Field notes

Duffys Rehab Journal

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(anonymous Friend ): Field Note observations

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Film Observations: Methadonia (documentary)

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NPR (ARTICLE):

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The New York Times (Article)

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Field Notes

Ethnographic Essay: Maintenance Medications Writing & Rhetoric II

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Duffys Rehab Journal

December 2014 week before Christmas

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Site: Duffys Rehab Napa valley

Rehab Journal: Duffys

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• I have been up for 6 days. I got off an airplane only hours ago.

• The entrance looks like a living room, there is a fire place. It is a large beautiful facility, it is always sunny here but this week it happens to be gloomy and raining.

• Staff is friendly, I am with my father. They’re demeaner changes once they receive payment from friendly to authoritative. My father leaves in a rush to beat traffic.

I am searched, my belongings are removed and I am given a duffle bag branded by the rehab, a large binder and an AA big book and a small bar of soap also branded.

• I am taken to my room in the TC Unit (transitional care) where people are harbored under 24 hour supervision while they are at risk of seizure, suicide etc…

• The one bathroom for what I would estimate to be 12-14 people who are very ill is out of order. There is a small bathroom through the living room by the staff area. The bathroom lock is broken.

• Within 20 minutes I am approached by a young person asking me “what I am in for” he tells me he will have sticks (benzodiazepenes) tomorrow to sell me.

• There is a distinctive smell in the air of shit, vomit, lysol and the distinctive vinegar molasses smell of heroin being smoked from tin foil.

• I am told I cannot leave without staff supervision from my room to do anything. There is a rigorous schedule. The only way I will gain the privelage to shower or smoke cigarettes unaccompanied is to attend all the activites in a day starting at 6 am ending at 9 pm • I sit and the horrors begin, my skin is crawling with electric bugs, my brain seems to be releasing chemicals randomly causing drastic emotional changes. I am defeated.

I cry for the first time in years.

• There is no doctor on premise, I am driven to a doctor where I discuss with her what it is I will be treated for.

I am informed that Poly Substance treatment is thousands of dollars more expensive. It is clear this is a purely fiscally based decision. There is no reason for this extra charge. I have to choose one. I choose benzos.

• I am prescribed valium, clonondine, and gabapentin.

• The first few days, once I am given my meds I am pretty sedated. Higher than I was before while I was running out of benzos the weeks before.

• I attend many AA meetings. They are all poor representations of AA from my personal experience.

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• They have made their own version. They allow cross talk.

Not allowed by AA. • “When one AA member directly addresses another member during the sharing part of an AA meeting and offers advice. In AA, we are expected to share our experience, strength and hope with one another rather than offer advice or instruction. Therefore, it is against AA customs to engage in cross-talk during an AA meeting.”(AA Glossary)

• I make friends with a few different people. The meals are horrible. Today they serve the left overs of the past week. My stomach is sick. There is no bathroom to use. I lay in bed. They want me to beleive in god and pray. I now beleive in hell. I have found it exists.

• My one friend is in denial he needs to be here. He does too much coke and drinks. He was recently in the hospital but he is just here for a break.

• My other friends are two end of the road junkies from brooklyn. They were living under a bridge in west oakland they both have hep C they are a couple.

• I find out we have mutual friends from high school in the bay area and mutual friends in new york city.

• I know i am not much different from them. Am I? • I loan them a book in exchange for cigarettes • I finally take a shower one day. I share the shower with a man making advances on me, He asks if I smoke crack. You Know like those fucking niggers, they all smoke crack right. Oh man i want a drink. He starts to touch me and i step out of the shower.

• I go back and lay down to make phone calls. That is the one thing they let us have, and the one thing I wish they took away. I receive a call from my oldest friend and ex lover. She will never talk to me again.

• I speak to my new girlfriend she tells me she wont be able to avoid a new years kiss from another man.

• I become friends with the younger people, none of them wanted to be sober, many were there court ordered.

• There was a kid who stole a pack of cigarettes from a shared dorm room, he was beaten to a pulp before being kicked out to go to jail, his roommates filled his shoes and bags with bags of dip spit. He was 19 and an orphan.

• After a while i learned more about drugs that i already knew, and i thought i knew everything. I had made a decision to get high on opiates right after i left.

Something i had never craved in the past. I wasn't feeling

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any better. I was still on drugs, more drugs than before almost. • I left a day early, my friend picked me up and we raced out of there. I was high 7 hours later. I had picked up a new habit. Along with a formidable amount of guilt for the failure of my expensive treatment.

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(anonymous Friend ): Field Note observations

December & January 2014

• I have recently gotten out of a failed rehab attempt. I am visiting an old friend who is strugglling with heroin addiction.

After trying to use suboxone and gabapentin with no avail. She is sick and on the verge of death. Covered in absesses, shooting up a 400$ a day habit of up black tar heroin.

• I walk in to her room there are so many needles on the ground you cannot walk. I try and help her out. This is a picture after 20 minutes of cleaning. (seen right).

• I stay with her for the next few days, seeing her often over the next week. Talking to her parents about my experience in recovery.

• I realize the true hopeless nature of her situation •

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Film Observations: Methadonia (documentary)

“Michel Negroponte’s documentary about Methadone users is very personal. He follows several users who go to a Manhattan group, the New York Center for Addiction Treatment Services, on Broadway and Houston, just next to NYU. They talk about their drug experiences, their regrets, and their problems, as well as their hopes for the future. These women and men have lives that are in ruins. Many of the people we see have been addicted to various drugs for decades, and the prospect for their recovery is not good. Others do manage to stop taking methadone, but the documentary makes clear how difficult it is to do this.

According to the Office of National Drug Control Policy, “Methadone is a rigorously well-tested medication that is safe and efficacious for the treatment of narcotic withdrawal and dependence,” but most of the users in Methadonia take methadone with other drugs, especially

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benzodiazepines such as Xanax and Klonopin. We see several users nodding off while they are being interviewed, stopping in mid-sentence, falling asleep as they sit.”1 Methadonia Observations: • Various Talking heads speak of the fantasy they now have as what others might think of as a routine day.

• Lots of talk about normalcy being paradise. A lot of hatred, self loathing “you think i love this shit” Most people seem to be talking about looking for a place that provides comfort like home.

• Talking head referring to his late wife (paraphrased) “She was totally focused on the drug heroin addiction is work, its become the lousiest job you can imagine with a boss screaming at them from inside they're own head and no days of. Thats when some junkies finally say they finally want to cross over to straight land.”(picture of average family home, humble), Sounds Like paradise • These people are at the end of the line. Homeless, hopeless, having trouble staying awake in meetings

• opiate replacement therapy they exchange a heroin habit for a daily methadone habit because methadone is a slower acting drug that doest produce the extreme effects of heroin but does keep the addict from going into withdrawl.

Methadone is a synthetic opiate that works on the same opiate receptor that heroin works on. So a user cannot shoot up because the opiate receptors are already used up.

A lot of people here on methadone dont think for recovery, they are looking for a fix.

BILL: (paraphrase) “Nowadays methadone programs which used to level off at 80 mg in ny, jersey now have no ceilings. They're are people who are on 180 msg thats a “methodnian” because they walk around like a zombie all day. thats it they are a methadone robot and thats that. when you decide you want to get off it doesn't matter how much you're on it doesn't matter how hard it is to get off it. what matters is that you put the time in….and it take alot… mental help, sponsor, this isn't "Methadonia." Drug Documentaries. N.p., 03 Apr. 2014. Web. 24 Feb. 2015. <http://www.drugdocumentaries.com/ other-drugs/methadonia/>.

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gonna be easy you better be ready for the ride of you're lifeâ&#x20AC;? ***in the 1960s pill habits meant amphetamines and barbiturates today the more common pill addictions are to benzodiazepines a class of anti anxiety drugs. In methadone communities they call stix benzos and footballs you take a couple of them after a dose of methadone and the high iOS almost as good as a bag of heroin. You know what a take home bottle is? the bottles are so big now because the doses are getting so high.

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Npr (Article): Selling Sickness: How Drug Ads Changed Health Care 2 David Couper went to his doctor after watching a small green creature jump up and down on the nail of an infected toe.

For Anne Nissan, a 17-year-old in Prescott, Ariz., the image that stayed with her was of a party. Women were on a roof in a city, pimple-free and laughing, utterly unbothered by the cramps that immobilized her once a month.

And then there is Samantha Saveri, a transportation planner in Baltimore. She remembers bunnies and the promise of digestive regularity.

Three different people in three different places were all driven to contact their doctors after watching an ad for a prescription medication on television. Each walked into a doctor's office with a specific request, and walked out with a prescription for exactly the medication he or she desired.

The Rise Of Prescription Drugs In America Prescription drug spending is the third most expensive cost in our health care system. And spending seems to grow larger every year. Just last year, the average American got 12 prescriptions a year, as compared with 1992, when Americans got an average of seven prescriptions. In a decade and a half, the use of prescription medication went up 71 percent. This has added about $180 billion to our medical spending.

2Spiegel,

Alix. "Selling Sickness: How Drug Ads Changed Health Care." NPR. NPR, 13 Oct. 2009. Web. 23 Feb. 2015. <http://www.npr.org/templates/story/story.php?storyId=113675737>.

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While there are more medicines on the market today than in 1992, researchers estimate that around 20 percent of the $180 billion increase has absolutely nothing to do with the number of medications available, or increases in the cost of that medication.

To understand this change, one place to look is Wilder, Vt. There, in a tasteful housing complex on the side of a mountain, is the home of Joe Davis.

Davis is retired now, but in his speech and manner it's easy to hear the breezy salesmanship that made him so successful.

Davis was an adman: "I was trained — or I was toilet-trained as we like to say — in packaged goods," Davis says. "General Foods, Procter & Gamble — that kind of thing."

Until the 1980s, the kind of people who sold stuff like packaged goods were completely different from the kind of people who sold stuff like prescription drugs. In those days, drugs ads were for doctors, not the public. They were designed by people who worked at these small, technically minded medical advertising companies and targeted this small, technically minded audience.

"Nobody had ever thought that these drugs should be or could be advertised to the patients. It was just outside of people's brains," Davis says. "They thought that only doctors could understand the products. They're technical products. They're scientific products."

But it was more than that. There was a fear — shared by doctors and drug companies alike — that advertising drugs directly to consumers could be harmful. Both the drug companies and the doctors worried that even though consumers couldn't really evaluate whether or not a drug was appropriate, they might become convinced by an ad, and pressure their doctor to prescribe it.

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Not only might doctors end up passing out inappropriate medications, but also, drug ads could disrupt the doctorpatient relationship — a relationship that, at the time, was mostly a one-way street. Davis tells this story about his own mother, a sophisticated woman whom he found fumbling with a bottle of pills one day. When he asked what she was taking: " 'Well,' she said, 'I take a yellow pill, a green pill and a white pill.' I said, 'That's great. What are they for?' " His mother had no idea what they were for, Davis says. All she knew was that her doctor had told her to take them.

"It was very passive from the patient standpoint," Davis says.

"The patient just took whatever orders were given by the doctor."

An Advertising Revolution It used to work like this: Doctors decided what to prescribe.

Drug companies — through medical advertisers — tried to influence doctors. Patients did what they were told.

The only problem, says Davis, was that the system wasn't working out for the drug companies. For them, the system was much too slow.

Because doctors exclusively held the keys to the kingdom, drug companies spent enormous amounts of time and money trying to get their attention. To give you a sense, the average doctor got around 3,000 pieces of mail a year from the drug industry, and to break through this noise often took years.

And so Davis, who had previously only sold packaged goods, approached William Castagnoli, the then-president of a large medical advertising company. The two came up with a solution: They would advertise directly to the patient. They'd get the patient to go in and ask the doctor for the drug. "Pull the drug through the system," Davis says with a certain amount of glee.

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There was only one small problem with this solution: It was almost impossible to do.

In the early 1980s, FDA regulations required that drug ads include both the name of a drug and its purpose, as well as information about all the side effects. But side-effect information often took two or three magazine pages of mouse print to catalog, and this wouldn't do for a major television campaign. As Castagnoli says, "We couldn't scroll the whole disclosure information over the television screen â&#x20AC;&#x201D; OK?" But then, in 1986, while designing an ad for a new allergy medication called Seldane, Davis hit on a way around the fine print. He checked with the Food and Drug Administration to see if it would be OK. "We didn't give the drug's name, Seldane," he says. "All we said was: 'Your doctor now has treatment which won't make you drowsy. See your doctor.' " This was one of the very first national direct-to-consumer television ad campaigns. The results were nothing short of astounding. Before the ads, Davis says, Seldane made about $34 million in sales a year, which at the time was considered pretty good.

"Our goal was maybe to get this drug up to $100 million in sales. But we went through $100 million," Davis says. "And we said, 'Holy smokes.' And then it went through $300 million.

Then $400 million. Then $500 million. $600 [million]! It was unbelievable. We were flabbergasted. And eventually it went to $800 million."

Pharmaceutical companies took note.

Today, drug companies spend $4 billion a year on ads to consumers. In 1997, the FDA rules governing pharmaceutical advertising changed, and now companies can name both the drug and what it's for, while only naming the most significant ETHNOGRAPHIC ESSAY

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potential side effects. Then, the number of ads really exploded. The Nielsen Co. estimates that there's an average of 80 drug ads every hour of every day on American television.

And those ads clearly produce results: "Something like a third of consumers who've seen a drug ad have talked to their doctor about it," says Julie Donohue, a professor of public health at the University of Pittsburgh who is considered a leading expert on this subject.

"About two-thirds of those have asked for a prescription. And the majority of people who ask for a prescription have that request honored."

Whether the increase in the number of prescription drugs taken is good or bad for patient health is an open question.

There's evidence on both sides. What's not up for debate is this: By taking their case to patients instead of doctors, drug companies increased the amount of money we spend on medicine in America.

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The New York Times (Article) Consumer Drug Advertising Should Be Banned3 Consumer advertising of prescription drugs is a massive public health experiment in which billions of dollars are spent each year.

But this advertising is a blunt instrument where a sharp edge is needed.

Drugs have harms as well as benefits, and the harms are greater when drugs are indiscriminately prescribed. Consumer advertising, delivered to the masses as a shotgun blast, rather than as specific information to concerned patients or caregivers, results in more prescriptions and less appropriate prescribing.

The decision to start long-term medication should be motivated by observations of patients and physicians, not stimulated by rosy ads.

There is no evidence that consumer ads improve treatment quality or result in earlier provision of needed care. Research has shown that the ads convey an unbalanced picture, with benefits and emotional appeals given far greater weight than risks. Clinicians can work to override these miscues, but this steals precious time from activities that can provide real benefit to patients. In the packed agenda of the patient visit, in which so many real concerns and evidence-based care are available to make a difference in people's lives, the intrusion of marketing risks harm.

Advertising also provokes a subtle shift in our culture -- toward seeking a pill for every ill. While there are many for whom stimulants and other medications can be a godsend, the case of attention deficit hyperactivity disorder is a prime example of how, 3

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too often, a pill substitutes for more human responses to distress.

U.S. clinicians prescribe stimulant medication for A.D.H.D. at a rate 25 times that of their European counterparts. The complex decision to start a long-term medication should be motivated by the observations of teachers and parents and children, in the context of a relationship with a caring clinician â&#x2C6;&#x2019; not stimulated by rosy ads.

Consumer drug advertising is banned in most of the world, although pharmaceutical companies are making a full-court press on the European Union, even while violating the limited guidelines for that advertising in the United States.

In the information age, in which more balanced sources of information on drugs should be widely available, biased pillpushing messages are a public health menace. To advance the health of the public, the United States should follow the lead of the vast majority of countries, and ban direct-to-consumer pharmaceutical advertising.

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