Treating chronic non-malignant pain should be fairly easy. We have excellent guidelines from the colleges, a reasonable array of effective narcotics and other analgesics, and the realization that addiction in screened patients is rare. But it’s not easy, and one of the main reasons is patient fraud.
The resulting diversion of drugs onto the street causes anger in the papers and in the colleges, increasing the pressure for draconian prescribing restrictions that might harm genuine pain sufferers. I still wince when I think of an empty bottle bearing my name that was found outside a school two days after being filled.
Close the loopholes
Yet a few simple measures could do much to calm physicians’ fears and improve patient treatment. A good start would involve linking pharmacists’ computers, demanding ID for opioid prescriptions, increasing the penalties for scamming and double-doctoring, and printing triplicate prescriptions (one for your records, one for the patient, and one for the college).
Audits for narcotics should always involve an interview with the patient. Only when face to face with a patient can you truly judge the analgesic need, and the risk. Many physicians come to grief basing decisions purely on a survey of their notes. No matter how detailed the notes, I think this makes a mockery of the maxim “know your patient.”
The truth leaks out
Urine tests should be part of standard practice, but they’re still too open to faking. We should upgrade urine tests, by measuring urine creatinine and electrolytes to detect dilution. There’s reason to hope that we’ll soon have a quantitative test that will give an accurate evaluation of medication intake. It’s not unusual for scammers to bring in a friend’s urine, which we often detect by temperature. One unfortunate man brought his friend’s urine in, but forgot to first check that the friend didn’t have a large quantity of cocaine in him!
Ideally, pain control would be recognized as a sub-specialty that can be taken on full time by family doctors. One favourite target of scammers is the busy doctor in a walk-in practice who feels tired at the end of a shift and is bullied into giving a narcotic prescription.
A rogue’s gallery of scammers
Scammers aren’t well covered in medical training. These are often not amateurs, but professional fraudsters faking illness on an organized basis. They may hit a new area in a pack or a couple. Scammers swap stories, sharing information on the weaknesses of doctors and their emotional profiles. The rewards can be great, when for half an hour’s work a scammer can lay hands on a box of pills selling for $30 each.
The first scammer I ever encountered was a young nurse, on crutches and heavily bandaged from recent back surgery, with an empty bottle of Dilaudid (hydromorphone) bearing the name and number of a doctor. Dilaudid raised a red flag, so I rang the doctor’s office in Northern Ontario. The secretary explained he was out on a call, but could she help? I gave her the patient’s name and she said she knew that patient well, as a nurse working in the area who had injured her back helping a patient out of bed. If I could wait, the doctor would call me when he got back. This all seemed very reasonable, a heroic nurse, a doctor doing house calls in a remote area. Having done due diligence, I gave her a small prescription for Dilaudid.
About a week later I had a visit from the police. It seems she had hit 6 doctors that morning, all young, somewhat inexperienced, compassionate, and above all, running on time, allowing her to fit all 6 appointments in one morning. She certainly had cased the area very well. She had the nerve two weeks later to make a repeat appointment. I spent a very anguishing day wondering what I should do. Should I inform the police? Set a trap? Or just show her the door? Luckily, she never turned up.
Cops and robbers
On another occasion the office received a call from the duty sergeant at the local police station. He asked if I could see an undercover policeman whose cough was echoing in the garbage container, which was his hideout — very dramatic. The policeman turned up in undercover clothing. I asked for his ID, which he presented, and it looked normal. He asked if I wanted to ring his station but I thought the evidence I had was enough, and gave him a bottle of narcotic cough medicine. It was only about six months later, when discussing scammers with a group of doctors, that I discovered he’d played this charade with several.
The worst case I had involved an elderly man with severe arthritic pain whose neighbour brought him in promptly every two weeks. She was wonderful, she wrote notes, she asked questions, she asked for books to help her understand his problem. I was about to write a letter to nominate her for the Mayor’s award for good citizenship when a routine check showed the patient had no opioid in his urine. He certainly didn’t look like he was selling the medication. A second test again showed negative and when I asked him to bring his medication it turned out to be Tylenol (acetaminophen) capsules. It seems that his good angel friend was taking his prescription to the pharmacist while he sat down waiting for it to be filled. Then she would switch the morphine for Tylenol. I still feel really bad about this case because I was berating the patient who wasn’t getting any better.
I remember one woman who looked like anyone’s dream grandmother, silver-capped walking stick, smartly dressed and over 70. She was the perfect patient, no suspicion at all, until she asked me a little out of keeping what drink I would like for Christmas. Her urine turned out to be loaded with cocaine. I really couldn’t believe it, but two more positive urines clinched the case. There was no evidence of my prescribed narcotic. When confronted she was not at all defensive regarding the cocaine, but turned the case into one of age discrimination: just because she was over 70 didn’t mean she couldn’t get a buzz. The fact that she was selling my pills seemed to be lost on her. As she whirled her silver-topped walking stick around my office, seemingly ever closer to my head, truly I was glad to see her go. Cocaine is so common as to be epidemic.
The great majority of physicians are doing the best they can, but government and the medical colleges could do so much more to close the loopholes, allowing patients who need treatment to have it, while stopping the diversion of narcotics from physician’s offices onto the street.
Alan Russell, MD, is a general practitioner in Brampton, ON, with a special interest in pain management.