TRIPLICATES

We are three sufferers in the cast room.

There's a little African-American girl about two years old and dressed
in a frilly dress. She is having some sort of shoulder yoke adjusted,
apparently to correct a congenital problem. Her mother sits nearby,
fussing with an infant. There's an African-American woman in her
seventies in a wheelchair getting a new wrist brace. And there's me,
the fifty-four-year-old doctor who broke his leg.

I'll be brief in describing my injury since I've been over this
territory so many times during the last 12 days. Even strangers on the
street will see me with my crutches and ask "what happened." Perhaps
they mean well. Maybe it's just another way of expressing sympathy.
But it gets old real quick.

I was working on the roof of my garage and somehow -- I'll never know
why -- the ladder slipped out from under me. I fell and my left leg
pile-drivered into the concrete driveway. Both leg bones, the fibula
and tibia, were fractured at the ankle. Within seven hours of the
accident I went to surgery to repair the damage with metal plates and
screws [I've reproduced my "before" and "after" x-rays on this page].
The surgery has been successful so far. In perhaps six months I'll be
my old self. In the meantime, the leg is swollen and painful. I am
restricted in my activities. I'm bummed.

An accident will transform a life in less than a second. One minute I
was happily going about my business doing minor home repairs and a
split-second later I was writhing in pain and realizing that I
wouldn't be going on vacation, and that I was probably going to have
to cancel hundreds of patient appointments for the next month (at
least), and that I probably wouldn't be able to exercise for the
foreseeable future. It is the very swiftness with which an accident
happens that causes the sufferer to believe that maybe, if he thinks
about it hard enough, he can change what has happened; that he'll get
a second chance on that ladder and maybe the landing will be softer.

Now the cast room technician has removed the cast. I'm pleased to see
that underneath the purplish bruising, my left leg connects smoothly
with the ankle and my left foot is back in its usual position. The
last time I saw this foot, the Berkeley Fire Rescue medic had just
split the seam of my Levi's and cut away my sock to reveal a left
ankle that was deviated more than an inch to the right. Since then the
ankle has had two hours of orthopedic surgery and resided in a cast,
while I have been subsisting on various combinations of morphine,
Demerol, and percocet.

Today I took percocet, an oral painkiller that is a blend of the
opiate oxycodone and acetaminophen. Percocet is classified as a
Schedule II drug by the United States Drug Enforcement agency, meaning
that it must be prescribed with a triplicate prescription form.

My surgeon is not here today. He's been called away to the operating
room and another orthopedist substitutes. He looks at my x-ray and at
the purple foot and decides that all is well. I ask him for a
handicapped parking certificate and some more percocet. He gets me the
certificate but tells me he can't give me percocet because he doesn't
have any triplicates.

"You mean you're out of triplicates," I ask.

"No," he says, I mean I don't *have* triplicates. But I'll leave a
message for your surgeon."

"Please do," I say, "because I'm down to my last tablet." And in my
mind I'm wondering why this doctor has apparently made the conscious
decision to give up the power to prescribe the most effective
painkillers. Is the application process too much of a bother for him?
Is he too cheap to pay for the special forms (about thirty dollars for
a large stack)? Does he think that since I'm no longer hospitalized, I
am somehow no longer in pain?

The license to prescribe controlled substances is issued by the United
States Drug Enforcement Administration or DEA. In order to obtain a
DEA certificate, one must provide evidence of completing an approved
course of medical education and submit a $210 filing fee for a
three-year license. The application process took me about two months
following the completion of my internship, most of that time being
consumed by bureaucratic inertia and background checks. Once the DEA
certificate is granted, physicians may file with their individual
state agencies -- in California it's with the Attorney General's
office -- to receive a supply of triplicate prescription forms.

The triplicate forms are configured such that they fit in a light
blue, plastic binder that fits comfortably in the pocket of a lab
coat. Two copies of any triplicate prescription are given to the
patient for presentation at the pharmacy. The pharmacist keeps one
copy and forwards the other to the relevant state agency. The third
copy remains with the prescribing physician. Most doctors keep their
triplicates locked in a desk drawer or a safe. In my experience, the
only physicians who routinely carry triplicates on rounds are the
oncologists -- the cancer specialists who constantly confront the
problem of intractable pain.

In the past, the DEA certificate was a spectacular engraved document
with pictures of medicinal plants and a legend proclaiming that this
was a license to prescribe various drugs including "marijuana."
Today's DEA certificate is a green sheet of paper about 5 x 8 inches,
printed in smudged carbon. The certificate grants authority to
prescribe drugs according to five different "schedules." Schedule I
includes experimental medications and several of the psychedelic
drugs, such as mescaline. Schedule I privileges are *not* granted to
the average physician. Schedule II includes the "triplicate" drugs,
medications deemed to have high addictive potential. Most Schedule II
drugs are opiates, painkillers derived from or based on the active
ingredient of the opium poppy. Schedule II also includes some of the
potent barbiturate sleeping medications, such as seconal. Schedule
III, IV, and V drugs do not require triplicates. Vicodin, an oral
painkiller, is a Schedule III drug. Valium is on Schedule IV.

A few years ago, as part of a scholarship payback arrangement, I was
dispatched by the Department of Health and Human Services to a
Midwestern town with a serious shortage of physicians willing to care
for its indigent population. The job was very hard. I shared call with
three other physicians, meaning that about every three days (and every
third weekend) I worked a 24-hour shift. The good part of the job was
that my partners were nice guys, the hospital was well-run, and the
nurses and other workers in the clinics were first-rate.

When my obligation was completed, I returned to California. My
replacement in the Midwest was a young physician just out of
residency. I had not been in California for more than a few weeks when
I began hearing stories of how things had worked out. My replacement,
it was revealed, had never applied for a DEA license and because of
this he was denied hospital privileges. The consequence for my former
partners was that they now were compelled to take call every other
night until the new doctor's license came. Again, the waiting period
can be as long as two months. My former partners were not amused and
neither were their wives and children.

Thirty hours have now passed since my appointment. My supply of
percocet is gone and I am very uncomfortable. I call the pharmacy and
learn that there is no record of a refill being submitted. I call the
doctor-without-triplicates and learn that he passed on the message to
my surgeon's nurse. He says he'll pass the message again. I say that
I'm in pain *now*. Then I hang up and call one of my own colleagues,
who immediately refills the prescription. Soon, I'm basking in the
warm glow of an opiate "high." I feel much better. I can also imagine
how angry a patient who was not a physician -- who did not have access
to a helpful colleague -- might have been feeling under similar
circumstances.

Throughout my ordeal I have received very good medical care. The
rescue squad was superb, the surgery appears to have been successful,
and the nursing care was attentive and sympathetic. Whether or not I
had received a prompt refill of my pain medications probably has no
bearing at all on how I will recover, but it certainly had a lot to do
with how I felt.

Physicians have been criticized for under-treating pain. I think the
criticism is valid. Why this is, I'm not sure. Perhaps it goes back to
medical training. Most of us do our internship and residency at large,
inner-city general hospitals. Many of our patients in these settings
are drug abusers, and others are just out to con a prescription for
pain medication that they can sell on the street. In this setting, the
request for a triplicate drug is a red flag. We get hardened and
cynical. Also, we are young when we are in training and many of us
have never faced a really long and painful illness or injury. Finally,
there is a deep puritanical streak that many physicians have but
rarely acknowledge -- a belief that toughing it out somehow builds
character.

I have had quite enough character building over the last twelve days.
Doctor E's advice to other physicians is simple: put yourself in the
other person's shoes (or perhaps his cast) and act accordingly. Pain,
as they say, hurts!

Dr. Alan Eshleman
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