Buprenorphine/Naloxone Treatment for Opioid Use Disorders Case Study: Jeff
Today, Jeff and I are checking in. For the last 7 months, Jeff had been stable on a combination of Buprenorphine and Naloxone (Suboxone, Zubsolv, etc): One to stop his withdrawal and physical cravings and one to block any high he might get if he did use. Jeff has also been in counseling once a week since the induction process.
Before being stabilized, Jeff was using a minimum of thirty Methadone 10 mg pills a day…just to feel normal. If he had more available, he would take it.
Jeff’s Initial Motivation for Seeking Treatment
“I am going to die and leave all these people behind.”-Jeff
Not Jeff’s First Attempt at Recovery
“Things have been pretty good,” Jeff volunteers at the beginning of our session. “Winter is hard when there is not a lot of work and stuff to do, but really, this has been night and day compared to the last time I tried this.”
The last time Jeff tried the Medication-Assisted Treatment recovery model he was not required by his doctor to do any type of counseling. He was given the medication and only monitored by the doctor occasionally. Jeff’s current doctor requires counseling for people new to the program and meets with him every month.
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Jeff’s Treatment Now Vs. Then
He tells me of how this time around he finds:
- He is still working on the same issues that came up before as far as cravings and behaviors but…
- His impulse control is better and is not as overwhelming this time.
- He is not “freaking out” and scared.
- Feels like himself again, and feels “awake again”.
- He is able to do the things with his time that were taken up by being distracted by the high doses of Methadone or the time it took to get them off the street.
The Power of Mindfulness
Impulse control is a hard thing to overcome, especially when it is rewarded by an opioid or seemingly justifiable anger. Jeff and I have done a lot of work on mindfulness in our many sessions.
Mindfulness Allows a Person to Go From: Stressful Situation →REACTION
- (Emotions Take on a Life of Their Own/Going Directly to a REACTION)
- This is sometimes called “going from 0-60 in no time flat”.
To: Situation →Mindfulness →Response
- (Pausing/Becoming Aware of and Naming The Emotion you are Feeling)
- This allows a person to see more clearly and respond instead of REACTING with haste. It gives choice to the action.
Jeff has credited practicing this mindfulness with some of his success this time. “My relationships are remarkably better,” Jeff tells me. “My relationship with my girlfriend is Way Better.” Jeff later tells me that he has only had one blow-up argument with his girlfriend in the past few months. He reminds me of how these blow-ups happened “all the time” before. He credits his practice of mindfulness and being physically stable for these changes.
Jeff was already in a relationship when he started his recovery, something that can be tricky when just beginning treatment. Fortunately for Jeff, his girlfriend has never used drugs and is very supportive of him.
Jeff tells me again as he has so often, “Since doing the self-work, my relationship with my girlfriend has really improved. She is very supportive. When I have cravings or get to feeling down, she is always there for me.”
“I am feeling real love for the first time,” Jeff states almost as if it surprises him.
The process of Recovery is by its nature the process of understanding the past, present and future in relation to each other. No place in the process is this more fluid than in the ever-changing concept of Self Image.
For Jeff, 7 months into his recovery there are currently two Self Images he holds:
Physically Stable and in Counseling vs Using
Question: How has the physical stability helped?
Jeff: “It is absolutely remarkable…it makes such a difference in doing your work on yourself without cravings.”
“It was also easier to transition to the Zubsolv than it was to Suboxone the last time. I don’t know if there is a big difference between the two, but it seemed easier.”
Like many who enter recovery after years of numbing anxiety and depression with drugs like alcohol and opioids, Jeff has experienced an increase in his anxiety. This is related to taking away the substances that were dulling the anxiety which makes it seem more intense. Jeff is not alone in this.
Depression is also a common mental health struggle with those in recovery. Jeff has found that the depression he experienced when he was using was more intense, and that now that he is stable and active in counseling, he does not experience the depth of depression that he did when he was actively using. Attempting to deal with guilt can help avoid depression.
Many times patients who enter recovery feel enormous amounts of guilt. The type of guilt people experience is different with everyone. In Jeff’s case he had his own particular brand:
- Guilt over the things he did to get drugs
- Guilt over abusing drugs and what that did to his body and his life
- Guilt over the things he missed out on
- Things he could not or did not do for himself
- Things he could not or did not do for other
“There was just so much of it,” Jeff tells me.
In our sessions, we try to look at guilt as useful only in that it was enough to get him to make the call to get help and walk through the door for his induction appointment. Beyond that, guilt only serves to turn anger inwards leading to depression and helplessness over things in the past that the person cannot change. This is an ongoing process of self-forgiveness.
There are many challenges on the road to recovery. Jeff is no exception. Here are Jeff’s challenges in his own words:
- “Trying to plan the day. Challenges will get you every time.”
- “That feeling that I will do it again.”
- “I am so new in recovery, and my old habits are my normal.”
- “Still trying to prove myself to my girlfriend’s family. I am getting better, working on issues, but their overall perception of me is not good. This gives me the most anxiety about the future.”
- “Keeping busy is a big one. If I slow down or stop, then I feel the depression and want to escape.”
- “Trying to deal with problems as they come. I used to have a problem, and I would try to get away from it which led to using which created more anxiety. It was a vicious cycle. Dealing with problems head-on, dealing with issues head on and not letting things slide as much as before.”
- “Exercising emotional intelligence where a situation comes up and I pay attention to the emotions instead of just reacting.”
Jeff tells me that his biggest challenge is breaking what I call his Using/Recovery/Using cycle:
Get Clean→Using→Snowball→Get Clean→Using→Snowball…
Jeff describes this process as just getting bigger each time it repeated. He shares how it got to the point that he was not even feeling the euphoric effects of the drugs anymore, even at 30 Methadone 10 mg per day. He describes it as “like living in a shell, sitting behind your eyes and just looking out like you are only along for the ride, helpless and all you want to do is take more.”
Jeff is still young in his recovery. When you spend the better part of two decades using, 7 months can seem like a relatively short period to be in recovery. Still, Jeff has made remarkable strides in his recovery, and given enough time, skill, introspection and support, Medication-Assisted Treatment and counseling will continue to provide him the opportunity to excel and have the life he has wanted for so long.