Chapter 9 - Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold

Cracked: Putting Broken Lives Together Again - Drew Pinsky, Todd Gold (2004)

Chapter 9

AFTER TWO DAYS off from the unit, I come back and find out there’s good news about Amber. Now in her tenth day of treatment, she has participated in several groups and socialized with her peers out on the patio. She’s not exactly born again, but that’s not the way it works. Recovery is slow, incremental, and often imperceptible, like watching the grass grow. But at least the news is positive. That’s a pretty good way to start the day. But then Alexi seems unsure about letting me feel too upbeat.

“She still has her not-so-good moments,” she cautions.

“Don’t look so happy,” I say.

“If we could just get rid of her pain-in-the-ass husband, she might make a little more progress. She doesn’t react well after his visits.”

“When was he here?”

“Last night.”

“Do you think he’s bringing in drugs?”

“No, but we do need to keep an eye on him.”

After lunch, I spot Amber on the patio, soaking up some sun. She’s wearing silk pajamas that reveal too much skin. I ask Alexi to go out and get her to put on some decent clothes. No wonder she’s so popular with the male patients. Later, Alexi trails behind me as we enter Amber’s room. The floor is strewn with clothes. Amber has put on a baggy sweatshirt over her pajamas.

“How are you feeling?” I ask.

“How do you think I feel?” she says. “I want to get high. I just keep thinking about running out of here. But don’t freak. I’m not going to.”

“Listen, you’ve come this far. We can get you through this. It’s going to get better over the next couple of days. Going to group—”

I’m about to advise her to use group as a motivator, as a way to help get her mind off how bad she feels, when she interrupts me. “I’m going to group, but today PAT”—one of our counselors—“kicked me out.”

I glance at Alexi. “She was too disruptive,” she explains.

“Has anyone talked to you about doing a first step?” I ask.

“You’ve got to give me something for this diarrhea I have,” she says. “I shit on myself this morning.”

“Alexi, add Imodium. Two with each loose stool. Up to eight per day.”

There’s only so much I can do for the diarrhea from oral opiate withdrawal. And treating it often perpetuates the problem.

“Did Pat give her the first-step material?” I ask Alexi. She just stares at me.

I move closer to Amber and examine her heart and lungs. Her breathing sounds coarse.

“Are you smoking?” I ask.

“Everyone smokes in this place,” she says. “I hadn’t smoked in years.” She turns away from me and looks at Alexi. “I need some more of that phenobarb. I have two blown discs in my back, and I need something for the pain.”

I don’t know anyone who doesn’t have back pain. It’s our heritage from having come off all fours. But Amber’s pain isn’t from blown discs. I guarantee it. She is suffering from opiate withdrawal. She needs that repeated over and over, which is okay with me. I have those lines memorized.

“You have at least four reasons for back pain,” I say. “First, you probably have some disc problem that causes pain. But that discomfort would be tolerable if your brain’s endogenous morphine system weren’t so severely altered by all the pain meds you’ve been taking for years. Second, withdrawal from these causes crushing back pain.

“Third, you were severely abused. Abuse victims often complain of pelvic and back pain. It’s like your body is trying to tell us your story when you have no other way to express your pain.

“And finally, of course, there is your disease. People with addicted brains learn that if they have pain they get the reward their brain so desperately seeks. You are powerless over this mechanism. This is the first principle we want you to get your head around. Maybe we could get you the first-step material so you can begin to look at how this has made your life so chaotic and unmanageable.”

Without missing a beat, Amber says, “Okay, but what can I have for the back pain?” She looks to Alexi for an answer.

“You’re not going to cut back that phenobarb, are you?” she continues. “I heard someone on the patio say that you brought me down too fast.”

“Not true,” I say. “Let us worry about your treatment.” I turn to Alexi and give instructions that should help with the withdrawal pain. “Let’s D.C. the Motrin and begin Toradol thirty milligrams IM every eight.”

I am done. I signal Alexi, who can’t wait to get out of the room. We confer in the hall.

“Why are you wasting your time with trying to get her to do the first step?” Alexi asks. “You know she won’t remember any of this.”

She is right. Amber is too caught up in her own world to deal with the information I gave her. She wants one thing. Her addicted brain can’t get beyond the craving for drugs. She is gripped in that vise, and there’s no room in her head for anything else. Many experience amnesia early in treatment from the biological effects of withdrawal and the meds we give them to treat it. I don’t know why I kept talking to her as if she understood.

Actually, I do. I couldn’t help myself.

The rest of the day is uneventful, until Alexi asks me to help with a new patient in Room 257.

Linsey is on the bed, staring out the window. At first glance, she doesn’t appear to be trouble. She is twenty-eight, skinny, with a round face and short brown hair. Her left nostril is decorated with a thin gold ring. She had OD’d the day before, and spent the night in a South Bay hospital. Her mother brought her to Las Encinas this afternoon. As soon as I enter, Linsey makes eye contact and starts in on her symptoms.

“It hurts right here,” she says, rubbing the middle of her chest.

I take out my stethoscope and listen to her chest.

“It’s likely you had an overzealous paramedic, who got carried away with his CPR,” I say, continuing the exam.

Extremely agitated, Linsey rubs her arms and thighs and scratches at her calves as if she is trying to peel off several layers of skin. She might if she doesn’t stop. But she can’t. Several times I have to ask her to be still so I can continue the exam. She apologizes and sits on her hands, which stops the scratching for a few seconds, but then the poor girl starts up again, completely unaware that she can’t control herself. I don’t find any track marks on Linsey. Her nasal septum is intact. Her lungs are clear. She doesn’t have any murmurs. Neither does she have any scars from cutting or picking. Her hair isn’t banded. In fact, she appears to be in remarkably good shape.

While examining her head and neck I notice something I often find with my patients, fullness at the angle of her jaw just in front of her ear.

“Have you ever noticed this?” I ask.

Linsey rubs her finger over the spot. She feels the fullness.

“No, never,” she says, shaking her head. “What is it? Is it cancer?”

“No, it’s not cancer,” I say.

Her parotid or salivary gland is swollen. I don’t know whether it’s from chronic marijuana use, alcohol, or the effects of an eating disorder, but I find this in so many patients that it often provides a more accurate history than what the patient tells me. I take another look at her chart and reread the toxicology report. It turned up benzodiazepines, opiates, alcohol, and three different antidepressants. Nice job.

Time for a little conversation. Linsey, I learn, is an accomplished graphic artist from the 90210 zip code. She describes her upbringing as the dark side of the golden ghetto. She was twelve when her alcoholic father and “schizy” mother got divorced. That same year she began smoking pot. By fourteen, she was bulimic. In response, she was sent to boarding school in Colorado. She felt profoundly abandoned. The summer before her senior year she decided to get even with her parents by doing any drug she could get—coke, heroin, speed. Several times she prostituted herself out to friends for drugs.

When her parents found out about their daughter’s massive drug problem, they put her in treatment. She bounced from one facility to another as if she were touring colleges. According to Linsey, she’s spent time in Minnesota, Arizona, and several L.A. rehabs. But six months is the longest she’s ever stayed clean on her own, though before this most recent binge she put together nine sober months by attaching herself to another addict. They mistakenly believed that they helped each other stay clean, but when that relationship ended so did her sobriety.

“What were you taking yesterday when you OD’d?” I ask.

“I don’t remember,” she says. “All I know is that I woke up in the hospital yesterday.”

“Is that why you’re here?”

“No,” she says. “I’m here because I’m fucked up.”

I don’t write that down. She can see by my lack of reaction that she hadn’t given me enough. This is not an assembly line. Treatment isn’t like a bad public school, where students are passed to the next grade just for showing up.

If Linsey is going to get better, she has to start with something real. I don’t want to hear the standard lines: “I got tired of living like this.” “My life is screwed up.” Something profound must have happened to get her into treatment. I want to her to tell me about that. That’s the best starting place.

I warn her that she’s going to go through withdrawal. I tell her some of the things she should expect and assure her that we’ll do everything within our power to keep her comfortable.

“You’re going to feel pretty lousy,” I say. “But tell Alexi all of your symptoms.”

“Okay,” she says.

Once Alexi and I are alone, she raises a red flag. She thinks Linsey is withholding details about recent use. She predicts trouble. I blow some hot air into my fist and prescribe a protocol of medication that should help get Linsey through the discomfort she’s going to experience over the following week.

After twenty years of treating addicts, I’ve learned not to expect anything. Every time I have felt as if I have someone figured out, they surprise me. It never fails, for better or for worse. I have become so used to being lied to by my patients. We have a saying: “If their lips are moving, they’re lying.” We just lost a young nurse who seemed to be doing well in treatment—or so I thought. It turned out she was continuing to chip heroin. Her peers found her dead at home when she didn’t show up for her meetings. This disease can be cunning as well as baffling.

At the end of the day, Amber is visited by her husband again. I’m not aware of it until I hear him badgering the nurses outside his wife’s room for medication. He insists that Amber is supposed to be getting more phenobarbital for back pain, and invokes my name when the staff doesn’t comply. That doesn’t work, either, which instigates a belligerent tirade that rattles the hallways and escalates a handful of patients, including his wife.

The nurse who finds me describes the man causing the disturbance as a “pain in the ass,” and right away I know who it is. I hurry to the med window. Amber’s husband is still carrying on. He stops yelling upon seeing me. Rather than feel embarrassed, he thinks I’m going to help him. I see the way he suddenly changes. I can tell what he’s thinking: Finally, the guy in charge. He sidles up to me and puts an arm on my shoulder. I step aside, putting a little distance between us.

This guy may think he’s trying to help his wife, but he’s more the problem than the solution. Not that he could see that for himself, of course. “Drew, I’m glad you’re here,” he says. “My wife is in pain. Amber is suffering real bad.”

“We’re doing everything we can for her,” I say. “You have to trust us. We know what to do.”

“But I just saw her and she’s not doing well,” he says. “I mean, we could do this at home. She could be in bed there.”

“I think this is the best place for her,” I say, leading him away from the nursing station and down the hall. I glance over my shoulder toward the nursing station and see Alexi and some of the others applauding in silence and giving me a thumbs-up sign. The nurses don’t deserve such treatment from anyone. Nor do they have time.

We stop outside Amber’s room. I look in and see that she is calm. She can afford to be calm. She has her husband acting out for her. She thinks he’s going to score.

“What’s going on?” I ask.

“Look, Amber is driving me crazy,” he says. “I know she’s a pain in the ass, but it kills me to see her like this.”

I reassure him that she’s okay. She’s doing fine. Her pain is completely normal. So is her desperation for relief.

“Can’t you just give her some more of that barbital and maybe just make her sleep?”

“She’s having a very intense withdrawal,” I say. “We’re giving her everything that we can safely.”

He takes a moment to digest this information. Then he shakes his head. All of a sudden he acts very chummy. “I’ve never had to deal with anything like this before,” he says.

“I know it’s tough to understand, but what you need to do is let us take care of her. These nurses know what they’re doing. They’ve done thousands of detoxes. What you need to do is go to family groups and look into Al-Anon.

“If she’s going to have a successful recovery, you’re going to have to change as well. I know you’re eager to get her back the way she was before the drug use really took off, but that is simply not possible. She has some real serious problems here, and she’s going to have work very hard at growing and changing.”

Hoping to get through to Jack enough that he’ll get off her back and maybe even start taking a look at his own problems, I take a stab at educating him. “I think a simple way to think of relationships is like a lock and key. Emotionally, when two people come together they fit together in much the way the jagged edge of a key fits with the tumblers of a lock. But any traumatic emotional change can change the way those tumblers are shaped.

“That’s what happens when a drug addict starts coming to terms with her problems—and it can be very scary to be involved with someone who’s going through those emotional changes. It can be very uncomfortable when you no longer fit the way you always did. It can feel like you’re losing your partner. Most people instinctively try to force the relationship back to the old familiar territory, but that’s usually very bad for someone struggling with recovery. Think of the lock and key again: If the lock changes, the key will have to be changed as well if it’s going to continue to fit. Forcing a key into a lock, after all, usually breaks the lock.

“She has no choice, Jack. Her survival depends upon making change. It’s your job to keep up with her. And having the important people in an addict’s life participate in codependency recovery programs like Al-Anon has a profoundly positive impact on how a patient will do in treatment.”

I’m not sure he’s really registered what I’m saying, though. “My brothers and I, we all grew up on a farm in Washington State. We went to college, but my dad and my grandfather were farmers. They taught us that if we had a problem, we had to grit it out. Just suck it up. You’re like us, educated. So you know, if you apply your mind to something, you can get through it. Amber doesn’t know anything about that.”

I take a deep breath, and try to answer this. “But I have to tell you, there are certain problems in humans that can’t be solved by sheer grit alone. Addiction is one of them. It involves changing some of the noncognitive parts of the brain. And that takes time. It also takes you making some changes along with her.”

Jack puts his hand on my shoulder.

“Just see if you can give her something more. There must be a way you can make her comfortable.”