Tough lessons on the Job: Addictions

This is a case of a young man who had developed intense paranoia after using methamphetamine extensively.  While in my care, he was stabilized on medication, and he stopped using drugs.  I wish I could say it was because of addictions treatment that he stopped using drugs but it was more because he lost access.  He did not ever leave his house.  Though his paranoia was gone,  he never returned to work, and pursued no hobbies.  He was like this for over a year: Not using drugs, but very much a lump on a log.  Like many patients with addictions, he also had ADHD that made his life more difficult.  One day he told me he had started a math course at the adult high school.  He then asked about restarting a stimulant to help him with school…and things got complicated.

I asked him to seek out addictions support prior to starting a stimulant, and he said he would look into it, but advocated for himself that he could safely start the stimulant first.  I had seen first hand the impact of his severe apathy and poor focus on his life.  I therefore decided to give him the benefit of the doubt and started him on the lowest dose.  It is important to mention that stimulants are a controlled substance because they can be abused recreationally and have street value.

We were 2 months in when the pharmacy called me about an inconsistency in the prescriptions.  In our next meeting, he confessed  that he had found more stimulants through another doctor.  He was very forthcoming  and remorseful, saying he would not do this again.  The stimulant was helping him and his grades were in the 80s, the first success he had had in a long time.  Because of his honesty, I continued the stimulant, but with stricter rules.  I called his pharmacy to ask them not to fill any other prescriptions for stimulants from other physicians.  I told him that if any further irregularities came to light, I would no longer be able to prescribe this medication and he would be discharged from my care.  He never sought out treatment for his addictions and so I reminded him to do this.

Unfortunately, the pharmacy called again asking if I would release the prescription for the stimulant early.  "The patient tells me he misplaced his previous bottle of medications," the pharmacist said.  Fool me once, shame on you.  Fool me twice…

I did not release a new prescription for the medication.  I discharged him from my care after having a final appointment with him where he admitted to taking more than was prescribed because he liked how it made him feel.  I remember in that meeting struggling with many different feelings.  I knew setting clear limits and consequences were important and so discharge was inevitable.  I remember feelings of betrayal and anger all the while attempting to highlight the positive aspects of his life and progress.

After the meeting, I felt hurt and raw.  I was also confused with this patient's impact on me.  What did it mean that I took this so personally?  From what I knew, a good psychiatrist does not get emotionally affected by her patients. 

Only now, with some distance and time away from this case and more experience under my belt, I see this patient as my teacher in what it is to treat someone with addictions.  With my inexperience and naivete, I had believed that our strong therapeutic relationship could protect him from relapse.  I now know how silly this is and how powerful and severe addictions can be.  What happened here was that my patient had his addictions reactivated from the stimulants and what followed are the unfortunate consequences of this mental illness: pursuit of the drug at all costs.

From this case, I appreciate better not only what it must be like to be a loved one to someone with addictions, but the blurry space of accountability in this illness.  I also now understand better the hurt, pain and regret someone with addictions must reckon with during their recovery and why this can be just as difficult as the addictions itself.

I know this patient did not mean to hurt me but I also know I will no longer prescribe any addictive medications to a patient with a history of substance abuse unless he is in addiction treatment, no matter how much I like and trust him.