What’s the value of the work I do? What’s the value of me becoming a specialist in addiction medicine? I’ve written thousands of prescriptions for buprenorphine, for hundreds of people. What has it added up to?
I started doing this work because this was where people were dying. Where the overdoses were. And so I decided: I would not stay in the place down the road where our waiting room was safe and quiet. I would run towards the fire. To the pain. To the place where I could matter most. I’m a decent all-around doctor. I spent a few years trying to prove that to myself as an attending in the primary care clinic where I’d trained as a resident. I think I did OK. They gave me a party when I left, anyway, and they had cake.
But what I’m good at, and occasionally very good at, is being present for people’s pain and then, with the trust I earn from that, helping them learn to use new tools for health and for change. Also I knew that I liked taking care of people who use drugs, for what reasons I am not totally sure—and just liked a lot of those patients much more than did most of my colleagues. So an overdose epidemic was a good place for me to be.
Someone asked me, not long after I’d started the job I have now, to write a mission statement for myself. Easy, I said: “I am a doctor who responds to epidemics of early death.” That came out in an effortless tumble. I’d come from HIV work—which had brought me to medical school and then helped define me after residency. I had started doing Hepatitis C treatment. And I was in my new job partly because the mortality rate among homeless people in Boston was the same in 2003-2008 as it was before effective treatment for HIV. The mortality rate had stayed the same even though AIDS deaths were way down, because overdose deaths had nearly directly replaced them. And we knew in 2014, when I was contemplating taking this job, that overdose deaths had increased sharply since 2008. They increased more after 2014, largely due to fentanyl.
Now it’s been a bit more than four years since I started my new job. I know a lot about how to do this work. Though a lot of my colleagues do a lot of addiction work, I’ve become a specialist even among those specialists. I am a doctor for people with dope problems. And right now that’s almost all that I’m doing.
I went to the fire. And I’ve stayed there.
Here’s the thing, though. If you’re honest with yourself as a clinician for individuals, with a public health argument for your work, you have to sometimes reckon with the obvious:
If you’ve got one hose and the whole building’s on fire, the building is going to burn down with or without you. So maybe you’re just impressing yourself. Wear your fire helmet. Spray the water. Take your medals for heroism. The building is turning into ashes either way.
In my work, mortality in my patient population is probably less likely to be determined by what I do, than by how some middle-manager in a drug trafficking organization sets up the cut for the fentanyl-heroin combination, and how sloppy or precise they are in regulating the proportions of fentanyl to the rest of the mixture. In other words, in the absence of larger policy changes that would bring a regulated and reliable supply, the true public health hero might be the drug dealer who insists on creating a consistent and predictable product.
Meanwhile, consider the much lower-level drug seller walking around my neighborhood saying “sobos sobos sobos” as a way of advertising buprenorphine (Suboxone) for sale. Is that person, distributing stacks of Suboxone in our neighborhood, accomplishing something different than what I do? I’d like to think so. I’d like to think that regular monitoring, checking in, coaching, empathetic listening—that it all means something. And there are various things I do to try to help people increase the amount of time they’re on buprenorphine and decrease the amount of time they’re using dope.
But I’ll be the first to tell you that the most important part of what we’re doing by prescribing buprenorphine is blocking mu-receptors. This biological effect of buprenorphine is why it works to prevent deaths, which is the main outcome I care about. And the biology is the same whether you pick it up from a pharmacy as the result of a prescription from me, or you buy it off some guy who’s also selling “pins” and “dines” down by the Mass Ave Connector.
Even if you look at the frightening mortality statistics among my patients, the number-needed-to-treat is still probably pretty high to prevent one death. There are many ways to do this math, and not enough data to be sure of my particular answer even if I could do the math. I think my ballpark guesses mean I’ve saved some lives, but in four years that number could still be in the single digits. What’s enough? The answer can’t be, just one is enough.
A good part of the worth of what I do is probably more intangible—and harder to measure. It’s something about human connection. Maybe even a spiritual kind of love. Maybe it’s about inspiring people or helping them believe in their own worth. Maybe you can believe that with persistent loving kindness for my patients I address the root of the problem—that I’m doing something to heal the open wounds of traumas that lead people to use drugs in the first place. But if I invoke love or inspiration or kindness when I’m hedging about my value as measured by epidemiology, I think you would have every right to suspect that I’m some kind of do-gooder grifter. Even if the intent is deeply felt. It can’t be just one person I saved and a lot of loving kindness I dished out to everyone else. Because as a public health mentor of mine used to say, paraphrasing an old article: “Whenever I hear someone say, ‘If we just help one person, it’ll be worthwhile’, I know I’m looking at a failing program.”
When we sell ourselves on individual connection as the social value of what we do, we’re blurring the lines between two different kinds of work: the work of caring for our fellow humans, and the work of actually helping them survive. These two kinds of work are both important, but one can be quantified, and the other can’t. And to the extent we can look at either process, in the caring part we’re considering what the doctor does, and in the epidemiology part, whether the patient survived. Any truly caring or decent person should favor the epidemiology, right?
I followed my work towards the epidemiology. To where the fire was. To where the most people were dying early, and to where my skills would save the most lives. But now that I’m here, I can only estimate my effects in the broadest terms, with a good deal of uncertainty. So now I’m trying to make sense of patients I’ve lost, setbacks I’ve watched, the constant grind of the tough world I visit regularly, and I’m asking myself—what is it I’m doing here exactly? Not like I’m about to quit doing it. But I’m trying to figure out what I’m up to.
Amidst that questioning, I’m asking myself whether maybe this work is really some kind of spiritual mission about loving my fellow humans. Maybe that’s an important personal realization. Maybe it’s just an excuse. Most confusingly? I feel almost certain that it’s some combination of both.