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 15^th 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.

On being old enough to know better

Dave Chappelle, comedian, does a very funny yet thought-provoking skit on age and responsibility. The question arose about musician R. Kelly’s 2002 arrest for urinating on a girl who at the time of the alleged incident was 14 years old. The girl in question at one point is said to have consented to being peed on, but still everyone criticized Mr. Kelly because in either case the “girl” was underage and shouldn’t have been sexually involved with an adult. Poor girl, right? Didn’t realise the consequences of her consent, etc. etc.

Then another incident Dave Chappelle discusses is about Lionel Tate, who when he was 12 years old was play-wrestling with a 6 year old girl using moves similar to what he had seen TV wrestlers do. The 6 year old girl died from injuries sustained from this “game”. The boy was arrested and sentenced to life in prison without the possibility of parole. Apparently he should have known by the time he was 12 years old that his actions have consequences, etc. etc.

Finally he talks about Elizabeth Smart, a girl who when she was 14 years old was abducted from her home and taken captive by a couple who lived not very far from her own family home. According to the way Dave Chappelle tells it, she wasn’t physically restrained or locked up, but was advised by her captors not to flee. She obeyed. She remained at this site from June to August 2002 before being relocated elsewhere for a further six or seven months. But for at least two months she was situated very close to her own home, possibly within walking distance, often unsupervised at this place, not locked up or restrained – and yet she remained docile to her captors without allegedly even attempting to flee. Of course, it was unfortunate and not her fault at all that she was abducted, but shouldn’t she have known by the age of 14 years that her actions have consequences, that she could and should act, etc. etc.? Poor girl, right? Didn’t know what to do.... But wait, Lionel Tate knew exactly what to do and how to do it apparently by age 12!

The reason that these stories have come to my mind recently is because of the “poor boy” who was arrested in Indonesia and is being tried for drug-related charges. He is an Australian citizen and he is 14 years old. Those two facts are the main reasons we are enticed to have sympathy for this “boy”. He is alleged to have bought drugs while on holidays in Indonesia. Apparently he didn’t realise the gravity or consequences of his actions either because of his young age or because of his alleged addiction to the drug he sought, etc. etc.

So how old is old enough? How old is 14, really? Old enough to know better, or too young to know what you’re doing? If it’s not old enough, then let the “poor boy” in Indonesia out of prison to live his life and learn what is good and what is right and what isn’t. And let 14 year old girls decide if they want to have sex with adult men or whether they want to get peed on or not without prosecuting the adult involved. But if 14 is really too young to know better, then Lionel Tate deserves a big apology for the malice attributed to him when he was 12 and killed his 6 year old playmate. Luckily for him, this did in fact happen and he was eventually released from prison and went on to learn what is good and what is bad... (Almost a “and he lived happily ever after” story, except for the fact that when he was released from prison he went and committed other crimes  that bought him a fresh 30 years incarceration that he can no longer blame on his young age.)

The ability to make “adult” human decisions relies on the prefrontal cortex of the brain. This part of the human body does not reach its full developmental peak until you hit your early 20s. To me this has some interesting implications not only related to criminal law (as demonstrated in the examples above), but also to medical ethics, and to psychosocial development. In medicine we accept that children (by Australian law, under the age of 18 years) may competently consent to some things like taking a contraceptive tablet, having a blood test, allowing a physical examination by a health professional, etc. By the same token, the same person at the same age may be considered not competent enough to consent to, for example, reproductive sterilization or an organ transplantation / donation. It’s a matter of being competent enough, recognising that a person’s cognitive development is a dynamic thing evolving across multiple tracks until, hopefully, they all eventually reach a maximum and you reach your “adult” competence stage.

The other interesting thing about this gradual stepwise development in our ‘human nature’ relates back to the previous discussion on criminality. Maybe instead of focusing on “is 14 years old enough to be considered responsible for a crime?”, we should consider “is this person who is still in the dynamic stage of their cognitive development able  to be taught or rehabilitated to make choices that will decrease their chances of becoming further involved in criminal activity in the future?” Remember Lionel Tate? He was 12 in 1999 when he killed the six-year-old girl. In 2001 he was sentenced to life in prison without the possibility of parole. He was later released on appeal in 2004. In total he was in criminal detention from the ages of 12 until he was 17. What did Lionel Tate learn from the ages of 12 to 17? Who knows. But this would have been an amazingly opportune time to teach him exactly what the consequences to a person’s actions are, what taking responsibility means, how to get ahead in life without victimizing others for your own advancement. Would he have been a different person if this had happened? Who knows. But really, what have we got to lose?

On the rules

One day I told someone that I was struggling because there was something that I really wanted to do but that I didn’t do simply because it goes against my religious beliefs. And it wasn’t a fleeting desire, either; no, it was actually a very deeply-seated desire that penetrated and marked me to the core of my being. But, yes, I had a system that I lived my life by and it is religion. People often quote this feature of religion as being one of the “bad” things about it. It’s so restrictive. It rules people’s lives and is a great evil. But everyone lives their lives with at least some rules. Some are there to protect the ego, others to protect our survival, others to keep us out of jail, others to protect our conscience, etc. But every rule serves to protect something – and we all, even the most free-spirited ones of us, obey some sort of rule or rule system. My rule system is basically Christianity.

The friend I told how I was struggling with this feeling I had but had to hide because of my religious system gave me some advice: change or leave my religion. Of course! Why didn’t I think of that?! In fact I had thought of that, but before I tell you about that, let me tell you about something else I really really wanted to do one day.

I was at a restaurant once and this woman pushed me as she walked past. I was furious! I wanted to pull this lady back and pull her hair, punch her in the face, and kick her in the guts. I felt an energy surge through me, it was so strong. My expression changed to one of absolute spite for this woman, so much so that the people around me noticed my anger. They told me to let it go and move on. Someone moved in between me and the woman so I wouldn’t make a sudden lunge towards her. I thought to myself, “Move on?! Let it go? But I feel this feeling so intensely, so deeply, so in my core.” I let it go, though. Do you know why? Because there are rules in society, and even if I don't agree with them, they still apply to me as a member of society. Of course one can always break the rules and accept the consequences of doing so.

This incident is not the only time I've really wanted to hurt someone, nor am I the only human being who has ever had this desire. We have all wanted to hurt someone for even minor spites like being cut off by another car while you’re driving, being spoken to in a rude and impolite way, seeing someone purposely abuse an animal or someone who is weaker than them, etc. All these things can irritate a person and the human instinct may kick in to react with violence to serve our own ‘justice’. Now, should you? It's something you want so why should you have to resist? Because it's against the law? Because it's against social norms? Because it would be morally “bad”? Because it’s against your religion? But none of these norms and rules were devised by yourself, so why should you comply? Do you see what I’m getting at?

I rejected my friend’s suggestion that I change religions because I don't think everything in life should be solved this way. I think this attitude of always having things your way, if not changing your environment (the physical environment/religion/political party/professional membership, etc.) comes from our society's new rules of the self as deity. Our religions, the object of our worship, have become ourselves. We worship by seeking to maximize our personal pleasure and meeting all our desires – often at the expense of... ‘whatever it takes’. And what is wrong with that religion? Nothing. But our religions are not the only rules we face in our lives. Sure you can punch that guy who pushed in front of you in line at the cinema, or you can steal that item you really want from the shop, etc. but you’ll still have to face the consequences of doing so. That’s just how life is, with every rule comes a consequence.

I’ll tell you now how I overcame my struggle. No, I didn’t change religions just so I could obey my desires. I still believe in everything I ever did about Christianity. I didn’t suddenly lose the burning desires I once had. No. The only thing I changed was I accepted the consequences. There are some things that are worth the consequences.

Only God can judge me.

J

On what we don't know

Let me propose a very sinister scenario for your consideration. I propose it only because I don’t know exactly what to conclude from it but it raises a lot of very interesting ideas.

The scenario: There’s a 25 year old man; a man who you know to be a nice guy, who is studious, who is playful and just generally a fun guy. He is a foreigner and speaks with a somewhat funny Indoasian accent. He goes to university and he likes to tell jokes. He is respectfully religious but not over-the-top with rituals. He even volunteers in a community youth group. One day this guy is joking around, playing with a boy who is 11 years old. In the spirit of the moment he makes a penis joke and makes a move towards the child’s genitals. The child pulls away, pushes him, and the day proceeds. One day this man is accused (by a third party) of indecent sexual dealings with a minor because of this particular incident.

Now, all of which I described above actually happened, the actions are exactly as I described. You can picture the man, you can picture the child, you can picture that they were having a laugh and engaging in the physical play which all children enjoy. Even the man in question clearly admits the incident occurred as described. However, the only things we don’t know are the thoughts and intentions of the 25 year old man. The matter went to court and the man was ordered to have no further unsupervised dealings with children, especially not in institutional settings like in his university studies. He was sentenced to 12 months probation and nothing else. Now, most people’s responses to this story are either 1) ‘the pedophile got away with it!’, or 2) ‘I know that guy and he’s totally a nice guy. It is such a shame that he has had his name tarnished with such a terrible accusation’.

Further from this, let’s consider one possibility. In the case it was alledged that the man meant no ill-harm because when the child pushed him away and said ‘no’, he obeyed. It follows from this that the man was acknowledging that this contact was against the child’s wishes. They added this to his character references from people who knew the man prior to this incident to conclude that he was a good man who was innocently playing with a child, joking, and incidentally happened to have made a move towards the child’s sex organs while in the course of a non-sexually intended activity. Makes sense, right? Good guy made bad move.

But imagine for a second that he wasn’t a good guy; propose he is a big bad pedophile. What would a pedophile do in the same situation? He would play a non-sexually-seeming game with the child to “groom” him, to teach him increasingly more sexually-explicit acts that the child will not associate with “bad” (or sexual) things. In the way of this grooming he will “accidently” touch the child’s genitals or allow the child to accidently touch his. The child thinks ‘we’re playing!’, meanwhile the pedophile just scored sexual contact. As I mentioned, the “play” will become increasingly more explicitly sexual, but the grooming for the pedophile involves a bit of trial and error. Sometimes he overestimates his steps; sometimes the child is more docile than first imagined. If the child were to become uncomfortable in a situation, he knows he has to slow down – because a comfortable child is much easier to take advantage of! Can you see where I’m going with this? If the child in the scenario had not pushed the man away, what would have happened? The man would could either have just been playful with the child and possibly never meant to even touch him (like a ‘normal’ person); or he could have sexually fondled the child to his own sexual gratification (like a pedophile). So therein lies my problem with judging the man either guilty or not-guilty of a sexual crime against a child: the fact that he withdrew his attempt does not prove his actions either way.

The second question this case raises for me is which is better? When this case went to court there were four possible outcomes that could have come from a verdict of either guilty or not guilty: 1) an innocent man walks free, 2) an innocent man is punished, 3) a pedophile receives deserved punishment, and 4) a pedophile goes free. All of these outcomes have an equal probability of happening. I would hate to have been a judge in this case and have to make that very hard decision. Ideally the evidence of the case helps you make the right decision (options 1 or 3 above), but as we saw in this case, judging intention is something that maybe only God can do. So now the judge has to make an even harder decision, which is the least unjust finding: set a guilty man free or convict an innocent one? Of course, the case we are considering here is not just any case, but an accusation of pedophilia. And in fact, that is what the judge based his decision on in setting the man free. He reasoned that if the man is innocent because he didn’t actually “do anything” to the child then he hasn’t been unfairly deprived of his freedom. Yet if he is guilty then his punishment will be that his name will be always be known and associated with ‘that guy that tried to touch that kid’.

Of course, to the general population this may not seem be enough (punishment to a presumed offender). After all, don’t the courts and governments also have a duty to protect the public from exposure to harm (e.g. pedophiles and other villains)? Yes, it’s in the constitution of most countries’ governments. But before I consider this last point, you have to excuse me as I recede back a step.

The man in the scenario we discussed in the beginning in fact pleaded guilty to the actions of that day as they happened (and conceded the possibility that they could be deemed to be pedophilic in nature – thought he never said that it what he intended). So the judge never even had to make the judgement of labelling the man “guilty” or “not guilty”, he just had to decide on the punishment for the man’s actions. So in a way you could say that a guilty man walked free based on the judge’s reasoning as was discussed earlier. And maybe that is what we need to focus our attentions on: setting adequate penalties for crimes against children. I know the frustration of victims and of police officers who strive to find the bad guys only to have them go to court and receive a sentence that seems to be but a mere formality and without any intention to actually punish offenders, to rehabilitate them, or even to protect the public.

(P.S. I hope the guy whose story I based my scenario on can forgive me for using his example to illustrate my point. Only God can judge you.)