I was never a big prescriber of narcotics. I grew up “country,” in a tougher world where your parents taught you to accept pain as a part of life. Pain is how you know you’re still alive. They’d tell me, “if you’re hurtin’ you ain’t dead yet.” You fell down; it was going to hurt. You learned not to fall. Twisted your ankle doing something stupid (and it was always while doing something stupid, like jumping off the roof), well we’ll wait a day or two and see how it goes. Put ice on it, and next time think harder before you jump off the roof. Just because everyone else was doing it, yada yada yada.
So most of the time it never occurred to me to prescribe narcotics, except for severe crippling incapacitating pain. Cancer, broken bones, post-surgical pain, or severe arthritis. And after thirty years in practice, I knew I was an expert at figuring out who really needed the medication, and who was just scamming me.
And on those days when things were slow, I would sometimes play “the game” when a new patient wanted narcotics. You know how it goes. You get the history of some terrible trauma/ongoing problem/lost medications/etc. Then you ask, what were you taking? The patient can’t remember. It was “a round white pill” for pain.
I’d respond, “Ibuprofen!”
“No doc, that wasn’t it. It was kypo or depo or hypo something.”
“Ahh,” I’d reply knowingly, “It was Depo-Medrol.”
“No doc, that’s not it. Oh, I wish I could remember. It was hydro-something.”
Again, I would reply with a knowing smile: “Hydrochlorothiazide!”
Frustrated, the patient would decide to end the game and suddenly recall that it was hydrocodone. Or Dilaudid, or Percocet, or any number of high-powered narcotics. And of course, the game now over, I would deny any prescription. Sometimes they would yell or scream obscenities, sometimes they would storm out in anger, and sometimes they would just shrug their shoulders and leave. But I wasn’t worried. Because I knew the “druggies.” I could pick them out in the crowd. They were so obvious.
And then Ms. Bessie came to see me. She was 71 years old. Sweet, conversational, always on time, and followed all my instructions. She was the perfect patient. She did have bad arthritis and significant problems with her lumbar spine. Studies had confirmed this. The normal arthritis meds just didn’t allow her to be up and active. So I had been treating her with hydrocodone. One or two per day, if she really needed it. And every 90 days she would be back for a refill. We had been taught to take care of chronic pain. I had been to all of the lectures. I knew everything about how to take care of this type of patient. We had assessed her for depression, and she always filled out a pain scale. And then new recommendations came out recommending a drug screen. And so we did that too.
And on that day, even though she told me that was taking the medication as prescribed, her drug screen was negative for any codeine. It was, however, positive for marijuana. This sweet, 71-year-old grandma, was selling her codeine and buying marijuana. I was shocked. I knew who the druggies were, and Ms. Bessie was not one of them. But she admitted to the marijuana use, and told me that sometimes she would also mix a little crack or heroin with the marijuana cigarette.
And that was the day my office stopped prescribing narcotics. We posted a notice on the door and at the reception desk. Every new patient who called to make an appointment was told of our policy. When a new patient would be seen for the first time, they were informed at the front desk, and again by the triage nurse. And just like that, we stopped contributing to the ongoing problem rampant in this country with narcotics. We didn’t suffer a loss of patients. No loss of revenue. If anything we got busier. And all of the problems that used to occur with patients and their narcotics magically disappeared. No more lost medications, no more ineffective prescriptions, no more early refills, no more long conversations and lengthy documentation about proper drug use. My staff was thrilled with the change. In short, life actually became easier.
I still treat pain; but it is with NSAIDs, exercise, and physical therapy. I know that there are patients out there who truly do need help with their pain. But I will let the oncologist, the orthopedist, or the surgeon determine how much and for how long. I will stay focused on treating hypertension, diabetes, and multiple other chronic problems. Because after 30 years, I have learned that I can’t recognize who has a drug problem and I don’t want to play the game any longer. Ms. Bessie never came back to the office. And I have never looked back.
Alan G. Berg is a family physician.
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