the gaping nothingness of one’s future

large_wire-cost2

GREGGS: How long you been clean?
BUBBLES: Three days.
GREGGS: You serious about it?
BUBBLES: Who knows?

I just finished season 1 of the The Wire. (I know I’m way late to the party. What can I say? I have young kids and no HBO.) This Bill White post came out at about the same time I watched Bubbles trying to kick.

It is one of the most beguiling qualities of the experience of addiction:  it sucks up everything of importance in your life and casts those cherished assets into the remotest reaches of one’s heart, leaving nothing but itself. This all occurs an inch at a time and second by second–increments so small they escape the category of decisions.  It is at the end of such a process that one cluster of fears stands greater than the full awareness of what has been lost.  That is the terror of one’s own emptiness and the gaping nothingness of one’s future.  Those latter breakthroughs of consciousness can fuel unending cycles of oblivion and sickness and take damaged souls to, or beyond, the brink of suicide.  These same fears pose a significant obstacle to recovery initiation.  That’s why the promise of recovery must offer more than the removal of alcohol and other drugs from one’s life.  For the person staring into the abyss, the promise of recovery to a life of meaning and purpose may be far more potent than the promise of recovery from addiction.

There’s a great scene with Bubbles here. Check it out. (I can’t embed it.)

 


Filed under: Uncategorized

Prescription Opioids: A Dose of Reality

statistic.pngFor people with chronic and reoccurring pain, opioids, such as Hydrocodone and Oxycodone, not only relieve suffering, but can help support a normal lifestyle, alleviate stress and improve sleep. But there is a downside – prescription opioids can be just as addictive and dangerous as illegal drugs.

Prescription drug abuse is the nation’s fastest-growing drug problem and has been classified as an epidemic by the Centers for Disease Control and Prevention. Data from the Quest Diagnostics Drug Testing Index™ show that positivity rates for prescription opiates increased 40 percent from 2005 – 2009 and have continued to climb each year.

The over-prescription of pain medications has not only led to an increase in opiate-abusers, but has also contributed to a rise in heroin use. Research from the National Drug Intelligence Center shows that heroin use increased 79 percent from 2007 – 2012. It appears that with the high costs associated with prescription opiates, many drug users have turned to alternative, cheaper options such as heroin.

To create awareness around these alarming statistics, the Working Partners of Columbus, Ohio has developed the new video A Dose of Reality, with the goal of enlisting American workers in recognizing and combatting the prescription-drug problem.

Learn more about the dangers of prescription opioids.

Treating Sleep Problems Following Traumatic Brain Injury

Sleep problems are common following traumatic brain injury (TBI).

In a previous post, I reviewed a study of the risk factors for sleep disorders following TBI.

The most severe TBI is a risk factor for hypersomnia. Anxiety and depression following TBI increase risk for insomnia complaints.

Few large studies of treatment for sleep problems after TBI exist. 

However, a recent manuscript outlined the potential benefit of treatment of sleep disorders in a series of 12 subjects.

Catherine Wiseman-Hakes and colleagues from the University of Toronto described their experience with sleep and TBI in a manuscript in the journal Brain Injury.

Their study examined the impact of sleep disorder treatment in TBI on recovery of cognitive function including speech/communication. Treatment included sleep hygiene education, pharmacological treatment and continuous positive airway pressure (CPAP) for those with sleep apnea.

Twelve subjects with TBI completed a baseline assessment for presence of insomnia, communication function and neuropsychological performance. Subjects also completed a laboratory sleep study (polysomnography) for accurate diagnosis of specific sleep disorders.

Subjects then had treatment for sleep problems individualized to the specific sleep disorders diagnoses. After 2 to 4 months ofleep disorder treatment, follow up neuropsychological assessment was completed.

The key findings from the study included:

  • Sleep disorder diagnoses were diverse and included hypersomnia, obstructive sleep apnea, restless leg syndrome, circadian rhythm disturbances and insomnia
  • Treatment of sleep disorders produced a robust subjective reduction in insomnia severity ratings
  • Treatment of sleep disorders produced a reduction in depression, improved language function and increased speed of language processing
  • Pharmacological treatments selected by the treating physicians included modafanil, methylphendiate and fluoxetine for hypersomnia, trazodone for insomnia, pregabablin, gabapentin and pramipexole for restless leg syndrome

The authors note their findings "reinforce the necessity for routine screening for sleep disorders in persons with TBI".

Given the diversity of diagnoses in this study, screening in TBI needs to be linked to comprehensive sleep laboratory assessment.

This study supports sleep assessment and sleep disorder treatment as a key component of TBI rehabilitation. This component appears to have significant benefit to global cognitive and communication recovery after TBI.

Weaknesses of this clinical trial are the small sample size, lack of a control group and non-standardized pharmacological treatment.

Nevertheless, the results are impressive and point to the need for additional larger randomized clinical trials of treatment for sleep disorders in TBI.

Readers with more interest in this study can access the free full-text manuscript by clicking on the PMID link in the citation below.

Photo of juvenile great blue heron is from the author's files. 

Follow the author on Twitter WRY999.

Wiseman-Hakes C, Murray B, Moineddin R, Rochon E, Cullen N, Gargaro J, & Colantonio A (2013). Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain injury : [BI], 27 (12), 1364-76 PMID: 24070180

Ask the Expert: I am my son’s biggest enabler. How can I change?

chainsYour question: Our son has a real problem and he’s physically deteriorating. He’s 24 and is currently staying with me, his biggest enabler. We have tried so many approaches, I’m exhausted and depressed.

He’s so addicted to opiates. Finally he  has a job which will be his excuse of not getting sober. He thinks he can be a working addict. I am his biggest enabler; he’s currently living with me. His mother and I have talked about an intervention ????  He needs to get out of town.

Photo of Ricki TownsendAnswer from Expert Ricki Townsend:  You and I have spoken by phone, and I hope your son has received the help he so clearly needs and deserves.  But that won’t fully solve your problem because we cannot ever want recovery more than our loved ones want it.  When we want it more than they do, it consumes us. When we pursue their recovery more than they do, it cripples us and it cripples them.

Our beloved addicts and alcoholics are in fear whenever recovery is mentioned.  Even when their lives are falling apart, they just cannot seem to see a life without drugs/alcohol.  As we see so often, yes they can keep work going, and family life keeps moving ahead, often painfully.  BUT, eventually it all falls away.  We cannot save them or keep this from happening.  What we can do is take care of ourselves.

It is healthy that you recognize you are an enabler.  What you can do is take care of yourself and learn how to stop making it possible for your son to remain an addict.  There are therapeutic centers that can help you change.  One that I recommend is The Bridge in Kentucky, an excellent facility that helps clients learn how to let go of the unhealthy you  so they can let go of someone — anyone– who does not want to help themselves.

I wish you well and hope you take the steps to be present in your life for you, as much as you have been for your son.

Ricki

“Am I Going Crazy?!”

PAWS: Post Acute Withdrawal Syndrome
by Bill Abbott & Suzy W., SMART Recovery Meeting Facilitators

Post-Acute Withdrawal Syndrome (PAWS) is something that perhaps unfortunately, we haven’t discussed much in SMART Recovery®. It is a not yet widely known problematic syndrome (syndrome is a medical term which describes a grouping of varying symptoms) of addiction recovery. The following scenario can illustrate it:

    You’ve been through detox and all of the withdrawal symptoms and you are doing pretty well for perhaps a month or two. Suddenly, you start to realize that you’re feeling edgy and antsy. You are experiencing mood swings that range from being on a pink cloud to feeling down in the dumps. You find that you can’t concentrate. You are having trouble sleeping, you’re sleeping too much, or you’re having very vivid dreams. “What’s going on?” you wonder. “Am I going crazy?!”

No, you’re not going crazy. You are suffering from what is known as PAWS (Post-Acute Withdrawal Syndrome). Unfortunately, as noted above, we don’t often hear much about it in the recovery community even though it is an extremely common experience.

We know that recovery progresses in stages. After the initial acute withdrawal, one can enter a second phase of withdrawal symptoms. Weeks to months into recovery, a variety of symptoms can occur such as described above. Here we will discuss PAWS in some detail because understanding it can aid in successful recovery.

In a recent study of a large number of patients it was discovered that between 70% and 90% of people experience symptoms of PAWS. The number affected depended upon what the substance of abuse was: about 70% of former alcohol users and as high as 90% for former opiate users. These numbers are very high!

Mind you, usually the symptoms of PAWS are mild and not too troublesome. However, in some people the symptoms can be extremely bothersome, to the point of people thinking that they are losing it. Intense urges are a big part of PAWS and some consider this to be the number one cause of relapse within the first year.

PAWS can last for varying periods of time and be of varying intensity with the duration usually being measured in months – occasionally over a year. The good news however is that, barring relapse, the symptoms will go away. Like urges, they decrease in frequency and intensity with time.

The list of the various symptoms of PAWS is quite long! It includes 20 symptoms. The following list presents some of the most prominent:

    • Urges and cravings
    • Sleep disturbances – insomnia, hypersomnia (too much sleep) or vivid dreams
    • Mood swings – from depression to euphoria
    • Anhedonia – technical term for the inability to feel pleasure
    • Trouble concentrating
    • Anxiety and even panic
    • Memory problems
    • Irritability or edginess
    • Fine motor coordination problems

Symptoms are not always present — they occur intermittently.

Symptoms are made worse by stress or other triggers and may arise at unexpected times and for no apparent reason. They may last for a short period of time or for a long time. Any of the following situations may trigger a temporary return to, or worsening of, the symptoms of post-acute withdrawal syndrome:

    • Stressful and/or frustrating situations
    • Multitasking
    • Feelings of anxiety, fearfulness or anger
    • Social conflicts
    • Unrealistic expectations of oneself

There is little in the way of specific therapy for PAWS. That said, if the symptoms are prominent, it is wise to consult one’s physician because certain medications may be helpful. If you’re consulting with your regular physician you might mention that you believe you are experiencing PAWS. Perhaps like you, your physician might not be aware of the syndrome’s existence.

Mindful Awareness Practice is likely to be helpful as well. Also, SMART tools such as urge-surfing are always there for you.

The science in SMART Recovery tells of something called neuroplasticity. In review, neuroplasticity is the phenomenon whereby during the development of a new maladaptive behavior, such as the repeated use of a mind-altering substance, the repeated and habitual use of the substance leads to changes in the brain. Neuroplasticity also aids in the reverse process, which is good news. Once you have become abstinent from the mind-altering substance via your new behaviors, thoughts and feelings, the brain will rewire itself back to, or nearly to, your pre-addicted state. Thus, it is likely that PAWS is due to that very rewiring of the neural circuitry. Remember, neurons that fire together wire together.

Although there’s no easy remedy for getting through PAWS, it is often a great help to know that you’re not going crazy. PAWS is just a temporary set of symptoms, which you can accept, knowing that it is merely evidence that your brain is healing.

PAWS helps you recover!!!
 


Bill Abbott and Suzy W. are SMART volunteers who, along with other SMART volunteer activities, both facilitate weekly SMART meetings in the Boston area.

 


 

Second Circuit Overturns Win for Nonprofit Groups in Litigation with FDA Over Subtherapeutic Uses of Penicillin and Tetracyclines in Animal Feed

By Kurt R. Karst –      

In a 2-1 decision handed down last week, a panel of judges from the U.S. Court of Appeals for the Second Circuit reversed both a March 2012 decision and a June 2012 decision from the U.S. District Court for the Southern District of New York (Magistrate Judges Theodore H. Katz and James C. Francis IV) granting Motions for Summary Judgment to the National Resources Defense Council (“NRDC”) and other nonprofit advocacy organizations relating to Notices of an Opportunity for Hearing (“NOOH”) FDA issued in 1977 on proposals to withdraw approval of all subtherapeutic uses of penicillin in animal feed and nearly all subtherapeutic uses of tetracyclines (oxytetracycline and chlortetracycline) in animal feed, as well as to two Citizen Petitions requesting that FDA withdraw approval of subtherapeutic uses of penicillin and tetracyclines in animal feed because of a threat to human health.  The reversal was immediately criticized as a blow to the public health.

Both district court decisions stem from a lawsuit the NRDC, et al. filed in 2011 (see our previous post here).  The groups allege in their Complaint that FDA, in violation of the Administrative Procedure Act (“APA”), failed to comply with the Agency’s statutory duty to withdraw approvals of subtherapeutic uses of penicillin and tetracyclines in animal feed as required by FDC Act § 512(e)(1) (21 U.S.C. § 360b(e)(1)) and as proposed in 1977.  That statutory provision, which addresses FDA’s authority power to withdraw approval for new animal drugs, states:

(1) [FDA] shall, after due notice and opportunity for hearing to the applicant, issue an order withdrawing approval of an application filed pursuant to subsection (b) of this section with respect to any new animal drug if the Secretary finds . . .

(B) that new evidence not contained in such application or not available to the Secretary until after such application was approved, or tests by new methods, or tests by methods not deemed reasonably applicable when such application was approved, evaluated together with the evidence available to the Secretary when the application was approved, shows that such drug is not shown to be safe for use under the conditions of use upon the basis of which the application was approved . . . ;

The Plaintiffs further contend that FDA’s failure to timely respond with final decisions to Citizen Petitions submitted to the Agency in 1999 (Docket No. FDA-1999-P-1286) and 2005 (Docket No. FDA-2005-P-0007) on the same topic is an unreasonable delay in violation of the APA.  FDA denied both petitons in November 2011, saying that an alternative strategy to withdrawal of approval would be more efficient (i.e., less costly and lengthy), and then withdrew the 1977 NOOHs in December 2011.  The Plaintiffs then amended their Complaint alleging that FDA’s petition denials was arbitrary and capricious. 

In its March decision, the District Court ordered FDA to institute withdrawal proceedings as discussed in the 1977 NOOHs and then withdraw drug approvals.  In its June 2012 decision, the District Court agreed with Plaintiffs that FDA’s denial of the 1999 and 2005 petitions was arbitrary and capricious.  According to the District Court, FDA failed to offer a reasoned explanation, grounded in the statute, for its refusal to initiate withdrawal proceedings.  See our previous posts here and here for a more detailed discussion of the decisions.  

On appeal to the Second Circuit, the Court framed the “required hearing claims” – i.e., the circumstances under which the “shall . . . issue an order withdrawing approval” language at FDC Act § 512(e)(1) comes into play – as follows:

The principal question presented by this appeal is whether 21 U.S.C. § 360b(e)(1) requires the FDA to proceed with withdrawal hearings for certain previously approved subtherapeutic uses of antibiotics in animal feed because the FDA has made a finding that those uses are not shown to be safe for humans.  The text of § 360b(e)(1) clearly requires withdrawal of approval once such a finding has been made; it does not equally clearly specify when the agency makes such a finding, and in particular whether the type of finding that mandates withdrawal of approval is a conclusion based on internal agency deliberations that precedes (and then requires) the holding of a hearing, or a finding that represents the conclusion reached as the result of such a hearing.

Not surprisingly, FDA and the NRDC interpret this provision differently.  On the one hand, FDA

reads the statute as requiring the sequence: hearing, finding, order. In effect, it reads the provision to say, “If, after notice and a hearing, the secretary finds that a drug is not shown to be safe for use,” she is required to withdraw approval of the drug.  In this interpretation, the withdrawal process begins with a notice from the FDA to a drug sponsor of its concerns about an drug, and offering the opportunity for a hearing regarding the safety of the animal drug.  If, at the conclusion of the hearing, upon consideration of the evidence presented, the secretary finds that the drug is indeed not shown to be safe for use, she must then issue an order withdrawing approval of the drug.  That order of events depends upon the conclusion that a finding that an animal drug is not shown to be safe can be made only after the drug’s sponsor’s due process rights – notice and an opportunity to be heard – have been respected.  Therefore, the mandatory “shall” applies only to the action – withdrawal of approval – that the Secretary must take if the hearing results in a finding adverse to the drug.  On the government’s reading, the mandatory “shall” does not apply to the holding of the hearing itself, which the government argues is a discretionary action that the agency may undertake, or not, in its discretion, based on its judgment about whether the scientific evidence and sound public policy warrant instituting proceedings to withdraw approval.

On the other hand, the NRDC read the statute as requiring the sequence: finding, hearing, finding, order.  In effect, wrote the Second Circuit, Plaintiffs

read the statute to say, “If the secretary finds a drug is not shown to be safe for use, she shall provide notice to the applicant, hold a hearing, issue a second finding, and then withdraw approval.”  In their interpretation, the initial finding that the drug is not shown to be safe is based on the agency’s internal investigations of the scientific evidence, and comes before any hearing is held.  On plaintiffs’ reading, once the agency reaches the conclusion that the drug is not shown to be safe, the mandatory language of the statute becomes applicable – the agency must issue an order of withdrawal, though it must hold a hearing first.  The mandatory “shall” thus in effect governs not only the remedy that must follow a formal conclusion after a hearing, but also the process itself; after reaching its initial conclusion that the drug is not shown to be safe, the agency is required to institute proceedings and effectuate them through a hearing, after which (if the evidence present at the hearing sustains the finding) she must issue an order of withdrawal.

Circuit Judge Lynch and District Judge Forrest (sitting by designation) ultimately agreed with FDA, stating:

Our survey of the text, the context, the regulations, and the background legal principles leave us firmly persuaded that Congress has not required the FDA to hold hearings whenever FDA officials have scientific concerns about the safety of animal drug usage, that the FDA retains the discretion to institute or terminate proceedings to withdraw approval of animal drugs by issuing or withdrawing NOOHs, and that the statutory mandate contained in § 360b(e)(1) applies to limit the FDA’s remedial discretion by requiring withdrawal of approval of animal drugs or particular uses of such drugs only when the FDA has made a final determination, after notice and hearing, that the drug could pose a threat to human health and safety.

. . .  Although the text is not unambiguously clear, we believe that the FDA put forth the more natural reading.  The statute requires the FDA to withdraw approval of an animal drug only “after due notice and opportunity for hearing” has been afforded, and then only “if the Secretary finds” that the drug is not shown to be safe.  21 U.S.C. § 360B(e)(1). That language most naturally refers to a finding that is issued as a result of the hearing. That interpretation, moreover, avoids injecting a second, unexpressed “finding” into the sequence of events mentioned in the statute.

Circuit Judge Lynch and District Judge Forrest also rejected Plaintiffs’ alternative argument that FDA’s Citizen petition denials and withdrawal of the 1977 NOOHs violated the APA as arbitrary and capricious.  According to the Court, “the decision whether to institute or terminate a hearing process that may lead to a finding requiring withdrawal of approval for an animal drug is a discretionary determination left to the prudent choice of the FDA.”

But FDA did not get off scot-free.  In a 48-page dissent (out of a 113-page decision), Chief Judge Katzmann vehemently opposed the majority opinion:

I cannot agree with the majority’s conclusions.  In light of the statutory structure and its purposes, I am convinced that 21 U.S.C. § 360b(e)(1) requires the FDA to continue the proposed withdrawal proceedings . . . .  I am likewise convinced that the agency’s decision to deny the citizen petitions was arbitrary and capricious . . . because it failed to address the statutory question of whether the animal drug uses at issue were shown to be safe.

Today’s decision allows the FDA to openly declare that a particular animal drug is unsafe, but then refuse to withdraw approval of that drug.  It also gives the agency discretion to effectively ignore a public petition asking it to withdraw approval from an unsafe drug.  I do not believe the statutory scheme can be read to permit those results. . . .

Given Chief Judge Katzmann’s strong dissent, Plaintiffs will probably appeal the panel decision and seek an en banc rehearing.  But as Second Circuit Courts Committee recently noted, the Second Circuit has proceeded to a full hearing en banc only in rare and exceptional circumstances.  Given the odds, the panel decision reversing the District Court’s decisions, remanding the case to the District Court with instructions to deny the Plaintiffs’ Motion for Summary Judgment, granting FDA’s Motion for Summary Judgment, and dismissing the action seem likely to stand.  

Controlling my Control Issues

Sorry, I have been remiss in keeping up with my blog and posting regularly. My job is overwhelming right now but this is not the time or place for that discussion.

Right now I am on vacation with the family. Son, daughter and 3 grandkids at the lake. Things are great to be on vacation at least for 24 hours before I was tested.

Anyone that has read my blog long knows I began this journey with control issues. Ten years ago I knew if I exerted just a little more effort I could control my son's addiction and we would all be back on tract. Five years later trying harder and harder I finally got it through my thick, hard head that wasn't working. That's when I began working on me. If he wasn't going to get better I needed to find a way for me to get better.

Yesterday I had the ultimate test of my control recovery. We are on vacation and Tyler my 3 year old grandson, Alex's son, fell off the top of sliding board onto the dock. He broke his arm in too. Alex and Kristy rushed him to the local hospital while still in their wet swimsuits. I followed them a few minutes later with dry clothes. It was a very complicated break and he was then taken by ambulance to another hospital in a larger city 50 miles away where they had the resources and personnel to take care of him.

If that isn't a test of controlling your control issues then I don't know what could be designed more difficult. Picture this grandpa with his little buddy his arm is broken and he is in terrible pain and crying. Grandpa stood on the side offering support to Tyler and mom and dad just the way he should. Probably wouldn't have happened that way a few years ago.

This morning my little buddy is doing well. A cast but he is managing much better than I expected.

Thinking about last night it became clear to me what was happening with me during this crisis. The question, "Is this mine to control or is this mine to support?"

Wish I was able to have seen that question more clearly a long time ago when we were dealing with a son in active addiction. It seems so clear and so much more simple now.

For a parent with a child addicted and using we are NOT in control. We are the support crew and support can only be effective when the recipient is willing and accepting.

This all falls back to understanding OUR boundaries. Continually pushing against your boundaries and straining the rope to its breaking point often leads to unintended consequences, for ourself and our addicted child.

Last night I respected the boundary, I stepped into my role of support. In the end it made me proud to be a father and it made me proud of Alex and Kristy too.

Finding the quiet moments – trading stress for serenity

When I hear the word ‘serenity’ I often think of a quiet moment alone preferably somewhere in nature. Yet serenity comes to us in many different ways. The definition of serenity is ‘the state of being calm, peaceful, untroubled.’ As a parent who has been on a journey of having a loved one struggle with addiction and has a quest to gain serenity I am very aware that serenity can be an elusive foe. What looks like serenity to me may not work for someone else. One of the ways that I seek serenity is through outdoor activity.  A long run puts me in a place that is very calming. I relax and concentrate on the moment. The farther I run, the more my troubles melt away as if I am leaving them behind. While this sometimes may only result in serenity while on my run, it is a welcomed respite when I am struggling to detach from what is bogging me down.

Everyone has their own image of what serenity means to them and how they work to get there. As parents we have a tendency to take our children’s troubles and worry about them. While we may not be able to get to a place where we are free of worrying about our loved ones, we can get to a place where we have moments of serenity. It’s important to think of how you can release yourself and enjoy moments of serenity. This may be having a cup of tea with a friend, going for a walk, baking, golfing, the list is very long and all depends on your interests. You might start out with a short activity and then increase over time. Trading your stress for serenity will lead to feeling healthy. We all know that stress causes so many conditions to our physical body, our mood and our behavior. By working on your serenity it will not only help you cope with difficult challenges in your life, it will also help you feel better and be more present in your life.