Sunday, June 10, 2012

On prescription drug abusers


Every now and again all doctors will come across a person who wants to access prescription medications for the wrong reasons. Some people will want them to feed their own personal addictions, and others will resell them for a profit on the streets. Personally, I am never one to judge people for their weakness or for their lifestyle choices, yet this scenario bothers most doctors for a variety of reasons. It bothers me because the false stories these people tell will make me second guess and misjudge the person who tells the same story but it is true and they have a real need for these medications. And, yes, it is also frustrating to have to deal with patients who are lying to you or who abuse your trust or become aggressive/threatening when you challenge them or deny them what they want when all you’re trying to do is get on with your daily job.

There are some government systems in place to help doctors identify people who abuse prescription drugs, but unfortunately they have big limitations. The biggest reason they probably don’t work is that a doctor has to first decide to enquire with them about a specific patient. Now, the patient who is a prescription drug abuser usually knows how not to arouse suspicion from doctors – therefore the doctor never decides to check their background! In medical school they taught us some basic things that should arouse our suspicion that a patient may be a drug abuser, but most drug abusers have figured these out and found ways to deal with us to make us believe they aren’t one of those people we learnt about all those years ago. For example, some of the things we were taught are that drug abusers tend to:
  •          book the last appointment of the day (no, not anymore. If anything, they tend to be morning people)
  •          ask for specific medication (they know how to calculate equivalent doses of whatever you give them if it’s from the same drug class. They also know to ask for an NSAID and paracetamol along with their opiates and benzos)
  •          can’t back up their stories with clinical data (they have scars to prove the “surgery”, the medical report from the hospital, the clinical signs on examination, the old packets of the medication they have been prescribed, the imaging report, the name of the interstate specialist who looks after their condition but is unfortunately unavailable right now, etc.)
  •          they become angry if you question them about drug abuse (“Oh no, doctor, not me. You can even call my specialist – oh wait, he’s not there today”…)
  •          refuse referral or liason with other clinicians (you have to admire these guys’ confidence in their lies. I once was  informed by a hospital oncology department that I was the 15th GP that week that had referred a patient for urgent review– a patient who did not actually have the metastatic cancer the CT report he provided from his interstate doctor, a doctor who knew nothing of the patient either)
Most doctors agree that a solution to the problem of prescribing to patients who abuse prescription medications is to have a real-time system of prescribing where the doctor is alerted to how many times a drug of abuse has already been prescribed to a patient. Would it work? Maybe, or maybe not. I hope it does if it's ever introduced.

To be honest, what bothers me most about the issue of prescription drug abusers is not that I was once duped by an amputee who claimed to be a war veteran but who had in fact lost a limb from intravenous drug use related disease (and not a war injury as he claimed) and I gave a script for opiates to. But that that experience made me doubt the next amputee war veteran I saw who had lost his limb through war injury and had severe phantom limb pain for which his pain specialist had prescribed a whole concoction of drugs, including opiates. Had his specialist not been available and his story backed up, I may well have let him go without receiving the proper medical care he deserved. That is my greatest fear regarding this: not that I feed a junkie’s addiction, but that I commit an injustice to a real and deserving patient.

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