I Had a Gun

I came out to the waiting room to see who was next, and sitting there was one of my favorite patients, Mr. P. He had walked in without an appointment and looked weak and frail, wearing a baggy flannel shirt and overalls that were clearly too big for him. Dark glasses hid his eyes as he sat hunched over reading a magazine. I met Mr. P on the chemical dependence unit where he had been admitted for heroin withdrawal. We developed rapport while he was in the hospital and he assured me he would follow-up in the outpatient setting. I was skeptical but, sure enough, he showed up at my office the following week. His whole life related to the subculture of the urban drug trade. He had dropped out of school after ninth grade and started using intravenous heroin at the age of 17. I had taken care of many patients with addiction, but Mr. P was different. He read classic literature and poetry, and spoke articulately, often using insightful metaphors to describe how he was feeling. I'm sure that it was these qualities that had attracted his prison social worker to him. She had let him move in with her upon his release from prison. They seemed an unlikely couple, but they interacted in a wonderful way. She came with him for all his initial office visits, worried about him because he had continued to use drugs after leaving the hospital. Then, one day, he came alone. Incredibly, he related to me that she had developed a heroin habit and had moved out of state to live with her parents. There had to be more to the story, but he would not tell me much else. However, he was interested in getting help for himself. Luckily, he was on a methadone program within 2 weeks. Initially, he rebelled at the notion of groups, but within a few weeks, according to his counselor, he was the most vocal member of his group. A few months later, he agreed to a research project at the methadone program that included intelligence testing. Of no surprise, he had an IQ of 135. To his surprise, Mr. P was doing well, not using drugs. Despite being HIV positive for over 10 years, he was asymptomatic and compliant with his antiretrovirals. He thought all of this would bring his friend back, but she remained with her parents and did not return his calls. On most of his visits, he now related a sense of loneliness that overwhelmed all of his other problems. So here was Mr. P now looking frail and thin. He would not look me in the eye and I immediately knew this was a sign he had relapsed. After a long pause he muttered softy under his breath, “I had a gun … I needed money for the coke so badly, someone I know lent me a gun.” He continued, “I had to do what I had to do, but yesterday I gave the gun back.” Now I was the one who could not look the other in the eye. Of course I knew that my patients who use drugs commit crimes to get money and drugs. In another circumstance, I felt Mr. P would have been a teacher or a writer. Now my image of him was as a thug on the street robbing one of my frail elderly patients in a back alley. The rest of the visit was a blur as I was unable to focus. One week later, Mr. P came by the office for what had been a previously scheduled appointment. He sensed my uneasiness immediately. His first words were, “I think you may have gotten the wrong impression last week. I wasn't stealing from any old ladies. I was getting money and drugs from dealers and from people who had just bought drugs.” I continued to take care of Mr. P, but I did not look forward to seeing him as much as I had in the past. We still talked about politics, literature, and life. He was still on methadone and taking his HIV medicines, but was dabbling with cocaine. Then a few months later, Mr. P missed an appointment. I tried to contact him, but his phone had been disconnected. I called the methadone program. He had disappeared from them too. It's now been over 1 year and I have not heard from him. Maybe he's in jail. Or maybe he moved out of state with his former social worker. I hope he is okay, for like an old friend, I truly look forward to seeing him again.