The Addict Read online

  The Addict

  One Patient, One Doctor, One Year

  Michael Stein

  FOR MY NEPHEWS AND NIECES,

  ANNA, SAM, DAVID, ADAM, BEN, IAN, SAM T., AND RACHEL

  OFF TO WAR AND AT HOME

  Contents

  Epigraph

  Author’s Note

  Part One

  Chapter One Wednesday, April 16

  Chapter Two Friday, April 18

  Chapter Three Monday, April 21

  Chapter Four Monday, April 30

  Part Two

  Chapter Five Monday, June 25

  Chapter Six Thursday, August 10

  Chapter Seven Wednesday, November 22

  Part Three

  Chapter Eight Tuesday, December 24

  Chapter Nine Wednesday, February 17

  Chapter Ten Friday, April 9

  Acknowledgments

  About the Author

  Other Books by Michael Stein

  Credits

  Copyright

  About the Publisher

  People make momentous shifts, but not

  the changes they imagine.

  —Alice Munro, Differently

  Author’s Note

  As an author of nonfiction who is also a doctor writing about his patients, I have particular storytelling challenges. When I began The Addict, I knew I wanted to portray a patient of mine, a young woman whose story touched me deeply. I knew that I would have to change names, places, and many details of her life to protect her privacy. If she were ever to read this book, I wanted her to remember things about herself but feel safely disguised. My goal was to illuminate her story while widening her view and other readers’ views of addiction.

  I am not a journalist; I am a doctor. As a writer, I have a very different relationship with my subjects than a journalist might, because what I learn from patients is personal and medical, and it is not solicited with publication in mind. I never audiotape my interviews, but I occasionally take notes.

  Beyond the requirements of journalism, but in keeping with my medical oath, I had to guard the confidentiality of all the patients included in these pages. This was of great importance to me and at times it conflicted with my oath as a writer—to give readers the most realistic sense as possible of an addict’s psychology and behavior from a doctor’s point of view. In writing about the patient whom I discuss most extensively here, I gave her some experiences and characteristics that belong to other patients. The main challenge was to tell true stories that my patients would recognize but not feel betrayed by in their reading.

  Just as there is no single right way to help addicts, there is no single perspective that captures the entire feel of addiction. I have tried to illustrate the range and variety of terrible moments and encouraging successes my patients live through. This is the story of one addict, but it is also the story of all addicts.

  PART I

  CHAPTER 1

  Wednesday, April 16

  It had rained the first week in April that year, and though the reappearance of the sun raised the temperature to only forty-five New England degrees, it made me hopeful again. My new patient sat on her black Converse high-tops, her legs tucked under, as if she was trying to keep herself from running away. She appeared to be in her late twenties and was wearing a loose gray sweater over a pink and green polka-dot blouse. With her chin tipped into her collar, eyes toward the floor, she appeared shy, or embarrassed. She was tall but slight and had rolled up her sleeves to the elbows.

  “I’m here for your program,” she said. “You still have openings, right?” Her soft voice gave me an impression of politeness.

  Sixty minutes isn’t enough time to learn a patient’s complicated history so I was happy to start at a gallop. I was grateful she required no transition from the general cheerfulness of just meeting each other to the serious conversation, filled with effort and nervousness and specifics, that would constitute the rest of the hour. The answer to her first question was a simple yes or no.

  “Yes, I do,” I answered, as if we were getting married, which in some sense, we were; from that moment forward, our time together would, like any pair’s, get snagged on expectations, hopes, and fears, mixed with promise and excitement.

  My exam room also serves as my office in the hospital clinic. At the far end, just past the examining table, is a large window with a fifth-floor view of the neighborhood and the two multi-family triple-deckers whose owners seem determined to hold on despite the encroachment of hospital buildings and parking lots. This window gives the room an unusual brightness every season, particularly on spring mornings. My new patient had chosen the metal chair whose bent rods and plain plastic seat and back offered, really, just the ideogram of a chair. This uncomfortable seat does not give the exam room a sense of well-being. I’d recently thought of bringing in a chair from home, my mother’s old chair, which my wife had reupholstered in maroon velvet for my birthday. But I hadn’t gotten around to it. On the wall behind the patient’s chair is a large photograph of vines that my brother-in-law, an artist, had computer-manipulated into the shape of a man kneeling. There are books on the shelves above my desk—text-books about renal and heart disease, dermatology primers with pictures of common eruptions, guidebooks for how to examine the knee and the shoulder—but I have no pictures of my children under glass, no diplomas in thin black frames on the walls; I’ve never liked that. Along the opposite wall, there is a small chrome sink next to which I keep square packages of bandages, paper-doll white, and cellophaned rolls of gauze in perfect soft cylinders along the back of the counter. The cabinet above is a cave of supplies, sticks, scalpels, and screw-lid cups hiding in the dark in undisturbed neatness, nothing loose, shaggy, or irregular.

  By 11:00 A.M. on that Wednesday, I had already seen three patients, listened to their uncertain stories, examined them, come up with plausible explanations for their symptoms, tried to bestow comfort, and made plans to see them again. I am an internist, a doctor for adults with heart disease, high blood pressure, headaches, hepatitis, and other ailments and illnesses. I take histories and perform physicals. Taking a medical history has a discipline to it, but it’s also like listening to gossip where the only topic is the patient who tells stories about herself. On the other hand, the physical, examining a vulnerable and tender body, trying to know its secret past of wounds and scars is exhausting. Physicals confirm histories, but also provide information that patients can’t, or won’t, communicate. Of course, what doctors don’t know about patients, after an hour, even after a year of providing care, is endless. Too often, we are wholly unprepared for what we learn along the way.

  What patients don’t know about me might be vaster but matters not at all. They expect to know little; few ever ask if I have children (I do) or where I went on vacation (I rarely leave home for more than four days), or even where I’d trained, my history of successes and failures. In my twenty years of practice, it has been the rare patient who mentions that they know I am a writer, even though several of my books are for sale in the hospital gift shop.

  When I look at patients, I immediately wonder, where, physically, the damage is. Although she was dressed like a teenager, Ms. Lucy Fields had turned twenty-nine recently—her date of birth was stamped on the upper-right corner of her purple chart, which lay open on my desk. She looked healthy—there were no physical signs of illness. Her mouth had a determined shape.

  “Can you tell me a little about yourself?” I asked.

  Sitting sideways, studying the back of my dark-stained office door and giving me only her profile, she shifted on the metal chair, keeping her feet tucked. She had put her tiny black purse, a white paper coffee cup, and a blue plastic bag with a drawstring on the floor beside her chair. Pretty with her
long, black hair that she parted in the middle and pale blue eyes, she was not pretty enough to create envy among the nursing assistants who were known to judge each of my patients. She looked like a girl I went to high school with who always covered herself densely in layers. There is often something in a patient’s character or looks or choice of words that binds me to them from the start. Without this connection, I am just a man in a white costume, and they are merely strangers asking me to guarantee they’ll live forever.

  “I’m tired, I use a lot of Vicodin, and somewhere, deep in the back of my mind, for some reason I still believe that I could have a meaningful life, maybe do something valuable.”

  This was a bold and risky statement. She couldn’t find it in herself to look at me, but I could tell she was ready to talk at length if I made myself available. I could see that there were huge forces at play for her. She was holding herself back from saying too much too quickly despite her opening statement; she didn’t want to make a mistake; she wanted a place in my “program.” She was wearing two silver and two blue bracelets on her left wrist that made the sound of wind chimes when she reached down and lifted the cup of coffee to her lips.

  In 2008, Vicodin was the most prescribed medication in the United States—far surpassing penicillin, Lipitor, and Prozac—a pill chemically related to the opiates (also called narcotics) morphine and heroin. It is offered by internists for back strain and by dentists for toothache, by surgeons postoperatively for incisional throbbing and by emergency room doctors for kidney stones and fractures. Plenty of people use Vicodin legitimately for pain. Occasionally, people who are prescribed Vicodin (or one of its medical opiate relatives, Percocet, codeine, or OxyContin) find that the narcotic not only takes away acute pain, but after only a dose or two helps in unexpected ways. Vicodin gives some users energy while it makes other users feel calm. I had recently seen an exhausted new mother who was given the drug after a hemorrhoidectomy; she was bathing the baby three times a day. These unanticipated gratifications sometimes lead to problems, dependency, and then addiction.

  Eleven million Americans take opiates for nonmedical, recreational purposes. Some start with a doctor’s prescription, others first try an opiate as a party drug—nothing any more scandalous than marijuana. Most partyers use it once or twice and decide it isn’t for them. Others get high and enjoy the euphoric escape. They look for Vicodin the following Saturday night as a reward for working hard, a treat to end the week. There is a spectrum of use (as there is with drinking alcohol), but the ones who make it to my program have been through a definable process: enjoying the Vicodin, having a little fun with it; using it more often, spacing their doses evenly across a weekend day, then evenly across an entire week; then doing anything to get it, having some physical need for it and finding themselves in search of an ever-increasing pile of pills, or moving on to heroin for a bigger, faster feeling. Then gradually they enjoy it less, realizing they can’t function without it, but are unable to stop, living with only memories of good times; then with problems mounting, wanting to stop more than anything on earth, disbelieving they ever liked using.

  I wondered how Lucy had started, and when, and who else knew she had come to my office.

  The “program” she was asking about involves a medication, buprenorphine, which blocks the effects of Vicodin by attaching itself to the same opiate brain receptor. Buprenorphine shares a basic atomic structure with opiates, but does not get the user high because its chemical properties are different. It allows the daily user to escape the urgent, constant, and often destructive calling of his or her habit. It quells the craving. Before buprenorphine, an internist had little to offer an opiate addict. The “program,” as far as Lucy knew, was simply my name and office location, which were listed on an Internet site about substance abuse treatment. The site was sponsored by the federal government agency that had granted me permission to prescribe buprenorphine. In early 2005, I was not a “program”—which in its jargon-y sound suggested a twelve-step group—I was simply one of the few physicians in my region specially licensed and trained to treat opiate-dependent patients with buprenorphine. If anything, I was a de-programmer, helping a few patients escape the physical and psychic lockdown of addiction. I was also a physician who was skeptical of easy answers, working alone without slogans or a dogma.

  Lucy had asked if I had an “opening” because she’d done her research; according to federal law, a buprenorphine provider is allowed to treat only a limited number of opiate-dependent patients at one time. Congress had determined that having a medical practice filled with hundreds of Vicodin, OxyContin, or heroin users was a recipe for diversion—for shoddy prescribing and unavoidable pill sharing among patients—the fastest way to establish a black market of buprenorphine among addicts, and a sure way to promote seepage of this powerful medication into the population at large where nonaddicts might unadvisedly use it for pain and other troubles that might best be evaluated by doctors.

  Diverse theories exist about how people become addicts and what should be done to help them. There is far from universal agreement about what constitutes the proper treatment of opiate addicts, how to define treatment success, and how to identify treatment failure—questions that continue to polarize the community of treaters but does little to help the individual doctor in his or her room working with a patient who has found a way to get high.

  “What’s making you so tired today?” I asked Lucy. What I really wondered was: Why now, why do you want to quit Vicodin now? And what was “tired” code for? But I didn’t ask that because addicts hear every judging comment as a reason to walk away. When an addict decides to see a doctor, it is far from decisive. One wrong move on my part and off Lucy Fields would go. She heard my question, then hesitated. I wondered if she thought I was being too personal or too pushy. Perhaps she wasn’t used to being observed so closely. My friends say my face is hard to read, that I have an elaborate range of looks, all of which might signal disapproval. I didn’t want Lucy to feel defensive. I was not expecting a full account. I didn’t know what “a lot of Vicodin” meant yet, but I leaned back in my chair and relaxed.

  “What if I tell you that I don’t remember what normal feels like? That what you feel every day, I feel only when I take my pills,” she said. She was bowed a little, curled into herself, as if she was expecting something to be thrown at her. It was a posture of no confidence, of unease. “I’ve done this for so many years I get tired just thinking about it. What if I tell you I’m so tired that I can’t get out of bed in the morning, and when I don’t get going until the afternoon, I’m sick, and I’m tired of being drug sick. I’m tired of making myself feel better by using.”

  Her delivery had an almost dreamy quality, as if she was trying not to hear what she was telling me. I’ve always found that the more emphatically an addict says he or she is ready to quit, the more exuberant the addict is about what he or she might achieve with my help, the less convinced I am that the person will be successful. And the more confident addicts are, the more I worry I’m being manipulated, and that they aren’t ready for the hard days ahead.

  “I’m just tired,” she said.

  She looked up for just a moment, regarded me candidly, with a faint smile. Her eyes were alive and intelligent, but she had little sensual presence; she had turned off that part of herself.

  I felt a protectiveness toward her.

  I looked again for any physical damage as she played with the sleeves of her sweater. Her arms were thin, her skin was not as pale as mine—she obviously tanned easily.

  She hadn’t yet explained why she had come in that morning, that April Wednesday; she had probably been tired for months. My impulse was to make her be more exact, which would oblige her to tell some greater truth about herself. She looked up again quickly.

  “I want to go to South Carolina in a few weeks to see my parents. They moved down there a while ago. They used to live here. Now they live in Hilton Head. I haven’t seen them in almost
two years. It’s hard to get away. It’s hard to take enough pills on the plane. And it’s not worth getting caught.”

  When patients in pain are prescribed Vicodin, they are expected to take four or six or at most eight pills a day to control their discomfort. By the time most Vicodin addicts come into my program, they are typically using forty, sixty, or eighty pills a day (needing higher doses to achieve the same effect over time), often spending a few hundred dollars daily on their drug use. In the beginning, a pill or two got them high (or relaxed or energized them, or took away their pain); later, when their bodies adjusted, they needed more for the same effect.

  “Do they know you’re using?” I asked.

  “My mother would say she doesn’t. Her powers of denial are really incredibly impressive. If my parents knew about my life right now, my mother would drop dead on the spot.”

  “But they know you’ve used in the past.”

  “They know. But they hate my boyfriend because he’s an addict. He’s the one with the drug problem, they believe. Someone else has the problem, not me. Maybe I used some drugs when I was sixteen, or I had a little trouble when I was twenty-four, they might tell you.” She smiled and shook her head in frustration, as if she couldn’t believe how blind they were to the facts of her life. She didn’t expect me to be sympathetic; she was talking mostly to herself.

  All patients invite me to be complicit in their stories, to agree, and to question only as a friend would, without agitation. I am careful not to overstep, waiting to build their trust.