The Use and Abuse of Controlled Substances

After you've been in practice for a while you develop different kinds of reputations. Of course you want to be known as a good doctor, a competent doctor, a compassionate doctor. One of the labels physicians learn to avoid early in their careers is that of being a "pain pill" doc. Every new primary care doctor gets a plethora of patients who "need" pain pills and/or addictive anti-anxiety drugs, like alprazolam. If those patients are disappointed you are attributed with another kind of reputation, that of a "hard sell" and those types of patients quit calling.

As practice years accumulate you find yourself in a quandary. Who are the patients truly in pain who need medications, who are the patients who believe themselves in pain but would benefit from less medication and more mental health assistance, who are the true "drug-seekers" and how to tell the difference. It's a lot like the Serenity Prayer, so beloved by AA. Sometimes I need to say the prayer a few times after seeing a particularly difficult patient.

In Kentucky, we use a tool called the KASPER. This way we can see if a patient is going to multiple doctors to obtain controlled substances.  For instance, a few days ago a young woman came to my office that has seen me for years. She is on an amphetamine for Attention Deficit Disorder. This visit was unusual for a couple of reasons. She wanted to increase the dose but had recently been seen in an ER and had been found to have multiple drugs, legal and illegal, in her system. She was pushy, almost demanding, that she have her medication. It made me very uncomfortable so I did a KASPER report. Unknown to me, she had been obtaining the amphetamines from another doctor for a year or more. At least an abuser, at worst she is selling them. I felt used and abused by the patient at this point--angry and disgusted but at the same time sad and disappointed. Hopefully, she will get the help she needs soon, before she ends up in prison.

The AMA publishes guidelines to help doctors make decisions about prescribing these medications. So does the KMA (although these were last published in 1996--given that Kentucky is a state know for it's drug pipeline, it might be time to update them). These are helpful. The other skill doctors learn to listen to is their gut feelings. Unfortunately one's intuition may be swayed by prejudices deep in the subconscious--the place where racism, sexism, ageism, and other cultural influences hide and haven't yet been flushed out by thoughtful self-analysis.

So I turn to another William Osler quote, "Medicine is a science of uncertainty and an art of probability." Add a little wisdom to that and I will hope to make the right decision.