An Overdose Story

Dr. Daniel Smith, a  Family Practitioner at Mary's Center and the Clinical Lead for our Medication Assisted Treatment (MAT) program for heroin-opioid abuse, shares the moving story of one of his patients, who lost the battle against addiction. Dr. Smith reflects on the many challenges to sobriety.

Maria is not one to cry easily. Decades of case management in addiction services in DC have given her a pragmatic stoicism. I was naturally anxious at seeing tears in her eyes as she walked out of the exam room. These tears were for J, a patient we had been seeing regularly for buprenorphine maintenance for 9 months who was now dead.

J had been using heroin for 43 years and had easily been through a dozen traditional rehabilitation programs. He had spent a total of 30 years incarcerated on drug related charges and his only extended periods of sobriety were while he was in prison. After his last incarceration, he had returned to the DC streets staying in downtown homeless shelters with the constant opportunity to use. Without employment or a support system his chances at sobriety were slim. Nonetheless, his first appointment with me revealed a warm, grandfatherly DC-native focused on sobriety. His entire adult life had revolved around heroin, its pursuit, withdrawal, health effects and legal consequences. He had watched dozens of friends die of opiate overdose and had narrowly escaped death by overdose several times thanks to emergency responders using naloxone. This is not a unique story.

When I asked him why it was finally his time for sobriety he said, "It's been too long. I'm just tired". J was tired, but in our program he thrived. Buprenorphine helped him escape the constant cycle of using heroin and the inevitable withdrawal that would follow. The diarrhea, vomiting, body aches and anxiety of opiate withdrawal had driven him to snort or inject three times daily for decades. Without those withdrawal symptoms, he was able to actively participate in twelve step meetings and other components of his recovery. We saw him weekly for two months and then less often as he progressed. He used heroin occasionally when the constant temptation of drugs in his environment caught him at vulnerable moments. But he and Maria spoke on the phone frequently and she always got him back in the office when he lapsed, avoiding a full relapse. They pursued stable housing and employment. which would be essential in maintaining his sobriety. With his criminal history, both were nearly impossible to find and each night he went back to the shelter and challenged his recovery.

Buprenorphine can be prescribed by appropriately trained primary care providers. As such, J could take advantage of all the services at our community health center. His blood pressure was under control for the first time in his adult life. He had colon cancer screening. He was engaged in counseling services, taking on his PTSD and major depression. These were successes.

Last month, J missed his appointments and did not return our calls. He had relapsed. Maria's tears came after meeting with one of J's childhood friends, also our patient. He had gone to visit J to bring food, as he did most days, and was told his lifelong friend had been found dead from a heroin overdose.

At our first encounter, J and I discussed the main goals of his buprenorphine treatment: to reduce the amount of heroin he used, ideally to none, and to reduce his risk of overdose. Death and overdose were part of our conversation at each visit. J would not have been surprised to know that an overdose would ultimately take his life. We had reviewed that heroin users not in treatment have an annual death rate of around 7%. The rate for those in treatment is closer to 1%. When patients fall out of treatment their mortality rates unfortunately revert. I have seen relapses result from issues ranging from insurance lapses to inadequate housing to mental health issues to lacking bus fare. With constant threats of Medicaid cuts, I am terrified that J's story will be repeated thousands of times over. Every single patient on buprenorphine maintenance in my practice is covered by Medicaid or managed Medicaid. Let us not force our opiate dependent neighbors into this high overdose risk in the name of healthcare reform.

Many patients on buprenorphine maintenance therapy return to full employment and are able to repair the damage addiction inflicted on their lives. J's life ended too early in his recovery to achieve these goals. But his last nine months had been overwhelmingly sober and he had frequent, positive and respectful interactions with a health center that viewed him as a person, not a felon or a junky. In this, I find solace.

Dr. Daniel SmithAbout Dr. Smith

Dr. Smith joined Mary’s Center in August 2015 After his undergraduate studies at the University of Virginia, he worked as a high school teacher in Anacostia, DC. He then attended the University of Pennsylvania School of Medicine and completed his residency at Swedish First Hill Family Medicine at the Downtown Public Health Center in Seattle, WA. Dr. Smith has had very rewarding medical experiences working and volunteering in Peru, Guatemala, Haiti and Malawi. In his free time, Dr. Smith enjoys spending time with his wife and children, hiking, fishing and cheering on University of Virginia sports teams!


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