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Verstehen, through shared perspectives


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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:

  1. Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested case control study. Depress Res Treat. 2011;2011:936327. [Medline]. [Full Text].
  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].
  30. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. Sep 23 2009;302(12):1294-300. [Medline].
  31. Frank E, Carrera JS, Stratton T, Bickel J, Nora LM. Experiences of belittlement and harassment and their correlates among medical students in the United States: longitudinal survey. BMJ. Sep 30 2006;333(7570):682. [Medline]. [Full Text].
  32. Moutier C, Norcross W, Jong P, et al. The Suicide Prevention and Depression Awareness Program at the University of California, San Diego School of Medicine. Acad Med. Mar 2012;87(3):320-6. [Medline].
  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


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WHY I WOULD SUPPORT NEEDLE EXCHANGE PROGRAMS

syringes“I don’t understand. Why would you, with all your experience and training, vote for a needle exchange program that supports the habits of drug users?” Her question was not rhetorical. Her face flushed with emotion, angry tears in her eyes, she radiated the frustration behind her outburst. Though the need for answers was obviously deep, she was too overwhelmed to wait through any discussion and stormed out of the room.

I fully understood her point of view, as well as her expectation that I should know better than to entertain what she saw as a completely irresponsible position, counter to all that I should know. But it was precisely my experience, as well as all my education and training, that over the years had brought me slowly but convincingly toward my present convictions on the subject. Like many of us, she may have had close and painful experiences with the devastating results of drug abuse, and with addiction. She may even have taken courses where professors taught the evils of drug use with passion, hoping to spare their young charges the life changing downward spiral of drug use. Or, she could easily be a social worker, or health care provider, daily living with the emotional draining and burnout of working with abusers and addicts. Who would blame her for her perspective on the subject? As I often tell my students, where we stand on a given issue depends on where we stand in life. Experience is valid; it is real. With social problems, however, it just can’t be generalized to explain the whole issue.

Without comprehending the whole issue, we fail to take other valid points into our understanding. And without those other valid points, we make decisions that are almost guaranteed to produce negative unintended consequences.

What are some of those other valid points?

  1. Drug abusers use and share dirty needles. This leads quickly and devastatingly to increased numbers of diseases, primarily HIV and Hepatitis C. Even if only drug users were to be affected, the incidence of disease could reach epidemic proportions.
  2. When users respond to and comply with the regulations of a needle exchange program, they can be tested for HIV and HepC, and immediate treatment begun. The cost of a needle exchange program is high, and the additional cost of treating one HIV patient could be as high as $100,000. There will be more than one patient. This is a commitment of both financial and emotional proportions that is, and should be, taken seriously by any community.
  3. The cost of not doing it is exponentially higher. First, an untreated HIV victim is likely to progress into full-blown AIDS. THE COST OF TREATING ONE AIDS PATIENT FROM THE TIME OF DIAGNOSIS TO DEATH IS, ON AVERAGE, ONE MILLION DOLLARS. Second, that untreated carrier of HIV and/or HepC is eventually going to infect any number of others in a variety of ways: Family, sex partners, healthcare workers, First Responders, law enforcement officers, good Samaritans…all are at risk. They are not the limit, however. And each one infected is going to generate costs of $100,000 to $1,000,000. The financial costs do not even begin to quantify the emotional and productivity costs to everyone from family to the entire community.

In other words, no matter the cost of the program, the cost of NOT having the program in the presence of a proven epidemic is incredibly higher!

Given #s 1-3, we have only looked at the actual costs of having, or not having, a needle exchange program. But what about the perspective of those who resent what they see as a moral, or an ethical, objection to “helping” drug abusers and addicts?

To this, I would answer first of all that the issue is NOT only about drug addicts. IT IS A PUBLIC HEALTH ISSUE. It is simply not rational to fail to protect our families, neighbors, public servants and health care workers because of our antipathy toward ANY one group of people, no matter how deeply that antipathy is grounded in our being.

Second, I would remind those of us who claim to be Christians, that–all appearances to the contrary–these abusers and addicts are still human beings. Once, many were teenagers or young adults who in the blissful ignorance of their mortality succumbed to the desire for the drug-induced high, the shared forbidden experience with like-minded peers.

Others were veterans, returning with dependencies or addictions already in place as one of the costs of defending our rights to live in freedom. Still others began as patients, some who were denied proper medication and sufficient care by our laws; others who for any number of reasons (rational or irrational) took to the streets when their increased tolerance for drugs failed to meet their need for them.

And finally, the fact is that addiction is not something anyone deliberately chooses for their life. No one looks forward to that relaxing drink after a hard day at work, or even a drug-induced escape from the stresses of life, believing that one day in the future they will be a slave to a substance that no longer provides these things, but instead has become a painful, frightening and life-threatening craving, constantly demanding to be satisfied. Instead, we either say “I can’t handle [the substance]” and leave it alone; or we believe that “I can handle it,” and take our chances.

Many, in fact, may be able to handle it better than others. However, no one is fully immune from potentially developing the disease of addiction. We are learning more about risk factors on almost a daily basis, but we still cannot predict with certainty who will develop addiction.

The disease is one in which the reward center of the brain runs amok, refusing to turn off when the need for the reward is satisfied.  Aside from he repeated use of the “addicting” drug, there are risk factors:

1.  Genetic factors actually account for about half of the likelihood that an individual will develop addiction.

2. Environmental factors (i.e. where and with whom do you live and work) are influential.  Unstable social supports and problems in interpersonal relationships affect the risk.

3.  Individual resiliencies (through parenting or later life experiences) are important.

4.  Culture also plays a role, as does exposure to trauma or stressors.

Also at risk are those who suffer from chronic disease, depression, or who feel themselves alone in the world–that no one cares if they live or die.

We may never eradicate drug abuse. That is no excuse for refusing to accept the personal and financial responsibilities for changing our perspectives about those who become victims of it.

What have we got to lose by changing the ways we think about this issue and working to alleviate it? By helping users and addicts to stay alive long enough to be helped and encouraged onto a pathway out of active addiction? In our thousands of years of civilization, we certainly haven’t accomplished much with our old ways of attempted control of drug abuse. I believe it is worth trying, worth the effort to erase the stigma of addiction and restoring the will to change that must happen before an addict can fight their addiction.

After all, when a person repeats the same ineffective activity over and over, expecting a different and positive result, has this not become one definition of insanity? Haven’t we criminalized the disease of drug addiction long enough? Don’t we need to stop the insanity?  Dealing in a positive manner with addicts early enough has the potential to lower the rate of addiction that eventually leads to serious criminal activity in order to feed the addiction. Must we simply stand by and watch this happen? Programs like needle exchange and early testing in clinics don’t increase the problem. They are the only thing proven useful so far in decreasing the infectious diseases, the illegal drug use, and the consequent costs to the community.

I choose, however, to see this not as a dilemma of abandoning a moral issue for a practical one, but rather the blessing of making the right choices, for all the right reasons.

Reference for the risk factors and definition of addiction:

http;//www.asam.org/for-the-public/definition-of-addiction

Other Resources: 

http://www.cdc.gov/IDU/facts/AED_IDU_SYR.pdf

http://hcvadvocate.org/hepatitis/hepC/needle_exchange.html


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EXPECTATIONS: Helpful and Otherwise

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Overheard in a college hallway: “I am who I am! I cannot be responsible for his expectations of me.”

The tone of voice was stressed, angry. The speaker was obviously struggling in some relationship where she felt the pain of believing she was expected to measure up to some standard with which she did not agree, or believed she could not meet. Her anger at not being accepted for that of which she felt capable seemed fed by her guilt that she had not measured up to the standards of someone important to her.

Or, was I projecting? Was I reading too much into a simple declaration, simply because it resonated so deeply? Who among us has not at some time felt the pangs of inadequacy, having somehow failed to be the person that a parent, teacher, friend or spouse thought us to be? More important, who of us is not guilty of verbally projecting our expectations on another in a judgmental fashion, capable of stripping the other of self-confidence and a sense of belonging.

Strange Family

Strange Family

As the Academic Dean of a small college in an rural area where students received a suboptimal education, as both student and faculty advocate I was often called upon to mediate the issues arising when faculty from more cosmopolitan backgrounds failed to recognize the intelligence and potential of their students, judging them only on their failure to have been adequately prepared for college level work. Faculty would often disparage the students publically, claiming they would not work, could not learn, and should not be in college. Their expectations of the students were as low as their claims, and the relationships between those faculty and their students were broken and painful. Neither group expected anything good to come from the other.unhappy 1

Yet my own experience with these students was that on the whole (of course there were exceptions – there always are) the more I expected from my students and the more I recognized their exceptional qualities, the harder they worked and the more they succeeded. Further, they returned my love and respect for them, and for each other. The same was true for my students in Africa, as well as for my students in a large city-based university.

The principle, I believe, crosses cultures and generations. I first heard it stated from a young OB-GYN physician who had been charged with overseeing residents, interns and patients in a central city hospital clinic. I had the privilege of working for him as he changed the appearance, the attitudes, and the quality of care at that clinic. Where it had been said patients were “herded like cattle” into the clinic area itself, and then into exam rooms where they were prodded, talked about over their heads between the teaching and learning physicians as though the patient was a dumb animal, where the environment itself was dirty and depressing—there was change. In an attractive, welcoming environment where every patient was treated as well as paying patients in a private doctor’s office, we were able to observe the change from surly, quarrelsome and often unwashed patients to patients who were no different from those in any doctor’s office, where they trusted their caregivers and returned the respect they were given.

What that young physician believed and lived by, and helped everyone around him to emulate, was the statement he always made: “People will respect themselves and act accordingly if they are treated with respect and dignity.” Most did just that.

What I told my faculty members was “These students will live up to—or DOWN to—your expectations. Either outcome will be elicited by your treatment of them.”

Expectations make us or break us. Expressed in love as realistic possibilities that honor and dignify the humanity of the other, they can inspire. Expressed as a judgment of the failures of the other, or as a goal absolutely not in accord with the dreams and goals of the other, they are destructive. And that includes the expectations we have of ourselves.

self-confidence


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THE SKY IS FALLING

The expressions of a pervasive sense of impending doom are on the increase, whether you read/listen to the armchair experts on social media, or the professional experts in science, economics, philosophy, or religion. Yet as I look around me in the “real-life” portion of my world, people seem to be pretty much absorbed by the joys and/or challenges of daily living rather than wondering whether the world is going to end in a financial meltdown, climate change disasters, the extremes of social anarchy, or World War III. Then, of course, there are others who only argue about who is to blame for any of these terminal disasters, as opposed to those who fatalistically refuse to think about it: “Whatever will be, will be.” Finally we have those who are totally unaware, perhaps desensitized by a lifetime of failed threats of the immanent End of Time.

-Remember the back yard bomb shelters of the Cold War era, complete with supplies to support a family until it was safe to return to the earth’s surface (however long that would be)?

-Remember the End Times and the Space Ship arrival cults? (True, these are not entirely gone).

-Remember Y2K, and the Mayan Calendar date of December 2012?

Or, just pick up the New Testament and read the words of the prophets who followed Jesus, claiming the Rapture would occur just any day, despite the words of Jesus himself, who stressed that the date could not be known. Yet the Second Coming of Christ has been predicted many times in the past 2000 years. It seems that when we are not fearing the end of the world, we are happily anticipating it.

Widespread dissatisfaction with and/or fear of the world as it is, however, have always been accompanied by cries that “the sky is falling.” And sometimes, it does – though not even close to earth-wide since the destruction of the dinosaurs. It happens to us as individuals, too. When everything goes wrong in our lives – economically, health-wise, or in relationships – the suicide rates go up, while others still consider ending it all or pray to die, because their situation is intolerable. The reasons for coming disaster mount up, while our ability to think rationally enough to take action for positive change in our own lives rapidly disappears. If that is our individual coping mode, how can we expect to fare any better in large groups, or as a nation?

Where is the leadership that can put aside their personal fears and aspirations, and show us the way to work together to solve the problems that have solutions, and learn how to prepare for the “new normal” when change is inevitable?

Where are the families and the communities that can help each other to get through the bad times, and show their children how to deal with disaster and failure as well as with success and wealth? I know for a fact that these exist, but perhaps there simply are not enough of them. Or maybe they have forgotten.

Where are the teachers who used to show us how to apply theory and practice to real life situations, and how to think critically in order to separate truth from fiction when possible? I do know of some.

Finally, we can’t blame all these people for our individual and collective feelings of impending doom. I believe that our lives will improve when we stop rushing head-long and helter-skelter into the end of time and stop to get our common sense back.

Yes, indeed, there are threats to our safety and well-being. There are major changes coming to life as we know it. (In fact, there always have been – they just come faster now). We can’t afford either denial or complaisance, and we never could. We have, however, succeeded grandly as a human race when we have cooperatively put our mental and physical resources together to figure out how to meet the challenges of the day, how to be good stewards of our resources, and how to live together in relative peace. This works for nations, for communities, for families, and for individuals.

The sky is not falling yet. It may never fall. But there are definitely some threats. While those who can, work together to see that the potential for damage is lessened as much as possible, the rest of us need to be cooperating – with those who are knowledgeable, as well as with each other — and not giving in to fears of the future or to total denial.

The way to get through a challenge is to work it out, and work it through. Life has always been like that.


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A 21ST CENTURY FAIRY TALE

THE OWL, THE ELEPHANT, THE DONKEY AND THE DREAMER
It was a fine summer day in the Magic Forest, where a Wise Old Owl, perched on the limb of one of the lovely old oak trees, kept turning his head (as owls are wont to do) to peer wide-eyed at the impressive sight behind him. Just that morning, he had come upon a huge stone wall through the middle of the forest, and no matter how high he flew, he could not get over it to the other side. Nor could he discover an end to the wall, in either direction. It was now well into the morning aowlnd the owl, being a nocturnal creature, was ready to call it a night and go to sleep. Unfortunately, he could not rest. The puzzle of this huge wall was in itself distracting enough – but what was on the other side?

Even though he had turned his back to the wall, he was unable to resist turning his head to look at it, time and time again. After a while, he began to discern what appeared to be a door, or a closed gate in the wall. The more he focused on the potential opening, the more clearly it began to take shape. Finally, it seemed as though a huge wooden door, shaped and hinged much like the door of a medieval European castle, was now as solidly embedded in the wall as the wall itself was an unchanging and solid part of the landscape. The magical nature of this phenomenon did not bother the Wise Old Owl, because he was perfectly aware that he lived in a magical forest, where strange things sometimes happened.doorway of truth

But the occurrence of strange things in magical forests is usually a sign that something of importance is coming into being. Being wise, the owl knew this to be a fact. So, giving up the idea of sleep altogether, he flew to the door in the wall to investigate. The first thing he determined was that it was very real and very solid, as he was quite elderly and in his sleepy state he misjudged his flight pattern and bumped into it. Rubbing his sore beak with the edge of a wing, he cautiously approached the wall on foot. He tried the latch, (did I mention that he was a very tall owl?) to see if he could open the door. He could not. Next, there appeared a keyhole just below the latch, and in his wisdom, the owl understood that the door was locked. Lacking the key, he would not be able to open it.

Just as he was gathering himself to fly back to his perch in the oak tree, the wall delivered a final manifestation – a sign shimmered into place above the door. Peering through the morning sunshine, the owl sounded out the letters:

T–R–U–T–H

The Wise Old Owl grew very excited. Because of his wisdom, he had always sought Truth. And now here it was, just on the other side of this locked door in an impenetrable wall. Surely, as old and as wise as he was, he could review all of his knowledge and past experience and discover how to open the door to Truth. So he set his mind to it.

Meanwhile, crashing his way through the Magic Forest, there came a very large, very noisy and very ponderous elephant. Upon seeing the wall, exactly where it had never been before, (and he remembered this, because he was an elephant and as everyone knows an elephant never forgets) he became enraged, lowered his head, and charged the wall….. And charged the wall again, and again, until he knocked himself silly and had to sit down.elephant

Determining that the elephant was now quiet and still enough to hear him, the Wise Old Owl asked the Large, Strong Elephant if he could see the door. Once the stars from banging his head against the wall cleared, sure enough, the elephant could clearly see both the door, and the sign above it: TRUTH. He gingerly stretched out his sore trunk, and tried the latch.

“It’s locked” the Owl told him. “Any lock can be forced open” the elephant grumpily responded, still convinced that his wealth of size and power was the answer to everything.

“Listen to me! I not only have the experience of this particular wall and door, but I have reviewed all of the learning and experience since the beginning of time in the Magic Forest,” trilled the Owl. “If you will hear what I know, perhaps we can open the door.”

“Nonsense,” replied the Elephant. “Only my strength and persistence will open the door.”

Several days later, after multiple periods of alternating rest, arguing, and failed attempts to open the door of Truth, the Owl and the Elephant were joined by another wanderer in the Magic Forest. The Burdened Donkey, a descendant of the very colt that carried Jesus the Messiah into Jerusalem on that famous Passover week, had found her way through the forest to the Door in the Wall. Her entire life had been one of compassion and advocacy for the burdens of others; as well it should be for one of her noble ancestry. She cared nothing for power or size, though in all honesty she thought a little wealth would have been nice, in order to have something to share with those who had nothing at all.     donkey

The Burdened Donkey readily became part of the group, despite stating quite firmly that the others were wasting their time. She insisted that if they gathered more seekers to the wall, whoever – or whatever — controlled the Magic Forest would have to hear their combined voices seeking Truth, and unlock the door.

Weeks later, our trio of Truth Seekers were each even more determined than ever that he or she alone had the right answer to opening the Door. But they were still on the wrong side of the Gateway to Truth when a beautiful, radiant human-like creature seemed to just suddenly appear in their midst. OK, sorry – that phrase was a little too Biblical for a fairy tale. The Dreamer/Adventurer appeared like a mirage taking shape before their eyes (Better?). This rare being was androgynous, (a blend of male/female, not either-or) but only when appearing in its magical, ephemeral state. It will be correct to refer to the being as s/he.

enlifghtened being

S/he was actually more able to see and understand the Wall and the Gateway to Truth better than the other three combined. Being a dreamer, s/he could imagine possible solutions from ideas that the others had overlooked, because even though they had a lot of combined knowledge and experience, they lacked the gift of imagination. Because they therefore lacked the gift of dreaming, they also lacked the magnificent will to risk adventure. So the Dreamer might have added surprising and wonderful routes to the search for Truth, but the four Seekers nevertheless each continued to argue that their own talent was the sole means of opening the Gate, and to individually try old and new ways to unlock the door.

Almost another year passed, and one late night our quartet of seekers was once again outside the door of Truth. As usual, the Owl was perched on his oak tree limb, his back to the Door. The Elephant stood in front of the owl and to his right, where there happened to be more room to accommodate his huge size. To the owl’s left, and facing the Elephant, was the Burdened Donkey. Weary from her many tasks and the futility of debate; she reclined on a mat of fallen leaves. The Dreamer/Adventurer was directly facing the Owl, but far enough back not to invade the sight line between the Donkey and the Elephant. The dreamer, therefore, was the only one who consistently looked forward, to the Gateway of Truth. This pattern had become the default physical setup for their frequent, but fruitless, debates.

By now, each member of the group was unshakably entrenched in their own belief about the correct route to a solution, and the debates were bitter and filled with accusations that cast aspersions on ancestry, intellect and integrity. In other words, the debates had become ugly, and personal.

An aside: Rumor has it that this is when and where major basic political views were founded and named: The Traditionalist (the owl, wise but always looking back), the Donkey (the liberal, burdened with concern for the poor and oppressed), and the Elephant (with wealth, power and size, who was channeling Puritan predestinarianism in his belief that these things indicated that he alone was a Chosen One). The Dreamer/Adventurer, though strong in the days of our Founders, would have no counterpart within the bounds of this rumor, representing a view that is no longer taken seriously by our rational world. But I believe the rumor to be completely unfounded and without merit. After all, even in a fairy tale there is no discernible connection between the Gateway to Truth and political activity.

To bring our fairy tale to its conclusion…as our quartet was fiercely and loudly debating the reasons for their failure to solve the problem of the locked door of Truth, they were joined by an excited colony of bats, all clamoring about the Gateway to Truth. The bats had somehow heard of the Gateway phenomenon, but being blind, were not even aware that they were just outside that much-to-be-desired place. By using their sonar, however, they sensed the presence of our Seekers and inquired of them if they knew how to find the Gateway.

bats

Rendered both cynical and uncaring of others by their prolonged debate, the four Seekers each offhandedly responded to the bats:

“Of course. As always, it is directly behind me,” said the Owl.

“Can’t you see it?” the Donkey responded crossly, then…”Oh, sorry. I am so sorry for your disability. Please, can you locate it if I describe where it is? It is directly to my left.”

To which the Elephant trumpeted a huge blast of disgust, remarking “Even my strength has not opened that door! How do you think that a colony of tiny, blind bats is going to achieve this? But never mind. Be my guest! Go ahead and try. The door is to my right.”

The Dreamer, withdrawn and wan after suffering prolonged ridicule and rejection, was only barely aware of the presence of the bats. As usual, s/he was staring dreamily at the gate, imagining all the wondrous truth that lay just beyond. S/he finally murmured: “You are all wrong. The door is in front of ME.”

As each member of the group spoke his, her or its truth, a solid gold nugget appeared in the hand (trunk, wing or hoof) of the speaker. By the time the Dreamer said the final word, all four were staring dumbfounded into their respective appendages. Then, as one entity, they all ran toward the gate, golden shapes held before them. One by one, each tried to open the gate with their piece of gold, turning it first this way and then that. They tried inserting the gold pieces in a different order, then with yet other permutations of that order. Alas, the gold pieces did not unlock the door of Truth.

Dropping In a sorry heap of adrenaline withdrawal, the group had finally returned to their original places. The bats, having been quiet as they tried to interpret the chaos of sound and activity, now tried to question the Seekers. “What happened? What did you do? Did the Door open?”

As a final gesture of complete submission to their failure, the Seekers turned the pieces of gold over to the bats. “Here,” they told them. “Follow our directions to the Door, which has a key hole but no key. Take these pieces of gold, since they appeared when we told you where the door was, but they do not seem to be of any use.”

“But you each told us something different,” challenged the bats. “How do we know which one of you was telling the truth, or if any truth is in you at all? How do we know where the door really is located?”

The Seekers looked around, and recognized that they had fallen into their accustomed formation. So they told the bats that they would repeat their directions, and the bats should use their own bat sonar to identify where each speaker was located. They could then use at least three points to triangulate the location of the door from the positions of the speakers, combined with their spoken directions. “We have all told you the truth,” they chorused.

And of course, the bats did just that and of course, it worked. They were now hanging on the wall, as well as on and around the door. They located the latch and the keyhole. But also “of course,” they could not open the door, either. But they kept touching the pieces of gold, and then reaching into the keyhole, feeling around and chattering to one another in bat-speak. The air became tense with anticipation, for it was well known that the blind bats understood the magic of the forest better than any other beings. Unlike other beings, they felt things about the environment, and heard more. Suddenly, the bats came together in an outbreak of cooperation and began to reposition the pieces of gold. The Magic Forest once again intervened and did its thing, and the pieces of gold became welded together in the shape of a key. The key opened the Gateway of Truth, and they all (including the original Seekers) went through the Door to the land of Truth and lived happily ever after.

golden key

THE END