Adventures in Faith: Caring for Opioid and Heroin Users

Preacher: Patricia Schram
Date: August 9, 2020
 
00:00

Scripture: John 9:1-12

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I grew up in Sao Paulo, Brazil, as a Roman Catholic. I also studied medicine in Sao Paulo.  In Brazil, you go straight from high school to med school and I started it when I just turned 18.   As soon as I started, my mother was diagnosed with breast cancer. The first half of med school was while she had surgeries, treatments, and a lot more. She died soon as I started my fourth year of med school. I felt as if God had forgotten us!

--breath— 

I was so disappointed with the medical establishment, and I felt torn; should I believe in this kind of medicine that could not save my mother and go ahead and finish Medical School, or should I give up and look for something else?  Instead of giving up, I decided to look for a specialty that would prevent disease, instead of trying and failing to cure it! Pediatrics was my choice because it was the only specialty where I saw any preventive intent.

While I was doing my residency, one of my mother’s sisters (who was extremely supportive of my career) was diagnosed with pancreatic cancer. Nothing could be done to cure her, but I realized that simply holding her hands had a powerful healing effect. I realized that God was using me as her instrument. 

 

As I finished my pediatric and adolescent medicine training, I got a job with Brazil’s national health system. I was placed in a small pediatric hospital doing outpatient care for an extremely poor population. I found my call; I loved to work with those families, and they appreciated my care. I felt that my work, care and attention to their needs made a difference in their lives, and they gave me such powerful feedback, so much human warmth and love!

I was also moonlighting at a maternity hospital (I love the delivery room and newborns! It is a magical place where you can see God’s work! The Portuguese translation for giving birth is “giving light”, as giving a new life).

Pause

 

A few years later, I met my husband Bob who was working in Sao Paulo. After we married, he was transferred back to NY.  I started working in the US, and I was shocked to see that “medicine is treated as an industry” and “doctors as service providers”! I grew up as a doctor seeing myself as a minister for my patients: listening and holding their hands, besides providing whatever medical care they need. It seems to me that part of the healing we, doctors, can provide is done by touch as well.

 

When we moved to Boston, I did a fellowship on developmental and behavioral pediatrics, and I was offered a position to work with teenagers who use drugs. I accepted the challenge and worked hard to learn how to treat a disease that was completely new to me. I immediately felt that I was called to this work; it seemed there was a perfect linkage between their needs and how God acted through my hands.

I like to work with patients who use opioids because their disease is very debilitating and severe, and they really want to get better. Besides treatment, they need someone who will listen to them, without any judgement, give them as much time as they need, let them know that they are loved, let them know that they are good human beings, and are able to get better. Also, to remind them that they have strengths (it is a sad fact that these patients only hear negative comments about what they are doing or happening to them).

As we heard in John reading earlier: Neither this man nor his parents sinned; he was born blind so that God’s works might be revealed in him. What continuously surprises me is that, in no other disease, is the patient judged for getting sick. No one blames the patient who has diabetes, heart failure or cancer. Why blame a patient who has this terrible disease of addiction that promotes so much brain damage to the point that the patient is not able to make healthy decisions?

Over and over again, I educate my patients and their families that the brain has been damaged in such a way that it will hijack any attempt of making healthier decisions. Addiction is a chronic brain disease (with brain damage) that is manifested by behaviors (lying and manipulation are some of them) and relapses are expected (and we should have a plan ready for when relapses happen). One example of damage is the activation of the reward pathway, the brain center that keeps the  memories of everything we like.  Once activated, the reward pathway will boycott any healthy decision, because it will keep demanding that the patient continue using. The patients are being stigmatized because people expect them to make different decisions. However, their sick brain has lost the ability to think clearly and is NOT able to make healthier choices. I often tell them: you are such a good kid, but your sick brain is hijacking your healthy decisions.

Here is an example of the reward pathway boycotting a healthy decision:  when you go to a buffet style restaurant and you see people going for the third serving, what do you think their stomach is messaging to the brain? “I am full” is the only thing the stomach can signal. What is the message the reward pathway is sending to the prefrontal cortex (the decision center)? “Do not stop eating, because I am loving it!”. That is how addiction works!

The activated reward pathway is constantly reminding the patient that it loves the effects of the drugs and keeping asking for more. The use of opioids promotes another damage in the brain, specifically in the opioid receptors. Receptors are the keyhole in a cell, and the opioid is the key that opens that cell and promotes the release of dopamine. Once the brain cell is exposed to opioids, the opioid receptors started multiplying themselves to ask for more, so there are many, many more receptors asking for more use. This increased number of receptors is constantly torturing my patients! You can visualize a bird’s nest; the parents bring food for their babies. However, instead of the baby birds getting fed and quiet, more baby birds are created, and more mouths are noisily asking for more food. It seems to me like torture!

Sometimes when I recommend a residential/inpatient program (to remove the patient from their difficult environment), the families are resistant.   I try to educate them about the neurobiology of this disease, and the need for hospitalization but sometimes they will not change their minds. The thought that always comes to my mind is: If it was a brain tumor, would you have refused my recommendation for inpatient care?

Poor patients! They are not well understood by our society and culture who blame them for their disease, as if it was their willing choice.  No, they had never chosen to have this illness. They feel miserable. And, no one sees the goodness in them. The use of opioids compromises their immune system, besides interfering in their mental health and their ability to function. Too often, these patients are not seen like humans who need compassion and care. First and foremost, they need to be heard with respect, need to be educated about this disease and provided the care for all their needs.

I have come to realize that my substance user patient needs love and care. In this setting, I find my strength imagining myself as one of God’s many hearts and hands.  I feel blessed and honored to be God’s instrument in my work.  

Amen

 

 

 

14 min version:  I grew up in Sao Paulo, Brazil, as a Roman Catholic, in a family that followed all rules and regulations set by the church! And I grew up thinking that God was always seeing all the wrong things I could do and could be punished for.

 

I also studied medicine in Sao Paulo.  In Brazil, you go straight from high school to med school and I started it when I just turned 18.   As soon as I started, my mother was diagnosed with breast cancer. The first half of med school was while she had surgeries, treatments, and a lot more. She died soon as I started my fourth year of med school. I felt as if God had forgotten us!

--breath— 

I was so disappointed with the medical establishment, and I felt torn; should I believe in this kind of medicine that could not save my mother and go ahead and finish Medical School, or should I give up and look for something else?  Instead of giving up, I decided to look for a specialty that would prevent disease, instead of trying and failing to cure it! Pediatrics was my choice because it was the only specialty where I saw any preventive intent.

While I was doing my residency, one of my mother’s sisters (who was extremely supportive of my career) was diagnosed with pancreatic cancer. Nothing could be done to cure her, but I realized that simply holding her hands had a powerful healing effect. I realized that God was using me as her instrument. 

 

As I finished my pediatric and adolescent medicine training, I got a job with Brazil’s national health system. I was placed in a small pediatric hospital doing outpatient care for a very poor population. I found my call; I loved to work with those families, and they appreciated my care. I felt that my work, care and attention to their needs made a difference in their lives, and they gave me such powerful feedback, so much human warmth and love!

I was also moonlighting at a maternity hospital (I love the delivery room and newborns! It is a magical place where you can see God’s work! The Portuguese translation for giving birth is “giving light”, as giving a new life). Arriving there for a 24hour Sunday call, they notified me that a newborn baby boy had been sent to another hospital to investigate the cause of heart failure. When the baby returned, I was told that he had a severe malformation of the heart, and there was nothing we could do to save him and that he would pass away in a few hours. I checked the baby, went to see his family to let them know I was the doctor responsible for him. During that shift, I did all my duties, checked the baby and went to see the family as often as I could. I would say a few words about his condition and then sit and keep them company in silence. I still remember the face of the grandfather and how much he was suffering; he had beautiful blue eyes, and as the time passed, the brightness of his eyes seemed to be fading  and the skin of his face was getting wrinkled like a prune!

The baby passed away during my shift. I was not expecting to see this family ever again. However, a few weeks later, the family found me to let me know how much they appreciated my care (I really feel that God used me as her instrument to send love to them). Many months later, I arrived at the hospital to see that the same mother had a baby girl, now 2 days old and healthy. The parents let me know that they named the baby Patricia, after me! 

Pause

 

 A few years later, I met my husband Bob who was working in Sao Paulo. After we married, he was transferred back to NY.  I started working in the US, and I was shocked to see that “medicine is treated as an industry” and “doctors as service providers”! I grew up as a doctor seeing myself as a minister for my patients: listening and holding their hands, besides providing whatever medical care they need. It seems to me that part of the healing we, doctors, can provide is done by touch as well.

 

When we moved to Boston, I did a fellowship on developmental and behavioral pediatrics, and I was offered a position to work with teenagers who use drugs. I accepted the challenge and worked hard to learn how to treat a disease that was completely new to me. I immediately felt that I was called to this work; it seemed there was a perfect linkage between their needs and how God acted through my hands.

I like to work with patients who use opioids because their disease is so debilitating and so severe, and they really want to get better. Besides treatment, they need someone who will listen to them, without any judgement, give them as much time as they need, let them know that they are loved, let them know that they are good human beings, and are able to get better. Also, to remind them that they have strengths (it is a sad fact that these patients only hear negative comments about what they are doing or happening to them).

As we heard in John reading earlier: Neither this man nor his parents sinned; he was born blind so that God’s works might be revealed in him. What continuously surprises me is that, in no other disease, is the patient judged for getting sick. No one blames the patient who has diabetes, heart failure or cancer. Why blame a patient who has this terrible disease of addiction that promotes so much brain damage to the point that the patient is not able to make healthy decisions?

Over and over again, I educate my patients and their families that the brain has been damaged in such a way that it will hijack any attempt of making healthier decisions. Addiction is a chronic brain disease (with brain damage) that is manifested by behaviors (lying and manipulation are some of them) and relapses are expected (and we should have a plan ready for when relapses happen). One example of the brain damage is the activation of the reward pathway. Once activated, the reward pathway will boycott any healthy decision, because it will keep demanding that the patient continue using. The patient is being stigmatized because people expect them to make different decisions. However, their sick brain has lost the ability to think clearly and is NOT able to make healthier choices. I often tell them: you are such a good kid, but your sick brain is hijacking your healthy decisions.

Here is an example of the reward pathway boycotting a healthy decision:  when you go to a buffet style restaurant and you see people going for the third serving, what do you think their stomach is messaging to the brain? “I am full” is the only thing the stomach can signal. What is the message the reward pathway is sending to the prefrontal cortex (the decision center)? “Do not stop eating, because I am loving it!”. That is how addiction works!

The activated reward pathway is constantly reminding the patient that it loves the effects of the drugs and keeping asking for more. The use of opioids promotes another damage in the brain, specifically in the opioid receptors. Receptors are the keyhole in a cell, and the opioid is the key that opens that cell and promotes the release of dopamine. Once the brain cell  is exposed to opioids, the opioid receptors started multiplying themselves to ask for more, so there are many, many more receptors asking for more use. This increased number of receptors is constantly torturing my patients! You can visualize a bird’s nest; the parents bring food for their babies. However, instead of the baby birds getting fed and quiet, more baby birds are created, and more mouths are noisily asking for more food. It seems to me like torture!

Sometimes when I recommend a residential/inpatient program (to remove the patient from their difficult environment), the families are resistant.   I try to educate them about the neurobiology of this disease, and the need for hospitalization but sometimes they will not change their minds. The thought that always comes to my mind is: If it was a brain tumor, would you have refused my recommendation for inpatient care?

Poor patients! They are not well understood by our society and culture who blame them for their disease, as if it was their willing choice.  No, they had never chosen to have this illness. They feel miserable. And, no one sees the goodness in them. The use of opioids makes them more susceptible to infectious diseases and compromises their immune system, besides interfering in their mental health and their ability to function. Too often, these patients are not seen like humans who need compassion and care. First and foremost, they need to be heard with respect, need to be educated about this disease and provided the care for all their needs.

I have come to realize that my substance user patient needs love and care. In this setting, I find my strength imagining myself as one of God’s many hearts and hands.  I feel blessed and honored to be God’s instrument in my work.  

Amen