Posts Tagged ‘opiates’

Taking call as an addictive process

November 10, 2013

Let me talk about my predilection,

Which looks a lot like addiction

I keep taking call

After I’ve hit the wall

But improvement is my prediction.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  Since August I’ve done a working vacation in Petersburg, Alaska, Continuing Medical Education (CME) in San Diego and Denver, and 4 days In Mexico for our daughter’s wedding.

In 2001 a government Task Force declared pain the 5th Vital Sign that needed to be assessed at every visit along with temperature, pulse, blood pressure, and respiratory rate.  In the aftermath, pain management did not improve.   But the unintended consequences marched forward, with non-suicidal lethal overdoses of prescription opiates quadrupling in the course of ten years, until last year those drugs killed more than traffic accidents did.

Since September I’ve logged more than 70 hours of CME; about one-fourth of those hours have concerned addictions, pain management, and narcotics.

All addiction processes share certain characteristics.  The behavior continues despite adverse consequences, and occupies time to the detriment of other important activities.  Loss of control strongly indicates a pathologic behavior, where, for example, a person might say at the beginning of the night, “I’ll only have two drinks,” but loses count.  Or the runner who, intending to just do a quick 5 miles, ends up doing 14.  Loss of control counts even if it happens rarely.

The part about the addictive behavior robbing time from family hit home when I thought about my years taking call.  When I have call, my family knows they can’t depend on me.  I need increasing amounts of time to recover afterwards, both because I am aging and because the call burden has grown.

I have had adverse consequences.   About a year ago I started having palpitations corresponding to runs of atrial tachycardia from the stress of staying up too many nights in a row.

And I have lost control.  In residency, one can understand the naïve young doctor volunteering to help another resident out, but I failed to learn.  Recently I found myself working at 2:00PM though my call had ended at noon.

Yes, my employment depends on my taking call.  But I also have a friend in the wine and spirits business, who drinks for a living.  That he does it professionally does not negate his alcoholism.

To the best of my knowledge no one has examined taking call as an addictive process, but it sure looks that way to me.

I have only two bad nights of call until my clinic hands over our hospital business (with the exception of patients under the age of 18) to the hospitalists.

I wonder if I’ll backslide when I can’t find (or start) a Calloholics Anonymous meeting.

Pathognomonic names the disease: swearing to the truth means admitting to a lie

November 3, 2013

You swear to no drugs, me o my.

If it’s the truth, can you tell me why

My belief you demand

As you raise your right hand

When you know perfectly well that you lie

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m back from a working vacation in Petersburg, Alaska, and an educational trip to San Diego.

Pathognomonic comes from the words pathos meaning disease and gnomon, meaning name; roughly speaking, it names the disease.  Koplik’s spots, for example, a particular sort of lesion on the gums, occur only in measles.  If I would see Keiser-Fleischer rings in the irises I would know instantly that the patient had Wilson’s disease.  A bull’s-eye rash happens only in Lyme disease.

When I was a med student an intern told me that palpable lymph nodes just above the elbow, on the inside of the arm were “almost” pathognomonic of infectious mononucleosis (they aren’t).

Imagine a patient fixing his or her eyes on yours, raising a right hand and saying emphatically, “Doctor, I swear to God…”  (It doesn’t matter what comes after that.)  Such a vocalization and gesture rate as pathognomonic for patient lying about drugs.

Bill Clinton used the same facial expression when he said, “I did not have sexual relations with that woman.”

Really, a person telling the truth doesn’t need to swear or use righteous indignation.

I let the patient finish prevaricating.  I nodded.  “I live in the real world,” I said.  “You’re sick.  You need to be in the hospital.  Just like I’m ordering a patch for your tobacco addiction and an ultrasound because your tummy hurts,  I’ll put you on the detox protocol.”

The righteous indignation had faded after I said I lived in the real world.  “For what?”

“For the drugs we found in your urine.”

The urine drug screen has never rated 100% for accuracy.  It has false positives and false negatives, and I know it.  I suspected drug use, and the patient admitted to marijuana.  But as soon as the patient fixed my gaze, and raised the right hand, I knew that I needed to start detoxification procedures for those amphetamines and opiates, and to test for hepatitis C and HIV.

I walked away from the interaction proud that I had dealt with the problems without backing the patient into a corner.  I had communicated my concern about the patient’s well-being, I didn’t try to be right, and I finished the admission with more energy than if I’d tried to get to the patient to admit wrongdoing.

No illusions: lies and drugs.

December 15, 2012

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.

Blog end: I’ve reintegrated

January 16, 2012

I had a great time, it’s a fact

My life had been so out of whack

I flew cross the sea

From Barrow to Leigh

Now I’m home and it’s good to be back.

I received an email from a doc who went walkabout to New Zealand for a good deal longer than I had, and asked me questions about my reintegration.  I asked for permission to post the original missive, but three weeks later haven’t heard back.

I replied: 

It’s interesting that you emailed me six months to the day after I started back into work here in the States, and if it’s OK with you I’ll use your email and this return as a post.

I’ve enjoyed reintegrating to US society and the medical care system.  I’m back doing hospital work, which, strangely, I really enjoy.   I know my consultants on a first-name basis and I like the camaraderie in the hospital.

It helps that I’m working for a Community Health Center.  For a lot of reasons, our patient population gets sicker earlier.  The pathology load weighs heavy on them.  At any one time, half of our twenty to thirty hospital patients also appear on the nephrologists’ list because of chronic renal failure and dialysis.  Usually we have three people in active DT’s and three others in liver failure. 

I have had to get used to the paranoid reality of defensive medicine.  Our patient population has made the transition easier because many have no money and no insurance and hence can’t pay for procedures that probably weren’t needed in the first place.

For those with insurance, I worry that I overuse medical technology.

Getting labs back the same day, like glycohemoglobin and TSH, makes patient management easier, as does having in-house x-ray.  

I liked MedTech32, the electronic medical record (EMR) system that makes documentation so easy throughout New Zealand, and the hardest part of coming home has been dealing with Centricity, whose software engineers remain isolated from any contact with this particular end user; for example, I have to click through five data fields to make a back to work/school slip and I have no way to fix it.  My productivity has gone way down; eleven patients in a morning or afternoon taxes my resources; not that I spend more time with each patient but I spend more time fighting the computer to enter data.  And about half the problems could be fixed easily.

I miss the way I always started on time in New Zealand because I brought my own patients back from the waiting room, and I miss the way the patients (mostly) respected my time.  In my current situation I limit the patients to three problems per visit.

Narcotics seeking remains a problem here as well as everywhere.  I’m building up a reputation in the street-drug community here, just like I did in the South Island, as parsimonious with opiates and benzodiazepines. 

Still, my practice swells with new patients every day.  I like pediatrics, and I find that a new practice attracts young people and young families, even with an old practitioner.

In the long run, most people either fit into the category of wanderers or homebodies, and I am definitely a homebody. 

But man, did I have a great time.