The car payment

I’d been seeing Derek for just under a year. He was 29 and told me he had moved here from Oklahoma to help care for his aunt when she was diagnosed with cancer. He was not married but had a child ‘back home’ in Oklahoma, about whose mother, a former girl friend, he had nothing good to say. He came with a thick stack of records and several disks with MRIs, which told a history of a fall at work resulting in severe back pain with radicular symptoms (pain and some numbness into his right foot and little toe). The records described multiple courses of physical therapy, several physiatry evaluations including facet joint injections and TENS through an interventionist, culminating in a two level laminectomy and fusion from which he had had no benefit. His current diagnoses were chronic opioid dependent back pain, from a work related injury, RLE neuropathic pain, failed disk surgery, chronic depression, and daily marijuana use. He was on Paxil and Cymbalta, a topical lidocaine patch, a substantial dose of methadone three times daily, with oxycontin for break through pain, and said that this was working for him as long as he was ‘careful not to do too much.’

At his first ‘get established’ visit, we agreed that I would provide both primary care and pain care, that our goal would be to see if we could minimize his medications without impairing his function, and that I would arrange a fresh evaluation by our local pain clinic of his back disease, neuropathy and pain control regimen. As always, we reviewed a chronic narcotics plan (I never use the word contract), which he and I both signed. He was well dressed, soft spoken, polite and kept his appointments with me. We did the standard primary care stuff without incident, getting baseline information about past and family history and lifestyle, assessing risks, and updating his immunizations. During this time we continued his medications unchanged, other than changing from Paxil to the generic paroxetine in accordance with MaineCare limits. In many ways he was an ideal chronic pain patient. He never asked for more medication or called between appointments for early refills, he filled his prescriptions only at one pharmacy, and he declined pain medication from an oral surgeon (who called me to let me know) after a tooth extraction. And the Maine PMP (prescription monitoring program) did not show him obtaining narcotics from any other sources.

During this time I was bothered by the discordance between how good he looked, and he description of how much pain he had. Not every patient with chronic pain is miserable all or most of the time, thank goodness, but his ever present energy and positive outlook struck me as inconsistent with his description of his life. Over a period of about 6 weeks, however, there were a series of excuses that popped up to keep the pain evaluation from starting and my receptionist said she liked him because he was always so ‘bouncy.’ At his next visit, I asked him to leave a urine specimen for us to do a drug screen. He didn’t object, and reminded me that I knew he used marijuana daily. 

The test result showed marijuana - but no narcotics and no EDDP (a metabolic breakdown product of methadone). Unless there was a mislabeled sample, he had clearly not been taking his 40 mg of methadone 3 times daily or his 5 mg of oxycontin 2-3 times a day for breakthrough.

At his next visit, I asked him how his pain was, and he replied - as usual - that it was tolerable if he was careful, but that if he did too much, it got bad and kept him from sleeping or helping his aunt. He added that he was careful to avoid this because he didn’t want to have to call for additional medication and be labeled a ‘bad’ patient, because he was happy in our office.

I explained that his urine had shown no evidence that he had any narcotics in his system, meaning he could go for a number of days not taking any medication, and that this meant that I could no longer trust his reports of pain symptoms. Because of this, I explained, I would be happy to remain his doctor and arrange the pain evaluation, but that I would not prescribe any further pain medications for him. At this point, based on previous experiences, I expected anger and excuses and even threats of suits or retribution. Instead, he just shrugged his shoulders and asked if I would please write just one more prescription, today, after which he wouldn’t bother me. But he had a car payment due at the end of the week.

I always struggle some with how trusting to be, and in general I would rather be taken in than deny pain relief to someone in need. But it is a difficult problem, trying to divine ‘the truth.’. On the one hand, a patient-physician relationship cannot exist without considerable mutual trust. On the other hand, physicians routinely use the relationship between subjective reports and more objective data from exam and lab to sort out what is going on. In the setting of abusable medications like narcotics, I am legally obliged to ‘take due diligence’ to ascertain and document that the patient needs the narcotic and that is it used appropriately and not ‘diverted’ to street sales. Penalties can include fines, loss of license and jail time.



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