When was the last time you used heroin? In the past have you injected heroin or any other drugs? Are you currently using drugs besides opiates like methamphetamines, cocaine, benzodiazepines or alcohol?
After two years of family medicine residency, I ask these questions like they are questions that everyone asks in a casual conversation with a patient. Although these types of interviews are customary for me, I recognize that it takes a great deal of courage for a women who is pregnant to speak openly about her opiate dependence with a doctor whom she neither knows nor trusts. For this women, I can sense the internal struggle she faces as she searches for words to explain her current situation. Like many of my patients, her struggle has involved constant rejection, a lack of finances, and in general a lack of health care.
For three years she has been trying to get opiate replacement therapy, and for three years her life has slipped into worsening chaos and instability. After hearing her story I reassure her that we will take care of her, and I ask her how she is feeling about her pregnancy. She pauses and tentatively explains that she initially did not want to continue with her pregnancy, but now she has changed her mind. She continues by explaining that no one has helped her until becoming pregnant, and now she does not want to lose the much needed medical care she can get during pregnancy. For this patient, pregnancy is the cost of getting medical care, and this is a price she is willing to pay.
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