Trainee psychiatrist meets opiate user, with significant outcomes for both
by JP Sutherland
Although I wanted the experience of illegal substances – any drug, every drug – I never tried a single one. Let that be my character note; curious, open-minded, yet ultimately limited by being so rigidly law-abiding.
“We should do them all.” Said Harry.
“Just to see what they’re like,” I replied, “but only once.”
“And all the medications we prescribe too. How can we meaningfully discuss side-effects of antipsychotics with our patients if we haven’t taken the same medication ourselves?”
“I don’t fancy taking haloperidol.” I added, having recently seen a rare but horrible dystonic reaction to the drug in a most unlucky patient.
“But that’s the point. A truly caring physician would want to know what he is subjecting his patients to.”
“But it’s illegal,” I said, causing him to raise an eyebrow, and reinforcing my suspicion that many recreational drugs would not be novel experiences for him, “and we could lose our licenses if we were discovered.”
This last point seemed to strike home and, like someone reluctantly coming down off a high, his enthusiasm for the plan gradually waned.
Harry and I were both in our third year of psychiatric training, and were just starting work together for six months in the city’s addictions clinic. I wasn’t looking forward to the placement, partly because of my absolute unfamiliarity with the drug scene. However, I hoped that it would be a useful experience, because most syndromes of mental illness can be mimicked by drug-induced disorders, and I needed experience with the subject and those who suffered from addictions.
“No-one wears a tie around here. Haven’t you noticed?”
“You’re wearing a tie.” Said Helen.
“Yes.” I said, wondering if I had done the right thing, and guessing that she was a long way from seeing any tie-wearing people in her life. Her jeans and T-shirt were torn, and although the holes may have been fashionably placed originally, that was probably a long while ago. Strands of dirty hair hung down from a hastily made bun, reminding me of nothing more than the hanging tendrils in a mangrove swamp, an image that I immediately regretted and felt guilty about ever allowing.
“No-one wears a tie around here. Haven’t you noticed?”
Actually, I had. The clinic’s staff looked casual, as did the clinic itself, appearing even more threadbare than the usual settings of publicly funded healthcare. Though I couldn’t help thinking that we ought to be discussing opiates rather than dress codes.
“Dr McLaughlin wears one.”
“Yes, but he’s the boss. Plus, he’s also a hundred years old. You’re just the young intern.”
“Resident.” I corrected her, though that was also the wrong thing to do.
“Whatever.” She said, leaving me with the impression that I had failed on all fronts; a feeling that I was getting repeatedly as I struggled to adjust to this most personally challenging of all the placements in my training.
“What I need is methadone.” She said, finally abandoning her oppositional assessment of me, and turning to the matter at hand.
“That’s pretty restricted.” I replied. “We ought to look at a gradual detox and rehab first.”
“I’ve done all that. Endlessly. Or haven’t you read my chart?”
I had, but I was still feeling my way into an understanding of how to practice addiction psychiatry, and was reluctant to prescribe what was at the time a heavily controlled medication. So I finished her assessment interview, and booked her in again for the following week. I promised to review her request with my boss, and then scurried out of the room before she could make me feel any more out of place.
Methadone is useful for helping people with an opiate addiction, since it is absorbed slowly and doesn’t cause much of a high, but still prevents withdrawal symptoms. But because it involves supplying a somewhat addictive drug to someone already diagnosed with opiate dependence, governments (then as now) are reluctant to make it easily available, despite its proven ability to stabilize people’s lives, and keep them away from crime. When I was in training, doctors weren’t routinely allowed to prescribe it, but I had a special license to do so in this clinic. That wasn’t because of any great skill on my part, but because my work was supervised by addiction experts. I had proudly written my first prescriptions of this highly regulated medication before I met Helen, but only to those already taking it and needing a refill.
She wailed, while I glanced at the door, half-hoping that someone would look in as a result of the noise, and half-fearing the embarrassment if they did.
“She wants to start methadone,” I told Dr McLaughlin in our weekly supervision session, “but I haven’t ever initiated it, and I don’t know if I should.”
“Well laddie,” he replied, immediately making me feel smaller, “let’s hear what she’s done so far. Detox?”
“A dozen times.”
“Rehab?”
“Two stints in a residential setting, and ongoing attendance at the outpatient clinic.”
“Longest period of abstinence?”
“She says three months, after a rehab placement. But we have a positive urine test on file after just two months of that.”
“Does she inject or smoke the heroin?”
“Inject.”
“Still HIV negative?”
“Yes, as of last month.”
“And how is the addiction impacting her life?”
“How do you mean?” I asked, still learning how to assess this complex but vital question.
“Can she hold down a job? Keep a relationship? Or does the addiction get in the way?”
“’No’ to both of those.” I answered. “Her most recent boyfriend was in rehab with her, but when she relapsed he left her. And she lost her last two jobs each time she was charged with theft.”
“She certainly sounds like a potential candidate. But how motivated do you think she is? Will this make the difference, or will she just keep using street drugs on top of the methadone?”
“I don’t know.” I paused, feeling my novice status all too clearly in the presence of this seemingly all-knowing man. “How do you judge that?”
“Och, it will come with time. See how you feel about her at the next meeting, and if you think she’s serious then give it a try.”
And with that nebulous advice he left me.
“You’re not wearing a tie. You must be trying to fit in.” Said Helen at our next meeting, with a warmer tone than before. “But you’ll always be too square to really belong here,” she added, unable to stay friendly for long. “How about my methadone?”
“I don’t know.”
“You said you’d talk to McLaughlin. What did he say?”
“Maybe.”
“What kind of an answer is that?” She said, tensing up in her seat.
“Helen, how serious are you about this?”
“What do you mean?”
“Well, if you start taking methadone, will you be able to stop the heroin?”
“Of course, that’s what it’s for.”
“But how can I know for sure?” I said, blundering on with words that I wouldn’t use now.
“You think I’m lying to you?”
Helen had become increasingly agitated during these last exchanges, and as she sat there glaring at me, I thought for a moment that she was going to explode. But her anger suddenly collapsed, as did her posture, and she began to cry – quietly at first, and then with great gasping sobs that shook her body.
“I can’t go on like this.” She wailed, while I glanced at the door, half-hoping that someone would look in as a result of the noise, and half-fearing the embarrassment if they did.
“I’m not a bad person, honestly. I only steal because I have to. There’s no other way to fund my supply.” She looked up at me, and my hesitant reluctance crumbled in the face of her desperation. “You’ve just got to give me methadone.”
And so I did, though as soon as I left the room I could see that my decision wasn’t the logically thought-out assessment of her motivation that was planned, as much as a panicked attempt to settle the issue and escape from a situation where I had lost control. Which hardly boded well for the outcome.
“You’ll always be too square to really belong here.”
“So, how’s it going?” Asked Harry as we sat down for lunch together. “We’re six weeks in, are you finding your feet?”
“Slowly,” I answered, “but I still feel very different here.”
“You don’t look like your usual relaxed and confident self,” he said, looking totally comfortable and self-assured in this new role.
“No. Elsewhere in psychiatry I feel at home, and I seem to build rapport without much trouble. But here I can tell that my presence just puts some people off. And no-one seems to get better.”
“Yeah, the recovery rates are certainly low. But our job is to offer a route to abstinence, and help those who are ready to take that step. Don’t you love it when someone gets clean, and you’ve helped them turn their life around? Maybe even helped save their life?”
“Hmm, I haven’t had a lot of that. But I’m not sure I could do this for a career, there’s just too many relapses.”
“‘Relapse is just a step along the road to a possible eventual recovery’”, he quoted at me, “I’m thinking this could be the job for me.”
“Well, bless you if it is. I know I couldn’t do this, but there’s obviously a great need for addiction specialists.”
“Yeah, I feel like I could be happy here,” he said. And then, probably wanting to encourage me, he added, “But you look the same way in general psych, that’s where you’re headed isn’t it?”
“It is. And I know that I need a familiarity with addictions to help me with that work, so I’m just hoping to get better at it before our time here is up.”
“Och laddie, I’m sure you will.” He said, mimicking his boss and new role-model, but leaving me just as doubtful as when we started.
Helen looked better, but her urine test did not. We were now well into her methadone treatment, and I had been slowly increasing the dose twice a week as we were taught to do. In the early days she had been angry at the small quantities of medication I allowed, but as the dose rose beyond fifty milligrams, she reported an end to the withdrawal symptoms that would previously have sent her back into the arms of her dealer, using the proceeds of crime (or worse) to fund her next hit. I had noticed other changes too. Her sarcastic edge had gone, and our meetings now proceeded in a calm and professional way. At least they had until now. She sat across the room from me, dressed casually in jeans and a sweater, but with none of the previous dishevelment that had reflected her disorganized life, perpetually on the edge of opiate withdrawal.
“What are you looking at?” She asked, noticing my downward gaze, while I hesitated about what to say.
“It’s your latest urine test.”
Her smile froze. “And?”
“It’s positive for heroin.”
“Damn.” She paused, and then stammered. “I thought it would have been gone by then. I only did it once. It was Jack who pushed me to take the hit. I should stay away from him, I know I should. It won’t happen again, I promise.” And then with most intense look she added, “You can’t stop the methadone because of this, it’s working. I need it.”
“Helen, methadone is supposed to help you stop using heroin. If you’re going to keep injecting opiates, then we can’t supply methadone as well.”
“But I have stopped! This was just a single slip!”
“How do I know that?”
“Because I’m telling you! I’m not lying anymore.”
I knew that an occasional relapse was far from uncommon, even amongst those who would eventually achieve their goal of abstinence, and so I knew that I could continue the prescription for now. But I couldn’t help feeling pessimistic about her prognosis. I had discovered the heroin use, rather than her telling me, and so I was skeptical about what else she might be hiding.
“If you give me another chance, then I’ll prove I’ve quit.”
“Helen, I’m going to be leaving the clinic in just over a month, so I might not get to see that.”
“What, so soon?”
“We just get six months in each training position, so I’ll be moving on.”
“Who comes next? Do I get another resident, or do I switch to McLaughlin?”
“I don’t know who’s coming, but I expect you’ll stay with a resident.” I said, feeling (not for the first time) how some patients always seemed to get a raw deal by being passed endlessly from one trainee to another.
“How will I know if I can trust them?”
“Oh, I’m sure they’ll be fine. They might even have a bit more street credibility than me.”
“That wouldn’t be hard. Sorry. But you’ve been OK in the end. You are keeping me on the methadone, aren’t you?”
“For now, yes. But any time you use on top of the prescription you risk losing the treatment.”
“I get it. You’ll see”
But in the end, I didn’t. I booked Helen for our final appointment in the week before I left, but she didn’t show. Missed appointments are not unusual in medicine, and are even more prevalent in psychiatry, given the disorder and impairment that can result from mental illness. So I shouldn’t have been surprised, but I nonetheless worried that something was wrong. Helen hadn’t missed an appointment with me before, so I strongly suspected that she had been unable to stay off heroin, and was avoiding me as a result. And behind that worry lay another, less likely but so much more significant. While working in general psychiatry I had learned to live with the ever-present if relatively unlikely risk of suicide, and I knew that addiction medicine had its own variation on this somber reality. Suicide certainly was a risk amongst those suffering from substance-dependence, but so was death from an accidental overdose. I knew that Helen’s tolerance for street drugs must have declined since methadone started, and that she might have been caught unawares by the strength of a new supply during another ‘slip’. I shared my concerns about this with the team, and tried unsuccessfully to contact her by phone, but with no luck. Then I said goodbye to the addictions clinic and went back to work on an inpatient unit for the next stage of my training.
It was a relief to return to the treatment of psychosis, and mood disorders, and the assessment of suicide risk that makes up the day-to-day routine of a general psychiatrist. Once again, I felt that I fitted easily into this role, and as I relaxed I could see how stressed I had been for the previous half-year. But I noticed something else too. When treating someone who had substance abuse issues as well as schizophrenia or depression, I saw myself to be better at discussing it with them, and assessing the need for a parallel addictions treatment. This was the benefit that I had hoped for from the addictions clinic, and it has stayed with me since, making me grateful for the experience even as I was thankful that I would never have to return.
Harry and I continued to meet, and although he too had to leave addictions for some other mandatory placements, he had found his true calling. He returned to work with Dr McLaughlin again in his final year, hoping to take a job in the clinic after graduating.
“I saw an old friend of yours this week.” He said, smiling, as we met up after work one day. “Do you remember Helen?”
“I do. She missed our last appointment, and I was sure she had used heroin again despite the methadone. Is she OK?”
“She’s doing great. I wouldn’t be surprised if she had used as you said, she certainly had a few setbacks along the way to stability. But now she’s back in control of her life.”
“That’s so good to hear.”
“She’s working again, in a stable relationship, and is even beginning the process of getting access to her children once more.”
“That’s wonderful Harry, thanks for telling me. I had worried that she was going the way of so many of my addictions patients.”
“It’s not all doom and gloom you know, some people do make a full recovery. Oh, and she’s just won a bet with me.”
“You bet with patients?”
“Oh, it’s just for a cup of coffee. It helps strengthen the therapeutic alliance. She asked if I was seeing you, and if so, she bet me that you had gone back to tie-wearing. I knew she would be right but agreed to take the wager anyway.”
“Well,” I said, instinctively glancing down at my chest, “I guess she wins.”
All names and other identifying details have been changed to protect patient confidentiality.
This story was first published in the journal The Perch
JP Sutherland 