Some background: Opioids like fentanyl, heroin and methadone are full agonists. Basically this means they have a strong effect. On the other end of the spectrum, you have opioid antagonists, such as naloxone—these kick the aforementioned full-agonist opioids off your receptors, which is why naloxone is great for reversing overdose.

Opioid overdose causes respiratory depression, and the right dose of an antagonist clears out just enough of the full agonist to let someone start breathing on their own again. But an excessive dose—one that doesn’t leave enough of the full agonist behind—puts the person into withdrawal. But all at once, rather than over the course of hours, and trying to make the symptoms go away is difficult and dangerous. This state is called precipitated withdrawal. It sucks.

Buprenorphine, AKA Suboxone or just “bupe,” is a partial opioid agonist. This means it’s a very effective MOUD for some people, while for others it’s just not enough. But it also means that bupe can precipitate withdrawal, too, if someone takes it while they still have too much of a full-agonist opioid in their system.

Over my many years of using many different opioids, I’ve adapted the Bernese method to my daily life.

The traditional way of getting on bupe is that you have to wait until you’re way into regular withdrawal before you start taking it, to avoid precipitating withdrawal. And if you get desperate and take it too soon, or a doctor misgauges how long you should wait, you end up precipitating withdrawal anyway.

There are a small number of alternative methods that are much more humane, the best known being microdosing through the Bernese method. This basically involves starting with tiny doses of bupe that you gradually increase while you continue using your usual opioids, and doesn’t require you to be in a miserable state to get started. It’s a short-term thing, just for the period of transitioning away from the full agonist. But over my many years of using many different opioids, I’ve adapted the microdosing protocol to my daily life.

This works for me for two reasons. First, I’m semi-regularly in situations where I need to switch over fully to bupe for a few days—family gatherings, that type of thing. Second, my tolerance is pretty high. If it weren’t for those two things, I wouldn’t be doing this. Nothing in this article is medical advice, just in case that wasn’t obvious.

Let’s say I’m using a bundle—10 bags—of fentanyl per day. (Or rather, fentanyl plus whatever else ends up in there these days.) And let’s say in 10 days I’m going to get on a plane to visit family, and I’ll need to get by on just the bupe until I’m back home.

I can’t just switch over from fentanyl all at once. So at T-minus 10 days I’d get one of my 8-mg Suboxone strips and take just a tiny piece—about one-tenth of the strip. And I’ll take that on top of my 10 bags. At T-minus nine days, I take two of those pieces, and drop my street supply intake down to nine bags. At T-minus eight days, three-tenths of the Suboxone strip and eight bags of dope, and so on and so forth.

Once a day, about three days a week, I take 1 mg of Suboxone.

This is not a perfect system. Of the dozens of times I’ve done this, only one single time did I manage to pull it off flawlessly; if you graphed it, with bupe going up and the fent going down, it would have made a perfect X. Bernese himself would have given me a kiss. The Bernese method is actually named after Bern, Switzerland, but that’s not the point.

So even though I’ve been doing this over a decade, I still almost always end up with some withdrawal symptoms here and there. What I’ve found makes the process smoother is to keep a low level of bupe in my system at all times, not just special occasions. 

Once a day, about three days a week, I take 1 mg of Suboxone. I’m just eyeballing one-eighth of a strip as I tear it off, so each piece is probably between 0.75 mg and 1.25 mg.

Despite the concern about using bupe too soon after using a full agonist like fentanyl, it’s never made that much difference whether I take the bupe before or after I start using fentanyl for the day—but this is because I use a lot of fentanyl. For someone using smaller quantities, or a less-potent opioid, 1 mg of Suboxone could easily throw them into vicious precipitated withdrawal if they take it too soon. 

Usually I do my two-bag wakeup dose of fentanyl first thing in the morning, and then see how I’m feeling. If I’m feeling good, and it’s one of the three-ish days a week I’m microdosing, I’ll take the little piece of bupe right then and get it out of the way—because while I appreciate bupe as a useful tool, and know what a literal lifesaver it is for so many people, personally I kinda hate it. I don’t get any effect from it, and it often dulls the fentanyl. So I have to keep an eye on whether my fentanyl use goes up as a result of the microdosing, and sometimes it does. But overall this has been manageable, and the constant microdosing seems to help acclimate my brain to the partial agonist—both physically and mentally.

Image via New Mexico State Legislature

The post Why I Microdose Suboxone, While Continuing to Use Lots of Fentanyl appeared first on Filter.

Cotton fever is a kind of short-term bacterial infection that generally comes from reusing old cottons to inject drugs, though most people associate it with opioids specifically. When you can feel withdrawal coming on and you don’t have any opioids, or money, and you’re checking all your pockets and looking everywhere but can’t find any, often what you do have lying around is a cooker or other container with used cottons. AKA the miniature cotton balls used as filters to keep unwanted particulates from getting inside a needle and thus inside your veins. Now those old cottons are like tiny dried-out sponges, which you can rehydrate to squeeze out the dregs of whatever they’d previously soaked up. 

That’s when people get cotton fever. If bacteria have grown in the cottons since the last time they were used, injecting can be unpleasant. Vicious nausea, fever, chills, all that, but it won’t kill you; it’ll be over in a couple of hours, or by the next morning. But a lot of good cottons go to waste because of cotton fever, and it doesn’t have to be that way.

The general advice that people give is if you know you’re going to reuse your cottons at some point, throw them in the freezer to cut down on the amount of bacteria that can grow in the intervening time. This can help, but it’s no guarantee.

For years, I tried everything under the sun to beat cotton fever. I would take cottons that I knew had to be full of bacteria and I’d save them in the freezer anyway, then guinea-pig myself by putting them in a cooker with 400cc of water and boiling it all the way down. Which takes several minutes of continuous boiling to do. Guess what? Still gave myself cotton fever. 

I can’t say whether this is the absolute best method, but I can say that I haven’t had cotton fever since I started doing things this way.

The last time I ever got cotton fever, I was in a bad spot. Not with my drug problem, but with my running-out-of-money problem. So it was the sort of situation where I was just rounding up every old cotton I could find. No idea how old they were, whose they were, what used to be in them. Within about 10 minutes of doing the shot I felt the leg cramps coming on. That’s often an early warning sign.

I could tell this was going to be a bad one, and that in another 10 minutes I probably would be in the fetal position, in withdrawal on top of the cotton fever. Hobbled out the door and down to the apartment of a neighborhood supplier, and of course in addition to having no money I’d also neglected to charge my phone, so I had to knock on his door, which he despises. At first he wasn’t going to front me anything, but then I threw up in his doorway kind of close to his shoes, and he gave me two nickel bags and told me to get out.

I sniffed one on the way back, but sadly my tolerance isn’t at a point where sniffing does anything useful for me, plus I was viciously retching the whole way. I actually might have called an ambulance, if my phone hadn’t been dead. It was almost impossible to make the shot but when I finally managed to do it and the withdrawal symptoms were gone, from there I was at least able to get my head on straight enough to take a pile of Advil and Tylenol and start hydrating.

Early in the COVID-19 pandemic, you’d end up with cottons that were yellow or purple or red and you’d remember who’d been selling dope that color.

After that, I decided I was going to do things the right way. The system I came up with has seen me through ever since.

I use a plastic pill organizer, preferably the 30-day kind, that I keep in the freezer. Once I’ve used a cotton—making sure to pull as much of the liquid out as possible—it goes straight in there, one cotton per compartment. That way you can label them so later you have some idea of what they once were.

Early in the COVID-19 pandemic when every color of fentanyl was coming through the neighborhood, that was great. You’d end up with cottons that were yellow or purple or red, and you’d remember who’d been selling dope that color. But in regular times cottons are brown and interchangeable, so you want some sort of system.

Cotton fever won’t kill you, but underestimating the quantity of opioids left in there and using them alone might kill you. It’s not that uncommon for people to overdose and die because someone else gave them their old cottons to help them out. So label the compartments, in whatever manner helps you remember what’s in them.

In addition to labeling, I put the whole plastic container inside a heavy-duty gallon Ziploc, and then throw in about 10 of those little silica gel desiccant packets that come inside shoe boxes or pill bottles. I can’t say whether this is scientifically the absolute best storage method, but I can say that I haven’t had cotton fever since I started doing things this way.

When it’s time to use them, take however many cottons you might need—there’s no correct number because every situation is different—and put them in a cooker with your usual amount of water, plus about 40 percent because it’s going to boil off. As it’s boiling, smush the cottons with the butt end of the plunger to press out as much of their contents as you can. Once said contents are floating around in the water that remains, draw it all back up through each cotton one by one. Once all that liquid is in the syringe, set the syringe aside. Don’t throw away the cottons; they’re not done yet.

Take a second syringe, which you’re basically going to use for parts rather than use it to inject—I call these “working” syringes—and remove the plunger. Then take the cottons from the cooker and put them inside the barrel. In that same cooker, boil up a little more water, maybe 30cc, and once it’s boiling use a third syringe to draw it up and squirt it into the barrel of the syringe with the cottons.

Put the plunger back in, and sloooowly force that boiling-hot water down through the cottons and back into the cooker. When you get to the bottom, squeeze as hard as you can to get those last drops; those are the most valuable. After that you can throw the cottons out. Now they’re done.

Images via Kastalia Medrano

The post How I Freeze My Cottons, So As to Never Get Cotton Fever Again appeared first on Filter.

But New York City wasn’t too far away, and so by the second semester of my freshman year, I was driving down every weekend and hitting as many clubs as I could. My first year of college also happened to be my last year of college. 

Pretty soon I started selling the nightlife drugs I was using, in order to afford going out that much. By that fall, when classes started up again for what would have been my sophomore year, I was full-on wheeling and dealing. Liquid acid, paper acid, acid gel tabs, ketamine, mescaline microdots. And ecstasy pills.

Ecstasy, or MDMA, all came from the Netherlands in those days. The pure “molly” that you’d hear whispers of—the kind that smells like sassafras, that’s been synthesized properly and will blow any pressed pill you’ve ever taken out of the water—was already over by 1998. But for a short time the pressed MDMA pills were still quality.

There were blue dolphins. Green RNs. Speckled crowns. There were so many kinds of the Mitsubishi-stamp pills it was getting out of hand. Mitsubishi GTs. Mitsubishi GT turbos. Double-stacked Mitsubishi GT turbos. Triple-stacked Mitsubishi GT turbos. They did stop after quadruple-stacked, since most people don’t actually want a pill that’s approaching the dimensions of a Big Mac. 

Everything was advertised as MDMA, but often you’d end up with MDA, or MDEA, or some other amphetamine derivative. There were two kinds in particular—Yellow Sunshines, and the Skull and Crossbones—that were outrageously speedy; one pill could keep you up for three days, reminiscent of a different well-known amphetamine.

Often I distinguished MDMA from the speedier, more hallucinogenic MDA by just taking a pill and figuring the rest of that batch was the same. But for sales purposes I needed something a bit more reliable, because once I started picking up 1,000-packs there were way too many different stamps and color and shapes. I didn’t want to sell something if I couldn’t even tell the buyer what it was.

We’ve just released what is effectively an all-new reagent instruction pamphlet, as well as a fully redesigned heatstroke pamphlet! More info on our website, in the most recent article posted. pic.twitter.com/uKpJ2VLbTv

— DanceSafe (@DanceSafe) May 1, 2024

Nightlife harm reduction nonprofit DanceSafe had just been founded in 1998, and when they started selling drug-testing reagent kits I was all in. When the chemical reagents interact with different drug samples they change to different colors, which you then cross-reference with a corresponding color chart. This gave me a sense of whether a pill was MDMA-based or MDA-based, and allowed me to share the info with people who were buying.

Reagent testing wasn’t something most people were doing, but I wasn’t the only one; people who were really serious about MDMA, whether for personal use or for business purposes, were ordering the kits too. The results didn’t indicate anything about potency, but were still helpful in determining how much to take because we knew MDA was more potent than MDMA.

According to my test results at least, MDMA was fading away while more pills seemed to comprise MDA and things that reagent testing couldn’t identify. And then around 2001, the market shifted toward ecstasy pills people began producing domestically.

The new supply was a lot cheaper than what we’d been getting from Amsterdam—around $1 to $3 per pill when you bought 1,000 at a time, whereas before it had been $7 or $9 per pill. But the quality went way down, to the point that I stopped using them. And because of that, I didn’t feel comfortable selling them anymore.

Image (cropped) via National Science Foundation

The post Props for Public Drug-Checking, From Someone Who Sold MDMA in the ’90s appeared first on Filter.

Oxycodone, oxymorphone, hydromorphone, methadone. It was the golden age of doctor-shopping. Anything was possible. One general practitioner wanted to wean me off the 10 mg Percocets he’d been prescribing and switch me to fentanyl patches. He said that because fentanyl was a designer drug, there was less risk of me getting addicted.

At first I was just sticking to prescribers inside the Medicaid network, but that would only cover one prescription of each class of drug per month. So I branched out to those who generously allowed me to pay in cash. Sometimes you’d have to give the doctor $100 on your way out, then give another $100 to the receptionist—his wife—but for the most part the out-of-pocket costs were really negligible. A lot of us made a living this way, reselling the drugs to people without prescriptions of their own.

Not all generics are created equal, or at least what people believe.

It wasn’t just opioids. But, as pharmaceuticals go, opioids are cheap. The rectangular white “coffins”—methadone tablets, the kind there was a market for—I was getting prescribed at 60 mg per day for pain. Each tablet cost me about $0.71, and would resale for between $6 and $8.

A prescription for 8 mg generic hydromorphone tablets, three times a day—the circle-shaped kind, not the shield-shaped kind—cost me $1.09 per tablet. Those sold all day long for $8 per tablet, and that was for bulk buys of 100 at a time. If someone was buying singles, they paid $12 per tablet.

Not all generics are created equal, or so people believe. People wanted not just any generic Xanax, but the 2 mg “G3722” manufactured by Greenstone LLC. They wanted the Teva Pharmaceuticals generic Klonopin, not another kind. The 30 mg orange ovals of generic Adderall were the most popular, though the round pink 20 mg tablets were up there too.

Some preferences it’s fair to chalk up to mythology, or individual things people had convinced themselves about the properties of one generic versus another. But, not to attach a moral value to drugs, some pills are obviously better or worse than others. 

One company’s 2 mg buprenorphine tablet might be just a little microdot, the way it ought to be, but Roxane Laboratories made a 2 mg that was huge. All filler. Even if you weren’t going to crush and inject it, it was just this big ball of chalk no one wanted to deal with.

In the first couple of appointments one doctor kept sticking me with generic Adderall tablets that were not 5 mg, not 10 mg, but 7.5 mg. As if anyone had ever heard of such a thing. They had tons of filler, and nobody wanted to buy them in the first place because they were weird. 

A monthly prescription of roxies could pay your rent, and that was just one scrip from just one doctor.

But 30 mg Roxicodone (roxies) tablets, if they were the M-30s everyone wanted, were going for $30 each. A monthly prescription could pay your rent, and that was just one scrip from just one doctor. I knew so many people who, in 2014 when the PDMP really came into full swing, man that was it for them. Their rent wasn’t paid, they had nothing. Had to figure everything out from scratch if they could.

These days, PDMP are how the Drug Enforcement Administration tracks controlled substance prescriptions—mainly opioids, especially if they come with a benzodiazepine and a muscle relaxant—by doctors who catered to such doctor-shoppers as myself. Whereas in 2012 my 11 doctors didn’t know about each other, or at least could pretend they didn’t, now prescribers are generally required to check a state database before they write you a prescription for anything interesting, and pharmacists must do the same before they fill it.

It’s been probably 10 years now since I’ve seen methadone pills on the street. PDMP and the opioid prescription crackdowns cut off tons of chronic pain patients from the pharmaceuticals they were using for an approved medical purpose, and many ended up navigating the much riskier street supply.

Doctor-shoppers like me were blamed for the crackdowns. But when you moralize drug use, there’s never a black-and-white line between the people whose need for pharmaceuticals is legitimate and the people whose need is not. All of us were cut off or suddenly faced with barriers to everything except street supply. When the supply we’d been using was safer.

Image via Wyoming Department of Health

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Prescriptions for an opioid, a benzodiazepine and a muscle relaxant is what the Drug Enforcement Administration calls the “trinity cocktail.” Some rehab programs will prescribe you benzos, and in my case it was always ideal if I could get them on the push—through an IV rather than in pill form. Midazolam (Versed), temazepam (Restoril) and of course diazepam (Valium) all took the edge off of withdrawal, both physically and mentally.

Best-case scenario was getting the “nursing dose”—when you’re getting meds on the push, the ampule they’re coming out of usually has about double whatever your dose is. The extra dose is supposed to go to waste, unless the nurse dispensing it decides you should have it instead.

If benzos weren’t an option, barbiturates like phenobarbitol helped. But if the barbies too were off-limits, then it was down to muscle relaxants, anticonvulsants and blood-pressure medications. Some of which have a lot of nonprescribed value to squeeze out of them, as many people who use opioids have learned to do.

The intake staff who conduct your initial screening call are often of the mindset that it doesn’t matter whether you’ll be detoxing from just opioids, or from opioids plus alcohol plus benzodiazepines plus barbiturates, because you’re gonna get detoxed the same way—cold-turkey from everything. But when they saw me as someone with a really serious opioid problem, who really needed to be saved, they were often eager to steer me toward “non-narcotic” alternatives. Opioid stigma at its finest. If staff weren’t already pushing these options on me, I basically just had to say what they were already thinking.

On the street I’d be getting Dilaudid, but I’m trying to be “good” so I just want a non-opioid option like gabapentin.

I really don’t want anything heavy for my anxiety, I only take clonidine because I’m trying to avoid the narcotics.

Baclofen? I’ve always been on it for my back pain. Heck of a lot better than an opioid, right?

Medications like pregabalin (Lyrica) and gabapentin are invaluable here for the same reason people use them with opioids on the street—they potentiate the effects. Research has shown that short-term use of muscle relaxants combined with opioid analgesics isn’t associated with increased overdose risk, compared to just the opioids alone.

Lyrica is sort of the unofficial gold standard in this context, but has always been under Schedule V of the Controlled Substances Act and is more readily available in some states than others. You’ll more likely get gabapentin, which a handful of states have scheduled according to their own CSA but isn’t a controlled substance at the federal level.

It’s anticonvulsant medication that’s technically for nerve pain, but to hear prescribers tell it gabapentin is a panacea for everything these days. Seizures, anxiety, insomnia, post-surgical pain, menopause, dogs that don’t want to go to the vet. I remember this actually being an even bigger phenomenon back when it was mostly available as the branded version Neurontin. I once saw docs write my detox roommate a Neurontin script when he had a cough and the hiccups.

The muscle relaxant part of the “Trinity” equation used to be synonymous with Soma, the brand name for carisoprodol. It metabolizes into meprobamate, which is basically a barbiturate. Hence the “Soma Coma.” You used to be able to get Soma in Medicaid rehabs but in 2012 it was placed under Schedule IV of the CSA, after which it became less popular with prescribers. 

But baclofen, a different muscle relaxant, is still pretty accessible. So is clonidine, the blood-pressure medication that has helped just about every drug user I know through withdrawal at some point. Three times a day, along with your gabapentin and anything else staff will keep on standing orders for you. They won’t make you taper down off non-narcotics like those. And besides, anything’s better than an opioid, right?

Image (cropped) via Vermont Department of Health. Inset graphic (cropped) via United States Drug Enforcement Administration.

The post All the “Opioid Alternatives” Are at Least Making Rehab More Bearable appeared first on Filter.

In the mid-aughts when I was buying Opana (oxymorphone) and Dilaudid (hydromorphone) off the street, my tolerance was under control in the sense that the pills were working fine for me. Because they’re a sure thing. As long as you’re dealing with legitimate pharmaceuticals, you know what you’re getting every time.

A regulated supply means you can have a tolerance plan. You can budget yourself something that keeps you in that balanced, happy medium between withdrawal and overdose. Not so little that you’re alternating between the toilet and the bed. Not so much that you forget to breathe. 

Anyway, what was getting out of control was the expense. When 80 mg pills are going for $20 and you’re going through 10 or more 80s in a day, that’s your problem. Time to shuffle. Deal yourself a new opioid.

Going through one $10 bag of dope—I personally reserve the term for heroin, which is what we were still getting in those years before fenta-dope came along—in a day was a much more manageable habit than the pharmaceutical analgesics. And the potency didn’t wreck your tolerance so you could still mix in buprenorphine if you happened to have access, as long as you knew what you were doing.

It used to be easier to find the 8 mg Dilaudid tablets. Then just the 4 mg tablets. Then the 2 mg. Some people say the 2 mg is actually better, because physically it’s so small that there’s not a lot of binder—the adhesive powder that holds a tablet together—so it’s easier to inject. Personally I say it’s better to have the bigger pill and figure it out.

I used to be able to get Subutex (buprenorphine) prescribed without too much trouble, but only for six months or so. Any longer and docs start insisting on Suboxone (buprenorphine with naloxone), which is more likely to end in precipitated withdrawal when you’ve got short-acting opioids in the mix. For a while you could say the color additives that made the Suboxone tablets orange gave you a headache and they’d prescribe the white Subutex instead, but they figured that one out eventually.

Opana and Dilaudid seem scarce these days. And the street price of legitimate pharmaceuticals is such that when you do have access, it’s more economical to sell them and put the money toward fenta-dope anyway.

Availability. Price. Tolerance. Inevitably one of them changes. Whatever balance was achieved is now lost. Time to shuffle, deal yourself a new opioid. If it weren’t for the running-out-of-money problem, I wouldn’t be so vulnerable to the unregulated supply problem. Or the methadone clinic problem.

Used to be that if you were on buprenorphine and using dope on the side, the dope would let you linger in that tolerance range where under 24 mg of bupe did something for you. But past 24 mg, past 32 mg, time to shuffle and go from bupe to methadone.

Soon it’ll be time to shuffle again. Taper the methadone down until it’s low enough to jump back to bupe. Stabilize at 24 mg bupe. Try to maintain on bupe and fenta-dope. Jump to fenta-dope and methadone. Honeymoon periods, followed by the long straight shot down the highway—as long as possible, please—of functional usage, and eventually arriving in the familiar position of holding my head in my hands asking myself how I wound up here. Hopefully there were some pharmaceuticals along the way.

The running-out-of-money problem. It foretells the true battering of my psyche, the fear felt in my very soul when the first faint chill of withdrawal slides down my spine. A harbinger of what’s to come if I don’t fix the problem in time.

The dread of impending withdrawal is difficult to separate from withdrawal itself. I find that benzodiazepines ease passage through both. My collection of nicotine vapes also eases the omnipresent anxiety of that mental calculus: How much dope do I have left? So does coke, but the vapes do less to exacerbate the running-out-of-money problem.

Shuffling from one opioid to another is so often a gargantuan task that leaves little room for anything else, which may or may not be an issue depending on what kind of responsibilities you have in life. Some people tapering off methadone try to speed up the process with short-acting opioids, like the ones that got them on methadone in the first place. You can forget to take a step back and check in with yourself about what exactly is your goal here.

Sure, I want to get high. That cozy mellow buzz, like a warm blanket and a cup of hot chocolate milk—opioids have served me well with their ability to temporarily delete emotions, when those emotions are too much. The stages of grief after a loved one’s passing? Too much agony. Too much aching. Starting over after losing a job, perhaps due in large part to an opioid problem, or rather a running-out-of-money problem? Too much guilt. Too much shame. Do I have to feel those things? How much dope do I have left?

But my objective is always maintenance. A long time ago I came to terms with the idea that I will be on opioids, in one form or another, for the rest of my life. It surprised me at first to find relief in accepting this, even an affirmation of my conviction that opioids are helping me through life. Why leave behind something that smooths the sharp edges the world throws our way? Why not regulate the supply, and stop overregulating methadone, so that we can achieve this without gambling on respiratory failure? That shouldn’t be the only way to solve the running-out-of-money problem.

Top image (cropped) via Canadian Centre on Substance Use and Addiction. Inset images via Substance Abuse and Mental Health Services Administration.

The post The Opioid Shuffle appeared first on Filter.

Treatment and recovery centers tend to be very moralizing places, and you’d think a lot of the people who work at them would approve of someone wanting to stop using all opioids including prescribed methadone. But mostly these providers don’t want to be involved with methadone at all, even to get someone off of it. The ones inclined to help still haven’t known how, because they’ve never heard of someone doing it this way. But as much bureaucracy and judgment as I’ve voluntarily subjected myself to in the rehab system, it’s worth it to bypass the methadone clinic system.

In New Jersey at least, the treatment facilities that take Medicaid will start you at their short-term programs—usually 28 to 35 days. Or 21 to 28 days, if you spent your first week going through their detox. A lot of the ones I call are non-starters because they don’t provide methadone at all, or they’ll only work with you if your dose is 40 mg less. A lot of the places that do provide methadone are still non-starters, because they make it clear that whatever dose I come in at, they’re going to keep me there.

First I write a “sick call,” and within the next three to five days I see a provider. That’s when I explain my plan.

The facilities I’ve stayed at so far have been the ones that told me I’d be able to manage my dose myself, higher or lower, no problem. Of course, sometimes that would change once I was done signing the paperwork. But either way, for the minority of patients on methadone these facilities will run a little in-house mini clinic. Line up every morning for your cup of Methadose, drink it in front of them, drink a cup of water, speak some words, drink another cup of water, say some more words until they trust that you’ve swallowed it. But generally they’re less inclined to make your life miserable than their counterparts out in the real world.

First I write a “sick call” slip saying I want to adjust my dose, and within the next three to five days I see a provider. That’s when I explain my plan—every seven to 10 days they can lower the dose by up to 10 mg, so I tell them I want to drop 10 mg per week.

If all goes well then a month later I’m discharged into their longer-term program, which lasts three to four months. Or if by the end of that month I hate the place, as I often do, I make a lateral move to another facility’s short-term program. Or sometimes I can go straight into their long-term. 

After that the next stop on the conveyor belt after is a halfway house, but I usually jump off before then. Unless I haven’t figured out the next roof over my head, halfway houses don’t make sense for me—no methadone dispensed on the premises. They just send you out to a regular clinic every morning on your own, which is what I’m in rehab to avoid in the first place. So once I’m discharged from a long-term program, I go to the short-term at a new facility and start over.

Like homeless shelters, these places share a lot of common elements with jails and prisons.

For my purposes at least, the short programs are too short. The long programs are too cult-y. All of them are too much like jail.

Like homeless shelters, these facilities share a lot of common elements with jails and prisons—more than just the urine testing and bunk beds and general surveillance. At one place they didn’t even tell me that at night they locked everyone inside the building. Had to get myself kicked out of that one in order to leave.

None of them let you have a cell phone during your stay. The reason is always that they don’t want anyone making a private phone call and then heading out to buy drugs. One place kicked me out when they found my phone, which is the kind of thing that makes a person head out to buy drugs.

Vapes aren’t allowed, for basically the same reason; they just assume you’ve put marijuana in there. In my experience about the Medicaid facilities are about 50/50 in terms of whether their policies allow residents to have cigarettes, but I’ve never heard of any that will allow you to vape. The only residential facilities I’ve heard where you can have vapes are the “sober living” houses, which unlike the halfway houses are privately run and not tied to Medicaid. If someone’s paying out of pocket, no one cares what they do.

Most people I go through rehab with aren’t there because it was their idea. Sometimes it’s because their family pressured them, but a lot of the time it’s because of drug court. Over time, the more I’ve talked to other patients the more I’ve noticed that the ones who come in by way of drug courts get a lot more leeway than the rest of us. The general feeling is that the people who run these facilities want to stay on the good side of judges who refer people into their program, so they’re not in as much of a rush to do an administrative discharge over a cell phone.

Unlimited Xanax and Klonopin helped me drop from 170 mg to 90 mg in under six weeks.

I first got on methadone in 2009 and stayed on it until 2014. This was right before New Jersey prescription drug monitoring programs expanded their reach, so I had a dozen prescribers at a time writing me whatever I could pay for in cash. Unlimited Xanax and Klonopin helped me drop my methadone from 170 mg down to 90 mg in under six weeks.

I wasn’t in any residential program at the time. By the end I wasn’t even in a methadone program—I’d lost my take-homes due to a “community violation” (got arrested) and since I happened to have a stockpile of take-home bottles at home and was super pissed at the program, I figured I’d do the last leg on my own.

It’s hard to imagine the stars ever aligning quite like this again, but I actually pulled together my own case management team. I had a primary care physician, a talk therapist and an addiction specialist who were all in communication with each other and would check in with me on conference calls. When I got my methadone down to 30 mg, the addiction specialist prescribed me a 10-day supply of the 30 mg roxies (AKA oxycodone) to bridge me through the transition to bupe.

The roxies only lasted a couple of days, but that was okay. Since I was doing this unsupervised, I could just keep going to get the benzodiazepines that saw me through the rest of the way.

And it worked. I got off methadone. I spent the next three years with a 24 mg prescription of Subutex, which I never had to take in full if I wanted to take less. Around 2019 I started screwing around with street supply again, which had become fentanyl-based in the intervening time. But in between I had a great year or so of just … being normal. Being treated like I belonged in the world.

A lot of programs won’t even help you move from methadone to bupe, let alone prescribe Xanax along the way; too much paperwork. So access to benzos—or to whatever actually works for you, in whatever amounts actually work for you—is the upside of doing this on your own. It’s also the downside of doing this on your own, you’re inevitably putting yourself back in the same environments you’re trying to get away from.

I hold no ill will toward methadone. It served its purpose.

Even at 60 mg, I’m feeling the nod much more deeply than I want to. But I hold no ill will toward methadone. It served its purpose. It kept me alive through the shitshow of the early pandemic, through neighborhood sellers trying to figure out their xylezine ratios. I hold a lot of ill will toward the clinic system. 

I don’t know anyone else whose methadone taper took anywhere near this much time. I didn’t realize I’d be doing it this long when I started, but of course it hasn’t been a linear process. I’d often lose a lot of progress during the transition from one facility to the next. Two steps forward, one step back, that kind of thing.

But I feel good about what I’m doing. It’s been a winding path, but I’ve managed to avoid setting foot in an actual clinic, which is saying something. And I’ve learned a lot about myself over the past year or two. I’ve spent most of my rehab time journaling, as there isn’t much else to do in the Medicaid places. You get what you pay for, which is nothing. And a much better deal than you’ll get from the clinic system.

Image via Helen Redmond and Marilena Marchetti

The post Tapering Off Methadone Without a Clinic, in Just Two Years and 13 Rehabs appeared first on Filter.

I‘ve been using opioids for 20 years, but injecting didn’t become my regular route of administration until 2019. I’d just come cold turkey off benzos, one week of death—vomiting, visual hallucinations. And newly unmedicated anxiety and ADHD, which in hindsight was the real reason I switched from sniffing to shooting. I needed things to hit harder.

No disrespect to the 27 gauge needles everyone’s used to, but I want no part of them. I’ve never liked needles. Plenty of people who shoot three bundles a day have never liked them. Outside the neighborhood, most people in my life—family, friends—didn’t know I’d started shooting, and I wanted it to stay that way. Meaning: no track marks. Hence, the 31 gauge short-tips—you know, the ones with the 5/16″ needles, not the 1/2″. The needle so thin you almost can’t see it.

Their reputation is that they bend, they break, they clog. They’re too short to reach a vein. They’re so narrow you’ll miss your shot if even you do reach a vein. They’re only suitable for hands and feet.

For me, the obvious benefit is no tracks. But reducing the diameter of the holes in your skin also reduces risk.

But bending and breaking can be mitigated. Used properly, 31s don’t clog much more than the 27s. I’m less worried about a 5/16″ needle not reaching a vein than I am about a 1/2″ inch one going all the way through. To me, it seems easier to thread a small needle into a vein than a bigger one, but to each their own. And you can use short-tips anywhere you can find a topical vein—not just hands and feet.

The main barrier for almost everyone I’ve talked to about 31s—other than maybe the assumption about hands and feet—is that they just don’t know how to use short-tips, and they’re used to the 27s so it never really occurred to them to ask. No one I knew used them when I started out, either. But I was fortunate enough to have stable housing (at the time, anyway) where I could take the time to learn my veins, and that was enough.

For me, the most obvious benefit is no tracks. But reducing the diameter of the holes in your skin also reduces risk of infections and scarring. And it also means that whenever the 27 gauges are in short supply, you won’t be without options. Never a shortage on short-tips, at least in my part of the East Coast.

Backloading

Short-tip needles are delicate, soft. They dull at the slightest touch, which is why the first surface they ever touch should be your skin, not a metal cooker.

I do use the 27s (or whatever larger-gauge needle is around), just not to inject. I use them to draw up the liquid dope from the cooker. Then instead of injecting it into a vein, I backload it into a 31. Boom—now your dope’s in a syringe with a mint-condition sharp that hasn’t touched so much as a cotton.

Pound a bottle of water, whether or not you think you’re hydrated. Then take an EasyTouch 27g .5cc, or anything with a plunger and barrel the same size as the 31s. Draw up with your 27. Keep the bevel facing down so it doesn’t dull any more than it has to; we’ll get to that in a minute. Leave at least a few units of airspace. Pull the plunger out from your 31. Put the 27 syringe in its place. Plunge. Make sure to keep the 31 tip angled down slightly, so you don’t lose your shot while the barrel is still open at the other end.

Once you’ve transferred your shot, put down the 27—don’t bend the needle or anything, remember we’re not done with it. Take the plunger you’d set aside and reposition it, pushing in just far enough to reform the seal with the barrel so you don’t have to hold them together. Turn the whole thing upright.

This is why you want airspace—otherwise the plunger will be pushing out precious units of dope, not air. If you only used enough to fill the barrel partway though, you can just turn the needle upright and suction will prevent any from falling out. Flick until all the bubbles are at the top, then slowly plunge to close airspace. Done right, you’re not losing more than two drops. Use an alcohol prep to—gently—wipe off the outside of the needle. Not the tip. Give the alcohol a few seconds to dry.

Back when I started I’d usually hit my upper arm, because I didn’t have the control or knowledge of my own veins to go anywhere else. These days, I usually go with lower leg. I always wipe the injection site with an alcohol prep—one direction, not back and forth—and I always shoot toward the heart, bevel up.

Don’t worry if your veins don’t exactly pop like that. You don’t find them by sight—you find them by touch. If you feel the vein suck in the needle, you know you’re really on. When it gets picked up by the current. 

If you’re dehydrated, dopesick or still learning your veins, try feeling for one along your calf. You can use a tourniquet to tie off below the knee. Once you register, wait a couple of seconds, then go. 

This shot I went in almost perpendicular. Not because that’s advisable, but because I know my veins and it felt like the right angle for this one, and it was—perfect shot. That’s just how it goes sometimes.

If you’re unsure, stick with something between 15 and 45 degrees. You can still go through the vein with needles this short; I’ve done it before. Not often though. Not as often as I see people go through with the 1/2″ tips.

Wait a few extra seconds before withdrawing the needle, ideally while you or someone else holds a benzalkonium chloride wipe or gauze over the site. Don’t use an alcohol pad, it’ll just make the opening take longer to close.

Every once in a while I’ll get dope where the actual fentanyl dissolves fine, but something in the cut isn’t quite water-soluble, and even with multiple cottons will clog a 27. Xylazine can do that, too. Even if you don’t usually cook your dope, it might help when the mixture in the cooker looks looks thicker than usual. Cook twice, if there are still undissolved solids after the first pass.

Wounds on hands and lower legs may be higher-risk for xylazine complications relative to other parts of the body, so keep a close eye on whether they’re healing the way they should.

I know we’re all still figuring out xylazine harm reduction, and I’ve heard short-tip needles could increase wound risk by shortening the distance between the opening in your skin and the site where the drug is deposited. But done carefully, without being rushed, short-tips vastly reduce the size of the wounds that xylazine could turn bad. That’s been the risk reduction in my experience.

Last thing: The used 27 from earlier—no harm in reusing it, so you can cap and save for later. I’ll burn one side, so I know which is which when I’m carrying it around with 31s. You’d think EasyTouch would realize these things shouldn’t be impossible to tell apart without taking the caps off, but that’d make too much sense, right?

Images courtesy of Kastalia Medrano

The post How I Use Short-Tip Needles: A Harm Reduction Guide appeared first on Filter.