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- Nov 21, 1998
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A Doctor’s Painful Struggle With an Opioid-Addicted Patient
"I’m not writing this to expiate the guilt of doctors or excuse my complicity but as a testimony of the 12-odd months of mutual assured destruction that characterized my first encounter with addiction. We had no training in this kind of medicine. If the addict was helpless, then so, too, was the young physician: To try to treat addiction was to discover an inverted form of doctoring, in which the patient and doctor turned into wary, suspicious aliens circling and jabbing at each other. Medicine depends implicitly on a therapeutic alliance between a doctor and a patient, but addiction, I learned, distorts that alliance. The doctor shifts from healer to dealer. To the addict, the doctor is contorting the truth; to the doctor, it’s the addict who is constantly inverting reality. The doctor is, at first, the enabler and the supplier, and then the tormentor, the withholder, the liar, the enemy. Perhaps the reason that the methadone clinic had worked for S., albeit fleetingly, I realized, was not only because of the drug’s pharmacological effect but also because the clinic had forcibly re-established the alliance: There was, at least, a transactional transparency in what she was giving and getting. Rather than trying to fix her, here, at last, was a doctor who would willingly give her a fix."
"I’m not writing this to expiate the guilt of doctors or excuse my complicity but as a testimony of the 12-odd months of mutual assured destruction that characterized my first encounter with addiction. We had no training in this kind of medicine. If the addict was helpless, then so, too, was the young physician: To try to treat addiction was to discover an inverted form of doctoring, in which the patient and doctor turned into wary, suspicious aliens circling and jabbing at each other. Medicine depends implicitly on a therapeutic alliance between a doctor and a patient, but addiction, I learned, distorts that alliance. The doctor shifts from healer to dealer. To the addict, the doctor is contorting the truth; to the doctor, it’s the addict who is constantly inverting reality. The doctor is, at first, the enabler and the supplier, and then the tormentor, the withholder, the liar, the enemy. Perhaps the reason that the methadone clinic had worked for S., albeit fleetingly, I realized, was not only because of the drug’s pharmacological effect but also because the clinic had forcibly re-established the alliance: There was, at least, a transactional transparency in what she was giving and getting. Rather than trying to fix her, here, at last, was a doctor who would willingly give her a fix."
