#Medication For Opioid Use Disorder

[patriciafortunato]

I wrote about some personally meaningful topics here and here.

Thank you to wonderful colleagues and friends.

[sopranoentravesti]

Sorry to be a member of the intelligentsia on main, but I’m really not interested in hearing your takes on psychology or neuroscience when you get all your information from YouTube videos and refuse to read a book or a paper on whatever your chosen topic du jour is

[intheroomblog]

Medication-Assisted Treatment: Pros And Cons Of MAT For Recovery

Medication-Assisted Treatment (MAT) offers a balanced approach to Medication addiction recovery by combining medications with counseling. MAT can reduce withdrawal symptoms and cravings, helping patients stabilize their recovery journey. However, MAT may not suit everyone, as some fear reliance on medications or potential side effects. Understanding MAT’s advantages and challenges is essential for making an informed choice about addiction treatment.

[shrinksinsneakers]

I recently had an interesting discussion with one of our residents about the risk of developing schizophrenia after experiencing substance-induced psychosis. 

[allthecanadianpolitics]

A study conducted by the B.C. Centre for Disease Control has found that prescribing medical-grade opioids dramatically reduced the rates of deaths and overdoses for drug users living in B.C. The study, published in the British Medical Journal, is described as "the first known instance of a North American province or state providing clinical guidance to physicians and nurse practitioners for prescribing pharmaceutical alternatives to patients at risk of death from the toxic drug supply." Researchers looked at anonymized health-care data of 5,882 people between March 2020 and August 2021, all of whom had opioid or stimulant use disorder. Those individuals filled a prescription under the B.C. Risk Mitigation Guide — clinical guidance developed in March 2020 to allow for physical distancing during the COVID-19 pandemic, and to reduce deaths through harm reduction.

Continue Reading

Tagging @politicsofcanada

[macgyvermedical]

Reference Guide to Writing Drug Withdrawal

So your character has a substance use disorder (or physical dependence to a substance for another reason). This post will tell you how to write a scene (or story) in which they go through withdrawal.

NOTE: THIS POST DOES NOT INTEND TO COVER ANYTHING EXCEPT WITHDRAWAL, WHICH IS A VERY SMALL PART OF SUBSTANCE USE DISORDER AND PHYSICAL DEPENDENCE.

Substance Use Disorders and Physical Dependence:

Substance use disorders are chronic illnesses in which a person continues to use a substance (commonly nicotine, alcohol, cocaine, opioids like heroin or fentanyl, benzodiazepines, etc...) even when acquiring or using the substance can be dangerous or cause significant problems in their life (such as problems with money, safety, law enforcement, job security, child services involvement, or physical problems like wounds, infections, side effects, hangovers, and withdrawal). Substance use disorders are a common cause of physical dependence.

Physical dependence is also it's own problem and can occur for other reasons too. For example, many people take prescription medications that they would go through withdrawal from if stopped abruptly (say, because the pharmacy couldn't fill it in time and they ran out). Assuming that the medication is being taken as prescribed, physical dependence in itself does not mean someone has a substance use disorder.

So what is withdrawal? Withdrawal (sometimes called "detox") is the process by which a body stops being physically dependent on a substance. Generally speaking, it is unpleasant. This is because when a body is exposed to a substance repeatedly, it changes how it functions to accommodate that substance. When the substance is removed, there is a period of time where the body has to re-adjust to not having the substance.

For example, alcohol is very similar to the neurotransmitter (brain chemical) GABA. If you drink a lot of alcohol (more than about 4 drinks per day) for longer than about a month, the body decreases the amount of GABA it makes naturally to accommodate the "fake" GABA from the alcohol. If the alcohol is suddenly removed, the body doesn't have enough GABA, and the effects of not having enough GABA result in withdrawal symptoms.

The difference being, someone taking a medication they no longer want to take can slowly reduce the dose to minimize withdrawal symptoms. Someone with a substance use disorder usually finds cutting back nearly impossible. Because of this, managing physical dependence in someone with substance use disorder generally means giving them a similar substance which they get from a pharmacy and take continuously (methadone, buprenorphine), or a similar substance they can then taper off of in a controlled way (benzodiazepines, gabapentin).

Specific Withdrawal Syndromes:

Alcohol/Benzodiazepines:

These are the only two substances that result in a potentially life-threatening withdrawal syndrome, and it's essentially the same syndrome. As stated above, when taken for either 2 weeks for benzodiazepines or 4 weeks for alcohol, the body decreases the amount of GABA it produces naturally. GABA is the "brake pedal" in the brain, slowing things down and decreasing the amount of activity. If you don't have enough GABA, you get too much activity, which can result in severe anxiety, insomnia, seizures, hallucinations, high blood pressure, temperature, and pulse rate, heart arrhythmias, and confusion.

6-12 hours after a person's last drink, they will experience insomnia, anxiety, tremors, and headache.

12-24 hours after a person's last drink, if untreated with benzodiazepines or gabapentin, they may start to experience hallucinations (they typically know they are hallucinating at this point).

24-48 hours after a person's last drink, if untreated, they may start to experience seizures.

48-72 hours after a person's last drink, if untreated, they may start to experience a severe symptom known as delerium tremens. This is a state where they are hallucinating severely and they don't know they are hallucinating anymore. This is also a state where the person has heart rhythm problems that could result in death. This is the most dangerous period during withdrawal.

If a person makes it through 72 hours, they are usually in the clear as far as life threatening symptoms go, though they may experience mild symptoms like headaches and insomnia for long periods afterwards.

Note that medication for alcohol or benzodiazepine withdrawal like other benzodiazepines, phenobarbital, and gabapentin are given only for the first 5 days of withdrawal, tapering to lower doses each day. This gets the person through the dangerous part hopefully with no life threatening symptoms. It does not mean all symptoms are controlled, but they are hopefully kept on the milder end while the brain learns to make it's own GABA again.

Opioids:

Opioids include a range of drugs including prescription medications like oxycodone, hydromorphone, and morphine, as well as street drugs like heroin. Today, the street drug supply in many places is heavily adulterated. Many samples of heroin (and even "pressed pills" made to look like prescription opioids) contain the much stronger opioid fentanyl (which increases risk of overdose) and the sedative xylazine (which causes wounds) in addition to the expected heroin or oxycodone.

Opioids work by pretending to be endorphins- another neurotransmitter usually used by the body to reduce pain and stress. Similarly to GABA in alcohol use, the body reacts to having sustained high amounts of fake endorphins by decreasing the amount of endorphins it makes itself. This means, when the opioids are no longer present, the body can't make itself feel good or recover from pain.

There are many parts of the body that endorphins work in, including the brain, gut, nerves, and spine. When they are removed, symptoms include:

Nausea and vomiting.

Diarrhea.

Insomnia.

Anxiety.

Increased body temperature.

Racing heart.

Muscle and bone pain.

Sweating.

Chills.

High blood pressure.

There is not really a universal timeline for these symptoms like there is with alcohol. For someone who primarily uses short-acting opioids, withdrawal begins 8-24 hours after the last use (though anxiety and cravings can start much sooner). For people who primarily use long-acting opioids, withdrawal can take up to 36 hours to begin following the last use. Generally, symptoms peak within 1-3 days after they start, and acute symptoms last 10-14 days.

Unfortunately, someone who has an opioid use disorder will frequently experience cravings for very long periods of time (potentially the rest of their life) after they stop use. For this reason, people do significantly better at reducing or stopping use over the long haul if they are taking an opioid replacement drug like methadone or buprenorphine.

Methadone and buprenorphine are prescription medications that a person goes somewhere each day to get (methadone) or picks up each day from the pharmacy (buprenorphine). The drugs essentially make it so the person won't go into withdrawal and will have significantly fewer cravings for as long as they take the drug.

The management of opioid withdrawal is usually done by switching the person from a street drug to one of these opioid replacement drugs. However, it is important to note that methadone doesn't work immediately (usually it takes about 2-5 days of titrating it up to get it to a high enough dose to work, longer if the person has a very high tolerance). Buprenorphine requires a certain amount of time in withdrawal (usually a day or two) before it can be given, or it can make withdrawal worse instead of better (something called precipitated withdrawal).

Once someone is on one of these medications, they can choose to stay on them (recommended) or taper off (nice to be off meds in theory, but high rates of return-to-use).

Cocaine/Amphetamines:

Instead of pretending to be a neurotransmitter, stimulants like cocaine and amphetamines prevent the body from re-absorbing the neurotransmitter dopamine, leading to a whole bunch of it hanging out in the brain. This increases concentration and energy and boosts mood. However, taken over long periods of time, the brain kind of burns out and fails to respond to the high levels of dopamine.

You may have heard that amphetamines and cocaine don't have withdrawal states. That would be a myth. People who use stimulants repeatedly for long periods frequently have a withdrawal that is essentially the opposite of the effects of stimulants- they feel very tired, have trouble focusing, and feel depressed because their brains can't use dopamine the same way they did before the drug use. This may last for weeks after cessation of stimulants.

Unfortunately, unlike with alcohol and opioids, there's not a ton that can be done for this withdrawal. There have been several studies, including testing medications like the antidepressant mertazapine, the migraine medicine topiramate, as well as naltrexone and buproprion (also an antidepressant).

In Conclusion:

There is so much more to drug use, substance use disorder, and physical dependence than I am covering in this post. I am just covering a small part of physical dependence, however the cause, by discussing the effects and common treatments for withdrawal.

Thank you all for reading this far! I hope you learned something and will use it in your writing!

[writers-potion]

i was wondering if you could give some points and tips on writing about a character who is suffering from DRUG ABUSE

Writing A Drug Addict Character

Know Your Drugs

Was the drug invented? A scene using insulin set in 1820 is problematic since this treatment wasn’t discovered until the 1900s. Fentanyl shouldn’t be used in a 1930s scene since it wasn’t available for use until the 1960s—opium or morphine would be more accurate choices.

Was the method invented? Since insulin must be given as a shot, that scene is even less authentic as the hypodermic needle wasn’t invented until the mid-1800s. Older historical fiction could involve the use of poultices and mustard packs, while skin drug patches (transdermal patches) are only appropriate in more modern scenes.

The most common drugs abused by gangs are: Marijuana, Methamphetamine, Heroin, Cocaine

Or, it can be prescription drugs

Although many medications can be abused, the following three classes are most commonly abused:

Opioids—usually prescribed to treat pain;

Central nervous system (CNS) depressants—used to treat anxiety and sleep disorders; and

Stimulants—most often prescribed to treat attention deficit hyperactivity disorder (ADHD). (common example? caffeine)

Write In Stages

Stage 1: First Use

Some people use a substance for the first time out of curiosity, while others use substances due to peer pressure. People may also be prescribed medication, such as opioids, by their doctor. Individuals may view their first use as a one-time occurrence, but this opens the door for future use. Some people try a substance one time and never use it again. 

You character will feel:

Angry and/or desperate

Miserable

Lonely

Trying to run away from a certain problem

Persuaded into doing drug

Guilty

Stage 2: Regular Use

If a person uses a substance and enjoys how it makes them feel or believes it will improve their life, they may start to use the substance regularly. They may use drugs or drink alcohol on the weekends while at parties or hanging out with friends. Occasional use may become a regular occurrence. It might become a part of a person’s routine.

Your character:

Will start getting in careless activities while doing drugs

Will probably be violent

Won’t think he has any issue whatsoever and shrug it off

Start associating themselves with harder drug users

Have a false sense of security that they’re able to quit whenever they want.

Stage 3: Risky Use

The next stage after regular use is risky use. A person will continue to use a substance despite the physical, mental, legal or social consequences. Their use likely started as a way to escape or have fun with peers but has now taken priority over other aspects of their life.

Your Character will feel:

uncomfortable around family members/friends who start to notice

Exhibit more reckless behavior

Driving under influence, stealing money to finance substance use, etc.

Underperforming at work or school

Experience tension in personal relationships

Stage 4: Dependence

The next stage is a physical, mental and emotional reliance on the substance. The individual is no longer using the substance for medical or recreational purposes. When a person doesn’t use the substance, their body will exhibit withdrawal symptoms, such as tremors, headaches, nausea, anxiety and muscle cramps.

Your Chracter Will:

Develop a sort of rountine/typical place where they abuse

Believe that the substance is essential for survival

Use substance even when it's unnecessary

Stage 5: Substance Use Disorder

While some people use dependency and substance use disorder interchangeably, they’re very different. Once a person develops a substance use disorder, substance misuse becomes a compulsion rather than a conscious choice. They’ll also experience severe physical and mental side effects, depending on the substance they’re using.

Your Character:

Has noe developed a chronic disease with the risk of relapse

Is now incapable of quitting on their own

Feel like life is impossible to deal with without the substance.

Lose their job, fail out of school, become isolated from friends and family or give up their passions or hobbies.

Research the Trends

Medical knowledge changes over time and with it the drugs prescribed. This then impacts the type of prescription drugs available on the streets.

late 1800s: chloral hydrate used for anxiety and insomnia > bromides > 1920s: barbiturates, barbital > benzodiazepines ("benzos") > early 2000s: opiod drugs > opiod drug bans led to growth of black markets: ilicit fentanyl > and so on...

Different countries/locations will have varying trends of drug abuse (depending on laws, availability, costs, etc.)

Research the Slag

look for "[drug name] trip report" on YouTube, etc. to get first-hand accounts of how drug addicts behave.

The main focus should always be to use the words your characters would use in ways that suit the world you have created.

The slang for certain drugs is a difficult vocabulary to maintain as it is ever-changing and varies based on country, region, town, even by streets. Some writers use what they know or have heard locally, others invent their own.

Resources

FDA (Food and Drug Administration) and DEA online databases and drug resources

Social networking groups focusing on related specialty writing topics, such as trauma or emergency medicine

Newspaper articles and medical journals are great places to find real cases.

The US national poison center 

Helpful Vocab:

Addled - sense of confusion + complete lack of mental awareness

Crazed - emotional anguish experienced by the addict

Desperate

Despondent

Erratic

Fidgety

Hopeless

Impressionable

Struggling

[transmutationisms]

I was reading your porn addiction post, and I just wondering what you consider addiction if not some sort of disease? I also think porn addiction and stuff in that vein is fake but I also can’t think that addiction is just people choosing to be that way even though they hate it. I say this as someone who was actually addicted to substances like I feel like there was something going on there that can’t be explained by the idea that addicts just choose to be like that. (I don’t think you think addicts just choose to be like that I just don’t really know any alternative schools of thought lol) I don’t mean this in an accusatory way I’m sorry if it comes off that way, I am genuinely curious what you think cause your posts are always so enlightening.

first of all you have to keep in mind that 'addiction' has no singular meaning. even if we confine ourselves to talking about psychoactive substances, 'addiction' can range from the 'classic' case of increasing, compulsive, self-destructive use, to cases where a person's usage may actually be stable in the long term but they're chemically dependent on the substance (think: the way doctors talk about chronic pain patients who are dependent on opioid painkillers; then compare to how they talk about psychiatric patients who are dependent on SSRIs. for example). you can get dx'd with a 'substance use disorder' purely on the basis of how much you take/consume, even if you don't feel it's causing impairment in your life, particularly if you let slip that someone else in your life has expressed concern or tried to stop you. race and class contribute to distinctions here as well, where certain people have leeway to be seen (even in a psychiatric setting!) as 'experimenting' with substances, or using them 'recreationally', where the same usage pattern in a person who's otherwise marginalised might be flagged as 'addictive' and in need of intervention. all of this gets even messier when psychiatrists and physicians try to justify applying discourses of 'addiction' to eating, gambling, sex, social media, and so forth. recall that 'addiction' in the roman republic and middle ages had contested legal and augural meanings that could be positive as well as negative, and that by the seventeenth century it was largely used as a reflexive verb with a predominantly positive meaning—as in, "we sincerely addict ourselves to almighty god" (thomas fuller, 1655) or, of plato, "he addicted himself to the discipline of pythagoras" (thomas hearne, 1698). it was not until the twentieth century that "addict" came to be widely used as a noun defining people who were passively suffering on a medical model.

i don't mean to be evasive here but to point out that asking "how do we define addiction besides a disease model?" presumes already that the disease model is the singular and inescapable way of understanding addiction in the first place—this is not true historically or presently. addiction is a muddled concept and has always involved moral discourses; attempts to present it as a 'pure' or 'objective' medico-scientific judgment are in fact recent and still unstable.

to the extent that it is useful to talk about addiction as a disease—that is, as a state of suffering that is imposed upon the sufferer, that is a disruption of a desired state of health and well-being—i think it is critical to keep in mind that such a disease is social as much as biological. you can start here by pointing out that substance use is often precipitated by the necessity of withstanding miserable life conditions (ranging from extreme poverty, domestic abuse, social marginalisation, &c, to the 'standard', inherently alienating and miserable conditions anyone endures in capitalist society). but there are other social factors that contribute to the presentation of substance use as compulsive, escalating, and self-endangering. eg, lack of a safe, steady supply is a huge factor here! when people are forced to rely on inconsistent, unregulated supplies to get high, this contributes greatly to drug 'binge' behaviours and endangers users. there is also the fact that drug users are often already marginalised (esp along lines of race, class, ability, &c) and are then further marginalised on the basis of being drug users. what would substance use look like in a society where using didn't relegate people to the social margins, or render them socially disposable? what if people had social supports, and weren't forced to toil away their entire lives at jobs that make them miserable for pay that's barely enough to live on? what sorts of patterns of substance use would we see then? so then, is it the drugs themselves that are the problem here, purely neurobiologically? or is there a larger story to tell about how people come to exist in such a state where substance use is increasingly hard for them to engage in with safeguards; where being a substance user causes them to lose whatever degree of social connection and support they may have had, which was often insufficient already; where they are often unable to integrate substance use into a full and connected life because they are told they must either give up enjoyment of a substance entirely, or be continually branded 'relapsing', 'non-compliant', 'dangerous', &c &c.....?

at the end of the day i don't think it's helpful or accurate to talk about addiction as a disease because it decontextualises drug use from all of these factors: why people do it, why it becomes harmful for some, why it's assumed we must simply 'stop' and 'resist' in order to 'get better'. disease explanations blame the substances themselves on a reductive bio-mechanical level (& again, this becomes especially untenable philosophically when we think at all about 'behavioural addictions'). the point here isn't to say that addicts are just blithely waltzing into addiction—or, indeed, to say that drug use is intrinsically a bad thing that should be avoided! it's a pretty typical feature of human existence that many of us enjoy consuming substances that alter our mental and physical states, and that's not inherently bad. when i push back against a disease model of addiction, i'm not invoking a model of personal responsibility or individual choice. i'm asking how we can understand drug use within a much broader social and historically contextualised frame, and how that can help people who are in many different states wrt drugs, from 'currently engaging in patterns of usage that feel compulsive and terrible' to 'never done a drug in their life'.

[genderqueerdykes]

I'm so glad to hear your surgery went well, lots of good luck for your recovery <333 i'm chronically ill myself and went through the whole being treated like trash by the ER staff song-and-dance too while looking for a diagnosis (i was also on the verge of death), so i was really scared for you when i saw you liveblogging your experience. But again, really happy that everything went well for you in the end ! :)

hello there! thanks for sending such a kind message!

i'm sorry you've been through it too. i totally understand that working in an ER is a horrific job. i know that the nurses and staff have to put up with an insane amount of stress, even from patients who are "well behaved". i understand that there are many people who come into the ER who expect to be treated right away, treated like they're special, or handed all the best medications right away

i saw many people in there who would literally get pissed off when the nurses would bring them tylenol, aspirin or ibuprofen instead of opioids. i watched an older woman literally start SCOWLING and her tone turned completely bitter and hateful once the nurse brought her some aspirin for her pain. a man sitting next to me started grumbling angrily because he overheard the nurse bringing me oxycodone and got pissed off that he wasn't getting any. it bothered me that so many people in there were clearly just trying to get handed opioids despite not being in a lot of pain. i get that there were a lot of people in here who were upset because they weren't getting high and i get how that could be upsetting to the nurses.

i wasn't getting high- i was in way too much pain and in hysterics. i wasn't having fun. it really upset me to overhear that people near me thought i was having a "good time" or having fun or just there to get high off of pills. like it made me really uncomfortable to hear that people around me were literally getting jealous over me being given oxy for an ungodly amount of pain. i get that many people can be rude and expect special treatment, i'm never going to sit here and say that being an ER staff member is easy by any stretch of the imagination. i DO understand that drug seeking people do exist, and i witnessed a lot of them in that ER, but it doesn't mean that you should treat the drug seeker, or anyone else like shit. drug seeking can still be a sign of a greater problem and people who engage in this type of behavior deserve to be talked to like people instead of treated like absolute shit. even if the behavior was affecting me, personally, i still don't think someone who goes to the ER specifically to seek drugs should be treated in a subhuman manner

but when i told the surgical staff about how i was being treated, they were utterly appalled. one of the nurses told me that she understands that compassion fatigue is a thing, and that burnout happens, but too many ER nurses resort to become so cold and bitter than they're just mean to their patients because they view them as a nuisance, and start viewing everyone as whiny drug seekers or people who are faking for attention. it's not good, i feel like when one gets to that point it's a good idea to switch jobs. being burnt out isn't a sign that you're weak or have bad character, it just means that you're overwhelmed

it really bothers me that ER staff tend to want to look down on patients who are there and assume that they're seeking attention. my best friend told me one of her friends got told it was "faking a stroke" because borderline personality disorders "make us do funny little things for attention." how the hell do you even fake a stroke? you can't fake the entire left side of your body drooping and failing to function

overall i'm sorry that you have received that treatment as well, there's no reason for you to get ignored or treated like garbage for being sick. i didn't want to worry anyone but i wanted to liveblog my experience to show how difficult it can be to be chronically ill, especially in America, and how people do not take health problems seriously-- even certain medical professionals

the fact that a nurse decided to get pissed off at me and berate me for becoming hysterical from pain was just out of this world. i told her that i wasn't sure how much longer i could wait because the ER waiting room was freezing cold and loud as hell (eveveryone either had several people there with them to talk to, were on the phone/facetime or were blasting music or videos from their phones), and that sitting upright in the chairs was making the pressure and pain in my abdomen worse... she decided to snap at me instead of offering even a modicum of comfort

she scoffed and went "well if you leave, and your symptoms come back, WHICH THEY WILL, you're going to have to come right back here and start all over again. we can't make special exceptions just for you, you wouldn't keep your place in line, you'd have to start all over again and wait all over again. you're an adult, you can make your own decisions, but it's just going to be the same thing all over again if you leave."

she could've went "hey, i get it, it's really stressful in here. surgery is busy and we're going to get you in there as soon as we can, it's just very busy right now." or something like that or at least checked to see if i was due for pain medication, but instead she just got mad at me for "whining". i told a member of the surgical staff team about this and her response was "they're completely discompassionate down there- there's no compassion whatsoever, they just don't... care." as much as it was shocking to hear her say that, it was validating, because it was true

i hope you don't have to deal with that again the next time you need help, i hate it when chronically ill people get branded as annoying, drug seekers, fakers, etc. because that's literally what chronic illness is. just because our situations are complicated doesn't mean people should throw their hands up in the air and give up and consider you a burden. you shouldn't have to go through that in the first place

thanks for your kind message i appreciate it! best of luck in your future care as well, it's not right for anyone who's sick to be turned away or treated like garbage. the focus should be on the patient's care, not the ER nurse's feelings or assumptions about that person. yes medical professionals are human and deserve to have their emotions respected, but they should never supersede the safety and well being of someone who is sick, whether or not they're on death's doorstep or not. take care of yourself, thanks for stopping by!

[myosotisa]

Like Real People Do - e.m.

Part 1/2 - Why were you digging?

ǁ  summary: 30 days into your stay at the Betty Ford Center for Rehabilitation, Eddie Munson gets brought in against his will. While in the middle of trying to figure out your own issues, you find yourself being followed around by a detoxing rockstar who won't take a hint and get lost.

ǁ  tags: angst, hurt/comfort, heavy themes. depictions of inpatient rehab in the 90s. implied fem!Reader, no pronouns used, no y/n. strangers to reluctant acquaintances to lovers.

ǁ  content warning: both parts will contain mentions of drug use, struggling with addiction, self worth, society's view on drug users, grief, and death by drug overdose. brief mention of domestic violence and drug assisted disordered eating. please consume thoughtfully and if you have any questions before reading, feel free to message me.

ǁ  word count: 7k

ǁ  Part 2 ǁ  Read on AO3 ǁ

The lock on your door clunks open at exactly 8am every morning. A glaring alarm that your new day is about to start whether you want it to or not.

At 8:15, one of the workers on staff is barely knocking before pushing in to make sure you and your roommate will be ready for breakfast at 8:30 sharp.

At 8:30, you’re standing in line with everyone else to get your morning meds. Amoxaphine for depression. Atenolol for high blood pressure. Methadone for opioid withdrawal. Acamprosate for alcohol withdrawal.

A little paper cup of water to wash them all down, your mouth presented to prove you did actually swallow them, and then a verbal pat on the back before sending you over to the breakfast line.

A styrofoam plate of scrambled eggs and toast with jam on a plastic tray, balanced carefully with a cup of whatever juice they decided to buy this week. Carefully set down on one of the small tables by the window where you’ll sit and eat alone – appreciating the quiet and serenity for the few moments a day you get it before you’re shoved off to the next task.

The same thing for the past 28 days since you were deposited in the Betty Ford Center. You’d gone from euphoric, cold, and totally out of it to anxious, shaky, unable to sleep, and just fucking miserable. And while some days were getting easier and others seemed more difficult than ever, at least you had gotten into the routine of inpatient rehab. At least you knew to expect the same thing everyday. At least you were prepared to deal with what the external world threw at you.

Until you weren’t.

The moment the doors to the main hall are thrown open – impacting the opposing walls with a slam –  you get an overwhelming feeling that something is about to change. Something big.

“Hey fucker! Hey! Get your meat hands off me, lughead.”

Most of the heads in the room turn toward the source of the yelling, a parade of 5 coming through the double doors. Two you know, the medical director Mr. Ford and one of the doctors Dr. Lincoln. They both look annoyed and uncomfortable as they walk ahead of a set of 3 men. 

Flanked on either side by a buff orderly, getting borderline dragged across the floor, is a man you’ve never seen. His long, messy waves whip wildly around his head as he lets out expletives and pulls against the sharp hold on his biceps. His voice is ragged and slurred as he makes nonsensical arguments towards the two men leading him away. He’s in regular clothes – outside clothes – with torn jeans and metal chains hanging off his hips, ripped sleeves showing off his tattooed arms, and large rings on every finger.

Someone new?

Having gotten their eyeful, half the room goes back to pushing around their breakfasts with plastic cutlery while the other half continues to watch with amusement. A new person only comes through every 15 days or so, and this was only the second since you’d arrived. The first one, a meek boy named Thomas, had been admitted so quietly that he all of the sudden appeared one day in group, already through the worst of the detox, before you had ever even heard of him.

It makes you wonder if more inpatient admissions are like that or like this.

You wish you could remember yours.

In a whirl of movement, the man rips his arms free and flies backwards with a stumble. Had he been more coordinated, and probably more sober, than he is, he might have made a decent break for it. As he is, he’s barely able to turn toward the doors they came through before the men are grabbing him again from behind, hooking their arms around his to now actually drag him down the hallway toward the hospital wing.

The heels of his black boots drag against the beige tile floor as he slumps in their grip, eyelids fluttering slightly before he manages to bring back enough energy to yell another, “Fuck you!” at his captors.

Just before they disappear behind another set of locked down double doors, the two of you make eye contact. From this distance, you can still see how bloodshot his eyes are – deep brown ringed by red toned white. They are steadily falling closed with each blink as he most likely loses the fight against some kind of sedative. But somehow, with what must be the last moments of consciousness he has left, he sees you watching him. The corner of his mouth tilts up in a lazy smirk. And he winks.

The motherfucker winks at you right as his head lulls to the side before falling forward and the group of 5 disappears.

Something new indeed.

You don’t see the stranger again until 6 days later.

New admissions normally spend anywhere from 3 days to a week and a half in the hospital wing after arriving. IV fluids, heavy meds, and a more prepared medical staff to deal with the worst of the detox period. Depending on what you were on, how recently you took it compared to when you arrived, and the length of your addiction makes a huge difference in how much time you spend there before being sent back to the rest of the floor.

4 days is average, which is the amount of time you spent in the hospital wing before being put into room 102 with Melissa Redding. Teen beauty queen of the Betty Ford Center who got hooked on meth after a consultant for the pageant used it to help her lose weight.

The center had a neat little tradition of having your roommate show you around on the first day. For you, that had meant busy bee Melissa whispering in your ear in and outs of who was who and all of the drama entailed even though you didn’t care in the slightest. That continued through the rest of the day as she showed you around the main hall, gave you a tour of the garden during your mandated 1 hour of outside time, and into the Therapy House.

While she had initially been excited to have a roommate, she very quickly learned you would not be the entertainment she wanted. So she went back to gossiping with Kathy the housewife, who was in for a bad habit of using too much Adderall to get through the day with her kids. Leaving you to your own devices.

It was better that way.

You’re already in your seat by the window with breakfast by the time the stranger stumbles in after Howard, the gruff old man whose family sent him here for drinking too much (drinks the same amount as any other man his age, but who are you to judge?). He gets right into the med line, now half diminished due to their late arrival, and doesn’t seem to pay any attention to the stranger as he wanders away.

Guess he decided that wasn’t his job.

Tall, dark, and lanky looks like he’s been through the ringer. Skin pallor and clammy, hair pulled into a bird’s nest of a bun on the back of his head with the top and bangs matted flat with what you assume is sweat, hands fussing in front of him like if he doesn’t move as many muscles as possible at once he’ll explode. There are deep purple bags under his wide eyes as he approaches one of the other windows in the space, 30 feet away from where you’re sitting. 

He looks over the frame like he’s trying to find a way out, coming back with nothing before heading to the next window, closer to you. His appearance and behavior make you think of a wet rat trying to claw its way up the side of a bathtub – unable to grip onto anything and getting sent back down into the water again every time he tries to climb.

Hoping not to catch his attention, you direct your gaze down, focusing back on your under salted eggs and grape jam. Between the lack of seasoning and the juice of the week being some kind of weird pineapple mix, you’re left wanting even more so than usual over your bare bones breakfast.

Despite your half assed attempt to be invisible, the single chair across from you at your table is pulled out, flipped around, and then settled into by the stranger. In your shock, you look up at him before you can second guess the reaction.

“I saw you, I remember,” his voice is deeper than you thought, raspy at the edges with exhaustion and hardship. His gaze flicks rapidly from the table, your food, your face, the rest of the room, his hands. Everywhere at once it seems. “The day they brought me in.”

“Yup,” you confirm with an awkward nod of acknowledgement before looking back at your food.

Please leave, please leave, please leave.

“I’m Eddie. Eddie Munson.”

Looking back up at him, he has a bit more life in his face. Something that looks a little bit like hope.

“Okay.”

His face falls.

“You… Doesn’t ring any bells? Eddie Munson, guitarist, Corroded Coffin, biggest rock-metal band of the 90s?” The longer he goes, his wet eyes widen, making him look like a pleading animal looking for food scraps. When you show absolutely no recognition for anything he’s saying, he brings his hands together, fingers moving to twist at rings that no longer sit there. When he doesn’t find them, his leg starts to bounce under the table and his palms start tapping on the top of the chair at his chest.

“If you’re looking for celebrity worship, I’m sure Melissa or Kathy would be happy to provide.” You inform him, hoping he will lose interest and go searching for them to give him the attention he seems to be looking for. You go back to spreading jam on your slightly burnt toast.

He doesn’t take the bait. “How, uh, how long have you been here?”

Taking a long inhale through your nose and out through your mouth, you set your plastic knife back down. “A month.”

His hisses out air through his teeth, eyes searching over the rest of the room, like he’s waiting for something bad to happen. “How long do people normally stay locked up in here?”

Ah. 

“I dunno. A couple months? I’m not exactly some kind of authority here. You should go ask–”

“Has anyone ever broken out?”

Though you’re not sure why you’re surprised, you still struggle with the question. He makes eye contact with you again and the look in his eye is different now. Smaller.

He’s scared.

“I don’t know. I don’t think so.”

He scoffs, using his hand at his chin to crack his neck in either direction, looking unsatisfied with your answer. “Come on, like nobody has ever tried to get out? You’ve never tried?”

A weight presses down on your chest. “No, I haven’t.”

“Yeah right, I’m sure that there’s some–”

“Mr. Munson!”

An orderly stalks toward the table, looking crabby and annoyed this early in the day. Eddie looks about ready to bolt after their bark but somehow remains seated until they arrive. “I’m sure Howard didn’t inform you, but first thing in the morning you’re supposed to come up to the nurse window to receive your medication.” They present their arm back to where the now empty med line stands, everyone else settled into seats with their breakfasts. “After you’ve taken your medication, you can grab some breakfast and…” They make eye contact with you that you’re quick to avoid. “Converse with whoever you want.”

“See, your mistake was that I don’t need any medication, so I don’t need to wait in line.” His voice is slowly raising in volume, drawing more and more attention as he goes. “In fact, I’m not even supposed to be here!”

“Mr. Munson, please lower your voice, you’ll disturb the other residents.”

“Fuck the other residents,” he slams his palms down on your table, almost knocking off your plastic cup of juice when it rocks and you jolt back from the show of aggression. All eyes in the room are on him now, and by extension, you. Other residents, other orderlies, nurses, the kitchen staff.

Too many eyes.

While the attention makes you want to crawl into a hole and die, it seems to please Eddie. He pushes up off of his chair and makes a show of arguing with the annoyed orderly all the way over to the nurse’s station. All eyes in the room follow him and his suddenly animated features, looking like he has gained 10x more energy than when he walked in. You use the distraction to your advantage.

By the time Eddie has had medication forced down his throat, a plate of shitty eggs deposited in his hands, and he turns around to look at your table again, you’re nowhere to be found.

He finds you again in the garden before group therapy.

You’re tucked away in a painted white, wrought iron chair that’s bolted to the ground next to a tall shrub. It’s still in the gated off outdoor area, but mostly hidden from view. The orderlies know to find you there if they need you because that’s where you always are – sitting on that single chair in the sunshine with a paperback book on your lap. Today it’s Good Omens: The Nice and Accurate Prophecies of Agnes Nutter, Witch.

When a body blocks the sun over your book, your first assumption is that it’s an orderly coming to tell you it’s time to head to Therapy House. But it seems too early for that, and you’re normally a pretty good judge of time (at least, in here), so when an unfamiliar voice clears its throat in front of you, you huff a breath before you raise your head to acknowledge him.

“Is that seat taken?” He asks with a grin, motioning to the empty table bolted to the ground beside your chair. It’s obviously a rhetorical question – maybe to get you to smile or laugh. You do neither and give him a flat look.

“Actually, I’m saving it for someone.”

This seems to delight him even more, eyebrows raising and eyes getting some more life in them as he takes a seat on the table anyway. “Well I’ll keep it nice and warm for them until they show up.” He pulls his facility-issued navy sweatpants covered legs up to cross under him, effectively draping his knee over your arm.

Accepting your fate to not get rid of him, you open your book again to where you left off. 

“Best not to speculate, really,” said Aziraphale. “You can’t second-guess ineffability, I always say. There’s Right, and there’s Wrong. If you do Wrong when you’re told to do Right, you deserve to be punished.”

“I checked the perimeter of the garden,” his voice is lowered, as if someone would overhear him, “looking for weak spots.”

You hum an acknowledgement, keeping your eyes on your book as you reply in a sarcastic monotone, “Because that’s definitely not suspicious.”

He waves you off out of the corner of your eye, beginning a light tap of his hands against his knees. Even with the medication. He either needs a higher dose or he’s hyperactive at baseline. “They probably just thought I was giving myself a little tour or something, I don’t know. I don’t really care if it’s suspicious, actually. All I know is there’s like… Nothing. At all.”

“Shocker.”

Continuing to ignore your lackluster responses, a bopping of his head joins the beat of his palms. You attempt to reread the same paragraph over and over to try and comprehend it through his talking and fidgeting, failing time after time. “Not even like a locked gate or anything. And the fence itself is too high to get over with no footholds, unless you got something to stand on to grab the top and pull yourself over. Yeah…” 

“Oh!” The sudden volume of his voice makes you jerk away from him again, not expecting the sharp change. “What about your chair, is it loose?” One long fingered hand grips the backrest between your shoulder blades and the other the chair arm closest to him, attempting to give it a shake. “Maybe we could get the bolts out and use it to climb the fence.” He only succeeds in making an annoying rattling sound and jostling you back and forth.

“Fuck, Eddie, will you –” Using the paper cover of your book, you smack at his forearm a few times, causing him to quickly withdraw and hold his hands up in front of his chest like he’s worried your attack will continue. “Fucking, stop it.”

“Geez, sorry,” he mutters, looking slightly sheepish but still not exactly apologetic. “What’s your name, by the way? I forgot to ask.”

“Seems a little too late to ask now, don’t you think?” You turn the page of your book to make it look like you’re making progress despite the fact that you haven’t been able to finish a sentence since Eddie sat down beside you. Anything to help you look less interested in his attempted escape and, therefore, him.

An amused snort leaves his nose, tapping hands turning to a hold on his knees to let him lean back without falling off the table. “Well you are just a ray of sunshine,” he snarks back, looking more amused than annoyed. “Anyone ever told you that before?”

Finally lifting your head to give him a placating and overly artificial smile, you meet his eyes to make sure he can see your insincerity when you say, “Only every day.”

And while he opens his mouth to probably throw back another sarcastic retort, he’s interrupted by the “relaxing” (read: fucking annoying) gong by the Therapy House going off, signaling it’s time to head inside. You snap your book shut and push off your chair without a word to join the rest of the group outside in the unenthusiastic shuffle toward the birch wood doors. Another set of slip-on shoes, a matching pair to yours, sidles up beside where your own drag through the dirt path.

“So what happens now?” He asks, leaning a little bit closer to you as he speaks again, like the two of you are conspiring together on something. Based on your interactions so far, maybe he thinks you are.

“Therapy,” is your sharp reply. And, as if finally understanding he probably isn’t going to get much more information, he shuts up and just walks beside you toward the two story building off of the main facility.

All 12 of you wander through the doors in your similar outfits – sweatpants, t-shirts, and hoodies in shades of blue, grey, and black. Crossing from dirt and stone pathways onto the pristine wood floors of the Therapy House that’s awash with sunlight. As many windows as possible in all directions and a huge circular skylight above leaves the whole room bright and airy.

There are 13 metal folding chairs set up in a circle beneath the skylight, 1 more than yesterday, and the one directly across from the door is already occupied.

Mrs. Penelope Windsor is the head of therapy at the Betty Ford Center for Rehabilitation and wears that title with the utmost pride. She’s put together, ambitious, intelligent, and damn good at her job. Not to mention attractive, with her long legs crossed under her black pencil skirt, her crimson red button up blouse showing just enough collarbone to still be ‘professional’, and the long brunette braid draped over her shoulder. Her black heels are patent leather and perfectly shiny along with the matching briefcase sitting beside her chair. She stands out sharply from the white walls and birch wood floors of the Therapy House – but she commands your attention that way. A focal point in a room of white and tan and beige nothingness.

And the moment you walk through the doors with Eddie beside you, you feel her hazel eyes on you like a fucking hawk.

You avoid making eye contact, as per usual, and settle into the seat you’ve been using since the first day you came here. To your displeasure, Eddie immediately grabs the seat to your right, flipping it around to sit backwards in it, folding his arms over the back with a certain lazy confidence.

Tony, who normally sits there, hovers uncomfortably for a moment behind before scuttling over to the only remaining chair between Mrs. Windsor and Melissa.

As soon as he’s seated, heavy and tense silence settles over the room while the rest of you wait for Penelope to greet the group. You could hear a pin drop in the room in these moments, everyone shifting uncomfortably in the quiet as she takes a few moments to look over the group before her.

Almost like she enjoys making us all squirm under her authority.

Her sharp eyes settle on Eddie, her face as passive as always. He does very little to react to her stare but takes it as a sort of challenge – staring right back where most would shy away. The corner of her mouth lifts almost imperceptibly, like she appreciates the challenge.

The silent standoff is broken as Thomas’ wooden cane clatters to the floor beside his chair from where it had been leaning. He immediately turns bright red from the collar of his black t-shirt all the way to the tips of his ears. “Shit – Wait, oh, shoot, sorry!” Scooping it up in shaky hands, he is quick to tuck it between his knees, white knuckle fisting the handle in his embarrassment.

“That’s quite alright, Thomas,” is Penelope’s serene reply, a gentle smile directed his way before she addresses the group. “Good afternoon, everyone. Welcome back to our group session for today.”

No one says a word as she takes another uncomfortable moment to scan the group before doubling back to land on Eddie. “I see we have a new member of our group today. My name is Mrs. Windsor and I’m the head therapist here at the Betty Ford Center, but you’re more than welcome to call me Penelope. Could you introduce yourself for us, please?”

“Eddie Munson, guitarist, Corroded Coffin.” He answers cooly, and you watch his eyes do a quick scan to see if anyone shows any recognition. When there are a few reactions, his smile grows into one of satisfaction before he returns his gaze to Penelope. “Am I supposed to say what they locked me up for now or somethin’?” It comes out in a teasing lit, like he is trying to make a joke of it all.

No one laughs.

She takes it in stride. “You’re more than welcome to share what you’re struggling with, if you’d like.”

His shoulders rise slightly, like a cat going on the defensive. “Okay, first of all, I’m not struggling with anything. I’m not even supposed to be here. I keep telling them if they just let me call my manager we could get this whole thing cleared up so I can get the fuck out of here and back to my life.”

“Your manager…” She leans over, plucking a file from her briefcase and unfolding it on her lap. “Mr. Scott?” She looks up through her eyelashes for confirmation.

He settles again, looking slightly relieved. “Yeah, Jonathan Scott, Razor & Tie.”

“Mhmm…” She looks back at the file, flipping a page up in what looks to be a show. Like she already knows what she’s supposedly ‘looking’ for. “It says here Mr. Scott is the person who applied for your stay in our center and is the sign off as your legal guardian while you’re completing your treatment.” She lightly closes the file, sitting up straight again to look at him. “Did you know that Eddie?”

“No,” he answers, voice suddenly unsure, eyebrows drawing together on his forehead and shoulders falling. “No, I didn’t.”

“Well then,” her smile is nothing but satisfied when she slips the papers back into her briefcase. “It seems there’s nothing to be cleared up here after all. And I’m sure we’re all very excited to get to know you over the next few weeks, Eddie.”

Challenge won.

When he doesn’t respond, she moves on. “Now, Kathy, it looks like your nails are doing better…”

You tune out the rest of her interaction, focusing on the man beside you. He has his head slightly hung down, eyes on his hands as he holds one wide and uses the opposite thumb to rub along his palm. There’s an air about him – closer to one you saw this morning. Confused. Lost. Scared.

You almost feel sorry for the guy.

Two hours later, you’re in one of the ‘office lofts’ of Therapy House, a 5x5 closed room with a loveseat for you and an armchair for your therapist. After group is over, there are rotations of 1 on 1 therapy with one of the various counselors on staff, herding each of you into tiny rooms for an hour at a time. At the beginning of your stay, you had somehow lucked out to being assigned to Queen Penelope herself.

She sits across from you with her holier-than-thou attitude and a spiral notebook clutched in her well-manicured hands – filled with notes about you that you’re not supposed to see. In the sunken down cushions of the loveseat, you end up sitting below her eyeline even if you tried to sit up straight. So you don’t try – tucking your legs under you and crossing your arms under your chest.

As per usual, she starts the session with a few moments of horrifying silence. Almost as a dare to get you to talk first just to break it.

You never have.

“So, how are you feeling today?”

“Fine. Same as always.”

She clicks her pen, like she’s already prepared to start taking notes off that one sentence. “Indeed. Everyday is always ‘fine’, isn’t it?”

Eddie must have made you more snippy than usual, because you’re already ready to turn on her. “What point are you trying to make, exactly?”

“Everyday, every time anyone asks, the answer is always ‘fine.’ Fine is a noncommittal answer that means nothing.” She leans back in her chair, cool and collected as always. “Fine is the answer you give when you’re avoiding the answer.”

It takes everything in you not to roll your eyes at her. “Okay, what is my answer supposed to be then?”

“The truth, preferably.”

Wow, thanks, that’s helpful.

When you don’t respond with a new answer, she moves on. “Are you still having nightmares? Flashbacks?”

A shiver crawls up your spine, creeping toward the cold sweat that starts to build at the nape of your neck on instinct. “Sometimes.”

Liar.

“How often, would you say? For the nightmares?”

Clammy hands press into the fabric of your grey sweatpants. “Maybe once a week.”

Liar.

She scribbles something down in her notepad. “And the flashbacks?”

A vision of cold, blue tipped fingers reaching out toward you from the dark comes to the forefront of your mind before you blink it away. “Less than that, I think.”

Liar!

“And are they all still about her?”

The cold from those blue tipped fingers permeates through your body, settling into your bones in a chill that never seems to leave you anymore. “Not all of them.”

LIAR. LIAR. LIAR. LI–

“Actually, can we talk about something else?” Your request comes out quicker than you’d like, giving a show of desperation as you adjust in your seat. “Please,” you add as an afterthought.

Her gaze is sharp as ever and calculated in her perusal of you for another few moments, but she concedes. “Alright. What would you like to talk about then?”

When you flounder for an answer, mouth opening and shutting uselessly, she offers an alternative of her own. “I saw you walk in with the new guy today. Eddie, right? Did you talk to him at all?”

You let out a huff, eyes directing down to where your wandering fingers have landed on a piece of loose thread on your pants. “More like sat there while he talked at me.”

“He didn’t give you a chance to talk or you never took it?”

“I don’t exactly have anything I want to talk to him about,” is your cold response, once again looking up to make eye contact with her.

“You know, it wouldn’t actually hurt to try to connect with someone again. Maybe open up to a new friend?”

This time you’re not able to withhold your eye roll. “Junkie rockstar is not exactly the kind of friend I’m looking to make.”

“That’s a bit of a hurtful representation, don’t you think?” She is writing another note as she speaks, eyes looking between you and her page. “How would you feel if someone didn’t want to interact with you because you’re a ‘junkie’?”

Your gaze flicks back down to the thread between your fingers as you mumble, “They wouldn’t exactly be wrong.”

“Do you think you’re a bad person because of your drug use?”

I think I’m a bad person for a lot of reasons.

“It doesn’t exactly give you a glowing perception in the eyes of the public,” you answer defensively.

“That may be true. So you did something that was frowned upon by the general public, making it ‘bad’ or ‘wrong’.” She adds in the air quotes, even though her tone was enough to warrant the assumption that she was being facetious. “What about all of the good things you’ve done? Is there some kind of threshold for the amount of ‘bad’ things a person needs to have done in comparison to the good ones to brand them as a ‘bad’ person?”

“I don’t know, maybe.”

Her eyes flit over to the book beside you, resting on the cushion with the cover Good Omens facing up, before returning to you. “I think, personally, that it’s possible to have done bad things without it making you a bad person. It doesn’t make you a good person either, mind you. Because there’s also no such thing as a person who is wholly good either.” She folds her hands over her lap like she always does when she thinks she’s about to say something really profound.

“Good and bad are just malleable descriptions we give to things. People are not simply good or simply bad. People are just… People. Where good, bad, and everything in between coexist.”

Then why do I feel like this?

Eddie plops down in front of you at breakfast looking slightly less like a wet rat than he has so far.

"Good morning, sunshine." And he grins, way too fucking chipper for being 2 weeks into detoxing.

"Don't call me that."

"Whatever you say, sunshine," he repeats with the same grin, like he's glad you don't like it. "I have a plan for us to get out of here."

Get out? A plan? Us? You don't even know where to start with that. "Ah. No wonder you look like it's Christmas morning."

"I'm going to take that as a compliment." With a noncommittal 'mmfh', you go back to pushing around your over salted scrambled eggs. "Aren't you going to ask what my plan is?"

"No."

"Well, since you asked," he ignores you and leans over the table, once again lowering his voice to a soft murmur. "One of the night nurses is a fan of my band."

He pauses there, like he's looking for some kind of response. You offer up a completely lackluster, "Congrats."

"Sooo, maybe I can butter her up. Promise her VIP tickets or backstage passes or something. Bribe her to get us out."

Stabbing into a chunk of egg hard enough to almost pierce through the styrofoam beneath, you mumble, "Good luck with that."

He points his fork at you, eyes narrowing in a glare. "You don't think it will work."

"I don't care if it works," you sigh as you bring a hand up to rub at the sudden tension in your temple. "What do you think is gonna happen when you get out, huh? They're just gonna say 'Well, he got out of rehab, guess that's it then!' Your manager is just gonna have you delivered right back here."

"Then I get a new manager." Another flat look is leveled in his direction. "Seriously, I can figure it out once I get out of here. And if you're gonna be this negative about it, then maybe I won't take you with me," he says it like a threat, looking smug as he sips at his not-quite-pineapple juice.

"Good."

His plastic cup hits the table fast enough that a bit sloshes out and onto the vinyl cover. "What do you mean 'good'? You're telling me you don't want to get out of here?"

It's like he's finally hearing you for the first time. "Yes, that is what I'm telling you."

"As if." He scoffs, shoving a chunk of scramble egg in his mouth before continuing to talk through chewing it. "Nobody wants to be in here getting pumped full of happy meds and talking about our feelings with the Ice Queen."

A part of you actually wants to be amused at the term Ice Queen, but you're quick to beat it down. "Yeah, well, maybe I do."

He takes a big bite out of his stiff toast next, crumbs flying with the force of it. "I think," he pauses to swallow the bite before pointing the toast at you this time. "That you have Stockholm Syndrome. And have accepted defeat in your captivity."

"Whatever you say, Munson."

You should've known better than to assume it would end there.

After breakfast, all of you scatter throughout the main hall to do various things to fill your time. As usual, you sit down on a chair by the window so you can continue your book. You're quickly approaching the climax of the narrative, when the four horsemen begin their ride toward the end of the world.

Eddie has set up shop at a table nearby, bent over the top that's scattered with papers that are all covered in drawings of various mythical creatures. He's currently scratching away at a sketch of a three headed Hydra, mouths roaring fire toward the sky.

You'd never tell him this of course, but you have to admit that they are pretty good.

It's 30 minutes of blissful silence with plenty of progress made in your book until he starts talking again.

"Do you actually not want to get out of here?"

You exhale through your nose sharply, annoyed that you're being forced to continue this conversation. Closing your book with your thumb tucked in to save your page, you turn your upper body toward him. "Is that really so hard to believe?"

"Yeah, actually, it is. What are you even in here for anyway? Like what 'problem' do they think you have?"

"None of your fucking business," is your extremely grumpy reply, settling back into your chair and opening your book again in hopes he'll drop it.

"Well, whatever it is, it's not worth sitting in this glorified prison for months on end, I can tell you that much."

Something about the way he's talking really starts to grate on your nerves, making you want to fight more than you want to ignore him. "I'm sorry, would you rather be in actual prison?"

This makes his face drop, a muscle in his jaw rolling with tension. "What the fuck is that supposed to mean?"

"It means that coke and meth are illegal, in case you forgot. And can actually get you arrested." Your tone is condescending, tinged with venom. "So maybe you should be grateful to be in this 'glorified prison' instead of a real one."

"Grateful?" He lets out a fake laugh, looking at you in disbelief. "Yeah, let me just try to be grateful to have my every move watched and my entire day planned for me like I'm in a fucking daycare."

An orderly walks in through the double doors to the garden, propping them open in an invitation to move outside for the hour. You're quick to rise, tucking your bookmark into your spot and muttering a dismissive, "Whatever," as you pass.

You're barely off the stone path and into the grass towards your seat when he comes barrelling out after you.

"Hey, I'm not done."

"Listen," you continue forward, talking over your shoulder at him as he marches after you, "I get you're still in denial and everything. But it's not my job to make you accept that you're here for a reason. So why don't you just leave me alone."

A hand grips your shoulder, forcing you to turn toward him. The sun is behind his head from this angle, leaving him silhouetted in light and you standing in his shadow in the grass.

"And what exactly do you think the reason I'm here is?"

"I don't know," you push his hand off your shoulder, tucking your book in against your stomach. "Why don't you ask yourself that question?"

"I'm here against my will because a fucking corporate prick thinks I need 'fixing'," his voice comes out as a hiss through his clenched teeth. His hands tighten into fists at his sides. "Everybody thinks we need to be 'fixed'."

"Maybe we fucking do, Eddie! Did you ever consider that?"

Out of the corner of your eye, you see your argument getting some attention from other patients and an orderly standing watch, but you're too caught up in your anger to care.

You jolt in surprise when Eddie's hands grip your shoulders, forcing your attention on him. "Are you even fucking listening to yourself?!"

"Eddie, let go of me."

His hands only tighten, his wide eyes going wild. "They fucking infected you with their bullshit doctrine of what society thinks is right and wrong, but it's not true."

You try to pull away from him but his grip just turns bruising in response, fingertips digging into your skin painfully. Fear takes hold, tears starting to push at the back of your eyes as you plead, "Please, Eddie, you're hurting me–"

"They're hurting you!" He's borderline yelling in your face now, emphasizing his next point by shaking you where you stand. "Don't you fucking get it? They're the ones hurting you by making you think there's something wrong with you!"

An orderly appears beside him and grips his shoulder, ordering a tense, "Let her go."

This seems to shock him as his hands release you mid-shake, sending you backwards onto your ass. You make impact with a yelp, the tailbone pain enough to force the tears that were threats before to start to spill down your cheeks. You're sure that if your hands weren't pressed to the ground behind you, they'd be trembling.

Heels click along stones on the approach, heated and quick. "What the hell is going on here?" Penelope Windsor asks sharply, barely faltering as her heels meet grass and dirt.

You look up at Eddie with tears in your eyes, shocked and terrified.

He looks down, as pale as a ghost, the orderly's hand still on his shoulder as he stares at his own like they don't belong to him.

"Are you alright?" Penelope asks when she kneels to the ground beside you, fancy slacks of her pantsuit in the dirt. A gentle hand hovers over your shoulders, concern evident in the way she looks you over.

Swallowing hard around the lump in your throat, you break away from your stare at Eddie to glance at her and then the ground. "I'm fine."

"I…" Eddie's voice sounds small, scared. "I'm so sorry, I don't know what happened. I didn't mean to–"

"Come on." Penelope is calm as she interrupts him, more caring and gentle than you've ever heard her. "Let's go get you cleaned up."

You manage a nod before you allow her to help you to your feet and put a protective arm around your back as she leads you over toward the Therapy House.

Eddie stands there with the orderly, hands shaking and tears forming in the corners of his eyes as he watches you go. Hoping you'll look back. That you'll tell him it's okay, that you'll forgive him. Tell him that you will be okay.

You don't look back.

Once you've disappeared behind those birch doors, the orderly finally lets him go. Walks back over to the main hall without another word – leaving Eddie alone to his panic and shame while he stares at your copy of Good Omens from where it sits half open and abandoned in the grass.

Your chair is empty in group that day.

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thanks for reading!! please reblog if you liked it and let me know what you think, feedback means everything!! read part 2 here

[intheroomblog]

Effective Recovery: Medication-Assisted Opioid Treatment Programs

Medication-Assisted Opioid Treatment Programs provide a comprehensive approach to overcoming opioid addiction by combining medication with counseling and behavioral therapies. These programs help reduce withdrawal symptoms, curb cravings, and promote long-term recovery. By using FDA-approved medications, individuals can stabilize their lives, regain control, and focus on healing both physically and mentally. Whether you're battling opioid dependency or supporting a loved one, Medication-Assisted Opioid Treatment Programs offer an effective, evidence-based solution for managing addiction and achieving a healthier, addiction-free future.

[bethanydelleman]

Trope exploration: Man, usually a war veteran, with PTSD drowns his sorrows in alcohol

I was rewatching one of my favourite shows and I was struck by the fact that the main male character had severe Posttraumatic stress disorder (PTSD)* and yet didn't drink because it seemed like a big trope subversion. This made me wonder about the real world comorbidity** of substance use disorder (SUD) and PTSD, so I could determine if this common association was a reflection of real life or a trope.

PTSD & SUD co-occur at a rate of about 30-55%

(many of these studies are in veterans, source, source, source)

However, this is SUD in general, which means it includes any abuse of a drug, including but not limited to alcohol. The highest rates of PTSD are in cocaine and opiate users. Also, and this is very interesting, the direction of causation is unknown (does the substance or the PTSD come first):

Although PTSD and SUDs appear to be strongly linked, little is known about the nature of their relationship. The most widely held explanation of their frequent co-occurrence is the self-medication hypothesis. This hypothesis is based primarily on clinical observation and posits that traumatized individuals attempt to use substances in order to dampen traumatic memories, or to avoid or “escape” from other painful symptoms of PTSD. A second hypothesis, the high-risk hypothesis, posits that individuals with SUDs, because of high-risk lifestyles, are likely to experience a trauma and are, therefore, more likely than the general population to develop PTSD. Finally, a third hypothesis, known as the susceptibility hypothesis, states that substance use increases an individual's susceptibility to developing PTSD following a trauma. (source)

It was also noted as important that most patients who suffered from PTSD had multiple traumatic events in their lives, beginning in childhood. Also, more men had SUD than women, which holds true in the general population as well.

I think one of the best representations in popular media of PTSD might be The Hunger Games. They have SUD/PTSD Haymitch and the Morphling (opioid abuse) victors, but Katniss and Peeta deal with their experience in other ways, as do the others that we see. Also, it's clear that most of the victors have repeated trauma: Katniss's father dying and nearly starving to death; Peeta's childhood abuse; and Haymitch being forced to have a front row seat to subsequent games.

Conclusion: at most, only about 50% of patients with PTSD abuse a drug of any kind, less of them abuse alcohol. So it would be both interesting and scientifically valid to see more characters with PTSD who are not constantly drinking. Men are more likely to have substance use disorders, so the trope is partially supported.***

*Comorbidity is when two disorders happen in the same person at the same time. There are many conditions that are likely to co-occur, like depression and generalized anxiety disorder or Type 2 diabetes and obesity.

**Symptoms of Posttraumatic Stress Disorder, taken from one of the sources above:

The characteristic symptoms of PTSD can be divided into three clusters: avoidant, intrusive, and arousal symptoms. Examples of intrusive symptoms include unwanted thoughts or flashbacks of the event. Avoidant symptoms include, for example, attempts to avoid any thoughts or stimuli that remind one of the event. These symptoms are particularly relevant to this review because substances of abuse are often used by individuals with PTSD in an attempt to avoid or escape memories. Arousal symptoms generally include exaggerated startle reflex, sleep disturbance, and irritability, and are generally associated with hyperactivity of the autonomic nervous system.

***I'm not saying that this trope is bad or that we shouldn't see any people with PTSD resorting to substance abuse in media. Instead, I'm saying that the amount of people with PTSD who use alcohol as a coping mechanism is lower than most people probably think, and it would be interesting to see other representations of PTSD as well. PTSD & SUD are most likely commonly paired together in media because it's an easily visible sign of internal suffering.

Also, varied displays of different disorders are important, in my opinion. We don't want someone thinking they don't have PTSD or that a loved one doesn't have PTSD because they don't also have a problem with alcohol.

[heroinuser88]

Did you know that long term alcohol use is worse for your brain & organs than long term clean diacetylmorphine use? Or most opioids in general? Did you know that alcohol kills more people annually than any other drug? So why is it that the former is legal, socially acceptable & advertised on every street corner & the latter is unfairly stigmatized, criminalized & demonized? Did you know opioids use to make great antidepressants & were once legal & used for such in the early 1900s? There are many legal & commonly available things that are addictive & more destructive on your physical health. Yet the masses have been conditioned to believe opiates/opioids are some of the most "dangerous" drugs. Swiss study showing 15 years of daily heroin use resulted in no adverse health complications - https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-020-00412-0 "No serious heroin-related medical complication occurred during the 15-year window of observation among inmates with heroin-assisted treatment. Their work performance was comparable to that of the reference group." Opioids as antidepressants - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5189718/ " Historically, MOR agonists have also been applied in the treatment of mood disorders, notably including major depressive disorder (MDD). Indeed, until the mid-20th century, low doses of opium itself were used to treat depression, and the so called “opium cure” was purportedly quite effective.9 With the advent of tricyclic antidepressants (TCAs) in the 1950s however, the psychiatric use of opioids rapidly fell out of favor and has been largely dormant since, likely due to negative medical and societal perceptions stemming from their abuse potential. However, there have been scattered clinical reports (both case studies and small controlled trials) since the 1970s indicating the effectiveness of MOR agonists in treating depression. The endogenous opioid peptide β-endorphin, as well as a number of small molecules, have all been reported to rapidly and robustly improve the symptoms of MDD and/or anxiety disorders in the clinical setting, even in treatment resistant patients.10–17 These results have been recapitulated in rodent models, where a variety of MOR agonists show antidepressant effects.18–21 " One of the reasons heroin even became so heavily criminalized originally was so that they could target anti-war hippies & black communities - https://www.vera.org/reimagining-prison-webumentary/the-past-is-never-dead/drug-war-confessional “You want to know what this [war on drugs] was really all about? The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and black people. You understand what I’m saying?

We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. 

Did we know we were lying about the drugs? Of course we did.” - Nixon's Adviser The fact that you can drink yourself to death with alcohol or consume various toxic chemicals pushed by big names, but using opioids to enhance your life (be it pain or depression or both) makes you a "junkie" and a "criminal" who "needs help". This is a total hypocritical violation of people's right to bodily autonomy & their right to pursuit of happiness. END THE DRUG WAR