Monday, January 04, 2010

The whip

Now - I was going to write a bit more on the preceding "sex and medicine" theme, but I don't know that I will. It's probably enough to know that sometimes things catch you off guard, and hit you, and five years later if you look back you are still disquieted by them.

Meantime - the public methadone programme and the whip.

We in the south have a problem. About half of my two hundred patients are on methadone. Methadone, for those who came in late, is heroin unplugged - a slower, safer, acoustic version without that heady mix of outlaw edginess and frontal lobe infarction. It's safer, but it's in no way safe.

Whether or not the programme (and doesn't that sound like something from the Ministry of Clear Thought) saves lives is a matter of debate, but that debate was formed and now flourishes almost entirely outside medicine. From a medical point of view, the numbers are remarkably convincing - you get some one on methadone, they die later*. They get fewer infections. They are less likely to be breaking into your car as you read this.

But they do die. From what I can work out, for my patients, ten "should" die every thousand person-years. I have two hundred people on the programme, maybe two should die a year. Over five years, if they were average opioid dependent people, ten "should" die**. These rates are lower than in a lot of countries, partly because we have little HIV over here.
The rates of death for similar groups who are not opioid dependent is one fifth of that - maybe two in five years, maybe three.
The rates of death on the programme depends on who does it, and how well it is done, but for us it is still too high. We had two deaths last year - car versus tree, and overdose - , two or three in the three years before that - complications of pneumonia, a hanging. One this time last year, when someone stabbed Nicky Walker in the throat with a samurai sword. Maybe we're running at one a year, certainly less than two.

Why? Violence. Overdose. Alcohol. "Pills". The one we are falling down most badly on at the moment is the pills. Specifically, a lot of our patients are on alprazolam, and almost all of our patients who die, or are incarcerated, or are hospitalised are on it.

Alprazolam, as I have said, is like vodka to the frontal lobes. Amnesia, disinhibition, a complete shutting down of the part of the brain that says "uhh, maybe this isn't the best idea". Alprazolam plus methadone means long stays in ICU, constant cognitive impairment, increased chances of respiratory depression and of having six colours of shit kicked out of you.

I've tracked down a few of the dealers. They drive past in their big cars, wearing their fancy suits. Lately, some of the locals have been getting soft, and new guys, blank-faced men from south-east Asia or softly spoken men from the subcontinent have made inroads into their territory. I've got a decent idea of where they operate, who they see. I've even managed to get a few names - Dr Lung. Dr Chandraguptran. Dr Jones.

And I'm taking steps. I'm ringing and writing to them. I'm informing the relevant regulatory bodies. In the end, I might be ringing the medical board on them. One of my patients, a woman who has twice fallen asleep in the waiting room, has seen twelve different doctors in the last few months and been prescribed diazepam, oxazepam, temazepam, alprazolam, clonazepam and nitrazepam. Sedatives are a fair proportion of her caloric intake. She has had multiple overdoses and is only kept alive by being incarcerated.

Dr Jones thought this woman's interests would be best served by one hundred tablets of alprazolam in four days.

Anyway - that's the whip. I am uncomfortable cracking it. But otherwise we have the police in and out of the pharmacy, and the ICU on standby, and the coroner on speed-dial. We have a death rate that is edging closer to that achieved by the Triads and the bikie gangs. We don't have medicine.

I shall keep you informed. Thanks for listening,

*These are all population based studies, which are fine and noble things, but of utterly no use to those whose sons and daughters and family and friends die either "on" methadone or from diverted methadone. A population may have a decreased rate of mortality, but each person who dies remains absolutely dead. in the period during which I did not write, this happened to a relative of mine, a girl - and I chose that word - of twenty six, who died in her sleep over the summer.
These people are seen as side effects, as collateral damage, as the unavoidable consequence of what we do. I don't know to what extent that is true, but if this has happened to you, I and others like me are to a degree responsible, and I am sorry.

** I know the maths isn't like this, but the language is. it's like when I say "giraffes evolved long necks to reach succulent foliage", rather than "mutant giraffes with long necks survived and bred" and so forth.


Blogger Benedict 16th said...

you could encourage them to attend this?

9:19 AM  
Blogger dcpeg said...

Greetings! I came to your blog from I chuckled outloud when I read your marvelous description of methadone.

Then I read the rest of your post. SO SAD!! How dreadful it must be to be totally dependant on pills. Reading about the woman taking ten different prescriptions scared me!

I'm not sure what your occupation is, but it must be troubling. I wish you luck helping addicts to move beyond their despair and dependency!

3:31 AM  

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