Down These Mean Streets

Editorial Note: This post that neatly ties together drug induced violence and dependence and withdrawal, the theme of the next few posts, is by Mickey Nardo. It featured on OneBoringOldMan a few weeks ago. It has a ring of a Raymond Chandler novel. Hence the image and the postscript.

It was towards the end of today’s clinic. He was a big guy, friendly, seemed neither anxious nor depressed. He had come to have his meds refilled. He was on Paxil 60mg in the morning and Remeron 45mg at night. He launched right into his story:

He had always worked Construction, but when the housing market crashed, so did his livelihood. He couldn’t find work anywhere. His [sort of] wife was out of work as well. He got depressed and was started on Paxil 10 mg by a nurse practitioner. When it looked like he was going to lose his house, he went into the breaking and entering business for the first time in his life. After some early successes, he got caught in the act and found himself with no [sort of] wife, no house, and a five year prison sentence. I asked how the Paxil dose had gone from 10 to 60 milligrams. He asked me if I’d been to prison [first time I’ve ever been asked that]. But what he wanted to explain to me was how boring prison life can be and wondered if I already knew.

He said, “It’s like a grammar school playground. A bunch of guys with nothing to do except watch t.v., eat, and get in fights with each other. When you get in a fight, you end up on solitary for a few days. And I got really depressed in solitary so the doc increased my meds.” That happened several times, and up went the medication dose. I asked if they gave him medications on solitary, but that was what he’d already figured out on his own – that it was withdrawal symptoms. “But by the time I figured it out, I was on 60 —-ing milligrams.”

The Remeron had been started because of insomnia, something he had never had before. His description of the withdrawal symptoms was classic, down to the brain zaps [for which he had a more colorful but less printable name]. He had tried to come down on the Paxil dose, but invariably got the symptoms late in the day and so he took the skipped pills. He would squirrel away a half pill here and there to build a “stash” in case of getting sent to solitary, and he had definitely learned to avoid fights. He was terrified that he wouldn’t be able to get the medication. The withdrawal symptoms were that bad. And he was convinced that he’d never sleep again without the Remeron.

He had already given a few hints along the way about how to proceed. He was on two drugs with withdrawal syndrome possibilities, one he knew about – Paxil. So Paxil seemed the place to start. His own attempts failed at “the end of the day.” With the short acting drugs, people taking them only once a day often get evening symptoms and I even wondered if that was part of why the dose was so high [and maybe even wondered if that had something to do with the Remeron addition].

Something I’ve learned is that if one comes on too strong with the tapering meme, the patients get scared go elsewhere to someone who will just write the refills. So I suggested that the first order of business was to get him to a twice daily Paxil dosing. Move a half pill to the afternoon every week or two. When I explained why, he liked to idea. Once we got to a twice daily dose [30 mg twice a day], we could start a taper with less fear of evening withdrawal symptoms. And if half a pill doesn’t work, I told him to try moving by quarters. But the real point is that he seemed to be on-board once he felt comfortable I wasn’t going to “cut him off.”

My own experience is that you are often flying by the seat of your pants tapering these drugs. And I’ve found that it’s always important to convey that you’re not going to pull the rug out from under the patient. The other thing is that if I can engage the patient in the enterprise, they often find schemes on their own you wouldn’t have thought of. For a few patients, they never get off. For others, it’s a long slow process. And then there are many who can get off pretty quickly once they see that it’s possible to come down on the dose. But the rate seems to be a physically determined individual difference. Certainly, this is not a majority phenomenon. Even though I try to taper everyone, many just stop on their own with no problems. I know I can’t tell in advance who will fit into what group. I’m absolutely sure that most of the difficult cases are like this – where withdrawal has been misunderstood and some clinician has chased symptoms with escalating doses.

He seems pleased as punch to be out of prison and I doubt he’ll ever go back [even as I wrote that, I remembered that my track record predicting criminality has not been stellar]. But I’d bet the house that his illness started as situational and is now iatrogenic [caused by his medications]. I know nothing about SSRI being associated with non-violent crime, but who knows if that Paxil had something to do with his later life new profession?

I wish I could say that this was an unusual kind of case. It’s not at all unusual. I spend a surprising amount of time trying to figure out how to deal with medication messes like this. Because of time pressures, there’s not a lot of psychotherapy of any classic sort going on in the clinic, but I do have time to do a reasonable diagnostic evaluation though it’s often spread over multiple meetings. With the coming of Obamacare and Medicaid, I now see more patients that I can refer to local therapists, who will accept the low fees [if you don’t send too many] – and there are some decent ones around. While it’s an irony that a way overtrained psychoanalyst spends so much time untangling medication snafus, I actually kind of enjoy it. If it were a full time job, I think I would meet Mr. Burnout quickly, but it isn’t [a full time job], and I don’t [feel those burnout signs and symptoms that say “time to move on”]. I would love to live in a world where the medications were mostly solutions rather than frequently the problem, but for now, it just is what it is…

Down these mean streets

Describing what makes a Philip Marlowe, Raymond Chandler put it like this:

“Down these mean streets a man must go who is not himself mean, who is neither tarnished nor afraid. He is the hero; he is everything. He must be a complete man and a common man and yet an unusual man. He must be, to use a rather weathered phrase, a man of honor—by instinct, by inevitability, without thought of it, and certainly without saying it. He must be the best man in his world and a good enough man for any world.

“He will take no man’s money dishonestly and no man’s insolence without a due and dispassionate revenge. He is a lonely man and his pride is that you will treat him as a proud man or be very sorry you ever saw him”.

“The story is this man’s adventure in search of a hidden truth, and it would be no adventure if it did not happen to a man fit for adventure. If there were enough like him, the world would be a very safe place to live in, without becoming too dull to be worth living in.”

Difficult to find a better description of Mickey Nardo.