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Free Seminar: Acute and Chronic Wounds in Baltimoreans who Inject Drugs

I am generally somewhat leery of academic research on injection drug users (I just don’t think that the Institutional Review Boards take into account the level of secrecy and stigma associated with illegal drug use, and the way that doctors can use substandard treatment to punish IDUs) but I also think that lack of education of health care providers is a huge problem when it comes to treatment of drug users.  (Still remember being barraged by questions by med students when I was in the ER after an OD — in lieu of either medical treatment or being allowed to go home — and their generally abysmal level of knowledge.)

I have a lot of random thoughts on research on IDUs, but no formal training in bioethics (except a very cursory required course in graduate school). In general, being part of an underrepresented group and dealing with clinical trials or human research is a real catch 22.  It’s bad to not have your specific health concerns addressed by medical science, and it’s bad to be experimented on when you are part of a group with specific issues related to consent and privacy.

Here are a few, totally anecdotal things that have bugged me over the years:

-the way doctors talk about their drug using patients and scientists talk about research participants (especially in studies related to HIV and HCV) and assume that no one in the room would identify with the people they’re talking about

-the use of “pilot studies” for things like needle exchange that are already well proven, as a way to delay full implementation

-terrible survey instruments with choices/questions that make no sense to the participant, with no way to give a personal answer, and which you just know are giving bad data (I’ve been on both sides of this one, first as a needle exchange participant and later as a volunteer)

-supposedly anonymized participant IDs that are not really anonymous (usually to make them easier to remember) Also, the larger problem of only providing syringes to authorized participants, but that is usually a legal problem, outside the agency’s control.

-the wound care clinic at San Francisco General Hospital which in the 90s was notorious for treating abscesses in the most scarring/painful ways, which was seen as punishment by many patients.  Supposedly the clinic totally changed their training in the early aughts, and as a needle exchange volunteer, I told people it was much better now, even though I didn’t have any personal experience with it. Which I still feel bad about.

-use of ignorant and poorly trained medical students in free clinics (providing training for students and crappy care for patients) Also the larger issue of trying to have free clinics deal with chronic health conditions when we know how ineffective that is, but, again, that is an issues that is much larger than any given agency. Though the churn of services caused by various pilot studies or small projects with short-lived funding can really add to the problem.

On the other hand, I was a participant and the Women’s Interagency HIV Study for ten years, and they really seemed to do everything right.  They seemed really kind and professional (and their questionnaires seemed pretty good), and they helped me out getting a HCV test when I didn’t want to go to student health (where my thesis adviser’s wife worked).

Cravings

"I had left my San Francisco postdoctoral position disillusioned by the whole concept of craving. Some addicts certainly reported drug craving: there was no doubt about that. But it didn’t really predict whether they relapsed, according to the majority of research. Sometimes people would report severe craving but not use drugs; other times, they’d use drugs in situations where they said they’d experienced no craving at all. It seemed to me that it would be much more useful to study people’s actual decisions about whether to take drugs, rather than focus so much on what they said about what they wanted or craved in some hypothetical future."

—High Price: A Neuroscientist’s Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society, Dr. Carl Hart

I hate cravings.  I hate how, even after 14 years, certain drug dreams can send me into a total tailspin.  My skin feels wrong, tingling and crawling like all the hairs are sticking up on end. And my back and neck and shoulders tense up.  There’s a real obsessive/compulsive quality and my thoughts start spinning in on themselves, and I can’t focus on anything else.  If there were a well-studied treatment (with established risks and benefits), I would seriously consider it.  I think a lot of what I now experience as drug cravings existed before I ever did any drugs, but at that point, was focused on wanting to cut and hit myself and peel off my skin.  And was probably related to a lot of my drinking and random hook ups my first couple years at college.

But, no, there’s not a one to one relationship between cravings and getting high. (Did the researchers actually believe that? I guess so.)  For me, trying to get heroin was a long game, involving cultivating relationships with people with drug connections, trying to avoid getting lectured and guilt tripped but also trying to avoid being constantly surrounded by drugs, trying to give myself more control over when I used.  So by the time I actually got my hands on the drugs, there was never a simple path between the craving and the high.  And I think, after I first got the idea of doing heroin into my head, there was pretty much never a time when I didn’t want to do it, just times when it seemed like a better or worse idea.

Coke was different because I didn’t like it (and never craved it) but if people offered it for free, I didn’t say no.  And speed was also different, because I started really not liking it (I hated not being able to sleep), but finding it hard to say no when everyone around me was getting high, so that seemed like the situation where I had the least control (though a lot of that had to do with being in a very fucked up living situation, and also the fact that I never stopped liking heroin, so doing it never seemed so paradoxical).  Also, not being able to say no to something that is right in front of you would probably be considered distinct from cravings.