“We have a drug seeker in two,” the nurse declared. My preceptors responded with a long sigh, and they rolled their eyes in unison. My pulse quickened. I hadn’t seen a patient blatantly seeking drugs yet. I was immediately thrilled at the opportunity to watch my preceptor deny drugs to what I imagined would be a jittery, crazed addict. “You’ll see this a ton in the ER,” my preceptor announced.
As we walked down the long hall, I mentally prepared to be berated by whomever sat in room two. We pushed back the curtain to reveal a construction worker smiling at us behind tired eyes. He had pain in his shins that began a week ago and was not getting better. He hadn’t tried anything because he didn’t know what to take. He worked on roofs all day, every day. He wanted our recommendation so that he could get back to work. My preceptor stressed the importance of rest, ice and NSAIDs, and we made the trek back to the nurse’s station. I was left to deal with the myriad of emotions that is the third year of medical school. I remember a brief moment of solace when I realized he only wanted an opinion. Some part of my humanity celebrated the fact that he had proved us wrong. He overcame our stereotyping and his chief complaint was resolved without narcotics.
A few weeks later, in a family medicine clinic, I was again told that drug seeking happens all the time. I peered over the shoulder of my preceptor as he scrolled through a patient’s long history of chronic pain. The patient had broken pain contracts with other doctors and been dismissed from clinics. His medication list took a few scrolls of the mouse to make it to the end. I looked forward to watching my preceptor eloquently deny this patient’s demands and offer to refer him to a pain clinic. We printed his medication list and terminated contract, then entered the room ready for a verbal battle. The patient immediately launched into his frustrations, concerns and pain. He explained that he had gone through several back surgeries and that he had been prescribed 4 mg of Xanax two times a day for the past eight years. He had also acquired a prescription for fentanyl patches which he only used “when the pain was really bad”.
His original doctor had moved, so when he came to this clinic his new doctor immediately cut his prescription in half. He had reluctantly signed a pain contract saying that he would only take what he was prescribed, but he had told the doctor that he would take his fentanyl patches if the pain was unbearable. Fentanyl had turned up on his last drug screen, and he had been “kicked out” of the doctor’s practice. He begged us to legitimize his pain. He pleaded with us to validate his logic. He had tears in his eyes as he pointed out each drug that was not found in his urine. He told us that he thought doctors were supposed to want to relieve pain, not make it worse. With exasperation, he begged us not to send him to a pain clinic. He told us that, in his experience, all they wanted to do was talk about pain. He didn’t understand why we couldn’t just give him his medicine. It had worked for eight years.
He ended up walking out of the appointment without any referral and without any resolution. My preceptor explained to me that patients can be relentless, and that there isn’t always an answer. He explained that I would be worn down by these “drug seekers,” and it was important for me to stand my ground.
I found myself worrying about this patient. I wondered how long it would be before he bought illegally-sold narcotics and how long afterwards until his dealer told him about heroin.
Health care providers, just like I am aspiring to be, did this to him and had prescribed Xanax tablets and fentanyl patches to a man for eight years. He didn’t understand the mechanism of pain receptors and tolerance. He understood that he felt better taking the medicine and worse without it. He saw his old doctor as caring and his new doctors as heartless. Previous providers had done this to him, and his current providers were letting him walk away without a prescription.