Update and Commentary

meeting

Hey everyone!

It’s been a while since I posted, and for that, I apologize. Life happens.

I will likely be going to nursing school this fall. I have a 4.0 GPA in my prereq classes (Chemistry, A&P, etc.), rocked my TEAS exam, and didn’t act like a bumbling fool in the interview, so I’m waiting to hear for sure if they’re letting me in. (They probably will.) Moohoohahaha.

I mentioned this success to a young doctor the other day who smiled at me, tilted her head to one side, and said (more than a little condescendingly), “That’s great. See? It’s never too late.”

Okay. First of all, seriously? I mean, granted, I forget sometimes that I’m not 18 years old anymore. But it’s not like I’m a 90-year old great-grandmother going after my GED. Sheesh! Secondly, being a doctor you should appreciate how difficult it is to pursue any kind of medical degree; try doing that and working to support yourself at the same time AND maintain a 4.0 average. Yeah. So there.

*crickets*

Wow. Tough room.

So there’s that.

More importantly, I wanted to let readers know that I will be attending a get-together with people on the front lines of the loperamide issue very soon.

Do you have questions or concerns that you want me to carry forth?

Everyone who writes to me increases our knowledge of the scope of this problem and how to better approach it. So your input is important to me. Your letters inform and sometimes break my heart. I’m so appreciative for all you have written.

I know a few people have raised legitimate concerns regarding the present OTC status of loperamide and the potential impact if that changes. I promise to take all that into consideration and bring your thoughts to the table with me.

What do you want people to know? How has loperamide addiction has affected your life?

Comment below and let me know. Thanks!


“Be sure you put your feet in the right place, then stand firm.” — Abraham Lincoln


 

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Posted in + recovery, addiction, loperamide, loperamide abuse, Loperamide in the News, sobrietyland | 1 Comment

FDA Recommends Limiting Loperamide Quantities

51WOvornzjLThe FDA has recommended that loperamide (brand name: Imodium) be sold in limited quantity and in blister packs in the hope that such a move will stifle the growing problem of addicts abusing the drug.

If the manufacturers agree, it’s a terrific first step in preventing deaths from loperamide abuse.

My longtime readers know that I, myself, was addicted to loperamide for a couple of years. I was also the Index Case in this loperamide abuse crisis — having gone into cardiac arrest and almost dying in February 2012 from an overdose of the drug. Lots of research has gone on since then. (Please feel free to peruse my site for more information on this).

I became convinced that I could help prevent people from dying as I did. So, for a few years now, I have worked with the toxicologists at the Upstate Poison Control Center in Syracuse NY to battle this ongoing problem that has become part and parcel to the nation’s Opioid Epidemic. The doctors at Upstate have seen countless patients presenting in their emergency rooms, some of whom have sadly died as a result of abusing loperamide.

I’d like to think that my efforts, in some small part, have contributed to the research in this field and in changing attitudes of healthcare workers and the general public toward those with addiction issues. I hope that, perhaps this recommendation — requesting that the manufacturers and sellers of Loperamide voluntarily comply with the new FDA recommendations of limits on the packaging —  will save some lives.

In a nutshell (TL;DR) the recommendation is that loperamide be sold in smaller quantities — instead of selling bottles of 200 — and that they are blister-packed instead of sold loosely in a bottle. This allows the general public to still have access to necessary medication but limits the addict’s ability to get into trouble.

For those who are already addicted, now is your wakeup call. You may, like me, have been waiting for the “right time” to get off the drug. Now is that time. Get yourself into a treatment program where you can get the help that you will need! Outpatient may be all you need — you may not need residential treatment. Treatment for loperamide addiction follows much the same course as a traditional opiate with certain exceptions due to the nature of the drug. Talk to a treatment counselor. Ask lots of questions. Let them work with you to form a TEAM to fight the addiction. You CAN do this — I know because I did (and I’m the hardest-headed person I know!).

Don’t wait or it’ll be too late.

And to those on Amazon (and other sites) who sell Loperamide in ridiculously high quantities (like, 2400 tablets at a time) knowing that addicts are your number one customer: YOU ARE ON NOTICE. Enjoy your sales now because it will end soon. I have a particular set of skills. Skills acquired over a very long career. Skills that make me a nightmare for people like you. I will look for you, I will find you, and I will make you stop selling drugs to people and killing them. You will be held accountable.

Push your shit somewhere else. I’m shutting you down.

FDA NEWS RELEASE

WASHINGTON POST

From the FDA News Release:

Today, toward these goals, we have taken a new action related to how one opioid product is packaged as a way to help address a growing problem of abuse and misuse of this product. The FDA is requesting that sponsors of OTC loperamide ‒ an FDA-approved product to help control short-term symptoms of diarrhea, including Travelers’ Diarrhea – change the way they label and package these drugs to stem abuse and misuse that leaves us deeply concerned.

Abuse of loperamide has been increasing in the United States. When used at extremely high and dangerous doses, it’s seen by those suffering from opioid addiction as a potential alternative to manage opioid withdrawal symptoms or to achieve euphoric effects of opioid use. The maximum approved daily dose for adults is 8 milligrams per day for OTC use and 16 milligrams per day for prescription use. It’s sold under the OTC brand name Imodium A-D, as store brands, and as generics.

Loperamide is safe at these approved doses. But when higher than recommended doses are taken we’ve received reports of serious heart problems and deaths with loperamide, particularly among people who are intentionally misusing or abusing high doses. The majority of reported serious heart problems occurred in individuals who were intentionally misusing and abusing high doses of loperamide.

The FDA added a warning to the product label in the spring of 2017 to warn of ingesting high doses of loperamide, including from abuse and misuse. Evidence suggests that package limitations and use of unit-dose packaging may reduce medication overdose and death.

Today we sent letters to the OTC manufacturers requesting that they implement changes consisting of packaging limitations and unit-of-dose packaging. We’re requesting that packages contain a limited amount of loperamide appropriate for use for short-term diarrhea according to the product label. One example is a single retail package containing eight 2-milligram capsules in blister packaging. We asked the manufacturers to take the necessary steps to implement these changes in a timely fashion to address these public health concerns.

I also plan to reach out to those who distribute loperamide online, through retail web sites, to ask them to take voluntary steps to help us address this abuse issue. The new packaging should help make limits on sales more easily achieved. The abuse of loperamide requires the purchase of extremely large quantities. Often this is done through the purchase of large bottles of loperamide, which is a common configuration in which the pill form of the medication is currently packaged. Today’s action is intended to change how the product is packaged, to eliminate these large volume containers. We know that many of the bulk purchases of these large volumes are being made online through major online web retailers.

I believe anyone who is distributing health care products has an obligation to be a partner in helping address the most pressing public health challenges like opioid abuse. If you’re selling a drug with the potential for abuse and misuse through an online website, you’re no longer in the business of selling widgets, or books. You have a social contract to take voluntary steps to help address public health challenges.

Posted in + recovery, AA, addiction, loperamide, loperamide abuse, Loperamide in the News, sobrietyland, therapy | 7 Comments

Thinking Fast and Slow

System-1-vs-System-2.jpg

On Facebook this morning, I ran across a recommendation by ZDoggMD (government name: Dr. Zubun Damania) — a book called “Thinking Fast and Slow” by From Daniel Kahneman. This piqued my interest for a couple of reasons. First, Kahneman, despite being a psychologist, won the Nobel Prize for Economics in 2002. Second, the book’s subject matter is Human Irrationality. In other words, why do we do stupid shit despite the fact that it’s bad for us?

Take, for example, drug abuse. It’s estimated that over a half-million people die every year from various forms of drug abuse. So, with overwhelming evidence saying that using is a bad thing (whether it’s tobacco, alcohol, or illicit drugs), why do people still choose to light up, drink up, or shoot up?

According to Kahneman (and other researchers involved in the project), it comes down to the way the brain is wired. How we perceive incoming data. We have inherent biases in our thinking that influence our memories of experiences.

He postulates that we have two systems of thinking going on. System 1 (the fast one) is pretty instinctual. It makes a decision at a subconscious level. But it works fast and cheap  — yet it’s pretty inaccurate. Example: You see a bowl of cherries with a cockroach sitting on top. You may instinctively feel intense revulsion. Your brain thinks, cockroach is bad, therefore, cherries are bad. From then on, you think cherries=bad.

System 2 (the slow one) happens at a conscious level. It’s methodical. Takes time. System 2 would sort through the information so you can see that cherries are still good even if you saw the cockroach on it. It considers that situation in a more logical, “scientific” way.

But System 2 takes time and it’s exhausting. It’s lazy. If it gives up too soon, System 1 takes over and you remain cemented in your belief that all cherries suck because… well… maybe your brain won’t even remember that cockroach after a while. You just remember knowing in your heart of hearts that cherries are gross. Period. Stuck in that belief because that’s just how it is. Harrumpf!

I’ve only started reading this intriguing book, but let me allow the New York Times to summarize what I’m trying to say:

“… the remembering self does not care about duration — how long a pleasant or unpleasant experience lasts. Rather, it retrospectively rates an experience by the peak level of pain or pleasure in the course of the experience, and by the way the experience ends.”

So… example… someone like me takes a Vicodin tablet. I’d taken Vicodin before and, while I enjoyed it, I never really loved it. It was a slow release, and even though the experience was pleasurable, it wasn’t really all that great. But I DO remember the day it hit me like a freight train! For various reasons, the drug gave me an intense high one day unlike any other — and the intensity of the experience shifted my bias. I wanted that to happen again and again and again. I pursued it into the ground despite all evidence that my life was spinning wildly out of control. I almost died trying to recreate that experience.

This is what Kahneman describes as the “Peak-End Rule” — not so much the duration of the experience, but the intensity by which it is felt — that drives my recollection and pursuit of repetition despite all logic to the contrary.

In truth, I have wondered about this theory for a long time. I’m pleased to see that a Nobel Prize-winning psychologist/economist has done the legwork for me. That perhaps it is not the length of time we do it, but the intensity of the experience that drives addiction. They don’t call it “chasing the dragon” for nothing. Always chasing that first high.

And perhaps that is why so many drug treatment plans fail — they cannot overcome that cognitive bias created by the peak of the drug experience. Going to classes all day, going to meetings, plodding along in our recovery — how can that possibly compare to the fireworks created by your drug of choice?

It can’t. That’s why healthcare workers recommend that treatment last so long even though insurance companies only want to pay for a couple of weeks or the traditional 28 days. 28 days isn’t nearly enough for System 2 to kick in. Not nearly enough. A dear friend of mine has been in treatment for almost a year now — and he does everything he’s supposed to do. He takes all the classes. He does all the work. He goes to meetings. He does every assignment he is given. Yet, while they have quieted, the urges are still there. If Kahneman’s theory of a mild experience for a long time versus an intense experience over a short time is true, the likelihood that my friend will relapse remains pretty high.

Which isn’t to say that the “System 2” cognitive version of Drug Rehab — the most common here in the United States — can’t or won’t work. It can and does for many people.  It may work for my friend. But perhaps we need to consider that if most of our patients are failing in this method of treatment, we need to reassess what we’re doing.

I wonder if that is why the controversial treatment of Ibogaine for opiate addiction has found a modicum of success as a ‘cure’ in other countries where it is legal — because it proffers an alternate psychoactive experience, one that shares a “Peak-End” in direct conflict with the original episode. Perhaps the two cancel each other out? I would be curious to find out more.

(I’m not in any way, shape, or form recommending Ibogaine, but I DO find that its results present us with new data that should be considered.)

At any rate, I think this book is a really intriguing read! Although I’ve just started reading it, I think this book is offering some real insight given our current drug crisis. Check it out! (It comes ZDoggMD recommended too!)


“Intelligence is not only the ability to reason; it is also the ability to find relevant material in memory and to deploy attention when needed.” —Thinking Fast and Slow, Daniel Kahneman.

 


 

Posted in + recovery, AA, addiction, education, loperamide, loperamide abuse, sobrietyland, therapy | Tagged , , , , , , , ,

Relapse: The Silent Killer

Let’s talk about the thing nobody in recovery wants to talk about.

Many things can be talked about freely “in the rooms” — i.e., in a 12-step meeting. You can talk about relationships. You can talk about a particular step. You can even discuss having gone to jail or rehab. But there is one topic above all others that scares the living crap out of a 12-step meeting.

Relapse.

There. I said it.

Relapse.

How much more dangerous it is when it remains unspoken.

It happens. It happens to the best of people. The most hardcore. The ones with 20 years of sobriety under their belts. Relapse. It’s the thing people in recovery fear the most out of any word in the English language. But it happens all the time.

A friend of mine recently re-entered rehab for what seems like the four billionth time. Everyone worries whether or not this time will stick — and they have a right to be concerned. Everyone — that is — except those who abandoned him after he relapsed. Even family members and friends fear relapse because the consequences are so dire. Every time an addict relapses, there’s the possibility (probablility?) that they could die this time. That all the bad things will happen all over again.

When I initially quit taking loperamide, withdrawals were so bad that one night I couldn’t take it anymore and took a few pills just so I could get a few hours of peace and rest. The next day, I attended a meeting and confessed what I’d done — I was EVISCERATED by the group for my relapse. My main mistake was, in explaining what had happened, saying “I know it’s a part of recovery” — to them, this was pure blasphemy, so I was told, in no uncertain terms, that was unacceptable.

Yet, I was not wrong. Relapse is an expected part of recovery. It doesn’t have to be, but it happens more often than any of us would prefer.

relapserates

Source: JAMA, 284:1689-1695, 2000

Relapse in addiction recovery is no different than any other disease. (By the way, some people differentiate between a “slip” and a “relapse” but, to me, that’s just a matter of semantics. As I will be discussing it, they are the same thing.) Below is a chart that appeared in the Journal of the American Medical Association (reused by the National Institutes of Health) that compares relapse rates between drug addiction and other chronic illnesses such as Type I Diabetes, Hypertension, and Astham. Those illnesses require lifelong patient compliance, frequently with medication, and the breakdown of patient adherence to a treatment plan often causes a relapse of symptoms and repeated medical intervention.

 

Those who think Substance Abuse Disorder isn’t a disease need to consider this chart carefully.

Relapse is so terrifying because the consequences of it are so dire. As with any chronic disorder, it can quickly lead to hospitalization or death. The diabetic stops taking insulin, it doesn’t take long before glucose builds up and bad things happen. Untreated high blood pressure can lead to strokes and long-term irreversible damage. Untreated asthma can lead to hypoxia and death in minutes. Nobody wants this — but it can and does happen.

The important thing to remember is that relapse doesn’t have to be the end. It is a call to action. Renewed intervention in the disease process can lead to continued recovery with swift and decisive action.

But never give up. Never give up on the family member or friend who slips. And never give up on yourself. Recovery is an ongoing war; the loss of one battle doesn’t need to signal the end.

 

 

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Loperamide In the News… The Atlantic: Addicts Who Can’t Get Opioids Are Overdosing on a Diarrhea Drug

Loperamide is back in the news! This time it’s in The Atlantic, on Fox News, and in a few other locations. Apologies for not keeping up. School is sucking up all my free time (when I’m not sleeping, that is).

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From The Atlantic:

“Until just a few years ago, the cardiac effects of loperamide were unknown even to most doctors—simply because people weren’t taking the drug in big enough doses until the opioid epidemic. And the trend is unlikely to go away soon. “We will see more cases because the more restrictions [there are] on opioids, the more doctors are afraid of trying to extend their prescriptions, the more people will seek different substances,” said Rasla.”

From Fox News:1491595210382

The article from Fox News is basically a retread of the one from The Atlantic. “The number of calls to poison centers regarding the ingestion of dangerous levels of the diarrhea treatment, known as loperamide, doubled between 2010 and 2015, the magazine reported.”

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The Pressure Cooker

snidely

Ah, the end of the semester has arrived. In less than a month, final exams will be over and this school year will be past. It’s hard to believe, but it’s true.

This past week, New York State became the first state in the nation to offer free tuition to 2-year and 4-year state colleges. Dubbed the “Excelsior” Scholarship, it is hoped that this effort will attract more students to New York for educational opportunities AND that some of those better-educated individuals will decide to stay and make New York their permanent address. It’s a brilliant idea.

I love it and hope it is massively successful. No one who is willing to work for a degree (and maintain a B average or higher) should have to be burdened with student loans for the rest of their natural lives just to be able to get a decent-paying job.

That said… hahaha… now that I’m enrolled in a private college for the fall, the change isn’t likely to help me much at all.

The pressure to succeed has built to its crescendo. Yes, for those whom much is given, much is expected, and this pressure from this expectation is showing. I think that is true of many college students, particularly about this time of the semester when things are winding down and approaching final exams. And for some who face certain additional life challenges, the pressure is compounded.

Free tuition doesn’t help much with pressure-related stress, that’s for sure.

And even with college costs, free tuition is only part of the equation. I’ve actually been pretty fortunate so far in that 99% of my education costs (including books) have been covered by various scholarships and grants.

Books — make no mistake about it — can be almost as costly as the tuition itself (at least at the community-college level). In medicine, book costs are outrageous. No shit. I mean it. Outrageous. I am taking associate’s level courses, and I can expect to pay $350-$400 per book for an average 3-credit class; sometimes a bit less, sometimes more. The Anatomy & Physiology class I’m taking now required a $400 book plus another $79 for the school-exclusive lab manual.

And buying used books isn’t an option like it used to be in the olden-molden days, since much of the classwork is heavily dependent on online quizzes and assignments, only available via an online key and password, usable by one person only, and exclusively accessible with the new edition of any book (new editions come out about once a semester). Hence, no cheap used books.

People don’t comprehend the actual costs of returning to college. Even if you get the free tuition, the book costs alone will kill you. And then there are all the other fees they don’t warn you about. The lab fees. The equipment fees. The testing fees. The this-and-that fees. Every time you turn around, the college has their hand out saying you owe them for this-or-that and — like any good loan shark — if you don’t pay up now, very bad shit will happen. You don’t graduate. You don’t pass. You don’t get an A.

I was recently accepted to a fancy foo-foo private college for the fall for Nursing. Included with my acceptance letter was a request for a $50 matriculation fee deposit and a notice that I was expected to attend a uniform fitting next week (no cost listed).

Okay, first of all, if $50 is the matriculation deposit, how much is the actual matriculation? Are they aware that I am poor? Are they aware that I am dependent on financial aid for this? So yeah, I’ll have to come up with the fifty bucks or risk losing my spot. As for the uniform fitting, all I can say is, they can fit me, but I can’t pay for it until all the financial aid stuff is arranged.

And so it begins.

Some people say that when you’re young, going to college is easier. And to a certain extent, they’re right. There is a reason that MOST people attend college when they’re kids straight out of high school. Most will have the advantage of parental support (both financial and otherwise), many will have few responsibilities, means of housing and transport, most don’t work or have familial responsibilities yet, and many are young and foolish and have yet to learn to appreciate the sweet, sweet glory of 8 hours of sleep each night. In other words, they adapt well because don’t know any better.

But as a returning student, an adult with many years of experience doing various things under her belt, this shit is hard. Way hard. Maintaining a job and going to school? Oh my God, so hard. I can tell you that I know now — better than at any other time in my life — what I’m capable of and what I’m not. I happily push the envelope, but I recognize my limits (not that I always abide by them).

I have a healthy respect for sleep deprivation. I know the value of a buck, and I know first hand how important it is to keep the lights on. I know what it takes to study for an exam and pass. I also know when I can’t. When it’s too much. I can skate by, but I know the consequences that entails.

Moreover, I am at an age where I am prescient enough to see the low dark clouds of trouble on the horizon. And know what that means.

For instance, I know that this fall, should attending the foo-foo private nursing college come to pass as planned, I will be in over my head. No question about it.

It’s all about support though. Getting myself prepared for the onslaught. Will my life be set up well enough by then that I can survive it?

Let me just say — I don’t worry because school is hard. (Shit, I know that.) And I’m not worried because I’m not smart enough. (I know I am.) I’m worried because of the pressure of everything else. All those loose ends are the problem. They can do me in.

My depression has returned full-blast now. I suddenly started to cry uncontrollably on the way to class the other day and had to take a few moments to collect myself before I walked through the door. It almost blew into a full-on panic attack. That’s a very bad sign. I know it because I’ve seen it happen before. It just comes out of the blue like a rogue wave on the ocean — and like that tsunami, it is a sign of seismic activity deep under the surface. A low rumbling of real danger.

Compound that with the pressure of work, an end-of-semester project that I cannot complete, final exams in two difficult subjects, a total lack of transportation and support, unresponsiveness from my doctor regarding my depression, my best friend is in jail, no time, maintaining my sobriety, and no money at all to correct any of it — I know I’m in trouble. Any one of those things on their own would be difficult, but, yes, this is as overwhelming as it appears.

(Does anyone ever hear me, I wonder, when I ask for help?)

I see it happening, yet I can’t stop it. It’s as if I’m tied to the railroad tracks watching the train approach from a distance while Snidely Whiplash twists his mustache and cackles in cruel delight. Only for me, Dudley Do-Right isn’t coming. I’m lying on the train tracks wondering whether or not you feel your organs crush under the train’s wheels or do you black out before that kills you?

For many people in college, this kind of scenario can happen. MIT recently asked for feedback on college burnout and received several really interesting replies particularly from their overachieving A-students. One remark sums up my sentiments exactly: “Nothing ever feels like enough. I feel like I’m in the most amazing place in the world with the most amazing people in the world but all I can think about are shortcomings.” Yep. Most of the time, I feel like a disappointment, so success isn’t always felt nor enjoyed as it should be.

I was offered an invitation-only opportunity for a summer class that any med/nursing student would kill get in on, but I’ll probably have to turn it down. Why? Because I can’t get there. I don’t have a working car right now, and that’s not likely to change in the next three weeks. So, I can’t go, not because I’m not smart enough. Not because I won’t put forth the time and effort. Not because I’m unwilling to make the sacrifices necessary to do it. But because of something as simple as not being able to get there. It’s killing me that I won’t be able to go.

In an AMA article titled, “Students Under Pressure”, almost half of students questioned claimed to have sought help for mental health related issues (namely, anxiety and depression) during the course of their school year. 30% seriously thought of suicide. So it isn’t like this situation is new.

You could certainly argue that much of the pressure is caused by personal expectations, and that’s certainly true of me. Students under pressure want to find an escape valve. For some, that’s exercise. They run, punch, lift weights, or kick their way to mental health. For others, they just need to take some time off. Hell, I could just take a year off and wait, trying to get my life together before going back. And many young people could use that option.

But for me, what would that really achieve? And wouldn’t I be sacrificing the momentum built from all I’ve been able to do so far? Not to mention my age. Dudes, I don’t want to be retirement age when I graduate. The time is now.

The most important thing, all experts agree, is to maintain a healthy lifestyle that is supportive of the pressures of school and home. That’s difficult in the real world. You have to have a tremendous amount of support and love from the people around you to make that work. Being proactive about health concerns helps too. Staying on top of homework assignments (not procrastinating) is another assist. Eating well. Drinking enough water. Stuff like that.

The one thing I can tell you for sure is, going back to school as an adult isn’t easy. In fact, the bigger your dream, the harder it’s going to be. Wanna return to be a plumber? Okay. Wanna return to be a doctor? Good luck (HA!) The bigger the dream, the bigger the laugh from God.

It seems one has to survive the hard parts to make the good parts possible. So I press on.

Good luck.


“Nothing in the world is worth having or worth doing unless it means effort, pain, difficulty… I have never in my life envied a human being who led an easy life. I have envied a great many people who led difficult lives and led them well.” — Theodore Roosevelt


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