Last Tuesday, at 6 a.m., I kissed my toddler and husband goodbye, and coffee travel mug in hand, I went out to my car. As soon as I opened the door I knew something was wrong. The dashboard compartment was open and the contents were emptied out. The toll change was gone. The floor mats were askew. All the spare change that had been rolling around on the floor was gone.
I had left the car unlocked, and I got robbed. When the police came, they told us that this had been going on all over town. It was people looking for drug money. The officer said, “It’s probably someone who lives right around here, because there were several similar break-ins within a one-block radius last night.”
Our town is a really very nice, safe suburb. The neighborhoods are clean, the houses nicely spaced, the schools top-notch. But, it seems some of our own townspeople are getting into trouble with prescription drugs, and then slipping into heroin and cocaine use. Heroin especially is cheap. It’s easy for someone to give up or get busted on their prescription narcotics habit, and then convert to heroin use. There’s a reason it’s sold in “dime-bags”: it costs as little as 10 dollars for enough heroin to get high a few times: one to three “bundles”. (I used to work in an HIV clinic in an area rife with IV drug use, and I learned a lot from our patients.) Recently, I had seen reports in our local paper of needles being found near playgrounds, in parking lots, even in quiet cul-de-sacs.
But on our cute little tree-lined block, we have been accustomed to leaving the house for a stroll or to chat with neighbors, without even locking the door. We leave our downstairs windows open in the summer. And we were often leaving our cars unlocked at night.
No more. And, I am acutely aware of the link between my prescribing, and the epidemic around us.
Flash back to last month:
It was a typical Saturday on-call, and I was answering a page. The very sincere woman was requesting a narcotics refill on behalf of her mother, who was a patient of my colleague; the patient was an elderly woman with chronic pain from her osteoarthritis. The daughter was chatty, friendly. She mentioned the names of several of the physicians from the practice, as well as the staff; she emphasized several times how much she thought of us and the care we provided for her mother.
While she went on and on, I was able to pull the chart of the patient up on my computer, and I saw several notes to the effect that the daughter had called for refills quite a bit, on weekends, and it was not clear that the patient was receiving the medications. For the past few refills, no one had been able to actually speak to the patient herself; and she had not been in to see her PCP in over six months. Diversion was suspected. So I asked to speak to the patient directly.
“Uh, she’s napping right now. I wouldn’t want to wake her… It’s so hard for her to get to sleep, you know, due to the pain,” she explained.
I thought, Here we go again.
One of the things I dread about being on-call, more than perhaps any other part of being on-call, is the inevitable controlled substance prescription request. There can be a spattering or a slew of these, ranging from the totally obvious I-lost-my-Oxycodone-Rx to the really good story. It’s an old cat-and-mouse game.
Things that help us to not be the dupe on these: the electronic medical record, and being able to access this from home. I am anal about checking the charts of anyone who calls for a controlled substance, and more than once I have been on the phone with someone requesting a narcotic refill on behalf of themselves, their elderly mother, or their chronically ill spouse, only to find well-documented warnings in the chart: “Suspect diversion, no refills other than PCP” or “Narcotic contract in place: No refills on-call” or something like that. It’s huge.
So, in this case, I was able to say, calmly and firmly, “Sorry, I can’t refill these for you, until we see your mother in clinic”. And get a urine toxicology test to see if she’s been getting any of these painkillers, I thought.
But this doesn’t mean that I haven’t fallen for the ruse, sometimes… and certainly I have noticed that not all of my colleagues fret about controlled substance refills. Basically, we’ve all been duped.
Anyone with a prescription pad and a DEA number: Yes, we’ve all been inadvertent drug dealers.
Not too long ago, I met a new patient, a healthy young woman who worked in politics. She seemed poised: stylish and well-spoken. She reported that before moving to this area, she had had a psychiatrist who had diagnosed her with adult ADHD, and she was on Adderall (an amphetamine-like drug for ADHD). She asked me if I could refill this for a few months until she was established with a new psychiatrist.
It is well-known that the ADHD meds are amazingly abused. The numbers of prescriptions for these have skyrocketed in the past decade, particularly among young adults. I knew at the time that any and all of these stimulants were considered favored meds of abuse among young people: crushed and snorted or popped with alcohol, their effect is not much different from the amphetamines from which they are derived. Speed.
And yet I refilled the prescription for her- for more than a few months. Until, me being still clueless, she came to my office for an acute visit.
“Um, I need help,” she began, tearfully, and then recounted how she had gotten out of control, with her drinking and drugging. She was an alcoholic and an Adderall snorter. She told me that in her crowd, inhaled crushed Adderall was valued more highly than cocaine. “It’s INTENSE,” she added.
I did refer her to rehab and, after more than a year, she is clean. But if she hadn’t asked for help, I would have been none the wiser.
In our practice, as in most, we have quite a few patients on chronic controlled substances. There are legitimate uses for these meds, after all. My panel includes a woman with chronic pain from a terrible car accident, who is on the Fentanyl patch, Valium, and Oxycodone. Her doses have been stable for over five years, and she comes in regularly. I am not worried about diversion or abuse in her. I have elderly folks for whom NSAIDS (Ibuprofen and all those) are contraindicated, who are awaiting shoulder or knee replacements, and thus they have p.r.n. hydrocodone or oxycodone; people with various and sundry anxiety/ panic disorders on as-needed Xanax or Ativan; many patients with herniated discs who use some combination of muscle relaxers (Valium is one) and antiinflammatories for neck and back pain flares; sinusitis sufferers who use Robitussin with codeine once or twice a year when they suffer with their postnasal drip cough; patients who have Oxycontin prescribed by the pain clinic who need the occasional refill from us, etc etc.
It’s possible that some of those folks are diverting: either selling the meds or abusing them or giving them to someone to abuse. It’s almost impossible to know for sure, but we can limit this by keeping careful tabs on who is refilling these prescriptions, and when. We can limit refills to monthly only, and by the PCP only. We can try to do this, but we all have varying degrees of vigilance, and we surely miss some.
And so, we have created the prescription drugs epidemic that has spilled into our suburbs. Like, my suburb. And I’m wondering if the drug addict in our neighborhood has cased out our house. Do they know I’m a doctor? Do they think I keep my prescription pad at home?
What else can we do about this?