Category Archives: addiction

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A timorous culture

Over 20 years ago, when I first start practicing in Washington State, I get a letter from the state. It frightens me. It says that there is a complaint to the state from a patient and that I am being investigated. I think, “What did I do?” The letter says that they will notify me when they are done investigating. I am not allowed to inquire about it until they are done.

I worry, then shrug and go on working.

Eventually I get a letter from the state saying that the investigation is complete and has been dismissed. Now I can request information. I do.

The complaint is that on a yearly exam, I had asked if a patient had guns in the house. Since too many US citizens die by gun suicide and children can find guns and accidentally kill themselves or others, I was taught to counsel regarding guns. If a person has guns in the house I am to counsel them to keep the gun locked up with the ammunition locked up separately.

I was charged in the complaint with trying to find out how many guns this person has and “reporting it to the government”. I thought, that is ridiculous, but it did change my practice. Since there are paranoid timorous gun owners, I no longer asked if they had guns. Instead I said, “If you have guns in the house, as a safety measure, keep them locked up with the ammunition locked up separately.” We are supposed to counsel people to keep addictive drugs that can overdose and kill people locked up too.

I get three replies to the gun counseling. 1. “No guns!” 2. “I am a policeman (or hunter or retired veteran or gun collector) and all guns are secured at all times.” 3. Silence. The silent ones clearly have guns and do not lock them up. Truly I have had people tell me that they sleep with a loaded gun under the pillow. Really? That is our fear based timorous violent culture. We are terrified of….. someone. People on drugs, criminals, immigrants, people of another ethnicity, invaders, alien lizards in human disguise. Whatever.

I don’t have guns. I do have a fairly high level Tai Kwan Do belt, but my main home defense is that I am a packrat. Anyone trying to sneak into my house at night would trip over a cat or cat toy or the cardboard boxes in the kitchen that Elwha loves to sleep in. My house is seriously dangerous. I need to removed the stuff on the stairs by the time I turn 65 so that when they counsel me about fall risks at my medicare wellness visit, I can say that my stairs are clear.

Well, I do have a pop gun, loaded with a cork on a string. Also an Archie McPhee potato gun. Don’t shoot it in the house because those little bits of potato are hard to find. We have a 2 inch plastic ray gun that makes great sound effects and oddly has worked for years. I have a wooden katana and various instruments of garden destruction which could be deadly. I also have a lot of beach rocks and fossils, also fairly deadly, and other things. I’d rather not use any of these ever. Ok, I chased the 4 point buck out of the front yard with the baseball bat twice because he’d jumped the back fence and was eating my roses, but he’s allowed the run of the back yard. I was really mad at him.

We have to get past the fear based timorous culture, because it is making people crazy. Who are you most afraid of? In high school my daughter states, “Well, young white males with guns are the ones most likely to come shoot us, so that is who we should be afraid of.” That’s a sad, sad statement about the US culture.

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For the Ragtag Daily Prompt: timorous.

Hummingbirds are not timorous at all! They guard the feeder and seem to enjoy chasing other hummingbirds and bigger birds away and aren’t afraid of me either!

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Shame and anger in overuse illnesses

“amongst those who treat addicts of any kind generally agree that anger and shame help no one and is actively counter-productive.”*

Wait.

I have to think about that statement.

I do not agree at all.

Ok, for the physician/ARNP/PAC, anger at the patient and shaming the patient are not good practice, don’t work, and could make them worse. BUT anger and shame come up.

In many patients.

Sometimes it goes like this with opioid overuse: the person shows up, gets on buprenorphine, and is clean.

It may be a long time since they have been “clean”.

One young man wants to know WHY I am treating him as an opioid overuse patient. “Why are you treating me like an addict?”

I try to be patient. I recommended that he go inpatient, because I don’t think we will cut through the denial outpatient. Very high risk of relapse. “You have been buying oxycodone on the street for more than ten years.”

“I’ve been buying it for back pain, not to party.”

“Did you ever see a doctor about the back pain?”

“Well, no.”

“Buying it illegally is one of the criteria of opiate overuse.”

“But I’m not an addict! I’ve never tried heroin! I have never used needles!”

“We can go through the criteria again.”

He shakes his head.

He is in denial. He is fine. He doesn’t need inpatient. He is super confident, gets work again, is super proud.

And then angry. “My family still won’t talk to me!”

“Um, yes.”

“I’m clean. I’m going to the stupid AA/NA groups! Though I don’t need to. I’m fine!”

“What have you noticed at the groups?”

“What a bunch of liars!” he says, angry. “There are people court ordered there and they are still using! I can tell. They are lying through their teeth!”

“Obvious, huh?”

“Yeah!”

“Did you ever lie while you were taking the oxycodone?”

Now he ducks his head and looks down. “Well, maybe. A little.”

“Do you think your family and friends could tell?”

He glances up at me and away. “Maybe.”

“Your family may be angry and may have trouble trusting you for a while.”

“But I’ve been clean for four months!”

“How many years did you tell untruths?”

“Well.”

Shame and anger. Anger from the family and old friends, who have heard the story before, who are not inclined to trust, who are hurt and sad. The first hurdle is getting clean, but that is only the first one. Repairing relationships takes time and some people may refuse and they have that right! Sometimes patients are shocked that now that they are clean, a relationship can’t be repaired. Or that it may take years to repair. My overuse folks are not exactly used to being patient. And sometimes as they realize how upset the family and friends are, they are very ashamed. And some are very sad, at years lost, and friendships, and loved ones. I have had at least one person disappear, to relapse, after describing introducing someone else to heroin. He died about two years later, in his forties.

Shame and anger definitely come up in overuse illness.

The above is not a single patient, but cobbled together from more than one.

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*from an essay titled “F—ing yes, I’m a fatphobe” on everything2.com. Today there are two with that title. The quotation is from the second essay.

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Chronic pain #I forget

The CDC has a new set of recommendations for chronic pain.

I will write about them. I have to read them first. Hurts too much, right now, the election, and all the pandemic fighting. Stress people and you see what they are really like.

My church has melted down into a huge fight. I was in a chorus singing instead of being in a meeting. Apparently there is a group that says brown people have “taken over” the national organization of the church. Um. Hello. That is discrimination. Does the color of the skin matter if it is a good leader? Why are people insane? I filled out a county survey on drug use today. I know we have methamphetamines and heroin in our high schools because patients have told me. But then I get to the race question. What race am I? I checked OTHER and wrote HUMAN. The race bullcrap is NOT SCIENCE. I haven’t done any genetics testing. I DO NOT KNOW WHAT RACE I AM THOUGH I LOOK WHITE.

It is important for medicine in that there is proven discrimination with less screen health services offered to “brown” people, whatever the heck “brown” people means. I wish the heavens would turn us all the same color over night. Or perhaps blind us. That is not nice of me and I do not care.

I am glad that this horror came out in my church. Because now the discrimination is out in the open. And the committee has sent out a message saying NO. We WILL stay part of the national organization. We WILL not give in to this discrimination. AND I SAY HOORAY AND BLESSINGS ON THEM.

Here is the new CDC set of recommendations for chronic pain: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm . You can read them yourself.

I read to this sentence so far: “Approximately one in five U.S. adults had chronic pain in 2019 and approximately one in 14 adults experienced “high-impact” chronic pain, defined as having pain on most days or every day during the past 3 months that limited life or work activities (5).”

Part of me is horrified and part of me is calm. Because pain is a part of life. Pain, love, joy, fear, it’s all part of our emotional evolved systems to survive, right? If God is love, God is also pain and fear. It is not a split. It is both.

This song is a love song. But to me, it’s a love song from heroin to a woman. One lovely day, a place where there is no pain. There will be pain on the return, the withdrawal. I have patients say, “You need to get me pain free.” My reply was “I will not get you pain free. Pain free is dead. Or at least, they can no longer tell me if the next form hurts.” In this song, “she won’t let on, that the feelings have got so strong.” Addiction, opioid overuse.

I took the photograph of Elwha yesterday. He is my relaxation mentor.

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Defiance

Ok, this is a beautiful and romantic song, and yeah, George Strait is pretty.

And then there’s the Offspring. Singing Self Esteem. Guess which I like better.

The Offspring: defiance and singing about all sorts of things that we don’t talk about: “The more we suffer the more we really care!” Some of my patients needed to listen to this song. Often the mom, with a spouse and three children, who was taking care of all of them but not herself. “Who takes care of YOU?” I would ask. “No one,” some moms would say. “Look. There are FIVE people in your family. You are one of them. You deserve the same level of care that the rest of them are getting. I want you to include yourself in the people you take care of.” “BUT” “NO BUTS. If you don’t, then you are setting expectations for your children: the boys that a wife will take care of them and the girls to be walked on. Is that what you want?” “NO.” “Change it.” They often would, slowly but surely.

And The Offspring are further my heroes because of this song: Opioid Diaries. Ok, a punk band telling opioid overuse people to get help. MY HEROES! Thank you Offspring!!! It’s not easy to watch but wait until the ending and what if offers. I treated opioid overuse for the last 12 years in my small family practice clinic along with everything else: diabetes, hypertension, whatever. I never felt threatened or frightened, but some of that is because I grew up in an alcohol family. I recognize addiction. Reminding my of my parents is not a good sign. And I had to learn boundaries at home first. This is an uncomfortable video to watch but to me it is beautiful, because it offers hope.

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Family

The photograph is from left to right, my sister Christine Robbins Ottaway, my (sort of but not blood) cousin Katy, and me. This is a fourth of July. We wanted to DO something. We were at my maternal grandparents’ in Trumansburg, New York. My mother suggested that we dress up and do a presentation. We wore her 1950s prom dresses, held a small parade involving three dogs and a cat who were also in costume, and read the Declaration of Independance and the Preamble to the Constitution to a group of adults in lawn chairs. This was in lieu of fireworks. We had fun but we still missed fireworks.

I am thinking about asking. I could not ask my mother for specific things I wanted as a child. She would get me a different and cheaper alternative. If I was disappointed, I would be guilt tripped or humiliated. I did not ask my father for things either. He would make and break promises, too sick from alcohol or he would have forgotten. I stopped asking because I did not like being disappointed and I did not like being shamed. Once I really really wanted something for Christmas. My sister and I made a quiet deal, showing each other exactly which toy we longed for. Then we each shopped with our mother and insisted on the toy the other wanted. Our mother did try to talk each of us out of the toy. We had arranged it so that we were spending the same amount of money: $20. She thought that was outrageous and that something cheaper would do just as well. We both stood our ground on the other’s behalf and then open the presents on Christmas day with faked surprise and real joy. We did NOT tell our mother.

On an earlier Christmas I sewed my sister a toy stuffed snake. My mother was discouraging, but she let me have cloth and needle and thread. “Why do you want to make her a snake? A snake?” I couldn’t really explain well. We had gone to a county fair and my sister and I both longed for the velvet snakes, six feet long and deep red. The snake I made for my sister was only a foot and a half long and I had flowered fabric, not velvet. I coiled it in a circle and wrapped it. My sister was delighted with it and held it all Christmas morning. My mother just shook her head. “A snake.” she muttered.

The things that I could ask for were books and music. I was the kid that the teacher would hand the scholastic book box to after she handed out one or two books to the other kids. I would order 20 books. My father said I could have as many as I wanted as long as I read them all. The only books I avoided were about television or movies. I loved a non fiction book about WWI Flying Aces. The technology of the airplanes and the problem of bullets ricocheting off the propeller were amazing. I also liked that it talked about the ACEs on both sides: German, English, French, American.

For the Ragtag Daily Prompt: ask.

I don’t know who took the photograph. I think it was one of my grandparents. Oh, I think “cousin” Adam is in the picture too, though he is nearly hidden behind the flag.

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Adverse Childhood Experiences 14: Hope

I keep reading bits about despair and about how a generation of children is being “ruined” by the pandemic.

Not so, I say. There is hope. We need to support each other to survive and then to thrive.

This generation WILL have a higher than average ACE score. If the Adverse Childhood Experience scale is from zero to eight, children in this time period will have at least one higher point than average and many will have three or four or more. Loss of a parent, a sibling, beloved grandparents during covid. Increases in domestic violence, child abuse and addiction. These are all part of the ACE score.

What does this do to children? They have survival brain wiring. They will do their best to survive what is happening. A friend and I both have high ACE scores, 5 or more, and we are both oppositional defiant. We showed this in different ways. He grew up in the same community. He escaped from home and knew all the neighbors. He walked to the local church and attended at age 3 or 4. He has lived in this community all his life.

His oppositional defiance showed up at home, where he consistently refused to obey. And in school, where he confounded and disobeyed teachers and passed anyhow.

My family moved every 1-5 years. I hated moving. I wouldn’t talk to kids in a new school for a year. It was very difficult. So my oppositional defiance was very very internal. I hid in books and in my head. In 6th grade I got in trouble for hiding novels inside the school book I’d already read. I also would just not listen and my respect for the teacher got even lower when she would be angry that I knew the answer to the question once she’d repeated it. I wasn’t listening because I was bored. She was the first teacher that I thought, well, she is not very bright. The next year they stuck me in the honors class and I stopped being bored, though I still questioned practically every opinion every teacher had. I wanted evidence and I did not believe it just because the teacher said it.

I am not saying that oppositional defiance is in every high ACE score. I don’t know that. Why oppositional defiance? Imagine you are a small child and you are beaten. There isn’t rhyme or reason. You can’t predict when the adult will be out of control. Why would you behave “well” if it makes no difference? You might as well do what you want, because nothing you do will change the adult. Or imagine you are a small child who is with one person, passed to another, then to another. You may not exactly trust adults after two or three repetitions. And you want to survive.

There is an increase in addictions, behavioral health diagnoses, and chronic illness in adults with a high ACE score. A researcher when I first heard a lecture about it said, “We think perhaps that addiction is a form of self medication.” I thought, oh, my gosh, how are we ever going to treat THIS? Well, we have to figure that out now, and we’ve had 30 years to work on it.

I was very comfortable with the oppositional defiant patients in clinic. I got very good at not arguing with them and not taking their behavior personally. They might show up all spiky and hostile and I might be a little spiky and gruff back: sometimes that was enough. I think the high ACE score people often recognize each other at some level, though not always a conscious one. With some people I might bring up ACE scores and ask about their childhood. Sometimes they wanted to discuss it. Sometimes they didn’t. Either was ok.

One thing we should NOT do is insist that everyone be “nice”. We had a temporary doctor who told us her story. Her family escaped Southeast Asia in a boat. They had run out of water and were going to die when they were found by pirates. The pirates gave them water. They made it to land and were in a refugee camp for eight years or so. She eventually made it to the US. She was deemed too “undiplomatic” for our rural hospital. I wondered if people would have said that if they knew her history and what she had been through. It’s not exactly a Leave it to Beaver childhood, is it? When she was telling us about nearly dying of thirst in the boat, my daughter left her chair and climbed on my lap. She was under ten and understood that this was a true and very frightening story.

We can support this generation of children. This has been and is still being Adverse Experiences for adults as well. Family deaths, job loss, failure of jobs to support people, inflation. Remember the 1920s, after World War I and the last pandemic, of influenza. “On October 28, 1919, Congress passed the National Prohibition Act, also known as the Volstead Act, which provided enabling legislation to implement the 18th Amendment.” (wikipedia). There were forces trying to legislate behavior, as there are now. The result in 1920s of making alcohol illegal was speakeasies, illegal alcohol, and violence. Some people acted wild after WWI and the influenza pandemic and some people tried to lock down control, by controlling other peoples’ behavior. It did not work then and it will not work now. The wildness is out of control grief, I think, grief dysfunctional and drinking and shooting and doing anything and everything, legal or not. We remember how the 1920s ended too. Let us not repeat that. Let us mourn and grieve and support each other and support each other’s decisions and autonomy.

Blessings.

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how to use a specialist

I am a rural Family Medicine doctor, board certified and board eligible. I have used the Telemedicine groups in the nearest big University Hospital since 2010.

Initially I started with the Addiction Telemedicine. I accidentally became the only physician in my county prescribing buprenorphine for opioid overuse in 2010. I panicked when I started getting calls. Dr. Merrill from UW had taught the course and gave me his pager number. I acquired 30 patients in three weeks, because the only other provider was suddenly unavailable. Dr. Merrill talked me through that 21 day trial by fire.

I think that I presented at least 20 patients to telemedicine the first year. The telemedicine took an hour and a half. First was a continuing medical education talk on some aspect of “overuse”, aka addiction, and then different doctors would present cases. We had to fill out a form and send it in. It had the gender and year of birth, but was not otherwise supposed to identify the person. TeleAddiction had a panel, consisting of Dr. Merrill (addiction), a psychiatrist, the moderator/pain doctor, and a physiatrist. Physiatrists are the doctor version of a physical therapist. They are the experts in trying to get people the best equipment and function after being blown up in the military or after a terrible car wreck or with multiple sclerosis. There would usually be a fifth guest specialist, often the presenter.

After a while, TeleAddiction got rolled into Telepain and changed days. They added other groups: one for psychiatry, one for HIV and one for hepatitis C. These can all overlap. I mostly attend TelePain and TelePsychiatry.

After a while, I pretty much know what the Telepain specialists are going to advise. So why would I present a patient at that point? Ah, good question. I use Telepain for the weight of authority. I would present a patient when the patient was refusing to follow my recommendations. I would present to Telepain, usually with a very good idea of what the recommendations would be. The team would each speak and fax me a hard copy. I would present this to the patient. Not one physician, and a rural primary care doctor, but five: I was backed up by four specialists. My patients still have a choice. They can negotiate and they always have the right to switch to another doctor. Some do, some don’t.

I am a specialist too. Family Practice is a specialty requiring a three year residency. The general practitioners used to go into practice after one year of internship. My residency was at OHSU in Portland, with rotations through multiple other specialties. We rotated through the high risk obstetrics group, alternating call with the obstetrics residents, which gave me excellent training for doing rural obstetrics and knowing when to call the high risk perinatologist. In my first job I was four hours by fixed wing from the nearest more comprehensive obstetrics, so we really had to think ahead. No helicopter, the distance was too far and over a 9000 foot pass, in all four directions. That was rather exciting as well.

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Don’t try this at home

https://news.ohsu.edu/2022/03/17/little-evidence-on-how-psilocybin-therapy-interacts-with-existing-psychiatric-treatments-review-finds?linkId=156952130

People are busily hopping on the psilocybin bandwagon. DON’T. Why not, you say, it’s NATURAL. Well, the death angel mushroom is also natural but it will kill you. So are red tides, poisonous snakes and sharks.

You wouldn’t take your buddy’s appendix out in your kitchen, would you? Don’t mess with your buddy’s brain either. Especially if there is already a behavioral health diagnosis and/or an addiction already on board. Either or both might get WORSE rather than better. Wait for the research.

And remember: one in four people meets diagnostic criteria for a behavioral health diagnosis at least once in their life. When there is also an addiction, we call it dual diagnosis.

And for pity’s sake, be careful with pot products, ok? It’s a total myth that they are not addictive. Yeah, people have told me for my entire career, over 30 years, “I am not addicted to (pot, heroin, alcohol, gambling, cocaine, meth, crack, whatever)”. ALL ALCOHOLICS say this the first time they are admitted for crashing a car or alcohol poisoning or vomiting blood or liver failure. “Not me. I am stopping today. I am NOT addicted. I do not need to talk to the substance abuse person.” We roll our eyes and send in the substance abuse person anyhow, because HEY, THE PERSON IS TOO ADDICTED AND IN DENIAL.

If you are going to use pot products, use them one or two times a week. Max three. Because a study of teens that paid them (with parental permission, consent, etc) to stop for a month found that almost none of the teens who used pot daily could stop. They relapsed. And they complained of anxiety and insomnia. And I have worked with adults trying to quit: again, anxiety and insomnia. The teens in the study who only used 2-3 days a week COULD stop for the month. The study monitored urine drug screens quite strictly.

And if you say, well, I can’t sleep without it. Um, yeah, that is addiction. I would wean. Reduce amounts and then start with one night a week without it. Good luck. Get help if you need it.

And don’t jump on the psilocybin bandwagon!!! Holy moly, humans are amazing, the ways they think up to hurt themselves and each other. If you want to be in a clinical trial, go find one. Don’t fool with Mother Nature, she can be a killer.

Happy solstice and blessings.

Here is the scientific paper for the science geeks like me:

https://link.springer.com/article/10.1007/s00213-022-06083-y

The picture is just a picture. No worries.

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Avoid death by fentanyl

Some of the West Point Cadets overdosed on March 12, 2022 are still on ventilators. They took what they thought was cocaine. It was laced with fentanyl and they all nearly died.

Not only that, but two of the bystanders who did not use the drug, but did cardiopulmonary resuscitation, CPR, also succumbed. They stopped breathing because they got a heavy dose of fentanyl giving CPR.

Fentanyl is being laced into ANY illegal drug, and being 50 times stronger than morphine, it can kill you by making you stop breathing. Also, fake pills are made. Do not buy pills on the street. And I don’t care if it is your friend. Remember that when someone is really addicted, the addiction is running the show. They need the drug more than your friendship. People will lie, steal and sell drugs. Protect yourself:

Please read the website at

https://www.cdc.gov/stopoverdose/

If you or a family member uses illegal drugs, please get naloxone to have at home. If the shot is given in time, very soon after the person stops breathing, it can save their life.

Here: https://www.cdc.gov/stopoverdose/naloxone/index.html

If you give someone a dose of naloxone CALL AN AMBULANCE. Because it is short acting and the opioid may take back over. The person may need to be on naloxone iv! You must get them to an emergency room as fast as possible.

Our local Health Department was giving out naloxone shot kits in the last few years for free. Our local police carry naloxone. If you are on prescription opioids, you should be offered a prescription for naloxone and your family should be instructed on how to use it.

And teach your children well. I interviewed my patients for years on the age they started smoking. Most of my patients started at age nine. One woman said age seven. We have to start talking to children about drugs and risk and not smoking anything by third grade. That is the horrific reality.

And Bless the punk band The Offspring for reaching out to opioid overuse people and saying, “Get help. You can do it. Please do not die.”

The Opioid diaries live by the Offspring.

And they too are inimitable.

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don’t kill your clients

I wrote this in 2016, when at least nine people died of overdoses in Vancouver, BC at Christmas, from fentanyl. I knew fentanyl was hitting my corner of the Washington State too. Warning, this contains a lot of swearing (edited so this does not become a “mature” site). I was in a very bad mood when I wrote it. It is meant to be black humor, to help me deal with grief.

http://www.cbc.ca/news/canada/british-columbia/fentanyl-crisis-up-to-9-drug-overdose-deaths-in-vancouver-last-night-1.3900437

But the news today is STILL talking about fentanyl and overdose: https://www.cnn.com/2022/03/12/us/west-point-cadets-overdose-fentanyl/index.html. When will we ever learn? And also, drug dealers are not actually trustworthy…. your cocaine might contain fentanyl. Don’t do it.

don’t kill your clients

oh, you think I’m talking to physicians….

….no, I’m talking to my fellow dealers.

See, heroin is rather labor intensive to produce, being from the opium poppy and all that. (When people say “I only take natural supplements.” I want to say, “You mean like opium and heroin? You know, plant based.”) Also, Afganistan, those fungkers shoot you as soon as look at you. It turns out that fentanyl is cheaper to make and you can source the ingredients from China.

And then, you can make fake oxycodone tabs and fake hydrocondone pills and sell them for bitcoin on the silk road. But you know, ya gotta mix the sheet right. If you mix it wrong and a buncha people overdose and die, there are complaints. Ya might get some scared clients, like, junkie friends of junkies. And then there are also those chronic pain people who aren’t junkies but been forced onto the streets to treat they habit, I mean, pain. We got a good thing going, the pill thing, because the junkies think that pills is safer than heroin. You might scare the fungkers and then how the fungk will I be able to buy that island with my bitcoin?

So dealers, ya’ll fungkheads, ya messing it up if you don’t get the goddarn mix right. See, fentanyl is not routinely tested for on the blood and urine drug screens. So the person gets labelled as an oxycodone overdose and no one knows that it’s fake pills. But when there are too many deaths, the goddarn feds and doctors get suspicious and start testing the pills.

Same with heroin. Cheapens things to cut it with fentenyl. But you gotta calculate right, because if you kill a whole bunch of clients at once, 1. you cut into profits 2. you make the cops and docs suspicious. You gonna ruin it for everyone, you goddarn morons.

And now I hear we got a new mix. Carfentanil, an elephant tranquilizer. Read the recipes carefully, morons, it’s 10,000 times as strong as morphine, you gotta dilute the sheet 10,000 times. Don’t you know math? Take a goddarn chemistry course.

Don’t fungk things up for the responsible drug dealers. A live client keeps on paying.

Be careful out there.

https://www.theguardian.com/global/2016/dec/11/pills-that-kill-why-are-thousands-dying-from-fentanyl-abuse-http://www.cnn.com/2016/08/24/health/elephant-tranquilizer-carfentanil-heroin/