What it’s like to take and withdraw from morphine
Guest author and former physician Liam Farrell shares his experience with the use and abuse of morphine here. If you find yourself in need of treatment for morphine addiction, we want to hear from you. Please leave your questions or comments in the section at the end. We respond to all questions about getting help for morphine addiction personally and promptly.
Transient pleasure, prolonged pain
By Liam Farrell
The vein stands up proudly. It’s good to look at, it’s inviting. The tourniquet is satisfyingly tight, the syringe waits like a shark on the bedside table, the new orange needle catches a glint of light, a silver gleam of expectancy, hungry for the vein; one of the small benefits of being a doctor and an addict is that new and clean needles are easily available, and the risk of AIDS and hepatitis B or C and other infections is accordingly low. New needles also won’t have been blunted by repeated use. I had used a bigger green needle to draw up the drug, a needle that can reach right to the bottom of the ampoule, so that not one drop will be missed. I use an orange needle for the actual injection because it is of smaller bore and will penetrate the skin much more easily, with less trauma, and will leave less visible evidence.
Beside the syringe lies the pack of Cyclimorph, empty now, and ominous, a small harbinger of doom, the rumble of distant thunder at a summer picnic. The particular colour of the red and blue packaging is like a beacon to me; when I see those colours alarm bells go off in my head, if a pack was lying by the side of the road a mile away I would spot it immediately. At this moment I don’t care that it’s my last dose; the future, and the price I am going to have to inevitably pay, is irrelevant. I’m living in the now, isn’t that the secret of happiness, and everything is focused on my preparations.
The discarded packaging of the needles, ampoules and syringe lie in a tidy little pile. I put the guard back on the green needle and set it beside the empty ampoule; these need more careful attention, as discarded needles can turn up anywhere and ampoules can shatter easily and leave small but sharp shards of glass. The detritus has to be kept together, so that it can be secretly disposed of; secrecy is paramount, nobody can know, nobody can suspect. If I wait till after I’ve used, I may forget, or become too casual, and leave some evidence behind. I don’t want questions I don’t want challenges, I don’t want tough love, I don’t want people who care about me, I want the drug.
The real face of morphine abuse
Everything is quiet, the doors are closed, the curtains pulled, all is dark except for the bedside lamp, just bright enough to see what I’m doing, a small island of light in this world i have created for myself, a world of shadows and self-destruction. I am alone in the house, just the way I have planned it; there is no glamour here, no drama, no heroin chic, no grande passion, no tortured artistic sensibility, it’s just a selfish, venal, deceitful, squalid, solitary vice.
I roll the vein lightly with my forefinger, testing the bounce, no, much more than that, not just testing it, enjoying the bounce; the vein you can feel is more reliable than the vein you can see. The vein is sweetly engorged, sensual, and will be easy to access, little chance of missing the vein and the drug leaking into the subcutaneous tissues, which would leave a painful and visible bruise and, even worse, would mean losing some of the drug. The vein I have selected is on my right forearm, on the inner surface. As I am right-handed, my left arm is a better choice, but after months of injecting, the larger veins there have collapsed, and the only veins that remain visible are thin and thready and would be unreliable. I still have some attractively superficial veins on the back of my left hand which would be easy to access, but the marks there will be too easy to see. The hand veins can wait for the time when I become more desperate; their day of service will come, and come soon.
My right forearm is doubly awkward, as not only will I have to use my clumsier left hand to access the vein, but also the skin on the inner surface of the arm is paler and will show up marks much more vividly, especially if something goes wrong and I bruise excessively. I am pale-skinned at the best of times, and months of regular using has turned me wraith-like; I’ve seen recent photos, I look detached, like a ghost.
But this vein looks good, not only is it visible and easily palpable, but it is also near a junction, which usually means that it is tethered down by subcutaneous tissues, and shouldn’t move around too much; veins can be capricious, as if they have a mind of their own and sometimes seem to deliberately wriggle away from the needle. I have also become more skilled even with my left hand, so it shouldn’t be hard to hit; I am confident.
Of course, even if I do bruise, I can always wear long sleeves; why should anyone be suspicious enough to want to inspect my arms? It isn’t any of their business, it’s my problem, I’ll handle it myself. Who do they think they are, interfering, are they perfect? Nobody asked them.
I lift the syringe, holding it up to the light, admiring the liquid clarity of the drug. I flicking the syringe to get rid of any air-bubbles; this is just another small piece of the ritual, small air-bubbles aren’t dangerous. I check the needle; it is bevelled, and I want the bevel on the down-side of the needle, so it will be less likely to pass through the vein and out the other side. I line up the needle along the length of the vein and push it in. The needle penetrates the skin easily and painlessly; like a kiss, just a moment’s resistance in the subcutaneous tissues till I feel it push through the wall of the vein. Yes, that’s it, perfect; I draw back on the syringe to confirm I am in the vein. The dark blood froths satisfyingly back into the syringe, a plume of red billowing into the clear liquid of the drug, intoxicating to look at, an unforgettable image, I have hit the mother-lode, a red flag signalling go; is it joy I feel, or is it more like relief? Joy is too decent an emotion for something like this.
Sometimes, even when I am sure I am in the vein, only a trickle of blood comes back. This might mean that the needle is outside the vein, probably gone through it; but it might also mean that the vein has a small lumen and I could still go ahead. I am then faced with an urgent decision. Do I try to deliver the drug? If I do, and I’m not in the vein, I’ll feel the resistance, the drug won’t go in easily, and I’ll see a little dimple appear at the injection site, a hateful little thing which signifies trouble and complications and delay in getting the drug. Then I’ll have no choice, I’ll have to pull out the needle. Morphine in the tissues is painful and will leave a big bruise. Even worse, I’ll have lost some of the drug; that hateful little dimple represents a lost rush. Common-sense would dictate I stop at once and start again; step back from the ritual, be patient, take out the needle, put pressure on the site to limit the bleeding and bruising, be sensible, start all over again, find another vein. But it’s hard when I’m so close, and addicts aren’t patient, I want the drug now.
And if I do have to try again, there is a danger that the blood which has trickled back will clot in the syringe, I may lose the drug, suddenly I am in a panic; quick, decide if I need to decant the drug into the spare syringe I have brought, as the clot would most likely occur in the syringe’s nozzle, but then I’ll probably lose some of the drug in the transfer, not much, but I don’t want to lose any of the drug, quick, strap on the tourniquet again, quick, quick, find another vein, anywhere, who cares if it’s a hand vein, who cares if it bruises and everyone can see it, quick, quick, it’s not the leisurely and pleasurable stalk I’d enjoyed just a few minutes before. When I pull out the needle, it may ooze blood, stain and spot the bed-clothes, stain my shirt, I usually wear dark clothes just in case, but pressure with a tissue is a secondary issue now, I mustn’t lose the drug. I throw away the needle, I’ll just have remember to look for it later. I have to find a vein and access it before I lose the drug, whatever I do I mustn’t lose the drug, I mustn’t lose the drug. And in that panic I may have trouble finding a vein, I may have to try a number of times, each time in increasing desperation, needles and blood and blood-stained tissues everywhere, sometimes I end up sticking in needles almost at random where I think a vein should be, there’s bound to be a vein in there somewhere, isn’t there, and each attempt leaving a bloody bruise.
But this time I am certain; the blood has bubbled freely and easily back into the syringe and there is no doubt I am in the vein.
Now there is nothing between me and the drug.
Everything is ready, all my careful planning has brought me successfully to this point. The pleasure of the anticipation is almost spent. Call me Pavlov’s addict; getting my hands on the new pack of Cyclimorph, arranging things carefully that I am alone and won’t be disturbed, assembling all the required paraphernalia, the tourniquet, a reliable one that won’t snap open when I tighten it but be easy to release when the needle is in the vein, two two ml syringes, the extra one in case I miss the vein and the first syringe looks in danger of clotting, two green needles and five or six orange needles, dark tissue paper, preferably, or if not a dark towel, then closing the door, looping the tourniquet round my arm and pulling it tight, seeing a suitable vein rise up, touching it, feeling it, taking the ampoule out of the pack, cracking open the ampoule, fitting the needle on the syringe, feeling the scrape of the green needle on the bottom of the ampoule, drawing up the drug, all these things become a pleasure.
I’ve tried other injecting other drugs which I knew wouldn’t provide any rush; hydrocortisone, diazepam, partly out of curiosity but also to satisfy these learned pleasures. The diazepam made me drowsy and the hydrocortisone gave me a prickling sensation in the perineum; I only tried it once.
Even when I’m not about to use I will catch myself looking at a vein in my hands and arms, rubbing my fingers over it speculatively. I’ll notice other peoples’ veins too; even having a drink with friends, I’d be observing who has prominent veins. This might partly, a very small part, I admit, be a hangover from my days as medical student and learning how to set up intravenous fluids; a patient with big, prominent cord-like veins could be sorted in moments, a patient with tubby arms and veins buried in layers of subcutaneous fat could be a problem.
I slip off the tourniquet and slowly press the plunger fully in; the drug goes in easily, no sense of resistance that might suggest the vein wasn’t patent.
I need to act quickly now to prepare for the rush, to experience it fully; I don’t want any outside stimuli which might interfere with the consummation. My movements are practiced; I whip out the needle, and throw the syringe away, I’ll pick it up later, I’ve no time to set it aside carefully. I press my left hand firmly on the site with a dark red paper tissue. A white tissue would show up the blood too obviously and might turn up somewhere inconvenient and hard to explain away. The firm pressure will restrict localized bruising and make the injection site less easy to spot, if someone was looking for it. There will inevitably be a mark of some sort, but I hope nothing too obvious, and as everything has gone smoothly it should clear up in a few days. Firm pressure will also help keep the vein patent for future use, so I’ll keep the pressure on even during the rush.
I take off my glasses, switch off the light, lie back and close my eyes. Alone in the dark, in my own little bubble, no light, no noise, I wait.
Within seconds, I feel the rush coming on, firstly a tingle coming up my right arm, then a wonderful warm tidal wave stroking my whole skin, my whole body; it seems to find a centre deep within my chest. I try to savour each moment, each instant, but just as quickly as it comes it is gone; that’s it, done, all over, it lasted a few breaths at most.
Was it worth it?
I’m disappointed it’s over and wish I could turn back time a few seconds. I also feel dissatisfied, a bit cheated; the rush wasn’t quite as good as I hoped it would be, because it is only a few hours since I last used. I wish I’d held off for a few hours, then I’d still have the drug, and the rush would have been better.
I am slightly sedated but not overly so. I could walk down the street and exchange greetings and take part in a normal conversation, and even those who knew me well might not be able to detect that something was different, something was very wrong; my voice might be deeper, my pupils dilated, but nothing very obvious. My wife would know, but she might not challenge me; I’ll meet any challenge with hostility.
I am comfortable and relaxed; the drug makes me feel pleasantly languid, like I’m wrapped in cotton wool. Morphine dries me up. My mouth is dry, my nose won’t run, my bowels won’t move, it’s hard to pass urine and I won’t get any erections. I feel the morphine itch, but it’s not distressing, just asking for an agreeable scratch.
I lie in the dark for a few minutes, hiding away as long as I can.
But even at this stage, even so soon after injecting, not much more than a few minutes, reality starts to pull me back in. The fog lifts, the modest euphoria which lingers after the rush begins to leak away. I start to worry about getting rid of the evidence. I get up, and first of all look on the floor for the syringe I hastily discarded. For this I need to turn on the wall lights, the glare harsh and unforgiving on the little piles of detritus. I stand blinking in the light, but the syringe is easy to find on this occasion, sticking point down in the carpet, as if it was a little dart. Sometimes I am not so lucky; the syringes can hide themselves under beds, behind books, and demand minutes of anxious searching and scrabbling. Sometimes I don’t find them, and they lie in wait like predators, choosing their moment to turn up.
I collect all the paraphernalia, the packaging and the sharps, to put them somewhere safe so I can dispose of them later; the paper stuff can go in the normal rubbish, hidden in a plastic bag, secreted at the bottom of the bin. In a few days I’ll take the needles and empty ampoules into the surgery, where there is a special sharps box for safe disposal. I check the floor again carefully to make sure nothing has dropped. Often I miss something and leave evidence, the syring wrapping, a blood-stained tissue, the top of an ampoule, the occasional needle. If I’ve had trouble finding a vein, I may have had to use four or five needles and together with the panic this brings on, it’s easy to lose count and miss one.
I am becoming more aware that that was my last ampoule of Cyclimorph. I already knew this, of course, but I had put off the evil day of facing up to it.
Now there is nothing between me and morphine withdrawal
I have no more supplies of the drug so withdrawal effects are inevitable. I’ve been through morphine withdrawal symptoms before and it was pitiless; I had read about it, of course, and I knew it was unpleasant, but nothing could have prepared me for how cruel it was, and having to go through it again frightens me. I know theoretically that withdrawal effects should not begin until about six to eight hours after the last dose, but such is my fear of withdrawal that I begin to feel uncomfortable after only a few hours.
Long before the symptoms start I can’t settle, I know what is to come, it hangs over me like a weight. The world seems to be painted grey, I start to feel cold and sweaty. I feel a draught from the window; just a draught, it would make even a normal person shiver, but it has more significance to me. Is it more than a draught, is it making me shiver because the withdrawal effects are starting? I know in theory there should be a few hours yet before their onset, but knowing this is no defence. My skin feels prickly and uncomfortable, the hairs are standing up, which is why they call it going cold turkey; or maybe I just think I am starting to feel that way, maybe it is my fear playing tricks. I have no defence. I am frightened and alone, facing into the oncoming storm, and it is all my own fault, all my own work. My fear is rising up to choke me.
I have looked it up, I have the medications which in theory should help alleviate the symptoms; loperamide for the diarrhoea, diazepam for the anxiety, mefenamic acid for the muscle cramps. But I also know from previous experience that they will have only a minimal effect.
As each hour passes the symptoms get worse; they are real now, and accompanied by muscle pains and abdominal cramps and diarrhoea and fatigue. I am cold, then hot, my skin rasps and prickles and burns. My nose is dripping constantly, my eyes water, I dab at them repeatedly with a paper tissue and by the end my eyes and nose will be red and raw. I glimpse myself in a mirror, my face is white, except for my cheeks, which are flushed bright red, beads of sweat on my forehead. I know that, unlike alcohol and benzodiazepine withdrawal, there is no significant medical risk and individually the physical symptoms aren’t that bad, no worse than a bad flu. Put me in a warm room, with plenty of fluids, and they’d be tolerable.
The anxiety is overwhelming
But the anxiety, the anxiety and the fear, is overwhelming; I am like a vibrating string. I cannot sit for even a moment without having to get up. Once up I have to sit down again. I try to go to bed, but I can’t get comfortable, I thrash and turn every second of every minute of every hour. The sheets are rough and unpleasant against my skin and my sweat soon turns them damp and rank. And I know this will continue for the next forty-eight hours at least. Only forty-eight hours, only two days, I tell myself, doesn’t sound very long, someone take this cup away from me. I’ve been ill before, I’ve had injuries before, I’ve had bad times before, and I’ve been able to handle them, able to put my head down and struggle on, but nothing has ever unmanned me like withdrawal, nothing has ever left me so scared, so lacking in courage, nothing has ever beaten down my resistance like this, there is no way out, no way to escape.
Except to take another dose, which would relieve all the symptoms instantly, it would be like a miracle. But I don’t have another dose and it’s too late to get any more. And if I did, I’d only be postponing the ordeal. I’ve had the pleasure, and now I have to pay the price. The preparation was elaborate and the consequences prolonged and grim, yet the gratification was only fleeting; it is a transaction that makes no sense, a fool’s bargain, a kind of madness. I am dancing between blades, one of them soft and desirable, and the other harsh and bitter; they both cut deep and take chunks of my spirit away each time. This is over-dramatizing it, there is no point to this, I am just a miserable damp heap of guilt and self-pity and self-loathing.
How did it come to this, I ask myself again and again, how did I let this happen to me? My mind races; I went through withdrawal before, vowed it would never happen again, that this time I would stay clean. Why did I have to start using again and get myself into this mess? And when I did start again why did not I show some self-control and use on an occasional basis, once a week or once a month, where I wouldn’t have developed a physical addiction again? And why did I have to use that last packet so quickly? There are five ampoules in each pack of Cyclimorph, I should have been able to string it out over at least three days. Even five days; one dose every night would have been feasible, the withdrawal effects might have been coming on, but they would be quite tolerable if I knew I had a supply and that within a short time not only would they be banished completely but that I’d be getting the drug.
How morphine addiction works
But that’s not how my addiction works. After I’ve used, even just a few hours, somewhere deep in my mind, the merest hint of a thought will come to me about using again. The pack of Cylimorph, that wonderful red-and-blue pack, is sitting somewhere, hidden away securely, but it’s calling to me, a whispering siren, eating away at my resistance. Even by the perverted laws of an addict’s world, this makes no sense; I know that the rush won’t be as good because I’ve used so recently, I know the longer I hold off, the greater the rush will be, but knowing my enemy is no advantage to me, and soon the ritual has started again, soon I’m closing the doors, taking out the ampoule and cracking it open and drawing up the drug. Once I even think, even the briefest passing thought, once I think of using again I can’t get it out of my head, and the deal is as good as done, and a pack of five that should have lasted me three days or more is gone in less than twenty-four hours.
Scared and alone, I shiver and sweat, and try to count down the minutes. I drink as much fluids as I can, staying well hydrated can help the symptoms, though I feel nauseated. Some junkies vomit copiously during cold turkey but that’s not how it affects me; neither do I hallucinate, and I don’t have nightmares. I have no appetite, when I do force myself to eat I have no sense of taste. Since I became an addict I’ve lost weight; taking the drug removes my appetite, going through withdrawal removes my appetite. I love reading, but I’m too distracted to concentrate, and my eyes are watering so much my vision is blurred, I look like I’ve been crying, and my emotions are so labile I do burst into tears regularly, great gusts of tears, of self-pity. Don’t feel sorry for me, I don’t deserve it, I am only crying for myself.
I switch on the television; George of the Jungle is playing, a comedy, but I am far away from laughter. I try to stay with the movie for a few minutes, but I find sitting tiring; I can’t hold my head up, and I slump forward, I have to get up and walk around. This is going to destroy me.
I go for a walk outside, trying to distract myself, take my mind of it, exercise is supposed to help the symptoms, use up some of that adrenaline that is surging round my body, protesting and looking for a release; it has been suppressed for a long time by the activation of the morphine receptors, now the dam has cracked and it is pouring out vindictively, seeking justice, seeking revenge. After crime comes the punishment. I am desperately tired, dragging one leg after the other. But even though it’s a fine warm day, the sun shining in an all-blue sky, everyone else in t-shirts and summer clothes, it’s much too cold for me. The faintest breeze is uncomfortable; I have a big coat on, but I am sweating underneath it, a cold, cold sweat. I can’t stay out for long anyway in case I get another episode of diarrhoea.
I am an outcast; I see a father walking along the roadside, holding his children by the hand. It’s like a knife, a small parcel of anguish, why can’t I be like that, be a normal dad, with normal interests and normal concerns. I remember it, I remember walks and family picnics, birthdays, holidays, Christmas. The memories seem to come from a far distance, a long-lost place. I’ve sent this happiness, this contentment, away from me. The normal world is a rainbow of colours, mine is dull and grey. Why can’t I be like that still, how did I lose it? It’s a selfish ordeal, I’m drowning, too immersed in my own misery to think about the people I am hurting, my wife, my children. “A devil in the house,” my wife calls it, no matter how many times she tries to push it out it keeps on getting back in again. The drug has come between us, has ruptured that bond, that presumption that we were a couple and a family, that we would meet everything together and handle it together. I have betrayed the trust, I have promised her again and again that I would stop, that no, I’m not acting strangely and no, I haven’t used and no, there’s nothing wrong with my voice, and yes, I’m clean, that this was definitely the last time, but I’m like all addicts; you know I’m lying because my lips are moving.
And I get angry when my lies are challenged, when she asks about a blood-stained tissue, or wants to see my arms to check for bruises, or finds a stray needle or empty ampoule. I make up some story, try to explain it away, I had a blood test today, or I banged my arm on the car door, the ampoule must have been there from a few months ago, it sounds stupid even as I’m saying it, but it’s all I’ve got. What about the kids, she asks, supposing Jack or Katie had hurt themselves on that needle, how would you feel, do you not consider them? I have no answer, I think I care, but the drug comes first every time.
I check the time constantly, willing the minutes to pass. Forty-eight hours, I tell myself, only forty-eight hours to get through, then things will get easier and I’ll know the worst is over, but only a few hours have gone, the time drags, the seconds inch along. I lie down again, I get up again, double up with a spasm of abdominal pain, go to the kitchen to drink some water, endure yet another episode of diarrhoea. I am dirty and sweaty, I take a bath, which helps warm me up, but I am too agitated to stay in it for long and getting out of a warm water is a shock; I am instantly freezing, I scrub myself urgently dry.
And then the first night; I dread the night, darkness was my friend, but now the hours stretch ahead of me, there will be no relief, no oasis, just a long darkness.
But, I promise to myself, this is the last time. This is definitely the last time, I won’t put myself through this ordeal again; this time I’ll stay clean. I promise.
Liam Farrell is a former family doctor from Ireland and a recovering morphine addict. He is an award-winning writer, screenwriter and broadcaster. His current columns include the British Medical Journal. He is married with 3 children. His twitter handle is @drlfarrell.
Photo credit: Don Berquist