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REFLECTIONS ON THE EFFICACY OF OPIOID PAIN RELIEF OVER TIME

pain photoBefore addressing the issues of this article, I will need to explain the position from which I write. At the present time I am a 76-year old, semi-retired sociologist and former nurse. As a sociologist, it was natural for me to include the sociology of medicine as one of my major interests. As a nurse, I worked for three years in the county jail nurse’s office, several years in the emergency room, and for six years as a hospital corpsman in the navy reserve.

I was introduced to the whole drug scene while working in the jail, where it was my job to treat substance abusers who were addicted to paint, glue, alcohol, and various drugs. This was in the very early ‘80s, and the majority of the street drugs were amphetamines, Quaaludes, heroin, and marijuana. It was necessary to control withdrawal symptoms from the time the inmates were booked, to keep them alive long enough to go to court, serve whatever time they were given, and be released back into the same environment with virtually no change in their lives except those imposed on felons. The recidivism rate was extremely high—more so than for any other offense. During the time I worked there, the fastest turn-around rate for a released prisoner being picked up drunk and brought back in to Booking was 30 minutes.

Of course, in the ER and even in the Navy reserve I saw evidence of substance abuse. As a corpsman I was also involved with both diagnosis and treatment. The most heartbreaking experiences, however, occurred while I was working at a private college in Appalachia from 1997-2013. I saw firsthand the growth of the OxyContin and heroin epidemic that Sam Quinones documents in Dreamland, followed by Meth and various other prescription drugs, soon followed by the amoral pill mills that so delighted students who were already dependent or in early stages of addiction. At their age, they were the most vulnerable to the brain disorder of addiction, and the main targets of the dealers who would actually supply their first pills free, to encourage a new customer. I saw so many beautiful, bright students succumb to the promise of a pill that would make their life better, more fun, or at least easier. I was able to help some, but not all, by far. They needed experienced and trained medical attention, and I was no longer in that field. I came to despise the very thought of drugs, dealers, and pill mill “doctors”.

But there is another side to my story. In 1968 I suffered the first experience of a bulging spinal disc. Within 3 years I was diagnosed with degenerative disc disease, and with osteoarthritis of the spine, hands, feet, shoulders and hips. By 2013, there was no part of my spine that was not affected; I had major stenosis at various levels, bone spurs, episodes of bulging and decayed discs, a vertebra that had decayed discs on both sides and was standing on edge, resulting in a spinal S-curve from my waist to the upper thoracic region. Unrelenting pain caused muscle spasms in my entire back and neck, adding to the pain. A meningioma would soon be discovered attached to my spinal cord at T3-4; it is benign—the only worry being that it will grow.

During those 45 years living with pain, I never had any medication stronger than NSAIDS. Like many patients, I could not tolerate narcotics or opioids. I had to learn meditation and “mind control” (pushing the awareness of pain to another part of my consciousness). I had a great deal of physical therapy. I played the piano and organ for distraction, until I could not. I walked from 1-3 miles every day, and I worked full time as a nurse, then as a college professor, usually working between 40-60 hours a week. I spent seven years in South Africa in the middle of a revolution. The more I could distract myself with external demands, the longer I could function. Again, until I could not.

In 2014, so disabled by pain I could neither work nor sufficiently care for myself, I was sent to a pain management specialist in Louisville, KY. After I was finally convinced that he was a legitimate pain specialist who would not try to get me addicted, we were able to work together very well. I learned to trust his judgement, and to follow his lead in determining my treatment.   As a result, I have been able to teach at a local university part time for the last two years, and it has been a year since I have had pain greater than 5 on the 0-10 scale. One of the reasons that the pain has not been greater, and has not persisted, is that when it gets to that point I take hydrocodone, at its very lowest dose. My pain doctor realized that I am able to tolerate very low doses of medications for other problems (many of which were caused or exacerbated by long-term use of NSAIDS), so we tried the opiate. The complete pain relief has been astounding to me. I have never before had medication do more than take the edge off the pain. Equally important, my need for the opiate is becoming less and less frequent. My chronic anxiety levels have dropped considerably, and that also is a source of pain relief.

Which brings me, finally, to the point of this article. I hope I have sufficiently established the experience and credentials that give me the foundation for writing it. I must write it, because for too long I have been reading articles by people who have based their judgement about the dangers and/or efficacy of opiate treatment for pain on short-term, inadequate research. In A World of Hurt, by Barry Meier, he quotes Dr. Jayne Ballantyne as saying that her studies, and those of others, show that after a short term of therapy, there is little to no efficacy (5% of patients) of opiates for pain. I have seen and heard these figures often; yet pain management physicians also have records of people who have been carefully managed on opiates and other pain relieving measures for at least twenty years, who are functioning without severe pain. None of these studies satisfy me that they meet the natural science or sociological requirements of longitudinal studies. The former studies fall far short of twenty years, and the latter are a matter of record but no sufficiently rigorous scientific research has been done to establish credibility.

Additionally, our understanding of the prevalence and range of chronic pain issues, and the new brain studies that have completely revised our knowledge of addiction, have rendered those studies irrelevant. But the continued widespread references to them has created a situation that is clearly morally and ethically bankrupt: Patients with persistent, severe pain—including, in many states, terminal cancer patients—are being deliberately, systematically deprived of relief and therefore from the ability to lead potentially productive lives, or at least to spend their final days in peace, without pain. This, while other substances that are addictive are legal and can be consumed by any adult, regardless of their risk factors for addiction, whether or not there is a “need” for the substance.

What would make opiate efficacy studies reliable and verifiable? First, to acknowledge that all pain patients are unique in their tolerance to pain, their response to pain, and their response to treatment. Not everyone can metabolize medications the same way. Not everyone responds equally to physical therapy, or to psychological counselling. Not everyone has the personality to effectively meditate, or to suppress awareness of moderate pain. But all of these treatments, as well as known risk factors, are variables that must be accounted for if you are judging the efficacy of pain treatment.

Then there is the issue of the selection of participants. When I read the studies done in past years, I found they were limited to a single practice, or a hospital, or other small group of patients with no concern for variables like age, risk factors, history of abuse, previous treatment and other illnesses. The participants were not chosen scientifically in order to be representative, so results are inevitably skewed. I am reminded of early anthropological ethnographic studies where small, isolated villages were researched, then the results extrapolated to all such groups: “from the particular to the general”. We now realize that you can’t do this and arrive at accurate conclusions. Yet, on the basis of these flawed opiate efficacy studies, people’s lives are being damaged, their families are suffering needlessly, and many patients who are cut off from their medication either take to street drugs with the risk of overdose, or just commit suicide in the first place.

We do need more research about the safety and efficacy of drugs. But it must be longitudinal and scientifically designed and the results assessed to be reliable and verifiable. We also need politicians to stop enacting laws and policies based on moral definitions of issues, which we can never come to consensus about, and work on the actual economic and environmental issues that they can actually improve.

Addiction is a disease, not a moral issue. Pain is a disease, not a moral issue. And we are not speaking of just a few people affected by the neglect resulting from ill-informed laws and regulations designed more to punish the innocent along with the guilty rather than to end the War on Drugs. We speak of hundreds of thousands, even millions of sufferers. When properly identified as scientific (medical) problems instead of moral issues, we can see the potential to improve conditions. People could be adding to the economy, rather than being forced to either live off of it, or to live in poverty while their pain continues to worsen.

Big Pharma—for example, Purdue Pharma– are far from innocent in this War. Additionally, the FDA is no longer as concerned with protecting potential patients as they are in protecting corporate rights to profit; witness the countless lawsuits for drugs improperly researched, improperly advertised, and improperly presented to physicians who must rely on that information in order to prescribe successfully. And the DEA is still, regardless of evidence that they are often destroying the lives of the innocent while failing to halt the spread of illegal drugs, using pain patients and their physicians as cannon fodder in their failed war on drugs.

A significant paradigm shift is required here. Educationally, culturally, legally and morally we must illuminate the darkness of our willful ignorance about the suffering of the innocent who have become scapegoats in the failed War on Drugs due to tunnel vision about the relationships between drugs, physicians, and pain; a tunnel vision that cannot see the greed and political will that perpetuates the drug problem. Every institution of our society has failed our physicians and their patients who are in pain, or addicted. Those institutions have either failed to adjust a false worldview that blames patients for their illnesses, or have just failed to assume responsibility for their role in finding solutions to the need for a collaborative approach to these widespread diseases, and to the devastation that has resulted from long term beliefs that they are moral issues that must be punished.

For over a century, that approach has not worked. And as the saying goes, insanity is defined as continuing to do the same thing over and over again (or doing even more of it), expecting different results. From family, to education, to religion, culture, economics and government we need a major overhaul of outdated and inaccurate beliefs, and development of procedures that decriminalize the treatment of chronic pain and addiction, as well as the afflictions themselves. Medical decisions need to be made by medical experts and their appropriate medical agencies, and the Criminal Justice system could concentrate on ridding our nation of illegal drugs by putting the same time and effort into stopping the dealers who daily increase the supply of drugs available on our streets. We might even look to the successes of other countries, and determine if their methods are importable.

I cannot bear the thought of more bright and beautiful college students ruining or ending their lives before they have even begun. The data suggests that it is not stopping with college students, but that high school and even middle school students are being targeted as “customers” of the illegal drug trade. I also cannot live with the knowledge that caring and dedicated physicians, who have spent nearly half of an average 70 year lifetime studying and working for the privilege of becoming practicing physicians, have lost everything they have worked for because they have tried to help their patients. (I am quite ok with pill mill “doctors” being brought to justice for their crimes, however!)

It is Christmas Eve as I write this. A time of hope, a time of expectation that the promises of life can be fulfilled. I am a sociologist because I believe in the amazing capability of human beings to solve the problems of life, separately and together. I am also all too well aware of our capability to create and maintain cultural and social institutions and structures that protect certain groups of humans at the expense of huge numbers of their fellow humans. I believe that most of us are better than this; that we can do better, and that bit by bit we can learn to adapt to change, to each other, and to the requirements of living in our world safely, together.

Please—let’s make 2017 the year we begin to deal with chronic pain and addiction as the disease processes they are, and begin to structure our corporate life accordingly, so that together we can end the war on drugs, and on patients and their physicians, and restore the rationality of the Enlightenment without killing the compassion of empathy.

enlifghtened being

RESOURCES: Books & Peer Reviewed Articles

Alexander, Michelle. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. 2012. The New Press, NY

Bateman, Dustin. Neurological & Sociological Aspects of Addiction.

Bertram, Eva and Morrris Blachman. Drug War Politics: The Price of Denial. 1996. University of California Press.

Levinthal, Charles F. Messengers of Paradise. Opiates and the Brain. The Struggle Over Pain, Rage, Uncertainty and Addiction.

Meier, Barry. A World of Hurt: Fixing Pain Medicine’s Biggest Mistake. 2013. New York Times Company.

Parsons, Talcott. “Illness and the Role of the Physician: A Sociological Perspective.” American Journal of Orthopsychiatry 24 March 2010. Copyright © 2010, John Wiley and Sons.

Quinones, Sam. Dreamland: The True Tale of America’s Opiate Epidemic. 2015. Bloomsbury Publishing Plc.

Sternheimer, Karen. Connecting Social Problems and Popular Culture:   Why Media is not the Answer.  2nd Ed. 2013. Westview Press, Perseus Books Group.

Webster, Lynn R. The Painful Truth: What Chronic Pain is Really Like and Why it Matters to Each of Us.  2015  Webster Media, LLC.

Hyperlinks to articles on Web:

Addiction is a Brain Disease http://www.attcnetwork.org/explore/priorityareas/science/disease/

Pain Medicine News – How Did We Get Here? http://www.painmedicinenews.com/ViewArticle.aspx?d=Guest%2BEditorial&d_id=351&i=March+2014&i_id=1042&a_id=26043&tab=MostEmailed#.U3PLVV6vdyI.twitter 

Report: Chronic, Undertreated Pain Affects 116 Million Americans http://ti.me/AAfT7q  via @TIMEHealth

New Pain Management Rules Leave Patients Hurting http://seattletimes.com/html/localnews/2016035307_pain28m.html#.U2mA77bwJzQ.twitter 

Chronic Undertreated pain affects 116 million Americans: http://healthland.time.com/2011/06/29/report-chronic-undertreated-pain-affects-116-million-americans/

Our Fear of Opioids Leaves the world in Pain http://edsinfo.wordpress.com/2014/10/27/our-fear-of-opioids-leaves-the-world-in-pain/

MT @toni_bernhard: My new piece. It should be of interest to anyone whose illness is questioned: http://www.psychologytoday.com/blog/turning-straw-gold/201410/i-m-sick-what-is-wrong-me …Dr. Paul Christo @DrPaulChristo  ·  Oct 27

California Doctor….   http://paindr.com/california-doctor-unveils-painful-abyss-facing-patients-in-pain/

Physician Suicide http://t.co/4vhF63eD6N

References from this article:

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  2. Adams D. Physician suicide: searching for answers. American Medical News [serial online]. April 25, 2005;Available at http://www.ama-assn.org/amednews/2005/04/25/prsa0425.htm.
  3. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. Jun 18 2003;289(23):3161-6. [Medline].
  4. Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. Jul 2004;57(1):1-4. [Medline].
  5. Holmes VF, Rich CL. Suicide Among Physicians. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle. Washington, DC: American Psychiatric Press; 2004:599-618.
  6. Middleton JL. Today I’m grieving a physician suicide. Ann Fam Med. May-Jun 2008;6(3):267-9. [Medline].
  7. Noonan D. Doctors who kill themselves. Newsweek. Apr 28 2008;151(17):16. [Medline].
  8. Petersen MR, Burnett CA. The suicide mortality of working physicians and dentists. Occup Med (Lond). Jan 2008;58(1):25-9. [Medline]. [Full Text].
  9. Worley LL. Our fallen peers: a mandate for change. Acad Psychiatry. Jan-Feb 2008;32(1):8-12. [Medline].
  10. Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94. [Medline].
  11. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302. [Medline].
  12. Gross CP, Mead LA, Ford DE, et al. Physician, heal thyself? Regular source of care and use of preventive health services among physicians. Arch Intern Med. Nov 27 2000;160(21):3209-14. [Medline].
  13. Myers M, Fine C. Suicide in physicians: toward prevention. MedGenMed. Oct 21 2003;5(4):11. [Medline].
  14. Myers M. Doctors’ Marriages: A Look at the Problems and Their Solutions. 2nd ed. New York: Springer; 1994.
  15. Charles SC, Frisch PR. Adverse Events, Stress, and Litigation: A Physician’s Guide. New York: Oxford University Press; 2005.
  16. Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. Nov 2011;213(5):657-67. [Medline].
  17. Sessions S. Dr. Ticktin and the Expert Witness Industry. 2005;[Full Text].
  18. Myers M, Gabbard G. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing; 2008.
  19. Lehmann C. Aggressive Intervention Urged for Depression in Physicians. Psychiatric News. November 17, 2000.
  20. Miles SH. A piece of my mind. A challenge to licensing boards: the stigma of mental illness. JAMA. Sep 9 1998;280(10):865. [Medline].
  21. Hendin H, Maltsberger JT, Haas AP. A physician’s suicide. Am J Psychiatry. Dec 2003;160(12):2094-7. [Medline].
  22. Hendin H, Reynolds C, Fox D, et al. Licensing and Physician Mental Health: Problems and Possibilities. Journal of Medical Licensure and Discipline. 2007;93:6-11.
  23. Schwenk TL, Gorenflo DW, Leja LM. A survey on the impact of being depressed on the professional status and mental health care of physicians. J Clin Psychiatry. Apr 2008;69(4):617-20. [Medline].
  24. Polfliet SR. A National Analysis of Medical Licensure Applications. J Am Acad Psychiatry Law. 2008;36:369-74. [Full Text].
  25. Altchuler SI. Commentary: Granting medical licensure, honoring the Americans with disabilities act, and protecting the public: can we do all three?. Acad Med. Jun 2009;84(6):689-91. [Medline]. [Full Text].
  26. Schroeder R, Brazeau CM, Zackin F, Rovi S, Dickey J, Johnson MS, et al. Do state medical board applications violate the Americans With Disabilities Act?. Acad Med. Jun 2009;84(6):776-81. [Medline]. [Full Text].
  27. Andrew LB. Survey Says: Many EPs Suffer in Silence. Emergency Physicians Monthly Online [serial online]. March 2006;13:3:1-7. Available at http://www.epmonthly.com/index.php?option=com_content&task=view&id=226&Itemid=15.
  28. Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).
  29. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1 2008;336(7642):488-91. [Medline]. [Full Text].
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  33. American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention. Available at http://www.afsp.org/index.cfm?page_id=05804002-E8F4-13AB-2D4B97A0815A2744. Accessed 10 March 2010.
  34. Goldsmith SK, Pellmar TC, Kleinman AM. Reducing Suicide: A National Imperative. Institute of Medicine Monograph. National Academies Press; 2002:[Full Text].
  35. Andrew LB. PHPs Are in Your Corner. Emergency Physician Monthly Online. 2006;13:6:[Full Text].

Physician Risks

The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …

Trial Verdict: Dr. Baldi Not Guilty on All Charges http://whotv.com/2014/05/01/baldi-trial-not-guilty-on-all-charges/

What are Patients to do when Law Enforcement Closes Clinics? http://missoulian.com/news/state-and-regional/ravalli-county-health-officer-says-patients-of-raided-florence-clinic/article_cf2e1690-bac0-11e3-848e-001a4bcf887a.html

Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html

Patient role in helping physicians

“Unless patients wake up and fight for the providers of care, we are headed for the sickest system in the world.” http://www.kevinmd.com/blog/2014/03/dissatisfied-doctors-provide-good-patient-care.html …

 

dr-murphyFrom James P. Murphy, MD, MMM;

Practicing Pain Management Physician

Board Certified in Pain Management & Addiction Management

https://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

https://jamespmurphymd.com/2016/07/24/comparing-apples-to-apples-the-morphine-equivalent-daily-dose/

https://jamespmurphymd.com/2016/06/21/prescribing-controlled-substances-in-kentucky-cme-presentation-for-flaget-memorial-hospital-in-bardstown-ky-june-21-2016/

https://jamespmurphymd.com/2015/02/13/pathway-to-partnership/

https://jamespmurphymd.com/2015/09/a-stellar-time-at-bellarmine

 


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COLLEGE STUDENTS GIVE MY LIFE MEANING

bare tree

The university academic year begins for me this week, and—not for the first time—my thoughts are heavy with the implications of the grave responsibility of educating the young. This year, though, seems to weigh heavy on my heart more than any such year in the past, with the possible exception of the years in South Africa during the end of apartheid and the first years of democracy. It could even be because of those years, and the comparisons that can be made between South Africa then, and the United States now, that my concern is great.

Of course, no comparative study would find a perfect correlation between the two countries. But there are many similarities, especially when observing the issues of race, intolerance, social injustice, disenfranchisement, rule of a power elite—I could go on, but already it become obvious that there are points to be made, as well as huge differences in the two situations. Can anything be learned from the past in another country, that would shed light on a way forward for us in the present?

My course load this semester consists of Intro to Cultural Anthropology, Social Theory, and Political Anthropology. All three courses contain a great deal of material that directly relates to August 2016 in the United States. Some of these situations, like the failed war on drugs and its ongoing, devastating aftermath, do not appear to be related to anything that occurred in South Africa. But when you look deeper at the combinations of political misinformation, low intensity violence incited deliberately by the government, and antipathy between police and the often innocent subjects of their brutality, a shared trend appears.

In fact, one can see that the troubles in both nations were not caused by failed societal structures so much as by a shared failed personal accountability for human actions. I always try to find an opportunity to explain to my students why it is true that to the extent we dehumanize others, we dehumanize ourselves. And the more often that we do that, the less human we become. At some point, it no longer matters who we hurt, or how much we hurt them. Having reached that point, nothing is sacred—we can lie to each other, cheat in personal and public relationships, and shame our religious traditions by turning them inside out and using them against each other, rather than in enjoyment of the sacredness of our existence. Some people blame this on the capitalist profit motive; I blame it on unrestrained greed grown to inhumane size, however you want to rationalize it.

Our inhumane behavior is seen in social media pages, day after day. Many posts are deliberate lies, some are propagated by people and organizations who make a great deal of money developing the ways and means of destroying political opponents, or spreading ideas in order to challenge inconvenient truths about how we should live. Our youth often do not trust our government, our news media, or our religious leaders. We have an entire generation of youth who have grown up in the midst of uncontrolled verbal and media bile, day after day. Yet many parents and teachers are still able to reflect the values of integrity and community to their children; too many others have failed.

I don’t want to be one of those who fail those precious young people. It would be safe for me to just present the information in the texts as is, and avoid controversy. Unfortunately, sociology and anthropology are not calculus. They exist to provide a learning situation whereby we may study, compare, theorize, and determine the state of our world, and consider possible ways to improve our situation and that of others. If we learn anything at all from these disciplines, it is that humans are not meant to live just for themselves. We are psychologically and mentally geared to living in community, from whence we learn our sameness as well as our beautiful uniqueness; where we learn to share, to care for others, and to be cared for. It is where we discover the meaning of our lives, as Victor Frankl explains so beautifully.

On the surface, our country is in what Durkheim would call a state of anomie; of “normlessness.” There are too many who live by disregarding the norms of human interactions, of human responsibility. The rest of us are not free of responsibility for this state of affairs. The rapidity of progress has allowed us all to enjoy an unprecedented mobility, separation from family and old friends, from the norms that defined our lives when we were young people. The sense of normlessness that has grown has produced political and religious apathy, as our values as a nation have withered into weapons for some groups to hurl at others in hatred.

It could appear that all is lost. It is not. We can, and must, regain our humanity by treating others as the precious human beings they were meant to be. We cannot separate ourselves from community, especially from communities of meaning. We can look to the examples of those around us who are good people, who live honestly and compassionately. We can seek justice for those whose lives have been broken by injustice.

…..We can demand from our government leaders the same values that we hold for ourselves, and make sure not to repeat errors in judgement on that score.

….. We can bring family life back into vogue, securing the early years of our children with the nuts and bolts of honesty, responsibility, and community.

….. We can demand improvements in our education systems so that our children learn to think, not just to memorize.

And we can treat the people we run into each and every day as though they were human beings like ourselves: imperfect, yet full of potential; sacred to their Creator and therefore sacred to ourselves. Deserving of respect—enough so as to inspire those who have none for themselves to strive for improvement.

 

……Yes, this is indeed a heavy responsibility to owe to the students in my classroom. But why else would I even want to be there? The intergenerational discussions and learning that will take place give my life meaning. My students, who are also my teachers, are the joy of my life. When I meet with them again, that “heavy responsibility” will be rediscovered as a great privilege. So begins another year.

classroom