A Country Doctor Writes:

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year old with track marks on her forearms. Her obstetrician and caseworker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates”, I ask with my fingers hovering over the keyboard. She tells her story, first in monosyllabic monotone, but as we move through the questions and she realizes I am not there to lecture her on anything, she warms up a little.

Because she is pregnant, she didn’t arrive here in withdrawal out of concern for the fetus. Her last use was the night before. I explain how to place the Subutex tablets under the tongue and avoid swallowing, so the medication is fully absorbed through the mucous membranes of her mouth. Then I fill out the prior authorization form for Medicaid. I make sure to put her due date on the form, so she will be approved until she delivers. Then I write the prescription, sign it and spell out my name and my special DEA number for opiate replacement prescriptions.

My next inductee is in a cold sweat. He is the same age as my own son. He snorted some Oxys and Ritalins Friday night. Today he has the shakes and the runs. He has no job, is in trouble with the law, and he has been here before, but was discharged because of repeated failed urine drug screens.

I document his COWS score, the degree of physical withdrawal he is in. He had been doing high doses, so I prescribe him 16 mg of Suboxone daily. I explain that since last time he was here, we have switched from tablets to strips that melt under your tongue the same way. He knows; he knows everything about opiates. Is he here again because of his circumstances, I wonder, more than from a deep desire to quit right now? His counselor’s notes in the computer record have a hint of skepticism in them.

“I hate coming here”, says my third patient for the morning. He is a foreman at a nearby factory, logging week number 178 in the program. He is on 2 mg per day. Going from 3 to 2 mg, he had a terrible time with both physical symptoms and cravings.

“I wish I didn’t have to be on this stuff. I want to be over this. I sit in the waiting room with these people who trade stories about what they have done, and I don’t want to hear it. I have a job, a family, and I hate having to come here for my lousy prescription, but I know I can’t keep my life together without it.”

Fourth up is a woman in her forties I haven’t seen before. She transferred in a week ago when Dr. Feiner sat in this chair. I recognize the woman’s name. She is a physician, who just lost her license a few months ago. She is stable on her dose. I write the prescription and she leaves quietly.

The next patient is a mother of two, who just had surgery for ovarian cancer. She is in obvious pain. We had talked last time about how Suboxone does help with pain, but it is not all that potent. She had told me then that she was more afraid of falling back into addiction than being in pain.

This time, she is tearful. Her cancer has already metastasized, and she speaks of what will happen to her two girls if she can’t be cured. She winces with pain, and I ask her again if she is sure she wants to stay in the program. Her husband already manages the Suboxone strips for her, and he could manage pain medications for her as well. But she knows that the naloxone in her Suboxone strips keeps her from feeling the same high that other opiates give.

“I am so grateful for what this program has done for me, that I don’t want to risk that, even for this”, she says and points to her abdomen. “Whatever time I have left..” She chokes, tears streaming down her cheeks, and blows her nose with tissue from the box on the corner of my desk. “Whatever time I have left, I want to be sober, and I want to be all there for my girls and for my husband. I don’t want to be strung out.”

“I hear you”, I say. But you are in pain, I can see that.” She nods.

“I’m going to increase your dose back up to our maximum. That will make some difference. But you may be helped by something like a fentanyl patch, that stays on for three days at a time…”

“Thanks, but this is fine”, she says as she takes her new prescription and strains to rise from the visitors’ chair by the window.

I rise and open the door for her. Then I close it and sit down quietly in my black swivel chair for a few minutes as I look out over the boarded-up windows of the empty storefronts across the parking lot.

I don’t hate coming here, as some of the patients do. It is sobering to think back on the ones who are forced to come here, the ones who come here when they can’t afford their drugs of choice, the ones who fight valiantly to get their lives back in order and the ones who have lost, or are about to lose, everything.