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Cure for pain
January 9, 2009 1:10 PM   Subscribe

In December 2003, Brent Cambron gave himself his first injection of morphine. Save for the fact that he was sticking the needle into his own skin, the motion was familiar--almost rote. Over the course of the previous 17 months, as an anesthesia resident at Boston's Beth Israel Deaconess Medical Center, Cambron had given hundreds of injections.
- Going Under by Jason Zengerle of The New Republic [print version] is heartbreaking article about the high rates of drug addiction among anesthesiologists. It tells the story of Brent Cambron and his spiral into addiction. His live was also sensitively chronicled in The Boston Globe by Keith O'Brien in Something, anything to stop the pain [print version].

Don't pass up on reading the comments to Zengerle's article, the first few of which are by medical doctors. Here's the Boston Globe story about Dr. Cambron's death and his obituary from the Tulsa World.
posted by Kattullus (96 comments total) 16 users marked this as a favorite

 
Almost like baristas who do nitrous.
posted by dunkadunc at 1:17 PM on January 9, 2009 [1 favorite]


Sad. I've never understood the appeal of morphine, in any form I've had it, but I'm sure that an anesthesiologist would better know how to administer a "fun" dose.

Kind of wish the article didn't end in the almighty Twelve Steps. I cannot wait until we, as a society, develop a better relationship with addiction than twelve step programs. I know twelve steppers — I hear potheads talk less about pot than I hear all about Working the Program.
posted by adipocere at 1:22 PM on January 9, 2009 [6 favorites]


The twelve step program is great as long as you ignore steps 2, 3, 5, 6, 7, 11, and 12.
posted by fusinski at 1:26 PM on January 9, 2009 [1 favorite]


Please, please, can we not turn this into another AA sucks/AA is the only answer thread?
posted by HopperFan at 1:35 PM on January 9, 2009 [3 favorites]


Sad. I've never understood the appeal of morphine, in any form I've had it

What?

Obviously if you're in intense pain when you get morphine, you'll mostly just notice the fact that you're in much less pain. Used as a true pain killer for non-chronic pain it's not that addictive.

But obviously it can get you high, I mean, anyone can figure that out and you don't need to be an anesthesiologist to figure out how to do it.
posted by delmoi at 1:36 PM on January 9, 2009


...Cambron stood out for his penchant to get to the hospital early and leave late--something one fellow resident attributed to his "Midwestern work ethic."

I like how in Boston Oklahoma is in the Midwest.

Great article, though.
posted by cmoj at 1:36 PM on January 9, 2009 [2 favorites]


adipocere writes "Sad. I've never understood the appeal of morphine, in any form I've had it, but I'm sure that an anesthesiologist would better know how to administer a 'fun' dose."

A wise person said, "Morphine: if you're in pain, it does the job. If you're not in pain, it does the job."
posted by mullingitover at 1:38 PM on January 9, 2009 [5 favorites]


One of the problems with these "overcoming drugs" stories is that you only hear about the cases where people are really in dire straits and fucked up. The narrative is this heroic overcoming of addiction and of course anyone who reads it comes away with the "drugs are bad!" meme further reinforced.

But, no one writes stories about people who use drugs, then stop, and have successful happy lives. Or stories about people who have happy and successful lives while still engaging in recreational drug use.
posted by delmoi at 1:42 PM on January 9, 2009 [10 favorites]


It’s interesting, the little stereotypes doctors have about each other, based on some tiny seed of impression they get in medical school. Anaesthesiologists are all drug addicts, orthopedists are all gym rats and muscle-heads, pathologists are all creepy misanthropic dungeon-dwellers. Etc.
posted by penduluum at 1:43 PM on January 9, 2009


Most of the craziest addiction stories I've heard happened in hospital settings, shit can just get so crazy bad in a hospital, and fast. I know a dude who used to be a hospital pharmacist and he got to the point where he would catheterize himself at the start of every shift because he had to inject so frequently. He would take boxes of Fentanyl patches straight from the delivery truck, smash them on the floor and then cut the corner of the box and collect all the fluid that seeped out. He got to the point where he had to use vet syringes that were so big he couldn't press the plunger with his thumb, he had to push the plunger against the wall to get his shot off. You know, outer limit shit.
posted by The Straightener at 1:44 PM on January 9, 2009 [9 favorites]


Reading the TNR article suggests to me that Cambron's story is very much akin to a typical street drug addiction rather than anything special. He has a history of substantial alcohol abuse and mild cocaine and amphetamine abuse. He's in an environment where drugs are available and he sees their (apparent) desirable effects. He starts using, cautiously at first, but then more often as he self-medicates to cope with personal problems. His frequency of use and level of abuse escalates after he meets a fellow abuser. He enters a cycle of sobriety and relapse, resorting to more and more flagrant theft to supply himself with drugs. Eventually, he overdoses, intentionally or otherwise.

Frankly, that same story applies to tens of thousands of crack, meth, and heroin addicts. The interesting part, to me, is that these articles portray Cambron as a sympathetic person powerless to stop his slide into addiction. A poor street drug addict, on the other hand, is more likely to be portrayed as a dangerous criminal or a lazy welfare recipient who prefers to spend taxpayer money on drugs instead of getting a job.

I did find the description of the arms race between drug abusing anesthesiologists and their minders to be a nice microcosm of the drug war. They institute diversion prevention programs, mandatory drug tests, etc, and yet the rates of abuse don't go down. Just like the larger world, it would seem.
posted by jedicus at 1:44 PM on January 9, 2009 [13 favorites]


I've never understood the appeal of morphine, in any form I've had it,

THAT'S GREAT I'M REALLY GLAD TO HEAR THAT CAN I HAVE YOUR LEFTOVER MORPHINE PLEASE
posted by infinitywaltz at 1:49 PM on January 9, 2009 [21 favorites]


Anaesthesiologists are all drug addicts, orthopedists are all gym rats and muscle-heads, pathologists are all creepy misanthropic dungeon-dwellers.

So what do you become if you're a creepy, misanthropic, muscled-headed drug addict?
posted by owtytrof at 1:52 PM on January 9, 2009


So what do you become if you're a creepy, misanthropic, muscled-headed drug addict?

A drug treatment counsellor, obviously.
posted by PeterMcDermott at 1:57 PM on January 9, 2009 [13 favorites]


I would also love to hear the other medical specialty stereotypes:

ENTs?
Cardiologists?
Urologists?
Neurologists?
Proctologists?
posted by leotrotsky at 2:02 PM on January 9, 2009


delmoi writes "Obviously if you're in intense pain when you get morphine, you'll mostly just notice the fact that you're in much less pain. "

For me, it was more like I didn't care about the pain, not that it went away (in fairness, I wasn't in a whole lot of pain before it was administered). A "no worries" state of mind. Is that not how it is for most people?
posted by orthogonality at 2:07 PM on January 9, 2009


I think for a lot of people it's more like an "MMMMmmmmnnnaaaahhhhh, delicious, so delicious, my precious, my precious," sort of thing.
posted by The Straightener at 2:10 PM on January 9, 2009 [3 favorites]


I like how in Boston Oklahoma is in the Midwest.

I once had a long argument with someone from Oklahoma about how people from the Northeast think Ohio is the midwest... who was, incidentally, a heroin addict.
posted by geos at 2:18 PM on January 9, 2009 [3 favorites]


I like how in Boston Oklahoma is in the Midwest.

Ha! To my cousins in Colorado, I live "out east"; to those in Connecticut, I live "out west".

I live in Illinois.
posted by sbutler at 2:20 PM on January 9, 2009


I like how in Boston Oklahoma is in the Midwest.

The Philadelphian wrinkles her brow, and goes "It's not?"

/slinks off
posted by kalimac at 2:21 PM on January 9, 2009


Well, count me as a southerner who thinks that Ohio and Oklahoma are in the midwest. Where are they?
posted by josher71 at 2:24 PM on January 9, 2009 [3 favorites]


My experiences were much closer to orthogonality's, and seem to be about the same no matter what opiate (Demerol, etc) I'm on. "I am in pain, but I'm just kinda sleepy now." I don't seem to get the high then, nor does it occur the times I've taken something to see what the fuss was about. I absolutely loathe how morphine makes me feel (about to fall off the bed, a little pukey, and so parched), but perhaps that's a good thing.
posted by adipocere at 2:24 PM on January 9, 2009


Oklahoma. We call that "Flyover Territory"
posted by Blackanvil at 2:24 PM on January 9, 2009


So what do you become if you're a creepy, misanthropic, muscled-headed drug addict?

President?
posted by ROU_Xenophobe at 2:30 PM on January 9, 2009 [6 favorites]


I would also love to hear the other medical specialty stereotypes:

Dermatologists: good-looking academic superstars from wealthy families
Psychiatrists: bottom of the class
Surgeons: Gods with scalpels
Radiologists: "Rich in the Dark"
posted by terranova at 2:36 PM on January 9, 2009


ENTs?
Cardiologists?
Urologists?
Neurologists?
Proctologists?



Urologists and proctologists: pretty much what you'd guess. Surgeons: also pretty much what you'd guess, egotists and perfectionists. Patrick Bateman-y. GPs and pediatric specialists: people who weren't smart enough to make it into another specialty. Plastics and dermatologists (and to a lesser extent, anaesthesiologists): just in it for the money, but because the money's so good and the work so light those residencies are extremely selective, so they're often also the gunners — the kids with the best grades. ED docs: low attention spans, and whatever the opposite of workaholic is (ED docs work shorter overall shifts and less overall hours). Can't really remember any others.

I only know these because my best friend/ex-roommate was a medical student. I'm sure one of the real doctors around here could elaborate. Although they would also probably have the propriety not to; luckily I am free of that particular virtue.
posted by penduluum at 2:44 PM on January 9, 2009


Yeah, "rich in the dark" is another one that gets passed around.
posted by penduluum at 2:45 PM on January 9, 2009


Well, count me as a southerner who thinks that Ohio and Oklahoma are in the midwest. Where are they?

I used to live near Cleveland. Ohio is just Ohio. Jimmy Dean sausage commercials and polka dancing on TV, Huntin', fishin', squirrel skins nailed to wooden sheds to dry, lots of bowling, high school wrestling, Stroh's beer, OH GOD
posted by longsleeves at 2:47 PM on January 9, 2009 [2 favorites]


I absolutely loathe how morphine makes me feel (about to fall off the bed, a little pukey, and so parched), but perhaps that's a good thing.

That always been my feeling. The last surgery that I had they gave me a lot of morphine and then I went home with opiate pain killers. I puked heartily and spent the next week juggling pain relief and nausea. The nausea got better, but I was very glad to be off opiates. While they kill the pain they turn my mind to mush.
posted by ob at 2:47 PM on January 9, 2009


Sad. I've never understood the appeal of morphine, in any form I've had it.

I don't remember much from childhood (who does?) but I do remember, prior to and following getting my appendix out, my first, wonderful and glorious experience with Demerol at the age of 14. It's an experience I will never forget.
posted by KokuRyu at 2:51 PM on January 9, 2009


"He'd ask me if something went wrong in his childhood that he felt he'd need them," [his sister] Kelly recalls. "I tried to help him figure that out and I couldn't. He was looking for any kind of reason for why he'd feel he needed them, because he couldn't figure it out, and it really bothered him."

OK, this is absolutely terrifying in a "behold, the power of opiates" kind of way. It's also interesting in that it challenges the traditional narrative of the addict/alcoholic who's "trying to medicate the pain", "fill a God-sized hole," whatever your metaphor of choice may be.
posted by availablelight at 2:52 PM on January 9, 2009 [1 favorite]


I would also love to hear the other medical specialty stereotypes

Some good ones
posted by a robot made out of meat at 2:56 PM on January 9, 2009 [3 favorites]


I like how in Boston Oklahoma is in the Midwest.

I went to college (in Massachusetts) with someone who thought anything west of Buffalo was the Midwest.
posted by ambrosia at 3:00 PM on January 9, 2009


The classical midwest is the old northwest territory, which is the great lakes states minus NY.
posted by ROU_Xenophobe at 3:20 PM on January 9, 2009 [1 favorite]



The classical midwest is the old northwest territory, which is the great lakes states minus NY.


This.

"Go West, young man," used to mean, Iowa.
posted by availablelight at 3:33 PM on January 9, 2009


Yeah, morphine is not so much fun when taken as a patient in a hospital. My experience has been like everyone else's here, before the morphine, the pain is the center of my being, has always been there, will always be there, I hope I could just die. After the morphine, the pain is still there, but it does not matter, it is as if it is happening to someone else, and they are just telling you about it.

When something else that sucks is in the center of your life, like you have no money, nobody loves you, there is no hope, you just realized you are never going to be what you dreamed you would be, or you are just bored, morphine does the exact same thing. Plus you get too feel like you just had great sex 5 minutes ago all day long.

The other thing that happens is that you realize that you are actually always in pain, there is always something hurting somewhere, just at the threshold of your awareness. Your feet hurt from walking, your jaw hurts from chewing, your insides hurt from eating too much or too little or too fast.

Not my choice of drug, I tried it during a long weekend on the beach with some friends, one of them had a bottle of pill and a couple of ampules left over from his grandfather dying days, lung cancer. We had no way of getting more, so we thought we would be safe if we craved more. Those were the 4 most mellow days i can remember. If I had access to unlimited quantities and thought of my self as an expert on its safe use, I might try it once in a while.


Oh, before I forget, it is very addictive.
posted by dirty lies at 3:37 PM on January 9, 2009 [2 favorites]


And regarding the article, I am still waiting for that story too, the one about all the happy productive people who also use drugs. I don't know if they are a majority or a minority of drugs users, but I'd like to find out.

I should specify 'users of illegal mind altering drugs', you can see all the stories of happy productive people using legal mind altering drugs on half the ads on TV.
posted by dirty lies at 3:39 PM on January 9, 2009


For me, it was more like I didn't care about the pain, not that it went away (in fairness, I wasn't in a whole lot of pain before it was administered). A "no worries" state of mind. Is that not how it is for most people?

That was my experience with it. I did have some really trippy dreams and sometimes when I was trying to fall asleep the trippy would start early and it felt like an acid trip that had lasted too long and you're just ready for it to end so you can zonk out. Please stop using the inside of my eyelids to screen your home movies Mr. Escher, KTHXBYE!

Now what it did to was make me hypersensitive to the minute vibrations being caused by the motor that adjusted my hospital bed, making it feel like the whole thing was shaking. Add the slight chill caused by a cold room and it felt like I was shivering and rattling my way into some sort of Tacoma Narrows situation where the whole bed was going to fly apart.

It got so bad that I finally tried sleeping in the various visitors chairs in my room, which I apparently rearranged with such vigor that I got a visit from the head nurse the next morning because the rest of the staff thought I was trying to barricade my door to keep them from waking me up. It didn't occur to me until the next night to just unplug the bed.
posted by Cyrano at 3:52 PM on January 9, 2009


A very long time ago, my then father-in-law, dying of cancer, was to be transferred froma hospital in NY to one in another state, so he could be with family before he died.A youngish cousin, a resident, went with me to the resident's hospital, and with ease, before nurses, gathered up a large bunch of drugs to take along to the airport etc..no one checked him, monitored him. He was let alone to take what he wanted. That struck me as odd then and it does now. No controls.
posted by Postroad at 3:52 PM on January 9, 2009


Do so not want my anaesthesiologist shaving a bit off the top for himself. One of my Dad's colleagues was caught doing exactly that. Dad himself would mention sometimes that sitting next to the equipment over hours made him pleasantly 'drowsy'.
posted by yoHighness at 4:04 PM on January 9, 2009


During the Cold War, the "West" began in Berlin. "Middle East" is perplexing on so many counts, and some might argue that the peril and promise of opiates begins in Afghanistan: 2007 saw record production, which decreased in 2008.
posted by woodway at 4:30 PM on January 9, 2009


A buddy of mine who goes to AA told me that the story Doctor Addict Alcoholic is one of the most popular stories in the AA text, got me to read it -- it's funny as hell, and also not funny at all, if you catch my drift..
posted by dancestoblue at 4:33 PM on January 9, 2009


Ok, where to start.

First of all, this article doesn't even mention the most likely hypothesis for why anesthesiologists get into drugs: UM, YOU CHOSE A SPECIALTY THAT'S ALL ABOUT DRUGS!!! WHY WOULDN'T THE ADDICTS WIND UP HERE? It's a stats 101 self-selection effect.

Number two, note all the comments here about not liking opioids like morphine: THAT'S BECAUSE MOST PEOPLE ACTUALLY DON'T LIKE THEM! Only about 1-3% of pain patients without a prior history of addiction become addicted due to exposure-- and only 10-30% of people who take opioids recreationally become addicts.

The idea of opioids as devilish seducers that will capture everyone who tries them is just wrong. Cigarettes are more addictive.

Number three: the people who he quotes as experts on physician-addiction? These guys run a completely 12-step focused addiction program that is absolutely not evidence-based and that has lost at least one lawsuit when it forced a physician who was admitted to admit alcoholism or never get his license back because that was part of treatment. Problem is, the guy wasn't an alcoholic!!! Problem 2: saying "I am an addict" or "alcoholic" has zero correlation with recovery. What matters? Wanting to deal with the problem, not accepting a stigmatizing label.

Number four: the idea that powerlessness is necessary to overcome addiction. False as well. IN FACT, PHYSICIANS IN GENERAL HAVE THE HIGHEST RECOVERY RATES OF ALL, TYPICALLY.

Who do you think is more likely to recover, the homeless guy who has no education and no skills and no family-- or the doctor? You'd be right if you said the doctor!!!!

Ugh, I know this reporter and I thought he knew better.
posted by Maias at 4:53 PM on January 9, 2009 [16 favorites]


The Anesthetists' Hymn
posted by terranova at 5:07 PM on January 9, 2009


You know, Maias, I was skeptical of your expertise at first, but upon reflection, the capital letters and redundant exclamation points won me over. You clearly know a thing or two about addiction.
posted by D+ at 5:20 PM on January 9, 2009 [1 favorite]


You know, Maias, I was skeptical of your expertise at first, but upon reflection, the capital letters and redundant exclamation points won me over. You clearly know a thing or two about addiction.

She certainly does.

Maias, I'd be very interested to read a more extensive rebuttal from you.
posted by availablelight at 5:29 PM on January 9, 2009 [2 favorites]


So I guess Radiology is the way to go, then. Could do a whole lot worse than being rich in the dark.
posted by paisley henosis at 5:29 PM on January 9, 2009


At Burning Man this year I heard that one of the camps near us consisted mostly of anesthesiologists. I mentioned this to someone else, and he said, 'ah that explains why they're into all the exotic drugs'.

More seriously I have also read that anesthesiologists get a significant dose of second-hand anesthetics exhaled by the patients they work on and that this may contribute to the rates of drug addiction in anesthesiology.

Ironically I'm reading this after having had general anesthesia for the first time ever today, getting my wisdom teeth out. It was pretty cool.
posted by pombe at 5:40 PM on January 9, 2009


You know, Maias, I was skeptical of your expertise at first, but upon reflection, the capital letters and redundant exclamation points won me over. You clearly know a thing or two about addiction.

I agree with him mostly. Access to, interest in, and familiarity with the drugs really is a good explanation. Most people don't become addicted to morphine. As to three and four, the physician assistance program in IL boasts an absurd success rate. Something like 75-95% (one treatment specialist told me) compared to typical AA 5-10%.
posted by a robot made out of meat at 5:43 PM on January 9, 2009 [1 favorite]


And on reading the article I see that the second-hand dosing theory is mentioned.
posted by pombe at 5:47 PM on January 9, 2009


I agree with him mostly. Access to, interest in, and familiarity with the drugs really is a good explanation. Most people don't become addicted to morphine. As to three and four, the physician assistance program in IL boasts an absurd success rate. Something like 75-95% (one treatment specialist told me) compared to typical AA 5-10%.


Actually, I'm a girl ;-)

Available, thanks-- I'll probably do one on my blog in next few days. For those interested in my credentials, see here and here and here and well, google for more. I've written on this for more than 20 years and got an award from the American Psychological Association for contributions to the addictions by a non-psychologist.
posted by Maias at 6:10 PM on January 9, 2009 [2 favorites]


Number two, note all the comments here about not liking opioids like morphine: THAT'S BECAUSE MOST PEOPLE ACTUALLY DON'T LIKE THEM! Only about 1-3% of pain patients without a prior history of addiction become addicted due to exposure-- and only 10-30% of people who take opioids recreationally become addicts.

What? Since when is not being addicted to something the same as not liking it? I hardly ever drink, but when I do I enjoy it. When I got codeine after having my wisdom teeth removed I certainly liked the codeine, and it was still nice once the pain healed.

I'm sure the vast majority of people like Opioids, perhaps not enough to get addicted on their first try -- or ever if they're taking it for pain, but I'm sure most people find it an enjoyable experience.
posted by delmoi at 6:55 PM on January 9, 2009


I would also love to hear the other medical specialty stereotypes:

How to pick your medical specialty.
posted by Slithy_Tove at 7:10 PM on January 9, 2009


I have a family friend who is a psychiatrist. He really doesn't seem to care for his patients, just hand out the meds and collect the dough.
posted by Buzzkilz at 7:12 PM on January 9, 2009


I used to not care for my patients, just handed out the meds and collected the dough. Then this bunch of thugs showed up and I lost my corner.
posted by dirty lies at 7:27 PM on January 9, 2009


I would also love to hear the other medical specialty stereotypes:

Internists: Allergic to children
Pediatricians: Allergic to adults
ER Physicians: Cowboys with ADD
posted by terranova at 7:32 PM on January 9, 2009


Delmoi, they've actually done trials of this. If you are really interested, memail me and I'll dig up the citation.

Basically, most people find the opioid "high" to be unpleasantly distancing and numbing. They don't find it euphoric.

In fact, according to Gav Pasternak of Memorial Sloan Kettering, one of the leading opioid researchers in the world, about 50% of clinical trials of opioids don't even find that they kill pain!!!! This is because there is incredibly wide variation in the human genome in terms of opioid receptors-- not because opioids aren't the best painkillers we have. But it's only in inbred rats that you get perfect data, basically-- and just like with SSRI antidepressants, different drugs in the same class have varied effects on different people.

Now, with humans, some of the lack of liking in the trials of drug experience (these are done to test for abuse liability) may have to do with "set and setting"-- ie, a lab isn't the funnest place to take a drug. But nonetheless, the fact remains that most people who take the "most addictive class of drugs evah!" don't actually like the experience.

Now, liking the experience is not *sufficient* for addiction-- in fact, it seems as though many people who really, really like opioids get so frightened by that that they never take them again recreationally and/or are extremely cautious only to take when absolutely medically necessary.

I've heard that story over and over from people who think that they are unique in being such a self-controlled person that they experienced the best experience they ever had and didn't do it again, rather than running out and becoming a junkie.

But the truth is, unless your life sucks, you don't tend to want to give up everything for drugs and such experiences are actually at least as common if not more so than addiction experiences but no one writes memoirs about them because they are kinda boring.

Anyway, while liking is not sufficient for addiction, it tends to be necessary except amongst the tiny minority people who absolutely hate the high but decide to do it repeatedly because they are masochists!
posted by Maias at 7:34 PM on January 9, 2009 [2 favorites]


For those interested in my credentials, see here and here and here and well, google for more.

Very cool!! I'm glad your challenging path through life turned into something so productive.

From your Washington Post article:
This compulsive aspect helps explain why we can now consider video games and, yes, even potato chips more addictive than we did in the past.

Cheetos. Cheetos are the heroin of the salty snack universe.
posted by txvtchick at 8:10 PM on January 9, 2009


Basically, most people find the opioid "high" to be unpleasantly distancing and numbing. They don't find it euphoric.

Huh.
posted by delmoi at 8:22 PM on January 9, 2009


Maias: Basically, most people find the opioid "high" to be unpleasantly distancing and numbing. They don't find it euphoric.

All the people I know who've told me that they've tried heroin didn't like it all. Since I have a lot of friends who've lost family and friends heroin I consider myself very lucky. But yeah, as Maias mentioned above, heroin doesn't hold a candle to nicotine in the addiction stakes.

And I found Cambron's story affecting. Perhaps it was his love for going to local music venues, that he worked as a doctor in Nepal or the story about his relationship with Margaret Yoh but I felt for the guy.
posted by Kattullus at 8:26 PM on January 9, 2009


Yeah, the only opiate I've taken was percocet, and I found it to be a real mixed bag: I was serene, confident, confused, itchy and nauseous.

The serenity and confidence would have been incredibly nice — and probably very addictive — if I coulda gotten them on their own. But along with that dumb, uneasy seasick feeling, they just weren't worth it. I had a week's prescription and I took two doses and called it quits.

The idea of using the rest recreationally didn't even occur to me. If I needed to relax, my first thought was still to drink a beer or smoke a cigarette or jerk off, just like I'd always done. Almost as pleasant, and they didn't turn me into the sort of person who needed to watch Bruce Almighty three times in order to sort out the plot.
posted by nebulawindphone at 9:23 PM on January 9, 2009


I'm dying to know. What does "rich in the dark" mean?
posted by desjardins at 9:25 PM on January 9, 2009


desjardins: it's literal. Radiology pays well, but you do a lot of work in the dark (looking at images on lightboxes).
posted by spaceman_spiff at 9:50 PM on January 9, 2009


I like how in Boston Oklahoma is in the Midwest.

Well, I'm from the Boston area and I once got into an argument with two separate friends from Oklahoma who swore it was in the Midwest. At least "parts of the state." I clung to the traditional, Great Lakes area definition. The argument lead to an informal poll of friends and acquaintances, actually. I don't remember what the consensus was, but I left feeling pretty sure I was right.

Moral of the story? Thanks, Metafilter, for given me further evidence. Vindicated at last!
posted by lunit at 9:52 PM on January 9, 2009


I don't think she was an especially happy drug addict, but Anna Kavan seems to have been an extremely productive one throughout her long life of heroin use.
posted by girandole at 10:01 PM on January 9, 2009


But, no one writes stories about people who use drugs, then stop, and have successful happy lives. Or stories about people who have happy and successful lives while still engaging in recreational drug use.

Those of us with a clue already know one or two of these types of people and take everything with a grain of salt.
posted by Dark Messiah at 10:04 PM on January 9, 2009


And no one writes stories about the incredible CONSTIPATION that's a major side effect of opioids. Otherwise they're great!
posted by subatomiczoo at 10:40 PM on January 9, 2009


subatomiczoo: And no one writes stories about the incredible CONSTIPATION that's a major side effect of opioids. Otherwise they're great!

Well, Trainspotting started out as a book...
posted by Kattullus at 10:47 PM on January 9, 2009


Devastating. I had this happen to a friend. We found her collapsed in the hall on our cardiac floor and she was still denying anything was wrong. I’ve never understood the appeal morphine has for some people. While in Amsterdam I smoked some opium and fell asleep in a park – freaked me out, hated the slow, drowsy feeling.
posted by rotifer at 11:32 PM on January 9, 2009


I would also love to hear the other medical specialty stereotypes:

Neurologists?


I used to work in a coffee shop in the lobby of a major research hospital. And we got all kinds. To me, all doctors were the same, with two exceptions: orthopedic surgeons and neurologists.

Orthopedic surgeons were the most bouncy, happy-smiling-joking tyes I've ever met. These are people who get to put someone together after he's fallen four stories, or been hit by a bus, but they all seemed to have this lighter-than-air attitude. And very little gallows humor (with exception of one guy, who confided in me, "We have a saying in my racket - if it won't fit, get a bigger hammer!"). I never understood how they could be so chipper.

Neurologists, on the other hand, were not so jovial. I remember once the chief neurologist ordered a triple cappucino with a single's worth of milk. "Damn, hope you're not about to put your hands in somebody" I said jokingly. He looked back at me, confused for a moment, then said, "I have no scheduled surgeries today." Uh, OK, here's your change, Chuckles.

I related this story to my Tigger-ish orthopedic friend, and he said all neurologists were humorless automatons. His reasoning was "you wouldn't be laughing much either if over 90% of your patients died". So my chances are better if I've fallen into an industrial dough mixer? "Well no" he said "I just won't take it out on the baristas."
posted by Marisa Stole the Precious Thing at 11:48 PM on January 9, 2009 [10 favorites]


All the people I know who've told me that they've tried heroin didn't like it all.

This is actually true of lots of people who become addicts as well. The things that non-addicts perceive as unpleasant also tend to be perceived as unpleasant by people who go on to become addicts -- but the pluses more than compensate for the minuses and cause those who become addicted to continue to repeat the experience until tolerance does away with those initial irritations like itching, puking, constipation, etc. etc.

And no one writes stories about the incredible CONSTIPATION that's a major side effect of opioids.

OTOH, I've never known a heroin addict who didn't think that the world shared their obsessive interest in the current state of their bowels.
posted by PeterMcDermott at 12:01 AM on January 10, 2009


You are confusing Neurologists with Neurosurgeons Marisa. Think Oliver Sachs vs. Dick Cheney.
posted by rotifer at 12:10 AM on January 10, 2009


Think Oliver Sachs vs. Dick Cheney.

Greco-Roman or Battle Royale?
posted by Marisa Stole the Precious Thing at 12:12 AM on January 10, 2009 [3 favorites]


Sad story that is all too familiar to anyone who has been in anesthesia for more than a few years. If you look at it from the "addiction as disease" model the prognosis is pretty grim. Left untreated the mortality rate is close to 100%; even with treatment some studies show a 30% mortality rate among addicted residents, lower among attendings (I don't recall how much lower, though). It often seems to be the smartest and best-liked who fall into this trap too, just as in the article.

While I think of myself as pretty non-judgemental when it comes to drugs, those who wonder about the stories of casual users who continue to have a good career do not appreciate the drugs we have access to in the OR. No matter what they start off with most anesthesiologist eventually migrate to fentanyl or sufentanil; synthetic opioids that are 100 and 1000 times more potent than morphine. Since certain anesthetic techniques (especially in cardiac anesthesia) require several vials of these drugs for each patient, it is pretty easy to start experimenting just with the small amount of overfill in each vial. I heard one addict describe his first experience as feeling like he was "complete" for the first time in his life, but within a few weeks his main concern was avoiding withdrawal and not getting caught. He re-entered the specialty but left for good after a life-threatening relapse.

I am glad that in both the article and this discussion there hasn't been an outcry for a massive drug testing program. Although testing does have its role, the potency of these drugs also means they are active at serum concentrations that require very expensive, sensitive techniques to detect. Even then they miss a lot of addicts, even if the addict doesn't have time to get some clean urine or otherwise beat the test. Several years ago we had a resident who we were concerned about and pulled him out of the OR one day without warning for a test. He passed, but a few months later (after he graduated) he was found dead from an overdose. The other downside to testing is that there is a false positive rate around 2%. In our department there are roughly 30 residents, 30 attendings, and 20 CRNAs; if everyone were tested twice a year (at a cost of several thousand dollars) then on average we would see 3 false positives a year (which is comparable to the number of actual positives we would be likely to see). What do you do with these people? How do you tell a real positive from a false positive and keep from labeling an innocent person as an addict based on a single result of uncertain value?

This is a topic that has been looked at closely in the anesthesia community for at least the last 20 years, but as you can see, it is a constant battle.
posted by TedW at 1:36 AM on January 10, 2009 [5 favorites]


Fascinating comments--best of the Web. My experience with opiates is from having dental surgery. Vicodin made me feel warm and happy. Strange that the antidepressants I take do neither...
posted by RussHy at 3:10 AM on January 10, 2009


He swiped some propofol from an operating room, locked himself in a bathroom near the endoscopy unit, and injected the drug into his femoral artery.

Not if he was as smart as this article suggests he was, he didn't. Unless he wanted intense pain, fountains of blood and the risk of gangrene, he'd have injected it into the femoral vein, not the artery.
posted by PeterMcDermott at 7:24 AM on January 10, 2009 [3 favorites]


subatomiczoo: Regarding constipation, a practitioner told me that this is going to be hot.
posted by a robot made out of meat at 8:00 AM on January 10, 2009


As someone who has spent the last few weeks in sometimes crippling pain, I'm also not a big fan of opiates for pain relief. They're great recreationally, and I used to have a small Vicodin problem. When I actually take some for my pain, I just end up feeling high and woozy, and still in pain. Caring less, certainly, but the pain is still there. But when I'm in pain, I don't want to feel high, I just want to feel normal. I recommend Tramadol, fyi, which works to a varying degree on pain with no high.

IV Demerol, on the other hand, is pure heaven. This is why I stay away from drugs. They feel really, really good.
posted by threeturtles at 9:27 AM on January 10, 2009


If you look at it from the "addiction as disease" model the prognosis is pretty grim. Left untreated the mortality rate is close to 100%; even with treatment some studies show a 30% mortality rate among addicted residents, lower among attendings (I don't recall how much lower, though)

I would really, really like to see a citation for this. First of all, the majority of addicts recover without treatment: so the notion that "left untreated" addiction is nearly universally fatal is simply wrong. How do I know the vast majority of addicts recover without treatment?

Look at the epidemiology. If you check out the large studies like the Epidemiological Catchment Area and the others done to check prevalance of DSM disorders, you will find that there are many more people who once had DSM-diagnosable substance dependence on opioids (the stupid name the DSM people gave addiction, it will likely be changed to addiction in DSM V) than could possibly have been through treatment, by large factors.

Also, check out the Lee Robins study that I cite in my Washington Post piece about Vietnam vets: vast majority of those who were physically dependent on opioids during the war quit and didn't become re-addicted back home, even if they used a few times back home!

Now, if you look at *treatment* samples rather than community samples, you will get higher mortality rates-- with opioid addiction, something like 1-3% per year, which adds up fast.

Why do untreated people do better? The cynical say iatrogenic treatment (and there certainly is plenty of that) but the main reason is that the worst cases wind up in treatment, the people who cannot quit on their own. So, you're looking at a selection effect.

You can argue semantics and say that the people who can quit on their own aren't "really" addicts-- but there are many people with problems of similar severity to those seen in treatment who do quit on their own, so there's no way of predicting this and therefore, I don't find that argument convincing.

Anyway, there's also a way to prevent a huge portion of opioid overdose deaths, which is to provide addicts and anyone who gets a script for a strong opioid and every first aid kit with the drug naloxone, which instantly reverses opioid effects. I wrote about that for the NY Times here: it really is an outrage that we let people die this way.

That would not have helped this guy who clearly was a suicide-- but when naloxone has been handed out at needle exchanges, overdose death rates have declined.
posted by Maias at 9:52 AM on January 10, 2009 [2 favorites]


The thing that I found most interesting about this was the revelation about the high prevalence of propofol among anaesthesiologists. This drug is pretty well totally unheard of outside of that limited cohort, but among them it's almost like it's the drug of choice.

Given that the controls aren't as stringent as they are for drugs like opioids, I wonder why this stuff has never leaked out of that particular population and into the wider community?
posted by PeterMcDermott at 10:36 AM on January 10, 2009


While that is a sad story, at least Dr. Cambron doesn't appear to have killed 4 people and infected hundreds of others.
posted by Skeptic at 11:34 AM on January 10, 2009


Maias: Anyway, there's also a way to prevent a huge portion of opioid overdose deaths, which is to provide addicts and anyone who gets a script for a strong opioid and every first aid kit with the drug naloxone, which instantly reverses opioid effects.

Every first aid kit? Don't you think that's a wee bit overboard?
posted by Mitrovarr at 12:23 PM on January 10, 2009


Think Oliver Sachs vs. Dick Cheney.

Greco-Roman or Battle Royale?


Spartan.
posted by homunculus at 12:36 PM on January 10, 2009 [1 favorite]


Maias: Anyway, there's also a way to prevent a huge portion of opioid overdose deaths, which is to provide addicts and anyone who gets a script for a strong opioid and every first aid kit with the drug naloxone, which instantly reverses opioid effects.

Every first aid kit? Don't you think that's a wee bit overboard?

In some states and counties, overdose deaths (a majority of which are "opioid plus other depressant AKA alcohol, benzodiazepines or other tranquilizers and can be reversed by naloxone since the respiratory depression is primarily opioid) near or even exceed traffic deaths.

Also, you want them to be in places where people don't know they have addicts around-- AKA the houses of parents in denial, the houses of parents who genuinely don't know, the houses of first time users (most overdoses occur in either first/new users or experienced users who have been recently clean and don't know they no longer have a tolerance), houses of people who are just out of rehab, and the houses of people with toddlers who take their parents' drugs.

If you put it in first aid kits, it defeats the "that's the stuff for scummy junkies" and "my kid would never..." stuff.

It's cheap, it's safe (it won't do anything to you if you haven't taken an opioid) and when someone's "under" seconds count. So, no.

If you were a parent and you found your teen passed out with drugs nearby, would you prefer to have it and not need it or need it and not have it?
posted by Maias at 1:16 PM on January 10, 2009 [2 favorites]


Over a decade ago, I dated a Surgical Resident who, as it turned out, had a staggeringly huge drug problem. Although it should have been glaringly, unavoidably obvious to me, I couldn't bring myself to admit it. This was in spite of the fact that he had an unbelievably HUGE stash of painkillers and muscle relaxants, weighed 125 lbs (he was 5 ft, 10 in) and only slept 2 -3 hours a night. He had what seemed to be reasonable explanations for all of the drugs he had - he had been diagnosed with fibromyalgia, he had lingering pain from a car accident, etc. They all had been prescribed to him by other doctors. Certainly, I thought, his peers wouldn't prescribe all that medication to him if they thought that he was abusing them. He often spoke contemptously of doctors who became addicts. I was sure that someone so knowledgable about the consequences of drug dependency wouldn't let himself get addicted.
Finally, three months into the relationship, he nodded out over dinner and face-planted into his bowl of lobster bisque. He had earlier told me that he has severe hypoglycemia and, because he often forgot to eat, was prone to fainting. Finally, he copped to being high when I tried to get him to eat a spoon of honey to get his blood sugar up. We had broken up earlier and were in the process of patching things up when this happened. I told him that I couldn't be with him if he had a drug problem.
I didn't see him again for several months until he unexpectedly showed up on my doorstop in filthy scrubs, claiming that he had locked himself out of his apartment and needed to use my bathroom. I let him in and he locked himself in the bathroom. I smelled something peculiar, the odor of burning styrofoam. I confronted him. He admitted that he had been smoking crack in my bathroom. He had been booted from his residency a few weeks earlier when a security guard found him passed out in the parking lot of the hospital. Even then he was in denial - he actually said, "I know I must look like a junkie low-life to you..." I interrupted him. "You don't look like a junkie low-life...you are a junkie low-life. Get out of my house and don't ever call me again." I called his parents about a half-hour later. Turned out that he had disappeared from their house two weeks earlier and had stolen all of their credit cards. We put our heads together, came up with a plan and had him arrested for grand theft larceny. I told his parent not to drop the charges until he was already in a locked drug treatment facility. I got a voice-mail from him three months later when he had been released from rehab and was sober. I've lost touch with him since and I often wonder if he managed to stay clean. I've never quite been comfortable around doctors since.
posted by echolalia67 at 1:49 PM on January 10, 2009 [2 favorites]



The other thing I think is relevant in this thread is the fact that using drugs--even being physically dependent on opioids-- doesn't necessarily make you a bad doctor.

A guy who came up with many modern surgical techniques-- some of which are still in use, and who is a giant in the history of medicine-- took morphine for virtually his entire career. He tried cocaine at suggestion of Freud, became an addict and switched to morphine as a "cure." Since he had access to a pure, medical supply, it didn't get in his way too much.

His name was William Stewart Halsted -- and if he were practicing today, he would have been struck off as an impaired physician and many of the advances he made would have come much later or been lost.

Essentially, he was on "maintenance" and due to tolerance wasn't impaired when he worked but people don't understand tolerance and assume people on maintenance are "always high" and are still "active addicts."
posted by Maias at 2:43 PM on January 10, 2009 [1 favorite]


Essentially, he was on "maintenance" and due to tolerance wasn't impaired when he worked but people don't understand tolerance and assume people on maintenance are "always high" and are still "active addicts."

Very true. A good friend of mine is on the maintenance program and can attest to his lack of highness. The only effect his methadone has on him is a lack of interest in sex. Which he sees as a plus.
posted by Marisa Stole the Precious Thing at 3:43 PM on January 10, 2009 [1 favorite]


See also Dr. Clive Froggatt
posted by PeterMcDermott at 4:14 PM on January 10, 2009


Damn, I can't resist one more comment about Halsted. Not only did he introduce complete sterility of surgical area into surgery, and control over bleeding, he also introduced the surgical glove, the mastectomy for breast cancer and the hospital chart!!! He also did the first blood transfusion and was a pioneer of medical education.
posted by Maias at 4:22 PM on January 10, 2009


I would really, really like to see a citation for this. (In reference to my suggestion that opiate addiction has a 30% mortality rate in certain groups)

I am not at work and so have limited access to the literature, but 31% is the figure given here; in fairness this is in response to this study giving a 9% mortality rate, so I was quoting the high end of the range (although a disease with a 9% mortality is still pretty serious). However, I have practiced anesthesia in an academic setting for roughly twenty years and the consensus of my colleagues is that the 30% number is closer to the truth. You look to be very knowledgeable about addiction and so you would probably agree with the statement that addiction is a disease of denial; this extends to the colleagues of the addict and is a big reason why deaths due to addiction are probably under-reported. As an example of this sort of denial, a resident at another program died while I was in training and his chairman talked to our program about the incident. He made the comment that the resident who died couldn't possibly be and addict because he used the smallest needle he could find to inject himself. For those not in the medical field, the smallest needle is exactly what someone would use who wanted to minimize scarring/trauma and save the vein for future use. You also mention addiction data from veterans; this is a very different group from anesthesiologists in terms of their attitudes towards drugs (our lives literally revolve around drugs, even if only to give them to our patients). You even mention they hypothesis that some people choose anesthesia because of the availability of drugs; although I am skeptical of that I am also not willing to dismiss it out of hand; once again this is a potential difference between anesthesiologists (and nurse anesthetists) and other groups of addicts.

Your suggestion to put naloxone in first aid kits is a good one, by the way. It is a component of the coma cocktail that many providers use when confronted with an patient who is unconscious from no obvious cause, and I can think of many celebrities who could have been saved in that situation; I would guess the number of regular folks is much higher. I also appreciate your comments regarding Halstead; I always trot his story out when my surgical colleagues start making too many anesthesiologist as druggie jokes. The truth is a lot of medical pioneers in the late 19th and early 20th centuries were addicted to various things; the topic is probably worth a post of its own.



The thing that I found most interesting about this was the revelation about the high prevalence of propofol among anaesthesiologists.

Moving to a different topic; from what I have heard propofol is actually rather uncommon as a drug of abuse, but it has been reported enough that we now treat propofol as a schedule II drug in terms of checking it in and out of the pharmacy, even though it is not a scheduled drug.


If anyone is interested, here is an article from the ASA newsletter looking at addiction in anesthesiologists.
posted by TedW at 4:47 PM on January 10, 2009 [2 favorites]


While I think of myself as pretty non-judgemental when it comes to drugs, those who wonder about the stories of casual users who continue to have a good career do not appreciate the drugs we have access to in the OR.

The thing I find interesting is that these aren't just "casual users" we're talking about. This is a population of some of the sharpest, most driven people on the planet. I wonder if there could be a treatment that better taps into their inflated sense of self control?
posted by Civil_Disobedient at 5:56 PM on January 10, 2009


For another data point indicating that addiction is a life-threatening condition for anesthesia residents, there is this: Death as the initial relapse symptom occurred in 16% (13/79) of the parenteral opioid abusers who were allowed to reenter anesthesiology training.

The thing I find interesting is that these aren't just "casual users" we're talking about.
I think you see the point I am trying to make; in this context it is pretty much impossible to be a casual user, at least of drugs that you have easy access to.

I wonder if there could be a treatment that better taps into their inflated sense of self control? If you could find one it would be a major breakthrough; in reality anesthesia is a very attractive job for control freaks, although also very laid back (as far as I can tell the only rotation where med students are routinely allowed to address attending physicians by first name is anesthesia; indeed, that is something that attracted me to the specialty).
posted by TedW at 7:27 PM on January 10, 2009


He swiped some propofol from an operating room, locked himself in a bathroom near the endoscopy unit, and injected the drug into his femoral artery.

Not if he was as smart as this article suggests he was, he didn't. Unless he wanted intense pain, fountains of blood and the risk of gangrene, he'd have injected it into the femoral vein, not the artery.


I noticed that too; along with the cliche that anesthesia is long periods of boredom interrupted by brief moments of terror. Although I have had plenty of moments of both boredom and terror in my career, they are far out-shadowed by the remarkable opportunity that I have to see physiology and pharmacology in action in a patient who is extensively monitored. It really is a rewarding field on many levels.
posted by TedW at 7:41 PM on January 10, 2009 [2 favorites]


thank TedW-- re: denial, yes, very common, but oddly not more common than in diseases like cancer, etc. People have gone a little overboard on it, basically.

Civil, that was the other thing I didn't have time to debunk ;-)

Actually, the idea that you need to accept powerlessness or *confront* denial to recover from addiction is an old and discredited one.

Indeed, there are treatments that do just what you suggest in terms of working with people's thoughts and not treating them as babies who need to be controlled and corralled: cognitive behavioral therapy and motivational interviewing are the best studied and are equally as effective as AA (more effective if you count that you need fewer sessions) according to the biggest study done (Project Match).

[Note: most stuff works across the addictions so the stuff for alcoholism can be applied to addiction typically-- unless you are talking specific medications and even these sometimes work in many addictions]

In fact, as the leading expert on relapse says in that article I linked above in Time Magazine online, the more you believe that you have a chronic, relapsing disease that makes you powerless over yourself once you "take the first one," the worse your relapses will be.

Which makes sense if you think about it: if you believe you are powerless once you take the first hit and that you are now an active addict again and all your recovery time is erased, well, hell, why not go for it? You can't stop anyway-- so if you have one, may as well go on a weeklong binge because you can't control yourself now. It's called the abstinence violation effect and it is one of the unfortunate things that 12-step programs get wrong.

They do get a lot right-- but that powerlessness stuff is really bad for a lot of people. And it's even worse when it's forced on them.

AKA, we will make you powerless, we will crush you, we will humiliate you because you are junky scum and we know everything even if you think you are mr. smarty pants doctor. so sit down and shut up, asshole...

How would you respond to being treated like that? That's the kind of stuff that went on at Talbott (the doctor rehab cited in the story) and may still go on. If you said, I'd respond by looking for every error in what they told me and building greater resistance to listening, you'd be right.

In fact, the research finds that the more the counselor confronts, the more the client drinks or takes drugs afterwards and the greater the odds of treatment drop out!

Self-efficacy-- not powerlessness-- is actually a plus when it comes to recovery, as is true with most other conditions. The thing is to be self-efficacious about your recovery skills, not to be so smarty pants that you talk yourself back into relapse.

The way to help people achieve this as a counselor is to empathize and ally yourself with them and help *them* recognize when their addiction is "talking to them," not get caught up in power struggles or order them around. That's exactly what motivational interviewing does-- it "meets the patient where he's at" and focuses on attaining *his* goals, not the counselor's goals.

Sadly, the American treatment system is still about 90% 12-step-dominant: and so trying to find actual evidence-based addiction treatment even if you are a doctor, bizarrely enough, is really difficult.

As a doctor, you can actually have situations where people who use outdated methods control whether or not you get your license back-- so you may have to "surrender to a higher power" before you can practice evidence-based medicine yourself again ;-)
posted by Maias at 7:42 PM on January 10, 2009 [4 favorites]


How would you respond to being treated like that? That's the kind of stuff that went on at Talbott (the doctor rehab cited in the story) and may still go on. If you said, I'd respond by looking for every error in what they told me and building greater resistance to listening, you'd be right.

And yet at Talbott, it doesn't seem to have a negative impact on recovery levels, given that those physicians programmes show better outcomes than all other programmes by a mile -- surely suggesting that the amount of social and economic capital that somebody has is a much better predictor of outcome than all of the therapeutic voodoo in the world?

Also interesting to me is that the evidence for the efficacy of methadone maintenance is probably better than for all of the other forms of treatment for opiate addiction -- validated as such by by NICE in their recent technology appraisal but I'm guessing that any doctor who wanted to keep their license to practice had better not be looking to enroll in their local methadone programme, regardless of how effective it is.
posted by PeterMcDermott at 8:09 PM on January 10, 2009


For those not in the medical field, the smallest needle is exactly what someone would use who wanted to minimize scarring/trauma and save the vein for future use.

The fact that he was injecting in his femoral vein was interesting as well.

In people who aren't doctors, using long needles to reach that vein by entering at that spot where the leg meets the abdomen -- just an inch or two away from your balls -- is almost only ever used by chronic IV drug users who have lost all of their other veins to thrombosis by things like injecting crushed tablets. Because its so counter intuitive, even hardened iv users will shudder at the sight of it.

But this guy seemed to be using that spot straight from the off -- presumably in an attempt to avoid detection should anybody seek to look in the more obvious places?
posted by PeterMcDermott at 8:21 PM on January 10, 2009


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