Wednesday, June 30, 2010

Step by Step

There is nothing quite like a double choclate chunk cookie that has been melted due to the summer heat. I can honestly say that I rarely indulge in such a wonderful creation. However, we all have exceptions to our rigid rules. And today, was the perfect day to indulge. The best part is devouring the cookie after a 9 hour test.

I completed Step 2- Clinical Knowledge Today. The mental marathon was long and at times felt endless. Every click got me one question closer to being done.

I am releived it's over. Now, it's time to catch up on life.

Friday, June 25, 2010

Lessons in Urban Survival

“You can tell a lot by a person’s shoes. One look tells me if they are worth my efforts.” he said.

My patient, a forty-something gentleman, was educating me about what he called “urban survival.”

As a native of the Tenderloin, he relied on certain tactics to make ends meet. He was an expert-level street hustler. He was one of the successful ones and was capable of making a small fortune, probably enough to pay rent and live comfortably in a nice SF apartment somewhere outside the Tenderloin.

Sadly, he burned through his earnings, spending massive amounts on one thing—crack cocaine.

“Sometimes, it feels like I am drowning just thinking about how much money I owe. But I want it (crack). I need it. And I have to get it.”

Cocaine is derived from Erythroxylon coca leaves, a plant endemic to the Andes. In historical records, cocaine chewing was documented in South America as far back as 4000 years ago and for the last hundred years has had medicinal uses because of its vasoconstricting effects (1,2). Cocaine has multiple actions, acting as a local anesthetic effects, CNS stimulant, appetite depressant, and vasoconstrictor. The effects are largely mediated through the inhibition of norepinephrine, dopamine, and serotonin (3).

Cocaine has become a popular street drug, which can be sniffed, smoked, or injected intraveneously. As a recreational agent, cocaine has variable purity. The purest forms are white powder, while less pure forms are more yellow and have been cut with other drugs, such as lidocaine, caffeine, methamphetamine, ephedrine, and phencyclidine (3). When cocaine is heated in an alkaline solution, it transforms into “crack,” which is sold in 100-150 mg “rocks” and can be smoked, while a “line,” weighs 20-30 mg and is snorted (3).

When I first met him, he was completely suicidal and was brought into the SFGH Psychiatric Emergency Services after being placed on a 5150 hold for being a danger to himself. After the initial evaluation, he was transferred to the inpatient psychiatric unit. At the time, he had no home and was completely out of money.
He was a tall, thin middle-aged man with a pinkish complexion. His hair was combed and slicked back. He wore a lime green collar shirt over blue hospital gown pants. His two front teeth protruded outward and had been eaten away and were stained brown.

During our first meeting, it was like everything was in slow motion. He moved aimlessly and spoke slowly when recounting the details of his suicide attempt. He had a flat affect, showing very little facial expression. He appeared remorseful, but remained deeply depressed. At times, he would become teary eyed when talking about being abused as a child and his life in the Tenderloin. He was diagnosed with bipolar and polysubstance dependence.

“When I get low, I get really low and go into these dark bouts of depression. There is no reason to live for me. No one gives a shit about me.” he said.
His past addiction was alcohol; his current substance was cocaine. His heavy drug use required excessive amounts of money, which he often did not have. Thus, he borrowed from street lenders and still had to pay back his debt.

The chronic use had left his life in shambles. He went from having it all—a condo, a girlfried, and a stable job—to now having nothing. He was living on the streets, had made many enemies, and relied on hustling to get his daily fix.
He had been admitted to our inpatient unit numerous times before for suicide attempts and was in and out of residential treatment programs. He was followed by a case manager and was plugged into an extensive network of social support services, but had difficulty committing to appointments and taking his medications. The hospital had become his security net, a revolving door for him.

Addiction to drugs results from alterations in neurochemical processes, which ultimately lead to increased drug-seeking behavior. Cocaine, like many other drugs of abuse, is highly addictive because it blocks dopamine uptake and results in increased dopamine levels in the nucleus accumbens (4). With respect to behavior, dopamine promotes reward-seeking behavior (5).

Interestingly, with increased cocaine use, dopamine release results in the setting of exposure to certain stimuli, such as drug paraphernalia or environmental cues, findings that have been demonstrated in animal models (6). This conditioned response explains the drug-seeking behavior observed in chronic users, who are driven to do whatever it takes to get their neurochemical fix.

Over his two-week hospitalization, I came to know him really well. Although initially reserved, he opened up and enjoyed talking about himself and his urban life; he was always seeking an audience. He became animated when he described the subculture of street hustlers.

He was vague when describing exactly what he did when he stood on the streets of the financial district wearing an expensive European blazer and pair of polished Italian shoes. He had mastered the art of “talk,” and was able to assume an entirely different persona, when he worked in the shadows of the black suits, he desperately desired to be.

Like himself, many of his colleagues were substance abusers, who generated funds through a similar fashion. He admitted that his tactics were aimed at getting money from the “sharks,” the men in business suits. Unlike other hustlers, he felt his tactics were less seedy; he did not pursue women and was not overly aggressive.
“I just have a way of getting what I want,” he said.

Despite his skills, he was consumed by what he called “self-destructive behavior.” He had made many street enemies and there was no escape living in the Tenderloin district, where every street corner harbors a dealer and the environment reinforces his addiction-forming habit. He felt powerless and weak, completely disabled with an inability to break the habit.

“I am spiraling and digging himself deeper and deeper in an early grave,” he said.

With an expanding drug economy, a subculture of hustlers has emerged as a powerful force with a unique social identity. In a study that examined the social identity formation of street hustlers in a group of 28 criminals prosecuted for violent street crimes, the authors cited how hustlers involved in the drug economy made every effort to differentiate themselves from the crack-heads, who represent a lower social status (7).

The following qualities were identified as central components of the hustler identity:
1. Being Clean- The hustler has morals and pays close attention to hygiene and dress.
2. Having Things- The hustler seeks to acquire material wealth
3. Being cool- The hustler is characterized by a detached persona and calm demeanor.
4. Being criminally able- The hustler has the knowledge to accomplish the necessary acts to sustain a living
5. Having heart- The hustler can protect oneself from victimization or danger.
The authors conclude, “The self-described hustlers in our research succeeded, at least in their own minds, in establishing an identity whose status is at the top of the crack economy rather than at the bottom,” much like my patient who prides himself for being successful at his line of work (7).

Closer to the end of his hospitalization, my patient laid out his requests— he wanted to be admitted into one particular residential treatment program in San Francisco and after he completed the program, he wanted a new apartment outside the Tenderloin. These were his stipulations for recovery.

At times, it felt like we were negotiating the terms of an agreement. And when we could deliver, his attitude changed. He instantly became invested in recovery and the treatment program, seeking immediate discharge even before the bed was made available. When we had trouble securing the bed, he drifted into a depressed mood and pleaded with us.

He intrigued me. A part of me was drawn to him, sympathizing with him, completely consumed by his story. I could not even fathom how he survived years of childhood abuse, living in the streets, and relying on urban survival. I wanted to see him recover to help me get back the life he once had.

At the same time, the skeptic in me awakened. At times, I wondered how much of his story was true and how much of it was actually concocted. He was well-versed in the art of talk. He knew exactly what to say to get what he wanted. After all, he was an expert hustler. I often wondered, was I being hustled like everyone else who had entered his life?

When he left the unit, I wished him well. I never knew what became of him. One can only hope he was successful this time in his residential treatment program. A part of me fears he might have tried to kill himself again, while another part of me thinks he may have ended up back on the streets, hustling his way to bricks of crack.

Whatever the outcome, his story reminds me about the intersections of substance abuse, addiction, and psychiatric illness, a sad reality in our urban neighborhoods. Although it easy to blame the patient for his addiction, we must remember that addiction is an illness, which like many other medical diseases, requires an interdisciplinary approach to treat the neurochemical and psychological basis of disease.

Works Cited
1. Nunes E,. “A Brief History of Cocaine: From Inca Monarchs to Cali Cartels: 500 Years of Cocaine Dealing.”NEJM- Nengl j med 355;11 1182 september 14, 2006
2. Murphy Nancy G, Benowitz Neal L, "Cocaine" (Chapter). Olson KR: Poisoning & Drug Overdose, 5e:
3. Luscher Christian, "Chapter 32. Drugs of Abuse" (Chapter). Katzung BG: Basic & Clinical Pharmacology, 11e:
4. Volkow N, Wang G, et. al. “Cocaine Cues and Dopamine in Dorsal Striatum: Mechanism of Craving in Cocaine Addiction.” The Journal of Neuroscience, June 14, 2006, 26(24):6583-6588; doi:10.1523/JNEUROSCI.1544-06.2006
5. Schultz W, Dayan P, Montague PR (1997) A neural substrate of prediction and reward. Science 275:1593–1599.
6. Di Ciano P, Everitt BJ (2004) Direct interactions between the basolateral amygdala and nucleus accumbens core underlie cocaine-seeking behavior by rats. J Neurosci 24:7167–7173
7. Copes H., Hochstetler A., Williams JP., “‘We Weren’t Like No Regular Dope Fiends”: Negotiating Hustler and Crackhead Identities.’” Social Problems. Vol. 55, Issue 2, pp. 254–270, ISSN 0037-7791, electronic ISSN 1533-8533

A Long Overdue Update

I've been spending my days staring out the window and at a screen, clicking away. I am still here. Officially a fourth year. And with that transition comes another test-Step 2.

Studying has been unexciting, to say the least. Needless to say, there is not much to write about. Just counting days to test day and being done with these artificial case vignettes.

Once this exam is over, I look forward to reflecting as I begin my fourth year.

For now, I am posting a recent essay I published in the San Francisco Medicine titled "Lessons in Urban Survival."