The games drug seekers play

ninguem -

“I see many people who started out with a pain problem with opiate use that went far beyond pain control.”

DR: Again, could you please provide your (estimated) percentage of the *total* number of your patients presenting with complaints of pain who you have treated who you would say fall into your above stated category?

Such information would elevate your input from the realms of “anecdotal” to “objective”.

I myself (or any person) could make a statement such as:

“Problem is, for every physician who proceed thoughtfully, honestly, and sincerely in their consideration of prescribing opioid analgetics in order to treat pain, you have another hundred who play the drug games.”

However, such vagaries would not serve to objectively (or necessarily accurately) inform the readership. You are in a position to (from your own experience) provide some context adressing the (actual) prevalence of such events.

We look forward to your enlightening input.
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ninguem -

With all respect due, it seems that you entertain a high degree of hostility towards those who might question social policies surrounding issues that are larger, and more important, than both of us individually, my friend.

If your employer(s) asked you the same questions, something tells me that you would not dismiss such inquiries as “tripe”. I feel that you have become quite abusive towards me – but I would rather the world see for themselves your incredible hostility than whine about it …

Your retort to my query:

“I’m not going to add up the statistics, as I know you’ve been told this sort of thing before, but you don’t care.”

is a patent “dodge” of a reasonable and pertinent inquiry. Methinks you are not fond of the numerical ratio that you derive – therefore, you choose to hurl verbal insults?

Please recognize that my “victimless-thought-crime” is one of mere *speech*, as opposed to the “self-medication” that I would imagine (from your own expressed attitudes towards patients) seems to threaten (what certainly appears to others to be) your sense of authority and self-righteousness so profoundly.

Let us (absent your willingness to be straightforward) draw some inferences from the numbers that you state:

“I’ve dismissed a dozen patients this year for obvious abuse and occasionally diversion of drugs.” …

… “I have thousands of patients.”

Despite your subsequent statement that, “I do not limit my practice to pain”, one patient per month does not sound like a major crisis situation in anybody’s book (excepting, perhaps, yours). Anyone else out there disagree?

You state:

“The DEA allows me one hundred Suboxone patients.”

No reasonable person would conclude from your statement above that you are specifically stating that you have placed 100 patients on Suboxone (although it appears that you have attempted to give the readers that impression, nevertheless). Please correct me if you *do* indeed have 100 patients presently receiving Suboxone. Maybe the DEA would make a “special-allowance” for you to take thousands under your steady and sure wings …

“None are heroid addicts.”

That’s good, because I hear that “hero-id” is so addictive that merely one taste of it’s power renders a formerly kind and rational individual into a self-righteous flailing autocrat with no regard for much of anything but maintaining the delusions of grandeur that this terrifying title is known to induce.

Regarding your prediction:

“You’ll be saying the same thing next week.”

I must say that, thanks to your most enlightening input, *next* week (were I to lose my sense of objectivity), I well might feel inclined to say things far *worse* about “certain individuals” who allege to represent your lofty profession, thanks to you …

It would be my hope that human beings suffering from intense acute/chronic pain would have the misfortune of interacting with a “bed-side-manner” such as you project on as small a percentage basis as (it certainly appears) you apprehend and medically incarcerate those who you are allowed to deem for all time to be “self-misusers”.

Thanks for the education, doctor. You have spoken volumes in so few words – and for all the world to see.

Obediently and Most Respectfully Yours,

DR …
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About the individual with the thick chart and the “three cases” I mentioned, as if I could stop with three. I am losing my ability to stay civil. I honestly could care less if you believe it or not.

Fortunately for you, you don’t have to care whether I find your story credible or not, since it’s not like I get to label you a drug-seeker, whiner or malingerer and destroy your medical care and maybe your life, too. Nonetheless you find it difficult to stay civil with someone who questions aspects of your story on an anonymous forum. I know it’s a pointless exercise in empathy, but you might sometime pause to consider what it’s like to have to remain civil with a demigod who writes in your chart that the pain you’ve endured for years is probably all in your head, or that you’re a drug-seeker or a malingerer or hypsersensitive to pain. Who thinks you’re a doctor shopper looking for drugs because, gasp, you have seen more than one doctor within a month.

saw the charts with my own eyes. The hospital asked if they could limit to the last year or so, to keep it only several inches. That you find it difficult to believe that the ER docs don’t check means nothing. Work in an ER some day and get an education.

Maybe it’s my lack of education showing, but a 4-inch stack of paper would be about two reams of 20lb copy paper or approximately 1000 pages. If your man went to an ER at least once a week as you claim, and assuming he went to the same ER that generated the note pile once a week, that would be roughly 20 pages of notes per visit, with none of the visits actually involving an evaluation, imaging, or tests of any kind. Now for comparison’s sake, the longest and most thorough medical evaluation I ever had in my life, which was with an expert on soft tissue injuries, was just 4 pages long. My initial evaluation with one of the top pain specialists in the country was just 1.5 pages long.

So, unless that ER you mentioned was producing some kind of performance art with 1000 pages of blank notes signifying the meaninglessness of life or something, it is difficult to imagine what they could have filled that many pages with if it wasn’t evaluations, imaging, and an occasional thorough workup or two. It simply doesn’t take 20 pages a visit to document a shot of dilaudid or Toradol and a script for 10 Lortab.

Deny the person narcotics, they complain to administration, and the ER doc has to defend self. Administration takes side of addict as “consumer”. ER doc is at disadvantage in most hospitals. I wouldn’t take their job for all the tea in China.

There is no law requiring you to treat a patient with narcotics, and I doubt many administrators would begrudge an ER doc refusing to give narcotics to a patient who had been there 52 times already and never had or refused a workup. ER docs routinely deny treatment to cpers and label them drug-seekers and even maintain illegal blacklists of those they suspect of being drug seekers, all presumably, with the knowledge of administrators. After all, administrators were very quick to respond to your request to not only stop administering narcotics, but to refuse to see the patient at all for his headaches, the former being perfectly legal with the latter causing potential EMTALA issues. Apparantly, the ER/performance artists who actually work at that hospital don’t have quite the clout you do.

http://www.ahcpub.com/hot_topics/?htid=1&httid=1532

Pain patients stop at analgesia and they don’t mix recreational drugs and alcohol.

Some of them do, just not to the extent an addict does. Sometimes they do so because their pain is being undertreated and are unaware that the results can be devastating. The question is, does this warrant a sentence of torture? Do doctors get denied medical care or kicked out of the medical profession every time they screw up?

Remember, there are docs out there who facilitate this crap, too. Look at this.

http://www.azcentral.com/news/articles/2009/07/14/20090714rxdrugbust.html

“ninguem” – In the same delicate spirit of respectfulness that KevinMD allows you to present in its unedited totality:

Seemingly little humanity left within your empty shell. So much knowledge, so little humility or capacity for empathy for the mere mortals you despise while alleging to benefit. A real burn-out from excessive doses of hubris, it seems.

You present as a bellicose “Nurse Ratchet” of humanity’s nightmares, bereft of shame. Perhaps you, yourself may be unfortunate enough to someday writhe in pain while self-inflated sadistic nannies look on in pitying condescension. If you willfully asked for such treatment, so be it. If not, welcome to Mudville …

An “Apostles of Hypocrites” needs a new oath more aptly describing such sanctimonious stoicism. I propose:

“I swear by Ceaser and Panapathogen, and I take to witness all the gods and goddesses comprising the Holy Inquisition, to keep according to my ability and my judgment, the following Oath and agreement:” …

… “I will prescribe regimens for the good of my own career, bank account, and reputation among co-members of my elite entitlement first and foremost, according to my ability to denigrate human beings and my super-human judgment, and never do harm to anyone who signs my paychecks” …

“… In every house where I come I will enter only for the good of my illustrious porcelain ego , keeping myself far from all intentional kind or humanitarian acts towards those who I subjectively deem as sub-human scum…”

… “All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will viciously spread in surreptitious, capricious, and unaccountable demonizations of those who would dare to anger my sense of paramount superiority over humankind, and will always reveal such pontifications to any/all Inquisitors of equal or greater rank in the Holy War on Untouchables” …

… “If I keep this oath faithfully, may I enjoy my privileged life and practice my sacrosanct art, respected by all fellow Inquisitors and in all times; but if I swerve from it or violate it, may the reverse be my lot, and may I reborn as an acute/chronic pain writhing and duly tortured (not only by debilitating personal suffering to the point of despair), but also by the same vapid and venal elite to whom I here pledge my unwavering allegiance and support.”

Note: Signatures are required by the Olympian gods to be inscribed in blood. However, it is here deemed acceptable (and even commendable) to use the patient’s own blood, thus conserving one’s own precious bodily fluids for strength in the service of the Holy Inquisition of shame.

If I were in common employ as your colleague, I would stay as far from you as (one would hope) your lowly “patients” would be well advised to remain (recognizing that you *might well* be a fine physician in other respects not broached within this particular pile of sardonic epistles, for all we as readers may reasonably know … ).

May you find some grace in yourself and others in your own time of sickness, disability, and death – and a friend and companion other than your net fiscal worth to console your evidently (IMHO) pompous, lonely, and angry soul.

In Patronage befitting your own Gentle Thoughtfulness,

DR
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“What I’m not good at, I admit, is I suffer fools badly. Because of attitudes like yours, more doctors will ignore the population. Why should they bang their heads against the wall, putting up with people like you?”

I applaud your sincere efforts to benefit humankind.

I differ in my opinions regarding social structures that affect the common good or ill, that being larger than (either of) our personal parts (or even our egos).

I suspect that things go much smoother around the office when patients (in their reasonable curiosities, desire for knowledge, and actual exercise of some rational choices in the matter of their physiological well-being and quality of life) find themselves persuaded to “leave the driving to you”. I understand that. Head-banging while suffering fools tends to diminish one’s quality of life, indeed. I’ve been “there”, as have you (it seems) … Ouch … !

There. You have spoken, I have listened, and there is peace once again in the land …
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Gentlepersons:

I once again pick up my pen and write (*not* merely in the spirit of injecting some “final word” meant to impose some sort of conclusion or closure favorable to my individual outlook upon that which has/will ensue amongst the protagonists of this century-old important and meaningful debate) involving: those presently in a position of absolute power with the assent and assistance of the State where it comes to the medicinal liberties afforded to other adult individuals; and those who in their lives experience the conundrum of experiencing genuine and debilitating physical chronic pain that is not mitigated by all best efforts otherwise (such as exercise, diet, or subscribing to externally generated advice-regimens – whether they involve either physiological, psychological, or spiritual measures held dear in the hearts of some).

All parties being human beings, I bear no envy toward the genuine trials and tribulations experienced by either: the societally appointed Solomonic arbitrators of adult human behaviors; or those who may rightly be said to genuinely suffer from the potential perils of such strictures imposed upon their own self-determination of that which they (and not some other person, regardless of their alleged level of acquired wisdom and insight as to how other adults ought to proceed) themselves, and no other, must live with every day, and attempt to somehow face and address.

It is assumed by me here that the issues surround *only* the private and peaceful self-determined actions of adult individuals specifically – and does *not* extend to either: specific and demonstrable direct harm to other persons; or tedious moral arguments where personal “thought-crimes” are alleged to, via elaborate moral projections, endanger “the public morals, health, safety, or welfare” of the constituents within the genuinely free, open, and enlightened society which those within our culture sometimes claim that we have successfully established.

We live in a world where (long before The Food and Drug Act of 1903 was adopted) human beings worldwide have made choices, for good or ill, to partake of a pharmacopoeia of psychotropic agents within nature (endogenous, as well as exogenous) in the course of the “pursuit and obtainment of happiness” (or, at least, in attempts by individuals to mitigate their human suffering).

Such choices are of a personal nature – despite any and all external moral judgments or sophistry made by (or resultant rhetorical formulaic dogmas that have in the past, do in the present, or may in the future, arise out of the minds of) others.

In various times and places, the cultural mores adopted, and dichotomies derived as to what does and does not constitute good or ill have been varied and innumerable.

Similarly, history demonstrates that the collective societal definitions of what has, does, and will constitute “mental hygiene” and “soundness of mind” are many and varied. Such declarations have been, are, and will likely continue to be, demonstrably exploited within human experience as strategic vehicles exploited for the purpose of rationalizing the entire gamut of human activities (from gentle attempts at persuasion to genocidal zealotry under the rubrics of theocratism or statism).

The Reformation, the Renaissance, and our Republic have both concerned themselves with, and affirmed, the inborn value and sovereignity (and not the negation and exploitation) of the individual human spirit and mind. I here assume that the personal and peaceful exercise of autonomy by a competent adult where it comes to the course of their personal life is *not* a negotiable societal privilege to be to be forcibly encumbered, mortgaged, or traded in by (either statist, or theist) moral polemics.

Further, should an adult individual deem themselves to be incapable of managing their own personal affairs, and *willfully choose* a path of deliberately sacrificing their autonomy to the discretion of other persons on a temporary (or even permanent) basis, if that it their wish, whatever victim-hood(s) may thus arise from such deliberate choices to invite the self-limiting of their personal liberty is by no means an issue other than one existing between the (we presume still-willing) slave and their chosen external masters, supervisors, etc.

We might be shocked and amused to learn that the 20th century’s human industries of inquisitive moral supervision and shame began with the “anti-self-misuse” movement (aimed at stamping out the scourge of the willful personal choice of releasing endogenous psychotropic molecules via masturbation), found re-employment amongst the legions of the “anti-alcohol-misuse” prohibition movement, and continued their careers onward, in the criminalization and ritual societal demonization of persons choosing to ingest opiates/opioids, and (even) substances as physiologically benign as cannabinoids. But, these are the “fears that we have come to favor”, and sometimes may attempt to validate via moral and/or medical arguments.

It seems an undeniable reality that the direct adverse impacts upon the public “health, safety, or welfare” of: infectious disease transmission; (molecular) impurities and contaminations of backyard and bathtub stills and laboratories; and the tragic and malignant harm wrought by the inevitable and ineluctable flourishing of criminal elements in response to such societal prohibitions, represent genuine and significant harm to humanity (whether or not wishes to dismiss those so harmed as sub-human garbage on the basis of their actions).

Mr. “Hertz” appears to be and individual who experiences significant and genuine human suffering of a physiological (and not a psychic, or spiritual) origin, despite any other best efforts or measures either available or affordable, and (as the sole individual who has to live with his predicament), a reasonably informed knowledge as to the potential disadvantages of the possible approaches that can be taken in an attempt to address his situation. Thus, his “obsessions” (if any, and meant in the most respectful of terms) with attempting to negotiate ways by which he (and other similarly situated human beings) might be taken seriously and have some discretion in the nature, course, and resultant qualities of their lives, is not something that it seems a responsible person alleging to serve other human beings could or should summarily dismiss.

It is true that opiate/opioid treatment for physiological pain is neither and panacea or a panapathogen, and one that can, indeed, in some instances, have genuine deleterious effects upon the quality of life of an autonomous individual adult. I do not think that either Mr. Hertz or myself have set out to refute such a proposition. The relevant matters of the questions asked and propositions made on our parts regard issues surrounding *who* should be allowed by the State to possess the power to influence and ultimately control such decisions.

Mr. “Ninguem”, while dismissing the same protagonists whom he freely chooses to converse with (here, at least) and to work among and around in his attempts to serve humanity (as we are assuredly *not* the only folks who have a brain, and choose to use them by asking reasonable questions) as baseless antagonists and charlatans of inferior intellectual ilk (”fools”) who would dare propose that the paternalistic supervision of adults who have not freely chosen to invite such interventions is not (necessarily) an absolutely appropriate prescription for the common good within our society.

Mr. “Ninguem’s” posted statement made regarding the “enrollment” of individuals involved in his Suboxone (the mixed opioid agonist/antagonist buprenorphine) treatments, his posted statement:

… “I’ve induced every one of them.” …

could (sub-lingually, though in a manner other than the absorptive pathway of the Suboxone wafers he procures) be interpreted in more than one distinct way. Whatever the circumstances by which his “addicts” have arrived at the doorstep of the buprenorphine maintenance therapy that he administers, it appears that Mr. “Ninguem” takes personal credit for effectuating decisions made by the individuals *themselves* (or by Mr. “Ninguem” *himself*, allegedly in the best interests of those other individuals). The moral distinction may seem trivial to some – or may appear as central and core to the issues of “who decides” to others.

What appears clear is that Mr. “Ninguem” perceives his involvement as an (albeit perhaps thankless) occupation beneficial to specific individuals – those who have in some manner allegedly (by others), or by self-declaration, lost psychological control of their own minds and destinies due to the use of opiates/opioids for *pleasure* (and *not* for pain), and (in some unclear manner no doubt involving members of the medical profession) been compartmentalized and relegated to the status of that of one (essentially) believed to suffer from a “mental illness” disqualifying those individuals from self-directed choices.

No amount of (perhaps) sanctimonious rationalizations on the part of the *supervisors*, or (perhaps) coddled senses of victimization on the part of the (even willingly) *supervised* belies the fact that (in/by some manner and process), with the assent and assistance of the “Theraputic State” (with or without the consent of those so compromised), such individuals have been relegated to a medical and legal status where their crime of “self-medication” has resulted in damage to their personal and professional reputations, their rights under law, as well as their basic human dignity as seen through the eyes of some.

I am certain that one could debate endlessly such matters – of the juxtaposition of the personal liberties of individuals in peaceful pursuit of feelings of “well-being”, amidst the also valid issues surrounding the “common good” (or ill) of humankind. However, I doubt that Mr. Hertz and I would find ourselves to be in significant disagreement over such matters – and it seems clear by this point that Mr. “Ninguem” would likely only proffer snarling despite and condescension in response to our sincere inquiries, allegedly based upon his academic and professional laurels – but, more centrally, based upon his (self-professed and admitted) intolerance and impatience when interacting with those who he summarily brands as “fools”.

So, I here present a technical question to the learned Dr. Ninguem. It seems likely that a significant percentage of your Suboxone patients may well be people who suffer from severe *chronic* pain (as opposed to having previously suffered from a more short-lived post-operative pain, or merely self-medicating for the purposes of some forbidden pleasure).

Sublingually administered buprenorphine (with it’s measured “ceiling effect” at around 4mg) does not appear to necessarily act with sufficient efficacy in terms of analgesia in order to address *severe* pain in a patient (please cite studies indicating otherwise if you disagree).

What do you as a physician advise and practice in the cases of patients who (once deemed by the medical profession, or by self-declaration, to be opiate/opioid “addicts”) continue to suffer from clearly genuine severe chronic pain (assuming buprenorphine is insufficient in relieving pain of this ongoing nature)?

Are such patients (as described in the paragraph directly above) doomed to a fate of writhing in pain before your eyes, or do you (personally) – and/or are you allowed under law to – administer opiate/opioid analgetics to such patients in order to relieve their intense sufferings to the extent that they arise out of a physiological origin?

We could say that such pain is “all in their heads”, or that such pain (due to their now-diminished status in society) must certainly be of a “clearly illegitimate” nature – but these tactics must certainly (at least in some cases) represent little more than patent dodges and deflections of a patient’s begging of the physician to relieve their suffering arising out of genuine physiological pain.

What options remain for such an individual somehow condemned (without anything remotely resembling due process of law, and solely by the hands of the medical profession) to such a diminished and demonized status?
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