…”number twos”.

Last Wednesday afternoon, as I sat in the waiting room at the methadone clinic – I had once before accidentally walked into thinking it was an ordinary walk-in medical clinic -  after being sent there by my GP who told me that it was now my only option aside from inpatient detox (an option I was not interested in as all of the people that I’ve met who have been only left detox with new connections to users and dealers of other drugs, and most often, a new addiction, switching from heroin to cocaine or vice-versa) if I wanted to get off Dilaudid (hydromorphone), the energy the space was friendly and boisterous, smiles and kinship all around, and I listened to a man describing some kind of new pill that was soon going to be available for those wanting to get off opiates of any kind.  I was told on the phone before my arrival that the clinic – the Royal Oak on East Broadway at Commercial, just a few blocks from home – dealt almost exclusively with heroin addiction and may not be able to help me, but other conversations I overheard suggested I was not the only one there post-surgery for help getting off prescription synthetic opiate painkillers, a huge relief, as I listened to the man describe how this magical pill eliminated the excruciating withdrawal that I am now all too familiar with.

“She said it was great – no shakes, no sweats, no shits.”

“That is great!  Wow,” the woman he was frenetically talking to, obviously a stranger, was being overly polite.  I’m overly polite in exactly the same way.  Am I that much of a caricature, interested in conversations with strangers, but so eager to prove that I am that I end up sounding like an overzealous nurse – no, an overzealous therapist.  Jesus, what could be further from the truth.  Who am I?  Who…

Whoever I am, whoever I’ve become, I know these three basic “s”s of opiate withdrawal, heroin or not, as well as I know the birthmark on the right side of my chest, trying unsuccessfully to hide under my breast.  Hydromorphone, a synthetic morphine derivative more often called by its brand name – Dilaudid – is said to be three times stronger than heroin.  Whatever that means.

I suppose it means, one morning back at the beginning of April, I had to change my pants three times because I ran out of Dilaudid too early.  Though I had brand new prescriptions in my wallet, they were post-dated for the day that I was supposed to run out and could not be filled until then or else my docter could lose her medical licence for even giving me the pieces of paper early .  So I went through three days of pure hell: a short preview of what was to come after surgery, though I did not know it at the time.  When it came time to hand over those prescription slips for pills – triplicate slips, as all narcotic painkillers, even codeine are ridiculously tightly controlled in this drug-addled province (ridiculous because, as you will read later, the system still doesn’t work) – I was so anxious with anticipation, and so suddenly no longer constipated, as opiates are incredibly constipating – that I lost all control of my bowels and disgusting liquid came pouring out of me in unison with the blood that refused to stop flowing out of my uterus before it was removed, this being the reason why I had taken extra painkillers.  Yes, I filled up two pairs of pants and three toilet bowls before I left the house and still had to run home from the pharmacy before the brown could start running down my skinny legs, as I had changed into a skirt, hoping that I would have more luck in looser clothing.  My little experiment was a failure.

It's a Pill Rainbow!: My psych meds plus extended release Dilaudid (green and pink) and Nabilone (THC for nausea, red and white)

Take one six milligram gelcap with one three milligram gelcap to add up to nine milligrams of extended release hydromorphone once in the morning and once at bedtime. It sounds incredibly simple, much more so than constantly popping immediate release pills as a previous prescription had me doing – three four milligram doses, at “breakfast, noon, and bedtime” and one three milligram dose at “supper” – as they had prescribed when I left the psych ward.  In truth, it was very complicated; any way of dosing Dilaudid was complicated.  But here is the real kicker: before the psych ward I was not addicted to Dilaudid.  I only took it during menstruation, and even though while in Winnipeg I had a period that lasted 18 days, and each day I took Dilaudid, I did not as much as a hint of illness when my uterus finally shut the tap off and I was able to stop taking the painkillers.  I had not been in constant pain around the month since before my first laparoscopy and DNC (the same procedure used to perform an abortion was used to get rid of endometriosis inside my uterus, and the scope took care of anything that had travelled beyond my uterus, into my abdominal cavity).  However, when I entered St. Paul’s hospital, known for having the best pain assessment team in the city (oh, then I had been lucky, or so I was told by every doctor I saw from that point forward, “incredibly lucky”, as there is a year-long waiting list to see a doctor that specializes in controlling pain at their special pain clinic), I just happened to be on day one of my period, one of the most painful days.  Unluckily, I was also force-fed a strong antipsychotic I had never taken before – Loxapine – upon my admission, literally rendering me dumb and mute for the first several days of my stay.

After one dose of Loxapine, I was able to show the doctors how much pain I was in, crying and curled up in the fetal position, but I was not able to tell them that the pain would end with my period - nor do I remember them asking me if the pain was an everyday event. I guess they assumed it was, as I was given liquid hydromorphone for the rest of my month-long stay: seventeen milligrams per day.  True, I did not refuse it, as I kind of just assumed that I was in pain everyday again, that these magic pain specialists had properly assessed me even though they never conversed with me.

I left the hospital completely physically dependent on Dilaudid.

A week later I switched from the immediate release form of the drug to the extended release gelcaps, as trying to snap a tiny two milligram tablet into half proved to be impossible.

But the next time I started menstruating again, I was still in pain despite being on the equivalent of nine milligrams of hydromorphone at all times, so I was given additional immediate release Dilaudid to take for “breakthrough pain” – up to four milligrams every four hours, totalling a potential 38 milligrams of Dilaudid per day.  40 milligrams is considered the level at which anyone is in danger of becoming very addicted to the drug.  As addiction is defined as not only a dependency on a drug, but also an increasing level of tolerance, I found myself needing to take more and more to kill the pain that radiated from my pelvic region down to the tips of my toes, and now I was in pain all month long.  This is a typical reaction to ’round the clock opiate painkiller usage, as the body’s natural means of combating pain shut off, being told by the opiates that their jobs have been outsourced.

Soon I was taking the pills faster than I was getting prescriptions.  However, I did not have to go through physical withdrawal, because in Vancouver, if you’re willing to pay for pain pills rather than, or on top of, taking the ones prescribed to you in your name and thus paid for (at least in part, depending on your income) by provincial “fair pharmacare”, there is a place anyone can go and make such a transaction in a matter of seconds.  Indeed, despite the annoyingly tight control of prescription distribution for the consumers, a huge black market for prescription pills of all sorts still exists.  Examples of annoyances include the fact that due to the triplicate pads used to write these ‘scripts, you must pick up a new one in person – not much fun for someone immobilized by pain – because they cannot be faxed to a pharmacy or called in, but must bear original signitures on the first sheet of the three; as well, doctors are not allowed to give refills on narcotic medications, so you must visit your doctor each time you need more, and you must go often, as they are not allowed to distribute more than about a two week supply at a time.

Actually, it is hardly a “black market” in the traditional, underground sense.  At the Carnegie Community Centre in the heart of the notorious Downtown Eastside, located at Main Street and East Hastings Street, there is a very large open-air pharmacy run by civilians.  At almost all times, at

The open-air "pharmacy" where you can buy and sell pills, undisturbed by police, at Main and East Hastings

least thirty or so people are outside, earning a living – or supplementing social assistance payments of $520 per month, a joke of a cheque that is purported to cover all living expenses in the most unaffordable city in North America, due to housing costs thrust up by the mass investment of wealthy people from Hong Kong in real estate, beginning in the early nineties when fear that they would loose their fortunes upon returning from British colonial to Chinese communist government caused them to hurriedly put it somewhere else, overseas, but in the nearest and most pleasing housing market, that of Vancouver.  My bachelor suite in East Vancouver is a “bargain” at $800/month, not including utilities.  Many people my age, including my roommate from first year university, who insist on living downtown for the “view” of the skyline, Ocean, or mountains, go without furniture because their monthly rent is over double what I pay.

At the steps of the community centre, someone will approach you and ask what you’re looking to purchase (“Dillies?”, I asked for on a couple of desperate occasions, the street name for Dilaudid), and then direct you towards individuals with huge bottles of your pill of choice in their pockets that they were prescribed themselves.  The motivation to sell one’s prescription is high, as one eight milligram pill of Dilaudid costs ten dollars.  One twenty milligram pill of Oxycontin goes for twenty. Street drugs like crack cocaine and heroin are also available, but buying these off street dealers comes with an additional cost – twenty people died this year when a “bad batch” of heroin was sold on those steps.

At the end of the day, it ends up being easier to purchase a few extra pills at the “pharmacy” in front of the Carnegie than trying to get a legitimate prescription from a doctor.  Thus, it is more likely than not that someone on a high dose of an opiate like Dilaudid taken for chronic pain will end up there during the course of their treatment at least once or twice, now diving into dosages that are above those prescribed and known about by one’s doctor.  It is basically impossible to be honest about things, as if a patient so much as mentions the open-air, civilian-run pharmacy, s/he will be confronted with the strong possibility of being immediately cut off all pain medication – a pain patient’s worst fear, as not only will s/he face the notion of being in crippling pain once again, but also in crippling withdrawal – a state that is characterized by many “s” words:

• Shakes
• Shivers
• Sweats, as one constantly shifts from being too hot to too cold, until one’s skin is covered in a film of sticky, smelly filth
• Sleeplessness, characterized by feeling exahausted all of the time, but also as if someone stapled your eyes open
• Spasms – both muscle twitches all over the body, and shooting pains in one’s bowels, as extreme constipation gives way to extreme diarrhea, or
• Sphincter, that is, the loss of control of it
• Stomach upset, nausea and vomiting
• Sensitivity to sound, light
• Spitting, as one’s saliva tastes toxic
• Swallowing, which becomes almost impossible as your throat seems to seal shut, so you get obsessed with trying.  And, last, but certainly not least…
• Shits, The – the worst you’ve ever had – e.coli poisoning in Peru seemed like a cakewalk compared with this

After my surgery, the pelvic pain I had experienced beforehand immediately went away, giving me a new lease on life.  However, I faced a brand new demon.

My wonderful surgeon had always admitted that she did not know much about pain control, aside from finding Dilaudid most useful in her experience.  Evidently, she does not know much about how to taper off painkillers either.  Added to the fact that I was, at times, taking more Dilaudid than she was prescribing, things became very messy.  After the successful surgery, she immediately took me off the nine milligrams per day of extended release hydromorphone, and prescribed a bottle of 60, 40 mg immediate release tablets.  She told me just to take them at further and further intervals apart as the post-surgical pain went away and I no longer needed the use of their painkilling effect, and to come back and see her in two weeks if I happened to still be in pain.  The bottle lasted me one week – I was taking approximately 38 mg per day, just to avoid withdrawal.  Each morning that week, I would wake up to the sound of construction going on at a building across the back lane, feeling like someone was sawing through my head, which was covered in that awful, sticky film of sweat that is specific only to this kind of withdrawal, my temples and forehead already being pierced by the light coming through my windows.  Then came the stabbing, shooting pains in my butt, and the feeling of needing to vomit, though I never could – it is very hard for me to throw up, even when I’m really sick I have to help myself along by fingering my gag reflex.  Never mind the pain around the places inside my body where incisions had been made – next to both ovaries and at the top of my vagina – everything was painful.  The bottoms of my feet hurt when I walked.

So I went to see my GP, explaining that I was desperate, and desperately wanted to get off the Dilaudid.  She put me back up to the nine milligrams of the extended release version of the drug – telling me we would “go slow, and taper down by a milligram or two every few weeks” -to be picked up daily from the pharmacy: six, three milligram tablets – three to take when I woke up, and three to take before going to sleep at night.  However, I took the three and waited an hour, an hour and a half – and nothing, no relief, I still felt like death, so I would take the other three.  This kept me out of withdrawal during the day, and my regular sleeping pill regimen – 15 mg of Imovane (zopiclone) before bed – allowed me to sleep at night.  The next morning it would all begin again, only by the fifth day, the eightteen milligrams were no longer eliminating the symptoms of withdrawal, and I felt like the pain from the latter, largest incision, was getting worse.

I went back to see her, worried that I had pushed myself too hard and done some kind of damage – I started walking to the grocery store and running other errands a few days before the pamphlet I had, labelled “Vaginal Hysterectomy: What to Expect”, said that I should, because I had become so restless, lying around the house and watching television – this is not how I usually spend my time, and coupled with withdrawal, time seemed to have slowed down exponentially.

The good news was that I had not – one reason why I hadn’t been worried in the first place about going out was doctors have told me before (especiallly when I mangled my arms) that I am a fast healer.  The bad news was that my addiction to Dilaudid was severe, and beyond her expertise.  And so I sat in the waiting room of the Royal Oak Clinic, praying that a doctor there would help me save my life, as I could not go through this – I would start buying pills off the street – the urge was involuntary, and much bigger than me.  I sat and listened to people of all ages, sexes, and colours, some of them sweating profusely, talking about the exact same way I had been feeling for the better part of a week.

When I was called in to see the doctor, a young woman whose angel wings were almost visible to the naked eye, it was an immense relief to be able to be completely and brutally honest about the past several months, as I have been here – about the “career” of my addiction.  I left with a prescription for 30 mg of methadone, to be taken daily at the pharmacy.  The angel explained to me that methadone is essentially heroin, but in pure form.  About half an hour after taking my first dose, I felt true, absolute relief for the first time, as the withdrawal was not only calmed, but so were my worries about my finances, as there was no longer a possibility that I would have to spend money just to feel human.

My joints are still achey though, yet another joy of withdrawal, and I still experience some hot flashes.  My wonderful pharmacist, Maggie, told me that I will probably need to increase my dosage by ten milligrams.  Thus, I will return to the clinic tomorrow, when my new doctor (yet another new doctor!  ) is scheduled to be on shift again.

(to be continued…  )