The road to Hell is paved with Good Samaritans

A few weeks ago I saw a guy in my clinic who had to evacuate from Louisiana during Katrina. He lived in a trailer in the woods in a backwater parish two hours from New Orleans, and was seriously wondering what he would have to go back to. He happened to have some friends in a nearby town who offered to put him up, and he was making plans to stay around once he found a place of his own.

(I was suspicious, but his accent was authentic, and when I tried to trip him up on Louisiana geography (since I know the state a bit), he didn’t hesitate.)

He was a young guy–younger than me–with a wife and three kids, but he had a couple of bad car and work accidents a few years ago with some serious joint injuries. He had been accelerated to some pretty hefty long-acting pain meds, far more than I’m usually comfortable writing. He had all his medical paperwork with him, and he didn’t set off a single one of my (usually) well-calibrated alarms, so I went ahead and wrote him a month’s worth of his medicine. I would ordinarily have sent him to the pain clinic, but this was a guy who lost everything, and we’re one of the few clinics in the area that sees patients on a sliding scale.

Fast forward…today he walked in to be seen, ostensibly for abdominal pain, but he told the nurse that he had been working so hard moving that he had to use extra pain medicine and was already out. He was at least two weeks early, and I was about to go and explain to him that it didn’t work that way, but first I ran a KASPER on him. (KASPER is the system we have in Kentucky in which every scheduled prescription filled is sent to a central database in Frankfort, available to physicians almost instantaneously.) In addition to the script I had written for him, he had one filled on the very next day, for the very same dose and amount of Oxycontin, from a different physician, filled at a pharmacy about an hour and a half away.

I went in, and he told me the same story about running out early and needing extra pain meds. “We won’t be doing that,” I said, “and I’ll tell you why.” I explained to him what KASPER is, and that we had run one on him, and (very diplomatically) informed him that someone with his (very unique) name and his birthday had filled a script for the exact same medication the next day in a nearby town. If he could get that straightened out, I said, with a letter from the doctor and the pharmacy convincing me that there has been some mix-up, I’d be happy to re-start his pain meds, but not before.

I went away to order some labs to work up the abdominal pain…and got back just in time to see him go out the door.

I’m used to the bullshit. People lie and exaggerate and manipulate to get pain meds all the damn time, both to take themselves and to sell, and getting mad about it is like getting mad at the sky for raining. But something about him playing on my sympathies about the hurricane…I can’t even find words for how much that pisses me off.

I still think his story is legit, up to a point; his documents were too good to be a forgery by someone stupid enough to come in for more narcotics two weeks early. My guess is that it’s all true, but he saw an opportunity to make a bundle in the wake of his family’s tragedy and he took it. I’m not calling the police…but I’ll be checking another KASPER on him every week or so, in case he’s dumb enough to try again.

Well yeah, a drug seeking addict patient is of course going to use as much of his harsh real circumstances to help his habit. I’ve run into these guys and gals, and they don’t know where the truth starts and stops and I assume that everything they are saying is complete scam. I feel very sorry for what they’ve done to their lives, but there is nothing I can do to help.

Well, um, at least he left peacably and wasn’t an asshole about it. That’s something at least. I guess.

So part of what he said was probably the truth, and part might have been a self-serving lie. I’m trying to think, apart from the lack of a probable addiction to painkillers, and, thankfully, the lack of chronic pain that might prompt such an addiction, and (again, thankfully) the absence of incentive to earn money by illegally trafficking in restricted drugs that might be prompted by losing every uninsured thing one owns in a flood, exactly how your would-be patient’s behavior might differ from an ethical man’s, given a sufficiently restricted list of choices.

Sometimes people act dishonorably, and I suppose they shouldn’t be rewarded for that. Good for you, I guess. Is the choice between perhaps abetting an addiction and perhaps failing to relieve real pain that clear for an M.D.?

It’s seldom crystal-clear. But generally a good history and physical will tell you enough to figure out the basics.

But the mere presence of real pain doesn’t automatically mean that a person needs a strong opiate narcotic. Requesting Schedule II narcs for pain from “old joint injuries” sure would have set my alarm bells ringing. Narcotics are never a first-line choice for chronic pain, even if the patient lacks a history of substance abuse. And things like Oxycontin should be reserved for malignant pain, such as from metastatic cancer and the like.

There are lots of ways of managing chronic pain that don’t involve narcotics. Any physician who finds him/herself in the position to prescribe narcs for chronic pain should be well-versed in the basic principles of treating chronic pain.

Don’t stay too pissed too long, DoctorJ. It’s not useful, and does you no good. What he did is what addicts do, as you know. Just like diabetics will run glucoses in the 400s until they’re adequately treated.

Try imagining yourself with my patient population: Guys sent to prison for drug trafficking and forging prescriptions coming to me constantly with their stories about why they need their narcotics! Usually tales of horrific MVAs years ago, which leave them in daily pain, but their exam is normal, and quiet reports from the guards indicate that the patient never seems to be in pain out on the rec yard, in the chow hall, or on his way to the showers! No, there he’s jumping and skipping and high-fiving his buddies! But put him in my waiting room, and his performance there should earn him an Oscar!

I don’t normally comment on Google ads, but c’mon. Four ads showing us where to score some easy pain medication? That’s comedy.

Is writing a script for a guy really a “Good Samaritan”-caliber favor? And if it is, should anyone be doing it?