Severe mental health disorders can complicate relationships. That goes double for families, when genetic predispositions and generational trauma can come into play. And it’s even more complicated when a loved one’s mental illness disconnects them from reality. In this episode, we’re talking about delusions with author and pharmacist Ruth Madievsky. Her book ALL-NIGHT PHARMACY explores how the mental health of parents — and their attitudes toward health and healthcare — can shape the experiences and wellbeing of their children. Mayo Clinic expert Dr. Robert Bright draws upon his psychiatry expertise to help tease out these often-complex dynamics. This episode was made possible by the generous support of Ken Stevens.
Severe mental health disorders can complicate relationships. That goes double for families, when genetic predispositions and generational trauma can come into play. And it’s even more complicated when a loved one’s mental illness disconnects them from reality. In this episode, we’re talking about delusions with author and pharmacist Ruth Madievsky. Her book ALL-NIGHT PHARMACY explores how the mental health of parents — and their attitudes toward health and healthcare — can shape the experiences and wellbeing of their children. Mayo Clinic expert Dr. Robert Bright draws upon his psychiatry expertise to help tease out these often-complex dynamics.
We talked with:
Ruth Madievsky, Pharm.D., is the author of national bestselling novel, All-Night Pharmacy. Her fiction, nonfiction, and poetry appear in The Atlantic, The Los Angeles Times, Harper's Bazaar, and elsewhere. She is a founding member of the Cheburashka Collective, a community of women and nonbinary writers whose identity has been shaped by immigration from the Soviet Union to the United States. She has recently completed a second poetry collection and is at work on a second novel. Originally from Moldova, she lives in Los Angeles, where she works as an HIV and primary care clinical pharmacist.
Robert Bright, M.D., is the chair of the Department of Psychiatry and Psychology at Mayo Clinic in Arizona. He is also assistant dean of Student Advising in the Mayo Clinic Alix School of Medicine and an assistant professor of psychiatry. He is the 2018 recipient of the Mayo Clinic Arizona Distinguished Educator of the Year award. He attended the University of North Carolina in Chapel Hill for his undergraduate studies and medical school.
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Dr. Denise Millstine: Welcome to the “Read. Talk. Grow” podcast, where we explore health topics through books. In the same way that books can transport us to a different time, place, or culture, “Read. Talk. Grow.” demonstrates how they can also give a new appreciation for health experiences. Books can provide understanding of health topics and provide a platform from which health topics can be discussed.
At “Read. Talk. Grow.,” we use books to learn about health conditions in the hope that we can all lead happier, healthier lives. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you.
Our book today is “All-Night Pharmacy” by Ruth Madievsky. Our topic today is focused on complicated mental health issues, particularly delusions. I am so excited about our guests today. Ruth Madievsky is the author of the national bestselling novel “All-Night Pharmacy,” which is the winner of numerous awards, including the California Book Award for First Fiction and the National Jewish Book Award for Debut Fiction. Her fiction, nonfiction, and poetry have appeared in “The Atlantic,” “The Los Angeles Times,” “Harper's Bazaar,” and many other places.
She's the founding member of the Cheburashka Collective, a community of women and non-binary writers whose identity has been shaped by immigration from the Soviet Union to the United States. She has recently completed a second poetry collection and is at work on a second novel. Originally from Moldova, she lives in Los Angeles, where she works as an HIV and primary care clinical pharmacist.
Ruth, welcome to the show.
Ruth Madievsky: Thank you so much for having me.
Dr. Denise Millstine: So interesting to have a health care professional as a fiction author. I can't wait to talk more.
Ruth Madievsky: Likewise.
Dr. Denise Millstine: Our second guest is Dr. Robert Bright. Dr. Bright is the chair of the Department of Psychiatry and Psychology at Mayo Clinic in Arizona, and an assistant professor of psychiatry. He's also an assistant dean of student advising at Mayo Clinic Alix School of Medicine. He's the 2018 recipient of the Mayo Clinic Arizona Distinguished Educator of the Year Award. He attended the University of North Carolina in Chapel Hill for his undergraduate studies and medical school and did his residency in psychiatry and fellowship in consultation liaison psychiatry were completed at the University of California in San Francisco.
Dr. Bright, welcome to the show.
Dr. Robert Bright: Thank you so much for having me. It's my pleasure to be here.
Dr. Denise Millstine: Our book today is “All-Night Pharmacy,” which is Ruth's first novel. This is a messy coming of age story of an unnamed narrator with layers of mental health conditions stemming from trauma, drug abuse and more. In large part, it's the story of two sisters whose lives are tangled and held in tension. We are going to focus today, however, on a somewhat side character, the narrator's mother, in an attempt to avoid any spoilers and also to dig a little bit into this character.
Ruth, I read your book and I was swept into what I can best describe as essentially a tornado. You feel pulled all different ways as you're reading this book. And I was thinking about it for Read. Talk. (Grow.) and I happened to see a patient that very next week who had a delusional disorder and paranoia. And I felt better empathy and better understanding for her because I had recently spent time with the narrator's mother. Can you tell us about your choice to create the mother character?
Ruth Madievsky: Absolutely. And that's really nice to hear that you felt a special connection with the patient after reading the book. I feel like that's one of my, you know, secret hopes for it, especially for when health care providers read it, is that it's not just kind of an entertaining read for people, but something that can affect how we relate to our patients.
Yeah, I came up with the mother character because I was thinking about the ways that kind of historical traumas can embed themselves in people in ways that are often not really easily teased out. So the mother character, she has this kind of family history of immigration from the Soviet Union to the United States and Jewish trauma, Soviet trauma of having had a grandfather who was murdered as an enemy of the state back in the Soviet Union on what was basically just, you know, kind of state sanctioned anti-Semitism reasons.
And the mom character, even though she didn't personally experience these things, like they happened before she was born, she has inherited her own mother's trauma in a way, or she thinks she has. And she becomes less and less functional in society as the weight of these traumas gets heavier on her. And just from talking with a lot of friends I've had who come from immigrant families, there is sometimes a history of these sort of mysterious, delusional disorders that pop up seemingly out of nowhere or become more serious very suddenly without really an obvious trigger. And it was something I was interested in exploring in this connection between, immigration trauma and mental health. And I didn't really have, like a pithy thesis about how the two are connected, but it just felt like kind of a (unclear) that I think a lot of us immigrants have something like that in our families, and there's not really good language often to talk about it.
Dr. Denise Millstine: I really liked how you said the trauma was intergenerational, and it was really directly affecting the narrator's grandmother, so the mother's mother, but we see it manifest down the line in the generations.
Bob, how are you seeing intergenerational trauma presenting in your patients and psychiatry?
Dr. Robert Bright: Well, certainly there's an impact and you can see trauma begetting trauma. There's you know, there's physical abuse or emotional abuse, substance abuse that marches from one generation onto the other. And the impact of that trauma, even if it's not carried on. Some people will make a conscious decision that this happened to me in my own childhood, but I'm going to do exactly the opposite; I will not carry this forward. And some people are not able to rise out of it and do repeat it. And that's what they have known their whole lives and that's the skills that they learn growing up, if you will, that were very maladaptive and very hurtful to the people around them. But it's what they carry forward in their own lives and with their partners, with their children, with the people around them. So definitely, you see that marching forward.
And in the case here where there was this immigration, where this was this history of trauma in the past, it certainly can generate this message, this thread, this experience, a lack of safety of the world, (that it’s) not a safe place. Bad things could happen. At any time things could be completely disrupted: they were then, they could be now. And how do I know now that things are safe? How do we know now that there's not somebody going through the events and listening in to what's happening right now is, I think, was alluded to in the book, where do I find that space now to know what's safe and what's not? And that gets spoken through the generations and passed down.
Dr. Denise Millstine: And you even say in the book, Ruth, that to some degree the mother makes the grandmother's stories her own. She tells them, as they're formative for herself, even though she didn't live them. But to Bob's point, she's heard them so many times that she's absolutely internalized them. And Bob, I like what you said about the trauma begets trauma. But then the other thing I thought with the grandmother character is she's so dismissive of the mother, calls her spoiled. Essentially tells her she has no right to be affected by this trauma, given that the grandmother had moved to the United States and been able to be successful in life. It's so twisty, Ruth. Well done.
Ruth Madievsky: Thank you. Yeah, I mean, that's something I think I've seen a lot in generational differences and differences between ones who immigrated and experienced the trauma versus the ones who grew up here, where there's a kind of toughness sometimes to the ones who did have to live the trauma themselves, where I think it makes it harder for the younger generation sometimes to feel like they are allowed to feel pain over things that they did or didn't experience. You know, I mean, I think of this a lot around sexual trauma, too.
I have a friend who when she was younger, she was on public transit or something, and some like guy who was sitting next to her was like masturbating. I think she was like 8 or 9 or something. And I remember telling that story to my mom when I heard it and her being like, “Oh, that's horrible. But, you know, if that happened to me, I think I would have just gotten over it pretty quickly, you know?” And I don't think she meant that as, like, “your friend is weak,” but more of like a, “that's the Soviet Union baby, bad things happen and you don't let them affect you,” because you don't, it's not an option for it to affect you. You know, things of that nature are happening all the time, and you just have to move on.
It's hard for the person who lives in that kind of environment where you just have to accept anything bad that can happen and not let it affect you for living your life and for, you know, the next generation who maybe aren't living in such fight-or-flight times and can feel deeply when bad things like that happen to them. Yeah, it's kind of hard in both directions.
Dr. Denise Millstine: Such amazing insight. All right, Bob, here's a challenging question for you. So there is no shortage of psychiatric conditions in the characters in this book. But in chapter three, the narrator remarks that her mother had a kaleidoscope of diagnoses that no two psychiatrists could agree upon. The mix possibly included major depression with psychosis, schizoaffective disorder, delusional disorder, borderline personality disorders, and others. Why is it so hard to make psychiatric diagnosis?
Dr. Robert Bright: Well, at any given moment in time, people can present in a way that looks exactly the same as some different causes. So someone could be intoxicated on amphetamines or cocaine and look as though they have bipolar illness, and though they are manic and psychotic from that. So it could be a primary psychiatric disorder, it could be secondary to a substance, it could be secondary to an underlying medical condition, that could be secondary to a medication we're prescribing.
And only over the course of time can we actually distinguish some of these things that you just mentioned. Whether this is major depression with psychotic features, where during the depths of profound and severe depression, people can develop psychosis where they are hearing voices, so they believe things that aren't true and can't be convinced that those things aren't true. Those are delusions, as you alluded to earlier. Only with time might you see an emergent manic episode where they're very high and racing and not needing to sleep and their thoughts are flying, and then they have these psychotic symptoms during those high periods of time, or as was alluded to there as well in that list, schizoaffective disorder, where even when they're not depressed or they're not high in mania, they have those underlying psychotic symptoms where they're hearing voices, they're delusional, they're out of touch with reality.
So for this character, the mother, what I think she had, if that's what you're asking at all.
Dr. Denise Millstine: Do tell, we’re anxious to hear.
Dr. Robert Bright: I thought she met criteria for schizoaffective disorder because it clearly is stating in there that she had depressive episodes. There are clear statements that she was manic. Now, I don't know. I wasn't there to establish whether she was manic or not. But those clear words were described. And it also seemed to me that there were many times that, as we referenced back to the mother had interactions with her, that she had the psychosis, but was not clearly manic or psychotic, or the manic or depressed, so that she wasn't in the depths of either a stream of the mood states, but still had that underlying psychotic illness thread.
So we talked about the intergenerational trauma, but there's also perhaps a misunderstood ending or dismissal of this woman's major mental illness that may not be related to the family history or trauma, that may well be biological or medical or organic and needing medications. It's not the factor of that. So to dismiss and say, “Oh, you have you weren't there and you didn't go through it,” is to miss serious diagnosis with a treatable illness that I think she may well have, based on what I read,
Ruth, I don’t know what you had in mind when you were writing it, but that's what jumped out at me.
Ruth Madievsky: So yeah, I think that makes a lot of sense.
Dr. Denise Millstine: Yeah. If only Dr. Bright had been able to see her as a patient.
There is a comment in the book that her insurance doesn't want to cover her personalized care that she goes through a series of what are essentially, if you'll let me paraphrase; the available medications, meaning she can get the, they are affordable, that either have side effects or they don't work. So that's probably a comment to some degree, Ruth, with your experience as a pharmacist.
Ruth Madievsky: Yeah, just fighting insurance companies constantly. And I don't even work in a pharmacy. You know, I work in a primary care and geriatrics clinic. But so much of what I get consults for is, you know, this medication. It's tier five. You know, it's not covered. It's going to cost $2,000 a month. What can we switch them to? And it's like, okay, well, here's the medications that cost pennies that they already failed. Let's try to appeal. Let's write letters. Let's request a peer to peer. And you know, it's just this endless sometimes loop of begging insurance companies to give patients the care they need and trying to prove that they need it. So that definitely, I'm sure, came out in the writing because it's a constant frustration for me.
Dr. Denise Millstine: But, Bob, to your point as well, it's hard when you've had these traumatic experiences within a family and then you don't see that there’s another cause here that needs to actually be looked at directly. And it's often dismissed because we think, oh, you're just, being spoiled or reacting to some bad things that happened in our family.
Okay, let's talk about delusional disorders or delusions. So give us that in a nutshell.
Dr. Robert Bright: So delusional disorder would be the absence of those mood symptoms. People have just a fixed false belief that doesn't respond to any evidence contrary to that. Someone may believe that their partner is being unfaithful to them, is absolutely convinced of that. And even though their partner has not left their apartment and the 10th floor of the apartment building and they've seen them never leave, they will come up with some explanation for how it's still happening. Somebody scaling the side of the building and they're coming in a two-by-two inch window and it's magically happening, or they're hiding them somewhere. There's absolutely no convincing them otherwise.
So it's a fixed false belief that's unshakable. Despite any evidence to the contrary, that it's just not real. And sometimes they're things like I just said, that's possible. Somebody could be having an affair. Right? And sometimes they're not possible. Sometimes it's, you know, there's an alien whatever. Or there's the government has a chip in my head and they're following me or those it can be kind of bizarre or kind of within the range of possible, but fixed and false, an unshakable.
Dr. Denise Millstine: Fixed, false and unshakable. Ruth, like there are micro needles in the bowling ball, extracting young children DNA. This is a scene from the book for our listeners who haven't read it yet, which begets more trauma, because then the mother rips the bowling ball off one of the friend's hands, tears her nail, causes her to bleed. And here you have what could have been this really beautiful, happy memory turns into now a memory of her mom's delusions.
That's a pretty specific example, Ruth. Is that even straight from your imagination?
Ruth Madievsky: That one was coming from my imagination. But, I have such sometimes complicated feelings about telling family stories about crazy things that happened to my relatives in the Soviet Union. Because even though I was born over there in Moldova, we immigrated when I was two, soI was shielded from a lot of the wackiness. But, you know, just talking. Anytime I talk to family, I just get these, this family lore that just it's all unfact checkable. And so in some ways unbelievable, but also very believable, just from the sheer amount of stories like this that I hear from my community. Just things like that. I mean, not that specifically, but I mean, you know, you were talking about the place where people could get poisoned by being poked with an umbrella, you know, so micro needles in the bowling balls. Ludicrous. But, I don't believe it that things like that have necessarily happened. But is it outside the realm of possibility? Not necessarily. And, you know, I think for the narrator's mother, whose grandfather was murdered as an enemy of the state under false pretenses, that actually did happen to my own great grandfather. And, you know, there's always some excuse. There's always some reason why that's not what happened. But, you know, it's exactly what happened.
And I think also for the narrator's mother, there is and for a lot of people, I think it can sometimes be really hard to know what to do with these gray traumas where it maybe it's something you didn't experience or something you did experience, but it kind of defies clear language and words where, almost if she had seen it happen or knew without any ambiguity that that's what happened and had to get over it the way that her mother did. Maybe it would be in some ways easier to process than to have it be this ambiguous loss that she didn't have the words for.
I’ve certainly heard that from patients and from people I know who have experienced you know, just for I feel like all my examples go to this just because of my age and the people I'm around. The writer, Mary Gaitskill, she has this essay where she talks about how she was raped once, like, I think at gunpoint in an alley by a stranger. And she also had, like a very strange situation where, like, someone she knew coerced her sexually, but in sort of a manipulative way rather than a physical force way, and how that the situation with the person she knew was a lot more traumatic than a stranger in the alley, because the stranger in the alley was so easy to categorize and have words for, and there was just no ambiguity about what happened.
But with the person she knew and the fact that there wasn't a lot of physical force, that made it really hard to understand what had happened. And I think for the narrator's mother, there's something similar happening there where she doesn't she didn't personally experience these things, and doesn't really have the exact words for what had happened and how it's affected her. Whereas her mom who did experience these things has kind of had to learn how to process them.
Dr. Denise Millstine: So interesting. Are delusions often sparked by some piece of reality or is it usually a turn? It's an actual question, Bob.
Dr. Robert Bright: You know, it's variable. There could be something that happened that really did trigger anxiety and paranoia and fear as you're describing, an assault or something that creates a sense of a lack of safety, as I alluded to earlier.
And sometimes the spontaneous and the result of a mental illness. There is in psychiatry, this concept of the stress diathesis theory where there may be a biological predisposition or stress, or the family history of schizophrenia, but that it may not express itself until the person is under a great deal of stress, such as a trauma, traumatic experience. So the two things I'm talking about are not mutually exclusive. One can be associated with the other.
Dr. Denise Millstine: We see the narrator thinking about her mother as she's getting into a fairly serious relationship and thinking through whether she's going to talk about her mother to her partner or not, and intentionally makes the choice not to. So, Ruth, you've created her to keep her mother's world separate from other people. Can you talk a little bit about that?
Ruth Madievsky: Yeah, I think that for people who haven't experienced what it's like to have someone in your life who has a delusion disorder or who is kind of difficult to incorporate into the larger fabric of your life and your social connections, it can be a very challenging and stressful thing for a lot of people, and it can feel shameful, as it is to the narrator.
I think not just because her mom can sometimes make a scene, but also because she feels like she's failed her mom. She feels like she hasn't found a solution to the problem and feels like in getting more invested in this new relationship, she's getting less invested in it with her mom, and she's pulling away, and she wants to move out, but is worried that her mom is going to completely fall apart without her there to help her take her medications.
But at the same time, she knows that it would be maladaptive for her to just forego having her own life and just be her mom's caretaker. So I think it's a complicated thing. And beneath all of that, of course, is the fear that she herself has some sort of submerged mental illness that might swallow up her life the way it has her mom's.
Dr. Denise Millstine: Is that what you see, Bob, with people who have a family member with psychiatric conditions, they often have a hard time navigating when it should be revealed, when it should be kept secret. Or do you find that it's kept secret very often.
Dr. Robert Bright: I think is very often held kept secret. And it can be culturally different within different cultures or ways of understanding or thinking about these things as well. Ruth, I really love the words you use, which was shame; shame and stigma and fear of judgment. A fear of, sort of alluded to, is this going to happen to me as well? Or will my partner or this person I'm bringing in from outside of this family, or what will they think of me and my predisposition to it?
What's going to happen to me? How will they accept my mother? How do I integrate them into this delicate dance I've done of navigating their delusions, helping them with the medications, understanding or responding to what they're saying, and these things that don't make sense. They're not based in reality. And how do I bring somebody from the outside in and help them understand that, to navigate this thing that has taken me a long time to figure out myself. It can be very difficult to do that.
Dr. Denise Millstine: So many layers to this character, Ruth. It's really impressive how you created her. So there's a quote in the book where she says, “I secretly relished my mother's brief inpatient stays,” which occurred after her mother swallowed batteries or broke into the neighbor's apartment. Were you trying to say that even though things had to get really bad to get a reprieve, it was to some degree worth it for the narrator?
Ruth Madievsky: I think that those were in some ways, hopeful times, because she thought, maybe this time we'll have some enterprising psych consult where finally a solution is introduced. Or maybe this time, insurance company will realize just how bad the situation is and approve some sort of expensive therapy. And I think it also meant less chaos at home because mom isn't here. Mom is getting 24 hour attention in the hospital and we don't have to be face to face with what can feel like foreshadowing to her and her sister of what their future might be if this is a very strongly genetically associated condition, and because no one really has a specific diagnosis for the mom, it's really hard for the narrator and her sister to know what to do with that.
Dr. Robert Bright: I have absolutely seen that many times where someone in the family who has mental illness, does get hospitalized exactly what you've described and written about there, that there is this sense of relief that for the moment at least, the family member is safe. They're being taken care of, that they don't have to be concerned about them hurting themselves or hurting somebody else. They themselves can get some sleep, even though their family members up 24 hours a day, doing things that have to be watched and monitored and cared for, that it is respite, that it is a break. It's a chance to breathe, as you were alluding to underneath it. I have seen that many, many times.
Dr. Denise Millstine: It's kind of like for us as health care professionals being on call, and even if you're in a period of relative calm, you're waiting for the pager to go off or something like that. And when you live with somebody who has a chronic condition like this, you never know if today will be a good day or will be a day where you face a challenge like that. So once again.
Dr. Robert Bright: When you're not on call and you know your pager is not going to go up and you can relax. Right?
Dr. Denise Millstine: That's right. That's right.
Dr. Robert Bright: It’s the equivalent of hospitalization.
Dr. Denise Millstine: I do like that element to the, Ruth, of hoping that maybe this time the combination will be right. I'm sure many family members of people with psychiatric illness have always hoped that it'll get balanced this time, or this will be the point at which we achieve stability. At least. And know what to expect, which does happen sometimes.
There's also a point where the narrator says, as I got older, I realized she would never get better. Bob, is this often true? Would this be true for somebody if your diagnosis of schizoaffective disorder was correct?
Dr. Robert Bright: So, you know, it really varies. Some people respond beautifully to medication, and one of the true privileges of my line of work is being able to help give people their minds back sometimes, who've been ravaged by auditory hallucinations or paranoid delusions, who are scared to go outside, who feel like whatever is happening --which is not happening -- is there.
There are available treatments that can be profoundly beneficial and really get people out of the throes of that, clear of the psychosis and get them their lives back. Some people, like with many things like whether it's diabetes or hypertension or other illnesses who don't respond as well and don't come out of it as much, or some people are very treatment resistant and don't get better. And some of these diagnoses are more responsive to treatment than others, schizoaffective. There are very effective treatments for that. People with delusional disorders, the medications are not as effective as that. If it's just a fixed delusion, it's harder to treat. Sometimes they do get better, but it can be more challenging.
Ruth Madievsky: And I think that's kind of one of the tragedies of the book, which is a tragedy that a lot of people in this country, experience of things could be a lot better if you just had better health care.
Dr. Robert Bright: Absolutely.
Ruth Madievsky: I think the narrator's mom is someone who just keeps falling through the cracks because there just isn't really a safety net for her beyond these kind of patchwork hospitalizations, which are just kind of a Band-Aid.
Dr. Denise Millstine: And essentially only follow a major escalation, are not triggered by, oh, we think we have the answer. Let's bring you in and use this bright idea. We have to wait for something to get really bad in our system, to then engage with those intensive therapies much of the time, anyways.
I do want to talk about your life as a pharmacist, Ruth, and how it impacts this book. So maybe we should start with the title, because for people who haven't read the book, they might think “All-Night Pharmacy” alludes to the 24-hour pharmacy down the street, but in fact it does not at all. And it's a pretty complicated title in and of itself. Can you tell us about choosing the title?
Ruth Madievsky: Sure. So I am not good at titles, and I did not come up with the title, “All-Night Pharmacy” by myself. The original title was “Prescriptions,” which I thought was so clever because prescriptions can be medication, but it could also mean like advice, like prescriptive advice, but it's a pretty boring, bland title. So that didn't last. And then a friend of mine came up with “All-Night Pharmacy.” And I just like that it sounded kind of like neon and a little bit sexy and mysterious. And someone who interviewed me about the book right when it came out said, is it called “All-Night Pharmacy” because it's an immigrant story. It's a detective story. It's a queer coming of age story. You know, it's like an “All-Night Pharmacy” where there's just so much (expletive) in here. You can find anything you need. And I was like, oh, I love that. Like, let's just say that's why it's called that. So a lot of different genres kind of melded in one, similarly to when you're wandering the aisles of your neighborhood all-night pharmacy and you can buy anything from a camping tent to diarrhea medication.
Dr. Denise Millstine: Well, thank you for all of that. And because we didn't talk very much about the sisters. There is a strong presence of a bar that is filled with all different people, from all different walks of life, from drug addicts and performers to soccer moms and you just see everybody in Salvation. I also thought it alluded to that place in and of itself. But I like the title, especially with your background.
Ruth Madievsky: That was one of the original titles too, “Salvation,” but I just kept thinking that it would end up being miscategorized as like religious fiction or something and would end up in the wrong section of the bookstore, or would make people who aren't that interested in books about religion think that that's what it was, and avoid it. So I like the mystique of “All-Night Pharmacy.”
Dr. Denise Millstine: I like it too. I also think if it was titled “Salvation,” we might think we were promised this moment at the end where everything is clean and, you know, the angels are singing, which we're not going to spoil the end. But that's not exactly what happens, right?
So, clearly your work in pharmacy is really impactful in this book. And shifting briefly to the narrator who deals with addiction and dependance on pills, I want to just touch on some of her experiences, particularly as they pertain to the use of benzodiazepines, which we talked about on another episode featuring the book “Blood Orange Night,” and also how she becomes dependent on opioids. Can you comment on those two within this context?
Ruth Madievsky: Yes. So it's very common in my clinical practice, my current job, previous jobs, and I think just America right now, that a lot of people end up with dependance to benzodiazepines and opioids for reasons that feel very societal or that didn't necessarily start out as them looking to numb themselves. So people who were prescribed an unnecessarily high quantity of opioids after some injury and then someone who wasn't paying a lot of attention just keeps refilling them, or people who don't have consistent psychiatric care. And so instead of taking like an SSRI, for example, for anxiety, are just constantly prescribed more and more benzos. Those are certainly things that happen and that people end up dependent on sometimes. You know, sometimes people start out with an injury that very much does cause pain and the pain isn't controlled adequately, so they have to take higher and higher doses of their opioids just to survive, basically, and function. And then that's not really something that you can walk back for a lot of them easily. So it's something I've seen in clinical practice. It's something that I can work with patients on, specifically with tapering off of benzodiazepines. But often it's not even people who are dependent on them beyond like elderly folks who need to take them every night to sleep, which can also be a challenging thing to taper off when people are starting to get cognitive impairment but feel like they can't sleep without something like that.
So it's an issue that was kind of at the forefront of my mind, and very much something we talked about a lot when I was in pharmacy school and just starting practice, just in the context of the opioid epidemic and kind of what a tough time a lot of people in this country have.
Dr. Denise Millstine: I really love how you framed that answer, because so much of this doesn't start in the same way that the narrator's experience with the medications started, which is, I think when Debbie, her sister, gives her a mystery pill as part of their celebration of her high school graduation night and makes fun of her for not wanting to take it until she knew what it was. So that's clearly misuse of pills and abuse. But for many people who are taking these medications, they started well-intentioned and with a good clinical effect being sought. But then because they are tricky in the mind, they end up really getting pulled into them and then realizing that now they have a second problem, which is how to come off of the medications.
Bob, we see this great character in the book at one point called Dr. Ramos. It's about halfway through the book, and she helps the narrator transition off her benzodiazepines, which has to be done slowly, of course, but then she'd also been using opioids. She'd been on oxycodone. So Dr. Ramos adds suboxone to her list of medications to help her with that. Can you talk about that medication and what we use it for?
Dr. Robert Bright: So suboxone is used for patients, people who develop opioid use disorder. And it does help as they're coming off of it. And she talks about the difficulty and challenge of it is you have to go into withdrawal before you can actually start the medication. You don't get too far into it, you know it's a day or two in, the symptoms begin and then you start treating it. But it is a combination of sort of reversing the effect of the opioid you've already gotten and replacing it sort of at the same time, a sort of a mixed kind of thing. But it's very helpful for people who have developed opioid use disorder and getting off of the substances they've been abusing and staying off of it.
The statistics are concerning for people who are able to come off and stay off forever without assistance of some of these medications. But suboxone specifically has been very, very helpful and it was helpful to her and getting off of that. And Ruth, if I could just build on what you said, you talked about dependance. What I want to just point out that for the narrator, absolutely. I think to some degree, her sister was less of a clear vision for me that there was there's the physical dependance on it, which is what we're talking about, these medications to help with that, but very much a psychological dependance developed for her as well. And I loved her use of the word numb. There's a numbing of the physical pain, but very much an attempt to numb the psychological or emotional pain, the cumulative effect of this trauma, all of the things that were happening in her life and one builds on the other. And as you were saying, if people get started on an opioid after surgery or a benzodiazepine to help with anxiety, but develop both the physical and psychological dependance of it. And as she started coming off the benzodiazepines she was developing significant withdrawal symptoms. It was kind of going too quickly and had to kind of go back up on the dose a little bit. But just to caution, I was listening. If you do are using benzodiazepines over a long period of time, that it is important to really come off of them slowly rather than stop abruptly because it can be quite dangerous if you stop them abruptly.
Dr. Denise Millstine: These medications are so, so tricky. Well, I do want to comment, Ruth, about the book because we've talked about some pretty heavy topics and the mother is really smallish character in the novel. It's really focused on the narrator and her sister and this whole cast of characters, some of whom are magical and many of whom are funny. I'm going to encourage our listeners to read “All-Night Pharmacy” if you haven't read it already, and hopefully it will be a means to help you better understand mental health, particularly complicated mental health.
I want to thank you both for being with me today to talk.
Ruth Madievsky: Thank you so much, and it's such a delight to talk about someone who's not the main character in the context of the book, pretty much all discussions of the book for me normally, and that focused on the main character and a lot of similar themes. So this is the first time I've really had a conversation focusing on her mom, and it's been such a pleasure.
Dr. Denise Millstine: Thanks for being up for it.
Dr. Robert Bright: Thank you so much.
Dr. Denise Millstine:
“Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard Pasque and our recording engineer is Rick Andresen.
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