Interview 1

Running head: INTERVIEW

Interview

Má rcio Padilha

College of Southern Idaho

ADDS 190 – Robb

Fall/2009
 Interview 2

Interview

Foreword:

For sufficing the "Interview with a Medical Practitioner" regarding "addiction-

related Issues" assignment for the ADDS 190 class, i.e. "Drugs, Alcohol and Society", I will

discuss some of such issues with Dr. Cathy Engle, a medical doctor who practices at Family

Health Services in Twin Falls, Idaho, who has graciously consented to help.

Interview:

Padilha:

I will start by asking Dr. Engle some questions pertaining to her personal,

academic and professional background as means to, first, ascertain her philosophy

towards the medical field and, subsequently, her scope of practice at different stages

of her career. So, with that said, I would like Dr. Engle to introduce herself by telling

us what led her to pursue the medical field as a profession, what medical school she

went to, her current scope of practice.

Dr. Engle:

Hello! Therefore, to answer your questions, I was one of those kids who always

wanted to be a doctor, and for the oldest reason of all: to Help people. When I was in

1st grade, I remember, we had to draw pictures of what we wanted to be when we

grew up, and I drew a ballerina, a cowboy, and a doctor. One out of three is not

bad. :)

After college, I went to Louisiana State University Medical School in New

Orleans, followed by a Family Practice Residency in Casper, Wyoming (University of

Wyoming). I have now been practicing full-spectrum Family Medicine in Twin Falls
 Interview 3

for 5 years. That means I take care of all age groups from birth to old age, I do clinic

and hospital work, and I take care of pregnant ladies and deliver babies. I work at

Family Health Services, which is a Community Health Center, which means it is

partially government-funded so that we can take care of folks with any, all, or no

insurance for as little as possible. We have a sliding scale fee based on income for

almost all of our services.

Padilha:

Therefore, how have your professional perceptions may have changed, i.e.

from prior to being a medical student to currently being an active physician?

Dr. Engle:

My professional perceptions have changed quite a bit since my clinical years

in med school. I am still very much a starry-eyed idealist at heart, and very much

believe in helping and serving ALL people who need my medical help, regardless of

ability to pay; but I have learned SO much, both good and bad about human nature

that I didn't learn in school. I have seen how strong and selfless people can be, how

families can really pull together in tough times. I have also, unfortunately, seen how

selfish and manipulative people can be to get what they want, especially if they are

addicts and what they want is a prescription for narcotics. It has been a very tough

lesson, but one I have learned.

Padilha:

How much, if anything at all, does Medical School address about the field of

addictions?
 Interview 4

Dr. Engle:

My medical school only addressed the field of addictions insofar as it would pertain

to a patient's medical issues. Example: IV drug addicts are at a much higher risk of HIV,

Hepatitis C, and sepsis. There was no discussion about the addictions themselves, how they

occurred, how to treat them, etc. There was a bit more in residency-- we got a talk of signs

and symptoms of meth addiction, for example-- but still not a whole lot.

Padilha:

What are your personal and professional opinions about addictions, both in terms of

the individual and in terms of society?

Dr. Engle:

Professionally, I find addiction to be a horrible, debilitating disease that is profoundly

difficult and frustrating to treat. It destroys peoples' lives, makes good people do horrible

things, and cultivates a whole host of counterproductive coping mechanisms such as deceit

and manipulation. It seems to do the same thing on a larger scale in society-- destroying

families, reproducing itself in generation after generation of addicted family members who

drop out of school, have difficulty holding down jobs or raising families of their own; and

simply because, as kids, the only world they knew was the one of addiction and cyclical

neglect or abuse followed by guilt and recriminations.

Padilha:

What was your first professional encounter with an addict like?

Dr. Engle:

My first encounter with an addict was in medical school, when I was young and

naive. I was on a service that had a lady with a bacterial infection in her blood and in her
 Interview 5

sternum that had come from a bacterial heart infection. She was in the hospital for her

birthday and had no friends and family come to see her, which broke my heart a little.

Padilha:

Did you instantaneously perceive that person to be an addict or was it cumulatively

progressive assertion?

Dr. Engle:

I only discovered about a week into following her that the bacterial infection in her

heart was from using dirty needles in her IV heroin use, which broke my heart even more.

Padilha:

Has the way you deal with addicts, since then, changed? If yes, how so?

Dr. Engle:

My attitude towards addicts has changed somewhat since then. On a basic level, it still

breaks my heart to see someone destroy themselves and their lives that way. I have found,

though, that many addicts will use my sympathy and compassion to try to get me to

prescribe them narcotics (for their horrible back pain, etc) or Ritalin (for "ADHD") with

which substances they feed their addiction. Unfortunately, I have had to learn to distance

myself emotionally from the patients that I know or suspect are addicts, so that I can

clearly see when I am being manipulated in an effort to get drugs and not fall for it. It's hard

for me because I do care a great deal for my patients, and have an instinct to help where I

can, but I have learned that giving an addict certain medicines is very far from helping

them, and it is much more helpful to them (though they don't see it in the short run) to tell

them honestly that I am worried about their addiction issues, and am declining to give

them controlled substances because I am afraid it will simply feed their addictions.
 Interview 6

Padilha:

This statement of yours [medical school only addressed the field of addictions

insofar as it would pertain to a patient's medical issues] is rather shocking to me as I was

under the understanding that such issues were amply addressed by medical schools. In our

textbook, there are references indicating that the American Society of Addiction Medicine is

working on creating a medical specialty fully dedicated to addictions. In addition, the

nursing field, per our textbook, seems farther ahead in the handling of addicts and

addictions as that professional class has a professional certification process via the

International Nurses Society on Addictions specifically for the addiction field. That is very

interesting... In any event, I would also like to ask you:

Padilha:

As a Certified Drugs and Alcohol Counselor, I would be required, legally and

ethically, to report any client who would indicate the possibility of harm to self and others

to the due authorities. Are medical doctors bound by the same ethical and/or legal

obligation?

Dr. Engle:

Yes, we have the exact same legal and ethical obligation.

Padilha:

Have you ever felt that your personal safety was in jeopardy due to your denying an

addict drugs?

Dr. Engle:

Yes. Though I have never actually had anyone get physically violent with me, I have

had occasional threats. Usually though, it is tears and the innocent-victim/callous-doctor

 Interview 7

routine. Oddly, I have had several patients threaten to sue me for not prescribing them

chronic narcotics.

Padilha:

There are multiple theories that address the process of addictions. For instance, the

case of the "Predominance of Alcoholism within the Native American Community" is

explained by "biophysiological adaptation", or lack thereof. In essence, this theory states

that Europeans had been exposed to alcohol for centuries ahead of the Native Americans.

Therefore, Europeans developed a much greater tolerance to spirits than the Native

Americans did given it is thought that they - Native Americans - have only been exposed to

alcohol for about 500 years now. Hence, the praxis of biophysiological adaptation.

The praxis of the addictive behavior, which claims addiction to be a disease, in

accordance to the Minnesota Disease Model, is by "neuro-adaptation"; meaning that

whatever the act or substance done by an individual causes greater than normal release of

dopamine in the brain. To that, the neuro-receptors, which intake and process the

dopamine, expand in size in order to accommodate and process that larger quantity of

dopamine. This happens cyclically, with both neuro-transmitters and neuro-receptors

enlarging progressively to accommodate both release and absorption of dopamine; thus

becoming "addiction". Tolerance takes place in that the neuro-receptors become

desensitized by the constant presence of the dopamine, which, in turn, requires more

dopamine to maintain euphoria and, consequently, suppress dysphoria. When, for

whatever reasons, the neuro-transmitters no longer produce as much dopamine, they

shrink. However, the neuro-receptors do not and that expectation of a greater quantity of

dopamine than what is actually available is the praxis of cravings and withdrawals.
 Interview 8

With that said, in your professional opinion, what are the strengths and faults of the

above theories that I roughly described?

Dr. Engle:

I think both these theories have their merits. I think with regard to the Native

American/alcoholism question, there are two schools of thought... one, that there is a

genetic predisposition to alcoholism that runs rampant in the Native culture that was not

discovered until they were exposed to alcohol... and two, that it was a total lack of

tolerance. The problem with this last one, of course, is that no one starts out with a

tolerance. It is built over a lifetime. In addition, that leaves the idea of genetic tolerance, and

there is no evidence to back that, so really it is all speculation. As to the second theory, that

I believe is the accepted scientific/medical explanation, and I find it extremely plausible.

Padilha:

In your professional opinion, is an addiction a disease? Please, explain.

Dr. Engle:

I believe that addiction is a disease, though partly because it helps me deal with

addicts in a more nonjudgmental, compassionate, objective way. Still I do. However, I

believe it is a very complicated disease that involves social, medical, lifestyle, genetic, and

psychological factors.

Padilha:

I would like to express that, at least at this stage of my academic training as a Drugs

and Alcohol Counselor; I struggle a bit in attributing the disease model to addictive

conditions so readily. Whereas I believe that all the issues pertaining to the post-onset of

the addiction to relate very closely to the disease model, I have certain reservations as to
 Interview 9

the role of one's volition as to the onset of the condition. To what extent must society hold

one liable for one's own choices, behaviors and consequences?

Further exemplifying out of the key point that scientific studies have shown that

children of addicts are at a higher risk to become addicts themselves, I cannot help, but

ponder:

- Should an addict be allowed exemption of self-responsibility due to being

"genetically predisposed" to the condition and, therefore, allow him/her to self-victimize?

Or:

- Should society hold the addict at a higher level of scrutiny in terms of self-awareness

of his/her "genetic predisposition" and thus expect greater preventive behaviors?

And:

- What should society's role be in terms of mediating the environmental issues

typically involved in the addiction acquisition process?

Whereas I do not feel that the actions leading to the subsequent chemical/behavioral

dependence are necessarily a matter of morals/character weakness, I do feel that a much

stronger and shocking education piece is lacking in the societal dynamics currently at play.

In addition to that, I further believe that there are powerful interest groups at whose main

interest does not include the promotion of public health at a global level.

Dr. Engle:

Thanks for making me part of your assignment.