I sit in my clinic’s office, looking at today’s schedule. It’s a pretty office with lots of white and pastels, modern furniture, a modern computer, and a desk. I always wanted my clinic to feel like something from the future and now, after twelve years, it finally does. In addition to the screen on my desk, there is a large screen on the wall to my left, to the patient’s right. From my main computer, which the patient can’t see because it’s facing me, I can project images to the patient as we discuss labs, spinal injuries, or images of a beating heart, whatever helps me educate them.
There are not many patients today. I see the more complicated ones at our primary care clinic, and they take at least twenty to thirty minutes, often forty-five or even an hour. This means that a schedule of twelve patients can fill my day and get me to the end of the afternoon when I see them all. All good. I have a nurse for the simplest problems and a licensed professional counselor for those who need psychological support. They are worth their weight in gold.
As I review the names and notes next to them on the schedule, I see that two of them had abnormal urine drug test results. One tested negative for his medications and the other tested positive for methamphetamine. This is always a concern. A negative result could mean they are diverting the medication, and that is what many doctors assume. But it could also mean that they are one of the approximately ten percent of the population with increased cytochrome P450 enzyme activity. This would mean they were processing the medication out of their bodies faster than average. Or they may have missed a dose for some reason.
The first patient is taking Xanax BID for PTSD. Missing a dose puts 24 hours between doses and can cause a negative result even with normal enzyme activity. Or they forgot how many they had taken and ended up taking three in a day or two, finishing them sooner. We tell them to be careful, but it happens. My staff is trained to check these things before the appointment, and they did. The pharmacy only had 55 of the 60 pills I prescribed. Taking the fifty avoided the other five. They tried to stretch the 55, but it was a bad month, luckily. They are still reeling from the death of a child after having already suffered from PTSD from the industrial accident that shattered their pelvis and left them disabled. It’s a difficult situation, especially since politicians and the DEA have decided to target doctors who treat with benzodiazepines and opioids. Nothing else works for a severe panic attack except Xanax. We make them breathe in a bag, and that helps a little, but not enough.
So what do I do? I took Tylenol #3 for the pain. It’s not enough to allow them to be active, but I’m already putting myself in danger. Should I leave them where they are taking their medications? I certainly can’t raise anything after a negative drug test. What would that look like to the DEA? But then, it’s not like the patient isn’t suffering. The death of a child. I already know that they are almost certainly tougher than me. I probably would have killed myself or gone to Las Vegas on Viagra and nitroglycerin. Anyway, I admire their strength and would like to see them more active and with a better quality of life. And I know that what I’m using now isn’t enough to achieve that. Still, with the opioid panic in full swing, I’d better wait. I could send them back to our local interventional pain specialist, but they already said there was nothing else they could do, not even ablation. That’s exactly what it is: intense chronic pain complicated by PTSD and the death of a child. It’s safer for me to leave them where they are.
The next one is taking opiates and tested positive for meth. A basic test, without isolated enantiomers. Many patients don’t know this, but over-the-counter Vicks inhalers can cause you to test positive for methamphetamine. This is not a false positive; the inhalers contain methamphetamine, levomethamphetamine if I remember correctly. It is not as strong as the right-handed isomer used in ADHD medications. Street meth is usually a racemic mixture of both. There’s no way to know. Should I stop medications while waiting for GCMS results to come back? What if I’m wrong? What if it’s a false positive, and I essentially accuse them of using drugs, causing them severe pain and withdrawals, only to find out they were telling the truth?
But if I write a prescription for your painkillers today, how will that look to the DEA? They will say that I ignored the results of a drug test that clearly showed illicit behavior. I can argue until I’m blue in the face about enantiomers and cytochrome P450 2D6, but it will be in front of a jury of twelve people who know nothing about medicine, and I won’t have the four years it takes to give them even a minimum education. . I’d better hold off on your medications. But what if he gets really angry? What if they write a letter to the medical board? I have already had to defend myself to the board about a patient who was suspended from prescription medications for two positive meth results on the UDS when he complained. Every time you go in front of the board, your entire career is at risk. They can take everything you’ve achieved for any reason, and there’s nothing you can do to get it back. Lawsuits are only an option when you HAVE income. Lose everything and you will be defenseless. Let me think about this.
The next one is a new patient, here with severe chronic pain. Many of these medical refugees are arriving as their doctors begin to refuse to treat anyone with opioids. Unfortunately for them, nothing else works very well, and once the patient uses them for a long period of time, their sensitivity to pain increases, making it almost unbearable to take them off. It’s better to just not accept them. I look in this person’s medical records for any excuse to deny the medication, but everything is perfect. The previous doctor has retired and we have a letter recommending continued treatment, PMP and initial UDS are perfect. Imaging and objective studies clearly document the reason for your pain. Seven failed back surgeries and metal plates and rods screwed into the bone. Anyone would get hurt by that. The perfect pain patient. Maybe too perfect? What if this is a plant? What if it’s an undercover DEA agent or a patient who will say all the right things here in the office, but at trial will tell the jury that he wasn’t really in pain, and clearly I should have known that? But there’s a commotion outside my office and I look at the waiting room security screen. The front door has been broken down and men are coming in, machine guns swinging from side to side and pointing at patients in wheelchairs and my receptionist. It looks like she’s going to faint. This solves all these questions forever. It wasn’t one of these patients I needed to worry about. He was someone else, something I completely missed. And I won’t have to worry about what to do. It’s out of my hands now.
L. Joseph Parker is a distinguished professional with a diverse and successful career spanning the areas of science, military service, and medical practice. He currently serves as chief scientific officer and chief operating officer of Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity toward mastery in space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions to the complex challenges of space travel, including space transportation, energy storage, radiation protection, artificial gravity, and space-related medical issues.
He can be contacted on LinkedIn and YouTube.
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