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,
* 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.