Wednesday, October 31, 2007

Crime and Punishment

Morning here. I’m doing Sarah’s shift at Central. We have a neurosurge appointment this afternoon, Sarah is at home in bed or sorting through MRIs and CTs. I don't know what the neurosurge will say - the pathology is definitely there, the symptoms are there, it's a question of whether he operates or not. From what we can work out the nerve root is being crushed, the one that runs down to her hand, but as well as that there is narrowing of the spinal canal itself, the bone tunnel through which the spinal cord runs. If he does advise surgery this will be a bigger operation than last time.

On the good side things seem to have stabilized in the last few days, but before that they had ben rather hair-raising: last Friday she lost sensation over most of the back of her hand, and it has not returned.

Since I would rather do almost anything than talk about this, I will write about something utterly unconnected.

Mr Grote is one of the patients about whom I worry pretty much constantly. I see him regularly, I discuss him with his care-worker whenever the occasion permits. I am in constant communication with his parole officer, his GP, his pharmacist. Unknown to Mr Grote, and on days carefully scheduled to ensure the two do not meet, I also see his ex-partner, a pale, thin woman with dirty blonde hair. Mr Grote is legally required to remain at all times five hundred metres or more from this woman, and faces considerable forensic penalties if he does so. He is also barred for life from three pharmacies and we are required to have a security guard present whenever he sees us.

Not that any of that was necessary Tuesday. I leant out into the waiting room and called his name, and Mr Grote looked up at me and smiled. Jamie, the soon-to-be second Mrs Grote, smiled too, one of those smiles like a flash of light, and offered to hold the baby. With evident regret, Mr Grote handed over a tiny someone swaddled in a clean white blanket, and followed me into the office.

He looked good. Put on a bit of weight – some of that was the methadone, but it often means the patient is taking less speed, maybe taking his prescribed dose of antipsychotics – and looking the better for it. His face had cleared up, he was notably calmer, he spoke mostly of his new child, his son. Half way through the interview he found the separation too much, excused himself to the waiting room and returned with his child in his arms.

"It happens, after a while" he said.

"What does?" I said, staring at one of the twenty or so new baby photos on his phone.

"You get over it. The smack. You sortof change. Different things become important. Since I had Blayde* everything's sortof come into place."

"You reckon? That's brilliant." I said, writing down what he had told me - no opiates, no benzos, no amphetamines for five weeks and three days.

"Sure of it" he said, his voice soft. "You know - I wouldn't recognize myself from when I was eighteen."

"Most of us wouldn't" I said. For a moment I remembered that line from "The Go-Between" - The Ram, the Bull and the Lion epitomized imperious manhood; they were what we all thought we had it in us to be; careless, noble, self-sufficient, they ruled their months with sovereign sway.

"No, but - " he stared down at the little bundle. "They change you."

"They do" I said. "You're doing bloody well. Congrats. And that's a beautiful kid."

The appointment stayed with me for most of the day, and it pleased and cheered me, and I told one of the nurses about it, and she seemed pleased and cheered too. And so we were all pleased and cheered, and it was in a pleased and cheered manner two days later I went through the pathology reports.

"Good Lord" I said. "Look at this."

It was Mr Grote's two-monthly urine drug screen, taken just before he saw me. Heroin. Amphetamines. Sleeping tablets. Buprenorphine (occasionally used as an adulterant in heroin, otherwise bought on the street). Six out of the nine illicit drugs we screen for, and two of
the remaining three we pretty much never see.

See, this is something I have to watch as a doctor. I believe anything people tell me. Always have done. That's why I ask for the urine drug screens, and I do the blood tests, and I measure all that stuff. Because I know if we ever have to rely on my keen clinical eye, or my innate sense of distrust, we're all doomed.

Anyway, as a result of this, Mr Grote goes from getting six doses a week unsupervised to having to go to the pharmacist every single day of the month and swallow his dose there. It's the loss of a recently hard-won privilege, and it will cost him time and money. He will, I imagine, be bitterly
disappointed. I feel bad about it.

See, the reason I am thinking about this is two articles I read recently. One was a letter by Tamara Speed**, the Treatments and Policy Manager of the Australian Injecting and Illicit Drug User's League to "Of Substance", the national magazine of alcohol, tobacco and other drugs. In her letter, she touches on a number of crucial issues which we as doctors rarely discuss. She talks about the unequal power dynamic, the frequently punitive response of doctors to client honesty, the range of issues that keep sick people away from their doctors.

Reading her letter was like listening to someone speak in a language in which I had once been fluent. She is sayingthings now that I said ten years ago, things I have not openly disavowed but things I suspect I don't take into account as much as I did.

Another, brief example of what I am talking about. Mr Hartley came to see us the other day. He is on a sizeable dose of methadone, no take-aways. His last urine test showed he was taking benzos, which are sleeping tablets. He frequently misses doses - two, three, four in a row - and when he does, he uses heroin, one hundred dollars at a time injected. When he turned up at the counter to see us he had a breath alcohol of 0.06 several hours after his last drink, and did not feel in any way intoxicated.

Later that day, I reviewed his notes.

Hepatitis C - not interested in treatment at the moment.

Several overdoses in the last few years.

Living from house to house.

I wrote him a letter, told him that I wasn't going to prescribe methadone for him any more, that his last dose would be on such and such a date, and that I had made an appointment for him to come in and discuss starting on buprenorphine treatment - a much safer, but less stonifying drug.

Unequal power dynamics. Punishment for telling the truth. Patriarchal, proscriptive, punitive. All of the above.

And the reason I did this is because of the second article I read that day. It's an overview of the characteristics of people who overdose. Basically, it points out that people who are on methadone are at much higher risk of overdosing and either dying or getting permanent brain damage than people on buprenorphine. People who drink a lot and are on methadone - they are at a huge risk. The homeless, people who attract a lot of police attention, people who inject publicly because they don't have a lounge-room crash out in, who buy large amounts because they don't know when they'll next be able to buy again, people who use large amounts because the don't want to be caught with it - each of tehse increases your odds of your methadone killing you.
People who take pills.
People with other illnesses.
People who are socially isolated, don't have friends, don't have a lot of fellow users.

People like Mr Hartley. I think he is one of the five or six highest risk people I have. They've done studies on this and those studies suggest that if I change him over to buprenorphine his life will be prolonged and his brain preserved.

But studies also show that people who die really fast are people who jump off the programme and then keep using. There are obviously a lot of factors that make people jump off the programme, but I can guess a few of them.

People who don't get treated with respect.

People who get their medications changed on them, without consultation by a doctor, who just get told about it.

People who get punished for being honest, people who get watched all the time, people who have their dose of medications cut if they don't obey.

I don't know. O don't know what would make Mr Hartley happy - to be honest I haven't asked, because his choices are fairly limited. I'm fairly sure what it takes to make the Drugs of Dependence Unit (who give me permission to prescribe opiates) happy, and I know I have to keep doing it, because if I deviate from what makes them happy they tell me pretty damn quick. I don't know what would make the Australian Injecting and Illicit Drug User's League happy, but from reading their fora I tell myself I can see the outline - respect, integrity, freedom.

So what's stopping me? The problem I have is balancing this with death, and overdose, and disease. There are less compassionate doctors than me - although I don't know that Mr Hartley would agree, and Mr Grote might be having his doubts around about now, when he gets his letter - but I don't know that they are any better at what they do. There are more compassionate doctors than me, but I know at least one of them has patients like zombies, has contributed to the vast benzo and opiate problems we have around here, has been called up before the medical board on many many occasions, has people who have died early, people addctied for years when they could have been clear-headed, had a normal life, people who can't get out of bed unless there's a pharmacist at the end of the trip.

I don't know. It's a balancing thing. Two years ago I was a lot softer, now I'm considerably more protocol-driven. The more I find out about this are the more I realise how dangerously ignorant I was and still remian. So I ring up for advice, and I read stuff, and I listen to someone tell me how much he's changed and then I send a letter telling him he's losing the very very few priveledges we've grudgingly given him.

And trying to manage all of that while knowing I am still as easy to fool as Mr Grote found me the other day.

Thanks for listening,
John Bronze

* Half-brother of Exavier and Jett. I am not making this up.

** Replaced the previous Treatments and Policy Manager, Elizabeth Smack, in a bloodless coup earlier this year. Her assistant is Gerald Cone and other members of the Treatment and Policy Team include Joanne Bong, Anh Whizz and David LickACaneToad. Okay, I made those names up. But not Tamara.
John Tablet.


Blogger Foilwoman said...

Not that my good thoughts do any good at all, but I am thinking them for Sarah and you. Hogs and peccaris and all that. Oink.

12:45 PM  
Blogger Camilla said...

Yep, more hogs, peccaries and a bonus side-order of armadillos from me too. This must be very hard on you both :(


2:23 AM  
Blogger Benedict 16th said...

Slightly off topic (which I know is about as rare for me as is me singing off key),

I set this up in my organiser to remind me 1 November every year - so that I can start using it again..

What's one really good thing about being an Ice Addict?
Only two sleeps to Christmas!!!!!

10:25 PM  
Anonymous ladyk73 said...

How is Sarah?

12:01 PM  
Anonymous catnip said...

Hi Bronze John, you articulate some of the difficulties GPs and pharmacists have managing drug dependent people very well.

I have used opiates, sometimes dependently, sometimes occassionally for 25 years. Cannabis is my other favourite drug (so much more civilised than alcohol) but I have used and enjoyed most of the drugs on offer over this same time period, whether they came via pharmacies, legal drug sellers (pubs, supermarkets etc) and those available on the black market.

I have experienced the legalised opiate maintenace programs as a client in 5 states over 15 years.

I have also worked in the alcohol and other drugs field as a peer educator, information officer, needle exchange worker and manager for over 15 years. Currently I am taking time off a phd to do the Hep C treatment.

So, lets be upfront about the relationship between doctors/pharmacists and people who are not satisfied with the three legal drugs on offer and have developed a physical/emotional dependency with opiates and/or benzos.

1. Some humans lie. Some of those will be people who are not satisfied with the 3 legal drugs on offer. Others include some people who have become doctors and pharmacists.

However, while I do consider myself a fairly honest person, I do not and never have told my doctors the truth about my drug use. Why? Because I know it will lead to worse health outcomes for myself.

Why? a) because most doctors, in my professional and personal experience have very little understanding of the pharmacology and effects of the currently illegal drugs. The subtle ways in which people mix drugs is totally beyond them.

b) Because drug prohibition ideology, a secularised Christian moral ideology of the body which emerged around 1800, which we have all grown up with, is powerful enough to override the scientific training that doctors and pharmacists recieve. It is not that this just makes them judgemental, it actually undermines their ability to thinking clearly about these drugs and the people who like to use them, it also undermines their ability to absorb new scientific information on the subject. If you think I am being a little over the top here, I can promise you that many doctors and pharmacists I have worked with in the AOD field, especially those working in some of the state pharmacy guilds and doctor organisations agree with this view.

I have experienced, as nearly all opiate users have, a substantial amount of discrimination not just socially, but most disturbingly, from health practitioners.

A simple example. A few years ago I went to the public dental hospital in Melbourne to have three wisdom teeth pulled out. Before they put me under I was spoken to by the anaesthetist and operating surgeon.

Anaesthetist: You have hep C, are you contagious at the moment?

Me: What are you talking about?

I was amazed at this woman's ignorance about hep C. And was disturbed about the clear dis-ease she had with talking to me. The feeling, oh so common: Am I some freaky monster from out of space?

Me to doctor: I am concerned about pain management after surgery. I take methadone daily, what will I be provided with?

Doctor: Panadeine forte.

Me, thinking paracetamol is not good for people with hep C: can't I get some other painkiller?

Doctor: Let me look into it.

So he waits until I have been given the pre-surgery relaxant (gutless prick) and it has started to work. I am on the trolley and he says: we will give you some anti-imflamatries.

Now, correct me if you think I am wrong John, but people with substantial opiate habits require more pain relief, not less.

I woke up after surgery and asked if they could please review their pain management decision. Answer: No. So, I lost it at them, knowing that making a big fuss was the only way I was going to leave with some pain killers. I got them.

Why, cause they just wanted to get rid of me. The expressions of disgust on their faces and the: "here are your drugs (you junkie)" from the nurse said it all. In their eyes I was just a junkie seeking drugs. The fact that I was clearly seriously anxious before the surgery about pain relief was not taken seriously. The fact that I am a university trained employed profession who speaks calmly and knowledgably and rationally about my drug use meant nothing.

Honestly John, it is against a person's interests to be honest with the health professionals regarding the use of criminalised drugs. That is the sad true fact of our current situation.

And this is one of the important issues we need to deal with.

As a health professional I have witnessed clients doing drug deals outside methadone clinics. I have had people steal from my work place. Had people lie to my face.

But in every case, I look at it in terms of the individual. To take the experiences of one or two people then make blanket generalisations about every one who uses a particular drug, or everyone who is drug dependent, is on a basic level, just sloppy thinking.

You have no idea whether other patients have lied to you, even if just glossing over any of their behaviour that would affect the outcome of treatment. I am sure they do, frequently.

The one problem with all this, is that doctors and pharmacists can become involved in the sale and provision of THE actual drug that a person takes and dies from. Not a nice feeling I imagine. But it also begs the question, if you feel concerned about this, which it is clear you do, then why don't all the people who produce, transport and sell tobacco and alcohol feel the same way?

Usually the response when I put this to people who work in shops that sell alcohol and/or tobacco is: It is their choice. Even if they are physically dependent on the drug.

Why is it you are not able to take this position? (I am not advocating you do, but rather want to hear you work through this issue)

At the same time, from my point of view John, I reject our current placement of drugs into legal, medical and illegal categories for 2 main reasons.

1. The classification of drugs was never made on scientific grounds but rather racisim and international diplomacy.

2. The hypocritcal stance of alcohol and tobacco users towards people who like and want to use cannabis and other currently criminalised drugs needs to be challenged.

3. I totally reject drug prohibition, as I said earlier, because it is part of a Christian moral theology of the body and not being a Christian I have no intention of bowing to their attempts to enforce this on the world.

The current classification of drugs in law got started in the late 19th century. Along with masturbation, homosexuality, abortion, euthanasia, all concerning how we interact with our bodies, non-medical drug use, was criminalised. (whoops masturbation wasn't, it was just medicalised as a mental illness)

The main player, the USA of course wanted alcohol included in this, but failed.

During the 20th century we saw people reclaim control over their bodies through the removal of Chirstian legislation banning abortion, homosexuality, while masturbation was de-medicalised. Euthanasia and drug use are the final two we need to challenge.

This is not to say I want a totally open market but rather I want one based upon scientific evidence, not (hypocritical) religious dogma. I want real debate, not the bullshit drug dialoge we get in our various medias.

As long as prohibition ideology continues to hypocritically stigmatise some people, not for drug use as such, but for using the "wrong" drug, then doctors and pharmacists are going to be caught in the middle.

Finally, on the issue of Mr Grote (I hope you didn't use his real name--am fairly sure you wouldn't) the blood and urine tests you got back on him, give no indication of how often he was using them. As you yourself said, he was looking well, was much calmer, and aborbed with a new child. ie clearly his health is improving, regardless of what drugs he is taking. Perhaps he had cut down heaps.

I don't think you made the right decision because no take aways usually makes life really difficult for people.

But, if you continue to work with people dependent on a currently illegal drug, and I hope you do, then this stuff will happen all the time. I think you need to understand that the current legal situation places you and your patients in a really difficult situation that undermines their health and wellbeing.

You might also be interested to know that during the 1920s in the USA after the provision of opiates to dependent people was criminalised, over 3,000 doctors (from my memory) were charged with criminal offences because they put the wellbeing of their patients before the law.

For some reason today's doctors seem to think they can work with illegal drug use without their work being compromised by the criminalisation of drugs people want to use.

Sorry John, but it aint true. The criminalisation of some drugs creates conflicts and problems for all of us. Those involved in anyway whatsoever (drug sellers, that includes you and pharmacists, drug treatment workers, consumers, policy makers) need to face this, as it seems you are beginning to do.

I also cannot understand how some pharmacists and doctors seem to think they can prescribe and sell drugs without it causing problems sometimes. If you make a living prescribing or selling drugs like opiates and benzos shit will happen, regardless of anything you do or don't do. Exactly the same can be said for alcohol etc sellers.

I hope I have not sounded patronising or rude John. I know I have not explored any of the issues raised in great depth, but rather introduced some issues and perspectives that can further this dicussion.

Thanks for reflecting on your work and for inspiring me to respond to a "blog" (sounds like something produced in a toilet) for the first time ever.


1:26 PM  

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