is faced with a more confident Lacey, who for the first time feels sure of herself in creating boundaries and consequences. He learns that if he uses, she will file for divorce. Two weeks later, when he overmedicates, drops food all over himself and the floor, and starts asking where his handgun is before he overdoses—all in front of her parents—Lacey not only calls the police but files for a divorce.
Lacey has turned the TV on maybe four times in the four months since she kicked Jason out of the house. After having it on 24/7, the sound of voices and assorted noises emanating from the box is now a source of trauma for her. Her youngest daughter is away at college, getting straight A’s after having initially flunked out. Her thoughts are now focused on her studies, rather than worrying about whether her mom is okay. Lacey and her daughters continue to get therapy, which she says has made a world of difference.