Category Archives: addiction

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Sleep

Our sleep doctor, a pulmonologist, gave us a wonderful update talk on sleep in early 2009.

He said, “First of all, I hate that blue butterfly.” For those who do not watch tv or read magazines in the United States, the blue butterfly was in advertisements for a sleep medicine.

“The blue butterfly lies,” he said. “Eight hours sleep is NOT normal and NOT average.”

He said the average amount of sleep for an adult is 7.5 hours. Some people need more, some people need less. I need 6 to 6.5 except on the first day of menses, when my body prefers 10-11 hours. Too much information?

“Catching up is a myth.” He said that we don’t catch up on sleep after the first night. I get people all the time in clinic who say that they haven’t slept for a month and “need to catch up.” The first night with a sleep medicine, people catch up some but that is it. After that, their body returns to their average.

Alcohol is bad for sleep. Yes, I know, it makes you fall asleep faster. However, it is not normal sleep and you will wake when it wears off, in 3-5 hours. And you may be a bit jittery and anxious, especially if you have more than 2 drinks a night routinely. Hello, I said that is the alcohol wearing off. Are you partly addicted? Tell me you can’t fall asleep at all without it? Want a pill instead?

Sleep pills are really alcohol in pill form. Really, really, really. We use benzodiazepines — that is, valium, ativan, librium, etc. for alcohol withdrawal because it has the same mechanism of action. In other words, we are substituting the benzo for the alcohol and then withdrawing you more slowly. Withdrawing from heroin or narcotics makes the pain receptors go completely gonzo, but it doesn’t kill you. It just makes you writhe with pain and wish you were dead. Withdrawing from alcohol can cause the blood pressure to go too high and can cause a stroke or seizures and kill you. So how enthusiastic am I about adding that lovely blue butterfly sleep pill to the 3-5 alcoholic drinks that someone has at night? NOT. Gosh, if we get the dose high enough, mix of alcohol and benzodiazepines the person could throw up and drown in their own vomit or just become sedated enough to stop breathing entirely and die, or just enough for brain damage. That’s fun.

And we don’t know if sleep pills are safe long term. Read the fine print. Ambien is tested and approved for use for two weeks. Right. Not 10 years. We don’t know what the hell they do to your brain if you use them for 10 years. One sleep pill has been tested for longer term use: that is, six whole weeks. Sonata. So I am stingy when it comes to sleep pills. I give people 8. Yes, 8, and tell them not to use them more often than once every three days because I am NOT going to give them 30 a month. I am going to give them 8 a month and that with reluctance. That is a conservative approach to long term use. And if they drink anything over 1-2 drinks a night, they have to cut that down first.

“But doctor, I wake up in the night!” And you are between 40 and 60 years old? That would be normal. Yes, I said normal. NORMAL NORMAL NORMAL. Ok, here’s the story. Little babies wake 4-5 times a night, right? Really. Ask any new mom or dad. Eventually they “sleep through the night”. No, actually they don’t really. They still wake 4-5 times a night but they fall back asleep really quickly and without howling. They keep doing this as children, teens, young adults, adults…..and then sometime in the 40-60 year old range the wake up periods get a little longer. And we remember them. It is normal. It is ok. Do not drug it.

“But I can’t go back to sleep.” Ok, here are the sleep hygiene rules. No violent tv or any screen time (yes, that includes computers, you addicts) for the last hour before bed. No caffeine after noon. Bed is for sleeping and sex only. If you want to read, get out of bed. A cushy armchair by the bed is fine, but get out of bed. Sorry, but you asked. Music is ok before bed and so is radio. The visual light in any screen activates weird parts of the brain, so that’s why no screen. Don’t listen to music or radio that sends your blood pressure through the roof. Exercise is best at least 4 hours before you are trying to drop off. A cool bedroom turns out to be better for sleep than a really warm one: turn down the heat and save money. Warm milk actually works.

“But doctor…” Ok, I know, you CAN’T do some part of the above. Do what you can.

“My teenager falls asleep in classes all the time.” Ah, teens are interesting. The brain essentially melts when puberty hits, at around 12, and is done with major hormonal rewiring by age 25. Teens need MORE sleep than kids or adults. 10-12 hours. They are working hard on puberty. Our sleep doctor said that the time the teen wakes up on the weekend indicates their real circadian rhythm. So, if a teen wakes at 1 pm on Saturday and Sunday, and is going to bed at two, that is where their circadian rhythm is set. Of course they are groggy as heck when they get up at 7 and trundle off to school and that history teacher is boring and drones in a monotone. How do we reset the rhythm? It takes time. The teen has to set an alarm on the weekend and get up progressively earlier. And they STILL need 10-11 hours so guess what? If the goal is 7 am, they should be going to bed by 9 pm. “HA, HA, HA, HA!” laughs the parent. Most teens are not getting enough sleep and are not catching up on the weekend. Parents can have influence. The sleep needs start to decrease as teens are entering their 20s.

Also, no screens in kids’ bedrooms. No tv, no computer, and the cell phone stays in another room. Start this with small children. Why? Kids are up texting at 2 am. Or surfing the net. Or watching whatever. It is a good sleep habit to get out of bed if you can’t sleep and go read something or listen to music. Out of bed, not in bed. Set a good example for your kids and get your television out of the bedroom….ok, now you hate our sleep doctor, not me.

What medicines do I use to help people sleep? I don’t like the benzodiazepine related drugs, which is most of the advertised New Fancy Expensive sleep medicines. I do use old medicines: antidepressants in low doses, very low. Trazodone, amitriptyline and nortriptyline. They are cheap and we are actually using the side effect; that is, they make people drowsy. I prescribe at doses way below the theraputic dose for depression.

Geriatrics. Well, it’s a difficult group. It’s not good to make someone drowsy who needs to get up at night twice to urinate and is a bit shaky on their pins and who won’t turn on the light for fear of disturbing someone. If I make them drowsy they trip and then we have a hip fracture. Mostly it is education: yes, they are waking up, maybe more than once and it’s normal. I have had people really cheer up once we’ve had this discussion. Oh, they say, I’m normal. They’ve been confused by that damn blue butterfly.

Sleep well.Moderate your alcohol, caffeine, television, computer, and cell phone; exercise, eat right, drink enough water and put your doctor right out of business. And the blue butterfly too.

revised. previously published on everything2 November 2009

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Adverse Childhood Experiences

I went to a sparsely attended lecture about the Adverse Childhood Experiences Study, or ACE Study, in 2005 and it blew my mind. I think that it has the most far reaching implications of any medical study that I’ve read. It makes me feel hopeful, helpless and angry at God.

The lecture was at the American Academy of Family Practice Scientific Assembly. That year, it was in Washington, DC. There are 94,000 plus Family Practice doctors and residents and students in the US, the conference hall had 10,000 seats and the exhibition hall was massive. At the most recent assembly, there were more than 2600 exhibitors.

I try to attend the lectures numbered one through ten, because they are the chosen as the information that will change our practices, studies that change what we understand about medicine.

The ACE Study talk was among the top ten. Yet when I walked in, the attendees numbered in the hundreds, looking tiny in three joined conference rooms that could seat 10,000. The speaker was nervous, her image projected onto a giant screen behind her. My experience has been that doctors don’t like to ask about child abuse and domestic violence: I thought, they don’t want to go to lectures about it either.

The initial part of the study was done at Kaiser Permanante, from 1995-1997, with physicals of 17,000 adults. The adults were given a confidential survey about childhood maltreatment and family dysfunction. A simpler questionnaire is at http://www.acestudy.org/files/ACE_Score_Calculator.pdf, but it is not the one used in the study. Over 9000 adults completed the survey and were given a score of 0-7, their ACE score. This was a score for childhood psychological, physical or sexual abuse, domestic violence, or living in a household with an adult who was a substance abuser, mentally ill or suicidal, or ever imprisoned.

Half of the adults reported a score over 2 and one fourth over 4. The scores were compared with the risk factors for “the leading causes of death in adult life”. They found a graded relationship between the scores and each of the adult risk factors studied. That is, an increase in addiction: tobacco, alcohol and drugs. An increase in the likelihood of depression and suicide attempt. And an increase in heart disease, cancer, chronic lung disease, fractures and liver disease. The risk of alcoholism, drug addiction and depression was increased four to twelve times for a score of four or more.

The speaker said that the implications were that the brain was much more malleable in childhood than anyone realized. She said that much of the addictive behaviors and poor health behaviors of adults could be self-medication and self-care attempts as a result of the way the brain tried to learn to cope with this childhood damage.

I left the lecture stunned. How do I help heal an adult who is smoking if part of it is related to childhood events? From there I went to a lecture about ADHD, where the speaker said that MRIs and PET scans were showing that children with ADHD had brains that looked different from children without ADHD. I thought that speaker should have come to the other lecture. And I did not much like my ACE score, though it does explain some things.

I feel hopeful because we can’t address a problem until we recognize it.

I feel helpless because I still do not know what to do. The World Health Organization has used the ACE Study in their Preventing Child Maltreatment monograph from 2006. But it is not very cheerful either: “There is thus an increased awareness of the problem of child maltreatment and growing pressure on governments to take preventive action. At the same time, the paucity of evidence for the effectiveness of interventions raises concerns that scarce resources may be wasted through investment in well-intentioned but unsystematic prevention efforts whose effectiveness is unproven and which may never be proven.”

Do I do ACE scores on my patients? With the new Washington State opiate law, we do a survey called the Opiate Risk Tool. It includes parental addiction in scoring the person’s risk of opiate addiction. But not the rest of the ACE test. At this time, I don’t do ACE scores on my adult patients. I don’t like to do tests where I don’t know what to do with the results. “Wow, you have a high score, you will probably die early,” does not seem very helpful. But I remain hopeful that knowledge can lead to change. And it makes me more gentle with my smoking patients, my addicted patients, the depressed, the heart patient who will not exercise.

I am angry at God, because it seems as if the sins of the fathers ARE visited upon the children. It is the most vulnerable suffering children who are most damaged. That does not seem fair. It makes me cry. I would rather go to hell then to the heaven of a God who organized this. I stand with the Bodhisattva, who will not leave until every sufferer is healed.

1. ACE study   http://www.cdc.gov/ace/about.htm

2. American Academy of Family Practice   http://www.aafp.org/events/assembly.html

3. ACE questionaire   http://www.cdc.gov/ace/questionnaires.htm

4. Score correlation with health in adults   http://www.ajpmonline.org/article/PIIS0749379798000178/abstract

5. WHO preventing child mistreatment   http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf

6. Washington State Opiate Law   http://www.agencymeddirectors.wa.gov/

7. Opiate Risk Tool   http://www.partnersagainstpain.com/printouts/Opioid_Risk_Tool.pdf

First published on everything2 November 2011.

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If you have to cry, do it on the boyfriend who wants you to be angry instead of sad

I used to have a temper that could be set off really really easily.

I had a boyfriend right out of college that said that I didn’t get angry “right”. He had a PhD and I was a mere done with undergraduate person, so what did I know? I went into counseling for a year.

Finally I said to him, “The counselor and I have tried presenting anger to you in every possible form and none of it is acceptable. So now she says you need to come to counseling too.”

His response: “What I want is for you to never get angry at me again.”

Mine: “You are dreaming.”

And so he broke up with me. Immediately. And said I was an ogre when I was angry.

I went back to counseling and was depressed for a year. Then I cheered up, met a boyfriend and went to medical school. I worked on my temper, remembering the ogre comment. I did not want to be an ogre. My boyfriend became my husband and he really liked my dark side and my silly side.

My sister was the person who could set me off angry the most easily. She and I fought like pitbulls, like honey badgers. Once we were in Colorado with my husband, her first husband and my parents. The two husbands had an imitation pretend fight acting as me and my sister. They were vicious. It was horribly embarassing and also funny, because they nailed us both.

In residency in Portland, I had a breakthrough. My sister was divorced from the first husband by then, and with the no meat, no dairy, really pain in the butt boyfriend. We were having a big party, lots of people, grilling salmon and cooking in a group. My sister walked in.

“Oh.” I said, “You didn’t RSVP.”

She fired up instantly. “What? Why does that matter? Do you want me to leave?”

I did not fire up. I held my breath and then said, “No. But if you are here with No Meat No Milk, I didn’t make any food for him, because I did not know you were coming. There is lots of food. You are both welcome to stay, but he will have to figure out his own food.” Then I held my breath again.

There was a long pause. My sister had her breath drawn in and held. She looked like she was going to explode. But I had answered quietly. She really had nothing to explode at.

“We will stay then,” she said, grudgingly. And there was No Meat No Milk. I was pretty happy when she ditched him. But I was also happy that I had not exploded back at her.

That was when I really got control of my temper. Not that I never lost it again, but I was no longer an ogre. I could hold it with my sister. My husband could set me off, but when I stepped back and started recording what he said and my responses, I could hold it there too.

After we divorced, I had one boyfriend who moved in. I had joked to a friend that my family had a lot of enablers and enablees, but that the latter lived longer. I said if I had to be one or the other, the latter seemed better for longevity.

And that boyfriend showed up immediately. I had just been “strongly encouraged” by my employer local hospital to open my own private practice. That is, I was not seeing patients. I was writing a business plan. I met him in a bar, salsa dancing. He said I was cute and I said, “No, I’m prickly.” I swear, it was that sentence and my dancing that attracted him. I always grin like a fool when I’m dancing. I love it. It lights me up.

Anyhow, I got mad at him exactly twice before he moved in. Boy did he come down on me for getting mad and punished me very thoroughly. By now you are wondering why I let him move in and frankly I was too. But my intuition was running the show and I just let it.

Well, he had kissed me like crazy at the start of the relationship. He stopped kissing me, almost as he moved in. He had insomnia. He’d fixed up one of the two upstairs bedrooms. He started sleeping with me less and less and sleeping in the other room, on cushions.

I would wake, worry. I started moving too. I moved to the guest room. I moved to the couch. Once I was out of the theoretically shared bed, I could go back to sleep. He protested that I shouldn’t move. Why not? I was getting insomnia from worrying about him leaving more and more.

He said we’d need couples counseling eventually. I said, ok, and scheduled it. He said, “I didn’t mean now!” I said, “Well, seemed like we might as well get it out of the way.”

He told the counselor I needed to either cut my sister off or do what she said, but instead, I was present and disobeidient. My sister had metastatic breast cancer and we came from an alcohol addiction family. Can you say complicated relationship?

I explained to the counselor that I thought many patients with cancer end up in a “cancer bubble”. Everyone tries to do what they say because they have cancer. This isolates them and does damage to the relationship. I was trying to stay present and real. That is, I did not obey. I was getting pressure from other people to obey, because my sister would complain about me. Whatever.

The counselor thought I was reasonable. I brought up the sleep issues. The boyfriend cancelled the counseling, saying that he needed a break.

At six months living together, he was saying that he might need to go back to the city to work. Two hours away. And I still was not doing what he wanted re my sister.

Counseling again. Again my behavior to my sister was examined. Same story. I turned to him. “I hear you saying you may need to return to the city for work. I hear you saying you may need to move there. What I don’t hear you saying is darling, we will get through a long distance relationship. Are you breaking up with me and not telling me?”

Long silence.

The counselor said, “You need to answer her.”

He finally said, “I wasn’t going to tell you until after I moved.”

I cried. We left. I kept crying.

He said, “You are angry and you are going to throw me out on the street.”

“No!” I said, “I am sad! You move out when you are ready! We will remain friends!”

So then I cried buckets. I cried on him, buckets. I cried every time I saw him, I cried daily, I cried about him, about my sister, about alcoholism, about the hospital getting rid of me. I cried about everything. I cried on him daily.

For six months. He kept saying “You are angry. You are throwing me out.” But I didn’t. I just cried more.

He moved out on the weekend I returned from seeing my sister in hospice for the last time. Her birthday was March 23. I saw her last on March 22. My birthday was March 28. She died March 29. He moved out on the 26th and 27th. I was not mad, I just cried and cried and cried.

I think that he was looking for an angry girlfriend. He thought he’d found her when I said I was prickly. He would have been the enabler and I would have been the angry dysfunctional enablee. It turns out that I was not really interested in being an enablee. Now I want a healthy relationship.

So that is my recommendation. If you have to cry, do it on the boyfriend who wants you to be angry instead of sad.

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Opiate overuse: a change in diagnostic criteria

In the DSM IV, that is, the Diagnostic and Statistical Manual of Mental Disorders, opioid dependence disorder and opioid addiction disorder are separate. Everyone on a chronic pain medicine for a length of time was expected to be dependent, but not addicted. Addiction was considered rare and was thought to be mostly people who abused opiates. Who took them for pleasure. Oxycontin, heroin, vicodon. Those bad people who were partying. Got what they deserved, didn’t they?

That has changed. My feeling was that it’s been a long time coming, but no one asked me.

In the DSM V, opioid dependence and opioid addiction have been combined into “Opioid Use Disorder”. They are no longer considered separate. They are a spectrum. Anyone who is on chronic opioids is on that spectrum. This is a big change. It has not really penetrated the doctors’ consciousness, much less the patients.

It is quite simple to score. There are 11 criteria. They are yes and no questions. Score and add up. The patients are scored mild, moderate or severe.

Here are the criteria:

Opioid Use Disorder requires meeting 2 or more criteria; increasing severity of use disorder with increasing number of criteria met.

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home.

2. Recurrent substance use in situations in which it is physically hazardous.

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.

4. Tolerance, as defined by either of the following:

(a) a need for markedly increased amounts of the substance to achieve intoxication of desired effect.
(b) markedly diminished effect with continued use of the same amount of the substance.

5. Withdrawal, as manifested by either of the following:

(a) the characteristic withdrawal syndrome or
(b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms.

6. The substance is often taken in larger amounts or over a longer period of time than intended.

7. There is a persistent desire or unsuccessful efforts to cut down or control substance use.

8. A great deal of time is spent in activities necessary to obtain the substance, use of the substance or recover from its effects.

9. Important social, occupational, or recreational activities are given up or reduced because of substance use.

10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

11. Craving or a strong desire to use opioids.

Mild substance use disorder is yes to 2-3 of these.

My chronic pain patients ask, “Why do you treat me like a drug addict?”

The answer now is, “Because you are on a chronic opiate.”

I am starting to use the criteria in clinic. When I get a new chronic pain patient, I give them the list. I let them tell me.

It is hard because they often recognize 3 or 4 or 5 or more things on the list. They say, “So this is saying I’m addicted.”

“I’m afraid so.”

They grieve.

I am posting this because people are dying. The number of people dying from prescription medicine overdoses taken correctly has outstripped illegal drug use deaths, approximately 27,000 unintentional overdose deaths in 2007.

Here: CDC Grand Grand Rounds: Prescription Drug Overdoses – a U. S. Epidemic.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

The CDC article says: “The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids, and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month.”That is “approximately” 14 million people.

Please tell your friends and those you love about this. Thank you.

first published on everything2 on June 4, 2014.

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Alcohol

Let’s talk about alcohol.

I am a family practice physician and I talk to people of all ages about alcohol. The current recommendation is no more than one drink daily for women and two drinks daily for men, no saving it up for the weekend.

“What?” you say “No way. Come on, that’s ridiculous.”

My patients don’t say “That’s ridiculous.” After all, they are paying me to do a physical exam and a preventative exam. I am supposed to give them advice. But what is the basis for that?

One drink is defined as a regulation 12 oz beer or 6 ounces of wine or one ounce of hard liquor. If it is a high alcohol beer or wine, the amount is less.

It is NOT the liver doctors that have given us these numbers. It is the cardiologists, the heart doctors. One drink in women or two in men, lowers blood pressure and in general, has good effects. Go over that daily and there is a rebound in blood pressure as the alcohol wears off. Alcohol works in the same way as benzodiazepines: it makes people less anxious and more relaxed and lowers inhibitions. Both alcohol and benzodiazepines are addictive in the long term.

Cardiologists qualify this recommendation as follows: there is no recommended daily amount of alcohol that is considered heart protective because there are too many alcoholics. The recommended daily amount of alcohol for an alcoholic is none. The recommended daily amount of alcohol for the general population is none.

Alcohol withdrawal can be very very dangerous medically. I think that the three most difficult things to quit are heroin, methamphetamines and cigarettes, but alcohol is more dangerous. In heroin withdrawal all of the pain receptors fire at once, so it is torture, but people don’t die. With serious alcohol withdrawal, the blood pressure skyrockets and the person can have seizures, a stroke, a heart attack, delerium tremens and can die. In the hospital, benzodiazepines are used to slow the withdrawal, replacing alcohol in a controlled manner.

Alcohol does more than affect the blood pressure. Over time, alcohol can damage the heart and lead to congestive heart failure. Of course, you know that it can damage the liver and lead to cirrhosis. Cirrhosis is sneaky: as long as there are a few functioning liver cells, the lab work can look pretty normal. The liver makes proteins for the blood and makes proteins that allow our blood to clot. Once there aren’t enough healthy cells to make those proteins, alcoholics will bleed quite spectacularly. If the amount of the protein albumin in their blood is low, fluid leaks from the blood into the tissues: so whatever part is “dependent”, that is, lowest, will be swollen. Alcoholics can have legs with swelling where I can push with my finger and there is a two or three cm dimple. Alcohol also can lead to gastritis and ulcers. If someone can’t clot and they are vomiting blood from an ulcer, the doctor gets a tummyache too, from worrying. Ow. The liver is also supposed to filter all of the blood in the body. As the liver gets blocked with dead liver cells, the blood starts to bypass it. The bypass is through blood vessels in the stomach. Remember that person vomiting blood? The swollen vessels in the stomach are called varicies and we don’t like them to bleed. They are big, swollen and can bleed really really fast. The person can die. I don’t like transfusing and really don’t like transfusing 12 units of blood. In end stage alcoholism, the liver no longer lowers the blood level of ammonia. Ammonia crosses the blood brain barrier and poisons the brain. We haven’t even discussed the lack of vitamin B12 and thiamine which can cause unraveling of the myelin sheaths on the long fibers in the spinal cord: this means that the person gets permanent asterixis and “walks like a drunk” even when they are sober. I’m sure I haven’t remembered all of the consequences of alcohol, but that will do for now, right?

How much alcohol daily causes the above charming picture? We Don’t Know. Really. And it is not okay to do randomized double blinded clinical trials to find out. Same with pregnant women: we don’t know if there is a safe amount of alcohol during pregnancy and we bloody well can’t test it. It is safer not to drink while you are pregnant.

In clinic, I ask how much people drink. If they say 1-2 drinks daily, I ask what the drink is. Sometimes they look confused. I explain that I have one patient who has two drinks a day: however, it is a 12 ounce glass with a little ice and a lot of whiskey. I asked him to estimate how much whiskey and he said, “6-8 ounces.” That is, each glass is 6-8 ounces. His blood pressure is not under control and so far I feel like a failure as a doctor with him; he is NOT reducing the amount. In medical school, the two jokes were: How much alcohol is too much? More than your doctor drinks. And: How much does the patient drink? Double or triple what they tell us.

The popular word in college used to be that you could drink one drink an hour and still be “okay”. “Okay” to drive and it would wear off. Sorry, nope. Breathalyzers are now pretty cheap; buy one if you are drinking more than the 1-2 per day. And the college students that are binge drinking 6-8 or more drinks on Friday and Saturday. It DOES have long term effects and it IS doing damage.

Lastly, sleep and depression. If you are having trouble sleeping, don’t drink. No alcohol at all. Alcohol is a depressant. It helps people to fall asleep. But they do not have “normal sleep architecture” and it works AGAINST them staying asleep. People often wake up as the alcohol wears off. And the blood pressure is having that rebound, remember, and often their heart will race. That is withdrawal. If you are having trouble sleeping or you are depressed, do not take a depressant. It makes it worse.

I saw a nineteen year old in clinic who admitted to “occasional” heroin use. “But I’m not addicted,” she said. I said, “Well, that’s good. But I took care of a bunch of people undergoing heroin withdrawal while I was in residency and it looked like one of the most painful things on the planet. So I would advise you to quit while you are ahead.” I saw her a year later and she said, “When I tried to quit, it WAS hard. I was addicted and didn’t know it. I’m off now and I won’t go back.” So if you tell me, no problem, I can quit alcohol any time, I say more power to you. Show me. And if it’s harder than you think, get help.