Letter 17.

Dear Mr. MAT,

I am sorry.  I should not have snapped at you the way I did.  An apology should never come with a qualifying explanation, but I this time it does. As a transfer from the upstate prison for a court date my job for you was to assess your health and essentially continue the care you had been receiving for the last 7 years in prison.  At some point you overdosed in the prison, then diagnosed with substance use disorder, and started on a pretty hefty dose of methadone.   Before the deputies escorted you to me and you uttered the need for your methadone, your chart warned me that this was going to be an issue. 

This was not an issue because of you, but because of the system.  You see methadone and other medications for addiction treatment (MAT) are not available in the jail even though there is an abundance of evidence proving that it prevents tortuous withdrawal symptoms and reduces the likelihood of relapse, recidivism, overdose and death. You were not the first patient that I have cared for who came in from another facility or even from the streets that needed to be restarted on their MAT.  Every single time, my hands have been tied and I am left with only one option— explaining that MAT was unavailable and then hearing the patient essentially freak out about the symptoms that were going to ensue.  You were no different than all of the others and said, “I am not going to be able to make it doc… you gotta do something!”  As a witness of many who were actively withdrawing from opioids, I knew that you were going to feel like shit and I told you so.  I tried to reassure you that I would order medications for every symptom of insomnia, chills, body aches, nausea, vomiting, abdominal pain, and diarrhea.  You knew what it was like to withdraw from heroin, and in your eyes I could see the fear of re-experiencing that.    When you asked how long it was going to last, I felt like you knew I was teetering a fine line of truth because I knew it would be longer because of how long the methadone lingers in your system. My reassurance was not enough so you kept pushing and asking about other options… “what about suboxone?”  It made no sense that you had been sober for so long on methadone and you had to relive withdrawal.  Knowing that there was nothing I could do, I tried to move on with other questions, but you persisted. 

As your frustration escalated so did mine.  I recognize that you were afraid and asking for help, but when you kept pushing your need for methadone my eyes sternly pierced yours and yelled, “LOOK, I CANNOT GIVE YOU METHADONE HERE!”  I caught you, the deputies, my staff and myself off guard. In the few moments of shared silence, I realized that you were forcing me to face the limitations that this system places upon my practice of service to others in need.  You see I went into the business of trying to help people, but I am working in a system that does not. 

I wish I could apologize for the system, but I know that it will likely continue this non-evidence-based standard of care that is a disservice to all individuals with opioid use disorder.  I am so very sorry for the role that I play in your despair. 

My sincerest apologies,

Dr. A