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A World of Pain
On that great day when all the single-issue groups assemble to pursue their mutual interests, cannabis users will find they have a lot in common with their fellow citizens who use synthetic opioids to cope with chronic pain. Patients in both groups have had to rely on a handful of doctors willing to approve their drug use without regard to bureaucratic constraints. Because opioids can be fatal, the pain specialists are taking an even greater risk, vis-à-vis law enforcement, than their cannabis-consultant colleagues. So struggle against self-pity, comrades, rise up out of the single-issue trap, and meet some prospective allies.
Joe Talley is an upstanding 67-year old North Carolina country doctor–tall, folksy, garrulous, a Navy vet, a skilled toy maker, a reptile collector–who expects to be indicted by the federal government on multiple murder charges before the end of the year.
Talley put out a shingle as a general practitioner in Grover, N.C. in 1969. Except for a brief stint teaching medicine, he practiced in Grover until April 2002, when the state medical board -acting at the behest of the federal Drug Enforcement Administration- revoked his license.
Talley had become known, over the years, as a doctor willing to prescribe opioids to patients who claimed to be in severe pain. "Word of mouth seems to travel faster in the pool hall than in church," he observes. He is being charged federally in the deaths of people who allegedly overdosed on opioids he prescribed and people who overdosed after buying opioids from his patients. While preparing his defense, Talley, who has not lost his sense of humor or perspective, has written up a number of "situations for which doctors aren’t trained." Here are two of them:
* A 27-year-old North Carolina farmer, a good ole’ boy I shall call Billy Bob, showed up at my office with a big lump on his shin. It turned out to be Ewing’s sarcoma (yes, at age 27!), and unfortunately there were already snowballs on the lung films. Johns Hopkins had one of their send-me-your-poor-downtrodden-weird-cancers programs going, but when Billy went up there, they had little of promise to offer him, so he returned home to die. To their credit, Hopkins sent along a generous supply of Dilaudid.
I had no hesitation in continuing the Dilaudid, and his rapid escalation to a fairly prodigious dose gave me no pause. I wasn’t going to let the guy die in pain, and if he was getting any highs on the side, hell, he deserved a break! Billy was a remarkably strong man, and he was able to remain on his feet and ambulate to the office until just days before the inevitable cascade of systems failures and eroding metastases brought the story to a rather quick and merciful close. The family expressed their profound gratitude for my keeping him comfortable until the end.
About a week later one of the most strikingly beautiful patients in my practice presented with tremors and shakes, in obvious withdrawal. Debbie could have been a model anywhere had her heroin addiction not destroyed he life (and incidentally got her kicked out of my office for selling my Xana to buy the stuff.)
Debbie: "Please, doctor, I’ve just got to have something for this headache!"
Talley: "Come on, Deb, we know each other. You know I can’t do that. Go see your supplier if that’s what you’ve got to have."
Debbie: "I CAN’T! HE DIED!"
Billy had the sarcoma all right, but it was one of those few cancers tha kills a guy without inflicting all that much pain. So he had pills he didn’t need. He couldn’t have gotten within 50 miles of Debbie, until he was furnished with the perfect gift certificate. I thought of writing tha one up in a journal: "New Palliative Treatment for Terminal Cancer: All th sex you ever dreamed of but couldn’t get until you secured the proper mediu of Exchange."
* This story involves a transient patient I’ll call Sam. He was a sligh little man, around 65, silver-haired and of dusky complexion, obviousl emphysemic. He told us he was from St. Louis, had come to North Carolin for the funeral of his uncle, then had been screwed over by USAir (entirely believable!) over a K fare, and was stranded for the next 5 days. But he had cancer, and he described how the surgery and/or the post-op radiation had damaged the nerves, making him hurt terribly all the time.
He said his doctor in St. Louis had been giving him Dilaudid, which was making his life bearable, but which was running out today. (Yeah, right!)
But when we asked him where his cancer was, he removed his coat with the high furry collar to reveal half his neck missing! He had indeed had a radical neck dissection. Then he produced a well-worn professional card, giving the name and address of his physician, a Dr. Fitzgerald in St. Louis. And so, of course, we called him.
Receptionist: "Dr. Fitzgerald’s office. This is Michelle."
Talley: "Yes Ma’m, we got your patient, Sam What’s-his-name, out here in Grover, North Carolina, and-"
Receptionist: "SAM? My goodness, what’s he doing way out in North Carolina? Oh Yes, now I remember, he said he had a real sick uncle out there! Isn’t he a dear, doctor?"
Talley: "Yes’m, he is. Uh, could I talk to Dr. Fitzgerald about him?"
Receptionist: "Well, Dr. Fitzgerald is at lunch. But could I help you in any way with him?"
I asked her to pull the record and confirm his story. After an appropriate pause… Receptionist: "Ye-ess, that’s right. Today is the 21st, isn’t it? Yes, doctor, his prescription for Dilaudid should be running out today. Could you help him out for a few days until he can get back? You know, we can’t call in a Skedule II."
That was enough for me. But my paranoid partner wanted to call the doctor’s office back, using directory assistance instead of the number on the card. (Dick saw an addict under every rug, and a wire under every lapel!) To humor him, I did so. Indeed there was a Dr. James Fitzgerald, General Surgery, with an identical address, although a different phone number, for some reason. The call went like this:
Receptionist: "Dr. Fitzgerald’s office, Michelle speaking (but with a different voice). What? You called 10 minutes ago? Doctor, I’ve been at this desk the whole lunch break, and nobody’s called in the past hour! I don’t know who you called, but- No, wait! Don’t tell me, let me guess! YOU GOT OLD SAM OUT THERE, HAVEN’T YOU?"!!!
Sam had an HEENT cancer, all right, but surgery apparently cured it. Now, at 63, with bad emphysema, who was going to hire him? So he stashed his girl friend in a Ramada Inn in St. Louis, ran a private phone line in, printed up some professional cards, and his itinerary was describing an ever-increasing spiral around the country.
We had long since learned that the local KGB had no interest in such as Sam unless we had actually bitten for the scam, and then they would only want him as a witness, so we didn’t even bother to call. (We did call a couple of nearby doctors in the area to give them a heads up, but Sam probably knew not to go to the well in the same area repeatedly.)
I asked him how often he successfully pulled off this scam, and he said about a third of the time. But 20 Dilaudid tablets, bringing $60 apiece on the street? It was a living!
So much for the expensive workups to determine if a patient has "generators" for his pain, also the bye that cancer patients get but others don’t get.
PS: Before somebody starts up about about my cavalier attitude about diversion leading to some nice kid in St. Louis going to a party, shooting up some of the Dilaudid Sam had passed along to his retailers, and coming to a tragic end, I would say, "Who thinks that kid wouldn’t have found something else to indulge his passion for incredibly dangerous behavior with, would have stayed home and done his homework that night, if only suckers like me didn’t keep getting had by the Sams of the world?" And before the feminists whom I know lurk amongst us start weighing in on my chauvinistic and sexist portrayal of a poor woman who was forced to sell her body to meet the demands of her disease, I would save them the trouble and say, "OINK."
Since his practice was closed down, Talley has been helping former patients arrange to see other doctors. He says he’s been struck by how many have volunteered the information that "they can make do with half the opiates if they have a joint." This jibes exactly with what researchers in Sandra Welch’s lab at Virginia Commonwealth University have learned from animal studies: cannabis use can reduce the need for opiates by about 50 percent.
Martin Klos is an Oregon MD who has been disciplined by the state board for "overprescribing" opioids. His punishment includes monitoring by another pain specialist. "During our last visit," Klos reported to a colleague, "he was very specific about working with me to find dosages for my patients that would treat their pain, but at the same time would be ‘below the horizon’ of the regulators’ radar to keep me out of trouble with the board, the insurance companies (which have been the source of the majority of complaints against my prescribing) and other doctors. These are the dosages of pain medication that he felt to be acceptable by Oregon regulators.
"Duragesic 150 mg [patch] wearing at a time
"Oxycodone 240 mg per day (3 Oxycontin 80’s per day)
"Morphine 300 mg per day and
"Methadone 100 mg per day.
"No pretense was even made as to therapeutic equivalents, or functional evaluation of the patient. These are the doses that ‘should keep me out of trouble.’ When I discuss this with patients, they universally have decided to try to lower their doses to meet these expectations, knowing these are artificially set by the threat of a regulatory system.
"I have been upfront with the patients, and have discussed this with them at length with each visit, so I do not feel this is unethical. They also have the ability to change doctors to a more technologically capable physician (I cannot have hospital privileges so long as my license is on probation with the medical board) for injections or medication management.
"Regulators have strongly affected medical practice in Oregon, and all the doctors and the medical school seem to agree with the medical board that this is a perfectly legitimate way to practice pain management in our state."
FRED GARDNER can be reached at: email@example.com