Episode 24

  • How does opiate addiction start?

  • What does progression look like in opiate addiction?

  • What keeps people stuck in a cycle of opiate addiction

The opiate epidemic is all around us. We hear about the deaths and the dangers. Most of us know a bit about it, but we may not know enough details to help clients who have opiate addiction.  This is the second part of a mini-series about opiates and heroin.  The goal is to help you get a clear picture of this issue, how it impacts people and what treatment looks like.

Helpful Links

**These links represent what I read and where I got information. Some information is conflicting, but included to show the full spectrum of information considered.

Opium Throughout History | The Opium Kings | FRONTLINE | PBS

[The history of heroin] – PubMed

Heroin, Morphine and Opiates – Definition, Examples & Effects – HISTORY

About the Epidemic | HHS.gov

Opioid vs. Opiate: What’s the Difference?

Opioids: Listed From Strongest to Weakest – PAX Memphis

What Is the Strongest Opiate?

Understanding the Epidemic | Drug Overdose | CDC Injury Center

Prescription Opioids | Drug Overdose | CDC Injury Center

Opioid Overdose Crisis | National Institute on Drug Abuse (NIDA)

Overdose Death Rates | National Institute on Drug Abuse (NIDA)

Opioid overdose

11 Commonly Abused OTC and Prescription Drugs

Prescription drug abuse – Symptoms and causes – Mayo Clinic

The Most Commonly Abused Prescription Drugs | The Recovery Village

How opioid addiction occurs – Mayo Clinic

List of Narcotic Drugs: Examples of Opioids & Other Narcotics

History of the Opioid Epidemic: How Did We Get Here?

Tracing the US opioid crisis to its roots

A Brief History of the Opioid Epidemic and Strategies for Pain Medicine – PubMed

The History of Opioid Addiction – The Long Opioid Drug Crisis

The Opioid Epidemic: It’s Time to Place Blame Where It Belongs

Narcotics (Opioids) | DEA

Free Treatment Tool https://betsybyler.com/treatment-tool/


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

Welcome  back to the All Things Substance Podcast. This is episode 24 today. Today we’re going to continue talking about opiates and heroin but at a more detailed level

As I was thinking about how  to share information with you about opiates and heroin. I wanted to do it in an interview format because I think talking with someone who has personal experience in this area I thought we would be able to get a better insight into our clients.

Over the last several years, I’ve had the privilege of working alongside a man named Justin Schmiesing. When I met him, I knew he had a natural talent for connecting with people. I just hoped that he wanted to become a therapist. 

Well, it turns out he did. He finished his undergrad and then went to work on his master’s degree. Now he’s a licensed therapist and chemical dependency counselor in Northern Minnesota.  He’s a person in recovery, an avid outdoorsman and an excellent therapist and friend. I’m honored that Justin was willing to speak with me about this topic and willing to share some of his personal story.

*Add 1m 27s to the timestamps below to account for the intro

Betsy: [00:00:00] Justin, thanks for being here today. 

Justin: [00:01:00] I am happy to be here. Thank you for having me.

Betsy: [00:01:03] What I want to talk about the use of pills, opiates, opioids, and heroin.  What I want to start with: why would somebody start using prescription pills in the first place? 

Justin: [00:01:17] I think it’s going to be somewhat different for each person, but there’s going to be a lot of overlapping similarities. I feel like the reason kind of lies in the word painkiller. And when the pain of living life becomes too much. Pain can take on many different forms. It can be like emotional pain, anxiety, more in the mental health realm. Think of different people who I’ve worked with throughout the years. People who have anxiety associated with obsessive compulsive disorder, coupled with debilitating depression.

That using  it tamed the need to perform these rituals. Can help pull a person out of bed. I think about pain in the form of childhood sexual abuse. I think of ADHD, the inability to hold a thought to complete a sequential task, to even sit still. I think of just chronic disconnection, not feeling a part of, feelings of emptiness, the swamp land of the soul that we call shame.

I think of chronic pain, hating yourself, not feeling like you’re in control, feeling like you’re a prison in your own mind and wanting freedom from that. All of these things kind of come together where the opiate, the painkiller is treating something. 

When it comes to emotional pain, it’s interesting because it lights up a similar area of the brain as physical pain. This idea of opiates being prescribed to treat physical pain, while people can find out that well, it also is treating all the other ways that pain can manifest. If it registers in a similar area of the brain, there’s going to be some overlap there. Painkillers can treat a lot of different things. Not saying that it’s an effective way of treating that, most certainly not, but it can treat a lot of different things.

Betsy: [00:03:08] Most people, at least that I’ve worked with, don’t start with pills. Although there is a population of people who do ( that’s kind of the post-surgery kind of people who haven’t really planned on it, haven’t been using).  And I kind of talked about that in last week’s episode. How do you feel like that progression goes for people who haven’t had it for a surgery type thing?

Justin: [00:03:31] I feel like it maybe starts with marijuana typically. While using marijuana and finding out like, okay, this isn’t as big of a deal as maybe I thought it would be. As time has gone on marijuana does have less stigma, but noticing that, okay, this is working: this idea of escaping this idea of not feeling, not dealing with things, using something externally to help what’s going on in the inside, whatever the substance is being kind of the go-to.

Marijuana, there’s less risk. It’s safer to start there. So I feel like that is one of the more common things that people start with. Alcohol too. Obviously, being super socially acceptable, even marijuana is becoming more socially acceptable as it’s legal and more States and being used medically more often.

I’d say those two, just open that door and once that door is open, it introduces options toward other medications, other drugs being available. Typically a weed dealer is going to have access to many different things. Maybe having a few Vicodin, a few Xanax that kind of adding that into the mix. And then people start to discover kind of what is helping them the best to get oughta right here right now.

Betsy: [00:04:51] I have found too, that after a while my clients who are smoking weed, it just stops working as well. You can only smoke so much in a day. Right. And it’s incredibly expensive over time. And so I find that we’ll talk about, well, a few pills we’ll hold them out for the day or maybe even one for that matter.

And they’re feeling good and they don’t have to smoke as much. And it’s more concealable. Do you see that the people you work with that smoke weed, do they have that experience? 

Justin: [00:05:19] Yeah, the marijuana. I mean, it’s only gonna do so much and like you said, as tolerance builds, it’s just not cutting it. A level of escape and not wanting to feel that marijuana can only take you so far, especially when opioid painkillers are introduced, the marijuana is just not going to cut it anymore as time goes on and once the dependence starts to develop.

Betsy: [00:05:41] When people get started using pills, how does that progress do you feel?  What have you noticed about the progression of types of pills or amounts and how long does it take typically? What is your experience around those things? 

Justin: [00:05:56] One thing I can speak to confidently is my own experience. Actually, it started out very similar as to what we’ve been talking about already. The marijuana, the alcohol kind of playing around with different stuff and experimenting. Being exposed to hydrocodone or Vicodin, lorcet; they’re all the same thing. So that’s one of the lower level painkillers, not as potent, but they’ve kind of been noticing like, Oh wow, this feels really good.

All of a sudden I have a lot of energy .Kind of okay with like everything. If only I could use this every day, everything would be okay. Like just all of a sudden feeling really, really okay and almost like it had like armor to face the world all of a sudden.  Noticing that this was something that it just helped everything it made just life easier. 

Slowing down thoughts, feeling less anxious, things just being more interesting, more of a flow to it, seeking that out, wanting that. Well, this feels this good. Well, why not more? Definitely more. Finding more of it. 

Right away, it can be depending on where you’re getting it from a little challenging to always get a hold of it because it’s prescribed. There are illicit ways of obtaining it. So prescriptions run out. So I remember right away, it was something that I had limited access to. So when it came to the dependent side of it kind of slowly developed over maybe three months for me, Having had it every day I’m very confident it would have happened much, much quicker. But over three months and having it maybe a few times a week at most.

 I’ll never forget going on this family vacation and then being cut off from everything. I didn’t have marijuana, I wasn’t able to drink legally at that point and I didn’t have any pills. And I wasn’t able to bring any. So we’re like in Florida and I can’t sleep, I’m starting to feel like crap and my stomach is a little upset. I’m just uncomfortable. It’s more on the lighter side of things on the spectrum of withdrawal, but I didn’t know it was withdrawal, but I just know that I feel super off and I don’t know why.

And I remember I’m like, I need to find some booze. I need to find something , to get rid of this feeling. I mean I ultimately did that just because I had to find something. And there was some pull and I didn’t really fully understand what that was, but I just knew that  what I had going on, I did not want to feel that way.

That sticks out in my mind as a time where like that was starting to cross the line right there. It slowly developed as time went on. It really, really snowballed. Got really out of hand where it was something I did need. Fast forward, maybe six months to a year, to the point where all of a sudden it’s daily, where I’ve had it daily for a while, I’ve gotten good at finding it.

I know people have it, people know that I’m looking for it. They’ll bring it to me or try to connect me with it. Then all of a sudden, I don’t have it for a day. I’m like, Oh my gosh, this is what withdrawal is. Holy.  this thinking that this is hell and I can’t handle this. I need to get away from this feeling by whatever means necessary, you know?

Calling people, like searching the internet, trying to find different sources to feed this because it felt so horrible. I mean, that’s the tip of the iceberg. It gets much worse, but that was a time where it’s just like, Oh wow, this is what this is, but it’s too late now the only thing that will fix this is more.

Betsy: [00:09:24] In the beginning it sounds like it was like Vicodin and hydrocodone. When did it become that you had to maybe step it up to a different level. Whether we’re going to oxycodone or whatever, like how long did that take, do you think? 

Justin: [00:09:39] How long did that take? I would say there were glimpses of other stuff here and there. By the time that I was using it daily, I noticed that it needed it. So going from taking maybe two hydrocodone 2 five milligrams.

So it may be 20 milligrams total. To needing like five and then eventually needing 10 at a time. And then eventually needing like 10 of the 10 milligram hydrocodone. So we’re talking about a hundred milligrams of hydrocodone. By  the time it was into that territory, starting to be introduced to things like morphine, starting to be introduced to like Percocet stronger than hydrocodone, which has oxycodone in it, the main ingredient and then Oxycontin.

So morphine, Oxycontin, and then even fentanyl as time went on. Fentanyl patches, Dilaudid oxymorphone. Just kind of opened the door where the hydrocodone as time went on, it was something that would more or less give me a stomach ache. Actually, because there’s a ton of acetaminophen  in the hydrocodone. And if you’re taking like,  a handful like 20, 30, 40 of those we’re getting at the level of acetaminophen toxicity where. You can only take so much in one day without there being repercussions.

So it just naturally it’s time to find something else that doesn’t have. Acetaminophen in it.  Something that is more potent, something that’s going to take me where I needed to be. 

Betsy: [00:11:14] So at that point where you’re getting introduced to morphine or Dilaudid, what kind of money are we talking about? I don’t need like a specific pill amount, but like on a daily basis, what is that cost?

Justin: [00:11:27] So pills are expensive.  they can be upwards of, and this is high end. It’s typically not higher than this, but it can be a dollar a milligram for some of these pills. So let’s use the hydrocodone example, for instance A five milligram hydrocodone. So paying $5 for that and needing 10 of those per day.

Or, you know, doubling that I’d said needing up to like a hundred milligrams of that today to have an effect still and stave off that withdrawal. So we’re talking up to a hundred dollars there and that’s more high end. There’s going to be deals. There’s going to be ways of not paying that much, but that’s how much they can be worth.

 It’s more common.  I’d say that that level of a price for things like Oxycontin  or the morphine being a dollar a milligram. I’m speaking from personal experience here needing upwards of 400 milligrams of Oxycontin to have an effect.  That can be really, really expensive. Well, there’s $400, but there’s going to be a deal cut by buying more than that. So I’d say it’s safe to say it could be a $200- $300 a day habit.

Betsy: [00:12:29] At what point does somebody start changing how they do it? Like whether they go from just swallowing it to snorting it or are they just snorting it from the beginning?

Justin: [00:12:38] It starts with taking it orally. It’s safer. I mean, that’s the way it’s prescribed. A doctor says to do it this way. Alright. I feel good about that.  That in itself, there can be a, more of a safety associated with, okay. This pill was made in a lab, by a professional. This idea of feeling more safe with pills. 

When it comes to orally,  not all of  the pill is being absorbed into your system.  There’s some of that gets lost as our body breaks it down. So if you are to snort it,  more of it’s going to be getting your system, faster as well.

And then even things like smoking it or injecting it .And let’s face it injecting  is the most efficient way to get a large percentage of it into your system and directly into your bloodstream. A scenario where I was talking about there being a $300- $400 a day habit.  That’s a lot of money and not easy to maintain.

Betsy: [00:13:32] Yeah. Nobody’s making that legally. 

Justin: [00:13:34] It’s not possible. It’s not going to be happening. And if it is, not for long.

When it’s this level, using $300-$400 a day of pills we’re talking about withdrawal where your skin hurts. Where the air on your skin is too much. Where the hair on your head hurts. Where your bones feel like they want to jump out of your body. Where aches and pains, and just no matter how you sit or what you do, you cannot get comfortable.

So this kind of presents a dilemma. Have this tolerance where I need to take all this medication.  It just costs a lot.  If you were to inject the medication, you could get the same high and not spend as much money. Like an 80 milligram Oxy where you could get high for much, much less money.

Maybe 40, 80 bucks,  versus if I’m taking it orally or even snorting it where I got to spend three, $400.  It kind of becomes like a no brainer. Like, why am I wasting my money? And I need this or else I’m going to be painfully ill. So it’s just naturally going to present itself eventually as time goes on. 

Betsy: [00:14:44] So a lot of people, I know that in our practice, when we worked together, they would have sworn up and down or were swearing up and down that they would never, ever touch needles. We had a certain response to that because we hear it a lot.

Justin: [00:14:58] The people who were using needles are like, yeah, you will. People who aren’t are going, no, I won’t. And there’s sort of this negative connotation. Like if you’re using needles, that’s really dirty, but it’s okay if I’m snorting it, that kind of thing.  What’s your experience watching that process going through that process where people are certain that they’re not going to go the needle route and then end up being there.

That’s a great example.  That’s certainly my experience. Watching people, working with clients where they’re just like, there’s no way. Hearing People talk about you know, okay, I’m an IV drug user and then just, almost being horrified, Oh, I could never,  I would never cross that line. And then the IV user they’d respond yet. 

Once this line gets crossed  your rational mind is not the one in charge anymore. So this person that was saying I will never, there’s no way I’m going to become a junkie that shoots up . There’s no way. I don’t roll like that. 

Well, yet. Because there’s this more primal drive, but there’s something more of an unconscious level that is pulling you towards it.  It has a hold of you. It’s just a matter of time before it gets to that point. Because that pull is strong.

 It’s extremely, extremely hard to avoid it because  you’re not going to be able to simply rely on thinking your way through it. It’s more of a disease  that affects your ability to think clearly about things. Affects your motivation. It shifts things that you believe you still have control of it, but you don’t. It’s the drug that’s making the decision.

Betsy: [00:16:43] When people are making that switch to IV use, A lot of times people will say I’m really afraid of needles. That’s their reasoning.  It seems like in the using community that people are more than willing to help you figure out  how to shoot up or to do it for you. 

Justin: [00:17:02] Yes. Yes. I think it’s kind of like that old adage, a water seeks its own level .Where as things progress you’re going to be running into people and being around people that are using IV.  Presented with some of  those factors  that I was discussing before with intense withdrawal, I’m only having a little bit, you’re going to have easy access to someone that knows how to you know, push that line back. That’s already there. And you meet them there.

 You hang out in a barbershop long enough. Well, you’re going to get a haircut.

Betsy: [00:17:41] So I know that for a lot of people, the idea of, okay, so you can shoot up pills, but they don’t really understand how you do that. Can you just briefly explain kind of what that’s like?

Justin: [00:17:53] So first off I would throw out there when there’s a will, there’s a way. Addicts are really creative people. They’ll find it. If there’s a way to break down a pill, if it’s out there they’ll get creative and they’ll find it. With many pills there are these protective coatings, there’s these sustained, released or extended release opiate medications out there that are designed to slowly break down in your system throughout the day anywhere, maybe 12 to 24 hours.

When it comes to Oxycontin, for instance, it was highly abused because all you had to do was suck off the coating and then crush it, then add some water, cook it down and then pull it up through a filter. And then injected directly into your vein.

So it was really, really simple.  As time went on, as the opioid epidemic progressed, they added other fillers into the pills  that made them more challenging to shoot up.  Like I said when there’s a will, there’s a way. So developing other methods.  Like using things like a lemon, citric acid, vitamin C to help break down some of these other impurities to kind of get to what they’re after. Things like cold water extraction where you’re dissolving it in warm water, then rapidly cooling it. Then taking out the part that separates. So that the drug itself is separating from the filler. 

Many different creative ways to go about that. It’s always been challenging for drug companies to stay ahead of that. Because like I said addicts are really, really creative and I’ve even heard clients saying that they’ve been able to shoot up Suboxone.

That’s something that you’re not supposed to be able to do. Right. Suboxone has something in it. That’s supposed to send you into withdrawal if you end up attempting to inject it. Shooting up Suboxone is not something that’s going to be crazy common to begin with because there is a ceiling effect with Suboxone. The opioid receptors, when they’re full they’re full.  You can only get so high on Suboxone as a result of that. And it’s supposed to get really gummed up.

That’s something that I hear people say often that certain pills, like it gets really gummy. Like it doesn’t easily break down. This goal of making it  more water soluble, that’s always what they’re shooting after And I guess pun intended there. 

 Betsy: [00:20:10] So you mentioned something earlier about fentanyl patches and I talked about that just for a minute last episode, because fentanyl was something that previously was really in patch form, end of life kind of thing. It’s top  of the heap in terms  of potency.  How would someone be using those patches?

Justin: [00:20:36] It’s something that you’re going to be on for, I think it’s something like a week that you’d have on your skin, it’s slowly released as time goes on. So 24 hours a day, it’s slowly released into your system based on things like body heat, things like that. Perspiration. So with fentanyl there is a way to inject it by simply cutting it off.  

There’s a couple of different kinds of patches. The one that doesn’t have the liquid on it. There’s one that  it’s more just like, within this sticky, like substance., so it’s within the patch. And there’s no really like scraping it off or anything like that, so they’ve tried to make it, so it’s not easy to shoot it up. But when addicts are creative,  they find a way. 

So by simply cutting it up, adding into a water solution, adding  one of those acids that I was talking about and heating it up a little bit. You’re able to break down  the solution that’s on the patch into something that is water soluble and able to mix into the water solution and separate from the patch and then be able to inject it. Highly dangerous because we’re talking something that’s designed to be slowly released over 24 hours for seven days.

And here you are taking a piece of it and dissolving it and then injecting it. So knowing exactly how much you’re getting, because depending on multitude of different factors: am I using too much acid? How much of the actual fentanyl do I have in this shot?

Well it’s not always clear. So most certainly the risk for overdose with fentanyl is always really high, even when it’s taken from a patch or even if someone who doesn’t have a high enough tolerance and it’s just put a patch on. I mean that could easily kill someone who is, may be able to take 3-4  Vicodin or hydrocodone and still experience a high from that.

It is super, super potent and has been in the news quite a bit where people are getting like hot batches of heroin with fentanyl in it.Sometimes it’s just straight fentanyl that is being sold as heroin. When addicts hear that there’s like a hot batch of heroin or fentanyl in town. Even if people are overdosing, it’s something that that’s still sought after because you know you want as much bang for your buck.

Betsy: [00:22:51] So this all sounds like a lot of work, right? Like having to shoot up things that were not meant to be shot up. Right.

Justin: [00:22:59] That’s  the priority,  Hell eating is not their priority, you know? It’s like the drug is number one. So doing whatever it takes to get there, to get to that place where you’re nodding out where you’re just completely disconnected, checked out. You know, heart and lungs, like barely working type territory. That’s the goal.

So it may seem like a lot of work to someone on the outside, it’s like a full-time job. It’s a ton of work, but someone who’s in it they’re just trying to survive. They need that more than they need air to breathe. Let’s say if you don’t Eat for a week or something like that.

Are you hungry? Do you have that gnawing, just like I need a hamburger. That’s what we’re talking about. This hunger for the drug. This need to chase it by whatever means necessary. Where it’s like you have blinders on. Every single other thing does not matter anymore because you need that and you need that to survive.

Betsy: [00:23:55] What happens to people’s veins over time? We know that people will shift where they’re shooting up. I wonder how long do you think it takes that you have to shift? Because the veins  are collapsing. 

Justin: [00:24:07] There’s a variety of factors that will contribute to how your veins are doing. We look at some of the prep work, so cleaning  your hands, cleaning the spot with alcohol, before you inject . Those are all things that are going to be more protective.

That are going to make it safer and less likely that you’re going to develop abscesses  or get bacteria  into your bloodstream or into that wound .  So people that are shooting up aren’t typically that healthy you know, overall they’re not hydrated and eating good,  sleep, everything that person needs to really have healthy veins.

I’ve had clients come in and tell me  they wanted to get high, so bad. And  they couldn’t find a vein, like no matter where the person tried they couldn’t find a vein. And this level of shame, like I’m so pathetic, I’m at the spot where I can’t even shoot up anymore.

So in regards to how long that’s going to be the main factor like how careful is the person being  using the same vein that’s easily accessible?  Eventually it’s going to blow out. It’s going to be something that you’re not going to use. So that’s where people start to get creative. They’re shooting up on their neck, they’re shooting up in between their toes.  wherever there’s a vein. So you name it That people can shoot up.

The needle size and the size of the vein are going to be factors that limit a person’s ability to be able to shoot up in that vein. But people are still going to try,

Betsy: [00:25:30] One of the things I know we both support are needle exchanges  or places that people can get clean needles. I know that that’s probably controversial in some areas. But one thing I know that our clients struggle with is finding clean needles. And so they’ll end up sharing. What is your experience in hearing people talk about that?

Justin: [00:25:54] I most certainly support needle exchanges. If a person’s in a scenario where there’s one needle there’s two people. They’re both withdrawing. The fear associated with getting hepatitis or HIV is not something that is really registering totally. It’s not on their priority list.

I’ve even read about safe injection sites.  They actually have a site where they can have people have access to clean needles. People have access to the equipment that they need to safely shoot up and they’re not providing them with the drug.

But there’s someone there  that can save them if need be. And here’s the crux,  you give them the supports they need.  Connecting them with food assistance, with housing, with just going to see the doctor  or maybe connecting them with a therapist .

 They’re sick. They have a disease. So putting them in a position where they’re in a safe place, able to use this and then get access to all these different services . That can be a game changer for them.

It kind of goes contrary to maybe how people would look at that. Well, why don’t we just you know make it hard to get the needles. They’re going to get it no matter what, so it’s really meeting them where they’re at and that can be the jumping off point. That can change a person’s life.

This idea of meeting people where they’re at and not criminalizing them for having a disease. 

Betsy: [00:27:14] At the heart of it is, is addiction a choice? I’ve talked about that in different episodes, I think that when we’re all using our behavior and addict’s behavior, it is so difficult to bear for people who aren’t using.

So much damage is being done, that they have to believe that somebody has blame. I usually try to explain, like, they’re responsible. Any appropriate recovery program is going to have you taking responsibility for your own shit, the stuff you did while you were using, like, we’re not asking people to let others off the hook, so to speak.

They did not choose addiction. They chose to use, which is something that humans have been choosing to do; to alter their state of consciousness since there have been humans.  They didn’t know that this was going to happen. You’re talking three months when you talked about your own experience, where the tolerance and the withdrawal developed, that’s frigging fast and you weren’t even using it every day.

It’s hard for people because they feel like it’s difficult to balance responsibility and disease concept. It’s just a difficult thing for people to get their brains around.  If it isn’t a choice, if it is a disease and we’re looking to arrest that somehow having a safe injection place makes sense, even though it’s pretty radical and I get that .

I made the argument a number of podcasts ago that we need both harm reduction and abstinence for a full recovery view. We need the harm reduction to keep people alive because if they’re breathing there’s hope and also that addiction is progressive. And so being able to use “normally” that’s off the table. That’s not going to happen anymore.

Justin: [00:28:57]  This whole choice argument can be really, really challenging for people to wrap their head around  .  It affects the area of our brain, where you’re making choices. . I was talking before about these different survival mechanisms,  it’s registered in your brain that this drug, this is something that I need to survive.  It’s at a more unconscious, subconscious level. It’s in the background, 

Betsy: [00:29:21]So  I want to ask about heroin because at some point people make the shift from pills to heroin and I don’t typically see them going backwards unless they can’t find heroin. I wonder if you can talk about what you’ve seen and why people would do that.

Justin: [00:29:43] Heroin happens to be much cheaper. For like a gram of it, maybe it’s something like 80 to a hundred dollars roughly.  So a gram goes a long way. That’s like 10 shots. Heroin is much more potent.

So if I’m needing 10 Oxy to get high and I’m spending like $400. Well if I can get high for just a fraction of that it’s a no brainer to use the heroin And it’s easier to get. It’s just much more accessible than pills with this opioid epidemic and doctors changing the way that they’re prescribing or they’re more cautious about it.

That there isn’t as much of the opioid painkillers on the street. So it’s just naturally led towards people using more heroin. And I feel like the stigma has changed too with heroin. It’s more common. I feel like there’s less stigma within the drug world 

Betsy: [00:30:33] I wonder if you can talk a little bit about heroin and the forms of it..

Justin: [00:30:40] Heroin  comes in a few different forms. You have black tar heroin. And then you have what I referred to as China White. So more of the powder form. So black tar heroin, it’s a little more messy.  You may need some of the acid to kind of break down.

I feel like that’s less common.  The China White is more common now and more commonly  it has fentanyl in it because fentanyl is well, it’s cheap. 

Betsy: [00:31:04] I know what we’re seeing in our area. I don’t know that we have batches of heroin without fentanyl. It’s just a matter of how much, I don’t know if you agree with that or not .

Justin: [00:31:13] Yes, I do definitely agree with that.  I’d say most of the heroin is cut with fentanyl. Some of it’s just straight fentanyl and I mean, we’re even finding fentanyl in methamphetamine. Cutting methamphetamine with it. So adding  this extra layer of addiction to it where people who are just strictly using methamphetamine are ended up in opiate withdrawal. And they’re like, what the heck? I’ve never even used fentanyl before. 

Number one, it’s cheap and it’s also going to lead to people  seeking it out more.  If they are sick, maybe not even realizing why they’re seeking it out. Kind of like an early addiction where a person doesn’t realize that their decision-making capacity  is starting to not work as good because they’re starting to be pulled towards that drug because of this physical side of it.

Betsy: [00:32:00] Speaking of things being cut with fentanyl,  I’ve talked a tiny bit about pressed pills, but it is something that we’re seeing a ton of. And I wonder if you can talk about what you’re seeing and,  how they’re made, what they look like, that kind of thing.

Justin: [00:32:17] These pressed pills are kind of terrifying because it’s very common for them to look like oxycodone where it looks exactly like it and would pass for oxycodone. But it’s not oxycodone.  It has fentanyl in it and really high levels of it. 

Where for people using just a sliver of that pill and it being super potent and even hearing about people who lost their life, who overdose thinking that they were taking oxycodone. It’s becoming more and more common. I noticed that especially with people that are younger. 

So if it’s someone  who maybe isn’t as savvy it hasn’t been around as long they could easily be more susceptible to accidentally overdosing on a pressed pill if you were to take a pressed fentanyl pill versus a five or 10 milligram oxycodone.

They’re night and day. One is going to be through the roof more powerful than the other. So, very risky, but much, much more common as time goes on. 

Betsy: [00:33:14] Just for the listeners, we’re talking about pills that they’re pressed into being that  these powders were pressed together in a pill form that look identical to the ones being produced by a factory.

Justin: [00:33:28] So it’s having a pill press that will mimic  the actual pharmaceutical version of it and this could be something where it’s maybe able to get under the radar easier. It’s mixed in with some filler and then just pressed and then stamped. So it has the same markings as oxycodone. 

 It’s definitely a risk that they’re willing to take.

Maybe even a false security, because it looks like a pill. Our culture we’re kind of designed to equate taking medication with wellness and safety. But in reality it’s super risky. Using fentanyl in general, even if it’s not pressed. When  we’re talking about fentanyl, you know, that’s micrograms.

Versus when I’m talking about Oxycontin, that’s milligrams.  There’s much more risk associated with it. When you’re cutting it and making it so it’s to be sold there’s a pretty big margin for error there.

It’s not easy to do and let’s face it. There isn’t quality control happening, 

Betsy: [00:34:23] I feel like people don’t understand the level of crazy that goes into being an addict or an alcoholic. I think people don’t understand why you would do such a thing. When it comes to opiates and heroin,  it’s  withdrawal. So I wonder if you could talk about what withdrawal is like, how long it lasts and why it’s so incredibly powerful that it is the reason that the opiate epidemic continues.

Justin: [00:34:54] Withdrawal is absolute hell.  And it is really challenging to explain and maybe put into words exactly what that is like. I’m going to do my best. I like to describe it as  your bones even hurt, your bones want to jump out of your body, the  air on your skin hurts.

Think about what it feels like to have the air on your skin, just to be super ultra mindful of what that’s like, that right there is the level of sensitivity  that we’re talking about with opiate withdrawal.

Your arms just resting against your skin is really painful.  Not being able to sit still.  Not being able to relax for one solitary second.  It’s almost like you’re slapped across the face with reality and this level of intensity of the world that is far, far too much to take in.

So experiencing emotions on a level that is, just terrifying, just super intense.  Like super awake all of a sudden, like your eyes are pried open, you’re so awake. With all of this,  it’s happening and you’re yawning all the time.

Your nose is running. Your stomach. You’re going to the bathroom all the time and just feeling super, super uncomfortable. We’re talking like a level of intensity that really drives a person to want to escape it at all costs.

I’m hesitant to bring up the flu because it’s so far beyond the flu. Maybe just like a little bit of a glimpse of just to think of the absolute worst flu symptoms you’ve had  and multiplied by a hundred thousand,

Betsy: [00:36:21] How long does withdrawal typically last? I know it can vary, but on average.

Justin: [00:36:29] I’m going to go back to personal experience. I remember being in  an inpatient program and missing tons of programming because super sick throwing up or kind of having a difficult time leaving bed for at least the first two weeks of it. Missing out a lot because of that. 

Let’s bring into the mix all of a sudden being more aware of you where you’re at in your life. And maybe some of the things that you’ve done while you were out using, all of a sudden being made aware, and realizing my family, what am I done? What have I been doing?  These people that I hurt. Starting to become more conscious of all the stuff that’s been happening around you as you were walking around in a haze for however long. All of that’s kind of comes full circle.

Without support and without kind of this sense of community from other people who have walked a similar path it’s challenging to navigate some of that stuff because you can feel really alienated really alone as a result of that. 

This withdrawal thing, there’s a lot to it. You know the physical side but the more mental side of things and a whole lotta reality, all of a sudden. 

Betsy: [00:37:38] Let’s say they’re a few weeks out and they’re starting to feel slightly more normal in their body. They’re not struggling with that every day. Then what happens that makes it difficult to stay clean.

Justin: [00:37:49] You look at like all of the behaviors that support addiction,  we’re talking about like switching up pretty much everything.  The way you’ve been living your life. And that’s not always easy or a simple process.  It’s challenging to navigate some of that stuff because there’s so many different factors that can pull a person back. 

The mindset of recovery  is really contrary to the way that the addict has been operating for an extended period of time.  It’s very, very different and foreign.  All of a sudden you are faced with a lot of the stuff that you were covering up for a really long time.  That’s really difficult to shift through without lots and lots of support. 

 Cravings are very challenging to navigate because there’s going to be all these different associations with the drug.  Your body and your brain is wired to go there.  There’s  this pull  that’s happening below the surface  within the limbic system, the amygdala.

Inevitably, there’s going to be a ton of wreckage that a person is experiencing after they get sober.  It’s going to be all around them, and it may be feeling like they’re in quicksand. Like the more they struggle, the more they sink. 

So that’s where  the support through it is really, really key.  Cravings are not necessarily  super linear either. That it’s not always really clear cut. What caused that and what kind of brought this up or what was going on there?

A person who is in early recovery, they’re not going to really be able to navigate or understand or kind of:  How okay, I’m feeling this way. And then that happened. Or I had this craving and then I, it led to this and processing through it.

Let’s bring up using dreams. Having dreams a bit where your brain is processing through a bunch of this.  Your brain is like, Hey, where’s this drug, you know, I’m used to this, what’s going on. We were good. Why are we off balance now? 

There are all of  these different things that add up that just make it really, really challenging to get sober, to get a person away from it. 

I want to extend my thank you to Justin for being willing to talk with me and share a part of his story, as well as his insight about how our clients are feeling and what things they’re involved in while they’re using .

Heroin and opiates are such a huge thing.  It’s a different world than it was years ago. Heroin was relegated to the dark city streets typically. The stigma around heroin in the using community has lowered. It’s not seen as any worse than a lot of other drugs. The trouble with it is that it’s so immediately lethal even if you’re trying to be careful.

Treating addiction to heroin and opiates is really complex. There are some really great options. Next week, I want to go through the different treatment options for heroin and opiates. It’s called medication assisted treatment. Of course you can have treatment without medication. However, our research shows us that the medications help tremendously in terms of prolonging and supporting sobriety. 

It can be a complex topic  with different medications that have different benefits and side effects. We’re going to break those down and talk about each one, as well as talking about Narcan which is described as being the antidote to opiate overdose. That’s going to be our topic for next week. I hope you’ll join me. Until then have a great week.

Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know.  Just send a message to podcast@betsybyler.com. I’ll see you on next week’s podcast. And until then have a great week.

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