The beau is feeling protective of me.

He demonstrates this via advice.

His experience of addiction has been through fellow workers, employees and family, and has been terrible.

Mine started in family, but I went to Al-Anon and started reading when I hit college. Claudia Black's excellent book, "It will never happen to me", about the roles that families take as an attempt to cope in the setting of drugs and alcohol. College and then five years working and then medical school and residency. I finished residency in 1996 and have worked as a rural family practice doctor ever since.

I did the training for buprenorphine (suboxone) at the University of Washington in November 2011. It is FDA approved in the US to treat narcotic addiction, only, and it requires a second, special DEA number. I took the class because over the years I've noticed that narcotics alone almost never work for chronic pain and I thought that the medical community was creating and enabling a huge number of addicts. The politically correct term would be "drug dependent".

There is physical dependence and then there is emotional dependence. The manual of psychiatric diagnostic criteria, the DSM IV, has separate diagnostic criteria for the two of these. Apparently the DSM V is going to replace the DSM IV soon, and that separation will no longer exist. The physical dependence is the withdrawal. The brain turns up the sensitivity of the narcotic receptors when they are blocked, so suddenly stopping long term narcotics or heroin leads to horrific symptoms: pain, sweating, diarrhea, racing heart, running eyes and nose, but pain, pain, pain, until the receptors calm down and slowly return to normal. The receptors start to change after 5-7 days of being blocked.

Severe withdrawal can be avoided by decreasing narcotics slowly. About 10% every week or two. Then the struggle is with the emotional side, the habits and beliefs. The fear of pain and the habit of taking a pain medicine for nearly every sensation. And with chronic pain, blocking the receptors doesn't fully block the pain no matter how much narcotic the person takes. Other medicines and other therapies are used. And everyone has pain in their life. The goal is to learn how to manage pain, to mitigate it, to handle it and sometimes, to accept it.

What does this have to do with love?

It is hard to tell if someone has chronic pain or narcotic dependence or both. Last week, a patient said to me, "If seven percoset a day work for me, and I know I'm not an addict, and I have pain, what is the problem?"

I replied, "Patients with chronic pain tell me that they need narcotics and they aren't addicted. Addicts tell me that they need narcotics and are not addicted. They look the same and say the same things. A hallmark of addiction is lying, not just to me, but to themselves. The only way that I can tell the difference between chronic pain and addiction is to monitor. And since short acting narcotics are more addictive than long acting narcotics, everyone is changed to a long acting narcotic. Those people who fight the switch and act like addicts, are addicts."

No one can be treated for narcotic addiction until they stop lying to themselves.

The beau says, "Why are you treating addicts? Some of these people are lying to you."

Yes, they are. That is the illness part. I am always sad when I catch someone lying to themselves and me. But if we both have the courage to discuss it and if I have the courage to stay present and set new boundaries, addiction can shift from active lies to a person who sees what they are doing and chooses treatment.

That is the love part. My goal is to be able to offer help to anyone who walks through my door. That, to me, is the point of family practice. I want to treat people, families, communities, chronic pain and addiction. Addiction is something that people have: so what is the best way to treat it?

I have chronic pain patients. I have chronic pain and narcotic dependent patients. I have alcohol dependent patients. I have some chronic pain patients who are also narcotic dependent and they have not admitted it to themselves or me. I monitor for the signs of dependence. I monitor myself: who is lying to me and I am not getting it? I have narcotic dependent patients who know that they are narcotic dependent, who are in treatment, who have been successfully treated for years.

Love is not enabling. Love is setting boundaries as you stay present. Love is tough sometimes, but it endures. I can offer a treatment plan: but some people will leave. They move on, to the next physician. Farewell, and I hope that next time they choose the path back to health.



Some have modest addictions,
a full pack of smokes at the bedside
an unopened bottle of Jack on the counter

Others have more exotic needs:
complicated pharmaceuticals,
expensive lines of powder,
Mocha flavored shoulders of Brazilian waitresses.

To each his own

My thoughts always go to you
two seconds after the alarm wakes me
pitch dark, disoriented
they stay with me all day and through the night,
into dreams, both passionate and terrible.

I don't deny my addiction,
I adore it.



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