Screening addicts the bane of the suburban doctor

Your editorial on prescription drug abuse in suburbia ("OxyContin in suburbia," July 31) was spot on. I live in Harford County and I know this has become a major headache to law enforcement here. In reply to your editorial, Tina Regester of Bel Air, manager of the American Pain Foundation, wrote to tell you that criminal behavior, not pain medications, are the problem in the case of prescription drug abuse. Her point seems to be that pain alleviation is essential and merciful in the practice of medicine, and that it can be done prudently with those taking opiates managing their pain judiciously without becoming addicts.

In the same issue of the Sun as Ms. Register's letter, you ran an article about the rising use of antidepressants by folks who are not depressed. The doctors who write these prescriptions, according to the article, are not psychiatrists but instead are primary care doctors and others who don't bother to verify if the patients they are treating are actually depressed. Not unusual in today's America, where secondary and tertiary care doctors — specialists — are derided and overworked primary care doctors are glorified. That aside, could the same be happening with opiates?

Suburbia is overflowing with drug seekers and doctors are witnesses to this phenomenon. When I recently asked a physician assistant friend of mine how life was treating her, she complained bitterly about the drug seekers in the office where she worked. Tackling several of these folks on a daily basis was destroying the pleasure in her job.

Drug seekers are the bane and the torment of all providers in the medical profession. Addicts manipulate and ingratiate to get what they want and when they don't get what they want because a doctor stands firm, they turn vile, loud and persistent. There is no worse bully than a drug seeker. All the symptoms that will produce the sought-after prescription will be carefully orchestrated and dramatized for the consumption of the doctor.

The doctor will be told repeatedly, "I am not an addict!" He or she will also be informed how sparingly and cautiously the opiates will be taken. The reason for the drugs — pain — will always be searing and unbearable, constant and sleep-wrecking, and on a scale of 1 to 10, invariably a 10. A physical exam will elicit exquisite tenderness all over the body serving to confuse the doctor. Emergency room physicians are the particular targets of tormented drug seekers. Most ER doctors can attest to the loud harangues, bullying, verbal abuses and sometimes physical threats of the opiate seekers. No hospital is spared their ubiquity, not even the ones in semi-rural or rural areas.

As Ms. Regester points out in her letter, pain is a valid, widespread and disabling problem in America. The onus falls on the doctor then to distinguish the malingerers from the genuine patients who need opiates to function without pain. This is not easy. Addicts and potential addicts don't announce themselves through their appearance, socioeconomic status or their gender, age or life circumstances. Many are clean cut and middle class, some are young, others in their 70s and even in their 80s, females equal in number to males and not easy to profile.

Intractable pain is a common complaint among these patients. Those with cancer, spinal injuries, recurrent back surgeries, bodily traumas or advanced arthritis are the easiest to recognize as genuine cases. But even they can start out with small and manageable doses of the opiates, then build up tolerance and demand more and more to ameliorate the perceived pain. In the case of the terminally ill, this wouldn't matter but in the case of others, the tragic march to addiction may occur under the aegis of the prescribing doctors.

These are hard times for doctors and their ability to say no to patients who demand opiates is directly proportional to their confidence level and the strength of their practice. The most popular doctors in a suburban community may not be the best diagnosticians but instead may be doctors who are easy with their prescriptions for narcotics. Patients form their own registry of "Who's Who of Narcotics Prescribers" because word travels fast in the suburbs. Doctors, hard pressed for time, may not follow all the rules and rituals necessary to diagnose true pain or depression. Some are terrified to say no for fear patients will not return. Others will write narcotics with the rationalization and conviction that patients will find someone else to give them the narcotics anyway so they may as well do it themselves. The line between true physical pain and mental agony gets blurred under these circumstances and the stage is set for addictions.

Criminal behavior is not the only major force behind prescription drug abuse. Narcotics can be shared innocently among family members and friends in response to complaints of pain. They can be hoarded and taken together to attain highs. If an adult is using these medications, they can fall into the hands of other family members, especially curious teens, eager to experiment. They can be discarded carelessly and fall into wrong hands. They can be sold by the desperate poor and the unemployed for sustenance, like food stamps.

Meditation, biofeedback, distraction techniques, physiotherapy, acupuncture, electrical stimulation, tai-chi and gentleyoga, all can be used to alleviate pain. Opiates have a role to play but in the United States, its role has grown monstrous. It is used as a first line therapy by many doctors. Even the old are prescribed methadone, of all the things, for pain and when any opiate drug addiction has established itself then out comes suboxone to fight fire with fire.

There are fundamental flaws in the way our medical system operates, with doctors appeasing and pleasing patients to grow their practices and patients ravenous for escapes and escapades from the harsh realities of life, making their moves against those susceptible doctors. Opiate addiction is often the result of such tragicomic games played out in doctors' offices.

America's impulsive nature, the country's proclivity for quick answers to complex problems, its thirst for oblivion, its predilection for taking risks and its hunger for entertainment and euphoria, all make it particularly vulnerable to opiate abuse. Americans play hard, work hard, get injured often, dust themselves off and repeat the self-inflicted wounds that wear out their bodies fast. Opiates are the natural friends of such a people.

Usha Nellore, Bel Air

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