Pain

Hail,
And herein a post where I try to work out what I'm going to do about Patrick Mawson.

Patrick Mawson - I suspect I have described him here under another name, but I tend to lose track - Patrick Mawson is a thin, chronically dirty, flaxen-haired man with a thin, vaguely mosquitoid face. He speaks in a low whine, and, if the analogy is to be pursued and the unpleasant truth be told, he has not worked since nineteen ninety two. He was recently returned to us from Central after a period of disciplinary pharmacotherapy, and from Thursday he will be my problem again.

And the problem is complex. First of, to my shame, is the problem of "negative counter-transference" - the phenomenon where the doctor experiences feelings of hatred, fear, etc. towards the patient. I don't know if this is true negative counter-transference - transference involves the unconscious redirection of feelings, and I am quite aware of the dull ache in my heart whenever I see Mr Mawson's name on the patient list, and the way the sun outside the office goes behind a cloud, and no birds sing.

(I just looked this up and it may be that the appropriate term for what I feel is parataxic distortion. I don't know if that is the right term or not, but it such a cool, fifties science fiction term that I am going to use it. I reckon with Mr Mawson I have about eighty dioptres of parataxic distortion - I may need glasses).

But another part of the problem is his pathology. Mr Mawson has back pain (a bulging disk) and chronic gastro-intestial reflux. Although he is careful to distance himself from "the junkies", and dwells on his disgust for them at least twice a visit, his records indicate he was sent to us because he was injecting his medication, which he says he was doing because of the pain. While in prison he was sent to a psychiatrist who suggested "a complex mix of cluster B and C personality disorders with predominant narcissistic, antisocial and dependent traits" (I know the psychiatrist - it's possible she had a bit of parataxic distortion, too).

But now he's out, and we are in the difficult position of managing Mr Mawson. The meetings rarely go well. He comes in wanting treatment for his pain, I am only trained in and authorised to treat his opiate dependency. Dependence on prescribed medications is a difficult area - in a narrow sense of the word I am dependent on ventolin. But doctors are okay with prescribing ventolin and are, almost always, not okay with prescribing some of the most efficacious pain and anxiety relieving medications.

This is because the medications only work really well initially. It's like alcohol - when you have your first drink, a glassful gets you drunk. Later, if you drink regularly, it's two or four or a carton and a half a day. And like alcohol, with the opiates and the benzos you get withdrawal if you stop suddenly, anxiety or pain or sweating or twitching or whatever. Shitting and vomiting ten times a day. Can't sleep. And so after a while you are drinking (or taking pills) just to feel normal.

And the tablets don't last as long as they used to, you have to take more and more. And now the doctors are getting iffy about prescribing for you, doctors who used to be alright, faces change, and you get the runaround, place after place closing up on you, and you're in pain and your guts hurt and your heart's beating a hundred times a minute and can't they see this is making you worse? The worst thing for your pain, the worst thing for your anxiety? Doctors, who are meant to help you?

Obviously, all of this - the cancellations, the last minute changes, the waiting for hours in the doctors surgery only to get nothing, be treated like a junky - it gets you angry. And a receptionist or a nurse says something, you say something back, you're banned.

No-one understands.

If it weren't for other people like you, people in the same situation who can spot you a couple of tablets when you're desperate, you'd go under. And they can't be expected to keep giving you tablets, that's not fair, so you end up buying them, fifty dollars for a grey nurse (100mg morphine), two bucks for a valium (5mg diazepam). So you pay.

And you know, because people tell you, people who've found themselves in the same situation, when things get out of hand, when things get really bad, you can make things go further by injecting. That way it doesn't get chewed up by the liver and you get more. Little needle through the skin, into the blood, straight to the brain.

Things tend to go bad relatively quickly after that. Mr Mawson got hep C, turned bright yellow, and while he was sick six big Asian guys* came in and beat him up and took his stuff, broke three ribs.

But how did it get to this? Injecting your medications? Having to buy stuff off some drug dealer instead of getting a script from a doctor? If the tablets were as bad as they say, how come they were willing to give them to you in the first place? Who's fault is this, anyway?

Anyway. Difficult things to manage. Because the pain is real, and the dependence is real, and Mr Mawson's suffering is palpably, demonstrably real. And doing this is not like other fields of medicine, where the patient comes to me because s/he's sick, and we both sortof agree on what's wrong, what s/he wants fixed, and we come up with a plan and the patient goes away happier. This is pleading, and concealing, and emotional blackmail, and on occasion threats (rarely against me directly, usually of harm the patient will suffer, and the dire consequences, and the guilt that will be on my head).

I don't know. I promised to treat pain, to relieve suffering, to help. And my prescription pad sits in my desk, probably glowing like an object in a video game. I can relieve pain, I can ease suffering, in the short term I can help.

But one of the big problems we have in the city is cleaning up after Dr Hindpaddock, a physician frequently under investigation by the medical board. Dr Hindpaddock (by all accounts a deeply pleasant man, bearded and jolly) is a private specialist, and so free of many of the restrictions the government places upon me. He believes, and I quote, "there is no maximum dose of opiates. There is no maximum dose of benzodiazepines." He has patients on three different opiates and two different benzodiazepines a day, he prescribes daily doses two or three times the dose that starts to get me worried.

I rang up one of his ex-patients a year or so back to change an appointment with her. She was a zombie. Horrible thing to say, but true. Slept all day every day, house all dark all the time, slurred speech, hadn't got out of the house except for a doctor's appointment for fifteen years.

That's what worries me. That plus the undeniable correlation between high doses of methadone, high doses of benzos and high risk of death. We had five deaths here in the south at the start of the year - none from people on the programme caused by anything I'd prescribed, but close too home. Someone who jumped off the programme, overdosed a month later. Someone bingeing on speed, didn't sleep for five days, car into a salmon gum on Stone Highway. Another died of pneumonia, another what I reckon was a bleeding stomach ulcer, another cut his wrists in the bath. People who die early.

Anyway. No real solutions here. Thursday I see Mr Mawson and I will disappoint him again. Another reel, another jig, another round of this danse macabre.

Sorry. And as a PS I wrote a letter to a senator which cheered me up a great deal and probably won't even get me sacked. I will see if I can post a bit of it.

Thanks for listening,
John

*This seems unlikely, if only for reasons of economics - six guys of any size would not be needed to force their will on Mr Mawson.

It's amazing how single white guys never commit any acts of violence in this town. It's all gangs of Aborigines or Asians. No wonder the National Front wants them out.