one pill makes you larger and one pill makes you small

I recently got a chance to watch Michel Negroponte's documentary, Methadonia. I highly recommend that you also see it. It moves quickly, isn't preachy, and packs a lot of information into an engaging structure.

The film has met a lot of controversy for many reasons. One is that Negroponte takes the "addiction is a disease" point of view, which many people reject. (For more about rejection of the addiction as a disease model you can read Gary Greenberg's book Noble Lie: When Scientists Give the Right Answers for the Wrong Reasons.)

Also controversial is the documentary's suggestion that methadone treatment is not, as previously thought, the best modality of drug addiction therapy. In fact, it might be just as harmful as addiction to illicit drugs in a lot of ways.

Methadone is a synthetic opiod. It is used both for chronic pain management because of its long acting analgesic properties, as well as to treat withdrawal from opiates.
The way it works as an opiod antagonist is by binding to opiod receptor sites in the brain. In doing so it effectively stops withdrawal cravings as well as blocking the "high" of any secondary opiod. (You don't get a buzz from shooting up while on methadone). When an individual is dosed properly they aren't getting high or nodding off from the methadone. They are simply avoiding the pain and unpleasant side effects of withdrawal and should be able to live healthy and "normal," lives otherwise.

In the United States methadone has been used as treatment of choice for opiod addicts for about 30 years. We are not alone, as of last year there were 69 other countries using methadone clinics. The Netherlands takes it a step further, as they are still carrying on research which involves some patients having heroin actually prescribed and administered intravenously in clinics designated for that purpose.

Both the legal doling out of heroin and the clinical dosing of methadone fall under the broad category of "harm reduction" therapy.

I understand the damage that can be done by removing all ownership of behavior from the addict's control. After all, "I can't help it, I'm addicted," is a phrase that isn't useful to anyone.
However, I do have enough belief in neuroscience to understand the relationship between behavior and nerve pathways. And I believe enough in chemistry to understand how opiates, (and any other chemical we put into our bodies), change the way our brain responds to those substances subsequently. I also know enough about pathophysiology to say with confidence that some people are more genetically predisposed to certain illnesses than others, including mental illness. This is why I believe that addiction is more like a disease than it is not like a disease.

As for methadone dosing being the best/worst treatment for addicts, I'm not convinced either way.
Clearly, a legal and safe dose of methadone is better than people shooting up bad batches of heroin with dirty needles. However, it seems to me that the system right now is flawed. Ideally, someone with an addiction would receive the lowest dose needed to stop cravings and would be able to live a normal life. As it stands there is a lot of abuse in the system. Many people on methadone "play" with their dosage because they aren't actually trying to stay sober, they're trying to get high. As Methadonia points out, it's cheaper and safer to get dosed and then to buy some "sticks" (benzodiazapines) on the street than to buy a bag of dope. The high from combining methadone with a benzo is just as good as (if not better than) shooting up, according to Negroponte's subjects.
Perhaps if all methadone treatment programs also involved counseling, groups, or mandatory day programs the mind could be trained along with the body.

Methadonia also points out that even those who are trying honestly to stay sober are never really free of "the liquid handcuffs." It's almost unheard of to completely taper off of methadone. It's like insulin for a diabetic, a life long medication. But unlike insulin there is a stigma attached to methadone that can be socially debilitating. Whether this is the fault of clinics being unwilling to help patients detox (as one addict in the film claims), or whether it is the nature of long term management of the disease or just an inherent flaw of methadone itself, is never really answered.

I guess for myself I'd rather see people taking methadone every day than living the desperate, dangerous and risky life of an addict. However I think that there needs to be a push for the next best thing. We've been doing it this way for 30 years, and there's got to be something better; a new and better way to treat addiction and the people who are still people underneath the label of their disease.

Mental Health Rant

The more I thought about the Goldfarb the more upset I became. Watching the video over and over didn't help.

Many people who believe they do not have issues with mental health (whether they do or not is another story) consistently downplay the significance of mental illness in our society. This attitude is not often actually put into words by educated people. No one who knows better says "They should snap out of it" or "It's their own fault anyway." But we feel that way sometimes anyway.

I work with people with mental illness every day. Still with all my experience, exposure and education I sometimes catch myself transmitting the message "Why can't you just knock it off?" and even when it's not directed right at the patient (maybe it's in a venting session with a co worker) it's always a harmful stance to take. It perpetuates a myth that all people are always in control of how they behave. They are not*.

Shutting down funding for Mental Health programs is like ignoring that people have arms.
("Hello, we are a hospital that only treats anything NOT having to do directly or indirectly with your arms.")
So is the practice of insurance companies denying authorization for mental health services.
("This insurance policy does NOT cover your arms. Sign on the line.")
What would you think if you went to a country where that was the case? You'd probably come to the conclusion that arms are not valued. They are considered expendable. People in that country for some reason just really don't need to worry about arms. For some people, it's because they have never had problems with their arms. So there'd be a lot of fine, two armed people. But then there'd be a ton of people with one or no arms just from minor injuries like broken fingers or infected lacerations.
Denying mental health services sends the message that this entire branch of medicine is less legitimate or important than others.

This is a dangerous message for health care companies and the state government to send because American society in general these days already sends very mixed messages about mental health. On one hand, we are more educated and comfortable about mental health than ever. Characters on popular TV shows have therapists, women are no longer diagnosed with 'hysteria,' when they cry, and men are encouraged to share their feelings with their wives**. On the other hand, women and men alike are feeling the pressure to save face. Think about how much the media harped on Hilary for crying when her polls were down. No one wants to see you break down when times are tough. People are expected to power through and write a book about it, produce some angry music, or create a stand up routine. Anything less is unacceptable. And yet... Oprah continues to have a tv show.

Depression, personality disorders, mood disorders, it's all neurological. It's physiological. It's very, very real. Whether the help is medication or therapy or a group or a program help is needed.
Providing mental health services is imperative for successful preventative health care. People who feel safe and happy drink less, smoke less, do fewer drugs, commit fewer crimes, and reach higher levels of self actualization. To go back to the arm analogy, what do you think will happen to all those people with disabled or missing arms? They will have to be supported even more by the people who do have arms.

I know you can't fix this. You can't re open the Goldfarb. And the money is just not there. But please try to be aware of how you view mental health. Our minds are amazing. I love my brain. If you are blessed with one that works well for your purposes please don't pollute it with bias against minds that need some help. And maybe do some thinking about how to fix these problems.

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* If you want to fight me on this I will probably ask you to meet me at 10 Shattuck Street in Boston. We can stand next to the preserved skull of Phineas Gage and have it out.
** Ugh. Ugh. Ugh. I apologize to my queer readers for this incredibly hetero sentence, but my writing is limited by my scope of experience. I would definitely welcome some guest writing on the subject of Mental Health in the Queer Community if you have some thoughts to share.

One Step Forward, Two Steps back for low income Mental Health

A short time ago I wrote about MGH's decision to put a substantial amount of funding towards a collaboration between the Department of Mental Health and Boston Healthcare for the Homeless.

This article today in the Globe brought some disheartening news: because of the state's budget cuts the Goldfarb is shutting down. Surely some of the clients from the Goldfarb will be able to get mental health services from BHCHP, but not all of them. This is terrible news for those clients, but also for society in general. Crime rates WILL go up, and public morale will continue to fail.

Scary Wagers

The recent Hib break out has everyone all up in arms. Mainly because out of the five cases there was one death. And the death was not a child too young to be vaccinated, but a child whose parents deliberately did not vaccinate. It's a kind of Holy War, these vaccine arguments because those who believe in the shots firmly believe they are saving their kids. But those who have reasons against it believe just as firmly that they are doing the same thing.

Parents chose to not vaccinate their children for many reasons. Religion is obviously on the list. Especially religions like Christian Scientists*. But religion aside, there are still a ton of parents who are opposed. Many parents fear the toxins used as preservatives in the vaccines, some of which have been loosely linked to the development of diseases such as autism, Multiple Sclerosis and other genetic, autoimmune or neurological conditions which have increased in prevalence since the introduction of so many new vaccines.

Or else they fear that the manner in which vaccines are prepared (generally in a blood broth from an animal like a pig or a horse or a monkey) is not safe. People have even questioned if this is the cause of some cancers. Not far fetched at all. In fact, the polio vaccine in the 1950s was largely contaminated with the cancer virus SV40. The FDA does not regulate the purity of the bio-materials vaccines are grown in. That is something left up to the drug manufacturers. That blood might not be clean. But it might be! But maybe not!

The reasons to vaccinate your children are largely to protect them from horrible and untimely deaths from preventable illnesses. In addition, vaccinating your own child helps to build up herd immunity. The concept of herd immunity is simple: if almost everyone in a community is immune to a disease, the disease will not infiltrate and harm those who are not immune (let's say, the 1% religious folks, and fetuses and infants too young to get the vaccines). Therefore some children of anti-vaccine parents enjoy protection just by living as a minority among those who have received a vaccine.
It is also true however that in the case of vaccines which involve the injection of a live attenuated virus - MMR and also the TB vaccine), that newly vaccinated members of the "herd," can actually pass the disease along to the unprotected in the days before the virus is killed off. The unprotected will either A) get very sick and possibly die or B) develop a passive immunity that is undetected because their immune system took care of the job on its own.

The benefits of having most of the population vaccinated are clear, however the risks seem great. Although I chided my friend Ayla for days about not vaccinating my godson, just one look at the site Think Twice shut me up for a while. Although no nationally recognized studies link Autism to the MMR vaccine, story after story of families turned upside down after a child receives one of these shots become hard to ignore. One of the greatest and most published case for a link between MMR and autism to this day is of course Hannah Poling.

The official stance of the Center for Disease Control, the FDA, and the American Academy of Pediatrics is that the MMR vaccine does not cause autism. They have studies that you can download and read online. The Institute of Medicine published this safety review. The CDC is quite sure that the Hep B vac doesn't cause MS, and would like you to be sure as well.

I feel like the number of immunizations children receive today is too high. I do not think babies in developed countries need Hep B vaccines, for example, unless the mother has Hep.
However, I also think that vaccination technology has come a long way, and several vaccines are absolutely necessary. But why stop where we are? I demand more regulation instated for vaccine preparation. Why isn't anyone testing the carcinogenic potential of sheep agar? Why isn't anyone searching for an alternative to thimerosal??
I'm irrationally angered by the lack of consensus surrounding this issue. I like my medical issues to be resolved by hard facts. But the hard facts don't appease me here because the data is as fuzzy as an ethical dilemma, not scientific at all. It says, yes some children developed autism after this shot, but they were outliers and so we are not even entertaining the link. It says, although mercury poisoning is rare you are a bad mother if you vaccinate your child because you know you're doing him harm. It's better to count on herd immunity to protect him from a meningitis that may take his life than to knowingly give him what may become cancer.

It says you're damned if you do and damned if you don't.

My heart goes out to the families effected by the Hib outbreak. Your choice to not immunize cost the life of a child. But I see how a choice the other way could have done the same.
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* and Jehovah's Witnesses but only until the late 1940s when someone (I forget his name) made the decision that possibly receiving a bit of pig blood in a shot is not the same as drinking blood, and therefore not against Scripture. Just in time for Polio. Phew!

Gum ,Your Bowels and Society

I once had a patient with severe constipation. Passing flatus, normoactive bowel sounds. But just couldn't go. One of the M.D's at that particular facility told me that he had recently read a study that linked gum chewing to bowel motility, and he even gave me a copy. Apparently it's not exactly novel research because several journals, especially surgical, onco, and GU focused journals have published similar findings.

Because of that I still sometimes write, "encourage gum chewing as appropriate to stimulate bowel motility" in the A/P section of applicable SOAP notes, especially for new post- op patients.

Then I sit and wonder why anyone lets me have a grown-up job.

In all seriousness though, it has been really helpful to several of my patients, and it is evidence based practice, so it's a legitimate plan. I mean, especially in conjunction with something like, "push fluids p.o and encourage prn laxatives as needed." But I just really, really love non pharmacological interventions that have measurable physiological responses. Hot packs and ice, ambulation, pursed lip breathing, weight bearing activity, elevation, relaxation techniques, massage, acupuncture, incentive spirometer use ... I love it all. Medications are very important. And nothing can take the place of getting the proper dose at the correct times (via the correct route!) But when you can add behaviors or actions to create a definable and qualitative increase in quality of health, I think it's even better.

So much can be done just by altering one's lifestyle. Changing diet. Changing exercise habits. In mild cases diabetes can be almost completely managed that way. So can hypertension.

So much can be prevented with life style modifications. But as a society not only are we all about pharmaceuticals but we're also not so much into primary intervention. We'd rather do the damage now and pay for it later.
The exception seem to be middle class 20 somethings who are into being non smokers, doing yoga, shopping at Trader Joe's and going to the gym. (So... Cambridge, MA.) But for the majority of Americans either lack of education or lack of resources or just plain laziness stand in the way of life styles that could prevent major problems down the road. Meanwhile our current health care system is mainly controlled by the Pharm Industry which means that no one at the top has any major incentive to change that.

And so I will continue to include things in my care plans like ginger ale for nausea, elevation for edema, and ambulating ad lib to prevent pneumonia post op. And finding the research to back it up. At least now you know that if you're having trouble with your bowel movements you can go grab a stick of gum. It tastes better than cod liver oil and is cheaper anyway.

sleeping on thin doors

Tonight is opening night of Three Hole Punch presents Flirty Laundry. We can't wait to see you there, so you better come. Yes, you.
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One of my former patients came to visit the facility last week. I didn't recognize him he looked so good. He was a sick, very sick and depressed dying man the last time I had seen him. he loves his new place. He decorated it. He stopped drinking. He said he often has his homeless friends over for meals. He is getting a cat.

Yesterday the Globe reported that in the past year the number of homeless families in the city has increased by 22%. Today an article appeared in my homeless news feed that explained the proposal for dealing with this growing vulnerable population. The breakdown is that Boston is trying to adopt a Housing First policy in the hopes of decreasing the total number of homeless individuals but especially to decrease the total number of families who have no homes.

The main concept of Housing First as a social policy is that before an individual can deal with the issues that caused their homelessness he or she needs a roof overhead. According to Maslow's hierarchy of needs, the physiological needs of a human being must be met before safety, love, esteem or self actualization. Housing First brings to our attention that people can hardly be expected to be successful at meeting even the most basic of physiological needs (sleep, food, sex) without a consistent (and safe) shelter.

Housing First style programs exist in major cities all over the States though the concept is relatively new (1990s or so). If you google "housing first," and "boston," you can find statistics on how successful of a policy it is. This is particularly relevant if you know much about (or care about) the history of how homelessness as a social issues has previously been approached. The other major approach to dealing with chronic homelessness (by which I mean to exclude "newly" or transitionally homeless persons) is known as the Continuum of Care. Continuum of Care is still very much also in practice and it is the movement of the homeless through a system of "levels," which would ideally and ultimately lead them to an independent and permanent living situation. This is more in line with Maslow's familiar pyramid design. Get them into shelters so they can meet physiological needs (treat their physical and mental medical conditions so they become stable) and then they can look to achieve the rest of the steps on the way to safety and security.

Each policy has its place. And each one has weak spots. Housing First works well because obtaining a stable and safe dwelling place does in fact create an overall higher success rate for meeting physiological needs and then some. It is especially effective, I need to point out here, for families. However, for individual people who have spent years and years on the street in a community of other homeless people, an apartment can be an isolating and lonely experience. And many of them report that they still sleep outside or at least on the floor. A house doesn't replace a social network. And a house can't cure mental illness or addiction. On the street, someone who ODs may be taken to an ER by a buddy. Unfortunately I have had several former patients die from overdoses once they were housed.

Continuum of Care helps to prevent that scenario. People are placed in public shelters, and then agency shelters, then transitional housing, and then (ideally), their own place. The transitions from level to level help people to network and make the changes they need. For example, an alcoholic may only be accepted to certain programs based on how long he or she is able to document sobriety. This is meant to ensure that by the time this person gets their own housing they will be functional enough to deal with it. However, many individuals will never make it to the highest "level." It is difficult to find decent work while living in a shelter, even an agency shelter. It's difficult to stay sober or clean living amongst others with similar addictions. And constant rejection from employers or future landlords because of CORIs, lack of background information or just straight up bias can be damaging enough to the morale that people give up and end up on the streets again. Also, I suppose it bears saying that this strategy is not as effective for entire families.

I think Housing First policies are far more useful because they work for solo flyers and families. They create a safe and dedicated place where people can become successful on their own terms. However, in the future of homeless outreach I would like to see more strategies put into place to prepare individuals for "inside," life after years of rough living. They need a place to learn skills. Like how to balance a checkbook or budget a paycheck or shop for food for a week. I would like to see programs to enable much more follow up from case managers, mental health workers and occupational therapists. And I would like more attention paid to the fact that people form their own families in the street and that depression and lonesomeness are very real problems when suddenly everyone you love and know are far away.

EMTs

NOTE: as usual when I write about my work environment all names and situations are changed in order to protect private patient information and to respect the privacy of co workers. Also, I am compelled to inform you that my opinions are my own and do not represent BHCHP as a whole.

Because I do not work at a hospital proper, there are certain policies and procedures in place for when a patient's condition deteriorates to the point of needing more acute care. These cases of course, can be broken down into emergent and non-emergent situations. For example, if Mr. A has a wound that just isn't healing, he may be considered for a hospital admission where he could receive more specialized care. That's non-emergent. Emergent could be a patient with a rapid change in condition such as a seizure, a heart attack or a loss of consciousness secondary to a fall.
Those types of rapid changes warrant a 911 call.

The other day I had a patient, we'll call him Mr. B, whose blood pressure began dropping over night. Mr. B can be said "run low" anyway, but this drop into a range of 85/58 was new. The night nurse reported Mr. B to be nauseous, had a poor appetite, and was hot and clammy to the touch, with a fever of 100.0. None of this is particularly strange during flu season, but Mr. B is a special case because he is a chemo and radiation patient. Fevers and changes in condition must be watched very carefully. The night nurse told me they had been encouraging fluids, but she was very concerned about the patient.

I went to go see him. It was just as the 11-7 nurse had said. He had been vomiting for the past few hours; we kept encouraging him to drink sips of juice and water as often as possible, but it was to no avail because after about an hour on my time his BP had dropped even more significantly. He was severely dehydrated, and needed to be checked out at a hospital. When his provider arrived, we called the hospital, notified Mr. B's oncologist, and sent Mr. B over via non emergent transportation.

This is where the trouble began. It wasn't a 911 call. Mr. B wasn't in crisis, he needed IV fluids, but wasn't in any imminent danger. He was breathing, had a steady pulse, and had not lost consciousness. So we called a private ambulance company. Now, I know it must be really crappy to be non emergent ambulance drivers in this situation. I'm sure these guys are not using their skill sets to the top of their game; they are very well educated, they know a lot about emergency care, but they are just being used as transporters. They are not responding to a crisis, they are there to wheel people like Mr. B onto the truck and stay with him in case his condition worsens on the way over to the hospital.
That being understood, someone has to do this job. It can't be paramedics, because we need them available for actual emergencies, and it can't be taxi drivers because they don't know anything about emergencies. So someone has got to do this non emergency handling of problems.

And more often than not, the people who are called in for the job take it out on the nurses. It began when I was called out to the hallway and they began drilling me about the patient's condition. I told them all I know, and then with a scathing look at his partner, one of them asked me, "so he's just.. vomiting? and has a fever?" Caught off guard, I stammered that his BP had dropped significantly. He stared at me. "So why this hospital? Why not a closer one?" I was stumped, of course the answer was that this patient was an oncology patient at the other hospital and needed to be seen by his primary, but I couldn't think. The EMT sighed dramatically, "Ok, so why is this guy here to begin with? " He was holding the patient's chart. In his hands. I had already told them he was there for respite during his chemo and radiation, and repeated myself and said we just needed him worked up because his vitals were tanking. Meanwhile, another patient began calling for me. Then Mr. B's NP appeared and took over. When she returned she told me how the EMTs had made fun of her for calling an ambulance for a patient just because he had the flu.

The patient did not "have the flu," as it turned out. He was dehydrated, and had some severe electrolyte imbalances as a result. He could have gone non responsive, or gotten a life threatening heart arrhythmia.

There is a lot of animosity between medical personnel of varying educational backgrounds and specialties. I had been following urban paramedic, until he was unable to write anymore due to being activated in the armed services again. Both my parents were EMTs. I get it. Sometimes the nurses who make a 911 call are not competent. They get scared, they dial three numbers. Ok, I can see it happening.
But more often than not people are just following policy. When I was a CNA working overnights in assisted living I had to call 911 for a patient with chest pain one night that wouldn't go away with aspirin. In this facility, there are no higher ranking medical people on at night than a CNA. I called my boss, an RN and he told me to call 911. I didn't have access to nitro or to oxygen, as we were an assisted living building, not a hospital. When the ambulance got there the paramedics checked her out and the pain went away with some 02. I asked that they leave her with me but they told me they had to take her. Protocol. Her family was FURIOUS with me. They called my boss and said that their mother often claimed she had chest pains when she just wanted attention. And now they had to pay for an ambulance an an ER visit. My boss stood by my actions. What if that one time she had not been doing it "for attention?" What if she died that night? If I hadn't called 911 and something had happened, then what?

Similarly, Mr. B had to go get checked out. He's a cancer patient. You don't mess around with a fever in a patient undergoing chemotherapy. He could be severely neutropenic. And it's not really an EMT's place to question why we're sending someone out. They can ask questions to get a feel for what care might be necessary on route to the hospital, but to question an order to send someone out seems ridiculous. Am I going to say, "Oh, you are right.. you better just be going then?" I believe their protocol demands they bring the patient with them unless the patient refuses outright. So are they going to talk me out of a concern and then just leave with no one in the truck? It seems unlikely. So their sarcasm and commentary only serves to belittle nursing staff, and to undermine authority. Which is not useful in high stress situations, even if they are not a matter of immediate life or death.

I do not want to perpetuate the bad blood between EMTs and nurses. Or nurses and doctors or nurses and aides or doctors and surgeons or nurses and nurses any of the like for that matter. And so I will refrain from saying some of the things that ran through my head during the rest of that morning. Instead I will make a plea to everyone, everywhere:

If you do not like your job; if you do not find joy in doing what you do; if you do not go home at the end of the day feeling good about what you've done... quit.

And if you claim that you'd like what you did if it weren't for the people, please re examine your motives. Most of us work in this field to help people. It's that simple. We've come here from different walks of life and for different reasons, but it all boils down to that one thing. We help people. So why be nasty to one another? It's only going to delay the service we provide. It's going to make us all feel badly about one another. How can we help others if we can't trust each other? How can I trust you when you are trying to make me look like an idiot? The system only works as well as one part can depend on the other. So EMTs, hold back your eye rolling. And for goodness sake stop asking me if this patient is homeless as if homeless is some new contagion. Nurses do not talk down to the EMTs, and if they do ask a reasonable question you just can't answer, admit it and grab the chart. Then maybe we can all go home at the end of the day and feel good about what we do.

If not, you're in the wrong place.

On Needles

I had a talk with one of my patients who is a former heroin user. I asked what he thought of syringe exchange programs. He said he has utilized them in the past to protect himself and others. I was really happy to hear that.

I am completely in favor of safe needle disposal and syringe exchange programs. I have never in my life met a drug user who stopped because she couldn't find clean needles, nor have I met someone who started abusing IV drugs because a needle exchange program made it easier.

I have however met many very sick people who have contracted illness and even died as a result of sharing contaminated needles. I have also known people who have gotten stuck with a needle improperly disposed of. Although the highest risk occupation for this is clearly medical workers it could happen to a garbage collector, or a janitor in any public area like a T stop or a McDonald's. Or even you or me if we didn't look or think and pushed down the paper towels in a public restroom down, or if we didn't watch our step in a park or on the beach.

Most programs involve participants filling out a registration form. This helps clinicians who work within the program to track their clients. This helps the Department of Public Health to get information about the incidences of drug use, disease and co-morbidities in a population that would otherwise never step into a doctor's office. These programs, where they are instated, also give clients access to things like treatment programs, counseling, and confidential HIV and Hepatitis testing. All of which they do not have otherwise. Why? Because none of these people became drug users because they are well adjusted people who easily form good working relationships. They are paranoid and mentally ill in many cases, and engaged in illegal activity in EVERY case which makes them hard pressed to even go to the ER when they are hit by cars never mind call up and make yearly appointments with the doctors you or I go see.

This is all a part of a philosophy we call "Harm Reduction." Because yes, yes that lady is using heroin, but now she is using heroin and has a doctor she trusts and he got her onto birth control pills so she doesn't have a heroin baby. And yes, that guy is on heroin, but now he is also seeking a treatment program. We save people from contracting the AIDS virus and from passing it on. We offer other options.

Until we can stop treating people with mental illness and addiction as if they are sub human we will never solve the problems which plague our entire planet, our entire humanity. It is not going to condone any drug use any more than the existence of narcan condones it.