Wondering what the big deal is with the Anna Nicole Smith trial? Hey, she died of an overdose, right? Who are they gonna charge for that? And how is it her doctors are saying 1,500 pills doesn’t mean she’s an addict. Sheesh, right?
Let’s play the game of You’re The Doc. Here are four scenarios related to the Anna Nicole Smith trial for you to fret and stew over.* Ponder them carefully, because you’ll be asked to give expert witness testimony (and be cross-examined) at the end:
1) You get a frantic page from the partner of one of your long-time patients. Mary, your patient, had a brutal childhood, followed predictably by an adolescence she barely survived. If there was a substance, she took it. Sometime around her late twenties, though, when she had reached the point where she was clinging to the crumbling cliff-edge of her sanity only by the pads of her fingertips, she managed – against all odds and the inexorable gravity-pull of addiction – she managed to pull herself back up and over the edge. It was, given the odds stacked against her, a Wile E. Coyote feat of cartoon-impossibility. You were her doc when she was sweating and shaking, and you’ve been her doc long after she got insurance that would let her see any provider, as well as a home, and then a degree, and another, and then her dream job as a therapist. Now, her partner, Rachel, is almost shrieking on the phone, snot and tears clogging her voice. “He gave it to her. He goddamn just GAVE IT TO HER.” When you get Mary’s partner talked down, Rachel explains that last Friday Mary fell and shattered her wrist in three places. And then the ER doctor gave her some Vicodin to take home.
In 72 hours, Mary stumbled and fell again – this time not onto her wrist, but flat on the ground into the sliding tentacled pull of an addiction that is dragging her back toward and headed over that cliff edge in time-lapsed speed, as though to make up for all the time Mary defied its clinging pull and drag on her soul. Mary took all her pills in the first 12 hours (my God, you’re thinking, we need to check her liver), and sometime after Rachel went to bed, Mary left the house, hit the ATM and started in with grain alcohol from the corner store. Between sobs and hiccups, Rachel tells you that she’s not sure where Mary is – there’s only been one garbled cellphone call since their fight yesterday. Rachel, frantic, jumps from thought to thought. Mary’s supposed to be at work tomorrow. Should she call in sick for her? Will you write her a note? Can someone do something about that ER doc? SOMEONE needs to hurt that man. You try to get Rachel to focus and Rachel confesses her worst fear. Is Mary, gentle therapist, maybe back in the Tenderloin?
2) You’ve got this guy. He comes to see you every month and says his knee hurts. This has been going on forever. Sure, his knee hurts. He’s 54, played college football and weighs 320. Trouble is, he’s been on the streets, got busted (for possibly drug-related charges?) and is on parole. And you, frankly, don’t want to know any more than that about his prison time, otherwise you’re afraid it will taint (perhaps even more?) your ability to care about his problems. Roger is built in a way only prison pumping-iron can cause, doesn’t make eye contact, and rocks on the tiny exam table. He uses drugs, from time to time, but really, he doesn’t stack up to your other patients in terms of hitting the heavy stuff. Every month he shows, on time, his hair neatly patted down, his musty clothes brushed and arranged. He asks you, each and every time, for pain meds. Each time you say no, and why. His exam is fine, given his age and size. He went to physical therapy, he says he’s doing the exercises and he looks like he’s lost some of his heavy sack of a gut. So you try to be upbeat and tell him to keep at it. Now he’s starting to say his back hurts too (sure, you think). You ask him to pee in a cup but he leaves without giving the sample to the nurse. You wonder if he’ll be back. But over the weekend, you get a call from the resident at the hospital. Roger’s been admitted. His spine (and right knee) are riddled with tumors. Probably metastatic prostate. His legs are weak and they’re right now emergently radiating his spine to try to prevent his growing tumor from turning your patient into a quadraplegic overnight. The resident wants to know how long this has been going on, what you’ve tried for pain, and what tests you did.
Clearly one of Bayer & Co.’s early, successful products…
3) You don’t know why, but every once in a while you get a patient who you can share a laugh with. It’s actually quite rare in medicine, since the risk of offending someone is so ever-present. Steve is one of those rare patients. He asks you personal questions, too, “new haircut?” which you, from long experience, know to expertly dodge. He’s been in recovery for eight years for heroin. He was stabbed when he was using, lost his spleen and part of his liver, and has got only half the amount of gut he should have. His pancreas was pieced together from scraps and, with no smooth outflow track, his insides caustically digest himself over and over. There are few circles of hell more horrible than the one Steve lives – a person with “dumping syndrome” from short gut, living on the streets, in constant auto-digest belly pain. After long discussions (and arranging a back-up visit with your clinic’s fabulous substance abuse counselor), you and Steve decide to try narcotics. Narcotic pills will both slow his guts and hold the pain at bay. You hand him the pee-cup, and then begin the dosing. Over the course of six months, you are shocked at how much Steve (and his guts) can absorb before the crap slows and his pain begins to back off just a bit. His urine stays clean (except for what you prescribe), and you realize at month five that he looks really different. He is, for the first time in eight years, standing up straight. Clear-eyed. No longer walking perpetually hunched as though trying to hold his guts in. His was, metaphorically, the stab wound that never healed, his guts spilling into his life every day afterwards. Until now.
But then Steve doesn’t show for his next, month-seven appointment and you wake that night at 3 am, worrying about what you might have done. The next day, you get a call. It’s Steve, his voice weak and wobbly. For the last four weeks, Steve has been in the hospital. His scarred and defiant guts twisted (as they do from time to time) and he was admitted for GI obstruction. He was put on nothing by mouth with a suction tube down the back of his throat. The team decided that no human should be on 900 narcotic pills a month, so they took him off all of them. Steve gives a harsh, short laugh and you can already picture where this is going, and your guts feel like they too are trying to climb up your throat. Sure enough, Steve’s pancreas shrieked into overdrive, and he got cholera-level shits-from-hell and between the digesting himself, mega-withdrawal-dumping and fluid imbalances, he nearly died. The last two weeks he doesn’t remember – he was in the ICU, in a coma. But, Steve says with a laugh, that was probably, in the long run, a good thing. Because the ICU team talking his resident into putting Steve back on some pain meds and he’s been turning the corner ever since. The resident wants him discharged and off his service so he’s probably heading home today, even though he hasn’t kept any food down yet. Can I drop in to see you this week? They won’t give me any pills to go home with. Shaking, you page Steve’s resident. Hey, the resident says over the phone, the sneer in his voice audible at twenty paces, didn’t you know this guy is an addict? What were you thinking giving him that many pills?
4) And then there’s Michael. You’ve taken care of him for six years. His body is a scarred battle ground of surgeries and traumas. No one, ever, would argue that the man is not in pain. But he shows up at clinic the last three times for his stable dose of narcotic refills a little too agitated and sweaty. His urine comes back positive for meth and when you ask him about it, he starts bellowing at you that he needs the money, he can’t take living on the street any more and you can’t cut him off like that, you can’t, DO YOU HEAR he’ll kill himself if you do, what’s he supposed to do, use heroin again, what’s he supposed to do? Security escorts him off, dragging his feet behind him as he turns and yells, and you wonder, your hands shaky, your skin clammy and sweaty as if you too are withdrawing, if you’ll get a call from the coroner’s office this weekend.
This, my friends, is the complex intersection of issues at the heart of the Anna Nicole Smith trial. Exactly when is a doctor a dealer? When is an addict using medical care to get “legally high”? How much is too much? Or is there even such a thing as too much narcotics? People who were continuously addicted have been shown to have altered pain receptors. Even the hard wiring of the brain, especially for pain and possibly for pleasure, may be permanently altered. The physiologic fact is, when it comes to treating pain in people who’ve been (or are) addicted, it’s just going to take more. So should an addict ever be prescribed on-going pain pills, and, if so, under what circumstances. What is the doctor’s responsibility – to inform, and to monitor? Who’s fault is it when someone, taking their exactly-prescribed meds, dies of an overdose? How do you verify “true” pain in a patient, as opposed to fake pain? Whose job is that?
Although a verdict is a forced yes or no choice – guilty or not – the issues this case raises are anything but simple. What do you think? Should a history of addiction mean you would never be treated for chronic pain? Should addicts hurt?
Got a pain story to share (but only if it’s not too painful)? Should doctors be arbiters of pain and pain meds? Where are the limits of responsibility? Share your take in the comments section. Are you a Doc Gurley fan? You can follow Doc Gurley on Facebook. When patient encounters are mentioned, *all identifying traits are changed to protect patient confidentiality. Doc Gurley is the only Harvard Medical School graduate, ever, to be awarded the coveted Shoney’s Ten Step Pin for documented excellence in waitressing, and is a practicing board-certified internist. You can get more health posts at www.docgurley.com, or jump on the Twitter bandwagon and follow Doc Gurley. Also check out Doc Gurley’s joyhabit and iwellth twitter feeds – so you can get topic-specific fun, effective, affordable tips on how to nurture your joy and grow your personal wellth.