Tag Archives: suboxone

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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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Liars and the lying lies they tell

This blog post: hanging from a telephone wire intrigues me.

Why do the liars lie?

I disagree with Ms. Kennedy.

The liars lie for the same reason that addicts lie. They are not lying to you or to me. They are lying to themselves FIRST. They want to believe what they say.

“My marriage is perfect.”

“I love all my children the same.”

“I never make an error.”

“I talk to my mother every Sunday morning because we are so close and love each other so much.”

“I can see right in to your head.”

“I don’t care about anything.”

“I am happy all the time.”

Whew. A totally easy list to come up with and I could go on and on and on…. and so could you. When someone says something like this… I am always (fill in blank) or I never (fill in blank)… stop. Think. They want to believe it. They might like you to believe it too. They might even kind of know that it’s a lie and very convincing one but the best liars have convinced themselves.

I saw it in clinic all the time. Over and over and over.

It’s the glitter that gives it away. When they come in all glittery and sparkly and their eyes shine and they are too beautiful for words and they charm your socks right off…. check your wallet. They are an addict or a manipulator or they WANT SOMETHING FROM YOU. And there are people who just do it automatically. They lie all the time.

Whatever. When someone reminds me of my mother or my sister… or the other extremely well trained enablers on the maternal side of my stupid family…. ooooooo. The person has my full focused attention. Which thing is the lie? What do they want? What are they going to try to get out of me?

When I trained in buprenorphine treatment, the guy (enabler) that I was dating was horrified. “You can’t treat addicts!” he said.

“Why not?” I asked.

“They LIE.”

I laughed. “ALL patients lie. There are studies. They lie about whether they are taking their blood pressure medicine. They lie about how much salt they are eating. They lie about exercising. The first question I ask if someone’s blood pressure is too high, is “Are you taking the medicine?” More than half the time I get a sheepish, “Yeah, well, no, I ran out of it two weeks ago.” “Yeah, well, then I can’t tell if it’s working or not, can I? And you’ll have to redo the stupid labs once you have taken it for two weeks and come back for another check.” “Ok, ok, I get it.” If you lie to your doctor, well, you might get hurt. Tell them about the pills your friend gave you, tell them about the supplements, and that infected toe? Might help if you tell the truth about it. Even though it was when you um inserted well we were just, like he has an infected um. That is important information and changes which antibiotics I use plus now I want to check for chlamydia and gonorrhea and same sex male so we gotter talk about HIV prophylaxis and this is a 15 minute clinic visit? I am now running late and annoyed. You need another visit in 1-2 days or else I gonna hospitalize yo dumb self.

And WHY do people, and especially people in addiction, lie to themselves?

Damage. ACE scores. Adverse Childhood Experience Scores. They wish that they were that close to their mother. They long for a perfect marriage. They were beaten in secret by the perfect father. The famous man, their grandfather, sexually abused them. The list is endless.

And how do we help? The person I just stopped dating told me that his children said to him “My picker’s broke.” Our pickers are not really broken. We are attracted to the people who can teach us.

In the book Passionate Marriage, the author writes about how we are attracted to the people who have what we lack. What we want to learn. What we are afraid of. What we need to learn. I needed to learn how to really look at anyone I date with my full on intuition right away and also that it is seriously Not Nice of me to get curious, activate my inner scientist and stick around. I recognize the projection on me at some point and then the scientist in me is intrigued. Really? The most recent one said that inside me there is a sweet innocent joyous tiny girl.

Well, I thought. No, not really. There certainly is a baby. But it’s a baby honey badger or a baby Iron Bitch Alien Lizard. Don’t care what you call it. But it is about as sweet as a pissed off porcupine or skunk. Polecat. Octopoggles done got us! Squirting ink and sliding into an impossibly small space and escaping from the acquarium over and over until the captors let me go…..

And that was actually the moment I should have spoken up. Calmly. Kindly. “Um, no. I was never a sweet innocent joyous tiny girl. I was bathed in antibodies to tuberculosis in the womb and no doubt alcohol and my parents were newly married and I came out saying, “What is happening now? Some new torture? Augh! Bright lights! Is there food? I am really really hungry. Feed me or I will eat YOU.” And then I lost my mother for nine months so that I would not catch tuberculosis from her and die. I didn’t really understand it. I thought people kept giving me away and that you couldn’t trust those evil adults.

In the end this is all actually necessary, says the Passionate Marriage author. WHAT? WHAT? Well, in a truly loving relationship, both people will withdraw the projection. The projection is the “falling in love” where the person is golden, perfect, your true love. No, they aren’t. But you love that aspect of them that you want/need/can’t do. True love is when you withdraw the projection and you see the real person and you love them.

It isn’t easy. But people do it. Birds do it, squirrels do it, trees do it, even elementary bees do it… let’s do it… let’s fall in love.

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Why care for addicts?

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.

I took the photo of my daughter on Easter years ago.