The games drug seekers play

Patients who are addicted to narcotic painkillers reveal methods to try and receive more drugs from an emergency room.

In the interview, the patient admits calling 911 and feigning chest pain. Why?

What the caller, and only the caller, knows is that his chest is not throbbing in pain. Actually, his chest is fine. What he has done is just reserve his personal medical limousine for transport to the head of the line at the area emergency room — an emergency room that may unknowingly feed his current prescription drug addiction.

The caller also knows that Lawrence County taxpayers are going to pick up the dime for the entire trip. Not a single cent is coming out of his pocket. He does not have insurance and has no intention of paying for the trip.

Indeed, statistics show for that particular area’s EMS services, 50 percent of their calls are not for true emergencies.

Although it’s true that patients often won’t know what is a true emergency or not, a growing trend is that “another chunk of the non-emergency calls [EMS] responds to comes from an underground society of prescription drug addicts who know how to beat the system and . . . taxpayers out of hundreds of thousands of dollars annually.”

Why do they do it? Well, according to one addict, “Because more often than not, it works.”

Read the whole piece. It’s quite sobering.

(via WhiteCoat)

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  • teet

    But, we have to keep those patient satisfaction scores high. Because, like Michael Jackson and Anna Nicole, patients know what’s best for them…always. Except when things go wrong…then the doctor “is the professional” and should “know better” regardless of what the patients wanted or thought they needed.

    EMS should be able to triage…and this triage should start on the phone. Names of users should be tracked, and when abuse is suspected, prescriptions for drugs should be withheld unless *clearly* indicated.

  • David

    The woman who gave the reporter an interview is the worst type of person. She accepts no responsibility for anything, has no ambition. Most addicts will at least say they have a plan to improve their lives – that’s too much for this woman to consider. She is simply a parasite off the hospital system. Of course, the real problem is that the laws that say ambulances must pick these people up. They should have some discretion in this regard.

  • http://drgrumpyinthehouse.blogspot.com Dr. Grumpy

    These people put us in a difficult situation. Obviously, everyone is afraid the one time they DON’T't take it seriously, it WILL be an emergency. And we live in fear of litigation.

  • Anonymous

    Why don’t we make the narcotics over the counter. This is going to save the society so much money. May be we can offer insurance to everyone then. Any thoughts?

  • hypnoid

    I don’t live in fear of litigation. But I do live in fear of making a mistake and letting someone die. A patient of mine called 911 for chest pain and shortness of breath, they did an EKG which looked normal and didn’t bring the patient to hospital. Unfortunately her large PE didn’t change her EKG and she got a lot worse. Erring on the side of taking the patient seriously is probably the best bet. Having said that, if your impression is the patient is faking symptoms to get drugs, there’s nothing wrong with declining to give them any. They do need assessment though!

  • Dan

    I read once that, at least in the past, narcotic addicts would go to the ER complaining of symptoms suggesting renal calculi. They would bring some blood with them- normally taken from an animal. The purpose of bringing the blood is to put it in a urine sample that the doctor will order for such a patient.

    However, if the urine sample is viewed under a microscope, red blood cells with nuclei are observed. Human RBCs do not have nuclei. So their deception has been detected in the past.

  • Doctor Rocktor

    A SAD STATE OF AFFAIRS, INDEED

    The patently absurd, and truly wasteful and tragic scenarios of EMS and ER capacities being exploited by people desperate to obtain relatively small quantities of a class of relatively physiologically benign molecules which enable adults to experience a sense of physical/mental well being is emblematic of the convoluted value system of a culture that places physicians squarely in the middle of a insoluble conundrum where they, too (along with the human beings ostensibly being protected and served), are obliged to participate in the ritual trivialization, demonization, persecution, and dehumanization of adults who might choose peaceful psychotropic endeavors.

    Our society’s (all too often considered as ineluctable and beyond reasonable debate) stuctures and strictures – where the State and the (profit-driven and litigation phobic) Insurance/Theraputic State imprisons both physicians and patients within such an inhumane system of mandatory paternalistic supervision of people’s minds as well as their bodies from cradle to grave – is the overlying tragedy out of which these imbroglios arise.

    Simplistic declarations surrounding the freely made choices of human beings (such as “abuse”, “self-misuse”) are, sadly, wielded with great hostility against the patient. The legal and corporate systems under which physicians are routinely confined and indentured, and the patently absurd war against human nature whose moral crusade masquerades under a medical mask should themselves be examined at their cores, and their tragic futilities be faced by lawmakers, physicians, and laypersons alike.

    Let it be understood that such tragically absurd events and waste of critical resources arise out of our society’s choice to presume that adults who would seek relief from their physical/mental sufferings via psychotropic pharmacology alone are to be presumed to be mentally incompetent, to be demonized, ostracized, and subjected to endless (itself quite profitable) supervision by corporately controlled, exploited, and law/policy-shackled physicians who (somewhat understandably) evolve into hatred of those that the system allegedly serves – as opposed to questioning the very premise under which drug controls place the physician in service to their patients, beyond physiological technology, and into the dubious and clearly ineffective secondary and tertiary realms of priest and policeman. We all reap the bitter fruit of such folly, with far too little questioning of the veracity of its core premises in the first place.

    It is no accident of fortune that physicians are held by the private health care system in a position where professional compensation may well follow in inverse proportion to the explanation and exercise of their most closely held moral and political character. The boss is faceless, nameless, and has no time for your platitudes …

    Such a sad state of affairs leads to the outright despite and misplaced antipathies (against the patient) of the frustrated bureaucrats that our existing system turns the medical profession towards, (with respect) demonstrated by the statements:

    “EMS should be able to triage…and this triage should start on the phone. Names of users should be tracked, and when abuse is suspected, prescriptions for drugs should be withheld unless *clearly* indicated.” (teet);

    and

    “the real problem is that the laws that say ambulances must pick these people up. They should have some discretion in this regard.” (David)

    Living in fear of litigation acknowledged, if this fear were to outweigh the actual humane concern regarding, “… the one time they DON’T take it seriously, it WILL be an emergency …”, we musk ask ourselves what we have become as professionals, as a society, as a culture.

    Thus I answer the lone proposition by “Anonymous” that this malignant masquerade (of “drug controls”, in addition to those whose drugs “are controlled”) cease – by removing the physician from their futile roles of priest and policeman on behalf of the State (not to mention the living in fear of the fate of their own reputations, net fiscal worth, and potential torment at the hands of their employing institutions, law enforcement, and public defamation), and allowing adults to decide for themselves what will be the private conduct of their lives (by allowing self-medication with psychotropic medications that do not *in themselves* cause significant *physiological* harm to the patient).

    If a person were then freely choose to forge their *own* fetters, cause themselves physical/mental malady, and decide to present their complaints, and a desire to be thereafter mandatorily supervised by the medical profession, so be it. This itself (as is) presents a fertile market for speculators, investors and employees of the medical professions (in the most cynical, avaristic sense).

    I am *not* proposing that such malignantly expensive procedures be financed by either: the taxpayers; the net worth and damaged reputations of physicians; or the coffers of the private/public insurance gods whose actuarials and attorneys imprison us all in one way or another, such that none of us (doctors or patients) are well served, and physicians are obliged to act as agents of the State, and their corporate employer, foremost.

    Thankfully, “Hypnoid” here interjects a sense of the humanity that we should ask ourselves *why* we are losing, by stating:

    “But I do live in fear of making a mistake and letting someone die.”

    and

    “Erring on the side of taking the patient seriously is probably the best bet. Having said that, if your impression is the patient is faking symptoms to get drugs, there’s nothing wrong with declining to give them any. They do need assessment though!”

    Probably the best “bet” indeed (though I do *not* perceive Hypnoid as applying this term as against the patients’ interests, and in the primary interest of the physician only).

    Should I land in the ER as a patient myself, I would hope to be fortunate enough to find myself in the hands of a physician such as “Hypnoid”, and not in the hands of physicians seemingly so burnt-out and hostile (toward the institutions that employ them , as well as the State which constricts them) that the patients ostensibly being served (themselves) become despised and abandoned – deemed innocent of the high crime of the potential desire to “self-medicate” only following inquisitions of the most exclusionary and dehumanizing manner. What a sorry state of affairs for all! A self-sustaining insoluble mess.

    This cult of drug-avoidance (the driving forces of which revolve around the material wealth of insurance/institutions/physicians at least as much as around the best interests of the patients) has been historically shown to be futile (as a war without end waged upon basic and age-old human nature). Only in the last century have personal morality, and victimless thought-crimes been made such a crucible of social control, and such an industry of those who would somehow ensure that adults do not engage in “self-misuse”, entering uninvited into their lives as alleged saviors, employed in the business of pat/mat-ernalism.

    The trivialization, dehumanization, control, and (even) exploitation by over-supervision of adult human beings who would dare to request the tabooed “pana-pathogens” of today (once hailed by the same industries and professions that introduced and described the same as “panacea”) is emblematic of a society obsessed with sin/absolution, crime/punishment, liability/litigation, facade/reputation, and judgmental pontifications made by all concerned post-facto; an “industry” sick within itself.

    It is these obsessive dependencies that have/will destroy trust and integrity of the systems and individuals who in (oath and at least in idealistic fantasy) once set out to serve humanity. Welcome to the private Theraputic State. It serves well neither doctor or patient alike, subjecting both to the iron fists of profit and indifference at cost to the quality and integrity of care resultantly even possible.
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    The article cited is obvious nonsense. I can believe that people often willfully abuse ambulance services or people may panic over mild problems like heartburn not realizing the nature of what ails them and imagining it is something more serious. The former is inexcusable, the latter understandable.

    I can also believe that a drug addict might call an ambulance complaining of chest pain in an effort to score drugs.

    What I can’t believe, and what this article expects me to believe, is that a drug addict would get away with this behavior more than once, if that. I can’t think of too many ER docs who would give you Lortab for nonspecific chest pain, and if by some chance they did it once, they sure as hell wouldn’t do it a second time particularly if you came by ambulance both times.

    The idea that a drug addict can use this method as a means to regularly secure a fix is complete, utter nonsense, and I suspect this article is simply sensationalistic invention based on existing stereotypes and fallacies, rather than on fact.

    Are doctors really so desperate to demonize the 70 million Americans with chronic pain that they need to resort to bogus articles like this as “proof” of their prejudice?

  • David

    Payne Hertz – I can believe it. Abdominal pain would probably work better though. The system is not so interconnected as you suppose. If you read the article, you will see that the patient requested different hospitals each time – thus reducing her chances of being found out.

    Doctor Rocktor – I love your statements. I think your position amounts to legalizing these drugs, and therefore, taking the physician out of the position of being policeman for them. If patient’s want a doctor’s *advice* they can seek it – but neither party should be forced to deal with the other.

    In addition, I believe that the illegality of drugs creates a lot of profit in the drug world, funds gangs, and endangers all of us in the end. Prohibition of alcohol led to the same gang profits and general endangerment of the public.

  • Doctor Rocktor

    David -

    Thanks for considering some possibilities for removing the “fear we favor”, and it’s long standing and ongoing failure to result in allowing the potential for the physician and patient to communicate as competent and responsible adults, freed from the miasma of criminal and civil structures and strictures which have and remain inefficient, ineffective, and based on a patient as childlike victim and physician as responsible parent relationship.

    Correspondingly, the patient community would have to be (in return for such liberties) understand that the very real potentially negative consequences arising out of choosing to willfully sacrifice their sense of free will to a molecule(s) are not a moral or financial obligation of other persons having no hand in the making of such choices on the part of the citizen.

    If the individual deems it desirable to employ the ways and means of medical system(s) that may (in order to succeed) ) requires them to willfully sacrifice their sense of free will, and in certain respects willfully forfeit certain individual liberties, it would remain the responsibility of the cost-paying *patient* to work to ensure that such requested interventions succeed. There would be little or no incentive for deception or phony rationalizations between physicians and patients within interactions surrounding drug use. Responsibility would be personal.

    In cases where forceful societal intervention would be necessary, it would seem more equitable and straightforward that the individuals patients (and/or the taxpaying public) bear the costs – and not the physicians and institutions already detrimentally slaven to the medical insurance industry and operating under endless frustrating and counter-productive limitations, as well.

    While (in fairness), the ethical “devils” arise in the details of who constitutes a “competent adult” (a function that an over-the-counter distribution system would not, and could not, fulfill), societies through the ages have grappled with both what is (as well as who should define) “soundness of mind” (sanity), and at what point the individual’s instinctual drives towards experiencing “feelings of well-being” (euphoria) has substantively, and in actuality, precluded that individual from being treated as a competent adult.

    Opining as to when/where thoughts (and/or essentially victimless behaviors) become crimes never has and never will be a cut-and-dried endeavor within societal history (and never will, or should, be in a genuinely free society).

    It seems that physicians grapple with enough under private corporate medical institutions (as well as in the now all-too-rare private practices) that is in itself physiologically (and not psychiatrically, or theistically, or criminalistically) critical and important to the well-being of the patient. Removing the unreasonable (and ultimately unworkable) robes of priest and policeman from the practicing physician may well be a fundamental change in societal approach to seriously and thoughtfully consider.

    We (should rightly be) rewarded and punished for the behaviors we display – not for the virtues or vices that others attribute to our character, or the drugs they detect in our urine. Our ultimate actions transcend our rhetoric (as it rationally, and rightly, should, I believe, be the case).

    You might also enjoy some of my thoughts (along similar lines relating to drug controls) recently expressed at:

    http://www.kevinmd.com/blog/2009/07/did-propofol-or-diprivan-kill-michael-jackson.html
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    I can believe it. Abdominal pain would probably work better though. The system is not so interconnected as you suppose. If you read the article, you will see that the patient requested different hospitals each time – thus reducing her chances of being found out.

    I am a chronic pain advocate with over 17 years experience listening to the horror stories from people with legitimate chronic pain conditions and how hard it is to get their pain treated. I don’t believe for a second this story is true, because it is completely at odds with the real life stories I have heard, and not the inventions of journalists using drug war propaganda to create moral panic and sell bogus stories.

    You overestimate the ease with which someone can get treated for pain in an ER, and you underestimate just how easy it is for someone to get labeled a drug seeker. If you are on Medicaid and show up at an ER complaining about legitimate pain, odds are good you will be denied treatment and labeled a drug seeker, simply because you’re on Medicaid. If you have sunken, blackened eyes, waxy skin, mottled hair, “flea-infested” clothes, show up in an ambulance, complain of chest pain and ask for narcotics to treat it, the odds are almost nill you will be given a script for Lortab. You will almost certainly be labeled a drug seeker and denied treatment. That is a simple fact.

    Read some ER blogs sometime and see how hateful and hostile ER docs are to people coming to the ER for pain, particularly if they’re on Medicaid. The comments of doctors on blogs and in forums reflects the real life experiences people have reported to me. When you see it from both sides, the picture of what is really happening becomes crystal clear.

    If you read the article, there are only four hospitals in that city and one ambulance service. At most, the person might get away with this 4 times, though odds are the ambulance service will catch on and report the problem by the second event, if not after the first. Once this addict is merely suspected of being a drug-seeker, she will be added to the ER’s blacklist which is most likely shared with other hospitals and also local pharmacies as well.

    I have seen this happen to legitimate patients with real chronic pain with good health insurance, nice clothes and clean-cut appearance. I have known people with the side of their face swollen up from an abscessed tooth who have gotten the “drug seeker” treatment and denied medication, simply because they didn’t ask for it the “right” way, whatever that is.

    In 17 years of hearing chronic pain patients and their stories, either in real life or online, I have yet to meet a single person who has not been abused or treated in a degrading fashion at some point by the medical profession. Not one. Denial of treatment is the norm and those that do get treated often take years to find a doctor who will do so. Along the way they are at risk of being labeled “doctor shoppers” or “drug seekers” and blacklisted as such.

    There is tremendous hostility, bigotry, hatred and ignorance in the medical profession towards people whose only crime is that they have chronic pain, and some of the stories I could tell you about patient abuse are without exaggeration like something out of the Gulag. If you don’t believe me, read some ER blogs and some medical forms. Do a Google search for “drug-seeker” and see the venom for yourself.

  • Doctor Rocktor

    “WHERE IGNORANCE IS BLISS, ‘TIS FOLLY TO BE WISE”

    Payne Hertz -

    In resonance with your most recent post (directly above), I would add that for an intelligent individual patient who actually educates themselves as to the pharmacological aspects of (particularly) opioid medications (including things as simple as the name-brand products generic drug names, dosage strengths available, etc.), the near universal reaction on the part of physicians, nurses, and pharmacists is immediate and lasting suspicion.

    Even a long-term chronic pain patient who has successfully maintained a steady-use level is somehow expected to approach the physician with a requisite level of ignorance regarding the pharmacopia at the disposal of the dispensers of opioids.

    One simply does not request 14-hydroxy, 6,7-dihydro, 3-methyl, morphinone for pain (oxycodone), or they would call out the canine-corps and block all entrances/exits …

    Instead (with head hanging duly down), the typical patient seeking pain medication is encouraged (if not required) to mumble some mispronounced partial tidbit of the brand-name of the drug (as if they were born yesterday down on the “pharm”), hoping the Solomonic physician will take pity upon their ignorance and innocuousness, and dole-out a small number of the tabooed grail …

    Thus, the more the patient knows and understands, the more that person represent a danger and threat to the system ostensibly existing to serve the best interests of the patient.

    The message that such attitudes on the part of members of the medical community sends is both paternalistic and condescending. The net result engendered is a society of patients forced to conceal their very (worthwhile, as well as important and useful) knowledge. This allows the physician the present/future option to engage in a gamut of phony rationalizations with which to deflect the patient’s present/future requests for pain medication.

    Sadly, for all concerned, the sorry truth is much closer to the fact that the physician is motivated by fear of the State and their (oft) corporate employers to act as a double (or triple) agent – allegedly serving the patient, actually taking orders from the state, and still looking out primarily for themselves.

    If the patient presents with accurate knowledge surrounding their physiological condition(s), they are too often surmised to be “hypochondriac” or “type-A”. If the patient presents with (what may well be legitimate) concerns or fears about potential treatment regimens, they may be written-up as “phobic” by the physician. Such being pejoratives against the knowledge/character of the patient then stands for all time upon their medical records.

    Medical support staff (and particularly pharmacists) chronically play along, trivializing and dehumanizing the intentions and needs of the patient.

    In short, a competent adult cannot well versed in the nature and potential solutions to their long-term chronic pain cannot win for losing – unless they feign a childlike ignorance and maliability, like a happy idiot willing to shell out lots of money to merely approach the oracles of the pharmacracy desperately hoping to not get run out of town by an irritated/suspicious physician or assistant, or (even more likely) a busy-body pharmacist who treats every tablet of opioid medication that goes into the drug container as the moral equivalent of hellfire and damnation.

    The “masters of the universe” who concern themselves with the alleged detection and persecution of “self-misuse” ought to try on the shoes of a long-term chronic pain patient who must endure such condescending and (reputationally) damaging treatment themselves. It is not at all likely that these people would find such a situation (as affecting them personally) to be either equitable or tolerable when *they* experience life on the “other side of the counter”.

    A travesty of a moral crusade wearing a medical mask, indeed. Such is the effect of endless wars upon human nature, and the forming of an indifferent and privileged elite becoming ostensibly involved in caring for humans. One might hope that we could do better than that …
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    Thanks for your thoughtful words, Docktor Roktor. I can vouch from personal experience and that of many chronic pain patients I know that what you are saying is Gospel truth. We often tell people in cp support groups that I’ve been in that “knowledge is not power,” at least when dealing with the typical doctor. For many doctors, there are only two kinds of people in the world who know what Oxycontin is: doctors, and drug addicts. Apparently, no one else has been given access to the sacred scrolls containing this arcane knowledge. It is a shame that intelligent, responsible adults have to infantilize themselves in the presence of doctors, lower their heads and keep their mouths shut lest they say something that can be perceived as evidence that they are just addicts looking for a fix.

    If you are too nice, beware, as many doctors consider excessive niceness as a classic sign of drug-seeking behavior. But if your are outspoken or assertive, that will really tick them off, so somewhere between loudmouth and doormouse is where you want to be. Do not underdress or overdress, because underdressing means you’re a street addict, and over-dressing a clever street addict or middle class addict. If you are stoic and hide your pain, you will be accused of faking it. If you are more vocal in your pain expression, you will be accused of exaggerating and faking your pain. No matter what you do, it all comes down to a crap shoot, whether Jupiter is aligned with Mars, did the doctor have a nice vacation or not and did the BMW require less repairs then expected. Because if any of these important factors are not aligned in your favor, you can receive a non-judicial sentence of torture that can be almost impossible to get a pardon for.

    I don’t blame the state exclusively, as these paternalistic and puritanical behaviors are the underpinning of state policy, and would exist in the absence of that policy. The drug war merely exacerbates this by creating a climate of fear and paranoia in the medical profession to add to the already existing atmosphere of condescension and contempt to create a potent brew of anti-patient venom the patient is required to swallow or be tortured.

    What’s sad is that few doctors can ever bring themselves to wonder what it must be like to be on the other side of the prescription pad, supplicating a god/commissar who has the power to destroy your life with a swipe of his pen. Sadly, far too many relish this power and even brag about exercising it on their blogs. I don’t believe such people can be educated. If you have to take a course in ethics to realize it is wrong to torture and abuse another human being, even a drug addict, then you are likely already beyond redemption.

    Let’s never forget that it was the medical profession that pushed for the Harrison Act and for a monopoly on prescription drugs which in my view, is the primary cause of the problem of both undertreated pain and drug addicts having to lie, manipulate and steal to treat their medical problem, which is addiction. That this behavior wouldn’t exist in the absence of draconian drug laws and physician monopoly over supply is obvious. It didn’t exist back in the 19th Century when opiates were available cheaply over the counter and opiate addicts like Emily Dickinson didn’t have to lift her petticoats in a back alley somewhere to get money to pay Pablo Escobar or Dr Feelgood for her fix. Nowadays, she would be dismissed and treated as a “drug-seeking scumbag” by our enlightened medical profession, rather than the amazing talent she was.

    Take away the drug laws, and take away the prescription pad, and you take away the problem.

  • Doctor Rocktor

    Payne Hertz -

    I took a look at your blog-site, and find your thoughts from the patients’ perspective to be both thoughtful and meaningful. It’s a healthy thing that folks such as yourself exist in order to advocate the interests of everyday folks who suffer harm at the hands of the existing “pharmacratic regime”.

    I would add that if society (in the case of federal/state scheduled controlled substances) were to legislate away the “drug laws” and the “prescription pad” (where relatively physiologically benign medications are concerned) a very profitable industry based upon State-sanctioned mandatory supervision and over-medicalization of the personal choices of competent adults would also disappear.

    As the “going nowhere fast” alleged health care reform debate on Capitol Hill again demonstrates, Congress is so corrupted by the venal influences of the private medical insurance/institution/pharmaceutical industries that the profit-mill that is represented by these pharmacratic monopolies is not likely to abate without a vicious fight.

    The “anti-self-misuse” industry is a very large, profitable, and well-entrenched fixture of our increasingly morally obsessive society. A great deal of (largely illusory) comfort for the patient is marketed as a facade of blameless victim-hood for the medical consumer (reminiscent of Greyhound Line’s old sales pitch of “Leave the Driving to Us”). Patients will have to come to recognize that such charades are, in fact, not always in their own best interests, and be willing to exert influence upon Congress.

    Nevertheless, the day (may, someday) come where physicians themselves – already controlled, exploited, and embroiled within so many structures and strictures which dangle them in the middle of trouble (privatizing the upside profits to their corporate employers, while socializing the downside risks upon the physicians’ own net monetary worth as well as professional reputations – may actually themselves find the wisdom and courage to (also) exert influence upon Congress to remove themselves from the futile role of playing responsible parent to competent adults who no longer desire to be treated like incompetent children.

    An over-the-counter distribution system would need to be legislated to be able to restrict sales to adults at the vendor’s sole discretion – without liability for those sales. Additionally, manufacturers should be required to provide comprehensive and accurate product labeling only, and be free from further product liability arising out of the use of their products.

    Finally, the American people will have to muster the courage to demand that their government cease from the prohibitions upon opioids that the Harrison Narcotics Act established (as well as the criminalization and prosecution of many thousands of physicians which occurred concurrent with the adoption of that legislation, and continue to this day).

    We must as a people actively choose against coddled victim-hood bereft of personal responsibility for our willful choices and actions, thus assuming personal (moral and financial) responsibility for our own behaviors. This may be a lot to expect of the populace, but it is a requisite price of the freedoms born from liberties, indeed.

    Without such insight and wisdom demonstrated on our own parts, we are likely to be ever doomed to buying the sales-job of the delusion of painless victim-hood in the allegedly benign hands of paternal and parasitic profiteers (of whom there will surely be a never ending supply).
    .

  • David

    “We must as a people actively choose against coddled victim-hood bereft of personal responsibility for our willful choices and actions, thus assuming personal (moral and financial) responsibility for our own behaviors. This may be a lot to expect of the populace, but it is a requisite price of the freedoms born from liberties, indeed.”

    Well said. Both of you have pointed out that government/physician control over narcotics (and, I think, other drugs) should be done away with and personal responsibility should come into the forefront.

    In the current, far less than ideal, circumstances, I think it is worth noting that the physician’s anger and distrust are not born of malice or hatred for the pain sufferer, but of true lack of knowledge. There ARE drug seekers (people who are looking for the high from drugs and are not simply avoiding pain with them). I treat many patients with chronic pain, be it from intractable migraine headaches, CRPS, back pain, neck pain. I am put into a position of responsibility for these patients (they can’t get narcotics and other pain meds by any other legal means) and yet I don’t always know who has ‘real’ pain and who doesn’t. My default position is to always believe the patient – but we also have them sign narcotic contracts and try to have them follow a strict code of behavior with respect to the narcotics. I have had patients admit to me, later, that they exaggerated their pain to get more narcotics. I had one migraine patient state that she used to see another neurologist in order to get narcotics -she liked the feeling from them, and her migraines weren’t really that bad.

    So physicians are placed into this bad spot. There are patients in real pain, and fewer (I think) patients who are not in real pain. We need an objective measure of pain, but don’t really have such (at least not yet). Therefore we become distrustful and try to come up with clear rules regarding narcotics – even though no clear rules can really be established. We don’t want to be fooled, taken advantage of, be made fun or by other physicians for outrageous dosages or poor behavior wrt narcotics. Thus, the distrust that occurs in the doctor patient relationship.

    Some doctors try to be too simple about it: I won’t give narcotics for migraine headaches – and end up allowing a great many patients to suffer needlessly. Other doctors have dose limitations or complex rules for when they will or won’t provide them. All such systems fail, in my opinion, because of the complexity of individual patients.

    My rule is simply to trust the patient until and unless I am faced with clear evidence of abuse or diversion. I err on the side of treating the patients in true pain, even though I may be taken advantage of by some who are not. I think this is the only reasonable position until/unless other elements of the equation change.

  • ninguem

    “……What I can’t believe, and what this article expects me to believe, is that a drug addict would get away with this behavior more than once, if that……..”

    I’ve seen it myself. For years, one person in my town would hit a ER in a two-state area at least once a week, with a rotating number of Urgent Care clinics and private physician offices. Ther person ended up in my office as a follow-up from a recent ER visit per hospital policy. It happened to be my day to see post-ER patients, so I learned about it. Shocked when I asked for the last year’s hospital notes, and got a 4-inch stack of paper…….all ER visits. Just one hospital. Found out about other hospitals, Urgent Care clinics, and some private physician offices.

    Alleged “headaches”. Claimed an extensive workup, and some nationally recognized headache expert who advised this course of treatment. I think person did not expect a doctor who would actually check this sort of thing. No evaluation, no imaging, no expert recommending anything. Person was privately insured.

    Fair to say, person was not seeking relief, person was seeking drugs. Someone seeking relief would actually have had evaluation of problem.

    Had another who gave me a reasonable story, prescribed the opiates. Back in ER a week later, I had to admit. Comatose. Person engages in a party with others of a similar habit. They trade their drugs for a polypharmacy party. ER doc notes frequency of this, I was the next doc taken in. Person moved on to another doc.

    Still another, an elderly person claimed the drug needed for various orthopedic pain issues from degenerative disease. Treated. Sure enough, in about one month, admission for aspiration pneumonitis. Husband finds me from name on prescription bottle. Says wife had been doing this for decades, one doctor after another. If relief-seeking, person would dose to relief. This person dosed to oblivion. Again.

    Emily Dickinsons all I’m sure……..

  • Doctor Rocktor

    David -

    Your further thoughts are interesting, and helpful in understanding your personal viewpoints and approach to prescribing opioids in a more comprehensive sense.

    (Quite honestly, and expressed in the constructive spirit that your subsequent posts reflect), I found your (initially posted) statement regarding your thoughts on what you appeared to describe as potential denial of emergency response to patients who had (in some undescribed manner) been alleged (by some undescribed person within the medical profession) to exist under the rubric of “drug abuser”:

    “… the real problem is that the laws that say ambulances must pick these people up. They should have some discretion in this regard.”

    quite disturbing as a proposal of social policy seemingly allowing the denial of care by the medical profession to any individual. The thought that a convicted murderer or rapist would have more rights than a citizen (somehow) suspected (or even convicted, for that matter) of violation of drug laws disturbs and deeply troubles my conscience.

    I could not help but imagine such a patient dying as a result, and their last thoughts being, “if only I had merely murdered or raped another person – instead of choosing to personally and (perhaps even) peacefully ingest a molecule(s) that gave my mind a sense of well-being …”.

    Agreeing that fraudulent use of EMS and ER services is an unfortunate, counter-productive, wasteful, and potentially dangerous (for other patients in need) habit for any person to engage in, it is also true that there are reasons why otherwise motivated individuals (such as an unharmed accident victim seeking to instigate a tort claim for monetary gain) can and do “use” EMS/ER resources.

    The legitimacy of their ailments and alleged suffering (as in the case of soft-tissue damage not accompanied by bone-fracture) are no less problematic to assess for a physician – yet we do NOT leave it up to EMS personnel in those cases to decide if they like to refuse to transport such a patient to an ER.

    The pursuit of money (“money-seeking-behavior”?) seems no more sacrosanct to me that the pursuit of peaceful personal pleasure, and the concept of a targeted “trivialization and dehumanization” of the latter class human beings (in part) inspired my statements in my subsequent post entitled, “A Sad State of Affairs, Indeed”.

    In your most recent post (July 10, 2009, 4:39 PM) I hear you expressing a more generalized frustration relating to discerning the patient’s true intentions when you say:

    ” … the physician’s anger and distrust are not born of malice or hatred for the pain sufferer, but of true lack of knowledge.”

    There are many things in medicine for which we do not possess “objective measures” for assessing. The same uncertainties apply to identifying and assessing the nature and severity of “soft-tissue” injuries at the time of injury, for instance. The relevant problem here seems to be the physicians desire not to be exploited (by and within) what are knowingly false claims made on the part of the patient intended for a purpose ulterior to the matter of their physiological health (such as money, or euphoric states).

    Decades of neuro-biological research has not succeeded in reducing the processes of “nociception” (pain) to any conveniently localized and measurable neural phenomenon or process. Similarly, decades of research into the pharmacology of opioids has not elucidated their actual “anti-nociceptive” actions, either. Much attention has been paid to attempts to understand (and summarily negate) opioid potentiation of “reward pathways” in the CNS. What has been one of the most intensively funded and pursued endeavors in the history of neural science has yet to yield a “holy grail” that would effect relief of intense/severe pain without resulting in the possibility of some patients experiencing a “sense of well-being” that they might desire to re-experience to an extent, resulting in a self-sustained physical dependence that can indeed exact a dear price upon one’s psychological well-being.

    “Therefore we become distrustful and try to come up with clear rules regarding narcotics – even though no clear rules can really be established.”

    It is honest and reasonable to acknowledge that no clear rules can (or thus should, I believe) really be established.

    “We don’t want to be fooled, taken advantage of, be made fun or by other physicians for outrageous dosages or poor behavior wrt narcotics. Thus, the distrust that occurs in the doctor patient relationship.”

    I can appreciate your valid desire not to become embroiled within intentionally false claims made on the part of the patient (regardless of their motivating incentive). Similarly, professional reputation, and the federal-level criminalization of providing “maintenance dosing” of opioids to patients alleging themselves to be “addicted” also contribute to the “bad spot” that your post does a good job of describing.

    Truly, a decriminalization (and de-medicalization, unless medical treatment is specifically requested) of voluntary self-medication with opioids (or other psychotropic substances) whose (oral) administration does not (in itself) result in significant physiological harm to the user would seem to go a long way towards removing you (as well as competent adults seeking such substances for either their pain or their pleasure) from the present conundrums so damaging to mutual trust and honesty between physician and patient, as well as allowing physicians to concentrate upon physiological health (free from the additional burdens and liabilities of psychiatry, priesthood, and police work).

    Further, the over-the-counter availability of effective oral opioid analgesics would largely mitigate (if not virtually obviate) the clearly more dangerous and harmful routes of administration of non-pharmaceutical (and so often both adulterated as well as impure) black-market opiates that promote both overdose, as well as disease transmission (not to mention the scourge of the black-marketeers, and their extremely detrimental effects upon society).

    Even if opiate habituation is a result, no pharmacologist worth their salt would claim that such opiate dependence is more physiologically harmful than a similar alcohol habit (the withdrawal from which we know can indeed be fatal)!

    Until such an unlikely day of enlightenment should occur, I am encouraged that you (personally) proceed with the realistic understanding of the non-universality of what (in each unique individual case) constitutes an “appropriate” approach where it comes to the administration of opioids:

    “All such systems fail, in my opinion, because of the complexity of individual patients.”

    This is a very important point that you have made – that (largely for political and professional reasons, I believe) remains either not understood, or patently ignored (both in medical school training, as well as by practicing physicians). Different patients may well vary greatly in their responses to, and benefits received from, opioid analgesia.

    Some examples contributing to this variability follow.

    John J. Bonica, in his excellent “Advances in Pain Research and Therapy: Opioid Analgesia, Volume 4″, states:

    [1] The dosage level to achieve efficacious analgesia using a particular opioid can vary by as much as an EIGHT to one ratio from patient to patient due to physiological differences affecting how the medication and its metabolites act upon the CNS of individuals.

    My note: This actuality is nearly universally ignored by physicians, where the recommended dosage levels are far more often dictated by political and reputational concerns, as opposed to the patient’s actual relief from pain. One size does not fit all, yet such attitudes persist.

    [2] Studies show that only around 3-4 percent of patients receiving a regimen of post-operative opioid analgesia develop a debilitating long-term psychological dependence upon opioids following cessation of such treatments. Thus, the development of dosage tolerance and physical dependence does not universally equate to psychological dependence.

    My note: It’s possible that the percentages may be a bit higher than the 3-4 percent that Bonica cites. Nevertheless, it is true that different people respond quite differently in a psycho-neuro-pharmacological sense to opioids. Some people despise how opioids make them feel, feeling dysphoric, disoriented, and nauseous when they take them. Others may enjoy the experience. Nobody enjoys feelings of nausea resulting from the cessations of peristaltic contractions. Few (if any) would seem to enjoy becoming constipated as a result of decreased intestinal motility. The headaches, irritability, and insomnia that can be experienced if a relatively constant plasma level is not maintained must certainly not be much fun, either …

    Such side effects (accompanying the daily use of essentially *all* of the available family of opioid receptor agonist “morphinans”) tend to act as self-limiting factors in folks who wish to be active and productive individuals despite the acute/chronic pain that they are experiencing.

    Therefore, I am thankful that you choose to trust the patient first – as there are many, many patients who experience “legitimate” pain whose quality of life, ability to productively function (and personal reputations in the eyes of the medical and law enforcement professions) are severely compromised and damaged – by merely looking to the medical profession to provide them with adequate relief from acute/chronic medical conditions that are not effectively (or affordably) addressable by means other than opioid analgesics. We should always remember that these folks are fellow human beings – and that, one day, we *ourselves* may possibly experience a similar need for relief from acute/chronic pain – without trivialization, overt condescension, or demonization of our personal reputations.

    Those who would seek opioids for the purpose of experiencing *pleasure* (of this we can be sure) are no more enamored with dealing with medical professionals in order to obtain them than medical professionals are enamored with dealing with them, either!

    I look forward to the day when society might wisely remove the (additional) cloaks of priest and policeman from the (already weighty) garments worn by physicians – allowing physicians to focus on physiology, and allowing adult individuals to choose (and take responsibility for) the course and conduct of their personal lives where it comes to the most personal of all “property rights” – one’s own minds, as well as one’s own body. If adults (instead) prefer guidance and/or to be supervised, there will no doubt remain an endless supply of guides/supervisors more than happy to provide such services for money …
    .

  • Doctor Rocktor

    ninguem -

    Those 3 experiences you recount sound like frustrating and disappointing ones, indeed.

    I would be curious to know (roughly) what proportion (on a percentage basis) those 3 episodes you recount represent relative to the total number of times that you as a physician have prescribed opioids to the patients that you have seen within the course of your entire career?

    (As it may affect the interpretation of your answer), did any/all of the 3 episodes you recount cause you to subsequently significantly reduce (or eliminate) your prescribing of opioid medications to your patients?

    Did the consequences of any of the 3 episodes that you recount adversely affect your career in any way?

    Did any of these 3 persons blame *you* for their ingestion of the opioids that they received as a result of your care?
    .

  • Doctor Rocktor

    THE TRUTH IS A LONELY HUNTER

    After reading the excellent LA Times article at:
    http://articles.latimes.com/2009/jun/08/health/he-lying8

    that is linked to the June 23, 2009 article at:
    http://www.kevinmd.com/blog/2009/06/should-patients-lie-to-their-doctors.html

    … I find *so many* reasons why patients (as well as physicians) are (for very understandable reasons) pressured and compelled to be less that truthful in their patient-doctor communications (of nearly all varieties surrounding their medical care that may well result in entries in their medical records, the content of which are out of their control, and in the hands of the physician) ..

    … the reality that some patients (wisely) would choose *not* to confide in their physicians that opioid analgesia may at times also result in their experiencing an additional “sense of well-being” (euphoria) seems like a “no-brainer”, upon the reflection of nearly any intelligent adult in this day and age of crimes/punishments, reputations/defamations, etc.

    Thus, a less than total honesty expressed in the Orwellian environment of drug controls (affecting the status of patients, physicians, and choices of treatment regimen) appears as a mere drop in a large bucket of issues about which a practicing physician cannot (and does not) expect to receive necessarily honest information from patients in response to their questions.

    Consequentially, it seems somewhat unreasonable for a physician to (pragmatically) expect to “single-out” personal patient information surrounding the use of opioid analgesia – holding such to the highest integrity (blandishing special written contracts, etc.) while all the while immersed along with the patient within of a miasma of other medical issues, all of which could, if entered in some particular manner into a patient’s medical record, would likely do harm to the patient’s future status and coverage with insurance companies, as well as treatment by medical institutions and physicians.

    The juxtaposition of all these technical matters surrounding the disciplines of corporate profit, medicine, and law is more than physicians (much less patients) can realistically hope to navigate merely in an idealistic spirit of total honesty all the time with all concerned. A pity, indeed – but a growing web of duplicities that has (perhaps quite understandably) rendered the possibilities for mutual trust and openness between physician and patient to be (increasingly over time) virtually nil.

    Physicians don’t expect the “whole truth” from insurance agents, employers, or patients – and are not disappointed. Patients have evolved to not necessarily share the “whole truth”, with growing awareness of the pitfalls of such disclosures. I believe that the private, profit-based “medical-industrial complex” (representing four times the percentage of GDP of that the “military-industrial complex”) has essentially (by moral and financial example) abolished all hope for the “Sunnybrook Farm” model. Who could or would actually believe the “color brochures”? How are ya gonna keep ‘em down on the “pharm” … ?

    The patients (allegedly served) dwell among the great unwashed at the bottom of a heap of half and mis-truths, serving in the financial service for capital gains of the stockholders of insurance companies and HMOs, with all too little genuine and sincere advocacy in the middle. Where ignorance is bliss, wisdom is folly, and no good deed may go unpunished, who expects to hear Truths?

    Perhaps a new thread should be started at Kevin MD entitled, “The Games that All Involved Parties Play primarily in order to Benefit and Protect their Own Self-Interests” …

    My, that would likely become a long discussion thread!
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    @David.

    I appreciate what you wrote here, and respect the fact that you are willing to give your patients the benefit of the doubt and treat pain aggressively. There are a few comments I want to touch on though, and I hope you will understand that what I have to say is based on my own, highly negative experiences with the medical profession and those of thousands of stories from chronic pain patients who have also had very bad experiences. I apologize in advance for the length but this is a complex topic that defies simplistic explanations. Let me also say that I agree with everything Rocktor says in his excellent response.

    In the current, far less than ideal, circumstances, I think it is worth noting that the physician’s anger and distrust are not born of malice or hatred for the pain sufferer, but of true lack of knowledge. There ARE drug seekers (people who are looking for the high from drugs and are not simply avoiding pain with them).

    No one disputes that there are drug seekers out there trying to scam doctors for drugs. What I would dispute, is that the number of chronic pain patients who are actually drug seekers is anywhere near as high as many in the medical profession make it out to be. I would also argue your opinion that a lot of the anger and distrust are not born of malice and hatred towards patients. I have simply heard too many horror stories of ignorant, abusive and degrading treatment towards people whose only crime is they have chronic pain to dismiss that as mere anger. When I read medical blogs and forums and see the seething, unbelievable hatred some doctors have towards chronic pain patients, who they call whiners, complainers, malingerers, wusses and drug addicts, it’s hard to see all that as the result of a bad experience or two with a drug seeker. When I see doctors openly bragging and expressing what is clearly sadistic delight in sabotaging the medical care of someone they perceived to be a drug seeker, I think there is something a little more pathological than mere anger there.

    In my opinion, the attitude of the medical profession as a whole towards cp’ers is a form of institutionalized bigotry as deep, as pronounced and as vile as anything we have ever seen in this country, even Jim Crow. Many doctors operate from a simplistic, bigoted, and stereotypical view of chronic pain patients that often has little or no relation to scientific fact or even common sense, and more to do with medical folklore, moral panic and puritanical judgementalism. Drug seekers do not force doctors to treat us like crap, to dismiss our legitimate complaints as whining, to refuse us treatment for our pain, or to sabotage our medical care by accusing us of being drug seekers and writing that in our medical records. For every drug seeker out there, there are 99 legitimate cp’ers who have been unfairly accused of being a drug seeker and either libeled in their records or denied treatment. It soon becomes a self-fulfilling prophecy as every patient falsely accused of being an addict by a doctor becomes one more piece of “proof” in that same doctor’s mind that most of his cp patients are addicts.

    In addition, I think there is lot of willful abuse of power going on by doctors and other medical professionals who have severe personality issues, and that a lot of the abusive treatment chronic pain patients have to suffer is coming from doctors who get off on it on some levels, and are both encouraged and protected in this behavior by the medical culture that exists in this country, which is authoritarian and doctor-centered. The very fact so many medical professionals feel comfortable expressing on their blogs their venemous hatred of chronic pain patients as well of violation of medical ethics and local laws without fear of repercussion or condemnation from their colleagues speaks volumes. What we have is far too many doctors who are acting not as healers, but as priests and cops, judging the character and behavior or their patients and pronouncing sentence, rather than administering medical care. Far too many doctors relish the role just a bit too much, and abuse the power their monopoly over pain medication gives them and the fact patients have no power to speak up without fear of losing their meds. I have heard of, and experienced, this behavior far too often not to think it’s common, if not the norm, and the medical blogs reinforce this view.

    We don’t want to be fooled, taken advantage of, be made fun or by other physicians for outrageous dosages or poor behavior wrt narcotics. Thus, the distrust that occurs in the doctor patient relationship.

    No one wants to be scammed or made a fool of, but any doctor who puts his ego above the welfare of his patients should not be in the medical profession. You might note that while you certainly face a risk of being scammed by a patient, we also face a risk of being scammed by doctors, too, though the damage we suffer as a result is grossly out of proportion of what you will typically endure at the hands of a drug seeker. We can be killed or injured by incompetent or careless physicians, or bankrupted by useless or counterproductive treatments. I read somewhere that over 25,000 Americans die every year as a result of unnecessary surgeries. 11,000 Americans die simply as the result of doctor’s handwriting errors with prescriptions. How many doctors are killed by patients every year? Other doctors get kickbacks for writing certain scripts or for ordering MRIs and other tests. This is the kind of scam we as patients have to worry about: the ones that cost us our money, our health, and even our lives. We can never really be sure if a doctor is recommending surgery for the sole reason of making money off us, or is writing us a script because he is getting a kickback, or just because he is trying to cover his rear and say that he is treating us when he is reluctant to prescribe opiates.

    Let me give you are a real world example of a doctor scam. I went for a surgical evaluation for low back pain to a neurosurgeon who was widely considered a specialist in his field. I brought my MRI with me, but he insisted that I get a CT scan and it had to be done at the lab he recommended. When I asked why he told me that “out-house labs bring outhouse results.” Okay, so I got the CT scan at his lab. When I go back to his office, he looks at the CT for less than 5 seconds, and says “congratulations, you don’t need surgery. Then he immediately does a double take, and says, “on second thought, you DO need surgery. You will need a blah, blah, blah (I couldn’t make out what he was saying, he talked so fast, but he was recommending a myofascial laminectomy). I will give you one month to decide whether you want to have the surgery or live with pain for the rest of your life.” Total elapsed time from the time the CT scan went up to his finishing his last word was less than 15 seconds, tops. The next doctor I went to for an evaluation suggested I needed a spinal fusion, and when I said that I would like to try acupuncture first, he told me that “acupuncture is fine, if you don’t mind getting AIDS from the needles.”

    These were two different doctors, both came recommended, who used scare tactics to try and get me to agree to two very different back surgeries.

    I know another woman with severe low back pain. She has had 15 different back surgeries, all performed by the same doctor. This doctor is also prescribing her a massive dose of Fentanyl, 750mcg, which is what she needs to control the pain caused by all those surgeries. The doctor is widely hated in the cp community and rarely treats anybody’s pain aggressively, even his post surgical patients, but he does so for this woman because her husband owns an insurance agency, she has platinum-plated insurance, and she has allowed him to perform all these surgeries. She is, in short, a cash cow, and the quid quo pro she has to endure to get the pain meds she needs is to acquiesce to these surgeries. How do I know this? Because at one point when she balked at having another surgery, the doctor told her that he could not in “good conscience” prescribe pain meds to a patient who was not actively seeking to improve her condition or was unwilling to follow his medical advice with regards to treatment options. When she expressed confusion at what he was saying, he spelled it out for her: I am a surgeon, and I cannot give you pain meds unless you have had a recent surgery with me. Thus, she has now had 15 surgeries as no one will ever give her that high a dose of Fentanyl in this area, and she knows it.

    These are the kind of things that convince me that by and large, the medical profession is more an impediment to the proper treatment of chronic pain than a benefit, and we need to put pain management into the hands of patients themselves and let patients decide what they will or will not put in their own bodies.

  • http://paynehertz.blogspot.com/ Payne Hertz

    @ ninguem

    <iI’ve seen it myself. For years, one person in my town would hit a ER in a two-state area at least once a week, with a rotating number of Urgent Care clinics and private physician offices. Ther person ended up in my office as a follow-up from a recent ER visit per hospital policy. It happened to be my day to see post-ER patients, so I learned about it. Shocked when I asked for the last year’s hospital notes, and got a 4-inch stack of paper…….all ER visits. Just one hospital. Found out about other hospitals, Urgent Care clinics, and some private physician offices….No evaluation, no imaging, no expert recommending anything. Person was privately insured.

    Thanks for your response. I appreciate that dealing with drug seekers can be frustrating, and I certainly acknowledge that drug seekers exist. I also thank you for keeping the tone civil. But I have to admit that I find your first example a little difficult to believe, and maybe if I present my objections you can set me straight on where I might be wrong.

    First, there’s the issue of how a patient can possibly generate this large a volume of notes from just one hospital without any doctor attempting an evaluation, ordering a test, or making a recommendation. What did they talk about in those 4 inches worth of notes, the weather? While I know some doctors are lazy and would rather throw a script at somebody than do the difficult work of diagnosing what might actually be wrong, this is far in excess of what even a cynic like me would accuse the medical profession of. And the scripts they throw at you are rarely narcotics. Given that it is incredibly difficult for real migraneurs to be taken seriously at ERs, it is very difficult to imagine they just opened the candy jar and dumped it out on this uber frequent flyer’s lap every time with out so much as an X-ray to justify it. He is either smooth enough to sell sand to Saudi Arabia or he just won the drug seeker equivalent of a trip to Disney World, because most ER docs just ain’t that easy. If this many doctors can see a patient without ever attempting something remotely resembling an evaluation, that is more an indictment of the medical profession than drug seekers.

    It is also difficult to believe that the same insurance companies who would deny you the cost of getting a broken leg fixed because you failed to get prior authorization would finance a multi-state drug jag involving multiple ERs and other expensive as hell venues without batting an eyelash or two.

    In your second example, it definitely sounds like you are dealing with a bona fide drug seeker, but in your third example, the elderly woman in question might in fact be a drug seeker who ODed. But it occurs to me that she might also have attempted suicide. Could it be that her doctor-shopping was the result of undertreated pain and that her overdose was a deliberate attempt at suicide as a result of her inability to receive proper treatment? It is actually very difficult for someone habituated to narcotics to OD unless they mix the narcotic with some other drug like alcohol, as in your second example. She would have had to have taken a pretty hefty dose and it doesn’t seem like that is very likely to have happened by accident. Just my take as I don’t know the whole story.

    As for Emily Dickinson, my point was not that every drug seeker is an Emily Dickinson, but that every Emily Dickinson would be dismissed as a “drug-seeking scumbag” were they alive today. In the 19th Century, respectable people who just happened to have an opiate addiction were able to function normally and remain respectable people. Nowadays, due to prohibition and the mindset of many in the medical and legal professions as well as much of society, Ms Dickinson would be condemned as the scum of the Earth and a plague on society and be forced to degrade herself, destroy her reputation and become a common criminal in her efforts to treat her addiction in the only way that works for most opiate addicts: with narcotics.

  • Doctor Rocktor

    Payne Hertz wrote (on July 10, 2009 at 7:03 am):

    “If you are too nice, beware, as many doctors consider excessive niceness as a classic sign of drug-seeking behavior. But if your are outspoken or assertive, that will really tick them off, so somewhere between loudmouth and doormouse is where you want to be. Do not underdress or overdress, because underdressing means you’re a street addict, and over-dressing a clever street addict or middle class addict. If you are stoic and hide your pain, you will be accused of faking it. If you are more vocal in your pain expression, you will be accused of exaggerating and faking your pain. No matter what you do, it all comes down to a crap shoot, whether Jupiter is aligned with Mars, did the doctor have a nice vacation or not and did the BMW require less repairs then expected. Because if any of these important factors are not aligned in your favor, you can receive a non-judicial sentence of torture that can be almost impossible to get a pardon for.”

    Payne, you are not alone in your observations and criticism of the modern privately based “Theraputic State”:

    “One of medicine’s classic conundrums is the distinction between legitimate and illegitimate pain. The distinction between these two kinds of pain may be entirely strategic, in other words, the distinction may not relate to anything in the patient at all, but may relate instead to what the physician treating the patient says and does. Prescribed medication for pain is an indicator of the credibility of the client’s complaints.” …

    … “It is morally praiseworthy to attribute drug use to mental illness, peer pressure, parental neglect, poverty, social injustice, drug pushers, the addictive properties of drugs – anything but the drug user’s free will. Although these explanations are patently false, their scientific validity is authenticated by the medical profession; and although these explanations are patent evasions of personal choice and responsibility, their moral legitimacy is authenticated by the courts.” …

    … “The War on Drugs is a moral crusade wearing a medical mask.”

    -Thomas Szasz, Professor Emeritus of Psychiatry, SUNY
    .

  • ninguem

    Maybe Emily Dickinson would have been considered a “scumbag”. Or maybe her painful condition would have been cured. I don’t know what her painful condition was, or if anyone knows. I scanned a couple of biographies to see if there was a mention, didn’t notice any. It could have been as basic as a uterine fibroid.

    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. I 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.

    The ER doc’s job is to take care of the acute problem. They aren’t expected to do primary care. They give a quantity of opiate and move on. To their credit, they didn’t run a CT every time the person came back to the ER. Add to this, the person hit up ER’s over a two-state area, they don’t necessarily talk to each other.

    Actually, the local ER finally DID put a stop to the practice with this particular person…….BECAUSE I FORCED THE MATTER. It’s a really big deal for a hospital to create a policy to deny emergency care to a person, but it can be done. It usually requires significant provocation. It was done. Even then, it only covers the particular hard-to-measure pain complaints the person was known for. Come in with a new complaint, the person will still get treated.

    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.

    The result of this was the person went even further afield. I got calls from hospitals over 150 miles away. Person forgot that I was no longer their doctor, person left for a new target. Gave ER doc 150 miles away my name as primary doc, Saturday night, figuring someone else would be covering anyway. Lucky day, it was my turn to cover everyone else, so I got the call. I had identified about ten doctors outside of ER’s, of course those were the ones I found, who knows how many more are out there. I’m not the first to realize I was being scammed, I was the first to put the brakes on the person’s scams with ER’s.

    Person was a professional in a position to take it out on my children. Person DID take it out on my children. I had to deal with it with supervisors, while respecting the context of medical confidentiality.

    Don’t know what makes Roktor think I stopped at three because that’s all I’ve had. I don’t want to burn out Kevin’s bandwidth. Pain patients stop at analgesia and they don’t mix recreational drugs and alcohol. I’ve had my share of patients who gave me a plausible story and promptly overdosed. As in, comatose in intensive care. Family members come by and remark he/she has done it “again”, as in found a new doctor.

    I’ve had the coroner calls. Dead person with my prescription bottle……and many other doctor’s prescription bottles.

    And yes, I HAVE been blamed by patients for “addicting” them. More than once. It is usually in the context of legal battles, as in they are facing DUI’s, domestic charges, prescription forgery, and blame me for their problems. In every case, it is obvious they were addicted long before finding me.

    I have boards in pain medicine (American Board of Pain Medicine) and a fellowship in same from an Ivy League program. I do general medicine and medical pain management.

    I’ve taken on the HMO’s and other parties when I felt the opitates were necessary, including the evil Oxy-Contin. Nothing wrong with the drug if you don’t misuse it.

    And I’ve had some Emily Dickinson types who use a small quantity of Morphine daily, constant for years. They stay on it. Problem is not surgically fixable…….or they’re little old ladies who’d rather go on as they are and they function and I let them. Willingness to prescribe the stuff means you WILL get burned. So, we get grief from the regulatory agencies who think the stuff is Plutonium and we’re the North Koreans, and clowns like the ones here who think the stuff is Holy Water From God and we’re evil for taking it away from the guy who made himself comatose for the fifth time with five sequential docs.

  • ninguem

    >>He is either smooth enough to sell sand to Saudi Arabia or he just won the drug seeker……………

    By the way, you CAN sell sand to Saudi Arabia. They import mass quantities of sand. It turns out, their local sand does not work well in cement manufacture. Look it up.

  • ninguem

    With all due respect to the late Dr. Bonica. I have some of his books, including the classic management of pain text, and I’ve been around long enough to have heard him lecture.

    In addition to general medicine and pain, etc…….I also have a thriving Suboxone practice. I see many people who started out with a pain problem with opiate use that went far beyond pain control.

    No they’re NOT functioning. I’ve had some who get their medicines by those mail-order places where they find some sociopathic doctor perfectly willing to prostitute self and write controlled drugs in mass quantities, sight unseen.

    In fact, sometimes I wonder why people who just want the drugs, even bother to consult local doctors. Sometimes there’s a candyman in town. I get spammed with offers to engage in the same prostitution, all the time. Seems to me, just order direct from these places, there’s all too many of them, unfortunately. Seems to me, the risk is more with the pharmacy and mostly with the doctor willing to prostitute self.

    The people had a pain problem that had long since disappeared, but the drug problem persisted.

  • Doctor Rocktor

    ninguem -

    Regarding your recent statements:

    “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.”

    and

    “Don’t know what makes Roktor think I stopped at three because that’s all I’ve had. I don’t want to burn out Kevin’s bandwidth.”

    DR: You cited 3 incidents. You did not indicate that more than 3 existed. Kevin has adequate bandwidth – but one can understand that you may have limited time to author your posts. You could have indicated that, if true. Fine.

    Your thoughts and experiences are meaningful and instructive in providing the substance and context of your personal experiences as a physician. Thank you.

    Regarding your statement:

    “And yes, I HAVE been blamed by patients for “addicting” them. More than once.”

    and

    “In every case, it is obvious they were addicted long before finding me.”

    DR: You indicate that (at least) 2 patients have attempted to project the responsibility for their own personal choices upon you – after soliciting you for those very same drugs. (Not to diminish the potential complexities that may have been involved in your defending your actions), it seems reasonable and fair that you prevailed in your defenses.

    I still think that it would be instructive to our readers to be allowed to benefit from a sense of context relating to your (roughly approximated) measure of the percentage of the *total* number of times that you have prescribed opioids to the patients who you have treated that these (greater than 3, as you have now stated) episodes represent. Rephrasing my original query to you (posted above):

    [1] (Roughly) what proportion (on a percentage basis) those “N” episodes that you state have occurred represent relative to the total number of times that you as a physician have prescribed opioids to the patients that you have seen within the course of your entire career?; and

    [2] (As it may affect the interpretation of your answer), did any/all of the “N” episodes you recount cause you to subsequently significantly reduce (or eliminate) your prescribing of opioid medications to your patients?

    Not to diminish the frustrations and disappointments that the “N” incidents that you allude to have caused you to experience, thank you (in advance) for providing answers to questions [1] and [2] directly above – as such information will help the readers understand what (in your personal experience) is the *actual* level of prevalence of such behaviors on the part of (your) patients presenting with complaints of pain, relative to the *total* number.

    It seems to me that the readers deserve to be provided with a sense of genuine perspective as to the actual prevalence of such behaviors on the part of patients in general (as you have, in your personal experience, found).

    More objective information would go a long way towards (either) corroborating or refuting statements such as:

    “Problem is, for every responsible narcotic user, you have another hundred who play the drug games.”

    made by the author of the KevinMD’s Oct 6, 2006 article (curiously, and ironically) entitled, “How pain patients are treated like criminals” at:

    http://www.kevinmd.com/blog/2006/10/how-pain-patients-are-treated-like.html
    .

  • Doctor Rocktor

    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.
    .

  • ninguem

    And I myself could make a statement such as:

    “Responding to this tripe gives it a dignity it does not deserve.”

    I’ve dismissed a dozen patients this year for obvious abuse and occasionally diversion of drugs. The DEA allows me one hundred Suboxone patients. None are heroid addicts. One hundred percent were prescription drug abusers. They started out with pain problems that turned into addiction. All of them. One Board complaint over cutting off opiates. Quickly dismissed. I’m not crazy enough to go before the Board alone, even with a simple case. Lawyer fees get folded into my malpractice premium. So I know it will be higher next year.

    Denominator, how many pain patients I have……I have thousands of patients. I do not limit my practice to pain. The Suboxone patients are mostly other doctor’s patients who ended up with me. Story remains, they had pain problems that turned into addiction problems.

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

  • Doctor Rocktor

    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 … ;)
    .

  • Doctor Rocktor

    Some Doctors, we find, have different viewpoints entirely where drug controls are concerned (and manage to hold those viewpoints without belligerence toward the “great-unwashed” who are ostensibly served by such fallacy.

    “The illusion that the physician is primarily a doctor rather than a detective – an agent of the patient rather than of the state – lingers on.” …

    … “Can such paternalism on the part of the rulers lead to anything but infantilism on the part of the ruled?”

    -Thomas Szasz, Professor Emeritus of Psychiatry, SUNY

    My mind boggles at how our society has evolved to be so *libertarian* where it comes to “money-seekers”, yet so puritanically *totalitarian* where it comes to personal choices in the (peaceful) practices of adult human beings.

    How many of those among us would don the dubious robes of “moral savior” were it not for the enticement of monetary gain? And how many of those among us would don the “constable’s clothes” were it not for the strictures imposed by the State and our corporate employers?

    Have we not, as “Apostles of Hippocrates”, abandoned our own consciences as human beings by (all too often, perhaps) serving the “money-changers” who profit from the denial and usurpation of human dignity under the rubric of “mental-hygiene” (until the money runs out) – while leaving the least among us to fend for themselves in the gutters of the streets of the “shining city on a hill” to which we only commute in golden chariots during banker’s hours?

    Have we (in such self-centricisms) evolved from relieving human suffering to (in all too many ways) serving to assist in engendering that which we originally set out to remedy?
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    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?

  • http://paynehertz.blogspot.com/ Payne Hertz

    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.

    Lol. Bravo. The “hero-id” can’t exist without an “antihero-id” to give it meaning. If drug seekers didn’t exist, it would be necessary to invent them. And invent them they do. If not in reality with our laws and their control of the candy jar, then in their imagination.

  • http://drgrumpyinthehouse.blogspot.com Dr. Grumpy

    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

    wow, a typo. You’re a real hero, sockpuppet.

    Twenty pages just to walk into a ER. Sounds about right. Face sheet, financials, consents, nurse’s notes, doc’s notes, progress notes, discharge instructions, the standard patient information stuff. Yeah, I’d say about twenty pages even if nothing was done. More if they actually did something.

    Does it take twenty pages to document such a minimal ER encounter? No. Are twenty pages actually generated? Yes.

    Suboxone management by FDA regulations is 30 the first yeat, a hundred the second. I don’t know if they have lifted that cap to unlimited for those who have done it a long time.

    Not many people want to deal with addicts. So yes, one hundred. I get them from all over the state. Not that I’m particularly special, but because not many people want to do it. I still have openings, those who have done it for several years are at their legal limit.

    I’ve induced every one of them. None of the ones in my practice were injection drug abusers, as in HEROIN. They were all prescription drug abusers. One hundred percent.

    Ask anyone else with a Suboxone practice and you will get similar numbers.

    Obviously no experience with any of this. So much mouth, so little knowledge. A real piece of work you two.

  • Doctor Rocktor

    “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
    .

  • ninguem

    In addition to general medicine, I’m treating pain patients and those with addictions, in case you didn’t notice from the posts. Most just ignore the population. I’ve been on several medical missions in Third World countries. I’m boarded in two medical specialties. What I’ve learned is opiates are a double-edged sword. They can help, but they can cause a LOT of trouble. From a suboxone practice, I see a lot of people made better when they are taken OFF the narcotics they thought they needed so much. Whether you care to believe it or not, the numbers max out at a hundred patients per practice by DEA rules.

    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?

    You would never be my colleague, don’t worry about that. You would have to go to medical school first.

  • Doctor Rocktor

    “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 … ;)
    .

  • http://paynehertz.blogspot.com/ Payne Hertz

    wow, a typo. You’re a real hero, sockpuppet./i>

    Get over yourself. I think most people reading this realize you can spell “heroin,” so no need to parade your intellectual superiority. It’s just that the typo ironically revealed a very important truth, a truth which you have reinforced with the arrogance and self-congratulation you show here.

    Obviously no experience with any of this. So much mouth, so little knowledge. A real piece of work you two.

    I have had plenty of experience dealing with your profession and its alleged “knowledge.” I learned much to my surprise that I am a drug seeker and addict, even before I had ever touched a narcotic in my life. I also learned that I had a “history of alcohol abuse,” which is news to me because I don’t drink. I was amazed to discover the pain that has destroyed my life was in fact the result of malingering and symptom magnification, but that I still needed surgery for some strange reason.

    This is why I don’t instantly and without question buy into many of the exaggerated and seemingly bogus drug seeker stories out there. Not because drug seekers don’t exist, but because my medical record is an exaggerated, bogus drug seeker story.

    But hey, don’t blame doctors, blame the “drug seekers,” right?

    What gets me about doctors like you is the rock solid certainty with which you wield your “knowledge.” You never have any doubts, your suspicions are always right. That’s why I can respect a doctor like David. He has doubts. He isn’t sure. He realizes the moral and existential implications of guessing wrong and decides to err on the side of treating pain. But you, and most of your colleagues, are dead certain. If you think someone is a drug seeker, they are, and you punish them accordingly.

    Certainty is not the mark of a scientist, but a fanatic.

    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?

    Oh, yeah, it’s all my fault doctors won’t treat pain. If doctors won’t treat pain, it has nothing to do with their ethics or lack of humanity, it is strictly because “patients like you” dare to question the abuse we have to endure from those very same doctors. Nothing is ever the medical profession’s fault. It is always someone else’s fault. This is the reality of the “personal responsibility” you authoritarian types always trumpet.

    You know, you really are a priesthood, not scientists. You’re running the same scam they have been running for millenia. If the rains don’t come, a tsunami strikes, or pain patients can’t get their pain treated, it is because “heretics like you” question the priests and their arcane “knowledge.” If only we would do what the High Priests of the Prescription Pad demand, then perhaps they would see fit to relieve the suffering of the people. But because yea, verily do we dare question, the suffering of millions left to writhe in agony falls squarely on our shoulders. Yeah, right.

    What I’ve learned is opiates are a double-edged sword. They can help, but they can cause a LOT of trouble.

    Wow, really? You mean, opiates can be addictive and can even kill you? Who knew? There I was thinking there was no downside to taking a drug that makes you constipated, impotent, has the potential for addiction, and can only be acquired at great cost from the medical profession and is always subject to being withheld at a moment’s notice.

    But what they apparently failed to teach you at Harvard, is that chronic pain can cause a “LOT of trouble,” too. It can destroy your health, your career, your family and your life. It can destroy your will to live, and make you wish for death. It can drive you to kill yourself. It’s not a double-edge sword, but single edge, with no upside. It only destroys, and never benefits you. I know there was a time your knowledgeable profession taught that patients should be denied pain relief because it enabled them to experience the suffering of Christ, and built character. There are still doctors running around saying that pain in kids shouldn’t be treated because it allegedly “builds character.”

    The simple fact is, that chronic pain left untreated is always destructive. So what are the options, then? Opiate medications are the safest and most effective treatment for pain, bar none. The overwhelming majority of patients will benefit from their use, and only a minority will suffer the more extreme consequences of narcotic use. So faced with something that is surely destructive and something that will more likely help you than hurt you, it is sensible to choose the latter, every time.

    What Rocktor and I are arguing is not that narcotics can’t hurt or kill. That would be insane. But that the harms to the individual or society that can arise from using these drugs either therapeutically or recreationally are grossly exacerbated by the medical profession’s control over these drugs and their criminalization through prohibition. Millions of chronic pain patients having their lives destroyed, and addicts reduced to criminals forced to prey on their fellow citizens to earn the money to feed their addictions, are all the result of our current policies and that is simply too high a price to pay for the medical profession, drug companies, and prison industrial complex to maintain their rice bowls.

  • Doctor Rocktor

    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?
    .

  • Copman

    I noticed a Dr. Posted that names shouldb be stored as abusers and then denied medicine. As a cop I deal with pharmacy robberies that could be life threatening.denying someone medicine is ridiculous.if they are adults and want it, give it to them. Let them screw up their life it’s their own choice. If the stupid DEA would ease up on doc’s then people wouldn’t resort to robbing someone at gunpoint for some damn pills. And doctors be reasonable it doesn’t hurt you or cost you anything to write a script

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