There is hardly a population that is seen in the emergency department that thinks it’s more special than our friends the substance abusers. After all, part of abusing substances is the feeling, the absolute conviction, that one is special and unique.
Now, before I write this morning’s post and alienate half my readership, let me give you this one whopping, multi-part disclaimer. A boatload of my patients in the clinic and the EDs abuse substances. I have family members who are or have been abusers of alcohol. My grandfather died of complications of alcohol dependence, henceforth known as Alcohol Use Disorder, Severe. He was younger than I am now at the time of his death. Some of my best friends and colleagues have been substance abusers.
I’m not writing today’s post to put people down or demean them or call them names or put them in a box (oh, yes, dear readers, substances abuser do just fine, thank you, putting themselves in their own boxes). I’m writing to show that they are indeed a special group in the ED, a difficult group for both ED doc and psychiatrist to deal with.
Oh, and one more thing. I do use the term substance abuser (as opposed to the more PC and sterile people who abuse substances) liberally here. Why? This group of patients, with their recidivistic bent and self-inflicted injuries and relentless march toward death if they’re not treated are viewed by many practitioners as alcoholics, addicts, junkies, poppers, pill heads, pot heads, crackheads, and worse. Oh, hell, they call themselves these names. Don’t be naive and don’t look so surprised.
There are a few glittering gold threads that run through the repeated admissions of substance abusers (SAs). I shall tell you about them here.
First, they are absolutely, unfailingly, supremely entitled. An addict wants what he wants when he wants it. Which is usually right now. Like 80 mg of morphine. Or another shot of Ativan. Or a couple of Lortabs. Or a totem pole (Xanax). They rarely care that the heart attacks and the broken bones lay littered across the ED and came in ahead of them. They are already starting withdrawal, they’re sweating and feel sick and have muscle aches. They hurt. They don’t give a damn about your lupus flare or your gall bladder. They came in with a good story, goddammit, and they expect you to swallow it hook, line and sinker and give them their drugs.
Secondly, they are liars. Now, again, before you throw the rope over the tree branch and come for me, think on this. I did not say that they were bad people. Some addicts and alcoholics that I’ve known would give you the shirt off their back if they thought you needed it. They are smart. They have advanced college degrees. Thye make lots of money. But, they are liars all. Why? Because first of all they lie to themselves. They can’t see life as it is. They can’t stomach what they are and what they’ve become. They must lie to you to be able to continue lying to themselves. The old saw about “When is an addict lying? Anytime he moves his lips” is true, my friends. It may make you angry, but there it is. Deal with it.
Third, they are searching for something. SAs have big gaping holes in their lives, their hearts and their psyches. Vast swaths of emptiness that will not be filled up. So they try to fill them up with Jim Beam and Wild Turkey and grass and horse and crystal. For a while, that intense ten minutes of rush or that three hours of blackout time, it works gloriously. They transport themselves to another world. They feel normal. They feel good. They have found nirvana. They fit in. They have found “it”. Problem is, when the high goes away, so does the answer, like the smoke from the crack pipe. Drifting upward and gone. Back to that profound, aching, lonely, absolutely black hole of nothingness that begs to be filled. Search for more drug. Do it. Feel good. Repeat. Good God, what a cycle of destruction. You know, you shouldn’t, but you do. Over and over again. Until you end up homeless, on the streets, in jail, or dead.
Finally, they are in great pain. Not just the physical pain, though that may have been what started them down the path to destruction. Psychic pain. A pain so deep that they will do anything, anything, to make it go away. A loneliness that street friends and protitutes can’t fix. A pain that cash cannot buy them out of. A pain that narcotics can chase away for while, but not for long. Oh, they will tell you that they need the alcohol to help them sleep or the liquid morphine to ease the back pain enough to walk, or the pot to keep them mellow and out of jail. They will try to win you over, spouses and friends and family members and doctors alike, to their side because you know what they need and you want to help them.
The problem, my dear readers, is that we do know. We know very well what the addict and the alcoholic and the pill popper and the crackhead need.
It’s just easier for us, in our own pain and uncertainly and self-doubt, to slip them another twenty dollars, write them another prescription, and detox them one more time.
For you see, my friends, you and I are not that different from the addict, are we?
We are entitled to our own delusions. (Everything is fine.)
We are consummate liars. (To ourselves first and foremost.)
We are searching for something. (Peace, just for once, would be nice.)
We are in pain. (Oh, please, let me ignore it and hope that it goes away. Oh, please.)
We live with them, we love them, we try to treat them.
We want to help them.
We have the very best intentions.
And we are all, addict and family and provider, in so much goddamn pain.