What Did He Die Of?

A colleague asked a group of us Addiction Medicine specialists if we had any guesses of what killed a patient who died in his care. If reading a clinical description of a death or the thinking that doctors do after a death to improve care might bother you, stop reading. If not, read on. The patient was in his late 20’s and had been treated for addiction involving opioids with medical withdrawal. Following the withdrawal, his treatment team implanted naltrexone, a long acting blocker of the opioid receptor meant to protect him from overdoses should he resume use of an opioid. He was described as stable on these monthly implants for 5 months after withdrawal and was found dead with no drug paraphernalia around him. At autopsy, there were no physical findings except a white power in his mouth, which turned out to be clonidine, a medication used to counter the anxious activation of opioid withdrawal or stimulant intoxication. Post-mortem toxicology showed he had a high level of naltrexone, higher than usually seen in fact. He was negative for all opioids tested including fentanyl, sufentanyl and carfentanyl. He was positive for amphetamines. The group gave a number of different theories. He had used amphetamine, overshot the mark, became nervous, took the clonidine to calm down which increased a specific electrical pause in his heart, that some amphetamines also increase, and this caused his heart to stop. Or he had taken a heretofore unknown opioid (probably a new, currently undetectable, even more powerful fentanyl analog) which displaced all the naltrexone, raising the level, and stopping his breathing. Or he had used cocaine long enough ago so that it wasn’t any longer in his system, but cocaine’s effect on the heart lasted long enough to interact with what he was taking to cause the sudden stoppage of his heart. All good theories. Complex and speculative, but good theories non the less. But my mind didn’t go down this path. I didn’t think about what stopped his heart in the last moment. I didn’t think about what combination of substances could interact in what way to do what damage. I didn’t think about that, because I don’t see the point. It’s a wonderful academic exercise, but if we know, what will we change? Will we warn people not to use clonidine if they are going to use amphetamine? Will we warn people not to use any new opioids from China until everyone in their neighborhood has tried them and survived? At that point in the life of someone with addiction, when they are using what they need to use to feel normal,...

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The Kissinger Cross and Beginner’s Mind
Jul22

The Kissinger Cross and Beginner’s Mind

The Kissinger Cross I learned about the Kissinger cross from an economist named Jim Rickards (twitter: @JamesGRickards). You may have guessed that the Kissinger Cross was named after former Secretary of State Henry Kissinger, but you might be struggling to figure out what it has to do with addiction. No, it isn’t that it’s his cross to bear. It’s something else all together. Kissinger said that when we enter a new situation we have all the options that exist but we don’t have any information on which option is best. As we learn more about a situation our knowledge rises, but with that knowledge comes a decrease in the options available. Some just don’t look good with that new knowledge. So he said there are two lines to be drawn as time moves on, the down sloping line of options and the up sloping line of information. The more we learn, the fewer options we have, so in the end, we know everything but can’t do anything. What the Kissinger Cross is, is the point at which the two lines cross. We no longer have all the options but we still have a lot, and we don’t know enough, but we know a good bit. It’s a chancy thing making decisions with incomplete information, but life is a chancy thing. What Secretary Kissinger gave us was a system with which to figure out when to act that is graphical, at least somewhat objective, and can be put on paper for clarity of thought. It’s a good idea, but what does it have to do with addiction? Well, it has to do with everything, but that’s not the point of your question, is it? You want to know what the Kissinger Cross has to do with the problem of addiction in our society. Well, it can provide us with a solution, but only if we use it correctly. To illustrate that, you’ll have to come with me on a little thought experiment. A World Without Addiction So imagine that we live in a world with no addiction, or, since you won’t be able to imagine that, just imagine that we’re not from this world. We arrive here and see addiction for the first time. We don’t know anything about it; it’s a completely new situation. We can do anything about it we want. We can shoot people, give them lemonade, pet the dog, or go home. We have all the options in the world, but we don’t know what to do. We’ve never seen addiction before. We don’t know what it is, what causes it, what it costs. We just know we’re...

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Linearity vs Cycles
Jul13

Linearity vs Cycles

Take a deep breath. Now hold it. Without letting it out, take another deep breath. You can’t do it can you? Now go back to breathing normally before you pass out. The point of all that was to show you in a visceral way that at the core of your being are cycles, in this case breathing in and breathing out. Cycles are all around us. The entire universe revolves on cycles: day and night, the seasons, the moon, and even most important for your immediate survival, breathing in and breathing out. Problems don’t arise from cycles, though we often look at the nadir of the cycle and say that it’s problem. It’s not; it’s just nature. The problems are invented in our own human cortex when we deny that cycles are necessary or we imagine were in a different part of the cycle from where we really are. An example of that is our country’s monetary policy. It’s based loosely on the Keynesian philosophy of stimulating the economy in a downturn and withdrawing that stimulation when the economy is an upswing. Our modern central bankers are very good at stimulating downturns but seem not to know how to take their foot off the gas during an upswing.  Their goal of a world with no recessions is like the house of a hoarder. At first he feels wealthy because he has so much stuff, but soon he isn’t able to move around to get anything done. By believing in linearity and not allowing the natural cleansing cycle of recession/expansion we have cluttered our economy and made it less productive. Another example is our national policy on addiction. For a hundred years this country has treated addiction like a set of voluntary behaviors that can be changed with appropriate legal and economic disincentives. This has led to endless repetition of a pattern of moving from one drug crisis to another only to find the next as soon as we solve the last. Only in the last 10 years, and especially the last two, have the leaders of this country come to call addiction an actual disease. And unfortunately it looks like it might be too little, too late. Strauss and Howe’s The Fourth Turning describe how national moods change every generation lasting approximately 15 to 25 years. They tell us that these moods repeat every 4 cycles like the seasons. Their work suggests that since the world financial crisis of 2008 we have left the autumn unraveling and entered the winter crisis period. Such periods are marked by increasing social order, lower crime, increasing government power, public condemnation of substance use, and in general would be consistent with the pull away from the idea of addiction...

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The Big Short
Jun06

The Big Short

By now, most American’s have heard of the book, The Big Short by Michael Lewis, and the movie of the same name. (To short is to sell something you don’t own because you believe it will go down in price or value a great deal) Most people know that the book is about people who saw the collapse in the housing market before it happened and made money from it. That’s not really what the book’s about. The book is about how hubris and cluelessness of government officials and establishment organizations allowed imbalances to get so great that when they finally balanced (as imbalances always do) the entire financial system was at risk. The fact that individual traders saw the imbalances and acted on them should be no surprise. What is a surprise is that those very traders tried to tell people something was wrong. They went to the rating agencies and told them they were wrong; they went to the big banks and told them they were wrong; they went to the government and told them they were wrong. The reaction of all these people was that the traders didn’t know what they were talking about. “How could they know?” the establishment seemed to say. “The system had worked just fine all these years. Who are they to tell us that there are hidden costs that we don’t see?” Well history has decided who was right and who was wrong on that score, and it was an expensive lesson for all of us. The problem behind the Big Short was the assumption that housing in America could never go down across the country at the same time. It hadn’t happened for over 70 years, so it couldn’t happen, right? As long as it didn’t happen, even the crappiest sub-prime mortgage bond would be good. Turns out the assumption wasn’t true, the bonds were worthless, and the pyramid of derivatives built on them were as well. Is there a “big short” in addiction today? Is there a situation in which entrenched establishment groups or regulators are so sure they are right that they can’t see the hidden costs of their system? Is there a situation based on an assumption so old that no one today can question it? I think there is, and it’s also about 70 years old, but that’s long enough for generations of academics and clinicians to have been trained by people who were trained by people who were trained by people who assumed that this was the truth. The Big Short was a best selling book with hundreds of thousands of copies in print. There’s another bestseller that is...

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The ICU
Feb28

The ICU

The young woman walked out of the ICU knowing she’d never see her friend again. At age 26, this was the second time she’s said good-bye to a childhood playmate in this ICU.  When the first of her friends to die was lying there with a machine breathing for her, there was a constant stream of friends and family coming to say good-bye. Now that her second friend was dead but for the machine pumping air into his lungs, there was the same stream of loving people to say good-bye. Both of her friends had struggled with genetic illnesses all their lives, both had done their best to stay alive, both succumbed. The first one died of cystic fibrosis; the second, of addiction. The friend with CF did everything she knew how to do. Took all the medication her doctors told her to take, ate only the foods her doctors told her to eat, exercised, stayed fit, everything. She had a loving family that got her to the best doctors who gave her the best care. But CF doesn’t have a cure, and it doesn’t have a treatment that does more than extend life into the 20’s. It’s genetic, and it’s unfair, but so is every illness you’re born with. The friend with addiction was really no different except for one thing. When his loving family took him to the best care, he heard that medication wouldn’t help. He heard that he should be able to “recover naturally,” that he didn’t need medication. The best doctors that his family sought out didn’t tell him about evidence based medical treatments for his genetic illness. Instead they told him his illness was caused by drugs and would go away if he just stayed clean and became spiritually fit. So in his 4th or 5th rehab he went to a religious based program to get that spiritual fitness. I don’t know his spiritual status when he died, but I know he couldn’t breathe on his own. I wrote a piece recently about what we die of when we die of something that has a treatment we aren’t offered. The young woman’s first friend died of cystic fibrosis and our inability to treat the illness better. Everyone did everything they could. It’s just beyond us at this point in time. But I’m not sure that the second friend died of addiction. There is a treatment available that has been shown to improve survival rates, but he was told it’s a bad thing to be on. There’s a known neurobiology of his illness, but his treaters were willfully ignorant and disdainful of that knowledge, believing that their spiritual superiority was enough...

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Disease, Ignorance, and Cruelty
Feb19

Disease, Ignorance, and Cruelty

I want to tell you a story about disease, ignorance, and cruelty. To make it interesting, we’ll make you the protagonist. The year is 1665, and you live in London. You’re trying to stay away from people because plague is sweeping through the country, and more than a quarter of the people you know have already died. In spite of your efforts, you wake up one morning feeling weak. Your body hurts. It’s hard to move. You know immediately what’s wrong, or fear you do, and you know there’s no hope. You don’t know anyone who has become symptomatic who has survived though you’ve heard a few rumors that there are such people. You’re eventually able to get up to void your bladder and notice large swollen masses in your groin. You throw up, and the effort has worn you out. You crawl back in bed, and later that day, you die. But what did you die of? I am confident in saying that you died of disease. In this case the disease was bubonic plague, a very virulent illness caused by a bacteria called Yersinia pestis. Now the year is 2000 and you live alone in Arizona about 2 hours from the nearest town. You’re out in your garden digging and you find the skeletal remains of an animal. You think nothing of it. A few days later you wake up feeling weak and feverish. You think it must be the flu because your body hurts and you have a terrible headache. You get out of bed and when you get to the bathroom you throw up, confirming for yourself that it’s the flu. You have a lot of survival gear in the house because you live far away from help. This includes antibiotics like doxycycline, but you know that they don’t help the flu, so you just go back to bed. You try to stay hydrated but it doesn’t work out. By the time you start considering this might be more than the flu you can’t get out of bed. After falling into unconsciousness later that day, you die. But what did you die of? I’d say you died of ignorance; you died of a lack of information. You didn’t know plague bacteria can live in the ground. You didn’t know it could be found in your area. You didn’t know you had plague. You didn’t know you had the cure 20 feet away. You died not knowing that you died of ignorance. Now the year is 2016 and you aren’t living alone. You’re a microbiologist living in a group of other scientists in Arizona. You go out...

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