Short
Order Medicine: Chapter Ten: Bad Luck and Trouble
Bad luck and Trouble Albert King
Marty Wells was one of the city refugees who, in the seventies, came to our redwood country for a better life. Along with the rest of the baby boomer exodus from high population densities, we arrived here after the naiveté, discovery, and wonder of the sixties gave way to the next phase of life - the productive years. One could move to the country for peace of mind and cleanliness of water and air to struggle to make ends meet. Or, one could become a new age bandit and grow dope (marijuana) in the hills. The early growers made fortunes when market value soared as a consequence of government efforts to wipe out the weed and its farmers. As American individual ingenuity usually is far more inventive and resourceful than that of government, a few growers made enough to buy land, a home, gold, and dangerous drugs. One of the liabilities of the successful grower was access to other more destructive drugs. With time on their hands in the off season, many a grower's pastime was to celebrate their success and 'freedom' with unending lines of cocaine, expensive wine and champagne, and, sometimes, narcotics. At this stage, when resourceful organic living had given way to cerebral debauchery, the grower’s career would inevitably end within three to five years. The next phase of life would be prison, a straight job, substance rehabilitation, or death. Living death was also an option - a fringe existence as an alcoholic on or off disability, with scattered islands of intact functioning. Marty had a college degree in English, one of the humanities that the generation before us had encouraged as an educational pursuit, but with which one could rarely make a living in the economic order of the post-sixties world. The graduate was certainly not assured of employment. A few were motivated and lucky enough to achieve success in academia or the media, but these fortunate individuals were in the minority. Marty looked like the guys with whom I had gone to college. He spoke in full sentences with proper diction, and brushed his teeth daily. He did not look like a drug addict. He did achieve moderate success growing pot, and also lost a considerable chunk of mental health in the off season, in his version of the above stated grower’s liabilities. His pain began soon after his arrival in God's country, in the late 1970’s. Whether his physical pain came from musculoskeletal abnormalities, or the cosmic pain of existence, the pain of disappointment that visions of the garden could not translate into life in the garden, one can not know for sure. But, innocently enough, doctors prescribed narcotic painkillers for his back problems. He would present himself to the family practice in town, pay his bills in cash at the time of visit, and return as scheduled for follow up. He was a good patient. He was appropriate. Over a seven-year period, Marty's back pain became chronic, and his doctors hardly noticed the pattern of increasingly frequent visits, especially in the winter off-season. The pharmacists in this and neighboring towns did not yet compare notes to learn that Marty was filling multiple prescriptions from several doctors, consuming increasingly large quantities of codeine. Ten grains a day (the usual dose is one half to one grain every four to six hours) escalated to thirty grains a day as Marty's pain and chemical dependency syndrome grew increasingly out of control. Marty could no longer satisfy his habit in this area, so he moved to the city for easier access to doctors, pharmacies, and street drugs. Federal agents seized his land where ‘friends’ had been growing weed in his absence. Marty was not seen in our area for several years, until the late eighties, when he resurfaced in my emergency department. His story was impressive. He still looked like my generation of college educated brethren, button up shirt, slacks, cut hair, glasses, clean teeth, but his innards had been gored by the brutality of a substance impaired life and considerable bad luck. Two years before, he spent a year in a residential drug treatment facility, graduating with hope and enthusiasm for the future. Six months later, while working under his car, the jack collapsed and the car crashed down on his vulnerable body, crushing his pelvis, breaking ribs, tearing away any semblance of pain free life forever. He spent months in a hospital and then at a physical rehabilitation center. He also was put on large doses of narcotics, appropriately at first, but with instant re-addiction to the poison of his best dreams. After eight months, Marty was walking with a cane, suffering from hip pain, off prescription drugs. He couldn't make it. Marty presented to me in our emergency department with a cane aided antalgic (limping in pain) gait and his terrible story of bad luck and painful torment. He thought it would be appropriate to have some prescription relief from his pain and I had to decide what my role would be in his life story. Surely, in many cases, some oral schedule 3 narcotic (such as codeine or Vicodin) would be humane and proper. I knew many patients with chronic orthopedic disabilities that were maintained on stable quantities of these drugs. Marty's story was touching but I thought that I had some obligation to his higher self, to the winner who did all that rehabilitation, who committed himself to a substance free life. I did not know how to integrate the reality of his terribly unfortunate accident and its painful curse. I also know that addicts unconsciously but intentionally cause injuries as the junkie brain wants an excuse to get the narcotic, at any cost. My general sense of responsibility and compassion kept me from flatly refusing his request for narcotics. I settled on the following approach. "Marty, I think that you deserve some relief from your suffering. Because of the conflicting issues I see, and you know, I don't think that I can come up with a long-term solution, but I have an approach for now. Because of my role as an emergency physician, I have great hesitancy to begin and perhaps commit you to a long course of narcotics. However, it may not be entirely inappropriate for some physician to do this, if your use can be closely monitored and you agree on a use contract (a written agreement between physician and patient covering type and quantity of narcotic use) with that physician. This is best managed by a family physician with experience in the area of pain management. I have spoken to Dr. Rivera (after breaking to make the call and confirm with this family practitioner) who has agreed to see you in follow up for your hip pain. He will discuss pain control issues with you, and will consider both narcotic and non-narcotic means of control. In the meantime, I would like you to try something. This is not a formally approved medical approach to pain in humans, but has a good track record in veterinary medicine and given the liabilities of other approaches in your situation, I think it's worth a try. I have seen this work when no other resource in western medicine has been effective. The name of the 'medicine' is DMSO, and can be purchased at any of the local feed and animal supply stores. This liquid, dimethyl sulfoxide, is an organic solvent made as a by-product of the paper pulp industry. It has the ability to penetrate through the skin to deep tissues where it seems to have anti-inflammatory and pain relieving properties. It also enters the general circulation and is excreted through the lungs. You will taste this in your breath - a subtle odor resembling garlic and oysters. Most people don't mind the scent though it is a bit strange. You use it by dabbing a small amount of a fifty-percent solution on clean skin over the area where you have pain. You do this two to three times a day. I want you to know that the only reason why this substance has not become a formal resource in medicine is because it is dirt cheap and widely available. Thus it wouldn't pay a drug company to go through the extremely costly process of obtaining FDA approval. So, as you've tried physical therapy, non-narcotic pain control measures, and the stakes are so high, I believe that it makes sense to try this unconventional approach. You have nothing to lose, as DMSO is safe, and much to gain, if it helps. Do you want to give it a try, Marty?" He agreed, much to my amazement, and his agreement reinforced my sense that he was not primarily drug seeking, that his condition and motivation were legitimate, and that I had done the right thing. I requested that he call me in three days to report effectiveness of DMSO. He did call three days later. He stated that the DMSO had worked extremely well. He was freer of pain than he could remember, and he didn't mind the odor. He was grateful and I was delighted. It was as if I had shot an arrow at a distant target I could barely see and it took three days for the arrow to reach its mark but it hit the bullseye. It made my day. He made my day. Marty saw Dr. Sands for follow up as scheduled and they both decided to hold off on prescription drugs while the DMSO was working so well. Marty was living in a trailer on some friends’ property, plugging in to their electricity to run a small electric space heater. The weather turned bone chilling cold so the heater was put on high in this small trailer and left on all night. Evidently, it was too close to clothing or bedding, and the smoke did not awaken Marty from poppy dreams. By the time the fire department arrived, the entire trailer was incinerated, along with Marty. Word filtered down (or up) from the streets that Marty had recently purchased either Percodan or Dilaudid (very powerful, highly addicting narcotics) from a local dealer of prescription contraband. Would we have prevented this tragedy by providing him with the relief he was seeking? Is narcotic addiction ultimately a death wish that can become manifest when least expected? Did he really have relief from the DMSO or did he decide that the street was a better source - less hassle? If I am my brother's keeper, with the power invested in me by society, how else might I have approached this poor unfortunate. I think that the answer lies in the truth that you can do all the right things and the outcome may be bad anyway. We only have control over a part of the picture, probably a smaller part than we would like to think, and certainly a much smaller part than the lay public would like to believe. Personally, I wish that the medical profession did not have to labor under the harsh narcotic laws that exist these days. As seems typical of the legal system that controls professional conduct, severe laws are enacted because of problems of a minority of patients. The majority is penalized as they are being ‘protected’ from the fate of the minority. Most people who take narcotics for medical reasons do not become addicts and are not harmed by the medicines. Because of the high profile of the minority problem cases, medical legislators find yet another soapbox on which to pontificate and control all of us. I am certain far more people suffer because of the constraints generated by the laws than if we professionals were left to our judgment and common sense. I wish Marty was still around, taking pills if he needed, but here in some form rather than forced in to a premature retirement from life. The drug issue was not worth his life. And sooner or later, any of us could be him.
I got a mind to give up living Traditional/Paul Butterfield Blues Band All Rights Reserved © 2004 Jon Sterngold |