Wednesday, February 22, 2006

Things Don't Go Better with Coke

A number of my patients have previous histories of cocaine addiction, and there are several active users on my caseload at this writing. Relapses and remissions of addiction are par for the course in this line of nursing which borders on social work, and I must often wrestle with the question of how best to approach my addicted patients, especially those who are also being treated for chronic pain with narcotics.

While many in healthcare may extoll the virtues of pain as "the fifth vital sign", it is popularly understood that pain is woefully under-treated here in the United States. Combine chronic pain conditions with an actively addicted patient---or even addiction in remission---and you have a recipe for less than stellar healthcare and even worse outcomes. Only very special providers are even willing to walk that fine line, and I'm proud to work with a group of docs and NPs willing to do so.

Observing my patients struggle with addiction issues is heart-wrenching and maddening. Even a well-meaning medical provider who agrees with the "disease model" of addiction---taking into consideration that it is an illness no different, really, than depression or heart disease---one can always fall into thinking that the individual is "weak" or "lacks will power". Within our practice, although we share gallows humor about our patients as a way to relieve stress and share our frustrations, at the end of the day we know that trauma, post-traumatic stress, mental illness, genetics, and complex psychosocial issues impact an individual's predilection for substance abuse. Yes, some people may have an easier time than others overcoming addiction, but it is generally accepted now that, like obesity, there are some factors out of our patients' control.

I sat across from a fifty-year-old woman today, discussing her continued sporadic use of cocaine. We're treating her for fibromyalgia-related pain with several forms of narcotics, and we do oral drug screens on a weekly basis when she comes to pick up her prescriptions. We're also screening to make sure that the prescribed narcotics are actually in her system and not being diverted to others. With her history of chronic pain, abandonment, psychic and physical trauma and past abuse, it's really no wonder that she leans on illicit substances for succor. When I broached the subject of my possibly discussing her cocaine addiction with her therapist, she refused to sign a consent for me to do so, cutting off an important and possibly effective aspect of her potential recovery and remission. Thus, when I speak with her therapist, my hands are legally tied and I cannot mention anything about substance abuse or divulge the numerous positive drug screens in her chart. Unfortunately, this handicaps our treatment of her condition, and forces us to refer her to an addictions specialist who will also be blocked from communicating with her therapist.

A patient of whom I wrote previously was recently on a cocaine and heroin-fueled binge after making great strides in his care. Eviction and homelessness notwithstanding, he was taken in by family and showed some signs of improvement. Sadly, when his check came on the first of the month, he disappeared from view, did not return to his sister's house where he had been staying, avoided the visiting nurses, and eschewed all medications and insulin for almost a week. Thankfully, he had the presence of mind to show up unannounced at the wound clinic and have his dressing changed, knowing full well that failing to follow up in a timely matter would eventually end in gangrene and amputation. Thanks for small miracles. Whether he shows up next week remains to be seen and I have not been able to reach his family to ascertain if he has again resurfaced. It's a waiting game, especially since I don't have the time to drive the city streets trying to find him.

Working with this poor, chronically ill and generally disenfranchised community, addiction and its unhappy effects are normal aspects of my work, and part and parcel of many patients' lives. Compassion and love are still called for, and judgementalness and criticism only fuel the flames of separation. While my compassion-meter is sometimes pushed beyond its perceived limits, I find there is always more compassion and love somewhere in the chambers of my heart. The ultimate goal is healing, and especially in the face of addiction, compassion and understanding must, in the end, be the energy which fuels the healers' fire.


mary said...

While my compassion-meter is sometimes pushed beyond its perceived limits, I find there is always more compassion and love somewhere in the chambers of my heart

What do you think explains your ability to find more compassion there "somewhere"? There are so many of us who talk about "burning out", for instance. What personal hints do you have for finding that compassion repeatedly?

I also feel we have to maintain compassion to continue to be effective nurses, but while my patient base is very complex, it is also personal to me because I also have a child with special needs. So, when my compassion well is running dry I just remind myself of shared humanity with my fellow parents.

And pray. :-)

What about you?

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

I think I am too tired to fully respond to your thoughtful question, but a quote by Mother Teresa that I use in my email signature is part of the puzzle:

"I find that if I love until it hurts, then there is no hurt, only more love."

Easy to say, sometimes excruciatingly hard to do.

More on this later.....

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

To elucidate further, I think that gratitude and the acknowledgement of one's relative priviledge and abundance goes a long way towards creating bottomless compassion.

Reading the words of his Holiness The Dalai Lama is also something I find quite helpful and heartening.

When faced with the suffering of others, I also consistently remind myself that "there but for the grace of God go I". It is only through an accident of birth and lucky circumstance that I am not an addict, a person with debilitating illness, a homeless person in search of a place to lay my head, a refugee....

Through all of this, I can't lose sight of the fact that many of my patients tax my comassion and stretch me sometimes to the point of psychic pain and emotional distress. I, too, sometimes wish they would go away and "get over it". But for many people, there is no "getting over", only getting through, and my purpose in this life is to do just that---help others through.....

Anonymous said...

From reading your account it seems like your personal and social values are in line with what is needed for excellence in your work. There is some discussion in the field of positive psychology that when an individual's character strengths and virtues are fully engaged in their work then they tend not to burn out as rapidly as others with different sets of strengths and virtues.

Thank you for such an interesting account.

Stephen said...

Perhaps the person with back pain resorted to self medication, and then became an addict. If so, is self medication evil?

A few weeks ago, i had a cold. I went across the street to the drug store, but many decongestants have no effect on me. I bought some orange juice and went home. At home, i decided to use the OJ to make a screwdriver. No idea where this idea came from. I added the vodka first. I wanted enough for a slight buzz, but not enough to make the room spin. For me, it doesn't take much. Then i added the OJ. It went down much smoother than Nyquil. To my surprise, it dried out my sinuses and let me get to sleep rapidly. Of course it wore off soon, but i didn't wake up. What's wrong with that? Alcohol - the miracle drug.

I'm not yet an addict. I was trying to drink red wine, because i'd heard it can reduce chances of heart disease. I forget to drink it. I've heard that grapes can have the same effect. I put them in my lunch and consume them without fail. Wine has the better shelf life, to be sure.

Keith "Nurse Keith" Carlson, RN, BSN, NC-BC said...

Sure, we all self medicate sometimes, and I would never argue with an individual's right to do so, especially when the medical community fails...However, self-medication is indeed potentially harmful if it gets in the way of one's daily life, interferes with relationships, or in any way becomes unmanageable.

Any of us might drink a Screwdiver to relieve stress or drink a beer to relax sore muscles. The problems begin when the use of such "self-medications" begins to take hold, especially in the absence of further symptoms.