Today I met a man who wanted to interview me before transferring his records.
He was about my age and seemed polite and pleasant enough. He told me his doctor of a dozen years had started to taper him off his long term narcotics after he reported some of them missing because of theft. He used to take the equivalent of about 1,200 mg of morphine per day for his back pain. Our office classifies anything over 120 mg of morphine as a high risk dose.
He left that practice and transferred his care to a hospital run clinic across his home town. His next doctor at first prescribed him the medications, and then quickly begun tapering him off them. The story was a little vague as to exactly why.
He then landed in the hospital for something unrelated, and the report from that admission was available on our state’s medical information sharing website. He told the hospitalist that he was on the high dose that actually two doctors had already tapered him off. The hospital doctor called his new primary care doctor to clarify things and was told the patient had failed a urine drug test because it contained a pain killer he was supposed to have run out of months before. He told me he wasn’t trying to deceive the hospital, he just thought they wanted to know what he used to be on before things changed. He also told me he had kept a few of the discontinued pills on hand, and had used them when his main medicine was being tapered.
The man said he had been off his narcotic pain killers for a few weeks now. He drove himself the 25 miles to our clinic, and he walked the long way from the parking lot to my corner office. He sat in a relaxed position in the office chair across from me, but he told me that he had suffered a big loss of quality of life when he lost access to his narcotic prescription.
After he was done telling me about what it felt like to be tapered off his pain medications, and as a by-the-way, he also told me he needed to get back on the amphetamine he had been on for his attention deficit disorder.
I listened carefully and told him with my most gravelly and serious voice that I didn’t think any doctor would prescribe the kinds of doses he used to be on, and that he did seem to function without them – at least to a degree. I told him that his best bet was probably to talk with the doctor he had known for twelve years. I told him that particular practice has a committee that reviews the care of their difficult pain patients, and he could ask for their involvement. I offered to take care of his other medical needs if he wanted me to, but that there was not enough trust between us for me to just give him narcotics again because of the history he provided me with.
He thanked me politely, rose from his chair, offered a firm goodbye handshake and walked slowly down the hall back to the reception area.
A Country Doctor Writes: 
Yes, I earned my buprenorphine waiver about 6 months ago and really; why do patients “insist” that they need narcotics (or suboxone) AND stimulants for ADD? Our hospital thankfully has a strict policy that if we are prescribing suboxone, we cannot prescribe stimulants.
A psychiatrist I attend meetings with (a controlled substance workgroup) speaks of the “holy trinity” of opiates, benzodiazepines and stimulants that some patients are on.
This business of overprescribing opiates for pain is not new but seems more prevalent now. I read about the increased rates of addicted newborns and deaths from opiates and have to believe this is a real phenomenon. It’s hard not to imagine a brisk secondary market for these pills, the revenue from which would surely relieve a lot of (financial) pain.
Thanks so much for posting this. You aren’t alone. There is nothing that alarms me more than an appeal for these medicines – especially at those doses – from someone without a clear need for them. Once I have excluded organic causes to the best of my ability, my answer is an appointment for the patient with Pain Management. Many people are addicted to opiates for musculoskeletal pain, and need a whole medical specialty to help them out of it and into a different regimen.
When I started seeing my current primary care doctor I showed up with a list of diagnoses that included Still’s disease at age 7, migraines at age 15 and stage 3 breast cancer at age 46. The list is embarrassing enough in itself without adding addiction into the mix. He was surprised when there were no opiates or benzodiazepines in my medication list. I explained that when someone experiences severe pain, and that pain is relieved with a pill, there is fear that the pain will return when the pill is withdrawn. That fear adds to the physical addictiveness of the drug. Mild to moderate pain like that of arthritis and migraines can be handled without those drugs. Soaking in epsom salts, therapeutic massage, gentle stretching, and dark quiet rooms go a long way in pain relief. But honestly, there is just a level of pain that can be expected. Who gets to live a pain free life? After a while your brain will filter out the pain just like it does with noise. If you live by a train track you barely notice the noise of passing trains.
I am surprised by the chutzpah of your patient. It takes a lot of confidence to walk in with that kind of history and ask for and expect that kind of care.