Friday, June 08, 2007

The Fighting Has Intensified Along The Road To Peace

Been thinking (it being night here, and winter, and only a few hours until I have to get up again anyway) about one of our clients whom we have cut loose. And Sarah's in Tasmania at the Intergalactic Cat Show, so I am allowing myself just a little bit of melancholy.

First things first. The drug and alcohol field is not like other fields of medicine. There are several ways medicine can be divided up - general versus specialties, internal medicine versus surgery, that kind of stuff.

Sometimes the doctors working in a particular field have their own methods of division, usually with their own specialty (good) separated from all the others (crap). Radiologists think doctors can be divided into "radiologists" and "people who have to ask radiologists for advice". Surgeons think in terms of other doctors (who can't actually cure what's wrong with people) and surgeons (who can). Emerge thinks in terms of "emergency doctors" - those who take the patient history, examine the patient, diagnose the illness and treat and usually cure the patient - and "other doctors" who do... all that other stuff. That's when they are not making our patients sick in the first place (GPs) or stopping us curing them (other hospital doctors).

Anyway - apologies to my fellow doctors. This is why I write under a pseudonym.

To me, drugs and alcohol is in the same division as psychiatry - there are the same issues of choice and capacity for judgement, the same problems of social justice, that kind of thing. Like the mentally ill, with whom there is a huge overlap, drug and alcohol clients can be told when and how to take their medication, can be prescribed medications they do not want to take and prevented from taking medications they want to take.

Additionally, they can be told to report to the doctors within twenty four hours to urinate in a pot, they can be prevented from driving, they can be told to do such and such or their medications will be compulsorily increased or decreased.

But there is one way in which drug and alcohol clients are separated from as far as I can tell all other patients. Drug and alcohol patients are the only ones where people can be too sick for doctors to treat them.

This is what happened to Jessica Jones. Jessica Jones is - or was - one of my five most unwell clients, along with the Maddest Man in Mordor Mr Jarusnich (deported to a private drug rehab centre in Queensland), the Amazing Belushi Siblings (back in jail, thank God), and Tina Jackson, the World's Unluckiest Woman*.

Jessica had been avoiding seeing me since I put her on the doctor shopping list. I also capped her dose of methadone at 120mg a day until the last moment of the last hour of the last day of eternity, or until we got three urine drug screens from her without benzodiazepines in them, whichever came first.

I did not do this purely out of malice, but because I believed Jessica was extremely likely to die on the opiate substitution programme. She was on a very substantial dose of methadone. She swallows entire bottles full of sleeping tablets - fifty at a time, doses that would put other people in extended comas. She has been in hospital several times with cellulitis (an infection of the skin from dirty injecting), endocarditis (an infection of a heart valve from dirty injecting) and reactions to tablets she "just picked up". She continues to drink alcohol, she suffers from recurrent chest infections.

Recently, however, two very bad things had happened to Jessica. Her partner, on again, off again, had managed to reduce off the methadone programme. Having conquered his heroin problem, he did as more and more of our clients do and began using crystal methamphetamines.

Amphetamines in very many ways are far worse drugs than opiates. If you don't actually overdose on opiates, they are relatively benign of themselves. Most of the harm my patients suffer from the opiates seems to come from the injecting and from the criminality. Amphetamines have both of those problems plus a few of their own - strokes, bleeds, psychosis. Amphetamine years are like cat years - ten years of speed makes a good twenty year old look like a very bad forty.

Correspondingly, Jessica's partner was one of the first people I thought of when I heard that a man in his thirties had driven his motorbike into a salmon-gum out near Innmouth. He had been four days awake, she said later, trembling, seeing things flicker across your field of vision. Apparently last time anyone at the clinic saw him he had been picking at his skin, saying there were insects beneath his skin**.

Anyhow. He was dead. And that same week she had come into money, a sizeable sum of money, several tens of thousands. When seen by Dr Grizzle had been using twelve hundred dollars worth of heroin a day. Plus methadone, plus whatever else she could find, plus three different kinds of sleepers and bottles full of all that stuff I had sent out the alerts about...

Anyway, to cut a long story short, where she had been very bad now she was worse. I rang Central and said I didn't think we could handle someone like her. Central, which means the senior drug and alcohol doctors, said to transfer her, which I did. And the next day I heard she was being reduced off the programme. Essentially this means they had had a meeting and decided that she had become too sick for our service - not just too high risk for me, too high risk for the National Drug and Alcohol Services, pretty much too high risk for anyone in Australia except some of the more experienced private prescribers.

Basically, we prescribe methadone to people who whom it is safe to prescribe, and she is not one. If we prescribe, said my boss, she will overdose on the methadone and die soon.

If we don't prescribe, however, if we cut off her supply like we are doing, what is called a "forced reduction" where the dose decreases ten milligrams a week or ten milligrams every few days, a long, protracted period of withdrawal, weeks of cramps and aches and sweats and chills and diarrhoea, I suspect she will die even sooner. Because this is not a woman inclined to take things on the chin, to be stoic, to endure. And down any street in parts of Mordor are people keen to relieve her pain. Unless she is physically stopped, locked up or something, she will overdose anyway.

(I should stress that we have offered her a third option, an inpatient detox, but there is no way on God's green earth she will take that up, and even if she did, I have never heard of a forced detox working. The idea itself is window-dressing, the "lipstick on the pig" part of punitive pharmacotherapy).

Don't know what to do. Well, I do, because there is nothing I can do. Basically, I am not allowed to prescribe for her. To be honest, I don't know that I would if I could, I did call my boss about her and I did say she was too much for us to handle... maybe I'm just using the fact that someone else has done the actual cutting off to allow myself to feel I wouldn't have done it.

At night now, something about it seems wrong, although intellectually it is right and in some ways I am less worried (I had almost been rehearsing my coroner's speech).

I feel we should do something, but to be honest I can't think what. Wherever this woman goes, bridges burn.

Anyway. I shouldn't worry. I will try to talk to someone about this, some of my less close medical friends. They are, mostly, sensible, restrained people, whom I suspect may wonder at my continuing to work in this field. They are people who will remind me that you can't make someone give up drugs, that in the end it's someone's right to do whatever they want, even if that is die. They will say, and they will speak truly when they say, that my job isn't to make sure everyone has a happy ending, my job is to make sure I do my defined task within certain very narrowly defined boundaries.

"You can't save people from themselves" my deeply reasonable friends will say, over a bottle of very good wine. I will perhaps protest a little, like people do when they want people to continue to compliment them, and after a glass or so I will allow myself to be convinced. These are difficult patients. There is a high intrinsic mortality and morbidity, the rules are there for a reason. There is only so much one person can do. I'm doing my best.

"You might be right" I'll say.

"You know your problem? You care too much" they'll say.

"Don't be fooled" I'll laugh, but I'll like hearing it, and maybe I'll get tehm to say it again. Afterwards I'll drive home, elecric windows closed against the cold night. If I time it right I get to catch the sacred music programme on the ABC.

Hopefully ths will not precisely coincide with Jessica Jones being brought into Florey ED, that clammy grey-blue, breathing three times a minute, frontal lobes darkening, damage already done.


Enough about that, about all of this. Things are not that bad. And this is not how I am feeling all the time, it's just what I am writing. I don't know exactly what I'm trying to say here, and I get the feeling I have not succeeded, which is a pity.

Next post maybe about something cheerfuller.

Thanks for listening,

* Actual given reasons for the presence of drug metabolites in her urine:
1 (heroin). I was asleep at a party and someone must have injected it into me.
2. (unknown opiates) I tongue-kissed my boyfriend and he's on drugs - I must have sucked it through the pores on his tongue
3. (amphetamines) There must have been some amphetamines in that new diet drink I've been drinking - sustagen or something. The medical records indicate a similar "something I drunk" justification being attempted for the presence of methamphetamine metabolites in her urine around about the time they brought out New Coke.
4. (benzodiazepines) They gave me valium at the hospital when I went there with my sprained ankle - see, here it is written in felt-tip pen, poorly spelled and unsigned, at the bottom of this typed discharge letter from the hospital you work at.

** and for some fucking incredible reason, the person who saw this did not detain him, and three days later he was dead.


Blogger Benedict 16th said...

1) "except some of the more experienced private prescribers"

-- Are you talking to me?

2) re ** -- Shit - if I detained every patient I saw formicating, they would have to open the new Royal Benedict Hospital just for all of them...

Benedict, opioid substitution program accredited prescriber

9:05 AM  
Blogger Foilwoman said...

Would massive amounts of chocolate and wine (alternately, not simultaneously) work as an opiate substitute?

12:01 PM  
Blogger Camilla said...

I reckon that must be one of the hardest part of any of the helping professions - those people who just cannot be helped, despite all your best efforts.



5:32 PM  
Blogger Benedict 16th said...

Actually Camilla,
They have made their beds and get to lie in them. Still I will try the best I can, but I refuse to feel guilty if they feel imposed upon because they have to drop a dose or lose all takeaways because of amphetamines and benzos in their systems.

The hardest part to me - is the dependents*, like the 13 yo recently trying to suicide, because she gets picked on at school, her mother doesn't give her cuddles any more (she has a new bloke in the house) or tell her that she loves her... And won't let her live with her auntie's family because her mother doesn't want to feel she is an inadequate parent. What do you do then?


* Pun intended

6:10 PM  
Blogger Benedict 16th said...

and I just read this
UK Times article

6:19 PM  
Blogger Camilla said...

Benedict, that's not actually what I meant at all. Perhaps I should have worded it "those people who just will not be helped". However, that goes against the grain a bit for me because although I believe we all have the opportunity to make good choices for ourselves, I think some people are less well equipped (for whatever reason) to make the best choices. So I think, at least in some cases, it's a mixture of "cannot/will not".

I agree with you about the dependents. Those are the very people who are not learning how to make wise or healthy choices for themselves. I see it a lot where I work too (divorce law office).


4:52 AM  
Blogger Midwife with a Knife said...

How come nobody injects me with heroin when I'm not looking?

9:38 AM  
Blogger Ladyk73 said...


I think you have done the best you can. I really do. I mean, well, I guess I could make a case for her behavior as being suicidal and commit her and force her through a detox (Being in NY state in the US)... I know it can be done. But why?

But...I don't know it will not help her. You cannot save everyone. And I believe that people have have the right to self destruct.

It seems that to treat to increase her suffering. She is suffering now, she was suffering before and she will continue to suffer. She obviously has the means to illicitly self medicate her physical and mental pain.

She is dying, and in someways...I hope her death is ironically peaceful. As those with terminal cancer are allowed to drift to death with morphine. In some ways, I hope her death comes in an opiate dream.

1:46 AM  

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