Senora Demasiado

by Robert Lanz LCSW

 

I quickly grew accustomed to biker junkies, crack heads, homeless speed freaks and alcoholics of all walks of life and the occasional novice pot smoker who got some super bud and had an anxiety attack landing them in the emergency room and needing some Xanax or other benzodiazepines to calm down.

Pot, even the killer weed you can now buy legally is never a true medical emergency, although in the midst of a panic attack I’m sure it feels like one. Opiates are generally medically benign when taken appropriately. Taken in excess, of course, they are a central nervous system depressant and an overdose will ruin an otherwise blissful high. I always thought the most dangerous part of the most commonly abused opiate, Vicodin, was all of the Tylenol that came with it. By the time you develop a bad Vicodin habit, 20-30 pills a day, you end up taking the equivalent of about 25 Tylenol Extra Strength capsules and it’s kind of hard on the liver. Not as bad as alcohol but close overtime.

I’m not sure why opiates are so rampant these days because my working experience was mostly prior to a bunch of Millennials on Oxycontin who somehow got strung out enough to actually stick needles in their arms and steal their parents jewelry to support a heroin habit when they couldn’t get any more pills. My colleague Dr. Drew has some ideas on all those things and he’s way smarter than I am about the neurochemistry and the neuroanatomy that seem to make it almost impossible not to rob fast food joints.

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In the nineties I took a class in why internet porn took off so easily and they had an interesting thesis that may explain why Oxycontin took off too. Basically the premise was that the porn, through a pesky pop up, got the attention of the person on the internet and the curiosity turned into a greater pursuit and soon an otherwise “normal” person was getting very excited about it. Then it sort of got away from him and the next thing he knew he was downloading weird stuff from the net. These were the same guys who wouldn’t think of stopping at an X-rated bookstore somewhere. They didn’t know they had the weakness until it had them.

Same thing could happen with opiates too I’d say. If you have some pain that needs tending to and you aren’t on your game, the next thing you know you’re in the ER making up stories or even throwing yourself down the stairs just get some Vicodin. The good part about pain medications is they work really well. The bad part is that people with minimal insight let that get away from them when they discover opiates kill all the pain. Marital pan. Financial pain. Family pain. Unemployment pain. Not enough Likes on Facebook pain. An otherwise non-pathological person is strung out and then he is a pathological person and he’s turning into a junkie. Like the porn guy, something that most people would be able to handle, this guy can’t. Genetic? Lame? Not paying enough attention to the downstream possibilities? Not looking at the WTF moment that we in the ER see every night. What did you think would happen when you (fill in the blank here).

I don’t know, I’m more of a 60’s guy myself. The junkies from that time started out pathological in the first place and got addicted from there. Most of us hipsters never experimented with opiates or any downers for that matter, preferring to go the other direction and squeak out all the pleasures of the decade choosing psychedelics and good smoke. We could never understand why junkies chose to sleep through those most interesting times ever and the thought of a needle or cooking with a bent spoon was anathema to our crowd. Weed and acid were a lot more fun, in moderation of course.

I had friends, gangsters mostly, that I grew up around, who became addicted to heroin-  Vicodin hadn’t been invented yet- but it was no big deal to most of them. When their habit got too expensive, they didn’t escalate from robbing the local 7-Eleven to the local Bank of America. That was too dangerous when all they really wanted to do was get their habit back under control and affordable. No programs out at the beach featuring yoga, massage and 12 Steps with an ocean view. No alteration of neurochemistry or neuroanatomy for them. They had a much simpler solution. They had Desert Hot Springs, a small town, dying without dignity ninety miles east of Los Angeles in the cactus shadow of its more upscale neighbor, Palm Springs, across the I-10 Freeway and a few golf courses away. It was the perfect place to dry out, kick the heroin habit or at least get it back to affordable, holing up in a dilapidated motel with a friend or lover along with whatever was available to ease the week-long discomfort associated with cessation of opiates. Jonesing is what they call it -Jones being the emotional and physical pain of the body crying out for a better refill of opiates than the drugs available to make it more bearable.

They would use the Mother’s Little Helpers of the time, the infamous barbiturates in sleeping pills- Reds, Blues Rainbows (seconal, amytal and tuinal). Alcohol and weed would work too in a pinch along with the ever-present Valium.  Cramping, vomiting, diarrhea, the shakes, a runny nose like a bad case of flu and acute emotional anxiety for a week really sucked but in and of itself it is not medically dangerous. Psychologically dangerous for sure. Really hard for sure. But thousands of folks go through opiate withdrawal cold turkey in jail all the time. You’d think that such a journey might serve to develop a little insight in these guys or in fact even terror. Nope, that’s not part of the junkie experience. Not when they can get barbiturates and alcohol and benzodiazepines out there in the faded glory of that funky motel. Those drugs could cause addiction themselves but not in the short amount of time it took to kick opiates. So there you are, using dangerous drugs to get off less dangerous drugs and in ten days or so, all better and ready for the next round. Faster and cheaper than the thousand bucks a day for a program out in Malibu with stunning ocean sunsets. Not near as much fun though. That’s my story and I’m sticking to it.

However there was a different story too. The story of Senora Demasiado (Mrs. Too Much) the name we gave to the elderly Cuban refugee woman who showed up in the ER one night in what appeared to be the middle of a gigantic anxiety attack. We’re not mean and generally preferred to treat those acute symptoms with some benzodiazepines like injectable Ativan because it works quickly and efficiently and then we can do a reasonable medical/social work-up to see what the right treatment plan would be. Senora Demasiado was in line for one of those. Mr. Too Much was with her and he eventually fessed up that she had made this sort of presentation for years at several emergency rooms and had burned through more than a few family physicians while she became very addicted to Valium.

Well, with valium addiction there is no week long runs out to the desert with some heroin or Vicodin to help with that withdrawal. While the overuse of Valiums alone won’t kill you, even taken by the handful, once you’ve got to that handful stage, trying to stop without acute medical intervention is dangerous. You can have seizures the same way during withdrawal from alcohol or barbiturates if there is abrupt cessation after chronic overuse. You also get sleep disturbance, confusion, vomiting, headache and the one symptom that is usually the withdrawal deal breaker, acute anxiety.

Yeah I know. Confusing. After forty years in the business and growing up in Hollywood in the sixties I’m still a little befuddled about all this addiction stuff when it seems like a person with even a little insight, judgement and impulse control could stop self destructing before, say, prison, AIDS, hepatitis C, loss of money, friends and family or even death. Just saying, pretty lame. Time for a trip to the desert….

Anyway that’s how the staff saw Mrs. Too Much who came to the ER several times so acutely anxious it would have been malpractice to not give her some relief-and in fact, over time, it became obvious that would be the only way we could ever get any relief from her. Unrelenting crying, screaming and begging and over the top anxiety. We called her prescribing doctor and he felt the same way. What to do? Cut her off?  She consistently refused programs to go through a supervised withdrawal. She would doctor shop all the way down to the Mexican border and when that burned out she just started to go across the border into Tijuana and walked into the farmacia there and bought a couple of hundred pills, stuffed them in her bra and walked back to America.

For all I know she may have been caught by the customs guys who, just like us, soon discovered they were as clueless as we were as to what to do when the several Valium she had taken while still in Mexico wore off when she was in custody. I’m sure they didn’t want her in their space any more than we wanted her in ours. A couple of hours with her and in my fantasy when the border guards saw her coming after her next discount medical trip to TJ they just gave her a wink and a nod and a welcome back to America. Lucky guys.

We couldn’t do that wink and a nod thing in the ER, of course. Nevertheless, we remained clueless about what to do. Her family doctor was clueless too and her husband was so stressed out he was about to start an addiction of his own. If I remember right even the ethics committee got involved. They weren’t sure what to do either. Finally, in desperation they consulted the night shift social worker in the ER. Since we had tried everything else, well, everything but a trip out to Desert Hot Springs, it seemed to be resting on me. In my desperation to have a workable answer when no one else could it I  sort of suggested that since she seemed to have unfettered access to her drug of choice on both sides of the border and since the drug was rather benign other than the addiction part and given that she had never overdosed and since she had been addicted since she was in Cuba several presidents ago it was obviously pointless to try and get her to stop now.

Jack Johnson, a surfing folk singer, has a famous song, “On and On” that sort of summed up our dilemma. And there we were. We give up Senora. You get to be a benzo addict for the rest of your life and if your doctor calls and wants you to get a shot of Ativan in the
ER then so be it. We wouldn’t give her a prescription. We would continue to offer a program if she wanted to get “well.” All we did was sort of get in the middle of a bad deal. The other part of the deal was up to her regular doctor, and the pharmacist in Tijuana I guess,

It’s rare for us in the ER to concede defeat. Rare but not unheard of…..

 

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About robertjlanz

Author and health care professional.
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One Response to Senora Demasiado

  1. Ryan says:

    Hey Bob. My name is Ryan and I’m a new Social Worker in an ED in Oregon. I was looking for some guidance as to the scope of SW in the ED and couldn’t find any real consensus but did find my way to your blog. I’m also a cancer survivor, nine years next month, so I have an added layer of connection. I just wanted to thank you for your stories as they’ve promoted insight in me that has substantially accelerated my learning curve here. I recently faced my first dangerous crisis with my team and I see them looking at me with new respect as I’m sure they weren’t ready for a SW to jump into the mix to back them up. I spend most of my time on the floors but am one of the few floor SW willing to pitch in down in the ED, so I spend a lot of time here and I have a number of patients who owe you thanks for the smaller learning curve I’ve experienced as a result of your blog. I’m only through September 2014, ninety some entries in, but still going and still learning. Thanks a million Bob.

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