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Lessons from day in court

July 27, 2003 1:07 am

MY RECENT VISIT to court taxed my "bleeding-heart" liberalism, my view of drug addiction as a disease model and made me side with the commonwealth's attorney and his "string 'em up" rhetoric.

The occasion was a visit to the Stafford County courthouse to appear as a witness in the case where one of my patients had falsified his prescription.

A reputed, "slip of the pen" and the prescription I wrote for 20 Percocet, suddenly become 120. The sharp-eyed pharmacy technicians caught it and called the sheriff.

In the course of the proceedings it transpired that my patient had quite a history, including distributing Oxycontin--a pain medicine that has built itself quite a reputation for abuse and distribution.

So there I sat with this uncomfortable thought gradually percolating through my brain, "How many other of my patients are taking me for a ride?"

A large part of family practice involves dealing with people's pains--back pains, arthritis pains, headaches, fibromyalgia pains, neuropathies. They have (or they are) a pain in the neck.

Maybe I'm too liberal and accumulate more than my fair share of pain patients. One always worries about patients abusing their pain medicines, or becoming addicted to them. Some even come with a pre-existing diagnosis of drug dependency of some kind.

But when someone is sitting before you telling you they are in excruciating pain, and there's no test you can do to tell if they are or they aren't, what do you do? Tell them, "Sorry, I don't believe you?"

But as you write out their prescription for abusable, saleable narcotics, there's a little voice niggling in the background, saying, "Sucker."

One woman I saw the other day complained about how everyone treated her as a criminal when she asked for Percocet for her back pain. She was obviously naïve about these things, or a very sophisticated "hitter," judging how she nearly fell off the exam table when I talked about the court case.

The medical literature claims that doctors overall undertreat pain, and it has recently been cited as "the fifth vital sign," so that nurses in the hospital are obliged to rate a patient's pain on a scale of 1 to 10, as well as check their conventional vital signs.

The finding of abnormalities of the dopamine regulation in the brain has led to the conclusion, at least by the boffins in their laboratories, that drug addiction is "firmly entrenched as a brain disease," according to an article from the Department of Cellular and Molecular Biochemistry of Finch University in Chicago.

Dopamine (DA) is the neurotransmitter that mediates the pleasure and reward centers of the brain. Addictive drugs enhance DA neurotransmission, according to the Chicago team.

Incidentally, tobacco/nicotine works here also, and the drug buproprion that is the ingredient of Zyban, used to help people quit smoking, works by stimulating the dopamine receptors to replace the effect of the missing intoxicant.

Other drugs of addiction work on other neurotransmitters. Cocaine, for example, works on serotonin and norepinephrin, both of which are involved with mood regulation and are deficient in depression.

Antidepressants boost the amount of both of these chemicals in the brain--but a hit of cocaine seems to do in one jolt the equivalent of about a year's worth of antidepressant, so far as I can see.

Intoxicant use is well ingrained in the nature of our constitution. People have been getting "three sheets to the wind" on alcohol for some 8,000 years. Cannabis has been used at least since the days of the ancient Greeks and cocaine (at least in the form of chewing coca leaves) has been used for some 1,200 years. Then there's the ubiquitous use of caffeine.

You could almost postulate that we are wired for intoxicant use judging by the fact that our brains, for some reason, have been found to have receptor sites for cannibanoids and opiates.

There are all the other kinds of addictions in the form of compulsive behaviors: Gambling, compulsive consumerism, sexual promiscuity, TV and video games, Internet use, workaholism and overeating.

Many of us have several addictions, or jump from one to another demonstrating cross addiction. I have an alcoholic friend who has been sober for 25-odd years, but you should see what he can do to a box of Godiva's raspberry creams.

It is not for me to moralize and chastise you for your weakness and inability to control your various addictive type behaviors.

Unfortunately, however, I hold the requisite papers to prescribe a lot of medicines that have the potential to be addictive, and it is a grave and onerous responsibility deciding if it is appropriate to prescribe Oxycontin, Percocet, Xanax, Valium or whatever potentially habituating medicine to this or that patient.

To then find that patients are abusing that responsibility and conning me into prescribing for them, or falsifying their prescriptions, gets me fired up.

In court, the commonwealth's attorney was forcefully pleading my patient's case to the judge to, if not actually string him up, at least incarcerate the guy and get him off the streets. In my indignation, I had to agree with him.

In the end, the guy was convicted and sentenced to three years in jail, with all but 60 days suspended.