I'm all ears.
My original question has gotten a little side tracked. I'd appreciate anything you'd like to add.
I'm mostly interested in dual-diagnosed patients I am prescribing meds for who continue to use.
Well apart from a dodgy Doctor over prescribing Xanax for GAD/Panic Disorder, I wasn't really being treated for any of my other diagnoses when I was using, or after for that matter -- so I guess I can't really talk from a treated dual diagnosis point of view . Unfortunately it was during one of my earlier attempts at getting clean that I was abused under the care of a (male) Psychiatrist, which made me distrustful of male Psychiatrists in the extreme for years after, and also made it extremely difficult for me to get proper help because I ended up placing an entire gender on a 'will not see' list...hence I wasn't really ever being treated for a dual diagnosis, just for the addiction side of things. I can discuss drug use in general and having a diagnosis of mental illness in a separate post though, just not the experience of being treated for both at the same time.
Warning in advance, this has ended up being rather lengthy (sorry about that). 
It did take me several attempts with a number of different treatment approaches before I did finally get clean. So my personal opinion is that the best treatment is the one that works for the individual person. Having said that when it came to being addicted to heroin any attempts I made trying to at least cut down were laughable at best. Most of the time I was only using just enough to stop myself from going into withdrawals and feel normal as it was (because at a certain point actually getting high on a regular basis just became too expensive), but even so whenever I said to myself 'Okay, I really need to stop using this ****, I have to start cutting down soon' it was like my mind just went into complete panic mode, like heroin was going to cease to exist entirely and I had to scramble to use as much as I could afford before that happened. Every damn time I thought "I'll do this by cutting down gradually, and then stopping" it was the same response..."OMFG, quick, panic and go on a massive binge!" It was the same with the times I decided to go cold turkey, especially if I made the mistake of treating myself to 'just one last hit' before I stopped, which more often than not very quickly turned into several weeks of 'just one last hit, and then I'll stop, no really, I mean it this time, this is absolutely my last hit' -- yeah I didn't believe me either. It's hard to explain but as soon as you think about cutting down or trying to quit heroin for good, and you do think about it in terms of 'this is it for me, I am never touching this stuff again in my life', it's like your mind just focuses even more on needing to obtain the drug and it sends you into a mental tail spin. I eventually learnt not to tell myself, or think along the lines of 'I'm quitting heroin for good, this will be last ever hit', but to just do the whole 'one day (one hour, one minute) at a time' thing, which may be a bit of a cliche, but it does work in my experience.
The other thing I had to learn/realise when I was finally getting clean was a) I didn't just have a heroin problem, I had a drug problem full stop, and if I wanted to stay off the gear then I couldn't just go replacing it with something else (so being clean meant clean off all illicit substances), and b) It wasn't just heroin I was addicted to, it was everything surrounding and involved with it as well. Again it's hard to fully explain, but even though being a junkie, and living that whole junkie lifestyle completely sucks, you also miss the rush and drama of it in a way when you're no longer a part of it - I guess it's like you spend however many years doing the same thing day in and day out, and then one day it's over, but you feel like you're at a complete loss because you've forgotten any other way to live. In regards to this particular aspect I did undergo a form of counselling for several months that was designed to not only help you identify and manage things like what might trigger you to use, but also to help you kind of reintegrate back into a somewhat regular way of life instead of just leaving you sitting there going 'okay, great, I'm clean, now what?!' (there's a specific name for this approach, I wish I could remember what it was). For me as well the other really big, as in pretty much the main aspect of the whole 'being addicted to everything surrounding heroin, not just heroin itself' type deal, was the fact that, physical dependence aside, I was also just as addicted to the act of injecting as I was to the heroin that was going up my arm. There was a saying among the other addicts I hung out with, "better four holes in the arm than one in the ground", well with me it was more like "the more holes in your arm, the better". To be honest I found giving up the act of injecting to probably be the most difficult aspect of getting clean, because most of the time when I was dealing with cravings it wasn't always the drug itself I was craving, it was the needle. And I'll be honest again and admit that in the first year of treatment there were a few times when I ended up injecting water, including going through the whole process of 'mixing up', just to satisfy those cravings and give myself some mental breathing space again.
Going back to the aspect of 'learning how to actually live outside of the junkie lifestyle' for a moment, that was another mistake I made in previous treatment attempts -- I placed too much expectation on the outcome. So in order for treatment to work I had to realise that getting clean did not mean a lifestyle movie was suddenly going to spring up around you. Whatever previous problems you had before you became an addict were still going to be there, you weren't suddenly going to be handed a fantastic career, and a completely new and successful life just because you no longer stuck a needle in your arm several times a day. I suppose because being addicted to heroin feels like this enormous thing that just sinks it's teeth into you and takes over your entire life, you kind of expect that getting off heroin is going to feel equally enormous - like as low as your lowest times were on heroin, that's how amazingly and awesomely high the times are going to be when you finally get clean...and it's a bit of a crash back down to earth when you realise that isn't actually the way it usually happens. So in regards to that aspect I learnt to start appreciating the small things, such as being able to sit outside a cafe and drink lattes whilst watching the world go by, or being able to rug up and go to the beach in Autumn, and just sit there watching the waves come in and appreciating the beauty of the ocean -- both things that would have been impossible beforehand because I would have been too busy running around and peddling myself on the streets to make enough money to score more heroin.
As for what treatment worked for me personally, and what really helped me finally decide that I was going to get clean come hell or high water. By the time my first attempt with the methadone program had failed (after I'd also failed with umpteen dozen different treatments before that), and I was back out on the streets, I had seriously reached the point where I'd just given up all hope of ever getting clean. I'd more or less accepted there was no way out, I was always going to be a junkie, and it would kill me eventually one way or another -- and I was okay with that, with the dying part, because I didn't really think I deserved to exist anyway (I was a junkie, what possible value did I have to anyone?) And then a really amazing group of street outreach workers came along and started handing out free condoms and lube, providing a needle exchange service, offering basic on the spot health checks through a couple of nurses who worked with them, and always with a counsellor on hand as well in case anyone felt like they needed to talk, or wanted to get information on treatment options, services available to help them get off the streets, and so on. There was no judgment, they never tried to force help on us, and what I found most important was the fact that they always treated, and spoke to us with dignity and respect. I'm not saying 'Oh someone came along and they were nice to me and suddenly I wasn't an addict anymore, yay! happy ending', but when you're a junkie a lot of the time the people around you, or that you come into contact with, have trouble seeing, or relating to you as anything other than a junkie, and then you start seeing yourself the same way -- it's like you cease to exist as a person in your own right and just become this amorphous lump with the word 'junkie' stamped across you. So when someone comes along and actually treats you like a person, and shows you respect, and speaks to you like you're still worth something, that's a pretty big deal. Like I said it's not as if these outreach workers showed me a bit of respect and kindness and hey presto I immediately sprinted off to the nearest treatment centre and finally succeeded at getting clean, but what they did do was help plant a seed. It might have only been a small seed at first, but it was enough that it started to make me stop and think differently (like maybe just admitting defeat and waiting to die was the wrong way to go about things, and perhaps there was something there worth saving). Fast forward several months and I'm standing on a street corner, getting dope sick, freezing my ar5e off at some ungodly hour, and arguing with my girlfriend at the time, and then I had one of those really cliched 'moment of clarity' type epiphanies (like 'OMG, I'm a heroin addicted street prostitute, what the eff am I doing with my life?!). So I spent a last few hours with my girlfriend, packed my bags, kissed her goodbye (she wasn't ready to go into treatment, and I knew I couldn't get clean if we stayed together), headed straight to my then former Methadone prescriber and just basically went 'Help! I've really f**ked up'.
So I went back on the methadone program for a second time, gradually titrated up to a dose that was more in line with how much heroin I'd actually been using (60mgs of methadone as opposed to 20), booked in for 6 months worth of solid counselling, did a complete lifestyle change (places I visited, people I hung out with etc etc), and then tapered off of the methadone over a period of 2 years. I took my last dose in December of 2002, and I've been clean ever since.
🙂
