The quote above is from a patient, R, whom I was starting to treat for a mixed addiction, including opiates. 23 years before he came to my office, he was married, the father of two young daughters, he had a good job, he was a bodybuilder, proud of his good health and the careful diet that maintained his weight, and proud to be a good provider for his family.

In an early session, after a two minute silence, R began to describe what was on his mind, he continued the above quote by saying “I can hear the windshield smashing, I can feel the glass on my chest, I can hear my wife saying I think I am going to die, and right now, I can smell the antifreeze and gasoline that was released when we were hit.

R said all this without feeling.  He was reporting an experience that was stored in his memory for 23 years, but experiencing it  as if it just happened, a flashback.  Through the years, he said he tried very hard not to think about the accident, when he experienced some kind of trigger to the memory.  When this failed he had a panic attack.

R lived with the threat of flashbacks like this intruding into his daily life for years.  But that is not all, after the accident, R’s life was forever changed…

He was seriously injured in the accident. Luckily his wife and daughter were spared.  He had back surgery, then was put on opiates post operatively.  At the appropriate interval, the opiates were withdrawn.  At the time, R was unaware he was addicted. It led to immediate withdrawal that was disorganizing.  He found that resuming the use of opiates alleviated the withdrawal symptoms, and that the only way he could keep the withdrawal at bay was to keep using.

This pattern of daily use of potent opiates took place over the next decade, plus.  While in this impaired state, he lost his job, his wife divorced him, his health deteriorated, as did the relationship with his children.  R ended up on disability, living alone, and was socially isolated when he presented in my office.

I’m sharing this story to put a human face on the lessons I have learned in a thirty year time span working with individuals addicted to opiates.  Few people who come into contact with opiate users have the time or support to get to know them well.

I was fortunate to have the time and interest to get to know many of them in amazing detail. My experience is the basis of this report.

At that time I started this work there was a war on drugs.  I wondered at the time, if the problem was the drugs, why the millions of people who receive opiates post-operatively in hospitals never became addicted, except a very very few.  It suggested those very few had some factor or factors that made them vulnerable to the central effect of opiates.  It seemed likely that others who took a different path to addiction might have similar vulnerabilities.  Any drug experimenter’s response to opiates is mixed, some call it a “high”, others describe the experience negatively.  Perhaps this posited vulnerability explains the difference.  For the moment there is not a consensus as to why these differences exist, which may be a reason there is no consensus about what causes addiction.

The last time I Googled causes of opiate addiction, there were eighteen different ideas expressed.  Without a known cause, treatment is problematic and uncertain.  The many thousands who die each year of opiate causes attests to this fact. The many individuals addicted to opiates I have come to know over time and in considerable depth, have educated me to the effects of opiates on mental function.

No matter who takes an opiate, it impairs their ability to feel feelings. Because memories are stored with feelings, memory is also impaired.

Opiates do not erase feelings or memories, they are blocked as long as there is an opiate blood level present.  If the blood level drops both begin to return, not always in an organized form.  The memory impairment bolsters the idea that we only remember what we have feelings about.  If the user maintains an opiate blood level every day, the blockade remains.

If the blood level drops, the blockade lessens, permitting the return of the suppressed memories and feelings. This return is the start of withdrawal.

Withdrawal is a somewhat gradual process starting with a tired feeling, yawning, anxiety, nausea, headache, and watery eyes.  If the blood level continues to drop, the symptoms increase to include abdominal cramps vomiting and diarrhea, the latter two are often protracted.  Historically, withdrawal has been characterized as solely a somatic event, involving just the body.

What has usually been overlooked is that this entire upheaval has been triggered by the blocked feelings emerging from memory.  Our understanding that feelings start out in our body comes from observations of infants.  They are born with feelings that start out in their body as some kind of discomfort.  The changes in our body when fear or anger are present are clear evidence that the somatic origin of feelings persists.  The withdrawal symptoms are not in the user’s control, being out of control can be a terrifying experience, some liken it to a nervous breakdown.  Users quickly discover that resuming using opiates stops the withdrawal. Fear of withdrawal is a common reason given for continuing the addiction even though the user desperately wants to stop.

Additional evidence that feelings play a major role in addiction comes from reports from users who say they use to keep from feeling “bad”, and that use of opiates results in a “high”.  Calling a feeling bad indicates it does not have a name and can become an emotional threat.

Because opiates impair an individual’s capacity to feel their feelings, they also impair access to memory, as was stated earlier.  This clinical finding mandates the study of memory contents as a significant factor in understanding opiate addiction.

The emergence of post traumatic stress disorder (PTSD), a disorder of memory, has revealed that the contents of memory can be a source of suffering. This phenomenon was first reported by VietNam veterans who described  combat flashbacks in excruciating detail.

Flashbacks are memories without words.  When life-threatening events occur there are no words, for most its sheer terror.  They are described as a reliving experience, akin to a panic attack.   No-one wants to talk about such an experience and relive the terror.  The panic state may not consciously be associated with the precipitating memory, causing some to feel they are out of control, in danger of losing their mind, or having a nervous breakdown.

Since the 60’s and 70’s research has shown that any life-threatening experience has the potential to cause the symptoms of PTSD.  Auto accidents, acts of nature, assaults, rapes, and all manner of child abuse and neglect can be a cause. To be more precise, it’s the memory of these events that is the cause of the suffering. Opiates, with their memory blunting effect, provide relief as long as there is a blood level, without a blood level the flashbacks return.

What experiences in your memory may play a role in self-destructive behavior?

The bulk of the information about the effect of opiates on mental function has been obtained from opiate users who are addicted.  It has informed the program I developed to create an intervention to enable users to end up drug free.  The program goes under the heading of medical assisted treatment (MAT).

Buprenorphine is the medication used.  It is referred to as a partial opiate in that it is thought to fill a reduced number of opiate receptor sites in the brain. Clinically, it blocks withdrawal and most craving, it does not induce euphoria enabling users to participate in the psycho-educational recovery program as well as to function in work, social, and relationship settings.

People seeking help with an opiate addiction are asked to fill out a screening and history form and are given a detailed description of the recovery program.  It describes opiate use as a very self-destructive process.  Since no-one is born self-destructive, the essence of the program is to discover what experience or experiences, now stored in memory, play a role in fostering self-destructive behavior.  Since most users know or know of people who have died from opiate use and are aware of the media coverage, this is not foreign news.

Also, a careful history will reveal that opiate use is not the only way users are self-destructive.  They usually smoke, ignore their physical and dental health, drive while using, and their work and relationships suffer. The reason that self-destructiveness is emphasized up front is because the goal of the program is to discover the cause of the self harm.

Recovery takes place in a therapeutic relationship, one of mutual respect, that is non-judgemental, and one of evolving trust.

The psycho-educational process occurs in half hour, monthly sessions that initially emphasize increasing self-awareness.  This is accomplished by encouraging the user to listen to their inner dialogue.

Everyone talks to themselves, it’s the way our brain is wired.  They are also encouraged to listen to the sound of their voice, both are conveying emotional signals (feelings).

Our feelings, if we are fortunate enough to learn about them, name them, and have words for them, are there to guide us about what is in our best interest and what is not.

Feelings also have to do with conscience:, no feelings, no conscience.  Many users have reported that while using they were faced with activities that they knew were harmful or illegal, but just didn’t care about consequences, i.e. no feelings, no conscience. The change from potent opiates to the far less potent buprenorphine, permits a limited reconnection to their feelings and conscience.  By developing the ability to pay attention to emotional signaling and having words for the feelings, it prepares for the next step in recovery.

Our recovering individual is encouraged to lengthen the interval between doses of the buprenorphine.  The lower opiate blood level also lowers the memory blockade permitting a bit of what has been repressed to emerge, meaning memories with their feelings, sad, happy, angry, curiosity, guilt etc.

Now with words, feelings can be identified and incorporated into a new self-regulating structure, one not so linked to bodily arousal, i.e., now just feelings. This very gradual lowering of the opiate blood level lets the person, who is now paying attention, to know the effect of opiates on their mental function, more specifically, what they have been hiding from themselves with the opiates.  If the user gradually continues to lower the dose and thus lowering the blood level, he or she has more and more access to contents of memory with the associated feelings.

The end point is reached when the recovering individual is comfortable with everything in memory, they have words for their feelings, and they can see clearly in their mind (memory) the source of their self-destructiveness.  When in this state of mind there is no need for opiates, the previous addict has, in fact, cured themselves.

This report is based on my work with individuals recovering from an opiate addiction.   It describes the genesis of opiate addiction having to do with difficult or painful memories blocked by the effect of opiates on memory. It included explaining the complexity of opiate withdrawal and the details of a recovery program.  The recovery process emphasized the self-destructiveness of opiate addiction, then provided a method of discovering the cause of the self harm by examining the contents of memory.

Patient R has continued his efforts to process the emotional impact of the accident and the losses that ensued with increasing relief.

The information contained in this report has been reviewed by several individuals who have recovered  or almost recovered to verify that the content of the report is valid.

Then a copy of the report will be shared with members of the community who come into contact with opiate addicts in their work settings.

It is my hope that the report will deepen the conversation about addiction, alter some of the stigma, and reveal, in a convincing way, that opiate addiction, perhaps all addictions, are about coping with pain.

Thank you for your time,

Dr. John L. Bulette