Comfort Zone

Chapter 4

Miriam's thoughts were still racing.

Years before, pain had become the fifth vital sign, measured routinely like temperature and blood pressure. Miriam knew it was hard to separate pain from addiction, but Mr. Gill's face was a definite "ten" on her pain assessment scale.

She also knew the trend in medicine had gone from almost never prescribing opiates for pain, to freely prescribing them, and was now in fast retreat, based on studies showing lack of efficacy and grave harm to patients, including frightening reports of opioid related deaths.

But chronic pain was terrifying too. Until they found a balance, until better treatments came out, what was a doctor to do?

Mr. and Ms. DEA, she imagined protesting, my patient has neuropathy from diabetes. His legs feel like they're on fire all the time. He's already tried all the non-narcotic options, except for acupuncture and yoga because they're not covered by his insurance. Remember that in addition to being prosecuted for overtreating pain with narcotics, doctors have been prosecuted for undertreating it.

The imaginary DEA howled their objection. But patients have obligations, too, they would say. Like avoiding illegal drugs!

"Dr. G?"

A one-time slip, Mr. Gill had called it. Maybe he's lying and he is addicted to cocaine, Miriam thought, and of course he should go to Narcotics Anonymous, but some say the success rate of twelve step programs is as low as five percent! By definition, addiction is a "chronic, relapsing disease of the brain," not a moral failing, and we don't have good treatments for it. Do we stop helping a diabetic who keeps eating pastelitas and coming in with sugars of 500? Pastelitas weren't illegal, of course, but maybe they should be!

Did he really forfeit his right to relief?

Specialists can sign off, she thought, but I'm the PCP, the primary care physician. Should I throw him out like the pain doctor did because he was bad and that's what he deserves? Tell him there's no forgiveness? He can use cocaine, and pick up some black market "oxys" for his pain, go to one of the pill mills Florida was infamous for if he can find one, or a pain clinic that doesn't take insurance and charges patients two hundred and fifty dollars a visit. Or maybe buy them through one of those internet pharmacies that deliver counterfeit Viagra and the like.

Sometimes I feel like we're just trying to punish people with our guidelines, or take the easy way out. You can't stay clean, you're doing something illegal, so stay in pain. Can't help you. Don't want to anyway.

Miriam's righteous indignation suddenly deflated. Dear DEA, she silently pleaded, can you please tell me the right thing to do, and not just what's legally safer? Better yet, come to the office and tell my patient.

"Dr. Gotlin? Are you still thinking?"

What would JK do? she couldn't help wondering, wrenched by the thought she couldn't ask him. Since no one from the DEA showed up to help, Miriam checked the online database to make sure Mr. Gill hadn't gotten a script from anyone else, then wrote for a month's worth of opiates, and exacted a promise that he would go to Narcotics Anonymous--no excuses! She told him she was obligated to do a urine toxicology screen at his next visit and she expected it to be crystal clear.

Then she went to the computer and documented the visit, justifying her plan on the screen as best she could, asking herself all the while: am I right, or wrong?

She really didn't know.

A call from the emergency room interrupted her rumination, almost a relief until she heard the name of the patient. Lisa Phillips needed to be admitted again. This had been happening with increasing frequency, and Miriam's heart sank. The woman had scarcely been home three weeks this time, and was now back with diarrhea and a low white blood cell count. White cells, the infection-busting cells in the blood. Without them, villainous microorganisms can roam unchecked in the body and wreak havoc.