Wednesday, July 2, 2008

Fun With Drug Testing, Volume 2

The call was routine. At least it should have been. You know the old saying about how "no good deed goes unpunished"? It's true. It wasn't even my case. My comrade at our other clinic was out of town, so his drug test reviews fell to me. Just my luck.

The donor had popped positive for methadone. At this point I should make a confession about something. I know less than I probably should about methadone. For example, having never prescribed it myself, I know less than some about its effects on the patient. I have to assume that it has some effect. Otherwise there would seem to be little reason for prescribing it. There are two main reasons for taking methadone - that much I do know - (1) chronic pain that is poorly-treated with more traditional narcotics, and (2) management of opiate addiction.

There are those who believe that methadone is as close to a harmless medication as exists. I have found that these people are generally the doctors who prescribe it and the patients who take it. On the other hand, the Department of Transportation forbids its use in drivers. Somewhere in the middle is the probable truth. If the reaction of the drug testing donors is any indication, however, then it probably needs to be better regulated. They display many of the same denial characteristics as those who take the drugs commonly abused. This brings me to my story.

The donor was very cordial. I went through my routine with him; he acknowledged the use of methadone. He gave me the prescription number and the name and phone number of the pharmacy where it was filled. I thanked him and hung up. Only one little red flag went up - he had a loudmouth wife in the background. She kept interrupting him and I could tell that she was disappointed with the fact that he wasn't giving me the earful that she wanted to. I called the pharmacy to verify the prescription, and it got interesting. The prescription was six months old.

Methadone should not be prescribed for "as needed" use. Whether for pain management or opiate addiction, it should be taken constantly to provide a baseline level. I called him back and asked him about this. It was really a moot point anyway. His job called for him to perform safety-sensitive duties - driving a forklift, working 50 feet or more above ground, etc. His company would not have hired him even if he was taking it appropriately. He tried to explain that he hadn't needed it for a long time, then he began having some acute knee pain so he took a couple. This may have been true - he may have been that boneheaded. Or it may have been a lie. He may have been taking illicit methadone for months. Either way it was not good. I reported the result as "negative" but recommended against his working in safety-sensitive duties.

About 30 minutes later, he called me back. Actually his wife called me back. And she was not happy. I was not able to tell her that I couldn't discuss his test results with her because she wouldn't shut up telling me what a sorry S.O.B. I was. Eventually he got back on the phone. She had apparently done a superb job of spurring him into action. He was very believable as a creep.

"I've gotta work. You are gonna cause me not to get this job. I'd looove to be sitting up there where you are, bein' the doctor, tellin' people whether they can work or not. But I'm just a construction worker, tryin' to make a livin'..." I imagined him - eight feet tall, massive, but with chronic, crippling back pain and tobacco-stained lips and hands. All the while, I could barely hear the harpie in the background.

"You tell him it's your medicine, and you can take it any way you damn well want!"

"You tell him he just cost you a job!"

"You find out where he is!"

Eventually, even I'd had enough.

"I'm not going to listen to any more of this. I didn't make your back hurt. I didn't make your knees hurt. I didn't make you take methadone. I didn't tell you to take it wrong. In fact, I didn't even call you positive, although maybe I should have. I just said it wasn't safe for you to do dangerous things while taking methadone. So I think we're done talking now."

And that was that. I'm sure that in his mind, I do have a pretty great job. If he only knew what it feels like to be in constant fear and real jeopardy of some dead-end loser taking everything my family has for something like that. I have to content myself with knowing that I may have saved his co-workers from injury due to his inattention while taking massive doses of narcotics. They will never know. All they'll think about is what a jerk the "company doctor" is the next time they lie to me and I call them on it. God, I wish I could escape this sometimes. I'd just take back the $250,000, turn in the license so dearly purchased, and stop being everybody's favorite target.

Health Care: Rights and Responsibilities - Part II

Here is a quick recap of yesterday...

The belief held by many that health care is a right is plagued by some inherent difficulties. Among these are the following:

(1) Health care is difficult to adequately define and as such is difficult to promise to anyone.

(2) Freedom from illness has not traditionally been considered a "right", as health is impossible to guarantee, even under ideal circumstances.

(4) Universal health care, like the partially-socialized plan of today, would suffer from serious inequities in the real world, with a small group paying most of the bill and a different minority reaping most of the benefit.

(5) In order to guarantee this benefit, the government would have to crush the objections of the practitioners - through force if necessary.

It is primarily for these reasons that I do not believe health care is a basic human right. Instead, I believe that it is up to each of us individually. Admittedly, my way is not perfect, and I will discuss these weaknesses of my position today.

If health care is not guaranteed, then what are we to do with the uninsured?

I admit that there is no perfect answer to this question. Almost immediately, though, I am reminded that ours is not a perfect world. Historically, though, these less fortunate citizens were cared for by private citizens and their organizations. I believe strongly that they do a better job of dealing with specific issues than the government does. The government requires, by its nature, a large beauracracy for even the smallest task. This causes the work of the government to be particularly wasteful. A church or civic organization, on the other hand, requires almost no additional manpower, is quick to act, and by acting, strengthens its community in ways the government can not hope to.

What about the children?

Children, due to their vulnerability and their inability to completely care for themselves, must be cared for by others when things go wrong. Continuing to care for all children without other resources under the age of 18, even expanding coverage for them, seems to be the right thing to do. I am a capitalist, but I am not heartless.

By requiring all able-bodied adults to care for themselves, it allows them the opportunity to make conscious decisions about their health, not just their health care. Worrying about one's health and taking proper steps to ensure it should never be the responsibility of some third party. Why would it be? This mindset betrays the worst sort of authoritarian parentalism in our government. If I were a cynic, I might think that the people who want to create this sort of dependency for even the most personal of matters are only trying to create a large segment of the population who will continue to vote for the person or the party who will continue that life-support. If I were a cynic.

The notion that the medically indigent are somehow unwitting victims of circumstance is held only by some of those who have never actually worked with this population. The generations of dependency have caused them to be completely irresponsible, in many cases, making poor lifestyle choices and further increasing their need for health care. It is a vicious cycle. They choose cigarrettes instead of medicine, then complain about the limits on the numbers of medicines they are allowed under the Program. This is ridiculous. I am exhausted, both as a hard-working taxpayer and as a physician. It is high time for us to begin the process of withdrawing benefits - not just for financial reasons, but because it is cruel to continue to convince people that the government can do a better job taking care of them than they themselves can.