Asymptote

Two o'clock in the morning here, the house is quiet, the chickens are locked away, the dishwasher and my favourite oriental cat is purring, and sleep is elusive.

And as usual, whenever I can't sleep my mind fills with unusual thoughts.

One of the new cats, by the way, miaows like someone rather ineptly imitating a cat. You're sitting at the computer and from the darkened kitchen someone says "miaow". It's rather unsettling.

A moment of scene setting. For the last month or so I've been working at the South Mordor drugs and alcohol unit, seeing people who have some kind of problem with what we call drugs of dependency. That means the thirty nine year old mother on methadone for twenty years, the forklift driver who drinks, the nineteen year old man with the amphetamine psychosis, the twenty three year old woman who smokes heroin.

It's interesting work, and it's learning how to manage something I (and the ED and medicine and the whole of society) don't manage very well at all, and it's something I believe in. And it's interesting stories, told generally by pleasant, articulate people with few pretensions, and it's a glimpse of something that I feel I was perilously close to, something that touched my friends and family but for no apparent reason spared me. That drop of rain that falls just the right side of a hillstop - that kind of thing.

I have been having odd thoughts lately, too, about stories, about how ... fundamental they are, how irreducible they are. Wondering (bear with me) if it makes sense to think of people being constructed of stories, as much as they are made up of atoms. Because it seems to me that when I meet someone and talk to them, while it is true that what you have is two temporary coalescences of atoms squirting air at each other, there are other possibilities.

Sometimes (usually at night, when night shifts are approaching or have just gone) I think we are all made up of stories. Sagas, not cells, memoirs instead of molecules, dramas rather than DNA. If you looked at us under some new kind of microscope there would be immeasurable numbers of tales: miniscule tragedies jostling with comedies, epics entangled with jests, myths forming and reforming as we watched. But unlike the democritan atoms (but like fractals and other objects of one and a bit dimensions), you can't break those stories down to clean, irreducible parts. The more you look, the more story there is. Stories all the way down.

But I digress.

I have been spending the last month or so hearing the stories of patients, and in the last few weeks, one ugly fact has been protruding from the water, upright like a jagged rock. The ugly fact involvement of my profession in so many of these stories. And I don't mean the (relatively common) stories of misprescribed drugs and poorly managed pain and the almost ecclesiastical condescension some doctors display (almost on the level of a deep tendon reflex - someone mentions methadone and the physician's lip curls)... I mean something much worse.

I mean the doctor as a deliberate and significant and knowing player in the drama, not as some disapproving chorus but a character in the tragedy. The doctor in the in the much less savory roles. The doctor as addict, as dealer, as pimp.

The first time I heard this was seeing a patient for a script review. Script reviews are bread and butter addiction medicine. You see someone and see how they are going on their dose of whatever, you help them out with what you can, you occasionally do a urine test, and that's that. It can be full on (some people have a lot going on in their life) but in the low maintenance longer term patients, it's pretty low maintenance medicine.

Anyway, I was speaking to a patient whose main worry was reducing his methadone dose in time for his working holiday (he does "private security work" in the Middle East and South Africa, doesn't seem like a holiday to me) and we were just running through the drug side of it and he mentioned that he occasionally used a bit of morphine "that he got from a friend who's a doctor".

I sortof glanced at him and he at me and we let that go by.

And a few days later I heard about someone else, a psychiatrist, who had apparently been "involved" with a younger patient for whom he prescribed opiates. There had been reports and investigations, but these things are very hard to prove, and the relationship was rumoured to be still going on. More discreetly, of course. And she was still using morphine.

And everyone said how truly terrible and abberant this was, and got on with our work.

Then another guy who went on occasional ("every two, three months max") ketamine binges with his local doctor, and another who was a cray-fisherman, and apparently had quite a good lobster-for-morphine exchange thing going on.

And then Rebecca Glissade, late thirties, upper class Melbournian accent, all silk shirts and pearl necklace, and the only woman I have seen at SMACHEAD who I think will be dead in five year's time.

She was - is, I presume - a psychologist, not a doctor but the wife of a doctor and one of a close circle of friends, all doctors. They had been together all through University (she pronounced the capital U), wonderful friends, dinners at each other's houses in the hills, holidays together in Europe, restaurants in the city. A wonderful, artuculate, exciting, extremely close (and closed) circle.

And they were all on drugs. Well, it was so easy to get. Morphine, ketamine, oxazepam. Medical grade purity, guaranteed supply. None of this haggling in the back streets with some toothless pimp for your third grade product cut with epsom salts, this was clean and pure and exciting and wicked and not at all like that at all. And none of them would ever get caught, because they were so clever, and they didn't have to worry about disease or anything, because weren't they all doctors after all?, and they were so rich, and young, and the way I heard it it was roses, roses all the way.

Well, almost. There was the matter of James. He was in Queensland, in prison, on a remarkable eight hundred and eighty charges of fraud. Presumably still able to dispense medical advice, but no longer a member of the Royal Collage of Physicians. And there was Malcolm - and she didn't say anything more about that, but it had all been a shame, a terrible waste. They drove him to it, you know.

And there was the matter of her, having been kicked off the methadone programe a few months back and only now being reinstated. That matter of the forging the methadone scripts. Her husband - ex husband - now practicing out near Broken Hill somewhere. Took the car, took the money, left the kids. Having to walk half an hour to the nearest bus station to get to see me - Brigadoon, in the hills where she lived in her big house, was known for its public transport routes.

Going into the clinic for a seven day detox, coming out with contacts and someone who could score her some stuff, scoring the same day. Using four hundred dollars of heroin a day, going through the savings at a prodigious rate. The kids (four, six) not knowing, but knowing enough not to knock on the bathroom door when mummy's in there.

And now what? She wasn't holding up on the dose of methadone she was on, she needed an increase. Otherwise she'd be forced to keep on using. It wasn't right that she should be punished, that she should be subjected to this. She wasn't some junky. And her lawyers were trying to talk to his lawyers, try and arrange a reconciliation. Anyway - James, he'd be out of prison soon. His dad had a pretty good lawyer, there were still avenues. He'd be out, and although he couldn't prescribe opiates again, they'd slip up. They wouldn't remember, he'd get under the radar, he'd be back.

He was dux of St Peters, you know that?

Anyway. She left (with her dose gradually increaing over the next few weeks, her deeply unsatisfied), and as she left I noticed that underneath her black woollen slacks was a pair of old running shoes.

Since then I have been struggling to articulate what it is that concerns me so much about this woman. Because there are others in far worse states, others who take more drugs, who live on the streets, who have diseases this woman hasn't even heard of.

And I cn't pin it down. Part of it is the rapidity of the decline, the plunge from the silk shirts to the junkie hiding in the bathroom, walking everywhere because she has no car. Part of it is the sheer number of barriers that have been crossed - a lot of people after ten years on opiates still don't inject, she's well over that. Part of it is the demand we fix her problem in the way she wants and when she wants it.

But I think it's something else. Most people, if something like this had happened... there would be some period of self-analysis. There would be at least some suspicion that what you had done or what you had failed to do had played at least some part in what had happened to you. There would be, if not an acceptance of responisbility, at least a sign that the questions had been asked.

But she's a good way away from that. She is coping via a mixture of denial (her husband will come back, with the car and the cash. James will emerge from incarceration in Queensland with a magnum of morphine under each arm. People will realise she's not a junky like these other disgusting people) and diversion. It's SMACHEADs fault she injected heroin. It's the police who trapped James. It's the medical board who drove Malcolm to do what he did. It's everybody else.

And so, what do you have? You have a woman with great expectations and few resources. You have someone who is injecting heroin from a disreputable source and is defying us to stop her. You have someone in a strnge place who won't even open her eyes. You have someone who, to be honest, does not have the skills to survive in the place that she has brought herself to, the place in which she now lives.

Anyway. Three AM, I have to get on with sleeping. I hope I am wrong about this woman.

Thanks for listening, will reply to comments tomorrow night.

John