“First Bird,” photo by Sarah Rosenbaum, MD
“My painkillers were stolen,” the old woman told me one cold winter night.
This line doesn’t play well in the psychiatric ER. We hear it a lot. It’s a nightmare for doctors. Maybe it’s true, but we have no way to verify it, and it’s generally code for “I’m addicted to opiates.”
I was weighing my options of how to best approach the situation when she gave me an easy out.
“I’m not looking for pills. I’ll call my cancer doctor in the morning. I’m just here for depression,” she said, tears welling in her eyes. She looked frail and in pain.
I breathed a sigh of relief. She wasn’t drug seeking, just depressed. She started feeling suicidal when she lost her job as a secretary, which had occupied her days for more than 30 years. A widow with no job and a lot of medical appointments, she started feeling like a burden to her grown children. I really wanted to help her.
I asked to call her family. She begged me not to. “Please don’t, doctor,” she said, “It’s nearly midnight. You’ll wake everyone for nothing and then they’ll worry all night. I’ll call them first thing in the morning.”
This was a red flag, but I told myself it made sense. She was a woman in her 70s with cancer willing to spend all night sitting upright in a hard chair in the ER waiting room while in pain. Not feeling like a burden was important to her. I wanted to respect that.
As I wrote my note recommending inpatient psychiatric hospitalization, I checked the state prescription database. I confirmed an oncologist had been prescribing oxycontin, so I offered her painkillers. She didn’t even ask, I offered.
She thanked me for my kindness. She said she felt better already. I felt like a good doctor.
An hour later, her lab results were in. A nurse hit the desk with her hand. “Aha!” she grunted triumphantly, vaguely in my direction. “That’s why we don’t give oxy’s here, doc.”
Heroin was in my patient’s urine. I stared at the computer screen. I blinked a few times. I couldn’t believe it. Lab error?
I looked back at the nurse. She looked smug. I felt stunned. I marched back to the waiting room to find my cute little old lady. How could this be?
She cried telling me that as she had struggled to control the cancer pain, she started needing extra pills. She ran out early at the end of the month. She didn’t want to ask her doctor because she was embarrassed, so she started buying pills from a neighbor, another old lady on a fixed income who said she needed the money more than her meds. Soon, she was spending more than she could afford and was still in pain. The woman’s grandson offered her heroin. It was cheap and it worked.
I felt duped. I was angry, mostly at myself, because it was a story I’d heard a million times before. She was a typical user – about three quarters of heroin users start with doctor-prescribed opiates – but I missed it because she didn’t look the part.
“Never in a million years did I think I’d use heroin. I can barely even say the word, heroin. Drugs! This isn’t me. I’m a grandma. I go to church. Please don’t tell my family. You have to believe me,” she begged.
Heroin was her hero, at least for a while, she explained. It helped save her relationships. On heroin, she wasn’t in pain, and she didn’t need as much care and support from her family. Her heroin habit was a burden to no one but herself.
Hearing this, my anger melted to sadness. It wasn’t about getting high, it was about being self-sufficient. What looked like manipulation was really self-preservation.
I understood. Talking to her, I remembered the euphoria I felt on Percocet after my wisdom teeth were removed in high school. I lay in bed doing nothing for three days, flying high, and enjoyed the deepest, most satisfying sleep of my life. Fear, shame, and worry simply weren’t accessible to me. Nothing seemed to matter. Then, I struggled to sleep for nearly a month afterwards. Though nobody ever told me my “medicine” was highly addictive, I concluded that I could never take anything like that again. Too powerful.
Opiates are too powerful. That’s how they silently climbed to the #1 killer of all Americans under 50. No age, education, wealth, family, or religion is impervious to the power of heroin. My mistake, as a doctor, was forgetting that. The little old lady will always be my reminder that opiates are an equal-opportunity offender and heroin always wins.
Lisa Jacobs is a fellow in child psychiatry at Stanford University and the founding editor of this magazine.
“Veiled Tears” by Danielle Couture, MD