As I wait for the next patient to be brought in, I start reviewing their chart. Past medical records have been received and scanned in per protocol, I see. This won’t be the first time I’ve seen his chart as he had to submit medical records and be approved before he could get an appointment to see me.
A forty-something African American male has been complaining of chronic back pain for several years off and on. It has been hurting now for several months this time, an old sports injury. He can’t be as active as he once was. There are no current prescriptions, but he has been treated with oxycodone for this in the past, as confirmed by past medical records. Currently, he is taking NSAIDs over the counter without relief. He has no allergies, holds a GED, and is self-employed. He travels a lot and lives with his girlfriend. His mother died in her fifties from heart problems, and his father died at fifty from a stroke. He has medical records from a physician a few hours north of us. Here’s an MRI taken several years ago showing degenerative disc disease and a central herniation at L3-4 without canal stenosis or epidural defect. He had been on Roxicodone 30 mg QID and oxycodone 10 mg TID PRN last time. That doctor is no longer in practice, and we can’t get any more information there.
I look a little closer at the last appointment chart. It’s a little sparse. It might be a former surgeon or ER doctor; they learn to be succinct or just old school, only putting what’s relevant to the issue at hand. It’s not the best, but I’ve seen worse.
The point of this entire meeting is that I need to give him some news he may not like. Having reviewed his chart, I’m not convinced that he needs anything nearly that strong for this problem. It’s intermittent, and he’s on nothing now, so this is the time to try to make a change.
If he’s used to 210 MDE a day, I’m not sure how he will respond to 50 mg of tramadol four times a day. Using the old conversion factor, that would be about 20 MDE. However, since the CDC just recommended doubling the calculation factor, it’s now 40 MDE, which is ridiculous. There is no way that 50mg of tramadol equals 10mg of hydrocodone for most people, but what can you do?
The paradigm has shifted, and it is now politically correct to “power taper” people off of medications they have been on for decades. Power taper means cutting the dosage drastically, risking withdrawal complications, and putting the patient at risk of overdose and death from self-medication and the street. It may be a shock for some doctors to hear, but people don’t tolerate agony well. Who knew? Well, except for all doctors going back to before the Civil War. Those doctors knew that pain could kill you. They had a few tens of seconds to get someone’s leg cut off without anesthesia, or the patient’s heart would stop. None of those doctors were stupid enough to say, “Pain never kills anyone.” They saw it happen.
But today, the physician is only in danger if someone dies while ON a medication he prescribed. It doesn’t matter what they died of. No one gets prosecuted when their patient blows their head off or overdoses on the street. That’s just used to justify having cut them off.
So the patient comes in, and I discuss his past history, do a physical exam adequate to the visit purpose, and give him the bad news. I don’t feel that the records I have justify the medications used by the other doctor. Perhaps he saw something I don’t, but we will need an outside expert opinion recommending that treatment. I also wrote for a new MRI as it had been a while. Surprisingly, he took it well. I didn’t think much of it until later.
When I found out he was an undercover DEA agent and that his medical records were fake. That previous doctor had gone to prison. But then it was my turn. Charged with prescribing “without a legitimate medical purpose,” despite the fact that we only treated patients who were already on opiates and who had been seen and treated by specialists. But at trial, none of that mattered, and neither did my treatment of the undercover agent. The jury was told that I shouldn’t have charged the agent for a visit at all. Clear proof of my greed. Ignoring the fact that if you only charge when someone gets medication, that can be used as evidence that you’re selling the prescription and not getting compensated for your time. You can’t win. But in today’s environment, you’re not supposed to. They are. And they do. Almost every time.
L. Joseph Parker is a distinguished professional with a diverse and accomplished career spanning the fields of science, military service, and medical practice. He currently serves as the chief science officer and operations officer, Advanced Research Concepts LLC, a pioneering company dedicated to propelling humanity into the realms of space exploration. At Advanced Research Concepts LLC, Dr. Parker leads a team of experts committed to developing innovative solutions for the complex challenges of space travel, including space transportation, energy storage, radiation shielding, artificial gravity, and space-related medical issues.
He can be reached on LinkedIn and YouTube.
