This is a story about Michael and his experiences with substance use and treatment. There are no “average” stories about substance use as each story is someone’s life but Michael’s experiences are very typical for someone dealing with substance use.

Michael started experimenting with substances as a young man. He started using some weed and snuck into his parent’s liquor cabinet a few times when he was in high school, just like a lot of kids. He graduated high school and went off to college. Michael lasted at school to the end of his freshman year, but just barely. With the freedom to spend his time as he chose, all the parties, the girls, the grain alcohol and beer flowing freely, and access to drugs of all descriptions, Michael didn’t see the inside of a classroom very often. When he did make it to class, he wasn’t always in the best shape for learning. Michael was overindulging in substances as many young people do at that age. Most stop entirely on their own as their interests and goals change and they “age out” of using as heavily.

It might have been a fun, eye-opening introduction to the world beyond his hometown but the end of the school year signaled an end to Michael’s party life at college. The college suggested Michael reapply when he was more ready to be away from home on his own and attend to his studies. His mother cried and his father yelled. Michael told them everyone was partying. When that explanation didn’t work, he agreed to come home, work the summer at his father’s business, and try to “grow up” in the words of his dad.

At first, Michael was getting to work every day and earning money working in his father’s construction business. Some of his high school friends were on the crew and Michael resumed his friendships with the guys. He also started a pattern of cashing his paychecks on Fridays and partying with his pals over the weekend as many young men do. He and his buddies would drink, do drugs- whatever they could get their hands on – and party with girls. It became harder for Michael to make it in on Mondays and he wasn’t in great shape to work.

Soon Michael had a hard time putting the brakes on his partying when the weekend ended. Sometimes he would drink a bit too much weeknights and use a little something to get him going in the morning or keep him going through the day. Michael started calling out of work here and there when he wasn’t in shape to make it in. His father yelled, his mother cried, and Michael promised to change.

One day, about two months in to working construction, Michael was at work but feeling a little the worse for the wear from the previous night’s partying so he wasn’t paying attention. He ended up injuring himself on the job by being careless with the equipment and narrowly missed hurting one of his friends as well. Between the pain of the injury and the guilt he felt over almost hurting his friend, Michael decided to quit using substances immediately.

He went to the ER, was patched up, and got a prescription for painkillers for his injury. It was a few days worth of painkillers and Michael took them to help with the pain. After all, he had legitimate pain from the injury. He found he liked how the pain went away – and everything else he felt too. Michael used his pills up early and went to his family doctor, Dr. Webster, for more. Dr.Webster talked to Michael about physical therapy and other pain approaches but refused to extend Michael’s prescription. Michael was angry with Dr. Webster for not helping him with his pain but he left empty handed.

Bored at home while he was recovering, Michael went through the house and found some old Oxycontin® that his mother got a year earlier after her gall bladder operation. He also found some Ambien® his father took occasionally to help him sleep. Michael decided to take some Oxycontin®and a few Ambien® to help him relax and sleep as he had had a restless night before worrying about running out of his pain meds. Michael knew alcohol also helped him relax so he took a couple drinks. He started to feel warm, heavy, and sleepy, and soon drifted off.

Michael woke up bewildered. He didn’t feel quite right and it was very bright. He noticed the IV in his arm first and guessed he was in a hospital. The ER doctor explained Michael had overdosed and they would need to keep him overnight to be sure he was stable. The doctor asked him if he had intended to commit suicide. That question shocked Michael. He assured the doctor the overdose was an accident and he was probably just a bit mixed up from the injury. It was just a mistake. The doctor warned Michael that he had been lucky this time as mixing opioids, barbiturates, and alcohol increased their effects exponentially and depressed his central nervous system, especially the respiratory system. Michael assured the doctor it was a onetime accident.

His mother and father came in to see him. His mother looked very shaken and small. She told him how she had come home and found him pale, clammy, and unresponsive. She said he was barely breathing when she called the ambulance. His father was furious with him for putting his mother through this and for being so “stupid”. Michael started to get mad to but he looked at his mother and felt terrible.

The doctor came back in with information on a rehab that Michael could go to for help with his addiction. Michael didn’t feel he needed any help. He certainly wasn’t addicted. This was all just an accident and it would never happen again. Why didn’t anybody see that? Michael’s father insisted if Michael was going to come home that he had to go to either meetings or rehab. Michael decided to go to support meetings and return to work when he was finished healing.

Michael found a nearby AA meeting at one of the local churches. Michael knew he wasn’t an alcoholic or an addict so he felt uncomfortable, especially being in the spotlight as a new person at the meeting. He started to tell the story of his accidental overdose. A man stopped him and told him he was in denial. The more Michael explained or protested his overdose was just a mistake, the more the man insisted Michael wasn’t admitting his problem of his powerlessness over drugs and alcohol. Michael felt he didn’t fit here. Michael drank and used drugs because he liked how they made him feel. No, he didn’t relate to the people in AA and he wasn’t coming back.

Michael went back to work and fell back into his pattern of working and partying, after all he was 21 and single. He had to be more careful about hiding his use as his family thought he was “sober”. He went off to his “meetings” regularly but would meet friends to hang out at their home or at a bar instead.

When his parents found out and confronted him about not attending meetings and breaking his promise to stay sober, it was decided he would go to rehab. His father didn’t give him a choice about going to rehab this time – unless you count choice as choosing between going to rehab and living on the street.

Michael stayed at rehab the usual 28 days including a few days as he detoxed off the alcohol and pills he had been doing. Going to rehab was a little like going back to AA meetings. He attended meetings while in rehab as well as talking with his counselor. Michael quickly learned he wouldn’t get anywhere unless he “admitted” to being an alcoholic and drug addict. Being ”in denial” didn’t get him anywhere so he decided to “play the game” and give them the answers they wanted. He got more privileges doing that and was discharged from rehab sooner. Instead of going to a sober home or halfway house for aftercare, Michael returned home.

Michael was glad to be out of rehab and away from its restrictive rules. He hadn’t been able to talk to his friends or family on the phone or use his computer. He didn’t miss anything about rehab, except maybe a couple of the guys and a girl he met there. They had all shared their drug use experiences while there. Some of them had done substances he hadn’t or used in ways he hadn’t tried yet. One thing he learned was to start using prescription drugs that were prescribed to his friends and family. He would go into medicine chests or bedside tables and take a pill or two when he could. He enjoyed the feeling he got from using opioids. When it became harder to find a source for prescription pills, he would buy them from a dealer. Sometimes he couldn’t find a source for pills and then he tried heroin. He wasn’t addicted. He was just using because he liked how it made him feel.

Michael met up with some of his new friends as they had all gotten out of rehab within a few weeks of each other. They met up at an apartment and hung out, drinking, talking, and sharing how it was to be out of rehab. One of the guys produced some pills and heroin. Michael had some. He was careful to use at a dose he previously used safely before going to rehab. He felt the familiar rush of warmth and just sank into it.

Michael woke up by being jolted into awareness and feeling awful. He saw concerned faces hovering over him and was confused. Michael later found out he had overdosed again and his friends had called 911 for help. One of the EMTs had given him Narcan® to reverse the overdose. It also had the effect of making him feel pretty awful almost immediately.

Although Michael was used to taking that dose of heroin and pills prior to rehab, he hadn’t accounted for the fact that he was detoxed and his body wasn’t used to that level anymore. The doctor at the ER explained this actually happens a great deal. People go to rehab, get out after being detoxed and not using regularly for some time, and then when they use at a level that was safe before, they overdose. The doctor talked to Michael about what he wanted to do from here. Did he want a referral to intensive outpatient treatment, back to rehab, or maybe try sober living?

Michael decided to think about it. He didn’t want to tell his parents about this last overdose until he had a plan. They would know when the ER bill came in but he still had a little time to think. After staying a few hours for the Narcan® to wear off and make sure he was not going to overdose again, Michael went home.

Michael decided to look up treatment centers online himself and get ahead of it before his father sent him somewhere. Within a few hours, Michael was overwhelmed. Looking up a few centers and making preliminary calls wasn’t getting him anywhere. It was very confusing and much of it started to sound the same.

Most of what he heard was asking about what health insurance he had. As he was still covered under his father’s policy, the people on the phone were eager to get him to commit to coming in. He wasn’t hearing much other than the same stuff from the rehab he went to before – working it to make it work, the need to go to meetings before, during, and after his stay, etc. It was all the same stuff all over again.

He called a couple places about MAT (medication-assisted treatment). Some of them suggested he should stay on MAT for a lifetime, almost like being a diabetic with insulin. Others talked about tapering the medications gradually, but when he asked how long that meant, most of them said timing was really individualized and they couldn’t say. His friends told him most of the people they knew on MAT never came off it or ended up on higher doses so Michael crossed that off his list. He didn’t want to feel dependent on a medication to function.

When Michael did find a non-12 Step center, it seemed a lot of them blended 12 Step and non-12 Step ideas which confused him. It sounded like he wasn’t getting anything new and he would have to accept going back to a rehab and getting through it to please his parents. He really couldn’t see how doing the same thing over again was going to help him change, but he felt he needed to do something. He really didn’t feel he had a choice. Michael decided he needed to go back to rehab.

Michael told his parents about the overdose. They were very disappointed. Although the cost of returning him to treatment was beginning to weigh on his parents, they felt he needed to go back to detox and treatment as soon as possible. He went through a detox and treatment again at the same rehab as before.

When Michael got out of rehab the second time, he didn’t feel things had changed much. Michael did try to stay sober. He would succeed for short periods of time, sometimes months, sometimes weeks. He tried to really go to meetings for support but he didn’t get into a regular habit of going. Something would happen and he would drink or use a little and suddenly he felt out of control again. Michael would feel guilty and decide to get sober again. Eventually as it seemed pointless to try, he was sober less and less and using drugs and alcohol more and more.

Michael wasn’t talking about continuing his education, getting a steady job, or moving on with his life. He felt stuck in a rut and unable to manage much of anything. His parents would threaten to make him leave. Eventually he got an apartment with a friend and moved out. He saw less of his parents and his friends and seemed to be drifting aimlessly. He didn’t come up with his share of the rent a couple times and eventually his buddy kicked him out.

Michael started to inject heroin, a line he had thought he would never cross when he first started using. Now it didn’t seem to matter as long as he could get away from life for a little while. His goals became to not feel much of anything and avoid withdrawal for a little longer.

He would visit his mother occasionally. His father had decided not to support or speak to Michael until he got clean. Michael’s mother would see him occasionally at the house when his father was away or sometimes just around town. She would give him a little money and tell him he needed to stop. Michael would agree even as he had no idea how to stop using.

Michael ended up one day going to the hospital hoping to get some meds. He felt withdrawal coming on and he hadn’t felt well enough to get more. The doctor at the ER told Michael he wasn’t going to give him painkillers but he did need treatment for Hepatitis C. He had probably gotten it injecting heroin. It was a 12-week course of treatment and he needed to stop drinking entirely. Continuing to drink alcohol could lessen the effectiveness of the treatment as well as lead to more complications including developing cirrhosis, chronic hepatitis, or liver cancer. The doctor felt confident that Michael could be treated and recommended he be admitted to the hospital for detox and to begin the hepatitis treatment. He could go to addiction treatment in the hospital and possibly finish out the treatment while he was there. Michael agreed to do that.

Michael went through detox and treatment and was discharged to a sober living home where he finished the Hepatitis C treatment. He does still need Hepatitis C treatment at times but hasn’t developed any more complications yet. Michael still struggles with substance use and he hasn’t quit drinking entirely.

His mother visited him while he was in the hospital and he even saw his dad once. They hoped going through all this would make him quit using and it did for a while. Michael tried to get a job but it was really hard without much experience or education and a spotty work history. Most people weren’t interested in giving him a shot. He would get odd jobs here and there but nothing to support himself or make a new start. He stayed in sober living as long as they would have him.

No one is really quite sure where Michael is now. He turns up now and again. His mother fears every time the phone rings it will be a stranger on the line saying Michael was found dead.

Michael is one of a small minority of people who use substances excessively but this small minority is the majority of people who end up going to treatment. It’s estimated that over 90% of people overcome heavy substance use on their own without any formal interventions like treatment. When people do start treatment, it can lead to a vicious cycle of rehab, recovery, and relapse. Many people who have been to treatment have learned to expect and accept the cycle of rehab, recovery, and relapse. Many of these people learned they are powerless and aren’t sure how to end this cycle. Some don’t believe they can ever end this cycle. Some people, like Michael, give up trying to deal with their substance use at all, and may end up suffering any one of a number of natural consequences of long-term heavy substance use.

Michael contracted Hepatitis C but there are many other common issues of heavy substance use including Hepatitis B, HIV, tuberculosis, and other illnesses and infections. In addition, in medically treating overdoses, complications can arise such as brain damage, organ failure, dialysis, aspiration pneumonia, sepsis, and a need for mechanical ventilation and ICU support to name a few. People with substance use disorders who give up are likely to have one or more of these health care crises and be super utilizers of health care resources.

Michael has cost himself and those around him a great deal in both direct and indirect costs of long-term heavy substance use. Michael is lost and feels unable to find a way out of his circumstances permanently. He is not employed, paying taxes, or contributing to society. His father and mother have suffered the loss of their son and all the hopes and dreams that go with that. Their own health and relationship has suffered from their different ideas on how to handle helping Michael or not. The stress of knowing Michael is out there is hard on both of them.

If Michael had had other options with substance use, his life might be quite different. If he had had hope to deal with his substance use and know he could successfully move on from his temporary heavy use, he might be leading a very different life now. Who knows what Michael would be doing? Would he have a family? Would he have a career? Would he have continued his education? What is clear is Michael , his family, and his community have been changed by Michael feeling powerless and giving up on dealing with his substance use issues but we will never know exactly how much it truly cost us all.

If there had been a different option available for Michael, what would his life be now? With the resources spent and pain suffered, in the end, was it really worth it?