Substance Abuse Update

                   

Today was a good day, much better than most ...

Those who follow my writings know of the growing dissatisfaction and frustration I have developed toward drug addicts, in general, especially crack cocaine addicts. Despite those emotions, I continue to work part time in a detox facility. 70% of those in addiction recovery will fail within a year of starting treatment, some will fail multiple times within that 12 month period.

Who would want to bother treating a group of people with such lack of promise? I grew up around many such people which is probably where the commitment originated. At a recent CME workshop I commented to one of the presenters that I felt I could help, to some degree, any individual who was willing to comply with my recommendations and cooperate with treatment. He told me that I was grandiose in my thinking. Maybe I was. Maybe that is why I have had so many problems within my clinic over the past couple of years since beginning to treat more chronic pain cases. It has been one of the greatest learning experiences of my career if nothing else. My new sub specialty has seemed to become identification of drug abusers and criminals and removing them.

Though, only a small percentage of my practice is actually pain management, the majority of my stress originates from substance abusing sociopaths disguised as normal patients. I suppose I have always felt compelled to accept a challenge and this has led to taking on patients that most other doctors would refuse to treat. I am pleased with the progress made in establishing better defined limits for those patients likely to benefit from treatment and those who are high risk and a waste of time. Medical school gives the false impression that a good doc will one day stamp out most pestilence and disease. Advancing along in the training process reveals a more clear truth in that there is a limited amount of patients in which a physician can make a major and lasting improvement in their condition. This is especially true for the specialty of psychiatry. Even though we have trillion dollar miracle pills for certain conditions, those pills aren't worth diddly squat if the patient doesn't comply with your instructions for taking the medication. So even in the best of circumstances we may significantly improve the lives of 50-60% of our patients, usually the patients able to comply well with treatment.

I find that most physicians avoid or shy away from treating severe anxiety and chronic pain because of the infiltration of the medical community by substance abusers who may put their license at risk. In my state, usually, persons who break the law with behaviors such as altering prescriptions, calling in their own refills, obtaining meds fraudulently, or selling controlled drugs are not aggressively prosecuted in my experience. The DEA system is set up more toward finding and weeding out physicians who prescribe inappropriately. This system has created a more concentrated and vicious population of substance abusers and divided physicians into those who will treat and those who won't treat. I'm still one who follows my conscience when it comes to treating chronic pain with opioid medications and severe anxiety with benzodiazepines. I still believe that about 75% of these patients benefit from the use of these medications when appropriately used. It is the other 25% of those seeking treatment for these disorders that carry a very high risk and cause problems for well intending physicians.

I have learned that most of these people in that 25% bracket are just sociopathic and must be identified as so and dismissed or avoided. They can be offered treatment for substance abuse but most will refuse or not comply due to their denial and lack of useful insight. It isn't considered a challenge to treat one who doesn't want appropriate treatment but is more so an exercise in futility. My practice had to release over 50 patients for violations of the controlled drug use agreement or outright criminal behavior during 2006. I will not allow those bad apples to cause me to deny treatment to my honest patients who do benefit by refusing to prescribe any controlled drugs where I feel appropriate.

I believe in principle, and the threat of having my DEA license suspended hasn't stopped me from doing what I feel is ethical and the right thing to do. I went before the State Medical Board in an informal inquiry last year to defend my developing practice policies in regards to the matter of prescribing schedule 2 narcotics. The main advice I received was to make sure my Continuing Medical Education was up to date and to improve my chart documentation and know when to refer or dismiss inappropriate patients. I tried to use the opportunity to shed more light on the practice environment for the average practitioner outside the metropolitan areas. It was made clear to me that wasn't included in their scope of concerns. Basically, I was told to work on saving my own hide and forget about social science. This caused me to feel conflicted and depressed for a while. I finally accepted that the only way to survive in the world of private practice is to practice self preservation which is to treat as few high risk patients as possible by learning to quickly identify those who probably aren't sincere about help and allowing them to flow downstream to the next unsuspecting but compassionate practitioner. This may be a bit poignant but this is reality in our health care system. Also accept referrals from reliable sources only. Eliminate walk-ins without a referral from a legitimate provider. Use well defined written agreements signed by you and the patient. Enforce violations of the agreement promptly and effectively. Improve communication with pharmacies and become working partners with law enforcement.

Today was a good day because in it I felt some hope. I saw a recovering alcoholic with panic disorder who had been sober and clean for almost 6 months and was working a full time job and handling his stressors without the use of alcohol. I had met him in detox several months ago. Today, I wished him well and felt good about being involved with his treatment. I also saw a chronic pain patient with Post-traumatic Stress Disorder who I feared greatly was primarily a substance abuser during previous visits. Today we talked about how the evils of incest had affected her life and her ability to mother her 4 children. She expressed readiness to accept help from an outside agency with the 2 oldest kids whose behaviors have become unmanageable. She arrived at this decision herself despite opposition from family members who offered no better solutions yet were critical of her. Today I know that she heard me and I felt more comfortable that she wouldn't choose to medicate herself into numbness as a primary coping mechanism. Finally, I saw a young post-partum mother who was on methadone for chronic pain for the past 13 years for pain associated with spina bifida. She had no significant history of substance abuse or mental illness. Her OB-GYN saw her through a successful pregnancy last November and had the courage to keep her on her methadone to avoid the complications that would arrive through withdrawal if it were stopped. He then had to refer her to a primary care doc whose main agenda was to taper her off the methadone. Methadone can be a miracle for one with a chronic pain syndrome and no substance abuse issues. It is perfectly legal for any doctor to prescribe it for the purpose of chronic pain control but not for addiction maintenance. Most doctors avoid it due to risks and inviting the Federal government into their practices. I thought she was a perfect patient for me to treat and accepted her care without a problem. She rose from near despair to elation upon discovering she could get the help she needed from me. I felt good about the decisions I made over the past year refusing to allow addicts to make me be unable to provide care to the truly needy. Today was a very good day.

Comments

[small town girl]

I just ran across your blog for the first time. I find it to be great!! Hang in there, it's a tough field to be in right now. I just posted on a similar, but not really, topic on my blog

[Caio]

I can't imagine dealing with crackheads is that rewarding, but you're still a Saint for doing it. Trying to give substance abusers what little help they'll receive, especially when most probably aren't going to use it, is God's work (to coin a phrase).

[srikanth]

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