(Editor’s note: Note this above picture is of someone I have NEVER met nor related in any form to the below post, but, I wanted a picture to illustrate what out of control prescribing of controlled substances can create. To anyone offended by the image, my apologies, but, I hope it visualizes what is described below. Read at your own peril!)
I was working at a Locum job a few years ago at an out patient site, when at the end of the day not only did the scheduled patient show, but so did her daughter, who insisted in coming in and having a chance to voice her opinion about her mother’s treatment. After much argument in the hallway outside the office, the patient relented and allowed the daughter in to speak,
The following is a summation, but I swear is not an exaggeration of what the daughter related in front of her mother, as a last chance effort to get the mother to save herself:
The patient was in her late 40s, had issues with depression and anxiety for years prior to my meeting with her, and from what I gleaned from the chart and what the daughter related in the visit, a terrible history of abuse in childhood and struggled with a terrible marriage with an abusive man she had finally left about 2 years earlier. The patient had in fact been fairly compliant with therapy and medication for years on and off, and amazingly, never had been placed on controlled substances during that time, as her first psychiatrist was not supportive of use of benzodiazepines and provided the patient what sounded like effective behavioral-cognitive therapy along with antidepressant meds. The patient stayed true to this and stopped therapy at the time she left her husband, because she felt the decision was therapeutic in and of itself, and seemed to do well with her circle of friends and family as supports and defacto “therapists” as the patient said in our visit.
But, the story obviously does not stay on a positive course. About 4 or so months after she ended the marriage, she was in a horrible car accident that injured the left side of her body, as she was broad sided by a truck while waiting to turn left at an intersection. She spent 2 months in the hospital enduring several surgeries to reset multiple fractures, lost her spleen, and while never fully diagnosed with any neurological injuries, it was suspected she had serious concussive repercussions as she had cognitive struggles while inpatient. She had psychiatric support while in the hospital, which the daughter was NOT happy about, as the doctor advised the patient be medicated with not just 1 or 2 meds, but was on 4 psychiatric Rxs at the time of discharge, including, if you haven’t guessed it already, xanax at 2mg TID on discharge.
Oh, wait, it gets better, as better living through chemistry seems to conclude these days. She had to be on opiates after the accident due to the multiple bone fractures alone, and the post op courses (I think at least 6 surgeries in 4 weeks?), but, did anyone think of weaning her as she neared a discharge course? Nah, in fact the orthopod doc INCREASED her Fentanyl patch dosage one week before leaving, and then added po oxycodone tabs with a prescription amount of 150 tabs as a PRN, mind you. And then she started her odyssey with seeing, what the daughter roughly estimated, was at least 10 different doctors to manage her pain alone, as well as the 3 different orthopod follow ups and the general surgeon who handled her abdominal surgery inpatient care for almost a year.
OK, here it comes, as the daughter told me without hesitation, nor any dispute from the patient, at one point the patient had in her bathroom, take a guess how many DIFFERENT opiate RX bottles in there? Sitting down? 12 different Rxs, an average of 90-100 tabs each, all within a 2 month period as dated, and yes it gets even better, She had as well Rxs for Xanax 2mg QID (4X a day), Valium 10mg TID (3X day) and Restoril 45mg for HS (sleep) use, all benzos, all absurdly high dosages, and all being used close to as written.
So, how did I get involved in this? After the patient had an “incident” about 6 months earlier when I met with them, where the daughter found the patient unconscious and barely breathing and paramedics had to perform CPR in the ambulance, the patient actually had tox levels done in the ER to define the levels of meds in her system. At that point, the daughter was told opiate levels exceeded high monitoring numbers for the lab, and benzos also were high, but also included metabolites from other drugs the patient did not have legitimately prescribed. The patient denied it was an OD attempt, but admitted she was impaired at times from the use of, again, ready for this guesstimated amount, about 300mg/day of opiate use, and there was a slip when she was on the hospital floor she might have taken about 200mg of Methadone from a “friend” earlier that day the daugther found her. So, at the time of discharge, the patient was advised to seek psychiatric care for depression and “reckless behaviors”. NO, not for addiction issues.
Oh, but then here is the proverbial final straw to this toxic cocktail. My predecessor at the clinic I was temping at met with the patient (without daughter of course) 2 months earlier, and at the patient’s incessant and demanding coaxing, got a Rx for Adderall to help her get moving in the morning, oh, and she alleged a “possible” ADD hx per her cognitive impairments experiencing NOW. And how much did my colleague give her on day 1? 20mg BID! Hey folks, that is a dose you consider after working with a LEGITIMATE patient for at least a month of titrating from 5mg BID first. So, you want to ask what she was on walking in on me (60mg/day) and asking for in her visit, while she had the gall to tell her daughter to butt out and let me give her “what she needs”: the patient, per a friend who advised her what is an average dose, she wanted me to write for 20mg 5 TIMES A DAY, and admitted without hesitation she was still getting Rxs for 2 opiates and still insisted on Rxs for Xanax 2 QID and Valium 30mg HS.
Well, for the sake of space for this post, the session ended with this: she rudely accepted the Rx for 20mg BID Adderall I told in so many words “I reluctantly will agree to continue this for now” and told her I would not write for Valium on top of QID Xanax, but would go back to Restoril 45mg HS for now with a “hope” she would try to look at other options for sleep management that ended a need for 2 different benzo Rxs a day.
Yeah, she did not follow up with me again, but, interestingly, I did meet up with the daughter again the last week I was working that assignment. The daughter told me a few things that were, well, interesting is a nice way to put it, but incredulous and outrageous are the words I would prefer to use. The patient upon leaving the visit with me walked out and refused to stay with the daughter, and per a conversation with daughter 2 days later related the patient went to the administration building for the organization I was working for, demanding I be fired for unprofessional care. Then, after the official who met with her did not comply (wow, thank god for that, eh), the patient left the building and called the police to report her daughter stole her prescriptions and wanted the daughter arrested, but the police in fact found them after they fell from her pants pocket while she was looking for something while they talked. They threatened to arrest her for a false report, but the patient found a way to talk them out of it.
Ah, but not over yet. A week later the patient called the daughter to ask her to bail out the patient after being arrested for charges of prostitution and selling prescription drugs on the street. The daughter actually did bail her out, and in the car, the patient actually had the nerve to ask her to take the patient to the nearest pharmacy to fill an unused Rx for an opiate, as she was going through withdrawal. The daughter told me she took the patient to the pharmacy, and when the patient got out of the car, the daughter told her to find someone else to pick her up, and then left with the patient standing in front of the store.
The daughter hadn’t spoken to her since, which was about 2 weeks earlier, but heard through a mutual “friend” of the family that the patient had begun smoking crack to replace the Adderall she probably used up in the week before the arrest.
What is the clincher to this story? This patient had no real history of addiction or substance abuse for the most part until her MVA, possibly a bit of alcohol abuse in her early 20s, but didn’t drink to the daughter’s knowledge growing up with her. And, the patient was not a smoker, and no real caffeine misuse issues as well. Nope, this is the tale of addiction created, fostered, and maximized almost solely by the “good deeds” of providers, who either weren’t paying attention to what was being created in front of them, or, worse, didn’t care, and you have to wonder were trying to profit from increased visit needs to maintain these prescriptions.
So, remember these 2 adages, colleagues reading here:
THE ROAD TO HELL IS PAVED WITH GOOD INTENTIONS,
and, more importantly,
NO GOOD DEED GOES UNPUNISHED.
This is such a terrible vignette to relate, but, to go along with the prior post about middle aged women being the fastest growing demographic in the addiction population, I hope it gives pause, perspective, and hesitation to write for controlled substances for patients who might not need them, or at least not need them for long.
I’ll leave you with this image to reinforce the point:
Not the way you want to find a loved one, hmm?