Tuesday, September 1, 2009

An Unfairly Treated Patient

I saw a patient who had injured his neck while reaching for something.  An MRI showed severe disease in his cervical (neck) spine which could account for his symptoms and he was referred to a surgeon.  The surgeon felt he was a good candidate for surgery and I planned to manage him with pain medications and injections until his surgery, as he was in quite a bit of pain.

He was a patient who I liked.  He was pleasant and his style was friendly and easy to be with.

As per our routine, when starting a patient on narcotic pain medications, I ordered a urine drug screen to make sure he was not taking illegal drugs, or already on pain medications and just doctor shopping. 

Much to my surprise, a week later I received the results of his urine test and it was positive for the drug Ecstasy.  At our next appointment I asked the patient about this and he adamantly denied ever taking Ecstasy.  This is one of those difficult situations in medicine when a patient may be lying, or may have an addiction problem, yet still has a legitimate disease that is appropriate to treat with pain medications.  I refilled his pain medication and obtained another urine specimen.  I asked him point blank what I would see in the results.  He told me that there would be no illegal drugs.

Yet again, a week later I received the results and they were positive for Ecstasy.  The patient's next appointment was with the surgeon who was quite disturbed by these results.  He suggested that the patient get his addiction treated before having surgery.  The patient became indignant, angry, and perhaps hostile, and was asked not to return to our hospital.  I never saw him again.

Months later a bulletin arrived from the pathology lab, informing us that they had been having many false positives for Ecstasy in urine specimens.  In other words, they were finding urine specimens that tested positive for Ecstasy even though the patient had not taken Ecstasy.

I thought about my patient and wondered what had become of him.  It seemed to me that if I were a patient in severe pain who was told that surgery would help me, and then was told that I was a drug addict based on a urine sample that had a false result, I would also be angry and hostile, especially if I was told that surgery was to be cancelled until my "addiction" was treated.

I felt sad and hoped he had received the care he needed elsewhere.

In the field of Pain Medicine one encounters many patients with addiction.  Addiction is a disease and not a character flaw.  The treatment is not well defined and not readily available, and usually not paid for by insurance.  This is an example of how "mental illness" is treated differently than other illnesses, even though mental illnesses are legitimate illnesses that involve the brain.

There was a time that multiple sclerosis was felt to be a disease of crazy people.  Fibromyalgia, ADD, and others are finally being recognized as real diseases.  In medicine we have a hard time accepting disease that we cannot either quantify, or successfully treat.  Insurance companies don't like to pay for things that they don't have good evidence for a successful mode of treatment, or for diseases that are controversial.

Addiction is a disease that takes a significant toll in lives and deserves to be treated aggressively.  The twelve step approach is a caring approach, but unfortunately has a poor success rate and certainly does not address the pathology but just the behavior.  It has been shown that there is true physical pathology in addiction.

I hope that we, as a society, are willing to spend the money needed to fund research and treatment for the disease of addiction, and to remove the stigma of the disease, just as the stigma of depression has essentially been eliminated.

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