Evan Lavender-Smith
"I've also been feeling a little depressed," Evan said. "I broke up with my girlfriend."
"I'm sorry to hear that," John said. "How long have you been feeling this way?"
"Ever since we broke up," Evan said. "Two, two and a half months."
"Two and a half months," John said. "And would you say your depression has affected your concentration at school?"
"I don't know," Evan said. "Maybe."
"How old are you?" John said.
"Sixteen," Evan said.
"Sixteen," John said. "How about we get you going on twenty milligrams of fluoxetine, in addition to the antibiotic. You should perk up in no time."
"What's fluoxetine?" Evan said.
"Prozac," John said. "It's an anti-depressant. I'll write you a prescription and then see you back here for a follow-up in two weeks. Sound good?"
"Sounds good to me," Evan said.
"Great," John said. "The cough and sore throat should be gone by then too."
"Great," Evan said. "See you in two weeks."
"Great," Evan said. "Cough's gone, sore throat's gone."
"And how's the Prozac treating you?" John said. "You've been on it for how long? Two weeks."
"I feel pretty good," Evan said. "I don't think I'm depressed anymore."
"Good," John said. "Let's keep you on it for now. And we'll meet again in, say, three months."
"So you want me to," Evan said. "You think I should stay on it?"
"If you think it's helping you," John said.
"I think it is," Evan said. "What do you think?"
"It sounds like it's working well," John said. "You say you're feeling pretty good, right?"
"Yeah," Evan said. "I feel great."
"Great," John said. "So I'll see you in three months. To reevaluate."
"So it's been three months now," John said. "How's the Prozac treating you?"
"Pretty good," Evan said.
"Are you experiencing any side effects?" John said.
"What do you mean?" Evan said.
"Have you noticed anything going on that seems out of the ordinary," John said. "Physically."
"Well, now that you mention it," Evan said. "I'm having a little bit of trouble with my. Penis?"
"What seems to be the trouble?" John said.
"I'm having a little trouble getting it," Evan said. "Hard?"
"Decreased libido is a common side effect with fluoxetine," John said. "How much is it bothering you, would you say?"
"A little," Evan said. "A lot, actually. Is there anything I can. Is there anything we can do about it?"
"Maybe," John said. "Do you smoke, by chance?"
"Cigarettes?" Evan said.
"Yes," John said. "Cigarettes."
"Sometimes," Evan said.
"I ask because I can smell it on you," John said. "How much do you mean when you say a little?"
"I don't know," Evan said. "Five a day?"
"Five a day," John said.
"Maybe ten?" Evan said. "On some days."
"Maybe ten on some days," John said.
"Maybe," Evan said.
"There's a drug called bupropion," John said. "Wellbutrin. It should reduce your nicotine cravings and also help with the decrease in libido brought on by the Prozac. I've got a number of patients taking both at the same time. It seems to work well for most people."
"OK," Evan said.
"I'll get you a prescription slip," John said. "And I'll see you back here in. Two weeks, let's say?"
"Sounds good to me," Evan said.
"Good," John said. "See you in two weeks."
"Good," John said. "And how do you feel the Wellbutrin is working?"
"I feel pretty good," Evan said. "It was a little difficult getting used to it at first. I had some trouble sleeping the first week. But I've definitely noticed a difference with the. In the penis department."
"Your libido is stronger," John said.
"Right," Evan said. "My libido's all good now."
"Great," John said. "And what about the smoking? How's the smoking going?"
"It's not," Evan said. "Cigarettes, they taste horrible. I get sick to my stomach even when I'm around someone who's smoking."
"That's a very good thing," John said. "So why don't we do this. Let's keep you on the Prozac and the Wellbutrin for now. And we'll meet again in, say. Three months?"
"OK," Evan said.
"I'll get you set up with some refills," John said. "Sound good?"
"OK," Evan said. "Sounds good to me."
"OK," Evan said. "I'm not so sure about the Wellbutrin, though. I mean, it definitely helps me in some ways. You know, with the penis stuff and the smoking. But I'm always kind of like, I don't know. Jittery?"
"Sure," John said. "But I'd rather not take you off it because it appears to helping with the side effects from the Prozac and with your nicotine cravings. Instead, why don't we try adding a little diazepam, a little Valium into the mix, to even things out. Five milligrams, twice a day. We'll try this for a while, see if things improve. And then we'll meet again in two weeks to."
"To reevaluate," Evan said.
"That's right," John said. "To reevaluate."
"OK," Evan said. "We'll meet again in two weeks. To reevaluate."
"OK, I guess," Evan said. "Maybe kind of OK. The Valium is helping me relax. I mean, it's helping me out. The thing is, I'm feeling stressed. Especially about school. Like around midday I start getting pretty antsy. If I'm in certain situations, like if I'm around a lot of people, my heart'll start beating really fast and I'll feel like I'm about to, you know. Completely lose it."
"I see," John said. "How about we try increasing the Valium to ten milligrams, three times a day. See how that works. Remind me of your other medications?"
"Prozac," Evan said. "And Wellbutrin."
"Prozac and Wellbutrin," John said. "And everything's fine with those?"
"I think so," Evan said.
"OK, good," John said. "Let's give the new dosage of diazepam some time to settle in."
"OK," Evan said. "And I'll check back in with you when?"
"In a month," John said. "I'll have you check back in a month and we'll see how you're feeling."
"How are you feeling today?" John said.
"Not so great," Evan said. "I think we may need to increase the dosage on my Prozac."
"We may be able to do that," John said. "What seems to be the problem?"
"I've been feeling pretty down," Evan said. "I think I'm depressed again."
"Let's see," John said. "How long have you been on Prozac?"
"I don't know, half a year," Evan said. "A year. I don't know."
"And you were on it before, correct?" John said. "A few years back?"
"No," Evan said. "I don't think. I don't believe so."
"Didn't we have you on an anti-psychotic at some point?" John said. "Seroquel?"
"No, I don't think," Evan said. "Wellbutrin. Prozac, Wellbutrin and Valium. I'm taking the Wellbutrin to help with the side effects from the Prozac. And the Valium to help with the side effects from the Wellbutrin. But now I'm thinking I might need more Prozac to help with the side effects from the Valium. Or the side effects from the, you know. The whole arsenal."
"I see," John said. "We do have you on a fairly low dose of Prozac. Why don't we go up to forty milligrams and see how you respond. How old are you? Seventeen."
"Will I need to up the Wellbutrin, though, in order to deal with the side effects from upping the Prozac?" Evan said.
"Maybe," John said. "Right now you're on three hundred milligrams of Wellbutrin. We could bump that to four-fifty. What are the side effects you experience from Prozac, remind me?"
"The sexual kind," Evan said. "Can't get it, sexually, you know. Up."
"And the Wellbutrin," John said. "It helps with that."
"Yeah, but it makes me jittery, which is why I," Evan said. "That's why I need the Valium, remember? So if we increase the Wellbutrin, should we increase the Valium too, is what I'm asking."
"Let's see here," John said. "You're on thirty milligrams of Valium. I suppose we could go to forty, but I'd prefer not to increase that one. What we might do instead is get you on something more efficient. Something like Xanax."
"OK," Evan said.
"But let's take it one step at a time," John said. "First let's increase the Prozac to forty. Then we'll meet back here in a month and reevaluate."
"OK," Evan said.
"Let me get you a prescription slip," John said.
"OK," Evan said.
"If OK's a seven, then I'm maybe a four," Evan said. "No, a three. I'd say I'm just shy of half OK."
"Tell me what's going on," John said.
"The side effects from the Prozac are fairly debilitating," Evan said. "In terms of my libido. So I think we're going to need to increase the Wellbutrin after all."
"We can go to four-fifty on Wellbutrin," John said. "I wouldn't recommend going higher than that."
"Then four-fifty," Evan said.
"OK," John said.
"OK, now let's talk about the Valium," Evan said. "You mentioned last time I might try something else, something that begins with the letter Z, but I don't remember what it was. And if I'm going to go higher with the Wellbutrin, then I'm going to need to go higher with the Valium, or with the Valium substitute, because I can't stand how jittery the Wellbutrin makes me feel, and I'm going to need to nip that jitteriness in the bud before it becomes a problem. Before it becomes a bigger problem. I'm starting college in less than a month and I really can't be dealing with jitteriness while trying to focus on my classes. So can we talk about my options with the Valium?"
"Sure," John said. "Let's talk about them. Right now you're on thirty milligrams. I could go up to forty, maybe even fifty or sixty, but I'd rather switch you over to Xanax. That's Xanax with an X, like the X in xylophone. X-A-N-A-X. I could put you on half a milligram three times a day, although if you're on ten milligrams of Valium, and you're looking to increase it in order to counter the side effects associated with the Wellbutrin, you might want to start the Xanax at one milligram three times daily."
"Is that a high dose?" Evan said.
"No, not really," John said. "When you get into the six-milligram range that's when you begin entering the high end of the spectrum. Three milligrams is right in the middle."
"Where would you say I am on the Prozac and the Wellbutrin spectrums?" Evan said.
"Starting dosage for Prozac is usually twenty," John said. "With a max dose at eighty. So at forty you're still low-medium. But if we go to four-fifty with the Wellbutrin that would certainly put you on the high end, four-fifty usually being considered the max with Wellbutrin. Although I've had patients on six hundred. It's all relative, really. Different patients can tolerate different amounts."
"So we still have at least a little wiggle room with the Wellbutrin," Evan said. "And a lot of wiggle room with the Prozac."
"In a manner of speaking, yes," John said. "And we can always try other medications as well. Until we land on the combination that works best for you. That's what we're looking for here."
"Why don't you give me a prescription for the Wellbutrin and the Xanax with an X," Evan said. "Oh, and another thing. I'm having some trouble sleeping lately. I think it's because I'm about to start college. I stay up practically all night worrying about it."
"Sure, it's understandable," John said. "A major life change. There's a light sleeping pill, zolpidem. Ambien. It tends to work well for most people."
"That sounds good," Evan said. "Give me some of those. And I'll see you back here when?"
"Are you going to college here or somewhere else?" John said.
"Here," Evan said.
"Good for you," John said. "In that case, why don't we check back in a month or so."
"Great," Evan said. "See you in like a month."
"Like shit," Evan said.
"I'm afraid I'm going to have to ask you to be more specific," John said.
"I can't sleep," Evan said. "I'm jittery all the time. The Ambien was working great, but then it stopped working. For no reason. Now I take it with no hope of sleep. So I'm going to need either way more Ambien or I'm going to need to get on something else. And then there's the situation with the Xanax. My current dosage still isn't enough to get rid of the Wellbutrin jitters. So what I'm thinking is, I'm either going to need way more Xanax or I'm going to need to get on something stronger. I think the dosage on the Prozac may be fine. As for the Wellbutrin, I don't know, I'd love to scale it back, I hate it. But I'm scared I won't be able to have sex with my girlfriend if I get off it. And I can't risk that. So here's what I'm thinking. Let's increase the Xanax in order to deal with the Wellbutrin jitters. Or maybe switch me over to eighty or a hundred milligrams of Valium per day. But either way we've got to change up the sleeping pill."
"Hold on," John said. "Slow down. I'm not going to put you on a hundred milligrams of Valium. That's a terrible idea. We may be able to increase the Xanax by a little. How much are you on again?"
"I don't know," Evan said. "Not enough. I need way more."
"Just calm down a second," John said. "Let's see here. Three milligrams. I suppose we could increase the Xanax to one and a half milligrams three times a day. How does that sound?"
"Honestly, Doc, that doesn't sound like enough," Evan said. "I'm on four hundred and fifty milligrams of Wellbutrin and you want to put me on what? Four point five milligrams of Xanax?"
"Xanax is a more efficient medication than Wellbutrin," John said. "That's why the dosage is lower."
"I don't know," Evan said. "I guess I'm feeling like my life isn't going very well these days. And I have a sneaking suspicion that all these drugs, all these medications, have something to do with it."
"In my opinion, we simply haven't landed on the right combination of medications," John said. "I'm confident that we will, though."
"Are you?" Evan said.
"I am," John said. "Now, listen. As it concerns your sleep, I have a number of patients who are taking Halcion with good results. Why don't we get you going on that."
"Are you going to give me a really high dose?" Evan said.
"Why don't we start you off on a medium dosage, an average dosage," John said. "And we'll meet again in a few weeks to reevaluate."
"Fine," Evan said. "Whatever you say. I'll give it a try."
"Is there anything else I can do for you?" John said.
"No," Evan said. "I'll just see you next time, I guess."
"How's college going, by the way?" John said.
"Like shit," Evan said. "That's why I need all these drugs."
"Calm down," John said. "Let's give this new combination a try and then meet again in a few weeks."
"To reevaluate," Evan said.
"We need to completely reevaluate the Halcion," Evan said. "At first, I thought it was working pretty well. In fact, I thought it had solved all my problems. I was sleeping through the night. But then it stopped working. I couldn't get to sleep. So I had to start taking a second pill. That worked for a while. But then that stopped working. Instead of taking a third pill, I cut a pill in half. That was OK. I mean, I did eventually fall asleep, but not as quickly as I would've liked. I did that for a few days. But then I started taking three pills, because it occurred to me there's no big difference between taking two and a half pills and taking three. Three pills worked great. I was out like a light. But then I ran out. So I called you and left a message with your answering service on Friday. And I didn't sleep Friday night, Saturday night, or last night. So I need to get a new prescription from you right now and then go to the pharmacy and then go home and take three, maybe three and a half pills. And then I'm going to sleep for like two days straight and finally get back to living my life."
"Hold on," John said. "You're taking how many milligrams of Halcion?"
"Three pills at a quarter milligram each," Evan said. "
"Three quarter milligrams of Halcion per night?" John said. "I'm sorry, but I'm not going to be able to give you a prescription in that amount. The highest I can go on Halcion is half a milligram."
"I guess we're going to have to get me on something else then, because there's absolutely no chance I'm going to be able to sleep on only half a milligram of Halcion," Evan said. "You might as well give me half a milligram of Tylenol PM."
"Slow down," John said. "Listen. Something else I could give you for sleep is a barbiturate, a few secobarbitals. Seconal, an older drug. That should get you back to sleeping. But you can't take more than the prescribed amount. What I'm thinking is we get you on Seconal for a few days, get you some relief, then put you back on a reasonable amount of Halcion. Or maybe temazepam, Restoril, which is chemically similar to Halcion. Restoril may work better for you. What I'll do is I'll give you a prescription for three Seconals. Take one of those for the next three nights, get your internal clock straightened out. Then we'll get you on a fairly potent dose of temazepam. Thirty milligrams, say. But please don't take more than that. If you feel thirty isn't working, you're going to need to come back in here and we'll figure something out. Remind me what other medications you're on?"
"Prozac, Wellbutrin and Xanax," Evan said.
"Prozac, Wellbutrin and Xanax," John said. "And what are your dosages on those? Let's see."
"I'm on forty milligrams of Prozac but I've been feeling a bit down and I'm wondering if we shouldn't increase that to sixty," Evan said. "Or eighty. I'm on four hundred and fifty milligrams of Wellbutrin and I feel like that's perfect. I'm not really experiencing any side effects with the Prozac, as far as I can tell, so I do think I'm ready to move up with that one. And then we've got me on four point five milligrams of Xanax, one point five three times a day, and I definitely feel like I'm ready to double that, maybe triple it. Because it's really helping me, Doc. Although I'm still getting pretty antsy from time to time."
"I'll increase the Prozac to sixty and we'll see how that goes," John said. "I can go up to nine milligrams on the Xanax. But I really don't want to go any higher than that."
"You know, I think I'd be fine with eighty on Prozac," Evan said. "I think eighty might be my magic number."
"We can go to eighty," John said. "But I want you to check in with me and let me know how it's going. I also want you to let me know how the transition from the Seconal to the Restoril goes. If you're having trouble with it, you can complement the Restoril with one to three milligrams of Xanax. No more than that, though. But please give the Restoril a chance to work on its own."
"This sounds good," Evan said. "This sounds really good. I think we're on the cusp of discovering the perfect combination of drugs, the perfect combination of medications. When do you want to see me next? In a month, let's say?"
"Let's say if I'm even going to survive another day then I'm going to need way more Xanax," Evan said.
"More Xanax," John said.
"The Seconal was working great," Evan said. "But then."
"Hold on," John said. "Let me take a look at your chart. We had you on Seconal. Why did we have you on Seconal? Did I put you on Seconal?"
"Of course you did," Evan said. "You're my doctor."
"Let me take a look at," John said.
"Aren't you?" Evan said.
"Just hold on and let me," John said. "Prozac, Wellbutrin, Xanax, Seconal, Halcion, Restoril. Remind me, who's your psychiatrist?"
"What?" Evan said. "You're my psychiatrist."
"No," John said. "I'm a primary care physician. You need to be seeing a psychiatrist. You're on quite a few drugs, quite a few medications, and you need to see someone to help you manage them."
"Isn't that what you're for?" Evan said. "If you're not for that, what are you for?"
"No, look," John said. "I can get you started on these things, but you're going to need someone to help monitor your dosages. That's what a psychiatrist is for."
"OK," Evan said. "Do you know any good. Can you recommend any good psychiatrists?"
"Absolutely," John said. "Dr. Holloway's good. I can have Darlene schedule an appointment for you."
"Fine," Evan said. "But here's where I'm at today. I'm completely out of Xanax. I had a really hard time switching from the Seconal to the Restoril, so I added a little Xanax to the mix, like you suggested, and before I knew it I was having to take three Xanax, in addition to the Restoril, just to fall asleep. That cleaned out my Xanax supply. So I'm going to need more Xanax, like, now. Right this minute. Definitely today. The Prozac is wonderful. I feel terrific about the Prozac. The Wellbutrin is fine. I think we've finally landed on the combination that's right for me. With the exception of the Xanax. As long as I can get a shit ton more Xanax, I'm pretty sure everything's going to be perfect."
"OK," John said. "Let's take a look here. I have you on point two five milligrams of Xanax three times a day, correct?"
"Point two five," Evan said. "What? No. Three. Do they even make it in point two five?"
"I see," John said. "The highest I can go with Xanax is ninety at three milligrams."
"Ninety," Evan said. "Ninety? Ninety would be. Ninety would be fantastic. I didn't realize you could. Ninety per day would be wonderful. Thank you. Thank you so much."
"Not ninety per day," John said. "Ninety per month. Three pills per day for thirty days."
"No," Evan said. "That's crazy. That's not going to work. I need to take at least three, in addition to the Restoril, just to fall asleep. Three per day won't leave me any for my regular life, you know? For the things that happen to me when I'm awake."
"How much Restoril are you taking?" John said.
"Thirty milligrams," Evan said. "Look, everything else is great. The Prozac, the Wellbutrin, the Restoril. All I need is to get the Xanax squared away and then my life will be perfect."
"Taking nine milligrams of Xanax and thirty milligrams of Restoril at the same time is really pushing it," John said. "How old are you? You're nineteen. Do you drink alcohol?"
"Not really," Evan said. "Why? Should I start?"
"For heaven's sake, no," John said. "Look, I suppose we could add some clonazepam into the mix to get you through the day. Klonopin. You can take a quarter milligram four times daily. But you need to go and see Dr. Holloway in order to get all of these dosages straightened out."
"Quarter milligram four times daily," Evan said. "But that's only one milligram."
"Between the temazepam, the alprazolam and the clonazepam, you're putting quite a bit of benzodiazepine into your system," John said. "At some point you're going to develop a dependency on these medications. We need to be careful here."
"How about this," Evan said. "I'll start on one milligram of the new thing and after a day or two if it's not enough I'll call you up let you know and you can call the pharmacy and tell them to give me more."
"We'll see," John said. "I want you to try this, though. I want you to give it a real try."
"OK, I'll give a try," Evan said. "I'll give it the old college try. I'm in college now, you know."
"Are you?" John said. "Gosh, I remember your mom bringing you in here when you were just a little guy."
"I'm all grown up now," Evan said.
"I guess so," John said. "OK, I'll have Darlene schedule you an appointment with Dr. Holloway. Sound good?"
"Honestly, I don't think it's necessary," Evan said. "But if you think it's for the best, sure."
"Honestly, I don't think it's a problem," Evan said. "It's a solution. I just need to find the combination of medications that's right for me."
"You're obviously a smart kid," Richard said. "Surely you can see that taking this many medications is excessive. Prozac, Wellbutrin, Xanax, Restoril, Klonopin. These are not vitamins. They are habit-forming psychopharmaceuticals. The benzodiazepines are especially pernicious."
"But they're helping me," Evan said.
"They're helping you to do what?" Richard said.
"You know," Evan said. "To live my life."
"Why do you need help living your life?" Richard said. "You told me yourself you don't believe you suffer from depression or anxiety."
"I didn't suffer from them at first," Evan said. "The pills are what gave me depression and anxiety."
"Then don't you think it would be a good idea to get off the pills?" Richard said.
"I can't," Evan said. "As soon as I stop taking them, my anxiety goes haywire."
"What do you mean by your anxiety, exactly?" Richard said.
"You know, my anxiety," Evan said. "My freaking out. Like when I stop taking Xanax. I'm a total nutcase. My whole body starts, like, revolting."
"I don't know if that's bona fide anxiety so much as it is symptoms associated with the cessation of ingesting alprazolam," Richard said.
"What do you mean?" Evan said.
"One of the most common symptoms of benzodiazepine withdrawal is anxiety," Richard said. "It's not necessarily that you have an underlying condition called anxiety that Xanax is treating. You've become dependent on Xanax, and when you stop taking it, the withdrawal results in a symptom that you're calling anxiety. Why did you started taking Xanax in the first place?"
"To reduce the side effects from Wellbutrin," Evan said.
"And why did you start taking Wellbutrin?" Richard said.
"To reduce the side effects from Prozac," Evan said.
"And why did you start taking Prozac?" Richard said.
"I don't know," Evan said. "It was a long time ago. I think it was because my girlfriend dumped me. In high school."
"Here's what I think we should do," Richard said. "Since you've just started on Klonopin, let's try tapering you off of that one first. Why don't we start by reducing your daily intake by a quarter milligram."
"I don't know," Evan said. "I was actually hoping to get my Klonopin increased. Like maybe to two milligrams per day? Somewhere in that ballpark? Maybe two point five? The Klonopin seems to really be helping."
"May I ask you a question?" Richard said.
"Sure," Evan said.
"Do you have any interest in getting off these things?" Richard said. "Or do you feel fine continuing to increase your drug intake indefinitely?"
"I'm just trying to find the right combination," Evan said. "We need to keep experimenting with different combinations of drugs, different combinations of medications, until we find the one that works best for me."
"I don't think I'm going to be able to go along with you on this," Richard said. "I think what you need to do is start working to get off some of these drugs. I'm perfectly willing to help you do that, but I won't enable your dependency by continuing to increase your dosages."
"I'm not sure that's quite what I'm looking for here," Evan said. "I'm going to need to think about it."
"OK," Richard said.
"Can I get back to you?" Evan said. "Give you a call?"
"You can call me any time," Richard said. "Thanks for coming in."
"It's been a real pleasure," Evan said. "Thanks, Doc."
"It's been a total fucking nightmare," Evan said. "I need more Klonopin. Like we discussed. You said when I came back you'd put me on two point five, no. On three milligrams per day."
"I don't remember saying that," John said.
"You've always been kind of forgetful about these things," Evan said. "I think we can agree on that, wouldn't you say?"
"I very clearly remember saying you should go see Dr. Holloway," John said.
"That's the thing," Evan said. "I did go see him, but it didn't go well. We just didn't, you know. Hit it off. It happens."
"I'm sorry to hear that," John said.
"It's too bad," Evan said. "He seemed like a good guy. But I couldn't get him to understand the situation with my medications. That's why I came back to you. I just need more Klonopin, Doc. I finally feel like we're on the cusp of discovering the perfect drug combo for me. It's been a long time now of the two of us trying out all these different combos. All I need is more Klonopin and then I'll stay on this combo forever, I promise. Deal?"
"Unfortunately, I don't think I'm going to be able to do that for you," John said. "I'm afraid I can no longer prescribe these medications to you."
"But you're the one who put me on this stuff," Evan said. "And now you're going to just, what. Cut me off? I'm going to be a basket case. Didn't you take that oath about not hurting people on purpose?"
"I'm sorry," John said. "But this is the way it's going to have to be. If you need help, Dr. Holloway is perfectly willing to provide it. I've already spoken to him about your situation."
"Why would you," Evan said. "Hold on. Are you breaking up with me? Is that what this is?"
"Of course not," John said. "I'm still happy to remain your primary care physician. But you'll be seeing Dr. Holloway for your mental health care needs from here on out. His specialty is treating people with chemical dependence."
"My mental health care needs?" Evan said. "Why do you have to say it like that?"
"Listen," John said. "This is for the best. Why don't I have Darlene schedule you another appointment with Dr. Holloway. He's an excellent doctor. Will you give it another try?"
"I don't see what other option I have at this point," Evan said. "But just to go on the record, I want to say that this whole situation seems like, I don't know, total horseshit. You're the one who forced me to take all these drugs and now you're telling me you can't help me when I run into a bit of trouble with them. I thought we had something good going between us, you know? I trusted you. How could you do this to me?"
"Look," John said. "I'm sorry. But Dr. Holloway is."
"I just can't even," Evan said.
"I'm sorry," John said. "I really am. But look. Evan. Evan. Please."
"What a fucking prick," Evan said.
"What a fucking hellish existence," Evan said.
"Could you be more specific?" Richard said.
"No," Evan said. "It's a fucking hellish existence. That's what it is. And I know why. Because I've been rationing my Klonopin."
"Tapering it," Richard said.
"Tapering, rationing," Evan said. "Whatever."
"I'm very glad to hear you're on board with this," Richard said.
"I'm not on board with it," Evan said. "I'm opposed to it. I'm only doing it because you aren't giving me a choice."
"You can do this," Richard said. "I know you can. Let's take it one day at a time."
"And how are we feeling today?" Richard said.
"Horrible," Evan said. "Why are you making me do this?"
"Because this is the best thing for you," Richard said. "It isn't going to be easy, but you're going to be much better off in the long run. Trust me."
"I'm one hundred percent certain I'm not going to be able to go through with this," Evan said. "I don't want to do it."
"So what are you going to do instead?" Richard said.
"I don't know," Evan said. "Go to Campus Health or something."
"Do you think that would work?" Richard said.
"Maybe," Evan said.
"And give up on the progress you've already made?" Richard said.
"Maybe," Evan said.
"I don't think that would be wise," Richard said. "Let's see if we can keep going a bit further with this, OK?"
"And how are we feeling today?" Richard said.
"I'm scared," Evan said. "I'm really scared. I'm freaking out, man."
"What are you scared of?" Richard said.
"I don't know if I can do this," Evan said. "I can tell my body is not happy about this. I'm really fucking scared, Doc."
"You're scared of failure?" Richard said.
"No, I'm scared of dying," Evan said. "I'm not sure my brain and my body can handle this, you know? All I think about is Xanax, all day long. Sometimes I feel like my head won't be able to physically contain that many thoughts about Xanax. Like I'm going to have one last thought about Xanax and that'll be it."
"Have you given any more thought to your idea about going to Campus Health?" Richard said.
"I walk by every Tuesday and Thursday," Evan said. "Haven't gone yet."
"That's good," Richard said. "We've got a good thing going here. I'd really like you to try to see this process all the way to the end. You're already off Klonopin and you're down to less than half of your original dosage of Xanax. You're doing incredibly well. Let's keep going with this for a while. Don't you think that would be for the best?"
"No," Evan said. "I think it would be for the worse."
"No," Evan said. "It's the worst it's ever been. I'm tired, I'm depressed. I'm freaking out. You name it. Much worse than last time."
"I'm sorry to hear that," Richard said. "Tell me what's going on. What withdrawal symptoms are you experiencing?"
"Visual and auditory hallucinations," Evan said. "Everything in my apartment smells like either shit or vomit. I must be moodier than anyone has ever been in the history of the world. I can't imagine someone being moodier than this. It wouldn't make sense. That person wouldn't be considered a single person. My skin feels like it's vibrating all day long. My teeth and gums are always achy. Too many things to list. Terrible nausea. Real bad IAS. That's what I've been calling my itchy anus syndrome for short. Can't eat. Can't sleep. Don't want to be around people. Don't want to not be around people. Pretty much every possible shitty side effect you can imagine. Can barely poo. Not going to classes. My joints make funny sounds when I move. My nightmares are like the most disturbing horror films ever made. A new vision of the most torturous death imaginable reveals itself to me every night. My fingernails look so weird even though I know they're not. I just feel like shit, you know?"
"I feel like shit," Evan said.
"I feel like if shit took a shit," Evan said. "I feel like shit squared."
"Extremely unwell," Evan said. "Sort of teetering on the edge of nearly suicidal. Nearly nearly suicidal."
"Verging on suicidal," Evan said. "But more on the verge's verge, I'd say, than on the actual verge."
"OK," Richard said. "I suppose we can work with that."
"And how are we feeling today?" Richard said.
"Not so good," Evan said.
"You're off the Xanax completely," Richard said. "I'm proud of you. Shall we try tapering the Restoril next?"
"I guess," Evan said. "We've come this far, so, you know. Fuck it."
"You've come a long way," Richard said. "Let's keep taking it one day at a time."
"And how are we feeling today?" Richard said.
"Rather not talk," Evan said. "I'm going to sit here in silence and then I'll see your secretary about my co-pay."
"This couch," Evan said. "This ugly fucking couch. I hate this couch so much. Your couch makes regular appearances in my nightmares, did you know that?"
"My mouth is all gums," Evan said. "My whole face. I'm pure gums now. A pair of gums on legs."
"A seventeen-year-old in San Diego broke the sleep deprivation record in nineteen sixty-four," Evan said. "He did it as an experiment for his high school science fair. It was the most well documented voluntary sleep deprivation experiment in history. Scientists got wind of it and showed up to monitor him. Until then there hadn't been many closely monitored sleep deprivation experiments. The few that were done were performed on animals. Some nineteenth-century Russian scientist tried to keep a litter of puppies awake for four days and they all died. A woman in England nearly doubled the San Diego high schooler's record during a rocking-chair marathon in nineteen seventy-seven. She rocked for eighteen days. Guinness stopped keeping the record back in the sixties out of fear that people trying to break the record would end up like those Russian puppies."
"I'm tired," Evan said.
"I'm tired even when I'm sleeping," Evan said.
"I'm really tired," Evan said.
"I'm so, so tired," Evan said.
"I'm tired of this," Evan said.
"You're off the Restoril completely now," Richard said.
"I am," Evan said.
"That's excellent news," Richard said. "I'm proud of you."
"Thanks," Evan said.
"Do you want to talk about the Prozac and the Wellbutrin?" Richard said.
"I think it's time for me to get off them," Evan said. "I think it's time for me to get off everything."
"I'm so glad to hear you say that," Richard said. "The good news is getting off Wellbutrin and Prozac is far easier than getting off benzodiazepines and sleep meds. Not even the same ballpark."
"Great," Evan said.
"Why don't we start with the Wellbutrin," Richard said. "Right now you're on four hundred and fifty milligrams a day. Let's cut it back to three hundred for a couple weeks and go from there."
"Let's give it a shot," Evan said.
"You're doing great," Richard said. "Everything is going to be OK. Let's take it one day at a time. All you have to do is get through today."
"And how are we feeling today?" Richard said.
"I don't know," Evan said. "A little blue, maybe."
"Any side effects associated with coming off the Wellbutrin?" Richard said.
"Drinking lots of coffee," Evan said. "Smoking tons of cigarettes."
"That's not ideal, but we can work with it," Richard said. "Anything else?"
"Bit of trouble in the penis department," Evan said. "My penis is only good for peeing now."
"That's not uncommon," Richard said. "It's the Prozac. You were taking the Wellbutrin to offset the side effects from the Prozac. And the primary side effect was erectile dysfunction, correct?"
"Correct," Evan said.
"So it makes sense that the ED would return," Richard said. "It's been two weeks. Why don't we go down a bit more on the Wellbutrin, to one hundred and fifty milligrams per day and we'll see how that goes."
"OK," Evan said.
"Try to be careful with the caffeine and the nicotine," Richard said.
"OK," Evan said.
"OK," Evan said.
"Glad to hear it," Richard said. "Any further side effects associated with coming off the Wellbutrin?"
"There's still the issue with the caffeine and the nicotine," Evan said. "I drink coffee nonstop all day long. And smoke two, no. Two and a half packs of cigarettes."
"Two and a half packs," Richard said.
"Maybe three," Evan said.
"That's a lot," Richard said. "But we can worry about that later. What about the erectile dysfunction?"
"Still more or less completely dysfunctional," Evan said.
"Still more or less drinking coffee and smoking cigarettes from the moment I wake up until the moment my head hits the pillow," Evan said. "But you'll be happy to know I've kicked Wellbutrin to the curb."
"Congratulations," Richard said. "Are you ready to hit the Prozac?"
"As ready as I'll ever be," Evan said.
"As bad as it's ever been," Evan said. "I'm getting these, like, shocks in my head. Right here. They hurt so much."
"Not uncommon with SSRI withdrawal," Richard said. "People call them the brain zaps."
"That's right," Evan said. "It's a zap. In my brain."
"Do they tend to happen at a certain time of day," Richard said. "Does something seem to bring them on, or do they seem to happen at random?"
"Don't know, haven't," Evan said. "Jesus fucking ouch. Thought about it."
"From now on, when they happen, why don't you try to write down the time of day and isolate any specific activity you're doing," Richard said. "We'll call it your brain zap diary. Let's keep you on sixty milligrams for another couple weeks and see if they don't subside a bit. Then maybe we'll try going down to forty."
"And how are we feeling today?" Richard said.
"Hard to say," Evan said. "I've been trying not to feel anything."
"How are the brain zaps?" Richard said. "Any better?"
"I don't know," Evan said.
"Have you been keeping up with your brain zap diary?" Richard said.
"Here," Evan said.
"Wow," Richard said. "That's impressive. This covers only two weeks' time?"
"You'll be happy to know I've isolated the trigger," Evan said. "I've narrowed it down to two possibilities, anyway."
"Wonderful," Richard said. "What are they?"
"The first is the inhalation of," Evan said. "Jesus H. ouch. The second is the exhalation of God fucking damn it."
"God fucking damn it," Evan said.
"The brain zaps, I take it," Richard said. "You think you can hold out for a few more weeks?"
"I do," Evan said. "Because I have a routine now. I wake up at the same time every day, wear the same clothes, eat the same foods, go to the same oh my God please no. Places. I'm working to eliminate all choices from my life. That way I can focus every last ounce of my creative energy on sparring with the zaps."
"So you think you're ready to go all the way?" Richard said.
"And how are we feeling today?" Richard said.
"And how are we feeling today?" Richard said.
"And how are we feeling today?" Richard said.
"Pretty good," Evan said.
"Good," Evan said.
"Really good," Evan said.
"Great," Evan said.
"That's great," Richard said. "It's been, what, a year in the coming? I'm proud of you. And I'm impressed. I've got to say, when you first came in here, I had you pegged for rehab. I didn't think you'd be able to pull this off on your own. How does it feel?"
"It feels good, Doc," Evan said. "It feels really good."
"Not so good, Doc, not so good," Evan said. "I'm really, I don't know, anxious. Maybe it's my classes, final exams coming and all. I'm so jittery all the time. Having trouble being around people. Lots of trouble sleeping. Is there something I can take for that? I had a doctor who put me on something back in high school. I was having these panic attacks. I think it was something that started with a Z? I can't quite remember."
"It was probably Xanax," Elliot said.
"Yeah, that's it," Evan said. "Xanax. With an X."
"Do you remember how much you were on?" Elliot said.
"Five millisomethings, maybe?" Evan said.
"It was probably point five milligrams," Elliot said. "Here. This is for half a milligram, three times daily. You can get it filled at the pharmacy downstairs. I'll need you back here in two weeks for a follow-up. We'll schedule you for the Thursday after next. I'm going to be out of town that week. You'll probably see Dr. Reynolds. She'll have your chart and see my notes."
"Dr. Reynolds," Evan said. "Got it. Thanks so much, Doc. I can't tell you how much I appreciate this. You're a lifesaver."
"That's the idea," Elliot said.
"Right," Evan said. "Thanks again. I'll be back in two weeks."
"Thank you, Doctor," Evan said. "I thank you from the bottom of my heart. I'll see you in a month."
"So I'll check back in two months," Evan said.
"Thanks for understanding," Evan said. "And thanks for all your help. Two months from today."
"Three months," Evan said. "Thank you. This is going to help so much."
"Excellent," Evan said. "I'll see you in three months. To reevaluate."
"You're the tops, Doc," Evan said. "Early May. Right before graduation. We'll reevaluate."
"But if I'm not allowed to come in here anymore, where am I supposed to go for help?" Evan said.
"Help me out," Evan said. "Please, I'm begging you. Is there anything else I could do? I mean, something besides the money? Like something I could do for you personally?"
"I don't know," Evan said. "I haven't been to a doctor in a while. I can't remember exactly."
"I haven't been to the doctor in a long time," Evan said. "I can't remember. I think it was a pretty high dosage, though."
"Help me out with a point," Evan said. "Just one. I'm begging you. Anything you want. I just need your help."
"I need your help," Evan said.
"I need your help," Evan said.
"I think it started with a Z," Evan said. "Or maybe an X? Like the X in xylophone?"
"I think I need help," Evan said.
"I think I got dumped or got a C on a test or something," Evan said. "This was way back in high school. I thought it was the end of the world. Honestly, I don't remember the beginning very well. I went to my doctor. A really nice guy. I remember that. He didn't have the best memory. Maybe he was overworked. I kept going back to him and back to him and he'd give me pretty much anything I wanted. I'm not blaming him. I'm definitely not blaming him. But he did make getting stuff easier than it probably should have been."
"Getting on one thing, trying to get off that thing," Evan said. "Getting on another thing to help with withdrawal from the first thing. Trying to get off the second thing. I spent years piling drugs on top of other drugs. Then I spent years trying to make the pile smaller. As soon as I'd finally gotten off everything, after I'd done all that work, I'd start in on my next pile. The way I finally came to think of it was I had all the individual dependencies, all the drug-specific addictions, the anti-depressants, the sleeping meds, the anti-anxiety meds, and later the harder stuff, but I also had the dependency associated with the whole process. I think that's what we really mean when we introduce ourselves in here. I don't say my name and give you a laundry list of the things I've been hooked on. My problem is way bigger than with any one or two or ten drugs. My problem is I'm hooked on being hooked on things."
"Hello, my name is Evan," Evan said.
"And I don't see how I'm going to get better without something," Evan said. "Doc, she's threatening to call off the marriage."
"Hello, my name is Evan," Evan said.
"And if I ever come in here asking you to prescribe me anything in the least way prone to dependency, don't give it to me," Evan said.
"Hello, my name is Evan," Evan said.
"My anxiety," Evan said. "My depression. But the last time I took anything for it was way back in high school. I guess I'm here because I think it's time for me to start taking care of myself again. It's time for me to get back on something. I need to start thinking about myself again. I need some relief."
"Hello, my name is Evan," Evan said.
"And that's when I finally decided to switch up the order," Evan said. "Because I'm not even really a person. Not in the first place, anyway."
"Not in the first place," Evan said. "That's what I have to keep telling myself. That's how I finally wrapped my head around all of this."
"I finally wrapped my head around it by switching up the order of the way I thought about myself," Evan said. "That's why I say it the way I do now. The addict part comes first. I say the addict part, and then I say the name part. The name part isn't important. The name part is arbitrary. Because I'm not defined by me, by what I think of as me. Not anymore. Maybe way back when that was the most important thing, but now it's practically an afterthought. These days I know that the whole process of me is just a byproduct of processes that having nothing to do with what I think of as me. It's a small thing, but it seems to be helping. Maybe more than anything else I've tried."
"I'm an addict named Evan," Evan said. "Hello."