Image by Margherita Barrera.
Sarz Maxwell, whose LOTR erotica we explored in Part 1, returns for a very different story about her day job as a psychiatrist, and her controversial treatment of opioid addiction.PLAYLIST
Syrinx – Ibistix – Tumblers From The Vault
Capitol K – Goatherder – GOATHERDER
STEPHEN VITIELLO & TAYLOR DEUPREE – First Variation – Fridman Variations
Shanyio – h1 – Hedera Helix
Craig Leon – The Twenty Second Step As Well As The Tenth – Anthology of Interplanetary Folk Music Vol. 2: The Canon
Shanyio – h8 – Hedera Helix
Biosphere – Hilsondis – The Hilvarenbeek Recordings
OSSIA – Radiation – Devil’s Dance
Deaf Center – Red Glow – Low Distance
The Boys Will Work It Out
Sarz Maxwell – Psychiatrist
Sarz Maxwell: People don’t understand. People don’t understand addiction and in particular, opioid addiction is the most misunderstood. All I was doing was prescribing in a manner that was outside the norm but nothing I was doing was against any regulation or rule, certainly not against any law and yet I have been treated with no hint of the compassion that I was given before when I was a real criminal.
I went to medical school through the national health core scholarship and then I had to pay back by spending four years practicing in an underserved area. I went off to Northwest Missouri. I remember my residency as some of the happiest years of my life. It was thrilling learning how to be a doctor, learning how to do what I had wanted to do. During that time also, I was having a lot of trouble with drinking. I was mostly in the gay bars then. I was dating a drag queen. We both wore the same size in lingerie, so we were a perfect couple. I was drinking either scotch or white wine and if it was scotch, I would drink a fifth in a night. If it was wine, I would drink one of those four liter boxes in a night. I was also self prescribing diet pills. It was an amphetamine like drug. I had a whole bunch of false names with false addresses. I had a little book with all of the names and addresses on them and went to pharmacies all over about three counties to fill all the prescriptions. I was well known. I was the only psychiatrist for 100 mile radius and a lady doctor too.
That last year was really scary because I knew that I was dying. Waking up in the morning, the first thing was fear and shame. One becomes so ashamed of using that all you can do is use. Shame tells me that I am myself, basically fundamentally bad, flawed.
And is that what you were feeling?
Oh yes. Still do. That’s a sense I’ve had all my life, that I’m pulling something off, some day everyone else is going to figure it out and see what I really am.
Do you think that’s because you’re a human being or do you think that’s because of a pretty traumatic childhood?
Well shame is a response to injury and I was injured as a child, so yeah. That shame was there. Most people I’ve talked to who were injured as children have that sense. Mom raised the three of us alone, which was not at all fashionable in the 50s and early 60s. She was fortunate to find a couple who were professional babysitters. It was idyllic. They had this house on an acre or so of land, apple trees to climb, a little playhouse, a little pond. Unfortunately, they were child pornographers. I was one of their stars.
Ive always liked hyped up drugs. I developed quite a tremor and everybody around me knew. I still thought I was hiding it but everyone around me knew. This is in the 80s, remember? Addiction treatment programs were popping up like mushrooms everywhere. They were all 12-Step oriented, they all had posters of distressed gorillas saying, boy, do I need a meeting, kittens hanging from branches saying, hang in there baby. I knew that if I went into one of those programs, I’d just eat them fucking alive. There was no way that these slogan mouthing nitwits were going to be able to help me. There was no way that I was going to be able to let them. I was terrified. I thought I was dying and there was no help for me anywhere.
Two agents from DEA knock on my door and they have a bunch of print outs and they say, we’d like to see the charts for these patients. I immediately said, look, you know as well as I do what’s going on. Those aren’t patients, those are all me. I wrote all those prescriptions for myself. What do we do now? They were so compassionate and understanding. I mean they were amazing. They said, here’s what you have to do, you have to relinquish your DEA and they said, and you have to get into treatment. My mother used to say, there’s no impetus like no choice. Quit bitching, just fucking do it. I just fucking did it. I went to AA meetings at first, of course. It was required by the program. After the first couple of years, I didn’t go to meetings much anymore. I never got a sponsor. When I talk about that, people still sort of sneer at me. That’s going to lead to relapse, you know? And I’ll say, well it hasn’t yet and it’s been 24 years, so I’ll take my chances.
For some people, it’s when they’re under stress or having bad times that’s hard. For me, it’s celebrations. A friend of mine’s wedding was a renaissance wedding. She rented a castle here in town. It was beautiful and they had a martini bar with an ice sculpture of a glass slipper and the bartender would make the martini and pour it up at the heel of the slipper and then it would come out the toe all chilled. You just can’t do that with diet Pepsi. It just doesn’t work. Once I got into recovery, then I became interested in treating addicts and that became my sub specialty.
When Suboxone came out in the United States, I was immediately intrigued, of course, because having to go to a methadone clinic is such an incredible barrier to care. I was sure I wanted to know more about it and wanted to be a provider.
What was it like when you got licensed and started being able to prescribe it? Can you tell me a little bit about those first few patients?
I loved it. I loved giving them a prescription that they could take to the pharmacy and get it filled and take home a bottle of pills, just like they were a patient having a disease that was treated by their doctor. The theory that I subscribed to of what causes opiate addiction is this, we know our brains create natural opiates. They’re called endorphins. Everyone has heard of endorphins. In people who may become addicted to opiates, there is a preexisting deficit in endorphin, so for these people, using an opiate is exactly precisely like a diabetic using insulin. What treatment does is it provides a dose of opiate to meet that underlying need. When they’re at the correct dose, they don’t feel intoxicated. They feel like you and I feel sitting here talking. They feel normal and that’s what they’re trying to get with their drug. It’s Earth people who get high from drugs. Addicts use drugs in a desperate attempt to feel something that might be called normal.
More and more of the patients coming to me for Suboxone treatment, they had gotten addicted to prescription pain medicines. In my practice, six patients also had legitimate, well documented chronic pain problems. One guy had been in a very terrible motorcycle accident and broken a whole bunch of bones. Another had AIDs and had peripheral neuropathy. I had these six people, I was treating their addiction, but they were continuing to buy opiates on the street for their pain.
And any idea what they were buying?
Mostly Oxycontin. I got some extra training, I taught myself how to prescribe pain medications for these opiate addicts who were taking Suboxone. They bloomed.
John: In third grade, I was about nine years old I guess. I was diagnosed with a bone disease called Legg-Calve-Perthes disease, which is basically a deformity of the right hip joint that restricts blood flow into the joint. It prevents it from developing normally. I went to work in construction and after about 15 or 20 years of pretty hard labor, it just got worse and worse and the pain was so bad, when I would move my leg, it basically sounded like a stalk of celery breaking and eventually, I ended up going on social security disability. At that time, I looked up on the Internet and I found Doctor Maxwell and I also did want to see a psychiatrist too. That was another attractive thing that I felt maybe I was depressed and so I was hoping she could help me with that as well.
Sarz: He came in using a walker, inching across my floor, letting himself down inch by inch into the chair and grimacing at every movement. When I met him, he was sleeping two hours out of every 24 and the only way he could sleep was he would get in his car and drive and drive and drive until he was almost unconscious with fatigue and then he’d pull into a parking lot or a wildlife preserve and sleep in his car for an hour or two and then start the car and do that over again.
Was he someone who had been addicted to opiates?
He had been diagnosed with addiction to opiates. I am convinced that his was a pseudo addiction. Pseudo addiction is a disease that looks exactly like addiction. People crave the drug, they seek it out, they do illegal things to get it, they forge prescriptions, they steal, whatever. What differs in pseudo addiction is the cause. Addiction is caused by a preexisting, probably genetically determined glitch in the brain. Pseudo addiction is iatrogenic. It’s caused by under treatment. In this case, under treatment of pain. He was buying all sorts of other opiates and heroine in order to try to manage his pain because his doctors told him he was using too much. Now when someone can’t sleep more than an hour at a time, I don’t care how many milligrams they’re taking, it’s not enough.
So you started treating him with what?
Methadone. I don’t remember if he was … Yeah, and with Oxycontin. It was, at the time, one of the most powerful opiates that’s on the market for pain. Now I did have to prescribe unusually high doses of those opiates because Suboxone occupies the opiate receptors like those plastic things that you put in wall sockets when you’ve got a baby in the house and in order for the other opiates to react on those receptors, they had to overcome that blockade. It was maybe eight months later, he walked into my apartment, sat down, played with the cat, and said, I got a part time job. After three years with me, he was working. He was sleeping eight hours at night. He had started playing his guitar again. He was working, even a republican will say that’s a good thing.
John: I would say that woman turned my life around. She knew immediately what to do. The pain was almost completely gone. When I had to stop seeing Doctor Maxwell, she helped me find another psychiatrist, pain management specialist. He wanted me to reduce the amount of Methadone. He wanted to get me off the Oxycodone completely, which I did. I find it harder and harder to be able to get the medication I need. Every month I go to see my doctor and I’m nervous because he’s always saying to me, I want you to switch onto Suboxone or I want you to get off Diazepam. He tells me about the DEA come to me and they interview me and I could lose my license and he goes on. I want to get off the medication because I’m scared what’s going to happen if I can’t get it or my doctor says to me, the DEA came and it’s happened once.
How did the DEA get involved? When did they show up?
Sarz: I came home from doing a talk and there were two agents that I’d never met sitting on the stoop in front of my house. Now, my lawyer, she said, they’re the government. They’re not there to make friends. Never talk to a government agent without your lawyer present but you know me, Anne, I’m a dummy. I talk to anyone. I invited them in. I had plans for that evening where they were going to show, on big screens, the move, Fellowship of the Ring, which CSO did the music live. I had been looking forward to this for months. They told me, you are not qualified to treat pain. To which I replied, silly me. I have a very distinct memory of going to medical school. In fact, one of them said, no psychiatrist is qualified to treat pain. We went around in circles for a couple of hours. They also made me lock up my cats. Go figure. I ask him and I finally said, what do you want of me? And they said, we want you to quit doing this. I said, I have an MD. I need to do what’s right for my patients. If I’m doing something illegal, arrest me. She called the licensing board and asked them to discipline me.
They wanted to have a hearing to see if I should still have a medical license. They went through and they just kept saying, these doses that you’re prescribing are outrageous. They’re just too high. They’re too high. It’s too much. I kept saying, but you can’t tell about a treatment just by looking at the numbers on the dosage sheet. You have to look at what the patient’s response was and my patients were getting better but they didn’t see the patients. They just looked at the charts and on the charts, the doses were too high. They put my license on probation for no less than two years.
There is nowhere, nowhere, that will hire a doctor who’s license is on probation. I couldn’t get a job at a prison. I applied for probably more than 300 different jobs, including jobs at Subway and never got so much as a call back.
How are you surviving?
Barely. For almost a year, Chicago Recovery Alliance let me live in their warehouse and then this past year, I was living in my sister’s basement. While I was involuntarily unemployed, I started writing standalone fiction. All of my work has gay protagonists, gay male protagonists, but I want to be a clinician. Whenever I say that I treat addicts, people say, oh, that must be so depressing but it’s really uplifting. The patients get better. I can help them. I can do something that makes a difference and their lives turn around. It’s thrilling.[Driven by escalating opioid addiction, drug overdoses are now the leading cause of death among Americans under 50.]
There’s a Suboxone doctor for about one in every 50 opiate addicts.[A new report shows that opioid overdoses led to more than 4,700 deaths in 2017. West Virginia, Ohio, and New Hampshire have the highest …]
I’m needed and I can’t do anything.
With Oxycontin, you can get high on it but they weren’t getting high on it. It was just for their pain.
I don’t know how to define what getting high is. Opiates feel good. They just do. Yes, they may have been feeling some pleasure with it. I don’t have a problem with my patients feeling good. I think that they should. For all I know, all of them were sometimes having a lost weekend. As do we all. Everything to do with addiction in the United States is defined not by medical knowledge, not by common sense, but my morality. It’s frustrating because it’s so intertwined with bullshit. Abstinence based therapy came from alcoholics anonymous. We forget that alcoholics anonymous is about alcohol. That’s a completely different drug.
Abstinence treatment of opiate addiction carries a relapse rate of up to 90% in the first year. What kind of doctor would even consider giving a patient a treatment with only a 10% chance of success when there are readily available treatments with a 70 to 80%? And you know, I have had colleagues, doctors, who say, but don’t you want to give your patient that 10% chance to be clean? And I say, I don’t know about yours but my patients aren’t dirty.
Imagine if there were clinics that managed the distribution of clean drugs to people who are physically dependent on them with no intention of getting anyone off anything. Would that be okay?
That makes perfect sense to me. It would be a wonderful income generator, plus no longer having to spend the billions of dollars that we spend on totally ineffectual enforcement. Yeah, that makes perfect sense.
I got in touch with you because I am doing a podcast episode about an addiction psychiatrist in Chicago. One of the things that she is telling me is that she subscribes to a theory of addiction that people who use opioids have some kind of preexisting endorphin deficit.
Dr. Kolodny: The theory that people who develop opioid use disorder have some preexisting opioid deficit or what sometimes termed, low hedonic tone, doesn’t really make much sense. Opioids are not like alcohol. If you think about alcohol, we know that most of the population can take alcohol repeatedly and doesn’t get addicted to it and about 10% of people do get into trouble with alcohol and although we haven’t identified the gene or the genes, we’ve got suspect genes and we know that alcohol addiction runs in families. With the highly addictive drugs, the individual’s characteristics, their genetic background, what makes that individual unique, is much less important than the drug’s inherent addictive properties and what happens to the brain through repeated exposure. With a highly addictive drug, anybody who uses that drug repeatedly can easily become addicted to it.
The reason we’re in the midst of a severe epidemic of opioid addiction and overdose deaths in the United States is because, starting in the late 90s, the medical community became much more aggressive in our use of these medications, that prescribing began to really take off and as the prescribing went up, rates of addiction and overdose deaths went up right along with the increase in the prescribing. The reason we started to prescribe opioids so much more aggressively is because that we were responding to a brilliant multi faceted marketing campaign that changed the culture of prescribing in the United States and it wasn’t just that doctors started hearing from good looking drug reps working for Purdue Pharma were visiting our offices, telling us that opioids are not addictive. We weren’t just hearing this directly from a drug company that we should prescribe much more or we would have been less gullible.
We were hearing these messages from pain specialists, eminent in the field of pain medicine. We were hearing it from our professional societies, from our hospitals, from our state medical board, from almost every direction, we were hearing that if you’re an enlightened doctor, you’ll be different from those stingy puritanical doctors of the past. You’ll understand that opioids are a gift from mother nature and should be used much more for just about any complaint of pain and the different individuals and organizations who were promoting these messages had financial ties to opioid manufacturers and part of that messaging was that opioids are non toxic, that they don’t damage any organs, which was totally not true. It was one of the many lies that were told. This was a brilliant campaign. It worked very effectively. The prescribing took off and it led to where we are today.
Another claim that this clinician is making is that unlike alcohol, that opioids, setting the question of dose aside, are completely non toxic to the body.
Dr. Kolodny: Opioids damage the brain. If you take an opioid around the clock every day for about 30 days, the brain begins to change in a way that’s so significant, you can see it on an MRI. 30 days of regular opioid use causes certain regions of the brain to shrink and there are other problems associated with regular opioid use. Both men and women, you’ll see that their hormones, their testosterone level is suppressed and that can have an impact in fertility, it can decrease energy, libido, and they veg out on the sofa every day instead of really being active in their family or community. Another problem with chronic opioid use is immune suppression and with immune suppression from opioids, there can be an increased risk of cancer. The fact that there’s so much misinformation out there and so many folks with really wacky views, makes it much more difficult and there are unfortunately, debates about preventing addiction, debates about treating addiction, when in reality, these aren’t controversial areas but they’ve been controversialized.
I talked with a psychiatrist, he’s an opioid policy researcher. You had told me that the reason that people become addicted to opioids is that they have this preexisting deficit of endorphins in their brain and he said that there is no evidence to support that and that in his view, they’re inherently extremely addictive and just about anyone, if they take them long enough, is going to get addicted.
Sarz: I agree that there is no hard evidence. Nobody does that research. I don’t know how you would do that research. It’s hard to get people to agree to brain biopsies, you know? It is the only hypothesis that fits the experiences that I’ve had with patients. If he’s a hard scientist, I understand him not subscribing to a theory that has no empiric evidence. That’s fine.
I asked him what you said about heroin itself being non toxic. He said that in fact, opioids cause neuroendocrine dysfunction, suppression of testosterone, and decrease in energy and libido changes in the regions of the brain that mediate affected impulse and immune suppression that’s been linked to increased risk of cancer.
Those things are true to a point, particularly Methadone. Methadone is really hard on the libido and on testosterone and yes, it affects immunology but it’s non-toxic probably at about the level that artificial sweeteners are. I was comparing heroin to other intoxicants, alcohol, that is viciously toxic to every tissue in the body. If someone is going to intoxicate, please use heroin or marijuana, you know? Nothing is safe.
What happened to the six patients that you had been treating for both addiction and pain? Were you able to find anyone else to help them?
I sent them to colleagues of mine that are Suboxone doctors. I spoke with these colleagues and told them what the situation was and they all told me that they would not immediately stop the patient’s opiates but what happened to them, I’m ashamed to say I don’t know. I’m almost afraid to find out because I don’t imagine they’re doing well.
I have some sad news, which is that, as you know, you put me in touch with your former patient, John, the one who had the degenerative bone disease.
Is he dead?
Yeah. He passed away in February. It was an overdose. They believe that it was an accidental one.
I was not exaggerating when I said that firing my patients was essentially a death sentence. A lot of people on Methadone and Suboxone want to get off because they’re afraid they might not always be able to get it.
Do you think this would have happened on your watch, if he’d still been able to be under your care?
No because treatment keeps people alive.
Anything new from DEA or the licensing boards since the last time I saw you?
Well DEA claims that they are going to give me a registration and a contract, where I’ll be on probation for them for X period of time.
Will you go back into private practice and start seeing Suboxone patients again?
Oh yes. I love seeing Suboxone patients.
And if a Suboxone patient shows up and says, I have chronic pain, what will you do?
I’ll treat them as best I can. I’ll document a lot better but I’m still not going to let a cop how to practice medicine. All this will have been in vain if I still allow cops to tell me how to practice medicine.
Doctor Andrew Kolodny
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