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Nathanial Rateliff and the Night Sweats: SOB is a rather good description of alcohol withdrawal.

At the start, he is surrounded by police, told to come out with his hands on his head.

"Son of a Bitch," he says, "I need a drink."

Because he knows that he will withdraw in jail.

This is a reality in my area, that the people who can best describe drug and alcohol withdrawal, besides the people enduring it, are my local sheriff, police and jail employees. Especially the jail employees. Opioids, methamphetamines and alcohol are our big three. Oh, well, cigarettes too. One heroin user tells me that he will go around and harvest the tops of opium poppies from people's yards to try to stave off withdrawal. "Doesn't really work," he says, "But it might slow it down a little." I've also written about the leaf from Southeast Asia already, kratom. That leaf is not good for the gut, I think, because my two biggest users both had very bad digestive systems. I did write to the gastroenterologist who was going to do an endoscopy on the older one for the fourth or fifth time and explained that this gentleman had switched from his dose of hydrocodone to a titration of the leaf using a jeweler's scale and that I suspected the leaf was messing up his guts. I also explained that it could be tested for with a send out urine drug screen.

People can die during opioid withdrawal. We've known for years that alcohol withdrawal is dangerous: delerium tremens, including formication. Nathanial Rateliff sings "bugs are crawling all over me." Not a fun feeling. Disney's cartoon of the dancing pink elephants and Hunter S. Thompson's description of the bar knee deep in blood with all the humans having insect heads and feelers and extra legs. I do not want to take whatever he had in the trunk of the Great White Shark.

Once I was wheeling a stretcher with a patient into the ICU because he was going in to delerium tremons. He looks up at me and says, "I take ten oxycontin a day." "Shit!" is my response. Not only alcohol withdrawal but serious opioid withdrawal. "Shit!" I talked to the intensivist at the next bigger hospital. My nurse anesthetist and I intubate him and we transfer him to the intensivist, on an iv drip of benzodiazepines. The opioid withdrawal has not hit yet because the oxycontin half life is 12 hours. The intensivist says he needs a diprovan drip. Yeah, the stuff that killed Michael Jackson. Don't try this at home, folks, even if you buy a doctor.

I went to one of our local disaster meetings once. I had a question. "What do we have set up for withdrawal?" I ask. "When I see disasters I think of all the people who are running out of medicine, not just blood pressure medicine and congestive heart medicine but legal and illegal benzodiazepines, alcohol, meth, opioids..." The head of our local disaster group is silent for a bit. "Nothing." he finally says. "We have nothing set up." Yeah, well, shit. I instruct my opioid and buprenorphine patients, "If we have the big earthquake, first thing you do is cut your dose in half." The patients get that look in their eye. They don't want to think about a disaster. "You will feel like shit, but you can stretch the medicine out. Keep cutting it if you can't get more." They do not look happy. One gentleman wants to know WHY he should Quit Smoking. "Ok," I say, "Picture a really big earthquake. All the roads are out. Many people hurt and needing rescue. And no cigarettes." He has the look in his eye. "Ok, ok!" he says. "I will quit!" He would rather quit in a controlled manner than during a natural or unnatural disaster. Are human wars an unnatural disaster? Aren't we natural? Or are we unnatural? Hell if I know.

Methamphetamine withdrawal is tweaking. My long term meth gentleman, who successfully quit after 17 years, clued me in. "Anxious," he says. "Can't sit still. Itchy or pick at their skin." I became more likely to request a urine drug screen before starting an anxiety medicine. If someone refuses a urine drug screen, well, the doctor might suspect there is a substance in it that the patient is not admitting to.... I pretty much blame meth withdrawal for the spread of Methcillin Resistant Staph Aureus, MRSA, in our community. Only takes one itchy meth user to share it with a second person and then they each share with the third and fourth and then, well, shit, it's all over the county. Meth labs blow up or burn down. At one point 2/3 of the people in the burn units at Harborview in Seattle were from meth labs. It's bad enough if they are cooking meth. If they are on meth and burned and withdrawing, you have to about double the usual iv fluids because their metabolism is so fast and fucked up. And it's toxic as hell so their liver and kidneys don't work right. The burn unit doctors were not enjoying it. Especially when the victims include small children of the meth users. Ugh. And then you get a meth and alcohol user or meth and opioid user or all three! A challenge!

The sickest man I ever took care of here was on meth, septic emboli to his lungs, turned out they were coming from a giant clot in his inferior vena cava and he had osteomyelitis, yeah that is infected bone, MRSA of his lower spine. I transferred him to Harborview as soon as I saw him. He survived intubation, gallons of antibiotics, a forty pound weight loss and was sent HOME (said he didn't need drug treatment) to my area after nearly two months in the hospital. I had a fit. "SO, we are going to learn how COUMADIN interacts with METH! He needs inpatient drug treatment! WTF are you thinking?" The resident points out over the phone that you can't MAKE them do inpatient drug treatment. Yeah, well, I would have STRONGLY ENCOURAGED him. At any rate his mother calls our clinic crying after he misses two visits, about a month after he comes home. "Can't you lock him up?" she cries, "Can't the police put him in jail? He's going to die!" Yeah, well, he already nearly did. He may bleed out because the meth raises the coumadin level, nice. Ick. I hope he went to jail and survived, but many don't. My opioid people who call for appointments, about 1/3 refused to see me. "Too strict." Of those who saw me, about half did well and the other half relapsed and refused inpatient and disappeared. I would try to comfort myself: they do have the opportunity to try again. But I did hear of the deaths. Many of the ones who relapsed died, all ages. So, 2/3 failure rate with maybe half of those dying within a year or two. Ah, well.

Sometimes I think about these people when I hit the culture of positivity. "Think positively!" "Have a good attitude!" "Attitude is everything!" Like HELL, I think cynically. And then the person lecturing me about positivity is on their third drink and going out to have a cigarette or some pot. Yep, I don't envy your positivity, thanks, fungk that. If we have a disaster, I will withdraw from caffeine only. How will my super positive friend be feeling? Will they be able to maintain positivity? What a load of stupid bullshit. Reality, thanks, which includes drug addiction, withdrawal and death.

Have a nice day and be careful out there.

I am adding this to my Songs to Raise Girls category because I think that parents should be talking to their children about addiction and substances. From what age? asks my Gentle Reader. From age 8 or earlier. AGE EIGHT? ARE YOU NUTS? No, I choose eight because I asked my smokers for years what age they'd started smoking. Most of them said age 9. Why would they lie? One woman told me age seven. Her home was an addiction center. Then there are the parents giving their children alcohol or worse from very young. And the toddlers from methamphetamine homes hide food around the house as soon as they can: because their lived experience is that you cannot trust adults to feed you regularly. I have food insecurity too. I want to know that there is food for the next meal, all the time. B recognized it and would lure me hiking by saying, "I have food..." Ok, I will hike! Food! Food is good! So apparently I could not rely on the adults to feed me either. It's slowly becoming clear that my father was not the only alcoholic. I guess that the best way to hide being an alcoholic: marry a worse one. Sigh.