Reference no: EM133548363
The following case study is connected to the questions below:
Brief Overview of Client
DSM Diagnosis and rationale (Including code)
Approach to Treat Disorder (including assessment techniques or tools)
Treatment Plan (Minimum THREE goals with measurable objectives) with following format:
Goal 1:
Objective 1:
Objective 2:
Objective 3: (Complete for minimum three goals)
Anticipated discharge criteria (i.e., When is process complete?)
Additional Information (What more information about the client would need to be gathered to better understand the client?
What were the protective and risk factors for Jimmy in childhood and adolescence?
How did the boyfriends of Jimmy's mother influence him when he was younger?
What principle of reinforcement did oxycodone have on Jimmy's drug use behavior?
What social and cultural factors may have played a role in the development of Jimmy's prescription drug dependence?
How was the experience in the IOP different from what might be expected in usual outpatient therapy?
How did Peggy-O define addiction?
What was the main symptom of dependence that Jimmy experienced?
What psychological factors likely contributed to Jimmy's early drug use?
What is the difference between medications with agonist and antagonist effects? Was suboxone an agonist, antagonist, or both?
What factors led to Jimmy's final relapse?
Do you think treatment in judicially mandated programs can work? If so, why? If not, why not?
Case Study
Standing slouched in the back corner of a musty jail cell on charges of vehicular manslaughter and driving under the influence, Jimmy closed his eyes and said under his breath, "How did I get here?" Thinking back to his childhood, Jimmy, a 53-year-old white, heterosexual, cisgender man from rural Ohio, knew his life didn't have to end up like this. He was raised by a loving mother in a small rural town where everyone knew each other. He never moved, had decent grades in school, and had no major health problems. On account of his dad passing away when he was seven and being the oldest of two boys, Jimmy had become very good with his hands. Plumbing, electrical, engine repair - he could fix just about anything by the time he was out of high school. During high school, he worked at Hinshaw's, the local auto repair shop and, for a brief stint, as an apprentice for Mr. Buckner, the electrician in town. After graduating high school, he worked for a handyman service, where he would work for 10 years in all. Recalling the many things he did well when he was younger, Jimmy shook his head and muttered to himself, "How the hell did I end up a criminal with an addiction to painkillers?"
Misused or abused prescription opioids are a significant problem in the United States, causing an extraordinarily high number of overdoses and emergency room visits every year. Approximately 37,000 people in the United States die from overdoses of prescription pain relievers each year, compared to 15,000 deaths from heroin overdoses (Niles et al., 2021; CDC, 2020a, 2020b; NIDA, 2020a).
Despite the early life factors that could have helped protect him from getting into trouble, the cards also were stacked against him in certain ways. His mother had a serious drinking problem and was often unavailable for him as a child. She was home most of the time, on disability caused by chronic pain and severe posttraumatic stress, but she generally stayed isolated in her room. Though loving and kind when sober, most of the time she was more like a dependent roommate for Jimmy and his brother. They took care of her and the house most of the time. When their mother had a boyfriend over, the brothers were subjected to physical intimidation and emotional abuse. They overheard stories about drugs, drinking, and breaking the law. They were frequently around when her boyfriend would be drunk or high on various drugs. To them, drug use and heavy drinking were normal things men in their town did. When he was a teenager, Jimmy used to think it was funny to see his mother's boyfriends and their friends acting so wild when they were under the influence of drugs. They might break things, shoot at things, or tell raunchy stories. Outlaw country music played loudly at home as the soundtrack of his youth - legends like Willie, Merle, and Johnny. Wherever he turned, the men around him talked about getting into trouble, challenging norms, and breaking the law. By the time he was 16, Jimmy and his friends would spend weekend nights at a clearing in the woods listening to music around a fire, drinking cheap beers, and smoking whatever pot they could score.
Jimmy was older than his brother, but a little less wise. His younger brother avoided using drugs after the age of 16, drank much less, and had no arrest record. Jimmy, on the other hand, was arrested for the first time at 21 for disorderly conduct after getting into a fight at the Chicken Bridge bar. At 26, he was pulled over (with more than an ounce of weed in his car) for going 64 in a 45. The ticket was expensive, but the police never checked the car for drugs. He knew he was lucky. Around these same years, Jimmy's brother went off to college and then moved to Cincinnati to begin work, knowing that he needed to escape their hometown. Jimmy, on the other hand, did one semester of community college, then quit, unable to attend class due to a conflict with his work as a handyman.
One important approach to substance use disorders is to try to prevent them. Drug prevention programs keep growing in number and are offered in schools, workplaces, activity centers, and other community settings, as well as on social media, the Internet, television, and radio (SAMHSA, 2021, 2019; Tremblay et al., 2020).
At age 35, Jimmy was single, out of shape physically, and living alone. His brother had long ago moved away. His mother died from stomach cancer when he was 30. He inherited the house he grew up in, the same as his father had when his parents had both passed. He was now working at Hinshaw's as a repair technician, a job that was unchallenging but kept him busy. After work, Jimmy and Ritchie continued their tradition of tinkering in the garage on anything with an engine. For over a year they had been working on a '78 Trans Am that Ritchie had acquired. It had been in very bad shape, but Ritchie and Jimmy upgraded engine parts, cleaned up the interior, and repainted it. Eventually, after many long weekends, light beers, and chain-smoked Camels, the slick, black Trans Am was ready for the road.
Ritchie wanted to be the one to drive it first. Jimmy sat in the passenger seat. They pulled out of the driveway, turned right, and drove slowly on the gravel road, coming to a stop sign at the county road. It was a windy summer day, and the windows were down. No cars were coming in either direction. A gust of wind replaced the thick humid air for a moment. They laughed as they saw Jimmy's spent can of Bud Light from the night before blow along the edge of the highway. Ritchie turned to Jimmy and asked, "You ready boy?" Jimmy's seat was positioned high and forward. They had forgotten to shift it back after working on the back seat. Jimmy turned to Ritchie and smiled, then took his right hand and moved it from his lap to the front of the window frame. He slapped the windshield with his palm three times, then said, "Let's do it!"
They had retrofitted the engine to boost the horsepower and acceleration. Ritchie spun the wheels in neutral, then jolted the engine into gear, fishtailing left onto the old county road. The Trans Am lurched forward, and Jimmy clamped his hand hard onto the front windshield and the metal frame separating the door from the windshield. Ritchie squealed and yelled, holding the wheel with both hands. The Trans Am sprinted and growled.
It only took a few seconds for the accident to happen. As the car launched from stop, Jimmy instantly knew by the sound that their engine work had paid off. He felt proud. It was the result of nearly a year of work and an impressive accomplishment. Unfortunately, before driving away, they had forgotten to secure the latch to the hood. It only took a few seconds for the car to hit 65 miles per hour. It was at that speed that the hood violently slammed backwards. Jimmy's right hand had no chance. His fingers were smashed by the impact. Ritchie stopped the car and started anxiously laughing. Somehow the windshield was not damaged. Jimmy held his hand to his chest, wincing and screaming in severe pain. Ritchie drove back to the house and took Jimmy in his truck to the local emergency room, located 45 minutes away. By the time they arrived, Jimmy's right hand was significantly larger than his left hand. It was swollen, purple, and disfigured, fingers twisted and mangled.
Prescription drug abuse can happen to anyone who has an injury and is prescribed oxycodone or similar opioids, but certain risk factors further increase the chances of such abuse, including certain genetic predispositions, unemployment, and problematic personality factors (Duncan, 2020; NIDA, 2020b; Thomas, 2020).
In the emergency room, the medical personnel immediately gave Jimmy an intravenous painkiller. He stayed at the hospital overnight and was discharged the next day. Ritchie picked him up and drove him home. Jimmy was given oxycodone pills to manage the pain and instructions to keep his hand elevated and immobile. He received surgery soon after, and he was unable to work with his hands or drive for months.
At home, Jimmy took his pain medications as instructed. The pain was intense without the medications. He experienced sharp pains when he moved his wrist or fingers and dull throbbing pain at other times. It was all frustrating as well. If he couldn't work with his hands, what good was he? It was the only work he knew. He felt relief every time he took his medication, and he quickly came to think of it as his lifeline. When his pain increased, he would take an extra pill. Take more as needed, the doc had said. It didn't take long to learn that oxycodone was the only thing keeping him from utter misery. He had never taken oxycodone before, so he didn't worry about becoming addicted. His brother was worried, however, and routinely checked on Jimmy. Ritchie and friends came by after work most days. Most of the time they would make jokes about Jimmy being high on "oxy," or ask him if they could have one of his pills. Jimmy thought it was funny but noticed that he was beginning to feel possessive over his pain pills. He even snapped at Ritchie's friend Shannon, who picked up his prescription bottle and held it up to read the label. "That ain't yours, Shannon. Put it down!" he said urgently. Like hell would any of the guys get their hands on his oxy.
Months later, Jimmy had recovered and was back to work. He had successfully tapered off oxycodone. From then on, he joked about how "good that stuff was" and how he might get himself into another accident sometime. "Just sayin'." It would be another 10 years before his next accident, and it was not intentional. By age 45, Jimmy had become highly skilled as a welder. He had helped build bridges and worked in several nearby manufacturing factories. He was confident as a welder and often did welding projects alone in his garage. He had recently begun to take pipes and car parts and fuse them into strange angular shapes. He made one for fun while high on pot one night, and when he showed his friends, they suggested he make a few more and try to sell them. "City folks will buy anything they think is original art from the country. Charge 'em up, brotha. Make 'em pay." He did exactly that, and the artwork sold. He started an online store on Etsy and figured this could be an easy side hustle. One night, while alone and drinking heavily, Jimmy decided to cut a large steel pipe in half as part of a new project. He hoisted an end of the pipe onto his sawhorse table, pulling the other end up on an angle until it rested awkwardly on top, both ends hanging over the much smaller wooden platform. It must have weighed over 100 pounds. Sweat dripping from his forehead, Jimmy grabbed another beer and took a few large swigs. It was the last of the six pack he had bought earlier in the day. He figured he would switch to bourbon and call it a night after he made some progress on the new pipe art.
Jimmy lit the torch and began cutting the pipe. As the flame cut through, Jimmy realized he had not properly clamped down the pipe. It was too late. The pipe split in half, both sides dropping to the floor and making a hideous clanging sound. Jimmy's right foot was instantly broken by the force of the pipe. It didn't matter that he had shoes on. He knew right away he needed to go to the emergency room. It felt like déjà vu when he called Ritchie and his friend arrived to take him, 10 years later, on a familiar ride to the local hospital.
After his previous accident, Jimmy was prepared for what was to come. He asked for oxycodone as soon as he was greeted by medical staff. They did an X-ray and quickly administered a pain killer with a name he didn't recognize. Like before, the medicine was instantly relieving. And, like before, after discharge and subsequent surgery, Jimmy was given a prescription for oxycodone. His recovery from the broken foot did not go smoothly. Compared to when he broke his hand 10 years earlier, Jimmy was in worse physical shape. In addition, he was single and unable to hold a steady relationship with a woman. He didn't have anyone to help him around the house. His friends had all gotten married and had kids. As a result, even before breaking his foot, Jimmy had become lonely and hopeless about his future. He usually tried not to show it to his friends, but he wished he could be young again, free to camp and hunt and fish, free to fix cars and ATVs and motorcycles. He longed for those days but knew they were over. His drinking had become worse too. He drank a six pack on weekend nights, and often drank on weeknights while working in the garage. Now he was home for months again, out of work and in pain, wishing he could get rid of both his physical pain and emotional misery. For the first time in his life, he started to think about what could happen if he killed himself. They were only fleeting thoughts, and he tried to get rid of them by thinking of other things. But still, the mere presence of occasional suicidal thoughts was a sign. He knew he was not doing well.
In the year following the emergence of the COVID-19 pandemic, the number of persons with opioid use disorder rose to new heights - a rise attributed to pandemic-related factors such as losses of employment, decreases in social interactions, declines in drug testing, and reductions in in-person treatment (Niles et al., 2021).
The orthopedic surgeon at the hospital told Jimmy at his surgical follow-up visit that he needed to lose weight and decrease his alcohol use. He warned Jimmy about the problems that would happen if he drank alcohol while taking oxycodone. He counseled him about the risk of addiction, explaining that he could become dependent on oxycodone. It was an opioid, he explained, like heroin or morphine. It had a similar chemical structure. It produced similar effects. It was legally prescribed but commonly misused or abused, causing many deaths and emergency room visits due to overdose. Jimmy listened and nodded, but he had heard it all before. He wasn't worried. He could handle it. He knew why the doc was telling him these things. He had experienced the effects of oxycodone 10 years earlier. He knew how much better it made him feel, how well these pills could take away his pain. But he told himself that he wouldn't become addicted.
Eventually, Jimmy began tapering down the oxycodone under the physician's orders. He felt confident, and his pain was less severe than it had been. His foot would be in a cast for more time, but he decided he would try to go back to work. When he arrived, his boss took one look at his cast and crutches, then shook his head. "No, sorry Jimmy, but you can't come back to work like that. You'll need to wait until you are able to walk without a cast or crutches. Sorry." Jimmy was devastated. He wanted more than anything to get out of his house and back to work. He was lonely, depressed, drinking, and still taking oxycodone. "Come on, boss, for real?" Despite his pleas, he was turned away and went home. He wasn't supposed to be driving yet, but he did anyway. Jimmy stopped at the ABC store for some liquor, then went to the Walmart for groceries and beer.
His old friend Jody was now out of prison and back in town. They saw each other in the Walmart parking lot and talked. As much as he knew hanging out with Jody was risky, Jimmy wanted to do something to escape from his mental anguish. Jody said he would come by later that evening with another old friend, Frasier. "Shoot, you seen Frasier?" Jimmy said. "I ain't seen that man in years. Bring him by, I'm still at the same place." Jimmy felt a surge of excitement.
Late that night, Jody and Frasier arrived. The three caught up, laughing about old times and drinking in the garage. Jody asked Jimmy what pain medications he was taking. "Oh, you on oxy?" Jimmy chuckled, knowing where the conversation would go next.
At the end of the night, Jody whispered to Jimmy that he could get more oxy if needed. He knew a guy who had a friend with a diversion scheme from a rural urgent care clinic. Oversight was loose, and the guy had gotten ahold of enough oxy to sell to Jody. Plus, Jody knew a friend whose mother had a prescription for oxycodone that her son kept refilling and diverting, giving his mother half the dose she was prescribed and selling the rest. Jimmy knew he would soon be running out of oxy, so he told Jody he'd call him if he needed to. When Jody left, Jimmy wondered if he would ever feel the need to call him.
When his prescription ended, Jimmy went to get a refill. The doc told him that he could not justify another refill, that Jimmy was supposed to be tapering his dosage as directed, and that the pain should have subsided by now. Jimmy didn't realize that he could be refused a prescription. He was stunned. Anger surged, and he exploded at the doc. He demanded that he be given a refill, raising his voice and getting the attention of a nurse outside the clinic room. "Everything okay in here?" she asked. The doctor responded, "Everything is okay, thanks." Jimmy left the clinic feeling shocked. He didn't feel intense pain in his foot, but he did still have some pain, and the oxy was the only thing that worked. When he didn't take his oxy on time, he would start to feel increased pain. He didn't get it. Why couldn't he have another refill?
Surveys suggest that 0.7% of adolescents and adults in the United States (around 2 million people) display opioid use disorder in a given year (SAMHSA, 2021, 2019). Approximately 75% of them are addicted to prescription pain relievers and 25% to heroin.
He called Jody and later met up with him. Jody sold him oxy at a discounted price. "Friend rate," he said with a serious face and businesslike tone. Jimmy couldn't believe how expensive the friend rate was, thinking it was a rip-off compared to what he paid for the prescription. Still, he was angry and feeling worked up from the doctor's visit, so he said nothing about the price and immediately took a dose twice what he had last taken the day before. "I need to catch up," he told no one as he drove away. He drove home and went to sleep, drifting away and feeling like he was floating on a cloud, held up in the air by tiny balls of electricity that touched him all over, creating a warm buzzing sensation. His pain was gone. His anger and depressed mood were things of the past.
The next week he gradually took more and more of the oxycodone. As he neared the end of his supply, he began to feel anxious about whether he would need more, or if he would need to call Jody. Sure enough, he met up with Jody and bought another week's worth - then another the next week, and another the following week, and so on. He was taking more and more in order to get the same effects. By this point, he knew he was becoming addicted and felt ashamed. He was more alone than ever before, out of work, depressed, and socially isolated. Worse, he felt desperate whenever his pain would increase. When that happened, he could be irritable, petty, and reckless with his decisions.
Since he had inherited his house, Jimmy never had to pay mortgage or rent. As a result, he had saved quite a bit of money over the years. It was quickly being whittled away by his oxycodone addiction. As the months went on, his foot healed and he was able to work again, but he still felt emotional and physical distress most days, and oxy was the antidote, bringing him relief from misery each time. After missing work multiple times due to sleeping in after a night of drinking, Jimmy was fired. His boss had noticed a change in his behavior since the foot injury. "He just isn't the same person anymore," he told his wife the night before letting Jimmy go. Now without a job or a family, and seeing his friends infrequently, Jimmy felt more depressed than ever. To feel better, he drank more and more and smoked more marijuana and cigarettes than he had in years. He didn't have a car payment, and without kids he had no other significant expenses. He filed for disability and began receiving monthly payments, enough to help temper the loss in his dwindling savings account.
Over the next few years, Jimmy slowly deteriorated. He ate less, lost weight, became even more isolated socially, and spent increasing amounts of time planning how he was going to acquire oxycodone. When Jody had no oxy, Jimmy bought morphine or fentanyl. On several occasions, he bought heroin. All of these drugs had the same general effect. Jimmy would be feeling physical pain and discomfort, then take an opioid, then feel better. He learned that injecting opioids was the fastest way to feel better, and he began using needles to shoot up whenever possible.
One of the most powerful prescription pain relievers is fentanyl, which is more than 20 times stronger than heroin (Niles et al., 2021; CDC, 2020a, 2020b; NIDA, 2020b).
Jimmy had never been to therapy before. The idea of talking to someone seemed unhelpful and unnecessary. What could they say or do that would help him? He preferred taking medications for treatment, and, as his luck would have it, the mandated treatment approach included both medication and psychotherapy at a local treatment center. He had been prescribed an opioid replacement medication, suboxone, which was actually a combination of two drugs, buprenorphine and naloxone. Suboxone was a newer alternative to methadone, a long-used opioid replacement medication. Within the suboxone, the buprenorphine component acts as a so-called drug agonist by attaching to opioid receptors in the brain and thus reducing the patient's urge to use opioids, whereas the naloxone component works as a drug antagonist by blocking the desirable effects that taking an opioid would otherwise produce. It was a smart medication, and Jimmy was willing to take it as prescribed.
Rural settings often lack access to certain evidence-based interventions for addiction, such as suboxone. Suboxone can be an expensive medication, limiting its use; however, research indicates that it is efficacious and helps reduce the risk of both fatal and nonfatal overdoses (Grinspoon, 2021).
The clinic was nearly 45 minutes from his house. He would need to attend an intensive outpatient program, also called an IOP, for several months. The IOP required him to attend individual therapy sessions two times each week, where he would receive treatment based on a type of cognitive-behavioral therapy called dialectical behavior therapy skills training. He also was required to attend group therapy sessions four times each week in the evening. Two of those group sessions per week were like classes, where Jimmy would learn to monitor and manage his cravings to use substances by developing skills at reducing the negative stimuli in his life, tolerating distress, regulating his emotions, and improving his interpersonal behaviors and choices. The other two groups per week were designed to be fellowship-based support groups - a place where substance users could share their stories and support each other through the difficult process of recovery. In total, he would need to drive to the treatment center six times each week. Three of those times each week, Jimmy was also required to provide a urine specimen, so that the treatment team could routinely and objectively assess whether he tested positive for a wide range of substances. Because it was an abstinence-based treatment program, if Jimmy tested positive for any substance, he would be removed from the IOP and would have to return to jail.
His first week of treatment went well. Jimmy was feeling better now that he was taking suboxone. He didn't have the urge to use or buy anymore, and as a result he felt less emotionally distressed. He knew that he was lucky not to be incarcerated and was grateful to be given a second chance. Jimmy also knew that he had a problem with opioids. He admitted it to his brother, his friends, and the police. When treatment began, Jimmy felt cautiously optimistic. On one hand, he was feeling more hope and readiness to change than ever before. He wanted to stop using, and he had felt helpless on his own. On the other hand, he was anxious and relatively unmotivated to go to therapy. True, he didn't really understand what was involved in therapy, but he had heard stories. Would they make him interpret those weird-looking inkblots, talk about his childhood traumas, or try to interpret his dreams? In his mind, the suboxone was a godsend. The rest of it he could do without, but he would go through with it anyway because he didn't want to go back to jail.
Once persons with opioid use disorder begin opioid replacement medications, they may need to take such medications for many years, if not the rest of their lives (Seligman et al., 2021; Strain, 2021b).
Despite his reservations, Jimmy complied with the IOP requirements. To his surprise, he even liked his individual therapist. Her name was Peggy, and she was a middle-aged woman with a degree from a masters' program who openly talked about her own past history of addiction. Her last name was O'Neill, and Jimmy asked if he could call her Peggy-O, since he had recently had a one-night stand with a drug-addicted woman named Peg and wanted to associate his counselor with a different name. Peggy-O helped Jimmy learn to pay attention to the people, places, and things that were associated with his substance use. For example, he came to recognize that Jody, Frasier, and the ABC store all were associated with his use of opioids. They were, as Peggy-O called them, classically conditioned reminders, also known as triggers for cravings and substance use; because Jimmy had used opioids in the presence of those people and places, his brain associated them with the pleasurable effects of opioids, and so they increased his cravings.
Peggy-O also taught him about the basics of addiction - tolerance, withdrawal, and dependence. He understood these concepts intuitively, but it was helpful for him to have names for his experiences. He learned that tolerance happened when he needed to use more opioids to get the same effect. The physical pain he felt when he wasn't using was his primary withdrawal effect. Jimmy learned that for most people this was the worst part of addiction to opioids and a primary reason to continue using. Peggy-O called it negative reinforcement. The relief Jimmy would experience whenever he took an opioid during a withdrawal reaction was so powerful that it increased the probability of him using again in similar circumstances. Instead of using the word addiction, Peggy-O called the pattern dependence, and she helped him recognize that he had become dependent on opioids, unable to function in his daily life without them.
Although opioid use can cause intense sensations of pleasure, many researchers believe that the opioid drug's removal of withdrawal-produced physical pain often plays a major role in the development of opioid dependence and associated problems such as crime, shared use of needles, and high-risk sexual behavior.
In group skills training therapy sessions, Jimmy learned about how to make changes to his home environment to reduce the probability of drug cravings. He threw away all of his drug paraphernalia. He ceremonially destroyed all of his old pill bottles. He removed Jody and Frasier's numbers from his phone. As the weeks went on, he learned how to assertively ask for what he wanted or to say no effectively, how to regulate his emotions better, and how to tolerate physical and emotional discomfort without using drugs. Such cognitive-behavioral interventions were, as mentioned earlier, all part of the dialectical behavior therapy skill training program. The skills training took place in two-hour groups of around 10 people. In the first hour of the group, two co-therapists would go around the room to each person and review their efforts at implementing recently learned skills. In the second hour, the group members would be taught new skills. Members took notes while they learned new ways to cope with life's stress and the challenges unique to substance use. They sat around a large round table. They shared their homework with the group. It reminded Jimmy more of school than what he had imagined therapy would be like. In one session, this is what happened:
Therapist 1: Who would like to start by sharing their homework practice?
Patient 1: I'll go first. I tried to use the worksheet you gave us about emotion regulation, but I didn't get very far.
Patient 2: (laughs) I didn't try it at all. You did better than me.
Patient 3: Me too.
Therapist 1: Let's look at what you did. Start at the beginning. We are on Emotion Regulation Worksheet 3, the one titled "Addressing Myths about Emotions."
Patient 1: So I tried, like I said. I circled number 3 and number 6 on the worksheet. Two myths, or whatever you call 'em. Then I tried to challenge them like the instructions say to do. The first one says "negative feelings are bad and destructive," and I challenged it by writing in "negative feelings are just a part of life." They ain't bad or good. Know what I mean? Just real. I also wrote down that when I get mad or upset about stuff, it can get me motivated, and I can use it to help me to communicate if I need to."
Therapist 1: That's terrific, you did great.
Therapist 2:I agree! Those are really helpful ways to challenge that myth.
Therapist 1: Can anyone else relate to this myth or how he challenged it?
Patient 2: I really don't like feeling any emotions. It's why I always used drugs. Know what I mean?
Therapist 2: (looking at Patient 2) That's a common reason to use... to deal with emotions. (Looking around to everyone else) I'm wondering if any other group members can relate to the myth and how he challenged it in his homework?
Patient 5: I struggle with this one.
Patient 6: Oh this one is impossible for me.
"I just felt bad for the dude. I've known Jimmy my whole life, and he is my best friend, not including my wife of course. We did everything together as kids. I seen him go through a lot and be strong. His daddy dyin'. His momma's old man used to be hard on Jimmy. He treated him like a dog sometimes. It got scary. And then his momma gettin' cancer. It was real bad too. She was in a lot of pain. Jimmy was tough, man. He was a rock. Helped his little brother more than that ingrate appreciates. His brother leavin' town hurt Jimmy somethin' fierce. I get it, going to make more money in the city and all, but it just ain't right leaving Jimmy without any family around. And he never came back. Never was there for Jimmy when he broke his hand or his foot. My man needed help and his own brother, not even two hours away, couldn't get off his ass to come back to his roots to help out. Anyway, I think this hit Jimmy pretty hard.
Jimmy never seemed to be able to hit it off well with the ladies, so he never had a long-term girlfriend. Most of his women were short-term, like one-night stands or maybe a couple of weeks. Jimmy never seemed to want to be serious about women. So he was alone for a long time. I got my wife and kids, so when I would leave Jimmy's place, I'd go home to a family. Jimmy? He would go to bed alone, wake up alone, and had no one. To tell you the truth, I always felt bad for him.
So it wasn't a surprise that he got mixed up on oxy. Yeah, looking back, I guess you could say that we could see it comin'. But man did he change after the foot injury. He was real quiet, stayed away from people, seemed like he was becomin' a different person. Not gonna lie, it was a real tragedy. A real tragedy. I'll always be there for him. He's my friend. But I ain't gonna let him around my kids or family, I'll tell you that. Nah, I'll keep goin' to his house. Some of our best times we spent in his garage. I miss those days." After his intensive outpatient care program, Jimmy was abstinent for several years. He ate healthier, smoked and drank less, and maintained a healthy weight. He was proud. He tapered his suboxone dose down low. He did weekly outpatient therapy, "counseling" as he called it, with his therapist Peggy-O from the IOP. He spent time with Ritchie in the garage. He sold industrial art on Etsy. He never did return to work, but between his art, disability checks, and savings, he had enough money to get by.
Relapse rates are high even in the most efficacious treatments for opioid use disorders, suggesting that new and more effective treatments are needed (Strain, 2021a, 2021b).
He even started dating. The first few dates he went on didn't pan out, but then he met Tammy, a short, redheaded middle-aged divorcee from Bear Creek, an even smaller town 20 minutes away. She had a thick country accent and a sturdy determination to live healthy. Her kids were grown and independent. She was emotionally stable, had a job, and had a tender, loving way about her. She was unlike any woman he had known. Just what he needed. She was devoted to her church and faith and wouldn't put up with any nonsense from Jimmy on Sunday mornings about skipping church. Jimmy found church surprisingly tolerable, and in time, he even liked it.
Tammy refused to move in together unless they were married. Jimmy wanted to propose to her, but he was nervous and kept delaying. After more than a year, Tammy started to distance herself from him. She no longer immediately answered when he called or texted. She was sweet and kind to him when they were together, but it seemed she would give all sorts of reasons that she couldn't spend time with him as much as they used to. They still went to church, but she was increasingly distracted and aloof with him there. Sometimes after church, she would talk to everyone except him outside, leaving him alone for long periods of time. Why was she changing, he obsessively wondered. Jimmy had no experience in dealing with relationship conflicts like this. As a result, he simply resorted to avoidance. He stopped calling Tammy as much. His texts were shorter, less warm, and less frequent. After church, he would go to his truck and wait for her while she talked to her friends. Even when he saw her from afar talking to other single men, he stayed in the truck, unsure what to do. He started to feel hopeless about their future together.
When Tammy broke up with him, Jimmy became so depressed that he hardly left the house or spoke to anyone. He was empty on the inside, angry at himself, at a loss for what he would do next with his life. Now in his 50s, Jimmy was starting to think about the next phase of his life. His father had died at the age of 48 and his mother at 57. Suicidal thoughts crept into his head on nights when he drank too much. Having these thoughts worried him, although not like the first time he had them. He had stopped seeing Peggy-O for counseling, and rarely saw Ritchie anymore. Spiraling deeper into depression, Jimmy felt worse and worse.
Depression and substance dependence commonly co-occur. It is not always clear which causes which. The two conditions can interact and intensify each other, with increasing substance use making depressive symptoms worse and increasing depression putting one at risk for more substance use.
Tammy may have been gone, but Jody and Frasier were back in town, both out on parole. In addition, Frasier and Shannon stopped by Jimmy's place, letting him know Perkins was around and could hook them up with whatever they needed. They called him Perk, and Jimmy thought that was an appropriate nickname. Jimmy hadn't seen these guys in a long time. Crestfallen and dejected, Jimmy was glad someone - anyone - wanted to see him. "Sure, I'll go with y'all to see Perk."
Given his depressed state of mind and the re-emergence of such profound negative influences, Jimmy's life took a fairly predictable turn from that point forward. Using, as it always had, brought instantaneous escape from his emptiness. He felt like his psychological weight vaporized with each pill or needle. It felt like freedom. Though he still remembered the negative consequences of his last bout with dependence, those memories felt insignificant compared to the urgency of his current feelings of emptiness. This time, he resigned himself to this as his way of life. He met a bunch of new people - friends of friends. They used together. He was no longer alone at home all the time. He still saw Jody and Frasier some nights, and Shannon or Perk on other nights. He went back to making art in the garage, believing that while high his creativity would kick into high gear. At first, he had tried to apply some of the techniques he had learned in therapy to keep from becoming dependent again, but eventually, he talked himself into thinking that using was, in a way, good for him. It gave him more friends, more energy, fewer negative emotions. Ultimately, it would end a life as well. But, as it turned out, not his own.
According to some studies, the mortality rate of persons with untreated opioid use disorder is 63 times the rate of other persons (Strain, 2021a).
It was late one fall night, near the fairgrounds by town, when Jimmy first saw the police following him. Already riding a buzz of heroin and alcohol, Jimmy decided to drive over to the ABC store to get more bourbon. Shannon and Frasier were coming over, and he wanted to have some brown liquor to share. The police car turned in each direction that he turned, keeping a distance. Jimmy pulled into the ABC store lot, and the police car kept driving. Jimmy went into the store and stocked up - Bulleit, Jack, and his favorite Buffalo Trace. Sitting in his truck, he texted Shannon and Perk, "Where y'all at?" He waited a minute for their response, taking in the brisk air and flickering stars. Inhaling deeply and feeling devoid of emotions, he pulled out of the lot. There were no police. Jimmy sighed.
Passing by the fairgrounds he was taken by the lights and people. He saw parents with children eating cotton candy, teenagers flirting and laughing, carnival barkers, and rides - oh, the lights of the rides! The Gravitron spun like a UFO planted into the earth, swirling lights blinking rapidly. The Salt and Pepper Shaker flipped people in rickety metallic cabins upside down and right side up, alternating back and forth with increasing tempo. Gleeful screams could be heard with each vertical drop. His car slowed, and he let a woman and two children walk by. He stared out the window, then closed his eyes, feeling like he was floating, in a dream, or perhaps in the slice of time between sleep and awakening. He remembered being at this same state fair when he was young. He closed his eyes and saw his mother holding his hand, and his father walking in front of them to get a turkey leg and deep-fried Snickers. Sounds were muffled and disjointed. He couldn't tell if they were his memories or the sounds outside his truck. It didn't matter. He smiled and opened his eyes.
Pulling away impulsively, Jimmy pressed down on the accelerator without looking to see if anyone was crossing the street. His truck jumped forward, lurching, belching at the fairgrounds with its loud upgraded exhaust. A teenage boy darted in front of the truck, running at high speed from his friends, who were chasing him playfully. The boy had no chance. His back was turned as he was running backwards, pointing and hollering at his friends. It happened quickly. Jimmy was looking up and into the clouds, which swiftly moved under a full moon. He felt a thud, then a bump, like there was a speed bump. But it was only on his right side, and it was the back wheel. People yelled and shrieked, and he stopped his truck. Within seconds, he knew what he had done. He looked into the rear-view mirror, watching as a gaggle of teenage boys and girls covered their mouths and circled the boy's lifeless body.
Jimmy spent 10 years in prison before being released. While incarcerated, he completed substance abuse treatment and managed to remain abstinent from all of the temptations of drugs smuggled into the prison. He read, took community college classes, and stayed out of trouble. Ritchie came to visit once a year, on his birthday. His brother never did come to see him but sent him cards and remained in touch. It turned out that substance use treatment in prison was helpful, and being incarcerated ensured that he was less likely to use. As his cravings to use subsided, Jimmy became less depressed. He knew what he had done, and he felt terrible. At the same time, he knew he had no other option but to continue to improve himself. He couldn't give back the life he took. He couldn't fix all of the relationships he had broken. So he devoted himself to the only thing possible - moving forward. When he was released, now a man in his 60s, Jimmy contacted the family of the young boy he had accidentally killed. He apologized deeply, and they graciously accepted his apology, but they would forever be scarred because of his actions, and Jimmy knew it. He spent the remainder of his life making welded art, staying abstinent, and going to church. When he died of a heart attack at the age of 66, he left all of his savings and home to the family of the boy.