Only the Good Die Young
If you've ever lost a patient, this story is dedicated to you.
“I always assumed I would die shooting up in the back of a Wendy’s bathroom.” We laughed. He started again. This time, quietly. “I’m scared. Scared shitless.”
I’d been treating Zane for opioid use disorder since September 2014. Twenty four when I first met him, he was now twenty-seven. He was eager to conquer the world (and addiction) with talkative, fiercely passionate, and often brooding moods.
Zane was a reader. He often brought thick, 400 plus page novels to our appointments. Tolstoy, Dostoyevsky, Chaucer. He worked as a pizza delivery guy during the day and struggled with heroin cravings by night. Despite these daily challenges, Zane was often more interested in debating the literary merits of iambic pentameter in the Canterbury Tales than discussing his current Suboxone dose. As a former English major myself, I always looked forward to our appointments.
From September 2014 through February 2018, Zane and I debated the merits of literary masterpieces while working against the insidious, all-consuming war of addiction. Zane was all too familiar with this war. His many adversaries included cocaine, cannabis and the ever-looming specter of heroin. Some days he won. Some days he lost. He lived with his grandmother, who was now his sole family connection. At every appointment, he would plead “Please don’t ever tell my grandmother about my drug problems.”
Like most folks who struggle with substances, Zane had trouble staying sober for long periods. Sobriety is hard. Like hard AF. Somebody once compared it to trying to go for long periods of time without eating: the hunger pangs set in. Soon it’s all you can think about. The 1980s “Just Say No” anti-drug campaign was definitely not written by anybody who knew someone struggling with substances. It’s like saying “Just don’t drink water” to a dying person in the desert… surrounded by Aquafina.
Zane also struggled accepting the reality that he needed to take a medication every day in order to stay sober and keep physical withdrawal at bay. He would go on and off Suboxone- the medication that helps people with opiate addiction stay sober. He suffered from depression. Then, in early 2017, things looked up. He began taking Suboxone regularly. He got a regular job at Dominoes as a manager. And even though he said “they don’t let me read during my break and they boss me around too much,” I could tell he liked being busy. He smiled eight times during our March 2017 appointment, which was more smiling than all of 2016. And, for the first time, he even had a girlfriend. He was as content as I had seen him. Ever. Maybe even happy.
Sometimes life is just like the movies. Just when things look up for people you root for, the bottom falls out. It’s like that part in Forrest Gump when Forrest finally heals from his butt gunshot wound, becomes a national war hero, and a ping pong superstar. He’s touring around the world, winning championships, even giving a big television f-you to all of those bullies back home. He’s busy getting glory and sweet redemption. That is when he gets the call that his mama is dying and the world stops.
Zane was finally cashing in on the bitter sweet rewards of sobriety when he got the call. Except it wasn’t from his mama. It was from his stomach. He began experiencing sharp, stabbing pains from his lower abdomen in early October 2017. Like most 26-year-olds, he ignored it. It got more frequent, more intense; an aching, now constant pain that radiated to his back. He still ignored it. After a thirty-pound weight loss (which he admittedly did not mind at the time), he went in to “just get a quick look see.” By Christmas he received the call from the Surgeon- the Forrest Gump call. He had stage four neuroendocrine carcinoma. The cancer had spread throughout his body.
My good friend and brilliant urology oncology surgeon Dr. Dim performed Zane’s tumor resection surgery on January 4, 2017. The case was expedited due to the shear size of the tumor. “Tough case man. Tough case.” Dr. Dim remarked nonchalantly, in the doctors’ lounge a few weeks later. “Was it a complicated surgery?” I responded, being intentional to keep his same laissez-faire tone in my voice. “No. I mean a 26 year-old getting stage four terminal cancer. That sucks” Dr. Dim said. “Of course….” I replied. Then I re-considered his words. “It’s terminal? How much longer does he have?” I asked. Dr. Dim starred at me with the unmistakable surgeon’s “you’re an idiot” frown as his eyes narrowed. He took a sip of diet coke, looked away, and quickly reset. He took an enormous bite of a biscuit and chewed exceptionally slowly. He was considering how to word his response. Had I given away that I knew him? That I cared? Unlike Psychiatrists, Surgeons aren’t known for their verbosity. After a big swallow, he simply stated, “It’s terminal. The surgery only prolongs what life he has left.” “Which is?” I earnestly followed up. Ugh. He’ll for sure catch on now. Great job, Lauren. Dr. Dim simply shrugged. He took another swig of diet coke and went back to working on a chicken wing. Suddenly I wasn’t hungry.
February 2018 was my first appointment with Zane after surgery. He had just completed the first round of chemotherapy. He was noticeably pale and seventy pounds shy of his last appointment. An elderly woman with soft curly white hair and stooped shoulders in a pink Sunday dress accompanied him to the front desk to check in. She held a large paperback book in her right hand. The often talked about grandmother! Was she also a reader or was she holding his book? I had so many questions…This was the first time I had ever seen him come without book in hand. He had a very large gauze-like mass wrapped around his waistline and nestled near his groin. Catching my eye, and giving a big wave, he limped very cautiously and slowly from the waiting room to my office; a stark contrast from his previously brisk gait. It occurred to me that he would have greatly benefited from a cane.
“I know what you are thinking,” he pointed to me, weakly, shaking his index finger. “I’d make a perfect before and after male model for a slim fast commercial!” he beamed. I smiled.
When I saw Zane in April 2018 he had lost even more weight. He was gaunt. He was tired. “How’s chemo going” I asked. He responded, “Exhausting. I had a guy come out to look at removing some trees in the backyard for my grandmother last week. I couldn’t make it from the back door to the end of the back deck, which is five feet, without sitting down.” He paused, with a smile. “And?” I said. “You do get great sympathy looks from the hot onc nurses though. I wish I coulda used the ‘I got cancer’ line when I was single. It’s a slam dunk every time.” We both laughed. He winced as he chuckled, looking away. He asked to increase his suboxone dose for pain that day. Addiction Psychiatrists typically don’t use suboxone to treat pain. The pain from the cancer was now constant. “How much do you want to go up to?” I asked.
When Zane came in for his appointment in mid July, he said, “My friend told me that doctors never tell you the truth about how much time you have left when you have cancer. Is that true? What’s my timetable?”
What’s my timetable. I’m not an oncologist. I’m a psychiatrist. I thought back to Dr. Dim and the chicken wing. Of course, I did not have the answer to what was most important to him: how much longer do I have left with those I love? When will my time here be up? I looked in his chart and could not even find a single comment on, much less estimation on Zane’s predicted “timetable” or estimated lifespan for his clinical condition. I could understand his concern though. I finally responded, “As I gather, there’s only one source who knows exactly what your “timetable” is. As of today, that source ain’t told me, or any other doctors, or written it anywhere in your chart.” He sighed, “Man, that’s what grandma says too.” Neither of us, at the time, realized how short his remaining “timetable” actually was.
In early August 2018, Zane’s urine drug screen came back positive for heroin and negative for suboxone. I sighed one long big, deep sigh. When Zane answered the phone, I started with, “When did you decide you wanted to go out with the Wendy’s heroin overdose?” “I know, I know.” He replied. “I don’t want my girl and my grandmother to know about my habit, my problem,” He said. There was a very long silence. “Zane? Zane? Are you there?” I repeated. Did he hang up? Did I lose the connection? I was getting ready to hang up and dial again when I began to hear soft crying on the other end. It intensified. “Zaaane?” I said slowly. “I’m so scared, Dr. G. Scared shitless.” I didn’t know what to say. I was quiet. He was quiet. He finally continued. “I don’t want to die.” I didn’t have words for this. I was unprepared, caught off guard with his sudden vulnerability. I listened. This time he didn’t speak. I scrambled, trying to think of what to say. I too was scared of dying. And at 26? I had no idea how to console him. I just felt deeply sad.
I took a deep breath, “What are you most scared of?” There was a pause. And then, after a deep breath, he whispered, “The pain.” He was barely audible. It was like a secret he was afraid to utter aloud, even to himself. “I’m in excruciating pain. I’m terrified of dying a long, slow painful death. I asked, “Is there anything that helps you get through even a few dark moments?” “My grandmother,” he replied.” Even though I could not see his face over the phone, I knew he smiled when he said this. “If I don’t die of an overdose, I’ll make her and my girl real proud.”
Those were the last words I heard from Zane. He died on September 8 2018. It was Dr. Dim who notified me. “I saw in the chart that you were on the care team, so I thought I’d give you a heads up,” he sputtered over a mouth full of fried rice. “Oh yeah? What was the cause of death? Overdose?” I always prepared for disappointment in the field of addiction. “Nope.” He shook his head. “Hospice note says that he died quietly in his sleep from the cancer.”