Recovery spaces and the adjacent possible


DJ Mac recently picked up on Bill White’s post on the need to create and protect recovery spaces, given current trends toward legalization.

He followed up by sharing another blogger’s reaction to Bill’s post.

White asserts that “any policy discussions of marijuana legalization should include the voices of people in recovery and should include a serious discussion about recovery space. Such space must be protected regardless of the future legal status of psychoactive drugs.” I have a great deal of respect for Bill White; but I disagree strongly with this line of reasoning. I submit that in an atmosphere of true destigmatization of addiction and recovery, the identification or designation of “recovery space” becomes unnecessary and, in fact, perpetuates the stigma that we are working so hard to shed.

. . .

The world will never be recovery-friendly; but to ask our communities and legislators to be sensitive to recovery space perpetuates the misconception that people in recovery are passive victims, hopelessly susceptible to environmental cues and in need of sheltering. In this context, people in recovery will never achieve full empowerment.

All of this seems like a bit of a straw man. I re-read Bill’s piece and I’m not picking up on any anti-drug or pro-prohibition message.

Look at alcohol.

  • We regulate advertising.
  • We control outlet density through limiting the number of liquor licenses.
  • We say it can’t be consumed in certain places–schools (except Ann Arbor Pioneer on U-M game days) and many parks, for example.
  • We have open container laws.
  • We impose some responsibilities on servers.
  • We have age limits on purchasing.
  • We have age restrictions on many events where it’s served. (All-ages shows can’t serve alcohol.)

We impose all of these regulations/restrictions (and more), and alcohol is still a celebrated and freely consumed drug.

I hear Bill saying that recovery is worth protecting in the same way that schools, churches, hospitals, community centers, etc, are worth protecting.

One can disagree with Bill on this, but I think we all could agree that some people live in recovery-hostile areas where there are no visible examples of recovery and that this inhibits people finding recovery. Isn’t in our community interest to address that? Isn’t in our public health interest to do something about that?

It’s not about creating a bubble.

How is hope to be kindled if there’s no visible living proof of recovery? This reminded me of another post from a couple of years back on “the adjacent possible”.

I discussed a guy who wrote a book and gave a TED talk on the topic.

During an interview he discussed the concept of the adjacent possible and it’s importance in forming new ideas. During the interview, he described it as the building blocks of new ideas. Without the right building blocks, any innovation is not possible. He described it another way in a WSJ article:

The adjacent possible is a kind of shadow future, hovering on the edges of the present state of things, a map of all the ways in which the present can reinvent itself.

The strange and beautiful truth about the adjacent possible is that its boundaries grow as you explore them. Each new combination opens up the possibility of other new combinations. Think of it as a house that magically expands with each door you open. You begin in a room with four doors, each leading to a new room that you haven’t visited yet. Once you open one of those doors and stroll into that room, three new doors appear, each leading to a brand-new room that you couldn’t have reached from your original starting point. Keep opening new doors and eventually you’ll have built a palace.

During the interview, he pointed out that it doesn’t matter how smart one is, it was not possible to invent a microwave in 1650, because the building blocks, the adjacent possible, just wasn’t there.

One factor is that the physical building blocks did not exist. The other factor is that the imaginative/inspiration building blocks did not exist.

This reminded me of a metaphor Bill has used when talking about hope-engendering relationships offering kindling for hope.

So, back to our critic. I admire his bootstrapping spirit, but, like I said earlier, he seemed to be arguing with a straw man and he seemed self-contradictory at times. In one paragraph, regulation is good,

. . . the legalization of marijuana is not about making it more accessible. Marijuana has always been more accessible to those under the legal drinking age than alcohol; which suggests that regulation will actually reduce its availability.

In another, regulation is bad,

Recovery space will not be achieved through restriction or regulation of those who can enjoy the recreational use of substances, legal or otherwise.

It seems that what he really wanted was a debate about legalization, which is a fine thing to debate. He just picked a piece that, rather than arguing against legalization, was suggesting that we be mindful enough to mitigate a potential pitfall of legalization.

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Suicide and aloneness

alone by Lst1984

alone by Lst1984

I’m not the type to get into speculation about the circumstances around Robin Williams’ suicide–his recovery, his mental health diagnosis, the care he received, etc. However, I read a few pieces that picked up on a theme of aloneness in suicide.

From the New Yorker [emphasis mine]:

Robin Williams’s suicide was not the self-indulgent act of someone without enough fortitude to fight back against his own demons; it was, rather, an act of despair committed by someone who KNEW, rightly or wrongly, that such a fight could never be won.

. . .

Suicide is a crime of loneliness, and adulated people can be frighteningly alone.

From addictiondoctor.org:

By now you’ve figured out what the three groups have in common; they are alone. It may not look that way to you, but that’s how it feels to them. It’s not the fault of their family or friends. It’s nothing that anyone is doing wrong.

From Jennifer Matesa, mulling over the coroner’s report:

And here’s the thing. He wasn’t found by his wife. He was found by his personal assistant. The employee knocked on the door at 11:45 a.m., more than 12 hours after Williams’s wife had last seen her husband, and couldn’t raise his boss. So the assistant went into the room, the assistant found the body.

I’m thinking about this report in this way because I think a lot these days about the commonalities of people who are suffering for various reasons. If Williams died in this supremely lonely way, then you can bet there are hundreds, thousands of others who have died this way

All of this brings to mind David Foster Wallace’s 2005 commencement speech from Kenyon College [emphasis mine]:

And I submit that this is what the real, no bullshit value of your liberal arts education is supposed to be about: how to keep from going through your comfortable, prosperous, respectable adult life dead, unconscious, a slave to your head and to your natural default setting of being uniquely, completely, imperially alone day in and day out.

. . .

And the so-called real world will not discourage you from operating on your default settings, because the so-called real world of men and money and power hums merrily along in a pool of fear and anger and frustration and craving and worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom all to be lords of our tiny skull-sized kingdoms, alone at the center of all creation.

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What Happens When People Discontinue Taking Alcoholism Medications?

Here’s an interesting abstract from looking at relapse patterns for alcoholics taking medication for their alcoholism–they increased their drinking before discontinuing their medication.

Aims

We use intensive longitudinal data methods to illuminate processes affecting patients’ drinking in relation to the discontinuation of medications within an alcohol treatment study. Although previous work has focused on broad measures of medication adherence, we focus on dynamic changes in drinking both before and after patients discontinue.

Design

We conducted secondary data analyses using the COMBINE study, focused on participants who discontinued medications prior to the planned end of treatment. Using an interrupted time series analysis, we analyzed drinking in the weeks before and after discontinuation and also studied outcomes at the end of the COMBINE follow-up.

Setting

Unites States of America.

Participants

We describe the sub-sample of COMBINE participants who discontinued medications (n=450), and compare them with those who were medication adherent (n=559) and with those who discontinued but had substantial missing data (n=217).

Measurements

The primary outcomes were percent days abstinent (PDA) and percent heavy drinking days (PHDD). Medication adherence data were used to approximate the date of discontinuation.

Findings

For many patients, an increase in drinking began weeks before discontinuation (PDA: F(1,4803) = 19.07, p < .001; PHDD: F(1,4804) = 8.58, p = .003) then escalated at discontinuation (PDA: F(1,446) = 5.05, p = .025; PHDD: F(1,446) = 4.52, p = .034). Among other effects, the amount of change was moderated by the reason for discontinuation (e.g., adverse event; PDA: F(2,4803) = 3.85, p = .021; PHDD: F(2,4804) = 5.36, p = .005) and also whether it occurred in the first or second half of treatment (PDA: F(1,4803) = 5.23, p = .022; PHDD: F(1,4804) = 8.79, p = .003).

Conclusions

A patient’s decision to stop taking medications during alcohol treatment appears to take place during a weeks-long process of disengagement from treatment. Patients who discontinue medications early in treatment or without medical consultation appear to drink more frequently and more heavily.

The medications involved were naltrexone and acomprosate.

In the discussion, the writers say the following:

Not surprisingly, the patients who stopped medications on their own initiative did badly, especially those who stopped early in treatment. Such patients may be poorly motivated, demoralized, or unprepared for the demands of a rigorous treatment protocol. Perhaps no professional intervention could reach all of these patients, but at least some doors should be left open to encourage their return to of treatment. Clinical policies favorable to patient admission of relapse and/or continued alcohol use could serve to improve dialogue between provider and patient, and perhaps prevent discontinuation.

The “demands of a rigorous protocol”? As far as I can tell, subjects participated in up to 20 outpatient sessions over 16 weeks. Talk about low expectations.

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we should never allow the sterile language of science to obscure [blank]

evidenceThe NY Times published an op-ed on a controversy over evidence-based sentencing.

Advocates of punishment profiling argue that it gives sentencing a scientific foundation, allowing better tailoring to crime-prevention goals. Many hope it can reduce incarceration by helping judges identify offenders who can safely be diverted from prison.

While well intentioned, this approach is misguided. . . .

It is naïve to assume judges will use the scores only to reduce sentences. Judges, especially elected ones, will face pressure to harshly sentence those labeled “high risk.” And even if risk scores were used only for diversion from prison, it would still be wrong to base them on wealth and demographics, reserving diversion for the relatively privileged.

. . .

Of course, judges have always considered future crime risk informally, and it’s worth considering whether actuarial methods can help make those predictions more accurate. The problem isn’t risk assessment per se; it’s basing scores on demographics and socioeconomics. Instead, scores could be based on past and present conduct, and perhaps other factors within the defendant’s control.

. . .

Criminal justice policy should be informed by data, but we should never allow the sterile language of science to obscure questions of justice. I doubt many policy makers would publicly defend the claim that people should be imprisoned longer because they are poor, for instance. Such judgments are less transparent when they are embedded in a risk score. But they are no more defensible.

imagesI hear an interesting echo from recent arguments about the evidence for the treatment models developed for addicted health professionals, pilots and lawyers. Professionals treated with this model have outstanding outcomes. You’d think this would be welcomed, especially by treatment critics who question the evidence-base for much of the treatment that is being provided. But, the model is controversial. (See here, here and here.)

Why? Because the evidence is derived from programs that treat relatively affluent and culturally empowered patients. The critics believe that it couldn’t possibly work as well for poor addicts. They argue:

See this comment from the UK Advisory Council on the Misuse of Drugs second report of the recovery committee [emphasis mine]:

…our optimism about recovery should be tempered. Evidence suggests that different groups are more or less likely to achieve recovery outcomes. For some people, with high levels of recovery capital (e.g. good education, secure positive relationships, a job), recovery may be easier. For others, with little recovery capital or dependent on some types of drugs (especially heroin), recovery can be much more difficult and many will not be able to achieve substantial recovery outcomes.

So, do these critics want to build upon these programs and explore modifications that might meet the needs of poor and disadvantaged patients? No.

This question brings John Rawls and his “original position” to mind.

In the original position, the parties select principles that will determine the basic structure of the society they will live in. This choice is made from behind a veil of ignorance, which would deprive participants of information about their particular characteristics: his or her ethnicity, social status, gender and, crucially, Conception of the Good (an individual’s idea of how to lead a good life). This forces participants to select principles impartially and rationally.

We have a situation where the health professionals provide one kind of treatment to their peers and another kind of treatment to other patients. If they had to assume the original position and operate from behind the veil of ignorance–if they were to be reborn an addict of unknown class, race, gender, economic status, etc–what would they want the de facto treatment to be?

They just say they are just following the evidence. What else are they following?

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How much cultural space will we give to marijuana?

P0IRA.AuSt.39Bill White puts his finger on an important question in the midst of our marijuana policy changes.

The issue of concern is not simply the legal availability of drugs, but the larger visibility and status of these drugs within American communal life.  A problem with the legalization of any drug in a free-market economy is that those who profit from the growth, manufacture, sale, and use of the drug invest enormous resources in expanding the pool of people who use their product, expanding when and where the drug may be purchased and used, influencing norms on socially approved frequency and quantity of use, creating more biologically rewarding forms of the drug, and introducing novel and more efficient methods of drug administration.  The history of American alcohol and tobacco products and their advertising and related promotional strategies offer vivid examples of these processes.  Similarly, effective public health strategies aimed at the containment of drug problems seek to affect these same dimensions in opposite directions, e.g., reducing global consumption, reducing drug access to vulnerable populations, limiting dose exposure per use event and cumulative lifetime exposure, limiting the public space where use can occur, and restraining promotional forces.

MJBizConfExpoLogoThis gets at one of the sticking points in my mind, I’ve never supported people going to jail for possession of any drug in quantities consistent with personal use, but I’m also concerned about a culture that celebrates marijuana the way we celebrate alcohol. Think about it, almost every event I go to, there’s an expectation that alcohol will be served–weddings and parties of all kinds. It doesn’t matter whether it’s a baptism party, a birthday party for a 1 year old, a graduation party for a 17 year old (who we don’t want to drink), a baby shower, sports events, youth league banquets, etc.

Where alcohol is concerned, we also know that things like alcohol outlet density and exposure to advertising influence consumption.

box-closed-pen-02_grandeDo we want to yield that amount of cultural space to marijuana? If not, how do we manage that?

Along these lines, two writers have been rolling around in my mind.

First, Bill’s own social designations of drugs–celebrated, tolerated, instrumental and prohibited. To me, marijuana seems to have been straddling prohibited and tolerated, and seems to be moving in the direction of celebrated. (Though, somehow, managing to live in all 4 designations.) The question on my mind is, how, culturally, do we keep it in the category of tolerated?

The second writer is Andrew Sullivan and his advancing the idea of a “cannabis closet“. His status as a gay man and gay rights advocate who has written about the corrosive effects of the closet on gay people, gives the idea a little extra power. This seems to me like and idea that is too easy to dismiss and too easy to overstate. I’d want to prevent marijuana from holding celebrated status without stigmatizing users. One big battlefront in this will be workplace drug testing policies.

If it seems like this post has no point, it’s probably because I have more questions than answers at this point.

I’d love to see a bloggingheads episode with Bill White and Mark Kleiman on this topic.

 

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The Emperor of All Maladies

Throwback Sunday – I thought this old post on parallels between cancer, oncology, addiction, addiction treatment and recovery would be a good pairing with yesterday’s post on professional attitudes toward difficult to treat illnesses.

==================

I’ve been reading The Emperor of All Maladies and I’ve been very struck by the parallels between the is philosophical and practical challenges faced by cancer and addiction researchers, advocates and practitioners.

One of the pioneers of cancer research, treatment and advocacy faced difficult decisions about whether to disclose his own illness:

Proud, guarded, and secretive—reluctant to conflate his battle against cancer with the battle—Farber also pointedly refused to discuss his personal case publicly.

The rhythms of hope and despair

the clinic seemed perpetually suspended between two poles—both “wonderful and tragic . . . unspeakably depressing and indescribably hopeful.” On entering the cancer ward, Goldstein would write later, “I sense an undercurrent of excitement, a feeling (persistent despite repeated frustrations) of being on the verge of discovery, which makes me almost hopeful.

“The mood among pediatric oncologists changed virtually overnight from one of ‘compassionate fatalism’ to one of ‘aggressive optimism.’”

“ALL in children cannot be considered an incurable disease,” Pinkel wrote in a review article. “Palliation is no longer an acceptable approach to its initial treatment.”

The zeal and necessity of the advocates:

She had found her mission. “I am opposed to heart attacks and cancer,” she would later tell a reporter, “the way one is opposed to sin.” Mary Lasker chose to eradicate diseases as some might eradicate sin—through evangelism. If people did not believe in the importance of a national strategy against diseases, she would convert them, using every means at her disposal.

The tension between the patient’s welfare and the professional and intellectual needs of the doctors and researchers:

“There is an old Arabian proverb,” a group of surgeons wrote at the end of a particularly chilling discussion of stomach cancer in 1933, “that he is no physician who has not slain many patients, and the surgeon who operates for carcinoma of the stomach must remember that often.” To arrive at that sort of logic—the Hippocratic oath turned upside down—demands either a terminal desperation or a terminal optimism. In the 1930s, the pendulum of cancer surgery swung desperately between those two points.

Political feminism, in short, was birthing medical feminism—and the fact that one of the most common and most disfiguring operations performed on women’s bodies had never been formally tested in a trial stood out as even more starkly disturbing to a new generation of women. … It was as if the young woman in Halsted’s famous etching—the patient that he had been so “loathe to disfigure”—had woken up from her gurney and begun to ask why, despite his “loathing,” the cancer surgeon was so keen to disfigure her.

“We shall so poison the atmosphere of the first act,” the biologist James Watson warned about the future of cancer in 1977, “that no one of decency shall want to see the play through to the end.”

The demands of caring for patients with such an all-consuming illness:

As Carla’s doctor, I needed to be needed as well, to be acknowledged, even as a peripheral participant in her battle. But Carla had barely any emotional energy for her own recuperation—and certainly none to spare for the needs of others. For her, the struggle with leukemia had become so deeply personalized, so interiorized, that the rest of us were ghostly onlookers in the periphery: we were the zombies walking outside her head.

“To some extent,” he wrote about his patients, “no doubt, they transfer the burden [of their disease] to me.”

The tension between physicians offering palliative care and patients wanting more:

The daughter looked at me as if I were mad. “I came here to get treatment, not consolations about hospice,” she finally said, glowering with fury.

The fear and existential implications of cancer:

Will you turn me out if I can’t get better? —A cancer patient to her physician, 1960s

“I don’t know why I deserved the illness in the first place, but then I don’t know why I deserved to be cured. Leukemia is like that. It mystifies you. It changes your life.”

The pull of palliative care:

As trial after trial of chemotherapy and surgery failed to chisel down the mortality rate for advanced cancers, a generation of surgeons and chemotherapists, unable to cure patients, began to learn (or relearn) the art of caring for patients. It was a fitful and uncomfortable lesson. Palliative care, the branch of medicine that focuses on symptom relief and comfort, had been perceived as the antimatter of cancer therapy, the negative to its positive, an admission of failure to its rhetoric of success.

The movement to restore sanity and sanctity to the end-of-life care of cancer patients emerged, predictably, not from cure-obsessed America but from Europe.

she encountered terminally ill patients denied dignity, pain relief, and often even basic medical care—their lives confined, sometimes literally, to rooms without windows. These “hopeless” cases, Saunders found, had become the pariahs of oncology, unable to find any place in its rhetoric of battle and victory, and thus pushed, like useless, wounded soldiers, out of sight and mind.

Saunders responded to this by inventing, or rather resurrecting, a counterdiscipline—palliative medicine. (She avoided the phrase palliative care because care, she wrote, “is a soft word” that would never win respectability in the medical world.) … she created a hospice in London to care specifically for the terminally ill and dying, evocatively naming it St. Christopher’s—not after the patron saint of death, but after the patron saint of travelers.

“The resistance to providing palliative care to patients,” a ward nurse recalls, “was so deep that doctors would not even look us in the eye when we recommended that they stop their efforts to save lives and start saving dignity instead . . . doctors were allergic to the smell of death. Death meant failure, defeat—their death, the death of medicine, the death of oncology.” Providing end-of-life care required a colossal act of reimagination and reinvention.

Saunders refused to recognize this enterprise as pitted “against” cancer. “The provision of . . . terminal care,” she wrote, “should not be thought of as a separate and essentially negative part of the attack on cancer. This is not merely the phase of defeat, hard to contemplate and unrewarding to carry out. In many ways its principles are fundamentally the same as those which underlie all other stages of care and treatment, although its rewards are different.”

A hint of recovery-oriented palliative care?: [emphasis mine]

Opiates, used liberally and compassionately on cancer patients, did not cause addiction, deterioration, and suicide; instead, they relieved the punishing cycle of anxiety, pain, and despair.

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They don’t expect to see [blank] patients doing well

blank signThis post quotes extensively from a Health Affairs article on how acute care training influences physician views of chronic disease patients.

The author starts out with the stories of two patients and the stories physicians bring to the helping relationship.

Martin is one of the few patients I remember who could make a three-hour treatment session at our hemodialysis unit last all day. With his advanced kidney failure, Martin—and the rest of my patients in the dialysis unit—couldn’t survive without the thrice-weekly sessions of hemodialysis that filter out harmful wastes and extra fluids from the bloodstream. Most people would try to get in and out as quickly as possible, but after years of the treatment, Martin was still coming early and staying late. He would let his fellow patients get started on their dialysis machines first while he went around greeting them. At the end of his own treatment, he’d welcome the next set of patients before heading downstairs to go home to his family. Slim and athletic, he was in generally good health other than his kidney disease.

Another patient, James, also arrived early to his hemodialysis appointment, but that was because he arrived via ambulance, on a stretcher. James had been a talented athlete when he was younger, but heart and kidney problems and advancing age had sapped his strength. The burly young ambulance drivers who lifted him in and out of their vehicle barely had to work at all, as James was skeletally thin, his limbs too frail to support him. The clinic staff greeted him and checked his logs from the nursing home where he’d been living since his last fall. When they asked him to confirm whether his name was James, he would say “yes,” and then fall silent again. He curled onto his side in the dialysis chair, trying to shift his weight off of his sore hip bones, unable to move without help. In that fetal position, James endured the three-hour treatment quietly and, at the end, was rolled away again.

I had admitted James to the hospital many times. Each time, the medical residents took care of him. Later, I would read over their notes and discharge summaries from his hospital stays. At least half of the medical trainees in our hospital had, at one time or another, taken care of James for his pressure ulcers, his failing heart, his pneumonias and infections, or his repeated strokes.

The residents knew James very well. But they had never met Martin. As one of my healthiest patients, Martin had never been admitted to the hospital. To the residents at the hospital, and indeed to most physicians, a dialysis patient looks like James, not Martin. But in my work as a nephrologist, dialysis patients look like Martin, not James. The gulf between the residents’ understanding of chronic disease and mine has, I believe, profound implications for the care of such patients and the policies we craft around them. I saw that clearly when my healthiest dialysis patient suddenly fell very ill.

meet them where they are atThe author goes on to illuminate how acute care practitioners tend to encounter chronically ill patients and how it fosters pessimism, despair and frustration. When she got to work in a chronic care setting, it completely changed her narrative.

As a new nephrologist, I didn’t expect my work at the dialysis unit to be especially interesting or fulfilling. During my own general medical training, I preferred the urgent, fixable problems of the hospital. Kidney failure wasn’t one of those fixable problems, and, as an intern and resident, I admitted many sickly patients like James to the hospital with a growing sense of futility.

Much to my surprise, the dialysis unit soon became my favorite place to work, in part because of people like Martin. I saw men and women who had adapted to chronic illness, whose lives were changed by illness but not subsumed by it. I got to know them better than I had ever had an opportunity to know my patients before. I learned their life stories, celebrated birthdays with them, and watched them do more than just survive.

Before I started working at the dialysis unit, I had never met a dialysis patient who spent most of his life outside the hospital rather than in it. Now I was responsible for many patients who rarely saw the inside of a hospital, and I began to recognize a completely different side of this disease.

beware of pity by shawnzrossi

beware of pity by shawnzrossi

Martin passed away suddenly and the author saw a stark contrast in her reaction (informed by her chronic care experience) and the reactions of her peers who operated from an acute care model.

The medical team did talk about him, afterward. We reviewed the symptoms, the workup, the tests. The heart specialist discussing the case was philosophical, explaining to the residents that there was nothing more we could have done. After all, he explained, dialysis patients don’t have strong hearts. They don’t do well with cardiac issues. They don’t survive as long as people with normal kidney function after a heart attack. They have recurrent heart disease. I myself was all too well aware of the statistics for dialysis patients with heart disease. Everything he said was entirely true.

I saw the students and residents nodding in acceptance and agreement. They had seen this before, over and over again, even in their short exposure to internal medicine. Dialysis patients don’t do well, the group silently concluded. Everyone shuffled away, to continue their day.

I sat in the conference room, feeling utterly alone in my sense of sorrow. Why did it seem I was the only one who found Martin’s death so difficult to accept? Why did the residents accept the facts so easily?

I thought about a few revealing interactions I had with physicians-in-training regarding my dialysis patients over the years. The ophthalmologist who saw one of my favorite older patients, an avid reader and the patriarch of a warm and loving family, when cataracts were impairing his vision, said in an off-hand comment, “What a terrible way to live. Does he really want to go through a surgery?” The emergency department (ED) resident who recognized my phone number when I called the ED asked, in a bored voice, “Which of your hopeless cases is it today?” The medical intern who, after knowing one of my patients for less than twenty-four hours during an acute hospitalization for a treatable pneumonia, suggested that we should consider less aggressive care and perhaps withdrawal of life support—after all, the patient had kidney failure. These physicians had worked at many different hospitals and clinics but had never been to the outpatient dialysis unit. They only knew the apparent futility of caring for the sickest, repeatedly hospitalized dialysis patients they saw during their inpatient medical training. Patients like James. They had little hope or expectation of making these patients better.

It’s not their fault: Medical training is heavily skewed toward acute, inpatient hospital experiences rather than chronic care. When the average resident goes on to become a primary care physician, a cardiologist, a hospital administrator, or a policy maker, their impressions of the dialysis patients I care for persist from their in-hospital training days. They don’t expect to see a dialysis patient doing well.

How does this play out in addiction care?

How often do helpers just expect death? How often do they frame death as an end to suffering?

Does this imply pity and, if so, what does that do to the relationship? To the patient’s hope and motivation?

How often does that lead to premature palliative care for patients who have plenty of life–high quality life–left in them?

To me, a bigger question is, how they would treat a loved one with that chronic condition?

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