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PostPosted: Sat Dec 10, 2011 9:45 pm 
Lassoed one today...

Patient was a "slippery" 20 yr old young lady addicted to prescription meds but spiraling into heroin.
Legal problems, STDs, and increasing medical issues all exacerbated by substance use.
Involved and concerned family had tried everything they coiuld and was at "wits end."

She was referred to me by a good friend who owns a treatment center.

She has been scheduled for induction 4 times... but was either not in withdrawal/acutely intoxicated or simply did not show up.

So today... [between inducing a patient and debating with folks on here and doing my taxes]

I go down the street to pick up some lunch and as I go through a underpass I look over and see her panhandling.
I pull over and tell her to get in the car.
She gets in and I call her CDP... inform her that I "had secured the package" and ask her to meet me at my practice.

I knew that I needed to get her "hooked" on suboxone if we were gonna save her young life.
She was high... but I knew that after 4 missed opportunities... it was "now or never."

So...
I had my daughter run down the street to pick up a few 25mg tabs of naltrexone from the pharmacy that I called in.
Then while the CDP talked to her... I dosed her with 25mg of naltrexone every thirty mins until she was in moderate withdrawal (about 1.5hrs later).

She looked and felt like shit... and I let her feel that way for another 20-30mins.

Then we started with the Suboxone... and I watched her "transform." 8)

She left the clinic ... with her family... after a total of 4 hrs ... comfortable and on 14mgs of Suboxone.

I'll see her for follow up on thursday. Sooner if she needs it.

Moral of the story:
I lecture my students on the need to "grow from Rote to Reasoned" daily.
Tossing pills at people and or simply doing scripted things doesn't suffice.
A thorough under/over standing of anatomy, physiology, and addiction psychopharmacology is required to provide "gold standard" care.

Today was a good day...!!!
:D


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PostPosted: Sun Dec 11, 2011 12:51 am 
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docnusum wrote:
Lassoed one today...

Patient was a "slippery" 20 yr old young lady addicted to prescription meds but spiraling into heroin.
Legal problems, STDs, and increasing medical issues all exacerbated by substance use.
Involved and concerned family had tried everything they coiuld and was at "wits end."

She was referred to me by a good friend who owns a treatment center.

She has been scheduled for induction 4 times... but was either not in withdrawal/acutely intoxicated or simply did not show up.

So today... [between inducing a patient and debating with folks on here and doing my taxes]

I go down the street to pick up some lunch and as I go through a underpass I look over and see her panhandling.
I pull over and tell her to get in the car.
She gets in and I call her CDP... inform her that I "had secured the package" and ask her to meet me at my practice.

I knew that I needed to get her "hooked" on suboxone if we were gonna save her young life.
She was high... but I knew that after 4 missed opportunities... it was "now or never."

So...
I had my daughter run down the street to pick up a few 25mg tabs of naltrexone from the pharmacy that I called in.
Then while the CDP talked to her... I dosed her with 25mg of naltrexone every thirty mins until she was in moderate withdrawal (about 1.5hrs later).

She looked and felt like shit... and I let her feel that way for another 20-30mins.

Then we started with the Suboxone... and I watched her "transform." 8)

She left the clinic ... with her family... after a total of 4 hrs ... comfortable and on 14mgs of Suboxone.

I'll see her for follow up on thursday. Sooner if she needs it.

Moral of the story:
I lecture my students on the need to "grow from Rote to Reasoned" daily.
Tossing pills at people and or simply doing scripted things doesn't suffice.
A thorough under/over standing of anatomy, physiology, and addiction psychopharmacology is required to provide "gold standard" care.

Today was a good day...!!!



DEAR DOC: Please don't be offended by what I am going to say , but something you said in your post worried me for you.

I am an R.N with B.S. degree in Nursing (minor in psy/soci), a Master's degree in Nursing and a M.S. degree in Education.
I worked for 36 years in Nursing with the last 20 teaching High School and doing School Nursing. I say all that to say this:
Since I worked in the medical field as well, I understand what you do but you should have NEVER TOLD THAT GIRL TO GET IN YOUR CAR! Once she is in the car it's just you and her and she could say anything about you...such as you touched her..you know the deal. She is already unstable and could have accused you of anything. It's your word against hers, meanwhile it ruins you!! I never took a student home without someone else in the car with me for this very reason.

You will not believe how quickly parents can change and believe anything their little darling says and are ready to ruin you and go to court. We had this happen to a teacher in our school system and he lost his teaching certificate and his reputation and was not guilty of anything. The kid was a nut case always causing trouble and the family jumped right in.

Just so you know.............Judy










:D


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PostPosted: Sun Dec 11, 2011 1:00 am 
Thanks Slipper...

Oh... I know that I should have never put her in the car.. as it has been a rule of mine for decades.
As a general rule... I don't put addicts in my car. Why...?
Because if we get pulled over by the cops... and they are dirty... whats to stop them from dropping their works, tools, etc. under my seat...?? And if its found by the police... I KNOW the drill. Nobody says shit (accepts reponsibility) until 13 months later in court.... :roll:

So yeah... I know.
It was impulsive and out of character... but it worked.

Thanks for your wisdom and concern...


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PostPosted: Sun Dec 11, 2011 2:02 am 
Doc-

As someone else pointed out, it's scary to think of all the possible "what ifs" that could have happened here by picking up a young female active addict and driving them to your clinic to induct them...Thankfully, it sounds like it turned out well for the people involved. Bottom line, it sounds like reckless behavior but *I* can't help but feel impressed by it!

My question in this scenario is why did you administer Naltrexone rather than just allowing Suboxone to cause precipitated withdrawal by utilizing its natural potent partial-agonist properties? I can see that you would want a client to perceive Suboxone as an agent that alleviates withdrawals brought on by another agent rather than one that causes initial misery/withdrawal on it's own. I know very well that even the slightest discomfort could leave a bad taste in an active addicts mouth and thus give them an easy "out" or excuse to not further explore Suboxone (especially since from the history you've listed, they don't seem all too interested in prioritizing induction on her own..)....Just curious your reasoning was at the time for administering Naltrexone.

-Travis


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PostPosted: Sun Dec 11, 2011 3:33 am 
Travis...
I jumped from moving aircraft with a pack and rifle for 8 yrs.
I provide general medical care and some addiction medicine for homicidal psychotic psych patients in the mornings...
I provide general medical care and some addiction medicine for "crisis respite" patients in the afternoons and evenings
I provide general medical care and some addiction medicine for "social/community detox patients in the evenings.
Those are just my day jobs.

Prior to this I volunteered to deploy to Iraq and then later Afghastan and Darfur.
Taking calculated "risks" periodically seems to be part of who I am.

Yeah it was a moment of spontaneous, calculated reckless behavior that should be avoided, but the reality is, I take calculated risks all the time in my pursuit of the practice of medicine.

For clarity... I had interacted with her family extensively over the last 2 months, know and have worked with the mother professionally (nurse) and was compelled to act. Also, I was literally 2 blocks from my clinic and had we been on the other side of the street, we could have seen the door to my clinic. I had her "get in the car" because I wasn't sure if she would simply walk down the street if I had told her to... or disappear again for a few weeks. It was almost instinctual as if I as talking to my daughter and in retrospect... I don't remember much of itprior to us walking into my clinic and tellling my daughter to get the emesis basins and get the pharmacy on the phone.

As for my naltrexone rational...

I used it because its predictable. I can pretty much titrate the dose as needed to get a patient where I want them... when I want them there.

Not so with simply giving them Buprenorphine and waiting for them to get sick. Then I'm stuck in the situation where the patient is sick from bupe... but I'm trying to figure out how much more bupe to give them... Or if they have had too much bupe. When according to published protocol... I should only be giving up to 8mg on day 1 of induction anyway.

The theory is that the naltrexone is displacing the opiates from the receptor sites and then the Buprenorphine displaces the naltrexone.

And you "hit the nail on the head" with the whole perceptual thing about not getting them sick on the drug you are trying to get them treated with. "White pill made you sick... Orange Pill made you well"... :wink:

YMMV


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PostPosted: Sun Dec 11, 2011 3:55 am 
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docnusum wrote:
So...
I had my daughter run down the street to pick up a few 25mg tabs of naltrexone from the pharmacy that I called in.
Then while the CDP talked to her... I dosed her with 25mg of naltrexone every thirty mins until she was in moderate withdrawal (about 1.5hrs later).


Dosing an unwilling patient, still under the influence of an agonist, with naltrexone, is grossly negligent docNusum. And choosing naltrexone? Sadistic.

Have you ever had to endure the pain of precipitated withdrawal?

Inducing precipitated withdrawal with Naltrexone is STUPID, plain stupid. People have been known to die in rapid detox. I guess you believed you could kick the agonist off with naltrexone, then calmly induced her on buprenorphine? You could have induced a MUCH lesser degree of precipitated withdrawal by placing her first on Subutex, then Suboxone.

Even still, why would you use naltrexone with its unnecessarily long half life? Why not just use Naloxone?

Naltrexone boots the agonist straight off all the receptors with ZERO agonist effect to relieve the precipitated withdrawal. If you induced direct onto buprenorphine, her withdrawal symptoms would have still been significant, but less. Precipitated withdrawal direct onto Suboxone rarely extends past an hours.

And inflicting unnecessary pain on a patient, just for some kind of "mind fuck".

If what you say is correct, and you actually did this, and are not trying to stir up our community here. Practices like this could have your license revoked. And by the way you've been carrying on, I'm sure some here would not hesitate to lag your arse in.

It's called sadism, DocNusum. And I tell you now, if you continue with this kind of stuff... your clinic isn't going to have a very long "half life" at all.

I'm forwarding this to Dr. J to get an opinion.


Last edited by tearj3rker on Sun Dec 11, 2011 4:21 am, edited 3 times in total.

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PostPosted: Sun Dec 11, 2011 3:56 am 
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docnusum wrote:
Then while the CDP talked to her... I dosed her with 25mg of naltrexone every thirty mins until she was in moderate withdrawal (about 1.5hrs later).

She looked and felt like shit... and I let her feel that way for another 20-30mins.

Then we started with the Suboxone... and I watched her "transform." 8)

She left the clinic ... with her family... after a total of 4 hrs ... comfortable and on 14mgs of Suboxone.


Sorry "doc", but I'm calling BS on this. From personal experience. I took 50 mg of naltrexone once, several years ago, about 7 hours after my last oxy dose. Within one hour I was in the worst withdrawal of my life. We're talking fetal position on the floor, shaking, throwing up, kill-me-now withdrawal. Knowing that sub has a slighter higher affinity for the mu receptor than naltrexone, I immediately started dosing subs along with some clonidine I had on hand. The severe wd's did not go away until later the next day, almost 24 hours after my naltrexone dose.

So, throwing 75 mg of naltrexone at this girl, while high on a short acting opiate, would have put her into severe withdrawal that sub could not have touched, certainly not in "20-30 minutes". Besides, don't real doctors take an oath to do no harm? What was the indication for naltrexone in this case? Short of an overdose, there isn't any!

But let's pretend this story is true. I'm sure the licensing board would be interested in hearing about it.

What is your real motivation for posting here?


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PostPosted: Sun Dec 11, 2011 11:56 am 
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Quote:
opioid antagonists (naloxone and naltrexone).

Buprenorphine has higher affinity for µ
opioid receptors than the opioid antagonists. In the event of overdose of buprenorphine,
very high doses of naloxone are required to reverse its effects (10-35 mg have been
reported). Naltrexone can precipitate a delayed withdrawal reaction in patients on
buprenorphine.



Quote:
Commencing naltrexone following buprenorphine maintenance treatment

There is limited experience in commencing naltrexone following the cessation of
maintenance buprenorphine treatment. The initiation of naltrexone must be delayed until
several days after the last dose of a full opioid agonist (generally 7 days after heroin use and
10 - 14 days after methadone use).
However, naltrexone can generally be initiated within
days of the last dose of buprenorphine. The following procedures are recommended.

- In circumstances where the last dose of buprenorphine was 2mg (or less) for at
least one week, naltrexone can be initiated 4 - 5 days after the last dose of
buprenorphine (providing there has been no heroin use in the previous 7 days).

- Where the last dose of buprenorphine was greater than 2 mg, and to reduce the
likelihood of precipitating withdrawal symptoms, the first dose of naltrexone can
be delayed until more than 7 days after the last buprenorphine dose. Buprenorphine Clinical Guidelines 33

- The initial dose of naltrexone (12.5 mg orally) should be administered in the
morning. The patient should be monitored for up to 3 hours after the first dose of
naltrexone for features of opioid withdrawal.


- Symptomatic withdrawal medication should be available for the patient to use in
the 12 hours after the first dose of naltrexone, including clonidine (up to 150 mg
3 - 4 hourly), benzodiazepines (eg diazepam up to 5 - 10 mg every 3 - 4 hours as
needed), metoclopramide, hyoscine butylbromide and NSAIDS.


- Subsequent doses of naltrexone can be 25 mg for a further 2 - 3 days and then 50
mg per day as usually recommended. Clinical guidelines regarding the use of
naltrexone should be consulted (Bell et al 1999).


Like Jimmy said, naltrexone certainly has some blockade effect on buprenorphine, even though it has less affinity!

http://www.health.vic.gov.au/dpu/downloads/bupguide.pdf


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PostPosted: Sun Dec 11, 2011 2:27 pm 
Ha...ha...

You "Pharmacologists" are hilarious.

Copying and Pasting isn't the same as actually knowing the pharmacodynamics and pharmacokinetics of a pharamaceutical agent.

People dying during the "rapid-detox" sequence isn't people dying from opiate withdrawal.

But hey... YOU are the "medical expert"... and KNOW all this stuff.

I'm just the guy who has never been an addict so couldn't possible understand.

Forgot to ask... Where exactly did YOU attend medical school and/or get your pharmaceutical degree...????

I await your esteemed and learned response...

Standing by.


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PostPosted: Sun Dec 11, 2011 3:39 pm 
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It amazes me how some people can turn shuch a great thread/story into a dick measuring over nonsense. This is were you ask the sub doc to chime in and let the true medical proffesionals speak.

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PostPosted: Sun Dec 11, 2011 5:42 pm 
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docnusum wrote:
Lassoed one today...

Patient was a "slippery" 20 yr old young lady addicted to prescription meds but spiraling into heroin.
Legal problems, STDs, and increasing medical issues all exacerbated by substance use.
Involved and concerned family had tried everything they coiuld and was at "wits end."

She was referred to me by a good friend who owns a treatment center.

She has been scheduled for induction 4 times... but was either not in withdrawal/acutely intoxicated or simply did not show up.

So today... [between inducing a patient and debating with folks on here and doing my taxes]

I go down the street to pick up some lunch and as I go through a underpass I look over and see her panhandling.
I pull over and tell her to get in the car.
She gets in and I call her CDP... inform her that I "had secured the package" and ask her to meet me at my practice.

I knew that I needed to get her "hooked" on suboxone if we were gonna save her young life.
She was high... but I knew that after 4 missed opportunities... it was "now or never."

So...
I had my daughter run down the street to pick up a few 25mg tabs of naltrexone from the pharmacy that I called in.
Then while the CDP talked to her... I dosed her with 25mg of naltrexone every thirty mins until she was in moderate withdrawal (about 1.5hrs later).

She looked and felt like shit... and I let her feel that way for another 20-30mins.

Then we started with the Suboxone... and I watched her "transform." 8)

She left the clinic ... with her family... after a total of 4 hrs ... comfortable and on 14mgs of Suboxone.

I'll see her for follow up on thursday. Sooner if she needs it.

Moral of the story:
I lecture my students on the need to "grow from Rote to Reasoned" daily.
Tossing pills at people and or simply doing scripted things doesn't suffice.
A thorough under/over standing of anatomy, physiology, and addiction psychopharmacology is required to provide "gold standard" care.

Today was a good day...!!!


Dear Mr. Nusum.

You have a Master's degree in Psychiatry. I have a Master's degree in Nursing. You also have your FNP/PA (Family Nurse Practioner/Physician Assisant license. I have a Master's degree in Education, three Teaching Certificates, and I forgot to mention in my last post to you that I also have MY PEDIACTRIC NURSE PRACTIONER'S LICENSE. I got my PNP back in 1974 at the University of Texas in Galveston, Texas.

I suppose it is real nice that I have all these degrees and I have listed them just for you because basically I am AN ADDICT, just like everyone else here on the forum. They don't give a damn about my education, or how many degrees I have. I don't have to list all of them every time I post. The people here on the forum had much rather help me with an addiction question or problem and they do and they are great at it. See the problem is YOU DON'T GET IT. It is not your fault...you are just not an addict. You WILL NEVER GET IT!

One more question. When you go into a patient's room do you introduce yourself as "Dr. Nusum?" I sincerely hope not.
I would hope you would say something like hi I'm Mr. Nusum, or just give them your first name. Also when I was doing PNP I had to have a doctor (M.D. or D.O.) over me somewhere to sign off on what I did. Yes I could work alone, write scripts, own my own building I guess If I wanted to....but somewhere in there had to be a doctor that I was responsible under. I don't understand how you can practice medicine without having some doctor somewhere sponsor you.

Maybe states are different, maybe times have changed. I didn' stay with the PNP too long because I had worked my ass of in hospitals and got the school nursing job in this small town we lived in and it was a snap. Of course my PNP helped me alot in that area but we had 1200 kids in the entire school system. I had a school car, phone and an office at each school so I could do pretty much what I wanted. Also I was off all summer, two weeks at Christmas, Thanksgiving, Spring Break....my God I could not believe i!!! I had 3 children and was off when they were off...went to work at 8am and was off at 3pm...what a job..and they paid me more than I ever made in the hospital.

Ok..kinda got off track there... guess my point is you want to be a doctor. You are not a doctor. You are a P/A. Don't confuse people...your patients need to know your true credentials. If you are for real I will say one thing...anyone who serves as a medic during wartime comes home knowing about as much as any doctor especially in the ER.

Sincerely,

Slipper









































































































:D


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 Post subject: Confused...
PostPosted: Sun Dec 11, 2011 7:54 pm 
Slipper...
You wrote, "A question for you"... but never asked me one... but only made statements.

To respond to a few statements:

1.) My patients all call me by my first name... I address them as Mr./Mrs./Ms.
2.) I'm NOT a addict... so no... I'm NOT like most on this forum
3.) As for whether I "get it"... hmm. So based upon YOUr logic... and carrying it to its conclusion:

A Interventional Cardiologist need to have had a MI and CAD and HTN to understand and effectively treat Heart Disease.
A Psychiatrist need to have had Schizophrenia/Be BiPolar/Anxious, Psychotic to understand and treat Psych disorders
A Brain surgeon (neurologist) need to have had a brain lesion/tumor to understand and effectively treat them.

Am I understanding you correctly...???

4.) I work with/collaborate with several physicians, the requirements vary from state to state and have changed considerably since 1974.
5.) My credentials are: on the door, on my jacket and ID tag that I wear, on the wall, and as required by law... prominently displayed in the entrance/lobby of my clinic. (if you look at the pics you will see this)
6.) I DO NOT "want to be doctor"... I had that option, but chose a dual FNP/PA program instead.
7.) I served as a medic during the first gulf war... got out of the military... then served as a Emergency Medicine PA provider in Iraq (3months) and Afghanistan (6months) in 2005... and Darfur/South Sudan 2006/20007 (18months)

Finally...
You have confused me.
First you castigate me for having my credentials in my signature.
Then you lecture me about making sure folks I'm dealing with know my credentials.


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PostPosted: Sun Dec 11, 2011 8:43 pm 
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(NOT A) Doc,
I am appalled at all most all of your posts, you come off as an egocentric asshole who feels he is better than the rest of us bc he is NOT an addict..and has an education. Well I too have an education, a masters in counseling, along with a variety of other degrees, and really, I am not impressed with yours. You own a building and run a clinic where your wife and daughter work. It really seems like you are more interested in making money and bragging about yourself than helping those of us struggling with an ugly disease. Aside from that, it sounds like what you did with that client seems unethical if not possibly illegal. You titled your post "I lassoed one" making it sound as if we are nothing more than cattle. I am very concerned that your posts will scare people away. I thought this was a forum to discuss openly the subjects of addiction, recovery, and suboxone in a nonjudgemental environment. With the way you belittle others that post, picking apart what they say in petty ways. ( your response to slipper "You never did ask me" a question. Just seems increadibly petty and belittling. People need to feel comfortable in this forum to share, no matter how they spell or word their posts, who cares????I really hope the monitors will take a look at your posts and realize how destructive someone like you can be to people who are fragile, in the first stages of recovery, trying to decide to use subs or not, and those one ther verge of relapse...let alone just how annoying you are to the rest of us. (yes, I know, as I am sure you will point out that I have just judged you after I said we should not do that, but then again, you are NOT like the rest of us, you are special)


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PostPosted: Sun Dec 11, 2011 9:15 pm 
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mrssky (and everyone else),

First, thank you for standing up to this bully.

Second, the mods have been looking into docnusum since the very begining. I can't go into details, but I'm happy to say that he has voluntarily left the forum and his account has been deleted, at his request.

As always, whenever you see a post that you think violates the rules (or the spirit) of the forum, please don't hesitate to PM a moderator.

Thanks!

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PostPosted: Sun Dec 11, 2011 10:06 pm 
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Thanks for the update DoaQ,

I've been trying to figure this doc nusum out from the very beginning. A few days ago, he replied to one of johnboys posts/replies in a most horrible way and I was shocked by this "doctors" behavior. I, for one, am glad he won't be back.

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PostPosted: Sun Dec 11, 2011 11:14 pm 
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It took a little while, but docNusum is no longer on this forum.


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 Post subject: treatment centre
PostPosted: Mon Dec 12, 2011 1:04 am 
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The friend that runs the treatment center, aint gonna be to pleased.
If that person who got in the car really exsist's, man, I feel for her.
Regardless, after all my years of belittlement I still can't understand those perception's.


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PostPosted: Mon Dec 12, 2011 1:57 am 
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This guy had certainly ruffled some feathers, mine included.

I could feel some anger every time I'm reminded of his name, but I honestly don't want to give him the rent-space in my head, if you know what I mean. I don't want to say much because he's not here to defend himself, but looking back on all his posts, consider the possibility that he might just be a very sick guy.


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PostPosted: Mon Dec 12, 2011 9:14 am 
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Tear,
I hadn't thought of it that way, but you may be right. Definately a Narrcissictic personality disorder. I probably could have said what I had to say in a bit nicer way. I can't imagine myself responding to someone who is actually struggling with addiction in that way. I just felt like he was really stepping over some lines. I'm glad he is gone and I really hope someone looks into what he claims he did with that client. As stated before Very unethical, and may border on illegal for a medical provider to do what he did.
SKY


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PostPosted: Mon Dec 12, 2011 9:35 am 
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i'm not that educated" but i welcome his first post" and said" how can we help you and what is your problem :lol:


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