Medical Ethics - as Required of MD's

In My Humble Opinion
81

It doesn’t work.

It’s killing you.

It’s making you incoherent, not only in this thread, but in many others.

It’s making you paranoid.

It’s made you fixate on unimportant things like your doctor’s job title and payscale.

It’s making you make poor decisions that are not in your best interest.

It’s not working.

That you’ve managed to bully your poor PCP for years into prescribing inappropriately does not mean that she is beholden to keep on doing it now that she’s had that pointed out to her by her colleagues. You have put her very license at risk. And, despite all that, she’s not come even close to “medical abandonment.” She’s not fired you as a patient. She’s changing her treatment strategy to keep pace with current best practices. There’s nothing actionable here.

Not correct.

Even if she were not treating you, she doesn’t have any obligation to find someone who will. She has the obligation to tell you she’s no longer going to treat you in enough time to give you “proper notice” (poorly defined in the law but generally recognized as 30 days for a PCP) to find another doctor. That’s it. She does not have to help you find another doctor.

But that’s besides the point, because she has not stopped treating you. She has stopped treating you exactly how you want her to. That’s a completely different topic.

82

What the dickens does her salary have to do with anything?

Michael Jackson is dead. Do you know why? Because his doctors gave him the medicine he asked for so that he could sleep.

Regards,
Shodan

83

I just quoted her statement that she “had no plan to” ever restore the original dosage.

and did you miss the part where she refuse to renew the script entirely with no notice, warning, or alternative?

If that ain’t abandonment, then there is no such thing.

I got about 3 hours total sleep last night/this morning.
I actually got a dream in somewhere between 08:30 and 10:00 - and that kids, is a trick.
Dreams usually require REM sleep phase, which does not start for an hour or more.

yeah, sleep is a special interest of mine…

Somebody actually posited that the doc would have been willing to renew the script if I had asked nicely.
Bwaaaaaaaaaaaaaaaaaa!

84

Almost - the stuff he died using was stuff he bought himself.
The MD testified that he had NEVER provided the drug - just the IV injection of Propofol (or whatever the top 95% of lethality drug he was using).
The drug Blue Shield of CA AND Medicare cover is not quite the same class.

Nice effort at trying to draw false analogy, though.

Don’t take that aspirin! It’s a pain pill and pain pills KILL! See DEA!

I already answered the point of the pay scale.

Please try to read along…

85

Do you have AN friggin idea of how “controlled substances” work?
The new MD would not write a script for more than the PCP had written.
She could, however, write a second script of the same dosage.

This is the difference between Sch II and SCH III drugs.
The DEA’s shiny new tattletale database (which, of course will NEVER be hacked or compromised in any way :smiley: ) prevent the dup script for SCH II.
Sch III is you everyday, plain paper script and there is no rule against multiple scripts.

Both the MD and I are well aware of the difference. Perhaps those wishing to judge her actions and/or mine should look up this shit before making such statements.

86

Aside from searching for every known sleep aid, how do I “take responsibility” for either the insomnia (remember: idiopathic) or the level of treatment required.
I tried OTC
I tried non-drug
I tried benzo
I tried Z class

What did I miss?

OK, I did not try Choral Hydrate or barbiturates. My bad.

87

Thank you for that profound observation.

It helped the conversation immensely.

88

The pharmacy world is STILL reeling from this. I mean, who uses propofol for sleep?

It reminded me of this new thread.

http://boards.straightdope.com/sdmb/showthread.php?t=822046

:dubious:

89

And given that her treatment plan is to wean you off that drug entirely, her lack of a plan to go back to the original dosage is entirely appropriate and expected. She told you that’s her goal, and that is consistent with current treatment paradigms.

This may be where things are getting confused, because according to your initial post, she DID tell you that she intended to taper you off it, and she has suggested alternatives (such as the referral to the sleep dept and the pain specialist). You understand the sequence of events, but like several others above, I’m having trouble following along, because your accounts are not entirely consistent and coherent.

Telling you that she’s changing your treatment plan ain’t abandonment. Period. Full stop. She is not obligated to continue an existing course of treatment against her judgement (or the judgement of her supervisors).

If you had displayed a better attitude towards her than you have displayed in these messages, and shown a willingness to work with her to find a solution instead of fight her, I think it likely her attitude would be better. I think there is plenty of fault as to her bedside manner, but you apparently are actively trying to fight her, her supervisors, and basically most of the American medical establishment. You will not win.

The analogy was that Michael Jackson thought he knew what drugs he wanted better than his doctors did, DEMANDED his doctors supply his chosen drugs, and died. As near as I can tell from this thread, you’re working on step 2 of Jacko’s plan. You are actually pretty lucky that your doctor, her supervisors, and your insurance are not willing to cave so readily as his doctors did.

You are trying to argue, apparently, that a senior doctor wouldn’t care what the DEA says and would just go along with whatever you wanted. I don’t believe that is true. A senior doctor is going to have exactly the same trouble justifying heavy prescribing, simply because the standard of practice has changed. Doctors used to prescribe more benzos and narcotics, and then they started seeing how much that hurt and even killed patients. Doctors, as a group, don’t enjoy hurting and/or killing patients.

As I understand your account, you convinced a 20-something brand-new doctor to write you a second prescription so you would have 2 bottles of 15 mg, and in effect could continue to take 30 mg just as if the original doctor had not tried to taper you down. Is that accurate, or am I misunderstanding?

If this is accurate, then your intentions may have been perfectly decent, but this screams DRUG-SEEKING BEHAVIOR!!! Having a second prescription isn’t illegal, but there are figurative lights and sirens going off, and you will have done permanent damage to your relationship with that medical practice, with any future medical practice that ever sees those records, and to any faint hope you might ever have had of a claim against your doctor.

If I am misunderstanding the second prescription, then please clarify what the intent of that second 15 mg was.

90

Have you tried all the options a sleep doctor, or a doctor that is working with a sleep department, suggests NOW?

Have you tried a mix of drugs, as RivkahChaya is taking?

91

Bolding mine - actually, I believe it was suggested that IF YOU HAD WORKED WITH HER, FOLLOWED SUGGESTED TREATMENT PLANS and STILL had no success,s he might have been wiling to review your script. Instead you are saying to her (and to us) “I hate pills! Unless they make me feel good. Give me my addictive pills!”

92

I give up.

You’re right - I’m a manipulative druggie who hates a competent, caring MD simply because I like to sleep and prefer to be pain-free.

Did you not notice that she had been prescribing TWO benzos for sleep for years before the dreaded “UCD List of Drug Users” had HER name on it?

Were you privy to the conversation in which she announced that she was cutting the pain pills from 45 to 15 - effectively immediately, and she knew my objections were phony because all drug users say that?

Still miss the fact that she simply refused to renew a drug I had been getting in the mail for years, with no notice?

I didn’t expect anyone to notice the timeline of script stop vs my rapid deteriorating/failing health.

I was too far gone to notice the exhaustion of reserve. When I got out of hospital, I had 4 pills left and was too weak to call the office.
My subsequent noise got her to call in the 1/2 dosage and call me personally to blame the hospital docs for the cut.

I just checked the MyChart email system - her absence has been extended again - shw was supposed to have been back 3/9. It now says 3/20 (why yes, that IS today, so why is her address still blocked? So far, it has always meant she was “out of office”.

Try this summary:
2008 - diagnosed with kidney failure
2009 - PCP changes pain med from dilaudid to morphine ER
2017 - patient admitted to hospital with acute kidney failure caused by morphine

Now - want to guess why she has been "unavailable for the last 4 weeks (I was discharged 2/21).
The only way I can email her is by pulling up a message from her and using “reply”.

I have been using email since 1985.
Yes, circa 1985.
This time, YOU figure how the “how did that work?”. Hint - I mentioned this on another thread on these boards

back to bed - maybe tomorrow I’ll be strong enough to drive. Doubt it

93

Find a pain specialist. Don’t walk in and say “give me drugs.” Find a sleep specialist. Don’t walk in and say “give me drugs.” Don’t get a lawyer and try to sue. Maybe use an advocate, because you, in the comfort of your own home and at your leisure, sound like a drug addict. You weren’t abandoned, just because you no longer get addictive substances on demand. Ask your doctor for other options to the pills you prefer. You may actually find something better, that DOESN’T screw up your kidneys any more.

Or get mad at us. Up to you.

94

You are still focused on what she used to do, without apparently noticing that medical standards are changing. What used to be considered perfectly acceptable prescribing practices are no longer thought to be all that good for patients: they’re no longer “state of the art” medical care.

Yes, she’d been prescribing two benzos for years, until her supervisors said, in effect, “here’s a list of users–please review and make sure you can continue to justify all of these prescriptions as meeting current standards of care.” She thinks your prescriptions don’t meet those standards anymore; regardless of whether she is right or wrong, your hyper-focus on “she used to do this” is causing you to ignore changing standards. You don’t want to be treated with 1985 technology and 1985 drugs anymore; why would you expect that 1985 prescription practices should not ever be changed?

No, I am not privy to that conversation, and the drips of it I am getting from you lead me to think that NEITHER ONE OF YOU handled it very well. However, I continue to have difficulty understanding exactly what she said, and what you said–you are leaking little bits of the conversation along the way, but have yet to give a single cohesive argument.

If the only way you can email is by using reply, then something is going on, and you or somebody on your behalf should CALL the office and talk to somebody. Is her address still blocked by mistake, or is she still gone, and if so, who is covering her patients?

A couple of people have asked, and you have not answered: do you have a friend, a relative, or some other person who could accompany you to appointments?

95

Doing the same thing that didn’t work the first time seems a faulty idea, too.

I honestly don’t get why being “forceful” is even something people try, especially on angry people. Being forceful in the best times just makes you want to fight back. When you’re angry, that’s basically all you do.

The way to help is to show empathy. Show you understand what they’re going through. So many posts in this thread seem to be about blaming the guy. Even if you think his “attitude” is wrong, how in the world is blaming it on him going to help him listen?

I don’t blame the guy at all for wanting to do what he’s trying to do. This is a horrible thing that is happening to him. The doctor is not following best practices–even if a benzo taper is necessary in this situation. The correct way to do this is to bring him over to a long acting benzo like Valium, and then slowly, SLOWLY taper. Cutting his dose in half could leave him with a medically induced anxiety disorder.

If he actually did try to take the lower dose, I wouldn’t be surprised if he just literally cannot cope right now. I know I couldn’t for a long time. He got a death sentence, basically, and now they want to remove what helps him function?

His anger make total sense. His anger at people not acknowledging his anger makes total sense. His anger at people giving him solutions he’s already told you aren’t an option makes total sense. His anger at people using fear as motivation make sense. His anger at people being angry at him for daring to “defy” them makes sense (and is why I never ask for advice on important stuff here).

I actually have recommendations for the OP, but I will make them in a separate post. I don’t know how much of this one he’ll read.

96

So, usedtobe, here’s what I have to say.

First off, I want to say that what you are going through is absolutely horrible, and I understand your anger. I understand it probably more than anyone else here. You have every right to be mad.

Unfortunately, the lawyer option is not likely to work. Blame the shitty world we live in, but lawyers are not likely to prevail when a doctor claims that they are treating you. Only actually refusing to treat would be a problem.

So here’s my suggestion. Give your doctor this. Show her how benzo reduction is supposed to be done, in such a way that it’s much less likely to cause you sleep problems or anything else.

I don’t know if it will work in convincing her, but it’s a better thing to try.

Hate your doctor all you want. I know I would. But pretend to be nice to her. Use her to get what you need.

I’m actually tearing up over here, so I have to go. But please try this sort of thing. I really think it may actually be what works for you.

And, while this may sound cheesy, I’ll say it. I love you. You are valuable. And even the people seeming mean here only want to help you, even if they’re not doing it the best way.

97

Unless, like the OP, the patient has severe kidney issues, in which case a “long acting benzo like Valium” is specifically contraindicated. His doctor would rightly refuse to follow your internet advice, which makes it clear that as usual you’re only interested in your white knighting, and not in the issue at hand.

Multiple people here have proffered a variety of medicinal options that take into account the OP’s alleged issues; he has ignored all those posts in favor of complaining about his doctor’s pay scale. We have proffered a number of non-surgical options to address his alleged pain issues, which likely contribute to his sleeping issues; he ignored those posts in favor of bragging about mixing benzos with alcohol for years. We have pointed out that he is incomprehensible and needs a patient advocate; he ignored those posts to complain that he hates medications except for the ones he’s not taking as prescribed.

He won’t even consider an option other than the one that he no longer- rightly or wrongly- has access to. He’s not sure if he’ll be up to driving tomorrow, but he has the ability to make multiple posts saying the exact same thing instead of finding someone IRL to fight on his behalf. He refuses to help himself, in even the smallest of ways, because like a 4 year old he wants what he wants no matter how bad it is for him.

The drugs he thinks have been working for him have not been working for him. There’s no clearer way to state it. It’s not helping him, and is actively harming him. Coddling him is not what needs to happen right now.

98

He doesn’t want Valium; it does not last long enough. He wants temazepam and clonazepam.

He seems to want morphine, even though it put him in the hospital.

99

A taper plan appropriate for his specifics may be a good idea BigT. Maybe not that one given his specifics and maybe he needs someone with more expertise than his PCP to create it. Don’t know.

Thing is that he first has to accept and sign onto the goal of the plan: to get off the benzo completely.

He had an ICU admission which he, in the op, describes as being caused by the morphine and resulted in his “near death” … and what he seems to want is to have the same meds written. He is by his description baffled as to why someone might view that as cause to develop a drastically different approach. The high dose morphine did not do it alone though. His metabolism being whack from his poor kidney function, his concurrent benzo use, and more, set him up. If he was offered as the answer to the test question of who is at greatest risk of death from prescribed medications then you could circle that letter without even reading any other choices.

You are 100% correct that being forceful won’t work with him … but neither will being nice.

He does not accept that the major difference between a “more senior doctor” and his PCP is that the more senior one probably never would have overprescribed so much so long in the first place and would have been quicker to recognize when the risks of harms were exceeding the benefits.

He does not understand that no doctor is going to put him back on what he was on. He remains sure that if raises enough hell he’ll get his meds. And what will happen instead is that he will end up being dismissed by not only his PCP (with the requisite 30 day notice to provide urgent care) but the entire organization that she functions as part of.

I can’t even imagine how horrible chronic pain mixed with insomnia, other chronic disease, and an inability to function normally within the world (worsened by the drugs) are. Pretty sure it is bad and as I’ve said before his anger and desperation are to no small degree understandable. Dysfunctional but understandable.

Nevertheless his current course and sets of actions will go very very badly for him. The least poor path he has is to work with the PCP, negotiating a slow withdrawal plan and getting help getting in to sleep and pain medicine specialists.

The odds of him doing that? Let’s leave it at not so high.
I don’t know him and I don’t love him. He is literally no one to me. But it is still sad and frustrating to see someone essentially killing himself and to know that there is nothing you can do to change the course.
The only person that can stop him from harming himself further is himself and he won’t.

100

He can be angry all he wants. It’s not going to help his sleep, nor help him get inappropriate medications.

At some point, a person needs to hear it straight. You may be unaware, but this is not (even close to) the first thread this poster has posted about his medical issues and drug misuse. Many posters, including myself, have been using your strategy for some time now. It’s, much like the OP’s drug cocktail, not working.