Last week on psychiatry. I am paired with an outpatient psychiatrist who specializes in addiction medicine. He splits his time with group therapy sessions and individual appointments for general psychiatry patients.
Monday morning begins at 8:00 am. The psychiatrist explains the suboxone program enrollment agreement. A psychiatrist accepts the patient into the program at an initial consultation, also called “intake.” The patient then attends weekly group sessions for 6 months in addition to two individual appointments per month. Once stabilized, the patient attends a monthly one-hour group session and quarterly individual appointments. At each appointment, the patient takes a drug screen. “Most of my patients do multiple types of drugs, so although we call this opioid addiction therapy, each patient is unique in their social situation and drug addictions,” the attending notes.
Our first group session begins at 9:00 am. Of ten patients, two patients are brand new to the meeting, having just enrolled for addiction treatment. Most have been with us for 6 months to 2 years. Two are “oldtimers”, having been in this group for over 5 years. One female oldtimer is actually off suboxone completely.
The meeting starts off with short introductions. Our oldtimer: “You all know me. I’m a recovering addict of alcohol, heroin, pills, and cocaine. I’ve been sober now for 10 years.” The psychiatrist asks how her daughter is doing. “Well most of you know I got custody back of my daughter from my ex husband. She’s starting middle school!”
[Editor: Why should a plaintiff’s consumption of alcohol, heroin, pills, and cocaine interfere with an ultimate family court victory?”]
One of the two new members, a 22-year-old unemployed male addicted to pills, introduces himself. “Hello, I’m [Brad].” The psychiatrist asks him to share some hobbies or interests. “Well, I recently lost my job as a construction project manager. I play video games.” The oldtimer mother asks. “Great to meet you, Brad. Do you have a girlfriend? ” He responds, “No, my girlfriend overdosed last year.”
The psychiatrist goes around the room. He calls out one who tested positive for cocaine. “[Johnny], if this happens again I will have to kick you out of the program. This group is based on trust.” (He later tells me some psychiatrists have a zero tolerance policy, but he prefers to tailor it to each circumstance. Johnny had recently been sued for divorce by his wife.)
After the group session, he writes notes until the afternoon appointments, which start at noon. We see depressed and anxious patients and have new consults for addiction and bipolar disorder. I begin the interview of a new consult. The 30-year-old male electrician presents for methamphetamine addiction. He was arrested for possession, but our city has a program that enables those accused of drug crimes to avoid jail if they seek addiction help.
I ask about his employment. The patient makes $4,000 per week constructing power lines, “when I work.” The psychiatrist chimes in. “How many weeks a month do you work?” He responds, “Maybe one. Whenever I need money I find a job.” The attending acknowledges this, “You can be quite functional after a weekend cocaine binge, but coming down from meth, you’ll be out for a week.” He responds, “Yeah, cocaine didn’t do it for me after I found meth.”
“How badly do you want to be clean?” asks my attending. “How much are you willing to give up?” He responds, “I’ll do anything, Doc.” The psychiatrist states “Okay, I will set you up at the rescue mission. Take only a backpack. You will be gone for 6 months.” The patient looks distressed. “I need to think about it.” The psychiatrist acknowledges. “Okay, you let me know when you have decided.”
Once the patient leaves, the psychiatrist turns to me. “The patient is here only because he has to be. He has no interest in quitting.” He continues, “Meth is a destroyer. To get over meth, you have to hit rock bottom. The only times I see a patient conquer a meth addiction are via incarceration or if they drop everything in their life, leave all their friends and family, and move away for several months.” He asks me, “How do meth addicts die?” I cite heart attacks and strokes, recalling my internal medicine rotation where massive heart attacks and intracranial hemorrhages were common among the meth-addicted.
My attending adds, “I see a lot of female meth users. Meth, intensifies sex. It makes women do things they would never imagine. The acts they tell me they did is scandalous. Their boyfriend keeps getting it for them for more intense sex. Eventually, the woman cannot have sex without meth. I see so many pregnant meth addicts.” He concludes, “Once you treat meth addicts, alcohol and opioid addiction seem like nothing.”
Our next patient is a 40-year-old morbidly obese female nurse with major depressive disorder and anxiety well controlled on a serotonin and norepinephrine reuptake inhibitor (SNRI). She reports proudly that she finally got around to divorcing her husband. “He is addicted to pornography. He doesn’t acknowledge me. We haven’t had sex in eight months.” My attending congratulates her.
Another attending stops by the office to chat. He complains that the community service board (CSB, the regional safety net mental health organization) keeps prescribing the newest antipsychotics as a first-line agent. “I don’t understand why they jump to these new medications, which are so expensive.” My attending responds, “Medicaid pays for it. I completely agree, the older ones are cheaper and just as effective.”
[Editor: See the book Bad Pharma by Ben Goldacre, a British physician, regarding the typically marginal improvements (at best) of new expensive meds compared to old generic meds.]
Wednesday’s group session features a new patient, a 24-year-old male with schizophrenia and opioid use disorder. His psychiatrist managing schizophrenia started him on risperidone. “Google says I am going to grow tits. I’m not going to take it.” Another member exclaims, “Oh my God, don’t take that.” My attending responds, “[Jimmy], this is not the time to discuss this. Remember why you take this medication. I want you to talk with me afterwards and call your psychiatrist.” He agrees. After the session, a 35-year-old female asks if she can get an additional film of buprenorphine. She explained, “One of my friends overdosed on heroin. I ground up suboxone and injected it. I saved her! But now I don’t have enough to get through this week.”
We take the psychiatry exam. Example question: Which of the following patients should be admitted to an inpatient psychiatric bed? Answer: a patient expressing suicidal ideation with a clear plan rather than vague expressions of hopelessness and no plan. We then have a debrief session with the clerkship director who asks, “What surprised you on this rotation?” Sarcastic Sally, “The inpatient pediatric psychiatry wards were eye opening. There are so many troubled kids. Without protective factors, such as having a safe home without addicted parents, we could’ve been them.”
Statistics for the week… Study: 2 hours. Sleep: 8 hours/night; Fun: 3 nights (gatherings at various bars with various classmates and their dogs).
The rest of the book: http://fifthchance.com/MedicalSchool2020