13 June 2011

Crohn's + Depression + Medication = Tragedy

Some time earlier this afternoon I came across a link to an article from a local news service in Buffalo, NY. On 4 June, 23 year old Michael Israel took his own life after a decade of living with Crohn's disease.  He battled depression for most of this time, it seems, and was in significant physical pain.  His mother, Julie, reported that, “Michael’s sophomore year of high school was the last year that he actually had any quality of life. He suffered. He ached all over. Sometimes, he would walk around like an 80- year-old man.”  To manage this pain, Michael had been prescribed hydrocodone, Xanax for anxiety and Cymbalta for depression.  Apparently, Michael reached a breaking point and shot himself in the head.

Avi Israel.  Photo by Harry Scull, Jr.
Naturally, every paragraph in this article hit home for me.  Crohn's, depression, anxiety, derailed life, pain, Cymbalta...only the names and dates would be distinguishable to casual readers of this article and my own story.  It reminds me of how the Columbine shooting unnerved me all those years ago, leaving me wondering just why these people have zigged when I've zagged.  Now, if the Israel family should find this blog post (and I can't imagine why they would), I want them to know I'm not insensitively trying to make their tragedy somehow about me.  His story--at least, what little of it was conveyed in Dan Herbeck's article--really does hit home for me in an eerie way.

His parents are understandably upset by their son's medical treatment.
Israel and his wife, Julie, said too many of the doctors who treated Michael over the years would simply give him pain pills and send him on his way, rather than sitting down with him and talking to him about his disease.
“We’re not on a witch hunt for doctors,” Israel said. “Mike had one wonderful doctor who refused to give him pain pills, but used to sit with him, answer his questions and talk to him about his disease. We wish more doctors would do what this doctor did.”
I've read some comments that argue Michael Israel should have done more to ensure his physicians were all on the same page.  Trust me, when you have Crohn's and you're seen by a doctor, there's a strong probability it's in an urgent care center or emergency room because you're having an out-of-control flare.  You'll allow Fozzie Bear to treat you, so long as he promises to make it stop.  This is my account of my first hospitalization in 2008.  The short version is that I resisted the gastroenterologist assigned to me at the hospital and managed to stave off surgery (three years so far, thank you very much) and upon being discharged I met with my regular G.I. at the University of Louisville Ambulatory Internal Medicine clinic.  He agreed with me on the matter of my treatment plan.  In that one anecdote alone, you've got an overwhelmed patient handed over to a doctor who doesn't know him, and who disagrees with another doctor about how to treat said patient.  Believe me, it's awfully easy to fall through the cracks in the American health care system.

I know they have WiFi there.
I understand that the Israels are dedicating themselves to organizations meant to discourage over-medication of youthful patients, and I can appreciate their need to do something in response to their tragic loss.  One of the most important things that can be done--and really should have already been done--is to create a national patient database.  This nonsense of having to request medical records from another physician's office has no place in the 21st Century.  There's no reason we can use cloud-based information sharing to store our MP3s from Amazon but not our medical records.  Patients who are paranoid about invasion of privacy should, of course, have the option to decline participation, but the technological infrastructure should already exist and those of us who do desire our medical treatment to come at the hands of fully informed physicians should benefit from such a system.

The Affordable Health Care Act provides for, and promotes, this kind of much needed technological advancement.  I'm sure the Republicans will cry that it's an outrageous "overreach" of government that will saddle hypothetical future generations with an unacceptable bill to pay, but I suspect the Israels would very much have appreciated a system where each of their son's physicians knew what the others had done with/for him.

To be fair, this only addresses the situation where one physician is ignorant of another's treatments.  It does not address instances where a physician disagrees with his or her colleague.  That, of course, is the nature of the practice of medicine.  It may be that there's room for refinement in the guidelines for treating patients, but of course that's a matter for the Department of Health, American Medical Association and other such organizations to decide.  I'm just a patient.

One last thing I want to address is the subject of physicians as drug-dealing middlemen.  It seems in 2011 America, we have two kinds of physicians.  The first only listens for specific words in the exam room before scribbling out prescriptions.  I cannot stand this kind of doctor, as this kind cannot be bothered to let a patient finish describing his or her symptoms.  Does it make a difference if you stopped me before I told you my left arm was numb?  I'm not a doctor, but that seems important enough I was gonna tell you about it.  The least you could do is let me tell you and then decide whether to ignore me.

The other kind of physician, of course, is the wannabe detective.  Each patient this physician treats is a criminal suspect.  I sustained second-degree burns on my left hand a few weeks ago and went to an urgent care center. The doctor initially offered me Tylenol, which I refused because my wife had some in her purse and we all know how much they jack up the price.  I thought it was more prudent to take the pills we already had, than to be charged $10 for the same damn thing.  Rather than applaud my sense of thrift, I was now viewed as a drug-seeker.  Right.  I rejected Tylenol because I really wanted to get my fix.  I wanted it so badly I gave myself second-degree burns.  I went through about ten cold packs in the span of an hour because the moment they stopped being cold they were useless to me for containing the heat and pain.  But somehow this was all just a pretext for asking for hydrocodone?  Are you fucking kidding me?

Look, either you're a doctor or you're a cop.  You can't be both.
Which brings me back to Michael Israel.  I avoid hydrocodone and similar pain drugs whenever possible for two reasons.  Firstly, I figure the longer I can go without resorting to them, the better.  This way, I have something to fall back on later.  Secondly, those drugs aren't good for one's digestive system and since the nature of my disease is digestive, it doesn't seem prudent to hit my guts with too much of that stuff.  But then, I haven't felt his pain.  I'm sure it's a shock to someone in good health, but just because two people have the same diagnosis doesn't mean they have the same experience.  Maybe I have a stronger constitution than did Michael Israel, or maybe I've just been a hell of a lot luckier.  I don't know.  I'm not qualified to pass judgment on him or anyone else (and I'd appreciate it if you'd refrain from doing so).

Were drugs responsible for Michael Israel's suicide?  Again, I'm not qualified to answer that.  I suspect he'd tell you that the depression was the real reason even if the side effects from the drugs exacerbated his sense of helplessness and frustration.  Depression is awfully powerful, as I've already shared.  Cymbalta, like other anti-depressants, is risky.  It can have the opposite effect, making a patient feel even more despair than before.  I only took it twice, and each time it hit me like I'm told a date rape drug works.  I slept for about a day after taking it and had no memory of anything I said or did during the brief time I was conscious.  I have not taken a third Cymbalta pill and do not intend to do so.  If I had tolerated it even just a little bit more, who's to say?  Maybe I'm the news story in March and Michael Israel sees the red flag, changes his treatment and is here today.