I had a conversation with a patient yesterday. Well many of them actually, about 40 different encounters, but this one struck in my mind. We have recently updated our controlled substance agreement to make it more strongly worded, and emphasize that there will be more random drug testing, and monitoring their activity on the State’s narcotic and dangerous drugs data base, and he, like many others had some questions about it. I am not really certain why this update inspired so many more discussions than previous updates, but everything from the selecting a pharmacy to how the drug screens will be done and how they had Severe pain this weekend so they found an old Diluadad from a previous provider that they took so it might be in the screen. Or they smoked a joint, and they are really sorry, but what is going to happen to them.
But back to this particular case. He was wanting to know what if another patient of mine had a positive drug screen for something else. Methamphetamine. He has been worried about her, and would really like her to get help. The problem with an addiction to something like methamphetamine is that it changes chemistry in the brain, so people appear to be willing to lose everything for that drug.
Unfortunately I see a lot more chronic pain patients in my practice than I would like, I struggle to decide who is truly in pain, and who is not. I was referring them all to pain management specialists but the one I was using has put up barriers making it almost impossible to refer people there. The next closest places are 2 and a half hours away making it almost impossible for those that are legitimately in pain to obtain the treatment that they need.
In an attempt to be in compliance with the state drug laws we screen patients, we look them up in the data base and we try to monitor what they take, but we are often left wondering who is truly in pain, and whose pain is due to the narcotics that we are giving them. We do diagnostic studies to find the cause, but unfortunately unlike blood pressure and temperature, the pain scale is very subjective. One person’s four is another’s 8.
Drug contracts are necessary and may help provide a means for conversation with the patients that might not have been otherwise. And yet the next question is what to do when there are medications that are not supposed to be there, or even worse, what happens when the screen is completely negative?
I live in the state that is ranked first in the abuse of prescription medications, and it bothers me that I may be contributing to that number. We take calls reporting someone selling their medications seriously, and attempt to investigate.
But then there are those that are truly addicted to narcotics of any type? Those that truly want help. There are supposed programs around here. A program that does rapid detox that has turned into a program for a weekend fix. A methadone clinic that I have never seen decrease the dosage of methadone on a single patient. That is it. And honestly, I don’t have the training to treat addiction in my practice. We look at best practices, but I was trained to treat diabetes, not pain management.
It is estimated by the National Center on Addiction and Substance Abuse that only 10% of alcoholics receive the treatment they need. I would guess that the number is even less for those substances that are illegal. In the war on Drugs, we have created a group that cannot find treatment because their addiction is to something illegal, so there is a fear of incarceration. And yet despite all of the laws we have against drug use, we have not decreased usage at all.
There are a few medications approved for detox and to treat addiction, but I am not trained well enough to deal with such a complex disease. And while I would be willing to obtain such training, I don’t know that I would have time to treat these patients with all of the other requirements on the disease processes that I am qualified to treat.
So we are at a crossroads in treatment. What do we do with those that are addicted, but want help? We need to have an open dialogue with our patients that we can treat them. It has to be honest. If I have a patient who is honest about their addiction, I will do what I can to help them, but unfortunately my training is not enough for what they need.