THE NINTH CIRCLE

1. nausea and discomfort, compelling the patient to cease using the drug; or
2. euphoric high, and calming effect on nerves…not so much eliminating pain, as simply causing one to not care as much about it.

 
If you’ve been subjected to modern medicine in the past twenty-five years, you know exactly to what I refer; and if you’re in the first group, consider yourself immensely fortunate – you do not have an addictive brain disorder.  If, however, you’re in the second group, it’s likely you have – at some point in your past – peered down a dark chasm, past your soul, at something beyond.  That, dear reader, is the hell of addiction to the pharmaceutical industry’s ingenious invention: “pain pills.”  It is that level of hopelessness and despair that Dante Alighieri referred to as the “Ninth Circle of Hell.”  For me, addiction has been my life’s ninth circle.
 
Legal, readily available, and lethal beyond your darkest ponderance, these gems of American capitalism have wrought havoc and destruction to entire communities throughout these United States, tearing apart families, bankrupting life savings, and subjecting victims to suspicion, prosecution, and stigmatizing reputations. Unless, you’ve been in a ten-year coma, you’ve already read about, heard about, or seen first-hand the damage inflicted from a macro view.  I could recite the grim statistics ad nauseum.  For reliable background and statistical reference, you may look to the National Institute on Drug Abuse:  https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis  
 
Bottom line, fully one in four people exposed to this scourge will adopt it, embrace it, hide it, and ultimately die of it…unless grace intervenes.  In my case, that grace came in several forms…this is my story.

​October 22, 1987 – a date known as “Black Monday” among financial investors and analysts.  It was my “Black Monday” too, for far different reasons.  Having just undergone the first of three orthoscopic surgeries to remove damaged cartilage, I sat in a recliner, watching what I thought was apocalyptic investor behavior.  What I had no way of knowing was the avalanche of dark impulses being unleashed by these delightful little pills called, “Hydrocodone,” prescribed by my surgeon.  Oooh!  The very name, “hydrocodone,” sounded so delightfully amped up!  Indeed, I would exhaust my bottle of thirty, and refill once more, extending the euphoria a full two weeks.  Suddenly work, the stock market, life’s disappointments, our struggles as a young married couple – all diminished in importance before the effect of taking another little pill.  What glorious release!
 
Not until more than a decade later – undergoing full bi-lateral knee replacement – would I experience that same, sublime sensation, while recovering from a hellish surgical experience.  February 2001, I laid in a hospital bed, watching repeat footage of the Daytona 500 race and Dale Earnhardt’s death on camera, and felt…nothing.  No sense of loss, no cosmic ripple of untimely death.  Nothing blunted the euphoric thrust these pills – Hydrocodone and Percocet – provided me to skate through my days and nights of painful recovery, observing the world turn as I writhed in pain through physical therapy…and didn’t care a jot. 
 
That prolonged encounter with opioids enabled me to escape inside myself, to embrace the delicious agony of regular withdrawal, every six-to-eight hours…and to quench that pang with another dose…and another…and another.  My hips were worn out, my lower lumbar deteriorating rapidly, and all other major joints of my body cried out in unison for relief from the scourge of my degenerative bone disease.  Whatever insidious malady befell me, I knew my little friends would be there to make it all, somehow, more bearable.
 
Enduring one hip replacement after another, one knee revision upon another, my regular attendance at the chapel of pain management became a monthly requiem of my spirit.  So what…they regarded me suspiciously, month after month, for possibly abusing my drugs?  Who cared if they required me to pee in a cup, answer litanies of probing questions regarding my suicidal tendencies?  These were small prices to pay for engaging a full regimen of Hydrocodone, Percocet, Hydromorphone and Methadone.  Who needed heroin or other street drugs, when scoring these beauties month after month with shows of false contrition enabled me to remain comfortably numb?  As my job responsibilities grew, so did my attraction to the only form of relief from such stress I could easily find.  It didn’t matter, because I needed these, I told myself.  They kept me calm, in control, and able to manage the stresses of my job and daily life…
 
…until they didn’t.  I had lost my job and my ability to cope with the pain of spinal deterioration, my daughter’s debilitating illness, my wife’s job-related injury and challenges resulting from that “line of duty” – and my depression.  I had tried injections – nine in total, over a two-year period.  Only by the grace of God did I find myself in therapy, with a psychotherapist whose otherwise heroic efforts at shrinking me had included full justification of my drug habit.  “Medically dependent” had become the mantra by which she justified my continued access to opioids…for three years.  She wasn’t technically incorrect; I was dependent.  But more than that, I was now in the “ninth circle” of a hell of my own design:  using more than the prescribed amount; seeking early refills; seeking other prescriptions…be they from dentists, doctors out of town.  Any and all ploys to feed this pang were now fair game – and I became consumed with an overwhelming sensation to claw out my guts, feed on them, and go back for seconds.  No longer did I think in terms of long-range planning; I knew I was going to die…soon – and I didn’t care.
 
After three exhaustive years of intense psychotherapy, my sessions drew to a close with a renewed sense of necessity:  to undergo, once and for all, a surgical procedure with a 50/50 chance of survivability.  If I survived the eight-to-ten-hour surgery, I may – under best of circumstances – experience a slight reduction in pain, renewed use of my debilitated left leg, and ability to maneuver without excruciating pain in each step.  None of that, however, would alleviate my lust for the forbidden lover, opioids.
 
And so, with increasing sense of ultimate fate, I sought six separate “second opinions,” each explaining why my “opiate dependency” would further hamper the probability of a successful outcome from surgery:  this surgery – more than any other – would require more than extraordinary amounts of Delaudid, Propofol, or other anesthesia to blunt the profound pain of spinal fusion surgery.   Would such quantities flatline my heart?  Would they promote renal failure?  Would I even regain the use of my left leg, rendered infirm by years of nerve obstruction?  Would I ever wake up…?
 
September 10, 2014…along toward evening, consciousness for me began with a voice.  I will not tell you what the voice said, only that it asked something of me.  Then, slowly, I became aware of other voices – human ones.  I heard first my wife, asking the doctor what was wrong.  I heard the blaring alarms of heart and blood pressure monitors.  I heard my surgeon’s voice in reply.  Unable to open my eyes, I could only say: “Dilaudid…give me a lot of Dilaudid – now!  It will slow the BP and stop heart panic.”  It worked.  By then, I’d become quite aware of my body’s response to each opioid.  Where alcohol had failed me, and street drugs had left me hollow, I knew my way around an opioid cabinet.  But I didn’t fathom, in that moment, ever walking again.  
 
Not until the next day, when physical therapists came and got me up for a walk in the hallway, did I believe in miracles.  Something remarkable had been imparted to me:  the familiar leg pain was…gone!  Like it never happened!  Certainly, the pain of spinal fusion surgery alone is excruciating, despite the best of drug therapy.  But it seemed I’d been spared twice by the angel of death: 
first, in simply awakening; 
secondly, all of the old familiar physical pain had washed away.
 
Among my responses to that voice, so clearly articulating my choice, I knew I needed to accomplish three things; one of those was to stop using opioids!  It was that particular obstacle that scared me most.  Nobody knew better than me how impossibly steep that hurdle could be…and that removing pain does NOT remove addiction.
 
Barely six weeks later, I revisited the pain management clinic, hoping for an articulated path toward removing all opioids from my life.  The pain management doctor’s response:  write scripts for more pills!  Respectfully, I asked him to help me kick my addiction to the pills.  “Isn’t it possible,” I pleaded, “for me to break free with your help?  Maybe you could wean me down, help me get clean of these drugs, once and for all…?”
 
His response: “If you want to stop using them, you need a detox program.  That’s not what we do here.  Are you really sure you don’t have pain…?  I’ll write you a half-month’s prescription.”
 
“But what happens at conclusion of a half-month?!” I pleaded, in horror.  “What do I do then…?!”  My doctor’s response: “Frankly, that’s not my problem.  But I’ll give you a full month’s worth of methadone if you like.”  He handed me a second script.  Numb, I lurched out. 
 
My mind reeling, I took my two opioid prescriptions to a compounding pharmacy.  In despair, I offered up the scripts to the pharmacy tech.  She took them to her boss, the lead pharmacist.  Soon, that pharmacist (let’s call him, “Ben”) approached.  I explained – through my blurry vision, withdrawal shakes, runny nose and visible anxiety – the urgency:  I HAD TO get off all these opioids!  Ben must have seen the panic in my expression, leaning in, staring at me.
 
“I think,” he began in hushed tones, “…there may be a way for you to beat this.” (Finally, a voice of hope!)  “But why the hell is he giving you TWO prescriptions…?  This is insane!  You told him you wanted to taper off, right…?”
 
“Yes,” I explained, “…but I think he’s not listening to me.”
 
“Well, of course not!  You’re just another junkie to him…his job is to turn you into a junkie, NOT detox you!  He’s in ‘Big Pharma’s’ pocket.  They make this poison, he slings it, you take it.  Next month, and every month thereafter, you’re a guaranteed revenue stream.  That’s how their business model works.”
 
I stared, mouth agape, in disbelief.
 
“Here’s what you need to do,” he continued, “...return to doc’s office, make another appointment to see him as soon as humanly possible.  You want to ask him for a very specific thing:  patches you wear on your arm, with the active drug, Buprenorphine.”
 
“Write it down,” I mumbled, “I’ll never remember that.”
 
“Well…there’s more…and you really need to pay attention.  I’m going to work on a compound formulation of the active ingredient that will eventually take the place of the patches.  But for the first couple months, your dosage needs to be set at between fifteen micrograms (mgs/hour) and twenty-five micrograms.  The reason is, you’re at a very high level of dependency, considering all of those opioids you’ve been on for twelve years.  Frankly, it’s a wonder you’re still breathing.”
 
Stupefied, I asked, “Can that actually work…? And if so, why hasn’t doc mentioned this possibility?”
 
Ben stared at me for long seconds, then replied, “Because ‘Pain Management,’ from his perspective, is about making – and keeping – you a customer for life…or until they catch you breaking the law, and turn you over to the police.  Weren’t you listening…?  Addiction IS the ‘Pain Management’ model,” he said, making air quotes.  He continued, “For that reason, doc will only take you so far toward ridding your system of opiates – the companies who currently make these patches stop at five microgram per hour.  The remaining gap – from five micrograms to zero – is too great for people to leap across; for that part, you’ll require an ointment that I’ll formulate and compound for you.  Otherwise, you’d never make it.”
 
“Why is that…?” I asked.
 
“Because the greatest hurdle won’t be physical…it’ll be psychological.  But don’t worry about that now.  Let’s get you transitioned to those patches, and I’ll get to work on a formulation for you.”
 
A bit of technical detail here is helpful…the human brain has cell clusters referred to as pain uptake receptors – both agonist and antagonist.  The most powerful receptors are the “Mu uptake receptors,” functioning to deliver pain blockage and euphoric sensation directly to the amygdala of the Limbic System…the pleasure & pain center. These Mu receptors are normally tickled in a manner to provide a pleasure response by not just blocking pain, but also invoking euphoria.  Buprenorphine – while technically an opioid – blocks Mu uptake receptors without invoking the same euphoric response -- thereby providing pain relief without the usual “high” that addicts crave.  The result is a dramatic shift in sensation, providing pain relief to other uptake receptors, WITHOUT stimulating the Mu receptors.  (All of this was yet unknown to me.)
 
Off I went, mind awhirl, armed only with hope in an unknown pharmacist’s word, and a thinly-veiled plan to turn the pain management model inward on itself in order to build a bridge toward a narrower gap than that currently separating me from a drug-free life.  As you might imagine, my pain management doctor was reticent to help with prescribing these patches; but after explaining the pharmacist’s plan, he said, “Okay…I can put you on twenty microgram patches, and wean down every two weeks, by five micrograms.  We’ll get you down to five micrograms…that’s as low as they go.”
 
That night, after thirty-six hours of torturous absence of opiates, I stood naked in a shower, shivering through a hot stream of water, cold sweat pouring down my flesh.  Off to bed, I writhed in agony to the usual sensations – a driving compulsion to rip out my guts from the cavity of my torso, while my wife applied the first patch to my arm.  I lay under covers, coiled and shivering for about twenty minutes.  Suddenly, as though sucking the wind from my lungs, I was struck by a sensation emanating from my brain to my heart, causing palpitations, rippling down my torso, out through my limbs!  I couldn’t breathe!  “Am I having a heart attack…?” was all I could think.  Over the next ten minutes, my blood pressure spiked, then levelled back; my heart raced, then resumed beating normally. 
 
I stood, staggered over to the bathroom, leaned against the vanity, and stared at a rendition of my addicted self…one that was both dependent on opioids, and suddenly liberated from the physical curse of addiction to getting high.  Indeed, I wasn’t high…I was undead.  Yet, an inexplicable craving for more “high” remained…a self-contradiction in self-abuse.  I still wanted the drug, but felt no actual pain.  I craved getting high, but without the underlying physical sensation of “needing” the drug.  This was a darker impulse than ever!  How could I possibly fulfill it…?   And therein resides the underlying conundrum:  do I want to get high more than I want to be free…?
 
For six weeks, I transitioned, step by step.  The interim between those steps was filled with trepidation, fear and phone consultations with my pharmacist…fear that I wouldn’t make it out alive, that I wouldn’t survive the psychological attraction to my kryptonite (narcotics), that I would slip back into using, just to get high, and finally blow my fucking brains out.  How could I possibly think such dark thoughts, yet be faithful to a plan as audacious as this…?  Was I even still alive, or trapped in my own self-deluded simulation of life, projected by a brain craving freedom from such exquisite torture?
 
Long Story, Short...
 
I searched for and found a new pain management doctor in the area…one willing to invest the time in order to provide me strategies for surviving my “ninth circle,” suggesting herbal teas and writing prescriptions for the ever-decreasing, bi-weekly ramp-downs of Buprenorphine, in ointment form, that Ben had defined.  I’d rub it on my belly daily, go about my business, and gradually began to again feel normal.  By February 2015, with no narcotics lying around for me to sneak, I had discussed every dark facet of my psychological addiction with my wife, my pharmacist, my new pain doctor…and my own addicted brain – beckoning me to use…just – once – more! 
 
I have now been clean and sober for five years.
 
This is not a tale of self-aggrandizement, nor self-congratulatory accolades.  As I told you, I received purifying grace…and I did NOTHING to deserve it.  I paced the floors nights, becoming intimately obscene with God in my protracted insistence that He “fix” me, that He hear my pleas for salvation from the enslavement of addiction.  As is often the case, He sent me angels…in human form.  My angels were my wife’s willingness to listen and be my sounding board for weird thought distortions; my new doctor, who felt encouraged in her choice of profession by witnessing my journey to wellness; and my pharmacist, without whose knowledge and willingness to intervene I would have, doubtless, remained a blurry-eyed addict…until blowing my brains out, or simply downing an entire bottle of poison, in the glorified form of “pain pills.”
 
It’s not a pretty story, but I have hope.  I would like to share this hope.  If you’re reading this, and know someone who might benefit from “a different approach” than our society’s entrenched acceptance of the pharmaceutical industry – and the network of doctors who violate their Hippocratic oath every day – I implore you to share this perspective with them.  I am happy to speak with them in confidence…just my humble way of trying to pay it forward, by helping them climb out of the “ninth circle.”

Photography & digital editing, H.J. McEnroe