Intricate

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“Doc, I am deploying to Germany. I am trying to get myself off of prednisone and hydrocodone but I need one more refill to do it.”

I searched the computer system. His name was not there. Was it possible there was a fluke in the system? I didn’t trust the electronic health record enough based on prior experiences that it was somewhat plausible though highly improbable.

I verified the spelling. I checked by date of birth. Not there.

He had said he was seeing one of the doctors that I cover for that works in another office and had just been in on Tuesday for a head cold but had forgotten to ask her. Now it was Saturday. He said he was shipping out on Sunday. Tomorrow. 

I checked that doctor’s clinic schedule. He wasn’t there. 

“What time were you seen?”

“2PM.”

There was a blank spot at 2PM. The only blank spot on her entire schedule was 2PM. How did he know that? Coincidence?

Opiate withdrawal can be unpleasant. Sometimes it is dangerous. I did not intend to fill that prescription, though. What I was most concerned with was the prednisone. Abrupt discontinuation of long term steroids can be deadly. Especially at the doses he said he was taking.

“You are in the military?”

“Yes.”

“Which branch?”

Mumble, mumble.

“I’m sorry. I didn’t catch that. What did you say?”

“Oh, sorry. I’m on a pay phone. It’s kind of windy.”

Who the hell uses a pay phone in 2015 anyway? 

A pay phone?”

“Yeah, I had to cancel my cell phone. Leaving the country and all…”

Hmmmm. Plausible. Maybe.

“Why aren’t you using a military physician?”

“I get better care in the private sector.” 

That might be true.

“What branch are you in again?”

“Uh. Army.”

“Which pharmacy do you want me to use?”

He told me. Joy and relief crept into his voice. “God bless you, Doc!” I could hear another voice in the background but could not make out what was said before they hung up.

I was highly skeptical at this point. No. Let me restate that. I KNEW he was a fraud but I wanted to get the rest of the story. Curiosity, you know.

I dialed the pharmacy.

“Can you tell me if this fellow has ever gotten prednisone or any narcotics filled there before?”

“Oh. That guy? You are the fourth doctor to ask that question today.”

Bingo.

I dialed the number given by the answering service as the contact for this “patient”, the same number I had dialed before, but it went straight to voice mail. Pay phone my butt.

“I just wanted to let you know that I will not be filling that prescription for you, sir….” Why did I call him back anyway? I wanted him to know that I knew.

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112 thoughts on “Intricate

  1. In my experience (at least here in Canada) as long as all parties follow-up, like you did Victo, the system is pretty hard to scam. Which is making black market drugs more expensive now. I take replacement vitamins because they dialyze out and the pharmacy won’t even give me more vitamins unless i am within 10 days of running out (by their calculations). If the docs increase the dose, I have to get a new prescription to buy more, I can’t just purchase them. Here we have to present government identification to fill narcotics prescriptions..Many clinics have signs in the window now that state that they do not have any narcotics in the building and they do not prescribe to walk-ins. Here’s one for you that you may or may not have seen before Victo. I currently have a fistula for hemodialysis access but they take about 8-10 weeks to mature after surgery to create it. In the meanwhile, they install a venous catheter into the jugular for access [for readers, this is a plastic tube that is inserted into the jugular in the upper chest area and protrudes onto the chest. It has two internal tubes and threaded ends to connect to the dialysis machine]. I was hospitalized for another issue and the catheter was a god-send – the nurses and docs could give any injectables into the catheter and direct to my bloodstream without any needles. I was joking with the male nurse one night about how handy this was and he rolled his eyes. He told e that they get a lot of infections with the homeless who had the catheters because they would use the catheter to get narcotics and heroin and street drugs directly to the bloodstream. Of course they were not using a sterile environment so infections developed and quickly became septicemia.

    The recreational drug culture certainly presents some unique challenges to your profession Victo. I’m glad that you are suspicious and follow-up. .

    Liked by 3 people

  2. Luckily this is something I didn’t have to face much in peds, though we are careful with stimulant refills and such. Sometimes students sell them to others or parents use them for themselves.

    That’s quite the situation you faced. Those are the times EMRs really come in handy. With old paper charts, it would be harder to check on what the patient is telling you.

    Liked by 2 people

  3. Is this type of thing fairly frequent in your professional life or more occasional? Disturbing to think of how many people are living on the razor’s edge of addiction. They seem to come up with awfully persuasive arguments for getting their next fix prescribed.

    Liked by 3 people

      • There must be tremendous genetic variation in how the opiates affect different people. Doesn’t this cause a problem for doctors and computing dosages? Body weight wouldn’t be sufficient.

        For one example, Vicodin does nothing for me, or never has thus far. I wind up with unused bottles of it–so wasteful (despite insisting I don’t need it and it won’t work for me, it is ridiculously pushed upon me or issued anyway, after surgeries). Yet it drives others mad with craving. And Percocet–so close a drug–does work on me, and well. I’m betting there are folk who are the exact opposite.

        For another, there is this whole redheads issue, where we are freaks, pain-wise.
        😦
        (I say, we are all meant to be coddled.)
        😉

        Liked by 1 person

      • So if I were to say to you “Doc, Vicodin doesn’t work for me, but Percocet does.”, you would prescribe it? Because never has a doctor of mine been willing to do so (since Percocet is viewed as the stronger narcotic, although you and I both know that both V. and P. can be written for the equivalent strengths).

        Liked by 1 person

      • The most recent bottle I received was after the famous westside hospital caused me to walk repeatedly, unnecessarily, on my un-iced unsplinted broken ankle. Three times in 24 hours. Ow. Ow. Ow.

        Liked by 1 person

      • Yikes! You guys can still get Vicodin? I was prescribed it once and it made my heart race really bad- it scared me and I never used it again. A sort time after that more info came to light implicating Vicodin in heart attacks of users.It didn’t surprise me. Shortly thereafter it was the banned in Canada and everyone who had any was encouraged to return it to their pharmacy and they were refunded their money. That is dangerous shit Batman.

        Liked by 1 person

      • Paul, I had three bottles still until recently I didn’t know what to do with. One of them, still viable, went somewhere–I cannot say where–and now have two. I don’t want to flush them into our waterways. So I’m “holding”! Ridiculous. Some folks in actual pain could use these pills.

        The worst part is that each bottle represents a situation where I had to tough it out, again, because I was given no pain med that helped ME.

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      • I remember clearly when that happened Victo – but i just tried to confirm online and I cannot find any record of that recall and withdrawal . I’ll look some more. i can actually remember returning the pills to the pharmacy. It is possible I am wrong. However there are some issues with Vicodin and it isn’t with the hydrocodone- it’s with the acetaminophen. Apparently there has been a high incidence of liver damage with dosages over 325 mg per pill and the FDA is limiting the acetaminophen to that level or lower per single dosage. http://en.wikipedia.org/wiki/Hydrocodone/paracetamol

        “On June 30, 2009, a U.S. Food and Drug Administration (FDA) advisory panel voted by a narrow margin to advise the FDA to remove Vicodin and another painkiller, Percocet, from the market because of “a high likelihood of overdose from prescription narcotics and acetaminophen products”. The panel cited concerns of liver damage from their acetaminophen component, which is also the main ingredient in commonly used nonprescription drugs such as Tylenol.[10] Each year, acetaminophen overdose is linked to about 400 deaths and 42,000 hospitalizations.[11]

        In January 2011, the FDA asked manufacturers of prescription combination products that contain acetaminophen to limit the amount of acetaminophen to no more than 325 mg in each tablet or capsule.[12][13][14][15] Manufacturers had three years to limit the amount of acetaminophen in their prescription drug products to 325 mg per dosage unit.”.

        Liked by 1 person

      • You must be right Victo – it had to have been Darvon. the effects – heart arrhythmia – and the time frame match. i just read a bit about Darvon and, as a manufacturer,you have to know your drug is about to be banned when it is declared the drug of choice for euthanasia cases. “High toxicity and relatively easy availability made propoxyphene a drug of choice for right to die societies.”

        Sorry OB.

        Liked by 1 person

  4. I’m glad you found a way to avoid contributing to this guy’s addiction. But this seems like a heck of an opportunity for an unscrupulous doctor who wants to make a few extra bucks.

    Liked by 1 person

    • I was going to write something pithy, but John’s comment here, Yeah. This. When I severely sprained my knee in Kentucky I was given crutches. I was given a piece of paper that explained my diagnosis, which stated that my severe soft tissue injury is painful, often more painful than a broken bone. They were correct. I was also given… ibuprofen. When I asked if I couldn’t have just a few pills of something stronger, for when the pain was severe and/or I needed to sleep? No. No discussion. No. This repeats what happened when I had a botched gallbladder surgery in Cinci in 2013. They tore me apart trying to remove a stone that was bigger than a hen’s egg. I got infected because the enclosure bag ripped into my abdominal cavity. Etc. etc. It was a nightmare. It took me WEEKS to get ANYthing stronger than ibuprofen for THAT, too. Why? Because some people abuse it. WTF?????

      Liked by 1 person

      • This is the biggest problem. It is so hard to know the right way to handle things. I am generally left frustrated and angry- wondering what the best course of action will be. It makes me feel guilty- especially when the best course of action is to demure to another provider.

        Liked by 2 people

      • Well, I worked for an inner city podiatrist and the drug seekers were pretty obvious. Even the one described in this post, who was far more clever than most of what we encountered, set bells ringing. Drug seekers call for drugs. People who just had a botched operation, who have just received a description of a diagnosis from “you” which includes “lots and lots of pain associated with this,” people who have a well-documented history of an illness or condition where pain is a common symptom; those people are a world apart in presentation from the drug seekers. For those of us who legitimately need help it seems that all common sense has left the building. Simple, common sense.

        I don’t totally blame the doctors or staff because I know state regulating agencies can make business a living hell for practitioners. And woe to you if you practice in an area labeled “high risk.” In Kentucky the area I lived in was one of the worst in the country. Funny (not), I probably could have gotten all of the illegal drugs I wanted had I known where to look.

        Liked by 2 people

      • I would certainly hope that the treating physician for a botched surgery would take care of this better. I am so sorry for the pain that you went through. It is not fair, and it is a symptom of the problems our medical system is facing.

        Liked by 2 people

      • Well, first, I was and am poor when I had this surgery. Despite the protests to the contrary, poor people get crappier care than rich and well-insured people. I’ve been both and have seen this to be true, in my own life and with others. Then you have a problem with a surgeon, in a big, inner-city teaching hospital being willing to admit that he screwed up or that there was even a PROBLEM. (I realize stuff happens. And stuff doesn’t equal screw up.) Then there is never seeing the actual surgeon but all of the minions, no matter how much you squeal and swear and cry and thrash…because poor & inner city teaching hospital.

        Liked by 1 person

      • Personally- (keeping in mind- I don’t work for a poor, inner city, teaching hospital) money is only an issue for me when I am considering what the patient is going to be able to maintain. I give the same care to everyone- I seek resources and help for those who cannot afford it. I have not experienced this kind of discrimination, and that really makes me sad.

        Liked by 2 people

      • The level of care is all over the place in the USA. Reading the comments on this blog (not just this post) when “Victo” talks about something that just seems “normal” behavior to her (which often is empathy, common sense, professionalism…) you’ll read 50+ horror stories about “not my doctor…” Sad.

        I was clueless when I was rich and insured about what happens when you no longer are either. I think most people are.

        Liked by 2 people

      • PS. What finally got some attention, not necessarily for pain meds (which I eventually got after a student/resident/maintainance man, somebody, nearly killed me with a very bad wound cleaning)… Is that I am smart and well spoken and I started writing everything down, I showed what I had written down, with names and dates, and mentioned the local newspaper as well as the big “underground” paper who would have loved it. Huh. Things changed.

        Liked by 1 person

      • I am frustrated by the new schedule for hydrocodone thy requires the handwritten rx because yeah, people who need it can’t get it now. Makes my nice, respectable patients with real pain feel like criminals and makes my life all that much more difficult.

        Liked by 2 people

      • Yeah. I realize that some of the problem comes from the providers, so many have just thrown up their hands with a “fuck it” attitude and so no one gets the meds, and some of the problem is all the stupid regulations y’all have. Not all regulations are stupid, but a lot of them are, and are lacking in common sense.

        Liked by 1 person

  5. It’s such a scary thing. Glad you trusted your instincts (Trust but verify!).

    But it is a really terrible thing. I had what I considered minor outpatient surgery in October 2008. My husband dropped me off at home and then went and filled my Rx for pain meds. I don’t use many of them, I’d generally rather be uncomfortable than take stuff — it makes me feel weird. So imagine my surprise when my husband came back with 60 oxycodone pills. SIXTY! As it turns out, it was in fact the most painful surgery I’ve ever had and I did use some of them. 10. Which left me with 50 pills left. It’s crazy.

    Liked by 3 people

  6. Nice catch. Around here, the ambulances are marked no narcotics aboard or something like that. We have special units that roll on high end cases that also roll in certain locals with sheriff in tow. Even some of our nurses have been accosted. They don’t carry a bag in some locations and are told to always take an escort which we have on staff. They are off duty cops. Here we are going into areas to help the people and their kin want to rob us. Such a nice world.

    Liked by 2 people

  7. This is such a problem! The real shame is for the patients who need opiates. I would give anything if there were nonnarcotic options that were effective for chronic pain patients.
    I do not like feeling like a dope pusher though.

    Liked by 2 people

  8. Trusting our intuition is very useful most of the time. It’s good that he didn’t fool you. Though I guess that you got use to this kind of situation in your profession, right?

    Liked by 1 person

  9. Unfortunately in India the system is so lax, you can get most steroids and pretty strong non-opioids from the chemist without any prescription. The number of people high on Codeine based cough syrups is unbelievable. I wish it was as difficult to buy meds as it is to buy a gun here. Your instincts were bang on, though. 😉

    Liked by 1 person

  10. *Shakes head after a long tiring day, ending in the final 20 minutes of filling control and narcotic Prescriptions* Why do they always have some mysterious flight that leaves at 5 am the next day??? And working at a pharmacy being at the other end of the phone call is always interesting as well, but of course we have to deal with them in person because they think if they just show up (with or without a legit Rx) we are going to give them any narcotic they so desire if they shout and give us continued creepy stares…-_-‘

    Liked by 1 person

  11. There seems to be a wide range of physician responses to this complicated issue from never prescribing narcotic pain meds, to giving too many. But you seem to have found the good middle ground which is harder and more time consuming to walk. I’ve been written prescriptions for pain I didn’t fill, and my usually pain sensitive daughter only needed a few of the pills prescribed after her oral surgery, leaving her with about 2/3 of the bottle left over. I got rid of them when the next drop off came around. I wish it was easier to turn in unused narcotics safely. I wish addiction treatment was more accessible. Most people (not you) underestimate the power of addiction and what it takes to fight it.

    Liked by 1 person

      • Here’s another scandalous confession for you: I hate junkies. I know I’m supposed to be compassionate but I lived in a neighborhood that was swarming with junkies and they made my life a living hell. One of them used to deficate in our building foyer every night. Some have tragic histories, but a lot of the are self-entitled brats who feel they’re owed something. They think there’s a dark, poetic majesty to taking heroin but then they become addicted burdens to society who have to be mollycoddled and understood. Morons. I never kicked one but I was tempted to a couple of times.

        Liked by 1 person

      • There is something to be said for distance. Having never lived among it, I don’t have your experiences to filter what I see now. When I see/talk to addicts I just see the drug. Doesn’t mean I am kind and understanding all of the time or that I am a saint. If that conversation had occurred at 2AM it would probably have gone very differently…

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  13. I was just talking with my boss, they attorney, about these drug seekers yesterday, and I shared with him some of your stories. In our office, we get all kinds of clients who are also drug seekers and try to lie about it as if we are stupid. How sad.

    Liked by 1 person

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