Patient: Has an addiction to opiates (which he does **not **disclose to any doctors). Also has some physical abnormality (generally painful) that can be treated with a risky surgery, after which he is prescribed strong post-operative opiates.
Doctor A: A surgeon sympathetic to Patient’s abnormality. Finds Patient a candidate for surgery, and would willingly operate on him.
Doctor B: Someone who can prescribe opiates, but not a surgeon (think general practitioner, Pain clinic doctor, etc.)
Patient goes to Doctor B asking for opiates. Doctor B turns Patient down because, while Doctor B acknowledges the presence of a physical abnormality, he suspects that Patient’s primary objective is to obtain opiates. Patient then tells Doctor B that if he is not prescribed the opiates, he will elect to undergo surgery with Doctor A, after which he will end up the opiates anyways.
What is Doctor B supposed to do in this scenario? On one hand, Doctor B’s gut tells him that Patient is an addict, and prescribing him opiates will only facilitates his addiction. On the other hand, Doctor B knows that if Patient gets the surgery, he will be exposed to a number of risky complication, and he’ll end up with the opiates anyways.
Is there any effect if any of the variables are changed? For example:
Surgery is more/less risky.
Post-op opiates are prescribed for a longer/shorter duration.
The patient openly tells Doctor B that he is an addict.
Doctor B decides that Doctor A can prescribe the opiates if he thinks they are indicated given the patient’s symptoms, history and prognosis. And there are always alternatives to opiates, even if they may not be as effective.
Doctor B can share her feeling (as well as the ultimatum offered by the patient) with Doctor A - it’s considered “continuity of care.” Doctor B doesn’t have to ask the patient if they can share the information and it isn’t protected under doctor/patient privilege because it’s continuity of care.
If Doctor A will still perform the surgery - maybe because he doesn’t trust Doctor B’s conclusion that the patient is trying to get opiates - well, I’m not sure what can be done.
I would think the only variable that would matter in this situation is how necessary the surgery is, and even then, as a previous poster noted, there are alternatives to opiates.
This would be my take on it. And saying that while this patient may be a addict, it may be the pain that caused that addiction, so I don’t fault him for that (not that addiction is someone’s fault anyway IMHO), and not really knowing much about this addiction, would consider such treatment, carefully monitored including counseling, if nothing else seemed to work.
(again to me) Doc B’s choice is to treat him with pain management which using Doc B’s best judgement at first would also steer the patient away from those drugs, and manage any withdrawal while trying non addictive treatments and help in overcoming addictions. Let the patient know that is the plan. But Doc B should not leave the patient in pain, if opiates are needed (no other way found effective), then carefully monitor their use and the affect of addiction on the patient.
Also would write a referral to Doc A if the patent would like to consult with this surgeon on the operation as that is his choice and then Doc A would be the one treating him and the followup after care. As Doc A’s specialty is surgery, and it is not Doc B’s specialty. It would be Doc A’s responsibility to determine if this patient would be a candidate for this surgery. And Doc’s A’s responsibility to explain the risks vs benefits as well as recovery medication to manage pain.
So The decision is really not in Doc B’s hands, just a regular path to follow, and the blackmail falls flat here IMHO. Doc A however has a choice to make and that’s where the issue lies IMHO. Does Doc A operate, and get to manage the aftercare, or does he refuse and let the patient find one who will perhaps a bit more free flowing with the pain meds.
But to your above 3 post questions, no they don’t make a difference. As the 1st and 2nd have to do with Doc B, not Doc A, the 3rd one would open the door to treatment for addiction, or at least managing a needed addiction because of the pain.
IANA medical anything. But I think **yearofglad **nailed it.
If the patient actually gets the surgery, then they have a legit need for some pain meds for some time interval. Like a week or maybe 2. Which Dr. A would/could/should legitimately provide.
But … after that’s over the patient is back to square one: They have an addiction, or at least a predilection, for opiates. And they have no connection to get them from. So whether hypothetical Dr. A does or doesn’t do the surgery is a temporary blip in the long term situation.
And once Dr. A’s post-op prescriptions run their course the patient needs to persuade Dr. B or C or D of the legitimacy of their fake need. They’re also going to need a new story since Dr. A supposedly solved the painful problem they used to have.
Drug seekers live fix to fix. So it’s real plausible the patient might try the Dr. A gambit to get another month’s (?) supply. But then what? And how much harm is done to the larger world by this month of surgery, recovery, and opiates? Not much IMO.
IME, doctors talk / fax to one another a lot about their shared patients. And they are all pretty familiar with drug seeking behavior. Some actively fight it, most are disgusted by it, and others (a few) actively profit from it.
Last of all, even drug seekers can have legitimate medical problems unrelated to drug seeking. Which ought to be treated per the normal standards of care irrespective of the drug issues.
This was sort of the situation the doctors treating one of the patients in the “Three Stories” episode of House found themselves in. The patient, an obvious drug seeker, was also clearly in extreme pain from a circulatory problem in his leg.
The patient was House. Probably not necessary to spoiler this, as everybody knows, but…
That was a really good episode that explains how situations are sometimes not as they seem to “obviously” be. I thought, and I think most people assumed, that the patient who was going to “die” was
The farmer, whose story about being bitten by a snake and his advanced leg problems just seemed to smell of doom.
He really was being dishonest about what happened, because he didn’t want to lose his out-of-control dog, which the doctor would have to report (under public health laws) if he found out that the dog was the cause. Thus the wild goose chase with looking for the right snake and all the rigmarole over finding the right antivenom.
I didn’t realize that so much happened in the background, ie. continuity of care. It must be difficult trying to balance gut feelings, ethics, lawsuits, egos/opinions, and others trying to manipulate you, just to arrive at the best judgement call.