Chapter Fifteen: Drug Hypes
Emergency departments are legal drug stores for people with chemical dependency syndromes. There is a large body of literature regarding identification and management of these drug seekers. Over the twenty years of my medical practice at the time of this writing (1995), I evolved from a naive helper to a seasoned clinician keenly sensitized to ferret out the most devious of fraudulent drug dependents or junkies. A few might slip by, but very few compared to my early years. The following is an account of three experiences in this realm. The first happened around 1978, the others in the early ‘90s.
In the days before our hospital had twenty-four-hour in-house ER coverage, daytime emergencies were taken care of by the family physicians. We would be called up to the ER (the hospital is on a hill near our offices) as needed, and this would occur several times daily (a far cry from the thousand visits per month we had starting in mid ‘80s).
At about 7:30pm on a November evening in 1978, I was called to the ER to see a patient in severe pain. As I entered the room, a man in his mid forties was standing next to a gurney, leaning over a counter, moaning in pain. We'll call him Joe Dixon. When he saw me he suddenly straightened up and started to talk rapidly. He stated that he was a trucker and had stopped just down the hill from the hospital to cinch down his load when the chain snapped and the ratchet bar slammed into his groin. He fell back and within minutes developed pains identical to his prior kidney stone pain. He quickly pulled his pants down to show me a bruise between his scrotum and inner thigh. As fast as his pants went down, they were pulled up and he pleaded, "doc, please give me something for my pain. I already peed for the nurse, but this pain is killing me." He was watching me carefully. Taking what I saw at face value, I agreed to give him a shot of Demerol as soon as the urine test was back. Within minutes the urinalysis was back showing blood. I told him that we would admit him and get an x-ray of his kidneys to see where the problem was. He replied that we couldn't do that because he was allergic to IVP dye (the older iodine containing intravenous substance used to radiologically highlight the kidney system). He was moved to an inpatient bed and a short time after his Demerol shot, I went to his room to take a more complete history. Before I could begin a formal interview, he said, "You sure are a great doctor. Where did you go to school?"
Flattered, off base, I replied, "Stanford."
He asked me about my family. "You got any kids, doc?"
"Well, yes. Several."
"Look, doc, I've been hauling pallets of canned hams. There are twenty-eight pallets on the truck and each pallet has three hundred pounds of ham. If your family could use the food, I'd be happy to give you one of the pallets. No one will miss it. My truck is parked just down the hill and we can get to it in the morning. How does that sound?"
I was taken. Those were economically very difficult times for me. With an ex, some step kids, two babies in diapers and a practice that generated minimum wage, the fantasy of thousands of dollars of ham was appealing. Not that I liked ham all that much, just the notion of all that food, free.... Before I could digest that image much further, he asked if we had any injectable Dilaudid (powerful narcotic with a heroin-like appeal to addicts) because that worked so much better for his kidney stones in the past. I doubted that we stocked this drug for intravenous use, but said that I would check for him. He re-expressed gratitude and I said I'd be back later. I went to the pharmacy with the nurse to discuss his medication when she said, "Jon, there's something wrong with this guy. His thigh was like wood. I could hardly get the needle in." Oh, my. If this is the case, and his thighs are scarred from countless injections, he may not be what he seems. Are we being defrauded?
I went home, troubled that the pieces weren't fitting right. I ran my inner tape of the interaction over and over in my head, and my gut told me he was not for real. Why would he have a groin contusion AND a kidney stone? What is the possible relationship between minor trauma and stone movement? Why was he falling over himself in appreciation of my work? And why would he say I was so competent when I didn't really do anything except give him narcotics? And, offering me all that food?
I called the police. We decided that we would play along all night, allow him medication, but in the light of day, he would be checked out and arrested if the puzzle fell together.
It turned out that Joe Dixon wasn't Joe Dixon. There was no truck. He was Albert Bean, wanted on multiple warrants for defrauding several hospitals to the tune of about $80,000. He was arrested after breakfast and months later I heard that he was serving a new twenty-year sentence for multiple related crimes. And to think, I was so close to that much ham!
It was 1991, the last two hours of a twenty-four-hour shift, and I had gotten two hours of sleep after 2am. During one of the phases of sleep critical for brain recovery, in the early morning hours, I was awakened by a call for a woman with a migraine. The half of my brain that was awake from the call, the responsible professional, was an angry, frustrated, but responsible doctor doing battle with the other half of my brain that was hanging out in the garden of sweetness, sipping the healing juices of dreamy R&R, with no mission beyond reclining along the shores of forever. The two halves of my brain did not fit together and all I could do was lie motionless on the mattress. The fragments of thoughts included musing over how long could I get away with not coming down to see the patient. Perhaps I could order some lab or an x-ray, or something to buy a few more moments of peace and grace. Of course, the dreamer must acquiesce to the professional, or the professional looks for work elsewhere. For the seventh time in as many hours, I put my underwear back on, donned my scrubs, rinsed a mouthful of toothpaste and water, spit, brushed my hair, and I'm on my way, still wondering how I’d get back to the source of life. How could I take care of this patient and get back to bed without dropping a beat. Right.
As I gathered my wits, I saw that the sun was coming up and I’d probably be awake until later that day, or night. Entering an otherwise empty emergency room, I see my patient, a fifty-something thin woman, well dressed, made up, wearing a lot of gold jewelry, and having obviously come from somewhere else. And I believe that a patient from somewhere else coming to our ERs for narcotics, for ANY diagnosis, is phony until proven otherwise. I lucked out on this one. I recognized her! At least I thought I remembered her from a couple of summers ago when I checked out her story and couldn't locate her supposed treating physician or any other legitimate record of her medical history as given. I wasn't sure, and I didn't want to be too sure until I could back up my suspicion with supportive new data. She wore sunglasses indoors.....
Part of her story included a recent biopsy of a suspicious lesion on her neck, presently covered with a 2x2 gauze pad and tape. The particulars of her migraine story are not as important as the total picture and the fringe details. Suffice it to say that she was traveling, had run out of her medication, and had a ‘horrible’ migraine. Of course, at six in the morning, it was going to be very hard to check out her recent history by phoning her physician. I listened to her story without moving my face, body, or mouth. I kept a poker face, listening intently, looking for the chink in the armor, the keyway. All the while checking my sense of familiarity, a distant recognition from thousands of patients ago, but touching a deep raw nerve. Even at this hour and state of mind, my craving for sleep was displaced and replaced by a craving for professional success, for conquest, for triumph of right over wrong, for capture of the criminal in her intent to defraud me for drugs. She already defrauded me out of short-term mental health - sleep.
How appropriate it seemed to put the target - her gauze dressing, over her jugular. "Ms. Krimeny, I think we better have a look at that dressing, just to make sure there is no infection."
"Oh, no, doctor. My doctor changed the dressing two days ago and said that under no condition was I or anyone to touch it."
"Well, Ms K., I'm going to have to have a look at it."
She pleaded, "Please, don't take the dressing off."
At that point I ripped it off, revealing nothing. Normal skin. Nothing. I said, "There was no procedure done here."
Her final plea, "He said it was healing very fast."
"Ms. K., it is over. The game is done. I will give you no drugs and you will leave now. If you come back with intent to defraud us for drugs, I will be here and I will bring legal force to bear on your criminal intentions. I suggest that you return from where you came and pursue a drug treatment program. Your happiness as a recovering drug addict is likely to be far greater than what is left of you now. Good-bye." I left the room to find some coffee to greet the new day, one up and one down. My nurse later informed me that she left quietly in no apparent distress.
Experiences with chemically dependent people come in many flavors. One hundred and eighty degrees from the above story is that of Jack Whitefeather, a thirty eight year old mostly Native American man who first came to my emergency department in the early nineties, complaining of back pain. He had undergone a laminectomy (back surgery) several years prior and had recurrent bouts with pain which had been treated with narcotics, a week or two at a time, with generally good resolution, short term. This had taken place in southern California and he had recently moved to our impoverished garden paradise to "live in the country". Given his non-resident status, chronic pain problem, and request for narcotics, I proceeded slowly and methodically and discussed with him my view of treatment options. Narcotics were not at the top of my list. His appearance was that of a new age eagle, proudly tattooed, feathered here and there, and wearing a power amulet of some earthy origin. He interpreted my hesitancy to give him his requested drugs as bigoted, assuming that I viewed him as a second class citizen.
He said, "I'll bet that if I came here dressed in a suit with short hair you would treat me quite differently".
If there's one thing that pushes my buttons, it is someone calling me bigoted. It has been a long time and a lot of miles, but I came from the sixties and I lived the dream, as long as anyone could, and my hair was abundant and still is generous, though my beard is now short and gray, and I KNOW that we are all in this thing together. I'm not perfect, and I have a hard time loving my enemies and lawyers in general, but as a Jewish object of childhood anti-Semitism, I am very sensitive to this issue. I thought about rolling my sleeve up over my shoulder to reveal MY tattoo, my power ally from a different time in life, but maintained my professional demeanor and just looked him straight in his eyes and said "hey man, you've got the wrong guy. You and I are equals on this planet and don't give me any of that white man crap. If you want my care, you'll get the best. If you want to play power games, take it somewhere else." The warrior spoke to the brave.
I didn't take my eyes off his until he looked down, backed off, and said, "OK, I'm sorry, I'm just in a lot of pain and this gets real frustrating. I've had some hard times." I replied, "it’s OK Jack, I know about hard times. Let’s go on."
I ended up giving him the benefit of the doubt because he deserved it, and gave him a week’s worth of Vicodin (moderate strength oral narcotic painkiller). I figured that he would be one whose true colors would show with time. There was no need for me to force any of the issues.
Five months later, he returned with a recurrence of back pain. Five months seemed like a reasonable interval, so I again let him have some more Vicodin. Several weeks after that, there was a phone message for the nurses in which Jack was requesting a "refill" of his pain medication. This is a simple issue for me. I don't do refills. I run an ER, not a family practice. My staff knows this and patients generally know this and I am suspicious of anyone calling my ER for a refill of a narcotic. I pulled his chart. It had grown. Jack had been in three other times in the last few weeks with the same problem, each time getting more medication, and had seen a different physician each visit. I doubted that they had checked the hospital chart for prior visits. The game unraveled when a call came, within an hour of the first message, from the hospital down the road, requesting our records on this patient as he was in their ER requesting narcotics. One of their ER docs called Los Angeles to check on his medical and surgical past. These calls revealed that he was a management problem down there and had trouble with abuse of Schedule 2 narcotics (the major narcotics such as Demerol and morphine). He was a 'druggie' after all! They offered and he took a prescription for twenty Vicodin. He left angrily after being refused a Demerol shot. They also observed him in their parking lot moving about with the grace and fluidity of a healthy strong man. Two days later he came back to my ER. When I saw his chart in the rack, I called down the road to do my homework. It was at that point that I found out how much medication he had gotten and when. I became anxious over the impending confrontation. How much of his anger and potential violence was I going to have to deal with? How can I humanely judge his pain, his medication use or abuse, and what are the personal consequences for calling it wrong? Would he become a threat to my health? How can I creatively transform an unpleasant confrontation into something other than a lose-lose situation? And again, was he dangerous? My basic strategy was to first catch him in a lie, then I'd do what I usually do - play it by ear. One of the more reliable traps I set, when medical data is gathered on patients about recent visits elsewhere, when they've gotten drugs, is to ask them when they last saw a doctor, or had any medical attention. Doing so, Jack stated that it had been a week or two (analogous to the alcoholic’s statement of recent consumption of 'one or two beers'), at least.
"So, Jack, you've been out of medication for at least a week?"
"Yes, that's right."
"OK Jack, let me grab a chair. We've got to talk." I was anxious, but determined. "It seems to me that you've got two problems right now. The first, and simple problem, is your back pain. I have no doubt that your back hurts (doesn't everyone's - mine does) but that's not really what is important right now. Your second problem, which may be massive, is your problem with drugs, pain medication in particular. I don't want to put you in a position of having to defend yourself and wasting both of our time, so let me just tell you something. I know that you got twenty Vicodin two days ago and whatever you did with them, you're back today misrepresenting yourself to get more. So now we both know that you have a drug problem. When you first met me you implied that your life was led with a degree of integrity worthy of respect and I took that at face value. If that was a scam and you want drugs for drug’s sake, you can leave now. If you are a man of integrity who has a drug problem and you want some help, then let's talk some more. Before you say anything, let me finish. It may be that you have the kind of back pain problem for which it is not grossly inappropriate to use a regular but small amount of narcotic pain pills. If that is the case, you might get those in the context of a working relationship with a family practitioner or clinic where your problem is followed regularly and all other reasonable routes of treatment could be examined. I don't have any problem with that, but this is not what I do in the emergency department. If what you have is a monkey on your back and you need to be withdrawn or managed in some other short-term manner, I can start this today. The emergency department will not be a place you can come to get pain killers any more so it is time for you to tell me what is going on."
Jack listened quietly, looking down at the floor, seemingly in resignation to his capture, but without appearing agitated or angry. "I'll tell you doctor, it's really gotten out of hand lately. I haven't been in my right mind. The drugs have been screwing me up. I have had problems with these drugs before and when it got away from me, I just stopped and got through it. I used to earn a lot of money in trucking before I hurt my back. I know how to live, but my back has gotten me way off track. I know I need to stop again. I'm ready. My life is really difficult right now. My girlfriend is having her own troubles and whereas she usually leans on me for support, I can't help her now and I can't really lean on her. I need to get better."
In appreciation of Jack's honesty and in my personal relief at having chosen a best approach, I went on. "Jack, if you took all twenty of the pills in the last two days, it's probably going to be hard for you to stop suddenly. Also, I want you to know and agree before hand that this is not where you will ever get pain pills again for your back or anything else. This way, you won't have to come in with false pretense and deal with rejection. You know beforehand and you agree. I'm going to offer you some medicine called clonidine that helps to reduce the discomfort of narcotic withdrawal. You can use this wisely or, you can seek drugs elsewhere. This well has just dried up. OK? If you're going to stay in this area, you will need to establish a relationship with another physician in the community. I'll be happy to talk to whomever when you do, in support of your case."
"No, doc, I know what to do. I've done it before and I need to get my life back together. Thank you for talking to me like a human being. I really appreciate it." He meant it. If he comes back, in violation of our agreement, I have firm ground to stand on - a signed agreement on the ER form. If he doesn't return, I solved my own problem in terms of ER fraud and drug abuse. If he gets his act together, we both win. In any case, I was able to leave that interaction satisfied that I did the right thing and turned a potentially ugly confrontation into a positive experience for both of us. I think that the factors that motivated me to take this approach with him, as opposed to the former case, were that he lived locally, did not push the lie very far, and I had the visceral sense that I could work with him. Sometimes, the gut sense is our wisest guide. Of course, time will tell. I get to go home with a clean conscience and I got to play doctor instead of cop. And, I don't have to look over my shoulder. This is a small town and everything that I do potentially is out there to haunt me. It happens. These are strange times.
All Rights Reserved © 2004 Jon Sterngold