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.

An open letter to cokeheads

Dear Friends,

You know that doctor that calls you to talk about your drug test? Well, there's no easy way to say this...I'm that guy. I'm what we in the party-pooping industry call an MRO - a certified Medical Review Officer. I know - sounds made up. Anyway, yes, I am the one who calls you and - well, I have to assume from the way that you usually sound when you answer - interrupts your good time with friends to notify you that you will not be funding your habit with a real job any time soon. This isn't the most pleasant work sometimes. Despite what you might think, I take no joy in calling. But I've noticed something you should be aware of. You guys are making this too easy for me. It's almost like you're all reading from the same playbook. Just know that if it seems a logical way to counter me, believe it or not, somebody else already thought of it and has tried it. About a thousand times. Do you have any idea how difficult it is to truly invent something unique???

Anyway, I have decided to write this letter in order to save you the trouble of embarrassing yourself in your attempts to convince me that some terrible mistake has been made. There are a few of you that are really, really good. Keep that up, folks. You are almost (almost) believable. It makes this much more entertaining for me, and believe me, the money isn't all that good so entertainment is about all I'm getting out of this. So here is a little help for you. If we are going to have to spend this time together, we might as well sort this out.

First of all, you must realize how alike you all sound. So much so, in fact, that I have decided that it is not even you talking. It is cocaine. I don't know you, it's true. But cocaine? Ah, I know cocaine very well - at least from a distance.

Cocaine is one gregarious character. You just find yourself wanting to believe cocaine. He has a zest for life that is infectious. To be sure, he usually outlasts all his friends, leaving them a miserable, tired wreck. But they love him all the more. Oh, don't try and cover for him. You'll only look silly. Cocaine does a fine job protecting himself, thank you very much.

Cocaine is also the eternal optimist. No matter how many times we've spoken, he always insists on playing our little game...I let him know I've found him in someone's urine, he vehemently denies it, cursing me, the prospective employer, etc. He is especially fond of threatening to call his attorney on me. In typical fashion, I assume that his attorney is Mark Geragos or someone high-profile. Why wouldn't it be? This is cocaine we're talking about here, right?!?

But, in the end, cocaine knows I have him dead to rights. He'll talk a good game, but he knows when he should leave the party. After all, only amateurs make principled but doomed stands. And cocaine has been around this block a time or two. At least.

So the next time you get a call right after you've gone to sleep at one-o'clock in the afternoon and you don't recognize the number - that is, if you still have your phone - just answer it, okay? I won't be a jerk. And save yourself the trouble and exhaustion of feigning outrage and bandying your threats about. I know who I'm dealing with here. And tell cocaine I said hello. I'll catch up with him later on.

Close the door! And put something heavy against it!

There is definitely something about the full moon. Or maybe it is some other cosmic phenomenon; I don't know. What I do know, and what just about any emergency room employee will tell you, is that there are times when it seems that the flood gates of craziness open and pour directly into your place of work. Yesterday was such a day.

I know that nuttiness is out there somewhere. You run across it from time to time so you know it exists. The law of averages would seem to suggest that you should have a homogeneous mix of craziness throughout the year - some percentage of your total - but that is not the case. They lurk, out there in the world, until the time is right. What I can't figure out is what sort of signal causes them to attack en masse.

Rather than tackle this weighty issue, which is definitely beyond me, I choose to describe these people. I am in the process of creating a sort of taxonomy system so that all of us who deal with the public can simply name them instead of wasting our precious time and energy describing their activities. No one would bother describing how a tiger took down a gazelle in detail - that's just what tigers do. I welcome your input during this process. I think a dictionary or encyclopedia of misfits might be in the pipeline. I will try to add to this list as I am reminded of other types.

Class One - "The squeaky wheel":

These nuts have discovered that they can raise the stakes in a conversation or interaction to a place where no sane person would dare follow. They have become masters of manipulation - using our own common sense against us. They bait us into interaction, usually by appealing to our genuine desire to help others - only to bring the axe down when we are within their grasp. They have discovered the secret of social blackmail - that if they are the most irritating person in the room, they often get served first and best in order to avoid a scene.

Class Two - "The Mr. Wilson":

A little advice - just because you are advancing in years does not give you the right to be a grumpy, uncompromising jerk. I know, I know. I'm not doing my job the way you would. I'm sure I'm not doing it the way doctors used to. And I'm sure that you, like me, disapprove of the majority of what you see going on in the world these days. None of that, however, is the fault of me or my staff. So lay off, dude.

Class Three - "The Over-Protector":

I actually had one of these yesterday, too. It is usually a husband, but may also be a parent. Whether for desire for some sort of secondary personal gain or because they are maniacally self-centered, believing that no one can care for the object of their affection the way they can, this type is disposed to violent outbursts that take on the appearance of legitimate concern. The problem is, their nuttiness drives a wedge between the patient and the person who has the ability to help them. My feeling is, if you could do this yourself, then why are you here right now? Back off and let me do my job. Please.

Class Four - "The Shape-Shifter":

This is one of my personal favorites. This looks somewhat like what we doctors have termed Borderline Personality Disorder. You start out as "the best doctor in the world", then slowly become the Adolf Hitler of modern American Medicine as you consistently fail to live up to the ridiculous expectations and demands of the patient. These people are exhausting, especially if you make the common rookie mistake of trying to reason with them and prove that you really are not the evil anti-Christ they accuse you of being. Listen to the voice of experience, people.

This is so much fun, I really hate to stop. I'll try to add some more later. Thanks for your patience.