Letter 10.

Dear Mr. Relapsed,

You plopped into the seat in front of me and told me you were withdrawing from heroin, but differently than most, you weren’t complaining too much about the symptoms.  You told me that you started injecting heroin when you were 11 years old, which meant for half of your life you had been using.  You proudly explained that after your most recent treatment program you had found sobriety for over a year.  I simply asked what happened.  You looked at me puzzled so I repeated, “What made you use again? What was your trigger?” For you it was simple and mumbled, “my Grandpa.”  The passing of your grandfather was meaningful to you because he and your grandmother were your world.  As you went on to describe with tears, “My mom killed my sister so she’s been in jail…. My father was deported back to Mexico…. I was in the foster care system until my grandparents took custody of me. … I found sobriety because of them.”    Your 22 years of life were filled with experiences that people twice your age could not fathom.  To be honest, you left me sitting still in my privilege and in awe of your resilience.  Your grief was beyond expected and to be honest so was your use of drugs and now your relapse.  But the weight that your relapse carried was so much more for you because as you said— you were disappointing the one person who believed in you and loved you when it felt like no one else did. 

I am not sure why your story was written the way it was and I told you so.  I meant it with every ounce of my being that there was a meaning to it all and you would discover it.  I wonder often if the nurses and medical assistants that I work alongside get bored or even annoyed when I say, “addiction is a disease, it is a process to work through, and you are expected to relapse.”  It may sound repetitive to them, it may even seem like I am wasting my breath because so many people come in with stories of withdrawal that a provider in jail could become so numb to it.  You see, medicine is just coming around to acknowledging the disease of addiction, but because it is so complex we struggle with how to treat it.  Most people don’t understand that advances in medicine have resulted in following a script supported by evidence to diagnose and manage disease so that the majority would benefit from such treatment; truly being patient-centered and meeting individuals “where they are” is innovative.  So when it comes to the disease of addiction that doesn’t follow a script, its criminalization brings people to jails (not hospitals or clinics)— a place that will only exacerbate the emotions that drive you to use.  Even if it did bring people to hospitals or clinics, the limitations to care range from provider bias and training with medication-assisted treatment, access to mental health care and rehabilitation. 

In the time we had together, outside of talking to you about your experiences and feelings, there wasn’t much I could do.  In the jail, for a number of reasons, I can’t actually prescribe the medications that are available on the outside to taper your withdrawal and actually treat your addiction.  Instead I can give you my ears, encouraging words for your steps to sobriety, a few medications that help with some of your symptoms, and tell you that with time you will feel better as your body gets used to not having opioids anymore.   I know it is not enough.  But I’ll keep trying and I hope you do too.  More importantly, I hope that we can be part of the evolution of society’s views on addiction that leads to the systemic improvements that are overdue to address its root causes. 

Always trying to do more,

Dr. A