PTSD and opioid addiction apparently go hand-in-hand.
This story begins on day three.
Day three is infamous in the addiction community. When it comes to withdrawal from heroin, day three is deemed the Very Worst Day.
"If you can get past day three," we like to tell ourselves, "you're in the clear."
By day three, I was a swamp creature: eyes roving and sunken from sleep deprivation, skin cold and slick with sickly sweat, pupils dilated, jaw set in a ceaseless grind, body slouched limply over my mattress—which was on the floor and fetid with the stench of withdrawal. My thoughts had begun to distort visually, in that way that accompanies several days without sleep, food, or heroin. Nothing quite made sense the way it had when I was still high and decided to quit.
Now, the only barrier between myself and my memories was the thin veil of fatigue that would be cast away once I got some sleep. Then, after the physical pain of withdrawal wore off, I would be left with the memories of being beaten and raped and controlled by an older man for four years. It was years since I had last been in contact with my abuser, but living with post-traumatic stress disorder is like being stuck in time. On heroin, time moved forward. Off heroin, I was seventeen and being beaten endlessly . It seemed to me then, as the agony of recovery grew nearer, that I was better off strung out.
I have lived day three more times than I can count. It was not the pain of days one, two, or three that caused me to relapse; it was the relief from withdrawal—relief I knew awaited me in days four, five, six, and beyond—and the looming reality of life without heroin to mask my trauma. It was not withdrawal, or even a fixation on a drug, that made my addiction so difficult to escape—it was having PTSD, and the relief from those symptoms that the drug brought me. This is a reality that continues to play out every day for thousands of people living with co-occurring PTSD and substance use disorders, which are closely connected.
I am one of about many of people with PTSD who has also experienced an addiction. Trauma is highly correlated with opioid addiction specifically, says John McCarthy, assistant professor of psychiatry at University of California with over 40 years experience with research and clinical work on opioid addiction.
"PTSD is an anxiety disorder," McCarthy explains, "so you get all this stress and anxiety and stuff and opiates calm it down." The concern, however, is that while a short-acting opioid like heroin might reduce some symptoms of trauma, it can also exacerbate others. "If you're in and out of withdrawal, any symptoms are going to be harder to manage or even diagnose."
This was my experience, again and again, while I was in the mire of addiction. I recall the painful clarity of life after detox; how everything I experienced felt as though it had a sharp edge that was cutting into me. I remember also how volatile I was when I was using, rising, and sinking from withdrawal to high, my memories and emotions in flux with my biochemistry. I yelled at everything. My anger became its own beast that lurked beside me like a shadow.
It was intoxicating—not just in the literal sense of opiate euphoria—but also because heroin allowed me to dissociate from everything and everyone but my own inner world. I became consumed by my own experience, which was overwhelmingly traumatic. My PTSD felt all-important. I could spend hours examining my abuse, distanced enough by the numbing effect of the heroin that it didn't feel painful or selfish to spend my time that way. There's not supposed to be a magic cure for post-traumatic stress disorder, but heroin sure felt like one—until I ran out.
Shilo Jama, the executive director of the People's Harm Reduction Alliance and an openly active drug user, agrees that re-experiencing trauma has always been the most difficult withdrawal symptom he's dealt with. "When I was on a big run and I detoxed and had the flu-like symptoms, the physical illness wasn't really that bad compared to the emotional hit," says Jama. "Actually having to realize I have to deal with all my shit, all the fights I got into, or all those feelings [I] have, I've found that's worse than the physical [symptoms]."
Bessel van der Kolk, medical director of the Trauma Center at the Justice Resource Institute and a professor of psychiatry at Boston University, has authored several books about the way human minds and bodies process trauma. His essential finding is that PTSD develops when a traumatic experience become trapped within the body. This physical experience of trauma creates a disconnect between a traumatized person and her body—basically, a divide between a person and her own self. He refers to it as a lack of self-ownership.
For this reason, he says, PTSD and substance use are very closely connected. "Trauma is not a story about the past, it’s about how the past continues to live on in your body; that’s the core issue," van der Kolk says, "When you’re in a constant state of heartbreak and gutwrench...that’s an unbearable thing, so you do stuff to make your feelings go away—like take drugs."
So how do we heal bodies that have both trauma trapped within them, and a compulsive addiction controlling them?
"At the core of trauma is helplessness," van der Kolk says. "[Systems of] reinforced helplessness, like prisons, would rob people even more of their agency so being able to take action is a very important part of recovery."
Unfortunately, while trauma-informed care is gaining some leverage in treatment communities, it’s the exact opposite of what I have experienced in a variety of facilities ranging from Seattle, Washington to South Florida. These centers—which other interviews and research lead me to believe typify the current addiction treatment standard in the United States—reinforce that same helplessness van der Kolk warns against.
In my early recovery, for example, I quit using heroin in earnest when I discovered I was pregnant. The first doctor I visited told me that if I wanted my baby to live, I had to take methadone, a drug I had vowed I would never use because of its negatively stigmatized reputation within the addiction community. It has been called “liquid handcuffs,” due to the stringent regulations and rumored difficulty detoxing.
When I watch my daughter—now four years old—play and grow, I am glad I agreed to take methadone maintenance, but I was repeatedly denied information or agency over my care decisions. I doubt it's a coincidence that during the first few months of recovery, I experienced the most difficult PTSD symptoms of my life.
When I ask van der Kolk how we should help all these people suffering from PTSD and addiction to opiates, he laughs, then says, "We don't know. We have a terrible track record in this country. Right now it's still based on getting in groups...and admonishing people, which we know doesn't work well."
Much of van der Kolk's theorizes that yoga can help restore physical and mental equilibrium after trauma. But yoga can also be triggering initially for the same reasons it is ultimately healing; an effective practice demands that a person focuses on feeling her body. That can be more than a little uneasy for people whose bodies were once crime scenes. Van der Kolk acknowledges that, adding that it’s very helpful to have a therapist willing to push trauma patients to continue through the painful beginnings of trauma recovery. "Having PTSD means that you keep running from yourself...There's no painless way to do it," he adds.
"Trauma is about your fight/flight response going crazy. Morphine blocks that fight/flight response, so your body gets quiet and you don’t get stuck in fight or flight," van der Kolk explains, but that is also exactly why opioids have such a high addiction potential for people with PTSD. "That's what the whole damn opiate crisis is about."
For me, a combination of daily buprenorphine/naloxone and weekly yoga has proven the single-most effective treatment, and the only one that has allowed me to remain in recovery for closing on five years.
"Being able to take action is the most important thing in the world," van der Kolk says. “Address your body first, address learning to feel the feelings that you have, no matter what.”
Lede image: Elizabeth Brico