Thursday, February 14, 2013

Do's and Dont's for Narcotic Addicts

A guest post by Post Peak Medicine
(Warning: I realize that narcotic addiction is a serious problem, I take it seriously in real life, and this article is for entertainment purposes only. Don't try this at home.)
Narcotic addiction is a growing problem throughout the industrialized world. Nobody seems to be quite sure why this is happening, but it may be related in some way to the parallel increases in obesity (food addiction) and anxiety / depression (tranquillizer and antidepressant addiction). Maybe these things are a subconscious reaction to our hyper-complex, unstable society and its imminent collapse, which people intuitively feel rather than consciously understand. As a result, doctors spend an increasing amount of time dealing with narcotic addicts who are not particularly ill but who are trying to wheedle narcotic prescriptions. This often causes doctor-patient friction, but much of this friction could be avoided if narcotic addicts would follow a few simple rules. Here is a list of a few Do's and Dont's:
DO have something physically wrong with you. Strange but true: in order to get a prescription from the doctor, you have to be ill. The doctor may take your back pain or fibromyalgia at face value for a while, but he is likely to want some x-rays, scans or specialist reports to back him up if he is ever audited. So you need to co-operate with any tests or referrals he orders. If you persistently "no-show" for your test appointments, your doctor-patient relationship isn't going to last long.
DO understand the limits. Most countries, states and provinces have guidelines for an upper limit for narcotic prescriptions. In Canada, for example, it's 200 Morphine Equivalents (MEQ) per day. This means a daily total of 200mg of morphine, 130mg of oxycodone or 40mg of hydromorphone. You can find out what the guidelines are for your area by looking on the Internet. Your doc is unlikely to prescribe in excess of the guidelines because if he does, he puts his license at risk. That's why, if you keep pestering him to raise your narcotic dosage, you will eventually reach a "glass ceiling" after which he won't raise it any further. Accept that that's the limit and don't push your luck by arguing with him. I had one patient argue with me for half an hour about his narcotic dose (which was over the limit) at the end of which I refused to give him any prescription and removed him from my practice, which wasn't an outcome which either of us wanted.
DO try to remain invisible. By this I mean don't pester your doc every week for narcotics. If he gives you a three month prescription, that is a strong hint that he doesn't expect to see you again until it's time for renewal. When your chart lands on your doc's desk, you do not want him to groan and think "Oh no, not him/her again". You want him to think "who is this?" because he only sees you four times a year.
DO make sure that any excuses or explanations you give to the doctor are consistent with the known laws of physics and biology. One druggie claimed that she wanted an early renewal of her narcotic prescription because she was flying out to help her daughter who was about to have a baby. I gave her the benefit of the doubt and gave her a prescription. She came back again three months later with exactly the same story, having forgotten that was what she said the last time. She didn't get her prescription the second time.
DO be prepared for follow-up questions from the doc. Here is a faithful reproduction of a conversation I had with one druggie, which illustrates how not to do it. Again it concerns a supposedly pregnant daughter. There must be a lot of it about.
Druggie: I need an early renewal of my narcotic prescription because my daughter is about to have a baby and I am flying out tonight to help her.
Me: Of course, I'm happy to help. Tell me where the nearest pharmacy is to where your daughter lives and I will fax your prescription there.
Druggie: I don't know which is the nearest pharmacy.
Me: That's OK, I can look it up. Which village or town does your daughter live in or near?
Druggie: I don't know.
This druggie's brain must have been so addled with narcotics, or withdrawal from narcotics, that she hardly knew what she was saying. Which was a good reason for stopping her narcotics. Which was exactly what I did.
DO give your doc gifts from time to time. I'm not talking about large gifts. If you want, you could try giving your doc an envelope full of cash, and if he accepts it, that could be the start of a very interesting conversation which is beyond the scope of this article. But that's not the kind of gift I am talking about. For example, when I was working in Newfoundland, I frequently received gifts of live lobsters from the fishermen during the lobster fishing season. At first I assumed that this was an example of the open hearted generosity for which the Newfoundlanders are justly famous, but then I realized that nearly all of the lobster bearers were on long term narcotics initiated by my predecessor. Then I began to wonder if there was something more to the lobsters than met the eye and whether I was expected to reciprocate in some way. Other gifts which I have received include: a home written poem, the loan of a book (which I read and returned) and a souvenir of the 2008 Beijing Olympics. Most of these gifts have no little or no financial value. If you give your doc a gift like this, what you are trying to do is create the impression in his mind that you are a nice person and that he should be nice to you in return. It often works.
DO try to brazen it out if you are in a tight corner and there's no alternative. It may not work but it's worth a try. Here's an example of a patient I saw, and I'm fairly sure he had learned this trick by watching his defense lawyer cross-examine the prosecution witnesses. This patient was well known to my reception staff. He used to walk into the office for his narcotic prescription renewals very slowly, limping and apparently in great pain. However, my staff had seen him in the town walking briskly with no limp at all. After he got his prescription, I and two of my staff surreptitiously watched him leave. When he thought nobody was looking, he jumped on his bicycle and rode off at speed, weaving athletically in and out of the cars.
The next time he came for his prescription renewal, I challenged him about this and told him what we had seen. Poker-faced, he denied it, insisted that we had made a mistake, that it must have been someone else who looked like him, that we were too far away to get a good view, that he wouldn't dream of doing anything like that, and so on. He seemed so genuinely hurt by my suggestion that I began to doubt the evidence of my own eyes, and thought "well, I did mostly just see the back of his head from a distance when he was riding off, maybe I was mistaken and it was someone else" and I gave him his narcotic prescription. And then I surreptitiously watched him as he left the office – and he did exactly the same thing again. He almost got away with it, but he pushed his luck too far, and he didn't get any more narcotic prescriptions from me.
DO consider medical marijuana as an alternative to narcotics. It's probably more fun and better for you. Not all docs are sympathetic to this, but it's worth asking. You will have to comply with whatever the local eligibility regulations are.
DO NOT take cocaine within 5 days of going to see your doc for your prescription renewal. If the doc does a random urine drug screen and finds cocaine, it's basically game over and you will be finding yourself another doc in fairly short order. And don't waste time trying the old excuse of "Somebody spiked my drink" because he's heard it many times before. Weight for weight, cocaine is similar in value to gold dust, and you don't get generous strangers putting gold dust in your drink.
DO NOT think you can beat the system by filling your urine specimen bottle with water. That's the first thing the lab looks for. If the doc finds water in your random drug screen, he is going to assume that if it was urine it would have contained cocaine, and the result will be similar.
DO NOT be rude to the reception staff, or you will be out of the office faster than you can blink.
DO NOT double-doctor or double pharmacy. Docs and pharmacists talk to each other and are backed up by electronic cross-checking systems. Anything like this is likely to be picked up very quickly.
DO NOT tell the doc that you need some more narcotics because you accidentally flushed them down the toilet. Or that the kid you were babysitting flushed them down the toilet. Or that your mother in law was cleaning your apartment and flushed them down the toilet. When talking to your doc, the words "narcotics" and "toilet" should not occur in the same sentence. Telling your doc that your narcotics were flushed down the toilet is equivalent to taking a permanent marker and writing "DRUG ABUSER" across your forehead.
DO get a life. I can think of few things more boring and pointless than spending a large part of your day trying to score narcotics prescriptions.

"Post Peak Medicine" is a family physician in Ontario, Canada.

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