I sit in my clinic office, looking at today’s schedule. It’s a nice office with lots of white and pastels, modern furniture, an up-to-date computer, and a desk. I always wanted my clinic to look like something from the future, and now, after twelve years, it finally does. Besides the screen on my desk, there is a large screen on the wall to my left, the patient’s right. From my main computer that the patient can’t see, as it’s facing me, I can project images for the patient as we discuss labs, spinal injuries, or images of a beating heart—whatever helps me educate them.
Not too many patients today. I see the more complicated ones for our primary care clinic, and they take a while—twenty to thirty minutes at least, often forty-five or even an hour. That means a schedule of twelve patients can fill my day and send me into the late afternoon by the time I see them all. That’s okay. I’ve got a nurse practitioner for the simpler problems and a licensed professional counselor for anyone who needs psychological support. They are worth their weight in gold.
As I review the names and notes next to them on the schedule, I see that two of them had abnormal results on urine drug screens. One was negative for their medications, and the other was positive for methamphetamine. This is always a concern. A negative result could mean that they are diverting their medication, and that’s what many physicians assume. But it could also mean they are one of the approximately ten percent of the population with increased cytochrome P450 enzyme activity. This would mean they were processing the medication out of their bodies faster than average. Or they could have missed a dose for some reason.
The first patient is on Xanax BID for PTSD. Missing one dose puts 24 hours between doses and could cause a negative result, even with normal enzymatic activity. Or they forgot how many they had taken and ended up taking three on one or two days, running out early. We tell them to be careful, but it happens. My staff is trained to check on these things before their appointment, and they have. The pharmacy only had 55 of the 60 pills I prescribed. Taking the fifty obviated the other five. They tried to stretch the 55 out, but it was a bad month as luck would have it. They are still recovering from the death of a child after already having PTSD from the industrial accident that shattered their pelvis and made them disabled. It’s a tough situation, especially since politicians and the DEA have decided to target doctors who treat with benzodiazepines and opiates. Nothing else works for a severe panic attack except Xanax. We have them breathe into a bag, and it helps somewhat, but not enough.
So, what do I do? I’ve got them on Tylenol #3 for the pain. It’s not enough to allow them to be active, but I’m already putting myself in danger. Do I leave them where they are on their medications? I certainly can’t increase anything after a negative drug screen. How would that look to the DEA? But then, it’s not like the patient isn’t suffering. The death of a child. I already know they are almost certainly tougher than I am. I would have probably shot myself or gone to Vegas with Viagra and nitroglycerin. At any rate, I admire their strength and would like to see them more active and have a better quality of life. And I know that what I have them on right now isn’t enough to accomplish that. Still, with the opioid panic in full swing, I had better hold off. I could send them back to our local interventional pain specialist, but they’ve already said there was nothing more that they could do—no shot, no ablation. It’s just what it is—severe chronic pain complicated by PTSD and the death of a child. It’s safer for me just to leave them where they are.
The next one is on opiates and tested positive for methamphetamine. A basic test, no enantiomers isolated. Many patients don’t know it, but over-the-counter Vicks inhalers can make them test positive for meth. This is not a false positive; the inhalers have methamphetamine in them—levomethamphetamine if I remember correctly. It’s not as strong as the dextro isomer used in ADHD medications. Street meth is usually a racemic mix of both. There’s no way to know. Do I stop their medications while waiting for the GCMS results to come back? And what if I’m wrong? What if it is a false positive, and I essentially accuse them of using drugs, putting them in severe pain and withdrawals, only to find out that they were telling the truth?
But if I write a prescription today for their pain medications, how will that look to the DEA? They’ll say I ignored the results of a drug test clearly showing illicit behavior. I can argue until I’m blue in the face about enantiomers and cytochrome P450 2D6, but it will be to a jury of twelve who knows nothing about medicine, and I won’t have the four years it takes to give them a minimal education. I better hold off on his medications. But what if he gets really angry? What if they write a letter to the medical board? I already had to go defend myself to the board over a patient who was taken off controlled medications for two positive meth results on UDS when he complained. Every time you go in front of the board, your entire career is at risk. They can take everything you have accomplished for any reason, and there is nothing you can do to get it back. Lawsuits are only an option when you HAVE an income. Lose everything, and you’re defenseless. Let me think about that one.
The next one is a new patient, here for severe chronic pain. So many of these medical refugees are coming in as their doctors start refusing to treat anyone with opiates. Unfortunately for them, nothing else works very well, and once a patient is on them long-term, their pain sensitivity increases, making it almost unbearable to take them off. It’s better to just not accept them at all. I look over this person’s chart for any excuse to deny them the medication, but everything is perfect. The previous MD retired, and we have a letter recommending continued treatment, PMP, and initial UDS are perfect. Imaging and objective studies clearly document a reason for their pain. Seven failed back surgeries and metal plates and rods screwed into the bone. Anyone would hurt from that. The perfect pain patient. Maybe too perfect though? What if this is a plant? What if this is an undercover DEA agent or a sting patient that will say all the right things here in the office but at trial will tell the jury they weren’t really in pain, and clearly, I should have known that? But there’s a commotion outside my office, and I look up at the security screen from the waiting room. The front door has been kicked in, and men are filing through, machine guns sweeping from side to side, then pointing at patients in wheelchairs and my receptionist. She looks like she is going to faint. That settles all these questions for good. It wasn’t one of these patients I had to worry about. It was someone else, something I missed entirely. And I won’t need to worry about what to do. It’s out of my hands now.
L. Joseph Parker is a distinguished professional with a diverse and accomplished career spanning the fields of science, military service, and medical practice. He currently serves as the chief science officer and operations officer, Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity into the realms of space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions for the complex challenges of space travel, including space transportation, energy storage, radiation shielding, artificial gravity, and space-related medical issues.