How Cocaine Kills

Cocaine is a potent, illegal stimulant that affects the body’s central nervous system. It is extracted from the green leaves of the coca plant, and people in South and Central America have chewed these leaves and used them in teas medicinally and as a mild stimulant for thousands of years. But somewhere along the line, these people learned that this humble leaf could be processed in a way that extracted and concentrated its active components to create a substance called cocaine, a white powder stimulant that is anything but mild. 

Cocaine goes by a lot of different slang terms and street names, mostly based on its appearance, effects, or drug culture: C, blow, coke, base, flake, nose candy, and snow are some examples. At the peak of its use here in the 1970’s and 1980’s, cocaine began to influence many aspects of American culture. Glamorized in songs, movies, and throughout the disco music culture, cocaine became a very popular recreational drug. It seemed everyone was using it, from celebrities to college students to suburban moms looking to turn up at the disco on Saturday night. It was so popular in the disco scene that people openly snorted it on the dance floor at Studio 54. But powder cocaine would soon take a back seat to its trashy cousin from the wrong side of the tracks: crack cocaine, or crack. Crack is an off-white crystalline rock made by cooking down powder cocaine with God knows what else for bulk, and the crack rock is then smoked in a pipe. This form of cocaine created a scourge of epidemic proportions and ruled the streets throughout the 1980’s and early 1990’s. Crack is whack and crack was king then, and it’s still around today. It’s actually named for the cracking sound the crack rock makes when it’s smoked. While it’s the same drug as powder cocaine and has the same effects, smoking crack gives a more immediate high than snorting powder cocaine. But it doesn’t last long, so to stay high, crack users have to “hit” the pipe over and over, constantly, 24/7, for hours and ultimately days on end. Crack also has street names: rock, gravel, sleet, and nuggets to name a few. And combined drugs also have street terms, like speedballs, which are a mixture of cocaine with heroin or other opiate. Every illegal drug and drug combination you can imagine has a list of street names…Cocoa Puffs, Bolivian Marching Powder, Devil’s Dandruff…Every time I think I’ve heard them all, a patient uses one that’s new to me.

So, what’s the attraction? What does cocaine do for you? Captain Obvious says… it gets you high. Cocaine creates a strong sense of exhilaration. You feel invincible, carefree, alert, and euphoric, and have seemingly endless energy. It makes you more sensitive to light, sound, and touch. It makes you feel confident, competent, and increases performance and output. For intense Type A individuals, cocaine is a requirement, on par with oxygen. These individuals want maximum performance, maximum fun, maximum sales…maximum everything. Period. And cocaine delivers. It works by increasing the  feel good neurotransmitters dopamine, serotonin, and norepinephrine by blocking their reuptake. No reuptake equals more feel good neurotransmitters equals more feeling good. To be candid, when just starting to use, and in small amounts, people can actually do fairly well using cocaine. They feel great and are more productive, and that’s how smart people get involved with it. At first, it seems there’s no down side, it’s up up up….on top of the world. But as they say, what goes up must come down. Whether you snort, smoke, shoot, or suck on it, using cocaine is a very sharp double-edged sword. I’ve seen people go six, eight months, using every day, and for a short time, for all appearances it works for them; they feel great, they’re focused, performing well. But then without warning, they’re not. They crash, their performance sinks into the abyss. They go into an impaired state, a mental fog, and their neurotransmitters betray them. They become paranoid, confused, disorganized, hopeless, and lost. 

Using cocaine even once can lead to addiction. As with many drugs, the more you use it, the more your body gets used to it, and that creates the need for a larger dose and/or using the drug more often in order to get the same effect. Cocaine is a potent chemical, and both the short-term and long-term effects of using are dangerous to physical and mental health. Riddle me this: how many old crack addicts are out there? I can tell you, not too many. Why? Because they’re all dead of heart attack, stroke, arrhythmia, respiratory failure, seizures, and sudden death. Whether you use cocaine once, use on occasion, or you’re a habitual user, the risk of seizure, stroke, cardiac arrest, respiratory failure, and even sudden death, is equal. Equal. No matter how little you use or how rarely you use. And the first time you use can also be your last chance.

So exactly how can you kill yourself with cocaine? Let us count the ways….cocaine’s potency and molecular makeup causes serious physiological consequences. No matter what form you use it in, it increases your blood pressure, increases your heart rate (aka your pulse), and it constricts the arteries that supply blood to your heart, all at the same time. So now, you’re asking the heart to pump faster and harder (because it has to pump against your increased blood pressure), and without as much blood flow (and therefore not as much oxygen and energy) as it was getting before the cocaine was in your system, and tah-dah! What can you get? Arrhythmias. Simply put, that’s when your heart can’t keep good time, it beats erratically and sporadically. Without conversion, you have a heart attack. Your heart basically stops beating and you die. And just remember, as you get older, your body is not as resilient. You may or may not have a lethal heart attack at 20, but you sure will at 50. How else can you kill yourself with cocaine? Using can cause you to go into a state where you’re unable to control your temperature, so it gets very high, you get restless, have tremors, dilated pupils, nausea, vomiting, complete disorientation, and mental confusion. If the fever gets too high, you can have seizures, which can lead to death. It happens every day. You also have to take into account potential accidents resulting just from being high, without your normal faculties, and being unable to take care of yourself. Freak accidents while high can be deadly. Remember too that cocaine is cut with crazy stuff- ground glass can cause internal bleeding, and diuretics and laxatives can cause electrolyte imbalance, both of which can kill you. And these days, cocaine is often cut with fentanyl- an opiate 50 times more powerful than pure heroin- which causes hundreds of overdose deaths each day. If you freebase cocaine or smoke crack, the chemicals used to cut it can cause sudden acute respiratory failure where you stop breathing and die, or they can damage the lungs over time and cause respiratory failure and the same result- death. If you use IV (intravenous needle injection) and share needles, you expose yourself to all sorts of potentially lethal infections, including Hepatitis, HIV and AIDS. If you choose to suck on crack, the chemicals used to cut it may be caustic and potentially damage the throat and/ or stomach and cause bleeding, or they may cause intestinal death and decay; these can potentially lead to death. 

So in the beginning of your cocaine career, you’ll feel great- super powerful, confident and competent. High. But shortly into your cocaine career, you’ll find that the magic is gone. The genie is out of the bottle. The high just isn’t the same, no matter how much you use or how you use it. So you chase that high…and you’ll chase it for the rest of your life, but to no avail. The high is replaced with the craving for the high. I’ve never seen a drug with cravings as powerful as cocaine. They’re just unbearable cravings, and they can last indefinitely. I’ve seen many, many cases where they last for years. I see patients now who have had these horrendous cravings for years, and I expect they’ll have them for the rest of their lives. They were lured in by the shiny bauble that is cocaine, and cocaine showed them a great time. Then cocaine turned on them, closed the door and threw the bolt, leaving them to want/need/crave what they had, likely forever. It’s just not worth it. I treat addictions of all kinds: heroin, alcohol, marijuana, benzodiazepines, you name it. For the most part, people with these addictions comply with treatment and come to their follow-up appointments. But cocaine addicts are a different story. They’ll come to my office once, all committed to stopping the cocaine, but you never see them again. They vanish…poof! They don’t do well in treatment, because the cravings are so strong that they can’t resist, so they take off and use again. The cocaine cravings are bar none the strongest I’ve ever seen. Now, the withdrawal from cocaine isn’t bad at all. It’s not like an alcohol withdrawal or withdrawing from Xanax or heroin. Those are gnarly, even potentially dangerous. With cocaine withdrawal, you can get depressed, you sleep a lot, you get vivid dreams, you want to eat a lot, you can’t think super clearly for let’s say three to seven days, but there is no real treatment needed for it, just comfort measures- keep the person cool, keep them hydrated, keep them fed, and allow them to rest- and they’ll bounce back. Now, one thing that sure does come up is that, because the cravings for cocaine are so intense, as soon as they’ve slept and ate and they’re back on their feet, it’s sayonara sucka! They bolt. They’re out again, they’re using, they’re smoking, they’re shooting, they’re shoving it up their nose, they’re putting it in their mouth, wherever and however they can use it. If they had a decent time period of not using, they may get that first super awesome high; but then they’ll inevitably spend the rest of the binge chasing that high, but they won’t find it.   

Now, you might ask how intelligent, successful, type A people get involved with cocaine when they know it will lead to their eventual mental and physical collapse and  possible death? Because these people know that in the short term it will increase their work performance, their ability to think, their social acumen, and their confidence. I always ask my patients what price they’re willing to pay for this temporary condition. Most don’t have an answer. I think that’s because they think nothing bad will come of their using, but I know different because I’ve seen different.

A true story from when I worked in the emergency department at Roosevelt Hospital: there was some sort of summer festival in Central Park, and evidently a guy locked himself in a portajohn so he could smoke crack. It’s summer, there’s no ventilation in the portajohn, and crack causes an increase in body temperature, so this guy had to be hot. But he was also high, so he was confused as to where he was and how to get out. People reported hearing him freaking out in the portajohn, kicking the walls and pounding on the door, but they couldn’t get past the locked door and he couldn’t follow their instructions to unlock the door and open it. So he was all worked up on top of being overheated, so his muscles heated his body up even more. Eventually, NYFD came and got him out of the portajohn, and he was brought to the ER, where I saw him. He was very hot and very dehydrated and very high. I started cool IV fluids and ordered an alcohol bath, but the damage was done. In short order, he developed something called rhabdomyolysis, where the muscles begin wasting away and all the muscle fibers enter the blood stream and shut the kidneys down. Despite our best efforts, he died. The family was very upset. They knew he was smoking crack, but couldn’t stop them. Every attempt to put him in treatment ended with him running away to use. And he was no slouch, no crack bum; he was a regional manager for Ace Hardware, in charge of like 20 stores. And he wound up basically killing himself in a portajohn. What a waste.

When I think about the stereotypical Type A individual doing cocaine to excel in the workplace, I think of a  Wall Street broker. I had a patient, a broker who worked on the Exchange floor. This guy was 40 when he first came to me, said he was on the fast track, that he wasn’t going to make $700,000K a year for much longer. He said he had to be sharp, had to be quick at all times and at all hours, no complacency, so he’d been using cocaine. I warned him about the potential dangers of piling cocaine on top of such a high stress job, but no matter what I said, he wouldn’t give it up. His motto was “Damn the torpedoes- full speed ahead!” He was getting away with using. Six months, seven, gaining on eight, he worked constantly, but he was the man, top trader, taking home fat 6-figure bonuses. After just over eight months on the cocaine, the piper insisted on his payment. He had a heart attack at 41, and when the ER doctor took his history, he readily admitted to using cocaine for eight months. With further questioning, he also reported having periods of confusion over the previous six months. His solution was to use more cocaine in an attempt to regain the sharpness it had once brought him in the beginning, but it didn’t work. What the cocaine did do was really keep him up at night. His solution for this was to drink four martinis every night in order to come down and get some sleep. He was doing this every day of the week for about seven months: cocaine throughout the day and martinis in the night. The cardiologist ordered a whole bunch of tests and it soon became clear that the heart attack that sent him to the ER was not his first. And unfortunately it wouldn’t be his last. His heart muscle was quite damaged from the ups and downs of the cocaine and alcohol fueled roller coaster he had boarded months before. I suspect that he never totally got off that ride, despite having another three heart attacks. Each one was progressively worse and made more obvious his mental and physical decline. At the age of 43, a massive fourth heart attack punctuated his life with a period. The man that burned the candle at both ends had burned himself out. 

No tales of caution would be complete without mentioning the models and the housewives. They like cocaine because it helps them lose weight and stay thin. And because the cocaine stimulates them, they like to take Xanax and drink alcohol at night to come down. I can spot the cocaine/alcohol/Xanax Barbies at 50 yards, because they actually turn gray. I’m serious- their skin turns gray and they get too thin. The whole program makes them look like victims of concentration camps. And they wind up forgetting normal daily activities- forgetting to pick the kids up, forgetting when dinnertime is, forgetting how to do the homework with the kids, forgetting how to accomplish simple banking transactions- everything gets screwed up. In my career, I have lost count how many husbands have sincerely asked me if I think that their cocaine/alcohol/Xanax Barbie wives are: A. Going crazy, B. Exhibiting symptoms of early onset Alzheimer’s disease or dementia, or C. Showing signs of having a brain tumor.

I’ll tell you this one last quick story about a patient I saw a few days ago. Her name is Julia, and she is a 33-year-old out, loud and proud lesbian. She’s very intelligent, a paralegal, and lives with her girlfriend of several years, Paola. She was introduced to cocaine after coming out and getting involved in the lesbian scene at age 21. She used cocaine daily- and in increasing amounts- for ten years, because she said it stimulated her libido and helped her reach orgasm. She stopped using cocaine when she had a heart attack at age 31. Unfortunately, the heart muscle was significantly damaged, and now she is unable to tolerate even mild exertion, such as that which happens during sex. So…the cocaine she used for ten years to increase her libido and help her reach orgasm has caused her current inability to have passionate sex with her girlfriend. How’s that for cruel irony? 

Cocaine is relentless and seductive…initially it can feel amazing, a ladder that lets you climb to the top of the world. Then cocaine is vicious, it sinks its hooks into you, which very few people manage to completely free themselves from. The perceived benefits aren’t worth the cost, which, as with some of my former patients, can be your life. It’s simply not worth it. I hope you get the take home message of all the many ways that cocaine can kill you, and that you understand how smart people find themselves tangled up in using cocaine, but also how even smarter people manage to stop using cocaine. 

For more details and stories about addictive drugs like cocaine, check out my book, Tales from the Couch, available in my office and on Amazon.com.

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Given the legalization of marijuana in many states, I wanted to have an open discussion on the ramifications and repercussions of its legalization, and why choosing to use might not be the best choice for everyone.

Marijuana is so readily accepted everywhere now, in both legal and illegal states and in any and every social circle; regardless of its legal status, its use is suggested by so many people for everyone and everything under the sun…it’s a revolution that makes Woodstock look like a quilting circle. Grandmas and grandpas, CEO’s, lawyers, actors, the butcher, the baker, and the candlestick maker….everyone’s using marijuana, legal or not, and they’re not afraid to tell the world. And the marijuana of today ain’t yo mama’s marijuana…today many people prefer to smoke marijuana wax rather than the green herbacious stuff, because wax is a minimum of 90% pure THC, miles away from the 15% green stuff.

The legalization of marijuana has created a slippery slope. Now it’s basically off the radar for police, meaning that most officers will give a pass for possessing up to a certain amount of it, even in illegal states. The police officers have discretion in the field, and most just confiscate it and maybe write a fine ticket for it, or maybe not…it’s not worth the time or effort for them to fight it any further, even in illegal states. If they just wrote every possessor a fine ticket for marijuana possession, they’d be buried in tickets, so imagine the paperwork if they arrested them all. I watch a live police program on weekends, and the first question an officer asks the driver they’ve pulled over is if they have any weapons or drugs in the car. They then emphasize that “honesty goes a long way” when it comes to their decision-making process in drug possession. Sometimes they’ll employ a K-9 officer to find drugs, and I swear that at least 85% of the cars they pull over contain drugs of some sort. And most times (after the officer makes it clear that they can’t get in trouble for it) a driver will readily admit that they have smoked within the last hour or minutes before getting behind the wheel, or even just smoked while driving. This is apparently due to a general consensus that marijuana doesn’t cause impairment, which is debatable; more recent studies are suggesting otherwise.   

Because marijuana has essentially vacated its spot in the illegal drug hierarchy, the next “least worse” drugs, meaning cocaine and methamphetamine, have moved up, becoming “less illegal” in a way. Now officers even have some discretion when it comes to the possession of cocaine and meth; if the possessor only has a small amount, they may not necessarily go to jail. As hard as it is to believe, I have seen it on the live police program, people issued a ticket for possessing a small amount of coke or meth. The only difference is the type of ticket issued: while a marijuana ticket is just for a steep monetary fine, the ticket for coke or meth possession is essentially an order to appear before a judge, who then decides if the offender goes to jail or gets off with just a steep monetary fine and/ or probation, community service, etc. I wonder if lawmakers ever imagined that the legalization of marijuana in some states would lead to the near decriminalization of even minute amounts of drugs like coke and meth, but it seems it has. Similar to marijuana, I think it’s likely due to the amount of time and effort it takes to haul every coke and/ or meth possessor to jail: small amounts are permissible when weighed in the face of 100% rule of law…it’s certainly faster, easier, and more profitable to fine someone through the nose (no pun intended) than to house them in our overcrowded and expensive jails.  

Enough of the legal ramifications. Of course as a physician, I see the more personal, medical side of the legalization of marijuana. I am literally asked about it by patients every day, and I am a medical marijuana prescribing physician- I jumped through all of the state’s many hoops so that I can prescribe marijuana. I believe that used properly, marijuana has definite value as a drug. The key is for whom. I think it’s good for someone with cancer, with brain tumors, for AIDS, for neurologic disease like ALS (Amyotrophic Lateral Sclerosis), for Crohn’s disease, irritable bowel syndrome, for post-traumatic stress disorder, for specific types of chronic pain, and for certain seizure types. While I don’t prescribe marijuana willy-nilly, I definitely do prefer prescribing marijuana over other controlled drugs like opiates. But as I tell patients, just because it’s legal doesn’t mean it’s useful for everyone or even reasonable for everyone to use it. In fact, I think that for a subset of the population, up to age 30-ish, marijuana is counterproductive at best and damaging at worst. I call marijuana “the nothing drug.” If you give marijuana to a young developing mind, let’s say someone aged 14, the person belonging to that mind has their life course altered. From the day they start smoking marijuana, nothing happens. Their motivation drops off. They think a lot of good thoughts about what they can do or would like to do, but they do nothing. So nothing gets done. That’s what alters their life course. Dreams are great, but the key is to act on them. I tell my patients that when they use marijuana, nothing happens. Nothing bad, but nothing good. Nothing scary, but nothing awesome. Just nothing. Users do nothing, and if they continue to use habitually, they may amount to nothing. They may not fail, but they definitely will not excel. When you ask that marijuana-smoking 14-year-old what they’ve been up to, they’ll say ‘’nothing.’’ When you ask what they did in school that week, they’ll say ‘’nothing.’ When you ask them what they did over the weekend, they’ll say ‘’nothing.’ When you ask them what happened at the football game, they’ll say ‘’nothing.’’ When you ask them what they do when they get high, they’ll say ‘’nothing.’ Now you get the picture. Marijuana… The Nothing Drug. There’s a PSA campaign for ya’.

Using marijuana is mostly about being alone, being high, and being out of touch. You cause no problems. As a matter of fact, the last thing you want is conflict…it would harsh the mellow. My patients who smoke tell me that when they use it, they just want to keep using it, because it makes them feel so good. But there are qualities to marijuana that make people prone to isolation, where they don’t communicate with others as much. Think about it. When was the last time you went to a wild, raging party with people smoking only marijuana? Do you hear a lot of meeting and greeting, talking and laughing? Nope. But you do hear the sounds of lots of lighters striking and water bongs gurgling. And some muffled coughing- that wierd upper throat/ nasal cough that comes from people holding their breath and trying hard not to cough up the hit they just took. You may hear a woo-hoo or two, but that’ll come from the direction of the couch, which will be replete with reclining stoners. In my experience, people who smoke pot waste a lot of time doing so. It’s the kind of drug that can be used constantly, for hours and days on end, because there’s no concern of overdose. There’s a lot of time wasted, no pun intended, on thoughts not thought through and things left undone. When I warn patients about isolation, I often hear back from them that they do spend time with people, that in fact, they get high with people. I tell them that they may think they’re spending time with friends, getting high with their buddies, but that most of the time they’re getting high and playing video games or listlessly bobbing their heads to music and they just happen to all be in the same room. There’s no real interaction…it’s a very solitary pursuit, but in the presence of others, a mental masturbation marathon.

Obvi, I have many patients that complain that their lives aren’t going well, that they’re depressed and generally unhappy, and many of them smoke marijuana to “relax.” When I ask the marijuana users why they’re unhappy, they seem completely devoid of any insight as to what’s going on. I have a list of questions I ask, and it starts with “How much do you smoke?” I can probably count on one hand the number of people who tell me the truth, that they smoke a lot of marijuana; they always say they smoke “a little” marijuana. When I ask what form they use and how much “a little” is, some admit to using wax, and many tell me they use “only at night, never during the day” like that makes all the difference in the world, given that there are basically 12 hours of night in a 24 hour day.  

The best “medicine” I can dispense to these marijuana-using patients is education. I have given a version of the same talk at least a thousand times, tailored to the patient’s age and condition. It basically goes something like this: “You’re unhappy because marijuana alters you. It makes it so you’re just going through the motions of life; when you’re directed to do something, you can do it, but you never do anything of your own volition. You have no original thoughts or ideas or insight into your life, because you don’t bother to examine it. You don’t have any meaningful interactions with other people. You spend your time playing video games and eating junk food. You never see the sun, unless you have to venture out in daylight for a marijuana-related errand. You’re lacking a creative outlet, because marijuana isn’t conducive to creativity. Marijuana is robbing you of motivation, memory, ambition, desire, and energy. It blunts your emotions so that you feel nothing, so you smoke more to feel high because that’s better than feeling nothing. It’s a vicious cycle. You’re just like a rat on a wheel in a cage.” These facts are why marijuana is most damaging for people up to about age 30, because by this time at the latest they should be expending great effort trying to establish themselves and their lives, deciding where they want to go and setting goals to get there. Instead, they use marijuana and all that goes out the window. For an 80-year-old woman with cancer or rheumatoid arthritis, marijuana isn’t going to affect her life nearly as much as a 20-something-year-old looking for a job or deciding what career path they want to take.

As an example to show that using marijuana is not exclusively for the young, take my patient Frederick, who is 68 years old. He started smoked marijuana at ten and basically smoked all day, every day since. Consequently, he did nothing his whole life, so 58 years. That’s 58 years completely wasted, again no pun intended. Somehow he got on disability years ago. As far as I could tell, his only disability was that he wanted to smoke all day, that he liked to be high. I have another patient, a 23- year-old named Skylar. He’s basically a trust fund baby, living in his parents’ Palm Beach mansion full time while they spend 48 weeks of the year living up in Massachusetts. Skylar’s “job” as caretaker of the mansion, supposedly overseeing a staff of six, has always left him with more than ample time to do, well, nothing…except smoke wax. And he was a hard case, because he was able to afford the strongest wax and he smoked a lot of it- one of the handful that admitted to doing so. I saw him in my office a couple of months ago, and he told me he had wasted enough time using marijuana, he wanted off, and would I help him? Once I recovered from the shock and picked myself up off the floor, I of course told him that I’d be glad to, and I explained the deal. Most people think there’s no withdrawl from marijuana, but that’s not true. There is about a ten day withdrawl period that typically includes insomnia, restlessness, and irritability. It then takes six weeks for green marijuana to eight weeks for wax for all traces of THC to leave the body. I use medications like clonidine and trazodone to minimize the effects of withdrawal, and they make it much easier. At the two-week mark, the four-week mark, the six-week mark and the eight-week mark, patients are amazed at how they feel clearer and clearer at each point. They’re able to see how impaired marijuana was actually making them- they were totally unaware of their impairment at the time, how slow they were, how dopey and lazy. Once it’s completely out of their systems, they tell me how they’re more active, how they’re getting up in the morning and showering and getting dressed, how they’re going outside and exercising, and how things are happening in their lives. I’m happy to report that Skylar was no exception. His withdrawl from marijuana wax was uneventful, and after eight weeks, he was shocked at how different he felt, describing it as like being awake after years of being asleep. For the first time in recent memory, he was thinking, he was weighing his options (now that he had some) and he was planning his future. When I asked his greatest revelations, he said, “I have to make things happen. I have to be proactive. I have to look for and seize opportunities. No one can do that for me.” I really couldn’t have said it better than that. 

Re-reading this, I noticed that I said that marijuana is ‘robbing you’ of this and ‘taking away’ that, but really, marijuana doesn’t take things away from you, you give those things away when you choose to use. Marijuana has its place in treating certain illnesses and diseases; but remember that just because something is legal to use doesn’t make it reasonable to use it. If you’re faced with a choice to use, just think about Frederick, with 58 years wasted, no pun intended, and Skylar, who got a late start in adulting but has an unlimited future…now that he’s no longer letting marijuana limit his present.  

For lots more entertaining stories and information about marijuana and other drugs, check out my book, Tales from the Couch, available on Amazon.com. It makes for a great read and an ever better gift!

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(And by ‘Might Be’ I mean ‘Are’)

The “Opioid Crisis” is all over the news these days, thanks to cheap heroin cut with fentanyl and heaven-knows-what-else that’s filling up morgue drawers throughout the country. If you think the numbers of overdose deaths are staggering now, medical examiners would be up to their elbows in bodies without Narcan, a drug that scrubs opioids off of the brain’s receptors during overdose, literally snatching people from the grip of the Grim Reaper. Many people that have stopped breathing and whose hearts have stopped beating are only on this side of the grass because of tthis wonder drug. While addiction has recently become a hot topic, it’s certainly not like it’s new, though we do seem to find plenty of novel substances to become addicted to all the time. Also not new is the stigma and overwhelming shame attached to addiction, attached to being an addict. It elicits such a strong negative response that we’re not even supposed to use the word ‘addiction’ anymore- it’s too derogatory- so now we’re to refer to it as ‘substance use disorder,’ lest we offend anyone. That said, to save myself some aggrevation, I am still going to use the word addiction in all of its various forms (shhh!) so I apologize in advance if anyone takes offense. I’ll also be using the term ‘using’ when referring to the use and abuse of drugs and alcohol.  I’m actually amazed that the word addiction is so stigmatizing that even physicians aren’t supposed to dare utter the term. That just goes to show that no matter how we raise awareness about addiction, about how it affects people in every walk of life, and that anyone can become an addict, nobody wants to be labeled as one….especially an addict in denial. It ain’t just a river in Egypt.

I’ve been listening to people’s deepest and darkest thoughts for over 30 years, and in that time I’ve heard people rationalize every behavior and habit under the sun, but none as vehemently as the abuse of alcohol and drugs. The way these rationalizations percolate through people’s minds is interesting. They’ll say, “I’m not an addict because I don’t use that much” or “I’m not an alcoholic; I only drink a little here and there.” To this I tell them that it’s not how much they do or don’t use that makes them an addict. That’s generally when they say, “Well, I know I’m not an addict because I don’t have withdrawls, I don’t get tremors and I don’t shake, even when I don’t use for weeks.” Hmmm. I think they think that one stumps me. But it doesn’t. “Nope, I hate to tell you, that’s not at issue either. Just because you don’t have withdrawals does not mean you don’t have an addiction.” To this they say, “But, but, I only use in certain situations, like at weddings, or funerals…” Blah, blah, blah, blah.  Doesn’t matter- where you use or how often- it just doesn’t matter in terms of whether you’re an addict or not. And then there’s the flotsam and jetsam of rationalizations: “I would never shoot up, I just wouldn’t do that; I never drink shots, I only drink beer; I don’t use marijuana wax, I only smoke a joint every now and again; I would never take pills, I only drink.” The list goes on. The truth is that the amount you use, when you use, how often you use, where you use, whether you withdraw or not, and the means by which you get the drug into your system does not factor into determining if you’re an addict; those things matter not. Right now you may be wondering, ‘So what does matter?’ How do you tell if someone’s an addict? There are behavioral, physical, and psychological factors that can be examined to make the determination. First, I’m going to cover the behavioral stuff, and then I’ll get to the physical and psychological stuff. There are essentially five general behavioral criteria to consider if You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The first criteria centers on relationships with the people around you. Does a significant other- a lover, partner, spouse, parent, sibling, grandparent, etc- complain about your using? Do they say you change when you use…that you’re a different person? Sound familiar? Do you blow off responsibilities to use? Does finding the money for the drug, getting the drug, and using the drug occupy your mind above all else? Does it change the priorities in your life? Do people in your life complain you’re irritable or that you’re no fun anymore? Do you withdraw and isolate yourself to use or while high? The complaints of family, friends and loved ones are signals that using is impacting significant relationships. This is a definite sign that addiction is present. I have patients say, “I get up and go to work every day, blah blah blah blah; I make money to support my family; I’m a good provider; I do this, I do that; I still go to the gym every day, yada yada yada…” Yeah, but you come home and drink three martinis and yell and scream at your children and your wife. Yeah, but you spend all day Saturday locked in your study in an Oxycontin haze. Those things are problematic! If using impacts significant relationships, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The second factor to consider is the use of drugs and/ or alcohol in spite of physical, emotional or personal damage; damage to mind and body. Some examples: the alcoholic who is gaining weight and having liver failure. The woman who smokes tobacco but needs oxygen to breathe. The man who smokes marijuana who can’t think clearly, has memory deficits and thought and decision-making issues. The woman who’s smoking meth even though it’s killing her lungs and rotting out her teeth with meth mouth. The guy who’s injecting heroin even though he’s got gnarly scabs and infected abcesses all over his arms and legs. The man who has a cocaine problem but continues to use in spite of arrhythmias and strokes. If using causes physical and/ or mental issues but you still use regardless, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

The third factor focuses on work, your employment. Problems at work, starting to miss work, starting to come in late, making mistakes at work, poor relationships with co-workers, lacking follow-through, becoming lackadaisical or flippant at work, and not excelling/ achieving at work, especially if the behavior is new or recent. These are all drug-related signs. People say, “Oh, for 23 years I’ve gotten up and gone to work every single day and I’ve done fine.” Sure. Okay, but in that 23 years, how many times have you been promoted? Have your reviews and evaluations shown consistent improvement? Or does your boss complain about your personality, how you don’t have a good attitude, how you’re forgetful of things, how you seem to have no energy, how it seems like you’re not enjoying your work? If using affects your work performance in any way, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).  

Factor number four is pretty simple: legal issues and their consequences. DUIs come to mind, but any legal problems stemming from the use or abuse of drugs and alcohol count here. That might include anything from charges for possession of drugs, fighting in public, assault, disorderly conduct, disturbing the peace or domestic violence all the way to charges associated with vehicular collisions, even manslaughter. If using has put your attorney’s kids through private school, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). 

The fifth and final criteria is a two-fer; it’s super important because the first part is the one thing you can never get back once it’s gone, and the second part is something very hard to get back once it’s gone. Any guesses? Give up? They are time and money. Time spent using is wasted; (no pun intended) it’s time gone from your day, your week, your month, your year, and ultimately gone from your life for good. That time could’ve been better spent being productive, doing literally anything but using. As for money, Captain Obvious says that money spent on drugs or alcohol is also wasted; it too could’ve been better spent on literally anything but drugs or alcohol. The amount of time and money spent using may prevent you from making more money, because the time you might have spent on a money-making opportunity is spent on using. What’s more, time and money act as a barometer for the severity of addiction…when one goes up, so does the other, and the more of both spent, the more severe the addiction. If you waste your time and money buying and using drugs and alcohol, You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

So just to review, what are the five behavioral criteria to help determine if You Might Be an Addict? If friends and family complain; if there are physical and psychological issues from using drugs and alcohol but use continues regardless; if there are job-related problems from using drugs and alcohol; and if there is time and money misspent and opportunities lost to using…You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’).

Family members, friends, and co-workers are usually in the best position to recognize a drug problem as they are familiar with the person’s habits and behavior, but considering the weight of the word addiction, you can’t just point an accusatory finger at someone. You must educate yourself on the signs of drug abuse. Above we discussed five behavioral factors that can signal drug addiction, but there are also physical and psychological signs to be aware of as well. Recognizing the signs of addiction is the first step to ending addiction, so I want to give some practical information on the physical signs of addiction, overdose, and withdrawl. These signs are the body’s physical manifestations resulting from the presence of drugs or alcohol in the body. 

General physical signs of addiction include, but are not limited to:– Enlarged or small pupils (opiate use often causes pinpoint pupils)– Sudden weight loss or gain– Bloodshot eyes– Insomnia– Unusual body odors– Poor physical coordination– Looking unkempt– Slurred speech

Overdose is a medical emergency. In case of overdose, please seek immediate emergency care. Typical signs of an overdose may include, but are not limited to:– Drowsiness or trouble walking– Agitation– Aggression or violent behavior– Difficult/ labored/ ceased breathing– Nausea and vomiting– Hallucinations– Delusions

– Loss of consciousness

Withdrawl can be a medical emergency. Please consult a physician during withdrawl events. Typical signs of withdrawl may include, but are not limited to:– Shakiness, trembling, jumpiness– Loss of appetite– Nausea and vomiting– Depression– Insomnia and fatigue– Headaches and fever– Confusion and hallucinations– Seizures (lasting over 5 minutes is immediate emergency)

In addition to behavioral and physical signs of addiction, drug abuse also impacts a person’s psychological state. When they’re in the grip of active addiction, the person might not realize or recognize these changes. The psychological signs of drug addiction may include, but are not limited to:– Anxiousness– Inattentiveness– Lack of motivation– Irritability or angry outbursts– Changes in personality or attitude– Emotional/ mental withdrawl– Sudden mood swings

– Unexplained paranoia

We’ve covered the behavioral, physical, and psychological criteria that indicate You Might Be an Addict (And by ‘Might Be’ I mean ‘Are’). Or should I say You Might Have Substance Use Disorder (And by ‘Might Have’ I mean ‘Have’). I like the first better. No matter what you call it, you don’t have to live life in addiction. Actually, that’s an oxymoron- there is no living life in addiction. And if you do oxy, are you a moron? An existential question to ponder. 

For more information and stories about addiction, check out my book, Tales from the Couch, available on Amazon.com.

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Ivan’s Addictions: Alcohol Detox

I want to discuss what people can expect when detoxing off of alcohol, inspired by my patient Ivan. He was a long-time patient, though I hadn’t seen him in a while. He was big time addicted to opioids years ago, and he had dragged his sorry butt into my office, barely coherent, begging for help. That’s how we met. I managed to get him clean off of the oxy’s he so dearly loved, but I would learn that Ivan had a very addictive personality…this guy could get addicted to oxygen. Anyway, that’s where it started with Ivan, and over the subsequent years I saw him in the office here and there. Now fast forward twenty years and in walks Ivan. It looked like the years had not exactly been kind to him. He looked like an alcoholic. Red swollen nose, check. Ruddy grey skin, check. Blood shot eyes, check. Balance just slightly off kilter, check. Gaunt frame with distended belly, check. I could go on, but suffice it to say that after so many years of doing what I do, I can spot an alcoholic from 50 yards. He said he was still clean, off opiates, but admitted to drinking in excess for many years. I burst his bubble with a sharp prick of  cold harsh truth: he was an alcoholic. When I said it, he might’ve flinched, but he didn’t argue. 

I asked him what he was doing for work. He said he was rehabing properties. He had inherited some money, bought a bunch of properties, fixed them up and rented them out. He collected the rent paychecks every month from his “magic money mailbox.” That sounded great, but the down side of this equation was that he wasn’t expected to be anywhere at any given time. And that left a lot of time for drinking. When I asked how much he was drinking, he admitted to drinking at least ten of those 2 ounce airline mini bottles a day. He had found some place where they only cost a buck a bottle. I was floored. That is an incredible deal. But I digress. I told him that we would have to do a medical detox, and he was on board. What follows are all of the things I told him.

To start, I explained that he needed to hydrate. Even though alcohol is liquid, it is very dehydrating, so there must be copious amounts of water during detox. As I told Ivan, drink water until you think you’ll burst. Next, start eating healthy foods. This is critical, getting food in your system, because alcohol causes irritation of the walls of the stomach and intestines. Also, you have to kick start the digestive tract, because alcoholics don’t eat well, if they eat at all. Next, start taking an over the counter stomach proton pump inhibitor like Prilosec or Prevacid. This will help to decrease the acid in the stomach as well as heal the stomach wall and the esophagus. Next, start taking B complex vitamin and multivitamin to replenish the system. He said he understood as he dutifully wrote all of this down. 

Next, I explained the important warnings about detox, the reasons why it’s important to medically detox. We have to use a type of drug called a benzodiazepine to prevent severe alcohol withdrawal. Without it, you will start shaking, you can become delirious and confused and have grand mal, full body seizures. There is a possibility of death: up to 25% of people actually die from severe alcohol withdrawl when they don’t use the benzodiazepines. I use medications liberally to prevent the withdrawl and safely detox. My goal is to keep patients comfortable with meds, but never nodding out. I wrote a scrip for 2mg alprazolam and told him to take one 2 or 3 times a day. I also gave him one to take immediately in the office because it had been 16 hours since his last drink and he was really starting to feel it. He had all of his instructions, so I told him I’d call him at 8pm that night as well as every six hours thereafter, and that he could call my cell phone anytime with questions or problems. With that, he left.

That night when I called, he said he was feeling not so great, but that he had eaten, was drinking lots of water, and taking the vitamins. When I called him the next morning, he said he woke up feeling very uneasy, very tense, and with some slight tremor. I told him to take the alprazolam right then and to take another in the afternoon around 2 or sooner if he felt tremulous. He repeated the alprazolam schedule on day 2 and also took it that night. When day 3 came, I explained that this is the most dangerous time. While seizures and delirium can happen at any time, they are most likely to happen on day 3. It’s also the worst day. It was really tough for Ivan. He was sweating. He had tremors. He was a little confused. His girlfriend came over and made him chicken soup, served with some TLC, and checking to be sure he was hydrating and taking the vitamins. He took the alprazolam three times that day, but didn’t sleep much. I gave him a drug called mirtazapine for sleep, and this helped. The fourth day dawned and Ivan saw the light at the end of the tunnel. Day 4 was better than day 3, but he was still feeling tremor, still sweating, and still needed 2 alprazolam that day. On day 5, he had no tremor. The sweating had lessened, but he still felt restless. He took just 1 alprazolam that day. As of the 6th day, he didn’t need the alprazolam at all. The detox was done. I told him to continue the vitamins and the Prilosec stomach meds for 2 months, keep up the improved diet, and keep hydrating. 

Ivan followed all of my instructions and he came out the other side and did pretty darn well. He got in great shape by walking his dog Malcom for a minimum of 3 hours a day, and he felt better every day. In fact, Ivan had dodged some serious bullets in that he had no major organ damage from the alcohol. There are several very common things that go bad with alcoholism. Most didn’t happen to Ivan, but let me caution you what can happen with alcohol abuse. Pancreatic issues are common. The pancreas is the most important organ for blood glucose regulation and digestion. You become a diabetic if your pancreas shuts down.  Gastritis quickly becomes a potentially lethal problem. Gastritis is extremely dangerous, it is irritation or bleeding of the stomach, leading to bleeding ulcers. Aspiration pneumonia is a concern: where you are so drunk that you throw up or cough up stomach contents and you breathe the stomach contents into your lungs, causing a serious and life threatening infection. A very common issue with alcoholics is that they get drunk, fall, and break a bone or hit their head, causing subdural hematomas of their brain. And you can’t forget liver disease. One of the key features of chronic alcohol abuse is liver failure and liver cirrhosis. The liver shuts down and so the body diverts the blood flow around the liver because the liver is so scarred and gnarly that it no longer accepts blood. As a result, you get big vessels forming in the esophagus and rectum, and they explode, causing hemorrhage and death. Ivan was lucky… he didn’t have any of those things. But he didn’t get off scott free. The most common thing I see with alcohol- that no one escapes- is cognitive damage. The brain slows down. It is permanently damaged. As a result, you cannot think straight. You are not as coordinated as you were. You become less active so there can be muscle wasting. These had happened to Ivan. As I said, no one escapes this. So Ivan was little bit slower, a little less coordinated, legs a little weaker. But he’s not drinking, and that’s a major accomplishment. I’ll continue to follow him in his clean and sober life. If you are abusing alcohol, Ivan would advise you to medically detox, as would I. If you would like to read more about alcohol withdrawl, medical detox or more patient stories, check out my book, Tales from the Couch, available on Amazon.com.

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Her real name is Nicole, but everyone calls her Nicky. I want to tell you her story. She comes from New Jersey, but the family also has a Palm Beach estate where they spend a fair amount of time. Her family brought her to my office, and in that first appointment I spoke with all of them together to gather as much background as possible. She was 24, the baby of the family, with a brother named Vinnie and sister named Sasha. Nicky and her sister Sasha took after their mother; they were all beautiful, with dark hair, light eyes, and tan skin, but Nicky had a more striking exotic appearance that was unique among the three of them. The family is Italian, very wealthy, with the father owning several large car dealerships and car washes all over the place in Jersey. Nicky’s siblings Vinnie and Sasha both work for their father. He runs dealerships while she manages human resources. And then, there is Nicky. Nicky had her share of issues, but not everything was her fault. She came from a home where her mother stayed home with the kids, doing everything for them, while her father worked a lot and wasn’t home much. When he was home, he was drinking wine. Her mom also drank wine. Nicky had few memories of either parent without a wine glass in hand. They were alcoholics, but wine was where it began and ended for them, and it didn’t seem to be an obvious source of family strife. Her brother Vinnie was a bit of a partier, drinking more than he should and smoking marijuana, but he showed up at work everyday and did a great job running his assigned dealerships and making big profits for the family business. Her sister Sasha was an exercise fanatic; she worked out every day, and was in great shape. And then, there was Nicky.  

Now, you’re reading a story written by a psychiatrist who works with a lot of patients with addiction, so you probably know where this is going, but I’d like you to go on the ride anyway. Based on information I gathered from speaking with her parents and siblings, and of course Nicky herself, I learned that Nicky was an extremely precocious kid, both physically and in mind set and attitude. The journey that brought her to where she was now seemed to begin when she was 10 years old. Nicky at 10 was already obsessed with herself. She was into internet porn and pay-for-play live camera peep shows. She was fascinated by those and the people in them, and even thought the live camera show was something she could set up and operate for herself. She never even considered the thought that her very young age should stand in the way of her doing something she wanted to do, so she didn’t let it. She was also very preoccupied with social media, always posting inappropriate pictures and cyber-courting older men with provocative messages. She would get tons of likes and messages and friend requests, and she revelled in the attention, needing it as the very oxygen she breathed. Her mother showed me pictures of Nicky circa age 10, and I was somewhat disturbed by what I saw. The 10 year old in the picture was striking. Nicky certainly didn’t look 10….she looked closer to 15 or 16. Her hair was the blackest black, her green eyes were impossibly bright, and her skin was tanned. She had the kind of looks that could cause unwanted attention for any female, much less one that was only 10 years old. But then again, I knew that the attention she got was not unwanted…it was by design. 

As Nicky got older, her behavior and habits only got more concerning. In a picture taken of her at age 12, she absolutely looked over 18. As a result, she was able to buy cigarettes, so at 12 she started smoking on a daily basis. She was also drinking on weekends, courtesy of the creepy dude that worked at the liquor store….he wanted her and she knew it, so she did whatever with him, and in return, he let her buy booze and beer. In doing so, he also reinforced her notion that she could use her looks to get things in life that she wanted, a tactic that would serve her purposes well and often in the coming years. 

By 13, she expanded her repertoire by picking up marijuana and drinking more frequently, almost on a daily basis. She had no use for her very expensive private Catholic school. There is no question in my mind that she had undiagnosed attention deficit disorder. When she went to classes, she could not sit still. She was always hyper. At 13, she had a habit of smoking in the school bathrooms because she said it helped her to calm down. She was always getting in trouble, always acting out in her classes. Her parents were constantly getting called to school because she was impulsive, talking out of turn, always causing trouble, disturbing her classmates, and acting sexually provocative. 

At ages 14 and 15, she was still skipping classes to hang out with the wrong crowd, drinking every day and smoking marijuana. She was honing the art of how to exploit her own sexuality for her benefit and became even more impulsive, especially with spending money. She was spoiled, and had several of her father’s credit cards. She put these to good use, ordering thousands of dollars of merchandise online, whatever her heart desired. As she maxed out all of the cards, her father would pay them down and she would be back in the saddle again. 

By 16, she graduated to having sex on a regular basis. I’m not certain, but I strongly suspect that she was turning tricks for money. I hate to say these things of a 16 year old, but she was dressing far too provocatively; a lot like a prostitute, and she was acted like a prostitute, hitching her hip, smiling and waving at men in cars. What came to mind was, ‘if it looks like a duck and walks like a duck….’ Anyway, at this point, she would easily pass for 21, so her weekends and many weeknights as well were spent smoking marijuana and getting drunk in a dark and nasty local bar. One night, another bar fly introduced her to cocaine, and taught her how to line it up and snort it. And suprise suprise, she liked it. 

Her 17th year looked a lot like the one before, just with more of everything. She was now smoking cigarettes and marijuana every day, drinking every day, and snorting cocaine on weekends. She wasn’t hiding things as well at this point, and was barely passing her classes at school. But private schools are in business to make money, and evidently they were fine with keeping her barely passing….as long as daddy wrote them a check each semester. 

Once again, Nicky’s 18th year was a lot like the one before, with regular abuse of alcohol, marijuana, and cocaine. The big news was that Nicky somehow managed to graduate from high school, despite almost never going to class in her senior year. It was a Catholic school, so I guess her graduating could’ve been considered a miracle. More likely her father made a substantial “donation” for Nicky to walk across that stage to get her diploma. After graduating, she decided she wanted a change, so she moved into her family’s Palm Beach house. She supposedly had decided that she was going to get her act together and take some college courses at a nearby university. At least that’s what she told her father. Apparently she was convincing, and he gave his blessing, along with one of his credit cards and his first support check for $4,000.00. They had made a deal that he would send her that check every month, as long as she was getting her crap together. It was a pretty sweet offer, especially since she’d also have his credit card. That meant that his monthly check for $4 grand was pretty much gravy. A lot of gravy. And when she arrived at the Palm Beach house, guess what awaited in the driveway. A brand new car! She was spoiled, but that wasn’t really her fault. It was just the way her folks rolled. And surprise suprise, she liked it. 

She had time and money on her hands and wasn’t really working to get her life together, though she gave her father glowing narratives on how well she was doing. In reality, she had found a source for cocaine and marijuana and was still drinking all the time. She started dating a guy of like mind and similar habits and he introduced her to his friends. At a party shortly thereafter, somebody gave her some 10mg oxycodone tablets, Percocet, aka percs and told her to take two, so she did. And surprise suprise, she liked it. 

In no time, she was taking 4 to 5 percs a day, then after a month, 8 to 10 a day. She was spending a lot of cash buying as many as she could from the original guy that gave them to her as well as other drug-using acquaintances. One day while driving high, she wrecked her new BMW and was taken by ambulance to the hospital. She wasn’t seriously injured, but she complained of pain and flirted with the ER doc and managed to get a scrip for 60 percs. That lasted her all of about 5 days. Now she had an opiate habit, she was totally addicted to the percs. But then it became impossible to get scrips because Florida shut down pill-peddling docs and adopted super strict opiate guidelines. Nicky was out of choices. She talked to her friends and various contacts and hooked up with another opiate addict that was in the same boat. Unfortunately, his solution to his inability to supply his opiate pill addiction was to do heroin. **Please see the comment on this subject at the end of this blog.** 

Now back to Nicky. She was then officially introduced to heroin….how to buy it, the amount it takes to get high, its price, how to snort it, how to cook it, how to load a syringe and shoot it, the whole nine yards. And suprise suprise, she liked it. 

Nicky had only been in Florida for about four months. Her father had replaced the car she had wrecked and had it delivered. She wasn’t working or going to school, but she was drinking, smoking cigarettes and marijuana like a chimney and doing coke everyday. She was also thoroughly hooked on heroin, buying and using at least 10 bags a day. And her appetite for heroin was only growing with each passing week. 

It wasn’t long before her father’s $4,000 a month wasn’t sufficient to cover the cost of her booze at the bars, her 2 packs of cigarettes a day, marijuana, cocaine, and the newest addition, heroin. After only two months of using the heroin, she was doing tricks on the street to get more money, because the cost of her various addictions exceeded the $4,000 check her father sent every month. But that didn’t stop her. She just used more. And the more she used, the more she wanted to use, then the more she needed to use. She was up to 15 to 20 bags a day now. So, she was having to prostitute on the side even more frequently to get the money to support her ever-growing habits. She had also had a drug using friend move in with her in exchange for $750 a month, which she always used promptly after getting it. Then one Friday night after finishing with her “clients,” Nicky pointed her car toward home. It was about 3am, and the roads were quiet; traffic was mostly drunks recently kicked out of the bars. And wouldn’t you know it? Boom! Crash! She wrecked the car. She gave a story centering on a drunk guy and it was all his fault, not hers, yada yada. Thankfully, she wasn’t injured. But the car was toast.

She took a cab home and joined her roommate in snorting some heroin. She felt kind of wired, so she may have used a little more than usual. That little more was evidently too much, and she overdosed for the first time. Thankfully, her roommate was there and called 911. At the hospital, she was treated terribly. It was basically like ‘hey, you’re an addict and you overdosed. It’s your fault, so get out of our ER’ and she was discharged very quickly. Unfortunately, the overdose didn’t stop her. She didn’t even consider stepping down on, or getting off of anything she was using.

Nicky said her life at that time was a drug induced blur, reduced to a cycle of drinking, hooking, snorting, smoking, repeat. Before long, she had overdosed twice more and totalled her second and third new cars sent by her father. For the life of me, I cannot understand his thought process, what he was thinking when he kept sending new vehicles to Nicky like lambs to the slaughter.   

So, now, we are into this odyssey for about 14 months or so, these episodes of using, prostituting, crashing her car, overdosing. She was losing weight and started looking a little haggard, worse for wear. Still, she brought guys home from her hangout bar and they paid $300 to $500 for the pleasure. There was one guy that hung out at the bar named Jimmy, and she’d forged just a friendship with him, no business involved. He really had a front row seat to Nicky’s decline and truly wanted to help her. He knew of my practice vis a vis his friend that was a patient, and he begged her to see me. He was pleased when after only a couple of days she agreed. 

He brought her into my office and he said “Doc, please, you’ve got to help get her off all this stuff.” After learning that “this stuff” was alcohol, marijuana, cocaine and heroin, I knew we were going to have an uphill battle, but Nicky was willing to try, and Jimmy was willing to help. I explained that we had to detox her, because she had a $300 a day heroin habit, which was most likely laced with fentanyl. I continued to explain that she had to be off of the heroin for 24 hours before we could start the detox drug, buprenorphine. I could see that both of them were about to freak out, but I assured them that I would give him several prescriptions to dose her with. My plan was to basically knock her out to get her to sleep for most or all of those 24 hours. I gave him scrips for clonidine 0.1mg to give every 3-4 hours, quetiapine 50mg every 4 hours, mirtazapine 30mg every 12 hours, phenergan 25mg every four hours so she doesn’t throw up all these meds, and lorazepam to throw in there every hour if she’s not sleeping and for withdrawl symptoms. I figured the whole combo would knock out a moose, so she should be okay. I gave him my cell number and asked him to call me every four hours and whenever with any questions. I told him to make sure she hydrates and eats, and that I want her zonked out so that she won’t run and use. That was my concern. I explained that the first 24 hours would be the hardest, but that once that’s over, you take the buprenorphine and everything starts to improve. But I also again explained and reiterated not to take the buprenorphine until after the 24 hours. That if it’s taken sooner, it will throw you into an immediate and horrifying withdrawl. Everybody seemed to understand so I sent them to her house to start the process with Jimmy taking care of her. 

Nicky made it through the 24 hours, and she got on the buprenorphine.  She took one, then a couple hours later, another; then three to four hours later, she took a third; then three hours later, a fourth. And tah-daaaaah! She was completely clean of heroin. She still wasn’t happy, but I think that also coming off of cocaine, marijuana and alcohol at the same time was giving her a hard time. She continued with the buprenorphine the next day and the day after. On that third day, I saw her in the office. She had just barely started to clear cognitively, and that chaotic thinking, erratic behavior, and impulsiveness, it was starting to simmer down a bit, and she was just beginning to get real. She said that she didn’t want to be addicted to the buprenorphine. I always worry when newly detoxed patients want to go off the buprenorphine, because it may be a sign that they want to use, and they don’t want the buprenorphine to block the opiate so they can’t get high. I explained that it is not like heroin at all in terms of addiction potential. And I said that her life had been so unsettled since the age of 10, but especially in the last few years or so, her life was total chaos, fueled by drugs, heroin, cocaine, heavy alcohol use and marijuana. I told her she should just stay on the buprenorphine for a little while to stabilize her behavior and get into a healthy, clean and sober daily routine. Her neurotransmitters needed a vacation off of dope, and she would need time to see what life looks like when she isn’t gorked out of her mind, going without sleep for days on end. I told her that once we got her into a ritualized life where her behavior was more routine, then I would consider getting her off the buprenorphine. I convinced her to stay on it. I don’t do this with everyone. For people who only relapse for say a month, I would give them a week detox and they’d be fine. Maybe, if they got regular cravings over the next 10 days, I’d have them take a little of it here and there if needed. But with someone who has lived a chaotic lifestyle for nearly their whole lives and had been living a very heavily drug-addicted and dependant lifestyle for the past few years, there is no way I’d take them off right after detox. So, I followed Nicky for the next two or three months, and Jimmy was her strength and support; I don’t know that she could’ve come that far without him. She came for one visit in a month, then a second visit, but just before her third visit, Jimmy told me she was out and using again. She was back to the whole enchilada- heroin and coke and weed and booze and prostitution to help pay for them. Four months later, Jimmy brought her back in, just out of the big blue sky. We went through the whole detox shebang all over again. Unfortunately, this is not unusual. I got her back on the buprenorphine,16mg twice a day.  Again, I told her she had to stay on it to block the cravings and stabilize her lifestyle after the detox. 

On this second run, she followed up for six months, but then relapsed again, went out drinking, and that lead her back to the marijuana, heroin, coke, and prostitution. She was snorting heroin and she ended up overdosing. She was in the hospital for like five days, on a respirator for three of them, because she had aspiration pneumonia, which happens when you’re so gorked out that you puke up stomach contents and then inhale them into your lungs. It’s an easy way to die. She came back to my office about three weeks after she was discharged. She grudgingly said that the hospital stay was sort of beneficial because she obviously wasn’t doing any drugs while in there, but she also added that the doctors had told her that she had major lung damage and needed to quit smoking if she wanted to live to reach normal life expectancy. 

I think that this was the first time where Nicky saw that her behavior, her extreme drug and alcohol abuse, had serious physical consequences and repercussions. I told her point blank that if she wanted a life, it would have to be a clean and sober one. To this she just nodded. She went back on the buprenorphine once again; this time she would stay on it for two years. She started to build a normal life, and she wound up taking a job at a local dealership here owned by a friend of her father’s. She was actually very intelligent, very capable, and she did a good job for him, though she complained about the pay. I told her to keep the job regardless, at least for a couple of years while she was still settling her clean and sober life. At this point, she did not smoke, drink, take any illicit drugs, or prostitute. She kept the dealership job for two years, almost to the day. I started tapering her off of the buprenorphine, and at that point, I put her on something called modafinil for her attention deficit disorder and as a pre-emptive strike against the fatigue she would likely experience when I stopped the buprenorphine. As it turned out, she got so fatigued that she could not drag herself out of bed. Once on 200mg of the modafinil each day, her focus and energy improved a great deal. She was much more alert and active on the modafinil. 

Nicky moved back to New Jersey a while back, but I still see her in Facetime visits every month. She takes the modafinil everyday. She followed her brother and sister’s cue and now she’s working in one of her father’s car dealerships, and she’s training to become a manager. All in all, she seems to be doing well. She’s not dating because she thinks it’s too risky to go to the bars and such. She says she spends time with her “crazy, loud, obnoxious Italian family” her words, not mine. She eats a healthy diet, and goes to spin classes with her sister Sasha. She learned that she enjoys yoga, and practices it often. This is the part where I’d like to say that Nicky lives happily ever after, but unfortunately, I can’t right now. For the past several months, Nicky has told me that she goes through the motions of life, but she cannot enjoy life anymore. She said that after doing so many drugs, and so much of them, that she can’t be happy. Nothing lifts her spirits. I’ve tried antidepressants, and nothing seems to work. She feels like her life while drinking and drugging was so crazy, so chaotic, that now her sober life is so boring, monotonous, and mundane. And I can imagine that that’s true. She wasn’t just addicted to the drugs and alcohol, she was also addicted to the life and lifestyle that came along with them. In addition to our monthly Facetime visits, she also has a therapist she sees in New Jersey, but so far there has been no resolution to her problem with her boring life. After watching her struggle so hard to get clean and sober, it’s such a bummer when she tells me how she doesn’t enjoy life now. It’s kind of like when you were a kid and you could hardly wait to finish the whole box of cereal so you could get the prize they promised on the front of the box, only to find that they didn’t put one in your box….you got gypped. That’s how I feel about Nicky. She got gypped, and that sucks. But, she takes care of herself and keeps to her routine, dull as it may be to her. I’ll keep following her, and I think that with time, she’ll find a new normal and new happiness. That’s what I hope for Nicky. 

For more patient stories, check out my book, Tales from the Couch. It’s available in the office and on Amazon.com. 

**Comment from above

As most people know, this country is in the grip of an opiate crisis. Staggering numbers of people are dying of opiate overdose every day. Very often it’s from heroin, often laced with fentanyl. People that were addicted to pills found they couldn’t get pills anymore, so they started doing heroin. Please, if you are addicted to opiate pills, do not turn to heroin to replace the pills. And if you’re hooked on heroin, stop. Go to detox and get off of opiates entirely. I detox people all the time, and I assure you that with the medications I utilize, it is far safer and easier to do than you think. 

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January 6, 2018 THE RIGHT APPROACH TO THE OPIOD CRISIS

As a practicing doctor with certification in psychiatry and having worked in Palm Beach County for the past 25 years, my views on the current opioid epidemic are the result of my daily contact with addicts, their families, the medical community, law enforcement and the judicial system. My work has taken me from the E.R. to the inpatient treatment centers and rehabs to the courts to our psychiatric hospitals and to our coroners offices. I have watched this epidemic from its earliest stages to its current existential threat status. As a result I have come to the following conclusions about this tragic situation our community and communities across the country find themselves faced with. WE MUST CHANGE THE WAY WE THINK ABOUT THIS AND TREAT THIS PLAGUE. 1.) Move away from the concept of a war on drugs. Move towards providing an aid package for these vulnerable and impaired individuals. 2.) Move away from concepts of criminalization, imprisonment, and that they are deserving of severe punishment. Move towards treatment and therapeutic interventions. View individuals with OUD as impaired and of need of help. 3.) The concept of opiate-dependent individuals as merely addicts that are weak, self-indulgent, hedonistic, and who are scorned by all is not helpful in resolving this national issue. There certainly is a volitional component to this illness. While personal responsibility and accountability is the only path to a healthy life, opiate-dependent individuals need a support system and tools to help get them on that path. Individuals suffering from OUD hate themselves, the behaviors in which they engage, and the resulting consequences. People with OUD are reckless with their lives because they feel their lives have little or no value. The mind-set of the opiate-dependent individual is one in which it doesn’t matter if they live or die. These vulnerable individuals are also prone to abuse and exploitation. 4.) Society must track these individuals and intervene when necessary.

5.) Society as a whole must be educated about opiates and all aspects of drug dependency, starting in grade school. Opiates come in pill form, patches, lollipops, and can be snorted and inhaled. Drug dependency can begin after one dose. Five days of continued use of opiates can result in drug dependency. Individuals who are genetically predisposed to dependency are more affected.

Like many drugs, over time the same amount of opiates has less and less affect which results in individuals increasing the drug dose and decreasing time between doses. This is the concept of drug tolerance. People spend more time getting the drug and doing the drug, and it becomes a vicious cycle. OUD individuals start to live a life of lies to cover their drug use. They spend a majority of their time planning to get money and make time to use drugs. They become psychologically consumed by thoughts of procuring opiates, using opiates, and disregarding everything else, including family, friends, job, health, and finances. All that matters to them now is getting high. When in withdrawal, these individuals can become very desperate and dangerous. They will go to great lengths to get high.

What can we do in terms of how society should deal with the problem? When treating an OUD patient, both incentives and consequences need to be geared towards keeping them off the drug of abuse. These five areas are conceptual changes needed towards resolving the national opiate use crisis and treating patients with Opiate Use Disorder:

1.) There needs to be a massive education campaign similar to the education campaign against tobacco including the danger of opiates and treatment options for OUD individuals. Explain the dangers of opiates, what opiates are, how they affect our brains, and, importantly, how easily it is to become dependent. The potential of overdose and death needs to be underscored. For example, the opiate called fentanyl, in amounts barely visible to the human eye, can cause individuals to stop breathing. Fentanyl is measured in micrograms. There are 100 milligrams in a gram. There are 1000 micrograms in a milligram. There are 100,000 micrograms in a gram. Two hundred micrograms or maybe less is lethal, which hardly covers the tip of a needle. 2.) The streets must be flooded with Narcan inhalers. One to three sprays in a nostril can revive an opiate overdose. 3.) The streets must be flooded with test kits to determine what is in the drugs and how much is in them. People make better decisions when they know what is in the drug they are taking. For example, if someone makes a street purchase of a drug with fentanyl or methadone in it, they need to be extra careful because those drugs can easily kill you. Methadone is dangerous not only because it is so potent but because it lasts so long. There is an even more dangerous drug on the street called carfentanyl which is 100 times more potent than fentanyl! Note: methadone has been useful in the treatment of OUD, however, it is so dangerous that the dose must be given out on a daily basis. While methadone blocks cravings, it provides a high so can still be abused and lead to an overdose. Buprenorphine is another drug used in treating OUD, and it has been found to be safe enough to prescribe on a monthly basis. The negatives and stigma associated with methadone should not be associated with buprenorphine. 4.) Laws need to be changed. Instead of charging people with accessory to murder when a friend overdoses and dies, give them immunity. Give complete immunity to people in the presence of someone who overdoses if they call 911 during the overdose. Encourage people to call 911 and save lives, not run and hide fearing prosecution. 5.) The court system for individuals with OUD must change. Once in the system, these individuals must be tracked with drug testing and given treatment when needed. Criminal records for possession or use can be wiped away if the individual stays sober. Incarceration should be a last resort. Charging people with felonies for drug possession scars people for life. Once labeled a felon, re-entering society becomes very difficult. OUD individuals are not sociopaths or criminals, they are ill with a disease. Treat the illness and there are no criminal problems.

This perspective demands basic changes in our societal and individual thinking about opioid dependency. Equally as important is the way the established medical community regards and treats this diagnosis and it is just that….a medical condition.

I have many thoughts for my peers and given the opportunity, I would welcome the chance to share them.

No matter what our circumstances in life, we are all touched by this epidemic in some way. We all have skin in this game. Time is precious, costly and limited. Soon may become later and it is already too late to wait.
More comprehensive explanations about how to deal with addictions in my book Tales From The Couch on amazon.com

Mark Agresti, M.D.

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www.dragresti.com ~ (561) 444-7044 Dr. Mark Agresti, West Palm Beach Mental Illness, Drug & Alcohol Detox Specialist — Psychiatrist, discusses how to assess persons contemplating suicide. The “whys” are not as important as other questions when speaking to someone talking about committing suicide. Dr. Agresti explains in this video. Call Dr. Agresti today to get help if you or a loved one is considering suicide. There is help.

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www.dragresti.com ~ (561) 444-7044 Dr. Mark Agresti, West Palm Beach Mental Illness, Drug & Alcohol Detox Specialist — Psychiatrist, continues his discussion about a highly difficult and sad topic — Suicide. Dr. Agresti discusses suicides in the media, suicides related to sexual orientation, and bullying. He, also, gives common signs to look for in your loved ones to know when to be concerned that they may need help. Call Dr. Agresti today to get help if you or a loved one is considering suicide. There is help.

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I want to share two stories to help those with drug problems — or those with loved ones who have drug problems — see how addiction works and how it can be overcome.

My clients, Belle and Bob, were both addicts. Belle managed to dig herself out. Bob did not. At the most basic level, these two people had bad relationships with themselves. It really all comes down to that. Improve your relationship with yourself and you can get better. Continue to hate yourself, and the ending can be very bad.

Belle’s Story

Belle, a 23-year-old woman working as an actress in Manhattan, was using Oxycontin and Adderall. She had gotten to the point where she was staying up all night, going to bed at 6 a.m. and waking up at noon. She had been very attractive, but her drug use had given her acne, a sickly skin tone and damaged her hair.

She looked like a drug addict and her life had become totally disorganized. Thankfully, her family recognized that Belle was in trouble. They brought her to a treatment center in Florida where I work and had an intervention with her.

Belle’s Family Intervenes

Belle did not come into treatment because she wanted to. Her family, who had been supporting her, had threatened her that they would cut her off if she didn’t.

Belle would tell you that she had a successful acting career, but she was actually making no money. Her mother was sending her a check for $6,000 every month. (more…)

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Dr. Mark Agresti, West Palm Beach Drug & Alcohol Detox Specialist – Psychiatrist, explains how to tell if a family member or friend is suffering from alcohol or drug addiction.  He explains the signs, symptoms of behavioral, social and physical changes of someone with Drug & Alcohol Addictions.  Alcohol & Drug Addiction should be treated with help.  Learn how to approach your loved ones with drug and alcohol addictions.

Call Dr. Agresti today to get your loved ones help!

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http://206.189.200.158 ~ (561) 444-7044

Dr. Agresti, West Palm Beach Mental Health Specialist – Psychiatrist, talks about drug addiction rehab options.  If you or a loved one has a problem with drug or alcohol addictions, you should know the options for addiction detox rehab.  Not all drug addictions require in-patient treatment.  Many drug addictions can be treated in outpatient care.  Dr. Agresti, in this video, shares the time periods to expect for drug addiction rehab.

Call Dr. Agresti today to get help with Alcohol & Drug Detox.

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http://206.189.200.158 ~ (561) 444-7044

Methadone detox is possible within 6 to 8 weeks. Detox from Methadone safely and without pain. Dr. Agresti, West Palm Beach Psychiatrist, talks about how you can detox from a Methadone addiction safely.

Methadone detox is possible! Call Dr. Agresti today to start life Methadone free.

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How do you know when alcohol is negatively affecting someone you love? What should you do when you suspect that someone you know is suffering from an alcohol addiction? This article will help you discover signs and symptoms so that you can be prepared to take the proper action against alcohol abuse and addiction.

First, let’s consider the facts. Someone you know or love drinks heavy amounts of alcohol on a regular basis. They seem fine, and their alcohol consumption doesn’t seem to disrupt their daily life. So how do you know if they are abusing alcohol or if an alcohol addiction is forming? Take a little extra time to notice how alcohol currently integrates with your friend’s or family member’s life. Do they drink alcohol every day, or several times a day? Is alcohol a “necessity” for them at every function or celebration? Does alcohol change their behavior significantly? And finally, do they turn to alcohol to deal with difficult situations such as job loss or grief? If you can answer yes to any one of these questions, your friend or family member may be beginning to abuse alcohol or on the verge of an alcohol addiction. If you can answer yes to more than one of these questions, then it may be time to step in and take some action to ensure the safely and health of your loved one. (more…)

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