There were red specks flying all over the table and floor— She was scratching off a lottery ticket when I walked in; her blue-glued nails picking off the rows and columns, revealing numbers in vulgar font. Jumbo Bucks in bold. Win up to 20 times. I sat down and as she scraped I let her cuss out the ER doctor whom she saw two days ago.
He wanted urine. They were in the hallway. She only used coke and it was more than two weeks ago. I have heard this story many times. If not hers others. What can I say? I can only understand what he wrote about you. This visit was scheduled to follow-up on the tests you did not stick around to do. You left AMA. You’ve done this before. You look at me— Your eyes titanic glaciers melting and breaking. You spread your left arm and tell me they tried to pry open your veins. You felt it. You woke up and they were at your groin. I explain about veins. She knows but still. How ill? Very. You should have stayed. She turns and goes back to picking
numbers. I would have told her I hate it when she comes late to our appointments. I would have said I will not prescribe your adderall anymore. I would have ended the visit and moved on to the next patient. You tell me your mother is dying. You left to be with her. You were with her when they decided to send her home to die comfortably. Her legs became huge. Tree trunks. She groans in pain and her heart is all to shit, excuse me. I stop
looking at my computer. Three years ago I remember touching your arms and legs for the first time— craters and valleys, an archipelago of scars and atrophy. You do know about veins and you ran out of them. You stopped using years ago but new ulcers appeared and that’s how I came to know you. Finally, one day you let me biopsy them. The results showed vasculitis and that’s why I needed more tests. Your lungs are affected. I advised you to go to the ED.
You hate being here. We all have that ache of blood. You tell me you have been taking the train to Boston every day. Your mother lives there and now she is dying there. You sit down on the plastic seat, look out the window, and remember how the times she held you while you were in withdrawal; stole you from dark rooms; sat by your lying body on the bed. You were the oldest child and the worst. Methadone saved your life but you must return here daily to receive it. I hand the tissue box
to you as an offering. You sit no longer speaking. In pain you wait in your monastic corner of a cell. We breathe and my heavy hand reaches to your shoulder. We share of sacrifice and the physics of taste. Heads down. Hand on hand. We prayed for your mother and for ourselves; my blood cells flowing so close to yours.
Testing for drugs of abuse (DOA): Time frame for positive urine assay with acute exposure: amphetamine (1-2 days), benzodiazepines (1-5 days), cocaine (2 ays), LSD (1-3 days), marijuana (1-3 days), opioids (1-3 days), methadone (1-5 days), PCP (4-7 days).
“Coke” – “Pure cocaine was first isolated in the 1880s and was first used as a local anesthetic in eye surgery. It was particularly useful in surgery of the nose and throat because of its ability to provide anesthesia and constrict blood vessels, thereby limiting bleeding. Cocaine was legal and widely used in the United States during the second half of the 19th century and was a main ingredient of the original Coca-Cola.”; Onset of action and duration of action for various routes of exposure: intravenous (<1 min, 30-60 min), nasal (1-5 min, 60-120 min), smoking (<1 min, 30-60 min), gastrointestinal (30-60 min, unknown).
Heroin – “The intravenous (IV) route is rapid and produces high bioavailability but is also most dangerous to the user. Injection is the most efficient means of producing euphoria when relatively low-purity heroin is being used. Most overdoses occur when heroin is taken intravenously.”
Against medical advice (AMA): “To persuade patients to remain hospitalized, 85% of trainees and 67% of attending physicians in one study incorrectly informed their patients that insurance will not reimburse a hospitalization if they leave AMA; Because all competent patients have the right to decline recommended inpatient treatment, the ethical and legal standard is that the physician obtain the patient’s informed consent to leave by communicating the risks, benefits, and alternatives to leaving and fully documenting the conversation in the medical record. The additional steps of formalizing the discharge as AMA and providing AMA forms for the patient to sign have never been demonstrated to improve quality (and add needless clerical work).”
Hypertrophic and atrophic scars: “One study that examined the pattern of addict-chosen injection sites found that the veins in the antecubital fossae are initially used; however, after 3 to 5 years, these veins become sclerosed and inaccessible. Other peripheral sites are then used for intravenous access, with the hands, neck, feet, legs, and dorsal vein of the penis having been described in the literature. A patient has been described who attempted venipuncture 50 times per day trying to find a patent vessel.”
Vasculitis – “is an inflammation of the blood vessels. It happens when the body’s immune system attacks the blood vessel by mistake. It can happen because of an infection, a medicine, or another disease. The cause is often unknown.”
Origin of “cell”: early 12c., “small monastery, subordinate monastery” (from Medieval Latin in this sense), later “small room for a monk or a nun in a monastic establishment; a hermit’s dwelling” (c. 1300), from Latin cella “small room, store room, hut,” related to Latin celare “to hide, conceal;” From “monastic room” the sense was extended to “prison room” (1722). The word was used in 14c., figuratively, of brain “compartments” as the abode of some faculty; it was used in biology by 17c. of various cavities (wood structure, segments of fruit, bee combs), gradually focusing to the modern sense of “basic structure of all living organisms” (which OED dates to 1845).
Methadone – “By the 1970s, the system for delivering methadone that we know today had been fully developed. Patients visit a designated clinic, typically every day, take methadone under observation, and get specialized, highly structured care, including counseling and periodic drug tests.”