A letter to my classmates:

[The following was a letter I addressed to my classmates following an in-class discussion that triggered, for me, some of the frustration evident below. Make of it what you will, I've only edited it slightly to remove specific references to that discussion]

I dislike the way that "drug seeking" is described and discussed by doctors for a number of reasons. I actually think the term relates to two separate phenomena. The first, simply put, is medical addiction, and those people who, through recreational or medical use of narcotics or anxiolytics, have become habituated and dependent on those (or similar) drugs, and obtain or attempt to obtain them from medical professionals. The second is the fear doctors have of such patients, and the way that fear generates suspicion, dismissals, and overall poor health care and poor outcomes for people who may or may not even fall into the first category.

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The first meaning of "drug seeking" is actually the easier to handle; addiction is your patient's problem, not yours, and your responsibility to them doesn't end when you detect that they are habituated or dependent. After all, imagine a patient comes to you and says:

"Well, doc, I was in this car crash three years ago and had to get a triple lumbar fusion and even still the pain wouldn't go away and goshdarnit, doc, now I'm addicted to narcotics. I've run out all my prescriptions and no other doctor will talk to me. Can you help?"

To punt and drop back to play defensive medicine with this patient, to refuse them treatment or to offer them only large doses of NSAIDs ("for the pain") and send them on would be inhumane. So how different is their situation from that of the worst imaginable "drug seeker"? This patient is certainly being more forthcoming, and honesty always builds a better rapport, but what does House always say- "everybody lies." I've lied to doctors about far less important things, chances are you have too ("how many hours a week would you say you exercise?") and a good clinician knows and anticipates that they will learn things about their patients that perhaps their patients are not eager to share.

I'm not writing a rant about addiction medicine- that's above my pay grade- but protocols and plans do exist, and absolutely none of them require an initial step of humiliation or immediate forced withdrawal, which is essentially what the get-out-of-my-office reflex produces. Enforced withdrawal doesn't cure addiction, or every user who spent the night (or week) in jail would come home cured; humiliation merely establishes a further barrier to an open therapeutic relationship. There are plenty of ways of addressing drug habituation, and since narcotics and anxiolytics reliably produce tolerance and dependency (though not necessarily social or behavioral changes associated with "drug addiction") no matter how obtained- i.e. even for legitimate, prescribed use- approaches to a patient who wishes to address their addiction, or who hasn't yet reached the stage where they can elaborate that as a clear goal, or who doesn't yet believe they can, in fact, clean up, are a learning issue we should all look into at some point. Addicted patients, regardless of their motivation, or the degree to which they are willing to describe their addiction, deserve excellent care. But, no matter.

I *am* writing a rant about the second meaning of "drug seeker"- the phantasmic imaginary drug seeker who appears in doctors' nightmares tearing up medical licenses with their stained, rotten teeth. These spectres drive otherwise decent providers to chase patients with non-addiction related complaints out of ERs and offices every day. Sometimes this will be because a patient seems "sketchy" or inconsistent in their story, sometimes because a patient's complaint is difficult to image, but always the victims seem to be those who already experience significant barriers to care- the poor, the informally employed, the homeless, the mentally ill, the complexly sick.

Lets start with the "sketchy" idea. I mentioned blithely above that I lie to doctors. Gee, doesn't everybody? I am also highly educated, thin, healthy, and fluent in doctor jargon. If I we're not these things, would a doctor be as cheerfully willing to overlook variances and inconsistency in my stories? More importantly, I come from a social position to which doctors can relate- I am, after all, a medical student. We can't forget that we live in a stratified culture in which "winners" are expected to pass judgment on "losers," and doctors not only occupy one of the highest rungs of "winners" but are also empowered to define, quite literally, what is normal, what it means to be human. Before 1973, homosexuality was a mental illness, after 1973 it wasn't. Why? Doctors said so, then they said otherwise. When doctors define overweight, normal blood pressure, good parenting practices, or social drinking, the world listens; preschool teachers, dietitians, and ministers are expected to take note and follow along.

Conversely, poverty culture requires self-blame. We can't have a "free country" without implying that those who are poor, sick, or miserable must have had- and ignored- the opportunity to become the next Bill Gates. When a poor person comes to see a doctor, all their sins and pecadillos lie just beneath the surface, ready to be cut open and revealed by their "better." When a person who is complexly ill, poor, disabled, and miserable seems always to be on the verge of flinching, hiding secrets, running for the door, can we really be surprised? And, is this not a pretty good definition of sketchy?

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Posted in Dentistry Post Date 07/07/2020






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