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    Rx drug use: Treat, don't indict

    Robert MabeeRobert MabeeGovernment involvement with drugs has a long and troubled history. In the latest effort to combat the growth of prescription drug abuse and enforce stiffer criminal penalties for the distribution or abuse of prescription drugs, new regulations have been initiated nationwide.   

    In theory, this was a good idea. But the timing was a bit odd. At the same time as the United States decided to clamp down on patients who may have become therapeutically addicted to psychotropic or pain medications, there was a growing push to legalize cannabis, a Schedule I drug used “recreationally.”

    Pharmacists and physicians are now concerned that law enforcement might find their decisions to prescribe or dispense a controlled substance as criminal.

    See also: Filling prescriptions for controlled substances: Establish a protocol

    The role of treatment providers 

    Confusion of roles leads to poor decisions. Physicians and pharmacists are not policemen. Their job is to provide preferred treatment to all patients. Preferred treatment is the treatment you want for yourself and your family. Not the most expensive treatment, but the one that’s most effective. Most pain medications are inexpensive.

    The decision to treat addiction as a crime is not a subjective approach with a clinical perspective. Patients with legitimate chronic pain or terminal illness are always at risk of developing therapeutic addiction. And terminal illness and the associated therapeutic addiction are by definition self-limiting.

    Physicians, however, have always been reluctant to prescribe pain medications. My brother used to make regular visits to a friend and mentor who had been a clinical professor when my brother was in med school. The older surgeon, as a patient in hospice, regretted that he had not been more aggressive in treating pain during his career. Faced with the pain that often accompanies an end-stage disease, he realized that he could have given his patients better care if he had provided appropriate pain control.  

    See also: The pain-med choke point

    Law vs. medicine

    A well-documented dilemma unfolds when doctors decide to practice law and lawyers decide to practice medicine. Lawyers and judges are trained to take an adversarial approach to decision-making. Physicians are trained in a collegial environment that encourages decision-making by consensus. Doctors’ perception of the risk of malpractice is exaggerated. In reality they are at greater risk of being struck by lightning.

    Healthcare administrators nurture this misconception and heighten physician paranoia. They inculcate a siege mentality and encourage a “team loyalty” that requires silence about any act of medical negligence. Some speculate that “fellow team members” are willing to engage in technical perjury to preserve their employers’ assets, perhaps motivated by hope of a bonus in the future.

    Robert L. Mabee, RPh, JD, MBA
    Robert L. Mabee is a pharmacist and attorney practicing in Sioux Falls, S.D. He also holds an MBA. Contact him at [email protected]

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    • SteveAriens
      It has been stated that for the last 100 yrs.. we have had 1%-2% of the population abusing some substance - other than alcohol and tobacco - even if that fact is off by a factor of 5 to 10... it would mean that 90%+ of the time that you believe that you are dealing with a drug abuser - YOU ARE WRONG !.. 15 + yrs ago it was claimed that only 20% of chronic pain pts got adequate pain management.. given today's "corresponding responsibility " environment.. is probably 10% at best... the rest of the pts are being grossly under treated... Those "drug abusers" are really pts with undiagnosed/untreated mental health issues including an addictive personality... that are self-medicating the demons in their heads and/or monkeys on their backs.. opiates tend to be their "drug of choice" unlike the acceptable part of society.. whose drug of choice is ALCOHOL to treat their demons.. Of course it is estimated that abt 20% of the population is a borderline alcohol at any given point in time. 3-6 million drug addicts vs 60 + million alcoholics... no epidemic there ?
    • Anonymous
      We recently had a 55 year old patient who was the typical "red-flag" consumer of Hydrocodone for several years. Wanted it six days early, lost his bottle, dog ate it, neighbor stole it, multiple pharmacies, etc. He used only one doctor, who was known for writing Hydrocodone easily. We did not refuse his prescriptions, but never filled them early. We counseled him on several occasions concerning his increased usage, possible acetaminophen toxicity, etc. He admitted he used "too many", so the doctor prescribed Fentanyl patches. Two weeks later, his father told us he was on life support. Seems he had advanced lung cancer but never knew it and was treating the pain that must have been intolerable. The prescribing physician had never mentioned cancer to him or his family. Three days after being put on life support, they pulled the plug. How the system came to this point, I do not know. I also do not know the answer. We are torn between "abusers" and patients truly requiring pain relief. How can we possible get it right every time? We truly thought the guy was an abuser, and the guilt associated with finding out we judged wrongly weighs on our conscience.