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.
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