Expert: Peter L. - 2/13/2010

Question
QUESTION: My son is 23 years old with a back injury.  He started to abuse his pain killers then last year was introduced to heroin.  He stopped using heroin in May 2009 and was clean for a few months.  September he started abusing pain killers to using 8 - 10 times a day of oxycontin.  He just got out of detox but we had a very rough weekend with him.  He took percs again.  He has been attending AA meetings but the lying continues.  He's nearly emptied all his bank accounts.  He just started intensive outpatient services and they put him on Suboxen 8 mg 3 times a day.  Yikes!  He only took 2 the first 2 days and he gets tested today.  We think he used again but we're not sure because he's still lying.  We don't know what to do, we told him he'll have to move out if he's going to continue to use because we won't support him we will only support his recovery.  How do we ever throw him out and stick to it?  My husband is ready to have a heart attack over this, we're not sleeping and we are living and breathing this addiction.  My son is engaged and his fiancee lives with us too because they were about to buy a house but now that is all on hold.  SHe doesn't know how she can stick with leaving him either.   HELP HELP HELP!!  I am going with him today for his appointment and pee test.  I pray it is negative to any drugs.  Thanks in advance for any advise.

ANSWER: Hi Jackie,

You are seeing first hand the devastating effects of addiction.  Your son seems very similar to a number of folks with whom I am now working.  Any addiction is hard to overcome, but opiates (heroin, oxycontin, etc.) in my view present particular challenges.

I have found that it is necessary always to treat opioid dependence with an opioid replacement therapy.  Suboxone is a very effective medication for management of opiate cravings, but should be used along with an overall program of recovery.  I have found opiate abusing clients to have significant problems achieving a normal mood state.  They appear very unregulated, edgy, irritable, and just generally uncomfortable in their skin. This will persist for a number of weeks or even months.  As those watching this, it's heartbreaking, but there is little that can be done until the brain biochemistry begins to right itself.  

Opiate users have, perhaps unfairly, garnered one of the worst reputations of all the classes of individuals abusing substances.  I believe their difficult and problematic behaviors stem from the uncomfortableness they feel when not using.  If you can imagine the best vacation, best dinner, best movie, best sexual experience, etc. all at once, that is what it feels like to use opiates.  Hence, the withdrawal both physically and psychologically is very difficult.  Opiates are at the top of the list in addictiveness, right there with tobacco.  I think the impact on brain chemistry is extremely significant in this population. Opiate abuse in the numbers we see today is very alarming. So you are not alone in this struggle.

You have a right to have a substance-free home, and if he is living in it, should conform to your rules and expectations.  I find when limits are set, it gives the substance abuser more incentive to pursue abstinence.  Those of us in the addiction treatment field don't always like to admit this, but recovery is almost always motivated by consequences that develop from chronic drug use.  

Be supportive, but firm about treatment.  While he takes Suboxone he should be in some form of group based treatment.  Intensive outpatient treatment is strongly suggested.  No drug paraphernalia should be in your home.  

It is up to you in terms of what you will want to put up with if he continues to use while staying in your home.  I usually do not advocate for an open-ended approach; rather I think family and partners should look our for their own welfare, and understand there's only so much support that can be given.  The substance user in the end must be the one who pursues change.

I hope this helps!

Peter

---------- FOLLOW-UP ----------

QUESTION: Hi Peter,
update on my son's recovery.  It has been 2 weeks since he started the intensive outpatient program with Suboxen and he was just suspended from the program because he is unable to do the urine test.  I have waited there with him and his bladder is full and in pain and upon entering the room with the lab person all urges leave him.  He just can't pee in front of them.  The program requires 2 tests per week and he hasn't been able to do any.  He has done the test with me or his father in the room but he can't do it there.  The circumstances in which they conduct the test is horrible everyone waits in line in a room and one at a time they go into the toilet with the lab person and if you don't pee within a minute or so you go back out and wait in line again.  I'm not making excuses for him but I don't know if I could do it either but we've told him there is no choice but he just can't do it.  His doctor sent him today for an ultrasound of his bladder and testicles because he has tenderness there and takes awhile to pee at home as well.  If there is a medical problem they will let him back in the program.  We have a month's worth of suboxen which I am the gatekeeper for but he needs counseling.  He's been sick with a cold this week and now kicked off the program.  He went to an AA meeting today and left there frustrated because it was all geared to alcoholism.  He ended up stopping and buying an 80 pill and did it before he came home.  He told me about it right when he got home and said he didn't know why he did it because he knows it won't help because of the suboxen.   What do we do?  We threaten that's it he needs to leave but we know we can't go through with it and we read how it takes months till the brain levels the mood swings.  Do we continue to try and support or lay down more rules?    The mental health care in this area is horrible and the choices limited.  Health care still does not recognize this as an illness.  We are having real trouble in finding counselors that accept our health insurance and we can't afford to pay out of pocket.  Any advice will be appreciated. Thank you in advance.

Answer
Hi Jackie,

Most Suboxone providers will be firm about the urine screens, but not all.  If his medical tests come back negative, he will have little defense to offer the clinic, and they will continue to demand the urine sample.

The problem has to do with the numbers of individuals who abuse substances like marijuana and cocaine, while on opioid replacement therapy. Tests are monitored because false samples have been and can be brought in by dishonest clients, to hide actual use.  I've seen this many times.  It's possible the staff might allow him to to into the bathroom without his coat (depending on where you are) and maybe having him empty his pockets.

It's also possible he can find another Suboxone provider who will be a bit more lenient.

Perhaps your son should go to Narcotics Anonymous rather than AA.  You can do a web search for meetings in your area.

The point is, as before, that he needs treatment.  He has to not fault programs or staff for  doing things other than the way he would like.  At my program we have to set limits all the time, and our clients get defensive and angry.  Many later see that they needed the pressure to get past their resistance.  

Bottom line is, at that program you mention, he has to pee in the cup.  Probably no way around it. See if something can be worked out with the director.  There may be some flexibility, ultimately.  

Continue to show your concern and willingness to work with him, but he has to do his share.  No parent or program should work harder than the individual.

I wish you the best with this tough situation.

Peter