Claudia P. Rodriguez, MD

 has many faces. The face of the active user, who appears high and sedated, lost in a state of intoxication. There is the face of desperate withdrawal, recognized as individuals seeking immediate relief of symptoms. We see the face of recovery, that which is proud, yet careful. Finally, there is a face we aim to avoid, and fear most, that of overdose and death.

We can only imagine what happens when our patients terminate treatment. Many of us assume that relapse occurs and hope that someday the patient will return with greater readiness and motivation towards recovery. Unfortunately, many patients do not return. Some may die of an overdose.

In the consult/liaison setting, we may see the face of an 

 in an unstable patient, where family serves as a primary source of information. It is in talking with the family that one recognizes addiction as an illness that extends far beyond the individual. Parents and siblings live with the pain and suffering of their loved one. Feelings of guilt, shame, and fear reside in them as well.

When loss occurs, there is not a sigh of relief, but rather a sense of helplessness, sadness, and multiple “what ifs.” As clinicians, we too, process these thoughts and emotions. Importantly, we must appreciate the individual, rather than focus on the addiction itself. Every person struggling with addiction has a valuable story.  

As an addiction psychiatry fellow, I shared my silent doubts with the patient’s mother and cousins, and thereafter, wrote this in his memory.

I met him–
Intubated, sedated, motionless, and swollen.
His eyes shut and he, surrendered,
Embodied in defeat of an addiction that now lay still–
Attached to life like a puppet,
Through lines and tubes that carried fluids through his veins
And oxygen through his lungs and his body.

I knew him–
Not now, not as my patient, but as echoes of stories in my past.
I recognized the story of a person living a broken life,
Hanging on by lines that carried heroin through his veins,
Allowing for an absent existence of
Scheming, feening, using, [barely] breathing.

And then I saw him–
His life, his struggles, his anger, and his hurt
Through the eyes of his mother.
She could not accept this awful disaster.
She sat across from me, tearing,
Looking to me for answers.
She asked for hope and strength.
She wanted forgiveness and relief, but more than anything,
She wanted her addict.

That’s when I noticed me.
I could not offer any of it.
It was a disaster.
The fear was palpable,
And his death, came thereafter.

I knew she’d suffered through years of distress, angst, and fear,
Of the very situation that brought her, today, here.
I felt relief, for her, for a moment,
Though quickly realized how worthy, to her,
Was the life of this addict–

And as soon as he took his last breath,
A hole was left in the middle of her chest.
For despite the pain, the tears, and the struggles,
In moments of health, he was close to his mother–
And the hope of recovery far surpassed the pain,
So that living with his addiction,
was much easier than surviving with his death.

Dr Rodriquez is a Fellow in Addiction Psychiatry at Boston University Medical Center.

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As clinicians, we can only imagine what happens when patients terminate treatment. Thoughts from an addiction psychiatry fellow.

The Death of an Addict

Itching, sticking, sweating, sniffling, tearing–
Crying.
Cramping, fetal position, dry heaving, pounding–
Stigmatizing.
“Feening,” scheming, planning, trying, feels like–
Dying.

Dilated pupils, hairs on end, goose bumps, close to–
Collapsing.
Anger, fear, sadness, can’t stop moving, although it’s–
Transient.
Screaming, cursing, fighting, interactions–
Short lasting.

[[{"type":"media","view_mode":"media_crop","fid":"27110","attributes":{"alt":"drug withdrawal","class":"media-image","id":"media_crop_8070927406797","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2605","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]Pain, discomfort, “crawling out of my body”
“Leave me alone!” [but stand beside me].
Methadone, suboxone, “You have to help me!”
Heroin, oxycontin-“pain is gone”
but still so lively.

Cycle, revolving door, if I fall
“Who will catch me?”
Uncertainty, loss of confidence, locus of control
Outside of scope, not “inside [me].”

[[{"type":"media","view_mode":"media_crop","fid":"24455","attributes":{"alt":"Claudia Rodriguez, MD","class":"media-image","id":"media_crop_3008570854075","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2114","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]In a world in which substance use disorders are no longer suffered in isolation, treating addiction is a challenging journey with obstacles, intermittent failures, and life-altering successes. As relapse is part of the illness, acceptance on the part of the physician becomes an integral part of the interaction that allows for reflection, change, and ongoing commitment to treatment.

One role of the addiction specialist is to recognize symptoms of withdrawal, clearly identified in psychiatric scales used to manage its treatment. These scales are clinically helpful, but witnessing the despair, helplessness, and loss of identity suffered by some of these individuals leads to a greater understanding of the underpinnings of addiction and the loss of control that identifies the illness.

The neurobiological changes that occur with the use of drugs become most evident in the stages of intoxication and withdrawal. The drug, or lack thereof, as if possessing the soul, reveals an individual different from the patient’s true self.

I wrote this poem to reflect on the experiences that I have witnessed in many patients, who-after treatment-transform into entirely different human beings.

In a world in which substance use disorders are no longer suffered in isolation, treating addiction is a challenging journey with obstacles, intermittent failures, and life-altering successes. A poem on drug withdrawal expressed through the eyes of a fellow in addiction medicine.

Jonesin’

Time does not pass, when it is near.
The patient feels frozen, by her fear.
To speak, is to relive, that moment in time–
When she thought, “This body, it’s no longer mine.”

She tried to consider, to forgive and forget,
Instead recognizing, how much she would regret.
She would blame herself for a heart broken–
For many years, lived suffering, unspoken.

“Avoidance is a core symptom of PTSD.”
“But how can you ask me to stop protecting me?”
“Your present is being affected by your past.”
“I know that, please help me get through this fast.”

“Breathe deeply. Let’s focus. Look at me. You’ll be fine.”
“It’s like it was yesterday; it’s not better, with time.
This world, this place, it doesn’t feel safe.”
“You’ve dealt with this alone, with strength, with grace.”

Victim, provider, abuser, survivor.
I want you to be, your utmost admirer–
Of your strength, your resilience, your admirable perseverance,
“But first, let’s ensure, your medical clearance.”

“I don’t want to talk about this,“
As she’s sweating and tearing.
“I can tell that you’re anxious.”
“It just feels like I’m reliving.”

“I’m not a victim. I don’t want anyone to feel bad.”
I think, I want you in my clinic; I too, feel very sad.
I see her crying, and it is only clear.
That she, and I, are both frozen in fear.

I was born in Bogota, Colombia, and raised in South Florida, before I moved to Boston to attend medical school at Boston University. Following graduation, I began a residency at Boston Medical Center in the field of psychiatry. Currently, I am in my last year of psychiatry training, and I am looking forward to a fellowship in addiction medicine at Boston Medical Center starting next academic year.

It has been some time since creative writing played a role in my life, though I often find myself thinking about what I would write when faced with moments that inspire my inner author and generate sparks of ideas that likely deserve to be written on paper. On this particular day, I felt drained after a long, busy day at work, and decided to sit with my thoughts and attempt to soothe my discomfort. For some reason, I chose to begin writing. Almost immediately, I noticed that my thoughts quickly transferred into words in my notebook, otherwise filled with notes from therapy sessions from the days prior.

I always talk to my patients about the concept of self care, in the form of exercise, journaling, music, etc. This random act of catharsis resulted in my recognition of the use of writing in my life as a form of self care. It reinforced the concepts that I share with my patients and allowed for me to deal with the rest of the day in a more mindful way. Finally, it reminded me that you do not have to set time aside to do something that helps validate your experience, while simultaneously coping with it.

We do not have to set time aside to do something that helps validate our experience, while simultaneously coping with it. The lesson expressed in this psychiatry resident's poem.

Author | Claudia P. Rodriguez, MD

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