Community A&D Service

[ NOTE – This is probably not ethical, legal, or even marginally interesting… But it is the letter written from Sam McBride, Consultant Psychiatrist, Wellingtons Capital & Coast District Health Boards “Addiction dis Services” (CCDHB ASS) to my General Practitioner whilst I was on day five of withdrawal. I have sent him copies of this, and got no response (surprise not).

The bits in italic are my thoughts on proceedings… Also note that in PART TWO, bottom half of this post,  I am not a qualified examiner. Merely making shit up ]

CCDHB Logo used without permission

RE – NZFiend D.o.B 1973 etc etc

Problem list:

  • Opioid dependence
  • history of inattention (who me… whatever….)
  • history of cauda equina syndrome (pity that’s not Cludia Schiffer syndrome, I could do with some of that….)
  • hepatitis C

Thank you for the referral of NZFIEND who I saw along with E.M, specialist nurse on 31 May 2013. He is a 39 year old man who is currently unemployed and not in a relationship though cares for his six year old child (she is nine, cloth ears, NINE…) He was referred by for consideration of managed withdrawal from opioids. (The typo in the last sentence is theirs, not mine…)

He reports that he was previously on the methadone programme however withdrew from this over ten years ago (almost twenty cloth ears… TWENTY)Since then he describes ongoing but largely controlled use of opioids. He reports he uses these to manage stress, maintain his concentration, sleep and control pain. (And cos he just plain likes getting wasted…) He recognises (actually, I reported) that there has been increasing dyscontrol in the context of multiple stresses including the recent illness of his sister. (Hey, dickwad, lung cancers, multiple health fuck ups and my loverly 37 year old sister dying is not a “recent illness. It is a fucken death. Most painful to watch it was too – as I was caring for her at the time.) At present he is largely using methadone intravenously in doses between 30mg to 100mg most, but not every, day.

He is ambivalent (poor word really ; chose from –  borderline, clear as mud, clouded, disreputable, DUBIOUS, fishy, muddled, muzzy, open, puzzling, questionable, suspect, suspicious, tenebrous, unclear, undecided, unexplicit, unintelligible, vague, with mixed feelings… Personally I like “QUESTIONABLY SUSPECT”) about the methadone programme feeling that the contained regular scripts are inappropriate to the context of his own use. He saw withdrawal as offering at best a temporary solution recognises that he was likely to continue to use in the context of pain, inattention and stresses. He is currently on the waiting list for interferon (first I have heard of that – My last appointment with them was over a year and a half ago) and realises that he is unlikely to complete this without resorting to further use (fucken what???????????? Where the hell do you get that from? Fuck me. Honestly, just fuck me, do it now. Do it hard. Fuck….. Your dick and your lime green dyson are good special friends Sam…. Go fuck it….)

He denies significant use of other drugs including amphetamines, cannabis and alcohol. (That’s because I have given up drinking over ten years ago, smoking pot fifteen years ago and a large crystal meth problem around the time my daughter was born, nine years ago,  and am here to stop using opiates too retard…)

He reports persistent difficulties with impulsivity and inattention. He believes he is suffering from ADHD and is frustrated by the failure of clinicians to treat this with stimulants (this is seriously pissing me off now. I did not say this. I said “I am fucked off that no one listens and no one has taken the time to diagnose this possibility“. I did not mention stimulants other than in describing my “non euphoric response to crystal meth intake.” Obviously, by even knowing what “non euphoric” meant got another black mark against my name and you wrote this down as “drug seeking behaviour”….. Asshole.)

As noted he has hepatitis C and has been seen by Dr S. at gastroenterology. (I was seen two years ago, told I would die soon, got totally screwed up, put plans on hold to do the treatment programme and then heard nothing from them for nine months. Then I have another appointment, get the idea re-inforced that my liver is going to die soon, and then don’t have another appointment for 14 months. That’s over a year. I still don’t have an appointment now. I should be dead according to Dr S. already. Assholes, the lot of you.)

He presented as a pleasant and engaging man (you have not seen my psychotic test results mate!) Unfortunately he had been required to wait prior to the appointment and he tolerated this frustration without difficulties (I was talking shit with old junky mate about his mayoral campaign for twenty minutes and giving ourselves a good dose of the famous junky gallows humour. Once I realised you were watching me on camera and started acting agitated as a test, you appeared with minutes Sam…) He was engaged in conversation in a non defensive and appropriate manner. (I appeared honest??….) His affect was reactive and appropriate (whew, you didn’t read that I was prepared to throw you out your third floor window then… I may be cleverer than you think ballbag,……) He did not appear to be either intoxicated nor in withdrawal during the interview (years of practice mate. I know people who would have spotted I was off my trolley straight away… Top of the list are all my ex-partners……) His mood was euthymic* and there were no psychiatric symptoms of note.

Impression

NZFIEND is a 39 year old man who presents with diagnosis of opioid dependance. This occurs in the context of chronic pain, impulsivity with possibility of attention deficit disorder and a range of stresses that include his sister’s terminal illness and potential interferon treatment.

NZFIEND is requesting withdrawal as a means of attempting to contain his current use which he is finding difficult to sustain in context of escalating requirements and associated demands. I advised [him] that I did not think withdrawal was appropriate for him. It is unlikely to lead to sustained benefits particularly in the context of of enduring difficulties with pain, inattention and the range of stresses he is under. I feel that he would do well with maintenance which would allow him a platform to address some of these issues (oh my f ck n higher power. You what? Think that putting me on a high dose of drongo juice every day will give me a chance to address my mental health and pain issues? You fuckwit, honestly….)

I advised him that we would place on the waiting list for maintenance treatment backdated to original referral (waiting list is at least six months)I was impressed with [his] capacity to tolerate this obviously frustrating news. (As I had already figured the system would bugger me with a large bat, I was not surprised when being buggered with a large bat. I had made my mind up to quit, and you would either help or not. I told you this. Go figure. Maybe I am clever. Maybe just getting old and jaded. Either way, your stance was unsurprising and I left non-plussed. So to speak. I then took one or two more doses of methadone and went cold turkey and resorted to asking you for some suboxone two weeks later, which you denied too. Good work Sam. You are the man…. By the way, I think I am day 21 or 22 now…. I even had a dream and sleep last night. And hung onto my sanity by a thread thanks to some legal sleeping pills and a large dose or five of totally illegal meds sourced totally illegally…. Thanks for making me go see drug dealers when I am going through serious withdrawals Sam. That was brilliant. Another one of your tricky psychiatric tests for me to navigate or something?)

Yours sincerely,

Dr Dyson lover.

Notes from NZFiend…

*Euthymic is a psychological term that refers to a normal mood. It refers to when a person is in a reasonably positive mood or where one’s mood is not extreme. The word euthymic comes from the word ‘euthymia’ which refers to a normal, non-depressed mood.

NZFIEND SAYS – His mood appeared to be sweet as bro. Bloody euthymic, made up psycho babble…..

Also note that other psychiatrists have read this blog page by page from the beginning and are very supportive (if only as they are using me as office humour)

Please read some books Sam. Romancing Opiates has some good points, but is wrong on its central basis. I have withdrawn many many times and can vouch for the effects, mental and physical. Better off, have a look through Dr Gabor Mate on You Tube (you know, that tv site)… Also, Sam and anyone else with an even passing interest in addiction and mental health have a SERIOUS read of 

Also note that I did not say anything like I was annoyed about not being prescribed stimulants. Here is an alternative even, if it is found I would benefit from such… I know I can sort of keep concentrating. At times. You should see this computer right now Sam. This one page has taken me three hours to edit, as I have been all over the place doing other things (like re-finding god) at the same time. I spend five minutes on this, five on that and about two hours later remember that I was actually not finished telling Sam McBride stuff that he should know but couldn’t give a fuck about. 

Atomoxetine
Systematic (IUPAC) name
(3R)-N-methyl-3-(2-methylphenoxy)-3-phenylpropan-1-amine; (R)-N-methyl-3-phenyl-3-(o-tolyloxy)propan-1-amine

Actually, Sam… Forget it — Side effects include  ;

Confirmed cases of severe liver damage have been reported by Eli Lilly and Company. A black box warning was issued by the FDA in 2004. This would, no doubt, be pretty bad for me considering I’ve already outlasted the good Dr S’s estimate of how long my liver had left.

Other side effects can include psychosis, mood swings, mood disorders, depression, abnormal thought patterns, suicidal thoughts or tendencies, and self injury

Side effects that I have normally as part of my standard life… Interesting….! This drug is NZFiend in a capsule. Cool. LittleMe’s. In soluble form. Neat.

PART TWO

Hey Sam, your scores from the Te Whare o Tiki are back. Please consider these carefully and look at the future role you see yourself in. Addiction Services doesn’t quite seem right for you. Sorry.

———–

Te Whare o Tiki

Just got given a copy of Te Whare o Tiki, The Healing House of Tiki apparently. Cheese. At least it is not as bad as calling a lockdown ward RANGIPAPA. Ahem. Cough. Splutter – Almost like calling a jail Rangipo, bloody white men.

Anyhooooooo….

This booklet has been adapted by Dr Fraser Todd and a bunch of people under the banner of joint mental health and addiction workforce. This workfarce has based its work on Dr Tom Flewett and the co-existing disorders team of Capital Coast Health DHB, Community  Drug and Alcohol Service (CCBHD ADDICTIONS disSERVICES).

It is really long.

It has 42 qualifying factors. I will chose one at random by throwing the book up in the air and seeing how it lands…. Here goes….

Well, that didn’t work. It kept landing closed.

Here is a random entry (page 10) as produced by closing eyes and using fingers instead…

2 WELL-BEING & RECOVERY
Consider problems as barriers to well-being and see well-being as the key recovery outcome rather than the absence of dysfunction 
(nzfiend says ; well written… well done… Now, apply that to addiction -Well BEING as the KEY RECOVERY OUTCOME rather than absence of  dysfunction!) 
Knowledge and Skills
Foundation Level
(Base Knowledge)
Capable Level
Knowledge and skills to support people with less complex needs
Enhanced Level
Knowledge and skills to support people with complex needs
2.3 Supporting Recovery
  • Has knowledge of recovery concepts relevant to people with substance abuse, gambling and mental health problems
  • Acknowledges and works with people to determine and define their own recovery processes and goals
  • Advocates for recovery approaches
Demonstrates support for people with less complex co-existing problems to achieve their stated recovery goals
Demonstrates the ability to collaborate with people with complex co-existing problems to achieve [STATED] recovery[GOALS]
(for some reason they left “stated recovery goals” off this bit, and simply put in “recovery” which is a bullshit open ended statement not worthy of such publication)
 

Wow. Well and good and proper. I chose a bad example. In some ways it is a good example. I will (attempt to) explain…

This handbook is full of “Demonstrates Skills” or “Demonstrate Abilities“. But it seems to fall very short of real empathy, caring, justice, relating. You have to have knowledge. You have to have ability. You don’t, it would seem, have to actually practise using these skills in a real world manner in a client considerate way. How about the ability to listen to clients as individuals. The word “individual” does not appear in this guide. We are ticks in a box.

This handbook could be less of a guide and more of a “cover our asses in case the panic buttons go off“, however well written and justifiable most of its content appears at first glance. As a checklist for someone entering the professional arena of addiction / mental health services it is very handy (until you get a job – then throw it away)…

But at the end of the day, someone who has been through the system from the “user / client” end is probably going to have their own take on proceedings that will include a few things not covered in a overly rigorous list

Empathy, out of the box problem solving and the willingness to do the right thing for theclients set recovery goals.

I have actually been referred to the original author of this work, Dr Tom Flewett I think, by my GP for my ADHD tendencies. He sounds like a good guy, but have heard various things from others. Including the rather unpleasing report he gives lip service to being all at one with the consumer and then resorting to the command and conquer corporate health structure as soon as you’re out the door. I hope I get to find out for myself. I hope he doesn’t disappoint me as much as his offsider, Sam McBride.

I have good reason to be spewing at Sam McBride. Other than the fact he botched my treatment and report (see here) but he failed on the above checklist too. This was taken at random, as I said. It was a good and a bad choice, as I said.

    • Acknowledges and works with people [I guess they mean “client”to determine and define their own recovery processes and goals
      Ahah. Not so much……
    • Advocates for recovery approaches
      Really? Must have been really wasted, missed this bit entirely. Sorry Sam, my fault for being too wasted.
    • Demonstrates the ability to collaborate with people with complex co-existing problems to achieve [stated / agreed] recovery [goals]
      Hey mate, I have complex co-existing problems. I am one big co-existing problem. I co-exist on this planet with you, and I am your problem. You just put me in the “too hard basket” or something Sam? I was clear on my goal. I told you I was giving up and needed a little help. You ignored me outright. Without referring me for inability to concentrate, without sticking your finger in my ass…. Nothing. METHADONE was your answer. GET FUCKED is mine.

Here’s another one (this time the book did fall open at a random page – page 28 as it happens)…

6 Management
Use clinical case management to coordinate and deliver multiple interventions appropriate to the phase of treatment
Knowledge and Skills
Foundation Level
(Base Knowledge)
Capable Level
Knowledge and skills to support people with less complex needs
Enhanced Level
Knowledge and skills to support people with complex needs
6.66
  • Has knowledge of and can recognise the signs and symptoms of substance withdrawal and the potential impact on physical and mental health
  • Has knowledge of who and when to contact for withdrawal management
  • Has knowledge of who and when to contact for outpatient detoxification
  • Has knowledge of the signs and symptoms of protracted substance withdrawal
  • Demonstrates skills in the assesment and management, including referral of acute and protracted substance withdrawal for people with less complex co-existing problems
  • Demonstrates use of detoxification protocols
  • Demonstrates withdrawal management skills, within professional scope of practice, for people with complex co-existing problems engaged in inpatient and outpatient detoxification

What the f ck? Are you serious? Is this really a random sample?

Uhm. I presented on day ten or thereabouts with serious, ongoing, protracted substance withdrawal. Sam McBride was rung by my G.P as, according to misleading information that would probably not stand up in court, Sam McBride had told my G.P that only Sam McBride could write a script for addiction services.

Sam McBride did nothing other than approve imovane* to sleep and a patch of transdermal stuff. He was told of symptoms including nervous twitching, dry mouth, dizziness, no appetite, diarrhea, nausea, aggression, sweating, palpitations, cramps, inability to sit still and a host of others including self harm and mental state that could have ticked off fifty different DSM categories including psychotic… My sister has just died, I am a depressed, emotional wreck, who only just managed to refrain from really hurting someone for looking at me less than ten minutes ago. As it was I shouldered the guy and sent his coffee flying all over the coffee shop in front of many professional people, including some nurses from the very ward I was heading to rapidly… I was sitting there grinding my teeth, displaying every sign of being very very very unstable.

So – He gets a tick for recognising the symptoms. There’s no way he could miss them. Just in case someone presents going through severe cold turkey, you’re the man Sam. He may or may not know whom to call for withdrawal management. He seems to have no interest in outpatient detox.. Did not demonstrate any skills of acute substance withdrawal or detox protocols. Showed very poor management of outpatient detox.

Overall, NEEDS DEVELOPMENT.

Not considered COMPETENT.

Please do 101 courses again, with particular attention to advancing your empathy and client relationships. Look forward to seeing you next semester where we hope for a fresh start. Maybe you shouldn’t be hanging around with all those druggies. They’re a bad crowd Sam.

.

.

(*) Imovane, Zopiclone, is regularly prescribed by idiot G.P’s and Psych wierdo’s as a “not-so-addictive” alternative to benzo’s. In actual fact, they sit on the same receptors and act alarmingly well (better than) most benzo’s do. As such, the withdrawal is the same (worse than) and you can go through acute withdrawal symptoms if stopping after only five days of use if you’re unlucky… As an ex halcion user with a large stash of Midazolam hidden in a safe place (now) I would have been better off taking the liquid Midazolam illegally than their Zopiclone. But there is no way they would listen to me. Oh no. In the end I went and bought some drugs illegally – Which kind of ruins the whole point of going through detox… I had to go visit the drug dealers whilst going through hell withdrawal. Lucky I hate myself, otherwise I would have got myself some f’ing good drugs.

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