Posts Tagged ‘substance abuse’

At the end of another Arctic assignment

November 27, 2017

After the lessons not learned

And the good advice has been spurned

Sometimes slow, rarely quick,

People get sick,

I do my best though the bridges are burned.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I just finished a month in the Arctic.  Any identifiable patient information has been included with permission.

Aside from well child checks, perfect people do not come to see me. Most of my patients have made a lot of decisions they regret, and, whether they realize it or not, when the consequences add up they get ill.

In my years in Community Health I learned that schizophrenia, bipolar (formerly called manic-depression), and substance abuse overlap so much as to be indistinguishable.

Sometimes patients are difficult to talk to. Schizophrenia, for example, can rob the face of expression and make speech slow and monotonous; Parkinson’s disease can do the same thing.

Alcoholics, marijuana abusers, smokers, meth heads, and narcotics addicts get sick more often and more severely than those who lead orderly, substance-free lives. Leaving the start line with mental illness that hampers learning from experience gets compounded with substances that do the same thing.

I do my best to focus on my job: fixing what can be fixed and preventing what can be prevented. Bringing up a person’s past mistakes brings nothing good to a medical visit.

Every day I attend patients in desperate circumstances. I do my best to listen to what they say, and what they don’t say.

When I start to fall into the trap of judging people who have come to the inevitable consequences of reality avoidance, I remember the many mentally ill I’ve cared for who tried so hard to stop the voices in the heads. Because it’s easier not to judge if the person has a diagnosis.

I sit and talk to someone who has burned a lot of bridges, brain cells, and assets using recreational chemicals, and I do my best to tease out the story from a wandering narrative. I nod and look into the face of devastated youth and beauty.  I listen to speech patterns that some find annoying, and when the patient finishes talking I ask the right questions.

I do my best to get them to the correct medicine. Often the patient requests drugs that will make their problems worse, not better, and I explain the rationale for avoiding them.  Mostly they follow the logic, sometimes they don’t.

A lot of the people here have asked me if I’m staying. I don’t plan to, but I’d like to come back.

Inevitably, I don’t get along with some people.

But then, perfect people don’t come to see me.



Denver Panhandlers, Then and Now.

September 28, 2015

On the street they reach their hand out

It’s money they’re talking about

If the world is a stage,

They’re here to beg,

They have problems, of that there’s no doubt

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. This summer included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, and two weeks a month working Urgent Care in suburban Pennsylvania. I’m attending a medical conference in Denver.  Any patient information has been included with permission.

Most docs finish med school with crushing debts, I finished with great poverty skills and a 2 year obligation to the Indian Health Service (I stayed 5).

I did my pre-medical education at University of Colorado at Denver, at the time a commuter college with no dorms and no parties.  Paying for your own education brings out the student’s motivation.  My classmates had other employment and wanted better.

Lower downtown Denver at the time had just renovated its Skid Row around Larimer Street with specialty shops, but the bums, drunks, and prostitutes still frequented the neighborhood, occasionally drifting away from the pawn shops to the campus.

In those years I rode my bicycle everywhere, and I confronted panhandlers only when my bike broke down and I had to take the bus.

I returned to Denver for the American Academy of Family Practice’s  FMX, a convention for continuing medical education (CME).  We drove in from Iowa over the weekend.  We visited family.  The classes start tomorrow.

We walked from a very nice hotel to a silversmith’s on Larimer Square.  I’ve known the owner for 40 years now.  We walked down the 16th street Pedestrian Mall, past the panhandlers.

During my pre-med days a lot of young people found themselves on the streets because of lousy economic opportunities and generational alienation, they had good mental health.  They figured that the difference between no pay and minimum wage didn’t justify 40 hours of structure.

But at the time a lot of Indians came off the reservation to drink heavily in Denver (the sober ones, the vast majority, stayed on the reservation, giving the non-Indians in Denver a false impression of Indian alcoholism).  One afternoon I found myself walking down 15th Street when a Crow Indain confronted me.  “I’m just got into town,” he said, “I’m trying to get together enough for a bottle.  Can you help me out?”

He had caught me at a bad time.  I had much to learn about softening my words.  “You want me to help you out?”  I exploded.  “I’ve got a quarter in my pocket and I don’t have enough to buy a patch for my bicycle tire because I used the last one this morning and I got another flat this afternoon.  I haven’t eaten since 6 this morning and I don’t have enough for the bus.  No, I can’t help you out.”

He was taken aback and reached into his pocket, offered me half of what he had.

Humbled, I took enough to buy myself a new patch kit.

The street people look better fed but less washed than they did 40 years ago, and not an Indian among them.  My years in the Community Health Center softened my reaction to those who beg for money.  I have treated so many mentally ill that I appreciate the overlap between bipolar, schizophrenia, and substance abuse.  Most but not all the people I saw asking for money had the bizarre affect of schizophrenia and the twitchy gait of the overmedicated.

I gave some money, I didn’t give to others.

I can afford it a good deal more than the Crow who helped me buy a patch kit.

Schizophrenia should not be a death sentence

May 1, 2014

Even the worst of the cynics
Support the function of clinics
It’s a seasonal flow
They come and they go
The homeless bipolar schizophrenics

Synopsis: I’m a family practitioner from Sioux City, Iowa. I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went for adventures working in out-of-the-way locations. After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took a part-time position with a Community Health Center. I just returned from my second locums trip to Petersburg, Alaska.
The young man I talked to in the clinic recently brought a distressingly familiar story; because so many have similar tales I can talk about the non-unique elements. From out of town, he couldn’t give me a good reason he had landed in Sioux City; he had no work or money and the word “tenuous” described his housing arrangements. As we talked the contradictions in the history started to add up, but I carefully avoided bringing inconsistencies to his attention.
I won’t discuss his “admission ticket,” the physical illness he described came second to his main problem.
A long, involved medical history with improbable descriptions of other health care facilities, led me to conclude that he maintained an uncertain relationship with reality, and, eventually, he mentioned his history of schizophrenia.
My 22 years as a co-owner of an upscale clinic brought me little contact with schizophrenics, but my current position has. Our facility cares for most of the schizophrenics in the city.
I have learned that schizophrenia, bipolar disease, and substance abuse overlap each other with terrible frequency. Most schizophrenics smoke, and trying to get them to stop ranks with trying to stop the tides. The majority of schizophrenics have difficult-to-control diabetes.
We have drugs to treat the bipolar, the diabetes, and the smoking. Yet we lack good, effective treatment for the basic disease process, where a person’s thoughts loses touch with reality.
(One very effective drug, clozaril, shows dramatic improvements not only in symptoms but functionality; the worst side effect, occasional and unpredictable bone marrow shut down, makes it too toxic for all but the most severe cases.)
Our society has failed our mentally ill. A Republican President with bipartisan support closed the mental hospitals and dumped the patients onto the streets. They form a disproportionate percentage of our prison and jail population and a majority of the homeless. Unable to cope with the real world, they can’t hold jobs, manage money or maintain interpersonal relationships.
If someone in our town stumbles out from under a bridge and into a clinic, they stumble into our clinic. They truly can’t afford to pay for their services.
The most conservative, fiscally stingy, small-government supporters I know agree that schizophrenia should not be a death sentence.
Some of my schizophrenics can maintain a semblance of a normal existence with regular medication; a few can manage part-time employment. But many just keep drifting, north in the summer, south in the winter.
I do what I can for them, recognizing the fleeting nature of the relationship.

No illusions: lies and drugs.

December 15, 2012

This rule I won’t even bend,

I no longer even pretend

I see no excuse

For those drugs of abuse

That make up a frightening trend.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Last year legally prescribed narcotics killed more Americans than the bullets or the cars.  This frightening statistic comes after a four-year near-logarithmic increase and matches the same trend in the number of narcotic pills prescribed.

Several layers of government keep track of the use of certain medications, the ones most susceptible to abuse, now referred to as controlled or scheduled drugs.  I have to have a slip of paper from any state government where I practice and the federal government to prescribe any narcotic, also addictive tranquilizers, most sleeping pills, and testosterone.

I tend to reach for those drugs as a last resort.  We have a lot of other things to treat pain and anxiety and sleeplessness; nonetheless controlled medications have their place in the work I do.

Of course a lot of patients disagree with me as to how big that place needs to be.

As required by my state licensing board, I took a two hour video course in the proper prescribing of pain medications, exhorting me to watch out for personal and family history of crime or substance abuse, past incarcerations, or frequent missed appointments.

More than half of my new patients don’t show for their first appointment, which leads me to wonder about substance abuse even before I see them.

Our practice includes a large number of people who have done significant time behind bars; I don’t want to know their crimes.  Everywhere I’ve practiced, abuse of alcohol and other substances runs rampant.

So, all in all, I keep my suspicions high, particularly when a new patient comes in with a long med list including tranquilizers and narcotics.

The number of good reasons to prescribe long-term narcotics continues to dwindle; for example, evidence-based medicine shows the opiates lose their effectiveness for back pain after 8 weeks.  I never prescribe large numbers of the two most popular short acting tranquilizers, alprazolam and lorazepam; if the person really has that much anxiety I recommend the long-acting but less marketable cousin, clonazepam.

Really, the problem comes down to diversion: someone other than the patient taking the prescribed drug.   

Thus, for those patients on long term controlled medications, we make sure they sign an agreement that says they won’t share those drugs, and that they’ll come in, when asked, for a urine drug screen and pill count.  And that they won’t seek controlled substances from more than one provider. 

I used to believe people who would tell me they used to abuse drugs but named a date when they quit.  Most can tell twelve-step stories. 

Two of my patients flunked the urine test this last week. 

I’ve asked our case manager to contact them, to see if they’ll come in to get counseling.

I don’t hold high hopes.