Getting Amphetamines In Other Places

I thought this person should be fired from the county clinic, but most counties don’t let me do that sort of thing.  The state of California has a nice service, where I ask to see who else is prescribing this person the same abusable drugs that I am.  I try to work with people who abuse drugs, I really do.  In one sense, it is the purest of pharmacologies, in that things I usually think are parts of a physician-patient encounter, like conversation and logic, play little or no role. House said that patients lie.  House is a Vicodin (opiate) addict.  Some of my more intelligent substance abusers are House fans. The same way that “Cops” was the most watched TV show in prison, when I was a jailhouse doc.

This person, was getting weaned off amphetamines.  After a lot of  years, I am not very sure I believe in ADHD, or “Attention deficit disorder.”  We all have problems of differential maturity.  These are just people who learn to concentrate later.  They may have other skills like class clowning that are way ahead.  My book learning was ahead of my social skills for a lot of my life. Besides, most anybody brightens up when you give them amphetamines.  Not that the effect lasts very long, mind you.  Even kids who take Ritalin in a quest to do better on the Scholastic Aptitude Test seem to revert pretty quickly to their previous state of dullness.

Even if ADHD does exist, my diagnostic criteria would be the narrowest of anybody’s. Someone who has the paradoxical receptor response that, that was there when the alleged “illness” was first described in 1937.  Someone who uses a cup of strong coffee as a sleeping pill. I have a very few patients who are documented well to meet older criteria, and who do so poorly without stimulants that they will be blown out of either special schools or foster home placements.  They get their stimulants, the tiniest amount needed to hold their lives together. People like this seem to get better when they are older.  The idea of residual ADHD in the adult is something that concerns me even more. Virtually every case of alleged ADHD in adults has turned out to be someone who wanted stimulants.Usually, a bipolar (wildly under-diagnosed) who wanted a bit more of the “up” side.

Sometimes if I get a good history and someone has been on these meds for a bit, I will keep them on for a bit.  But I go with the guidelines; American Psychiatric Association and Academy of Pediatrics and such.  The EKG, the “cardiocentric examination,”  these things can facilitate sudden cardiac death, you know.

These stimulant drugs (ritalin, amphetamine) are every bit as abusable as painkillers, which was why I was not surprised at this case, which folks who usually monitor pain med abuse found surprising.

Yes, someone whose doubtless decent and responsible primary was trying to wean them off amphetamines went to ER to get some more.

In rural California, the ER is generally overloaded.  My patient who did this exact same thing, getting amphetamines in an ER where he was not known, has planned recreational trips to the SF Bay area to coincide with ER visits. Half of the family waits in the ER; the other, reviews various tourist traps.

Something horrible has happened to truth, justice and the American way. Prescription of drugs is not an arbitrary power earned by credential. It can and should be thoughtful and appropriate. There is a wonderful concept,”the therapeutic alliance,” by which doctor and patient work together to make the patient well with lots of lying and little trust. There is less of this, despite the most serious of efforts.

People who want drugs seem to get them.  Drug companies advertise drugs to the public, who go to the doctor clamoring for what they want.  Sometimes they do not need what they want, which could kill them.

I think sometimes the best I can do is put little “stop” signs in front of people careening down the highway to self-destruction.