Why care for addicts?

I posted this in November, 2015. I am reposting it.

_________________

Why care for addicts?

Children. If we do addiction medicine and help and treat addicts, we are helping children and their parents and our elderly patients’ children. We are helping families, and that is why I chose Family Practice as my specialty.

Stop thinking of addiction as the evil person who chooses to buy drugs instead of paying their bills. Instead, think of it as a disease where the drug takes over. Essentially, we have trouble with addicts because they lie about using drugs. But I think of it as the drug takes over: when the addict is out of control, the drug has control. The drug is not just lying to the doctor, the spouse, the parents, the family, the police: the drug is lying to the patient too.

The drug says: just a little. You feel so sick. You will feel so much better. Just a tiny bit and you can stop then. No one will know. You are smart. You can do it. You have control. You can just use a tiny bit, just today and then you can stop. They say they are helping you, but they aren’t. Look how horrible you feel! And you need to get the shopping done and you can’t because you are so sick…. just a little. I won’t hurt you. I am your best friend.

I think of drug and alcohol addiction as a loss of boundaries and a loss of control. I treat opiate overuse patients and I explain: you are here to be treated because you have lost your boundaries with this drug. Therefore it is my job to help you rebuild those boundaries. We both know that if the drug takes control, it will lie. So I have to do urine drug tests and hold you to your appointments and refuse to alter MY boundaries to help keep you safe. If the drug is taking over, I will have you come for more frequent visits. You have to keep your part of the contract: going to AA, to NA, to your treatment group, giving urine specimens. These things rebuild your internal boundaries. Meanwhile you and I and drug treatment are the external boundaries. If that fails, I will offer to help you go to inpatient treatment. Some people refuse and go back to the drug. I feel sad but I hope that they will have another chance. Some people die from the drug and are lost.

Addiction is a family illness. The loved one is controlled by the drug and lies. The family WANTS to believe their loved one and often the family “enables” by helping the loved one cover up the illness. Telling the boss that the loved one is sick, procuring them alcohol or giving them their pills, telling the children and the grandparents that everything is ok. Everything is NOT ok and the children are frightened. One parent behaves horribly when they are high or drunk and the other parent is anxious, distracted, stressed and denies the problem. Or BOTH are using and imagine if you are a child in that. Terror and confusion.

Children from addiction homes are more likely to be addicts themselves or marry addicts. They have grown up in confusing lonely dysfunction and exactly how are they supposed to learn to act “normally” or to heal themselves? The parents may have covered well enough that the community tells them how wonderful their father was or how charming their mother was at the funeral. What does the adult child say to that, if they have memories of terror and horror? The children learn to numb the feelings in order to survive the household and they learn to keep their mouths shut: it’s safer. It is very hard to unlearn as an adult.

I have people with opiate overuse syndrome who come to see me with their children. I have drawings by children that have a doctor and a nurse and the words “heroes” underneath and “thank you”. I  have had a young pregnant patient thank me for doing a urine drug screen as routine early in pregnancy. “My friend used meth the whole pregnancy and they never checked,” she said, “Now her baby is messed up.”

Addiction medicine is complicated because we think people should tell the truth. But it is a disease precisely because it’s the loss of control and loss of boundaries that cause the lying. We should be angry at the drug, not the person: love the person and help them change their behavior. We need to stop stigmatizing and demeaning addiction and help people. For them, for their families, for their children and for ourselves.

werewolf

Time out word warning, in this poem. This poem is about discrimination. Substitute practically anything for werewolf…. disabled, bipolar, depressed, autistic, substance abuser. I am sick of discrimination. For human, substitute “normal”.

You know I’ve been a werewolf my whole life

Started in the womb
triggered by antibodies
to tuberculosis

And I am tired

of people telling me

I’m a werewolf.

Ok? I fucking know that.
I have known it since Kindergarten
where I arrived full of joy
ready to sing

and was shunned

we didn’t have a television

but I knew that wasn’t really it
I was different
I am different

and fuck you humans
different is ok.

I am a werewolf
and I am fucking proud
of all I have accomplished
in the teeth of humans hating me
and trying to shut me down
and shunning me
and reporting me
and doing everything short of shooting me
with real guns

I’ve been told to sit down
shut up
stop arguing
be nice
be good
go away
die
don’t read my writeups
don’t C! my work
don’t talk to me
stop making waves
been fired
been reported
been shunned
been alone

and fuck you humans

get ready
because I am middle aged now
for a werewolf
and I am ready

to be one all the timee

damn the torpedoes
full speed ahead
fuck you humans
for how you’ve treated me

I’ve turned the other cheek
for sixty years

and now
I
will
fight

released like stars

I have had strep A sepsis and pneumonia twice. It was terrifying and I ended up having to take care of myself. I would be dead if I was not a physician.

Everything2.com helped to sustain me, because it was a place I could go while I was alone, terrified and very very ill. The bout in 2014 took me out of clinic for six months and then I was barely able to work seeing half my usual number of patients. My local hospital refused to help me, but other people did. I am deeply deeply grateful to the people who did help me, including people on everything2.com that I have never met.

I wrote this in June 2014.

released like stars

________________

My sister used to tell me

“Everything2 is like a brain.

That’s what attracted me.

All the nodes, like neurons

Connected to each other more and more.”

Or something like that.


Isn’t it annoying?

Now that I’ve taken that memory out

Dusted it off

Embellished it

Who knows what she really said


Flashes of light now

And some where I blank out entirely

For just a moment

Only when I’ve eaten

I’m still avoiding carbs


Could be absence seizures

But she said seizures hurt

These do not hurt

And are accompanied by muscle twitches

Or muscles rolling gently across my frame


I am scared at first

Because I think they are neurons

Bursting into brain flame

And burning out

Brief candles


But I don’t think that’s right either

I think it is plaques

Deposits of antibody

Small pushpins in the wrong place

Being released like stars

A house for our lives

I wonder why we don’t design houses for our lives.

A family house could have everything on the first floor, with a bedroom, wheelchair accessible, and a full bath. The stairs could have an entryway that can be closed off. Upstairs, a sitting room, a full bath, two bedrooms or three and a pocket kitchen. Laundry facilities need to be on the main floor, but they could be in a mud room/entry that is part of the entry to the stairs.

The basement, if there is one, could be for storage or for another apartment.

A couple could buy the house, raise kids in the whole thing, then downsize to the main floor, rent the upstairs, perhaps rent the basement.

My daughter and son want less stuff. Neither has the packrat gene from me and they want to be mobile and have cleaning be very easy and moving be easy. I feel guilty that I have a big house alone, but it is full of stuff that I am slowly decreasing. It has a daylight basement, but there is no bathroom down there nor kitchen and the laundry facilities are there. Also the plumbing is 4 inch across 2 foot concrete sections from the 1930s and runs under the slab poured inside the 1930s garage foundation. The garage is built to the neighbor’s line in back and five feet onto the lot in the middle of the block at the side, so I have two lots. If I take it down, I could not rebuild there because of codes. I think that to do the basement as an apartment I’d have to redo the plumbing first, which is daunting. Also renting is tricky. That is, getting someone out if it is not working can be a challenge.

Friends are looking for a four bedroom house. They have three children so that is what they need now. But the eldest is 14, so it will not be long at all until they need less house. I picture bedroom modules that can be detached.

Our town is very short on long term rentals because now people can make more with short term rentals to the tourists for the many festivals. This in turn is messing up the traffic and increasing accidents, because there are two two-lane roads into town. And a ferry. The people who work in the shops and restaurants are having to commute. People own a fifth house that they may visit only twice a year. It looks like it will get messier, though we may have another housing crash. Right now houses are going up.

My daughter has been designing her future tiny house for a while. The second entry is to a mud room with laundry facilities and a tile floor and a shower so that she can climb out of swimming or running or mountain biking or sailing gear and have a place to hang everything before she goes into the rest of the house. She will want to be able to clean herself and her gear.

My grandparents had a house on Topsail Island in North Carolina. There was an outdoor shower under part of the house, to wash the sand off before we were allowed upstairs. Then another hose to wash our feet once we were up on the deck. Sand and the smell of the ocean, all the time.

Friends have a four apartment building. They altered the two on the top floor to make one apartment. The lower two they rent, sometimes to family. There are four bedrooms on top and two in each apartment. They have a big kitchen and a pocket kitchen in the top section.

Some of my patients need tiny houses, a place alone, even though they also need social contact. I hate the big ostentatious show houses, especially the ones with the play room on a different floor, let’s relegate the children to a different part of the house. Then the elders can also be relegated.

I wish housing were more about need and practicality and less about money and status. And still, we are spoiled….

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written 8/2/2017

Admitting diagnosis: old guy, don’t know

I wrote this in 2010, after I worked for three months at Madigan Army Hospital. I really enjoyed working there. It was the first time since residency that I had worked in a big hospital — 450 beds — and in a not rural setting. I kept asking to work with residents and eventually the Captain and I worked it out to both our satisfactions.

______________________________________

During my three months temp job at a nearby Army Hospital, I am asked to help the Family Medicine Inpatient Team (FMIT) whenever a faculty member is sick or out or deployed, which turns out to be fairly often. I enjoy this because I want to work with residents, Family Practice doctors in training. It is very interesting to be at a training program, watch the other faculty and work at a 400 bed hospital instead of my usual 25 bed one.

Two patients need to be admitted at the same time on our call day, so the second year resident takes one and I take the other. The report on mine is an 82 year old male veteran, coughing for three weeks, emergency room diagnosis is pneumonia.

The resident soon catches up with me because her person is too sick and gets diverted to the ICU. Mr. T, our gentleman, is a vague historian. He says that he has always coughed since he quit smoking 15 years ago and he can’t really describe his problem. He’d gotten up at 4:30 to walk around the assisted living; that is normal for him because he still does some o the maintenance. He had either felt bad then or after going back to sleep in a chair and waking at 10. “I didn’t feel good. I knew I shouldn’t drive.”

He’s had a heart attack in the past and heart bypass surgery. Records are vague. The radiologist reads the chest xrays essentially as, “Looks just like the one 3 months ago but we can’t guarantee that there isn’t a pneumonia or something in there.” He has a slightly elevated white blood cell count, no fever, and by then I do a Mini-mental status exam. He scores 22 out of 30. That could mean right on the edge of moderate dementia, or it could be delirium. I get his permission to call his wife.

“Oh, his memory has been bad since he spent a year in a chair telling them not to amputate his toes. And he was on antibiotics the whole time. He wasn’t the same after that. This morning he just said he didn’t feel right and that he shouldn’t drive.” So his wife called an ambulance.

The third year chief resident comes by and wants to know the admitting diagnosis. “Old guy, don’t know.” is my reply. “Either pneumonia or a urinary tract infection or a heart attack maybe with delirium or dementia or both.

The second year is helping me put in the computer orders, because I am terrible at it still. She could put them in upside down and asleep. “Why are we admitting him, anyhow? We can’t really find anything wrong, why not just send him home?”

“We can’t send him home because he can’t tell us what’s wrong. He might have an infection but he might not, and he has a really bad heart. If we send him home and he has a heart attack tonight, we would feel really bad. And he might die.”

I was getting a cold. I had planned to ask to work a half day but half the team was out sick so I just worked. But by morning I had no voice and felt awful. I call in sick.

At noon the phone rings. It is the second year. “You know Mr. T, who we admitted last night?”

“Yes,” I say.

“He had that heart attack during the night. Got taken to the cath lab. You made me look really good.” We had worked on the assumption that it could be early in a heart attack though the first labs and the ECG were negative. I had insisted on cardiac monitoring and repeating the enzymes. The resident had finished the note after I left and the night team had gotten the second and abnormal set of enzymes.

82 year olds are tricky. With some memory loss he couldn’t tell us much except that “I don’t feel right.” He was right not to drive and we were right to keep him in the hospital. And if it had all been normal in the morning, I still would not have felt bad about it. The residents are looking for a definitive diagnosis, but sometimes it’s “Old guy, don’t know,” until you do know.

Painting angels

You were an artist
You are an artist
You said that you’d have to live to 120 to finish all your projects
And died at 61
I keep wondering
what the art supplies are like
and if you work on sunsets
or mountains
or lakes

Trey, 9
made a clay fish last summer that I admire
He said grumpily “It’s too bad Grandma Helen died before I could do clay with her.”
He tells me he’s ready to make raku pots to fire in your ashes as you wished
I ask what he’d make
He considers and says, “What was Grandma Helen’s favorite food?”
I can’t think and say that she liked lots of foods
At the same time wondering squeamishly if maybe
he should make a vase and then being surprised
that I am squeamish and thinking of blood and wine,
too, I wonder if my dad would know. “Maybe guacamole.”
I need to find a potter to apprentice him to.

Camille, 4.
asks how old Grandma Helen was when she died.
I explain that she died at 61 but her mother died at 92.
Camille asks how old I am.
40.
When are you going to die?
I say I don’t know, none of us do, but I hope it’s more towards 90.

Camille studies me and is satisfied for now.
She goes off.
I think of you.

I perpetuate
the Christmas cards you did with us
upon my children.
They each draw a card.
We photocopy them and hand paint with watercolors.
Camille wants to draw an angel
and says she can’t.
I draw a simple angel
and have her trace it.
She has your fierce concentration
bent over tracing through the thick paper
She wants it right.
The angel is transformed.

My kids resist the painting after a few cards as I did too.
Each time I paint the angel
to send to someone I love
I think of Camille
and you
and genes
and Heaven
I see you everywhere


January 19, 2002

published in Mama Stew: An Anthology: Reflections and Observations on Mothering, edited by Elisabeth Rotchford Haight and Sylvia Platt c. 2002

For the RDP: another day.

people being people

There is a fascinating essay on the site everything2.com, titled Online Community Dynamics. I keep thinking about it. It inspires today’s poem.

people being people

people being people
they are often scared
huddle
in groups
it’s safest if a leader
identifies an enemy
so that everyone can come together
in hate

the leader
tells the group
who to hate
and why
whether it is true or not

I started out writing
under the title
mean stupid people

but that isn’t right
and anyhow I’d rather find a way
to forgive
again
and again
and again

so I started again
with the title
people being people

maybe we will mature as a species
some day

who do you hate?

now look in the mirror
and ask

who have you forgiven
today?

The AntiDating Patch

I wrote this in 2009. I was in one of THOSE moods, where I had completely given up on ever dating anyone or anything again. There are some anatomical terms in here but I don’t think it qualifies for x-rating.

The Antidating Patch!
New from Astronomical-Zenith!

Tired of dating? No one interesting around you? In fact, are the single people around you creepy losers who make your skin crawl?

You are not alone! You need the patch. FDA approved and tested, the AntiDating Patch will repel people of either sex who normally would want to date you. People are contrary beasts, so this will make them want to date you all the more, but you will remain aloof, pure and free of sexually transmitted diseases, as if you were hermetically sealed in a plastic bag or old refrigerator.

Herbal remedies make the same claim but they have not paid the large sum of money to the FDA to fast track their product or even to evaluate it at all. Also, 35% of dating sufferers using the herbal remedy are actually unhappy about their privates turning blue. We are unsure about the rumor that parts have fallen off. The herbal company did change its’ formulation recently, but they don’t have to tell you that on the label, because it is a natural product, no FDA evaluation needed, and in fact, it is treated just like other natural foods including carrots even though we remain unconvinced that it fell off the tree in patch form!

The Antidating Patch is safer, more thoroughly tested, doesn’t turn your privates blue (except for one person) and we price it to reflect those facts! For men, choose Thong, Old Lady Full Coverage Underwear, or Bikini style patches.* Consider shaving off all that nasty hair before applying to skin. You may want to wear it on your arm, where the ladies (and gents) can see it. NO, YOU ARE NOT, REPEAT NOT, TO STICK IT ON YOUR PRIVATES. THIS MEANS PENIS, WANG, DOINK, TUBESNAKE, DORK, BALLS, TESTICLES AND WHATEVER ELSE YOU CALL YOUR PERSONAL EQUIPMENT. DON’T STICK IT THERE. WE WON’T BE RESPONSIBLE FOR ANYTHING FALLING OFF IF YOU DO. For ladies, choose Boxer, Itsy Bitsy Tight Well Hung (ethnicity of your choice here) or Speedo. Don’t put it on or in your privates, but we know you have more sense then that. This would include boobies, tits, yumyums, mams, breasts, ‘gina, down there, silver beaver, box, cunt, slit, vagina, anus, hole and anything else you learned to call it.

Side effects are rare but include and are not limited to hearing alien voices, high blood sugar, we swear that your privates don’t turn blue or really mostly not. That’s just a faint tinge. Fainting, homicidal behavior, acting like George Bush the Younger, delusions of grandeur (oh, we just said that, didn’t we?), jumping off of buildings, hating sex, loving sex, becoming pregnant (only one man so far and some ladies) and irritation of the privates. Also they can get cranky from lack of use.


*Little Girl style will not be marketed since even though many gents loved it in premarketing testing, those damn strident militant feminists** were up in arms again. We just don’t get it. Those whacko women also didn’t like the Little Boy style for women.

**I qualify for all but the militant bit.

grounded

This is a poem that I wrote in 2015 or before. It was previously posted here and on everything2.com. I just read a blog where two hockey dads are dead of covid-19. The author is writing about grief. I wrote this when I was struggling with grief and how to really let it in.

grounded

grief is an ox
that stands in the room with me
and overshadows
everything

no
grief
is a plow
pulled by an ox
I try to guide it
in the furrows

no
grief is the heavy ground
the plow turns it
the ox pulls
I guide it
in the furrows

no
I am grieving
I let it be close
I don’t push it
in to an ox
in to a plow
in to the earth
I let it in
I grieve

Mask refusal in the 1918-1919 influenza pandemic

This is from an article about the history of medicine, about people refusing to wear masks in the 1918-1919 influenza pandemic:

“Adherence is based on three concepts: individualism versus collectivism; trust versus fear; and willingness to obey social distance rules. Jay Van Bavel opines that some countries tend to be more individualistic,16 and therefore more likely to reject rules and ignore attempts by public health authorities to “nudge” behavior change with risk messages or appeals for altruism. In collectivist cultures, people are more likely to do what is deemed best for society. Trust and fear are also significant influences on human behavior.17 In countries with political division, people are less likely to trust advice from one side or the other and are more likely to form pro- and anti- camps. This may also undermine advice issued by public health professionals. The last and most difficult to attain is social distancing. Human beings are social animals with bodies and brains designed and wired for connection. A pandemic, in many ways, goes against our instinct to connect. Behavioral psychologist Michael Sanders argues that if everybody breaks the rules a little bit, the results are not dissimilar to many people not following the rules at all.18

From another article:

“It was the worst pandemic in modern history.

The 1918 influenza virus swept the globe, killing at least 50 million people worldwide.

In the US, the disease devastated cities, forcing law enforcement to ban public meetings, shut down schools, churches, and theaters, and even stop funerals.

In total, 675,000 Americans died from the Spanish flu, named after the disease’s early presence in Spain.”

I read a book on the 1918-1919 influenza. It started in the U.S. The photograph that haunts me is the bodies stacked five deep in the hallways of San Francisco Hospitals.

And in a third article:

“The scenes in Philadelphia appeared to be straight out of the plague-infested Middle Ages. Throughout the day and night, horse-drawn wagons kept a constant parade through the streets of Philadelphia as priests joined the police in collecting corpses draped in sackcloths and blood-stained sheets that were left on porches and sidewalks. The bodies were piled on top of each other in the wagons with limbs protruding from underneath the sheets. The parents of one small boy who succumbed to the flu begged the authorities to allow him the dignity of being buried in a wooden box that had been used to ship macaroni instead of wrapping him a sheet and having him taken away in a patrol wagon.”

A CDC article about the history of the 1918-1919 influenza says this:

“The fully reconstructed 1918 virus was striking in terms of its ability to quickly replicate, i.e., make copies of itself and spread infection in the lungs of infected mice. For example, four days after infection, the amount of 1918 virus found in the lung tissue of infected mice was 39,000 times higher than that produced by one of the comparison recombinant flu viruses.14

Furthermore, the 1918 virus was highly lethal in the mice. Some mice died within three days of infection with the 1918 virus, and the mice lost up to 13% of their body weight within two days of infection with the 1918 virus. The 1918 virus was at least 100 times more lethal than one of the other recombinant viruses tested.14 Experiments indicated that 1918 virus’ HA gene played a large role in its severity. When the HA gene of the 1918 virus was swapped with that of a contemporary human seasonal influenza A (H1N1) flu virus known as “A/Texas/36/91” or Tx/91 for short, and combined with the remaining seven genes of the 1918 virus, the resulting recombinant virus notably did not kill infected mice and did not result in significant weight loss.14

The 1918-1919 influenza virus was sequenced and studied in 2005. We did not have the tools before that. Frozen bodies were exhumed with the permission of Inuit tribes to find the virus.

Later, that same article talks about future pandemics:

“When considering the potential for a modern era high severity pandemic, it is important; however, to reflect on the considerable medical, scientific and societal advancements that have occurred since 1918, while recognizing that there are a number of ways that global preparations for the next pandemic still warrant improvement.”

Let us now travel back to a worse epidemic: the plague in the Middle Ages:

“Did you know? Between 1347 and 1350, a mysterious disease known as the “Black Death” (the bubonic plague) killed some 20 million people in Europe—30 percent of the continent’s population. It was especially deadly in cities, where it was impossible to prevent the transmission of the disease from one person to another.”

I am hoping that people will awaken, get their vaccines, wear their masks and stop Covid-19 in its’ tracks, so that our death rate resembles the 1918-1919 Influenza. Not the Middle Ages plague.