“Doc…Don’t you know I’m way smarter than you”
I want to share an encounter I recently had with a patient, a guy who has been struggling with heroin addiction for well over 20 years. He’s had years of success with abstinence, buprenorphine and methadone. Each approach had its place and relevance to the time and recovery experience he was in. After 4 years of complete abstinence, he impulsively relapsed on IV heroin in the context of a bout of depression and relationship problems.
Over a year later he was hanging on by a thread. Three months prior to seeing him again, he had ODd on fentanyl laced heroin and was lucky enough to have a partner immediately administer 4 rounds of Narcan until EMS arrived. He had three failures on high dose buprenorphine therapy with me and two other providers – just stopped coming and kept using heroin.
When he came back, he looked like shit…muscling into his ass, wasted, 50 pound weight loss, a ghost (thanks Gabor Mate). His eyes showed total desperation and such deep longing for an exit, a way out of the deep hole, the hypodermic ritual trap he was in.
He contemplated going back on methadone, but he had an important job that required frequent travel and there was no way he could adhere to the rigid daily dosing requirements starting out in a methadone program. We revisited buprenorphine: “Subs are out doc…I just can’t take them and stop using heroin…the best it’s doing for me is helping me get to the next bag and I can’t keep living like this…I am literally dying.”
He decided to go with blocking treatment but had to check in to our detox program to make sure he was totally opioid free for a week to be sure he could tolerate the first dose. This was a huge step for him. The day he came in he texted,”Thanks, I’m terrified.” I replied…”Understood. It’s terrifying. Worth doing anyway.”
I visited him on the detox unit 6 days later. He was weak, drained but said “I’m good…I’m on the other side of this…I’m fucking done doc.” We talked about the last year of hell he’s gone through, the times he told me and other providers “I’ve got this.” His sense of humor was back. We joked at how insane it is to be in the grip of an addiction.
He told me, “you knew we’d be sitting here someday didn’t you?” I answered, “I was hopeful, but not before you were ready.” He looked at me with a playful glimmer in his eye and told me, “Doc…you know I’m way smarter than you. When I’m using I’m fucking Albert Einstein.” I said, “yeah…I’ve resigned myself that all the ‘sciency’ stuff hardly ever trumps ‘cunning and baffling’ side of the disease. When I try to be a ‘smart doctor’ with someone who isn’t receptive, I come off as an arrogant asshole so I have to wait for the right time. Most of us can only be convinced through lived experience. Then you connect to a new truth. You’re right, I’m not smart. I’m just a consistent idiot who tries to follow the evidence! Fortunately for me and for you, you stayed alive long enough to try something different. No guarantees, but we never give up…as long as you’re here we’re here.”