HANOVER, N.H. — “How am I feeling, Doc?” my new patient answered. “I’m feeling like a caged dog.”

Hospitalized for a heart-valve infection resulting from injection drug use, my patient had purple hair and arms covered with hand-drawn tattoos. She smelled unwashed.

“I can’t go out to smoke. My boyfriend can’t visit,” she said. She gestured to the security guard in the doorway. “I can’t even pee without her watching me!” The guard rolled her eyes.

So, rather than building a therapeutic bond through small talk or discussion of her symptoms, we spoke of her confinement. The ban on visitors and the other unusually restrictive terms of her hospitalization were not a consequence of her drug addiction. They resulted from her behavior in the hospital.

Once a nurse found the patient in the bathroom shooting heroin into her I.V. line, the sink spotted with blood. A housekeeper changing bedclothes was almost spiked by a used needle hidden under the mattress. A constant influx of boisterous visitors came to her room day and night, some delivering heroin.