Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: addiction research (page 1 of 2)

Suboxone: Amazing Detox Tool, Monster Maintenance Drug.

An Expert Talks About Suboxone: Dr. Steven Scanlan of Palm Beach Outpatient Detox

Steven Scanlan M.D.

Steven Scanlan M.D., medical director of Palm Beach Outpatient Detox

Steven Scanlan, M.D. is board-certified in psychiatry and addiction medicine. In his practice, Palm Beach Outpatient Detox (PBOD), on the Florida coast, he has detoxed more than a thousand patients off many drugs, including alcohol, benzodiazepines (Valium, Xanax, etc.), and sleep aids. But his specialty is opiate detox.

Scanlan has been practicing as medical director of PBOD for about two years. His practice, he said, is located in an area where more than two-thirds of all oxycodone prescriptions in the nation are issued—the south Florida coast that has become notorious for its “pill mills.”

Scanlan said 70 percent of his patients come to him addicted to oxycodone at levels of about 300 to 600mg per day. About 20 percent also come in with alcohol problems. “The rest use Vicodin and Ultram,” and a few come in addicted to Fentanyl, he said.

And then there are the increasing numbers who come to him desperate to get off Suboxonea drug that combines buprenorphine, a synthetic partial-agonist opioid, with another drug to prevent abuse. Suboxone (commonly known as “Sub” by people with addiction) is used in opiate detox and maintenance, it’s known and “prison-heroin,” and it’s now commonly sold on the street.

Scanlan says he has seen Suboxone work brilliantly as a detox tool and dangerously as a maintenance drug.

I first heard Scanlan speak on a podcast that’s now defunct. Two reasons I was eager to talk to him:

1. Scanlan chose addiction medicine as a result of his own recovery from opiate addiction. He understands addiction from personal and professional experience. While training to become an anesthesiologist Scanlan became addicted to Fentanyl, a strong opioid used in surgical procedures and for severe pain. After trying many times to quit on his own, he found a physician who helped him detox over two weeks using Subutex—plain buprenorphine—and other medications to ease the detox symptoms. He joined a recovery program, then decided he was well equipped to help others suffering from the same problem. Many of his physician colleagues didn’t like working with addicted patients, but he found he did. In his practice, he doesn’t just dole out drugs; he gives patients 24/7 followup until they’re physically comfortable and involved in some kind of support program.

2. I wanted to hear his clear-cut ideas about detoxing off opiates. He only does detox. He never does maintenance. Unlike so many other scientists, who believe people addicted to opioids can never stay off them, he believes we can get free.

“Believe me—it’s much more lucrative to do maintenance, to keep patients on Suboxone,” he said, adding that it’s even more profitable than, for example, doing Botox injections. Hundreds of practitioners—some of them with no experience with addiction—prescribe Suboxone as a maintenance drug, keeping patients on it for years at high levels and charging exorbitant cash fees. But for the vast majority of addicted people, Scanlan does not believe drug-maintenance is appropriate—or even safe. Buprenorphine is such a new drug, he says, and its long-term effects have not been adequately observed and researched.

He has said that Suboxone may curb cravings for other opiates and allow people to stop stealing and get their lives in order. But the problem is that, after three months or so, patients have terrible difficulties quitting Suboxone because of its sheer strength in binding to opiate receptors, its long half-life, and the fact that it’s a partial-agonist binding to receptors built for full agonists. And despite what the media tell us, there are many people who don’t want to spend a lifetime on high doses of Suboxone.

You know what? When I was detoxing off fentanyl in 2008, I felt so good on Suboxone that I thought about staying on it. Then something happened. I no longer felt so good. My feelings dulled. I no longer wanted food or sex. I realized my body was adapting to the drug—or trying to. Fortunately my outpatient detox doctor had no more slots for Suboxone maintenance patients, so I tapered off as quickly as I could. If my doctor had been operating under the new Comprehensive Addiction and Recovery Act, he may have had a slot for me, and I might have gotten trapped on Suboxone as so many others have.

Scanlan said most people, including physicians, do not comprehend the strength and effects of buprenorphine. “Everything changes in the body when you’re on opiates long-term—the way the body regulates pain, the way it regulates hormone production, sleep, emotions—everything,” he said. And buprenorphine, he repeats, is an opiate. Its effects are not just physical: as a psychiatrist, Scanlan has noticed in his practice that at long-term doses of just 2mg, Suboxone can block almost all of a person’s emotions.

In addition, buprenorphine’s half-life is 37 hours, which means it takes the body more than a day to excrete half the dose. When dosed once a day, the body doesn’t have time to catch up, so the drug builds up in the system—a phenomenon called “bioaccumulation” that Rachel Carson documented in the buildup of toxins among wildlife in her book Silent Spring. A patient dosing with buprenorphine at 8mg is not only getting 8mg—he’s getting the 8mg, plus the amount not yet metabolized from the day before (4mg). And 8mg is a low-end maintenance dose. In the U.S., patients are commonly dosed at 16mg or 24mg per day.

“There’s definitely a risk to going on Suboxone long-term—anything over three months,” he said. “It would be easier to detox patients if they were coming in at a year’s time at one milligram, or a half-milligram, which is where they should be. But they’re always coming in at 16 milligrams. Or 4 milligrams for four years but really they’ve been at 8 milligrams and they’ve lowered it just before they’ve come to see me. I have to get them to tell me what they’ve REALLY been taking.”

Scanlan is the only professional I’ve ever heard who can explain why the body reacts so differently to Suboxone than to full-agonist drugs like heroin, Vicodin and methadone. Read on…

Suboxone tablets

Suboxone 8mg tablets

G: Educate me about buprenorphine.

Scanlan: It’s the most amazing detox medication I’ve ever seen. But for maintenance—it’s harder to get off than methadone. Suboxone is 25-45 times as potent as morphine. It’s the king of the hill in terms of opiates—it displaces every other opiate off the receptors, except for Fentanyl. [Maintenance physicians] use way too much of it. When you build up to a serum level, it’s SO POTENT.

Americans should look at European countries’ use of buprenorphine. They’ve had it much longer than we have. They use lower doses; they have as much maintenance as we do. In Scandinavia, what do you think the number-one most-abused drug is?—buprenorphine. Simple facts: they’ve had it longer, and it’s the most abused drug. That’s what I’d like people to know about.

Buprenorphine is now the 41st most prescribed drug in the U.S. Five years ago, it was the 196th most prescribed. [Update, April 2016: Suboxone is now the 16th most prescribed drug in the U.S.] So you can see what a money machine it’s becoming. … The research to get Suboxone approved [by the FDA] was funded in conjunction with the NIH. Until the NIH is run by someone in recovery from addiction, this propaganda will continue. [National Institute on Drug Abuse Director] Nora Volkow is great, she’s smart, I’ve met her, but she doesn’t have a clue.

G: Why don’t you prescribe Suboxone as a maintenance drug?

S: I wasn’t against maintenance when I detoxed. But I’ve seen a lot since then. And I had a detox physician who told me, “Do NOT stay on this drug for more than three weeks, or else you’ll be dealing with a whole different problem.”

Buprenorphine is a partial-agonist opiate. It binds to the receptor and only activates it partway. Opiates are meant to bind to the receptors and activate them fully. But if you put something completely foreign in the body like a partial agonist, the body says, “What is this?” and it tries to reach homeostasis. It struggles to understand it as a full agonist, and it can’t. There is nothing in nature that is a partial agonist, and our opiate receptors are not designed to operate with partial-agonists. Buprenorphine definitely does something unnatural to the body.

I’m not against maintenance for a certain percentage of the population. I have a friend who runs a methadone clinic, and I think there’s a percentage of patients who need to be on maintenance for the rest of their lives. Perhaps five percent of the [addicted] population. If you want to do maintenance, though, you want to do methadone. Methadone at least has been used for a lot longer, and we understand it better.

G: How do you conduct detox?

S: To detox patients off long-term Suboxone, I use clonidine [a blood-pressure medication] and Librium [a benzodiazepine] because it’s more water-soluble. And I use Darvon, a weak opiate. Its half-life is short. … The Librium is the last to go. And they complain of disturbed sleep. I don’t use Seroquel because it can be abused. I use what acts on the antihistamine and melatonin receptors—the only two receptors they haven’t messed up yet. … It can take five months to get someone off long-term Suboxone.

For a Fentanyl detox, I give them Subutex. Fentanyl detox is the most brutal detox but it has the quickest recovery of the receptors because Fentanyl has such a short half-life.

I tell them to exercise. Studies show that 12 minutes of exercise per day with a heart rate of greater than 120 beats per minute restores the natural endorphin system in half the time. The people who do that, their sleep architecture returns to normal in half the time of people who don’t exercise. Twelve minutes. And of course you can do more.

G: And you urge them to join a recovery program?

S: They need some kind of support system. Let me tell you—everyone who’s stayed off Suboxone, they’ve been in AA or NA. Thirty-day inpatient programs have an average rate of 5 percent sober after one year. But from what I’ve seen in my practice, anyone who does an honest fifth step in AA or NA stays sober—the numbers are greater than 50 percent. And anyone who can do an honest ninth step and make amends, the number shoots up to over 90 percent.

Everyone who comes to me, I get them off opiates. One-quarter of the people I treat are sober at six months, and ninety percent of those are actively involved in some program. They’re not just going to meetings or involved in community service—they’re actively seeking some kind of spiritual growth. It all comes down to whether people want to do the work.

G: What about people who are afraid of becoming depressed after detoxing from long-term use?

I ask them, Was there ever a time you were sober? Did you have a bout of depression before then? If not, then it’s probably substance-induced. You have to take a thorough history. The statistics say: of all people who get clean, 15 percent have mental illness. Maybe a bit higher than the general population.

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Related posts:

How To Detox From OxyContin and Other Opiates

Reader Questions: Addiction, Chronic Pain, and Drug Maintenance

Have questions, or want to see someone interviewed here? Email me at guinevere (at) guineveregetssober (dot) com.

Can we cure drug addiction with drugs?

So the National Institute on Drug Abuse has given $3.7 million to a professor at the University of Maryland School of Pharmacy to make the first drug in the U.S. and maybe in the world for cocaine addiction from an ancient Chinese herbal remedy.

Corydalis

Corydalis—in Chinese, yan hu suo

This is the pretty little herb: it’s called corydalis—in Chinese, yán hú suo.

The active ingredient in this plant is called l-tetrahydropalmatine, or l-THP. Professor Jia Bei Wang and colleagues from the pharmacy and medical schools are going to take five years to study whether l-THP actually works to decrease cravings for cocaine. Apparently clinical trials could start within the year.

It’s interesting: l-THP, as corydalis herbal extract, is unregulated and available for purchase on the Internet. I wonder what kind of “drug” they’ll develop from it… considering traditional Chinese medicine practitioners have, according to my encyclopedia of herbal medicine, been using corydalis root successfully since the eighth century?

More from my encyclopedia about corydalis:

A painkilling herb that stimulates the circulation, controls spasms and nausea, and has sedative and antibacterial properties. Research also suggests action on the thyroid and adrenal cortex. Used internally as a sedative for insomnia, and as a stimulant and painkiller, especially in painful menstruation, traumatic injury, and lumbago.

This seems to jive with current thinking about l-THP—apparently the same orientation that Prof. Wang has—which says that the chemical blocks dopamine receptors (which by all accounts would give it sedative action). There are research papers out there that also suggest l-THP is good at ameliorating effects of chronic opioid administration in animals (so what’s called good for the crack addict will also likely be called good for the smack addict).

Jia Bei Wang

Jia Bei Wang, Ph.D.

This is important recognition for the validity of traditional Chinese medicine and its potential impact on Western practice, and I’m real happy for Prof. Wang. 🙂

But personally: I’d be kind of reluctant to take anything on a regular basis that fiddled with my dopamine receptors. Just because I’m personally kind of reluctant to take anything on a regular basis at all anymore. (I take a couple of anti-epileptics at low doses for my migraines and fibromyalgia, in fact the doses are so low that the pharmacist questioned whether one of them was even therapeutic… I have mixed feelings about taking pills every day, but the fact is, despite recovering from addiction, I still have pain.) And also, fiddling with dopamine receptors is a dodgy proposition. Dopamine is the neurotransmitter that controls desire, appetite, creativity, sexuality and joy. Man o man, fiddling with that… But if that stuff isn’t present, you’re stuck in the pit of anhedonia, you’re dying to experience life, and that’s why you snort your lines, I can see why you’d want to figure out some fast remedy for the cravings.

And about those cravings: I was taught that you can’t solve a problem with the same thinking that got you there.

In other words, to solve a drug problem, drugs might not be the best solution…

But here’s another point: I know cocaine addicts (and heroin addicts and Oxy addicts and alcohol addicts and fentanyl addicts, you name it) who don’t have those cravings or that anhedonia anymore. While it might be great to find a pill that would get rid of cravings—I know there are many people for whom they never dissipate—why aren’t they studying what’s going right in those of us who no longer have them?

Scientists are frequently holding up fMRI scans and pronouncing dire conclusions about the “warped pathways” in addicts’ brains. Have they followed up on us after we get the kind of help you can’t get in a pill? (And I’m not just talking about the spiritual solution… though that’s part of it, for me and many others. I’m also talking about good nutrition, good exercise, good sleep, being part of community, and productive work—all the stuff you can’t patent and sell in a bottle.)

Scan me. I’d be curious to see whether my own dopamine and opiate pathways are still warped.

From painkillers to heroin: A new study

Surprise, surprise. A new study by some researchers at the State University of New York at Buffalo (UB) has shown that increasing numbers of heroin users became addicted after being given legal painkillers for pain.

The study appears in June’s issue of Journal of Addiction Medicine.

The researchers found that many pain patients first got hooked by using legal prescription drugs, and then they progressed to buying illegal opioids off the street. “Later, they purchased heroin, which they would come to prefer,” the study states, “because it was less expensive and more effective than prescription drugs.”

More effective, you ask?

OxyContin 80mg

OxyContin 80mg tablets

If you look at the study results: more than 90 percent of the participants had purchased street-drugs at some point, and not just tidy little pills—almost two-thirds preferred heroin to anything else “and more than half had used drugs intravenously.” Any drug used intravenously is going to be “more effective.”

It also depends on the “effect” you’re looking for. But in terms of either pain- or mood-control, IV is the most bioavailable route (meaning there’s less drug lost to metabolism—it all goes into the bloodstream), and it’s going to give the strongest “effect.”

As to why they’d choose heroin over pills—I’ve never shot up or bought anything off the street, but I understand from friends who have that it’s more difficult to shoot pills, especially pills with non-opioid agents such as Tylenol and especially fillers that clog up the works.

Another troubling fact reported in this study that all the other digests have missed: 74 percent of these pain patients said the physicians who prescribed them opioid painkillers for extended periods never asked them about any personal or family history of addiction before giving them the drugs.

One of the authors, Richard D. Blondell, M.D., a family medicine doc at UB, made a comment in the UB press release that kind of stuck under my skin:

I tell patients that addiction can be an unintended side-effect that occurs occasionally with the use of these medications. . . . Doctors need to be able to help them if this occurs, so doctors will need to monitor the use of these medications closely.

Those are my bolds. I wanted to know what he meant by addiction being “an unintended side-effect.” I mean, when I think of a “side-effect,” I think of those annoying flies-in-the-ointment that disappear when you stop treatment—nausea, insomnia, even sexual dysfunction. But addiction?—it’s permanent, man.

If you took a pill that caused permanent erectile dysfunction, would you call that a “side-effect”? … And ED isn’t even life-threatening. (Although I guess some folks might feel it that way…)

So I asked the good doctor: This seems a rather diminutive way of looking at addiction. Is this really the way you conceive of it? Many physicians do not understand the nature of addiction, they’re afraid of it, and this is why they miss the signs of it in their offices. … I also wanted to know how he proposed to “help” patients with chronic pain who develop addiction, since the solution for many a physician is to kick the addicted patient out of the practice.

I got a reply a few days later, via his PR flak:

Here’s the sensitive issue: many patients are afraid that physicians will shy away from treating “legitimate” pain if doctors are too worried about the risk for addiction. Many patients take these medications long-term without problems. We don’t want to stop that. On the other hand, some patients do develop an addiction which neither the doctor nor the patient ever intended to happen. The use of the word “unintended” is meant to be a non-judgmental term for this. It means that there’s no blame for the patient or the doctor; sometimes it just happens. When it does occur the doctor must recognize it and manage it with care and compassion. Blaming the patient, blaming the doctor, or “kicking the patient out” are not answers that accomplish anything constructive.

He didn’t quite get it.  He was focusing on the word “unintended.” I wanted him to talk about the word “side-effect.”

But it’s great that he’s getting physicians to talk about being non-judgmental and compassionate, and helping patients manage addiction. Blondell has another paper out in this month’s Journal of Addiction Medicine about how chronic pain patients who are addicted do better on steady doses of buprenorphine (Suboxone) rather than tapering doses to become opioid-free. It seems this guy’s orientation is to help some people with chronic non-cancer pain and addiction help manage their pain with some sort of opioids…

Looking forward to seeing how he thinks he can help pain patients with addiction “monitor” their use of painkillers so that they don’t abuse them. That’s one of life’s $64,000 questions.

And since Reckitt Benckiser has just been given the FDA go-ahead for their fancy new Suboxone film, it also seems like it’s time for me to get on the Suboxone story… a whole nother can of worms. Anybody out there with experience with Suboxone??

How smoking reduces your lifespan—an interactive tool

Found this tool that calculates how much smoking will reduce your lifespan.

Smoking man

A smoker getting his dose.

I love interactive tools. They’re like toys. I tested it out on my mother’s smoking history and it was accurate… She lost about 20 years, and that’s about right.

See below for a set of facts about the benefits that immediately start accruing when you stop smoking.

For all the drugs I’ve bought legally over counters and ingested, I’m glad I’ve somehow escaped nicotine. The consequences are just so damaging.

An interesting read for those who want to quit: Glassbottom’s quit-smoking journal on Opiate Detox Recovery, one of my favorite recovery sites. On the first page of this journal the author, Glassbottom, says of a previous time having quit,

For me, quitting cigs changed my entire perception of time. This was frankly the most enjoyable byproduct of quitting. I hadn’t realized that every activity, every commitment, every damn thing that I did during my day was some how couched in the thought of “when is my next cigarette” If I was writing a paper for school, “How many pages till I go smoke a cigarette.” If I was watching a movie that I enjoyed, “When will this movie be over so I can go smoke a cigarette.” When it was time to eat, “I can’t wait till I’m done so I can smoke a cigarette.” … When we smoke a pack a day, that’s 20 cigarettes. Essentially we don’t go for much longer than a half an hour without a smoke. If two packs, then 15 minutes. Now consider how much of that half hour/fifteen minutes of non smoking time that the thought of the next cigarette crosses our minds. Yep, it’s an obsession.

This gave me insight into my mother’s addiction. Glassbottom wrote that the pride of quitting smoking was “just as great as dope in many ways,” though he said that, for him, opioids were “way harder to deal with” than nicotine. But knowing my mother, I don’t think it was that way for her, and I think it may not be for some others. Nicotine can truly be a “drug of choice”—or, as some on ODR might say, a “drug of no-choice.”

What happens when you quit smoking

(Source: Cleveland Clinic)

After 20 minutes

You stop polluting the air
Your blood pressure and pulse decrease
The temperature of your hands and feet increases

After 8 hours
The carbon monoxide level in your blood returns to normal
Oxygen levels in your blood increase

After 24 hours
Your risk of heart attack decreases

After 48 hours
Nerve endings adjust to the absence of nicotine
Your ability to taste and smell begins to return

After 2 weeks to 3 months
Your circulation improves
Your exercise tolerance improves

After 1 to 9 months
Coughing, sinus congestion, fatigue, and shortness of breath decrease
Your overall energy level increases

After 1 year
Your risk of heart disease decreases to half that of a current smoker

After 5 to 15 years
Your risk of stroke is reduced to that of people who have never smoked

After 10 years
Your risk of dying from lung cancer drops to almost the same rate as a lifelong NON-smoker.
You decrease the incidence of other cancers – of the mouth, larynx, esophagus, bladder, kidney and pancreas

After 15 years
Your risk of heart disease is reduced to that of people who have never smoked

Addiction and Art.

Book cover of Addiction and Art.

Addiction and Art has been sitting prominently on my coffee table. I’ve designed books, and it’s a beautiful book: a big flat hardcover bound in cherry-red cloth, with a reproduction of a painting in red and acid-green on the cover… a tightrope walker clad in the stars and stripes, balancing above a jagged forest of needles and bottles, reaching for an illuminated heart.

The reproductions inside are done equally well. The paper is thick and white and holds the ink nicely; the separations are clean. This is an art book.

It’s also a science book. The authors—Patricia B. Santora, Ph.D., assistant professor of psychiatry at Johns Hopkins University School of Medicine, and Jack E. Henningfield, Ph.D., professor of behavioral biology at Hopkins—directed Innovators Combating Substance Abuse, a $7 million program of the Robert Wood Johnson Foundation whose program office was at Hopkins from 2002-08.

Santora and Henningfield got involved with Margaret Dowell, a suburban-Baltimore artist, after she just happened to have an addiction-themed piece that she sent to them for their annual meeting. These little hotel-lobby shows went over so well among the addiction scientists that they decided to try community-level exhibitions. And the response was a landslide. The show they put on at the Carroll Community College in Westminster, Md., became the most popular art show in the college’s history.

These two scientists and one artist have four audiences in mind for this book:

  • in friends and family, they want to develop compassion;
  • in addicts, they want to foster not just hope but “knowledge that recovery is attainable and that they are not alone”;
  • in policymakers they want to develop the will to fund treatment and prevention from community to federal levels;
  • and in scientists they want to foster a better comprehension of the “human dimension of this treatable medical illness.”

I’m in the first two groups, and I spent 12 years interviewing policymakers and scientists. I’m also an artist. This book makes a vivid and multidimensional contribution toward shifting public perceptions of addiction away from morality-based notions and into the public-health sphere.

One of its best approaches: it lets everyone tell their own stories. It lets the scientists tell their part of the story; it lets the artists tell their part; they combine to create such an interesting cumulative picture.

The artists come from all over the map: recovering addicts; people who love recovering addicts; survivors of addicts who died; therapists and other providers; even a funeral director. Nearly 1,000 images were submitted for consideration; 62 were accepted—that’s how many artists are working on addiction as subject matter. Who would have thought?

But why not? As the authors note, when AIDS struck the nation’s consciousness in the early 1980s, community organizers enlisted the help of artists to tell the story of AIDS through novels, plays and memoirs. And then there was the AIDS Memorial Quilt, which defined art-in-action and forever changed the public’s ideas about AIDS from a moral problem (“the gay disease”) to a public-health issue that deserved scientific research and treatment.

So, these authors say: why not with addiction? As Joseph Califano recently said, addiction is the new AIDS. And there’s a lot of work to do:

Current research shows that addiction treatment

  • is not readily available for those who need it
  • is not integrated into mainstream medicine but remains segregated in programs offering treatments that are not science-driven; and
  • is forever vulnerable to pendulum shifts in funding priorities from one health risk to another (e.g., treating nicotine addiction versus childhood obesity)

Nicotine addiction and childhood obesity are both “funding priorities” of the Robert Wood Johnson Foundation. What they’re saying is, we need the public to fund this work.

I’ve featured art from this book elsewhere, and you can see Hopkins’s excerpts on the press’s Flickr page. But the work of two artists stayed with me.

The artist, addiction counselor and psychotherapist Deborah Feller of New York City has two pieces inspired by clients: one, Toy Soldier, shows a curly-headed seven-year-old boy playing with those green plastic soldiers our brothers all played with when we were kids, while his mother lies passed out nearby on the floor—the boy later became an alcoholic. The second, The Annunciation, shows a girl of maybe 15 sitting at a kitchen table with, in the artist’s words, “her sexual predator—her mother’s boyfriend.” Feller goes on:

The girl began shooting heroin and speed in her teens but now has a Ph.D. and an important role in helping children. This teen and the boy in Toy Soldier continue to exist unseen in the adults they have become. My drawings reveal what is rendered invisible by these inspiring recoveries.

I have a question in to Feller about these comments: have these traumas healed, or do they continue to live on “unseen” in the adults? I hope she gets back to me.

Oil-on-linen versions of Toy Soldier and The Annunciation can be seen on Feller’s website.

Julia Carpenter's painting of her sister Amy

"Goodbye" | © Julia Carpenter

Julia Carpenter's painting, Autopsy

"Autopsy" | © Julia Carpenter

And then there were Julia Carpenter’s portraits of her sister, Amy, which blew me away. I’d seen her painting, Autopsy, featured on Hopkins’s Flickr page… Somehow, alone on Flickr, this painting’s ghastliness didn’t touch me the same way it did when placed next to Goodbye, the portrait of Amy two months before her heroin overdose. (I hope she’ll forgive my reproducing it here. It’s copyrighted to her.) Accompanied by Carpenter’s thoughtful statements about her artistic process, as well as the documentation of the results of both treated and untreated addiction in work after work in this book, the effect was extraordinary in its understanding and feeling:

Amy died of a heroin overdose at the age of 24. After her death, I read her journal entries, went through her belongings, and made discoveries about her life I never could have imagined. . . .  The portraits reflect my ensuing anger over her death, my confusion about her life, and my questions about the physical death of the human body. Using the template of the human face, I discovered within the genre of portraiture the ability to go beyond the traditional to express the unspeakable.

It’s these authors’ dream that the science and the art will inspire readers to ask former Surgeon General C. Everett Koop’s question: “What can I do to help fight addiction instead of fighting those who have it?”

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