Cross-posted with AfterParty Chat.
Late last week it was suggested that a cultural stigma against maintenance medications such as methadone and Suboxone helped kill Philip Seymour Hoffman.
This doesn’t make much sense to me given the fact that, shortly after he died, it was reported that buprenorphine was found in Hoffman’s Bethune Street apartment. Buprenorphine is a long-acting opioid the FDA approved in 2002 for opioid detox and maintenance. It’s used mostly for maintenance: it’s the New Methadone, but it’s much easier to get, because while methadone is approved for addiction-treatment only in a clinic setting, buprenorphine can be dispensed in a doctor’s office. Refills can be called in or faxed to pharmacies.
So how did Hoffman get his bupe? Either he was being prescribed buprenorphine for his opioid habit, i.e. he was “on maintenance”—as so many opioid addicts are: buprenorphine maintenance is a booming business in this country. Or else, as many heroin users do, he obtained his buprenorphine on the street.
Poor heroin users often cop street “bupe” to tide them over between fixes. But Hoffman was far from poor. So it’s speculation, of course, but I think it’s more likely he got his buprenorphine from a doctor. That’s what doctors do these days with opioid addicts: When we get honest about our addictions inside the exam room (and because Hoffman had spent 23 years sober and abstinent via 12-step fellowships, it may be fair to say he had practice in being rigorously honest) the doctors’ fear kicks in and they boot us into Suboxone clinics, where we’re prescribed upwards of 16mg of this very strongly-binding, fat-soluble drug that stays in our bodies for days before it’s excreted. In painkilling power it’s weaker than morphine or oxycodone, but in binding power—in its ability to stick to the body’s opiate receptors—it’s the second-strongest out there.
Some publications are wont to report that opioid addicts—like Hoffman, like me—wreck our brains’ opioid receptors forever through drug-use. (This proves they don’t understand how the body’s painkilling system works: a great portion of the body’s opioid receptors actually reside in the gut. Which is why we get that lovely warm feeling throughout our bellies when we use painkillers or shoot heroin.) But there’s at least as much scientific and anecdotal support for the idea of neuroplasticity in recovery—the fact (it’s not just an idea anymore, it’s a fact) that the central nervous system is far more adaptable than we ever before believed and is evolved to use this resilience to recover from major traumas and illnesses, including addiction—especially if we help it by taking care of our bodies in basic ways, with exercise, good nutrition, and relaxation.
So the “old-school” idea is not 12-step programs, as these pieces suggest. “Old-school” is what I was taught as a kid: that once you lose brain cells, you never get them back, that our nervous systems cannot heal.
Still, these publications are putting the idea out there—and it is not a fact, it is just an idea—that if “most opioid addicts” don’t take maintenance medications forever to “correct” the “permanent damage” we’ve done through drug-use, we’re doomed to relapse.
The clearest example that this isn’t the solution exists in our states’ physician health programs (PHPs)—systems of recovery designed to help addicted and alcoholic physicians keep their licenses to practice. These programs vary from state to state but generally provide five years of continuous care and oversight. Success rates for PHPs are extraordinarily high—upwards of 80 percent of physicians finish five years of treatment and are able to keep practicing.
These programs ought to be considered models for our citizenry. But they remain off the radar because they’re rigorous, expensive and intensive—five years, as opposed to a 28-day rehab, or even a ten-day or three-day detox.
Also, studies of PHPs show that linking recovery to one’s work is one of the strongest incentives you can give an addict to take responsibility for healing. Addiction thrives in situations of un- and under-employment not because the poor are somehow more susceptible to addiction, but because the people affected don’t have enough, or any, productive work.
It’s sometimes said that PHPs are effective for “highly motivated” addicts. Which leads me to my last point. I find it astonishingly patronizing that some are suggesting that public prejudice against maintenance killed Hoffman. Hoffman was an extraordinarily intelligent, articulate, “highly motivated” man and consummate professional whose work, he said, required him to be extremely introspective and emotionally present. I find it hard to believe he would be so easily swayed by public opinion about his choices.
I can more easily see him protecting his ability to work.
To act with the depth of feeling and nuance that he managed required full use of his entire internal emotional range. And opioid medications—including buprenorphine—necessarily dull one’s range of feeling.
I think it’s more reasonable to suggest that Hoffman tried bupe and found that, while taking it, he couldn’t access his feelings to the degree to which he’d become accustomed.
To be sure, he likely felt a great deal of shame during his relapse. One of the more damaging aspects of some 12-step groups, in my opinion, is their focus on “sober-time”: to “come back” from a relapse after a sober period of 23 years—half one’s life—would have been not only extremely embarrassing for anyone but also physically difficult, given that the heroin available these days is wicked strong.
But no way could Hoffman have wrecked his neurology permanently by using heroin for less than a year. I think it’s likely he did what so many who use heroin do: he chipped heroin, then switched to bupe, thinking it might remove his cravings. In fact, buprenorphine reliably does this for many opioid addicts who take it.
But craving is a feeling, and you can’t numb feelings selectively. My bet is that, feeling not-high but not-normal—after all, he’d been sober for 23 years: he knew what His Normal felt like; he knew what it took for him to do his job with the precision and quality with which he was used to doing it—he said what so many of us say when we’re caught between a rock and a hard place.
What he needed was not more drugs. What he needed was a better form of treatment, perhaps the best evidence-based addiction treatment system we have going: the time-consuming, attentive one we give to doctors, the people we trust to protect other people’s lives.
But because Hoffman was “just” an artist, he followed the cheap, easy, brief trajectory that ordinary people in this country follow.
Pills. Then heroin. Then Suboxone. Then heroin again. Then death.
He had 23 years sober before he relapsed on painkillers and heroin in 2012.
The news literally knocked the wind out of me and I cried, the way I cried the day I heard David Foster Wallace (another addict) topped himself. My first thought in both cases was selfish: Now we never get any more of their brilliant work.
My second thought was for their partners, and Hoffman’s kids. Hoffman had—has? had?—three kids. “Young children,” they are described in the New York Times story. Village residents who saw him around the neighborhood are describing him on Twitter as a generous dude who was kind and unpretentious when he brought his kids to the coffee shops.
I loved him in this role in “Magnolia.” There is a video circulating on Twitter, a clip from “Before the Devil Knows You’re Dead” that shows him being shot up with drugs and mumbling while he nods. The author of the Tweet wrote,
How art more than imitates life.
Well, sure. Those of us who used to nod out may remember how to act like that. It’s more challenging to really BE kind and unpretentious. I prefer to remember him in this role—the attentive nurse who helps Tom Cruise’s father die.
The fact is, Philip Seymour Hoffman’s work made him an extraordinary artist, but with regard to this disease, he was just an ordinary person with addiction.
The illness of addiction is the most endemic and perhaps the most invisible in our society. It is connected with so many other illnesses—HIV, heart diseases, lung diseases, liver diseases, cancers of all kinds; and also depression, anxiety, and other mental illnesses—as well as car accidents, accidental shootings, murders, and other forms of death. PLEASE LISTEN: every 19 minutes an American dies of a drug overdose. Here in Pittsburgh two dozen have died in the past two weeks from a fentanyl-spiked cut of heroin. That cut is making its rounds to bordering states, and I wonder whether that’s what killed him. I’m glad fentanyl didn’t kill me.
These numbers ought to be unacceptable to any sane citizen or leader—and remember, we elect the leaders.
As someone who writes and speaks about the dangers of this illness and the possibilities of recovery, news like this makes me feel at once nearly despairing and also recommitted to letting the public know that with appropriate help people with this disease can recover.
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Goes to show that homo sapiens and canis lupus familiaris evolved together.
Our bodies respond to them.
If you knew me, you’d know how odd it is that I own a dog. I always had cats—all my life, since I was a kid, I’ve owned cats. I’ve had some awesome specimens of felix domesticus. My girl Sully was a loyal orange tabby rescued in the countryside, and she lived 19 years.
Sully would sometimes sleep beside me, and she purred—purring is a fantastic feature of felix.
But for as much as we loved each other, Sully never, ever smiled at me.
[For Jill at A Thousand Shades of Gray, in honor of the season of Puppy Advent.]
My first yoga teacher in this city was a woman named Rae Kline. I can’t remember when I started taking Rae’s classes—it was either around 1996, before I had my son, or in 1998, when he was a baby. Anyway it was a long time ago, almost 20 years.
Rae used to teach at the Friends Meeting House—the Quaker house, where my recovery home-group is now and where I’ve been going on Sundays for silent Meeting since 1992.
I was a yoga novice when I began studying with Rae—I still am a novice, really—so I don’t know what her discipline was. Yoga was so new back then that nobody talked about Iyengar or Bikram or Ashtanga or gurus or whatever. There was no Athleta or Lulu’s Crackhouse; yoga pants hadn’t been invented, much less recalled for being “too sheer.” Yoga was yoga. Vanilla. Generic. You brought your mat (there were no yoga studios in this city back then) and you did your Sun Salutations and your triangles and your downward dogs.
I learned one thing from Rae that has stayed with me all these years: Yoga is not about performance and twisting yourself into a pretzel. It’s about breath and coming back inside the body.
I did my first down-dog under Rae’s instruction. It was painful. I have broad shoulders and a persistent knot in my left shoulder blade that prevented me from achieving the flat back she wanted to see. “You may have some involvement in that shoulder,” I remember her telling me. I still have it.
But the center of Rae’s practice was the breath. She insisted we breathe into our lower bellies while inside the pose. She’d demonstrate what she wanted: She would sink deeply into the pose and show us that if a woman in her mid-60s could do this, then we could.
Then, after we’d spent what felt like some hours breathing into our lower bellies, she would tell us to “empty the breath from the lower belly,” and we emptied the breath from the belly—all the way. Completely empty. Then start again: breathe into the belly.
The same as what Thich Nhat Hanh says about breathing:
Breathing in, I know that I am breathing in. Breathing out, I know that I am breathing out.
I remember, around the time I was studying with Rae, being invited to join a friend for a yoga session at her gym. My friend told me it would be a combination of yoga and aerobics. I was like, Huh? But I went. And the session made absolutely no fucking sense to me. Here we were, a bunch of women in Lycra leggings and running shoes, dancing around in semi-triangles and quasi-warriors. I’d put my body into these half-poses, and all it wanted to do was sink in all the way and be still. And breathe into the lower belly.
I didn’t go back. I went home and put my body into downward dog the way Rae had taught me, and I breathed. And even though I was using drugs and headed into addiction, the practice stayed with me. It was a valuable foundation.
This morning I Googled Rae’s name just to see where she might be. Frankly I didn’t even know whether she was still alive. But I should have known better. Her body in her 60s is more awesome than mine is now in my late 40s, and she swore that yoga kept her youthful not only physically but also mentally and emotionally.
It turns out she’s now in California—teaching yoga, of course. Here is a photo of her from earlier this year, from a series of photos National Geographic did of folks who are living well into their old age.
She’s 83. Look at her!! And no Botox, no implants, nothing except her bright red lipstick.
That kind of flexibility can’t be confined to the body. When I become flexible in body, I also become flexible in mind and heart. (Of course the opposite is also true: when I become rigid in body, I also become rigid in mind and heart.)
Rae is the Athena of Yoga and she demonstrates the reasons a basic level of physical fitness is so important to our emotional and spiritual wellbeing. How lucky I was to have studied with her even for a short time.
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Cross-posted with Recovering The Body.
Today I have a guest-post about self-compassion running on Jill Salahub’s very cool site, A Thousand Shades of Gray. I love following Jill everywhere—on Facebook, in her emails that arrive so often. Jill is a sister on the trail of questions we’re asking together. Thanks for including my work in this wonderful group of essays you’re collecting.
One lesson I’ve learned this year: hurting people I love is inescapable. Unless I decide not to have relationships.
I really don’t see myself as a hermit.
I’ve hurt a few people I love recently. Earlier this year I committed series of acts that gave another person tremendous feelings of hurt. Just yesterday I found out from one of my best friends that I’ve been saying some things that I had no idea were hurting her.
The first hurt is an example of making choices in the service of myself, my own best interests, that just happened to hurt another person. I knew they were going to hurt this person. I avoided taking the actions because I knew it would cause great pain. Day by day, if I were going to stay sober, I had to take the actions, and I was appalled to watch the pain happening, like waves rolling into the shore.
For some weeks I sat at the window watching the waves rolling by, my heart squeezing in empathy and doubt.
I second- (and third-, and fourth-) guessed myself. I didn’t turn back.
In the second example, I found out I’d hurt my friend yesterday only because I’d taken the risk of telling her something she’d said just that minute that had hurt me.
Her hurtful speech had occurred in conversation yesterday. But it turned out that, when I rolled over and showed my belly (when I, in Brené Brown’s parlance that Oprah is now making universal, “became vulnerable”), she bared her teeth and let me know I’d been saying things that had hurt her feelings for a while. And then when I yelped in surprise and pain, she rolled over onto her back. And there we were, two puppies on our backs in the dirt, paws waving in the air, yelping our hurt.
After rolling back up onto our feet and talking about it, we were able to chase each other and play again, as our dogs do on our morning walks.
“I’m being vulnerable here!” I said. “I have to practice what I read about!! I can’t just read it and not DO IT, right?”
(You’re such a loudmouth, my mind says.)
“If we can’t tell each other these things,” she said, “who can we tell?” A space in my chest opened in gratitude for a friend who is willing to engage in honest conflict. Not many are.
Still, I walked away yesterday morning with my throat choked up. Interesting that it was my throat. Was my body trying to squeeze the words I’d said back inside me? Trying to keep myself from ever speaking again?
Or was it just that the throat is the locus of the voice, and this is where the hurts had occurred—with our voices?
I’m learning that the body and mind are in conversation. They’re one, they’re intertwined somehow, and I’m beginning to think that the way they’re intertwined is through this conversation, a kind of discourse. What kind of discourse is it? How is it conducted? These are some of the questions I’ve been asking lately.
The mind tries to force the body to walk away calmly and get on with the day. The body is able to cooperate only so far before rebelling with some action: butterflies in the stomach; pain in the head; fatigue in the flesh. Choking in the throat.
When the mind ignores these statements by the body and tries to push the body through, the body protests in a louder voice. Nausea, inability to eat; cluster headache, chronic daily headache, migraine; chronic fatigue syndrome. An inability to speak up, a silencing of the body’s voice in critical situations. Such as true relationship.
Craving to drink, smoke, use something.
So the mind and body engage in a struggle for domination.
Dr. Sally Gadow, a Ph.D. nurse and leading scholar in health care ethics and the phenomenology of the body, writes about this struggle in a fascinating paper, “Body and Self: A Dialectic.” This paper itself (my friend pointed out yesterday) is an academic paper, so its expression is in the language of the mind, the intellect, and Gadow herself offers this caveat inside the paper. But I think what Gadow enacts in it is an effort to respect and give voice to the body.
To report from the body, which has long been one of my projects.
The struggle for domination is the second of four levels of development Gadow says have to take place if the body and mind are to transcend their “dualism,” their two-ness, and begin to work together as one to express each other’s interests. In this second level, “the two are not only distinct but opposed—each alternately master and slave.”
The second stage describes addiction.
The transcendence describes sobriety. Freedom from slavery.
Yesterday, driving home with my throat choked up, I thought about self-compassion. My mother trained me early to feel compassion for the pain of others. Hurting someone else without knowing it is one of my worst fears in sobriety. I used to numb this fear, as well as the reality that I’d hurt other people, with drugs.
“How will I know I’ve hurt you if you don’t tell me?” I asked my friend.
“You’re right,” she said.
The question underneath the choking is, Does my friend really love me?
Doubt rises up. If you’re going to get her to love you, my mind tells my body, you have to fucking SHUT UP.
(And stop swearing so much!! She said I swear too much.)
But anyone who knows me know my language can be strong, fierce. Is it just who I am?
To make things right, I know I have to change my behavior. But do I need to change myself?
Do I need to change to be loved?—an old, old compulsion.