Posted by fachad on April 19, 2002, at 9:57:21
In reply to help! (rant; advice?), posted by Elizabeth on April 19, 2002, at 1:52:57
The Controlled Substance Catch-22 is my worst fear. Your post hit my brain like ice water on a root canal with a nerve-exposed dry socket.
I was totally freaked out about this last August when I got a letter in the mail telling me that my pdoc was closing his practice. I posted my angst about this dilemma here:
http://www.dr-bob.org/babble/20010804/msgs/73612.html
Now you know why I was so scared!
This situation is a Catch-22 - a classic double bind.
Any effort that you expend trying to convince your pdoc to keep you on a controlled substance (CS) will be interpreted by your pdoc as "drug seeking behavior" and will be counted as further evidence that you need to be taken off that CS.
On the other hand, if you do not expend any effort to stay on CS, he will take you off of it. So you are dammed if you do, and dammed if you don't!
Further, if you try to get the dosage changed to an appropriate level for you, and that dose does not jibe with what this pdoc arbitrarily started you out with, then you are further guilty of "dose escalation", which is more proof of drug seeking behavior, and further evidence that you need to be taken off your CS.
But it gets even worse! If you decide that your doctor is being irrational and you choose not to work with someone who does not trust you, and you then try to find another pdoc, you are guilty of the worst crime of the most pathetic, desperate drug seeker: you are guilty of "Doctor Shopping"
Drug Seeking. Dose Escalation. Doctor Shopping.
Those are some of the most pejorative words ever used in medicine and in behavioral health care. In so many ways both medicine and mental health has tried to get away from pejorative language and pejorative concepts, but when it comes to controlled substances, they sometimes become self-appointed judge, jury and executioner in a trial that is rigged with a built-in bulletproof Catch-22.
I have wrestled mentally with this worst-case scenario since the first time I realized that I had a unique and dramatic response to CII stimulants for depression. Thankfully, I have not yet had to face it in the real world. (Knock on wood.)
But I have thought it thru, comprehended the vastness of the dilemma from a theoretical standpoint, and tried to work out rational solution scenarios.
(BTW, this activity in itself would meet DSM IV Criteria 5 for Substance Dependence: "a great deal of time is spent in activities necessary to obtain the substance...” I had to interject that because I know how much you love DSM-IV. And it just further shows that this Catch-22 is all encompassing and bulletproof.)
The solution scenarios I have come up with so far focus on trust, personal and professional stability, and long term relationships with medical personnel.
Can you have your medical records transferred from your old pdoc to this new pdoc? Could you contact your old pdoc and ask for a "letter of introduction" that addresses you, your CS(s) and your responsible use of them over time?
Did you always fill at the same pharmacy where you lived before? Did you go into that pharmacy often enough that the pharmacists remembered you? I consider my pharmacy records to be sacred transcripts documenting my years of rigid compliance. They are a permanent record of my responsible use of controlled substances. If I ever find myself in the CS Catch-22, the first people I would call for help would be the staff of my pharmacy. Even if they did not like me personally, they have years of records that reflect very favorably on me. Even the fact that the same pharmacy has been used for years builds a case for stability.
I would hope that the combination of extreme openness, medical records, and pharmacy records would prevail to swing the benefit of the doubt in your favor.
If it did not, I think the appropriate move would be to try to find another pdoc. The key to avoiding the “doctor shopping” charges would be to preemptively tell the new prospective pdoc what is going on. Bring your medical and pharmacy transcripts, and tell the new pdoc right off about what happened to you and how you felt like you were not trusted from the start. Invite them to call the offending doc and discuss why this other doc thought you were an abuser.
I think any rational person, and most pdocs are rational, intuitively understands a Catch-22 situation. Besides, if you are not hiding anything, there is no reason to doubt your sincerity.
Please post some follow-ups for us, and let us know how it is going, and how it worked out, because the only thing standing between any one of us taking a CS and this awful situation is blind luck.
-fachad
> A few months ago I moved and had to find a new pdoc. She seemed pretty good at first, but it turns out that she has a lot of attitudes and assumptions that I recognize because a lot of people on PB have reported similar behavior in their (your) doctors. So I'm hoping someone here has some idea how I might approach this problem.
>
> This new pdoc wrote a prescription for Xanax as-needed, but she only gave me 10 doses per month (keep in mind that Xanax is a short-acting drug -- I think it wears off in about 4-6 hours for a typical adult). This month I ran out early and had to ask her to call in a refill. When I saw her the other day, she asked me if I'd been "overusing" the Xanax. (She said this in a way that strongly implied that she felt that I'd "overused" it the month before. The way I see it, the amount she'd prescribed hadn't been adequate.) I tried to explain that I'd been having problems with insomnia and back pain that had contributed to my need for more Xanax than the amount prescribed. Then she got freaked out and accused me of abusing it -- it's "not indicated" for those problems, and so forth. I explained that insomnia and muscle tension can be symptoms of anxiety. She gave me the generic heard-it-a-thousand-times lecture about how I should find other ways to "manage" chronic pain. (I've tried all that stuff, and besides, I don't want to "manage" it, I want to treat it!) In the end, she wrote another 10-dose prescription for this month.
>
> I also told her that I'd been having problems with early-morning depression sometimes, which I speculated was caused by the last buprenorphine dose of the previous day "wearing off" overnight. I don't remember exactly how I phrased it, but I did think it should have been clear what I meant. She somehow managed to interpret it to mean that I was becoming tolerant. (She also claimed that if I was becoming tolerant, it must be because I was using it to get high. Tolerance to benzos occurs almost exclusively in the context of abuse, but this isn't necessarily true of opioids. I didn't bother telling her that, though.) I pointed out that I had said "wears off," not "stops working." She backed off a bit, but she didn't think that this problem was worth doing anything about. (I'd thought that a small bedtime dose of buprenorphine might be worth trying, but I was scared to make that request after she verbally jumped on me -- it made me feel like I didn't deserve it, you know?)
>
> After all this nonsense (all in a single appointment, mind you), I was faced with having to remind her (I had told her this before) that I need 20 mg/night of Ambien, that 10 isn't adequate (I asked for a prescription for Ambien because I haven't been sleeping very well -- she put up a little resistance to this, too, of course, but compared to the other stuff, she was being very rational and laid-back!). Some background: I first took Ambien in 1996 and it has always been clear that 10 mg isn't effective, but 20 mg is (it's not like Ambien just doesn't work for me or I grew tolerant from "overusing" it or something). She insisted I "try" 10, even though I told her that she could confirm what I was telling her by talking to the pdoc I'd seen while I was in Boston. This is a big problem for me because I don't have another appointment for two months; sleeping fitfully and inconsistently for that long is bound to have nasty effects. This pdoc talks about wanting to see functional improvement from the medication, but she doesn't seem to want to do what it will take to bring about that improvement.
>
> I don't abuse or misuse or overuse any drugs, including psychiatric medications; and I've always been responsible about my use of medications, in particular of those prescribed for as-needed use. So the way my new pdoc has been acting is naturally off-putting -- it's clear she's just assuming that I'm up to no good, for some reason. (What that reason might be is a mystery to me: I've *never* gotten this much crap about supposed "drug abuse" from any doctor I've seen.) How am I supposed to deal with this woman??? I want (and need) her to trust me, but she seems bent on mistrusting me. What can I do/say?
>
> Any ideas?
>
> -elizabeth
poster:fachad
thread:103496
URL: http://www.dr-bob.org/babble/20020416/msgs/103521.html