No illusions: lies and drugs.


This rule I won’t even bend,

I no longer even pretend

I see no excuse

For those drugs of abuse

That make up a frightening trend.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Last year legally prescribed narcotics killed more Americans than the bullets or the cars.  This frightening statistic comes after a four-year near-logarithmic increase and matches the same trend in the number of narcotic pills prescribed.

Several layers of government keep track of the use of certain medications, the ones most susceptible to abuse, now referred to as controlled or scheduled drugs.  I have to have a slip of paper from any state government where I practice and the federal government to prescribe any narcotic, also addictive tranquilizers, most sleeping pills, and testosterone.

I tend to reach for those drugs as a last resort.  We have a lot of other things to treat pain and anxiety and sleeplessness; nonetheless controlled medications have their place in the work I do.

Of course a lot of patients disagree with me as to how big that place needs to be.

As required by my state licensing board, I took a two hour video course in the proper prescribing of pain medications, exhorting me to watch out for personal and family history of crime or substance abuse, past incarcerations, or frequent missed appointments.

More than half of my new patients don’t show for their first appointment, which leads me to wonder about substance abuse even before I see them.

Our practice includes a large number of people who have done significant time behind bars; I don’t want to know their crimes.  Everywhere I’ve practiced, abuse of alcohol and other substances runs rampant.

So, all in all, I keep my suspicions high, particularly when a new patient comes in with a long med list including tranquilizers and narcotics.

The number of good reasons to prescribe long-term narcotics continues to dwindle; for example, evidence-based medicine shows the opiates lose their effectiveness for back pain after 8 weeks.  I never prescribe large numbers of the two most popular short acting tranquilizers, alprazolam and lorazepam; if the person really has that much anxiety I recommend the long-acting but less marketable cousin, clonazepam.

Really, the problem comes down to diversion: someone other than the patient taking the prescribed drug.   

Thus, for those patients on long term controlled medications, we make sure they sign an agreement that says they won’t share those drugs, and that they’ll come in, when asked, for a urine drug screen and pill count.  And that they won’t seek controlled substances from more than one provider. 

I used to believe people who would tell me they used to abuse drugs but named a date when they quit.  Most can tell twelve-step stories. 

Two of my patients flunked the urine test this last week. 

I’ve asked our case manager to contact them, to see if they’ll come in to get counseling.

I don’t hold high hopes.

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