A Country Doctor, Duped

A woman in her mid thirties with a terrible limp and a past surgical history in the dozens became my patient two years ago. Her prosthetic left leg served her well, but her right leg was moving awkwardly because of advanced hip arthritis and a formerly shattered ankle.

She was on long acting morphine and short acting oxycodone. Her Social Security disability insurance didn’t cover the long acting form of oxycodone.

She told me several times how much she hated being on narcotics, but they kept her functioning. She was able to do her own housework and she was taking classes in medical coding and billing.

Her pill counts were always correct and her urine drug screens always showed morphine and oxycodone – never anything else.

A year ago, an anonymous caller told Autumn that my patient was injecting her morphine. I saw a couple of scratches on her arms, and she told me she had this nervous habit of picking at her skin. I said that habit could keep her from receiving future prescriptions for pain medications, and I never again saw any marks on her arms or legs.

Last summer, we got an emergency room report from Massachusetts that documented how my patient had presented with symptoms of opiate withdrawal. The story she had told there was that she had lost all her pain medication when her car was broken into at a highway rest area several days earlier. She was dehydrated and needed intravenous fluids.

When I saw her back, she was still shaky, and she asked me not to represcribe her long acting morphine. She said, tearfully, that she was determined to get off her narcotics. Just some oxycodone to take the edge off her pain, but she didn’t want to have these drugs in her system all the time, she told me.

Her next drug screen only showed oxycodone and its metabolite, oxymorphone, just as expected.

A few months later, she ended up missing her followup appointment because her mother fell ill and needed emergency surgery. “I stretched my oxycodones”, she said, “and I did all right”.

“Let me do another drug screen, to prove that you didn’t take anything else”, I said.

She tensed up, but didn’t say anything, except “will the results go up on the new patient portal?”

“As soon as I’ve signed off on them, yes.”

A few days later, the opiate confirmation test came in. Her oxycodone level was medium high, but there was no oxymorphone, suggesting only recent oxycodone intake, but not proving continuous use. That was reasonable as she had been taking her prescription less regularly. But, confusing at first, her morphine level was higher than the assay could measure. There was also a high level of codeine.

I had in front of me a test result that suggested probable heroin use.

I had to check my facts, but needed some extra time to do my research. Meanwhile, she called to inquire about her results. Autumn told her that they probably hadn’t come in yet, if they weren’t on the portal.

Heroin, also called diacetylmorphine, is rapidly metabolized to 6-monoacetylmorphine (6-MAM), which is six times more potent. Within a few hours, 6-MAM is transformed to morphine and no longer detectable in urine or other body fluids. Street heroin often has some acetylcodeine in it, which is metabolized into codeine.

I checked with the reference lab. They could run a test for 6-MAM, but because it is present only for a few hours, it might still be negative even if my patient was using heroin. The turnaround time for the analysis could be up to a week.

I picked up the phone.

“I’ve got your opiate confirmation test”, I started.

She was silent.

“It shows your oxycodone, but also more morphine than I’ve ever seen, and some codeine.”

She said nothing.

“That is the pattern we see with heroin use. And, in any case, you wouldn’t be expected to have that much morphine in your system when you are no longer prescribed morphine, and I never prescribed codeine for you. I have a confirmation test pending for 6-MAM, which is a breakdown product that we see in the body before heroin becomes morphine. But this disappears quickly from the system, so we don’t always see it in heroin users”, I explained, based on my recent homework.

She still said nothing, except “can you put the result up on the portal so I can look at it?”

That was it. She hung up. I never heard from her again.

A few days later, her 6-MAM report came back. It was positive. I signed off on it, and it went up on the portal.

8 Responses to “A Country Doctor, Duped”

  1. 1 meyati April 23, 2016 at 12:57 pm

    I hope that this doesn’t affect how you prescribe for other patients.

    I live in a state that’s highly regulated. I had part of my nose removed, including bone, and I’ll end with my cheek is under my nose and part of my lip-cancer-no I never smoked and I don’t drink.

    My surgeon was under investigation. I was 70 years old. I have stomach troubles, which precludes NSAIDs and young doctors aren’t alert to GI bleeding, and Acetaphinmin sets off my Surfer’s Ear-a simulated inner ear infection–nausea, dizzy, head movement sets that off.

    I only had popscicle slivers and ice for pain and the swelling that included the roof and gums. Nobody would belivee me that I didn’t have anything for pain. The receptionists cried when they saw me. My nose was turned sideways. I looked like a catfish from all of the stitiches. New visible cancer tumors came up in 4 days. They were busting my lip open.

    When my family doctor finally had an opening, he was screaming on the phone that I needed to get into oncology now, because he could see the GD cancers. That it was obviously aggressive.

    Then he asked me if I needed more pain killers. I told him that I wasn’t given any by anybody, and he cried. I turned down his offer and mumbled that I hate doctors- put this on my record. i could sleep for a few hours, as I had gone into complete rage and disdain. He cried some more and felt rejected.

    Because of my stomach and Surfer’s Ear, I’m called a drug seeker.

  2. 2 WILL April 23, 2016 at 3:45 pm

    I don’t understand her focus on seeing it in the portal. Why did she want this so much?

    • 3 meyati April 24, 2016 at 12:41 am

      She wanted to see the results. Actually by demanding to see the results, a manipulative way to control the doctor, she probably hoped that he’d post something that was more flattering.

      I have a troubled grandson that has an alcohol and drug problem. He’s in jail now for assault and car theft that I know of. he’s been to the maximum security at Florence, CO.
      That’s one of his tactics-to politely get into somebody’s face, and to convince the somebody that he’s nice, he will ask-demand that this is dealt with. She hoped that the doctor would say, “What a nice woman. I can’t hurt her with bad lab work. I’ll just change the labs, and I’ll help her with her pain.”

      When she realized that she couldn’t manipulate him, she left. At least that’s my reading. I also taught high school math to Cryps and Bloods. I had several students that shot clerks in armed robberies.

  3. 4 Lisa April 23, 2016 at 4:24 pm

    Would you have been prepared to help her through her addiction if she had returned?

    • 5 acountrydoctorwrites April 23, 2016 at 4:31 pm

      I have a license to prescribe Suboxone.

      • 6 Lisa April 23, 2016 at 7:29 pm

        I had to Google what that is, so that should tell you how much I know about it. But it’s that she didn’t return to you that has me wondering. Addiction is such a guilt-ridden subject. One of the top managers of the department that I work in became addicted to pain meds after surgery. He didn’t try to get help and was asked to leave the company. It seemed that he was so ashamed that he was addicted, that he couldn’t seek help.

  4. 7 Eileen April 23, 2016 at 7:57 pm

    I hate illicit drug use…prescribed or street…I have seen what it has done to the family I used to have…I lost my home, my marriage, my life as I knew it and expected it…all because of my daughter’s drug use..I am so angry that it ruined my life when I didn’t do anything…I played by the rules and expected a good life…it is all gone now…all because of my daughter’s drug addiction…eventually heroin..and the behaviors that go along with it…the stealing and the lying…it has been so terribly painful…

    • 8 meyati April 24, 2016 at 1:41 am

      On some level, I know what you mean. Above I stated that I have a bad grandson. He’s in jail now, and I hope they don’t let him out again.

      My son and DIL took him to many counselors, put him in private school to get him out of here, put him in programs. They took him hunting, camping, skiing, snowboarding, encouraged his art, tried to make him responsible. I gave him a horse and we worked in the corrals together, worked on model airplanes, etc. He was in sports, but he stole his first car when he was 12. Christmas 2014, he robbed his mother’s house. He knew that she was gone. He sweet talked the neighbors into believing that she was getting all new furniture, and he was paid to haul her things off. He even took the Christmas presents and food. He did leave the Chrismas tree. He’s had several girlfriends get pregnant, and he kicked them until they lost the babies. 4 years ago he spent his time stalking me and trying to kill me. Mostly he enjoyed the power of me being scared to death. It didn’t help that I was diagnosed with cancer. We try not to think of the sweet baby.

      I’ve lived,and still do live like a Mormon. It’s not because I was addicted. I just can’t understand addiction. I drink and enjoy coffee-that’s not Mormon-and I can quit and go without coffee. I don’t have any problems one way or the other. I’m drinking coffee now on the advice of my oncologists. I just don’t want it.

      I’m old and my cancer surgery usually hurts. I have constant RSD pain from a botched breast biopsy. My hand and fingers turned black. My fingers flopped. I seldom could sleep for 2 hours. I was going to commit suicide. The surgery room pain meds didn’t work, so I threw them at the doctors on day 4. I had stellate ganglion nerve blocks. They worked, but I always have a pain level of 2 or 3-that nugget of pain. I don’t and never had headaches. I don’t have a bad back. I have a bad hip-and it hurts.

      I keep saying that I don’t need anything for chronic pain. I just resent that because of people like my grandson that I can’t get anything for trauma. Part of this is because I’m old. They say that people in their late 60s can’t have pain killers for trauma-that’s the way this state is. When I had my cancer surgery on my face, the plastic oncology surgeon was under DEA investigation for drugs. She didn’t treat bad backs, she did skin grafts on burn patients. She did face reconstruction for cancer patients and accident victims- I think that the DEA dumped on her because she is a female Chinese-American Surgeon- loose dogs attacked me, and I didn’t get pain killer until I was admitted to the hospital surgery ward for pastuerella multocida a few days later-That sucks I was jogging with my hounds, and I fell. I jammed my arm into the rotor cup. It took several hours to X-Ray my arm. They never did my shoulder. I didn’t get any pain killer. Months later, I was unloading pavestones from my truck, and my arm popped out. I went into my PCP and I told him that American medicine is really great. he should start telling old women to unload rocks and pavestones from trucks, so their jammed bones pop out of sockets.

      I feel sorry for families that suffer from drug problems. I taught high school math to Bloods and Cryps. I dealt with addiction and worked with counselors and parents. I got stabbed-that doesn’t hurt, but it seems that a trauma victim could get pain relief.

      It seems like I could fly to Japan with one opiate in case I freak out over the North Pacific. I am in my 70s. I fully expected at this age to pop a pill and sleep to Spain or Japan. The anti-opioid Japanese give my 88 year old sister-in-law opioids for International travel. Last time I did freak out. Then I thought of being diverted to Siberia or North Korea. The flight attendents and passengers gave me some water, extra pillows and blankets. They asked me why my doctor didn’t give me an opiate. I told them that doctors in my state are poorly paid and are picked on by the DEA. It sucks.

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