Ep. 030 - Anna's Work With Drug Addiction

Anna returns to talk about addiction psychiatry, a subject that has shaped much of her professional life: .

How do people end up addicted to heroin? Why are addiction and mental illness still so often treated as moral failures rather than medical conditions? What actually happens inside detox units? And how did Anna cope with losing patients?

Drawing on over twenty years of experience, Anna shares powerful stories from the front lines of addiction medicine, including the unlikely patient who became a mentor. We also discuss shame, public attitudes toward mental illness, harm reduction, Switzerland and Sweden's different approaches to addiction, and why compassion should never depend on whether someone is considered "deserving."

A candid conversation about psychiatry, ethics, resilience, and the people society too often chooses to look away from.

🎙️ Dans Tous Les Sens is a bilingual (French/English) podcast from Geneva featuring unfiltered and candid conversations about life, psychology, creativity, relationships, work, and everything in between.

Transcript

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Brian
(0:00) Hello, Anna.

Anna
(0:01) Hello.
(0:02) Hello,

Brian
(0:03) Really nice to see you again.
(0:05) You were, my last guest, so episode 29, and we had so much to catch up on.
(0:11) I think we did a pretty good job of covering a lot of bases for Yeah.
(0:16) What, thirty years, did we say?
(0:18) I still feel that we had to cut it short because we had started getting into some some other things, and and so I wanted to pick things up with you.

Brian
(0:27) Now that we've put the podcast out there, how how did it feel afterwards for you?
(0:32) Because, I mean, you shared some really pretty private stuff and and, like, how how is it for you to listening to yourself again?
(0:42) And

Anna
(0:42) Interesting question because I I made my family listen to it, of course, and, people that I know, some people.
(0:51) And, I I don't think that I'm a private type per like, I am a open person, but it's a different thing to share it in a public way.
(1:02) I felt very good because one of the things that I have struggled with in life is, you know, shame.
(1:09) It's nice to be rid of it, but it's very hard to get rid of it.
(1:13) And there are consequences to being open.

Anna
(1:17) There are consequences to not acting in a way that as if you're ashamed of certain things and mistakes that you've made or things that you've experienced.
(1:27) And my strategy for a long time in life has been to just forget about it or, like, I'm and now I'm gonna remake myself as a perfect person, and I'm not gonna have to be someone who is burdened with faults or problems.
(1:43) And so so this type of forum is also a way to I think, is is helpful to me in practicing a less sort of shameful way to be.
(1:58) You know what I mean?
(1:59) And it's not necessary to be open with absolutely everyone.

Anna
(2:02) They don't have to know, like, details about you.
(2:06) But the behavior of, like, pretending that you're you don't have certain problems or that you're better or that you, you know, to act a certain way is is not always positive.
(2:20) So I'm very glad I had the opportunity to Cool.
(2:23) To be here.
(2:24) Yeah.

Brian
(2:25) Excellent.
(2:26) And what would you

Anna
(2:26) And you were also, in that sense, in that respect, a role model to me because you have been also very open and, I think very brave, and that also inspired me a little bit to learn.

Brian
(2:37) Thanks.
(2:38) In every direction.
(2:42) In every sense, kind of.
(2:44) Direction.
(2:48) All Certainly, for me, it was, I really came out of it being thinking, wow.

Brian
(3:18) Just to find out so much about yourself and about our our parallel stories.
(3:25) And, I mean, I always feel great after a podcast feeling that I learned something about the person, but in your case, it was it was extra special, I have to say.
(3:35) And Thank you.
(3:36) And I I I got some very nice feedback from from a couple friends who don't know you, but you know?
(3:44) And I think I sent you a text.

Brian
(3:46) There's there was a request for part two, so I was like, yeah.
(3:49) But, yeah, maybe so to to pick up on sort of where we we left off.
(3:54) I think we I mean, we started to talk about your your your work with addicts a little bit.
(3:59) Yeah.
(4:01) So maybe to backtrack a little bit, you had mentioned how and why you got into psychiatry.

Anna
(4:08) Yeah.

Brian
(4:09) And and then once you you discovered that you had, a talent or or or a skill for this and and a desire to to specialize in that, How did, you know, how did the evolution of this happen?

Anna
(4:24) At that time, you know, I was always not and have always been someone who is not, you know, for for many reasons, like, into, you know, getting a I I would like to have a good job, but, you know, I'm I'm very kind of missed the opportunity to apply and all those things.
(4:46) And addiction medicine was the not prestigious at all.
(4:53) And also Sweden had has still, but I especially then, some of the least progressive policies in addiction medicine and in the way that you view what addiction is.
(5:09) And in some way, that relates to what mental illness is.
(5:13) I was on many, many levels immediately fascinated by it.

Anna
(5:18) I mean, first of all, like, just the basic sort of human behavior.
(5:23) They say they're gonna do something and then they don't do it.
(5:27) But then there were also other things, the way that medicine relates to, you know, society as a whole, to culture, to politics, to ethics.
(5:39) These issues were it was just, like, so very exciting in in many, many ways.
(5:45) As you might know, like, if you have this kind of ADHD disposition, excitement is like, if if you become interested and fascinated, it it fuels you.

Anna
(5:57) So I was just absorbed in it.
(6:01) And, of course, I noticed that a lot of these people are mentally ill also.
(6:05) First of all, it was just, like, super exciting.
(6:07) You know?
(6:08) I had never met anyone who lived that type of life.

Anna
(6:11) He would probably die if I said that he was a role model to me and an inspiration to me, but he's already dead so I can still say it.
(6:20) But it was actually a patient who was, you know, at that time kind of like a an amphetamines dealer of a small caliber.
(6:29) When I started working, I was I mean, there was a superior person there for the rounds, but then I was alone, like, young, early twenties girl and 16 heroin addicts in in the ward.
(6:43) So it's, like, a tough tough gig.

Brian
(6:45) It was in a hospital or In hospital?
(6:47) Yeah.
(6:48) Okay.

Anna
(6:48) So tough gig.
(6:50) But he was he he said, you know, immediately, like, I'm not your friend.
(6:56) Don't ever think I'm your friend.
(6:58) And I immediately thought he was my friend and my savior, but he helped me and explained to me everything.
(7:05) Like, this is how what heroin looks like.

Anna
(7:07) This is how you buy it.
(7:08) This is how you rob a person.
(7:10) This is how you find someone to prostitute yourself to.
(7:14) This is how you like, all of these things, and he knew everything, and that helped me very much.
(7:21) And he helped me with arithmetic because you have to, like, calculate equipotent doses of benzodiazepines.

Anna
(7:29) I didn't know anything about that.
(7:30) If you if you're a drug adder, can become very resourceful.
(7:33) So he knew everything, and he he helped me.
(7:36) And and the reason he did that, I think, was because it put himself into, like, a a powerful position in the in the ward, but it was helpful nonetheless.
(7:46) I think that's why they have, you know, shows about crime.

Anna
(7:49) I mean, it's just, like, super exciting.
(7:52) And but also very interesting because Sweden has been super unprogressive in terms of addiction and narcotics in particular, but also alcohol.
(8:05) The policy was even stricter then.
(8:08) At first glance, you might think it's reasonable, which is that social security first, this is not a medical issue.
(8:18) This is a social problem.

Anna
(8:20) It's a social construct in a way.
(8:22) So you provide housing, you provide these types of homes, rehab center type places, and jobs, and try to work with criminal behavior.
(8:33) And then they will stop using, and they will become sober.
(8:37) And the methadone programs, which was one of the places where I worked, was at that time, they had a limit of one thousand two hundred patients in in the whole country could be treated for heroin addiction.
(8:51) If you think about it, well, it's good that you don't spread narcotics to the populace.

Anna
(8:58) It's it's good that you don't allow people to you know, sobriety has to be the norm and all of those things, but it also puts a moral burden.
(9:10) It kind of implies that it's a moral issue, that the reason that you're an alcoholic, the reason that you're a drug addict is because you're not you don't want it enough, you're not dedicated to sobriety, and all those things.
(9:22) And that, in my view and in my mind, and it was very obvious, was not true.
(9:28) That was a strong motivating force for me that it's it's immoral.
(9:35) But, I mean, sorry to go on a rant, but at that time, to qualify for methadone, you had to have four years of documented heroin use and four attempts of sobriety that had like, documented attempts to sobriety that had failed or three overdoses that were unintentional, which is like, you know, you can die from all of these things.

Anna
(10:05) And once you were accepted into the program, which only took one thousand two hundred patients nationwide, if you smoked a joint, if you used any other narcotic substance, they excluded you immediately.

Brian
(10:19) Okay.

Anna
(10:21) So the death rate is, you know, none of these people are now living that that that were in this patient group.

Brian
(10:32) Really?

Anna
(10:33) And, you know, they die super young, and the lifestyle is really hard.
(10:39) And the purpose of the methadone, the substitution program, and you could think it's it's oh, you just give them narcotics for free and whatever, but we know that if you don't, they will die.
(10:55) And a living person, you can get them housing, you can do other things, but, like, as long as they have to use illegal substances, they're gonna be criminals.
(11:05) And I was fascinated by that.
(11:07) And and the same with, like, AIDS, which was also I mean, now, I don't think people care about it, but then it was like, you know, you remember as well this problem.

Anna
(11:15) Yeah.
(11:17) Had HIV, a lot of them, because, you know, you you use needles.
(11:20) I mean, now it doesn't really matter and the treatment is good and, life expectancy is, you know, kinda similar to people who don't have it.
(11:28) But then it was kind of more of a death sentence or a worse life, and it was also a moral issue.
(11:35) Oh, you got it because you're sexually promiscuous or because you're using drugs or this one got it from a blood transfusion.

Anna
(11:42) It's a little bit better than someone who got it from, you know, living this lifestyle.
(11:46) Even ADHD is one of those things that people think, like, why should why should you need amphetamines to go to work?
(11:52) It's just like, what's right?
(11:53) How lazy can you be?
(11:55) So it it becomes a moral issue rather than a medical issue.

Anna
(11:59) It became unacceptable to me, and that gave me energy to keep working.

Brian
(12:05) Yeah.
(12:06) Around so around what what years was that when you started?
(12:10) And, I mean, were

Anna
(12:11) were you I started I started studying medicine in '99, and then in 2003, I think, 2003 2004, I started working.
(12:22) And at that time, you could work I mean, first, there was, like it's like a stash or, like, apprenticeship that you do, and then you also could do jobs that you could get paid for from a certain level.
(12:35) So I started doing that.

Brian
(12:36) As far as your your line of work, is it what were you told about it, or did you see a position that already had a bit of a description of what you were going to do, or was it kind of up to you to figure that out?

Anna
(12:50) Reading a description of a job is not my style.
(12:53) No.
(12:53) So

Brian
(12:53) It was Me neither.
(12:55) It was super cheap.

Anna
(12:57) It was an opportunity to pay rent that was available when all the other opportunities to pay rent hadn't been filled.
(13:06) But the formal requirements were to as like a junior physician, so you it's a closed ward.
(13:15) In that particular, ward, it was to, it was like a detox place.

Brian
(13:22) Yes.

Anna
(13:22) So you taper, because a lot of the patients were either going into a methadone program or on the waiting list for this methadone program, which was, you know, had this enormously long waiting list.
(13:39) In order to enter the methadone program, you had to be sober of not opiates, but or opioids, but you had to be sober of everything else.
(13:49) So you couldn't have any traces of cannabis or benzodiazepines or any other, like, drug that we could measure in your system.
(13:58) Otherwise, you wouldn't be eligible for the program.
(14:00) So the purpose was actually, like, a more like a detox center, but, I mean, they these people use it.

Anna
(14:07) It was alcohol.
(14:08) It was, you know, everything that you can think of.
(14:11) So that was the job.
(14:12) Opiate withdrawal is not, like, dangerous in in that sense.
(14:17) I mean, it's uncomfortable and they hate it and most people can't do it, but you can survive it.

Anna
(14:24) But benzodiazepines and alcohol, you know, you can get seizures or delirious states, and the medical community is more mindful of that.
(14:34) So to monitor those symptoms was one of the things.
(14:37) And that's why I mentioned this patient to maintain order.
(14:41) In order to achieve these things, you know, you can't have pills coming in the ward, and you can't have people, like, doing things that they that you they're not allowed to do.
(14:51) And to maintain order is a very hard thing, especially in this community.

Brian
(14:56) Yeah.

Anna
(14:56) Yeah.
(14:57) So that was that was that was the task.
(14:59) And I have to say that I I haven't, like, done anything to advance the field or anything, but I realized very quickly, like, the premise is stupid.
(15:08) You know?
(15:08) It's it's not it's not gonna work.

Anna
(15:10) It's not humane.
(15:11) And there are medical concerns that these people have that are not attended to.
(15:18) And and another thing that I learned I didn't know before and I hadn't learned it in medical school, is this something or is it nothing?
(15:26) Because a stomachache, you can present in a million different ways.
(15:30) If you're in the emergency room, you have to know, like, what is what is something and what is nothing.

Anna
(15:35) It's not necessary if if you have a cold, for example.
(15:38) It's not necessary to know very much about it.
(15:40) You know, it's gonna pass.
(15:41) You won't die.
(15:43) It doesn't help.

Anna
(15:44) We have nothing to to give you, really.
(15:47) But some respiratory symptoms are super serious, and then you have to look identify those.
(15:53) And so I learned a little bit about that as well.
(15:56) And the triage was contrary to the political system, if you will, because if you're gonna treat the people who are the sickest, you should prioritize the people who are the least likely to be sober.

Brian
(16:14) Yes.
(16:15) I

Anna
(16:15) it's The people who can be sober don't need your help.
(16:18) They can do it on their own.
(16:19) You know what I mean?

Brian
(16:20) Yeah.
(16:21) Yeah.
(16:21) Yeah.
(16:21) And it's, it it rings a bell with what hap what I see happen in Geneva where there's a a scarcity of, psychiatrists and and and beds available and treatment centers.
(16:35) And what I found out and also a a friend of mine found out was, in a way, we weren't sick enough to be able to be treated.

Brian
(16:46) And then it's like, well, what the fuck?
(16:48) Do I do I have to pretend that I'm suicidal or that I'm really not well to be taken care of and accepted?
(16:57) When you say 1,200 wait.
(17:01) 1,200 Mhmm.
(17:02) And you you you say it's not enough, like, do we have estimates of the number of people who would

Anna
(17:07) need treatment?
(17:09) Now, just to to be clear, like, that had the the roof number of 1200, I think it was lifted in 2000 maybe '5 or '6.
(17:17) So it was, like, on this way out.
(17:19) But at that time, it's just an example of how the culture was.
(17:23) I I don't know the exact numbers, but I worked in Stockholm and, obviously, like, there were more than one thousand two hundred heroin addicts in the city.

Anna
(17:31) And I think one of the methadone programs that was connected to the hospital where I worked, they had about 800.
(17:38) So it was one of the biggest ones.

Brian
(17:40) Yeah.
(17:40) Wow.
(17:41) Eight hundred?
(17:41) Gee.

Anna
(17:42) The practice of saying that we're gonna allow eight hundred people to get treatment.
(17:50) If you would say that about a heart attack, how would people react?
(17:56) And that's why I mentioned this sort of patient who is because he first of all, he was very good at, like, triage, like, who's something that you can do something with and who is what is something and what is nothing.
(18:09) And then he knew medicine, I mean, not from studying, but, like, from using everything.
(18:14) And he taught me, like, amazing stuff that I found out years later were good, but I thought he was, you know, just bullshitting me.

Anna
(18:24) But he said to me one time, he's like, if I had diabetes and I showed no symptoms of my disease, that is to say I had normal blood sugar, everything was okay, and you were to tell me that you could only get insulin if you show no signs of having this problem, How would that how would that sound in your ears?
(18:46) And, obviously, it's ridiculous.
(18:49) The thing that you mentioned about being sick enough and not sick enough is an addiction medicine and particularly in Sweden that is so kind of in the dark ages in this particular area.
(19:02) It's been obviously the people who have the most need of, you know, new needles or, like, help, they they're not getting it.
(19:11) They haven't been getting it, and now they're deceased because of it.

Anna
(19:14) In in psychiatry, it it has always been burdened with, I think, that type of issue.
(19:22) Oh, you have to be suicide you have to be like, how what what does suicidal mean?
(19:26) Like, how how many guns to your head?
(19:30) Do you how how, you know, how close to the edge of the bridge were you standing?
(19:35) Like, how how sick are you?

Anna
(19:37) But there's also an issue of, like, benefit.
(19:39) So, I mean, take ADHD, for example, which is one of the, I think, now sort of most clearest examples because people who are very successful have it.
(19:51) And, oh, if you're, like, in if if you're a sign if you're a PhD, why would you need Ritalin to go to work?
(19:58) Well, you can get a lot out of a scientist who has Ritalin more than a person who, you know, is is very disabled.
(20:06) There were those people as well.

Anna
(20:08) And and many sort of medical conditions, and particularly, I think, psychiatric, but also, I mean, as I said with the HIV thing, like, infectious, like, as soon as it's connected to something that is shameful or that you don't wanna be, you know, it it becomes a moral issue.
(20:27) And then it's it's all of a sudden, like, oh, you know, you got it because you were promiscuous.

Brian
(20:33) Yeah.
(20:34) Yeah.
(20:34) Yeah.
(20:34) You

Anna
(20:35) you can see it also in the public opinion because when I go to parties and I say, oh, my psychiatrist, they're like, oh, you're one of those people who think everybody should get medication just because, you know, they're depressed just because they hate their jobs, and you think everybody has ADHD just because they can't, like, pass a test, and you think, you know, everything is a trauma or whatever.
(20:57) Yeah.
(20:58) But, you know, as soon as there's, like, a school shooting or something, they're like, you should lock them up.
(21:05) You should medicate them.
(21:06) You should.

Anna
(21:07) So everything that brings disturbance to your own life, people want don't wanna be connected to.
(21:15) And and that's that's where the sort of moral issue, I think, comes in sometimes.
(21:20) Yeah.
(21:21) If you're able to exercise your way and eat your way out of depression, good for you, but then you're not a patient of mine.
(21:28) But the the people I see have already exhausted those opportunities.

Brian
(21:33) Right.
(21:33) And when when we hear that noise, I mean, it makes us feel even more ashamed and and, so it's it's, yeah, it's shitty.
(21:44) I know.
(21:44) Lack of a better word.
(21:46) So for you

Anna
(21:47) I'm sorry to interrupt you, but I just have to, I just have to say the thing about the beds.

Brian
(21:52) Yes.

Anna
(21:52) It's kind of similar to the thing is there's only 1,200 methadone places.
(21:58) The number of beds should be the number of patients that need to be hospitalized.

Brian
(22:02) Yes.
(22:03) Yes.

Anna
(22:03) You know what I mean?
(22:04) Like, if you would say the same thing about a brain tumor, it's like, we can only take a 100 brain tumors per per annum.

Brian
(22:10) Yeah.
(22:11) Yeah.

Anna
(22:11) The person who didn't get the brain tumor operation, it would be headline news.

Brian
(22:16) Right.
(22:17) Yes.
(22:17) Yes.
(22:18) Sorry.
(22:18) Yeah.

Brian
(22:18) No.
(22:19) No.
(22:19) I mean, that's a good point.
(22:20) It made me think of how shocked that I was when when I spent a night at at Beridou, so the the psychiatric unit in in in Geneva, felt like one flew over a cuckoo's nest.
(22:33) I mean, just to see that people were on top of each other, and and, it it was chaos.

Brian
(22:39) It was chaotic.
(22:40) And you and you could tell that the the nurses and and the doctors were couldn't manage, all of that.
(22:46) But in your case, how did it happen on which patients you would you would see and talk to?
(22:53) What was of it the the process of meeting these patients?
(22:56) Was it individual meetings?

Brian
(22:58) Were you with a nurse, or was it this, kodok, I think we call?

Anna
(23:02) Or Yeah.
(23:03) Kodok.
(23:04) No.
(23:04) No.
(23:04) No.

Anna
(23:04) You know, I've worked in this field for a long time.
(23:07) So, I mean, there are so many at one time, I worked in one clinic.
(23:10) It was like, know, you have to have a nurse or you have to have a psych There there are many different styles.
(23:15) When I first started out, it was like the Wild West.
(23:17) I mean, they just put, like, a young girl, 23, 24, in in a ward with, you know, all these people who were, for lack of a better word, like lunatics.

Anna
(23:27) I I didn't really understand psychiatry.
(23:30) I didn't know anything about, you know, society in that way.
(23:33) I didn't know there's a world that exists that is only kind of, you know, foster care and rehab and jail, and and and I didn't know anything about that.
(23:43) So at that time, I just did the best that I could, helped by this, you know, guy who was a hustler till the end, I will tell you, a criminal.
(23:55) And he he was like, you know, in that sense, maybe a bit of an existentialist because he said, like, I in Swedish, it's called which is like the pride of thieves.

Anna
(24:04) It's not like the code of ethics between thieves.
(24:08) It's the the thing that the job of the of the police is to catch me, but my job is to steal the the job of a thief is to steal something something, and he was very proud of of that life.
(24:20) And he demanded to be treated with dignity, And he said to me, one time he stole my prescription pad, and I didn't report him because I thought, you know, he's already been to jail, like, a 100 times, and I kind of know him, and it's gonna be and he said, I I respect you less because you didn't report me because it insinuate you think that I'm a hopeless case.
(24:41) It insinuates that you think that it's not a real crime because you know me.
(24:46) It insinuates that you think that the system, like the jail system, is not beneficial to me, but yet you represent the system.

Anna
(24:55) So which is it?
(24:56) Like, are you a person who think it's thinks it's wrong to to steal a prescription pad?
(25:02) Because if you don't think it's wrong and you don't report it, then you're a criminal yourself.
(25:08) So pick a side, you know.
(25:10) So he was very kind of strict that way, and that got me thinking a little bit, you know.

Anna
(25:15) To answer your question, sorry to go off on tangent, but that framing kind of helped me think that I mean, I'm an employee.
(25:25) I represent I mean, this is public health care, so I represent the state.
(25:30) But you also have your kind of ethics as a professional person.
(25:37) And there's a hierarchy in those things, and you can't accept anything.
(25:43) And you have to find a way to navigate those those parameters.

Anna
(25:48) And because, you know, they can tell you to do anything, and now they're telling us to, like, report illegal immigrants.
(25:54) I mean, a lot of people are not doing it, and I'm one of them.
(25:56) But another level is I mean, I work mostly without patients.
(26:00) So, like, say, five to eight patients a day for twenty years, I never get tired of, like, meeting them.
(26:11) It's just so interesting.

Anna
(26:13) You you wouldn't think it when you speak to me now because but it's just fascinating.
(26:18) Like, why, you know, why did you how did this happen, and what made you do this?
(26:24) And it's it's like a detective job in a way.
(26:27) I've worked with anxiety disorders, which is, like, super, I think, exciting, but then, you know, why did you do this?
(26:35) And I just was, like, interested in people's lives, I think.

Brian
(26:40) Yeah.
(26:40) Yeah.
(26:40) So that patient you you that Yeah.
(26:43) Left a mark on you, So that was one of your early patients.
(26:48) Yeah.

Brian
(26:49) And the way you speak about him, it almost feels like he's teaching you or I mean, almost like a mentor in a way.

Anna
(26:58) And he would he would as I said, he would be super disappointed if I would say that.
(27:03) I think everybody has to have their own style, so I'm allowed to say that even though he would be disappointed.
(27:08) In that particular time and place, he was a mentor because he helped me with the things that were practically important at that time.
(27:16) But then in the I mean, I still think about him today because in many of the moral like, how how to be as a physician, what what does it mean?
(27:25) And and, also, I copied him a little bit, you know, his style of of talking, and I kind of modeled a little bit of my clinical sort of on him.

Anna
(27:36) And and, also, he told me things that were, as I said, that were medically correct that I didn't know.
(27:43) For example, he taught me I mean, it was already published, but it wasn't practiced that to use naltrexone for alcohol abuse.
(27:52) So naltrexone is like the antidote for opiates, but it also blocks the opiate receptor that mediates reward in alcohol.
(28:02) The way you drink alcohol, have this good feeling.
(28:05) It's an opiate opiate mediated feeling.

Anna
(28:08) And if you can block that, it reduces the behavior of of drinking.
(28:13) And he said, you should put this one on Laltrexone.
(28:16) I didn't know what that meant.
(28:17) He didn't he hadn't read it, but he had lived it or knew about it.
(28:21) A lot of these heroin addicts that went on met in the methadone program became, like, men, young men who were vibrant is maybe not the word that you would use to describe, like, a heroin addict.

Anna
(28:34) Men in their early twenties, so you would think it's the prime of their lives, they became overweight, they became lethargic, they became kind of like pudgy, glossy, ugly type face and, never did anything.
(28:56) They were spoken about as if they're now showing their true character.
(29:01) If they don't have to chase heroin all the time, you can see how lazy they are.
(29:06) They sit around drinking, like, ciders all the time, like sugary beverages, and they get overweight, and they never do anything.
(29:14) And this patient or this guy, he said to me, like, you should put them on steroids, not anabolic steroids, but you should get testosterone from at that time, it was prescribed for people with brain tumors.

Anna
(29:27) You should get it from the neurologists.
(29:30) And I said, what are you talking about?
(29:32) Are you insane?
(29:34) Later on, I discovered it was already published that methadone blocks testosterone.
(29:40) So, like, they were sick.

Anna
(29:42) They had hormonal problems.
(29:45) Everything was explained in terms of they have bad character.
(29:49) And he said to me, like, don't you see the similarities between these people and the people who use anabolic steroids, which also blocks endogenous testosterone production?
(29:59) So they also became I mean, when they weren't using, you know, lethargic, bloated.
(30:04) Don't you notice the similarities?

Anna
(30:06) What does that make you think of?
(30:08) And I had never thought about that because the go to was they're just lazy and idiots and stupid and wasteful to society.
(30:15) So that ability to think critically, He he was also a thief, and I don't, like, count myself as one of them, but in other ways, like, a stand up person.

Brian
(30:29) Yeah.
(30:30) And, that he he sounds fascinating, but he so so he must have been very aware of his own situation and why he was here.

Anna
(30:42) I mean, I was, you know, early twenties.
(30:45) A lot of these patients were also early twenties, and some of the patients had, you know, been to to university for, like, a year, and I had only done, like, three or four years.
(30:55) So I thought I'm similar to them.
(30:57) You know?
(30:57) Like, they they could just if they just could get their shit together, they're gonna be in my class.

Anna
(31:04) Yes.
(31:05) You feel that there's more hope for them or that they're, like you you identify with them.
(31:12) And he was very clear with the thing that, like, there's no hope for these people.
(31:17) Like, you think that they're better off or they're gonna do better and you respect them because they're like you.
(31:24) A lot of them had, you know, mental issues, but I also had mental illness.

Anna
(31:28) I had also been to, like, a mental hospital, and the the difference was I wasn't on heroin.
(31:33) And that's the reason that I was in medical school and I wasn't in the ward.
(31:37) Right.
(31:38) It wasn't really easy for me to understand that when you see a patient, you become fascinated with them and you're interested in them and you feel compassionate with them.
(31:51) But don't forget, like, a thief is just as deserving of your respect and your treatment as someone like, the way you got HIV is irrelevant to your access to treatment.

Anna
(32:04) Everybody deserves a life.
(32:06) And if you can have a lot if you can live, perhaps that life can be dignified, and and there are ways to express that.
(32:14) I I hadn't ever thought about those things before.

Brian
(32:17) In every direction.
(32:21) In every sense, kind of.
(32:23) Don't call direction.
(32:26) In our previous podcast, you mentioned that the act of starting a drug is a lot related to accessibility.

Anna
(32:36) Yeah.
(32:36) Yeah.

Brian
(32:37) Did you find out that the reasons for starting heroin or some of those harder drugs, Are are there common factors, or, like, what's

Anna
(32:50) sort of I say that there are common factors, and I think I I think I mentioned also, like, the opioid thing in The United States, which shows that, you know, it's it's interesting than the social comment because previously, it was like, you know, they're idiots, and they're losers and they you know, the but but now it's like, oh, rich people also get addicted to OxyContin, so it's probably the pharmaceutical company that is the but but there are risk factors.
(33:22) One of the most potent risk factors is the proximity or the ex access to narcotics.
(33:29) And Right.
(33:30) Certain things that increase your access to narcotics is to live in areas of society where they are more prevalent.
(33:40) So per perhaps, like, in bordering criminal areas, you know, people with mental health issues.

Anna
(33:50) But then there's also, like, protective factor.
(33:52) I I think about my own case.
(33:54) I mean, I could've I it's it's it's amazing that I'm still living, you know, but but I had my father was super attentive to me.
(34:02) We had financial resources so that I could go to an expensive school, like, three years in a row, that I could all my, you know, bills that I forgot to pay were paid.
(34:13) I had friends.

Anna
(34:14) I had I had a lot of, things that were going for me and that helped me not but people who don't have those resources, like, if you miss a payment, then that's it for you.
(34:29) Or if you, like, fail high school, I mean, I got, you know, three chances to Yeah.
(34:35) To repeat and repeat and repeat.
(34:37) Yeah.
(34:37) And and this is one of the things, like, my husband, when he listened to the podcast, he's like, you didn't it it sounds like you did it all on your own.

Anna
(34:45) You know, like, he's like it's like you're you're the sole kind of, proprietor of this, success or whatever, which is I mean, success is, you know, success is only when you cross the finish line, you're the winner, and then you're just, like, defending for the rest of your life.
(35:03) So it's always it's always a challenge, but it's like it it sounds like it's only you.
(35:07) It's not only you.
(35:08) It's like everyone else who pitched in.
(35:10) And those factors are super important, and and the conversation about mental illness is very often focused on what did you yourself not do.

Anna
(35:20) And and sometimes it can be, no.
(35:22) I was traumatized.
(35:23) Therefore, I can never have a good life.
(35:24) That's not the case either.
(35:26) People who are traumatized can have good lives.

Anna
(35:28) The prognosis for PTSD is quite good, actually, if you get treatment.
(35:34) So the waiting list has to be shorter.
(35:35) And the people who have not as much resources socially, economically, intellectually, I would say also, like Mhmm.
(35:47) You know, life is harder if you're not bright.
(35:51) They need more help.

Anna
(35:53) And Yeah.
(35:53) If you're a thief or a liar, it doesn't matter.
(35:57) You still deserve it.

Brian
(35:58) And the risk factor just increases if you don't have those resources.
(36:03) And it's I mean Absolutely.
(36:04) I I certainly feel this that if I didn't have the the support system around me and and and parents and friends and and, you know, medical also because I've I've had some doctors that weren't great, I've but had some very good doctors and nurses and and and people in my surrounding.
(36:23) And like we said in the last episode, teachers.
(36:27) But, clearly, I know that I mean, I'm certain that if I did not have that, I might not be here today because I would have collapsed.

Brian
(36:38) I would have gone to the dark side kind

Anna
(36:41) of Of course.

Brian
(36:42) And, and more the reason to not treat these people as criminals or outcasts or or not worth, because it could be could be us.
(36:54) And, also, the other thing is that it's it's harming yourself in in the end.
(36:57) So to treat somebody who's struggling in life, who's who's injured, who's, as as a, you know, like, the the scrap of society is is is disgusting.
(37:11) And

Anna
(37:11) But it's very hard.
(37:13) If if you wanna be like a fatalist, could say, like, the reason that I was condemned to have this line of work is because I'm not naturally, like, compassionate.
(37:21) You know, I'm very judgmental, and I look down upon people all the time.
(37:26) So it this probably was very useful for me to to, like, get into it.
(37:31) But I remember when I was was, you know, also quite young, at that time, you could still get patients with, like, you know, concentration cap tattoos.

Anna
(37:42) Now they are also all dead.
(37:44) But then and then you say, oh, even if they just came in for, like, you know, some minor thing, if you see the tattoo, you already think, oh, they had, like, this and this life.
(37:53) You you already are aware of what it means.
(37:55) And then you can get patients with like, you know, the swastika tattoo.
(37:59) What do you do with them?

Anna
(38:00) Do you do you treat them with the same what what do they deserve?
(38:08) How do you behave?
(38:09) And and they're in the same waiting room, so it's not like in that sense, they're equal.

Brian
(38:15) Yeah.

Anna
(38:15) But how do you behave?
(38:18) And so I'm I'm glad I had the opportunity to think about it, and I have the opportunity to think about it all the time.
(38:27) But it's instinctively, I think, we gravitate towards, like, oh, the person with the concentration camp tat two, you already feel sorry for them even the before you heard what their trouble is.
(38:41) You know?
(38:42) And how do you relate to a person who represents things that you don't I mean, I have patients now who are disturbed in ways that I mean, of course, some of them have done things that are horrible, but some of them also are what you might describe as horrible.

Anna
(39:03) You know, they don't display signs of empathy or

Brian
(39:08) Yeah.
(39:09) In

Anna
(39:10) in a way that they're not likable, which is also, like, a super, like, risk factor for having a bad life because if if people like you, if you're pretty or charming, whatever charming is, but we know that people who excite people's compassion, they have they have it better.
(39:30) And and how do you treat those people who were, in some way, represent aversive or disgusting or provocative things?
(39:41) That's Mhmm.
(39:42) Not very easy, I think.

Brian
(39:45) It sounds pretty grim.
(39:48) You mentioned they I don't exactly remember the words that you used, but did they all die or that Yeah.
(39:54) I mean, is it is that unfortunate an un more than unfortunate, but a a reality that you you try to get treated, you do what you can to get treated, and then they go in the outside world and I think

Anna
(40:10) I think

Brian
(40:11) spirals.
(40:12) Or

Anna
(40:12) I think in the in the in the you know, when when you when you say something like, if it wasn't for my I mean, it's it's very hard to know, like, what is the I mean, I have patients who say to me, oh, if it wasn't for you, I wouldn't be living.
(40:26) Well, what does that really mean?
(40:28) Like, what does saving a life really mean?
(40:30) It it's not as easy as it may sound, and and maybe that's not the case.
(40:36) You know?

Anna
(40:37) Maybe you would have been fine without those things or maybe not.
(40:40) You you don't know.
(40:41) I I think that, like, the challenge is all always the same, which is can I do something to make it better or can I not do something to make it better?
(40:55) And what does better mean?
(40:57) You know, what does better mean?

Anna
(40:59) What is a good life and who am I to judge?
(41:01) And it may be the case that you would have died.
(41:04) You know what I mean?
(41:05) Like, depression is has a very high mortality rate if it's not treated.
(41:10) Emotional instability has very high it's like I think the factor is, like, twenty twenty times increased risk of, like, early death or something like that.

Anna
(41:21) So people who who are in this category already are are have a high risk of having a a life full of suffering, of dying early.
(41:33) And in terms of, like, substance abuse, most people who are in this world are not you know, it's not like, oh, I only drink alcohol, that's the only problem that I have.
(41:42) That's, you know, very rarely the case.
(41:45) But for the opiate thing, I mean, the mortality rate is extremely high.
(41:51) It's not a coincidence that those people that I saw then who were the same age as me most I mean, this guy that I'm talking about all the time, he was born in 1966.

Anna
(42:03) I still remember his birthday.
(42:05) Stupid.
(42:06) But, anyway, in my view, like, as old as time, I had never you know, and also, like, living on the streets ages you.
(42:13) So he was, like you know, looked like something out of Pirates of the Caribbean, probably.
(42:17) But they don't live very long if they're not treated and not helped.

Anna
(42:24) And you can say, did everything that I could.
(42:27) Did you really like, what does that really mean?
(42:29) And and so I think that for a lot of those people, the prognosis was already grim.
(42:35) But I know that for a lot of them, if you demand, like, you should get a job I mean, these are things that I think are part of being having a good life.
(42:51) You should get a job.

Anna
(42:52) You should cut your hair.
(42:54) I mean, you should you should stop using, you should not drink, you should be sober, you shouldn't smoke, shouldn't do this, then you will be worthy of this type of treatment.
(43:05) I am very strongly of the opinion that that approach was wrong and that if the approach had been you seem to be you you seem to be unable to handle the situation that you're in, more of them would be we would still see some of them around today.
(43:26) And they would probably still have problems.
(43:28) I don't know.

Anna
(43:29) A colleague once said to me, you know, it's better to be, prosecuted or, like, I don't know, like, what what you would call it, but, if they sue you for malpractice by someone who's living, then lose a patient and then you feel bad about it.
(43:46) And that's the worst.
(43:47) And in this life, you have to, unfortunately, it's like a thing that you have to experience.
(43:57) But, losing a patient and you don't feel that you had done your best is horrible.
(44:06) Horrible.

Anna
(44:08) Horrible.
(44:11) So

Brian
(44:12) Yeah.
(44:17) I mean, not, you know, not to get too curious, but, like, the cause of deaths are, like, relapse, overdose

Anna
(44:23) The causes of death

Brian
(44:24) or yeah.

Anna
(44:25) Or Usually, like, overdose.
(44:28) Yeah.
(44:30) Particularly with opiates.
(44:32) I mean, I would say a lot of drug addicts at that level, if you could say that, are very resourceful.
(44:40) They're not idiots.

Anna
(44:41) You know, they they know more about doses and not doses than you probably, But the drugs that you can get illegally, it's hard to know where they're from.
(44:56) You're in a desperate situation.
(44:58) It's not easy to access them exactly when you I mean, it's not like, you know, you you you you have to get your fix now.
(45:06) And if you can't get the good quality, you have to take something that's worse.
(45:11) And so there are a lot of those types of situations that, you know, the life style that you I mean, if you're not, you know, Keith Richards that you can afford to, like, keep the habit going.

Anna
(45:24) The positive side of heroin is, like, if you have enough money to continue doing it, you can you can I mean, it doesn't, like, age you, particularly?
(45:35) It pushes you into a very hard life where you become also vulnerable to a lot of things, a lot of decisions that maybe you wouldn't otherwise have made, like sexually in terms of, you know, criminal behavior, in terms of, like, oh, is this the level of purity that I need, or is this needle really pristine?
(45:57) I mean, it's not like they are unaware that if I use a used needle, there's gonna be hepatitis in it, but desperate times, desperate measures.
(46:08) Right.
(46:09) Right.

Anna
(46:09) And and and you think that, you know, when you're doing well and I think, as you said, you know, now you think that I I can manage everything.
(46:20) I don't have those problems.
(46:22) And if I if I had that problem, I would I would have a clean needle and I would have a condom in my back pocket and I would be prepared for everything.
(46:29) But that's not the way I mean, everybody who lives knows that that's not the way life is and you make stupid decisions.
(46:35) Yeah.

Anna
(46:35) So then and some people are in such such circumstances that the protective factors are so few that that every you know, they just they die.

Brian
(46:49) That's so sad.

Anna
(46:50) That's very sad.

Brian
(46:51) It's very sad.
(46:52) And and, you know, it's and it happens in the flesh.
(46:56) I mean, you can be very determined.
(46:58) You can want to get better, but it just takes a moment to, like, fall back into it.

Anna
(47:06) That's that's another sort of reason why I think it's important to kind of let a little bit go of the shame and as someone in the medical community because one of the sort of categories of people who are the most the least likely to seek attendance or help or care are people who are already professionals in health care because of of different reasons and and the but mainly shame, of course.
(47:36) And I think that you and I both know I mean, you were have been very open and talked about when you're depressed or when you're anxious, is it it's like when you lose your mind, you don't almost notice it.
(47:51) When you're well, you have access to all those sort of faculties and all the decisions and all the so you think that it's gonna be easy to make these choices, but the ease with which is it possible to think, I'll just jump off a bridge or I'll make this decision that is so stupid you can imagine it that you're then ashamed of is that line is so thin, and people who haven't experienced think think that it will never happen to me.

Anna
(48:21) Of course, it it can happen to it can happen to you.

Brian
(48:27) Yep.
(48:28) Yep.
(48:29) I mean, boy, we could do the whole two hours or how how much time we have about that.
(48:35) Just one one note, when you mentioned the quality of the products and everything, in in Geneva, I don't know if it's the case in the rest of Switzerland.
(48:44) I don't know if you remember this, but in Zurich, there was the Lethan, which was this this area next to the train station where Yeah.

Brian
(48:52) I mean, it was, like, so scary, that place, because it was like a drug mecca kind of it was it was chaos.
(49:02) It was chaos.
(49:04) Guess they did the same thing in Zurich, but in Geneva, they built a center to be able to get clean needles.
(49:10) On on the building, it says, like what is it called?
(49:15) I think it's called.

Brian
(49:17) Something about not judging is, like, one of their their mottos.
(49:21) It's like, don't judge.
(49:23) Yeah.
(49:23) Yeah.
(49:23) Don't judge.

Brian
(49:24) But there's also a place called, Nuit Blanche, I think.

Anna
(49:30) Okay.

Brian
(49:31) If you obtain drugs and they're not never gonna ask how you obtained it.

Anna
(49:36) Yeah.

Brian
(49:37) But you can bring your drugs there.
(49:40) It's anonymous, and you have, like, a fifteen or thirty minute, appointment with somebody who works there the first time that you go.
(49:49) And then they do with the lab an analysis of the drug, and three days later, they give you the the report to see that, okay.
(49:59) The it's 95% pure or Yeah.
(50:02) We we found traces of this or not.

Brian
(50:05) And, I find that pretty pretty remarkable because it's I don't believe in the yeah.
(50:11) But it's enhancing.
(50:12) Why are we helping these people?
(50:14) Well, no.
(50:14) We're we're not.

Brian
(50:15) What yeah.
(50:16) I mean, it's preventing deaths and prevent preventing accidents and no judgment.
(50:22) But, but yeah.
(50:25) So so much we could say about this.
(50:27) Maybe just to to finish on that, like, right now now that you've been working in this field a lot, are you still working in it?

Anna
(50:34) No.
(50:35) So now I'm in general psychiatry.

Brian
(50:37) Yeah.
(50:38) But was it, like, your decision to because you mentioned the the I mean, I can't even imagine.
(50:43) That's why I went speechless there because the idea that you start feeling responsible for not responsible, but that what could I have done to prevent somebody dying?
(50:54) This must be terrible.
(50:55) But

Anna
(50:56) It is terrible.
(50:57) It is terrible.
(50:58) But I understood that a lot of these people have you know, one of the risk factor is is it a risk factor for, you know, getting into that situation, or is it a risk factor for not getting out of it?
(51:11) I mean Yeah.
(51:12) You can you can debate, but but a lot of them had mental illness.

Anna
(51:17) So I went into general psychiatry, which is a different field in Sweden, to be able to help them a little bit more.
(51:25) I thought it was gonna go back, but then I got stuck in in general psychiatry, and there's stuff to do there as well.
(51:34) But, I mean, the burden of losing a patient and or of of, you know, I I didn't do my best.
(51:43) I mean, it's it's unbearable yet you have to bear it.
(51:47) And one one of the first patients that I ever discharged on my own committed suicide, and, you know, he just left the ward.

Anna
(51:56) And I was so you know, at that time, it was so like, oh, how are what are the the we brought the prescriptions by hand.
(52:03) So it was, like, I was so into into that.
(52:06) And he just went straight to this train station and jumped.
(52:09) Mean, it was, like, you know, five minutes.

Brian
(52:11) Yeah.

Anna
(52:13) At that time, I I I don't think I even you know, everything is so bizarre.
(52:18) Everything is so so I I didn't really know how to deal with it, but I I had to speak to the mother.
(52:25) And I couldn't really handle it.
(52:27) And I kind of broke down, and I was like, oh my god.
(52:30) I feel like a failure.

Anna
(52:31) I should become a florist.
(52:33) This is the worst.
(52:34) I hate myself.
(52:35) And she's like, well, first of all, this is not about you, so number one.
(52:38) Number two, she said to me, I'm gonna leave this room now because I see you're not, you know, handling this very well.

Anna
(52:47) And I'm gonna imagine I'm gonna forget about you, and I'm gonna imagine the last person that spoke to my son was someone who cared about him, who did their best to the to the best of their ability in the situation, and someone who is not a quitter, but who is going to spend the rest of their lives doing better.
(53:09) Like, don't quit.
(53:11) Learn something.
(53:12) Do better.

Brian
(53:13) Wow.
(53:13) That's like a brutal

Anna
(53:15) The only reason I ever went back was because, you know, I had to pay rent.
(53:18) I would otherwise never I would have quit immediately if I had the opportunity.
(53:22) But it it also is like a responsibility.
(53:26) Like, you have to face and and it also has a little bit to do with shame.
(53:31) Like, it's so horrible to face your failure or to know that you made a mistake

Brian
(53:39) or

Anna
(53:39) and that had such a terrible consequence that someone, you know, was their lives were affected or even that they lost their lives.
(53:51) That's so horrible.
(53:53) Yet, the only way to handle the grief and the is to do better.
(53:58) That that's also, like, a grief kind of process.

Brian
(54:01) And and

Anna
(54:04) and in terms of, like, even on a personal level, like, we talked about, like, family, and there are so many mistakes that you can make in relationships.
(54:13) Like, half of it is not enough.
(54:14) And with parenting, like, you oh my god.
(54:17) If I if I could just be a little bit less of an idiot, I would give, like, everything to not be as stupid as I've been.
(54:28) But the only thing that you can do is, like, face it, accept it, and what can I do better?

Anna
(54:35) I mean, that's, like, the dignified thing to do, but it's hard.
(54:38) Yeah.
(54:38) Of course.

Brian
(54:38) Definitely.
(54:40) Definitely.
(54:40) Thanks for for sharing those those insights because it's we you know, the the outside world doesn't really know about this, and I and we only scratch the surface, but I I I feel that your experience is is really worth listening to, especially because you're dealing with human beings and, yeah, not just not just addicts.