Evolution Of A Solution
Introductory Notes for the Reader...
S.C.A.R.E., or Sickle Cell Advocates for Research and Empowerment, is an independent not-for-profit community based organization (run by members of the sickle cell community for the benefit of members of the sickle cell community), dedicated to improving the quality of life of persons with sickle cell disease by developing essential skills of advocacy in said population, toward the ultimate objectives of individual as well as community empowerment.
I am a thirty-two year old man with sickle cell disease, and I founded the organization in 1994 with my wife Deborah Oster Pannell as a vehicle of empowerment for the sickle cell community. As such, a key instrument of empowerment utilized by the organization is language. Hence, the creation of a distinctive lexicon from which the term sickle cell defier derives. S.C.A.R.E. uses this term as a means of identification for the individual with sickle cell disease, in lieu of such expressions as "sickle cell sufferer," "sickle cell victim," "sickler," and the like, because we perceive this to be a more proactive term that better captures that certain independence of spirit vital to a healthy and centered co-existence with the disease.
Another important point to note before reading commences is that the medical knowledge contained in the following pages was acquired as a direct consequence of my participation in the clinical research efforts of Dr. Lennette J. Benjamin, Co-Director of the Bronx Comprehensive Sickle Cell Center at Montefiore Medical Center in New York City. The focus of much of this research was on physical dependency in sickle cell disease, as well as the most effective ways to clinically address it. Therefore, any credit for the medical ideas and stratagem expressed in this paper is due to Dr. Benjamin for her innovative and revolutionary work in this arena of medical research.
First we must clearly define physical dependency so that we may endeavor to discover how it comes to be. It should be noted here that in my attempt to do this I have used my personal medical experience as a model for similar experiences shared by sickle cell defiers everywhere. It should also be made clear that I do not use my own experience as a reference because I believe it to be typical of all sickle cell defiers, (especially since sickle cell is a disease of great variability with diverse manifestations), but instead because I believe I understand these particular problems and their respective solutions best in the context of my own medical circumstance. Let us begin our analysis with a clear definition. What is physical dependency?
Physical Dependency - state of being where one is gradually conditioned to be physiologically reliant on one or more pharmacological substances often including but not exclusive to those used as or in medicine, e.g., narcotic analgesics. A pharmacological property of narcotic opioids.
How does physical dependency manifest in sickle cell disease?
When a defier receives narcotic analgesics on a regular basis for his chronic pain, almost immediately his physiology will undergo a subtle modification. It is altered in such a way that the body actually begins to rely upon and even require the sustained chemical presence of the analgesic or analgesics in its system. If the use of these medications is suddenly terminated by the physician, the defier will instantly be thrown into a state of narcotic withdrawal.
What is narcotic withdrawal?
Narcotic Withdrawal - a reactive state of somatic, or bodily, distress initiated by the abrupt interruption or partial interruption of an otherwise sustained narcotic influence in a body that has, over time, been physiologically conditioned to depend upon said influence. Some typical symptoms of narcotic withdrawal are: trembling, cold sweats, an uncontrollable anxiety, restlessness, bone pain, diarrhea, insomnia, etc. The withdrawal occurs as a direct consequence of the body's circumstantial deprivation of the narcotic analgesic substance. However, once the substance is re-introduced to the defier in the appropriate dosage, the symptoms of narcotic withdrawal should discontinue in time.
Example #1:
1.1 - Defier X has been receiving high doses of either i.m. (intra-muscular) or p.o. (oral) dilaudid every day during a five day inpatient crisis.
1.2 - Defier X is released from the hospital after an abrupt suspension of his analgesic therapy. Furthermore, his physician does not prescribe any oral dilaudid for home use.
1.3 - Soon after his discharge, Defier X begins to experience intense symptoms of narcotic withdrawal...his system's way of demanding the continued presence of the dilaudid. He has no control over this because it is his body's natural physiological reaction to the privation of the pharmacological substance it has recently been conditioned to depend upon.
The above example illustrates how a physical dependency can easily and quickly develop in a sickle cell defier. However, it should be noted that not all defiers develop dependencies as swiftly and intensely as Defier X in example #1. There are certain physiological factors that help determine how quickly and easily a defier may or may not develop a physical dependency on a narcotic that will differ from individual to individual. For example, the rate that Defier X's body metabolizes the narcotic in his system may be quite different from another defier's on the same drug in an identical circumstance. Yet when Defier X is discharged from the hospital, he demonstrates clear symptoms of a developing physical dependency while the other defier's discharge picture is completely free of such symptoms. So, it is vital to remember that there is a great deal of variability in how physical dependency will manifest in sickle cell defiers.
Now, let's recap the chain of consequences we have established thus far.
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Chain of Consequences:
Link #1 - Sickle cell defiers are often prescribed narcotic analgesics as treatment for their recurrent painful episodes. As a consequence of this...
Link #2 - Sickle cell defiers may quickly and easily develop physical dependencies on the narcotics used in analgesic therapy for their chronic pain. As a consequence of this...
Link #3 - Sickle cell defiers will have to periodically endure symptoms of narcotic withdrawal when temporarily deprived of the pharmacological staple of their physical dependency.
This brings us to the next link in the chain...link #4.
What are the consequences for experiencing the symptoms of narcotic withdrawal for the sickle cell defier, if any?
Well, there are indeed consequences. However, in order to fully understand and conceptualize chain link #4, we must first focus our attention on one symptom of narcotic withdrawal in particular. This is the symptom of bone pain, (henceforth designated as withdrawal related bone pain), perhaps the most consequential withdrawal symptom of them all where the sickle cell defier is concerned. This lone symptom has the potential to greatly influence the path of the defier in a most inauspicious way. How?
To answer this question consider for yourself the difficult challenge confronting any sickle cell defier who must strive to discern and distinguish between the chronic bone pain which is classically characteristic of sickle cell disease and withdrawal related bone pain, a symptom of the reactive bodily state of narcotic withdrawal. As the reader's common sense may dictate, it is extremely difficult to differentiate between the two. In fact, there are times when it can be downright impossible for the defier to extricate the pains. Moreover, when one weighs the reality that most if not all, sickle cell defiers are psychologically conditioned from a very early age to conclude that any bone pain we experience is the result of a sickle cell crisis, (to the exclusion of all other potential causes), there emerges the strong likelihood of a dangerous misinterpretation occurring. If a sickle cell defier experiences withdrawal related bone pain and makes the unfortunate error in judgment of misconstruing it as crisis related pain, a very troubling sequence of events can commence. That defier, having made the incorrect determination that the pain he is feeling is crisis pain, will now further act in accordance with his conditioning by "appropriately" seeking proper analgesic therapy for his physical distress.
The problem here, however, is that the actual cause of the defier's bone pain is a narcotic withdrawal from the medication he has clearly become physically dependent upon...not a sickle cell crisis. Therefore, treating the withdrawal related bone pain in the way crisis pain would be treated, (with higher doses of narcotic analgesics), serves only to broaden the scope and ultimately deepen the defier's physical dependency on those medicines. After all, it can take as little as only 25% of the dose normally used to treat crisis pain to treat a defier's withdrawal related pain.
In order that the reader may see how this phenomenon can manifest circumstantially in the life of a sickle cell defier, we shall resume the example scenario with Defier X where we left off.
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Example #2:
2.1 - One of the symptoms experienced by Defier X during his withdrawal from the dilaudid is severe bone pain in his lower back and lower extremities. Assuming for the sake of this example scenario that Defier X has never been educated about the relationship between sickle cell defiers, physical dependency and the symptoms of narcotic withdrawal, it is safe to conclude that he will naturally misinterpret his withdrawal related bone pain to be classic sickle cell crisis pain. Once this occurs, his remaining behavior is simply a matter of his psychological conditioning.
2.2 - Defier X seeks relief for the severe "crisis" pain he is experiencing by returning to the hospital. At the hospital he describes the locations and the severity of his pain for his doctors, (who are in many cases just as uninformed as he is), and the decision is made by his physicians that Defier X will have to be re-admitted so that he may receive additional hydration and narcotic analgesic therapy until such time as his "crisis" is fully abated.
2.3 - Defier X is re-admitted as an inpatient and, over the course of a five day hospital stay, receives moderate to high doses of dilaudid, (and/or any other controlled substances his physician deems appropriate), in either p.o. (oral) or i.m. (intra-muscular) forms.
2.4 - By the fifth day Defier X is completely pain free. His doctors are convinced that his painful episode has concluded, and they release him from the hospital with a prescription for a three day supply of dilaudid tablets in the event that he should encounter any more pain after his release.
Within a few hours of his release from the hospital, Defier X begins experiencing varying degrees of bone pain along with any number of other symptoms of withdrawal. He responds by taking the medicine provided for him by his physician.
2.5 - By the start of the fourth day of his release, Defier X's supply of dilaudid tablets has been exhausted. Before the day is over, all of the previous withdrawal symptoms, including the bone pain, recommence.
2.6 - At this point it's only a matter of time before Defier X, no longer possessing the means to address this increasing bone pain himself, is likely to once again misread the withdrawal related pain he is feeling as crisis pain. And yet again his misinterpretation culminates in the perception that he requires even more narcotic analgesic therapy (inpatient or outpatient) to treat his "crisis" pain.
After all, when Defier X takes his medication, the pain usually disappears. Therefore, it must be crisis pain. Right? What else could it be?
2.7 - Finally, in view of this conclusion, Defier X will inevitably return to the hospital with these symptoms for more acute narcotic analgesic therapy. He may return for re admission as an inpatient. He may present to the attending physician in an emergency room, or some other outpatient facility that specializes in acute care for sickle cell defiers. Or he may just make an office visit to his regular doctor to secure another prescription for dilaudid tablets. Whichever option he exercises, Defier X will more than likely procure access to further narcotic analgesic treatment because ultimately that is what his body demands.
This brings us to the next point in our analysis.
Regretfully, the circumstance described above is not an isolated one. In fact, many sickle cell defiers will find themselves in similar straits as Defier X at some point during their lifetimes. And just as Defier X, so too will they become caught up in the perpetual nature of this physical dependency phenomenon by likewise addressing their withdrawal related bone pain with more and more narcotic analgesic medication, succeeding only in deepening their physical dependencies more and even more. And as a consequence of the dependent sickle cell defier's continuing need for medicine, there is born a continuing and potentially all consuming pursuit of this medicine. Unfortunately, this pursuit is often misunderstood and misinterpreted. After all, what are the prevailing superficial images here?
We have a person, (Defier X in this instance), who although in the beginning demonstrated a "legitimate" need for narcotic medication during his hospitalization while his crisis was in progress, no longer demonstrated such a need after his crisis symptoms expired. Therefore, concurrent with his medical discharge from the hospital, so too was any further "legitimate" need for narcotic analgesics equally discharged.
Ergo, when Defier X starts visiting the hospital more often for inpatient or outpatient narcotic analgesic therapy, and when Defier X begins obtaining more prescriptions for oral narcotic analgesics that he takes with greater and greater frequency in greater and greater amounts...one of the following interpretations is most commonly rendered by all but the most informed observers:
Defier X has grown more and more ill over time, necessitating more intensive pharmaceutical intervention by his physicians;
or
Defier X is addicted to the controlled substances prescribed for his condition and he will now return to the hospital as often as he must to procure the drugs he needs directly (or the prescriptions thereof) in order to ultimately indulge this overwhelming compulsion.
Physical Dependency and Drug Addiction - Not Interchangeable Terms
It is a sad but true fact that most individuals, when left to their own perceptions and biases, will more often than not misconstrue and mischaracterize the problem of physical dependency experienced by sickle cell defiers as rather a problem of drug addiction. In fact, anyone who takes narcotic analgesic medication regularly due to some sort of chronic pain condition, or for that matter anyone who is being prescribed narcotic pharmaceuticals to address some sort of emotional distress or chemical imbalance, will more than likely be subject to the same misconception as well. It is unfortunately a common error. However, in reality the terms physical dependency and drug addiction are anything but accurately interchangeable.
In order to successfully demonstrate this, we must first succinctly define the term drug addiction. Drug Addiction - state of being where one is physiologically and psychologically dependent on a drug or drugs that are not, or have ceased to be, medically indicated.
The reader will no doubt note that the phenomenon of drug addiction is not only defined by its physiological principle, (as in the case of physical dependency), but by its psychological component as well. It is the psychological factor to addiction, as it manifests in the psycho-compulsive behavior exhibited by the addicted that distinguishes it most from ordinary physical dependency. Then why do most healthcare professionals and most lay persons so commonly confuse physical dependency for drug addiction?
Well, besides the fact that most people who do this are ignorant to the subtle differences between the two states, it must be conceded that there are some superficial similarities to the way they both outwardly manifest. After all, both conditions are characterized by an ever-increasing physiological need for the indicated drug or drugs (e.g. narcotics), as well as the presence of new, oft times seemingly desperate behaviors aimed solely at the steady procurement of these drugs at what may appear to be any cost. Given these broad stroke likenesses, it isn't surprising at all that so many people misread signs of physical dependency as signs of drug addiction. Nevertheless, the two states are as different from one another as the proverbial apple and orange.
The key to truly understanding this difference in the overall context of the unique circumstance of the sickle cell defier is that physical dependency for a defier almost always results from the physiological need for medically indicated pharmacological substances. On the other hand, addiction for anyone (sickle cell defier or not) results from a physiological need for substances that are not, or have ceased to be, medically indicated... in addition to a psycho-obsessive compulsion that is clearly absent in the sphere of simple physical dependency. Remember, at the beginning of most if not all physical dependencies for sickle cell defiers is a legitimate medical necessity for the drug and a doctor who legally prescribes it. This circumstance is often conspicuously absent in the arena of addiction.
However, it is important to point out that there are aspects of either condition, (physical dependency or addiction), that will cross over into the other. Frequently, there is an obvious component of physiological need in drug addiction; and there is a potentially less obvious psychological component to physical dependency which manifest in the various types of mental and emotional distress experienced by the dependent individual (e.g. frustration, fear anxiety, anger, denial, depression, despair, etc.)
These are just some of the ways that the states of drug addiction and physical dependency differ from each other. It is important for the sickle cell community, (i.e. sickle cell defiers, their carepartners, family and friends), to begin to learn precisely how to distinguish between the two conditions for purposes of our own edification and protection. The question is: how can a defier expect to be able to successfully deal with a problem that may temporarily have the best of him if he is not even able to identify it for himself or his doctors? The answer is that it's not likely that he will. Therefore, the ability of the sickle cell community to accurately recognize and fully appreciate the significance and physiological implications of the phenomenon of physical dependency is a most crucial first step toward ultimately breaking the chains of that dependency.
Likewise, it is equally if not more important for medical and other healthcare professionals to learn how to clearly discern between the two conditions. Doctors, nurses or pharmacists who can't will invariably act on the negative stigma associated with drug addicts when treating or caring for defiers with a legitimate need for medically indicated narcotic analgesics. This is, unfortunately, a very common experience for the sickle cell defier who is dependent as well as for the sickle cell defier who is not. That is why it is in the best interest of the defier, dependent or not, to acquire a command of this knowledge. This way he is in the best possible position to protect himself against any actions originating from the unwarranted biases of those healthcare professionals who, for whatever reason, have not yet learned how to appropriately differentiate between these two distinct states.
This brings us to the next fundamental question in our examination of this phenomenon of physical dependency that binds all too many sickle cell defiers. To this point in our analysis, we have attempted to address the what, when and why questions. What is physical dependency? When does it occur? Now we must deal with the most important question: how?
How can these chains of dependency, that so unforgivingly grip us, finally be broken?
In order that our answer to this question be comprehensive, it must reflect what doctors can and should contribute to the overall resolution of this dilemma. And what way, the reader may ask, can a doctor contribute to the breaking of the sickle cell defier's dependency chains? For the purpose of this investigation, we will focus on just one of the most significant ways a doctor can successfully do just that. The answer is in a word: tapering.
The significance of the medical skill of tapering a patient who has been taking narcotic medication for a sustained period of the time should never be underestimated in the arena of treatment for the physically dependent sickle cell defier. Frequently it is the honed skill of tapering that can often permit a doctor to altogether circumvent a problem of physical dependency in a sickle cell defier before it even develops. It is, simply put, a key to the medical treatment of the inpatient (and sometimes outpatient) sickle cell defier contending with a potential or active physical dependency problem. Just how does this key contribute to the ultimate unlocking of these dependency chains? Well, the first step toward an accurate understanding of the tapering process is a clear and concise definition of the term.
Taper - to stop or decrease gradually over time.
Indeed, a simple definition. However, the actual medical process of tapering the physically dependent sickle cell defier can be anything but simple. Tapering vs. Reduction - The Need for Informed Doctors Although most medical doctors are convinced they know the proper way to taper a defier off a narcotic analgesic he has been taking for an extended period of time, (as in the case of an inpatient admission for a severe sickle cell crisis), the reality is that most do not. There is a common misconception amongst doctors that by merely reducing a defier's dosage of narcotic pain medication in regular increments and at regular intervals, that defier will have been properly and adequately tapered. In order that we may better understand how this occurs, let's employ yet another illustration.
In the following example scenario, Defier Y has been hospitalized for a severe sickle cell crisis. She has been receiving 8 mgs. of intra-muscular dilaudid every two hours for her pain for seven consecutive days. At the start of the eighth day of admission her pain begins to ease and her doctor decides to begin "tapering" her from the dilaudid.
Example #3: 3.1 - Day seven : Inpatient Defier Y receives 8 mgs. of dilaudid, q2 hours, i.m.;
3.2 - Day eight : Defier Y is reduced to 6 mgs. q4 hours;
3.3 - Day nine : Defier Y is reduced to 4 mgs. q6 hours;
3.4 - Day ten : Defier Y is reduced to 2 mgs. q8 hours;
3.5 - Day eleven: Defier Y is reduced to 2 mgs. p.o. dilaudid q8 hours p.r.n. (as needed).
3.6 - Day twelve: Defier Y is released from the hospital.
Now, most doctors who have treated me would consider the above defier adequately tapered from the narcotic analgesic and release her from the hospital as such. In fact, most doctors in my experience wouldn't even bother to reduce Defier Y's narcotic analgesic intake to the degree cited in the above example.
However I maintain, and my own personal experience supports the perception, that Defier Y has not been properly tapered. In fact, I submit she has not been tapered at all. Instead, Defier Y's physician simply reduced her dosage over a period of five days in regular increments and at regular intervals. My experience dictates that true tapering is anything but regular.
Tapering is a fluid process. There are many variables that must be considered when tapering Defier Y. For example:
How long has she been taking dilaudid as her inpatient analgesic? Is she on this same medication in its oral form at home? How long has she been on it? To what degree has her system become tolerant to the dilaudid, and what impact does this have on the tapering process?Will it be necessary to transfer to a different inpatient medication for the purpose of a more successful taper? Will it also be necessary to modify the way the analgesic is delivered in the hospital, (e.g. from injections to oral liquids), in order to improve the efficacy of the taper process? Will it be necessary to substitute a different analgesic for the purpose of pain control at home for Defier Y upon her release from the hospital?
Is it necessary to supplement her inpatient, short-acting analgesic with some long acting ones, (e.g. dolophine), in order to ease the often difficult transition to the lower doses intrinsic in the tapering process? If so, should this same medicine continue to be prescribed for her on an outpatient basis to offset some of the reoccurring symptoms of withdrawal?
Is Defier Y on any medication commonly used to counter the effects of narcotic withdrawal, such as chlonodine or ativan? If not, what impact does this have on how exacerbated her withdrawal symptoms will become?
Has the fail-safe of a rescue dose of some type been scheduled for her, should she encounter some significant breakthrough pain? If not, what impact will this unaddressed pain have on the otherwise uninterrupted flow of the taper process?
Has Defier Y been supplied with plenty of pain assessment forms (an evaluation tool that allows the defier to rate on a scale of zero to ten among other things, the severity of the pain he or she is feeling at the moment and the degree of relief that has been achieved by the most current dose of analgesic), to complete at regular and frequent intervals? If not, how is her physician actively monitoring and accurately documenting the efficacy of the taper process from the patient's perspective?
These are just some of the variables essential to consider when tapering any defier from narcotic analgesics. It is also important to remember that defiers whose chronic pain picture requires either prolonged or frequent but intermittent use of these narcotic analgesics will most likely be harder to taper from their medications. If a physician does not factor these and other considerations into his final tapering plan, he is not effectively tapering anyone. However, if he does and he succeeds in properly tapering the sickle cell defier, most if not all vestiges of physical dependency can cease in time. This is how absolutely crucial the true tapering process is to the defier's ultimate goal of breaking the physical dependency chains.
The reader of this paper will no doubt have noticed by now that I have focused a great deal on the responsibility of the physician in matters of treating, tapering and understanding the physically dependent sickle cell defier. However, it is my firmest conviction that ultimately the individual bearing the single greatest responsibility where the well being of the defier is concerned...is the sickle cell defier himself.
Now, I am fully aware there are plenty of my brethren who will adamantly disagree with this. They may feel with respect to the issue of physical dependency that it is the doctor's responsibility to fix the problem. For if it had not been for the doctor's horrible mismanagement in the first place, the defier would never have developed a physical dependency in the second place. This may or may not be true. Nevertheless, I maintain that wherever the point of origin for the dependency lies, the final responsibility for the recovery rests with the defier himself. It is he and none other who must reach deep down into the depths of his soul to gather and commit the emotional strength necessary to confront and successfully challenge the problem of physical dependency in his life. A physician can't do this for him,...nor for that matter can anyone.
However, what a physician can do is be sensitive, knowledgeable, skilled and practiced at the medical techniques involved in proper inpatient tapering, as well as ongoing outpatient pain management for sickle cell defiers. This will significantly reduce the risk of the development of a seemingly uncontrollable physical dependency. I believe we defiers have the right to expect at least this much from the physicians charged with the very important responsibility of our medical care. Only, the important question still remains: what are we defiers obligated to expect of ourselves?
The Philosophy of Defier Accountability
Just how does the defier begin the arduous journey of healing after a physical dependency seems to have gotten the better of him? I believe the first step lies in the fully committed embrace and application of what I call the philosophy of Defier Accountability.
Simply put, this philosophy mandates that we sickle cell defiers answer for our choices and our behaviors...finally taking full responsibility for our own lives. To that end, the tenets of Defier Accountability are as follows:
1. The need to be in a constant state of critical self-evaluation;
2. To develop and engage a working program of self-discipline as a means of achieving a greater level of control in our own lives.
As a defier who has dealt with many of the problems described herein, I have found that a most vital step toward becoming accountable for one's self is an honest and critical evaluation of the self. We defiers must feel free to admit to ourselves and others that there are times in our lives when we are spiritually weaker than others...times when we get away from ourselves. And it's during these times that we may often contribute negatively to our own medical and psychological circumstances.
For example, with regard to the issue of physical dependency, there are many defiers who have become extremely dependent on narcotic analgesics who are, in fact, aware they are dependent. However, instead of taking some initiative on their own behalf to seek out the proper care for this problem, (the appalling lack of knowledgeable care in this area not withstanding), they will persist in their present behaviors sustaining and even nourishing the dependency, all the while blaming others for the problem, (doctors, nurses, pharmacists, etc.), and never once claim any responsibility for their own participation in it.
This is a very unhealthy and potentially fatal posture for a sickle cell defier to maintain. If it's not fatal to the body first then clearly it possesses its next greatest lethality where the affairs of the spirit are concerned. However, if these defiers maintained a more self-critical posture, subjecting themselves to a constant and genuine self-evaluation, they would be far more familiar with the process of self-empowerment.
Except, recognizing your weaknesses and being self-critical isn't all there is to this philosophy. A defier must also have the internal means to act on these critical revelations. The process of on-going self-evaluation is rendered meaningless if there is not an equal significance placed on the instrumentation necessary to bring the determined changes to pass. That is why the second tenet of the philosophy of Defier Accountability demands the cultivation of a working program of mental self-discipline. It is this self-discipline that will act as a defier's most private chosen instrument of change.
The following are just some examples of how a sickle cell defier's tool of self-discipline can successfully empower him in his struggle to escape the shackles of physical dependency.
Self-discipline enables a sickle cell defier to:
a) commit the extra time often necessary during an inpatient hospital stay in order for his physicians to properly and thoroughly taper him off the narcotic analgesics ordered for the treatment of his crisis pain...indeed an important and primary precaution against the development of a physical dependency problem;
b) seek out and ensure regular access to psycho-therapeutic assistance to better deal with the general psychic strain of being chronically ill, as well as the specific emotional distress engendered by physical dependency; this distress (e.g. fear, anxiety, depression, etc.) can fuel a dependency as oxygen fuels a fire if measures such as this aren't taken to address it;
c) incorporate various mental and physical exercises into his daily order such as meditation and creative visualization designed to calm, center and empower the busy mind and spirit, or rhythmic breathing and sequential muscle relaxation isolations designed to tranquilize the individual in order to effectively release the physical tensions of the chronically ill and/or physically dependent body;
d) keep all scheduled doctor's appointments and maintain an ethic of honest and straightforward communication with his physician...no matter what;
e) work toward the eventual end of unlearning his conditioned responses to the withdrawal related bone pain often associated with physical dependency, (as previously illustrated in example #2); it is this skill that will ultimately prove invaluable in a sickle cell defier's battle to breach the perpetual nature of the dependency cycle.
Therefore, it is clear that once the physically dependent defier has taken the serious and critical moral inventory dictated by the philosophy of Defier Accountability, a blueprint for his renovation can then be conceived. And as this philosophy is designed to proceed from thought to action, reconstruction of the new spiritual edifice may then begin with each brick and stone being laid by the masons of patience and self-discipline.
| With aching hands and bleeding feet We dig and heap, lay stone on stone; We bear the burden and the heat Of the long day, and wish 'twere done. Not till the hours of light return, All we have built do we discern. |
In closing, it is clear that the problem of physical dependency in sickle cell defiers is not one that can be easily conquered overnight. Nevertheless, it is my sincerest hope that I have successfully proven to the reader that it is, however, a surmountable obstacle given the knowledge, skills and tools I have herein endeavored to elucidate.