White Coat Underground

A few months ago, DrugMonkey reported on a study about how we as health care workers view narcotic users. Narcotic use and abuse is something we deal with every day and presents many challenges. Narcotics are an important tool for controlling pain and many different strategies have been used to try to prevent their legitimate use from changing to abuse. Despite this, prescription narcotic abuse is very common.

But narcotics are not the most frequently used addictive substances. For example, about a fifth of Americans smoke. But we as health care providers react differently to different kinds of substance use. I certainly cannot speak for all doctors, but narcotic abuse seems to push our buttons in a way that nicotine and caffeine (and even alcohol) don’t.

So I asked around to try to understand why so many of us have negative reactions to people with narcotic use disorders. After talking to a few professionals in person and via email one factor stood out: narcotic abusers often use health care providers to obtain their fix. Most of us don’t like being lied to or being involuntarily enlisted as a drug dealer.

So what do you think, folks? The social and medical consequences of various substances of abuse don’t seem to track with our perceptions of the users. Do lay people differ from medical folks on this one?

Comments

#1 James Sweet
April 13, 2010

Speaking as a lay person, my first guess was exactly the conclusion you came to after talking to professionals.

And to be honest, I’m pretty sure that most doctors really ought not to worry about this. Having known at least one person who abused prescription narcotics for a period of a year or two, and from my wild college days knowing a few other times when people tried and failed to get their doctor to prescribe narcotics for recreational purposes… it seems like it’s easy enough to “doctor shop” for one who doesn’t much care, so doctors who don’t like the idea that they might be unwittingly turned into a drug dealer are very unlikely to be unwittingly turned into a drug dealer in the first place. To be more specific, in my anecdotal experience, if someone is trying to get narcotics for recreational purposes, all a doctor has to do is ask them a few questions the first time they request a refill, and the potential abuser will either give up or find a different doctor. For someone who is serious about getting it, a doctor who asks questions is too much of a hassle when there are plenty who don’t; and for someone who isn’t serious about getting it, a couple questions is all it takes to scare them off.

All of this is second hand, of course; even in my wild college days I never had the inclination to try this.
#2 Chuck
April 13, 2010

The primary question really is:

Did they become physiologically addicted due to “recreational purposes” or mismanagement of prescribed medical treatment?
#3 Jon
April 13, 2010

The cocaine and/or opiate abusers that I’ve known are much different socially that smokers and (usually) drinkers. They are generally more dishonest, manipulative, disengaged emotionally, and generally antisocial. Though, in my opionion, a lot of that difference is caused by the difficulty and danger of finding and paying for that next dose.
#4 anonymous for this one
April 13, 2010

As someone who takes several controlled substances regularly (no narcotics, though), I have to say that the shock and disapproval I encounter from pharmacy techs, the nurse assistant lady in my gynecologist’s office, my (former) therapist, my friends and family, and even random internet strangers make me extremely reluctant to tell anyone what I’m taking or even that I am being treated for narcolepsy, and it sometimes makes me question the wisdom of continuing the medications (even though I am not employable without something effective). Plus I hate second guessing a physician I trust.

Interestingly it is the lay folks and some of the paraprofessionals who seem to be most uncomfortable and judgmental about it.

But what I’m wondering is whether you would be comfortable prescribing nicotine or alcohol. Because I suspect if such things could only be obtained by prescription, you would be subject to the same ambivalence about it, and open to roughly the same kinds of manipulation etc. from drug-seeking patients.
#5 Nora
April 13, 2010

I totally agree with Chuck @2. I can think of several chronic pain patients who clearly have no idea that the medications they take are dangerous and addictive, or even that they have “recreational purposes.”
#6 WcT
April 13, 2010

I blame medical school.

Trust is so thoroughly ingrained into our medical education.

Every day of the first 2-3 years of med school, and with every standardized patient/patient case scenario, what gets drilled into our heads is “trust the patient,” “listen to the patient,” “the patient will tell you what you need to know,” “80 percent of diagnosis is by history, 10 by physical, and all the expensive crap gives us at best a measily 10%.”

But with narcotics abusers, all that gets thrown out of the window. The first thing you learn about narcotics abusers is that you can’t believe anything! You can’t even trust the subjective portions of your physical exam.

I don’t know about you, but catching my first drug seeker in the act felt like betrayal more than diagnosis. Intellectually I realise that narcotics abuse IS a medical problem, but my visceral reaction is still not a positive one.
#7 D. C. Sessions
April 13, 2010

I’ve seen only a tiny fraction of the DEA hassle that docs face when trying to get pain management to patients who desperately need it. I’d think that the reaction towards the people who provide the DEA with the justification for all that pain (literally and figuratively) would be more like “rage.”

The fact that so many of them have destroyed their own bodies [1] and done so much harm to others is just frosting (as in, “that frosts me.)

[1] Yes, I read Mark Crislip.
#8 SurgPA
April 13, 2010

@2 – Chuck, are you saying that narcotic users whose dependence arose out of recreational use are qualitatively different (personality traits, social interactions) from those whose dependence arose from presumably legitimate narcotic prescription as treatment for pain?
#9 Jon H
April 13, 2010

Wasn’t there speculation that Glenn Beck’s videotaped tantrum about his hemorrhoid surgery may have been due to him having a high opiate tolerance from his drug-abusing years, causing his prescribed painkiller to be less effective?
#10 SurgPA
April 13, 2010

At the risk of being too sexist/racist/ageist, Glenn Beck exactly fits the profile of someone who doesn’t tolerate hemorrhoid surgery very well.
#11 D. C. Sessions
April 13, 2010

At the risk of being too sexist/racist/ageist, Glenn Beck exactly fits the profile of someone who doesn’t tolerate hemorrhoid surgery very well.

Go figure. I was always taught that the brain doesn’t signal pain.

(Sorry — a straight line is a terrible thing to waste.)
#12 mxh
April 13, 2010

@#6 wct

Every day of the first 2-3 years of med school, and with every standardized patient/patient case scenario, what gets drilled into our heads is “trust the patient,” …

But, as a current 3rd year med student, all that gets thrown out the window on the psychiatry rotation. I agree with Pal that being an involuntary drug dealer is a big part of it, but my suspicion is that many narcotics abusers have underlying comorbid psychiatric conditions (especially various personality disorders that make those that interact closely with them not like them).
#13 Penelope
April 13, 2010

Not all doctors dislike narcotic users specially if they could bring money on their doctor’s bank account. However those genuine doctors who care are the one who dislike these patients.
#14 SurgPA
April 13, 2010

@12 But why should narc-abusers be more likely to have personality disorders or other psychiatric overlay than alcohol/nicotine abusers? If we accept that most narcotics abusers began using via prescriptions, is the link a history of somatic pain treated ineffectively (inappropriately?) with narcotics?

Some element of this must relate to the relative social acceptability of smoking, drinking and use of narcotics; an ongoing poll over at Drugmonkey’s blog suggests half of us don’t even view smoking as an intoxicating activity.

The element of coercion also comes into play, as does the anticipation that, eventually, I will be asked to become complicit in their dependence by providing access to drug. Personally I react most negatively to the new patient who has previously been prescribed chronic narcotics for an indication I may find dubious (inadequate workup, vague diagnosis, better alternative therapies) and who expects me to continue the prescriptions as previously written. The patient is dependent on me for continued access to drug (as opposed to alcohol/nicotine/caffeine) and may or may not be fully open and truthful with me as s/he negotiates for continued access.
#15 Pascale
April 13, 2010

I think PAL nailed it. Narcotic abusers use physicians to get their drugs, and I just hate having my trust abused. I feel far less antipathy toward those who use street drugs, and mostly sympathy for those using alcohol and nicotine which are, after all, legal.
#16 mxh
April 13, 2010

@SurgPA, I’m not saying that alcohol/nicotine abusers are any different. Its difficult to distinguish behaviors related to addiction from those related to a personality problem, but I suspect that there’s usually both going on at once. I say this because many addicted patients I’ve seen (which admittedly, isn’t a lot, so you may have better experience), seem to have an unpleasant interaction with their physician even when it comes to problems that don’t involve their drug of choice.
#17 mxh
April 13, 2010

Actually, I take what I said above back, thinking more about it, it’s entirely possible that the unpleasant interactions I described in #16, are because of the physician’s preconceived attitude toward the patient rather than from the patient him/herself.
#18 wmdkitty#83021
April 13, 2010

Honestly, as a layperson, -I- don’t much care for narcotic abusers — they really do tend to be obnoxious and irritating. I don’t know if it’s just something in the personality, or if it’s the drugs, but I think that it may be a combination of a particular personality trait(s) and a specific drug.
#19 DVMKurmes
April 13, 2010

Veterinarians occasionally run into addicts who try to convince us to prescribe for their pets. Usually it is the dog who is “suffering” (cat doses are way too small). Fortunately most dogs are not very good actors and it is fairly obvious what is going on, but it is unpleasant to be on the receiving end of such attempts.
#20 Nathan Myers
April 14, 2010

Am I being invited to speculate? I’d guess most physicians really just don’t much like patients, but aren’t obliged to pretend about narcotic addicts. And why should they like patients? Patients are a whiny lot, and you don’t get to choose among them. Retail clerks and waiters think ill of customers, politicians’ contempt for voters is legendary, and to the police everyone is a criminal who hasn’t been caught yet (unless they have). Why should physicians be any different? Any affection for humanity must burned in the first year interning, and after that it’s what, money? Pride? Puzzles?

I don’t know how else to understand resistance to washing your hands between patients.
#21 skeptifem
April 14, 2010

I know the lab/rns hate the ones who injected their drugs because it makes their job so hard. They tend to contract bloodborne illnesses more often as well so it makes any needle/blood related job more dangerous.

I have heard people have outright contempt for drug users though, moral highground “they are so dumb” kind of crap. The mental illness involved with addiction is trying, but I never looked down upon those patients. I felt bad for em, you can’t be happy when you are acting like that.

Nathan Myers-
“I don’t know how else to understand resistance to washing your hands between patients.”

That kind of thing hurts their own health as well though, so it can’t all be patient contempt. Way too many MDs are resistant to following precaution posters on patient doors in general. I have gotten angry enough to yell at them to wear masks before, when swine flu was all over the hospital. It seems to be an egotistical thing “Im a doctor, I don’t need to waste time doing petty mortal things like wearing PPE!”. Blah.
#22 Anonymoustache
April 14, 2010

I think there may be another factor in play here, even with medical professionals, and that is the difference between acute intox vs lower-level-chronic intox. This appears as somewhat of a gradual progression: People who smoke can simultaneously perform (effectively) many routine functions like driving a car. People who drink alcohol, less so—but they can still drive relatively effectively after, say, one beer. People who shoot up powerful narcotics are even less able to….
Further, a comparison of such performance after multiple cigarettes at a sitting vs multiple beers at a sitting vs multiple ‘narcs’ at a sitting only makes the difference more pronounced.
Maybe this contributes to the popular perception of viewing cigarettes and even alcohol as less harmful (more acceptable? less offensive to one’s sensibilities?) than narcotics?
#23 Mara
April 14, 2010

On behalf of people in pain, I resent the fact that I can’t just ask my doctor/dentist outright for painkillers, because that’s “drug-seeking behavior.” Damn straight it is!

I currently have a horribly infected tooth, which causes immense pain, but I was afraid to beg my dentist for painkillers because he might see that as a sign I’m an addict. Fortunately, he gave me painkillers anyway.
#24 Dianne
April 14, 2010

I don’t know how else to understand resistance to washing your hands between patients.

My theory (guess, based on anecdote) about why physicians (and nurses, lab techs, respiratory therapists, dieticians, etc) don’t wash their hands as often as they should is as follows: It’s hard to remember to do so. No one forgets to wash their hands after they’ve cleaned up blood, smeared stool on a guiac card, taken a urine sample, or induced green, blood tinged sputum. However, it is hard to remember to wash hands between physical exams because, essentially, you’re asking people to wash their hands after the same kind of casual contact that people have all day. Do you wash your hands after every time you shake hands with someone? You probably should: skin contact is a good way to spread bacteria, but it’s hardly part of the culture. Even worse, people get insulted: I’ve had people yell at me for washing my hands after examining them. Finally, do you know what happens to the skin on your hands if you wash them 30-50 times per day? It gets dry and cracks, increasing your vulnerability to infection in the case of an accidental exposure to blood or body fluids. So, no strong instinctive or taught incentive and several negative consequences to doing things right. No need to invoke an imaginary contempt.
#25 DuWayne
April 14, 2010

mxh -

…but my suspicion is that many narcotics abusers have underlying comorbid psychiatric conditions (especially various personality disorders that make those that interact closely with them not like them).

The statistics are between 60-80% of people with substance abuse problems have underlying comorbid mental illness. The vast majority of these are not however, personality disorders. Mood disorders are on top, followed by attention deficit issues. Personality disorders aren’t so close to the top, because they are both relatively rare and also because they are often exacerbated by high dopamine levels – thus the (exceedingly rare) correlation between cannabis use and psychotic episodes. In those circumstances cannabis is likely just the trigger for something that was a long time coming.

WcT -

But with narcotics abusers, all that gets thrown out of the window. The first thing you learn about narcotics abusers is that you can’t believe anything! You can’t even trust the subjective portions of your physical exam.

I don’t know about you, but catching my first drug seeker in the act felt like betrayal more than diagnosis. Intellectually I realise that narcotics abuse IS a medical problem, but my visceral reaction is still not a positive one.

I think it might help if you understood the nature of narcotic addiction somewhat better. I have dealt with rather few painkiller addicts, as heroin tends to be rather more the style of street junkies. While the pills are not nearly what heroin is, there are still issues of withdrawal that cloud what they are saying. Someone who is addicted to opiate pain killers quite likely really is in a fair degree of pain – that is one of the side effects of withdrawal from opiates.

That becomes far more complicated when you are talking about someone who developed acute dependence while on a long term (or even sometimes a short term) pain management regimen. It is very important to recognize that the brain has a truly remarkable ability to convince a person that they are still suffering the pain that put them on the regimen in the first place. So while there is no reason to believe that the injury they suffered is still causing pain, that pain may well be there nonetheless.

I am going on about this because I think it is important to recognize that it is not nearly so simple as you put it. Quite often the people we are talking about here aren’t lying to you. That they are not telling the truth does not equate to them lying about it, because it isn’t a lie when they truly believe what they are telling you.

Depending on the individual and what you can work out about them, clonidine might be an appropriate alternative to the narcotic pain killer they are seeking. Sure, it provides something of a “high,” but more importantly, it provides some relief from the symptoms they are dealing with and is far less habituating. In more extreme cases (especially someone who was on a long term pain management regimen) benzos might be appropriate. They are easier to work someone off of and if used as an intermediary to clonidine can be virtually problem free. This also becomes a very easy method for detecting people who are recreational users, experiencing minimal to no actual acute dependence. Quite often such people will work their way through their entire supply in half or less the time it should have lasted.

Finally, as frustrating as it is to be lied to – and some of them really are lying – it is important to recognize that they are suffering a mental illness. You wouldn’t get irritated with someone suffering depression or someone with bipolar disorder, OCD or any number of other mental problems (at least I should hope you wouldn’t). So please try to recognize that this patient who is taking up your time due to their addiction is absolutely no different whatsoever, from patients who take up your time because of any other mental illness.

Suck it up and accept that the person in front of you, possibly lying to you is still a patient with valid and very serious problems. We all have visceral reactions to being lied to – I get that. But when you are dealing with an addict, you are dealing with someone who is – first and foremost – mentally ill. And you are dealing with someone who is truly suffering. They may not be suffering in the way that they claim, but they are suffering nonetheless.

I am sorry for rambling on so, but I see a lot of people here either moralizing outright, or verging on it. Quite honestly, that really pisses me off – a lot. I have little doubt that most everyone – if not absolutely everyone reading this would have nothing but sympathy for someone suffering schizophrenia or anorexia nervosa. But when it comes to the illicit drug addict, sympathy is either limited or non-existent. I am sorry, but that is complete and utter bullshit.

At worst, the addict made the horrible error of using recreational drugs at some point before becoming addicted. Quite often a decision that was strongly influenced by a completely different mental illness. They aren’t maliciously thinking about ways they might use you – any more than many of them are maliciously thinking how they might use and abuse their families and friends.
#26 OleanderTea
April 14, 2010

On behalf of the chronic pain patients, can we not call those who USE medications as prescribed “ABUSERS”, or vice versa? The two are not the same.

I take my meds exactly as prescribed, have done for six years. I’ve never increased the dose, “lost” a prescription, or gone to another doc for more meds. And I damn well resent being lumped in with narcotic abusers who just want to get high. If I develop a tolerence (which is very common for ppl on long-term opiate treatment), I shouldn’t be treated the same the person who walks in and announces they’re in terrible pain and allergic to all NSAIDs and Tylenol.

As for the moralizing that goes on WRT narcotics abusers, I can see how a chronic pain patient would be tempted to take more to feel better. Chronic pain sucks. Taking opiates makes you feel good. That’s a damn powerful motivator — even moreso when you hurt every single minute of every single day.
#27 DuWayne
April 14, 2010

Oleander Tea -

I hope you did not take my comment to in any way equate you with substance abusers. When I mentioned people who have been on short or long term pain management regimens, I meant people who were no longer on said regimen. There is no equating people who are using medication as prescribed – or even people who are prescribed such drugs, who feel they need more.

Trying to lump that group in with people with substance abuse problems does neither group any good. If you thought that is what I was doing, I sincerely apologize as that was most certainly not my intent.
#28 Mu
April 14, 2010

I think the dislike is coming natural due to the image in reflects on the prescribing doctor.
You could be PAL, tobacco merchants, or PAL, purveyor of fine spirits, and still be accepted in country club and religious organization of choice, but PAL, dealer in narcotics, just doesn’t roll well with the rest of society. Plus it’s natural that we dislike people who are dishonest to us, and abusers who are trying to feed the habit (to set apart from patients seeking treatment) are nearly by definition lying to their doctors.
So I had an eye opening discussion the other day when discussing prescribing habits of doctors. A friend is having major dental work done after years of neglect due to lack of funds or insurance, involving several extractions. He pointed out that the amount of drugs he gets prescribed on a “fill if you need them” basis would pay for his whole treatment and then some if he’d be selling the pills on the “open market”. So, is that oral surgeon taking care of his patients, providing them with enough pain relief to satisfy even the most tender gum, or pandering to the drug addicts?
#29 Dianne
April 14, 2010

I don’t really mind the narcotics abusers so much-my patients have cancer so if they use a little more narcotic than is strictly necessary to control their pain I’m willing to cut them some slack: even if they’re curable they’re going through a lot. It’s the narcotics dealers that bother me: the people who insist that they’re taking all the meds prescribed and still have pain yet their urine tox screen is always negative. A patient who takes the drugs themselves I will assume to be relieving physical or psychologial pain. But I don’t want to be the neighborhood percocet wholesaler.
#30 Katharine
April 14, 2010

As a non-medical professional (biology undergrad), I understand fairly well that addiction is a psychological mechanism – even know what a lot of these drugs actually do on a neuron level – but my personal experience with drug users in general, as a person who is non-addicted and only occasionally uses caffeine or alcohol (and does not get intoxicated on either) has been affected by the fact that I grew up as the offspring of one non-smoker, who is quite healthy, and one smoker, who nearly croaked of a brain tumor (and had some personality changes after the surgery), has had two other kinds of cancer, and is overall EXTREMELY immature when confronted about their habit’s impact on them and others.

I have had the experience of nearly losing a parent to tobacco addiction. Ergo, I judge smokers extremely negatively, because since there are some people who are capable of quitting smoking, I judge them for not having the maturity and willpower to see that they need to quit and get the help they need to quit. This does not apply to those who are trying to quit, though. These behaviors have a real impact on other people; I faintly wonder if my allergies were made worse in my childhood by the fact that the parent who smoked did so often around me.

In addiction, I don’t for the life of me understand why any human being wants to descend down the path of screwing with their own mental clarity. Nobody should be doing shit unless they’re sober.
#31 Katharine
April 14, 2010

Er. Addiction isn’t just a psychological mechanism. It’s also physical.
#32 Katharine
April 14, 2010

Also, virtually every person I’ve ever seen who has been high on something has acted totally stupid when they were high, no matter how smart they were when sober. I’m not kidding, I’ve been tempted to make fun of them openly and harshly.
#33 D. C. Sessions
April 14, 2010

Some element of this must relate to the relative social acceptability of smoking, drinking and use of narcotics; an ongoing poll over at Drugmonkey’s blog suggests half of us don’t even view smoking as an intoxicating activity.

Bear in mind that DM’s poll is only for smokers — self-reported subjective perception. It says nothing at all about social perceptions of smoking, just reported smoker reactions.
#34 D. C. Sessions
April 14, 2010

RE: DM’s poll. Notably, a lot of the smokers’ comments are to the effect of “at first I got a real buzz out of smoking, but now it just makes me feel normal.”

I’m pretty sure I’ve heard that same observation elsewhere.
#35 Vicki
April 14, 2010

Does anyone know whether doctors dislike narcotics abusers more than non-doctors do? I suspect that a bunch of what’s going on–along with dislike of being lied to by addicts seeking drugs to get high on–is just that doctors had those attitudes before they became doctors, and those attitudes are reinforced by the culture around us. Doctor or not, you’ll hear negative comments about “junkies,” along with the assumption that recreational use=abuse, which is not assumed about alcohol.
#36 edselRN
April 14, 2010

As an advanced nurse practitioner with chronic pain (who takes chronic narotics at a relatively low rate of 30 vicodin/month), I can say that I see both sides of this issue. I think that there’s a current “push” to have those who utilize narcotics regularly to be on a “pain contract”. I have mixed feelings about this. I recognize the therapeutic side, where I take my meds as prescribed and not all in the first 5 days of a 28 day rx. I also see the “other” side, where I am labelled as a “chronic narcotic user” by some clinicians, who underutilize narcotics in acute situations.
I participate in a health care system that has electronic medical records, so every provider I see is aware that I am on a “contract” with my PCP for pain meds. I have a real chronic pain disorder that explains my usage of narcotics. I also see the ‘squinty eyes’ that some providers see me with when they see my “pain contract” in my electronic medical record. These are not providers from whom I seek pain meds, mind you, but this information is “published” in my electronic medical record.
I make sure that outside providers (who do not have direct access to our electronic records) are aware of the baseline narcotic needs of the pts I case manage. FYI, I work for my insurer. I’m a trauma case manager, so if someone routinely takes 30 mg of oxycodone for their pain, 20 mg will do nothing for their pelvic fracture pain.
I believe that caregiver bias sometimes affects the way I get pain managed in a negative way. I recently had a kidney stone, and was told that only my primary provider (who was on vacation) could prescribe pain meds for me. On the other hand, my primary provider and I have an excellent therapeutic relationship, where in we can adjust the amount of medication I need regularly, and he believes my “pain story” related to my personal medical condition.
I think that health care professionals (myself included) make judgments about people who utilize narcotics on a regular basis. I’ve certainly run across patients who I think over-utilize narcotics. And I’ve run across those who are undermedicated for their pain needs. It’s a challenging question for how to manage pts in the era of electronic records.
#37 D. C. Sessions
April 14, 2010

I participate in a health care system that has electronic medical records, so every provider I see is aware that I am on a “contract” with my PCP for pain meds. I have a real chronic pain disorder that explains my usage of narcotics. I also see the ‘squinty eyes’ that some providers see me with when they see my “pain contract” in my electronic medical record.

And then people wonder why some of us have reservations regarding the confidentiality of EMRs.
#38 WcT
April 14, 2010

@Duwayne above

I feel like alot of your comment is all a very detailed explanation of what I mean (but in no way explained) when I said “INTELLECTUALLY…” I get it, because I DO understand that. I also understand that when a drug seeker says they are in pain they are not lieing. When they say that haven’t filled a script for pain meds in 2 years while I’m holding a photocopy of the script they filled in our pharmacy last week is lieing to me.

BUt even then, I understand that they don’t necessarily have too much control over the lying when they’re actively withdrawing, and clonidine patches (while they’re in the ER, which last a week) plus a script for pills (which are more affordable. Intellectually I get all of that.

The problem is that my gut doesn’t listen to my brain, and doesn’t “Suck it up” just because I tell it to. And this is the part that I’m admitting is irrational. I DON’T get that gut reaction from my OCD patients, or my schizophrenic patients (one of whom smuggled a knife past security per rectum and attempted to assault my attending with it, which we laughed off).

@Nathan Myers at 20

Man that’s awful cynical.

I’d have to say if I didn’t love the majority of my patients there is no way I’d be able to get through the day. The money isn’t better than what I’d be getting in engineering (when you account for the extra years of school, and huge debt load), the hours are horrible, I generally work in the worst part of town, for generally underfunded hospital systems.

I think the problem docs (and everyone else for that matter) have with hand washing is that people as a whole are bad at discipline.

We are not good at doing the exact same thing every 10 minutes for 16 hours a day. Just to show us how difficult it was, our epidemiology people had us carry counters into the MICU and click them off each time we wash our hands throughout the day. In one 18 hour day, I washed my hands over 100 times, still realised that I forgot to wash my hands twice and that was while being acutely aware of hand washing, rather than it being 1 of a million background things I need to keep track of while also caring for patients.

@D.C. at 37

I’m not really sure what you mean by this. We use an EMR where I go/went (in the process of graduating) to medical school, and it’s invaluable for chronic pain patients.

Without documentation (usually the EMR) to confirm that a (non cancer) chronic pain patient has a pain contract, hospital policy limits how much narcotic pain control I can give a patient. On the other hand if I see that EMR, I can actually control the patient’s pain instead of having them scream at me for hours.

Squinty eyes are inappropriate,but squinty eyes or no, KNOWING what is on a patients chart is the only way for us to actually treat a patient. The complexity of medicine has outstripped the ability of most of our patients to keep up with their own medical problems in a meaningful enough way.
#39 D. C. Sessions
April 14, 2010

WcT (good to “see” ya, Dude!):

Squinty eyes are inappropriate,but squinty eyes or no, KNOWING what is on a patients chart is the only way for us to actually treat a patient.

The problem is that there’s no filter. There’s no limit on who can see what and that’s not how it’s being sold. The public is getting a lot of “you can control who sees your records” BS when the same public is also being sold on “if you’re found unconscious out of state EMS will have access to your full HX.”

Now, I’m not saying that the benefits aren’t worth it [1] — esp. for current Rx — but let’s not pretend that your orthopod needs to know about the abortion you had when you were 16.

[1] Especially if we block insurance companies from recision based on combing through your records for something that can be painted as a pre-existing condition.
#40 DrugMonkey
April 14, 2010

Ping!
#41 DuWayne
April 14, 2010

I am rather sorry WcT, I did not intend to rag quite so hard on you – especially as I did note the “intellectually” in your comment.

As much as anything, I was reacting to the general attitude reflected throughout the thread. I have dealt with a fair number of people suffering opiate addictions and it is fucking brutal. I mean I have my own experiences with substance abuse – having managed to abuse the hell out of my body and my brain with a great many substances. But my experience is a garden party compared to opiate (and meth or coke) addictions. I have managed to help a couple of folks through it, but have also watched a few people crash and burn – largely without any help from the general medical community.

One friend in particular actually provoked people to beat him, so he could be sent to the ER and get painkillers. I stuck by him on one of those occasions and talked to the EMT and the police – informing them that he is seriously delusional (paranoid delusional with mania) and a opiate addict. He was out of the hospital in less than five hours, a bottle of vicodin in hand. He even broke down and committed petty crime in hopes of getting some kind of help – kicking in someone’s door and grabbing their coffee table books – while they were home. He was in jail barely long enough for them to book him through, in spite of his explaining that he would just break into someone else’s home (which he did) and in spite of a rather lengthy arrest record.

I sincerely doubt he is alive today.

I have watched cops and EMTs deal with opiate junkies and treat them like they were worthless garbage. I have been in ERs with one and watched doctors act with only slightly more compassion and once a doctor who treated a young man even worse – offended that he didn’t manage to make it to the bathroom before vomiting a cup of water. Out and out longterm drunks who have pissed themselves get treated with more dignity and compassion.

Please accept my apology and understand that this is just something that makes me more than a little bit angry. These are human beings – people who had dreams and goals – people who are unfortunately very unlikely to ever get well. While there is more than stigma driving the likelihood that they will die a junkie, it sure as hell makes it’s contribution.

I also suspect some of my sensitivity to this comes from the fact that if things in my own life had worked out just a tiny bit differently, that could easily be me. It very nearly was.
#42 DLC
April 15, 2010

But how does this square with the plethora of “Pain management clinics” in Florida which allegedly hand out vicodin, oxycontin, roxicet, darvocet and even methadone as if it were so many six packs of beer ? There have to be doctors of some kind behind these places — you can’t issue prescriptions for the stuff unless you have a medical license and a DEA # to go with it. In the meantime, in another state, people with legitimate pain are going without medication because of red tape. It’s another inequity of the system.
#43 DrugMonkey
April 15, 2010

Bear in mind that DM’s poll is only for smokers — self-reported subjective perception. It says nothing at all about social perceptions of smoking, just reported smoker reactions.

There was no requirement or request that only smokers answer the poll, dude.
#44 Sophia
April 15, 2010

I’m a nurse and many of my patients are narcotic drug addicts. Whether officially diagnosed with it or not most of them appear to have dependent personality disorder (DPD).

http://psychcentral.com/disorders/sx13.htm describes this disorder. IMO a large part of the negative reaction towards narcotics abusers is due to their overbearing neediness. This may have been present long before starting narcotics. However, I believe that many people without DPD develop it as a result of taking narcotics originally obtained from physicians. In layman’s terms if you take narcotics long enough you’re likely to become a wimp. And such wimps are very irritating people! Not only do they need their narcotic fix but they (claim to) need help with nearly everything.

One way to figure out the mechanism of narcotic induced wimpiness is to look at a population that is even wimpier than narcotic abusers. I.E. the folks who prefer methamphetamine. PMID 18991953 explains that morphine and methamphetamine activate astrocytes in the brain with methamphetamine doing so more widely and with a longer lasting effect. The glial modulator propentofylline was found to prevent this suggesting it might be useful in reversing narcotic induced wimpiness. Of course this is hypothetical but my concept is that being a wimp is a medical disorder which has the potential of being effectively treated as opposed to maintained and worsened by our current practice of over-utilization of narcotics in the wimpy patient population.

Ann N Y Acad Sci. 2008 Oct;1141:96-104.
Implication of activated astrocytes in the development of drug dependence: differences between methamphetamine and morphine.
…
PMID: 18991953
#45 OleanderTea
April 15, 2010

@DuWayne: No offense taken, your post was well-reasoned. What has concerned me is the tone taken by some, best illustrated by Sophia’s comment:

IMO a large part of the negative reaction towards narcotics abusers is due to their overbearing neediness. This may have been present long before starting narcotics. However, I believe that many people without DPD develop it as a result of taking narcotics originally obtained from physicians. In layman’s terms if you take narcotics long enough you’re likely to become a wimp. And such wimps are very irritating people! Not only do they need their narcotic fix but they (claim to) need help with nearly everything.

I’m six years into a chronic pain condition. I work a more-than-full-time job in IT, travel, live alone, and tote my own laptop, books, groceries, packages, and garbage up and down a flight of stairs to/from my apartment. And it’s the bloody narcotic that lets me do it. Three percocet a day keeps me functional and fairly comfortable. There are milllions of people who are in the same boat. What’s more, if one lives with chronic pain daily, and continues to try to have a life, that person is no whimp.

And what’s so bad about a person who’s sick or in pain being needy anyway? You try being sick or in pain every day. Most people get pretty whiny after having the flu for a few days. Imagine feeling that bad or worse every single day of your life.

The readers of this blog are generally a well-educated and articulate group. If we can’t remember the difference between abuser/user and addiction/dependence, how the hell is the rest of society supposed to get it?

Sorry, Pal. I’ll get off the soapbox now.
#46 D. C. Sessions
April 15, 2010

There was no requirement or request that only smokers answer the poll, dude.

Question: “Does smoking a cigarette get you high?”

I’m curious how you expected non-smokers to answer that.
#47 Incognito
April 15, 2010

In addiction, I don’t for the life of me understand why any human being wants to descend down the path of screwing with their own mental clarity. Nobody should be doing shit unless they’re sober.

Did it ever occur to you that just maybe the reason they start becoming dependent on the drugs is because they are trying to medicate a *lack* of mental clarity? It’s no coincidence that the majority of drug abusers also have mental illness. With a manic episode, for example, one has so many thoughts swirling through their heads at once, their heart is pounding and they can’t even think straight enough to finish one. single. thought. in their head. They can become so agitated that they try to kill themselves; this happens often. Oxycodone, for example, remedies this psychological terror. (Not that it’s a preferable remedy or a long-term one, but it has extraordinary effects in the short-term.)

There are studies on opiates because they have this “magical” property when it comes to certain mental illnesses. We want to know what exactly occurs in the brain that causes this alleviation and if we can find a way to regulate and use the chemical(s) while removing what causes the addiction. Personally, I’m not all that sure on how this would be accomplished, but if they figure it out, great!

You can’t lump together all drug users and say that they’re trash or that they’re of substandard intelligence. These are people that are in a great deal of pain. They are someone’s son or daughter, brother or sister, mother or father… While I completely understand why doctors are rightfully suspicious of narcotics abusers, but the person doesn’t end where the addiction begins.

This is actually something that’s bothered me for a very long time. In America, what do we do with drug abusers? We imprison them. If this country had adequate mental health services in place of prison time, the number of addicts would decrease. I can’t recall–and I apologize–but there is one country that has designated places where users can get clean needles and shoot in sort-of-privacy. I think it was Britain. They’ve seen abuse rates decrease in this demographic. I also read of a place that’s sending their drug abusers to mental health treatment centers instead of jail or prison. This has also had a very positive effect.

I feel like an ass for not having the citations, but I have to do a conference call in about 7 minutes and can’t look them up. I’m sure they can be found somewhere online.

Anyway, I think the problem lies in 1) the national attitude toward people that abuse “hard” drugs, and 2) the deceit involved in obtaining opioid prescriptions from doctors. No one likes to be lied to, and no one wants their power abused. But no one likes to go through withdrawal either.

Personally, my doctor does not prescribe narcotic pain relievers. He claims he did once in 30 years. This isn’t the solution either. Serious pain requires serious pain relief. That some aren’t willing to treat their patients because some people try to get drugs for recreation. (Other than that he’s a great doctor, so I’m not about to boot him for that.)
#48 D. C. Sessions
April 15, 2010

In addiction, I don’t for the life of me understand why any human being wants to descend down the path of screwing with their own mental clarity. Nobody should be doing shit unless they’re sober.

Considering that I have two children who have been using methamphetamine since primary school (one has since quit needing it) I might perhaps point out that there are quite a few conditions (ADHD being just one well-known one) where teh DRUGZZZ make the difference between functioning and not functioning. When used in appropriate doses with supervision, they’re not addictive.

However that assumes that people actually, like, get appropriate medical and educational attention — something that’s not exactly universal in a social-darwinist country like the USA. Instead we leave them to get their stuff on the street where nobody tells them that small doses of relatively mild drugs taken orally do the trick — instead they get honking ginormous doses of stuff by inhalation or injection that puts them on the roller-coaster.

If you want a lovely description of what it’s like to discover what it’s like to think clearly for the first time in your life, have a peek at Joni Mitchell’s description of her first cigarette (jonimitchell.com, currently down.)
#49 DuWayne
April 15, 2010

Sophia –

Please don’t take this the wrong way, but screw you and your “wimp” patient attitude. Seriously, I want to be sure you understand just how absolutely repugnant your attitude is. I genuinely hope that you find yourself a position that doesn’t put you into contact with addicts or people with other mental illness. Characterizing someone who has any for of mental problems as being a wimp perpetuates counterproductive stigmas, not to mention being rather cruel and dismissive of the individuals you describe thus.

You quite obviously haven’t even the slightest clue what it is like to suffer from addiction or a long term chronic pain condition. The former are rather irritating, but they are also very ill. They aren’t sitting there trying to figure out how to annoy their nurse more, they are fucking broken and in many cases suffering a terminal disease. That the problem is in their brain doesn’t make it any less valid or any less potentially deadly than leukemia or Parkinson’s.

The latter are also sometimes frustrating to deal with. You try managing debilitating – day in and day out, that often works it’s way through the cushion of narcotic pain killers. You try suffering through a weekend of desperate pain that leaves you unable to sleep or function, because of some mistake that left you without pain killers for a few days. You try sitting down and considering whether dying might not be a rational response to what your life has become – that applies to both sufferers of chronic pain and people who suffer addiction or several other sorts of mental illness.

Congratulations on being the most repulsive person I have run across this month.

Oleander Tea -

I have never had to deal with chronic or significantly long term pain (except for migraines, but that is very different). I have back and knee problems that may eventually put me there, but I am also working hard to avoid it. I do however, have friends and family who do suffer chronic pain and you have my sympathy. It really sucks that you have to suffer condescension and suspicion, because of the problems of other people. Of course I also think it sucks that our society has the ridiculous and counterproductive attitudes it has about addiction and substances of abuse.
#50 gaiainc
April 15, 2010

My clinic is currently having a lot of discussion around this subject. I’m pretty sure we’re never going to come to a true concensus as there are very divergent views on opiates, opiate prescribing, and the risk of addiction thereof.

Recently, I was pulled into a patient’s custody battle with her partner because he had decided that her chronic, stable (>2 years) use of opiates was suddenly endangering his child, that her opiates made her dangerously sleepy, that she suffered long-term permanent psychological damage from her opiate use, and that she needed to stop taking all medications. However if she had to take a medication, she needed to take a medication that was a)not covered by her insurance; b) is stupidly expensive; and c) has sleepiness as one of the most common side effects. It was good that I could vent to her lawyer how stupid I found all this, because really? It was stupid.

I’m pretty sure that some of my patients who are on chronic opiates are addicted and what I’m treating is not physical pain so much as psychological pain (which I sometimes refer to as Bad Life Syndrome). At the same time, with the way insurance works in my state, my medicaid patients are specifically excluded from coverage for PT (except after surgery) or referral to a pain specialist. Actually, any diagnosis that involves pain is usually not covered. This does not leave me much in terms of options except pain medications. The irony? Medicaid will pay for rehab.

GAH!!!!!!!!!!!

I try to respect my patients on chronic opiates. I try to keep them functioning. Regretfully, my continuing to prescribe opiates is dependent on them following a few rules. If the rules are not followed, I have a hard time continuing to prescribe. It’s not perfect, it’s not great, and it’s overall a pain in the butt, but it’s the best compromise that I can make at this time.

To the poster above lamenting how poor our mental services are in the US, I completely agree. It’s disgraceful.
#51 v.rosenzweig
April 15, 2010

Sophia @44:

Seconding that.

A good friend of mine has chronic pain, which she manages with a combination of narcotics and large doses of NSAIDs. You know those 1-10 subjective pain scales?

Hers is at 7 on a good day, with the narcotics. And you dare call her a wimp, as she goes through her days, works and cooks and shops and does dishes and even manages the remnants of a social life around the pain and fatigue?
#52 DuWayne
April 15, 2010

incognito -

This is actually something that’s bothered me for a very long time. In America, what do we do with drug abusers? We imprison them. If this country had adequate mental health services in place of prison time, the number of addicts would decrease.

I am not sure if you realize just how true your statement is. It is an issue that I have meant to get around to writing about for a while and didn’t treat as thoroughly as I wanted at that. Prisons have actually worked out as the major repository for the seriously mentally ill – addicted to something or not.
#53 Incognito
April 15, 2010

D’oh. This is what I get when I try to rush through something and do work at the same time…

The paragraphs should say:

“While I completely understand why doctors are rightfully suspicious of narcotics abusers, ~~but~~ it is important to remember that the person doesn’t end where the addiction begins.”

and

“That some aren’t even willing to treat their patients that are in real pain because some people somewhere tried to get a script under false pretenses is inexcusable.”
(Does that violate the “do no harm” tenet?)

And DuWayne, yes, I fully understand and am very passionate about what I posted. I don’t know what the hell is wrong with this country. I don’t understand how the hell we create policies and legislation without looking out our own fucking back door. Why is creating laws based on evidence such a difficult thing? There’s this issue with drugs/mental health, and then there’s the whole “we’re overbudget–let’s cut school funding!”. And they wonder why we score so low on tests compared to other countries. Grr. I’m not going to get started on that here though…

I really hope one day our representatives take a logical approach to law. I’m not holding my breath though.

Are you aware of any organizations that are behind the push to reform drug laws? I can think of a couple, but I’m not very familiar with much outside of those.

Thanks.
#54 Alexandra Lynch
April 15, 2010

I find myself working very hard in public to never look as though I don’t care about my appearance, that I am tired, or “out of it”. I work to be gracious, thoughtful, modest, and generally the kind of person who you would never ever think uses drugs for fun. Because while I don’t abuse them, the sequelae from a car wreck has left me with chronic pain issues. I fought getting properly medicated for a long time because of these stigmas. Taking my medications every morning and night is the difference between me being able to be a productive citizen and me being childish, whining, and useless because I can’t stand. So yes, I do make a point of making sure to get my refills on time and see the doctor on schedule, and it’s a pity that being proactive and compliant gets looked at as drug-seeking. Fortunately, I have a good PCP.
#55 gaiainc
April 15, 2010

Alexandra, I wouldn’t label you as drug-seeking for getting your refills on time and seeing me on schedule. I’m more likely to cut you some slack if something goes haywire in your life and the prescriptions need to be filled early.

However, no-showing me twice in the same month, then whining that the appointment you made three weeks ago is suddenly inconvenient for you even though you know the clinic policy is opiate prescriptions only at scheduled appointments, and you want me to fit you into my overbooked schedule so you can get your prescriptions? Yeah… that might be a little on the drug-seeking side or at least on the side that will make me a lot less sympathetic to your cause.
#56 DuWayne
April 15, 2010

I really should update the links on my blog – there were several other drug policy organizations that I intended to list way back when…But I do have a fairly decent list in my blog side bar. At some point when I actually have a little spare time that isn’t being sucked up by stress management, I will add some more. Hopefully before I get through my post doc – keeping in mind I am an undergrad now.

LEAP (Law Enforcement Against Prohibition) leap.cc and VCL (Volunteer Committee of Lawyers) vcl.org are not listed and are both organizations that I am very fond of. LEAP includes members who have worked/work for federal, state and local law enforcement – including people who have worked for the DEA. VCL is a collective of lawyers and judges.

Some of the links under my “harm reduction” heading also connect with a couple of organizations of substance abuse counselors who support the repeal of prohibition. There are also some members who have been trying to push the APA into sponsoring a task force to explore the possible effect of ending prohibition on substance abuse treatment. I doubt that is going to come to much very quickly, but I think it is looking better and better as more psychologists who work in substance abuse treatment adopt harm reduction as an underlying treatment model.

As far as general mental health services go, I think the thing that really angers me is that the deinstitutionalization movement that got going in the late sixties, early seventies was a complete and utter failure on all counts – yet we do nothing to rectify it. More than just a cost saving measure, this was intended to provide the same sorts of benefits to the mentally ill that were touted as good reasons for “mainstreaming” special education kids. It was also assumed that freedom would be more humane.

The problem is that the majority of people who would be residents of state hospitals now, are either homeless or incarcerated. They cost us far more, because incarceration is far more expensive than hospitalization and because the homeless mentally ill tend to end up in the ERs and county lockups at significantly higher rates than any other demographic in the U.S. Some of the homeless mentally ill aren’t even technically homeless – many of them are, or were, group home residents who wandered off and couldn’t get back. For many others, prison will be their first time ever getting treated for their mental illness.

And the icing on the cake? This group home model that was touted as being so superior to centralized state hospitals is a great environment for abuse. County community mental health organizations are the one’s who provide oversight. I occasionally make it to our local CMH boardmeetings and know the members of the client safety oversight committee. All of them are involved in this in their spare time and the only people who can actually investigate any serious allegations of wrong doing on the part of group home providers in the local sheriff’s deputies. Mind you any investigation will be based on client complaints – while many of the clients are not of sound enough mind to file a complaint. At least in hospitals there was direct oversight by in house administration.

The situation as it stands has the vast majority of people who would be in a state hospital now, living in absolutely appalling situations. And costing taxpayers exponentially more.
#57 daedalus2u
April 16, 2010

I have been kind of busy lately, and haven’t kept up on reading blogs and leaving comments.

I think the “dislike”, derives from the same place that other “dislike” of whole groups comes from, from xenophobia, which I happened to just blog about.

http://daedalus2u.blogspot.com/2010/03/physiology-behind-xenophobia.html

Xenophobia comes from not being able to understand someone well enough to emulate their thinking with enough fidelity to predict what they are going to do, and to some extent influence what they are going to do via means that are acceptable. Social interactions are a give-and-take, a back-and-forth, a mutually satisfactory exchange where both parties get what they want and need.

What doctors like Pal want is to treat their patients, to be a good doctor, to help them get better, to improve their lives in meaningful and lasting ways. What most of Pal’s patients want is the same thing, they go to Pal to get better, to be listened to, to have their difficulties diagnosed and for Pal to come up with a treatment plan that results in improved quality of life in the long term.

With a narcotic abuser, that social contract exchange is not possible. All the abuser wants is more narcotics. They don’t want to get “better”, they don’t want to get over their addiction, they don’t care about their long term health, all they care about is the very short term. They see Pal as simply a potential source of narcotics, an object to use to get narcotics. Pal gets little or no job satisfaction from those interactions.

What the patient wants is counter to what Pal wants. Pal wants the patient to get “better”, but the patient simply wants more drugs and will take more drugs even if those drugs are bad for him/her. Since Pal is committed to “first do no harm”, treating patients who want to harm themselves with what they get from Pal is very problematic for him. It puts him in the difficult position of having to enable the abuser with narcotics, so as to maintain a semblance of a therapeutic relationship to have positive impacts in other areas of the patient’s health. I think this is the reason that Pal and most other doctors don’t like narcotics abusers.

The reason that “society” (read politicians, cops, and the criminal justice system) doesn’t like narcotics abusers is because the purpose of the criminal justice system is not to produce “justice”, it is to increase the political power of politicians. The primary purpose of the criminal justice system is to “other” people who commit crimes. That is why “white collar” criminals get such light sentences. Severe sentences are reserved for those lower in the social hierarchy, blacks, the poor, the uneducated, immigrants, people with no political clout. The politicians, police, prosecutors, and the general public move up in the social hierarchy by moving criminals down. That is why actual guilt doesn’t really matter. An innocent person who is convicted is just as much an example after he/she has been “othered” as is a guilty person.

This is why drugs like marijuana are illegal. It is certainly not because it is more toxic than tobacco or alcohol, it isn’t. It was lobbying from the alcohol industry that demonized MJ so that it was criminalized. It remains illegal because lots of money is made off of it as an illegal drug by the suppliers and the criminal justice system and lots of political capital can be made being “tough” on crime, even bogus stupid crimes like smoking MJ. The PAC of the prison guard union in California is the largest donor to political campaigns. Guess who supported all that criminalizing of drug offenses?

As far as the traits that Jon mentions in #3, I think those are a consequence of someone addicted having to get enough of an illegal substance to stave off withdrawal.
#58 DuWayne
April 16, 2010

With a narcotic abuser, that social contract exchange is not possible. All the abuser wants is more narcotics. They don’t want to get “better”, they don’t want to get over their addiction, they don’t care about their long term health, all they care about is the very short term. They see Pal as simply a potential source of narcotics, an object to use to get narcotics. Pal gets little or no job satisfaction from those interactions.

The problem with that Daedalus, is that like many things it is just not that simple. Addiction usually isn’t that cut and dry – the shit of addiction, is that many, possibly most addicts hold with two very intense desires. On the one hand, they desperately want a fix and not just because of acute dependence. They want that fix because they need to feel numb – numb to the world around them in an emotional sense and numb to physical sensation.

On the other hand, they also actually do want to get better. They want to be normal like everyone else. They want to be free of their addiction, but are also terrified of being free of their addiction. They are terrified of becoming a “real” person and failing. They are terrified of the specter of whatever might have driven them to the use of rather heavy handed drugs in the first place – usually mental illness of another sort. But even through all that they want to be better – or often enough failing that, they want to be dead.

The thing is, “better” is not just better in the sense of defeating their addiction – that is not enough. Better also means better in the sense that they are not being overwhelmed and defeated by whatever drove them to use in the first place. This is ultimately the biggest problem with dealing with people who suffer serious addiction problems. It isn’t getting them off the shit – whatever that shit might be. It is getting them off that shit while dealing with the problems that drove them there.

This is what really pissed me off about Sophia’s comment above – that is an attitude that is entirely counterintuitive to the process of treating the addict. It is the reason that the stigma and the attitudes cause so many problems. Addiction is not as simple as getting someone to change one specific behavior. Dr.’s Edward Khantzian and Mark Albanese wrote a very good book entitled Understanding Addiction as Self Medication. The book is well worth reading, but I would also suggest that you google scholar Khantzian, as he has published a couple of papers on it that are not locked behind a paywall (at least I don’t think they are – if they are email me).

And this is something that you can translate to most any addiction for a lot of different problems. I think that a significant part of the problem here, is that MDs are generally that, MDs. I don’t imagine they are trained beyond some specific procedures for dealing with addicts in specific situations (There are plenty of MDs around here to correct me if I am mistaken). Unfortunately most psychologists aren’t bloody well trained to deal with addiction and all too often those who are are trained in a ridiculous “abstinence first” model that is unrealistic and often enough ends quickly and badly.

Most psychologists just aren’t willing to deal with an addict where they are. Instead of accepting that “yup, this patient is high, but I am going to work with him/her on figuring out what they are running from.” Completely failing to understand that this is actually a very good time to bring this up – they are insulated from the brunt of it. Depending on what they are on and how much, they are also probably a lot easier to bring around to that discussion.

People who are addicted to narcotics and speed are really needy and irritating. But they are needy and irritating for very good reasons. The main reason being that their mind is filled with these contradictory drives, all of them important, all of them exerting a great deal of pressure – we are talking cognitive dissonance on steroids. Not to mention no small portion of complete and utter self loathing. They are lying, they are cheating, they are trying to take advantage of someone who just wants to take care of them – to help them. They are also decent people who know that this act of taking advantage is horribly wrong for so many reasons.

At best their psyche is fractured, more than likely it has broken under all of these contradictory and competing pressures. I want you to consider that for a moment – consider the implications. Their entire sense of self is in pieces, giving them just one more thing to self medicate for. Because of the further damage that substance abuse has caused – on top of whatever they were escaping early on in their addiction, their primary drive is to get that next fix. Even if it just makes it worse. And at some point they become pretty incapable of much anything else.

But that is not because they are a “wimp” as Sophia callously regarded it. That is because their entire identity – including whatever drove them to use in the first place – has become subsumed by addiction and has broken under the weight. I don’t care how fucking strong someone is, they can be broken just the same. Yet underneath all that is still a desire to be better and to be a better person. That desire is going to be present in there somewhere, until the neurons blink out, synopsis stop firing and their misery is over.
#59 daedalus2u
April 17, 2010

DeWayne, I think we are in complete agreement. The underlying problem(s) that led to the addiction are often not within the power of the doctor to fix, or treat, or even acknowledge. If there is no differential treatment, a differential diagnosis is of no therapeutic utility. I suspect that most addicts don’t understand the problems well enough to articulate them.

I think that many of these underlying problems relate to low NO/NOx status. They are systemic, non-specific problems, usually associated with stress (which is a low NO state), or maladaptive stress responses (often triggered by low NO), often from childhood trauma (which epigenetically programs for a low NO state and for hypersensitivity to entering a low NO state). I see PTSD as the normal consequence of prolonged stress, a semi-permanent transition to a persistent low NO state and hypersensitivity to entering a low NO state. Morphine is produced endogenously in humans, and is something that regulates and counters some of those adverse low NO stress effects.

The response of society to individuals with these problems is (usually) things that make the problems worse, applying more stress, more abuse, more maltreatment, more bullying. That certainly is the case for drug use. Putting people in prison, making drugs more expensive, making getting drugs more dangerous, forcing drug users to risk hepatitis, HIV and other diseases to take drugs, forcing women to prostitute themselves to buy drugs, none of these help any of the underlying problems, they just beat people who are already down.
#60 DuWayne
April 18, 2010

The underlying problem(s) that led to the addiction are often not within the power of the doctor to fix, or treat, or even acknowledge.

This is actually extremely important, so I want to make this a very categorical statement. Even if said doctor was qualified to make a legitimate assessment, it would be exceedingly irresponsible for that doctor to even try. Except for the acknowledgment part. When we are talking addiction those underlying issues are there – whatever they might be. The doctor acknowledging that would actually have some utility in at least trying to refer the patient to help.

If there is no differential treatment, a differential diagnosis is of no therapeutic utility.

This is not actually entirely true. It is also rather ambiguous ethical territory. Diagnosing a patient with a substance use disorder, undefined (an MD is simply not qualified to refine that assessment) may well be the best way to help them get help. In some locations a doctor’s referral may well be the ticket to getting that patient services from the state to help them. In other locations however, it may well be better to provide a tentative diagnosis of a different mental disorder. When you are dealing with addicts, that is not hard to do.

For example. In Portland there is a doctor who after retiring several years ago opened a free clinic. He donates his time entirely and the office help is volunteer. He is also able to regularly convince people he used to work with at OHSU to donate time to his referrals. Because of the nature of the system in OR, it actually circumvents a lot of problems if he can provide a general screen, make a tentative diagnosis and refer a patient for a psych evaluation.

If he were to simply provide a diagnosis of substance use disorder, it is not a given that that patient will ever see a psychologist. Even if they do, it is likely to take well over a year for them to get to that point. Unfortunately, it is not a given that even after that tentative diagnosis the patient will see a psychologist. The mental health care system in OR is truly abysmal. But it does make it more likely – especially if he pulls some strings.

I suspect that most addicts don’t understand the problems well enough to articulate them.

Most people with any mental disorder don’t understand their problems well enough to articulate them. The job of a good therapist is to ask the right questions so that they can. Addiction complicates things because as all encompassing as it often is, it creates a huge barrier between the conscious mind and the underlying problems. But the process of untangling the addiction from the rest and getting through that barrier is actually really exciting.

This is why in spite of my desire to end up in academia, teaching and researching, I will also engage in clinical work. Both because I absolutely love trying to help people with addictions (in spite of the biting pain that accompanies the knowledge that this or that person is extremely unlikely to ever get better) and because it is truly exciting to me. As hard as it is to deal with knowledge that someone you were trying to help is unlikely to ever get better, that’s what compartmentalization is all about. The absolute wonder of helping someone successfully get on top of their addiction of course creates a hell of a counter.
#61 Citizen Deux
April 21, 2010

My spouse, a general practice PA-C, detests “surfers”. She routinely sees them showing up with non-specific chronic back pain and as a believer in the “less is more” approach – usually sniffs them out pretty fast. In one instance – a couple presented in the same clinic, got the same “no” from my spouse and her colleague, and the stalked out in a huf – together!
#62 Ed Pullen MD
April 24, 2010

No doubt we feel abused,used, and just totally worn down by patients looking for opiates for every reason from their resale business to legitimate pain control and every nuance in between. The worst part about it is that we are so skeptical now that patients with terribe problems that really need opiates cannot find a doctor to prescribe the medications. Every day I get hits from search engines on a post of several months ago titles: Can’t find a doctor to prescribe pain meds? I feel I have lots of better posts, more insightful and educational, but what’s in demand. Information on how to find a doctor to prescribe pain meds, Sad but true.