LESSONS FROM DAY IN COURT

A Day In Court Changes Doctor's Perspective On Prescribing Pain Medications

MY RECENT VISIT to court taxed my "bleeding-heart" liberalism, my view of
drug addiction as a disease model and made me side with the commonwealth's
attorney and his "string 'em up" rhetoric.

The occasion was a visit to the Stafford County courthouse to appear as a
witness in the case where one of my patients had falsified his prescription.

A reputed, "slip of the pen" and the prescription I wrote for 20 Percocet,
suddenly become 120. The sharp-eyed pharmacy technicians caught it and
called the sheriff.

In the course of the proceedings it transpired that my patient had quite a
history, including distributing Oxycontin--a pain medicine that has built
itself quite a reputation for abuse and distribution.

So there I sat with this uncomfortable thought gradually percolating through
my brain, "How many other of my patients are taking me for a ride?"

A pain in my neck A large part of family practice involves dealing with
people's pains--back pains, arthritis pains, headaches, fibromyalgia pains,
neuropathies. They have (or they are) a pain in the neck.

Maybe I'm too liberal and accumulate more than my fair share of pain
patients. One always worries about patients abusing their pain medicines, or
becoming addicted to them. Some even come with a pre-existing diagnosis of
drug dependency of some kind.

But when someone is sitting before you telling you they are in excruciating
pain, and there's no test you can do to tell if they are or they aren't,
what do you do? Tell them, "Sorry, I don't believe you?"

But as you write out their prescription for abusable, saleable narcotics,
there's a little voice niggling in the background, saying, "Sucker."

One woman I saw the other day complained about how everyone treated her as a
criminal when she asked for Percocet for her back pain. She was obviously
naïve about these things, or a very sophisticated "hitter," judging how she
nearly fell off the exam table when I talked about the court case.

But it's a disease The medical literature claims that doctors overall
undertreat pain, and it has recently been cited as "the fifth vital sign,"
so that nurses in the hospital are obliged to rate a patient's pain on a
scale of 1 to 10, as well as check their conventional vital signs.

The finding of abnormalities of the dopamine regulation in the brain has led
to the conclusion, at least by the boffins in their laboratories, that drug
addiction is "firmly entrenched as a brain disease," according to an article
from the Department of Cellular and Molecular Biochemistry of Finch
University in Chicago.

Dopamine (DA) is the neurotransmitter that mediates the pleasure and reward
centers of the brain. Addictive drugs enhance DA neurotransmission,
according to the Chicago team.

Incidentally, tobacco/nicotine works here also, and the drug buproprion that
is the ingredient of Zyban, used to help people quit smoking, works by
stimulating the dopamine receptors to replace the effect of the missing
intoxicant.

Other drugs of addiction work on other neurotransmitters. Cocaine, for
example, works on serotonin and norepinephrin, both of which are involved
with mood regulation and are deficient in depression.

Antidepressants boost the amount of both of these chemicals in the
brain--but a hit of cocaine seems to do in one jolt the equivalent of about
a year's worth of antidepressant, so far as I can see.

An addicted society Intoxicant use is well ingrained in the nature of our
constitution. People have been getting "three sheets to the wind" on alcohol
for some 8,000 years. Cannabis has been used at least since the days of the
ancient Greeks and cocaine (at least in the form of chewing coca leaves) has
been used for some 1,200 years. Then there's the ubiquitous use of caffeine.

You could almost postulate that we are wired for intoxicant use judging by
the fact that our brains, for some reason, have been found to have receptor
sites for cannibanoids and opiates.

There are all the other kinds of addictions in the form of compulsive
behaviors: Gambling, compulsive consumerism, sexual promiscuity, TV and
video games, Internet use, workaholism and overeating.

Many of us have several addictions, or jump from one to another
demonstrating cross addiction. I have an alcoholic friend who has been sober
for 25-odd years, but you should see what he can do to a box of Godiva's
raspberry creams.

Don't make me your pusher It is not for me to moralize and chastise you for
your weakness and inability to control your various addictive type
behaviors.

Unfortunately, however, I hold the requisite papers to prescribe a lot of
medicines that have the potential to be addictive, and it is a grave and
onerous responsibility deciding if it is appropriate to prescribe Oxycontin,
Percocet, Xanax, Valium or whatever potentially habituating medicine to this
or that patient.

To then find that patients are abusing that responsibility and conning me
into prescribing for them, or falsifying their prescriptions, gets me fired
up.

In court, the commonwealth's attorney was forcefully pleading my patient's
case to the judge to, if not actually string him up, at least incarcerate
the guy and get him off the streets. In my indignation, I had to agree with
him.

In the end, the guy was convicted and sentenced to three years in jail, with
all but 60 days suspended.